Comparative Study of Hysteroscopy and 3D Ultrasound for Diagnosing Uterine Cavity Abnormalities.

Objective: Hysteroscopy is the most accurate method for diagnosing intrauterine pathologies related to abnormal bleeding and infertility. The accuracy of three-dimensional (3D) ultrasonography and hysteroscopy were compared in identifying uterine cavity abnormalities. Material and Methods: A total of 139 cases of abnormal uterine bleeding or infertility first had two-dimensional and 3D ultrasound performed before hysteroscopy. Findings on 3D ultrasound and hysteroscopy were compared, and sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio were calculated. Results: Mean patients' age was 36.5 (+/- SD 9.04). Three-dimensional ultrasound had a sensitivity of 88%, specificity of 94%, a positive predictive value of 96%, negative predictive value of 84%, likely ratio of 5,5, and accuracy of 90% in diagnosing uterine cavity abnormalities. Three-dimensional ultrasound had a high sensitivity and specificity for polyps (97% and 97%, respectively), congenital uterine malformations (100% and 99%, respectively) and submucous myoma (87% and 100%, respectively), but a low sensitivity and high specificity for uterine synechia (41% and 99%, respectively). Conclusions: For diagnosing uterine cavity anomalies, 3D ultrasound is a useful tool and could replace diagnostic hysteroscopy for certain conditions, such as congenital uterine anomalies.

Simulated training in colonoscopic stenting of colonic strictures: validation of a cadaver model.

AIM: There are currently no available simulation models for training in colonoscopic stent deployment. The aim of this study was to validate a cadaver model for simulation training in colonoscopy with stent deployment for colonic strictures. METHOD: This was a prospective study enrolling surgeons at a single institution. Participants performed colonoscopic stenting on a cadaver model. Their performance was assessed by two independent observers. Measurements were performed for quantitative analysis (time to identify stenosis, time for deployment, accuracy) and a weighted score was devised for assessment. The Mann-Whitney U-test and Student's t-test were used for nonparametric and parametric data, respectively. Cohen's kappa coefficient was used for reliability. RESULTS: Twenty participants performed a colonoscopy with deployment of a self-expandable metallic stent in two cadavers (groups A and B) with 20 strictures overall. The median time was 206 s. The model was able to differentiate between experts and novices (P = 0. 013). The results showed a good consensus estimate of reliability, with kappa = 0.571 (P < 0.0001). CONCLUSION: The cadaver model described in this study has content, construct and concurrent validity for simulation training in colonoscopic deployment of self-expandable stents for colonic strictures. Further studies are needed to evaluate the predictive validity of this model in terms of skill transfer to clinical practice.

Prognostic scoring systems-validation and their utility in patients with abdominal sepsis in colon peritonitis.

AIM: The purpose of this article is to analyze and validate the CR-POSSUM score in patients with peritonitis of colonic origin, considering mortality forecasting ability. METHODS: We conducted a prospective longitudinal study of the Surgery Clinic in the Emergency Hospital in Bucharest in January 2008-December 2011. Patients operated on for peritonitis of colonic origin were included in this study. The prognostic CR-POSSUM scores and Mannheim peritonitis index were calculated by using data from observation sheets. There have been a number of deaths and overall mortality was calculated. RESULTS: There were 58 patients with abdominal sepsis, hospitalized and operated, registering a 17.24% mortality rate. Time from admission until the time of operation was divided between up to 24 hours and over 24 hours, recording 27 (46.55%) cases operated <24 hours and 31 (53, 45%) of patients operated> for 24 hours. Operative severity scores were calculated by taking into account data provided by each surgeon on intraoperative appearance. CONCLUSIONS: The results of this study demonstrated that both CR-POSSUM score and Mannheim have a prognostic value for patients with abdominal sepsis in colonic peritonitis, both being surgery scores.

Laparoscopic treatment of perforated duodenal ulcer -- a multicenter study.

AIM: The aim of this study is to evaluate the results of the laparoscopic treatment of perforated duodenal ulcer performed in 6 Romanian surgical centres with experience in the field of laparoscopic surgery. MATERIAL AND METHOD: Between 1996 and 2005, 186 patients with perforated duodenal ulcer were operated on in the centers participating in this retrospective study, all patients being ASA I-II. Thirty-nine patients (20.0%) presented mild peritonitis, 120 (64.5%) medium peritonitis and 27 (15.5%) severe (20.0%) simple suture was performed, in 110 (59.1%) suture with epiplonoplasty, for 1 (0.5%) only epiplonoplasty and 1 (0.5%) underwent excision of the perforation and suture. RESULTS: The operative time was between 30-120 minutes, with an average of 75 minutes. No death was noted. Average hospitalization time was 6 days, with periods varying between 3 and 18 days. Postoperative complications included: 5 patients (2,6%) presented infections of the abdominal walls, 1 patient (0.5%) duodenal fistula, 1 patient (0.5%) intra-abdominal abscess, 1 patient (0.5%) a superior digestive hemorrhage by "mirrored ulcer" and 1 patient (0.5%) duodenal stenosis 6 months after operation. The patients were administered 50% less analgesics, used 70% less dressings, 30% less antibiotics and had 60% less complications in comparison with those operated by the classical approach. CONCLUSION: The laparoscopic approach of perforated duodenal ulcer constitutes the first choice for patients without important co-morbidities, allowing a quick recovery and a significant reduction in the consumption of analgesics, antibiotics and dressing materials.

A clinical case of Fournier gangrene.

OBJECTIVE: To present a case of Fournier gangrene and the specific surgical therapy CASE PRESENTATION: A 71-year old patient with a two days history of pain in the perineal region, swelling, developing necrosis and foul-smelling lesions was examined in emergency settings. The swelling of subcutaneous plane involved the flank regions, mainly on the left side. The investigations were performed (full blood count, blood urea, electrolytes, coagulation profile). A Fournier gangrene was diagnosed and surgery performed under general anesthesia. Broad spectrum antibiotics were given concomitantly. The first surgical procedure consisted in surgical debridement and excision of all the necrotic tissue. Cultures were taken. We performed counter incisions bilaterally on both flanks. The communication through the fascial planes was clearly demonstrated, especially on the left side. A loop colostomy was also performed. Multiple re-excisions were further employed. Due to a precarious evolution, the patient were on mechanical ventilation for 13 days. Inotrope medication was given for a total of 19 days and, the antibiotherapy adapted to the antibiogram (Bacterioides eggerthii was identified). The reconstruction of the perineum was later performed and, after 3 months, the colostomy was closed in good conditions without further complications. CONCLUSION: Early recognition and aggressive surgical excision are mandatory for success in patients with Fournier gangrene. Colonic diversion can be very useful if employed from the beginning.

[Selective nonoperative management of solid abdominal visceral lesions]. / Managementul selectiv nonoperator al leziunilor viscerale parenchimatoase in traumatismele abdominale.

Selective nonoperative management of abdominal visceral lesions is one of the most important and challenging changes that occurred in the traumatized patient care over the last 20 years. The main advantage of this type of management is the avoidance of unnecessary/nontherapeutic laparotomies. The trauma surgeons who deal with this type of treatment are worried of missed abdominal injuries. Modern diagnostic tools (spiral CT, ultrasound, angiography, laparoscopy) allow the trauma surgeon to accurately characterize the lesions to be nonoperative addressed. This literature review discusses the main elements of selective nonoperative management of principle solid visceral lesions (liver, spleen, kidney). We highlight the advantages and limitations of the main diagnostic instruments used for evaluation of trauma patiens allocated to nonoperative management.

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.

[Laparoscopic suture or open suture in perforated duodenal ulcer]. / Sutura laparoscopica sau sutura deschisa în ulcerul duodenal recent perforat la tineri.

Between Nov. 1994-Jan. 2001 we performed laparoscopic suture with omentoplasty of perforated duodenal ulcer (PDU) in 51 patients out of 56 it was intended (this constituted the laparoscopic group--LG). The selection criteria were young patients, age < 40 years, no associated diseases, onset of the operation under 12 hours from the occurrence of the perforation, absence of clear ulcer history. In the same period, we performed an open suture based on the same criteria in 105 patients (open group--OP). The results showed a difference between needed analgesia (2.8 days for LG vs. 5.2 days for OG) and a hospital stay of 6.1 days in LG vs. 7.7 days in OG. The incidence of postoperative complications was 5.88% in the LG and 7.61% in the OG with 1.96% and respective 1.90% reoperation rate. In conclusion laparoscopic suture of PDU with associated postoperative modern therapy of ulcer disease could be the treatment of choice in young patients.