Gastroduodenal Surgery in Cirrhotic Patients - Case Series and Literature Review.

Specific risk factors for gastroduodenal surgery in cirrhotic patients have been identified, which dictates for a more personalized management. The retrospective study was conducted between 2012-2019 on twelve patients (7 cases of duodenal ulcer, 2 cases of gastric ulcer and 3 patients with gastric cancer). We took into account a number of possible factors involved in the unfavorable evolution of patients, based on data published in the literature so far. In order to follow the involvement of each factor we compared two groups of patients, one with unfavorable evolutions, exitus and another with favorable evolutions. Emergency surgery, the presence of ascites at the time of intervention, a higher than 30 MELD score, alcoholic cirrhosis, liver encephalopathy and liver failure are common factors that are found in a high percentage (between 75% and 100%) in patients who have had an unfavorable evolution, exitus. The same risk factors are found in much lower percentages in patients who have evolved favorably postoperatively, most between 12.5% and 25%. We analyzed preoperative aspects, surgical approach, complications and risk factors for these patients, compared them with the results of our study and identified future therapeutic possibilities. For CHILD B or C patients, the indication for surgery should be discussed in advance with a multidisciplinary team. Endoscopic submucosal dissection or discontinuation of D2 dissection should be considered in these patients.

Cerebral Palsy. Considerations Upon 249 Consecutive Patients and Review of Literature.

AIM: to determine the prevalence of cerebral palsy (C.P.) among children and to describe its main characteristics (clinical forms, treatment plan, and results). MATERIAL AND METHODS: 249 C.P were studied (120 boys and 129 girls, aged between 0 and 12 years) during 2,321 consecutive clinic visits (incidence 10.7%) to a private pediatric orthopedic clinic in Jeddah, Saudi Arabia, between 2011 and 2016. Spastic type was the main clinical form (231=92.8%), spastic diplegia being the most frequent (166=71.9%). The treatment was complex: conservative only in 42.2%; surgery indicated in 149 (59.8%) cases was performed only in 81 cases, by means of muscle and/or bone procedures, depending on the lesion balance. RESULTS: The postoperative results were excellent in 2.4% of cases, acceptable to some extent in 93.8% and poor in 3.8%. We registered a recurrence rate of 14.8%, a postoperative morbidity rate of 6.17% with a postoperative mortality rate of 0. Treatment results could not be assessed in 129 (51.9%) cases due to lack of follow up. CONCLUSION: 1. C.P. represents the third most common diagnosis in pediatric orthopedic private practice. 2. The treatment results were acceptable in most cases, but not optimal. 3. Gait analysis using in the preoperative planning could improve significantly the outcome, especially in complicated cases.

Septic knee arthritis in Crohn's disease biological therapy-free patient. Case report.

UNLABELLED: A 52-year-old woman with Crohn's disease presented with septic arthrtis of the knee. This condition coincided with a symptomatic flare of her Crohn's disease due to an ileal inflammatory stenosis, manifested as a phlegmonous mass palpable in the right lower quadrant and a small bowel obstruction. Results of synovial fluid cultures showed the presence of Gram-negative bacillus, Klebsiella pneumoniae and the CT scan images were highly suggestive of abdominal abscess within Crohn's disease. The patient's condition improved after following an antibiotic treatment and after the initiation of Anti-TNF-alpha agent Adalimumab, with no further exacerbation. Septic arthritis in Crohn's disease should be considered to have a communicating source of sepsis consisting of an abdominal abscess or fistula. ABBREVIATIONS: Anti-TNF-alpha agent = anti tumor necrosis factor alpha agent, 5-ASA = 5-aminosalicylic acid.

Possibilities and limits in the treatment of congenital diaphragmatic hernia.

AIM: to establish a therapeutic strategy that will improve the prognosis and increase the survival rate in congenital diaphragmatic hernia. MATERIAL AND METHOD: 14 congenital diaphragmatic hernias (incidence 1/1597 live births, 12 boys and 2 girls with a sex ratio of 6/1, 10 term infants and 4 preterm first degree, 11 natural births and 3 by caesarean section) admitted to the Clinic of Pediatric Surgery Craiova, in a 5-year period (2007-2012), were analyzed from the therapeutic point of view. The "tension free" primary suture was the main surgical procedure to repair the diaphragmatic defect in all cases, preceded by a period of preoperative resuscitation and stabilization (2.8 days on average). RESULTS: We registered a survival rate of 64.29% and a postoperative mortality rate of 35.71%. CONCLUSIONS: delayed surgery preceded by a period of the preoperative respiratory resuscitation and stabilization (24-72 hours on average) significantly reduced postoperative mortality and increased the survival rate.

Testing rocuronium-induced neuromuscular blockade at the stapedius muscle using stapedius reflex measurements.

BACKGROUND: Neuromuscular monitoring prior to emergence from anaesthesia has been shown to be necessary to achieve adequate airway protection in order to decrease postoperative pulmonary complications. In the present study we hypothesized that stapedius reflex measurement allows the detection of residual neuromuscular blockade using the stapedius muscle following the administration of rocuronium. PATIENTS AND METHODS: Parallel stapedius and acceleromyographic measurements were performed on 20 patients undergoing cholecystectomy. Acceleromyographic measurements were continuously performed during the course of anaesthesia, whereas the stapedius reflex was measured on different occasions: (1) after premedication but before anaesthesia induction, (2) after induction, but before administration of muscle relaxant, (3) after administration of muscle relaxant, (4) during the course of surgical anaesthesia at regular intervals, and (5) continuously performed during emergence from anaesthesia, until the stapedius reflex threshold returned to normal. RESULTS: The intensity of the sound energy at which the stapedius reflex is detectable was similar: 89.5 ± 9.9 dB(mean ± SD) after premedication and after anaesthetic induction. However, after administration of rocuronium, when the twitch height decreased to 5%, the stapedius reflex disappeared, indicating a total block of the stapedius muscle.During the recovery phase (twitch>10%) significantly higher sound energies compared to baseline values were necessary to evoke the reflex, indicating residual inhibition of the stapedius muscle. At the point where stapedius reflex threshold returned to normal the twitch height averaged about 50% showing low sensitivity of the tympanometry in detecting residual neuromuscular blockade. CONCLUSIONS: The neuromuscular effect of rocuronium on the stapedius muscle can be detected using stapedius reflex measurements. Due to its methodological limitation and low sensitivity, the method cannot be recommended for the monitoring of residual neuromuscular blockade.

[The pancreatic pseudocyst--late complication of the severe acute pancreatitis. Therapeutic options]. / Pseudochistul de pancreas, complicatie tardiva a pancreatitelor acute severe. Posibilitati si optiuni terapeutice.

AIM: the assessment of the therapeutical methods in the pancreatic pseudocyst occurred after severe acute pancreatitis. MATERIAL AND METHOD: 30 (33.3%) pancreatic pseudocysts (18 men and 12 women aged between 28-64) occurred in the evolution of 90 severe acute pancreatitis in the last 5 years (2000-2004) were analyzed. The diagnosis was established on the clinical and imaging aspects on average 1 month after the onset of the severe acute pancreatitis. The treatment was different, depending on size, anatomo-clinical form, pseudocyst age, presence of complications and the biological status of the patient. 14 uncomplicated pseudocysts, with the diameter less than 6 cm, were treated conservatively, until their complete resorption. 6 cases were operated on (2 cysto-gastrostomy, 1 cysto-jejunostomy and 3 external drainage). We performed percutaneous external CT guided drainage in 2 cases and endoscopic drainage in other 8 cases (trans-papillary-trans-ductal drainage 3 cases and endoscopic US guided drainage in 5 cases: transgastric 2, transduodenal 2 and transesophageal 1). RESULTS: 28 (93.3%) cases had a fair evolution (complete resorption in 14 uncomplicated pseudocysts after 3-6 weeks of conservative treatment). We registered 2 gastro-duodenal bleeding during endoscopic US guided drainage, which required operation (haemostasis cysto-gastrostomy). Mortality rate was 0. CONCLUSIONS: 1. The pseudocyst is the main late complication of the severe acute pancreatitis (33.3% in our study). 2. The uncomplicated pseudocysts with the diameter less than 6 cm, benefit of the conservative treatment and monitoring in progress until their complete resolution. 3. There are 3 therapeutical methods for the pseudocysts more than 6 cm in diameter and/or complicated: the percutaneous external US/CT guided drainage, the endoscopic drainage and surgery. 4. The option for the drainage procedure must take into account the morphological and evolutionary aspects of the pseudocyst, the age and biological status of the patient.

Manual methods are suboptimal compared with automated methods for cleaning of single-use biopsy forceps.

OBJECTIVE: Most reusable biopsy forceps and all of the currently available single-use biopsy forceps do not have a port that allows fluid flow down the inner tubular shaft of the device. Reusable biopsy forceps are widely used and reprocessed in healthcare facilities, and single-use biopsy forceps are reprocessed either in-house (eg, in Canada and Japan) or by third-party reprocessors (eg, in the United States). The objective of this study was to determine the cleaning efficacy of automated narrow-lumen sonic irrigation cleaning, sonication-only cleaning, and manual cleaning for biopsy forceps. DESIGN: A simulated-use study was performed by inoculating the inner channel of single-use biopsy forceps with artificial test soil containing both Enterococcus faecalis and Geobacillus stearothermophilus at concentrations of 10(6) colony-forming units per milliliter. The cleaning methods evaluated were manual cleaning, sonication-only cleaning, and "retroflush" cleaning by an automated narrow-lumen irrigator. Bioburden and organic soil reduction after washing was evaluated. Forceps used in biopsies of patients were also tested to determine the worst-case soiling levels. RESULTS: Only retroflush irrigation cleaning could effectively remove material from within the shaft portion of the biopsy forceps: it achieved an average reduction of more than 95% in levels of protein, hemoglobin, carbohydrate, and endotoxin. However, even this method of cleaning was not totally effective, as only a 2 log10 reduction in bioburden could be achieved, and there were low residual levels of hemoglobin and carbohydrate. CONCLUSION: The data from this evaluation indicate that manual and sonication-only cleaning methods for biopsy forceps were totally ineffective in removing material from within the biopsy forceps. Even the use of retroflush cleaning was not totally effective. These findings suggest that in-hospital reprocessing of biopsy forceps with currently available equipment and cleaning methods is suboptimal.

[Postoperative biliary peritonitis--diagnosis and treatment difficulties]. / Peritonitele biliare postoperatorii--dificultati de diagnostic si tratament.

AIM: To point out the severity of the postoperative biliary peritonitis (PBP) and to established the most proper ways of diagnosis and treatment. MATERIAL AND METHODS: 14 PBP (6 males and 8 females, age between 42 and 76 years) admitted in the last 14 years were analyzed. The PBP occurred after biliary surgery in 13 cases and after gastro-duodenal surgery in 1 case. The delay between the first operation and the establishing of the diagnosis and reoperation varied between 24 hours and more than 3 days. All the patients were operated on; the operation had to fulfill 2 main objectives: the treatment of the peritonitis and to solve the biliary lesions. RESULTS: 6 patients had a fair evolution. We registered 8 complications with a morbidity rate of 57,14% and 2 deaths with a mortality rate of 14,3%. CONCLUSIONS: 1. Postoperative biliary peritonitis is one of the most severe complications of the biliary and gastro-duodenal surgery, due to preoperative unrecognized biliary lesions or occurring as postoperative accidents or complications. 2. The clinical picture, deeply modified by the complex postoperative treatment makes the early diagnosis very difficult and leads to a delay of the re-operation. 3. The treatment is exclusively a surgical one, with two main objectives: the biliary lesion repair and the treatment of the peritonitis. 4. The postoperative biliary peritonitis are charged by a high postoperative morbidity and mortality rate, the delay of the diagnosis and the time of reoperation being the main risk factor.

[Severity factors of acute renal failure in severe acute pancreatitis]. / Factori de gravitate in insuficienta renala acuta din pancreatitele acute severe.

AIM: assessment of the severity factors of the acute renal failure (ARF) in the severe acute pancreatitis (SAP). 28 (32.55%) severe acute pancreatitis with acute renal failure (19 males and 9 females, aged between 30 and 67), treated by hemodialysis, selected from 86 severe acute pancreatitis with acute renal failure, admitted in the Hemodialysis Department of ICU in the last 6 years, were analyzed. The severity of the pancreatitis was assessed using the following criteria: clinico-biologic scores (Ranson > 3 and APACHE II > 8), the CT-scan (Balthazar score D and E and CTSI > 4), the presence of the organ and system dysfunctions assessed by Tran and Cuesta criteria and the presence of the abdominal compartment syndrome (abdominal pressure > 25 mm Hg). 8 dialyzed cases (28.5%) were operated on: 2 cholecystostomy, 2 cholecystectomy+choledocho-lithotomy+T tube drainage, 4 exploring laparotomy + drainage. RESULTS: The following severity factors were identified: 1. the association of the ARF with other system and organ dysfunctions, the highest mortality rate being provided by the following associations: ARF + more than 3 organ and system dysfunctions and ARF + ARDS in assisted ventilated patients; 2. the abdominal compartment syndrome with abdominal pressure > 25 mm Hg; 3. severe sepsis and altered biological status of the patients. We registered a general mortality rate of 53.57% (15 deaths) and a postoperative mortality rate of 75% (6 deaths from 8 operated patients). CONCLUSIONS: 1. Summing up the pathologic changes proper to the acute pancreatitis (enzymes and mediators releasing) with sepsis and abdominal compartment syndrome worsens the humoral and metabolic syndrome of the ARF. 2. The simultaneous presence of other organ and system dysfunctions makes the ARF in SAP one of the most severe forms. 3. ARF with anuria + ARDS in assisted ventilated patients and ARF + more than 3 associated organ and system dysfunctions are the clinical forms with the highest mortality rate. 4. The abdominal compartment syndrome is an important severity factor of the ARF because of its direct impact against the kidney and the organ and system dysfunctions which produces and worsens.

Volatile induction and maintenance of anaesthesia (VIMA) with sevoflurane for surgical treatment of the choanal atresia in newborn.

A solved case of bilateral choanal atresia in a 10 hour newborn allowed the authors to make some pathogenic, clinic and therapeutic considerations. The paper underlines the high severity of the disease, which imposes the need of a quick diagnosis and an emergency surgical procedure assuring the airway patency and proper ventilation. The transnasal endoscopic approach is the procedure of choice, being quick, safe, providing direct and excellent visualization of the nasal cavity and posterior choanae, and having less postoperative morbidity than other surgical procedures. It is also emphasized the need of general anaesthesia with VIMA technique, which covers all the requirements of the anaesthesia in newborn.

[Severe nosocomial infection of soft tissue in general surgery]. / Infectiile nosocomiale severe ale partilor moi în chirurgia generala.

This paper aim is to emphasize the severity of soft tissue nosocomial infections, determined by anaerobic bacteria associated with Gram-negative aerobic bacteria: 50% mortality, higher economic costs, disabling morphologic and functional sequels. We present the pathogenic, clinical and therapeutically problems which characterize this type of postoperative infections.

[Primary retroperitoneal tumors--diagnostic and therapeutic difficulties]. / Tumorile retroperitoneale primitive--probleme de diagnostic si tratament.

This paper emphasizes the diagnosis and therapeutic difficulties in primary retroperitoneal tumors. There were analyzed 68 primary retroperitoneal tumors (1992-2002): 16 (23.5%) benign tumors, 39 (57.35%) malignant tumors and 13 tumors with unknown histological structure. The preoperative diagnosis was clinically suggested and confirmed by ultrasound and CT examination; the operability was always established by laparotomy. All cases were operated on: complete resection of tumor was possible in 39 cases (57.35%); partial resection in 11 cases (16.17%) and 18 (26.47%) cases were inoperable. There were 5 major intraoperative vascular lesions: 1 inferior vena cava lesion, 1 superior mesenteric vein lesion, 1 left common iliac vein lesion and 2 lumbar artery lesions. Postoperative mortality was represented by 2 cases. Postoperative complication was represented by 3 postoperative hemorrhages, 2 severe pulmonary infections, 1 postoperative evisceration, 1 postoperative acute pancreatitis and 1 acute myocardial infarction. In conclusion the primary retroperitoneal tumors represent a challenge for all surgeons, especially due to surgical approach difficulties, because of problems in tumors intraoperative exploration and resection and because of difficulties in hemostasis.

[Severe acute pancreatitis--diagnostic and therapeutic strategy]. / Pancretitele acute severe--strategie diagnostica si terapeutica.

To establish the optimal diagnosis and therapeutical strategy in severe acute pancreatitis. 94 (56.9%) severe acute pancreatitis (79 males and 15 females, aged between 26 and 81), selected from 165 acute pancreatitis admitted in the last 5 years (2000-2004) were analyzed. The disease was assigned as severe when one or more of the following criteria were present: Ranson score >3 on admission or at 48 hours, APACHE II score >8, visceral failures, Balthazar CT score C, D or E and local complications (infected necrosis, pseudocyst or pancreatic abscess). Medical treatment (aggressive supportive intensive care therapy, minimizing pancreatic secretion and antibiotic therapy) was the first therapeutical step in all cases. 49 (52.1%) patients were operated on: 20 as early surgery imposed by biliary sepsis (16 cases) or by an acute abdomen with uncertain etiology and unfavourable evolution, and 22 as late surgery (at least 12 days after onset), imposed by the presence of the infected pancreatic necrosis, visceral failures or other local complications, the necrosectomy being the main surgical procedure for infected necrosis. 77 (81.9%) cases had a fair evolution. The conservative treatment led to a complete recovery in 37 (37.2%) cases. We registered an overall mortality rate of 12.7% and postoperative mortality rate of 14%; we also registered 5 (10.2%) postoperative complications: 4 pancreatic and 1 colonic fistulae. (1) The treatment of the severe acute pancreatitis must be performed only in the specialized multidisciplinary well equipped centers with very well trained staff. (2) Medical conservative treatment (aggressive supportive intensive care therapy and antibiotic therapy) is the main therapeutical method within the acute phase (first two weeks). (3) Very restrictive surgical indications within the acute phase. (4) Necrosectomy is the main surgical procedure for the infected necrosis.

[The megaureter--a possible complication after resected retroperitoneal tumor]. / Megaureterul--complicatie posibila dupa tumori retroperitoneale operate.

The authors present a very rare complication of a retroperitoneal tumor resection: unilateral iliopelvic segmental megaureter. This condition was subsequently complicated with a diffuse peritonitis caused by parietal microperforations.

Manual versus automated methods for cleaning reusable accessory devices used for minimally invasive surgical procedures.

We undertook a simulated-use study using quantitative methods to evaluate the cleaning efficacy of ported and non-ported accessory devices used in minimally invasive surgery. We chose laparoscopic scissors and forceps to represent worst-case devices which were inoculated with artificial test soil containing 10(6) cfu/mL Enterococcus faecalis and Geobacillus stearothermophilus and allowed to dry for 1 h. Cleaning was performed manually, as well as by the automated SI-Auto Narrow lumen cleaner. Manual cleaning left two- to 50-fold more soil residuals (protein, haemoglobin and carbohydrate) inside the lumen of non-ported versus ported laparoscopic accessory devices. The SI-Auto Narrow lumen cleaner was more efficient than manual cleaning and achieved >99% reduction in soil parameters in both non-ported (using retro-flushing) and ported laparoscopic devices. Only the automated cleaning of ported devices achieved 10(3)-10(4)-fold reduction in bacterial numbers. Sonication alone (no flushing of inner channel) did not effectively remove soil or organisms from the inner channel. Our findings indicate that non-ported accessory devices cannot be as reliably cleaned as ported devices regardless of the cleaning method used. If non-ported accessory devices are reprocessed, they should be cleaned using retro-flushing in an automated narrow lumen cleaner.

[Coloesophagoplasty, a choice operation for postcaustic esophageal stenosis]. / Coloesofagoplastia, interventie de electie pentru tratamentul chirurgical al stenozelor esofagiene postcaustice.

OBJECTIVE: To evaluate the problems of approach, of technique and of care as a 20 years experience demonstrates. MATERIAL AND METHOD: a retrospective study including 45 operated cases where the large-bowel served as reconstructive material (in 33 cases the transverse colon and in 12 cases right ileocolon). RESULTS: Healing was obtained in 42 patients. Early postoperative evolution presented: peritonitis caused by anastomotic leakages--2 cases, hemoperitoneum--2 cases, cervical fistula --1 case, wound infection--6 cases, evisceration--1 case, acute respiratory failure--6 cases. Cervical anastomosis reconstruction for late stenosis--1 case. There were 2 postoperative deaths by haemorrhagic shock and peritonitis--mortality 4.4. DISCUSSIONS: Reconstruction by using the large-bowel was justified through anatomic argumentation (sufficient vascular supply), technic argumentation (easy anastomosis, tension free, short time of execution), functional argumentation (good compliance of large-bowel to the new function). CONCLUSION: Coloesophagoplasty is an efficient method on the condition of a strict planning: continent gastrostomy and evolvement of vascular arcades due to previous vascular "carving".

[Chemical obliterans bronchiolitis after azotic acid exposure]. / Bronsiolita obliteranta chimica dupa expunere la acid azotic.

The authors present the case of a 48 years old man having an exposure to irritant gases (azotic and lactic acids) in a closed space, inhaling them for 5 minutes. Shortly after the accident the patient displayed the signs of corneal and conjunctival burn; several days afterwards respiratory symptoms appeared: shortness of breath, dyspnea to minor efforts, then nocturnal dyspnea and orthopnea. Chest X-ray, CT scan, complex lung function tests and bronchoalveolar lavaje, together with the history of recent exposure to irritant gases led to the diagnosis of hypersensitivity obliterant bronchiolitis. Oral corticoids in dose of 60 mg/day determined a substantial clinical, radiological and functional improvement. The authors make some comments on the need of early diagnosis and efficient treatment.

[Tracheomalacia and secondary tracheopatia osteocondroplasica - a case report]. / Traheobronhomalacie si traheopatie osteocondroplazica secundara--prezentare de caz.

Tracheomalacia is a condition of the neonatal and infant airway, characterized by weakness of the supporting tracheal cartilage and widening of the posterior membranous wall. Together, these factors cause tracheal collapse, especially during times of increased airflow. The diagnosis of major airway collapse depends upon an accurate history combined with proper endoscopic evaluation. Tracheomalacia can be caused by a diffuse process of congenital origin or by a localized abnormality. The cases of acquired tracheomalacia occur with increasing frequency both in children and adults and are often not clearly recognized. These lesions may result from indwelling tracheostomy and endobronchial tube, chest trauma, chronic tracheobronchitis, inflammation (relapsing polychondritis), secondary to pulmonary resection, tracheal malignancy (cylindroma), and idiopathically. We present the case of a 59 years old male with acquired tracheobronchomalacia, associated with tracheopatia osteochondroplasica, secondary to COPD and a chronic parenchimal infection, on a diabetes mellitus type II background.

[Exceptional etiologies in upper digestive tract bleeding ]. / Exceptii etiologice în HDS.

7 cases, considered as being true etiological exceptions selected from 756 upper gastrointestinal bleeding, are presented. The causes of bleeding were: pancreatic pseudocyst with intracystic hemorrhage broken into duodenum (2 cases), the nonepithelial gastroduodenal tumor (3 cases), the aneurysm of gastroduodenal artery broken into duodenum (1 case) and the aortoduodenal fistula in one patient with a bilateral aorto-iliac by-pass (1 case). The etiological diagnosis could not be established in any cases before the operations. All the cases were operated on, the operation being imposed by the severity of bleeding and having the haemostasis as a main purpose.