WHEN SHOULD CLEARANCE OF THE HEPATODUODENAL LIGAMENT (STATION 12) DURING RADICAL RESECTION FOR GASTRIC CANCER BE PERFORMED

In Western countries gastric cancer continues to remain a biologically aggressive tumor, with poorlong-term oncological outcomes. In Romania, the estimated gastric cancer was the fifth cause ofoncological death in men and the eighth cause of oncological death in women in 2012.The objectiveof the study is to detail when should the hepatoduodenal ligament (station 12) be cleared surgicallyas a part of D2 dissection during radical gastrectomy.We have performed a review of the Englishlanguage literature using PubMed/Medline library. As keywords we used a combination of thefollowing terms: ‘gastrectomy’, ‘stomach’, ‘cancer’, and ‘lymphadenectomy’. According to theJapanese Gastric Cancer Association, the hepatoduodenal ligament includes the lymph nodesstation 12, which are further divided in 12a – along left side of the proper hepatic artery, 12b –right side of the ligament and posterior to the common bile duct, and 12p – posterior to the portalvein. For middle and lower third gastric tumors, station 12a represents the N2 tier, while for upperthird gastric tumors, it represents the N3 tier. Lymph nodes 12b and 12p represent N3, irrespectiveof the tumor location. For middle and lower third gastric tumors the clearance of the lymph nodessurrounding the proper hepatic artery is a part of the D2 dissection. Dissection of the lymph nodessurrounding the proper hepatic artery is a component of the D2 spleen and pancreas preservinglymphadenectomy, for lesions which extend further than submucosa.

Traumatic Tricuspid Valve Rupture after Blunt Chest Trauma - A Case Report and Review of the Literature

INTRODUCTION

Despite the high frequency of thoracic injuries secondary to traffic related accidents, the blunt cardiac valve rupture is extremely rare.

METHOD

Case report and review of the literature using PubMed/MEDLINE and EMBASE databases.

RESULT

A 38 year old female patient, victim of car accident was admitted. On primary survey the patient was conscious, cooperative and hemodynamic and respiratory stable. On secondary survey was found a bilateral open leg fracture and a seat belt sign. Whole body Computed Tomography revealed minimal haemorrhagic contusion of the cortex, left hemopneumothorax and right pneumothorax, bilateral rib fractures, liver contusion, left femoral neck fracture and fracture to the lumbar spinal column. After bilateral pleurostomy, the patient becomes hemodynamically unstable, but with no signs of external bleeding. The transthoracic echocardiography revealed an acute severe tricuspid regurgitation with hepatic veins reflux. After orthopaedic surgeries, the tricuspid valve rupture was managed by replacing the valve with a bioprostheses. The hospital stay was 122 days.

CONCLUSION

Only a high index of suspicion may reveal blunt cardiac lesions as a cause for hemodynamic instability in acute setting.

[Trauma scores: a review of the literature]

BACKGROUND

A quantitative method for measuring trauma severity has many potential applications: patient triage, a common terminology about injuries severity, prognosis assessment, trauma care audit and epidemiological.

METHOD

Systematic review of the literature using computer searching of Library of Medicine and the National Institutes of Health International MEDLINE database using PubMed Entre interface. We have selected articles about the main scoring systems used in today's trauma care.

RESULTS

Trauma scores were introduced more than 30 years ago, for assigning numerical values to anatomical lesions and physiological changes after an injury. Physiologic Scores describe changes due to a trauma and translated by changes in vital signs and consciousness. Anatomical Scores describe all the injuries recorded by clinical examination, imaging, surgery or autopsy. If physiological scores are used at first contact with the patient (for triage) and then repeated to monitor patient progress, anatomic scores are used after the diagnosis is complete, generally after patient discharge or postmortem. They are used to stratify trauma patients and to measure lesion severity. Scores that include both anatomical and physiological criteria (mixed scores) are useful for patient prognosis.

CONCLUSIONS

Despite their imperfections, trauma scores are very important tools in trauma patients management and research. Using large national databases allow a better research, validation and development of scoring systems.

[Mechanism of injury--trauma kinetics. What happend? How?]

INTRODUCTION

Understanding the mechanism of injuries represents a key element in blunt and penetrating trauma management.

METHOD

Systematic review of the main types of the modem trauma mechanisms, using Medline, Cochrane Library and Embase databases.

RESULTS

To properly understand the road car accident injuries, trauma surgeon should know as many details from the scene: the speed of cars, impact direction, if the car rolled over, if occupants were restrained, if airbags exploded, vehicle telemetry, extrication time. Motorcyclists are 20 to 30 times more at risk for severe injuries or death than the four-wheel vehicle occupants. Current evidence shows a significant decrease in injuries severity by increasing use of seat-belts, motorcycle helmets, childrestrains and speed limit. Despite this, few countries around the world have road safety laws relating to key factors that can be considered sufficiently comprehensive in scope. Many modern trauma systems use for prehospital triage mechanism of injury criteria.

CONCLUSIONS

The trauma surgeon should know the mechanism of injury. This allows a high suspicion for potential injuries, their early diagnosis and increased quality in the care of trauma patients.

[History of trauma care]

BACKGROUND

Since its inception, the man suffered injuries through falls, fire, drowning and interpersonal conflict. While the mechanism and frequency of different specific injuries has changed passing of millennia, trauma remains an important cause of mortality and morbidity in modern society. Although the war is presented as one of the four knights of the Apocalypse, we must emphasize the important developments of surgical experience during war. The purpose of this study is to highlight the lessons learned during the history and how they changed the modern trauma care.

METHOD

Systematic review of English language literature using computer searching of Library of Medicine and the National Institutes of Health International MEDLINE database using PubMed Entre interface.

RESULTS

The first historical record of a trauma medical care is 3605 years ago. Over the past decades, one of the most important changes in trauma patient care is the selective nonoperative management (SNOM) of significant abdominal visceral injuries. SNOM was first described in 1968, for splenic trauma, by Upadhyay and Simpson. It was accepted much later for liver injuries. Beginning from 1960 - 1970, SNOM was introduced for abdominal stab wounds. Exploratory laparotomy remains the standard approach for abdominal gunshot wounds until 1990, when centers from United States and South Africa first reported cases successfully managed nonoperatively.

CONCLUSIONS

The trauma surgery has evolved continuously over the centuries, according to more and more severe modem injuries.

[Trauma--epidemiology: where are we today?]

INTRODUCTION

Understanding the epidemiological data on injuries is the cornerstone of modern interventions targeting prevention and treatment to decrease their mortality and morbidity.

METHOD

Systematic review of English literature using computer searching and selecting articles that describe the epidemiological data for the main causes of nowadays trauma.

RESULTS

Trauma meets the conditions of a pandemy, 5.8 million people dying evey year and 8.4 million being expected in 2020. Trauma is one of the main five causes of mortality and morbidity for all age groups below 60 years. Most deaths caused by road car accidents occur in young adults aged 15-44 years. Over half of deaths by drowning occur between 0-14 years. Over 40% of mortality by falls occurs in people over 70 years. 60% of deaths by poisoning occurs in people 15-59 years. Over 60% of human aggression mortality occurs in young adults aged 15-44 years. Suicide occurs most often in people between 15-44 years. Alcohol consumption is closely correlated with mortality and morbidity due to trauma.

CONCLUSIONS

Modem trauma system management should always consider that trauma mortality is the number most easily to measure and to reporte, but it represent only the tip of the iceberg.

[Laparoscopic approach in gallbladder agenesis--an intraoperative surprise]

INTRODUCTION

The congenital absence of the gallbladder in the absence of biliary atresia is extremely rare, world literature recognizing only 413 cases. The aim of this study is to clarify the diagnostic and therapeutic approach of this rare condition.

METHOD

There were retrospectively analyzed the first 2 cases of gallbladder agenesis admitted and surgically approached in the Emergency Hospital, Bucharest.

RESULTS

The first case (woman, 23 years old) had typically biliary complaints at admission, shrinked gallbladder and lithiasis on ultrasound. There was a laparoscopic approach but we didn't find any gallbladder. After a non-therapeutic laparoscopy the biliary symptoms disappeared. In the second case (woman, 52 years old) the admission was for upper abdominal quadrant colicative pain and the transparietal abdominal ultrasound showed chronic cholecystitis. Common bile duct dilatation was revealed during laparoscopy. After conversion to laparotomy there was performed intraoperative colangiography, but no other biliary pathology was revealed. The initial complaints also disappeared after surgery.

CONCLUSIONS

We find the laparoscopic approach an effective method for the diagnosis of gallbladder agenesis. Postoperative Magnetic Resonance Cholangiopancreatography represents a very useful imagistic tool to rule out an intrahepatic gallbladder.

[Selective nonoperative management of solid abdominal visceral lesions]

Selective nonoperative management of abdominal visceral lesions is one of the most important and challenging changes that occurred in the traumatized patient care over the last 20 years. The main advantage of this type of management is the avoidance of unnecessary/nontherapeutic laparotomies. The trauma surgeons who deal with this type of treatment are worried of missed abdominal injuries. Modern diagnostic tools (spiral CT, ultrasound, angiography, laparoscopy) allow the trauma surgeon to accurately characterize the lesions to be nonoperative addressed. This literature review discusses the main elements of selective nonoperative management of principle solid visceral lesions (liver, spleen, kidney). We highlight the advantages and limitations of the main diagnostic instruments used for evaluation of trauma patiens allocated to nonoperative management.