Gastroduodenal ulcer with bleeding – a reconsideration of therapy

Spitalul Clinic de Urgență Sfântul Pantelimon, 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: Complicația hemoragică a ulcerului gastroduodenal cunoaște o incidența în creștere în ultimii ani. Studiul își propune reevaluarea atitudinii terapeutice în cazul ulcerului gastroduodenal hemoragic, cu stabilirea unor criterii de gravitate în care intervenția chirurgicală se impune. Material si metode: Studiul analizează retrospectiv un număr de 337 de pacienți cu diagnosticul de ulcer gastroduodenal hemoragic, internați și tratați în Clinica Chirurgie a Spitalului Clinic de Urgență „Sf. Pantelimon”, în decurs de 3 ani, în perioada ian. 2008 – dec. 2010. S-au analizat datele din foile de observație, protocoale operatorii, rezultate histopatologice. Rezultate: Majoritatea hemoragiilor digestive superioare de cauză ulceroasă au fost rezolvate cu tratament medicamentos (278 bolnavi). La restul de 59 de pacienți a fost necesar un tratament chirurgical, dintre care la 43 pacienți intervenția a fost impusă de pierderea de sânge ce amenință viața, iar la 16 pacienți intervenția a fost impusă de criteriile de gravitate/criteriile prognostice: repetarea sângerarii la scurt timp, criterii endoscopice de gravitate, grupa de sânge rară, etc. La 32 de bolnavi s- au practicat rezecții gastrice subtotale cu diferite tipuri de anastomoză iar în 27 de cazuri s-a practicat ulceroexcizie și hemostaza in situ. Concluzii: Evoluția ascendentă a terapiei farmacologice și endoscopice a scăzut semnificativ necesitatea intervențiilor chirurgicale. Intervenția chirurgicală rămâne mijloc terapeutic util în cazurile cu sângerare masivă și în cazurile neglijate terapeutic.As a complication of gastroduodenal ulcer, bleeding is more and more frequent. The study aims to reevaluate the therapeutic approach together with the development of criteria recommending surgery. Material and methods: The study evaluates 337 patients diagnosed with gastroduodenal ulcer, complicated with bleeding, between January 2008 and December 2010. Data was collected from patient charts, operative recordings, histopathological results. Results: The majority of upper GI bleeding, following the development of an ulcer was managed with medical therapy (278 patients). The remaining 59 patients required surgery, imposed in 43 cases by life threatening blood loss, and in 16 by gravity/prognostic criteria: frequent recurrence of bleeding, endoscopic gravity criteria, rare blood group, etc. Subtotal gastrectomy with various types of anastomosis was performed in 32 cases while in the remaining 27 cases we performed the excision of the lesion and in situ hemostasis. Conclusions: The evolution of pharmacological and endoscopic management significantly reduced the necessity for surgery. Surgery remains a useful therapeutic tool in cases with massive bleeding and in neglected cases

Current management of abdominal stab wounds

Spitalul Clinic de Urgență ”Sfântul Pantelimon”, 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 2011Cunoscând faptul că atitudinea de management selectiv non-operativ a devenit un standard pentru plăgile înjunghiate, studiul nostru și-a propus validarea atitudinii diferențiate față de plăgile înjunghiate ale abdomenului anterior. Materiale și metodă: Studiul este descriptiv, retrospectiv, analiza fiind centrată pe o experiență de 11 ani (2000-2010) cuprinzând 64 cazuri de plăgi abdominale anterioare. Media de vârstă a lotului studiat a fost de 32 ani (17-65), lot alcătuit din 41 bărbați, 23 femei. Etiologia a fost la toate cazurile reprezentată de agresiune fizică cu armă albă. Rezultate: 48 cazuri (75%) au fost supuse laparotomiei exploratorii immediate datorită semnelor de iritație peritoneală, instabilității hemodinamice sau semnelor paraclinice (hemogramă, biochimie, ecografie abdominală, CT) ce sugerau leziuni de organ. 16 cazuri (25%) au fost monitorizate clinic și imagistic, laparotomia exploratorie fiind necesară în 3 cazuri. Mortalitatea a fost nulă, morbiditatea de aproximativ 18% a inclus supurații parietale, 1 relaparotomie pentru hemostază suplimentară într-o plagă hepatică. Durata spitalizării fost similară la pacienții operați și la cei tratați non- operativ. Concluzii: Studiul relevă că nu s-a înregistrat morbiditate majoră prin acest abord selectiv, pacienții supuși laparotomiei tardive fiind fără risc vital. Aceste observații confirmă concluziile din literatură, și anume faptul că o perioadă de observație de 24 ore este adecvată pentru această patologie.Selective, non-operative management is now a standard for the management of abdominal stab wounds. Our study wishes to validate the differentiated approach to stab wounds of the anterior abdomen. Materials and method: Our study is descriptive and retrospective, centering on an eleven year experience (2000-2010), comprising of 64 abdominal stab wounds. The studied population was made up of 41 male and 23 female, with a median age of 32. All wounds were produced by stabbing. Results: 48 cases (75%) were subjected to immediate surgery because of the presence of peritonitic signs, hemodynamic instability or explorations that suggested organ injury (CBC, biochemistry, abdominal ultrasound, computed tomography). 16 cases (25%) were monitored clinically and by imaging studies, exploratory laparotomy being needed in only 3 of these cases. We recorded no fatalities, and overall morbidity was around 18% (surgical site infections, and one reintervention for supplementary hemostasis in a liver laceration). Duration of hospital stay was constant. Conclusions: Our study shows that the selective approach did not lead to major morbidity, the patients subjected to late laparotomy presenting no major or life threatening complications. Our observations confirm the recent consensus, stating that a 24 hour surveillance period is adequate for this pathology

Complicated small bowel tumors – limits and possibilities in emergency

Spitalul Clinic de Urgență ”Sfântul Pantelimon”, 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 2011Tumorile intestinului subțire sunt rare, reprezentând aproximativ 1-2% din neoplasmele gastrointestinale. Prognosticul lor este rezervat din cauza diagnosticului dificil preoperator și descoperirea lor în stadii avansate, însoțite frecvent de complicații. Materiale și metodă: Studiul este descriptiv, retrospectiv, efectuat pe o perioadă de 5 ani (2006-2010) și include 13 bolnavi operați în clinica noastră. Studiul evaluează elementele demografice ale lotului, mijloacele diagnostice folosite și eficiența lor și atitudinea terapeutică. Rezultate: Lotul a fost alcătuit din 13 bolnavi cu o medie de vârstă de 66 de ani, dintre care 8 de sex masculin și 5 de sex feminin. Cazurile au fost internate în regim de urgență datorită complicațiilor: 8 bolnavi s-au prezentat în ocluzie intestinală, 4 bolnavi s-au prezentat cu anemie severă și hematochezie sau melenă, iar 1 caz a prezentat pneumoperitoneu. Radiografia abdominală simplă a indicat intervenția chirurgicală de urgență în 9 cazuri (prezența de nivele hidro-aerice sau pneumoperitoneu) fără să aducă informații suplimentare legate de etiologie, stadiu evolutiv. Endoscopia digestivă superioară a exclus patologia gastro-duodenală la bolanvii prezentați cu hemoragie digestivă. La acești bolnavi intervenția chirurgicală a fost recomandată de cantitatea mare de transfuzii necesară pentru menținerea hemodinamică a bolnavilor. Soluția terapeutică a fost reprezentată de enterectomia segmentară și anastomoză primară în 13 cazuri și colectomie asociată în două cazuri; în două cazuri a fost necesară o derivație digestivă, în amonte, de protecție. 4 cazuri au prezentat metastaze la distanță. Concluzii: În ciuda arsenalului diagnostic și imagistic existent, diagnosticul tumorilor de intestin subțire se pune în majoritatea cazurilor la momentul explorării chirurgicale. Prezența complicațiilor îngreunează actul chirurgical și managementul postoperator al bolnavului, mărind mortalitatea.Small bowel tumors are a rare entity, accounting for about 1-2% of gastrointestinal tumors. Their prognosis is poor because of the difficult preoperative diagnosis and their discovery in advanced stages, frequently associated with complications. Materials and method: The study is descriptive, retrospective, over a 5 year period (2006- 2010) and includes 13 patients operated on in our clinic. The study evaluates the demographical characteristics of the group, the diagnostic tools that were used and the therapeutic approach. Results: The group was made up of 13 patients, with an average age of 66 years, 8 male and 5 female. The cases were admitted on arrival because of complications: 8 patients presented with intestinal obstruction, 4 with severe anemia and melena or hematochezia and one patient presented with pneumoperitoneum. Plain abdominal x-rays prompted immediate surgery in 9 cases (free air under the diaphragm or air-fluid levels) without bringing further information regarding etiology or disease stage. Upper gastrointestinal endoscopy excluded gastro-duodenal pathology in the patients presented with digestive bleeding. Surgery was performed, in these patients, owing to the large amount of blood transfusion necessary to stabilize them. The procedure performed was segmentary enterectomy with primary anastomosis in 13 patients, associated with colectomy in 2 cases; in two cases we associated a by-pass of the tumoral segment. Metastatic disease was found in four patients. Conclusions: Despite the sophisticated imaging and diagnostic modalities, diagnosis of a small bowel tumor is often achieved only at the time of surgical exploration. The presence of complications makes surgical and postoperative therapy difficult and increases mortality

Non-operative management of the sigmoid volvulus – case presentation

Sigmoid volvulus happens when the sigmoid wraps around itself and its mesentery. Sigmoid volvulus accounts for 2% to 50% of all colonic obstructions. This pathology generally affects adults, and it is more common in males. The etiology is multifactorial and controversial; the main symptoms are diffuse abdominal pain, distention and constipation, while the pregnant signs are abdominal distention and tenderness. Laboratory findings are not pathognomonic: abdominal X-ray radiographs show a dilated sigmoid colon and multiple intestinal air-fluid levels, abdominal CT and MRI demonstrate a whirled sigmoid mesentery. Flexible endoscopy reveals a spiral sphincter-like twist of the mucosa. The diagnosis of sigmoid volvulus is established by clinical, radiological, endoscopic, and sometimes operative findings. Although flexible endoscopic detorsion is advocated as the primary treatment choice, emergency surgery is required for patients who present with peritonitis, bowel gangrene, or perforation, or for patients whose non-operative treatment is unsuccessful. Although emergency surgery includes various non-definitive or definitive procedures, resection with primary anastomosis is the most commonly recommended procedure. After a successful non-operative detorsion, elective sigmoid resection and anastomosis is recommended. The overall mortality is 10% to 50%, while the overall morbidity is 6% to 24%

Cholelitiasis in an adult patient with mild hereditary spherocytosis – a case report

Hereditary spherocytosis (HS) is an inherited abnormality of the red blood cell, caused by defects in structural membrane proteins. The condition is dominantly inherited in 75% of people. The severity of the disorder is related to the type and amount of membrane disruption, which is genetically determined. A patient who suffers from this disorder is commonly found in a surgical ward when the disease becomes unmanageable by a hematologist. Surgeons encounter complications such as: jaundice, splenomegaly, gallstone sand severe anemia. We present the case of a 66-year-old woman with a history of hereditary spherocytosis who presented at the emergency room for pain in the right upper quadrant, jaundice and anemia and was diagnosed with gallbladder stones and common bile duct obstruction

The burden of breast, cervical, and colon and rectum cancer in the Balkan countries, 1990–2019 and forecast to 2030.

Background Despite effective prevention and control strategies, in countries of the Balkan region, cancers are the second leading cause of mortality, closely following circulatory system diseases. Objective To describe trends in the burden of breast, cervical, and colon and rectum cancer in the Balkan region and per country between 1990 and 2019, including a forecast to 2030. Methods We described the 2019 Global Burden of Disease (GBD) estimates for breast, cervical, and colon and rectum cancers in eleven Balkan countries over the period 1990–2019, including incidence, years lived with disability (YLD), years of life lost (YLL), and disability-adjusted life years (DALYs) rates per 100,000 population and accompanied 95% uncertainty interval. With the Autoregressive Integrated Moving Average, we forecasted these rates per country up to 2030. Results In the Balkan region, the highest incidence and DALYs rates in the study period were for colon and rectum, and breast cancers. Over the study period, the DALYs rates for breast cancer per 100,000 population were the highest in Serbia (reaching 670.84 in 2019) but the lowest in Albania (reaching 271.24 in 2019). In 2019, the highest incidence of breast cancer (85 /100,000) and highest YLD rate (64 /100,000) were observed in Greece. Romania had the highest incidence rates, YLD rates, DALY rates, and YLL rates of cervical cancer, with respective 20.59%, 23.39% 4.00%, and 3.47% increases for the 1990/2019 period, and the highest forecasted burden for cervical cancer in 2030. The highest incidence rates, YLD rates and DALY rates of colon and rectum cancers were continuously recorded in Croatia (an increase of 130.75%, 48.23%, and 63.28%, respectively), while the highest YLL rates were in Bulgaria (an increase of 63.85%). The YLL rates due to colon and rectum cancers are forecasted to progress by 2030 in all Balkan countries. Conclusion As most of the DALYs burden for breast, cervical, and colon and rectum cancer is due to premature mortality, the numerous country-specific barriers to cancer early detection and quality and care continuum should be a public priority of multi-stakeholder collaboration in the Balkan region

The burden of mental disorders, substance use disorders and self-harm among young people in Europe, 1990–2019: Findings from the Global Burden of Disease Study 2019

BACKGROUND: Mental health is a public health issue for European young people, with great heterogeneity in resource allocation. Representative population-based studies are needed. The Global Burden of Disease (GBD) Study 2019 provides internationally comparable information on trends in the health status of populations and changes in the leading causes of disease burden over time. METHODS: Prevalence, incidence, Years Lived with Disability (YLDs) and Years of Life Lost (YLLs) from mental disorders (MDs), substance use disorders (SUDs) and self-harm were estimated for young people aged 10-24 years in 31 European countries. Rates per 100,000 population, percentage changes in 1990-2019, 95% Uncertainty Intervals (UIs), and correlations with Sociodemographic Index (SDI), were estimated. FINDINGS: In 2019, rates per 100,000 population were 16,983 (95% UI 12,823 – 21,630) for MDs, 3,891 (3,020 - 4,905) for SUDs, and 89·1 (63·8 - 123·1) for self-harm. In terms of disability, anxiety contributed to 647·3 (432–912·3) YLDs, while in terms of premature death, self-harm contributed to 319·6 (248·9–412·8) YLLs, per 100,000 population. Over the 30 years studied, YLDs increased in eating disorders (14·9%;9·4-20·1) and drug use disorders (16·9%;8·9-26·3), and decreased in idiopathic developmental intellectual disability (–29·1%;23·8-38·5). YLLs decreased in self-harm (–27·9%;38·3-18·7). Variations were found by sex, age-group and country. The burden of SUDs and self-harm was higher in countries with lower SDI, MDs were associated with SUDs. INTERPRETATION: Mental health conditions represent an important burden among young people living in Europe. National policies should strengthen mental health, with a specific focus on young people. FUNDING: The Bill and Melinda Gates Foundatio

Burden of non-communicable diseases among adolescents aged 10–24 years in the EU, 1990–2019: a systematic analysis of the Global Burden of Diseases Study 2019

Background: Disability and mortality burden of non-communicable diseases (NCDs) have risen worldwide; however, the NCD burden among adolescents remains poorly described in the EU. Methods: Estimates were retrieved from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. Causes of NCDs were analysed at three different levels of the GBD 2019 hierarchy, for which mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) were extracted. Estimates, with the 95% uncertainty intervals (UI), were retrieved for EU Member States from 1990 to 2019, three age subgroups (10–14 years, 15–19 years, and 20–24 years), and by sex. Spearman's correlation was conducted between DALY rates for NCDs and the Socio-demographic Index (SDI) of each EU Member State. Findings: In 2019, NCDs accounted for 86·4% (95% uncertainty interval 83·5–88·8) of all YLDs and 38·8% (37·4–39·8) of total deaths in adolescents aged 10–24 years. For NCDs in this age group, neoplasms were the leading causes of both mortality (4·01 [95% uncertainty interval 3·62–4·25] per 100 000 population) and YLLs (281·78 [254·25–298·92] per 100 000 population), whereas mental disorders were the leading cause for YLDs (2039·36 [1432·56–2773·47] per 100 000 population) and DALYs (2040·59 [1433·96–2774·62] per 100 000 population) in all EU Member States, and in all studied age groups. In 2019, among adolescents aged 10–24 years, males had a higher mortality rate per 100 000 population due to NCDs than females (11·66 [11·04–12·28] vs 7·89 [7·53–8·23]), whereas females presented a higher DALY rate per 100 000 population due to NCDs (8003·25 [5812·78–10 701·59] vs 6083·91 [4576·63–7857·92]). From 1990 to 2019, mortality rate due to NCDs in adolescents aged 10–24 years substantially decreased (–40·41% [–43·00 to –37·61), and also the YLL rate considerably decreased (–40·56% [–43·16 to –37·74]), except for mental disorders (which increased by 32·18% [1·67 to 66·49]), whereas the YLD rate increased slightly (1·44% [0·09 to 2·79]). Positive correlations were observed between DALY rates and SDIs for substance use disorders (rs=0·58, p=0·0012) and skin and subcutaneous diseases (rs=0·45, p=0·017), whereas negative correlations were found between DALY rates and SDIs for cardiovascular diseases (rs=–0·46, p=0·015), neoplasms (rs=–0·57, p=0·0015), and sense organ diseases (rs=–0·61, p=0·0005). Interpretation: NCD-related mortality has substantially declined among adolescents in the EU between 1990 and 2019, but the rising trend of YLL attributed to mental disorders and their YLD burden are concerning. Differences by sex, age group, and across EU Member States highlight the importance of preventive interventions and scaling up adolescent-responsive health-care systems, which should prioritise specific needs by sex, age, and location. Funding: Bill & Melinda Gates Foundation

The burden of mental disorders, substance use disorders and self-harm among young people in Europe, 1990-2019 : Findings from the Global Burden of Disease Study 2019

Background Mental health is a public health issue for European young people, with great heterogeneity in resource allocation. Representative population-based studies are needed. The Global Burden of Disease (GBD) Study 2019 provides internationally comparable information on trends in the health status of populations and changes in the leading causes of disease burden over time. Methods Prevalence, incidence, Years Lived with Disability (YLDs) and Years of Life Lost (YLLs) from mental disorders (MDs), substance use disorders (SUDs) and self-harm were estimated for young people aged 10-24 years in 31 European countries. Rates per 100,000 population, percentage changes in 1990-2019, 95% Uncertainty Intervals (UIs), and correlations with Sociodemographic Index (SDI), were estimated. Findings In 2019, rates per 100,000 population were 16,983 (95% UI 12,823 - 21,630) for MDs, 3,891 (3,020 4,905) for SUDs, and 89.1 (63.8 - 123.1) for self-harm. In terms of disability, anxiety contributed to 647.3 (432 -912.3) YLDs, while in terms of premature death, self-harm contributed to 319.6 (248.9-412.8) YLLs, per 100,000 population. Over the 30 years studied, YLDs increased in eating disorders (14.9%;9.4-20.1) and drug use disorders (16.9%;8.9-26.3), and decreased in idiopathic developmental intellectual disability (-29.1%;23.8-38.5). YLLs decreased in self-harm (-27.9%;38.3-18.7). Variations were found by sex, age-group and country. The burden of SUDs and self-harm was higher in countries with lower SDI, MDs were associated with SUDs. Interpretation Mental health conditions represent an important burden among young people living in Europe. National policies should strengthen mental health, with a specific focus on young people. Funding The Bill and Melinda Gates Foundation Copyright (C) 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)Peer reviewe

The burden of injury in Central, Eastern, and Western European sub-region : a systematic analysis from the Global Burden of Disease 2019 Study

Background Injury remains a major concern to public health in the European region. Previous iterations of the Global Burden of Disease (GBD) study showed wide variation in injury death and disability adjusted life year (DALY) rates across Europe, indicating injury inequality gaps between sub-regions and countries. The objectives of this study were to: 1) compare GBD 2019 estimates on injury mortality and DALYs across European sub-regions and countries by cause-of-injury category and sex; 2) examine changes in injury DALY rates over a 20 year-period by cause-of-injury category, sub-region and country; and 3) assess inequalities in injury mortality and DALY rates across the countries. Methods We performed a secondary database descriptive study using the GBD 2019 results on injuries in 44 European countries from 2000 to 2019. Inequality in DALY rates between these countries was assessed by calculating the DALY rate ratio between the highest-ranking country and lowest-ranking country in each year. Results In 2019, in Eastern Europe 80 [95% uncertainty interval (UI): 71 to 89] people per 100,000 died from injuries; twice as high compared to Central Europe (38 injury deaths per 100,000; 95% UI 34 to 42) and three times as high compared to Western Europe (27 injury deaths per 100,000; 95%UI 25 to 28). The injury DALY rates showed less pronounced differences between Eastern (5129 DALYs per 100,000; 95% UI: 4547 to 5864), Central (2940 DALYs per 100,000; 95% UI: 2452 to 3546) and Western Europe (1782 DALYs per 100,000; 95% UI: 1523 to 2115). Injury DALY rate was lowest in Italy (1489 DALYs per 100,000) and highest in Ukraine (5553 DALYs per 100,000). The difference in injury DALY rates by country was larger for males compared to females. The DALY rate ratio was highest in 2005, with DALY rate in the lowest-ranking country (Russian Federation) 6.0 times higher compared to the highest-ranking country (Malta). After 2005, the DALY rate ratio between the lowest- and the highest-ranking country gradually decreased to 3.7 in 2019. Conclusions Injury mortality and DALY rates were highest in Eastern Europe and lowest in Western Europe, although differences in injury DALY rates declined rapidly, particularly in the past decade. The injury DALY rate ratio of highest- and lowest-ranking country declined from 2005 onwards, indicating declining inequalities in injuries between European countries.Peer reviewe