Pancreaticogastrostomy versus Pancreaticojejunostomy and the Proposal of a New Postoperative Pancreatic Fistula Risk Score

Despite the substantial decrease in mortality rates following a pancreaticoduodenectomy to less than 5%, morbidity rates remain significant, reaching even 73%. Postoperative pancreatic fistula is one of the most frequent major complications and is significantly associated with other complications, including patient death. Currently, there is no consensus regarding the ideal type of pancreatic anastomosis, as the question of the choice between a pancreaticogastrostomy and pancreaticojejunostomy is still open. Furthermore, worldwide implementation of an ideal pancreatic fistula risk prediction score is missing. Our study found several significant predictive factors for the postoperative occurrence of fistulas, such as the soft consistency of the pancreas, non-dilated Wirsung duct, important intraoperative blood loss, other perioperative complications, preoperative patient hypoalbuminemia, and patient weight loss. Our study also revealed that for patients who exhibit fistula risk factors, pancreaticogastrostomy demonstrates a significantly lower pancreatic fistula rate than pancreaticojejunostomy. The occurrence of pancreatic fistulas has been significantly associated with the development of other postoperative major complications, and patient death. As the current pancreatic fistula risk scores proposed by various authors have not been consensually validated, we propose a simple, easy-to-use, and sensitive score for the risk prediction of postoperative pancreatic fistula occurrence based on important predictors from statistical analyses that have also been found to be significant by most of the reported studies. The new pancreatic fistula risk score proposed by us could be extremely useful for improved therapeutic management of cephalic pancreaticoduodenectomy patients.

Experience of the Colentina Clinical Hospital Surgery Clinic in the Treatment of COVID-19 Patients Hospitalised in the Period March - August 2020

Introduction: SARS-CoV-2 is a Betacoronavirus belonging to the Sarbecovirus subgenus of the Coronavidae family, antigenically distinct from SARS CoV, with which it has a genetic similarity of about 76% of nucleotides (1). It causes the Covid-19 disease in humans, which mainly affects the respiratory system, through inflammatory and procoagulant mechanisms at the level of alveolar microcirculation. Material and method: There are 145 patients infected with SARS-CoV-2, treated in the Colentina Surgery Clinic during March-August 2020, whose cases were analysed to identify some elements that would help to improve the medical management of these patients from multiple perspectives. Discussion: There was a slight predominance of male impairments, and the ages of interest were mostly over 60 years. The cases that required surgery were in an absolute minority (14 cases). The operations were performed only in conditions of a surgical emergency. Mortality was high (24,13%).

Severe Bleeding Complications Resulting in Death Following Anticoagulant Treatment in COVID-19 Surgical Patients

Microthrombi formation in the pulmonary circulation is one of the main pathophysiological mechanisms responsible for the unfavorable respiratory evolution of CoViD-19 patients. Low molecular weight heparin (LMWH) anticoagulant therapy is a major pillar of treatment. But sometimes LMWH causes severe complications that can result in death. This is a retrospective, descriptive study, covering September 2020 and presenting 3 cases of severe hemorrhages followed by death in COVID-19 anticoagulated patients in therapeutic doses with LMWH in the hospital units of origin. Patients had hematomas of the rectus abdominal muscles and hemoperitoneum (2 cases) respectively hematoma of left gluteal muscles (1 case). The 2 patients with hematoma of rectus abdominal muscles were operated. The death occurred between 1-4 days after hospitalization.

New Options in the Management of Cystic Echinococcosis - A Single Centre Experience Using Minimally Invasive Techniques

OBJECTIVE

The aim of this study is to verify if the experience on 4 years in using minimally invasive techniques in the treatment of CE could match regarding the indications and results with the major studies on topic.

METHOD

During 03.2014 - 03. 2018 period, 38 PAIR, 28 MoCaT procedures and 7 percutaneous drainages have been performed at 51 patients from 76 cases of hydatid hepatic cysts (67,1%). There were 26 men and 25 women, and the age ranged from 19 to 78. 7 patients have had 2 hydatid hepatic cysts or more and 2 procedures were performed at 3 of those patients; other 11 patients needed the second procedure during the surveillance. Results: The evolution of the patients was favorable, and the surveillance was 2 years postintervention at least. There were no major surgical adverse effects. We defined as an expected result obtaining a scar lesion or a small cavity with calcified walls (hyperechoic). Only 2 (3,9%) patients needed conversion to open surgery. The complications we have faced were represented by the cystic-biliary fistula in 15 cases (29,4%) and the re-opening of the cyst's cavity in 11 cases (21,67%). Conclusions: The percutaneous treatment of CE is safe and effective, following the correct assignation according with the cysts type. The percutaneous treatment of CE is an easier alternative to the open surgery and has lower rate of complications and relapses, and a shorter hospitalisation. Now routine, it becomes slighty the first option for invasive treatment of CE. The role of open surgery is restricted to CE with severe complications.

RARE PRIMARY SMALL BOWEL TUMOR IN THE FORM OF CLASSIC KAPOSI’S SARCOMA: CASE PRESENTATION

The small bowel represents a rare site for primary neoplasms, with an incidence of less than 2% ofall that are located in the digestive tract. The early diagnosis of these tumors is often difficult due tothe lack of specificity of the clinical presentation, but it can make a difference in matters of 5-yearsurvival rates: 83% (early detection) versus 14% (late detection). We present the case of a malepatient, aged 66, with an apparently benign jejunal ulcer diagnosed endoscopically. Clinicalpresentation: diffuse abdominal pain, fatigability, melena; paraclinical evaluation: anemia,positive occult gastrointestinal bleeding test, superior and inferior endoscopy withouthemorrhagic lesions. The surgical exploration guided by intramucosal dye discovers a 2 cmtumor, 250 cm distal to the angle of Treitz with multiple mesenteric adenopathies. Segmentalresection is performed keeping oncological safety margins with the removal of the lymphaticdrainage elements. The postoperative evolution is favorable and leads to complete healing. Thehistopathological assay finds pathological changes consistent for Kaposi’s sarcoma and confirmsthe presence of HHV-8 in the nuclei of the tumor cells by means of immunohistochemistry. At theexamination of the skin, multiple purple patches were discovered. The particularity of this case isthat the Kaposi’s sarcoma manifests itself in the absence of an immunosuppressive treatment or animmunodeficiency state induced by an HIV infection. Although rare, the small intestine tumorsshould be considered when non-specific abdominal pain is accompanied by positive occult bleedingtest, with scarce endoscopic evidence. Since the Kaposi’s sarcoma is a highly angiogenic tumor, itis prudent to include it in the differential diagnosis when suspecting a source of gastrointestinalbleeding.

Hepatic hydatid cyst - diagnose and treatment algorithm

Introduction: the hydatic disease, caused by the larvae of Echinococcus granulosus, is a serious disease, potentially lethal, which can be found anywhere in the world, but especially in endemic areas such as the Mediterranean Basin, Australia, New Zealand, North Africa, Eastern Europe, the Balkans, Middle East and South America. The hydatic cyst is mainly found in the liver (75% of the cases), being asymptomatic in most cases and discovered accidentally on a routine abdominal ultrasound or an ultrasound performed for diagnosing other pathologies. The hepatic hydatid cyst therapy is multimodal, including medical, surgical, and, lately, minimally invasive techniques.

Materials and methods: 88 patients were diagnosed with liver hydatid cyst at the General Surgery Clinic of the Colentina Hospital in Bucharest where they were admitted from January 2014 to July 2017. Data collection was realized by consulting the patients’ observation sheets, followed by organizing a database of clinical, paraclinical and treatment parameters. Age, gender, place of origin, year and duration of admission, symptoms and signs at admission, paraclinical serological tests relevant for liver function and E. granulosus infection, imaging investigations performed and their results, type of treatment received and post-treatment progress with the complications that occurred were taken in account.

Results: some of the results of the study showed some differences comparing to the data from specialty literature, the possible causes being the small number of patients, the paraclinical examinations that were not sufficiently detailed to allow the study of a phenomenon in all its complexity, the lack of information from the patients’ first presentation to a doctor or from their previous admissions.

Conclusions: patients with hepatic hydatid cyst form a heterogeneous group, semiology being poor and unspecific. Among the laboratory examinations, eosinophilia is a sign of concern but is present in less than half of the patients. Imaging findings are the basis for the diagnosis of hepatic hydatid cysts. Surgical treatment remains the “gold standard” in therapy, but minimally invasive methods with high applicability, less frequent complications and lower hospital requirements are starting to gain ground.

Correction to: Hepatic hydatid cyst – diagnose and treatment algorithm

In the original publication, the corresponding author field has been omitted. The correct corresponding author name is: Bogdan Mastalier. The original article is now corrected.

Therapy of Stenosing Rectal Cancer

Develop a rectal cancer management aims to establish an algorithm diagnostic, surgical treatment strategy implementation, strategy and neoadjuvant and adjuvant treatment response and optimal methods for assessing response to specific treatment. In trying to track this management, we studied the issues listed above, we conducted a retrospective clinical study, descriptive and included the analysis of data obtained on a sample selected 90 patients diagnosed with stenosing rectal cancer between January 2008 and December 2012 treated on the General Surgery Clinic I of "Prof. Dr. Al. Trestioreanu" Oncology Institute and on the General Surgery Clinic of Colentina Clinical Hospital, in Bucharest and aimed at analyzing the therapeutic attitudes of stenosing rectal cancer. Choosing the surgery, especially when applying preoperative and postoperative radiotherapy, with or without concomitant chemotherapy, it took into account the presence of stenosis (obstruction complete or incomplete) and the evolutionary stage locally and remotely disease.

Multiple Intestinal Lymphoma

Gastrointestinal tract is the most common location for extralymphonodular lymphomas. The small intestine is affected only in 9% of the cases. Intestinal lymphoma may have single or multiple location. This paper describes a case of multiple location in the small intestine of a non-Hodgkin B-cell in a 53 years old patient, who was initially diagnosed with bilateral pneumonia with pleurisy with E. coli, steeper on the right side, but the persistence of symptoms as fever, malaise, despite appropriate treatment, required further investigation. The CT exam observed fluid collection in the hypogastrium around a digestive loop. The patient underwent surgery, the intraoperative foundings being: a large mesenteric tumor - 5 cm in diameter, a terminal ileal mesenteric tumor, a mesenteric tumor - 6 cm in diameter, omentum with nodular formations, a tumor - 3.3/2.5.1 cm in the abdominal wall, pseudotumoral appendix. Segmental. enterectomy with entero-enterostomy, excision of mesenteric tumors, appendectomy and omentectomy were performed. Pathological diagnosis was non-Hodgkin marginal zone B-cell MALT type lymphoma of the small intestine with extension to the appendix, meso, omentum and abdominal wall. Postoperatively, the patient received chemotherapy for remission.

Surgical treatment of colon cancer: Colentina surgical clinic experience

Most patients with colon cancer are surgically treated, with postoperative association of chemotherapy and possibly immunotherapy in advanced cases. Surgical treatment is chosen depending on the evolution stage, tumor topography and the existence of complications, colonic surgery being dictated by colonic vascularization. The radical character of the surgical intervention can be assured only in the early stages of the tumor. Colostomy is rarely necessary in patients with colon cancer. In the period of the last 5 years (2007-2011), 307 patients with colon cancer were operated in "Colentina" Surgical Clinic, radical intervention being possible only in 219 cases. 48 cases were emergency interventions for occlusion or perforation with peritonitis. Every time the mechanical preparation of the bowel was not possible, the intraoperative washout technique was used. Postoperative complications were met in 27 cases, being represented by bleeding (3 cases), peritoneal abscess (5 cases), anastomotic fistula (7 cases), abdominal wound infection (12 cases). In 5 cases the operation was done laparoscopically. Preoperative mortality was of 13 cases. Postoperative chemotherapy was done in the great majority of cases.