The prevalence of acute appendicitis as the number 1 inflammatory disease, occurring in 1 out of 500-600 inhabitants of the world population, has made it imperative for us to study the pathology of the inflammation in the presurgery stage. The present paper is a retrospective study, conducted on 147 patients diagnosted and operated for acute appendicitis in our clinic, between October, 1st, 2009 and January, 15th, 2012. The pre-surgical stage comprised clinical data, and also an important number of paraclinical data, out of which, for the purpose of this presentation, we selected bilirubin and leukogram. These pre-surgery biological markers were correlated to the post-operatory pathological anatomy results. These results confirmed our hypothesis that the paraclinical stage in diagnosing the acute appendicitis consists in the inflammation prognosis factors, which can be highlighted through a complex paraclinical range of methods, later confirmed by both the clinical stage, and its anatomo-pathological forms.
Amyand's hernia, a rare entity in the surgical pathology, presupposes the presence of the vermiform appendix inside a inguinal hernia sac (1). The hernia sac peritonitis by appendix swelling is even more rare, very few cases being presented in the surgical literature (1). The preoperatory diagnosis of Amyand's hernia is therefore very difficult. We herein present the case of a 71-year old male patient, operated on an emergency basis for hernia, which eventually turned out to be Amyand's hernia, a case which determined us to research the literature dedicated to this topic.
The 48 year old patient, admitted to the Clinic IV for Digestive Surgery – Emergency University Hospital, presenting with symptoms of acute abdomen: intense diffuse abdominal pain, paleness of tissue and mucous membranes, nausea and vomiting. Pain started abruptly and agressively in the epigastrium 12 hours before admission to the hospital and then it spread to the abdomen, analgezic, not responding to the usual analgesic treatment. The anamnesis showed the patient repeatedly accused pain in the superior abdominal compartment, associated with nausea and vomiting, interpreted as dyspeptic syndrome of (probably) biliary etiology, responsive to the antispastic treatment. Intraoperatively, a diagnostic was established: hemoperitoneum due to the spontaneous rupture of a voluminous tumor (>10 cm), with extraluminal evolution in the gastric fornix and the macroscopic outlook of a GIST. Total gastrectomy is performed, with DII lymph node dissection (lymphadenectomy) and reconstruction of digestive continuity through Roux-en-Y eso-jejunal-anastomosis. The anatomo-pathological exam highlighted a gastrointestinal stromal tumor (GIST), TNM staging: pT4; pN0 (0/17); LV0; Pn0; R0. The patient had a favourable evolution. Since this type of pathology is extremely rare and difficult to diagnose, we believed it would be useful to present and review its micro and macroscopic aspects.
During 1985-2014 in our Clinic nearly 4,925 gastrostomes were performed, for a large variety of pathologies: benign and malign esophageal stenosis, esophageal fistulas, posttraumatic ruptures, iatrogenic pathology, strokes. Among those, some were definitives and the others were temporary. We used Gavriliu technique with peritoneal collar in 96% of the cases. During those 30 years we managed to establish an immediate and long-term care protocol of the feeding gastrostomes. This protocol contains specific measures for the monitoring of the vital parameters, biological and metabolical ones, but also the close analysis of the gastric stasis, the imposing of the digestive repose during the first 48-72 hours, the continue follow-up of the quality and the rhythm of alimentation and the mechanical protection of the Pezzer tube. The efficiency of this type of nursing consists in the introduction of food after 48-72 hours, with the second stage of efficiency of the gastrostomy in the same time with the long-term care of the associated oncological and metabolical complications. Due to the importance of the moment of the surgical indication, the technique and nursing that has been used, the survival of the patient with definitive gastrostomy has significantly improved. The elimination of the temporary ones didn’t involve in most of the cases surgical closing.
We present the case of a 58-year old male patient admitted in the surgery section of the University Emergency Hospital of Bucharest and diagnosed with acute abdomen. The minimal clinical-paraclinical investigation (i.e., thorax-pulmonary Xray, biological probes) raises questions as to the differentiated diagnosis and other associated diseases, also suggesting the existence of voluminous diaphragmatic hernia. The CT thorax-abdomen examination confirms the diaphragmatic hernia suspicion, with intra-thorax ascent of the colon up to the anterior C4 level, but does not explain the abdominal suffering; thus we suspected a biliary ileus or acute appendicitis. Medial laparotomy was imperative. Intrasurgically peritonitis was noticed located by gangrenous acute apendicitis, perforated, with coprolite, for which apendictomy and lavage-drainage pf the peritoneal cavity was performed. Post-surgical status: favourable to recovery.
The article presents the case of a male patient, hospitalized due to severe pain in the upper abdomen area, nausea, and vomiting. The patient was diagnosed with surgical acute abdomen, for which emergency surgery is performed. Upon penetration into the peritoneal cavity, stomach inspection shows at the medio-gastric level, on the greater curvature, a callous gastric ulcer, with a central perforation. A large excision is decided up to the healthy (normal) gastric tissue, and the resulting pieces are sent to the pathological anatomy laboratory. The histopathological exam reveals signet ring cell recent gastric carcinoma. The biopsy performed 1 month after surgery, prelevated from the antropyloric zone, reveals antropyloric gastritis with moderate activity and Helicobacter pylori positive. Due to the fact that such cases when this gastric cancer type is diagnosed in recent stages are extremely rare, we considered it useful to present it and look into its macroscopic and microscopic aspects, as well as into the differentiating diagnosis.
We provide the description of a 77 year old patient, admitted into the IC unit, with whom the surgical intervention was required by the presence of a massive pneumoperitoneum observed during abdominal CT. Anamnestic and clinical information was scarce; the patient had been admitted into the gastroenterology unit with the following diagnosis: acute pancreatitis, renal failure, atrioventricular block, while the hemodynamic instability made hospitalisation into the IC unit mandatory. Anatomopathological lesions secondary to a major vascular damage at the level of the celiac trunk and at the superior mesenteric level were noticed intraoperatively: total gastric necrosis with perforation, splenic infarction, entero-mesenteric infarction, abdominal wall necrosis. The patient did not allow for a surgical solution. The anatomopathological examination of the gastric tissue fragment enabled the diagnosis of extensive gangrene of the gastric wall. The relevance of the case consists in the presence of an abdominal vascular damage detected in full development, where the pneumoperitoneum required surgical exploration. The intricacy of the anatomopathological lesions accounts for the acute painful abdominal onset, accompanied by quick hemodynamic, clinical, and biochemical deterioration. Thus, gastric perforation through rupture secondary to total gastric gangrene of vascular origin joins the many causes of pneumoperitoneum.
The occurrence of left colon neoplasm is increasing and, despite the continuous improvement of the surgical treatment, the death rate consequent to this disease has remained constant these last few years. (1) The economically efficient medical management is currently a general concern worldwide and – in this context – the cost analysis is an important step forward in the joint eff ort to reach medical economic efficiency. (2)
Objectives. The aim of the study was to compare the postoperative and oncologic outcomes of small bowel versus gastric surgery for gastrointestinal stromal tumors (GISTs). Background. The feasibility of the small bowel resection for GIST has been demonstrated; however, its impact on outcomes, particularly its oncologic safety for tumors greater than 5 cm, remains unknown. Methods. Among 93 patients treated for a stromal tumor in SUUB between 2001 and 2015, patients who underwent primary resection for a gGIST smaller than 20 cm (N = 66), by either small bowel (group S, n = 28) or gastric surgery (group G, n = 38), were compared. Multivariable analyses and propensity score matching were used to compensate for differences in baseline characteristics. Results. In hospital mortality and morbidity rates in groups S and G were 0.0% versus 2.6% (P = 0.086) and 10.7% vs 18.4% (P = 0.004), respectively. Small bowel resection was independently protective against in hospital morbidity (odds ratio 0.54, P = 0.014). The rate of R0 resection was 96.4% in group S and 92.1% in group G (P = 0.103). After 1:1 propensity score matching (n= 22), the groups were comparable according to age, sex, tumor location and size, mitotic index, American Society of Anaesthesiology score, and the extent of surgical resection. After adjustment for BMI, overall morbidity (9.1% vs 19.6%; P = 0.005), surgical morbidity (4.5% vs 9.1%; P = 0.048), and medical morbidity (4.5% vs 13.6%; P = 0.01) were significantly lower in group S. Five year recurrence- free survival was significantly better in group S (89.3% vs 82.6%; P = 0.011). In tumors greater than 5 cm, in hospital morbidity and 5 year recurrence- free survival were similar between the groups (P = 0.255 and P = 0.423, respectively). Conclusions. Small bowel resection for GISTs is associated with favourable short term outcomes without compromising oncologic results.
Surgical procedures with curative or palliative intention in colo-rectal neoplasm in subjects aged over 80 represent a surgical challenge due to the issue they raise: benefits versus increased morbidity. In Romania, according to demographic predictions, the population over the age of 65 will double in the next half century. This, correlated with the increased incidence of colo-rectal cancer in subjects pertaining to the 60- 69 age period and higher, determined us to identify the factors that can influence the occurrence of complications and post-surgery deaths in subjects over 80 years of age that were operated on for colo-rectal cancer.This paper includes a retrospective analysis of patients aged over 80, diagnosed and treated for colo-rectal cancer in the 4th Surgery Department of the University Emergency Hospital in Bucharest, in the period 2000 - 2011, following the type of surgery, morbidity and postoperative mortality. Out of a total of 297 cases of patients operated on for colo-rectal cancer, 36 were identified with the age over 80, age average being 83 years (80-91).Out of the total 36 patients aged over 80 years, 22 were subject to surgical procedures with curative intention (in 16 of these subjects a right hemicolectomy was performed and in 6 a left hemicolectomy), the remaining 14 subjects receiving palliative surgical treatment. The factors that negatively influenced post-surgery evolution were diabetes, pre-existing cardiac pathology, evolutionary stage of cancer and the urgency character. In the group with resections, we found a 27.2% (6 cases) morbidity rate and a 18.2% (4 cases) mortality rate. In patients undergoing palliative surgery, the morbidity rate was 28.5% (4 cases) with a mortality rate of 14.3% (2 cases).Between the 2 groups of patients postoperative morbidity and mortality appeared to be equal. Most often, they were caused by pre-existing cardio-pulmonary pathology and by the urgency character of the surgery, that did not allow a proper rebalancing, and in a lesser extent by the type of surgery. During those 12 years, the percentage of patients aged over 80 years diagnosed annually with colorectal cancer remained constant. Despite advanced age and associated comorbidities, we consider the postoperative evolution to be satisfactory, although postoperative morbidity and mortality were higher than in the general population, according to the literature. Preoperative compensation of associated comorbidities, a surgical procedure performed by experienced teams, together with the ensuring of adequate intensive therapies are required to reduce postoperative risks.
