Gallstone ileus- 20 years of interclinical experience

Universitatea de Medicină și Farmacie “Carol Davila”, Bucureşti, Clinica Chirurgie, Spitalul Clinic de Urgentă Bucureşti, Universitatea de Medicina si Farmacie “Carol Davila”, Facultatea de Farmacie, Catedra Matematici Aplicate şi Biostatistică, Bucureşti, 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: Ileusul biliar reprezintă o complicaţie rară a litiazei veziculare (0.3-0.5 %), a cărui incidenţă a rămas practic neschimbată în decursul timpului. Actual diagnosticul şi tratamentul acestei boli au suferit schimbări majore dar , cu toate acestea, mortalitatea a rămas crescută fapt explicabil prin patologia asociată şi prezentarea tardivă la medic.Material şi metodă. Studiul retrospectiv al cazurilor de ileus biliar internate în perioada mai 1991-mai 2011 în SCUB şi Centrul Naţional Stiinţifico-Practic al Medicinei de Urgenţă Chişinău.Au fost înregistrate un număr de 40 de cazuri (34-SCUB, 6 cazuri CNSPMUC). 3 cazuri au reprezentat sindrom Bouveret, 4 cazuri de obstrucţie colonică restul de 33 de cazuri au fost ileusuri biliare clasice. Incidenţa globală a ileusului biliar în studiul nostru a fost 0.15 % (din numărul total de cazuri de litiază biliară internate în perioada menţionată). Vârsta medie a fost 71,62 ani cu predominenţa sexului feminin (37 cazuri, 92,5 %). Diagnosticul preoperator a fost stabilit in 17,5 % din cazuri. Terapeutic, lotul a fost împărţit în 2 grupe de pacienţi : enterolitotomie (grup I, 28 pacienţi) şi enterolitotomie cu desfiinţarea traiectului fistulos (grup II , 12 pacienţi). Nu s-au constatat diferenţe statistice semnificative între cele 2 grupuri referitor la vârsta durata simtomatologiei şi scorul ASA. Timpul operator a fost semnificativ crescut la pacienţii din grupul II . S-a inregistrat un număr total de 14 complicaţii chirurgicale, 9 complicaţii (33,33 %) în grupul I, şi 5 complicaţii ( 41,66 %) în grupul II . Mortalitatea globală a fost de 25 %, 8 cazuri în grupul I (28,57 %) şi 2 cazuri în grupul II (16,66 %). CONCLUZII : Ileusul biliar , ramâne o provocare pentru chirurg. Dificultatea diagnosticului preoperator, starea generală alterată şi vârsta avansată a pacienţilor impun o decizie chirurgicală realistă şi adaptată situaţiei intraoperatorii. În situaţiile dificile enterolitotomia rămâne soluţia terapeutică optimă, în absenţa endoscopiei intervenţionale.Background. Gallstone ileus represents a rare (0.3-0.5%), but serious complication of a common illness – the gallbladder lithiasis and the incidence of this fascinating disease has remained the same over the years. Actually, the diagnosis and management of gallstone ileus had suffered major changes, but despite these diagnostic and therapeutic possibilities, the mortality remains high and the common causes are associated comorbidities and late presentation to the physician.Materials and Methods.A retrospective and descriptive study of patients with diagnosis of gallstone ileus admitted to the Clinical Emergency Hospital Bucharest and National Scientific and Practical Center of Emergency Medicine Chisinau, between May 1991-May 2011. 40 consecutive patients with gallstone ileus (34 cases- ECHB; 6 cases- NSPCEMC) were included. Bouveret’s syndrome was diagnosticated in 3 cases, gallstone colonic obstruction in 4 cases and “classical” gallstone ileus in 33 cases. The overall incidence in our study was 0.15 % (from the total number of gallbladder lithiasis admitted in the mentioned period). Results.The mean age was 71,62 years with the female gender prevalence (92.5 %, 37 cases). In 17.5 % cases the diagnosis was made before the operation. Enterolithotomy was performed in 28 patients (group 1) and cholecystectomy and fistula closure (one-stage procedure) were added in 12 patients (group 2).We found no statistically significant differences between group 1 and group 2 on age, duration of symptoms and ASA score.Operating time was significantly longer for the one-stage procedure. The morbidity and mortality rate still have a high percentage. Complications occurred in 9 of 28 patients (33.33%) from group 1 and in 5 of 12 patients (41.66 %) from group 2. The overall mortality was 25 %, 8 cases in group 1 (28.57 %) and 2 cases (16.66 %) in group 2.ConclusionThe gallstone ileus remains a challenge for the general surgeon. The difficulty of preoperative diagnosis, general malaise and the advanced age of patients require a realistic and appropriate surgical decision adapted to the intraoperative situation. In difficult situations enterolithotomy remains the optimal solution in the absence of interventional endoscopy

CRITERIA FOR THE EVALUATION AND ESTIMATION OF IATROGENIC PROSTHETIC FACTORS – SEMIOLOGY AND SYMPTOMATOLOGY

Introduction: The principles lying at the basis of a balanced dental occlusion cannot be analyzed separately, but only if considering the teeth (and, implicitly, dental occlusion) as integrated into the masticatory system, which includes the masticatory muscles, the temporo-mandibu‑ lary joint and the maxillary bones. Scope: The scope of the present study was to correlate and establish the interde‑ pendence between the morpholgically-incorrect prosthetic works and the tissular and functional damages suffered by the neighbouring structures, as a result of some incor‑ rectly-made prosthetic works. Also, the study aims at iden‑ tifying the factors and limits responsible for a prolongued maintenance of such irreversible pathological modificati‑ ons within an asymptomatic zone for the patient. Materials and method: The working hypothesis of the present inves‑ tigation started from the analysis of the various objective signs, versus the morphology of the incorrectly performed prosthetic works. The study, initiated as early as 2009, in a private stomatological clinics (DentEstet, Bucuresti), includes a number of 500 patients (250 women and 250 men), selected among the patients having addressed the stomatological office from various reasons (not always related to the prosthetic pathology of the cases here under investigation). Included in the study have been only the patients with fixed prosthetic works associated with one or several of the previously described objective signs, potentially induced by the iatrogeneicity of the prosthetic works. Results: The pathological effects of the iatrogenic works here under analysis, upon both the antagonistic and prosthetic support teeth, may be clinically identified during a minute examination performed prior to produ‑ cing irreversible final effects (abrasions, fractures, dental mobility, etc.). Such noxious effects of the iatrogenic pros‑ thetic works appear as a false masticatory comfort and as a common functional occlusion, tolerated by the patient, even if not in a perfect equilibrium with all components of the dento-maxillary apparatus. Discussion: The present study involved clinical examination and interpretation of the signs induced by iatrogenic prosthetic works. The main contribution to such signs was brought by the abrased antagonistic teeth, which is actually the first symptom in most of the cases. The causes leading to the occurrence of these clincal pathological signs are represented by an incorrect realization of the occlusal morphology (from the part of the dental technician) and by the absence of a pro‑ fessional occlusal equilibrium. The trophic chain of these iatrogenies assumes several stages, starting from the pre‑ paration of the prosthetic dies (the occlusal space), to the impression technique and materials, patterns’ mounting in the articulator (which prevents a complete simulation of the mandibular movements inside the masticatory system), ending with the final modelling of the prosthetic work. Conclusions: Realization of prosthetic works in full, active colaboration with the dental technician and for each case in part, along with a minute analysis of the works made in the oral cavity, may eliminate several of the conditions favourizing the manifestation of some undesired destruc‑ tive factors. Checking of the occlusion at regular time inter‑ vals, as periodical stomatological controls, should become customary for any stomatologist