Comparative Study of NOTES Versus Endoscopic Ultrasound Gastrojejunostomy in Pigs: A Prospective Study

BACKGROUND

Surgical gastrojejunal anastomosis (GJJ) is considered the standard palliative option for gastric outlet obstruction. The use of endoscopic GJJ has generated a lot of attention and has enlarged the horizon for patients with open surgery contraindications. Our study aimed to assess and compare 2 purely endoscopic GJJ approaches using a lumen-apposing hot tip double-flanged metal stent, with focus on technical and clinical success rates on experimental animals.

METHODS

Two endoscopic GJJ techniques using a double-flanged self-expandable metal stent were compared on 8 pigs. Natural orifice transluminal endoscopic surgery (NOTES) was used on 4 pigs, while the other group was subjected to an endoscopic ultrasound (EUS) balloon-guided approach.

RESULTS

On a 21-day follow-up, both EUS and NOTES-GJJ were technically successful in all experimental animals, and necropsy confirmed full integrity of the anastomosis. Adhesions were confirmed only on 2 pigs after NOTES procedure. The mean time for GJJ-NOTES completion was 31.375 ± 2.03, whereas EUS-GJJ was completed with a median time of 20.275 ± 0.65. The stent distance from the stomach varied; in NOTES-GJJ it was 47.8 ± 11.13 cm away from the pylorus, whereas in EUS-GJJ was at 37 ± 1.85 cm.

CONCLUSION

No major complications were encountered during both procedures. EUS-GJJ balloon-guided approach might be a more attractive technique by using sonographic guidance, because of less endoscopic instrument changing as well as in achieving the desired anastomotic distance.

Feasibility of a Portable Abdominal Insufflation Device for Controlling Intraperitoneal Bleeding After Abdominal Blunt Trauma

Uncontrolled bleeding contributes to 30% to 40% of trauma-related deaths and is the leading cause of potentially preventable deaths. Currently, there is no effective method available to first responders for temporary control of noncompressible intraabdominal bleeding while patients are transported to the hospital. Our previous studies demonstrated that abdominal insufflation provides effective temporary bleeding control. The study aims to prove the feasibility (insufflation to a target pressure) and safety (cardiovascular and respiratory effects) of a novel portable abdominal insufflation device (PAID) designed to control the intraperitoneal bleeding caused by abdominal trauma. The PAID prototype is based on a patented design and manufactured via additive manufacturing. PAID contains a 16-g CO2 cartridge and an electronic pressure transducer. PAID was tested on a bench top and a swine animal model. For the animal model study, the intraperitoneal pressure as well as cardiorespiratory parameters (hearth rate, SpO2 [peripheral capillary oxygen saturation], and blood pressure) were continuously monitored during the insufflation procedure. The prototype functioned according to specifications on both bench top and animal models. CO2 insufflation of the peritoneal cavity was delivered up the target 20 mm Hg and maintained for 30 minutes from 1 or 2 cartridges in the swine model. No intraoperative incidents were registered, and all the recorded physiological parameters were within normal limits. The PAID prototype is a feasible, easy to use device that provides quick, controlled, and safe insufflation of the peritoneal cavity. Future studies will focus on testing the next-generation, semiautomatic PAID prototype in a severe intraabdominal injury model.

Laparoscopic compatible device incorporating inductive proximity sensors for precise detection of gastric and colorectal small tumors

The accurate localization of small tumors of the digestive tract is of paramount importance in surgical oncology because it dictates the limits of resection and the extent of lymph node dissection. In this view, we have designed and fabricated a highly efficient sensing laparoscopic instrument focused on precise non-invasive extralumenal intraoperative detection of small colorectal or gastric tumors. The equipment is fully adapted for laparoscopic surgery and consists of an inductive proximity sensor encapsulated into a watertight stainless-steel case that is connected to an electronic functional block dimensionally scaled-down by the desired form and size for optimal surgical manipulation. The sensor-case unit and the electronic block are coupled together using a modular system which allows disconnection of the latter and sterilization by autoclavation of the former, followed by swift plugging of the electronic block just before surgery in a sterile-controlled environment. The instrument works in tandem with a modified endoscopic hemostatic clip which is attached endoscopically, before surgery, in the mucosa proximal and distal to the tumor. By scanning the serosal side of the digestive organ during the laparoscopic surgical procedure, the detector senses the modified clip and thus pinpoints to the location of the tumor. Additional engineering of the standard endoscopic hemostatic clips by coating them with various combinations of metallic alloys of Cu and Zn was necessary to improve the detection range and sensitivity without compromising on their functionality. The clips were also covered with nanometric layers of Au to ensure their biocompatibility. The ex-vivo dry-lab experiments showed a satisfactory detection distance which was later confirmed in ex-vivo wet-lab experiments on animal organs and human surgical specimens.

Incidental intraoperative discovery of a pancreatic neuroendocrine tumor associated with chronic pancreatitis

Pancreatic neuroendocrine tumors are a rare entity with an incidence between 2 per million to 5 per 100,000. Association with pancreatitis (acute or chronic) is rare and is considered to be determined by the tumoral obstruction of pancreatic ducts, but sometimes occurs without any apparent relationship between them. Non-functional neuroendocrine pancreatic tumors are usually diagnosed when either very large or metastatic. Small ones are occasionally diagnosed when imagery is performed for other diagnostic reasons. Intraoperative discovery is even rarer and poses problems of differential diagnosis with other pancreatic tumors. Association with chronic pancreatitis is rare and usually due to pancreatic duct obstruction by the tumor. We describe the case of a patient with a small non-functioning neuroendocrine tumor in the pancreatic tail accidentally discovered during surgery for delayed traumatic splenic rupture associated with chronic alcoholic pancreatitis. The tumor of 1.5 cm size was well differentiated and confined to the pancreas, and was resected by a distal splenopancreatectomy.

CONCLUSIONS

Surgeons should be well aware of the rare possibility of a non-functional neuroendocrine tumor in the pancreas, associated with chronic pancreatitis, surgical resection being the optimal treatment for cure. Histopathology is of utmost importance to establish the correct diagnosis, grade of differentiation, malignancy and prognosis.

VIRTUAL SLIDES

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/2114470176676003.

The Value of Staging Laparoscopy for Optimal Multidisciplinary Treatment in Patients with Gastric Cancer

Introduction: Despite improvements in the conventional preoperative tools used for staging of gastric cancer, their accuracy still needs to be improved. Laparoscopy has the potential to visualize and characterize the tumor, the peritoneal cavity and the lymph nodes and thus to better select patients for the optimal treatment strategy. Material and Method: Patients with gastric cancer staged initially with contrast enhanced computer tomography and endoscopic ultrasound were also evaluated by laparoscopy and laparoscopic ultrasound in a distinct preoperative staging procedure. The perioperative data was recorded in a prospective database and was used to decide within the multidisciplinary team the optimal treatment protocol for each patient. The database was retrospectively reviewed for this study. Results: Among the 20 CT-scan M0 patients analyzed, peritoneal carcinomatosis was detected in 15% of the cases. In other 15% of patients laparoscopy upstaged the tumor and directed the patient towards neoadjuvant chemotherapy. Laparoscopic guided percutaneous core biopsies settled the definitive diagnosis in 3 further cases. In total, laparoscopic staging brought important information in 65% of cases and changed the treatment plan in 30% of patients. Conclusions: In the era of neoadjuvant chemotherapy, laparoscopy has the potential to overcome some of the limitations of the conventional staging methods and offers additional informations which finally change the treatment plan in as much as a third of patients with gastric cancer.

Robotic-assisted laparoscopic surgery in uterine pathology

OBJECTIVE

The feasibility and safety of robotic surgery have been demonstrated by numerous comparative studies. The aim of our study was to compare several parameters related to robotic surgical procedures in uterine pathology, and to analyse clinico-biological parameters that may influence the post-operative evolution of the patients.

STUDY DESIGN

Retrospective analysis of 100 patients with uterine pathology who had undergone robotic-assisted laparoscopic surgery at the Santa Chiara Hospital, Pisa, Italy, between 2008 and 2010.

RESULTS

Duration of surgery, docking, hysterectomy, uterine suture, blood loss, and days of hospitalisation significantly improved in parallel with the increasing experience of the surgical team. Paradoxically, the length of myomectomy increased in the same time interval, probably due to operating on more complex clinical cases with this procedure as the surgical team's experience grew. None of the robotic surgeries was converted to laparotomy. No intra- or post-operative complications were noted.

CONCLUSION

Since robotic-assisted laparoscopic surgery is becoming the preferred surgical technique for uterine pathology treatment, more clinical studies and development of protocols are essential to increase the quality of surgical treatment.

Surgical Endoscopy Versus Endoscopic Surgery for Obesity

BACKGROUND

Obesity treatment options are of great interest worldwide with major developments in the past 20 years. From general surgery to natural orifice transluminal endoscopic surgery intervention nowadays, obesity surgical therapies have surely developed and are now offering a variety of possibilities.

AREAS OF UNCERTAINTY

Although surgery is the only proven approach for weight loss, a joint decision between the physician and patient is required before proceeding to such a procedure. With a lot of options available, the treatment should be individualized because the benefits of surgical intervention must be weighed against the surgical risks.

DATA SOURCES

Medline search to locate full-text articles and abstracts with obvious conclusions by using the keywords: obesity, surgical endoscopy, gastric bypass, bariatric surgery, and endoscopic surgery, alone and in various combinations. Additional relevant publications were also searched using the reference lists of the identified articles as a starting point.

RESULTS

Laparoscopic Roux-en-Y gastric bypass still is the most effective, less invasive, bariatric surgical intervention, although there are various complications encountered, such as postoperative hemorrhage (1.9%-4.4%), internal hernias, anastomotic strictures (2.9%-23%), marginal ulcerations (1%-16%), fistulas (1.5%-6%), weight gain, and nutritional deficiencies. However, the absence of parietal incisions, less pain, decreased risk of infection, and short hospital stay make room for endoscopic surgery as a possible valid option for obesity for both the doctors' and the patients' perspective.

CONCLUSIONS

The current tendency is to promote surgical treatment of obesity to a status of less invasive scars therefore promoting minimally invasive surgical techniques.

A Rare Case of Walled-off Pancreatic Necrosis Complicated by Splenic Artery Rupture Manifested After Surgical Internal Drainage - Diagnostic and Therapeutic Aspects

Large walled-off pancreatic necrosis (WON) is a well-known complication of severe acute pancreatitis, and it is associated with significant morbidity and mortality. This is the case report of a rare and potentially fatal complication of WON - a delayed splenic artery rupture close to its origin after surgical drainage. A 44-year old male patient admitted in our Surgical Department and diagnosed with WON evolving without infection for 6 months, after an episode of acute pancreatitis, underwent a Rouxen- Y WON-jejunostomy. In the 4th postoperative day patient presented melenic stools and a selective celiac trunk angiography was performed with the suspicion of a bleeding from the WON. At the initial injection of contrast a small leakage of contrast was observed but did not reappear despite repeated injection. The procedure was aborted, and the patient put under close observation. The 6th postoperative day bleeding re-occurred, and the angiography indicated a breach in the splenic artery. As the patient developed hemodynamic instability in the Radiology Department he was immediately transferred into the operating room and an exploratory laparotomy with suture of the splenic artery was performed. The patient had an uneventful recovery and at one-year follow-up was without any particular problems.

Which is the Optimal Method of Reconstruction After Laparoscopic Right Hemicolectomy, the Intracorporeal or Extracorporeal Anastomosis Technique?

Introduction: The laparoscopic approach to right colectomy is gradually gaining a leading role in the surgical treatment of right colonic diseases. However, not all aspects of the procedure are standardized and the method of reconstruction of the digestive tract is still under debate. The present study critically evaluates the extracorporeal (EA) and intracorporeal (IA) techniques used for creation of the ileocolic anastomosis during a laparoscopic right colectomy. Material and Method: The EA and IA anastomotic techniques are described in detail. The peri operative data of a cohort of consecutive patients operated by our surgical team was retrospectively recorded and analyzed regarding type of anastomosis, the path for transition from EA to IA and the incidence of postoperative complications. Furthermore, an analysis of randomized clinical trials, reviews and meta-analyses that provided a comparative evaluation of EA versus IA was performed to provide a more in-depth integration of our own data into the literature. Results: EA was used at the beginning of our experience but was later replaced by IA which became the favorite anastomotic technique. There was no anastomotic fistula recorded in the EA or IA groups but in our cohort IA was unexpectedly associated with higher incidence of peritoneal drainage, prolonged ileus, surgical site infections, anastomotic bleeding and chyloperitoneum. However, IA allows better visualization of the ileal and colonic stumps, avoids twisting of the anastomosis, prevents extraction-related tearing of the mesocolon and reduces the risk of post operative hernia. Data from the literature also shows that IA is generally associated with earlier postoperative return of bowel function, less morbidity and less postoperative pain. Conclusions: Based on this study and the data currently present in the literature it can not be concluded that IA should be considered as the standard of care for laparoscopic right colectomy. The decision for an EA or IA anastomosis ultimately belongs to the surgeon and is influenced by his surgical skill and experience. The results of ongoing randomized controlled trials on large group of patients may bring more clarity on this issue in the future.

Update on current pancreatic treatments: from molecular pathways to treatment

Pancreatic cancer is still diagnosed at a late stage although we have novel diagnostic tools. Pancreatic cancer chemotherapy treatment resistance is observed and therefore novel treatments are in need. Anti-cancer stem cell therapy, combination of chemotherapy and/or radiotherapy with immunotherapy, proteins/enzymes and gene therapy are currently under evaluation. Targeted treatment with tyrosine kinase inhibitors is also administered and novel inhibitors are also under evaluation. In the current review we present recent data from our search within the year 2018.

Scar tissue to lung cancer; pathways and treatment

Lung cancer still remains diagnosed at a late stage although we have novel diagnostic techniques at our disposal. However; for metastatic disease we have novel therapies based on pharmacogenomics. Tumor heterogenity provides us different treatments. There are several reasons for carcinogenesis; fibrosis and scar tissue provides an environment that induces malignancy. In the current review we will try and elucidate the pathways involved from scar tissue to carcinogenesis.

Feasibility study of EUS-NOTES as a novel approach for pancreatic cancer staging and therapy: an international collaborative study

BACKGROUND/AIMS

EUS guided Natural Orifice Transluminal Endoscopic Surgery (NOTES) could be a potentially viable approach for pancreatic surgery. EUS-guided access through the stomach wall may prove to be a safe and effective method for accessing the pancreas. The aim of the study was to assess the EUS-guided diagnostic and therapeutic procedures during NOTES for both anterior and posterior approach of the pancreas.

METHODOLOGY

The feasibility of peritoneoscopy through an anterior EUS-guided transgastric approach, as well as direct access to the pancreas through a posterior EUS-guided transgastric approach was tested for ease of access to the tail of the pancreas. Gastric wound closure was finally performed in several animals using various commercial and prototype endoscopic accessories.

RESULTS

The results showed the ability of EUS-NOTES technology to facilitate a transgastric approach and provide both an anterior and posterior access the pancreas. Identification the pancreatic tail by EUS with the aid of EUS-guided T-tag insertion, as well as posterior access and subsequent inspection/dissection of the pancreatic tail may also be possible.

CONCLUSIONS

It is technically possible by EUS-guided NOTES procedures to achieve a systematic anterior and posterior access for NOTES transgastric peritoneoscopy and direct pancreatic endoscopic procedures.

Interstitial Cells of Cajal-Origin, Distribution and Relationship with Gastrointestinal Tumors

The interstitial cells of Cajal (ICC) represent a particular network formed by some peculiar cells that were first described by the great neuroanatomist, S. Ramon y Cajal. Nowadays, the ICC have become a fascinating topic for scientists, arousing their curiosity; as a result, there is a vast number of published articles related to the ICC. Today, everybody widely accepts that the ICC represent the pacemaker of the gastrointestinal tract and are highly probable to be the origin cells for gastrointestinal tumors (GISTs). Recently, Cajal-like cells (ICLC) were described, which are found in different organs but with an as yet unknown physiological role that needs further study. New information regarding intestinal development indicates that the ICC (fibroblast-like and muscle-like) and intestinal muscle cells have the same common embryonic cells, thereby presenting the same cellular ultrastructure. Nowadays, there is a vast quantity of information that proves the connection of the ICC and GISTs. Both of them are known to present c-kit expression and the same ultrastructural cell features, which includes minimal myoid differentiation that is noticed in GISTs, therefore, supporting the hypothesis that GISTs are ICC-related tumors. In this review, we have tried to highlight the origin and distribution of Cajal interstitial cells based on their ultrastructural features as well as their relationship with gastrointestinal stromal tumors.

Preoperative Computer-Assisted Laparoscopy Planning for the Minimally Invasive Surgical Repair of Hiatal Hernia

Minimal invasive surgical procedures such as laparoscopy are preferred over open surgery due to faster postoperative recovery, less trauma and inflammatory response, and less scarring. Laparoscopic repairs of hiatal hernias require pre-procedure planning to ensure appropriate exposure and positioning of the surgical ports for triangulation, ergonomics, instrument length and operational angles to avoid the fulcrum effect of the long and rigid instruments. We developed a novel surgical planning and navigation software, iMTECH to determine the optimal location of the skin incision and surgical instrument placement depth and angles during laparoscopic surgery. We tested the software on five cases of human hiatal hernia to assess the feasibility of the stereotactic reconstruction of anatomy and surgical planning. A whole-body CT investigation was performed for each patient, and abdominal 3D virtual models were reconstructed from the CT scans. The optical trocar access point was placed on the xipho-umbilical line. The distance on the skin between the insertion point of the optical trocar and the xiphoid process was 159.6, 155.7, 143.1, 158.3, and 149.1 mm, respectively, at a 40° elevation angle. Following the pre-procedure planning, all patients underwent successful surgical laparoscopic procedures. The user feedback was that planning software significantly improved the ergonomics, was easy to use, and particularly useful in obese patients with large hiatal defects where the insertion points could not be placed in the traditional positions. Future studies will assess the benefits of the planning system over the conventional, empirical trocar positioning method in more patients with other surgical challenges.

Could there be an interplay between periodontal changes and pancreatic malignancies?

The term "periodontal disease" refers to a group of chronic inflammatory illnesses caused by specific microorganisms from subgingival biofilm, that affect the tooth-supporting tissues. Recent research has also shown that periodontal infection plays a role in aggravating systemic disease states at distal sites, reinforcing the significance of the oral cavity for general health. Additionally, it has been suggested that gastroenterological malignancies may be promoted by hematogenous, enteral or lymphatic translocation of periopathogens. In the past 25 years, the global burden of pancreatic cancer (PC) has more than doubled, making it one of the major causes of cancer-related mortality. Periodontitis has been linked to at least 50% increased risk of PC and it could be considered a risk factor for this malignancy. A recent study performed on 59000 African American women with a follow up of 21 years showed that participants who had poor dental health had higher chances of PC. The findings, according to researchers, might be related to the inflammation that some oral bacteria trigger. Regarding the mortality of PC, periodontitis considerably raises the chance of dying from PC. Microbiome alterations in the gut, oral cavity and pancreatic tissues of PC patients occur when compared to healthy flora, demonstrating a link between PC and microecology. Inflammation may also contribute to PC development, although the underlying pathway is not yet known. The function of the microbiome in PC risk has drawn more focus over the last decade. Future risk of PC has been linked to the oral microbiome, specifically increased levels of Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans and decreased relative abundance of Leptotrichia and Fusobacteria, suggesting that it may have an impact on the inflammatory condition by expanding, altering, and regulating the commensal microbiome. Patients who received periodontal treatment had significantly decreased incidence rate ratios for PC. By analyzing patterns in the microbiome composition throughout PC development and establishing strategies to enhance the cancer-associated microbial system, we can increase the efficacy of therapy and eventually find an application for the microbial system. The development of immunogenomics and gut micro-genomics in the life sciences will result in a significant advancement in our understanding of how microbial systems and immunotherapy interact, and it may also have intriguing therapeutic implications for extending the lifetime of PC patients.

Colorectal Surgery in Romania during the COVID-19 Pandemic

As the COVID-19 pandemic extends, its negative consequences on the effectiveness of therapeutic programs - previously assumed by the medical community and imperatively suspended for a difficult-to-predict period of time - are becoming increasingly worrying. In this context, as the evidence-based recommendations are not possible, most of the national and international scientific societies tried to develop balanced recommendations (1-4). The Romanian Society of Coloproctology (SRCP) and the Romanian Association for Endoscopic Surgery (ARCE) have created a working group that, taking into account recent publications, the statements of international academic societies, the national legislative context and the unique experience of countries severely affected by this pandemic (China, Italy, Spain, USA, etc.) proposes for Romania, the following recommendations for medical practice in colorectal surgery during the COVID-19 pandemic. These recommendations are subjected to continuous review, depending on the global and national situation of the pandemic, the particular needs of each hospital, the recommendations of the competent authorities and the evolution of the literature that publishes the conclusions of ongoing clinical trials.

Morphometric Assessment of Confocal Laser Endomicroscopy for Pancreatic Ductal Adenocarcinoma, an Ex-Vivo Pilot Study

Ex-vivo freshly surgical removed pancreatic ductal adenocarcinoma (PDAC) specimens were assessed using pCLE and then processed for paraffin embeding and histopathological diagnostic in an endeavour to find putative image analysis algorithms that might recognise adenocarcinoma.

METHODS

Twelve patients diagnosed with PDAC on endoscopic ultrasound and FNA confirmation underwent surgery. Removed samples were sprayed with acriflavine as contrast agent, underwent pCLE with an experimental probe and compared with previous recordings of normal pancreatic tissue. Subsequently, all samples were subjected to cross-sectional histopathology, including surgical resection margins for controls. pCLE records, as well as corespondant cytokeratin-targeted immunohistochemistry images were processed using the same morphological classifiers in the Image ProPlus AMS image analysis software. Specific morphometric classifiers were automatically generated on all images: Area, Hole Area (HA), Perimeter, Roundness, Integrated Optical Density (IOD), Fractal Dimension (FD), Ferret max (Fmax), Ferret mean (Fmean), Heterogeneity and Clumpiness.

RESULTS

After histopathological confirmation of adenocarcinoma areas, we have found that the same morphological classifiers could clearly differentiate between tumor and non-tumor areas on both pathology and correspondand pCLE (area, roundness, IOD, ferret and heterogeneity (p < 0.001), perimeter and hole area (p < 0.05).

CONCLUSIONS

This pilot study proves that classical morphometrical classifiers can clearly differentiate adenocarcimoma on pCLE data, and the implementation in a live image-analysis algorithm might help in improving the specificity of pCLE in vivo diagnostic.

Intraoperative cardiovascular response of natural orifice transluminal endoscopic surgery versus laparoscopy: A comparative animal study

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) emerged as a new alternative method in minimally invasive techniques. Although a very small number of studies have compared the physiologic response in NOTES to laparoscopy, the results remain controversial.

AIM

This experimental animal study aims to evaluate the intraoperative cardiovascular and respiratory effects of pure transluminal natural orifice surgery and conventional laparoscopy.

MATERIALS AND METHODS

Twenty female pigs (Sus scrofa domesticus) equally divided into two study groups were assigned to either pure natural orifice transluminal endoscopic techniques (Group 1) or conventional laparoscopic surgery (Group 2) and monitored intraoperatively in terms of heart rate (HR), systolic blood pressure (SBP) and O2saturation (SpO2) for 1 h. Both groups underwent simple surgical procedures such as gastrojejunostomy, oophorectomy and adnexectomy.

RESULTS

All procedures were successfully completed. The findings indicated statistically significant differences between SBP (P = 0.0065) and SpO2(P = 0.027) in the two groups at the beginning of the interventions. HR showed significant differences during the last 20 min of the interventions (min 40 and 45; P < 0.001). For the whole procedure (from the beginning of the intervention to 60 min interval), HR, SBP and SpO2values showed no statistical difference.

CONCLUSIONS

Although significant differences in terms of HR, mean blood pressure and SpO2were noted at specific intervals during surgery, no real variance of the cardiovascular parameters was observed when considering the entire procedure. Therefore, NOTES seems to be a safe approach with minimally intraoperative cardiovascular and respiratory implications.

Emergency and Trauma Surgery

According to the UEMS (Union Europeene des Medicins Specialises) Section of surgery Board of Surgery, "Emergency Surgery" can be defined "as surgery that is required to deal with an acute threat to life, organ, limb or tissue caused by external trauma, acute disease process, acute exacerbation of a chronic disease process, or complication of a surgical or other interventional procedure". Performance of emergency surgery require complex and varied skills and abilities to achieve procedures from different fields of surgery: abdominal, urologic, thoracic, vascular, soft tissue, skeletal) within an interval of 24 hours (1). In U.S., since 2008, Acute Care Surgery concept was introduced, and nowadays is an evolving specialty with three essential components- trauma, critical care and emergency surgery (2). In UK there is an increasing subspecialisation within general surgery over the last ten years. More recently, there has been an increase in focus on emergency general surgery (3,4). This may not come as a surprise given the fact that trafic crashes kill 1.2 million people annually around the world (3242 people/day) and 90% are in middle and low income countries. In US trauma is the leading cause of death in persons up to 40 years. Optimal care for emergency surgical patients is one of the major challenges for every healthcare system worldwide. An emergency surgery mai intervene during the daily schedule of elective interventions and create pressure on both the organisation and costs (5). Since it's birth, in 2007, the Romanian Society for Emergency Surgery and Trauma was involved in supporting the development of practice in emergency surgery in Romania by many actions: each year, during biannual National Congres and National Conference of the Romanian Society of Surgery 2 sessions were dedicated to emergency surgery, with invited foreign speakers; oragnisation of European Congres of Emergency and Trauma Surgery in 2017 in Bucharest, 1 tematic issue of Chirurgia Journal dedicated to surgery of the cirrhotic patients. This tematic isssue includes varia subjects from emergency surgery in valuable articles. The management of open abdomen management are depicted by Anastasiu et al, in a review summarizing definition, classification, indications, methods of temporary abdominal closure and fascial closure, and enterocutanous fistula. Turculet et al, perfomed a review of the litterature to describe the main advantages and disadvantages of the trauma systems in Europe and to present the last concepts regarding the management of the polytrauma patients and the newest sets of measures to prevent car crashes in European Union. A rare case of small bowel hemangioma with hemoperitoneum mimicking trauma is described by Iordache et al, with a review of the litterature. The series of reviews ends with an interesting article for daily practice in emergency hospitals about the diagnostic and therapeutic peculiarities in abdominal trauma associated with spinal cord injurie by Grigorean et al. Abdominal trauma is addressed in 7 original papers. The definitive surgery for liver trauma in tertiary HPB center, the nonoperative treatment of abdominal trauma involving liver and spleen, the timing of splenic interventional radiology, the management of colon trauma at a level II trauma, challenges raised by the retroperitoneal hematoma in abdominal trauma, predicition of evolution of patients with abdominal trauma using the usual biological parameters, and clinico-pathological correlations in the acute surgical abdomen in the pre and post COVID-19 pandemic period are presented, analysed and discussed in papers coming from specialized surgical units from Fundeni Clinical Institute, Emergency Clinical Hospital Bucharest, Emergency University Hospital of Bucharest, "Bagdasar-Arseni" Clinical Emergency Hospital, "St. Pantelimon" Clinical Emergency Hospital, Clinical County Emergency Hospitals of Craiova and Tg-Mures. The surgical technique of intraomental splenic implant and an attempt of reassessement is presented in a paper by Beuran et al. We hope that this tematic issue will be an interesting and very useful lecture for our readers and bring useful informations for those involved in emergency surgery.

Deep accidental hypothermia accompanied with cardiac arrest after alcohol and drug poisoning treated with extracorporeal life support

Deep accidental hypothermia is an unusual clinical entity in developed countries. We report a case of a 30 year old male Caucasian patient with accidental severe hypothermia who was transferred to the emergency department of our hospital after prolonged exposure in the urban city's night environment cold as a result of alcohol and drugs abuse. The patient was found unconscious in the first early hours from onlookers. The time that the patient remained unconscious is unknown. During the transfer to the hospital because of cardiac arrest cardiopulmonary resuscitation began. In the emergency department an extracorporeal life support system (ECLS) was implanted under cardiopulmonary resuscitation in order to achieve hemodynamic stabilization and rapid and safe rewarming. The patient's rewarming lasted 6 hours. The patient was extubated the next day.

Nonoperative Treatment of Abdominal Trauma Involving Liver and Spleen

Introduction: The management of this type of trauma has evolved considerably, especially with the introduction of interventional radiology (angiography, splenic artery embolization - SAE) but also the concept of non-operative treatment (NOT), defined as a follow-up of injuries, without surgery. Material and Method: We have established a strategy for dealing with cases of abdominal trauma with injuries by non-operative treatment (NOT). We applied NOT to 13 patients in 50 (26%), of which 8 were patients with spleen injuries and 5 were patients with liver damage. Most of the lesions were grade II (8 cases), 2 cases were grade I and 3 cases were grade III. Results: There was only one case dealt by NOT, in which surgery was performed 48 hours after admission. In two patients with extravasation of the contrast agent on CT and angiography, angioembolization of the splenic artery was performed, with good results. Control CT was performed at a period that varied between 24 hours and 5 days after admission. The average period of hospitalization of patients approached by NOT was 6,6 days. Conclusions: Contrast-enhanced CT examination remains the basis for NOT initiation, providing the necessary data on the degree of liver or splenic lesion, the size of blood collections and extravasation of the contrast substance but is also the essential imaging exploration in assessing NOT efficacy. Angioembolization can be successfully performed in cases where CT examination and angiography show contrast extravasation. There was only one case included in the NOT, which was operated laparoscopically, but most authors emphasize that this should not be considered a failure of the method.

Neutrophil/lymphocyte Ratio after Flow Citometry Periferic Blood Cell Detection - Predictive Marker of Anastomotic Fistula in Colorectal Cancer Surgery

Anastomotic fistula is a dreadful complication of colon and rectal surgery that can put life into danger, being common after colorectal surgery. The preoperative lymphocyte neutrophil ratio (NLR) is known as a prognostic marker for colorectal cancer patients. The existence of a predictive marker of anastomotic fistula in colorectal cancer patients is not fully undestood, so we proposed to investigate the utility of preoperative NLR as a predictor of anastomotic fistula formation. This study the Neutrophils and lymphocytes were detected from periferic blood using flow citometry. We retrospectively evaluated 161 patients with colorectal cancer, who were treated curatively, in which at least one anastomosis was performed, comparing NLR values between patients who had fistula and those with normal healing, then comparing the group with low NLR, with the group with increased NLR, after finding the optimal value of NLR using the ROC curve.The optimal value of the NLR after establishing the cutoff value was 3.07. Between the low NLR group (n=134) and the high NLR group (n=27), were observed statistically significant differences in fistula (p [0.001) and death (p=0.001). The odds ratio for failure in the group with increased NLR was 10.37, which means that patients with NLR]3.54 have a chance of developing anastomotic fistula greater than 10.37 comparable to patients with lower NLR. We suggest the preoperative use of NLR can be used as a predictive marker of anastomotic fistula than can increase the quality of preoperative preparation and therefore the establishment of the optimal surgical technique that can lead to anastomotic fistula risk decrease.

Peritoneal access, transgastric peritoneoscopy and oophorectomy - feasibility study on an experimental Swine model

BACKGROUND/AIMS

Natural orifice translumenal endoscopic surgery (NOTES) still poses numerous challenges, even in cases of relatively simple surgical procedures. This study aims to assess the feasibility of transgastric resectional interventions using commonly available endoscopic equipment as well as to offer a safe closure method of the gastric access site.

METHODOLOGY

Ten pigs underwent pure transgastric endoscopic oophorectomy using a single channel endoscope. The gastric defect was closed using over-the-scope clips (OTSC™, OVESCO Endoscopy). After 2 weeks the animals underwent autopsies.

RESULTS

All procedures were successful. Transgastric access time varied from 4.46 to 33.24 minutes. The peritoneal exploration took 31 minutes and oophorectomy needed in average of 21 minutes (range 15-28 minutes). The animals for which the gastric access site was closed with OTSC™ survived for 2 weeks without complications.

CONCLUSION

This study demonstrates the technical feasibility and safety of pure transgastric endoscopic oophorectomy using conventional endoscopic instrumentation in a porcine model. OTSC™ closure system is an easy to use and reliable gastric closure method.

Immunohistochemical evaluation of D2-40, Galectin-3, Maspin and MCM7 expression in palate squamous cell carcinomas

Squamous cell carcinoma (SCC) is the most frequent cancer in oral cavity and its prognosis has exhibited little improvement in the last decades. Although much less common palate SCCs manifests a higher local aggression invading very quickly the adjacent muscles and jawbones, thus being able frequently to lead to dysfunctions in chewing, swallowing, and speech. To elucidate what underlies such local aggression, we investigated the immunohistochemical expression in palate SCCs of Podoplanin (D2-40), Galectin-3 (Gal-3), mammary serine protease inhibitor (Maspin) and minichromosome maintenance complex component 7 (MCM7), markers that are known to be involved in tumor invasiveness. We found a progressive increase in reactivity for D2-40 and MCM7 from the normal epithelium toward dysplastic epithelium and respectively to SCC, which suggests the intervention of these markers in the early stages of squamous cell carcinogenesis in the palate. The highest D2-40, Gal-3 and MCM7 reactivity was observed in basaloid and in poorly differentiated (G3) palate SCCs, while for Maspin the well-differentiated (G1) palate SCCs were the most reactive. The first three markers mentioned above were most intensely expressed at the invasion front, while the Maspin reactivity was low or absent at this level. Statistically, we found significant stratification on localization, grading, muscle invasion, and survival for all investigated markers, but with very high direct correlations between D2-40, Gal-3, and MCM7 immunoreactive score (IRS) values, while between the Maspin and each of the previous markers there were very high inverse correlations. Overall, all these investigate markers proved to be responsible for the local invasiveness and regional lymph node metastasis, thus allowing a prognostic and therapeutic stratification of patients with palate SCCs.