Importance of cystic pedicle dissection in laparoscopic cholecystectomy in order to avoid the common bile duct injuries.

The dissection of the cystic pedicle represents the "main" issue in performing the cholecystectomy, as well as the surgical moment when many accidents may happen. The paper analyzes the most frequent causes, which can generate iatrogenic injuries of the common bile duct (CBD) during the dissection of the cystic pedicle, such as the ductal and vascular anatomical variants, the local pathological transformation, human errors, etc.

Surgical treatment of large median incisional hernia using the prosthetic mesh introduced behind the rectus abdominis muscle sheath procedure (Rives-Stoppa procedure).

A number of 77 large incisional hernias located on the midline of the abdomen were operated following Rives-Stoppa procedure, in a period of five years (2006-2011), in the Surgery Clinic I of the University Hospital Bucharest. The characteristics of the study group were mean age - 62 years, predominance of females - 63 cases (82%), the rate of obesity - 26 observations (34%). Immediate postoperative morbidity was represented by (no. cases): thrombophlebitis (3), prolonged postoperative ileus (6), seroma (12) extended hematic drainage (5), hematoma (4). There were no fatalities. Late postoperative morbidity (no. cases) registered granulomas (4) and recurrence (2). We obtained good and very good results in 71 cases (92%).

Tactical and surgical techniques issues in the surgical treatment of incisional hernias.

Within five years, between 2006 and 2011, a total of 368 incisional hernias have been operated in the Surgery Clinic 1, University Emergency Hospital Bucharest. The study followed the morphological and biological parameters, associated pathology, tactics and surgical technique used and postoperative morbidity. The average age of patients was 61.75 years, female sex was predominant (81.25%), and incisional hernias were large and giant in a percentage of 73.37%. Locations were predominantly median (83.42%). Recurrent incisional hernias and multiple relapsed hernias represented 25.54%. Associated pathology was dominated by obesity (51,09%) and cardiovascular disease (37,77%). We have used both methods of tissue procedures (22.83%), and the prosthetic procedures (77.17%). Prosthetic techniques, retro muscle fitting mesh in the rectus abdominis muscle sheath (Rives-Stoppa technique), fitting ov er the fascia and tissue replacement techniques were performed. Immediate postoperative morbidity was represented by seroma (14.13%), prolonged postoperative ileus (8.69%), prolonged hematic drainage (6.52%), and hematoma (1.9%). Late postoperative morbidity was given by granulomas (5.7%) and recurrence of incisional hernias (4.34%). Good and very good results were obtained in the 89.96% of the operated cases.

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.

Laparoscopic cholecystectomy for treating acute cholecystitis -- possibilities and limitations.

Our study analysed a batch of 1402 A.C., operated on within the S.U.U.B. First Surgical Clinic between 1993-2010. L.C. was possible in 90% of the cases, and conversion to open surgery was required in 10% of the cases. The causes that determined the necessity for this conversion were pericholecystic plastron - 49%, unclear anatomical orientation - 46.5%, haemorrhage - 9.7%, iatrogenic injury of the main bile duct - 0.23% etc. Statistical analysis has shown that male gender, over 50 yrs. age groups, gangrenous A. C. and fibrous plastron represent risk factors for the conclusion of L.C. Reinterventions were performed on 20 patients (1.4%). Postoperative mortality was not encountered.

Splenic sarcoidosis -- a case report.

Patient aged 66 years, was admitted for splenomegaly grade III/IV, haematological hypersplenism and medium / large secondary anemia, diagnosed in the hematology clinic, where a myeloproliferative syndrome was denied. Was performed splenectomy, splenic lodge toilet and drainage. Histopathology was established the diagnosis of splenic sarcoidosis. Good postoperative evolution. Main issues discussed are etiopathogeny, diagnostic and therapeutic, that this rare disease of unknown etiology is giving.

[Amyand's hernia--case presentation and a discussion about diagnosis problems and surgical treatment]. / Hernia Amyand--prezentare de caz si o discutie asupra problemelor de diagnostic si tratament chirurgical.

We present the case of a 62 years old patient, with multiple associated tares, which was operated in emergency for an Amyand's hernia. The appendix was perforated and generated a big pussy collection (aprox. 200 ml) in the hernia sac. The impossibility of mobilization of the appendix, which was just 2/3 in the hernia sac, made us perform a median laparotomy for safety reasons. The position and fixation of the cecum made impossible the exteriorization of the appendix in the hernia sac. The postoperative evolution, under a complex supervision, was favorable. Due to the rarity of the clinical entity, of the specific issues and of the literature review, we decided to communicate the clinical observation.

[Jejunal ulcer--therapeutical and diagnosis difficulties]. / Ulcerul jejunal--dificultati diagnostice si terapeutice.

We present a female patient of 70 years, admitted in emergency department for signs of high bowel obstruction. After preoperative intensive care, surgical intervention was performed. A complete stenosis of the bowel lumen was found about 15 cm from the duodenojejunal angle, due to a process of sclerosis. Segmental enterectomy was performed with lateroterminal enteroenteralanastomosys, with poor outcome due to a lung infection, which occurred amid COPD. The patient died in intensive care unit requiring mechanical ventilation postoperative. Jejunal ulcer diagnosis was established after pathological examination. Particular issues in discussion are: etiological, clinical, diagnostic and therapeutic ones, that this rare condition posed in practical care.

[Gastric metastasis of clear cell renal carcinoma]. / Metastaza gastrica de carcinom renal cu celule clare.

We report the case of a patient operated in 2003 for renal clear cell carcinoma (CCRC), when left nephrectomy was performed. In the years following occur: lung (2004) and brain (2006) metastasis, pathological bone fracture in right femur (2007), which needed a complex treatment: polichimiotherapy, cobaltotherapy, right temporal metastasectomy, right femoral fixation with metal rod. In our clinic was hospitalised for serious upper gastrointestinal bleeding, severe anaemia (haemoglobin 5.8 g%, hematocrit 18.3%) produced by a ulcerated gastric metastasis. The inefficiency of medical treatment, patient and family desire to operate, have led us to practise Péan type gastrectomy necessary for palliative role (raising the hemorrhagic metastasis). Scarcity of the gastric metastasising of CCRC are discussed and also the surgical indication in the context of a plurimetastatic patient.

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.

[Porcelain gallbladder--diagnostic and therapeutic features]. / Vezicula de portelan--particularitati diagnostice si terapeutice.

Porcelain gallbladder (PG) is a rare entity. It's frequently associated with cholecyst lithiasis (90%). Diagnosis is established based on imaging assays (simple abdominal radiography, ultrasound and/or abdominal CT). Pathologically is an extensive process of calcification of the gallbladder wall. The literature mentioned strongly PG association with cancer of the gallbladder. Therefore laparoscopic cholecystectomy was formally contraindicated. We present two cases of PG laparoscopically operated and with this occasion we review particular aspects of diagnosis and treatment of the disease.

[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.

[Tumoral form of abdominal and retroperitoneal actinomycosis]. / Actinomicoza abdominala si retroperitoneala--forma tumoral.

We present a case of abdominal and retroperitoneal actinomycosis, clinicaly evidenced by a large tumor in the left inferior abdominal quadrant, in a 72-year-old male. Following clinical and laboratory investigations (imaging), strong suspicion of a left colon neoplasm was raised. Surgery consisted in an exploratory laparotomy and multiple biopsies of the great omentum and retroperitoneal space, the case being considered above the therapeutic resources. Histopathological diagnosis was a surprise by setting actinomycotic etiologies and enabled the establishment of a proper antibiotic treatment, followed by a favorable evolution. Postoperative follow-up revealed disappearance of lesions and healing.

[Voluminous complicated epigastric hernia]. / Hernia epigastrica voluminoasa complicata.

Epigastric hernia, apparently minor injury, neglected can reach impressive sizes, with major un-esthetic effect. In an unfavorable clinically context (morbid obesity, chronic respiratory failure, ground cancer, diabetes, heart failure) complications occur (incarceration, strangulation) with a complex picture. We present three clinical observations, including a low occlusion by fixed transverse colon necrosis in a strangulated epigastric hernia with pyo-stercoral phlegmon.

[Merkel cell carcinoma in unusual location]. / Carcinom Merkel cu o localizare neobisnuita.

We present a case of Merkel cell carcinoma with buttock location at a 70 years old patient. In literature there are described about 600 observations, of which more than half located in the head and neck. Despite early diagnosis--less than five months after occurrence--a thorough exploration (ultrasonography of soft tissues, pelvi-abdominal CT, histopathological and immunohistochemical examination), correct treatment (broad surgical exeresis, local postoperative radiotherapy) and appropriate follow-up, the patient had a negative evolution. Death occurs 17 months after diagnosis by the occurrence of liver metastases, invading the hepatic hilum and hence jaundice.

[Short bowel syndrome due to a severe complication related to Meckel's diverticulum]. / Sindromul de intestin scurt chirurgical--consecinta a unei complicatii grave generate de diverticulul Meckel.

A 17 years old patient, admitted and operated in emergency with acute diffuse peritonitis which had been had the onset four days before. During surgery, a huge volvulus of the small intestine is revealed due to an adherence between Meckel's diverticulum and mesentery, with large intestinal necrosis. Extended enterectomy is performed with jejunostomy. The postoperative outcome is difficult due to severe metabolic insufficiencies which are managed by intensive therapy measures. The patient is readmitted to surgery and an anastomosis between 30 cm jejunum and 20 cm ileum is performed. Then the outcome is good, with digestive function recovery and weight gain. Unfortunately, the patient died one year after surgery, due to severe haematological and neurological disorders caused by the mal-absorbtion syndrome.

[Immunologic and bacteriologic study of severe acute appendicitis. Diagnostics and therapeutic considerations]. / Studiu imunologic si bacteriologic în formele severe de apendicita- acuta. Consideratii diagnostice si terapeutice.

Acute appendicitis remains an up to date issue, being the most frequent cause of surgical acute abdomen round the globe. The complications that occurs creates important therapeutically difficulties. The study, based on 114 cases, had analyzed not only the pathogen flora (type, association, frequency of certain germs, the relation between them and different pathological lesion), but also the immune response of the organism to septic aggression. The microbiological tests from the lumen and bont of the appendix and also from peritoneal cavity showed monobacterial infection (11%) and pluribacterial infection (89%). Association between aerobes and anaerobes germs was identified in 85%. The most frequent germs identified were E. coli (87%) and Bacteroides (55%). We didn't identify germs with particular pathogenesis and the immune response had no malfunction. We can conclude that time factor is the main element in constituting of complications during acute appendicitis. A late diagnosis and also a late surgical intervention are the bases for the gravity of the pathogenic process.