Double suturless hepaticojejunostomy

In iatrogenic lesions of the main bile duct, especially when the injury is above the level of the hepatic bifurcation, the surgeon ought to use two short and thin biliary stumps. It is necessary to perform separate anastomoses, using a "Y loop" and creating a double hepaticojejunostomy. Technical difficulties increase when the biliary ducts are thinner, tighter and separated from one another for a distance more than 2 cm. In such case we have attempted to develop a double sutureless hepaticojejunostomy by simply keeping the bilioenteric partners in apposition with continuous traction exerted via the biliary stents.

Juxtapapillary duodenal diverticula early and late clinical and therapeutical implications

The aim of this paper is to identify the early and late implications of JPDD for biliary pathology, as well as for endoscopic therapy and classical surgery dealing mainly with lithiasis. This paper is based on a retrospective study comprising a number of 675 ERCP performed on 601 patients between 1997-2007, out of which 399 cases were followed by therapeutic measures. A total of 79 procedures were performed on 65 cases with JPDD. The main criteria were: gender, age, indications regarding the performance of ERCP+/-ES, complications that occurred while carrying out these procedures. In all the cases examined (601) the percentage of JPDD reported was of 10.81%. The rate of complications in the sphincterotomized patients without JPDD was 5.75% and the rate in the sphincterotomized patients with JPDD was 14.89%. In conclusion, the paper discusses the clinical and therapeutic implications of JPDD in biliary pathology. It has been found that JPDD is an important etiological cause for the late diseases occurring after cholelithiasis surgery. JPDD also leads to immediate therapeutic implications such as: difficult cannulation and high incidence of ERCP+/-ES complications.

[The reassessment of indications in laparoscopic cholecystectomy]

The gallstone, with its potentialy complications, claims a surgical solution in asymptomatic forms too, often traced out with the abdominal echography investigations circumstances. In all the countries, the symptomatic gallstone, is a surgicaly section, but, the asymptomatic gallstone is a surgicaly indication in some countries, too. A number of transplantation surgeons have begun to recommend pretransplant cholecystectomy for asymptomatic patients to have gallstones. The indications can be extended to: young children, pregnant women, patients with very large gallstones diabetics, immuno-depressed (AIDS, radiation and multiple drug treatments). The asymptomatic gallstone seems to obtain in the last years, an extention of the surgicaly approach indications, the paper, suggesting a laparoscopic cholecystectomy assessment indications.

External drainage of the hepatic post hydatid remnant cavity

BACKGROUND AND AIM

The surgical management of the hepatic post hydatid remnant cavity includes conservative and radical methods. External drainage of the remnant cavity (with or without cavity-minimizing) is a simple conservative method that can be safely performed, and can be associated with endoscopic papillo-sphincterectomy (EPS) in case of cysto-biliary fistula.

METHODS

A retrospective study was performed on 112 patients operated in the Department of Surgery, "Caritas" Clinical Hospital, Bucharest between Jan 1997 and Feb 2007. Cavity was drained and the completely extraperitoneal approach for exteriorizing the drain was preferred, an original method conceived and put into practice by Prof. Dr. Burlui, using as pathway the round ligament, more precise the hepato-umbilical territory.

RESULTS

The mean hospital stay was 12 days, and follow-up till complete recovery was performed by clinical, ultrasound, CT-scan and X-ray contrast on the drainage tube. The drainage of the remnant cavity was maintained a mean period of 55 days (ranging 20 to 80), in accordance with the X-ray contrast control on the drainage tube. The postoperative morbidity was acceptable (remnant cavity infection was registered in 11% of the cases). Neither reintervention, nor mortality was registered.

CONCLUSIONS

the study shows that external drainage of the hepatic post hydatid remnant cavity can be applied in most of the parasite locations, especially for the central segments, with no hepatic parenchyma sacrifice, while total cavity fibrosis is achieved in a mean period of 55 days. This way we avoid a risky and laborious procedure (the anatomic or non-anatomic removal of a variable amount of normal hepatic tissue).

Late choledochal pathology after cholecystectomy for cholelithiasis

After "simple" cholecystectomy for lithiasis, biliary disorders can appear, with the onset more than 3 years postoperative, like cholangitis or transitory jaundice. Meantime, a whole range of congenital abnormalities initially ignored can become manifest: biliary tract congenital dilatations, duodenal para-Vater diverticulum, Oddi stenosis.

AIM

to establish the pathological circumstances that determine late choledochal syndrome, including an analysis concerning the therapeutical approach in these cases. Patients with cholecystectomy complains of late biliary disorders (least 3 years symptom-free) between 1997-2005, were retrospectively studied. Exclusion criteria were intraoperative incidents or accidents, recognised incomplete surgical procedure, early difficult postoperative course. Therapeutical approach was endoscopical, surgical or conservative. 46 patients entered the study group; 38 underwent open cholecystectomy. Mean interval between operation and disturbances onset was 10 years. Following etiopathologic causes of late choledochal pathology were recorded: incomplete cholecystectomy, retained or primary common bile duct (CBD) stones, choledochal cyst or stenosis, Oddi stenosis, duodenal para-Vater diverticulum, anomaly biliary tree. Thirty patients undergone successful endoscopic treatment; in 8 cases endoscopy failed, in 2 cases open surgery was the first choice; 5 diagnostic endoscopic cholangiography with conservative treatment were performed; 1 patient refused any procedure. Cholecystectomy indication is regularly based on clinical and ultrasound examination criteria. Even a simple cholecystectomy can be followed after first 3 years by cholangitis, obstructive jaundice, caused by initially ignored biliary tract pathology. To avoid such omissions, routine intraoperative cholangiography and duodenal endoscopy should precede cholecystectomy. On the other side, cholecystectomy itself can cause late complaints: retained CBD stones, gallbladder stump, and iatrogenic stenosis. The duodenal para-Vater diverticulum seems to have a more important role in biliary disturbances, before and after cholecystectomy.

[Acute necrotizing enteritis]

The authors present a retrospective clinical study done on a 13-pacients basis diagnosed during surgery with acute necrotizing enteritis. This study follows the complexity of pathogenic factors and the difficulties one confronts with when establishing a diagnosis since the clinical manifestations are non-specifical and shows the contribution of laboratory data to an earliest possible diagnosis. Both medical and surgical treatment are analyzed depending on the results achieved with an attempt to determine a therapeutic approach as beneficial as possible, aiming at making clear either enterectomy or a conservatory surgical decision should be made. Mortality rate under such therapeutical approach was 38%.

[Cefepime (Maxipime) treatment efficacy in surgical patients ]

Between September and December 2001 in the "Caritas" Surgical Clinic of Bucharest has been conducted a clinical study for the efficiency of Cefepime (Maxipime) treatment in surgical patients. Introduced in therapy in the last decade of the XXth Century, Cefepime (Maxipime) is the most active 4th generation cephalosporin, due to its extended spectrum of activity and its high resistance against beta-lactamases. Cefepime (Maxipime) has a very large spectrum, including the majority of the microorganisms implicated in surgical infections: Enterobacter, Klebsiella pneumoniae/speciae, Proteus mirabilis, Bacillus fragillis, Pseudomonas aeruginosa, Serratia, Citrobacter and other Gram-negative bacilii, Gram-positive cocci (Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus pyogenes). The clinical study included 30 surgical patients, the selection criteria being the severity of the present infection or the potential risk after major (abdominal) surgery. We introduced Cefepime (Maxipime) as first choice of monotheraphy, except: severe, life threatening nosocomial infections, when we associated Cefepime (Maxipime) with aminoglycosides; failure of another antibiotheraphy schema, when we associated Cefepime (Maxipime) with aminoglycosides; suspicion of anaerobe contamination, when we associated Cefepime (Maxipime) with metronidazole. The results of our study support the utilization of Cefepime (Maxipime) as the best choice antibiotic in severe surgical infections, especially in the intensive care and surgical units. Cefepime (Maxipime) can be synergically associated with aminoglycosides and imidazoles (metronidazole).

[Endoscopic sphincterotomy in the treatment of common bile duct benign lesions (experience with 100 cases)]

The authors present the experience of the first 100 endoscopic sphincterotomy performed in Caritas Hospital, Surgery Department between 1997 and 2000 for CBD benign lesions treatment. The patients to whom we performed this procedure had a biliary syndrome associated mostly to obstructive jaundice of unknown etiology previously diagnosed echographically or by ERCP. The etiology was in 72% of the cases represented by migrated, residual or primary common bile duct stones. The aim of the procedure was the removal of the stones. We performed endoscopic sphincterotomy either before or after laparoscopic or open surgery. The morbidity was 8% and the related mortality was 0%. Endoscopic sphincterotomy is an efficient procedure for the treatment of the benign obstruction of the common bile duct and not only. Our results were similar to those published by other authors.

[An endoscopic treatment method for postoperative stenoses]

The endoscopic procedures include a great variety of procedures for the treatment of the upper and lower gastrointestinal bleeding of the benign and malign jaundice, of the primary or secondary gastrointestinal strictures. The authors present the case of a patient with a postcaustic oesophageal stricture for whom the surgical treatment was an esogastroanastomosis. Quite early in the postoperative course the anastomosis got, very tight due to a anastomotic fistula, and we succeed to dilate it with endoscopic procedures.

[Intraoperative exploratory endoscopy in surgery of the digestive tract]

The intraoperative endoscopy as a way of the range of the surgical exploration of the abdomen is a valuable procedure combining surgical and endoscopical maneuvers. It proved useful in following conditions: A. delicate surgical approach of the anatomical segment; B. equivocal findings of the conventional endoscopy; C. as a way of achieving therapeutical goals. In 56% of the cases a transperitoneal approach was used and in the rest of the cases a conventional technique. Sterilization was performed using glutaldehide 2%, 20 minutes before the intervention. The methods was used in 50 cases, concerning reinterventions, as well as primary diseases of unclear origin. Some were high-risk patients. Therapeutically benefit was proven in all cases.

[A rare cause of postoperative digestive hemorrhage]

Despite all the diagnosis's technical progress achieved in the past years, there are possible haemorrhagic complications after abdominal surgery, creating problems of diagnosis and treatment. The author presents a rare case of postoperative gastrointestinal bleeding due to an ulcer of the jejunal mucosa, located quite close to a hepaticojejunostomy. The mucosal ulcer, with consequent severe, massive bleeding was caused by the migration of a thread from the hepaticojejunostomy, proved by histopathological examination.

[5-Fluorouracil (ftorafur) in the treatment of acute pancreatitis. Indications for and efficacy of its use]

The main aim of the complex medical treatment in acute pancreatitis is the inhibition of exocrine pancreas secretion and decrease or annulment of the proteolytic effect, of autolysis, of its enzymes, both on the gland itself and on the neighbouring tissues. The authors introduced cytostatics of the 5-fluorouracil type (ftorafur) in the medical and/or medico-surgical treatment of 30 cases of acute pancreatitis admitted to the "Caritas" Surgical Clinic, during 1986-1987. The drugs lead to DNA-RNA inhibition and reduce significantly the pancreatic exocrine activity. Efficiency of 5-fluorouracil within the other therapeutic methods is proved by the results obtained, especially by the favourable rapid clinical evolution, blood amylase normalization in 48-72 hours, arrest in evolution of the pancreatic lesions. The treatment is economical and has no side effects. It may be also used for the digestive fistulae with pancreatic content or for the pure pancreatic fistulae.

Ultrarapid induction

We report 250 rapid induction anesthesias performed for the purpose of preventing regurgitation and vomiting in patients with full stomach. The anesthetic technique includes administration of morphine 20 mg and droperidol 5 mg intravenously 10-15 minutes before induction, a voluntary air hyperventilation at the anesthetist's command, during which induction drugs are introduced and an induction with a mixture containing suxamethonium 2 mg/kg and thiopentone 1.4 mg/kg, administered within 1-2 seconds. Eighteen seconds after the onset of injection the loss of lid reflex is observed followed 7 seconds later by masseter muscle relaxation. Within the following 5-10 seconds intubation is carried out in full fasciculation process, before cardia relaxation. With this technique, a mean intubation time of 35 seconds is achieved. The interval of maximum regurgitation risk is lowered to 15 seconds, so that ventilation by mask and cricoid pressure are no more necessary. The technique is indicated in the young and vigorous adult and contraindicated in the old and tainted patient, in coronary patients, in those with low heart output and slowing of circulation.