The Bucharest ESTES consensus statement on peritonitis.

INTRODUCTION: Peritonitis is still an important health problem associated with high morbidity and mortality. A multidisciplinary approach to the management of patients with peritonitis may be an important factor to reduce the risks for patients and improve efficiency, outcome, and the cost of care. METHODS: Expert panel discussion on Peritonitis was held in Bucharest on May 2017, during the 17th ECTES Congress, involving surgeons, infectious disease specialists, radiologists and intensivists with the goal of defining recommendations for the optimal management of peritonitis. CONCLUSION: This document is an updated presentation of management of peritonitis and represents the summary of the final recommendations approved by a panel of experts.

Sarcopenia is a Predictive Factor for Postoperative Morbidity and Mortality in Patients Having Radical Gastrectomy for Cancer.

Introduction: Patients with gastric cancer are frequently malnourished with 30% to 38% of them losing more than 10% of their weight in preceding six months. Sarcopenia represents a decrease in the skeletal muscle mass and function and is usually associated with the aging process. The prevalence of sarcopenia in patients with gastric cancer is reported to be as high as 57.7%. Although many studies support the negative impact of sarcopenia in patients with gastric cancer, contradictory results are also present in the literature. The objective of this study is to investigate if sarcopenia is correlated with increased morbidity and mortality, in patients with gastric adenocarcinoma. Methods: We studied retrospectively all patients having radical resection for gastric adenocarcinoma managed in the Emergency Hospital of Bucharest between December 2014 and May 2016. ImageJ software was used to measure the patients' body composition. We identified the L3 landmark and extracted that corresponding single cross-sectional image contained within a CT study. Results: We reviewed 89 patients who had gastrectomy for cancer, but 11 Computed Tomography images were not available for analysis. Therefore, the study group consisted of 78 patients of which 50 were (64.1%) males and 28 (35.9%) females. The average age of patients diagnosed with gastric cancer was 67.7 years (range 22 to 92 years). The primary tumor location was the middle third of the stomach in 45 patients (57.7%), and the second in the lower third of the stomach in 29 patients (37.2%). There were 72 (92.3%) patients who were living on discharge, with mortality in 6 (7.7%) patients. 72.22% of patients are sarcopenic, and 27.78% were non-sarcopenic. The average sarcopenia value for both males and females is 43.77. The greatest number of patients had a skeletal muscle index between 40.00 and 45.00. The second greatest is between 35.00 and 40.00. The muscular skeletal index correlated with the age of the patients. The overall complications rate and the surgical site infection rate correlated with the sarcopenia. Conclusions: Sarcopenia is highly prevalent in patients having surgery for gastric cancer in Romania and correlates with increased postoperative morbidity. Especially with the increased trend for neoadjuvant therapy, the multidisciplinary team should evaluate and address sarcopenia through the perioperative period.

Nonelective Left-Sided Colon Cancer Resections are Associated with Worse Postoperative and Oncological Outcomes: A Propensity-Matched Study.

Background: Emergency general surgery patients are at significant risk of postoperative complications and mortality compared with their elective counterparts. Although challenged by some studies, increasing evidence shows that emergency colectomy for cancer is associated with worse early postoperative and long-term outcomes. Methods: We have included all patients with colon cancer admitted to the Emergency Hospital of Bucharest between January 2011 and January 2016. SELECTION CRITERIA: (1) colon tumor; (2) left-sided localization of the tumor; (3) pathology exam revealing adenocarcinoma. EXCLUSION CRITERIA: (1) rectal cancers; (2) benign pathology (e.g. diverticulitis). Results: We included 615 patients with left-sided colon cancer. 275 (44.7%) patients presented complicated disease. The complication was represented by obstruction in 205 (33.3%) patients (OG), hemorrhage in 55 (8.9%) patients (HG), and perforation in 15 (2.4%) patients (PG). The anastomotic leakage rate was similar between obstructive and elective cases (6.2% versus 6.5%, P 0.05), but was significantly higher for hemorrhagic patients (16%) (P=0.046). The 30-day complication rate and mortality were significantly higher in emergency patients (P 0.05). Conclusions: We found significant worse short- and long-term outcomes for patients with nonelective left-sided colon cancer resections. Correlating the ominous prognosis with the high incidence of the complicated disease, we may emphasize the impact on de complicated colon cancer on the general population.

Intraluminal Postpancreatoduodenectomy Hemorrhage - Last 5 Years Experience.

Background: One of the most significant complications following pancreaticoduodenectomy is represented by postoperative hemorrhage. AIM: This study undertook an analysis of the cases that presented intraluminal bleeding of mechanical gastrojejunal anastomosis following pancreatico duodenectomy (PD) in the last five years. Methods: From January 2012 until January 2017, 84 consecutive pancreaticoduodenectomies were performed and managed by the same surgical team. The preferred procedure of reconstruction was Whipple (76 patients). The gastrojejunal anastomosis was performed with Panther linear stapler GIA in all cases. ISGPS classification regarding postpancreatectomy hemorrhage was used to evaluate severity. Results: Out of 84 consecutive PD, a total of 7cases of intraluminal bleeding (8.33 %) were observed, detected on average on postoperative day 4. Relaparotomy was inevitable in two patients. Three patients from the studied group with intraluminal postpancreatectomy hemorrhage died. In the studied group there were no cases of bleeding from the pancreatico-enteric or bilio-enteric anastomosis. CONCLUSION: Mechanical anastomosis might be questionable, severe hemorrhage demanding urgent relaparotomy which is correlated with high mortality rates. Intralumenal postpancreatoduodenectomy hemorrhage is a significant complication whose management depends on multiple factors and with a potentially fatal outcome.

Microbiologic Safety of the Transareolar Approach in Breast Augmentation.

BACKGROUND: In aesthetic breast augmentation, especially by the transareolar approach, there is increasing concern regarding the occurrence of capsular contracture and its potential correlation with intraoperative implant contamination from putative endogenous breast flora of the nipple and lactiferous ducts. However, detectable bacteria cannot be considered synonymous with established resident microflora. OBJECTIVES: The authors sought to elucidate the existence of endogenous breast flora and assess the microbiologic safety of transareolar breast augmentation. METHODS: In this prospective study (BREAST-MF), the authors collected microbiologic samples from the breast skin, ductal tissue, and parenchyma of 39 consecutive female patients who underwent breast procedures in a plastic surgery clinic. Swabs collected pre-, intra-, and postoperatively were processed for bacterial and fungal growth. Positive cultures underwent identification through VITEK and MALDI-TOF, as well as antimicrobial susceptibility testing. RESULTS: Staphylococcus species accounted for 95 of 106 (89.6%) positive results from native breast skin, 15 of 18 (83.3%) positive results from decontaminated breast skin, and 4 of 4 (100%) positive results from the breast parenchyma. Methicillin resistance was present in 26.4% of S. epidermidis, 25.3% of S. hominis, and 71.4% of S. haemolyticus strains. CONCLUSIONS: During transareolar breast augmentation, in the nipple-areola region it is more likely to find bacteria populating the skin, rather than endogenous breast flora, as previously considered. Appropriate preoperative decontamination is essential for minimizing the risk of postoperative infections. LEVEL OF EVIDENCE 3: Risk.

Outcome of Laparoscopic Adrenalectomy in Obese Patients.

OBJECTIVES: To compare early morbidity of obese and nonobese patients with minimally invasive adrenalectomies. METHOD: Retrospective study of a prospectively maintained database, between June 2003 - December 2012, in a universitary affiliated tertiary hospital. Selection criteria: Minimally invasive adrenalectomy. Obese patients were defined as BMI over 30 kg/m2. RESULTS: From 205 patient with laparoscopic adrenalectomies we counted 30 obese patients (OG), 25 of them female and only 5 men with a median age of 54,20 years versus 47,94 years for nonobese group (NOG) (p=0.008). In OG were 15 right sided tumor, 11 on the left side and 4 bilateral all treated with transperitoneal antero-lateral approach. Median operating time was 92.20 minutes for OG versus 91.13 minutes for NOG (p=0.924). In OG, 5 patients had previous abdominal surgeries and we counted 4 conversion to open surgery, 2 postoperative complications (6.6%) and no mortality. All OG patients have diverse comorbidities, 50% of them more then 3. Median specimen size was 5.92 cm for OG versus 4.85 cm for NOG (p=0.057). The histology of OG was: adenoma 11 cases, hiperplasia 13 cases and pheochromocytoma 6. In NOG we had: postoperative hospital stay was 6.57 days in OG versus 4.11 days in NOG (p=0.009). CONCLUSIONS: Although obese patients had a higher rate for early morbidities, the minimally invasive approach has particular benefits for them. Although postoperative hospital stay was significantly longer, we believe that advantages of minimal invasive surgery for obese patients remains valid even in a BMI over 30.

Complicated diverticular disease--our recent experience.

Diverticular disease is more frequently seen in our practice. The aim of this retrospective study was to evaluate our experience with complicated diverticular disease in our surgical emergency unit. Between 2004-2007 46 cases with complicated diverticular disease were registered in Surgical Emergency Clinical Hospital of Bucharest. A male preponderance (sex ratio M: F 1:1.4) and a medium age of 62.9 +/- 15 years were recorded. Perforation was the main complication encountered and sigmoid colon was the most frequent involved segment (71.7%). Diagnostic procedures relayed especially on CT-scan. Three cases were operated laparoscopically. Failure of conservative measures was the main cause for interventions. A Hartmann procedure was performed in 7 patients (15.2%). Global mortality was 8.1% (4 cases). There were no significant differences among the surgical procedures employed. Diverticular disease is more frequently encountered in our practice. CT-scan is the most efficient diagnostic tool but there are limitations. Conservative measures are not always successful and urgent operative treatment is the only choice. Hartmann procedure is still frequently employed in our practice.

[Management for pseudoaneurysm of cystic artery with an arterio-biliary fistula after laparoscopic cholecystectomy: a rare case of hemobilia]. / Managementul pseudoanevrismului de artera cistica cu fistula arterio-biliara dupa colecistectomie laparoscopica: cauza rara de hemobilie.

Although laparoscopic cholecystectomy is considered to be the gold standard for treatment for symptomatic cholelithiasis, it is associated with an increased risk of biliary and vascular injury compared to the traditional technique. Massive hemobilia is a rare but potentially life-threatening cause of upper gastrointestinal hemorrhage. Arterio-biliary fistula is an uncommon cause of hemobilia. We describe a case of cystic artery pseudo-aneurysm causing arterio-biliary fistula and presenting as severe melaena and cholangitis that occurred 7 months after laparoscopic cholecystectomy. Gastroduodenoscopy failed to establish the exact source of bleeding and hepatic artery angiography and selective embolization of the pseudo-aneurysm successfully controlled the bleeding. Pseudo-aneurysm of the hepatic artery is mostly iatrogenic due to biliary intervention, as demonstrated in this case. Transarterial embolization is considered the first line of intervention to stop the bleeding for most causes of hemobilia. Hemobilia is a rare complication that should be considered when managing patients with bleeding or jaundice even several months after laparoscopic cholecystectomy.