What to Do When There Is Something Unexpected?

BACKGROUND

Myocardial infarction is currently the leading cause of death worldwide, followed by malignant neoplasms. The presence of both within the same patient obviously increases the risk of death, as many coronary events are detected in patients diagnosed with cancer. Diagnosis of an occult digestive cancer in the acute phase of myocardial infarction is most frequently prompted by a hemorrhagic complication.

CASE SUMMARY

This case features an 81-year-old male patient diagnosed with acute myocardial infarction, treated with primary percutaneous intervention (PCI), who developed post-stenting hemorrhagic complications in the first 24 h due to the presence of two different concomitant malignant neoplasms. The outcome was favorable in the acute phase, even if de-escalation therapy was given immediately post-stenting, and intrastent residual thrombotic risk was high.

CONCLUSIONS

The presence of bleeding complications in patients with acute myocardial infarction should mobilize resources in search of a neoplastic cause, especially a digestive one. However, other locations should be looked for, depending on the source of bleeding.

Arterial Hypertension and Serum Uric Acid in Elderly- SEPHAR III Study

BACKGROUND

Hyperuricemia is a frequent finding in patients with arterial hypertension, and there is increasing evidence that this entity is also a risk factor for cardiovascular disease.

OBJECTIVE

In the context of an aging population, this study aims to evaluate serum uric acid levels and arterial hypertension prevalence and control in a subgroup of Romanian adults (>65 years), concerning the influence of age on these parameters.

METHOD

The study sample consists of 1,920 adults included in SEPHAR III survey, of whom 447 were elderly patients (>65 years of age). During the two study visits, three blood pressure (BP) measurements were performed at 1-min intervals and serum uric acid levels, kidney function by estimated glomerular filtration rate, blood pressure, and intima media thickness measurements were conducted. Hypertension and controls were defined according to the current guidelines. Intima-media thickness evaluation was assessed by B-mode Doppler ultrasound evaluation. A significance level p < 0.05 was adopted for the statistical analysis.

RESULTS

Adult patients had a significant lower serum uric acid levels, compared to elderly patients, regardless of glomerular filtration rate levels. Adult patients showed a significantly lower intima-media thickness levels, when compared to elderly patients.

CONCLUSION

Similar to previous studies, in the present study, age represented one of the factors contributing to the increased level of serum uric acid. An increasing prevalence of arterial hypertension with age, together with a poor control of blood pressure, was also obtained.

Complicated Sonographic View of Diffuse Hepatic Steatosis

The aim of this study was to reveal the important role of CEUS in identifying correctly benign hepatic lesion vs a malignant one. We report a case of a diffuse hepatic steatosis particular sonographic aspect in a middle aged male presenting with general malaise. History revealed cardiac pathology, diabetes mellitus type 2 and chemotreated prostate neoplasia. The abdominal ultrasound (US) presented numerous hyperechoic lesions disseminated in the whole parenchyma. A contrast enhanced ultrasound (CEUS) of the lesions described an isoenhancement pattern of the lesions in the arterial phase, followed by the same aspect in the venous phase, with a high uptake pattern in the late phase. The CT and MRI also confirmed a diagnosis of a benign pathology. Hepatic steatosis may occur in chemotreated cancer patients, raising a suspicion of hepatic metastasis, but also due to the amount of lipid deposit distribution in the liver. Thus, CEUS was able to establish a correct diagnosis in a fast and reliable way.

Clinical and Laboratory Aspects of the Severity of Pulmonary Embolism in Elderly Patients versus Adult Patients A single centre study

Pulmonary thromboembolism is currently one of the leading causes of disease burden and mortality in Europe, also known as the great masquerader, for its ability to mimic other diseases or to present itself with few symptoms, especially when the pulmonary embolism is very small. With aging population, increased survival of cancer patients and the addition of multiple debilitating diseases such as dementia, heart failure, chronic kidney disease the rate of pulmonary embolism is spiking, with more and more small pulmonary embolism being diagnosed, that may have no immediate impact on mortality, but which may contribute to an increase in morbidity. We have examined retrospectively 108 consecutively cases of pulmonary thromboembolism that have presented in the Emergency Department of Municipal Hospital in Timisoara, Romania over the course of twenty-one months from September 2016 to May 2018 and we evaluated the clinical and laboratory findings in studying the influence of age over the severity of pulmonary embolism.

Contrast Enhanced Ultrasound of Splenic Lymphoma Involvement Case presentation

The study present a case of splenic lymphoma in a middle-aged male, showing up with abdominal pain, weight loss and recurrent oral candidosis. Blood test revealed remarkable leukocytosis, anemia and thrombocytopenia. Abdominal ultrasound showed marked splenomegaly with multiple hyperechogenic lesions. Contrast enhanced ultrasound (CEUS), performed on the lower pole of the spleen, showed a lesion lightly hypoenhanced in the arterial time, with progressive washout and marked hypoenhancement in the late phase, raising the suspicion of a malignant pathology. MRI results were consistent with a high suspicion of splenic malignancy, a possible lymphoid infiltration. The peripheral blood smear revealed lymphocytosis with villous lymphocytes, a variant form of hairy cell leukaemia. Iliac crest bone marrow biopsy confirmed the diagnosis. Our aim behind highlighting the topic is to underline the role of CEUS in identifying a malignant lesion, promptly leading us to further hematological investigation.

The value of contrast-enhanced ultrasound in the characterization of vascular pattern of solid pancreatic lesions

The AIM of our study was to evaluate the accuracy of CEUS in the characterization of pancreatic solid lesions, considering cross sectional imaging techniques (CE-CT/MRI) as the "gold standard" methods.

MATERIAL AND METHODS

We performed a retrospective, monocentric study that included 91 solid pancreatic lesions which were evaluated by CEUS and by a second-line contrast imaging technique (CT or MRI), considered as the reference method.

RESULTS

The rate of a conclusive diagnosis based on a typical enhancement pattern was 94% (78/83 cases). In 72 cases out of 83 (86.7%) there was a perfect concordance between CEUS and the "gold-standard" imaging method (CE-CT/MRI). In our study, 88% (73/83) of the pancreatic lesions were categorized as malignant due to their typical wash-out aspect in the late phase. The overall accuracy of CEUS for the differential diagnosis of solid pancreatic tumors was approximately 81%. The accuracy of CEUS for the diagnosis of hypoenhancing pancreatic tumors was approximately 89.1%; while for the diagnosis of hyperenhancing pancreatic tumors it was approximately 72.8%.

CONCLUSION

CEUS allows the differentiation between hypo- vs. hyperenhancing pancreatic solid lesions, with a considerable diagnostic accuracy, a fundamental step in the precise diagnosis of pancreatic tumors.

Contrast enhanced ultrasound in the pathology of the pancreas - a monocentric experience

The

AIM

of this study was to summarize the spectrum of pancreatic pathology assessed by contrast enhanced ultrasound (CEUS) in a single Gastroenterology Center and to emphasize its accuracy in assessing two of the most important pancreatic lesions: solid tumors and necrotic lesions in acute pancreatitis.

MATERIAL AND METHODS

Our retrospective study included 197 patients with pancreatic lesions (de novo pancreatic masses; acute, severe pancreatitis; other pathologies) evaluated by CEUS from October 2009 to May 2013, in which a reference method (contrast CT/MRI) was available.

RESULTS

A conclusive diagnosis was established according to the EFSUMB Guidelines in 87.8% of the 197 cases. In 87.3% cases there was a perfect concordance between CEUS and the reference method (contrast CT/MRI). 95 examinations were made for pancreatic solid masses: 41.1% (39) were hypoenhanced, 34.7% (33) were hyperenhanced, and 20% (19) were isoenhancing - chronic pancreatitis and autoimmune pancreatitis - while in 4.2% (4) cases CEUS was inconclusive. 60 examinations were made in severe acute pancreatitis and in 50% (30) cases pancreatic necrosis was diagnosed. 42 examinations were performed for other lesions: 64.2% (27) pancreatic pseudocysts, 11.9% (5) cystic tumors, 23.8% (10) other pathologies (abscesses, fibrosis, etc). CEUS accuracy for solid tumors was 92.9%. For necrotic lesions the accuracy was 97.4%.

CONCLUSIONS

CEUS has turned to be a good method for the characterization of different pancreatic pathologies and for evaluating acute pancreatitis. CEUS was conclusive in 90% cases and it should be considered as a first line imaging method in clinical practice.

The Correlation of Il28B Genotype With Sustained Virologic Response In Romanian patients With Chronic Hepatitis C

BACKGROUND

Multiple variables influencing the sustained virologic response (SVR) in chronic hepatitis C have been evaluated. One of them is genetic polymorphism near the IL28B gene.

OBJECTIVES

The aim of this study was to evaluate the influence of IL28B genotypes on SVR rates in a group of patients with chronic hepatitis C from the western part of Romania.

PATIENTS AND METHODS

A retrospective study was performed in 107 consecutive patients, previously treated with standard-of-care medication for chronic hepatitis C, identified from the databases of 2 centers. Patient demographics, viral load before treatment and at 12, 24, and 72 weeks from the treatment start, and IL28B genotype were evaluated.

RESULTS

Among the 107 patents in the study group, 54 patients had SVR (50.5%), and 62 (57.9%) showed a complete early virologic response (cEVR). The SVR rates according to IL28B genotype were as follows: 73.1% in patients with genotype C/C, 40.9% in those with genotype C/T, and 57.1% in those with genotype T/T (i.e., 73.1% among patients with the C/C genotype vs. 43.7% among those with non-C/C genotypes; P = 0.0126). The cEVR rates were 80.8% in patients with the C/C genotype vs. 51.2% in those with non-C/C genotypes (P = 0.011).

CONCLUSIONS

In our cohort of 107 Caucasian HCV patients, the SVR rate was 50.5% with standard-of-care treatment. The SVR rate was directly related to the IL28B genotype: 73.1% in the C/C genotype vs. 43.7% in non-C/C genotypes (P = 0.0126).

Contrast enhanced ultrasound for the characterization of hepatocellular carcinoma

AIM

Contrast-Enhanced Ultrasound (CEUS) is an imaging method that can discriminate between hepatocellular carcinoma (HCC) and other liver lesions. The purpose of this study is to present our experience concerning the use of CEUS in the characterization of HCCs.

MATERIAL AND METHOD

We included in our study all the patients evaluated in our Department from September 2009 to October 2010, with focal liver lesions (FLLs) on abdominal ultrasound (US) that were diagnosed as HCCs after CEUS examination, also patients with chronic liver disease with focal liver lesions highly suspected to be HCCs but with an inconclusive pattern on CEUS. One hundred patients with 148 HCCs were included. The enhancement pattern of the nodules was evaluated according to the 2008 EFSUMB Guidelines. Nodules displaying arterial hyperenhancement with "washout" in the portal/venous phase on CEUS were considered diagnostic for HCC. Nodules considered indeterminate after CEUS were evaluated by contrast-enhanced CT or MRI for diagnosis.

RESULTS

Among the 100 patients included, 96 were patients with chronic liver disease and 4 were patients without known liver disease. 71 patients had a solitary nodule, 16 patients had two nodules and 13 patients had three or more nodules. 112 HCCs had a typical enhancement pattern and 36 nodules were considered indeterminate after CEUS and were sent to CT/ MRI for diagnosis.

CONCLUSIONS

75.7% of the studied liver nodules were diagnosed by CEUS as HCCs, thus CEUS is an easy method, convenient to perform, avoiding other expensive examinations.

A case of a giant sacrococcygeal teratoma

Sacrococygeal teratomas are congenital tumors of newborns, originate from one or more of the three germinal layers. Most sacrococygeal teratomas are found in newborns, infants and children youger than 4 years. The prenatal ultrasound exams have increased the number of sacrococygeal teratomas presenting in fetuses. Radical resection, including the coccyx must be performed even if the primary lesion is benign in up to 70% of cases. We report a 16 days old baby girl presented with a large, type 111 sacrococygeal teratoma. The tumor was diagnosed only at 36 weeks of pregnancy. The teratoma was disected from the surrounding structures and excised en bloc with the coccyx. The postoperative recovery was uneventful. There are good functional and cosmetic results at six months follow-up.

[Surgical management of colonic diverticular disease]

Diverticulosis is a common condition and affects one third of patients older than age 45. The treatment of the diverticular disease and of its complications, especially the acute inflammatory ones, is both medical and surgical. It is essential to correlate the two therapeutic means and to set an adequate time for the operation. The present study evaluates in a retrospective manner a number of 231 cases, 49% of which represent complicated forms. Fifty-eight patients underwent a surgical operation, 25 of which needed an emergency intervention. The results of the study show the increase of 1-stage procedures for the complicated forms and recommend laparoscopy as an alternative to open surgery. Recent studies have challenged the prophylactic nature of surgical operations after diverticulitis indicating a need for further evaluation.

[Pancreatico-jejunal vs pancreatico-gastric anastomosis after cephalic duodenopancreatectomy]

Pancreatoduodenectomy has been for a long time a procedure with high postoperative morbidity and mortality. Several complications after pancreatic resections are known, but one of the most severe is the fistula of the pancreatic anastomosis. Avoiding the pancreatic fistula caused many surgical innovations regarding the procedure of reestablishing the continuity after pancreatoduodenectomy. The aim of this retrospective study was to compare pancreatico-jejunostomy vs pancreatico-gastrostomy with regard to safety of pancreatic anastomosis after pancreatoduodenectomy. No technique was proved to be superior so far, the benefits of these 2 types of pancreatic anastomosis being the subject for intense debates. From 2000 to 2004, 17 patients underwent pancreatoduodenectomy, for pancreas, ampulla, distal bile duct or duodenum cancers. Pancreatic anastomosis was accomplished by pancreatico-gastrostomy in 11 cases and by pancreatico-jejunostomy in 6 cases. There was no significant difference between the two groups (age, gender and primary disease). Comparison between the two groups was made mainly analysing postoperative mortality and morbidity. Postoperative morbidity was 9,1% after pancreatico-gastrostomy and 33,3% after pancreatico-jejunostomy. Postoperative mortality was none after pancreatico-gastrostomy and 16,7% after pancreatico-jejunostomy. This study seems to demonstrate the superiority of the pancreatico-gastric anastomosis, but in most cases the surgeon will choose based on his experience. These results have to be confirmed or invalidated by a prospective multicentric randomised study.

Evaluation of urinary and faecal continent stomas

OBJECTIVES

To evaluate the outcome and complications of urinary and faecal continent catheterizable stomas.

PATIENTS AND METHODS

Retrospective record review of all patients operated on in our institution within the last 6 years.

RESULTS

Fifty-five children received 63 stomas. The mean age at operation was 9.2 years and the mean follow-up period was 2.8 years. The diagnoses were: neurogenic bladder (n=22), bladder or cloacal exstrophy (n=20), anorectal malformation (n=6), persistent cloaca (n=3), Hirschsprung's disease (n=2), posterior urethral valves (n=1) and prune belly syndrome (n=1). There were 35 urinary stomas and 28 faecal stomas. Eight patients received both stomas. Both the appendix and a transverse tubularized intestinal segment (Yang-Monti technique) were used; in some cases a caecal flap was created. In three patients the appendix was divided and used to construct two stomas. The implantation of urinary stomas was into the native bladder in 24 patients and into the intestinal segment of an augmented bladder in 11 cases. The location of the stoma was umbilical in 20 cases, right lower quadrant of the abdomen in 35, neo-umbilicus in five and left lower quadrant in three. When an extra-umbilical location was chosen skin flaps were used. Excellent cosmetic and functional results were achieved in 53 (84.2%) of the 63 stomas, which are continent and easy to catheterize. Two had acceptable results with minor problems. There were eight re-operations (12.6% of stomas, 14.5% of patients). The reasons for the re-operations were difficult catheterization in two, incontinence in three, and mucosal prolapse in three patients in whom skin flaps were not used. Of the eight re-operations, seven were in urinary stomas and one in a faecal stoma. Urinary incontinence was attributed to shortening of the intravesical tunnel. No difference in results was observed between the different techniques used, with the exception that cutaneous anastomosis without skin flaps had to be revised because of prolapse, and two out of three incontinent channels had been constructed with tubularized ileum.

CONCLUSIONS

Catheterizable continent urinary and faecal stomas achieve the objectives of urinary and faecal continence and independence in most patients with a low complication rate.

Expression of β-Catenin in Hepatocellular Carcinoma

Alteration of β-catenin expression is involved in the development and evolution of hepatocellular carcinoma (HCC); β-catenin is able to influence tumor cell proliferation. We analyzed the immunohistochemical (IHC) expression of β-catenin on a group of 32 patients diagnosed with HCC using the anti-β-catenin monoclonal antibody (clone E247). We correlated the expression of β-catenin with the proliferation index of Ki-67 (PI Ki-67), the mitotic index (MI) and other clinical and pathological features. We observed an altered β-catenin expression in 58.38% of all HCC cases. This expression was insignificantly correlated with tumor size (]5 cm) (p = 0.683), histological grade G1-G2 (p = 0.307), vascular invasion (p = 0.299) and advanced pT stage (p = 0.453); we obtained a significantly higher MI in HCC with altered β-catenin expression (p = 0.018), as compared to HCC without overexpression (1.66 � 1.37) (p = 0.038) and a PI Ki-67 of 22.49 � 20.1 and 28.24 � 18.2, respectively in tumors with altered β-catenin expression with insignificant differences compared to HCC without overexpression (25.95 � 15.2) (p = 0.682 and p = 0.731, respectively). According to the results we obtained, aberrant β-catenin expression in HCC was correlated with a high mitotic index, therefore playing an important role in tumor progression by stimulating tumor cell proliferation; non-nuclear β-catenin overexpression can have a pathological significance in HCC, especially in cases of HCC associated with hepatitis B virus (HBV) infection.

[Retroperitoneal tumors of nervous origin in adults]

Adult's retroperitoneal tumours of nervous origin are infrequent clinical entities with characteristic evolution and treatment. We review 13 cases, dealt with in N. Gh. Lupu Surgical Clinic between 1975-1994 and representing 20% of the retroperitoneal tumour admitted in our clinic during the same period. Most of the patients were males (sex ratio 10:3). The main symptom was the abdominal pain (84.6% of all cases) and all the tumours were extremely big (15-30 cm diameter). The surgical approach always tried to remove the tumour, which succeeded, even if in 4 cases some of the surrounding organs had to be removed also. The two postoperative complications consisted in a severe wound infection and an acute pancreatitis; the second evolved poorly and the patient was lost. No complementary therapy was used. None of the five patients followed up for five years presented clinical evidence of recurrent tumour.

CONCLUSIONS

Due to an unexplained evolutive tolerance, adult's retroperitoneal tumours of nervous origin reach large dimensions and have late clinical expression, as the complications occur. Preoperative imagistic findings supply valuable informations for the subsequent surgical treatment. The surgical approach must aim to the ablation of the tumour, with or without the sacrifice of other organs which the tumours can include. This aggressive surgical conduite is sustained by the satisfying postoperative results.

[Displaced fractures of the middle third of the forearm in children. The therapeutic considerations]

There been studied 100 cases of fractures of the middle third of both bones of forearm in child for to assess the correctitude of the therapy, based on the analysis of results. The most correct surgical techniques consist of osteosynthesis with Kirschner wire of the both bones, knowing the particularities of the fracture linea in child and the minimal tissues' damages. In the child younger then 10 years old, the open reduction is rarely necessary. Any displaced fracture of middle third of both bones of forearm, whatever the age of the child would be orthopedically reduced, before performing the surgical therapy. The unstable osteosynthesis such as simple screw "osteosynthesis" with wire or thread are contraindicated.

[Surgical treatment in osteochondritis of the femur head in children]

The goal of surgery in the femoral head osteochondritis of children is, in the cases progressing towards extrusion, to ensure a good coverage of femoral head. Under the age of 5-6 years, the evolution being more commonly benign, the surgical containment is rarely indicated. In the child over 7 years, the extrusion of femoral head being common, a surgical intervention for correcting it is necessary. This paper is based on a statistics on 36 children operated upon at the Clinic of Pediatric Surgery and Orthopedics of Iaşi between 1980 and 1990. Eighteen femoral osteotomies, 10 Chiari pelvic osteotomies and 8 triple pelvic osteotomies were performed. It is assumed that femoral osteotomy is rarely indicated and Chiari osteotomy is required for hip salvage when other techniques cannot be used. The triple pelvic osteotomy, when indicated, has to be used more frequently, leaving aside the reticences towards this method.