Self-expanding metal stent for refractory bleeding esophageal varices - single center experience

Introduction: Bleeding esophageal varices (EV) is a severe and life threatening complication of portal hypertension (PH), while endoscopic failure to control hemorrhage is even a more dramatic situation. Aim: To assess self-expanding metal stent (SEMS) haemostatic efficacy in severe variceal hemorrhage in patients with bleeding EV and endoscopic treatment failure. Material and Methods: A total of 12 patients, (M=8) with the mean ±SD age - 46.92±3.09 (24-62 years) and liver cirrhosis induced bleeding EV (n=8) and esophageal post-banding ulcers (n=4) were enrolled in the study. The main selection criteria was endoscopic treatment failure. A removable covered SEMS (SX-ELLA stent Danis, 135x25 mm, ELLA-CS, Hradec-Kralove, Czech Republic) was used in all cases. The mean SEMS used per patient was 1.25±0.18 (1-3). All definitions were used according to Baveno Consensus (I-V) conferences. Results: Initial SEMS haemostatic efficacy was 100%. Partial distal stent migration was documented on X-ray and CT-scan in 5/12(41.6%) and stent reposition was achieved by second-look endoscopy. The 30-days mortality was 25% (3/12). Tanatogenesis was induced by hepatic failure (n=2) and bleeding EV distally to the stent distal end (n=l). Conclusions: The preliminary results demonstrate that stenting is an effective life-saving hemostatic procedure in high-risk patients with severe esophageal variceal bleeding and endoscopic hemostasis failure as well as postbanding esophageal ulcers. Final conclusions will be reached after gaining experience with this new method on larger series

Sentinel lymph node mapping for obstructive colon malignancy

Catedra Chirurgie n.1 „N. Anestiadi” şi Laboratorul de Chirurgie Hepato-Pancreato-Biliară, USMF „N. Testemițanu”, Chișinău, Republica Moldova, 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: Prezența metastazelor în nodulii limfatici reprezintă cel mai important factor pronostic de supraviețuire a pacienților cu cancer de colon potențial curabil. La momentul actual metoda de marcare a nodulilor limfatici santinelă pentru neoplaziile ocluzive colorectale nu este definitivată. Deşi nu modifică procedeul chirurgical, mappingul în cancerul de colon poate ameliora stadializarea conform criteriului pN şi poate reduce timpul necesar examenului morfopatologic prin limitarea acestuia doar la nodulii limfatici „pozitivi”. Material şi metodă: În studiu au fost incluşi 22 pacienți cu ocluzii neoplazice de colon, raportul B:F a fost 1.44:1 (13/9) cu vârsta medie 60.91±3.51 (28-84) ani. Scorul ocluziei a fost 8.41±0.49 (5-12). Marcarea nodulilor limfatici santinelă a fost efectuată utilizând colorant albastrul de metilenă 1% 10 ml (10mg/mL) ProMetic Pharma Inc. şi Patenbalu V 2.5% 2 ml Guerbet GmbH. injectate in vivo intratumoral. Nodulii depistați au fost examinați histologic HE. Rezultate: Rata de succes a marcării nodulilor limfatici santinelă a constituit 95.45% (21/22). În 4 cazuri sau colorat câte 1 nodul, câte 2 noduli sau colorat în 9 cazuri, 3 noduli au fost marcați în 4 cazuri, 4 şi 5 noduli sau colorat în 1 caz şi în 2 cazuri au fost marcați 6 noduli. În mediu au fost marcați 2.5±0.33 (0-6) noduli. Histologic pozitivi au fost 38% (n=8) noduli santinelă. Sensibilitatea metodei a fost 100%, specificitatea 7%. Stadiul tumorii a fost T3N0M0 (n=14) şi T3N1M0 (n=8). Nu au fost semnalate reacții adverse în cazul utilizării albastrului de metilenă şi paten balau V în condiții de ocluzie neoplazică de colon. Concluzii: Prezentăm în premieră metoda de marcare a nodulilor santinelă în condiții de ocluzie neoplazică de colon. Mappingul nodulilor limfatici santinelă poate fi utilizat cu succes în condiții de colon oclusiv neoplazic cu scop de stadializare mai exactă a tumorii conform criteriului pN şi a indicațiilor pentru chimioterapie.Introduction: Sentinel lymph node metastases are one of the most important prognostic factors for survival in patients with colorectal malignancies. Up to date there is no widely accepted consensus upon sentinel lymph node mapping for obstructed colorectal cancer. Although the method does not modify the surgical treatment, it could provide accurate staging according to the pN criterion, as well as focusing the pathologic examination just to the positive lymph nodes. Material and method: In the study were included 22 patients with obstructive colon malignancies, M:F ratio was 1.44:1 (13/9) with the mean age of 60.91±3.51 (28-84) years. Mean colon obstruction score was 8.41±0.49 (5-12). Sentinel lymph node mapping was achieved using methylene blue 1% 10 ml (10mg/mL) ProMetic Pharma Inc. and Patenbalu V 2.5% 2 ml Guerbet GmbH injected in vivo intratumoral. All stained lymph nodes were examined histologically HE.Results: The success rate was 95.45% (21/22). One stained node was detected in 4 cases, 2 nodes (n=9), 3 (n=4), 4 and 5 stained nodes were in 1 case respectively and 6 (n=2). The mean number of stained sentinel lymph nodes was 2.5±0.33 (0-6). Sensitivity was 100% and specificity was 7%. Histological positive were 38% (n=8) sentinel lymph nodes. Tumor staging was T3N0M0 (n=14) and T3N1M0 (n=8). There were no adverse reactions related to dye injection.Conclusions: We present the first report regarding sentinel lymph node mapping in obstructed colonic malignancy. Sentinel lymph node mapping may be successfully used in case of malignant colonic obstruction in order to accurately determine the tumor stage according to the pN criterion, as well as for postoperative chemotherapy patient’s selection

Gallbadder varices

Introduction: Gallbladder varices (GBV) are relatively rare ectopic varices in patients with portal hypertension (PH). The aim of the study is to investigate clinical, imagistic and endoscopic data of patients diagnosed with GBV. Material and Methods: Patients diagnosed with GBV over a period of 10 years were identified from the comprehensive database of our institution. Results: There were seven patients (F-4, M-3) with the mean age of 27.9 ± 5.2 (10 to 51) years. PH was caused by portal vein thrombosis (portal cavernoma): after splenectomy for trauma and hematologic disease (n=4), antithrombin III deficiency (n=2) and protein S deficiency (n=l). At time of presentation GBV (n=6) were associated with bleeding esophageal varices (F3, RCS++-i-, Li+m) managed by endoscopic band ligation MBL-6,10 (Wilson-Cook®, Winston-Salem, NC, SUA) and bleeding duodenal varices managed surgically (n=l). Doppler imaging showed the existence of portal cavernoma and GBV. After complete eradication of esophageal varices no GBV enlargement neither other related complications were noticed. Conclusion: Color Doppler sonography is a valuable noninvasive imaging technique for assessment of portal hemodynamic profile in patients with portal cavernoma as well as a useful technique to detect GBV. Preoperative correct diagnosis of GBV should increase the surgeon’s vigilance during biliary tract surgery in patients with PH in order to avoid hazardous complications

Surgical treatment of acute mesenteric ischemia

Introduction: Acute mesenteric ischemia (AMI) is an abdominal catastrophe. Advanced age and diagnosis delay are associated with increased morbidity and mortality rates. The optimal surgical strategy for AMI is under evaluation. Aim: To evaluate the early results of different treatment strategies for AMI. Material and methods: During last three years a total of 35 consecutive pts with AMI were admitted to our unit. The mean (±SD) time interval between AMI symptoms onset and admission was 34.7±2.1 h. Physiological parameters (mean±SD) of pts were: ASA score - 3.3±0.1, APACHE score - 25.2±1.6 and POSSUM - 36.9±1.8. In most cases AMI was induced by superior mesenteric artery (SMA) embolism (54.3%, n = 19) followed by SMA thrombosis (25.7%, n= 9) and venous thrombosis (VT) (20%, n=7). Results: The affected bowel segments were: small intestine (n=16), small intestine + colon (n=13) and total ischemia (n=6). Surgical procedures were as follows: small intestine resection (n=14) with SMA embolectomy (n=2), small intestine + right colon (n=12) and small intestine + subtotal colectomy (n=l). In two cases of VT affected intestinal segments were not resected, instead anticoagulation treatment was initiated and the intestinal viability was confirmed by second-look laparotomy. Explorative laparotomy was used only in advanced intestinal gangrene (n=6). Twenty five pts with massive injury were scheduled for staged damage control approach (immediate resection of the involved bowel without gastrointestinal continuity reconstruction, patients’ resuscitation in ICU) combined with Negative Pressure Wound Therapy (V.A.C., KCI or homemade) and later on definitive reconstructive procedure (delayed anastomosis). Primary anastomoses were performed only in 2 pts with short segmental intestinal infarction. The overall 30-days mortality rate was 24/35, 68.5% (in non-total AMI - 18/29, 62%, in VT zero). Conclusions: Early diagnosis and prompt surgery improves the AMI outcome. Colon involved in AMI is a poor prognosis sign. Damage control approach improves the AMI patients’ survival

Management of bleeding ectopic varices

Introduction: Bleeding ectopic varices (EcV) are uncommon and a difficult conditions to manage. The clinical data of patients diagnosed and treated for bleeding EcV were reviewed to investigate the treatment strategy. Material and Methods: Patients diagnosed with bleeding EcV over a period of 10 years were identified from the comprehensive surgical database of our institution. Results: There were six patients (F-2, M-4) with the mean age of 46.8 ± 7.3 (20 to 76) years. The location of the EcV was: duodenal (DV, n=2), isolated gastric varices type 2 (IGV2) according Sarin classification (n=2), and rectal (RV, n=2). EcV were induced by liver cirrhosis (LC) - 2, posthrombotic portal cavernoma (PC) - 1, LC+PC - 1, hepatocelullar carcinoma (HCC) +PC-1 and left-sided portal hypertension -1. The EcV were managed as an emergency in 4 (DV-2, IGV2-2) and elective in 2 with RV. Bleeding EcV were managed by endoscopic ligation with HX-21L-1 (Olympus®, ET, Japan) device with mini-loop MAJ-339 (n=2, DV and IGV2) and endoscopic ligation with HMBL-4 (Wilson-Cook®, Winston-Salem, NC, SUA) (n=2, RV). Haemostatic efficacy was achieved in all cases. Surgery was performed in 2 pts: for IGV2 - stapling fundectomy with splenectomy and for DV - surgical ligation of affected vessels. Inhospital lethality was - 1/6 (16.6%). Conclusion: Bleeding EcV’s are a challenging emergency, haemostatic procedures depending on the site, bleeding activity and local expertise