Deep venous thrombosis during pregnancy and the postpartum period: clinical and evolutional features

Catedra de chirurgie general semiologie nr. 3, Universitatea de Stat de Medicină și Farmacie „Nicolae Testemiţanu”, Chişinău, Republica Moldova, 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: Tromboza venelor profunde (TVP) a membrelor inferioare dezvoltată pe parcursul sarcinii sau postpartum are o incidență de 0,5-1 cazuri la 1000 nașteri; reprezentând un factor important ce sporește morbiditatea și mortalitatea maternă. Scopul: Studierea particularităților clinice, imagistice şi evolutive ale TVP survenite pe parcursul sarcinii sau lăuziei. Material şi metode: Studiul a cuprins 21 paciente cu TVP confirmată prin duplex scanare. În toate observațiile a fost iniţiată medicaţia anticoagulantă în asociere cu compresia elastică. În cazurile dificultăților de vizualizare la examenul imagistic primar sau progresării manifestărilor clinice pe fundalul tratamentului duplex scanarea a fost repetată peste 3-5 zile. Rezultate: Vârsta medie a pacientelor – 30,7 ani. TVP a fost depistată la primipare – 7 cazuri, pe durata celei de-a doua sarcini – 9, la gravidele cu a treia sarcină – 4 şi, într-un caz, pe durata celei de-a patra sarcini. TVP în antecedente au indicat 3 (14,2%) paciente. Tromboza a survenit în trimestrul I al gestației la 4 (19%) paciente, al II-lea – 4 (19%), al III-lea – 8 (38%) şi postpartum – 5 (23,8%). Afectarea extremității stângi s-a înregistrat în 16 (76,2%) cazuri. Localizarea TVP: vv.tibiale – 4 cazuri, v.poplitee – 2, v.femurală – 2, v.femurală comună – 2, vv.iliace – 9, v.cavă inferioară – 2. Duplex scanarea repetată a evidențiat progresarea trombozei spre segmentul anatomic venos proximal (n=2; 9,5%) sau extinderea în sens descendent (n=2; 9,5%). Concluzii: TVP se poate dezvolta în orice trimestru al sarcinii, precum şi postpartum; având sediul inițial mai frecvent în regiunea iliacă sau tibială și potențial de progresare chiar și pe fundalul anticoagulării inițiale adecvate.Background: Deep vein thrombosis (DVT) of lower extremities developed during pregnancy or postpartum period has an incidence of 0.5-1 cases per 1.000 births and represents an important factor which increases maternal morbidity and mortality. Aim of study: To highlight clinical, imaging and evolutional peculiarities of DVT occurring during pregnancy or postpartum period. Methods and materials: The study included 21 female patients with DVT confirmed by duplex scanning. Anticoagulants in association with elastic compression were initiated in all cases. In the event of difficult viewing during primary imaging exam or worsening of clinical manifestations despite treatment, duplex scanning was repeated after 3-5 days. Results: Average age of patients was 30.7 years. DVT was identified in primiparous women – 7 cases, during the second pregnancy – 9, in women with a third pregnancy – 4, and, in one case – during the fourth pregnancy. Previous history of DVT was indicated by 3 (14.2%) patients. Thrombosis occurred during the first trimester of gestation in 4 (19%) patients, II-nd – 4 (19%), III-rd – 8 (38%), and postpartum – 5 (23.8%). Involvement of the left limb was registered in 16 (76.2%) cases. Localization of DVT: tibial vv. – 4 cases, popliteal v. – 2, femoral v. – 2, common femoral v. – 2, iliac vv. – 9, inferior vena cava – 2. Repeat duplex scanning pointed out the progression of thrombosis to proximal venous segment (n=2; 9.5%) or downward extension (n=2; 9.5%). Conclusion: DVT can develop during any trimester of pregnancy as well as postpartum; being initially localized more frequently in iliac or tibial veins and having potential to progress even despite of appropriate initial anticoagulation

Аtypical giant lipomas

Department of General Surgery and Semiology, Nicolae Testemitsanu State University of Medicine and Pharmacy, Chisinau, the Republic of MoldovaBackground: The giant lipomas represent benign tumors of soft tissues. They are come across rather seldom and require a surgical treatment. According to the data of different studies, single lipomas are more common for women, while multiple lipomas are mainly characteristic of men. These tumors can develop at any age however they are rarely detected in children and youths. Patients usually describe lipomas as slowly growing formations, which do not cause any discomfort. Material and methods: A short characteristic of giant lipomas as well as two cases of atypical giant lipomas – on the neck and retroperitoneal region – are reported in this paper. In the latter cases the giant lipomas have been removed surgically. A histological analysis has confirmed the primary diagnosis. The postoperative course has been uneventful. Results: Roughly 60% of single cutaneous lipomas contain clonal genetic changes: the most frequent chromosomal aberrations include breaks of 12q13-15, but there can be changes in the arms of 6p and 13q. These mutations are not characteristic of the multiple lipomas. Typically, lipomas are identified in the subcutaneous tissues of the trunk and upper limbs, but they can seldom be found in internal organs. Conclusions: At the first examination retroperitoneal lipomas can be taken for gastro-intestinal tumors. Abdominal lipomas are usually identified only when they become giant. Large-sized lipomas can compress the blood vessels and nerves in the vicinity and, as a result, induce abnormalities in blood circulation and paresthesia. There are difficulties in the surgical treatment of large, unusually located lipomas, which compress blood vessels, main nerves and internal organs

Symptomatic duodenal diverticula: clinical case

Catedra chirurgie generală, Universitatea de Stat de Medicină și Farmacie „Nicolae Testemiţanu”, Spitalul Clinic Municipal nr.1, Chişinău, Republica Moldova, 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: Diverticolul duodenal (DD) este depistat la 23% din autopsii și la 27% din endoscopiile superioare (ES). DD poate fi intraluminal (congenital) sau extraluminal (pseudodiverticul). Raportul bărbați : femei – 1.0:1.6, vârsta medie 57 ani. Localizarea DD - D2 – 60%, D3 – 30% și D4 – 8%. Deși DD este relativ comun, doar 12% dintre pacienți prezintă simptomatică. Datorită manifestărilor nespecifice, diagnosticul DD deseori este tardiv sau chiar omis. Printre investigațiile de bază se enumeră: ES, ERCP, radiografia barietată, CT și MRCP. DD sunt, de obicei, tratați conservator, până la apariția complicațiile posibile. Mai puțin de 1% dintre pacienții cu DD necesită intervenție chirurgicală. Caz clinic: Pacienta C., femeie de 71 de ani, se internează cu o istorie de 7 ani de durere abdominală surdă în hipocondrul drept, asociată cu plenitudine postprandială și constipație. A fost tratată simptomatic, fără ameliorare. Din anamneză – Boala Crohn, activitate medie. Datele de laborator, USG și ES - normale. Irigoscopia a depistat colită cronică a hemicolonului stîng. La Colonoscopie virtuală - diverticuli a colonului sting (7). Studiul radiologic baritat a relevat un DD în D4 aproximativ 5 x 5,6 cm. După excluderea altor cauze ale durerii abdominale superioare, pacienta a fost preluată pentru intervenție chirurgicală: laparotomie median; mobilizarea duodenului, DD fiind identificat la nivelul D4; efectuarea exciziei cuneiforme a DD cu suturarea ulterioară a duodenului în 2 planuri. Perioada postoperatorie a decurs favorabil. Concluzii: Tratamentul chirurgical al DD este sigur, dar trebuie rezervat pentru pacienții cu complicații sau simptome necontrolate.Background: Duodenal diverticula (DD) are found in 23% of autopsies and in 27% of patients undergoing upper endoscopy (UE). DD are intraluminal (congenital) or extraluminal (false diverticula). Ratio women: men – 1.0:1.6, average age is 57. Localization of DD - D2 – 60%, D3 – 30% și D4 – 8%. Although duodenal diverticula are relatively common, only 12% of patients will develop symptoms. Due to non-specific manifestations, the diagnosis is often delayed or missed. Basic investigations are UE, ERCP, barium X-ray, CT and MRCP. DD are usually managed conservatively, until appears one of the possible complications. Less than 1% of patients with DD require surgical interventions. Case report: Patient C, a 71-year-old woman, has a history of 7 years of blunt abdominal pain in the upper right of abdomen, associated with postprandial fullness and constipation. It was treated symptomatically, without improvement. From history - Crohn's Disease with medium activity. Laboratory data, US and UE are normal. Irrigoscopy has detected chronic colitis of the left colon. On Virtual Colonoscopy - diverticulum of the colon (7). The barium X-ray study revealed a DD in D4 approximately 5x5.6 cm. Having ruled out all other causes of upper abdominal pain, the patient was taken up for surgery. Was performed median laparotomy. Mobilized the duodenum and DD. The cuneiform excision of DD with duodenal suturing in 2 planes was executed. The postoperative period was uneventful. Conclusions: Operative treatment of duodenal diverticula is safe but should be reserved for those with emergent presentations or intractable symptoms

Postoperative management of short bowel syndrome (case report)

Catedra chirurgie generală, USMF „Nicolae Testemițanu”, Chișinău, Republica Moldova, Al XII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova cu participare internațională 23-25 septembrie 2015Introducere: Prevalența sindromului intestinului scurt (SIS) este circa 3-4 la un million de populație. Acest sindrom se dezvoltă la pacienții cu lungimea intestinului subțire rămasă mai puțin de o treime (aproximativ 200 cm), circa la 15% dintre bolnavii care au fost supuși rezecției intestinale. Aproximativ 70% din pacienții cu SIS se externează la domiciliu și același procentaj corespunde ratei de supraviețuire peste un an. Supraviețuirea la distanță în mare măsură este dirijată de complicațiile survenite în urma managementului SIS.Caz clinic: În Clinica de Chirurgie a fost internată o pacientă de 30 ani, cu diagnosticul de sarcină 30-31 săpt., moartea antenatală a fătului (stabilită la USG), ocluzie intestinală (confirmată radiologic), peritonită generalizată. Intervenția chirurgicală – laparotomie mediană, cauza ocluziei fiind volvulusul intestinului subțire (torsiune la 360°). S-a efectuat histerectomie totală în comun cu fătul mort și anexectomie, rezecție totală a intestinului subțire cu duodeno-ileoanastomoză termino-terminală (lungimea bontului ileonului restant fiind 3-4 cm.). Complicație postoperatorie: anastomozită, tratată conservator. După tratament intensiv, cu alimentație combinată pacienta se externează la domiciliu pentru prelungirea tratamentului în condiții de ambulator. Moartea survine la a 121-a zi postoperator din cauza sindromului de malabsorbție, cașexiei și insuficienței poliorganice. Concluzii: SIS este o patologie chirurgicală gravă, care necesită un tratament complex, costisitor și cu pronostic rezervat, în funcție de zona și lungimea intestinului păstrat. În cazul sus-descris unica opțiune de tratament a fost nutriția total parenterală urmată de transplant intestinal.Introduction: The prevalence of short bowel syndrome (SBS) is about 3-4 per million of the population. This syndrome develops in patients with less than one-third (about 200 cm) of the remaining small intestine, approximately in 15% of patients, who undergo intestinal resection. About 70% of patients with SBS are discharged and similar percentages are alive 1 year later. The long-term outcome in most cases depends on complications related to the management of SBS. Clinical case: In Surgical Department was hospitalized a 30 years woman with a diagnosis of 30-31 weeks pregnancy, antenatal fetal death (confirmed by ultrasound), and bowel obstruction (confirmed by X-Ray) and generalized peritonitis. A midline laparotomy was done; the cause of obstruction was the volvulus of small bowel (360° torsion). There were performed a total hysterectomy including dead fetus in uterus, with anexectomy, and total resection of small bowel with end-to-end duodenoileal anastomosis (residual ileum length is 3-4 cm). Postoperative complications: anastomositis, managed conservatively. After the intensive treatment with combined nutrition, the patient was discharged home for further treatment in out-hospital setting. Death occurred on the 121-st postoperative day, due to malabsorption syndrome, cachexia and multiple organs failure. Conclusions: SBS is a surgical pathology, which requires complex and expensive treatment. Condition has reserved prognosis, depending on the area and length of the residual small bowel. Total parenteral nutrition followed by intestinal transplantation could be optional treatment in aforementioned case

Distal forearm fractures at children

SCMC „V. Ignatenco”, Chișinău, Republic of Moldova, Clinic „Medicort”, Orhei, Republic of Moldova, Al VIII-lea Congres Naţional de Ortopedie și Traumatologie cu participare internaţională 12-14 octombrie 2016The presentation elucidates the topicality, statistics, the tactics of treatment of distal forearm fractures at children. A high frequency of fractures, difficulties in choosing the treatment strategy, issues of recovery and possible complications (premature closure of the growth plate, posttraumatic deformity such as Madelung, joint stiffness etc.) make the distal forearm fractures at children a current topic which deserves attention. At S.C.M.C "V. Ignatenco " was made a statistics over a period of two years on a group of 488 children. From total number of traumatisms, the ones of hands occupy ~ 52%. From hands fractures they constitute 38,92 %. The average age of children is 11,2 years, more frequently at boys ~ 70%. Up to 10 years metaphyseal fractures prevail, but at 12-15 year childrenfractures at the growth plate.In 32% of cases both bones were fractured. There were 5 cases of open fractures 1-st degree after G-A and 3 cases of Volkmann syndrome all resolved without fasciotomies. The peak of the traumatisms is from June to August. The diagnosis doesn’t display great difficulties. An important value has the conservative treatment with osteoclasis if needed. An absolutely neccesary indication for a open reposition at children are fractures with neuro-vascular disorders, advanced degree open fractures, the failure of closed reposition. In our clinic the surgical treatment prevails, in particular closed reposition and osteosynthesis with wires under general anesthesia and are not used specific grown-up patient methods of osteosynthesis. We are guided by the principle that any angled displacement should be reduced. As a rule, when both bones of a distal forearm are fractured, the fixation with wires to the radial bone is performed. In case of a remaining displacement at the distal ulna, this doesn’t create functional and recovery problems, it can just remain a cosmetic defect, which can be well reshaped in the long run. At the next stage, under local anesthesia, wires are removed, their ends are left above the skin, but further care and aseptic dressings are needed.The subsequent results of up to 2 years are rated as satisfactory and good, but they require a continuous assessment. The basic objectives of the treatment are to restore bone alignment and clinical appearance, minimum soft tissue adjacent damage, preventing complications, pain relief, restore a functional forearm rotation, patient satisfaction and a good result afterwards

Global validation of the WSES Sepsis Severity Score for patients with complicated intra-abdominal infections : a prospective multicentre study (WISS Study)

Background: To validate a new practical Sepsis Severity Score for patients with complicated intra-abdominal infections (cIAIs) including the clinical conditions at the admission (severe sepsis/septic shock), the origin of the cIAIs, the delay in source control, the setting of acquisition and any risk factors such as age and immunosuppression. Methods: The WISS study (WSES cIAIs Score Study) is a multicenter observational study underwent in 132 medical institutions worldwide during a four-month study period (October 2014-February 2015). Four thousand five hundred thirty-three patients with a mean age of 51.2 years (range 18-99) were enrolled in the WISS study. Results: Univariate analysis has shown that all factors that were previously included in the WSES Sepsis Severity Score were highly statistically significant between those who died and those who survived (p <0.0001). The multivariate logistic regression model was highly significant (p <0.0001, R-2 = 0.54) and showed that all these factors were independent in predicting mortality of sepsis. Receiver Operator Curve has shown that the WSES Severity Sepsis Score had an excellent prediction for mortality. A score above 5.5 was the best predictor of mortality having a sensitivity of 89.2 %, a specificity of 83.5 % and a positive likelihood ratio of 5.4. Conclusions: WSES Sepsis Severity Score for patients with complicated Intra-abdominal infections can be used on global level. It has shown high sensitivity, specificity, and likelihood ratio that may help us in making clinical decisions.Peer reviewe

Ileocecal anastomosis in terminal ileum resection

Catedra Chirurgie Generală şi Semiologie, USMF „N.Testemițanu”, Chișinău, 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. Aplicarea anastomozei după rezecția terminală a ileonului, cînd capătul distal al acestuia ramîne scurt (3-5 cm) reprezintă o provocare pentru chirurg din cauza circulației insuficiente în regiunea respectivă. In aplicarea anastomozei ileo-transversale se exclude partea dreaptă a colonului. Cu scop de a preveni neajunsurile metodelor sus numite se folosește anastomoza ileo-cecală. Materiale si metode. In perioada de timp 1993-2010 la 15 bolnavi după rezecția terminală a ilionului a fost efectuată anastomoza ileo-cecală. Anastomoza termino-laterală s-a efectuat în 14 cazuri si 1 caz latero-laterală. Vîrsta bolnavilor a fost cuprinsă între 19 si 58 de ani. Distribuția după gen: bărbați 3 (20%) și femei 12 (80%). Intervenția a fost efectuată pentru: ocluzie intestinală acuta prin aderenta 46,6%(7 cazuri), tumoare tuboovariană cu abcese interintestinale și necroza porțiunii terminale a ileonului 26,6% (4 cazuri), eventrația ileostomei bipolare cu strangulare și ocluzie intestinală 6,6%(1 caz), volvulus ileosigmoidean 6,6%(1 caz), concreșterea tumorii ovarului drept cu stenozarea lumenului 6,6%(1 caz), boala Crohn 6,6%(1 caz). Rezultate. La 8 (53,3%) bolnavi s-a efectuat intervenția intr-o ședinta, iar la 6 in prima etapă s-a efectuat rezecția terminală a ileonului cu ileostomie terminală și peste 2-4 luni în mod planic s-a efectuat anastomoza ileo-cecală prin incizie în regiune iliacă dreaptă. În perioada postoperatorie tardivă (de la 3 luni pina la 14 ani) 12 (80%) din pacienți au fost examinați. Jumatate din ei sunt invalidizați din cauza: cirozei hepatice (1 caz), cancerului ovarian (1 caz), boala Crohn (1 caz), scleroza multiplă (1 caz), epilepsie (1 caz), sindrom de malabsorbție (1 caz). A doua jumatate din bolnavii examinați sunt apți de munca, nu au pierdere ponderală, scaunul regulat. Concluzii. Anastomoza ileo-cecală termino-laterală este recomandată pentru prevenirea sindromului de malabsorbție.Introduction. Application of anastomosis, after terminal ileum resection, when it’s distal part is short (3-5 cm), represents a challenging situation for the surgeon due to insufficient blood supply of the region. When the ileotransverse anastomosis is performed the right hemicolon is excluded. In order to prevent the deficiency of this method ileocecal anastomosis is applied. Materials and methods. In the period 1993–2010 ileocecal anastomosis after terminal ileum resection was performed in 15 patients. Termino-lateral anastomosis was made in 14 cases and latero-lateral anastomosis in 1 case. The age of patients was between 19 and 58 years. From total number of patients 3 (20%) were males and 12 patients (80%) females. The causes of terminal ileum resection were as follows: acute intestinal obstruction by adhesions 46,6% (7 cases); tuboovarian tumor with interintestinal abscesses and terminal ileum necrosis 26,6% (4 cases); bipolar ileostomy eventration with strangulation and bowel obstruction 6,6% (1 case); ileosigmoid volvulus 6,6% (1 case); tumor of the right ovary with invasion and lumen stenosis 6,6% (1 case); Crohn’s disease 6,6% (1 case).Results. One step surgery was performed in 53,3% (8 patients), for the rest 6 patients the first step of surgery was terminal ileum resection with terminal ileostomy followed in 2-4 months by scheduled ileocecal anastomisis through the incision in the right iliac region. In late postoperative period (3 months -14 years) 12 patients (80%) were examined. Half of them (6 patients) were affected by hepatic cirrhoses (1 case), ovary cancer (1 case), Crohn’s disease (1 case), multiple sclerosis (1 case), epilepsy (1 case), malabsorption (1 case). The second half of examined patients are fit to work, have no weight loss and have regular stool daily. Conclusion. Termino-lateral ileocecal anastomosis in terminal ileum resection is recommended for prevention of malabsorption syndrome

Conduct treatment of juvenile slipped epiphyses

IMSP SCMC ”V. Igantenco”, Chișinău, Republic of Moldova, Al VIII-lea Congres Naţional de Ortopedie și Traumatologie cu participare internaţională 12-14 octombrie 2016Introduction: mostly occurs in young adulthood. The disease occurs with frequency of 4-5 cases per 100 000 inhabitants, and patients with juvenile slipped epiphyses (JE) represent 0.5-5% of children with orthopedic pathology. The ratio of boys and girls - 3:2. Bilateral involvement is described in 20% of patients. Discussions: JE was described for the first time in 1572. Due to the relative rarity of the disease, many physicians are not aware of the existence of it. Until now the vast majority of children with JE were getting treatment lately. JE etiology is still far from being fully disclosed. The factors are well established: hormonal disorders, genetic predisposition, as well as hard exercises and micro traumas. Endocrine-orthopedic symptom of the disease is the breaking the correlation between sex hormones and growth hormones. Those two groups of hormones play an important role in the development and delayed puberty of the epiphyseal plates. According to some authors the obesity, anteversion on proximal femoral and bones immaturity are the causes of JE. The disease pathogenesis is a slow displacement of proximal femoral epiphysis down and dorsal. With JE the head of the femur remains acetabular fossa, so both femoral neck and femur lose contact with him. This balance is rotating around its longitudinal axis, "flips" to exterior and positions member in the position of external rotation. The clinic is pretty typical and severe form of the disease. The diagnosis is based on anamnesis, clinical examination, orthopedic, X-ray, CT and MRI. Depending on the clinical data, 3 forms of JE are determined: acute, chronic and acute form of the background chronic evolution. R-study must be carried out in two projections: anteroposterior and lateral after Lowenstein - to perform radiometric survey of Klein line. The aim is to obtain treatment of epiphysiodesis: I stage is skeletal traction which ends up with surgery. Conclusions: mandatory consultation at ortoped-pediatric doctor if there are disorders in children walking, pain in the limbs. Benefit of the treatment is directly proportional to the time when the disease was diagnosed. Support of the affected limb is excluded up to 6 months from diagnosis