CHANGES IN BONE MINERAL PARAMETERS AFTER SLEEVE GASTRECTOMY: RELATIONSHIP WITH GHRELIN AND PLASMA ADIPOKINE LEVELS.

CONTEXT: Metabolic surgery is currently the most efficient treatment for obesity, but concern is raised about the possible long-term nutritional side effects. Bone metabolism is often adversely affected after surgery, but literature data are contradictory. OBJECTIVE: The aim of this study was to evaluate the evolution of bone mass parameters in the first year after laparoscopic sleeve gastrectomy in relation to anthropometric and body composition parameters and specific hormones of obesity. DESIGN: We conducted a prospective study on 75 patients with obesity that underwent metabolic surgery over a course of 18 months at our center, with a follow-up period of 12 months. SUBJECTS AND METHODS: All patients underwent a complex preoperative assessment and were required to return for medical follow-up at 6 and 12 months after surgery. Each visit included anthropometric parameters, DEXA and determination of specific hormonal parameters. RESULTS: We noticed a significant improvement in anthropometric and body composition parameters after surgery. The value of adiponectin presented a significant increase after surgery and leptin showed a significant decrease at 6 and 12 months postoperative; ghrelin level decreased postoperative compared to preoperative, but without statistical significance. We observed no reduction in BMD after surgery, but a significant improvement in BMC at 12 months after surgery compared to preoperative. Ghrelin negatively correlated to BMD preoperative. CONCLUSIONS: Despite the significant alterations in anthropometric, body composition and hormonal parameters, we found no negative effect on BMD and BMC in our study population.

[General principles of clinical and therapeutic management in postoperative external enteral fistulas]. / Principii generale de management clinico-terapeutic in fistulele enterale externe post-operatorii.

Postoperative enterocutaneous fistulas represent a frequent complication in the emergency or cancerous digestive surgery. As to the high level of mortality and morbidity caused by this type of postoperative complication (4%), efforts are made to establish the principles of therapeutic management, on the purpose of decreasing these indicators and thus lowering the prolonged hospitalisation afferent costs.

[Intraoperative injuries of the biliary tract]. / Leziunile intraoperatorii de cai biliare.

Statistically speaking, the intraoperative lesions of common bile duct are rare clinical cases, but they have a high gravity potential. Our study was made on a lot of 11 operated pacients during 1995-2007 in our Clinic and it shows the tactical and technical approach used in solving these complications. The study also shows the high level of difficulty of these cases, as immediate recognition of this type of intraoperative lesions is needed. The successful evolution of these cases depends on how quickly the lesions are found and solved.

[Pancreaticoduodenectomy for pancreatic head cancer, 54 cases]. / Duodenopancreatectomia cefalica in cancerul de cap de pancreas--consideratii asupra 54 cazuri.

UNLABELLED: Pancreatic cancer has an increase rate in western countries. From the first pancreaticoduodenectomy (PD) performed by Kausch in 1909, the value of the resection in the treatment of pancreatic head cancer was disputed. AIM: To assess the PD with or without pylorus preservation as surgical treatment for pancreatic cancer. METHODS: Retrospective review of the clinical records of patients undergoing PD for pancreatic cancer. RESULTS: From January 1995 till December 2005, in the First and Third Surgical Units, "St. Spiridon" University Hospital Iasi, Romania, were performed 137 PD. From these, 54 cases were histologic diagnosed with pancreatic cancer; 23 cases underwent pylorus preserving pancreatico-duodenectomy (PPPD) and 31 patients, classical Whipple procedure (PDW). Mean age was 59.07 +/- 1.42 years old (26-75 years old), and male to female ratio was 29 to 25. Jaundice was presented in 51 cases (94.4%), abdominal pain at 39 patients (72.2%) and Curvoisier-Terrier sign at 37 cases (68.7%). Fever was observe only in 4 cases (7.4%). Other biological and imaging parameters (e.g. main diameter of the biliary duct, tumor and wirsung ) were also discussed, but no significant difference was found between PPPD and PDW. Pancreatico-jejunostomy was performed in 41 cases (28 during the PDW and 13 in PPPD) and 13 pancreatico-gastrostomy (3 during PDW and 10 during PPPD). Mean operating time and mean blood loss in the PDW group were 358.22 +/- 10.53 minutes and 587.74 +/- 60.87 mL. After PPPD, these figures were 326.08 +/- 15.04 minutes and 571.74 +/- 90.50 mL, but no significant difference was noted. Delayed Gastric Emptying (DGE) was presented at 15 patients: 8 in PPPD group and 7 in PDW group (p=0.322). Postoperative morbidity rate (excluding DGE) was 33.33% (8 cases in PDW group and 10 in PPPD group). Pancreatic leak has a rate of 5.55% (3 cases--one in PPPD group vs two in PDW group), biliary leak has a rate of 12.96% (4 in PPPD group vs 3 in PDW group)and duodeno-jejunal anastomotic fistula appeared in one cases (PPPD). Acute postoperative pancreatitis is presented in one case (PPPD group) and postoperative hemorrhage appeared in 4 cases (2 in PPPD and 2 after PDW). Hospital stay was 19.91 +/- 2.28 days in PPPD group vs 18.87 +/- 2.24 days in PDW group (p = 0.751). Postoperative mortality rate was 5.5% (one case after PPD and 3 cases after PDW). Histological exam diagnosed ductal pancreatic adenocarcinoma in 51 cases (94.44%). Mean long-term survival rate was 20.98 months (10.52-31.45 months; 95 CI) and no difference was revealed between PPPD and PDW (log rank test - p = 0.796). CONCLUSION: PD should be performed for any pancreatic tumor even without preoperative histologic confirmation. The results after PPPD (postoperative morbidity and mortality, long-term survival) are similar to that following conventional Whipple procedure, if the principles of viable and tumor free margins are observed.

[Pancreaticoduodenectomy with or without pylorus preservation: a retrospective analysis of 137 patients]. / Duodenopancreatectomia cefalica cu sau fara prezervarea pilorului: analiza retrospectiva a 137 pacienti.

OBJECTIVE: We performed a retrospective study to assess the postoperative results, long-term survival and quality of life after pylorus preserving pancreaticoduodenectomy (PPPD) versus standard Whipple pancreaticoduodenectomy (WPD). METHODS: A retrospective study was performed in a nonselected series of 137 patients who were operated in the Surgical Clinics of "St. Spiridon" University Hospital Iasi, Romania, from January 1st, 1995 till December 31, 2005. Demographics, preoperative and intraoperative data, as well as postoperative morbidity, mortality and follow-up were analyzed. Quality of life, after to at least six months after discharge, was also studied. RESULTS: There were no significant differences noted in demographics data. Jaundice was more frequent in the PPPD group as for WPD patients (p=0.047). For the most patients the digestive reconstruction after resection were performed as in Child technique: the first anastomosis was pancreaticojejunostomy (end-to-end or end-to-side), the second anastomosis was hepaticojejunostomy (end-to-side) and the last anastomosis was gastrojejunostomy end-to-side (duodenojejunostomy in PPPD group). For 31 cases a pancreatico-gastrostomy were performed. We also noted 14 cases with pancreatico-gastrostomy and duodenojejunostomy end-to-end, and a Roux jejunal loop for 3 patients with previous gastrectomy and gastrojejunostomy (Reichel-Polya). The operating time was shorter in the PPPD group as in WPD (p < 10-3), but the mean blood loss was the same. Postoperative morbidity rate was 46.8% in PPPD group vs 39.2% in WPD (p > 0.05), but the reintervention rate was significant higher in PPPD group (30.6% vs 15%; p = 0.027). We also noted no significant differences of Delayed Gastric Emptying, postoperative mortality rate (14.5% in PPPD group vs 10.1% in WPD group) and mean survival time (42.42 months (24.94 - 59.89; 95% CI) in PPPD group vs 46.78 months (28.07 - 61.50; 95% CI) in WPD group; log rank test p = 0.643). Pathological exam diagnosed a malignancy in 109 cases (54 cases with pancreatic cancer); we noted chronic pancreatitis in 22 cases. Quality of life was also the same in the two groups. CONCLUSIONS: PPPD and WPD were associated with comparable results, but, there is a tendency of increase rate of postoperative morbidity and mortality for PPPD patients. We also noted that postoperative quality of life is the same for both procedures.

[Internal hernia--a rare cause of intestinal obstruction]. / Hernia interna--o cauza rara de ocluzie intestinala.

Internal hernia is rare its frequency ranging between 0.6 and 5.8%. It results from the protrusion of one or more abdominal viscera (usually small bowel) through an intraperitoneal opening. The opening can be normal (e.g. Winslow foramen), congenital (paraduodenal fossa, ileocecal fossa), or abnormal anatomical entities (after trauma or surgery). The clinical diagnosis of internal hernia is difficult because of the lack of specific signs and symptoms. There is a 63.6% lifetime risk of strangulation and bowel ischemia. In such cases, computed tomography is essential in the preoperative diagnosis because of the high mortality rate (20%) (which justifies its costs).

[Spontaneous esophageal rupture in three patients]. / Ruptura spontana de esofag la trei pacienti.

Boerhaave's syndrome represents the most severe perforation of the gastrointestinal tract. The typical clinical presentation is by a sudden onset of pain after a vomiting effort on the background of an alimentary and alcoholic abuse. It usually associates the cervicomediastinal emphysema, altogether forming the Mackler triad. The atypical presentation and the rarity of this entity usually lead to the delay in diagnosis in 50% of the cases. The diagnosis requires native and hydrosoluble contrast radiological examination which may reveal, altogether with the esomedistinal or esopleural fistula, pneumomediastinum, cervical subcutaneous emphysema, pleural effusion or hydropneumothorax. The early diagnosis and surgical treatment in the first 24 hours after the perforation offer the best chances for survival. We present and analyze the cases of 3 patients with spontaneous esophageal rupture with their different evolution and the diagnostic and treatment steps in each case.

[Spontaneous rupture of the esophagus. Case report]. / Ruptura spontana a esofagului. Prezentare de caz.

We present a 50 years old man who was admitted for severe pain in the chest appeared after vomiting, dyspnoea, cardiovascular collapse. The diagnosis of spontaneous perforation of the esophagus (Boerhaave's syndrome) was confirmed by a radiopaque swallow. We performed a laparotomy, mediastinal drainage, cervical esophagostomy and jejunostomy. Postoperatively, the general state was severe--with high fever, important pleurezia, necessitating pleural drainage, mechanical ventilation for 8 days, parenteral and jejunostomy nutrition. It was possible to close the esophagostomy in the 43rd postoperative day. The patient has been dismissed on the 59th day. Five days later he presented in the ER with severe dyspnoea due to tracheal stenosis--emergency tracheotomy was performed, followed by resection of the stenotic cartilages.

[Intraoperative and early postoperative intraperitoneal chemotherapy--adjuvant treatment for locally advanced digestive system cancer]. / Chimioterapia intraperitoneala intra si postoperatorie--tratament adjuvant pentru cancerele digestive local avansate.

UNLABELLED: Surgical treatment for locally advanced digestive cancers (invasion beyond the serosa, adjacent structures penetration and perforated tumors) is followed by a high rate of peritoneal recurrence and distant metastasis. Simultaneous intraperitoneal chemotherapy with surgical resection, which is continued over the early postoperative period act on the tumor cells which can be mobilized during the surgical dissection. This adjuvant treatment could lead to better control of local recurrence. Moreover, high levels of the agents are reached in the portal circulation which could be profitable for preventing hepatic metastasis. The main drawback of the method is represented by the impaired immunologic activity of the peritoneum, which can cause, at least theoretically, detrimental complications. OBJECTIVE: The efficiency of the intraoperative and early postoperative intraperitoneal chemotherapy is the subject of a prospective randomized study, started 8 months ago in our department. METHOD: Patients with locally advanced (penetration of the tumor beyond serosal layer, without liver metastasis) are randomized for adjuvant intraperitoneal chemotherapy or standard treatment. Intraoperative chemotherapy is commenced after surgical resection but before accomplishing any anastomosis. We use 50 mg of cisplatinum for washing the peritoneal cavity and continue to instill 20 mg/m2 of cisplatinum intraperitoneally in the first four days after surgery. (8 patients were selected to be treated according to this protocol). CONCLUSION: Immediate postoperative outcome does not seem to be influenced by this treatment. The disease free interval and the overall survival rates can not be assessed at this moment of the study.

[Choledochal malignant hemorrhagic cyst, with cholangitis]. / Angiocolita supurata pe un chist coledocian hemoragic, degenerat malign.

The increased risk of cholangiocarcinoma in patients with congenital cystic disease of the biliary tree is well documented. The reason for the malignant transformation is taught to de related to chronic inflammation and bacterial exposure within bile ducts. Total excision of the choledochal cyst notably reduces the risk of cancer. Five to twenty percent of adult patients with unexcused cysts or treated with by pass will develop cholangiocarcinoma. We are presenting the case of a young female diagnosed with a choledochal cyst at age of four, treated with by pass procedure. Fourteen years later she presented with a severe angiocolitis, hemorrhage and malignant transformation within the cyst.

Familial adenomatous polyposis--which operation?

Familial adenomatous polyposis (FAP) syndromes are well recognized entities that benefit from surgical treatment which should not be delayed. Screening of first degree relatives is important. The aim of removing the colorectal mucosa with significant potential of malignant transformation can be achieved by means of three distinct procedures: pan-proctocolectomy and ileostomy, subtotal colectomy with ileorectal anastomosis, restorative proctocolectomy with ileoanal anastomosis. In a series of eight patients with FAP we performed mostly subtotal colectomy with ileorectal anastomosis. Of five patients who underwent a form of subtotal colonic resection, one was lost from follow up and two developed carcinoma in the remaining rectal mucosa, which necessitated completion of the resection with proctectomy and permanent ileostomy. Nevertheless, in the increasing number of patients amenable to regular outpatient supervision, there are strong points for recommending sphincter-saving operations.

Polipoza adenomatoasa familiala--care operatie? [Familial adenomatous polyposis--which operation?].

Familial adenomatous polyposis (FAP) syndromes are well recognized entities that benefit from surgical treatment which should not be delayed. Screening of first degree relatives is important. The aim of removing the colorectal mucosa with significant potential of malignant transformation can be achieved by means of three distinct procedures: panproctocolectomy and ileostomy, subtotal colectomy with ileorectal anastomosis, restorative proctocolectomy with ileoanal anastomosis. In a series of eight patients with FAP we performed mostly subtotal colectomy with ileorectal anastomosis. Of five patients who underwent a form of subtotal colonic resection, one was lost from follow up and two developed carcinoma in the remaining rectal mucosa, which necessitated completion of the resection with proctectomy and permanent ileostomy. Nevertheless, in the increasing number of patients amenable to regular outpatient supervision, there are strong points for recommending sphincter-saving operations.

Experimental and clinical correlation in acute pancreatitis pathogenesis.

Pathological aspects in 100 cases of operated A.P. different in severity are not strictly related to aetiological conditions. Clinical observations have suggested some components of pathogenesis: obstruction of bilio-pancreatic inflow in duodenum at the beginning of the attack, bilio-pancreatic reflux on cholangiograms, strong secretory digestive stimulation before attack. Some experimental animals models (dogs) which can mimic pathogenic mechanism (obstruction of pancreatic flow, common bilio-pancreatic duct, closed duodenal loop, acute cholecystitis) have revealed characteristic pathological changes depending on the initiating process. Our conclusion that severity of pathological changes in A.P. are determined by the initiating mechanisms which may differ in some aetiological condition or may be common for different ones.