Retrospective study minimally invasive management of postoperative lithiasis of the common bile duct.

INTRODUCTION: Postoperative common bile duct (CBD) lithiasis holds a significant place in the bilio-pancreatic pathology, both due to its high frequency as well as to the diagnostic and treatment issues it triggers. MATERIAL AND METHODS: Based on a 5-year experience (2008-2012), assessed retrospectively, totalling 51 patients with postoperative lithiasis of CBD, we tried to elaborate on several recommendations for the treatment of this pathology. The recommendations were guided by the existing alternative therapeutic options and by the ideas in the literature regarding the results achieved by every manner of treatment. RESULTS: The rate of clearance of the CBD was of 93.6%,the morbidity rate was of 10.65% and the mortality rate was of 0%, which entitles us to deem the effectiveness of the minimally invasive treatment as maximum in the treatment of this pathology. CONCLUSIONS: The endoscopic treatment of postoperative lithiasis of the CBD proved to be possible, efficient and we believe it good to be used as a principle; open surgery should be the solution in case of failures or of contraindications to minimally invasive treatment.

Minimally invasive treatment of cholecysto-choledochal lithiasis - "Rendez-vous" technique.

INTRODUCTION: In our paper we present the results of a study that was meant to provide a complex answer to the question:"Which is the most appropriate, most correct and least expensive treatment for mixt cholecysto-choledochal lithiasis(MCCL)?" MATERIAL AND METHODS: Based on a five year experience (2008-2012), analysed retrospectively, during which 143 patients with MCCL were treated, we are trying to find answers to some of the questions that we have asked ourselves from the very beginning of this period. The answers were guided by alternative therapeutic options, for a pathology that does not have a "gold standard", with respect to the solutions available. RESULTS: Given the fact that the period during which the study was conducted was chosen randomly and that the patients were included consecutively, the representativeness of the results is ensured for any other patient diagnosed with this pathology and admitted to a clinic with the same specialty, dimensions and equipment as the one presented. CONCLUSIONS: This paper compares the results of our study to those of others, in terms of different or similar approach therapeutic options, developed in other minimally invasive surgery centres in the world, the final conclusions being encouraging for the therapeutic sequence that we practice.

Spectrum, antibiotic susceptibility and virulence factors of bacterial infections complicating severe acute pancreatitis.

Secondary infection of pancreatic necrotic tissue and peripancreatic fluid is a serious complication of acute pancreatitis resulting in significant morbidity and mortality. The aim of this study was to find out the spectrum of bacterial infections, their antibiotic susceptibility patterns and virulence features in patients with severe acute pancreatitis (SAP). A total of 19 patients with acute pancreatitis were consecutively selected from 153 clinical cases of septic abdominal surgical emergencies (age 29-80, 12 males, 7 females) admitted during 2009-2011, in the First Surgical Clinic of the University Emergency Hospital of Bucharest. All 19 SAP cases were submitted to pre-operatory antibiotic empiric treatment. Ten cases were culture negative, in spite of the positive microscopy registered in eight of them. The rest of nine cases were culture positive, 17 different bacterial strains being isolated and identified as belonging to eight aerobic and four anaerobic species. Polymicrobial infection was seen in six patients and the etiology was dominated by Gram-negative bacilli, followed by gut anaerobic bacteria, attesting their colonic origin. The susceptibility testing of the isolated strains confirmed in vitro in all cases the efficiency of the antibiotics that had been used in the empiric pre-operatory treatment. Out of 19 cases submitted to pre-operatory empiric treatment, 14 proved a favorable evolution and five a lethal outcome. The host depending factors (sepsis and other co-morbidities), as well as the aggressivity of the isolated microbial strains (mediated by the presence of different factors implicated in adherence, toxicity and invasion) were found to contribute to the unfavorable, even lethal clinical outcome of SAP cases. In spite of all theoretical controversies, the antibiotic therapy remains at present a very important therapeutic mean for the SAP treatment; although it cannot solve the septic necrotizing pancreatitis in 100% of cases, however, associated with the surgery and all other medical means of intensive therapy, the antibiotic treatment can influence the clinical evolution to the benefit and recovery of patients in a significant number of cases.

[Duodenal carcinoid]. / Carcinoidul duodenal.

Carcinoid tumors of the duodenum are extremely rare. We present two cases (observation) of duodenal carcinoid tumors. The main clinical manifestation in both cases was upper GI tract hemorrhage associated to severe anemia.The tumors were high dimension (2.5 cm and 6.5 cm respectively) and were discovered by upper GI endoscopy. First observation presented a lymph node metastasis and the second one a massive invasion of the pancreas. In both cases the diagnosis was precised only postoperatively, through histological and immunohistochemical analisys. In the first observation we performed local transduodenal resection and in the second one cephalic duodenopancreatectomy. After six months we had a reintervention at the first case for a retroduodenal carcinoid tumoral reoccurrence--extirpation completed with total gastrectomy for neuroendocrine carcinoma. Despite the locoregional aspect of advanced evolution of the disease, the long-term evolution of the patient was satisfactory. Both patients are alive 42 months respectively 15 months after the operation. Carcinoid tumors of the duodenum are indolent and their impact on survival is uncertain.

[Periampullar diverticulum--related to bilio-pancreatic disorders]. / Diverticulul duodenal periampular--implicatii in patologia bilio-pancreatica.

UNLABELLED: Periampullar diverticulum (PAD) represent a particular type of duodenal diverticulum, with important pathological effect on the functionality of both the billiary tree and the pancreas. In our retrospective, randomised study, we analised 204 patients who underwent ERCP. We diagnosed 34 PAD (17%). We performed the endoscopic procedure for several pathological conditions of the biliary tract (cholestasis, jaundice, angiocolitis). Most DPA were identified in patients over 60 years (80%), beeing slightly more frequent in males (59%). We found in 25% of patients (over 65 years) with bile duct stones at least one PAD. Over 50% of patients with PAD had bile duct stones. Fibrous, obstructive papillo-odditis was found in 37% of patients with PAD. CONCLUSIONS: 1. PAD are related to bilio-pancreatic disorders, especially to bile duct stones. 2. The most common physio-pathological mechanism is a alteration of the bile flow, due to angulation, compression and/or obstruction of the final part of the bile duct and Wirsung duct, followed by secondary upper stasis. 3. Papillosphincterotomy has technical particularities, because of difficulties in incision orientation (a deformed papilla, with modified anatomical relationships, being situated profound inside the diverticulum cavity). Sphincterotomy depth was limited, which lead to less succesfull extraction of bile stones (89%, compared to the control group 92%). 4. We did not encounter major accidents. Secondary acute pancreatitis after ERCP was similar in both study groups. There was no significant difference in morbidity and mortality rates in both groups.

Bacteriological aspects implicated in abdominal surgical emergencies.

UNLABELLED: The purpose of the present study was to establish the microbial etiology of abdominal surgical emergencies as well as the relationship between the bacterial etiology and the virulence factors produced by the respective isolated strains. 110 bacterial strains were isolated from 100 randomized clinical cases, operated during 2009-2010 in the First Surgical Clinic of the University Hospital of Bucharest. The clinical cases (sex ratio 52 M/48F aged between 22-85 years old) were classified into three risk groups, as related to their severity. The isolated strains were characterized by cultural, microscopic and biochemical methods. After identification, the bacterial strains were investigated for their virulence potential (adherence to abiotic surface and production of soluble virulence factors). RESULTS: The specimens were collected from different clinical pathologies: diffuse acute peritonitis, biliary duct infections, severe acute pancreatitis followed by septic processes etc. The 110 bacterial (72 aerobic and 38 anaerobic) strains were isolated only in 70 out of 100 cases. Out of these 70 cases, in 45 already submitted to pre-operatory empiric broad spectrum antibiotic therapy, there were isolated 74 strains, whereas in 25 cases without any treatment, there were isolated 36 strains. The etiology was either mono-specific or multi-specific (aerobic-anaerobic associations, especially in old persons). Out of the 30 negative culture cases, 16 were already submitted to pre-operatory parenteral empiric antibiotic therapy at the moment of specimen collection. The aerobic etiology was dominated by Enterobacteriaceae. The most frequent anaerobic species belonged to Clostridium, Peptococcus and Bacteroides genera. It is to be mentioned that the isolation of Bifidobacterium and Veillonella spp. in 11 (10%) severe cases of the studied abdominal surgical emergencies is pleading for the fact that in certain conditions, bacteria belonging usually to commensal gut flora can turn to pathogenic becoming responsive for life-threatening cases. All aerobic and anaerobic strains exhibited some of the following virulence factors: mucinase, esculinase, pore-forming toxins (lecithinase), proteolytic enzymes, adherence ability (slime factor). The presence of these virulence factors (VF) could explain the severity of the clinical aspects. CONCLUSIONS: The bacterial etiology of the abdominal surgical emergencies exhibited a very large spectrum, the highest number of strains being of endogenous origin (Enterobacteriaceae and anaerobic strains). It was demonstrated that the isolated strains produced (cell associated and soluble) VF proving in this way their role as important virulence sources in the hospital environment and explaining the large diversity and severity of the clinical abdominal pathology. The results of the present study are also pleading for periodical readjustments of the pre-operatory empiric antibiotic therapy.

Numerical solution of stochastic differential equations with Poisson and Lévy white noise.

A fixed time step method is developed for integrating stochastic differential equations (SDE's) with Poisson white noise (PWN) and Lévy white noise (LWN). The method for integrating SDE's with PWN has the same structure as that proposed by Kim [Phys. Rev. E 76, 011109 (2007)], but is established by using different arguments. The integration of SDE's with LWN is based on a representation of Lévy processes by sums of scaled Brownian motions and compound Poisson processes. It is shown that the numerical solutions of SDE's with PWN and LWN converge weakly to the exact solutions of these equations, so that they can be used to estimate not only marginal properties but also distributions of functionals of the exact solutions. Numerical examples are used to demonstrate the applications and the accuracy of the proposed integration algorithms.

[Pancreas divisum--a rare cause of chronic pancreatitis]. / Pancreas divisum--cauza rara de pancreatita cronica.

Pancreas divisum (P.D.) is a congenital anatomic variant, characterized by the nonunion of dorsal and ventral pancreatic ducts. A 20 years old man followed for 8 years with reccurent abdominal pain and relapsing acute pancreatitis develope chronic calcific pancreatitis. He was diagnosed with P.D. on endoscopic retrograde pancreatography and operative pancreatography. The patient was treated with longitudinal pancreatico-jejunostomy (PUESTOW-GILLESBY procedure). His pain resolved following surgical drainage of the pancreatic duct. Evaluation of the clinical course of this patient and critical review of other such cases in the literature support the role of compromised ductal drainage of the pancreas in the pathogenesis of chronic pancreatitis in P.D.

[Gallbladder leiomyoma]. / Leiomiomul de vezicula biliara.

Leiomyoma, benign tumor generated by wall's smooth muscle proliferation, is extremely rare revealed. In our experience we only find one case, randomly discovered on the immediate examination of the bladder at the end of the laparoscopic cholecystectomy. The echographic exam may suggest sometimes the diagnosis but the presence of the stones makes it harder, especially when the bladder has scleroathrophic lesions. The differential diagnosis with gallbladder carcinoma is necessary especially for medium dimensions tumors. Laparoscopic cholecystectomy is the sufficient and recommended procedure; only even the benignity of the tumor is pathologically established.

["Rendez-vous" procedure. Mini-invasive treatment of biliary stones]. / Procedeul "rendez-vous". Tratamentul miniinvaziv al litiazei biliare.

Mini invasive approach, laparoscopic and endoscopic, represents these days a therapeutically standard in treatment of concomitant biliary stones: gallbladder and extrahepatic bile ducts. Had been suggested different procedures known as "rendez-vous" procedures. When choledocholithiasis is diagnosed or supposed, using biochemical and echographic criteria, we decided to make an ERCP just before laparoscopic cholecystectomy under the same anesthesia. Using ERCP we could confirm the choledocholithiasis. The endoscopic sphincterotomy was followed by extraction of the stones using the Dormia basket catheter. The laparoscopic cholecystectomy that followed was technically made in the same way that any laparoscopic procedure is made, according to the gallbladder lesion, the ERCP making no influence to the surgical act.

[Technic, indications and contribution of choledochoscopy in the diagnosis and treatment of biliary diseases]. / Tehnica, indicatiile si aportul coledocoscopiei în diagnosticul si tratamentul afectiunilor cailor biliare.

Choledochoscopy it's a common method of intraoperative exploring of the extrahepatic biliary ducts and partially of the intrahepatic ones. He is used both in the open and laparoscopic surgery. We consider the operative cholangiogram, preferably transcystic, as a first step who precedes the endoscopic exploration. The transcystic choledochoscopy has specific and relatively narrow indications: undulated biliary ducts, 1-3 gallstones. The transcholedocian choledochoscopy permit a direct and complete exploration of the biliary ducts. The important diagnostic help that fibrocholedochoscopy gives in, it's accomplished by the possibility of therapeutic maneuvers (especially the gallstones extraction), which offers the quality of a miniinvasive, elegant and harmless treatment technique.

[Laparoscopic cholecystectomy during pregnancy]. / Colecistectomia laparoscopica în cursul sarcinii.

Cholecystectomy is after appendectomy the second most frequent surgical procedure made in pregnant women. The operation is indicated in all cases of symptomatic gallbladder stones which do not respond to medical treatment and all complicated forms such as acute cholecystitis or acute pancreatitis. Laparoscopic cholecystectomy, considered in the beginning as a high risk procedure both for mother and child, is nowadays safer and useful comparing to open surgery. Our limited experience can confirm this. There were operated two pregnant (2nd and 6th month of pregnancy) with acute cholecystitis. There were no intraoperative incidents or accidents, no postoperative complications and no problems in pregnancy evolution after operation. This presentation emphasis the particular technical problems due to pregnancy during laparoscopic cholecystectomy, aspects concerning anesthesia and preoperative monitoring of mother and child.

[The Fitz-Hugh-Curtis syndrome in laparoscopic surgery]. / Sindromul Fitz-Hugh-Curtis în chirurgia laparoscopica.

The Fitz-Hugh-Curtis syndrome was diagnosed intraoperatory at 7.1% of the laparoscopic cholecystectomies in our clinic. The attitude in all cases was to perform a complete adhesiolysis. The reasons we consider that support this are: 1. the adhesions that fix the liver to the diaphragma do not allow the surgeon a comfortable access to perform cholecystectomy; 2. if these adhesions are torn accidentally during operation it could end up to the glissonian sheath rupture and uncontrollable bleeding; 3. adhesiolysis might be imposed in order to introduce the ports under visual control; 4. the traction determined by the perihepatitis process against the parietal peritoneum could be responsible for postoperative right quadrant pain; 5. the hepatodiaphragma adhesions make impossible the suction of the intraoperative secretions. A complete adhesiolysis allow a correct lavage of the suprahepatic area preventing the possible retention of clots, bile or even calculi. We didn't notice neither a longer duration of the intervention due to adesiolysis nor intra/or postoperative complications.

[Radiobiological considerations in radio-induced soft tissue sarcomas]. / Cosideratii radiobiologice în sarcoamele radioinduse de tesuturi moi.

Soft tissue sarcomas are relative rare tumors with an incidence of almost 1% of all malignancies. Although their etiology is not well understood, studies regarding the effect of ionizing radiation, showed their capacity to induce sarcomas in soft tissues, after several years from the treatment of other primary tumor. Their early diagnosis could be achieved by genetic analysis of radio-induced chromosomal translocations specific to each histological type. Dose-response curves reveals the dynamics of the process, taking into consideration the beam energy and linear energy transfer.

[Treatment with Ginkor Fort in varicose veins]. / Tratamentul cu Ginkor fort în boala varicoasa.

The study shows the experience acquired in our clinic concerning Ginkor fort administration in varicose veins pathology. The research comprises 32 patients who were treated by the well-known classical procedures (hygienic-dietetic, contention, surgery) and by Ginkor fort administration. The study rendered 71% good results consisting in evident amelioration of symptomatology, both subjective and objective.

[Breast cancer in men]. / Cancerul de sân la barbat.

In 20 years we registered 10 observations of male breast cancer (MBC), representing 1.3% out of 767 patients with breast cancer. Two observations of gynecomastia have been noted as a possible risk factor for MBC. A tumoral mass behind the areola suggested the diagnosis in 9 patients, whether in one case the attention was drawn by a bloody nipple discharge. In 3 cases we noted local aggravation clinical signs, and 6 observations presented homolateral palpable adenopathy. Diagnosis was completed by radiology, scintigraphy and pathology. As for clinical staging, we had 1 case in stage I,3 patients in stage II, 5 in stage III and I case in stage IV. Surgical treatment was the major therapeutical mean of the complex oncological procedure. We performed radical mastectomy in 4 cases. MBC prognosis was poor. Only one patient of the 6 ones in stage III and IV survived to five years; among other 4 observations in stage I and II, 2 patients have survived to five years, and other 2 being followed-up through the oncological network.

[Difficult laparoscopic cholecystectomy]. / Colecistectomia laparoscopica dificila.

The study analyses different situations encountered throughout the authors personal operative experience, susceptible to generate technical and tactical difficulties during laparoscopic cholecystectomy such as: postoperative perivisceritis, obesity, difficult liver mobilization, lipomatosis, acute and scleroatrophic cholecystitis, "porcelain gallbladder". They also point out different causes capable of generating important bleeding during the operation: cirrhosis, accidental adhesion tearing, anatomical arterial variations. Above all, the study presents the possible technical and tactical solutions which they applied when dealing with the already mentioned critical situations.

[Paget's disease of breast--a special form of breast cancer]. / Boala Paget sânului--forma particulara de neoplasm mamar.

The incidence of Paget's disease of the breasts (15 cases) among 701 operated breast cancer was 2.1%. All studied cases were women. Over two-thirds of the patients were at menopause at the time of diagnosis. The interval between the clinical onset of disease and the histological diagnosis was approximately of 21.4 month. The clinical diagnosis was based on the presence of the characteristic erythemato-squamous lesion. In five cases a palpable mass was found. We registered one case of bilateral metachronous Paget's disease. Four patients had axillary lymphadenopathy: three of them presented with palpable mass. Mammography, cytology and histological examination from biopsy were the principal means of diagnosis. There were 10 women in stage, two women in stage II, and three women in stage III. The surgical treatment was the major component of treatment. The best prognosis was registered in the cases without a palpable mass in the breast and axillary lymphadenopathy with 5-year survival in four of five cases.

A markov model for local and global damage indices in seismic analysis

Current methods for evaluating the overall seismic perfomance of structural systems are based on global damage indices which are usually obtained by heuristic combinations of local damage indices. The local indices qre related to the parameters of restoring force defined at the critical cross-sections of structural system. However, a global measure of damage can not characterize structural atate uniquely, provides only a crude estimate of structural perfomance during seismic events, and cannot be used to assess structural vulnerability to future loadings. In addition to the above limitations, current estimates of seismic reliability analysis of building structures are based on (i) incomplete representations of seismic hazard, e.g., by the peak ground acceleration a10 that id=s exceeded at least once in 50 years with probability 10

(ii) static method for estimating structural response, and (iii) elementary failure criteria that do not account for damage accumulation between consecutive seismic events. It is suspected that the reliability analysis based on above simplifications may not provide a satisfactory measure of structural perfomance.(AU)

[The diagnostic and surgical treatment characteristics in gastric ulcer]. / Particularitati de diagnostic si tratament chirurgical în ulcerul gastric.

The work analyses a number of 283 patients suffering from gastric ulcer, which were hospitalised and operated between 1981-1991. In 64% of cases the surgical treatment decision was an emergency one for major complications of this disease such as: the upper digestive hemorrhage (27%), penetration (22%), perforation (11%), digestive stenosis (4%). In 36% of cases the decision of operation was taken for different reasons: unsatisfactory evolution under the conservatory treatment, the existence of an irreparable anatomic lesion, the recurrent ulcer or the difficulty of differential diagnosis between gastric ulcer and gastric carcinoma. It is important to indicate that the two of the major investigations: the barium transit and the fiber gastroscopy failed in giving a correct relation in 5 to 10% between gastric ulcer and gastric carcinoma. In 87% of patients it was performed the gastric resection type Péan. The lifting of the lesion in 7% of our observations needed the gastric resection on type Pochet. In the gastric ulcers Johnson II type, when the duodenal lesion couldn't be lifted we added to the Hoffmeister-Finsterer gastric resection type with truncal vagotomy. In 9% of patients with perforated or hemorrhagic gastric ulcer, the vital rise was a major one, so we performed only suture the lesion. We registered 3 deaths (1.06%).