Timing of surgery in acute pancreatitis

Clinica de Chirurgie a Spitalului Clinic de Urgență Floreasca, Universitatea de Medicină și Farmacie "Carol Davila", București, România, Al XIII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” și al III-lea Congres al Societății de Endoscopie, Chirurgie miniminvazivă și Ultrasonografie ”V.M.Guțu” din Republica MoldovaIntroducere: Pancreatita acuta reprezinta o patologie cu evolutie impredictibila, cu potential letal, fiind insotita de o rata de mortalitate si morbiditate semnificativa. Managementul chirurgical al acestei patologii vizeaza faza tardiva de evolutie a bolii, in care riscul major este reperzentat de infectia necrozei pancreatice si peripancreatice. Literatura actuala arata ca abordul de tip interventional progresiv este asociata cu rezulatate: Corelarea momentului operator cu rata complicatiilor la pacientii cu pancreatita acuta. Materiale și metoda: Studiu retrospectiv, efectuat pe o perioada de 4 ani, in care au fost inclusi pacientii internati in Spitalul Clinic de Urgenta Bucuresti cu diagnosticul de pancreatita acuta, pentru care s-a practicat chirurgie deschisa sau minim invaziva. Rezultate obținute: Au fost inclusi 624 de pacienti diagnosticati cu pancreatita acuta din care in functie de gradul de severitate 44 pacienti (7%) au avut forma severa, 243 pacienti (39%) forma moderat severa si 337 pacienti (54%) forma usoara. In ceea ce priveste corelatia dintre momentul operator si gradul de severitate , pentru pancreatita acuta severa timpul mediu pana la interventia chirurgicala a fost de 26.43 zile, iar pentru pancreatita acuta moderat severa timpul mediu pana la momentul operator a fost de 9.8 zile. Mortalitatea pentru pacientii cu pancreatita acuta forma severa este una semnificativa, in proportie de 42%. Analiza curbelor de supravietuire corelate cu momentul operator au aratat faptul ca pacientii operati tardiv au avut o rata de supravietuire mai buna. Concluzii: Interventia chirurgicala efectuata in primele 28 zile se asociaza cu o rata semnificativa de complicatii si mortalitate. Managementul multidisciplnar al pacientilor cu pancreatita acuta, terapie intenziva asociata cu tehnici minim invazive, pot oferi timp pretios acestor pacienti, pentru a ajunge la momentul optim tratamentului chirugical.Introduction: Acute pancreatitis is a potentially lethal disease with an unpredictable evolution, with a significant morbidity and mortality rate. Surgical management of this disease targets the late evolution phase, when there are major risks from the infection of pancreatic and peripancreatic necrosis. Modern literature reports that progressive interventional approach shows better clinical results. Objective: Correlation of surgery timing with morbidity rate in patients with acute pancreatitis. Material and method: Retrospective study which included patients with acute pancreatitis admitted and operated (open and minimally invasive procedures) in the București Clinical Emergency Hospital during a period of 4 years. Results: 624 patients with acute pancreatitis were included; distribution according to severity: severe form - 44 patients (7%), moderate severe - 243 patients (39%), and mild - 337 patients (54%). Regarding the correlation between the timing of surgery and severity – median time until surgery for severe acute pancreatitis was 26.43 days, and for moderate severe - 9.8 days. Mortality rate for patients with severe acute pancreatitis is significant and reached 42%. Survival curves analysis corelated to the timing of surgery unveiled that the patients with delayed surgery showed a better survival rate. Conclusion: Surgical intervention performed during the first 28 days is associated with a significant rate of morbidity and mortality. Multidisciplinary management of these patients, intensive care combine with minimally invasive techniques may offer precious time to these patients in order to reach the optimal surgery timing

The management of traumatic diaphragmatic injuries

Introducere: Leziunie diafragmatice traumatice sunt rare si pot fi identificate prin intermediul radiografiilor toracice si al computer tomografiilor si sunt tratate chirurgical prin laparotomie folosind suturi nonabsorbabile. Leziunea initiala este de cele mai multe ori mascata de prezenta unor leziuni concomitente la nivel toracic sau abdominal. Pacienti si metoda: Pentru realizarea articolului au fost folosite datele medicale ale pacientilor internati cu traumatisme toracice sau abdominale in Spitalul Clinic de Urgenta Bucuresti in perioada 2017-2022 Rezultate: Au fost identificati 14 pacienti cu leziuni traumatice diafragmatice, 10 erau barbati si 4 erau femei. Scorul de severitate lezionala mediu a fost de 16. Metoda de diagnosticare majoritara a fost reprezentata de computer tomografie , 9 pacienti fiind diagnosticati astfel, 4 au fost diagnosticati prin intermediul unei radiografii toracice si 1 pacient a fost diagnosticat cu leziune diafragmatica in timpul operatiei. Localizarea traumei a fost pe partea stanga in cazul a 10 pacienti, iar 4 pacienti au prezentat leziune diafragmatica dreapta. Din totalul de 14 leziuni, 10 erau de natura nepenetranta si 4 erau de natura penetranta.Background: Traumatic diaphragmatic injury (TDI) is uncommon and can be identified by chest x-rays and CT scans and is repaired by laparotomy with nonabsorbable suture. The initial injury is often obscured by concurrent thoracic and abdominal injuries. Patients and methods: The medical records of patients admitted to Bucharest Clinical Emergency Hospital with thoracic or abdominal trauma from 2017 to 2022 were reviewed. Results: A total of 14 patients were identified with TDI, 10 of them were men and 4 women. The median Injury Severity Score (ISS) was 16. The diagnostic method of the TDI was mostly represented by a CT scan, 9 patients being diagnosed this way, while 4 were diagnosed by chest x-rays and only 1 patient was diagnosed during a laparotomy. The location of the trauma was on the left side for 10 patients and only 4 patients had a right sided TDI. Out of 14 TDIs, 10 were blunt TDIs and 4 were penetrating TDIs

The impact of patient-dependent risk factors on morbidity and mortality following gastric surgery for malignancies

Gastric cancer remains a leading cause of mortality worldwide. The treatment for gastric cancer is multimodal, in which gastrectomy remains the only curative approach. However, gastric resection is often associated with increased morbidity and mortality rates, depending on several factors. These factors can be attributed to the patient as comorbidities or effects of the disease upon him and, on the other hand, there are risk factors independent of the patient, such as aspects of the tumor (type, staging, location), experience of the surgical and anesthetic team, logistics of the hospital, yield of adjuvant therapies etc. We recognize the fact that patient-related risk factors are often overlooked and not taken into consideration prior to surgery, thus becoming a source of morbidity and mortality. These factors are more susceptible to modulating in order to better select candidates for gastric resection and thus create a better outcome. Therefore, identifying and modulating patient-related risk factors is paramount in order to decrease the incidence of morbidity and mortality following gastric resections

Multivisceral resection for a rare case of malignant left adrenal tumor

Vă prezentăm cazul unei femei în vârstă de 44 de ani cu o tumoră corticosuprarenală voluminoasă care a fost detectată la o examinare de rutină abdominala . Pacientul a fost operat în cadrul Secției de Chirurgie Generală. a Spitalului Clinic de Urgență București. Am efectuat ablația tumorii maligne mari a glandei suprarenale stângi cu nefrectomie stângă, splenectomie, colectomie segmentara de colon transvers și pancreatectomie parțială. Examenul histopatologic a relevat un carcinom corticosuprarenalian difuz. Cazul prezinta interes datorită incidenței scăzute a acestui tip de tumoră malignă și de asemenea datorită dimensiunilor impresionante ale acesteia ,avand diametrul maxim de 19 cm.We present the case of a 44-year-old woman with a bulky adrenocortical tumor that was detected during a routine abdominal examination. The patient was operated in the General Surgery Department of the Emergency Clinical Hospital Bucharest. We performed ablation of a large malignant tumor of the left adrenal gland with left nephrectomy, splenectomy, segmental colectomy of transverse colon and partial pancreatectomy. Histopathological examination revealed diffuse adrenocortical carcinoma. The case is of interest because of the low incidence of this type of malignancy and also because of its impressive size, with a maximum diameter of 19 cm

Tigecycline is efficacious in the treatment of complicated intra-abdominal infections

Background Empiric treatment of complicated intra-abdominal infections (cIAI) represents a clinical challenge because of the diverse bacteriology and the emergence of bacterial resistance. The efficacy and safety of tigecycline (TGC), a first-in-class, expanded broad-spectrum glycylcycline antibiotic, were compared with imipenem/cilastatin (IMI/CIS) in patients with cIAI. Methods In this prospective, double-blind, phase 3, multinational trial, patients were randomly assigned to intravenous (IV) TGC (100 mg initial dose, then 50 mg every 12 h) or IV IMI/CIS (500/500 mg every 6 h) for 5–14 days. Clinical response was assessed at the test-of-cure (TOC) visit (14–35 days after therapy) for microbiologically evaluable (ME) and microbiologically modified intent-to-treat (m-mITT) populations (co-primary efficacy endpoint populations in which cure/failure response rates were determined). Results Of 817 mITT patients (i.e., received ≥ 1 dose of study drug), 641 (78%) comprised the m-mITT cohort (322 TGC, 319 IMI/CIS) and 523 (64%) were ME (266 TGC, 256 IMI/CIS). Patients were predominantly white (88%) and male (59%) with a mean age of 49 years. The primary diagnoses for the mITT group were complicated appendicitis (41%), cholecystitis (22%), and intra-abdominal abscess (11%). For the ME population, clinical cure rates at TOC were 91.3% (242/265) for TGC versus 89.9% (232/258) for IMI/CIS (95% CI −4.0, 6.8; P < 0.001). Corresponding clinical cure rates within the m-mITT population were 86.6% (279/322) for TGC versus 84.6% (270/319) for IMI/CIS (95% CI −3.7, 7.5; P < 0.001 for noninferiority TGC versus IMI/CIS). The most commonly reported adverse events for TGC and IMI/CIS were nausea (17.6% TGC versus 13.3% IMI/CIS; P = 0.100) and vomiting (12.6% TGC versus 9.2% IMI/CIS; P = 0.144). Conclusions TGC is efficacious in the treatment of patients with cIAIs and TGC met per the protocol-specified statistical criteria for noninferiority to the comparator, IMI/CIS

Complex Perineal Trauma with Anorectal Avulsion

Introduction. The objective of this case report is to illustrate a severe perineal impalement injury, associated with anorectal avulsion and hemorrhagic shock. Results. A 32-year-old male patient was referred to our hospital for an impalement perineal trauma, associated with complex pelvic fracture and massive perineal soft tissue destruction and anorectal avulsion. On arrival, the systolic blood pressure was 85 mm Hg and the hemoglobin was 7.1 g/dL. The patient was transported to the operating room, and perineal lavage, hemostasis, and repacking were performed. After 12 hours in the Intensive Care Unit, the abdominal ultrasonography revealed free peritoneal fluid. We decided emergency laparotomy, and massive hemoperitoneum due to intraperitoneal rupture of pelvic hematoma was confirmed. Pelvic packing controlled the ongoing diffuse bleeding. After 48 hours, the relaparotomy with packs removal and loop sigmoid colostomy was performed. The postoperative course was progressive favorable, with discharge after 70 days and colostomy closure after four months, with no long-term complications. Conclusions. Severe perineal injuries are associated with significant morbidity and mortality. Their management in high volume centers, with experience in colorectal and trauma surgery, allocating significant human and material resources, decreases the early mortality and long-term complications, offering the best quality of life for patients

Comparison of quality control for trauma management between Western and Eastern European trauma center

<p>Abstract</p> <p>Background</p> <p>Quality control of trauma care is essential to define the effectiveness of trauma center and trauma system. To identify the troublesome issues of the system is the first step for validation of the focused customized solutions. This is a comparative study of two level I trauma centers in Italy and Romania and it has been designed to give an overview of the entire trauma care program adopted in these two countries. This study was aimed to use the results as the basis for recommending and planning changes in the two trauma systems for a better trauma care.</p> <p>Methods</p> <p>We retrospectively reviewed a total of 182 major trauma patients treated in the two hospitals included in the study, between January and June 2002. Every case was analyzed according to the recommended minimal audit filters for trauma quality assurance by The American College of Surgeons Committee on Trauma (ACSCOT).</p> <p>Results</p> <p>Satisfactory yields have been reached in both centers for the management of head and abdominal trauma, airway management, Emergency Department length of stay and early diagnosis and treatment. The main significant differences between the two centers were in the patients' transfers, the leadership of trauma team and the patients' outcome. The main concerns have been in the surgical treatment of fractures, the outcome and the lacking of documentation.</p> <p>Conclusion</p> <p>The analyzed hospitals are classified as Level I trauma center and are within the group of the highest quality level centers in their own countries. Nevertheless, both of them experience major lacks and for few audit filters do not reach the mmum standard requirements of ACS Audit Filters. The differences between the western and the eastern European center were slight. The parameters not reaching the minimum requirements are probably occurring even more often in suburban settings.</p

Highlighted Steps of the Management Algorithm in Acute Lower Gastrointestinal Bleeding -Case Reports and Literature Review

Etape importante ale algoritmului de management în hemoragiile gastrointestinale inferioare acute -raportare de cazuri aei recenzie a literaturii Hemoragiile gastrointestinale inferioare reprezintã o problemã majorã în întreaga lume, fiind o afecåiune relativ rarã cu o ratã a mortalitaåii situatã între 2 aei 4%. Reprezintã 1 -2% din totalul urgenåelor intraspitaliceaeti, 15% din ele fiind hemoragii masive aei pânã la 5% necesitând intervenåii chirurgicale. Pot fi clasificate în funcåie de localizare în hemoragii ale intestinului subåire sau ale colonului. Hemoragiile de la nivelul intestinului subåire sunt cele mai rare (5%). Atunci când terapia endoscopicã asociatã cu cea medicalã sunt insuficiente, intervenåiile endovasculare pot fi salvatoare de viaåã. Din pãcate, în unele cazuri de hemoragie digestivã inferioarã cu instabilitate hemodinamicã aei angiografie nonterapeuticã, ultima resursã rãmâne intervenåia chirurgicalã. În cele ce urmeazã exemplificãm douã cazuri de hemoragie gastrointestinalã inferioarã acutã care au fost rezolvate în modalitãåi diferite, descriem detaliat diferitele tipuri de tratament disponibile aei în final, concluzionãm, sistematizâd cele mai importante etape ale algoritmului de management în hemoragiilor digestive inferioare acute. Cuvinte cheie: hemoragii gastrointestinale inferioare acute, etape importante, algoritm de management Abstract Acute lower gastrointestinal bleeding is a major problem worldwide, being a rare and life threatening condition, with a mortality rate situated between 2 and 4%. Acute lower gastrointestinal bleeding is solvent for 1 -2% of the entire hospital emergencies, 15% presenting as massive bleeding and up to 5% requiring surgery. Lower gastrointestinal bleeding can be classified depending on their location in the small or large intestine. The small bowel is the rarest site of lower gastrointestinal bleeding, at the same time being the commonest cause of obscure bleeding. 5% of total lower GI bleeding appears in the small bowel. When endoscopic therapy associated with medical treatment are insufficient, endovascular intervention can be lifesaving. Unfortunately in some rare cases of acute lower gastrointestinal bleeding with hemo-dynamic instability and the angiography performed being unable to locate the source of bleeding, the last therapeutic resource remains surgery. In the following we exemplify two cases of acute lower gastrointestinal bleeding which were resolved in different ways, followed by a thorough description of the different types of available treatment and finally, in the conclusions, we systematize the most important stages of the management algorithm in acute lower gastrointestinal bleeding

Prognostic impact of Lymph node resection in stage II colon cancer: a prospective study from a tertiary hospital center

Background. The treatment of stage II colon cancer has been a subject of debate for a long time. In the last years, a few risk factors have been proposed in order to guide any treatment decision more accurately. One of these risk factors is the number of resected lymph nodes, and according to the latest guidelines, it is recommended that at least 12 lymph nodes should be resected for optimal staging. The aim of this study is to evaluate the role of lymph node resection, in stage II colon cancer and the implication of suboptimal lymph node resection on disease free survival and overall survival. Patients and methods. This was a prospective study that included 130 patients with stage II colon cancer who were monitored between October 2014 and October 2016. The relation between patients’ tumour characteristics that include number of lymph node resection and the use of adjuvant chemotherapy using Chi test and multiple logistic regression was analyzed. The disease-free survival and overall survival were estimated with the Kaplan-Meier method and compared with the log-rank test. Results. 130 patients with stage II colon cancer were recruited. 56 patients were treated with surgery alone and 74 patients received flourouracil- based chemotherapy after surgery. Patients' age varied from 37 years to 81 years. According to the number of resected lymph nodes, patients were divided into two groups - with less than 12 lymph nodes resected and at least 12 lymph nodes resected. The number of resected lymph nodes varied from 2 to 32 lymph nodes. Median follow up was 36 months. Suboptimal resections of lymph nodes confirmed to be a negative prognostic factor for survival without disease recurrence. Conclusion. Data results confirmed the importance of lymph node resection as a prognostic factor for stage II colon cancer and the role of chemotherapy for patients with suboptimal lymph node resectio