[Gastric cystic duplication--case report]. / Duplicatia chistica gastrica--prezentare de caz.

Gastrointestinal duplication is a rare surgical pathology, with unspecified symptoms, which explains why these malformations are difficult to diagnose correctly before surgery. The authors present a case of a gastric cystic duplication, that was diagnosed before surgery, as a pancreatic pseudocyst. The accurate diagnosis was established by surgery and based on histopathological examination.

[Precocious diagnosis in children's intussusception--a necessity]. / Diagnosticul precoce în invaginatia intestinala la sugar si copil--o necesitate.

Intussusception is the most common cause of intestinal obstruction in children. Despite the fact that this is a frequent and well known disease, sometimes clinical presentation is various and difficult to interpret, which leads to delay in diagnosis and treatment. Late treatment will sometimes require intestinal resection, with high morbidity and mortality. There are no laboratory tests useful in diagnosis of intussusception. The only diagnosis tools are history, ultrasound and radiology. We retrospectively reviewed medical files of 30 patients, admitted and treated for intussusception in Children Hospital Cluj-Napoca and underline the importance of early diagnosis and treatment. There is a connection between onset of the disease, presentation, treatment (conservative or surgical), complications and hospital stay.

[Sandostatin treatment in postoperative external digestive fistulae]. / Tratamentul cu Sandostatin în fistulele digestive externe postoperatorii.

The aim of the conservative treatment of postoperative external digestive fistulae is to obtain a reduction of the output, thus favoring spontaneous closure and shortening outcome. A retrospective comparative study has been performed on two groups of patients with postoperative anastomotic gastrointestinal and pancreatic fistulae. Group A included 18 cases (14 anastomotic, 4 pancreatic fistulae) receiving conventional treatment only. Group B included 25 cases (18 anastomotic and 7 pancreatic fistulae) in which Sandostatin was associated to conventional therapy, using daily doses ranging from 0.1 mg to 0.3 mg, administered after variable intervals after fistulas' occurrence. Duration of treatment ranged from 1 to 25 days. In group A, 27.77% of the cases were cured in comparison with group B in which the healing rate increased to 56%. Global hospital mortality rate was 25.58% (11 cases). In group A this was 44.44% (8 cases) in comparison with group B with 12% (3 cases) only. As a conclusion of our study, the use of Sandostatin is remarkable effective in the treatment of external digestive postoperative fistulae. Thus a doubling of healing rate and a reduction by 73% of mortality rate was achieved.

Nonparasitic abdominal serous cysts. A multiple case report.

A group of 35 patients with nonparasitic abdominal serous cysts is reviewed in order to investigate the diagnostic and therapeutic features of these rare conditions. In most cases the cysts were localised in the liver. Other localisations were the kidney (9 cases), the mesenteric area (2 cases), the adrenals (2 cases), the spleen and the pancreas (one case each). The clinical symptoms were essentially determinated by the size of the cysts, regardless their visceral localisation. Ultrasonography was the most efficient procedure for their detection, although this method's precision for the visceral localisation of the cysts was not entirely reliable (6 errors). The low incidence of such abnormalities as well as the absence of any relevant diagnostic elements for establishing the nonparasitic character of the cysts, favoured the confusions with nonproliferous hydatid cysts, especially in cases of solitary cysts (7 patients). The most frequently used surgical procedures were partial cystectomy (18 cases) and total cystectomy (8 cases). A personal technique based on obliteration of the cavity with the bulging wall of the cysts, was used in two patients. When choosing the surgical procedure, the size, site and number of cysts were considered. Immediate and late postoperative results were very good.

[Late reinterventions after the surgical treatment of gastric and duodenal ulcer]. / Reinterventii tardive dupa tratamentul chirurgical al ulcerului gastric si duodenal.

A number of 87 reinterventions performed during a 5-year-period for late complications of the gastric and duodenal ulcer surgery are analysed. In most of them (64 cases), the cause of the reintervention was a postoperative ulcer. A long afferent loop (6 cases), the dumping syndrome (4 cases), the stenosis of the anastomosis opening (6 cases) and the primitive neoplasm of the gastric stump (7 cases) represented other causes of reintervention. The immediate postoperative results were very good and good in 69 cases. The risks related to the specific character of this surgery materialized themselves in 14 postoperative complications (anastomotic fistulas, haemorrhages from the anastomosis, stress ulcers etc.), which required iterative operations; the postoperative death rate attained 3.4%. The analysis of these postgastrectomy syndromes is an opportunity to discuss about the failure factors in the surgery of the gastric and duodenal ulcer, the possibilities of exploration and the principles which should guide the reparative therapy.

[Sclerosing cholangitis in the evolution of a surgical hepatic hydatid cyst]. / Colangita stenozanta în evolutia chistului hidatic hepatic operat.

The retrospective analysis of 3 clinical observations points out the etiopathogenetic, clinical and therapeutical aspects of the diffuse stenotic cholangitis, which can occur after the surgical treatment of the hepatic hydatid cyst. Although rare (2.9% of hydatid cysts, 13% of those which communicate with the bile ducts), the diffuse stenotic posthydatid cholangitis represents a severe postoperative complication in cases of median cysts, exerting a compression upon the convergence of hepatic ducts and communicating with the biliary tract. Its presence should be clinically suspected if a mechanical icterus with septic angiocholitis, sometimes associated with an external biliary fistula (from the residual cavity), occurs in the postoperative course of these patients, especially if the primary operation has excluded the remanance of an obstacle at the level of the main bile duct. The lesional substrate is comparable with that of the primitive sclerosing cholangitis, from which it differs through its clear relation with the primary treatment of the hepatic hydatid cyst, through the rapid course of stenotic lesions which, although diffuse, may become more marked in certain segments, as well as through the constant suprastenotic dilatation of the bile ducts. In the pathogenesis are involved the caustic action of some scolicide solutions (2 per cent formaldehyde solution, hypertonic salt solution) on the wall of the bile duct and the cystobiliary communication which predisposes to the peroperative occurrence o-a migration syndrome and of angiocholitis. It requires an early surgical reintervention in order to solve the cholestasis and angiocholitis: according to the morphological situation, we have the choice between disobstruction and trans-stenotic calibration drainage, on the one hand, and biliodigestive derivations in the hilum, which are more efficient, on the other. The prognosis is burdened with the vital risk of septic angiocholitis and with the early occurrence of a secondary biliary cirrhosis or of stenotic recurrences. Prophylaxis consists in the performance of a primary surgical treatment, adequate in median and communicating hydatid cysts, avoiding the "blind" intracystic administration of scolicide solutions, which exert a caustic action on the bile ducts.

[The malignant degeneration of colorectal polyps]. / Malignizarea polipilor rectocolici.

The authors make a retrospective analysis of problems related to diagnosis and therapy raised by malignization of adenomatous rectocolic polyps representing 38.7% of the total number of adenomatous polyps (98 cases), and 5% of cancers of the large bowel (759 cases in all). It is stressed that the rate of malignization increases in direct proportion with the number of polyps, and it is higher in segmentary or diffuse polyposis, predominantly in the sigmoidorectal segment. The clinical, endoscopic and radiologic signs have an orientational value in the diagnosis of malignant polyps, but they are truly important for the detection of the polyps (the site, the number, the extent, and the morphology), and for certain indices of malignancy (density, bleeding, ulceration), which are not constantly found, and which occur at the later stage of the disease. The diagnosis is made by polypectomy and histologic examination of multiple sections, the major diagnostic condition being the identification of the malignancy in the initial stage. Directed partial endobiopsies is frequently followed by diagnostic errors (in 32.2% of the cases), and should be reserved for those cases where polypectomy is technically unfeasible. With regard to therapeutic problems the necessity for oncologic interventions is stressed, characterized by wide exeresis with ablation of all polyps, the type and the extension of the resections depending on the site of the malignancy, and the extent of the polyps. It is stressed that polypectomy, as a definitive therapeutic procedure, does not represent a radical type of surgery, and has exceptional indications for patients with major operatory risks and incipient malignancies. Detection and treatment of polyps in the benign stage is one of the preventive methods that can be applied in rectocolic cancers.

[Emergency operations in colorectal cancer]. / Operatii de urgenta în cancerul recto-colonic.

In a group of 161 patients subjected to emergency surgery of rectocolonic cancers with occlusive (111 cases), hemorrhagic (39 cases) or perforating (11 cases) complications, the authors analyze the immediate therapeutic results, as a function of the complication form and the surgical method used in emergency (primary colectomy, serial surgeries, palliative surgeries). Emergency colectomy (55 cases) performed deliberately in strictly selected cases or as the unique possible choice, was followed by immediate good results (the lowest rate of surgical morbidity and mortality) in comparison with the serial surgeries (cumulative morbidity and mortality). The paper discusses the indications of the proximal colectomy and of Hartman's surgery in primary emergency colectomies. Serial surgeries (secondary colectomy--30 cases) are mainly indicated in the complicated cancers of the left colon, in the patients with resectable tumours, but with critical biological state or with insufficiently prepared colon. Palliative surgeries (colostomies, internal derivations) used in patients with nonresectable tumours were followed by the highest surgical mortality, a consequence of the biological substrate weakened by disease and complications. The data reported show the necessity of a selective tactical behaviour in the emergency surgery of rectocolonic cancer and plead for the primary urgent colectomy in the patients meeting certain general and local conditions. Likewise, they point to the importance of discovering rectocolonic cancer in an early stage, before the appearance of complications requiring the emergency surgery.

[Hemorrhagic juxtapapillary duodenal ulcer with choledochal and Wirsung's duct stenosis and duodenojejunal fistula following biliojejunal en-Y diversion. The surgical solution]. / Ulcer duodenal juxtapapilar hemoragic cu stenoza coledociana si wirsungiana si fistula duodenojejunala dupa derivatie bilojejunala în Y. Rezolvare chirurgicala.

The paper reports on the clinical observation of a patient with bulbar duodenal ulcer placed in a juxtapapillary position due to a short bile duct, complicated with choledochal and Wirsung's stenosis and, finally haemorrhage and duodenojejunal fistula favoured by a gallbladder-jejunum diversion assembly. Three major surgeries, during 17 years, were required: cholecystectomy and choledochoduodenostomy for the choledochal stenosis induced by penetrating posterior bulbar ulcer; after 8 years, choledocholithotomy and gallbladder-jejunum derivation the loop in Y, (Roux) for the choledochoduodenostomy stenosis with the local lithiasis of the CBP; after 9 years, the resection of the proximal segment of the anastomosed jejunal loop with CBP and gastric resection with ulcer exeresis, followed by restoration of the gallbladder-jejunum anastomosis, gastrojejunal anastomosis and reimplantation of Wirsung's duct in the duodenal stump for juxtapapillary duodenal ulcer complicated with haemorrhage, penetration into pancreas, perforation in the jejunal loop anastomosed preduodenally and stenosis of Wirsung's duct. The final therapeutic result is good and lasts in time. The paper discusses the duodenum-gallbladder-pancreas interrelationships in the juxtapapillary ulcers, drawing the attention on the possibility of forming a duodenojejunal fistula in the patients with gallbladder-jejunum derivations.

Pathogenetic interrelations between cholesterolosis and cholesterol gallstone disease.

In order to define the relationship between cholesterolosis (COL) and cholesterol gallstone disease (CGD), risk factors were comparatively investigated in a great number of patients. Sex, age and metabolic risk factors were the same for both diseases, but gallbladder anomalies and neuroendocrine disturbances were more often associated with COL. The lipid composition of the gallbladder bile was determined in patients with COL. The bile acid decrease and the increase of cholesterol molar concentration (moles %) were found, similar to those known in CGD. The similarity of risk factors and of bile lithogenicity, as well as the frequent association of COL and CGD suggest a pathogenic relationship of both diseases. Local morphological changes in conditions of high biliary cholesterol levels may be responsible for the intraparietal precipitation of cholesterol in COL. Thus, COL seem to be a peculiar variant of CGD and its classification into the heterogeneous group of cholecystoses is at present questionable.