Simultaneous solving of concomitence of chronic calculous cholecystitis and ventral hernia

Universitatea de Stat de Medicină și Farmacie „NicolaeTestemiţanu”, Instituţia Medico-Sanitară Publică Spitalul Clinic Municipal “Sfântul Arhanghel Mihail”, Chişinau, 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: Asocierea litiazei biliare cronice cu o hernie ventrală prezintă o provocare pentru orice chirurg în alegerea volumului, tipului și etapelor intervenției chirurgicale. Material si metode: Este expusă analiza a 23 (1,52%) cazuri de intervenții simultane de colecistectomie laparoscopică (CL) și reparație a defectului herniar, selectate din 1512 cazuri de CL, tratate în SC ”Sf.Arh.Mihail” în perioada 2013 – 2018. Defectele de herniere au fost localizate: hernii ombilicale - 13, hernii epigastrice - 7, eventrații postoperatorii – 3. Rezultate: CL s-a practicat în prima etapă operatorie. Aplicarea primului port a fost dependentă de dimensiunile și localizarea herniei: 12 cazuri - supraombilical, 6 –subombilical, 5 - transherniar sub control digital. Trocarele ajutătoare amplasate tipic. Colecistectomie retrogradă cu evacuarea piesei prin incizia primului port. Ulterior efectuată herniotomie. Hernioplastie diversificată dependent de dimensiunile și tipul herniei: cu proteză sintetică ”Promesh ” 16 cazuri (3 - amplasate intraabdominal, 13 - subaponeurotic), plastie procedeul Mayo – 4 cazuri, plastie procedeul Sapejco – 3 cazuri. Morbiditate și mortalitate postoperatorie absentă. Concluzie: Tratamentul chirurgical simultan, constituie intervenția preferabilă în soluționarea litiazei biliare simptomatice și a herniei ventrale concomitente. Utilizarea protezei sintetice în închiderea defectului de herniere reduce riscul recurenței herniilor.Introduction: The association of chronic biliary lithiasis with a ventral hernia presents a challenge for any surgeon in choosing the volume, type and stages of surgery. Material and methods: The analysis of 23 (1.52%) cases of simultaneous intervention of laparoscopic cholecystectomy (LC) and repair of hernia defect, selected from 1512 LC cases treated in Clinical Hospital "Sf.Arh.Mihail" during 2013 - 2018, is exposed. The location of hernia defect was: umbilical hernia – 13 cases, epigastric hernia – 7 cases, postoperative hernia – 3 cases. Results: LC was performed in the first operative step. The application of the first port was dependent on the size and location of the hernia: 12 cases – over the navel, 6-under the navel, 5-through the hernia under digital control. Helpful ports standard located. Retrograde cholecystectomy with evacuation of the piece through the first port incision. Herniotomy was subsequently performed. Various hernioplasty depending on the hernia size and type it was been done: with synthetic prosthesis "Promesh" 16 cases (3-placed in the abdomen, 13 – under the aponeurosis), Mayo procedure plasty - 4 cases, Sapejco procedure plasty - 3 cases. Postoperative morbidity and mortality absent. Conclusion: Simultaneous surgical treatment is most common intervention in solving of symptomatic chronic calculous cholecystitis and concomitant ventral hernia. The use of synthetic prosthesis in closing the hernia defect reduces the risk of recurrence of hernias

Opportunities for diagnosis and treatment in degenerative complications in biliary lithiasis

SUMF "Nicolae Testemitanu", Chisinau, Republic of Moldova, The MC ”Sf. Arh. Mihail” Hospital, Chisinau, Moldova, Congresul consacrat aniversării a 75-a de la fondarea Universității de Stat de Medicină și Farmacie „Nicolae Testemițanu” din Republica Moldova, Ziua internațională a științei pentru pace și dezvoltareIntroduction 1-3% of patients with cholelithiasis develop GC. Difficulties in diagnosis and selection of the operation procedure, remain controversal issues. Purpose Analysis of experience treating patients with degenerative complications in gallstone disease. Material and methods The analysis of 14 cases of GC Conclusions clinically diagnosed and treated in 2010-2019. 9 patients had anamnesis of gallstones for more than 10 years. Women- 10 men- 4. The diagnosis included: clinical aspects, laboratory tests, USG, contrast CT, ERSP, MRI with cholangiography, laparoscopy. Results Increased efficacy in diagnosis had MRI with cholangiography and CT. Treatment methods: laparoscopic cholecystectomy with enlarged diathermocoagulation of the vesicular lodge(2), extended classical cholecystectomy with enlarged resection of the area of destruction and ablation of regional lymph nodes, Kerh drainage (2), classic cholecystectomy with external tumor drilling and Champeau drainage(1), cholecystectomy, tumor drilling and internal drainage (3), cholecisectomy, tumor resection, bihepaticojejunostomy a la Roux and ablation of lymph nodes (6) Morbidity (50%). Conclusions The volume of surgery in CVB correlates with the tumor stage. Radical surgery with enlarged tumor removal contributes to a higher survival rate. In advaexternal drilling and drainage interventions present the elective treatment optionnced stages, internal or

Association of two severe surgical emergencies - solution variant

Background. With an incidence of 0.7-4.4%, Mirizzi syndrome is considered a rare and severe complication of gallstones. Pathology is even less frequently reported in the literature in conjunction with other medical-surgical emergencies. Purpose. Analysis of the treatment experience of the elderly patient with associated severe surgical emergencies. Material and methods. Treatment opportunity in a 76-year-old patient with multiple severe concomitants is presented. Clinical diagnosis: Mirizzi II syndrome, with progressive mechanical jaundice; giant antral peptic ulcer, complicated with repeated digestive bleeding, grade III anemia; ischemic heart disease, angina pectoris, CI III NIHA, taxisystolic permanent atrial fibrillation; drug coagulopathy; hypertension gr. III. Results. Hospitalized for progressive mechanical jaundice syndrome. MRI cholangiography over 24 hours - complicated gallstones with Mirizzi II syndrome. FGDS - bile absent in the duodenum, at the same time - in the gastric antral region presence of giant peptic ulcer. On the 3rd day of hospitalization, against the background of hypocoagulability, caused by the permanent use of anticoagulants for cardiac pathology, the peptic ulcer was complicated by a spurt of digestive hemorrhage, stopped endoscopically. Despite the administration of a complex pathogenetic treatment, he had repeated hemorrhage over 24 hours with indications for emergency treatment without delay. Surgery: gastric antral resection with short-loop gastro-jejunal anastomosis, anterograde partial cholecystectomy, choledochotomy with removal of stones, choledocho-duodenoanastomosis with transcystic drainage of the bile ducts. Simple postoperative evolution. Patient discharged on the 14th day after surgery. Biliary drain removed in 3 months. Monitored 2 years. Evolution without complications. Conclusions. The individualized selection of the type and terms of surgery in an elderly patient, with severe urgent concomitants, is the key to success

Diagnostic and medico-surgical options in Mirizzi syndrome

Scopul lucrării. Prezentându-se cu o incidență rară la pacienții cu litiază biliară de 1 la 1000, sindromul Mirizzi(SM) rămâne o provocare serioasă atât pentru un chirurg începător, cât și pentru un bun practician. În pofida modernizării tehnicilor de abordare, subiectul rămâne unul dificil în chirurgia biliară. Scopul lucrării este evaluarea rezultatelor tratamentului pacienților cu sindrom Mirizzi Materiale și metode. Experienţa diagnostică şi terapeutică a 13 pacienţi cu SM, tratați în anii 2006 - 2019. Vârsta a variat 54-81 ani, cu media 69,9±2,6 ani. Raport f/b – 8/5. Anamnestic de litiază biliară -10,1±0,43 ani Rezultate. Analiza a confirmat la toți pacienții prezența durerilor colicative, icter obstructiv asociat și angiocolită recurentă, cu o suferință litiazică de 7- 14 ani. 11 pacienţi au manifestat un icter recurent tranzitoriu, icterul continuu a fost în 2 cazuri. Conform clasificării Csendez: tip I - 2 cazuri, tip II - 4, tip III - 5, tip IV - 2 cazuri. Metode elective sugestive de diagnostic preoperator: colangiografie RMN, CPGR endoscopică asociată cu PST și drenarea căilor biliare în sindrom icteric persistent. În 10 cazuri a fost utilizată colangiografia intraoperatorie. Volumul operator a fost selectat dependent de tipul leziunii. Înlăturarea calculului și lichidarea defectului fistular prin utilizarea de preferinţă a unui lambou vezicular menajat(4) cu drenare Kehr - 6 cazuri; colecistectomia, coledocolitotomia coledocoduodenostomie în 4 cazuri; colecistectomia, coledocolitotomia coledochojejunostomie Roux-în-Y în 3 cazuri. Morbiditate în 3 cazuri(27,3%), mortalitate - 0% Concluzii. Preoperator diagnosticul sugestiv de sindrom Mirizzi se axează pe colangiografia RMN şi CPGRE, diagnosticul de certitudine fiind dat de colangiografia intraoperatorie premergătoare disecției veziculei biliare. Obiectivele intervenţiei necesită adaptate tipului și particularităţilor morfologice, în funcţie de topografia fistulei.Aim of study. Presenting with a rare incidence in patients with biliary lithiasis 1 in 1000, Mirizzi syndrome(MS) remains a serious challenge for both the novice surgeon and the good practitioner. Despite the modernization of approach techniques, the subject remains a difficult one in biliary surgery. The aim of study was the evaluation of treatment outcomes of patients with Mirizzi syndrome. Materials and methods. The diagnostic and therapeutic experience of 13 patients with MS, treated between 2006 and 2019. The age ranged from 54 to 81 years, with an average of 69.9±2.6 years. f/m ratio – 8/5. History of gallstones -10.1±0.43 years. Results. The analysis confirmed in all patients the presence of colic pains, signs of associated obstructive jaundice and recurrent angiocolitis, on the background of 7-14 years of biliary lithiasis. 11 patients showed transient recurrent jaundice, continuous jaundice was in 2 cases. According to the Csendez classification : type I - 2 cases, type II - 4, type III - 5, type IV - 2 cases. Suggestive elective methods of preoperative diagnosis: MRI cholangiography, endoscopic CPGR associated with PST and drainage of bile ducts in persistent jaundice syndrome. Intraoperative cholangiography was used in 10 cases. The operative volume was selected depending on the type of lesion. Removal of the calculus and liquidation of the fistula defect by preferably using a managed vesical flap with Kehr drainage - 6 cases; cholecystectomy, choledocholithotomy choledochoduodenostomy in 4 cases; cholecystectomy, choledocholithotomy, Roux-in-Y choledochojejunostomy in 3 cases. Morbidity in 3 cases (27.3%), mortality - 0%. Conclusions. Preoperatively, the suggestive diagnosis of Mirizzi syndrome focuses on MRI cholangiography and CPGRE, the certainty diagnosis being given by the intraoperative cholangiography preceding the dissection of the gallbladder. The objectives of the intervention need to be adapted to the type and morphological particularities, depending on the topography of the fistula

Feasibility of hernia defect reconstruction with synthetic prosthesis in oncological patients after colon interventions

Scopul lucrării. Hernia incizională este relatată în 14-28% după intervenții pentru cancer de colon (CrCl). Cura herniei duce la o ameliorare semnificativă a calității vieții pacientului oncologic. Tehnica de reparație cu proteză sintetică prin separare a componentelor mușchiului drept, introdusă de Ramirez (1990) și modificată de Carbonell, Rives, Stoppa este cunoscută în tratamentul herniilor ventrale. Scopul este analiza eficacității reparării defectelor de herniere cu proteză sintetică amplasată în teaca mușchilor drepți la pacienți operați pentru CrCl. Materiale și metode. 11 pacienți cu hernii incizionale după operații pentru CrCl. Vârsta a variat 53-77 ani, cu media 65,3±2,6 ani. Raport b/f – 6/5. Rezultate. Din istoric - CrCl drept - hemicolectomie cu anastomoză primară(6), CrCl stâng - anastomoză primară(4), hemicolectomie stângă cu colostomie(1), operație de reconstrucție peste 1,5 ani. 8 bolnavi au fost supuși chimioterapiei pre- și postoperatorii. Eventrațiile au apărut în termeni 0,5-2 ani postoperator. Cura herniei s-a practicat în termeni 2-5 ani după intervenția oncologică. Tehnica: după herniotomie, teaca posterioară a mm. drepți a fost deschisă și separată. În 6 cazuri cu d.d. < 5 cm suturare cu reinserție completă a foițelor aponeurotice posterioare, în 5 cazuri cu d.d. >10 cm pentru protejarea viscerilor foițele aponeurozei posterioare fixate cu fir continuu neresorbabil de peritoneului sacular în 3 cazuri și omentul mare 2 cazuri. Proteza amplasată retromuscular, foița aponevrotică anterioară suturată in 6 cazuri, in 5 cazuri fixata de proteză cu aplicarea tehnicii de substituție. Morbiditate în 2 cazuri (18,2%), mortalitate - 0%. Concluzii. Tehnica reparării defectelor de herniere cu proteză sintetică amplasată în teaca mușchilor drepți este simplă, ușoară și fezabilă la pacienți operați pentru CrCl. Ea reduce la minim interacțiunea viscer-proteză, cu evident potențial „tension free”.Aim of study. Incisional hernia is reported in 14-28% after interventions for colon cancer (ClCr). The cure of the hernia leads to a significant improvement in the quality of life of the oncological patient. The technique of repair with synthetic prosthesis by separating the components of the rectus muscle, introduced by Ramirez (1990) and modified by Carbonell, Rives, Stoppa, is known in the treatment of ventral hernias. The aim is analysis of the effectiveness of the repair of hernia defects with a synthetic prosthesis placed in the sheath of the rectus muscles in patients operated for ClCr. Materials and methods. 11 patients with incisional hernias after operations for ClCr. The age ranged from 53 to 77 years, with an average of 65.3±2.6 years. Ratio m/f – 6/5. Results. From the history - right ClCr - hemicolectomy with primary anastomosis(6), left ClCr - primary anastomosis(4), left hemicolectomy with colostomy (1), reconstruction operation over 1.5 years. 8 patients underwent pre- and postoperative chemotherapy. The herniations occurred within 0.5-2 years postoperatively. The hernia cure was practiced within 2-5 years after the oncological intervention. Technique: after herniotomy, the posterior sheath of right mm. was opened and separated. In 6 cases with d.d. < 5 cm suturing with complete reinsertion of the posterior aponeurotic sheets, in 6 cases with d.d. >10cm to protect the viscera, the sheets of the posterior aponeurosis are fixed with continuous non-resorbable thread to the saccular peritoneum in 3 cases and the greater omentum in 2 cases. The prosthesis placed retromuscular, the anterior aponeurotic sheet sutured in 6 cases, in 5 cases fixed to the prosthesis with the application of the substitution technique. Morbidity in 2 cases(18,2%), mortality - 0%. Conclusions. The technique of repairing herniation defects with a synthetic prosthesis placed in the sheath of the rectus muscles is simple, easy and feasible in patients operated for ClCr. It minimizes viscer-prosthetic interaction, with obvious "tension free" potential

Probes on D3-D7 Quark-Gluon Plasmas

We study the holographic dual model of quenched flavors immersed in a quark-gluon plasma with massless dynamical quarks in the Veneziano limit. This is modeled by embedding a probe D7 brane in a background where the backreaction of massless D7 branes has been taken into account. The background, and hence the effects, are perturbative in the Veneziano parameter N_f/N_c, therefore giving small shifts of all magnitudes like the constituent mass, the quark condensate, and several transport coefficients. We provide qualitative results for the effect of flavor degrees of freedom on the probes. For example, the meson melting temperature is enhanced, while the screening length is diminished. The drag force is also enhanced.Comment: 31 pages, 17 figure

Dressed spectral densities for heavy quark diffusion in holographic plasmas

We analyze the large frequency behavior of the spectral densities that govern the generalized Langevin diffusion process for a heavy quark in the context of the gauge/gravity duality. The bare Langevin correlators obtained from the trailing string solution have a singular short-distance behavior. We argue that the proper dressed spectral functions are obtained by subtracting the zero-temperature correlators. The dressed spectral functions have a sufficiently fast fall-off at large frequency so that the Langevin process is well defined and the dispersion relations are satisfied. We identify the cases in which the subtraction does not modify the associated low-frequency transport coefficients. These include conformal theories and the non-conformal, non-confining models. We provide several analytic and numerical examples in conformal and non-conformal holographic backgrounds.Comment: 51 pages, 2 figure

The role of the right temporoparietal junction in perceptual conflict: detection or resolution?

The right temporoparietal junction (rTPJ) is a polysensory cortical area that plays a key role in perception and awareness. Neuroimaging evidence shows activation of rTPJ in intersensory and sensorimotor conflict situations, but it remains unclear whether this activity reflects detection or resolution of such conflicts. To address this question, we manipulated the relationship between touch and vision using the so-called mirror-box illusion. Participants' hands lay on either side of a mirror, which occluded their left hand and reflected their right hand, but created the illusion that they were looking directly at their left hand. The experimenter simultaneously touched either the middle (D3) or the ring finger (D4) of each hand. Participants judged, which finger was touched on their occluded left hand. The visual stimulus corresponding to the touch on the right hand was therefore either congruent (same finger as touch) or incongruent (different finger from touch) with the task-relevant touch on the left hand. Single-pulse transcranial magnetic stimulation (TMS) was delivered to the rTPJ immediately after touch. Accuracy in localizing the left touch was worse for D4 than for D3, particularly when visual stimulation was incongruent. However, following TMS, accuracy improved selectively for D4 in incongruent trials, suggesting that the effects of the conflicting visual information were reduced. These findings suggest a role of rTPJ in detecting, rather than resolving, intersensory conflict

Heart and systemic effects of statin pretreatment in a rat model of abdominal sepsis. Assessment by Tc99m-sestamibi biodistribition

PURPOSE: To evaluate the heart and the Tc-99m-sestamibi biodistribution after statin pretreatment in a rat model of abdominal sepsis. METHODS: Twenty-four Wistar rats were randomly distributed into four groups (n=6 per group): 1) sepsis with simvastatin treatment, 2) sepsis with vehicle, 3) sham control with simvastatin and 4) sham control with vehicle. 24 hours after cecal ligation and puncture rats received 1.0MBq of Tc-99m-sestamibi i.v. 30min after, animals were euthanized for ex-vivo tissue counting and myocardium histological analysis. RESULTS: Myocardial histologic alterations were not detected 24 hours post-sepsis. There was significantly increased cardiac Tc-99m-sestamibi activity in the sepsis group with simvastatin treatment (1.9$\pm$0.3%ID/g, p<0.001) in comparison to the sepsis group+vehicle (1.0$\pm$0.2% ID/g), control sham group+ simvastatin (1.2$\pm$0.3% ID/g) and control sham group (1.3$\pm$0.2% ID/g). Significant Tc-99m-sestamibi activity in liver, kidney and lungs was also detected in the sepsis group treated with simvastatinin comparison to the other groups. CONCLUSIONS: Statin treatment altered the biodistribution of Tc-99m-sestamibi with increased cardiac and solid organ activity in rats with abdominal sepsis, while no impact on controls. Increased myocardial tracer activity may be a result of a possible protection effect due to increased tissue perfusion mediated by statins