Achalasia at the Crossroads Between Specialties.

Background: Achalasia is a condition that can be treated either by surgery, such as Heller myotomy associated with an antireflux procedure, or by pneumatic dilation, the choice of type of treatment being a widely debated topic nowadays. Methods: We selected patients with the diagnosis of achalasia, calculating the Eckardt score on admission and they were treated by pneumatic dilation, respectively by myotomy associated with fundoplication. Therapeutic success at the end of treatment was analyzed, as well as that in subsequent follow-ups. At the same time, other important aspects of the study were quality of life and complications. Results: Forty-eight patients were included, 20 in the group of those treated by pneumatic dilation, and 28 treated by surgery. The results of the therapeutic success were to the advantage of the surgery, both after the completion of the treatment, and in the follow-ups from one year to 2 years (96.4% vs 90%, respectively 92.9% vs. 85%). The quality of life was better in patients with pneumatic dilation throughout the period. Conclusions: Surgical treatment of achalasia has a higher success rate than pneumatic dilation, but the latter is associated with a better quality of life.

Identifying the Sentinel Lymph Node in Patients with Cutaneous Melanoma - Preliminary Report of a Private Clinic in Bucharest.

Background: The accuracy of the staging, along with the reproductibility of intraoperative lymph car-tography, and lymph node biopsy in patients with malignant melanoma was unanimously validated in the last decade. This technique allows the discovery of lymph node micrometastses with the help of immunohistochemical methods. The goal of the present study is to present the experience of our clinic in identification and biopsy protocol of the lymph node. Methods: A year-long retrospective analysis was running between March 2019 - December 2019 con-cerning 57 patients with cutaneous melanoma on which detection and excisional biopsy of the lymph node was performed. The procedure was performed by the double method using vital dye and a ra-dio-active tracer. Demographic information was filed, as well as data on location of primary tumors, tumor histology, and radioactivity level. Results: The mean Breslow thickness of primary skin melanomas was 2.7 mm. At least one lymph node was identified in 56 of the 57 patients included in the study. Among those, 15 (26%) had at least one metastatic node. The mean number of excised lymph nodes per patient was 1.6. Conclusions: The cartography and biopsy of lymph nodes need the involvement of a complex multi disciplinary team made of nuclear medicine, surgery, and anatomopathology specialists. This way one provides both a correct staging of the patient with melanoma and access to adjuvant innovative therapies, thus considerably improving the prognosis.

Diabetes Mellitus as a Risk-factor for Colorectal Cancer Literature Review - Current Situation and Future Perspectives.

Colorectal cancer and Diabetes Mellitus represent a major public health issue, first, by the number of new cases which are at an alarming rate. Secondly, by the negative effect over the quality of life, socio-economic status and lifespan, representing high morbidity and mortality causes. Diabetes Mellitus is the disease of the century with a global prevalence (standardised-age) which doubled since 1980, rising from 4,7% to 8,5% in adult population. In 2012, the estimated number of fatalities caused by Diabetes Mellitus and other related complications was at 3,7 million, out of which 43% were patients under the age of 70. Neoplasia represents the second cause of death, after cardiovascular disease. The occurrence of Colorectal cancer (CRCA) is rated for men and women at 3rd and 2nd place. However, the rate of mortality from CRCA is in the 4th place, representing 8,5% out of the total cancer related deaths. 52% of these cases are recorded in underdeveloped countries, considering their level, this reflects a very low survival rate. Moreover, every year, approximately 1.4 million cases are being diagnosed out of which 55% appear in overdeveloped countries. Screening for colorectal cancer refers to the periodical evaluation of the asymptomatic patients who are at a risk of developing this type of neoplasia. The colorectal cancer contains a series of particularities which makes it ideal for screening. Since the end of the 19th century there has been a high suspicion that type II diabetes, through direct etiological mechanisms, may play a part in carcinogenesis (breast, endometrium, colorectal, pancreas, liver, non-Hodgkin's lymphoma). At the moment, the relevant published literature presents type II diabetes as an independent risk factor for colorectal cancer. Although, despite experimental proof, many epidemiological studies, case-controlled studies and meta-analysis, there still is the necessity for prospective studies which can intensify the existing results and can allow the colorectal cancer screening to adapt to these patients.

Current Surgical Approach in the Pathology of the Arteriopathic Predominant Diabetic Foot.

Introduction: The diabetic foot is a complex pathologic entity characterized by the totality of modifications appearing on the foot during the evolution of the diabetic disease. This survey aims to elaborate an algorithm of treatment for patients with arteriopathic predominant diabetic foot lesions, with the purpose of reducing the number of debilitating interventions and improving the quality of life. Material and Method: There were analysed a number of 188 patients admitted to the Surgery Clinic I of the Dr.I.Cantacuzino Clinical Hospital, in the year 2017, suffering from arteriopathic predominant diabetic foot lesions, based on several inclusion/exclusion criteria. Results: According to the type of foot lesion, most patients had the diagnosis of wet gangrene of the toe/toes (51.06%), followed by ischaemic gangrene of the toe/toes (40.4%); the surgical interventions performed on these types of lesions in 73.9% of the cases consisted of minor amputations (transmetatarsal amputation of the toe/toes/foot). Conclusions: The treatment algorithm developed as a result of this survey represents a feasible treatment solution for the pathology of the arteriopathic predominant diabetic foot and failure to comply with this treatment may lead to treatment errors in a sense in which disproportional surgery can be performed in correlation with an inexact diagnosis.

Soft Tissue Infections in Diabetic Patients.

Background: the patient with diabetes has an increased susceptibility to infections, with negative evolutionary potential leading to increased morbidity and mortality compared to the general population. The cause is the alteration of immune defense mechanisms, the hyperglycemic environment leading to alteration of neutrophil function, suppression of the antioxidant system and humoral activity, systemic micro and macroangiopathy, neuropathy, depression of antibacterial activity of the genitourinary and digestive tract. Infections localized at the soft tissue (skin, fascia and aponeurosis, subcutaneous tissue, muscles) in the diabetic patient require a complex medico-surgical approach in which aggressive surgical treatment should be complemented by metabolic balancing and sustained antibiotic therapy. Materials and methods: these peculiarities will be exposed and analyzed in a retrospective descriptive study performed at the General Surgery Clinic. Juvara of the clinical hospital Dr. I. Cantacuzino, during the period of Jan. 2013- Dec.2017, which followed the type of lesions, their localization, the germs involved, the comorbidities, the biologic parameters, the antibiotic and surgical treatment as well as the postoperative evolution. The study does not include patients with localized infections in the diabetic foot, a particular pathological entity that will be analyzed separately in a separate study. Results: 150 diabetic patients with soft tissue infections localized in the upper limb, calf, thigh, perineum, abdominal and thoracic wall were identified. The most frequent localization was found in the lower limb (54%). The incidence of these infections was higher in males (55%), and the most affected age group was 60-69 years (38%). Most patients had type II diabetes (93%). Among the associated comorbidities, cardiovascular diseases and obesity are the most common, explaining to a large extent the complicated evolution, potentially lethal of this pathology. From the bacteriological perspective, a plurimicrobian flora is identified, staphylococcus aureus being most frequently encountered. The antibiotic treatment was initiated immediately empirically, subsequently according to the antibiogram; the most commonly used antibiotic classes being cephalosporins and carbapenems. Surgical interventions were in their majority of debridement and necrectomy, but in a few cases limb amputation was necessary. In particular, the number of surgical interventions performed in the same patient and in the same hospital stay was between 1 and 7 interventions. Conclusions: Soft tissue infections in the diabetic patient have a heterogeneous aspect with specific particularities requiring careful clinical examination, multidisciplinary treatment including rapid, serial surgical interventions to control the growing aggression of the germs involved. Fast and caseadapted therapeutic decisions, careful observation of the patient's general condition and of the wound several times a day are essential to achieving favorable postoperative outcomes.