Accuracy of Point-of-Care-Ultrasonography in Confirming Shoulder Reduction in Emergency Departments.

Aims Accurate identification of the successful reduction of a dislocated shoulder could avoid additional episodes of procedural sedation and repeated performance of X-rays. The objective of this study was to assess the diagnostic accuracy of point-of-care-ultrasound (POCUS) in the confirmation of a successful joint reduction in patients with shoulder dislocation. Methods This was a single-centre, prospective observational study set in an urban academic ED in Ireland, with a convenience sample of adult patients with shoulder dislocation on X-ray. Ultrasound was performed on participants before and after joint reduction using a posterior approach technique. The operator's confidence levels were recorded after image acquisition. Results Thirty-three subjects were recruited. All dislocations were correctly identified on pre-reduction US, indicating a sensitivity of 100% (CI 89.42 - 100). Post-reduction US confirmed successful reduction in 30 subjects that were subsequently reported as such on X-Ray, giving it a specificity of 100% (CI 88.43 - 100). Failure to achieve reduction was correctly identified on US in three cases, resulting in post-reduction US Sensitivity of 100% (CI 29.24 - 100) and 100% accuracy (CI 89.42 - 100). Conclusion This study has shown that POCUS, with a posterior approach technique, has 100% sensitivity and specificity in confirming successful shoulder reduction in the ED.

Tuberculosis remains a public health problem in Romania.

BACKGROUND: Tuberculosis (TB) remains a major public health problem in Romania, which has the highest TB incidence in the European Union. METHODS: We undertook a retrospective study to describe changing trends in the main epidemiological indicators of TB in Romania from 1995 to 2016. Data were obtained from the Marius Nasta Institute of Pneumology, Bucharest, official data published by the National Center for Public Health Statistics and Informatics in Health Statistics Yearbooks, the European Health For All database and the World Health Organization 2017 global TB report. RESULTS: Overall TB notifications in Romania declined after 2002, from 142.2 to 74/100 000 in 2016. For new TB cases, the incidence declined after 2002, from 118.9 to 54.5/100 000 in 2016. After peaking in 2002, at 23.3/100 000, the notification rate of relapses declined to 11.8/100 000 in 2014, but almost doubled the following year. The number of multidrug-resistant TB cases decreased from 624 in 2009 to 530 in 2012, but then increased to 670 in 2015. The number of extensively drug-resistant TB cases tripled between 2012 and 2015, from 22 to 68 cases. CONCLUSION: Although the decline in TB nationwide after 2002 confirms the effectiveness of control measures, the current TB burden in Romania remains very high by European standards.

Severe asymptomatic coronary obstruction in chronic hemodialysed patient - a case report.

Introduction. Arterial stiffness and vascular calcifications are independent predictors of cardiovascular morbidity and mortality in the chronic kidney disease (CKD) stage 5D population. According to the guidelines, patients on renal replacement therapy represent a very high cardiovascular risk class. Case report. We report the case of a 67-year-old hypertensive male patient, known with CKD stage 5D on hemodialysis (three times per week), secondary bone mineral disease, admitted for progressive right leg pain. The physical examination detected right dorsalis pedis artery pulse absence. Blood biochemistry emphasized hypercalcemia, hyperphosphatemia, increased alkaline phosphatase, metabolic acidosis, hypoalbuminemia, iPTH values above upper limits. The X-ray of right shin highlighted a vascular calcification with a "train track" aspect on the tibial-peroneal artery trunk and the thoracic X-ray (performed with low ray regime) showed calcium deposits in coronary arteries walls. Legs arteriography and coronary angiography were performed revealing multiple lesions on investigated vessels with an 80% narrowing of right coronary artery. The particularity of the case lies in the absence of angina in a chronic hemodialysis patient in whom multiple significant angiographically stenosis of the coronary arteries were found and successful endovascular therapy was performed. Conclusion. The broadening of the indication for coronary angiography should be considered in certain asymptomatic CKD stage 5D patients based on a risk score involving calcium, phosphate, PTH and acid-base imbalances, while considering their major influence on the structure and tone of vascular walls thus on cardiovascular morbidity and mortality rates. Abbreviations. ABI = ankle-brachial index,CAD = coronary artery disease,CKD = chronic kidney disease,CT = computed tomography, EBCT = electron-beam computed tomography,ESRD = end-stage renal disease,GFR = glomerular filtration rate,iPTH = intact parathormon,PCI = percutaneous coronary intervention.

ERCP after bariatric surgery--literature review and case report.

Obesity is a disease which has become more prevalent in Romania. Bariatric surgical procedures are among the treatment options for obese patients. Obesity and the metabolic disorders induced by it are risk factors for gallstones formation and their complications. ERCP is a minimally invasive therapeutic procedure indicated in the treatment of choledochal lithiasis and its complications. ERCP is generally considered the most difficult endoscopic procedure from the technical point of view. The authors have proposed to consider the possibility of performing therapeutic ERCP in patients who have undergone bariatric procedures. Literature data are reviewed and the case of a patient treated in a minimally invasive (laparoendoscopic) way for cholecyst and choledocholithiasis after longitudinal gastrectomy is presented.

Post-ERCP acute pancreatitis and its risk factors.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is a complex endoscopic technique that evolved from a diagnostic to a mainly therapeutic procedure. This was due to the identification of post-procedural complications that can follow both simple ERCP and that associated with the instrumentation of the biliary and pancreatic ductals. The identification of post ERCP complications in a proportion of 5 to 10% of cases, with a mortality rate of 0.33%, imposed their analysis and study of risk factors involved in their occurrence. The significance of post ERCP complications reveals the necessity of their avoidance by adopting additional measures if risk factors are identified. MATERIALS AND METHODS: We have retrospectively analyzed 900 cases that underwent ERCP in the Surgery Department of "Sf. Ioan" Clinical Hospital in a period of 17 years. The complications of the procedure were studied. Among them, a special attention was given to post-ERCP acute pancreatitis (pERCP-AP), the most common complication that occurred in the study group. We also tried to find out and highlight the risk factors for this complication. RESULTS: ERCP is a relatively safe invasive procedure, yet it has complications (8% of cases), some of them potentially fatal (mortality 0.43%). The most common complications after ERCP are acute pancreatitis (3.7%), papillary bleeding (1.04%), retroperitoneal duodenal perforation (0.69%) and biliary septic complications like acute cholecystitis and cholangitis (1.21%). Acute pancreatitis is by far the most common complication. Risk factors for its occurrence are difficult sphincterotomy with precut use, failure of CBD desobstruction, pancreatic sphincterotomy, repeated injection of contrast in the pancreatic ductal system, dysfunction of the sphincter of Oddi and the absence of changes of chronic pancreatitis. When risk factors are identified, the patients' selection must be very strict and diagnostic ERCP should be avoided in favor of non-invasive diagnostic methods (MRI-cholangiography, echo-endoscopy).

Treatment of bilateral inguinal hernia -- minimally invasive versus open surgery procedure.

OBJECTIVES: The aim of this study is to evaluate and compare the treatment outcomes of the bilateral inguinal hernia repair in one stage using minimally invasive technique (totally extraperitoneal) and conventional surgery (Lichtenstein). MATERIALS AND METHODS: Records from all hospitalized cases in our institution between 2006 and 2011 that underwent surgery having the diagnosis of bilateral inguinal hernia were analysed. RESULTS: The study consists of two groups selected by means of the used procedure: the study arm which is laparoscopic (234 cases) and the control arm that consists of Lichtenstein procedure (91 cases). One conversion was recorded due to difficult dissection (0.4% of cases). There were complications reported in 2.5% cases in the laparoscopic group and 27.4% complications noted in the conventional group (p less then 0.01). Reinterventions were logged in 1.7% cases in the laparoscopic group and 2.1% reinterventions in the open group (p less then 0.01). The postoperative hospital stay was 2.1 days in the laparoscopic group and 4.7 days for the open procedure. Mortality was not recorded. CONCLUSIONS: In our department the procedure of choice for bilateral inguinal repair is the laparoscopic approach (TEP) which has a 10 fold decrease in complications rate than Lichtenstein operation and also a shortening by half of the hospital stay. Hernia recurrence is the same for both procedures.

[The problem of iatrogenic common bile duct injury, or the picture of an iceberg peak]. / Problematica leziunilor iatrogene de cale biliara principala, sau o imagine a unui vârf de aisberg.

UNLABELLED: The goal of this study was to increase the awareness of the problem of iatrogenic common bile duct injury. METHODS: A retrospective review of the biliary primary or redo reconstructions performed at our clinic, for iatrogenic injuries, was done. A total of 34 cases were followed for 2 to 16 (mean 8.5 +/- 4.5) years in order to asses their long-term outcomes. RESULTS: There were 8 Strasberg D lesions and 26 Strasberg E lesions. The mortality rate was 6% (2 patients). The mid and long term outcomes were good in 82% cases (28 patients). Over all there were 108 surgical, radiological or endoscopic interventions (mean 3.2 +/- 1.8). Only 2 patients didn't have a complicate course after the initial surgery. We have counted 87 (mean 2.5 +/- 2.9) complications, 107 (mean 3.1 +/- 2.2) hospital admissions, and 1182 (mean 37 +/- 25) hospitalization days. General and local sepses were the main risk factors for the failure of the biliary reconstruction. CONCLUSIONS: As a rule, iatrogenic common bile duct injuries have a complicated postoperative course, with many hospital admissions and surgical, endoscopic or radiological interventions. Before biliary reconstruction, every attempt must be done to prevent or control general and local sepsis. Biliary injuries are more easy to prevent than to treat.

[An experimental model of transgastric ooforectomy using a porcine model]. / Stabilirea modelului experimental de ooforectomie transgastrica pe model suin.

INTRODUCTION: Transabdominal routes for surgery entail general anaesthesia with its inherent risks and complications (prolonged hospital stay, abdominal incisions that may be difficult in obese patients). Minimally invasive procedures require shorter hospitalization, have shorter recovery periods, less postoperative discomfort, and lower morbidity and complications. The purpose of this study was to use a porcine model to determine the feasibility and the safety of organ resection (oophorectomy and tubectomy). MATERIALS AND METHODS: 10 Big White pigs between 25-30 kg underwent transgastric ooforectomy. The first 5 cases were performed in a hybrid procedure (laparoscopic-NOTES) in order to have a better control and supervise the maneuvers done by the mobile endoscope and to guide in the abdominal cavity. RESULTS: Adnexectomy was possible in all ten experiments. Full operative time (from starting endoscopy to complete gastrectomy closing) was 180 min to 270 min. The gastric defect closing was the most difficult manoever lasting from 10 min with OTSC clips to 100 using endoloops and clips. The animals have tolerated well the experiments and there have been no remarkable incidents during our 10 experments. In only one case a bleeding from gastotomy required electric coagulation. CONCLUSION: Transgastric ooforectomy in an experimental model is a procedure that requires advanced laparoscopical and endoscopical skills. Our early results are promissing. Its application in humans needs further confirmation of the method.

Electrochemically deposited Pd islands on an organic surface: the presence of Coulomb blockade in STM I(V) curves at room temperature.

Palladium islands with a thickness of a few monolayers were deposited on top of a self-assembled monolayer (SAM) fabricated from 4-mercaptopyridine. In the I(V) curves obtained using the scanning tunneling microscope (STM) clearly the signature of Coulomb blockade is observed, explicitly demonstrating that these islands are coupled to the underlying gold substrate only via a tunneling barrier; this spectroscopic feature also allows to distinguish the palladium islands from similar morphological features present on the gold substrate prior to palladium deposition.

[Minimally invasive approach in gallstone disease complicated with acute pancreatitis]. / Tratamentul miniinvaziv in litiaza veziculara complicata cu pancreatita acuta.

We have evaluated the minimally invasive approaches (laparoscopy, endoscopy) in the management of the gallstone disease complicated with acute pancreatitis. Hypothesis. Emergency ERCP in gallstone pancreatitis (GSP) associated with jaundice or angiocholitis has a beneficial effect on pancreatic inflammation, eventually favoring laparoscopic cholecystectomy. We have compared 18 cases of emergency ERCP for GSP associated with jaundice or angiocholitis (Group 1) with 72 cases of GSP where ERCP was indicated on a selective basis (Group 2). Laparoscopic cholecystectomy was done after the acute bout of pancreatitis subsided. The minimally invasive approaches were completed in 89% cases in Group1 and in 90% cases in Group 2, respectively. Pancreatic morbidity was better in Group 1 (0% vs. 15.2%), but without statistical significance. General morbidity was significantly lower (0% vs. 23.6%) as well as the mean hospital stay (13 +/- 5.5 days vs. 17 +/- 10.4 days). Only the lower general morbidity and the shorter hospital stay assert the hypothesis that emergency ERCP in GSP associated with jaundice or angiocholitis has a beneficial effect on pancreatic inflammation, eventually favoring laparoscopic cholecystectomy.

[Laparoscopic appendectomy--considerations in about 1000 cases]. / Apendicectomia laparoscopica--consideratii pe baza a 1000 de cazuri.

Laparoscopic appendectomy (LA) is a well spread method today, but not as largely accepted as cholecystectomy, the cure of gastro-esophageal reflux and some other procedures (relatively small in number) for which the laparoscopic approach is the golden standard. Otherwise it is improbable that LA will gain such a status, at least in the near future. On the other hand it is obvious that LA offers important advantages for some special situations: the right iliac area syndrome, obesity, professional sportsmen, abnormal localization of the appendix, as well for the cases when localized and especially diffuse peritonitis is associated. Our paper analyses the experience of General Surgery Department at the "St.John" Emergency Hospital Bucharest on laparoscopic appendectomy. The retrospective study includes 996 cases that were treated laparoscopic between 1996-2004. Of these 745 cases were catarrhal, 166 cases were phlegmonous and 76 gangrenous appendicitis. In 93 cases localized or diffuse peritonitis was associated. There were recorded also 3 cases of each of the following: chronic appendicitis, appendicular mass and mucocele. The number of conversions was 28 (2.81%). There were also 10 reinterventions (1.004%), 7 because of intraperitoneal abscess and we also recorded one death.

[Laparoscopic mini gastric bypass for the treatment of morbid obesity. Initial experience]. / Derivatia minigastrica pe cale laparoscopica pentru tratamentul obezitatii morbide. Experienta initiala.

The mini-invasive treatment of morbid obesity represents a priority of our surgical team. The majority of the patients have been operated on restrictive bariatric procedures. The technique we are presenting is indicated for the extreme and super obese patients (BMI >50 kg/m2) for whom the restrictive procedures are less efficient. In these situations we have performed a mixed procedure, combining two principles restriction and malabsorption by creating a low capacity gastric tube connected to the jejunum through a linear stapled anastomosis. The name of these procedure is mini gastric bypass and our experience is consisting of 7 patients, with BMI between 52.7 and 71.69 kg/m2, with very important comorbidities. In this paper we are describing the specifics of the laparoscopic approach and the postoperative results at 3-18 months. We have recorded one conversion to the open surgery, two hemorrhagic postoperative complications and one marginal ulcer (3 month post-operatively); all complications were treated conservatively. All the patients lost weight, the EWL at 12 months was between 45.26% and 77.65%, while the co-morbidities had a significant good evolution. The procedure was efficient, well accepted and tolerated by the patients.

[Combined laparoscopic and endoscopic treatment of gallbladder and bile duct stones]. / Tratamentul combinant laparoscopic si endoscopic al litiazei colecistocoledociene.

UNLABELLED: In the present study we have tried to find what is the best time for endoscopy in the treatment of gallstones associated with common bile duct stones. METHOD: We have selected on the intention to treat 89 patients suspected of cholecysto-choledocholithiasis. There have been 38 cases with preoperative endoscopy (Group A), 35 cases with postoperative endoscopy (Group B) and 16 cases with perioperative endoscopy (Group C). RESULTS: In group C it has been a significant higher proportion of successfully treated cases (94%) and a lower hospital stay (8.6 +/- 3.7 days). CONCLUSIONS: Combining the endoscopy and laparoscopy in the same operation ("rendez-vous" technique) is the best approach for treating cholecysto-choledocholithiasis.

[Is there a learning curve for laparoscopic cholecystectomy ?]. / Exista un prag de învatare pentru colecistectomia laparoscopica?

UNLABELLED: The use of laparoscopic surgery it is growing rapidly in Romania. We have tried to find if a learning curve for laparoscopic cholecystectomy exists and we have evaluated our training program to insure the quality of health care. METHODS: There where analyzed 2585 procedures performed by 22 surgeons. The relationship between operative incidents/accidents and laparoscopic experience was evaluated. With a regression model we have find the tendency of these relationship. RESULTS: Surgeons appear to learn this procedure rapidly. CONCLUSIONS: Training curses with hands-on experience with animal models and proctoring from an experienced laparoscopist at the first 30 operations is needed, for each individual surgeon, to insure the quality of health care.

[Transperitoneal laparoscopic right sympathectomy]. / Simpatectomia lombara dreapta laparoscopica pe cale transperitoneala.

Laparoscopic lumbar transperitoneal sympathectomy represents the miniinvasive approach of laterocolic procedure Adson-Diez. It is suitable to laparoscopic surgery, has a good reproducibility and it is more advantageous than total retroperitoneal approach because of a larger working space.

[The laparoscopic approach to cholecysto-choledocholithiasis.The "rendez-vous " technique]. / Tehnica "rendez-vous" în abordul laparo-endoscopic al litiazei colecistocoledociene.

A combined method of endoscopic sphincterotomy (ES) with common bile duct (CBD) stone extraction and laparoscopic cholecystectomy under general anesthesia for a single-session treatment of patients with colecysto-choledocholithiasis is described. The so called "rendez-vous" technique consists in: standard laparoscopic cholecystectomy with intraoperative cholangiography followed by ES if common bile duct stones are detected. The sphincterotome is driven across the papilla through a wire guide inserted by transcystic route. Nine patients were scheduled for "rendez-vous" approach. At intraoperative cholangiography 4 have had CBD stones. Endoscopic sphincterotomy and CBD clearance were successful in all patients. No complication was encountered. Mean postoperative hospital stay was 5 days. The laparo-endoscopic "rendez-vous" approach is feasible, it reduces the number of unnecessary ERCP examinations, it lowers the morbidity related with endoscopic sphincterotomy and shortens the hospital stay.

[Conversions and reinterventions in laparoscopic cholecystectomy]. / Conversii si reinterventii în colecistectomia laparoscopica.

From the introduction of the laparoscopy in our clinic, more and more of the cholecystectomies, reaching over 50% are done by this technique. Based upon the accumulation of an already important experience, the paper tries to analyze the situations in which, during or after laparoscopic cholecystectomy, intraoperative conversions (deliberate or of necessity) or reinterventions were necessary. We present a global view of the number of these cases and also (an in detail) analysis of the causes the imposed such decisions and of the solutions adopted. The percentages of 5.55 conversions and 1.49 reinterventions seem reasonable and acceptable in comparison with the initial results published by some experience surgeons in the field of laparoscopic surgery.

[A minimally invasive approach in choledocholithiasis]. / Abordul miniinvaziv al litiazei de cale biliara principala.

In the last years several less aggressive procedures diminished the role of open choledochotomy (CT) in the treatment of common bile duct (CBD) lithiasis. Between them are endoscopic sphincterotomy (EST) and laparoscopic choledochotomy. In a lap of 18 month were followed up, in a prospective way, all the cases of CBD lithiasis admitted in our department. Twenty-seven patients were treated by EST and 28 by CT. The endoscopy was as efficient as open CT in clearing the CBD (85% vs. 83%). Even if the endoscopic group was at a higher risk the morbidity was lower than in the classic approach and the mortality was the same (3.5%). The most common complication after EST was acute pancreatitis (7.5%). The mean hospital stay was lower after EST. Near by are discussed 3 cases of associated gallbladder and CBD lithiasis treated exclusively by laparoscopic approach.

[Right laparoscopic lumbar sympathectomy]. / Simpatectomie lombara dreapta laparoscopica.

Laparoscopic lumbar sympathectomy was performed on a young man with thromboangiitis obliterans (Buerger's disease). The surgeons disposition, trocars placement and dissection technique are described in detail. The retroperitoneal approach was done in a manner similar to laparoscopic properitoneal hernia repair. The operation can be carried out with common laparoscopic equipment (for cholecystectomy) and offers the benefits of minimally invasive surgery.