MANAGEMENT OF TRAUMATIC LIVER LESIONS.

AIM: To determine the correct therapeutic approach to the different grades of liver trauma. MATERIAL AND METHODS: The study is based on a retrospective analysis of treatment outcomes in 56 patients with abdominal trauma admitted over a 9-year period to in the IIIrd Surgical Clinic of the Iasi "Sf. Spiridon" Hospital. It is focused on operative or non-operative management of liver trauma, surgical technique used, morbidity and postoperative mortality. Data were collected from electronic medical records and observation sheets and processed and interpreted using Microsoft Excel statistical functions. RESULTS: In the interval May 26, 2005-April 19, 2013 56 cases of abdominal trauma were recorded, 31 (55.35%) residing in urban areas, and 25 (44.64%) in rural areas. The mean age was 39 years, range 18-83 years old. The male/female ratio was 2.5/1 and the group consisted of 40 (71.42%) male patients and 16 (28.57%) female patients. The causes of abdominal trauma were: car accident in 29 (51%) cases, fall from different heights in 6 (10%) patients, workplace-related accidents in 8 patients (14%) and direct hit injury in 12 patients (12%). In our cohort, 51 (91%) patients with abdominal trauma have been emergency admitted, 3 patients (5%) were transferred from different medical units, and 2 patients (4%) were referred by a specialist doctor. Two or more simultaneous lesions were diagnosed in 53 (96%) cases. Of the 45 patients with traumatic liver injuries diagnosed on admission, 32 (71%) required surgical intervention. In the remaining 13 (29%) patients, the therapeutic management was conservative. CONCLUSIONS: Hepatic traumas are often severe, and frequently associated with multiple injuries. The non-operative management is indicated in liver lesions grade I, II and III according to the American Association for the Surgery of Trauma (AAST), if abdominal cavity organs are not injured. Higher grade liver lesions (over IV) in which the hemorrhagic risk persists or reappears require surgical intervention as soon as possible, and according to the type of lesion, the right procedure should be chosen.

MONITORING OF RECURRENCE IN PATIENTS RADICALLY OPERATED FOR PANCREATIC CANCER.

Pancreatic cancer is a diagnosis that carries a poor prognosis. It is the fourth leading cause of cancer death in Europe and the United States, despite advances in operative technique and postoperative management. Furthermore, there is no consensus on the optimal follow-up schedule of patients after surgery for pancreatic cancer, all recommendations on surveillance being based on low level evidence or no evidence and the leading societies propose different guidelines. As a consequence, follow-up strategies may differ between hospitals depending on preference of physicians. The vast majority of patients develop recurrence within 2 years after surgery, suggesting the necessity of a more intensive follow-up the first 2 years after surgery. It usually occurs after surgery as migratory metastases along major upper abdominal arteries and veins to the liver or peritoneum (70%) and less commonly as loco regional disease as masses closely applied to the surgical margins in the neck or body of the pancreas (30%). Currently, there are no effective means to prevent pancreatic cancer recurrence, despite the fact that it is responsible for the majority of postoperative deaths.

The role of baseline inflammatory-based scores and serum tumor markers to risk stratify pseudomyxoma peritonei patients treated with cytoreduction (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

AIMS: Inflammation-based scores such as neutrophil-lymphocyte ratio (NLR) and Onodera nutritional index (ONI) have been identified as new prognosticators in several tumors. We conducted a prognostic analysis of these markers and performed a risk stratification of PMP patients submitted to cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: 226 patients from two peritoneal surface malignancies centers participated in this study. Cox proportional modeling was used to select predictors of overall survival (OS) among baseline inflammation-based scores, serum tumor markers, clinical and surgical variables. Risk stratification was done using conditional inference tree model. RESULTS: One hundred eighty-two cases had diffuse peritoneal adenomucinosis subtype. Fifty-four cases had received previous systemic chemotherapy. The means of ONI and NLR were 51.4 (SD = 9.8) and 3.2 (SD = 2.3), respectively. Two hundred ten cases were optimally cytoreduced. Cox analysis identified completeness of cytoreduction, histological subtype, previous systemic chemotherapy, NLR, and CA 19-9 as independent prognosticators. Conditional inference tree method identified two poor prognostic subsets: NLR ≤2.7 and CA 19-9>336 (5yr-OS = 15%) and NLR >2.7 and ONI ≤42 (5yr-OS = 30%). CONCLUSIONS: NLR, ONI, and CA 19-9 are new prognosticators that contributed to improve prediction of OS in PMP patients treated by CRS and HIPEC. These markers allowed a risk stratification that could optimize therapeutic management of PMP patients.

Assessment of different prognostic scores for early postoperative outcomes after esophagectomy.

OBJECTIVE: Surgery remains the best curative option for oesophageal cancer. This demanding intervention performed on a high risk patient is accompanied by high morbidity and mortality rates. The aim of this study was to analyse the preoperative risk assessment using different comorbidity models inpatients operated for esophageal cancer in a tertiary unit. METHODS: A retrospective study was conducted on aprospectively collected database. The performance of several prognostic scores (POSSUM, P-POSSUM, O-POSSUM, Charlson and age adjusted Charlson, ASA score) was assessed in terms of early postoperative outcomes. RESULTS: Out of 137 patients diagnosed with oesophageal cancer, esophagectomy was performed in 43 cases.Postoperative mortality (11.62%) was best predicted by POSSUM score (10.48; 95% CI 9.37 -11.66). The observed morbidity was 58.13%, higher than that expected by POSSUM (48.24%; 95%CI, 44.82-51.66) with a morbidity ratio O E of 1.2. The area under the ROC curve for the physiological score of POSSUM and age adjusted Charlson index showed a good discriminatory power. The best performance was obtained for POSSUM equation, who showed to have the highest area under the ROC curve (0.826; 95%CI, 0.67-0.92). CONCLUSIONS: A thoroughly assessment of comorbidities and the surgeon's clinical assessment remain the best tool for patient selection for surgery.

[Treatment of peritoneal carcinomatosis of gastro-intestinal origin--a retrospective study of 203 cases]. / Tratamentul carcinomatozei peritoneale de etiologie digestiva--studiu retrospectiv pe un lot de 203 pacienti.

UNLABELLED: Peritoneal carcinomatosis of gastrointestinal origin (PC-GI) is an advanced digestive tumor and is found in 10-30% of patients (P) with primary surgery for cancer (C) and up to 50% of C recurrences. AIM: To evaluate the main characteristics, ethio-pathogenesis, prognosis and imaging to track of P with PC-GI admitted to the Third Surgical Clinic, "St. Spiridon" Hospital, Iasi. MATERIAL AND METHODS: A retrospective study was carried out on series of 203 patients admitted in the period June 2006 - March 2011. The patients were aged between 27-80 years (average 62), with a women/men ratio of 95/108. The duration of hospitalization was between 1 and 61 days, with an average of 13.5 days for emergency cases and 15 days for elective cases. The data from observation files, the operating protocols, pathology reports and follow-up files were collected and analyzed. RESULTS: 136 patients were hospitalized with synchronous PC (the most common gastric N = 60) and 67 with metachronous PC (the most common colon N = 29). Imaging investigations consisted of ultrasound and computer tomography that showed a sensibility and specificity of 80% and 73% respectively, mainly in regard to ascites but less in assessing the presence of peritoneal deposits. The most common complication was septic shock and mortality was 9.5% (17 patients). Average survival was 5.7 months. CONCLUSION: PC-GI is a disease with a poor prognosis, posing difficulties in early diagnosis, establishing the surgical indication and protocol. Consistent advances in systemic and locoregional chemotherapy, surgical techniques, intraoperative radiotherapy, as well as immunotherapy are expected to improve prognosis.