Surgery in postoperator alkaline desease

Clinica de Chirurgie Generală şi Esofagiană, Spitalul Clinic “Sfânta Maria” Bucureşti, România, Al XI-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova și cea de-a XXXIII-a Reuniune a Chirurgilor din Moldova „Iacomi-Răzeșu” 27-30 septembrie 2011Introducere: Se analizează retrospectiv experienţa clinicii pe 30 de ani (1981-2010) privind diversia duodenală totală Y-Roux (DDT) în tratamentul bolii alcaline de reflux postoperator(BARP). Materiale şi metodă, rezultate: Din 89 de pacienţi cu gastrojejunostomie Y-Roux după rezecţie gastrică distală cu diverse indicaţii, am selecţionat 29 de pacienţi la care procedeul s-a folosit în tratamentul BARP. Am exclus 9 cazuri cu DDT pentru patologie primară de reflux alcalin. În 20 cazuri DDT a fost practicată ca o modalitate reconstructivă pe “stomac operat”: degastrogastrectomie sau conversie a montajului anastomotic preexistent (la bolnavi cu 1-3 operaţii în antecedente, cu tulburări severe de motilitate). Se constată o scădere a numărului de cazuri în ultimii ani. La 9 pacienţi DDT a fost utilizată ca intenţie curativă antireflux după chirurgia biliară:colecistectomie ± coledocoduodenostomie, constatând creşterea numărului de cazuri în ultima perioadă. Criteriile de indicaţie chirurgicală: clinice, radiologice, endoscopice, histologice au selecţionat pentru intervenţie cazurile severe. Se prezintă particularităţile tehnice ca şi consecinţele morfofuncţionale ale DDT. Rezultatele imediate sunt foarte bune: morbiditate minimă (o reintervenţie precoce pentru ocluzie digestivă înaltă) şi mortalitate postoperatorie zero. Rezultatele la distanţă –evaluate clinic, radiologic, endoscopic şi histologic- arată o ameliorare postoperatorie certă, cu excepţia anumitor forme histologice. Concluzii: Incidenţa BARP după chirurgia gastrică a scăzut, prin scăderea drastică a indicaţiei operatorii pentru boala ulceroasă; în schimb creşte relativ incidenţa acestei entităţi după chirurgia biliară. DDT este o procedură eficientă dar de rezervă, indicată în cazuri bine selecţionate. Se constată o ameliorare postoperatorie certa clinică, endoscopică şi histologică, cu excepţia gastritei atrofice şi a metaplaziei intestinale, care se ameliorează în mică măsură.Introduction. We analyzed the experience of the Clinic on past 30 years (1981-2010) regarding total duodenal diversion (TDD) with Roux- en- Y gastrectomy for postoperator alkaline reflux disease (PARD). Materials and method, results: Among 89 patients presenting Y-Roux gastrojejunostomy after gastric distal resection for various indications, we selected 29 patients in which the procedure was used as treatment of PARD. We excluded 9 patients with TDD for primary alkaline reflux disease. In 20 cases TDD was used as a reconstructive procedure on “operated stomach” : degastrogastrectomy or conversion of the existing anastomotic assembly (at patients with history of 1-3 gastric operations, with severe motility disorders). It is ascertained a decrease in the number of such cases in recent years. At another 9 patients TDD was used as an antireflux cure after biliary surgery: colecistectomy ± choledocoduodenostomy, noting the increase number of such cases lately. The criteria for surgery indication: clinicals, radiologycals, endoscopicals, histologicals selected for intervention severe cases. There are presentated techniques particularities and morfofunctional consequences of TDD. Immediate results were very good: minimal morbidity ( one early reintervention for acute digestive occlusion) and no postoperator mortality. Long time results – clinical, radiological, endoscopic and histological evaluated- showed a certain postoperator improvement, excepting some definite histological forms. Conclusions: PARD incidence after gastric surgery has decreased through drastically decrease of surgical indication for patients with gastroduodenal ulcer; after biliar surgery. TDD is an efficient procedure but as a backup, being indicated only in cases very carefully selected. It is observed a definite clinical, endoscopic and histological postoperator improvement excepting atrophic gastritis which is less improved

Diagnosis and surveillance of Barrett’s esophagus (BE)

Sp. Cl “Sf. Maria”, Clinica de Chirurgie Generală și Esofagiană, București, România, Al XI-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova și cea de-a XXXIII-a Reuniune a Chirurgilor din Moldova „Iacomi-Răzeșu” 27-30 septembrie 2011Introducere: EB este o afecțiune ce apare în urma refluxului gastro-esofagian cronic și care este factor de risc în apariția adenocarcinomului esofagian. Scop: evaluarea metodelor de diagnostic și de urmărire a pacienților cu EB. Metoda: În perioada 2006-2010, 36 de pacienți au fost diagnosticați cu EB prin Endoscopie Digestivă Superioară (EDS) cu biopsie. S-a folosit manometria esofagiană și pH-metria pe 24 ore pentru evaluarea răspunsului la tratament. Pacienții au primit 3-6 luni tratament medical. În urma lipsei de răspuns sau a complianței la tratamentul medical s-a efectuat tratament chirurgical. Pacienții au fost supravegheați conform protocoalelor. Rezultate: EDS a diagnosticat 15 pacienți fără leziuni asociate, 8 cu esofagită grd.A-C, 8 cu hernie hiatală asociată, 2 cu ulcer esofagian și 3 cu reflux biliar. Sfinterul esofagian inferior (SEI) incompetent și pH-metrie modificată au fost decelate la 3, respectiv 4 din pacienții fără leziuni asociate, la 5 din cei cu esofagită și la 8, respectiv 7 din cei cu hernie hiatală. Examenul histologic a decelat 2 pacienți cu displazie low-grade. După tratamentul medical sau chirurgical s-a obținut ameliorarea simptomatologiei și vindecarea leziunilor de esofagită. După fundoplicatura, parametrii pH-metrici și manometrici au revenit la normal, iar după Diversie Duodenala Totală s-a observat absența refluxului biliar esofagian. Concluzii: Diagnosticul și supravegherea pacienților cu esofag Barrett sunt foarte importante datorită riscului de evoluție către adenocarcinom.Introduction: BE is a disease induced by chronic gastro-esophageal reflux and is a risk factor for the development of esophageal adenocarcinoma. Aim: to evaluate the methods of diagnosis and follow-up of the patients with BEMethods: Between 2006 and 2010, 36 patients were diagnosed with BE using Upper Endoscopy (UE) with multiple biopsies. We used esophageal manometry and 24 hours pH-metry for assessing the outcome. The patients received initially for 3-6 month medical treatment. When lacking response or compliance at drug therapy, the surgical treatment was applied. The patient’s follow-up was made according to protocols.Results: The UE diagnosed 15 patients with no associated findings, 8 had grd.A-C esophagitis, 8 had hiatal hernia, 2 had esophageal ulcer and 3 presented biliar reflux. The lower esophageal sphincter (LES) was incompetent and the pH-metry was abnormal in 3, respective 4 of patients with no associated findings, in 5 of those with esophagitis and in 8, respective 7 of those with hiatal hernia. The histological exam finds 2 patients with low-grade dysplasia. The improvement of symptomatology and the healing of esophagitis were noticed after medical treatment and in all patients surgically treated. After fundoplication, the pH-metric and manometric values restored to normal and after total duodenal diversion no more biliary reflux was noticed. Conclusions: The diagnosis and surveillance of Barrett’s esophagus are very important due to the risk of development of adenocarcinoma

The Vascularization Pattern of the Colon and Surgical Decision in Esophageal Reconstruction with Colon. A Selective SMA and IMA Arteriographic Study

Rezumat Pattern-ul de vascularizaåie al colonului aei decizia chirurgicalã în reconstrucåia esofagianã cu colon -studiu arteriografic selectiv al AMS aei AMI Introducere: Indiferent de tehnica reconstructivã, conceptele de fundamentare din reconstrucåia visceralã au ca baza principalã suportul vascular necesar pentru grefonul de substituåie. Particularitãåile vasculare individuale pot înclina sau chiar obliga chirurgul la o anumitã opåiune cãtre unul sau altul dintre procedee. De aceea, vascularizaåia este, fãrã îndoialã, factorul care dominã mobilizarea colonului pentru reconstrucåia esofagianã. Material aei metodã: Studiul nostru arteriografic aei-a propus o investigaåie asupra tiparului vascular al celor douã surse principale ce participã prin vasele emergente la irigarea arterialã a colonului: a. mezentericã superioarã (AMS) respectiv a. mezentericã inferioarã (AMI). Nu am avut în vedere selectarea pacienåilor dupã un anumit criteriu dupã cum nu am realizat nici o excludere dintr-un anumit considerent. Lotul de studiu a constat din 49 de pacienåi care s-au prezentat în clinicã pentru o tehnicã reconstructivã, toåi aparåinând perioadei 2000-2010. În intervalul 1981-2012, au fost efectuate 187 de tehnici reconstructive pentru o indicaåie postcausticã. Din totalul de 49 de pacienåi, 11 bolnavi suferiserã intervenåii chirurgicale abdominale majore iar dintre aceaetia, 5 cu tentative nereuaeite de reconstrucåie. Rezultate: Din cei 49 de pacienåi la care s-a efectuat explorarea, arteriografia a evidenåiat o situaåie favorabilã reconstrucåiei la 31 dintre aceştia. La ceilalåi 18 pacienåi au fost identificate anomalii ori distribuåii atipice, 5 ale AMS respectiv 13 ale AMI. Decizia operatorie a fost ajustatã la 22 de bolnavi. Un lucru important de semnalat dpdv predictiv asupra viscerul de mobilizat: nu am avut necroze de grefon la pacienåii cu examinare arteriograficã preoperatorie. Concluzii: Dictate de necesitatea unei bune mobilizãri, ligaturile arteriale trebuie adaptate şi modificate în funcåie de particularitãåile de distribuåie vascularã, astfel încât sã se menåinã un flux sangvin suficient în arcada marginalã pânã la nivelul secåiunilor colice şi, implicit, în arterele drepte din vecinãtatea acestora. main grounds the mandatory vascular support for the graft replacement. Individual vascular particularities can influence or even oblige the surgeon to choose a certain procedure. This is why the vascularization is beyond doubt the dominant factor in mobilizing the colon for reconstruction. Material and method: Our arteriographic study entails an investigation upon the vascularization pattern of the two main sources that participate in the arterial irrigation of the colon via the emerging vessels: superior mesenteric artery (SMA) and inferior mesenteric artery (IMA). We did not consider certain patients upon a specific criterion; also, we did not exclude any patients due to various reasons. We took into account 49 patients as study group, all of them having registered into the clinic for a reconstructive technique, throughout the years from 2000 to 2010. From 1981 to 2012 there have been 187 reconstructive techniques performed due to post caustic pathology. From a total of 49 patients, 11 had suffered major abdominal surgeries, 5 of which had had unsuccessful reconstructive attempts. Results: Out of the 49 patients on whom we have performed the exploration, arteriography showed a favorable situation for reconstruction in 31 of them. In the other 18 patients anomalies or atypical distributions were identified, in 5 of the SMA and in 13 of the IMA, respectively. Operative decision was modified in 22 patients. One important thing to note from the point of view of the segment to be moved: we had no graft necrosis in patients with preoperative arteriographic examination. Conclusions: Due to the need for good mobilization, arterial ligations should be adjusted and modified depending on the particular vascular distribution, to maintain a sufficient blood flow in the marginal artery, in order to reach the colic sections and the straight arteries near them. Abbreviations: SMA -superior mesenteric artery; IMAinferior mesenteric artery; ICa -ileocolic artery; RCa -right colic artery; MCa -middle colic artery; LCa -left colic artery; LC acc.a -left accessory colic artery (or middle left colic artery); ILCa -inferior left colic artery; S trunk -sigmoidian trunk; Sa -sigmoidian artery; SRa -superior rectal arter

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND: The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting. METHODS: Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups. RESULTS: Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005). CONCLUSION: Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery

A survey of zoonotic pathogens carried by non-indigenous rodents at the interface of the wet tropics of North Queensland, Australia

In 1964, Brucella was isolated from rodents trapped in Wooroonooran National Park (WNP), in Northern Queensland, Australia. Genotyping of bacterial isolates in 2008 determined that they were a novel Brucella species. This study attempted to reisolate this species of Brucella from rodents living in the boundary area adjacent to WNP and to establish which endo- and ecto-parasites and bacterial agents were being carried by non-indigenous rodents at this interface. Seventy non-indigenous rodents were trapped [Mus musculus (52), Rattus rattus (17) and Rattus norvegicus (1)], euthanized and sampled on four properties adjacent to the WNP in July 2012. Organ pools were screened by culture for Salmonella, Leptospira and Brucella species, real-time PCR for Coxiella burnetii and conventional PCR for Leptospira. Collected ecto- and endo-parasites were identified using morphological criteria. The percentage of rodents carrying pathogens were Leptospira (40%), Salmonella choleraesuis ssp. arizonae (14.29%), ectoparasites (21.42%) and endoparasites (87%). Brucella and C. burnetii were not identified, and it was concluded that their prevalences were below 12%. Two rodent-specific helminthic species, namely Syphacia obvelata (2.86%) and Nippostrongylus brasiliensis (85.71%), were identified. The most prevalent ectoparasites belonged to Laelaps spp. (41.17%) followed by Polyplax spp. (23.53%), Hoplopleura spp. (17.65%), Ixodes holocyclus (17.64%) and Stephanocircus harrisoni (5.88%), respectively. These ectoparasites, except S. harrisoni, are known to transmit zoonotic pathogens such as Rickettsia spp. from rat to rat and could be transmitted to humans by other arthropods that bite humans. The high prevalence of pathogenic Leptospira species is of significant public health concern. This is the first known study of zoonotic agents carried by non-indigenous rodents living in the Australian wet-tropical forest interface

Tracking transparent monogenean parasites on fish from infection to maturity

The infection dynamics and distribution of the ectoparasitic fish monogenean Neobenedenia sp. (Monogenea: Capsalidae) throughout its development was examined on barramundi, Lates calcarifer (Bloch) (Latidae), by labelling transparent, ciliated larvae (oncomiracidia) with a fluorescent dye. Replicate fish were each exposed to approximately 50 fluorescent oncomiracidia and then examined for parasites using an epifluorescence stereomicroscope at 10 time intervals post-exposure (15, 30, 60, 120 min, 24, 48 h, four, eight, 12, and 16 days). Fluorescent labelling revealed that parasites attached underneath and on the surface of the scales of host fish. Parasite infection success was 20% within 15 min, and peaked at 93% two days post-exposure, before gradually declining between four and sixteen days. Differences in parasite distribution on L. calcarifer over time provided strong evidence that Neobenedenia sp. larvae settled opportunistically and then migrated to specific microhabitats. Parasites initially attached (<24 h) in greater mean numbers on the body surface (13 ± 1.5) compared to the fins (4 ± 0.42) and head region (2 ± 0.41). Once larvae recruitment had ceased (48 h), there were significantly higher mean post-larvae counts on the head (5 ± 3.4) and fins (12 ± 3) compared to previous time intervals. Neobenedenia sp. aggregated on the eyes, fins, and dorsal and ventral extremities on the main body. As parasites neared sexual maturity, there was a marked aggregation on the fins (22 ± 2.35) compared to the head (4 ± 0.97) and body (9 ± 1.33), indicating that Neobenedenia sp. may form mating aggregations

Endoscopic management of anastomotic fistulas after operated esophageal and gastric neoplasm

Introducere: In pofida multiplelor progrese efectuate in chirurgia oncologica si endoscopica digestiva interventionala, fistulele de anastomoza esofagiana continua sa ramana unele dintre cele mai severe complicatii ale neoplasmului esofagian si gastric operat. Noile metode terapeutice endoscopice duc la cresterea ratei de inchidere a fistulelor de anastomoza esofagiana. Dintre acestea amintim: sten-turile esofagiene autoexpandabile, montarea de clipuri OTSC, terapie vaccum, VacStent, stenturile plastic dublu pigtail. Materiale si metode: Decizia de management endoscopic al unei fistule de anastomoza esofagiana este luata in functie de cateva criterii: marimea fistulei, prezenta colectiilor, localizarea fistulei de anas-tomoza esofagiana. Prezentam 4 cazuri de fistula de anastomoza esofagiana, dintre care 2 cazuri post neoplasm esofagian operat si 2 cazuri post neoplasm gastric operat, la care managementul endoscop-ic minim invaziv a permis inchiderea completa fistulei de anasatomoza esofagaiana. Au fost utilizate multiple metode de tratament interventional: montarea de stenturi esofagiene totatl acoperite, sten-turi dublu pigtail, terapie vaccum si clipuri OTSC ( clipuri over the scope). Rezultate: Evolutiile dupa diferitele metode de tratament endoscopic au fost favorabile, cu inchidrea completa a fistulelor, fara recidive. Complicatiile aparute dupa diferitele metode de tratament endoscopic, cat si rata de succes in inchiderea fistulelor de anastomoza esofagiana, au fost intotdeauna un motiv de reflectie pentru medicii endoscopisti, inainte de a lua decizia terapeutica adecvata in functie de particularitatile cazului. Concluzii: Consideram ca utilizarea selectiva si alegerea corecta a diferitelor metode de tratament endoscopic in managementul fistulelor de anastomoza esofagiana ofera pacientului cele mai mari sanse atat de solutionare a acestei complicatii, cat si de supravietuire.Introduction: Despite the multiple advances made in oncological and endoscopic interventional digestive surgery, esophageal anastomotic fistulas continue to remain some of the most severe complications of operated esophageal and gastric neoplasms. The new endoscopic therapeutic methods lead to an increase in the rate of closure of esophageal anastomotic fistulas. Among these we mention: self-expandable esophageal stents, OTSC clip mounting, vaccum therapy, VacStent, double pigtail plastic stents. Materials and methods: The decision of endoscopic management for an esophageal anastomotic fistula is taken according to several criteria: the size of the fistula, the presence of collections, the location of the esophageal anastomotic fistula. We present 4 cases of esophageal anastomotic fistulas, of which 2 cases illustrate complications of operated esophageal neoplasm and 2 cases illustrate complications after operated gastric neoplasm. In all of the before mentioned cases minimally invasive endoscopic management allowed complete closure of the esophageal anastomotic fistulas. Multiple interventional treatment methods were used: fitting of fully covered esophageal stents, double pigtail stents, vacuum therapy and OTSC clips (over the scope clips). Results: The evolution of these patients after the different endoscopic treatment methods was favorable, with complete closure of the fistulas, without relapses. The complications arising after the different methods of endoscopic treatment, as well as the success rate in closing esophageal anastomotic fistulas, have always been a reason for reflection among endoscopists, before making the appropriate therapeutic decision according to the particularities of the case. Conclusions: We believe that the selective use and the correct choice of different endoscopic treat-ment methods in the management of esophageal anastomotic fistulas offer the patient the best chances for both solving this complication and also for surviving