Studii medicale - cura chirurgicala a eventratiei, traumatismul hepatic, pancreatita, stop cardiorespirator

Al XXIII-lea Congres National de Chirurgie Baile Felix, 2006

Cura chirurgicala a eventratiei:procedeu retromuscular prefascial tehnica Rives

V. Strambu, C. Iorga. S. Stoian, 0. Cirstea, R. Jitianu, P. Radu, C. Udriste. C. Puscu. F Papa

Introducerea materialelor aloplastice pentru repararea defectelor parietale postoperatorii cunoaste la la actuala o larga raspandire. In experienta Clinicii Chirurgie de la Spitalul Sf. Pantelimon au fast efectuate in ultimii 5 ani peste 250 de interventii de acest tip. In ultima perioada pentru eventratiile mediane supraombilicale am folosit tehnica Rives eu plasa neresorbabila de marlex retromuscular si prefasciaI. RezuItatele au fost incurajatoare si prezentam experienta noastra cu aceasta tehnica.

The introduction of aloplastic materials for incisional hernia repair is currently widly spread. In our experience in the last 5 years, we have had over 250 such interventions. In the last period for median incisional supraarcuate hernia repairs we have used the Rives technique. The results were satisfying and we present our experience with this technique.

PANCREATITA ACUTA LA VARSTNICI - STUDIU RETROSPECTIV 2002-2006

M. Paduraru, M. Calin, V. Strambu, P. Radu R. Jilianu, A. Ciudin, Cristina Puscu, N. Costinas, B. Socea, O. Carstea, V. Constantin, C. BaIaIau, F. Popa

Spitalul Clinic de Urgenta 'Sj Pantelimon ', Bucuresti

Obiectivul studiului este reprezentat de decelarea unor elemente particulare ale etiologiei, evolutiei si formelor pancrearitei acute la varstnici. S-au analizat retrospectiv cazurile de pancreatita acuta la varstnici (pacientii peste 65 de ani conform O.M.S.), prin prisma raportarii la numarul total de cazuri de pancreatita internate, a etiologiei, gravitatii si mortalitatii. S-au interpretat datele celor 694 de pacienti internati cu diagnosticul de pancreatita acuta din totalul de 29330 pacienti internati (reprezentand 2,36%), 112 fiind pacienti varstnici cu pancreatita acuta din cei 6804 pacienti cu varsta peste 65 de ani (1,64%). Studiul etiologiei, a gravitatii si mortalitatii pe categorii de varsta s-a efectuat pe un esantion reprezentativ de 327 pacienti cu pancreatita. Ponderea pancreatitelor acute de etiologie litiazica este mai mare la varstnici (58,4% fata de 27,1 % la cei sub 65 de ani), de asemenea cea de etiologie medicamentoasa (6,15% fata de 1,73% la adulti), etiologia etanolica in lotul persoanelor varst­nice scazuta in raport cu lotul celor sub 65 de ani de (5,38% respectiv 28,3%), un raport comparabil intre formele usoare si severe (de 2,26 la cei sub 65 de ani si de 2,42 la varstnici), in schimb o mortalitate mult crescuta (13,84% la varstnici) fata de mortalitatea generala a acestei categorii de varsta (6,34%) si a adultilor cu pancreatita acuta (2,89%). Pancreatita acuta la varstnici prezinta o serie de particularitati in special sub aspectul etiologiei, a prognosticului si mortalitatii, impunan­du-se o abordare diferita, judicioasa si nuantata a afectiunii la acesti bolnavi.

Conferinta Nationala Bucuresti 2007

TRAUMATISMUL HEPATIC - DIAGNOSTIC SI ATITUDINE TERAPEUTICA

V. Strambu, C. Iorga, V. Constantin B. Socea C. Moculescu P. Radu R. Jitianu, S. Stoian C. Udriste, Cristina Puscu, F. Popa

Clinica Chirurgie, Spitalul Clinic de Urgenta 'Sf Pantelimon', Bucuresti

Evaluarea metodelor diagnostice si a atitudinii terapeutice in traumatismele hepatice.

Au fost analizate retrospectiv un lot de 28 de pacienti politraumatizati cu interesare hepatica cat si altor organe intra si extraperitoneale, internate intr-o perioada de 3 ani (2004-2006) in clinica noastra. Au fost luate in discutie mecanismele de producere ale traumei, metode clinico-parac1inice de diagnostic, localizari1e si scala de trauma asociata, alte tipuri de leziuni intra sau extraperitoneale, tipuri de interventii, cantitatea de sange si produse de sange folosite, etc. Dintre cele 28 de cazuri de trauma. hepatica la toate s-a intervenit chirurgical practicandu-se diverse tipuri de hemostaza hepatica cat si alte interventii dictate de leziuni la nivelul altor organe abdominale. Diagnosticul a fost stabilit prin echo abdominal in urgenta si lavaj peritoneal in caz de rezultat dubitativ al acestui examen. Durata de spitalizare a variat intre 6 si 45 de zile. Rata reinterventiilor a fost de14,28%, dictate in doua cazuri de coleperitoneu, intr-un caz de ocluzie iar in altul de evisceratie. Rata de decese a fost de 10,71% (3 pacienti) datorata in general leziunilor altor organe. Traumatismul hepatic in ciuda aspectului dramatic si spec­taculos ramane o cauza destul de rara de deces in patologia traumatica, leziunile traumatice solitare de ficat putand fi manageriate chiar in mod conservator.

MOMENTUL OPERATOR IN FUNCTIE DE ETIOLOGIA PANCREATITELOR ACUTE

V. Strambu, C. Iorga, V. Constantin, 8. Socea, C. Moculescu, P. Rodu, R. Jitianu, S. Stoian, C. Udriste, Cristina Puscu, F. Popa

Clinica Chirurgie, Spitalul Clinic de Urgenta 'Sf Pantelimon' Bucuresti

Stabilirea momentului operator optim luand in considerare etiologia pancreatitelor acute. Este analizat un lot de 327 de pacienti diagnosticati cu pancreatita acuta, internati in Clinica de Chirurgie a SpitalulUi Clinic de Urgenta Sf. Pantelimon Bucuresti in perioada ianuarie 2002 - decembrie 2006.A fost studiata repartitia pe sexe, grupe de varsta, etiologie, simptomatologie, criterii de stabilire a diagnosticului, scorurile clinico-paraclinice, durata spitalizarii, intervalul de timp preoperator si intre reinterventii, complicatii pre- si post­operatorii, durata spitalizarii in sectia de terapie intensiva, tipurile de interventii chirurgicale, mortalitate. Din totalul de 327 de pancreatite acute internate un numar de 209 reprezen­tand 63,9% au fost tratate conservator, restul de 118 pacienti, adica 36,1 % au beneficiat de tratament chirurgicaL Lotul de 118 pacienti ce a beneficiat de tratament chirurgical are urmatoarea structura etiologica: etiologie biliara 78,4%, etiologie etanolica 8,2% si alte etiologii 13,4%.Indicatia de tratament chirurgical a fost reprezentata de cazurile cu litiaza biliara dovedita si cazurile complicate. Perioada preoperatorie a variat intre 0-15 zile, interventia chirurgicala adresata litiazei biliare a fost practicata in ziua a 3-a, dupa reechilibrare si ameliorarea simptomatologiei, iar momentul operator optim in pancreatitele de etilogie etanolica si de alte etiologii a fost ziua a 13-a, interventia chirurgicala vizand in principal necroza infectata. Pancreatita acuta ramane o patologie greu de 'manageriat' chirurgical din punct de vedere al gesturilor care se fac si al momentului operator, factorii care influenteaza notabil evolutia acestei boli fiind reprezentati de etiologie, momentul operator si starea la prezentare.

Sinaia I-a Conferinta 2005

BOLNAVUL CRITIC TRAUMATIZAT - ECOGRAFIE IN URGENT A SAU LAVAJ PERITONEAL?

Victor Strambu, Valentin Georgescu, Ioana Dimitriu, Ovidiu Carstea, Petru Radu, Alexandra Manoleli, Cristina Costin, Luiza Popescu

Spitalul Clinic de Urgenta 'Sf. Pantelimon', Bucuresti, Romania

Scopul lucrarii: Evaluarea celor doua tipuri de manopere diagnostice in decelarea cauzelor de sangerare la pacientii in stop cardiorespirator cu traumatism abdominal inchis.

Material si metoda: Studiul retrospectiv al cazurilor de SCR prin traumatism abdominal Inchis prezentate si internate prin UPU In perioada 2000 - 2005.

Rezultate: Din 185 pacienti cu SCR prin trauma, la 28 dintre ei a fost efectuat numai lavaj peritoneal, la alti 28 numai ecografie abdominala, alti 3 pacienti beneficiind de ambele metode diagnostice. Restul pacientilor au fost evaluati clinic si radiologic.

Din punct de vedere al sensibilitatii rata de rezultate pozitive este aproximativ egala, pe cand

din punct de vedere al specificitatii balanta inclinand In favoarea ecografiei. .

Concluzii: Cele doua metode diagnostice raman In actualitate, fiind complementare. In caz de rezultate echivoce lavajul peritoneal poate rezolva dilema.

Purpose of the study: The evaluation of causes of blood lost fram two types of maneuver, in cases of blunt abdominal trauma and cardiac arrest.

Materials and method: The study is based an a retrospective analysis of patient admitted in ED betWeen 2000-2005, of abdominal blunt traumatized patients.

Results: From 185 patients with cardiac arrest through trauma, 28 has been evaluated through OPL, another 28 has been performed ultrasonic abdominal evaluation and for 3 patients has been used both evaluation methods. The remaining patients were evaluated by clinical and radiologicaJ means.

No matter the method used from sensibility point of view the results showed no relevant differences, but from specificity point of view the ultrasonic evaluation method seems to be more relevant.

Conclusions: Both diagnosis methods are actual, being complementary. In case of inconcludent results, OPL can solve the dilemma.

STOPUL CARDIORESPIRATOR LA PACIENTUL POLITRAUMATIZAT ­ANALIZA RETROSPECTIVA  2000 - 2005

Victor Strambu, Valentin Georgescu, Ioana Dimitriu, Radu Bistea, Carmen Dochia, Mihaela Costinas, Luiza Popescu, Dan Dermengiu', Florian Popa

Spitalul Clinic de Urgenta 'Sf. Pantelimon', Bucuresti, 'IML 'Mina Minovici', Bucuresti, Romania

Scopul lucrarii: Stopul cardiorespirator de cauza traumatica are o mortalitate foarte mare, supravietuirea pacientului depinzand de recunoasterea si tratarea rapida a cauzelor ce determina instalarea stopului cardiorespirator. Studiul evalueaza cauzele ce conduc la instalarea SeR la pacientul critic traumatizat.

Material si metoda: Studiul se bazeaza pe analiza retrospectiva In stilul Utstein si in stilul clasic, a datelor din foile de observatie pentru un numar de 201 pacienti traumatizati care s-au prezentat si/sau au fost internati In spital In perioada 2000 - 2005.

TRAUMATISMUl HEPATIC - DIAGNOSTIC SI ATITUDINE TERAPEUTICA-

V. Strambu, C. Iorga, P. Radu, R. Jitianu, S. Stoian, C. Udriste, Cristina Puscu, I. Dimitriu, V Georgescu, F. Popa, L. Popescu

Sp. CI. de Urgenta 'Sf. Pantelimon' Bucuresti - Clinica Chirurgie

Obiective: Evaluarea metodelor diagnostice si a atitudinii terapeutice in traumatismele hepatice

Material si metoda: Au fost analizate retrospeciv un lot de 28 de pacienti politraumatizati cu interesare hepatica cat si altor organe intra si extraperitoneale, internate intr-o perioada de 3 ani (2004-2006) in clinica noastra. Au fost luate in discutie mecanismele de producere ale traumei, metode clinico-paraclinice de diagnostic, localizarile si scala de trauma asociata, alte tipuri de leziuni intra sau extraperitoneale, tipuri de interventii, cantitatea de sange si produse de sange folosite,etc.

Rezultate: Dintre cele 28 de cazuri de trauma hepatica la toate s-a intervenit chirurgical practicandu-se diverse tipuri de hemostaza hepatica cat si alt~ -interventii dictate de leziuni la nivelul altor organe abdominale. Diagnosticul a fost stabilit prin echo abdominal in urgenta si lavaj peritoneal in caz de rezultat dubitative al acestui examen. Durata de spitalizare a variat intre 6 si 45 de zile. Rata reinterventiilor a fost de 14,28%, dictate in doua cazuri de coleperitoneu, intr-un caz de ocluzie iar in altul de evisceratie. Rata de decese a fost de 10,71% (3 pacienti) datorata in generalleziunilor altor organe.

Concluzii: Traumatismul hepatic in ciuda aspectului dramatic si spectaculos ramane o cauza destul de rara de deces in patologia traumatica, leziunile traumatice solitare de ficat putand fi managerIate chiar in mod conservator.

LlVER TRAUMA - DIAGNOSIS AND THERAPY

Aim of study: The evaluation of diagnostic methods and the therapeutical attitude in Iiver trauma. '

Material and technique: Retrospective study on 28 politrauma patients with liver injury and other intra and extraperitoneal lesions, admitted in the surgery department dUring January 2004 - December 2006. The trauma initiation mechanism, the clinical and laboratory methods of diagnosis, the associated injuries and trauma scale, other types of intra or extraparitoneallesions, varlous types of operations, the amount of blood and blood products used, have been considered.

Results: Surgery was involved in aII the 28 cases of hepatic trauma using different types of liver haemostasis together with other surgical procedures for the associated abdominal injuries. The diagnosis was set using the emergency abdominal ultrasound scan and PLD.

The patients were admitted into the hospital an a period of time varying between 6 to 45 days.

The reoperations' rate was of 14.28%, due to choleperitoneum in two cases, occlusion in one case, and evisceration in another one. The mortality rate was of 10.71%, generated mainly by the associated lesions. )

IASG 2005

FACTORI DE PREDICTIE IN APARITIA PSEUDOCHISTELOR DE PANCREAS IN PANCREATITA ACUTA

V. Strambu, C. Iorga, S. Stoian. R. Jitianu, o. Cirstea. , P. Radu, C. Udriste, F. Popa

Scop: Analiza factorilor care duc la aparitia pseudochistelor de pancreas in pancreatita acuta.

Material si metoda: au fost analizate retrospectiv un numar de 34 pseudochiste de pancreas aparute la intervale diferite dupa un episod de pancreatita acuta internate si tratate in clinica in perioada 2001­2005. Factorii luati in discutie au fost: varsta, sexul, etiologia pancreatitei, forma clinica, scorurile de gravitate in pancreatita, perioada de constituire a chistului de la episodul acut, tipul tratamentului, mortalitate.

Rezultate: in lotul studiat varsta medie a fost de 52 ani (+/- 5) cu un sex ratia M/F de 25/9 cu forme clinice PANH/PAE - 10/24. Scorul de gravitate Ranson a fost urmatorul: 0-2 - 28 cazuri, 3-4 - 5 cazuri si 1 caz scor 5-6. Din punct de vedere etiologie distributia a fost urmatoarea: 7 cazuri de cauza litiazica, 5 de cauza etanolica si 22 alte cauze. Tratamentul a constat in: derivatii interne 15 cazuri, drenaj extern 2 cazuri, 7 punctii evacuatorii sub control CT si 10 cazuri tratate conservator. Mortalitatea globala a fost de 2 cazuri.

Concluzii: In opinia noastra consideram ca aparitia pseudochistelor de pancreas tine in principal de 3 factori: etiologia acesteia (in mare majoritate alitiazica) si de varsta si sexul pacientilor (decadele V­VI si sex masculin).

The aim of study : the analisys of factors that induces development of pancreas pseudocysts after acute pancretitis.

Materials and methods: retrospective analisysis of 34 pancreas pseudocysts admitted and treated in OUl' clinic between 2001-2005 developed after an acute pancreatitis episode. The analisys includes age, sex, etiology , clincal forms, gravity scores, development time, treatment, mortality.

ResuJts: in our trial the average age was 52 years (=/- 5), sex ratio M/F (25/9) and 10 haemorrhagic PA124 edematous PA. Ranson's scores recorded were: 28 cases 0-2, 5 cases 3-4, 1 case 5-6. The etioJogy was: 5 cases - ethanol, 7 cases cholelithiasis, and 22 other cases. Treatment was: interna! derivations in 15 cases, external drainage 2 cases, and 7 CT guided evacuatory punctions and 10 cases with conservatory treatment. Two patients died.

Conc1usions: We consider the appearance of pancres pseudocyst is determined by 3 factors: the etiology (non lithiasic), age and sex of patients (VI decade and male gender)

CONGRES NATIONAL DE CHIRURGIE BAILE FELIX 2006

PROPUNERE DE ALGORITM DIAGNOSTIC ETIOLOGIC AL TROBOZELOR VENOASE SIMPTOMATICE

V. Strambu, C. Iorga, S. Stoian, R. Jitianu, o. Cirstea, P. Radu, C. Udriste, C. Puseu, F. Popa

Scop: Pe baza analizei prospective a cazurilor de tromboze venoase interuate pe o perioada de 5 ani am urmarit elaborarea unui algoritm diagnostic.

Material si metoda: au fost analizate 73 de cazuri de tromboze venoase confirmate dintr-un lot de 187 de pacienti prezentati in perioada aprilie 2004 - octombrie 2005 in Sp. CI. de Urgenta 'Sf. Pantelimon' Rezultate: In cadrul lotului de 73 de pacienti 41(56,2%) au fost diagnosticati cu tromboza venoasa profunda (TVP), restul de 32(43,8%) fiind diagnosticati cu tromboza venoasa superficiala (TVS). Analiza factorilor clinici arata ca 30(41,1%) au avut o suspiciune clinica mare, 25(34,2%) suspiciune moderata si 18(24,7%) suspiciune scazuta pentru diagnostic. Un numar de 40 de pacienti(54,8%) au putut fi incadrati pe baza antecedentelor patologice in clasa de risc mare, majoritatea dintre acestia avand doi factori majori de risc (2M); 26 de pacienti(35,6%) au fost incadrati in clasa medie de risc cu un singur factor major (M) prezent iar 7 pacienti(9,6%) au fost incadrati in clasa de risc minor. Testul la D-dimeri a aratat o sensibilitate de 87,7% ( 64 de cazuri real pozitive) si doar 12,3% rezultate fals

Particularitati evolutive ale recidivelor pelvice si loco-regionale in cancerul de rect

A.Cuibac, C.Iorga, I.Motofei, T. Popescu, C.Puscu ,P.Radu, F. Popa

Spitalul Clinic de Urgenta ''Sf Pantelimon'' Bucuresti- Clinica Chirurgie.

Cuvinte cheie: recidive cancer de rect

Obiective: Lucrarea analizeaza valoarea comparativa a principalelor doua manopere chirurgicale utilizate in tratamentul cancerului rectal (rezectie anterioara de rect tip Dixon si amputatie abdomino- perineala de rect cu coloproctie stanga definitiva) ce ar putea imbunatati evolutia postoperatorie a bolnavilor cu cancer de rect, momentul aparitiei recidivelor si cresterea ratei de supravietuire la 5 ani. Material si metode: Sunt analizate 67 de cazuri de bolnavi cu cancer de rect operati in clinica de chirurgie a Spitalului "Sf.Pantelimon" in perioada 2001-2005, 13 beneficiind de operatia Dixon, 17 de amputatie de rect, 4 de electrorezectie, si 33 de operatia Hartmann sau coloproctie stanga. Semnificativ pentru studiu a fost selectat un lot de 24 bolnavi cu 8 recidive aparute intr-un interval de timp de 2 pana la 3 ani de la momentul operatiei. Rezultate obtinute: Frecventa aparitei recidivelor loco-regionale si pelvice la un interval de 2- 3 ani este de 20% la bolnavii ce au beneficiat de operatia Dixon fata de 50% la bolnavii ce au beneficiat de amputatie de rect. Concluzii: Momentul aparitiei recidivelor loco-regionale si pelvice este mai indepartat fata de prima interventie, iar prognosticul de supravietuire la 5 ani este mai bun la bolnavii cu cancer de rect la care s-a practicat operatia Dixon fata de cei la care s-a practicat amputatia de rect .

The evolutive particularities in recurrence of rectal cancer

Keywords: recurrence of rectal cancer

Aim: : The study analyzes the comparative value of two main surgical procedures used in the treatment of rectal cancer ( Dixon surgical resection and rectal abdominal-perineal resection) witch are able to improve the postoperative evolution in patients with rectal cancer, the appearance time of recurrence and increase the survival rate at 5 years. Materials and method: We analyzed a group of 67 patients with rectal cancer operated in our clinic between 2001-2005, 13 of them with Dixon procedure, 17 with rectal amputation, 4 with electroresection and 33 cases with emergency intervention (Hartmann operation or left colostomy). Significantly for our study we selected a lot of 24 patients in which 8 recurrences appeared between 2 and 3 years from the operation. All 24 patients were monitorised from diagnostic date until dead time. Results: The frequency of recurrence appearance at 2-3 years from the operation is 20% for the patients with Dixon procedure and 50% for the patients with abdominal-perineal resection. Conclusions The appearance of recurrences is delayed and the survival rate is improved in the patients diagnosed with rectal cancer in which we performed Dixon procedure compared to those in which we performed abdominal-perineal resection.

TRATAMENTUL EVENTRATIILOR PERICOLOSTOMA - VARIANTA DE TEHNICA ALOPLASTICA FARA TRANSPOZITIE

Referat: Vitaminele - surse alimentare de vitamine Referat: 41 de sfaturi pentru viata lunga recomandate de doctor

C. Balalau, V. Strambu, M. Calin, M. Paduraru, B. Popa, Fl. Popa

Clinica de Chirurgie Spitalul Clinic de Urgenta "Sf. Pantelimon", Bucuresti, Romania

Eventratiile dupa colostoma sunt cele mai frecvente eventratii peristomale, incidenta acestora, dificil de stabilit, fiind situata undeva intre 10-50%. Desi sunt in general bine tolerate de pacient, exista totusi situatii in care indicatia chirurgicala reprezinta o solutie necesara: incarcerarile si strangularile de anse intestinale, dificultatea protezarii si chiar aspectul estetic. Intentia noastra se incadreaza in randul tehnicilor de reparare fara transpozitie, reprezentand o cale de abord locala cu proteza plasata superficial. Tehnica o dorim a se aplica eventratiilor mici spre medii, la bolnavii cu anus iliac stang definitiv, cu intentia declarata de miniinvazivitate locala. Lotul studiat a fost compus din 6 pacienti cu anus iliac stang definitiv (4 dintre acestia cu operatia Hartmann si 2 cu amputatie de rect pe cale abdominoperineala). Acestia au fost urmariti la 1 an si 2 ani postoperator, rezultate fiind favorabile, fara recidive si cu imbunatatirea calitatii vietii.

The surgical treatment of paracolostomal hernias - a variation of a surgical technique without stoma transposition.

Parastomal hernias, especially after colostoma, are frequently; the incidence is hard to establish, somewhere between 10 and 50%. While often well tolerated, there are some situations when surgery is a must: strangulation, incarceration, colostomal prosthesis difficult to apply, and even the aesthetic aspect. Our technique is a variation of the repair techniques without stoma transposition, by using a superficial mesh. We wish to use this thechnique for small and medium size parastomal hernias, that occurs at the patients with definitive colostomy, with the declared purpose of miniinvazive surgery. There were 6 patients with left colostomy ( 4 after Hartmann procedure and 2 after abdominoperineal resection). Follow-up controls at 1 year and 2 years after surgery shown no reccurences and an improved quality of life.

INFLUENTA TRAUMEI TORACICE ASUPRA EVOLUTIEI PACIENTULUI POLITRAUMATIZAT

V.Georgescu, V.Strambu, S.Stoian, L.Dinu, A.Manoleli, I.Dimitriu, Fl.Popa

Spitalul Clinic de Urgenta "Sf.Pantelimon" Bucuresti

Introducere: Trauma toracica reprezinta principala cauza de deces la 25% din pacientii politraumatizati si contribuie la mortalitatea altor 25%. Identificarea cauzelor si recunoasterea gravitatii acestora si interventia rapida, calificata, in echipa multidisciplinara cresc sansa supravietuirii acestor pacienti. Scopul lucrarii: Obiectivul prezentarii este evaluarea efectelor traumei toracice asupra conduitei diagnostice, mortalitatii, morbiditatii si supravietuirii acestor pacienti. Materiale si metode: Studiu retrospectiv care a cuprins 740 pacienti politraumatizati prezentati in UPU Sf.Pantelimon in perioada Ianuarie 2001-Iunie 2005. Parametrii urmariti au fost leziunile cele mai frecvente, gravitatea lor, mortalitatea, corelarea supravietuirii cu ISS si RTS, folosindu-se datele extrase din foile de urgenta, foile de observatie din sectii si examenele anatomopatologice. Rezultate: Din 740 de pacienti politraumatizati, 445(60,1%) au asociat si trauma toracica, cu rata supravietuirii 79,1%. 410 pacienti au prezentat traumatism toracic inchis. Leziunile care au necesitat sanctiune chirurgicala imediata si cu

rata cea mai crescuta de deces: hemotorax masiv - 15 pacienti, (mortalitate 100%); ruptura de vase mari - 6 pacienti, (mortalitate 100%), pneumotorax deschis - 1 pacient (mortalitate 100%); pneumotorax hipertensiv - 10 pacienti, (mortalitate 50% ), volet costal - 30 pacienti (mortalitate 53%). Concluzii: Trauma toracica se asociaza frecvent politraumatismelor si contribuie la cresterea mortalitatii acestor pacienti. Se impune ca manevrele chirurgicale salvatoare sa fie executate rapid, la prezentare. Este necesara adoptarea de protocoale de interventie la pacientul traumatizat, personalului medical din Serviciul de Urgenta revenindu-i un rol determinant.

The influence of thoracic trauma upon evolution of politraumatised patients

Introduction: Thoracic trauma is the leading death cause in 25% of politraumatised patients and contributes to the death of another 25% of these fatalities. Identifying the determining causes, assessing their severity, early and qualified intervention in a multidisciplinary team may improve outcome of these patients. Purpose of the study: The goal of this paperwork is to assess the effects of thoracic trauma on clinical management, morbidity, mortality and outcome. Material and method: Retrospective study of 740 politraumatised patients admitted in the Emergency Department of St. Pantelimon Hospital between Jan 2001 and Jun 2005. The followed parameters were most common injuries, severity, mortality, survival rate correlated with ISS and RTS, using data from emergency charts, hospital charts and anatomopathologic exams. Results: Out of 740 patients, 445 associated thoracic trauma, with a survival rate of 79,1%. 410 patients had blunt trauma. Injuries that claimed early surgical intervention and had the highest death rate were: massive haemothorax 15 patients (100% mortality rate), aortic and great vessels injuries 6 patients (100% mortality rate), open pneumothorax 1 patient (100% mortality rate), tension pneumothorax 10 patients (50% mortality rate), flail chest 30 patients (53% mortality rate). Conclusions: Thoracic trauma is often associated to politrauma and may increase significantly the mortality rate of these patients. Lifesaving surgical procedures must be immediately performed, on patient arrival. It is important to adopt intervention protocols for multiple trauma, with a leading role of the Emergency Department medical staff.

SCOR DE EVALUARE A RISCULUI ANESTEZICO-CHIRURGICAL LA BOLNAVUL VARSTNIC

Dr. Paduraru G Mihai, Prof. Dr. Florian Popa Dr. I. C. Teodorescu Dr. M. Nistor

In scopul evaluarii preoperatorii a bolnavului varstnic si aprecierii fidele a riscului anestezico-chirurgical am elaborat si propunem un scor care sa raspunda cerintelor chirurgului si anestezistului-reanimator si care tine cont de afectiunile cronice comorbide si gradul lor de compensare, amploarea interventiei chirurgicale, urgenta si categoria de varsta. Valorile scorului sunt rezultatul analizei retrospective a riscului anestezico-chirurgical a 1093 de bolnavi cu varste peste 65 de ani operati in Clinica noastra in anii 2004-2005: 669 intre 65-75 de ani, 377 intre 75-85 de ani si 46 peste 85 de ani. Scorului propus incadreaza riscul anestezico-chirurgical in 7 trepte: scazut, acceptabil, mediu, crescut, extrem de ridicat, interventie chirurgicala cu sanse minime si MSOF-soc, in functie de punctajul obtinut. Pentru calcularea mai usoara si rapida a scorului propunem un soft de aplicare, valorile fiind incluse in baza de date a acestuia, conferind automat incadrarea si o serie de precautii. Acesta memoreaza valorile scorului fiecarui bolnav intr-o arhiva, flexibilizeaza scorul in functie de cercetarile proprii fiecarui colectiv, aduce rapiditate si usurinta in aplicare. Eficacitatea si veridicitatea scorului au fost testate pe un numar 91 de bolnavi peste 65 de ani operati in Clinica noastra in cursul acestui an.

Evaluation score of surgery and anaesthesia risk reffering an old patient

With a view to evaluate the pre-surgery of an old patient and the corect estimate (appreciation) of the surgery and anaesthesia risk, we have elaborated and we propose a score that answers the demandings of the surgeon and the anesthesiologyst and that depends on the chronicles disease and their rank of compensation, the ampleness of surgery, the urgency and the age category. The values of the score are the result of the retrospective analysis of the risk for 1093 patients being more than 65years old, operated in our clinic during years 2004-2005: 669 being between 65-73years old, 337 between 78-85years old and over 85years old. The proposed score frames the risk in 7 steps: low, acceptable, medium, high, extremely high, minimun chances surgery and MSOF-shock, depending on the number of points obteined. For an easier and faster way of calculating the score, we propose a soft of aplication, the values being included in the data base of it, confering the fraiming and a group of precautions. It memorizes the values of the score of each patient, in an archive, changing the score depending on personal researches each staff, it bring velocity and easiness in applying it. The efficiency and truthfullness of the score have been tested on a nuber of 91 patients aged over 65, operated in our clinic during this year.

Particularitati ale patologiei si abordarii chirurgicale la bolnavii cu varsta foarte inaintata - peste 75 de ani

Dr. Paduraru G Mihai, Prof. Dr. Florian Popa Dr. B. Socea, Dr. M. Calin, Dr. C. Balalau, Dr. V. Constantin

Fenomenul de imbatranire induce scaderea rezervei homeostatice, vulnerabilitate crescuta si capacitate de adaptare limitata la dezechilibrele hidro-electrolitice declansate de afectiunea chirurgicala. Studiul nostru cuprinde un numar de 423 bolnavi cu varste peste 75 de ani operati in Clinica noastra in perioada 2004-2005, 377 avand varsta intre 75-85 de ani, 46 peste 85 de ani, din care 10 peste 90 de ani, patologia chirurgicala fiind complexa, cu multiple asocieri comorbide si implicit risc anestezico-chirurgical crescut. Rezultatele postoperatorii au fost umbrite de morbiditate si mortalitate postoperatorie crescuta (21,2%), un maxim inregistrandu-se la pacientii cu afectiuni cronice comorbide severe decompensate la care s-a impus interventie chirurgicala de urgenta. Costurile ingrijirilor medicale si perioada internarii acestor bolnavi au fost crescute. Toate rezultatele acestui studiu contureaza pe de o parte severitatea patologiei si pe de alta parte fragilitatea bolnavului cu varsta foarte inaintata, stabilind anumite precautii in strategia terapeutica. O valoare deosebita la persoanele cu varsta foarte inaintata reprezinta diagnosticarea precoce si tratamentul corect al afectiunilor cronice comorbide. Abordarea medico-chirurgicala interdisciplinara la acesti bolnavi trebuie completata cu o terapie de sustinerea pre-, intra- si postoperatorie eficienta si alegerea tipului de interventie chirurgicala cu maxim de beneficiu si minim de agresivitate.

Particularity of surgical pathology and treatments to the very old patients - over 75 years of age

Ageing process conduces to physiologic reserves failing, high vulnerability and limited capacity of adaptation to the fluid and electrolytic imbalance. Our analysis comprise 423 patients over 65 years old who suffered surgical operation in our Clinic, 377 between 75-85 years old and 46 over 85 years old, 10 of them over 90 years old. Surgical pathology of these patients was complex, with more association of medical affections, implicit high surgery and anaesthesia risk. Postoperative outcome was shadowed by high morbidity and mortality (21,2%), and these were worst to the oldest patients with severe medical co-morbidities and to those who need emergency surgical operation. The cost and the period of medical care were high. All the results of this study approve severity of the surgical pathology, fragility of the very old patients and ascertain more caution in therapeutic strategy. A very important for the old patients is early diagnostic and a right treatment of chronic affections. Interdisciplinary therapy of these patients need to be rounded with a good sustain action in pre-, peri- and postoperative period; also we must choose surgical operation who have a minimum aggression and a maximum benefit for the patient.

OBSTRUCTIA ENDOGENA, CAUZA RARA DE OCLUZIE A INTESTINULUI SUBTIRE

F. Popa, V. Constantin, B. Socea, C. Moculescu, A. Ciudin, T. Popescu

Dintre cauzele ocluziilor de intestin subtire, peste jumatate sunt reprezentate de hernii/eventratii strangulate, pe locul urmator situandu-­se aderentele/bridele. Desi mai rare, obstructiile de cauza endogena - tumori (primare sau secundare), corpi straini (ingerati accidental, calculi biliari, bezoar), stenoze intestinale - trebuie intotdeauna avute in minte. In perioada 2001­2005 au fost internati si operati 26 pacienti cu ocluzie de cauza endogena a intestinului subtire. Am analizat retrospectiv informatiile medicale disponibile, cu privire la forma clinica de prezentare, etiologie, date paraclinice, tipul interventiei, rezultate terapeutice. Am intalnit 17 tumori primare de intestin subtire, 3 cazuri de tumori secundare (metastaze), 2 corpi straini ingerati, 2 cazuri de fitobezoar, 3 ileusuri biliare si 2 stenoze de ileon terminal de etiologie tbc. In 21 cazuri s­a impus enterectomia segmentara. Decesul in primele 10 zile postoperator s­a consemnat la 4 pacienti. Diagnosticul etiologic este rar precizat preoperator. Ocluzia/subocluzia la pacienti cu interventii chirurgicale abdominale in antecedente, la care am exclus cauza herniara, nu trebuie considerata a priori aderentiala. Amanarea interventiei duce la un procent mai mare de enterectomii si la agravarea prognosticului. Ileusul biliar ramane o afectiune cu prognostic infaust. Trebuie reconsiderata tuberculoza secundara ca posibila etiologie de ocluzie intestinala.

Endogen obstruction, a rare condition of small bowel obstruction

Among all causes of small bowel obstruction, over a half are represented by strangulated hernia, while adhesion syndrome occupies the second place. Although a rare condition, endogen obstruction - primary or secondary tumours, foreign bodies (accidentally ingested, gallstones, bezoar), intestinal stenosis - must always be kept in mind. During a period of five years (2001­2005), a number of 26 patients with endogen small bowel obstruction were admitted in hospital and suffered a surgical procedure. We have retrospectively analysed the medical information regarding clinical presentation, ethiology, paraclinical findings, types of surgical procedure, results. We had to deal 17 small bowel primary tumours, 3 secondary tumours (metastasis), 2 foreign bodies, 2 cases of fitobezoar, 3 gallstone ileus and 2 ileal stenosis (tuberculosis). In 21 cases we had to perform segmentar enterectomy. Four patients died in the first ten postoperative days. Ethilogical diagnosis is rare established preoperative. Small bowel obstruction occurred at patients who undergo abdominal operations and who do not present postoperative strangulated hernia is not always due to adhesion syndrome. The delay of operation aggravates prognosis and may lead to enterectomy. Gallstone ileus remains a serious condition. We have to reconsider the diagnosis of secondary tuberculosis as cause of bowel obstruction.

CARACTERISTICI MACROSCOPICE SI FACTORI DE RISC CARE FAVORIZEAZA DEGENERAREA MALIGNA A POLIPILOR ADENOMATOSI COLORECTALI

B. Socea, V. Constantin, C. Moculescu, M. Paduraru, F. Popa

Exista dovezi care indica faptul ca pacientii cu polipi adenomatosi colorectali au risc crescut de a dezvolta cancer de intestin gros (adenom - displazie - carcinom). Anumite caracteristici macroscopice ale polipilor (dimensiunea, forma, localizarea) si anumiti factori de risc (fumatul, consumul de alcool, obiceiuri alimentare, sedentarismul) ar favoriza degenerarea maligna. Studiul de tip retrospectiv cuprinde 81 de pacienti cu polipi adenomatosi colorectali la care am beneficiat de rezultate histopatologice, internati si tratati in Clinica noastra in perioada 1996 - 2005. S­a constatat o asociere mai frecventa a displaziilor (usoara, medie, severa) si a elementelor de malignitate (carcinom in situ, carcinom intramucos, carcinom invaziv) cu polipii de peste 10mm, sesili, localizati pe colonul stang (semnificatie statistica). Fumatul, consumul de alcool, dieta bogata in proteine animale si lipide si sedentarismul au fost mai frecvent mentionate la pacientii cu polipi ce prezinta elemente de displazie sau malignitate, insa doar asocierea cu fumatul de peste 20 de ani s­a dovedit a avea semnificatie statistica. Cancerul colorectal dezvoltat pe polipi este o afectiune ce poate fi prevenita. Atragem atentia asupra unor caracteristici macroscopice ale polipilor care sugereaza un risc crescut de degenerare. De asemenea, aducem noi confirmari privind implicarea unor factori de risc in carcinogeneza.

Suggestive macroscopic findings and risk factors for malignant degeneration of colorectal adenomas

There are proofs that patients with colorectal adenomas have a high risk of colorectal cancer (adenoma - displasia - carcinoma). Several macroscopic findings of colorectal adenoma can suggest a higher risk of degeneration. There are also some risk factors involved in polyp degeneration: smoking, alcohol consumption, dietary factors, lack of physical activity. The present retrospective study deals with 81 cases of patients with colorectal adenomas which have histopatological results. The patients were admitted and treated in our Clinic during 1996 - 2005. The polyps of sessile shape, located on the left colon and having more than 10 millimeters are more frequent associated with displastic lesions and with malignant findings (in situ, intramucos or invasive carcinoma). Smoking, alcohol consumption, diet containing more animal proteins and lipids, and lack of physical activity are more frequently mentioned at patients that have polyps with displastic or malignant lesions. But only the association with smoking for a period exceeding twenty years had proved to have a statistical significance. Colorectal cancer developed on colorectal polyps can be prevented. Some macroscopic findings of colorectal polyps must alert us upon the higher risk of malignant degeneration. We provide new proofs regarding the implication of some risk factors in adenoma degeneration.

AL XII-LEA CONGRES NATIONAL DE CHIRURGIE Sovata 2004

REPERE ETIOPATOGENICE SI TERAPEUTICE IN OBSTRUCTIILE ADERENTIALE ALE INTESTINULUI SUBTIRE

V.D. CONSTANTIN, G. CARAC, 1 MOTOFEI, C. MOCULESCU, F. POPA

Spitalul Clinic de Urgenta 'Sf. Pantelimon' Bucuresti - Clinica Chirurgie

OBIECTIVE. Lucrarea ia in consideratie doua aspecte: etiopatogeneza si evaluarea terapeutica a pacientilor cu obstructii de intestin subtire (O.I.S.).

MATERIAL SI METODE. Au fost analizate informatiile continute in foile de observatie si protocolul operator pentru 172 de pacienti internati in Clinica de Chirurgie a Spitalului Clinic de Urgenta 'Sf. Pantelimon' intre anii 1998 -2002. Se incearca stabilirea unor parametri de urmarire pentru evolutia posterapeutica a pacientilor: rata de reinternari, procentul de reinterventii chirurgicale si intervalul de timp pana la internare, precum si solutiile terapeutice care pot preveni obstructiile aderentiale ale intestinului subtire (substante de contact peritoneale, procedee operatorii).

REZULTATE. Cauza cea mai frecventa de obstructie a intestinului subtire e reprezentata de aderentele postoperatorii (53%), comparativ cu hernii si eventratii (21 %), tumori (10,6%), peritonite (7 %).

CONCLUZII. Probabilitatea de reobstructie se mareste, iar intervalul de timp pana la reobstructie scade odata cu cresterea numarului de internari. Profilaxia sindromului aderential este o problema importanta, de actualitate, a carei rezolvare va conduce la scaderea semnificativa a incidentei O.I.S.

EPITELIOAMELE FETEI - TRATAMENTUL CHIRURGICAL RADICAL

L. DUMITRESCU, M LAZAR, C. MARINESCU, F. POPA

Spitalul Clinic de Urgenta 'Sf. Pantelimon' - Sectia de Chirurgie Plastica si Reconstructiva

OBIECTIVE. Tratamentul epitelioamelor constituie inca subiect de ontroverse, situatie care ne-a adus in fata deciziei de a realiza analiza ~trospectiva a unui lot de 89 de pacienti cu tot atatea astfel de formatiuni lmorale situa te la nivelul fetei.

MATERIAL SI METODE. Tratamentul chirurgical radical urmat, in nele cazuri, de terapia oncologica adjuvanta adecvata, au fost realizate in )italul nostru, iar rezultatele examenelor morfopatologice au fost obtinute 'dusiv in laboratorul de specialitate al Spitalului 'Sf. Pantelimon', ceea ~ confera omogenitate diagnosticului, tratamentului si rezultatelor.

REZULTATE. Marja de securitate oncologica a constituit unul dintre ementele principale ale analizei noastre, avand in vedere ca la nivelul fetei sursele cutanate sunt reduse comparativ cu alte regiuni anatomice, iar :fectele de parti moi rezultate in urma ablatiei pot fi uneori intinse, ceea ce lliga la solutii reconstructive din ce in ce mai laborioase si uneori :multumitoare. Au fost analizate, de asemenea, tipologia morfologica morala, modalitatea de excizie, acuratetea rezectiei si relatiile dintre este elemente.

CONCLUZII. Concluziile studiului obliga la adaptarea marjei de curitate oncologica in functie de tipul de carcinoma. Solutia terapeutica acoperire a defectului prezinta o relatie de proportionalitate inversa intre mplexitate si utilitate, intrucat solutiile laborioase mascheaza ppsibilele :idive si pot complica tratamentul reconstructiv ulterior.

ATITUDINI TERAPEUTICE IN COMPLICATIILE POSTOPERATORII ALE PANCREATITELOR ACUTE GRAVE

H. GILORTEANU, V. STRAMBU, C. IORGA, A CUIBAC, B. SOCEA, C.PUSCU,F.POPA

Spitalul Clinic de Urgenta 'Sf. Pantelimon' Bucuresti - Clinica Chirurgie

OBIECTIVE. Pancreatita acuta grava ramane o entitate patologica insuficient reglata din punct de vedere terapeutic, referindu-ne mai cu seama la complicatiile postoperatorii care pun adesea chirurgul in fata unor decizii delicate privind atat tipul, cat mai ales momentul reinterventiei, precum si conduita ulterioara, adaptata nivelului de gravitate si evolutiei bolii.

MATERIAL SI METODE. Studiul retrospectiv efectuat in intervalul 1999 - 2003 pe un lot de 27 de bolnavi internati in clinica noastra cu diagnosticul de pancreatita acuta grava, la care s-a impus o anumita atitudine chirurgicala, grevata de complicatii postoperatorii ce au necesitat reinterventii, ne-a permis elaborarea unor concluzii asupra modalitatilor de abordare chirurgicala a acestor pacienti.

REZULTATE SI CONCLUZII. Evolutia pancreatitei acute grave este extrem de imprevizibila, pe fondul unor disponibilitati biologice minime datorita afectarii sistemice multiorganice, deci cu posibilitati reduse de apreciere calitativa si temporala a sanctiunii chirurgicale. Fara a avea pretentia de standardizare terapeutica, am incercat o optimizare a conduitei in functie de anumiti parametri pe care i-am considerat statistic semnificativi.

FISTULE POSTOPERATORII COLONICE - PROGNOSTIC SI ATITUDINE TERAPEUTICA

H. GILORTEANU, M. CALIN, B. SOCEA, A. CUIBAC, M PADURARU, F. POPA

Spitalul Clinic de Urgenta 'Sf. Pantelimon' Bucuresti, Clinica Chirurgie

INTRODUCERE. Fistula colonica postoperatorie ramane o complicatie redutabila a rezectiilor colice si are un prognostic rezervat chiar in conditiile unui diagnostic precoce si a unui tratament adecvat. Localizarea fistulei, durata, debitul si tarele bolnavului operat constituie variabile care trebuie corelate in deciderea momentului operator si aprecierea prognosticului.

OBIECTIVE. Studiul isi propune sa evalueze diferentele de atitudine terapeutica si prognostic intre fistulele ileo-colice si cele colo-colice, dehiscentele anastomotice reunind o serie de posibilitati terapeutice conservatoare si/sau chirurgicale.

MATERIAL SI METODE. Am efectuat un studiu retrospectiv pe un lot de 21 de bolnavi care au prezentat fistule postoperatorii colice (dehiscente anastomotice), tratati in clinica noastra in perioada 1994 - 2003. Dintre acestia, un numar de cinci bolnavi (lotul A) au prezentat fistule ileo-colice (la care se mai adauga un caz de fistula ileo-rectala), restul de 15 pacienti (lotul B) prezentand fistule colo-colice.

REZULTATE SI CONCLUZII. Din analiza cazuisticii noastre rezulta ca fistula ileo-colica postoperatorie este o complicatie rara, necesitand reinterventie chirurgicala rapida si fiind grevata de un prognostic rezervat. Fistula colo-colica, o complicatie care apare mai frecvent, necesita tratament conservator sau reinterventie in functie de debitul si evolutia clinica a bolnavului, prognosticul fiind superior fistulelor ileo-colice, cu mortalitate mai scazuta.

COMPARTIMENTUL DE CHIRURGIE CARDIOVASCULARA, LOCATIE OBLIGATORIE INTR-UN SPITAL DE URGENTA

GABRIELA OROSAN, 1. PA VELESCU, FL POPA, P. RADU

Spitalul Clinic de Urgenta 'Sf. Pantelimon' Bucuresti

SCOPUL lucrarii este sa demonstreze necesitatea si importanta unui compartiment de chirurgie cardiovasculara in cadrul unui spital de urgenta, in situatii care nu permit mobilizarea si transportarea bolnavului intr-un serviciu de specialitate din alta unitate medicala de profil (politraumatisme prin accidente rutiere sau prin agresiune, anevrisme arteriale rupte, ischemii acute ale membrelor). De asemenea permite rezolvarea unor leziuni vasculare survenite in cadrul interventiilor din sectiile cu profil chirurgical ca si a altor cazuri care, chiar si in prezent se adreseaza chirurgului generalist (simpatectomii lombare, amputatii de membre).

MATERIAL SI METODE. In perioada 2001 - 2003 au fost rezolvate noua drenaje pleuropericardice pentru tamponada cardiaca, cinci plagi cardiopericardice, cinci anevrisme de aorta abdominala, din care doua rupte la prezentare, trei plagi arteriale survenite in urma interventiilor pe coloana 10mbara si 20 de restabiliri de flux arterial pentru ischemii severe ale membrelor inferioare. Pentru ischemii ireversibile, depasite, afectand starea generala a bolnavului, s-au realizat aproximativ 65 de amputatii per pnmam.

CONCLUZII. din analiza cazurilor studiate, reiese necesitatea existentei unui compartiment de chirurgie cardiovasculara pentru rezolvarea cazurilor de urgenta si, eventual, infiintarea unor astfel de compartimente la

nivelul spitalelor judetene. .

FACTORI DE PREDICTIE IN EVOLUTIA POSTOPERATORIE A NEOPLASMELOR COLICE OCLUZIVE

V. STRAMBU, B. SOCEA, P. RADU, C. MOCULESCU, P. TONI, O. CARSTEA, C. BALALAU, 1. SERI, F. POPA

Clinica Chirurgie, AT.I., Spitalul Clinic de Urgenta 'Sf. Pantelimon', Bucuresti

OBIECTIVE. Lucrarea analizeaza valoarea diverselor manopere medicochirurgicale conexe actului operator principal care ar putea influenta evolutia postoperatorie a neoplasmelor de colon ocluzive.

MATERIAL SI METODE. Sunt analiza te 64' de cazuri, luandu-se in calcul urmatoarele gesturi: pregatirea mecanica si antibiotica a colonului, lavajul colic intraoperator, enterotomia de golire, lavajul peritoneal.

REZULTATE. t,a cele 64 de cazuri s-au efectuat urmatoarele manevre: pregatirea mecanica - 19 cazuri (29,7%), antibiotica - 15 cazuri (23,5%), lavajul colic intraoperator - opt cazuri (12,6%), enterotomia de golire - patru cazuri (6,3%), lavajul peritoneal- 35 cazuri (54,7%).

Rata reinterventiilor a fost de 11 cazuri (17,2%) dintre care doar patru cazuri au beneficiat de gesturile mentionate anterior. Numarul de decese in lotul studiat a fost de Il cazuri (17,2%), trei dintre decese survenind in urma reinterventiei.

CONCLUZII. Analiza factorilor enuntati arata ca asocierea acestor gesturi cu rata reinterventiilor sau a deceselor nu este semnificativa statistic. Succesul interventiei tine de gradul de antrenament al echipei si momentul (dium/nocturn) interventiei.

TEHNICA DE ABORD TRANSMEDIASTINAL PENTRU INTERVENTII CHIRURGICALE PE CORPUL VERTEBRAL C7-T2

V. STRAMBU, S. STOIAN, D. NICA, T. CECK, F. POPA

Clinica Chirurgie, Neurochirurgie, Ortopedie, Spitalul Clinic de Urgenta 'Sf. Pantelimon', Bucuresti

OBIECTIVE. Lucrarea isi propune sa descrie si sa ilustreze tehnica folosita de catre autori in Clinica de Chirurgie a spitalului mentionat in abordul multidisciplinar (chirurgie, neurochirurgie, ortopedie) al patologiei corpului vertebral in regiunea de granita cervicotoracica.

MATERIAL SI METODE. Sunt descrise si ilustrate grafic si fotografic trei cazuri de tumori de corp vertebral C7-T2: cervicotomie in Y, stemotomie partiala, patrunderea in profunzime pe linia mediana intre tiroida (cranial) si trunchiul brahiocefalic stang (caudal), cu sacrificarea vaselor tiroidiene inferioare si reclinarea spre lateral dreapta a traheei si esofagului si spre lateral stanga a carotidei si jugularei stangi.

REZULTATE. Calea de abord folosita, diferita de cea standard, ofera o buna lumina in campul operator permitand efectuerea in siguranta si fara constrang eri a timpilor operatori principali (rezectia de corp vertebral cu cimentare si eventual fixare cu placa si suruburi a corpilor vertebrali adiacenti).

CONCLUZII. Consideram aceasta tehnica drept un element demn de avut in arsenalul chirurgilor toracici sau generalisti. Buna cunoastere a anatomiei regiunii de granita cervicotoracica va permite, in aceste conditii, obtinerea satisfactiei unei reusite profesionale colective multi disciplinare.

A DOUA EDITIE A ZILELOR CHIRURGICALE ROMANO-SARBE

Kladovo nov 2007

THE EVOLUTION OF RECURENCES IN RECTAL CANCER

V. STRAMBU, C. IORGA, S STOIAN, P RADU, R JITIANU, C PUSCU, C UDRISTE, F POPA

Surgery Department - 'St. Pantelimon' Emergency Hospital, Bucharest, Romania

Aim of study: The study analyzes the comparative value of two main surgical procedures used in the treatment of rectal cancer ( Dixon surgical resection and rectal abdominal-perineal resection) which are able to improve the postoperative evolution in patients with rectal cancer, the appearance time of recurrence and increase the survival rate at 5 years.

Materials and method: We analyzed a group of 67 patients with rectal cancer operated in our clinic between 2002-2006, 13 of them with Dixon procedure, 17 with rectal amputation, 4 with electroresection and 33 cases with emergency intervention (Hartmann operation or left colostomy). Significantly for our study we selected a lot of 24 patients in which 8 recurrences appeared between 2 and 3 years from the operation. AII 24 patients were monitorised from diagnostic date until dead time.

Results: The frequency of recurrence appearance at 2-3 years from the operation is 20% for the patients with Dixon procedure and 50% for the patients with abdominal-perineal resection.

Conclusions: The appearance of recurrences is delayed and the survival rate is improved in the patients diagnosed with rectal cancer in which we performed Dixon procedure compared to those in which we performed abdominal-perineal resection.

THORACO-ABDOMINAL INJURIES - OUR EXPERIENCE 2000-2007

V. Strambu^l, S. Silviu^l, C. lorga^l, P. Radu^l, R. Jitianu^l, C. PUscU^I, C. Udriste¹, V. Georgescu², 1. Dimitriu², F. Popa

Surgery Department 'St. Pantelimon' Emergency Hospital Bucharest, 2Emergency Department 'St. Pantelimon' Emergency Hospital Bucharest, Romania

Aim of study: Among trauma patients the thoraco-abdominal injuries have their own specific issues as diagnose and therapy. This pathology is approached by the clinical point of view as well as by the theoretical standpoint. We tried ta propose a diagnose and therapeutical algorithm.

Methods and materials: We analyzed a number of 23 cases with thoraco­abdominal injuries admitted in the ER and Surgery Department between 2000-2007.

Results: We analyzed the mechanism of injury (blunt fopen), the associated injuries, the sex ratia and age distribution, the diagnose difficulties and tips, the initial and the complete treatments.

Conclusions: There are different approach ways for each type of injury and also different criteria concerning the time and type of surgical treatment. The multidisciplinary team is the key factor in most of these injuries.

Cluj pancreatic days oct 2007

NEW TRENDS IN SURGICAL TREATMENT OF ACUTE PANCREATITIS

Strambu V., Iorga C., Stoian S., Radu P., Puscu C., Jitianu R., Cirstea O., Udriste C., Popa F.

"Saint Pantelimon" Emergency Hospital Bucharest - General Surgery Department.

Introduction: Acute pancreatitis is probably one of the most studied disease but it remains also actual through his evolutive character, regarding the new diagnosis technique, stadialization and treatment optimization.

Material and method: Our study developed in Surgery Department in Sf Pantelimon Hospital over a period of 4 years on 327 patients admited with acute pancreatitis

Results: in 64,3% patients with mild acute pancreatitis surgery wasn't necessary, medical treatment including supportive care, fluid resuscitation, transfer to intensive care unit, enteral feeding, use of antibiotics, and only for 35,7% surgery was mandatory making differences of etiology (biliar ethiology 78.4%, ethanolical ehiology 8.2% and other ethiologies 13.4%). The indication of surgical intervention was represented by the cases with proven biliar lithiasys and complicated cases, at diferent time intervals from admision, beetwen day I to week 4-5.

Conclusions: Acute pancreatitis remains a pathology hard to manage surgicaly from the point of view of gestures made and the operating moment. We consider that surgery in acute pancreatitis need a reevaluatin of indications and timing, depending on etiology, clinical evolution and and the severity of organs failure.

PANCREATIC PSEUDOCYST - CLINICAL AND TERAPEUTIC CONSIDERATIONS

Strambu V., Iorga C., Stoian S., Radu P., Puscu C., Jitianu R., Cirstea O., Udriste C., Popa F.

"Saint Pantelimon" Emergency Hospital Bucharest - General Surgery Department.

Introduction: Pancreatic pseudocyst is an important complication occuring in the evolution of acute pancreatitis. There is particularities we know about pseudocyst bat there are also many questions waiting for answers.

Materials and method: For this reason we tried to develop a study in our surgery department : analisys of 411 cases of acute pancreatitis admitted beetwen 2002-2004, with 34 cases of pancreatic pseudocysts. The analisys includes age, sex, etiology , clincal forms, gravity scores, development time, treatment, mortality.

Results: in our trial the average age was 52 years (=/- 5), sex ratio M/F (25/9) and 10 severe acute pancreatitis/24 mild acute pancreatitis. Ranson's scores recorded were: 28 cases 0-2, 5 cases 3-4, 1 case 5-6. The etiology was: 5 cases - ethanol, 7 cases cholelithiasis, and 22 other cases. Treatment was: internal derivations in 15 cases, external drainage 2 cases, and 7 CT guided evacuatory punctions and 10 cases with conservatory treatment. Two patients died.

We tried to answer this questions: Risk factors asociated with pancreatic pseudocyst developement Why this complication is relatively well tolerated, the infected transformation (abscess) beeing rare in evolution? Which is the best terapeutic atitude?

Conclusions: The indications for surgery are complications of pseudocysts in all cases, either acute (bleeding, infection, fistula, or rupture) or chronic (pain, digestive, or biliary compression), persisting after treatment of symptoms. We consider the appearance of pancres pseudocyst is determined by 3 factors: the clinical type of pancreatitis (especialy mild), the etiology (non lithiasic), age and sex of patients (VI decade and male gender). We were not able to find any relationship between these three factors and the success of the treatment.

SURGICAL ATITUDE IN ACUTE SEVERE PANCREATITIS - IMEDIATE SURGERY VS LATE SURGERY

Strambu V., Iorga C., Stoian S., Radu P., Puscu C., Jitianu R., Cirstea O., Udriste C., Popa F.

"Saint Pantelimon" Emergency Hospital Bucharest - General Surgery Department.

Introduction: Acute pancreatitis remains a pathology hard to manage surgicaly from the point of view of gestures made and the operating moment, factors that notably influence the evolution The International Symposium, held in Atlanta, GA, in 1992, established a clinically based classification system for acute pancreatitis. Criteria for severity in acute pancreatitis included organ failure (particularly shock, pulmonary insufficiency, and renal failure) and/or local complications (especially pancreatic necrosis but also including abscess and pseudocyst)..

Material and method: retrospective analisys of patients with severe acute pancreatitis admited in Surgery Department beetwen 2002-2006. Early predictors of severity within 48 h of initial hospitalization included Ranson signs and APACHE-II points.

Results: Sex repartition, age groups, ethiology, simptomatology, criteria of determining the diagnostic, duration of hospitalisation, preoperatory and interoperatory durations, pre and postoperatory complications, intensive care hospitalisation period, types of surgical intervention and mortality have been studied. For all patients we aplied the same terapeutic protocol. The lot was analised on three etiologic categories: lithiasic, alcohol and others. The final results offered

Conclusions: Regarding the oportunity of surgical intervention: in acute severe pancreatitis caused by biliary lithiasis late intervention reduced mortality from 21,5% to 12,5%, in alcoholic severe pancreatitis the delay of surgery reduced mortality from 26% to 14%. For the rest of severe acute pancreatitis there was no significant diferences.

CONGRESUL MONDIAL IASGO 2008 BUCURESTI

IASGO SEPT 2007

PANCREATIC PSEUDOCYST IN ACUTE PANCREATITIS EVOLUTION

Strambu V, Iorga C, Stoian S, Moculescu C, Constatin V, Socea B, Jitianu R, Cirstea 0, Radu P, Udriste, C, Puscu C, Popa F

General Surgery Department, 'St. Pantelimon' Emergency Hospital Bucharest, Romania

The aim of study: the analisys of factors that induces development of pancreas pseudocysts aher acute pancretitis.

Materials aud methods: retrospective analisysis of 34 pancreas pseudocysts admitted and treated in our clinic between 2002-2006 developed after an acute pancreatitis episode. The analisys includes age, sex, etiology , clinca] forms, gravity scores, development time, treatment, mortality.

Results: in our trial the average age was 52 years (=/- 5), sex ratio M/F (25/9) and 10 haemorrhagic PAl24 edematous PA. Ranson's scores recorded were: 28 cases 0-2, 5 cases 3-4, 1 case 5-6. The etiology was: 5 cases - ethanol, 7 cases cholelithiasis, and 22 other cases. Treatment was: internal derivations in 15 cases, external drainage 2 cases, and 7 CT guided evacuatory punctions and 10 cases with conservatory treatment. Two patients died.

Conclusions: we consider the appearance of pancres pseudocyst is determined by 3 factors: the clinical type of pancreatitis (especialy edematous), the etiology (non Iithiasic), age and sex of patients (VI decade and male gender).

SURGICAL ATITUDE IN ACUTE PANCREATITIS

Strambu V, Iorga C, Stoian S, Jitianu R, Cirstea 0, Radu P, Udriste, C, Puscu C, Popa F

General Surgery Department, 'St. Pantelimon' Emergency Hospital Bucharest, Romania

Objectives: determining the optimal operating moment taking into account the ethiology of acute pancreatitis

Material and method: 327 patients diagnosed with acute pancreatitis admitted in St. Pantelimon Clinical Hospital's Surgery Clinic in the period of january 2002 - december 2006. Sexual repartition, age groups, ethiology, simptomatology, criteria of determining the diagnostic, clinic-paraclinic scores, duration of hospitalisation, preoperatory and interoperatory durations, pre and postoperatory complications, intensive care hospitalisation period, types of surgical intervention and mortality have been studied .

Results: From 327 acute pancreatitis cases cared for, a total of 209, representing 63.8% of the patients, have been treated conservatively while the other 118 cases, representing 36.1 % of the patients, benefited from surgical intervention. The patients that benifited from surgical intervention have the following ethiological structure: biliar ethiology 78.4%, ethanolical ehiology 8.2% and other ethiologies 13.4%. The indication of surgical intervention was represented by the cases with proven biliar Iithiasys and complicated cases. Preoperating periods varried from 0 to 15 days, surgical intervention adressing biliar lithiasys took place on the 3rd day, after stabilisation and lessening of the simptomatology, and the optimal operating moment for ethanolic ethiology pancreatities and other e'es has been in the 13th day, the surgical intervention primarily targeting the infected necroze.

Conclusions: Acute pancreatitis remains a pathology hard to manage surgicaly from the point of view of gestures made and the . g moment, factors that notably influence the evolution of this disease being represented by ethiology, the operating moment state of presentation.

MULTIMODAL TREATMENT RESULTS IN RECTAL CANCER

Cuibac A, Strambu V, Popescu T, Iorga C, Stoian S, Udriste C, Carstea 0, Radu P, Puseu C, Moculescu C, Popa F General Surgery Department, 'St. Pantelimon' Emergency Hospital Bucharest, Romania

The aim of study: This poster analyses the multimodal treatment (presurgery radiotherapy +' surgical treatment + radio-chemotherapy postsurgery) over the moment of recurrence apparition and increasing the hope of life for rectal cancer patients.

Materials and method: We analyzed retrospective 140 cases of rectal cancer patients who had surgery in our department between 2001-2006. Suggestive for this study was a 39 patients lot (lotB) who benefit of radiotherapy presurgery and radio-chemotherapy postsurgery, the rest of 101 patients being the control lot (IotA).

Results: For the studied lot(lotB) the frequency of loco-regional and pelvic recurrence apparition in 3 years period of time postsurgery is 5,13% comparing with 32,67% (lotA) and the average surviving rate at 5 years is 61,54% (lotB) comparing with 49,5% (IotA). Whole 39 patients had adenocarcinoma, in 19 cases stagell and 20 cases stageIII.

Conclusions: The moment of loco-regional and pelvic recurrence apparition, is far away from the first intervention. The surviving forecast at 5 years, is better for the rectal cancer patients who had radiotherapy +intervention +radio +chemotherapy postsurgery. In opposition with control lot(lotA) were the first option was surgical intervention(emergency ar not), with or without radio/chemotherapy postsurgery, but in all cases without presurgery radiotherapy.

RECCURENCE OF RECTAL CANCER - EVOLUTIVE PARTICULARITIES

Strambu V, Cuibac A, Iorga C, Popescu T, Puscu C, Stoian S, Jitianu R, Udriste C, Carstea 0, Radu P, Moculeseu C, Popa F

General Surgery Department, 'St. Pantelimon' Emergency Hospital Bucharest, Romania

The aim of study: The study analyzes the comparative value of two main surgical procedures used in the treatment of rectal cancer (Dixon surgical resection and rectal abdominal-perineal reseetion) witch are able to improve the postoperative evolution in patients with rectal cancer, the appearance time of recurrence and increase the survival rate at 5 years.

MateriaIs and method: We analyzed a group of 67 patients with rectal cancer operated in our clinic between 2002-2006, 13 of them with Dixon procedure, 17 with rectal amputation, 4 with electroresection and 33 cases with emergency intervention (Hartmann operation or left colostomy). Significantly for our study we selected a lot of 24 patients in which 8 recurrences appeared between and 3 years from the operation. All 24 patients were monitorised from diagnostic date until dead time.

Results: The frequency recurrence appearance at 2-3 years from the operation is 20% for the patients with Dixon procedure and 50% for the patients with abdominal-perineal resection.

Conclusions: The appearance of recurrences is delayed and the survival rate is improved in the patients diagnosed with rectal cani in which we performed Dixon procedure compared to those in which we performed abdominal-perineal resection.

CONFERINTA NATIONALA Iasi mai 2005

CORELAREA SCORURILOR CLINICO-PARACLINICE CU EVOLUTIA IN PANCREATITA ACUTA (P.A.)

FL. POPA, V. STRAMBU, V. CONSTANTIN, C. IORGA, R. JITIANU, N. COSTINAS, B. SOCEA, T. POPESCU, P. TONU, C. PUSCU Clinica Chirurgie, Spitalul Clinic de Urgenta 'Sf. Pantelimon' Bucuresti

 OBIECTIVE. Compararea scorurilor Ranson, Imrie, Scala Glasgow Modificata si APACRE II din punct de vedere al valorii predictive.

 MATERIAL SI METODA. Studiul scorurilor pe 327 de pacienti cu P.A. si valoarea lor predictiva.

 REZULTATE. Scorul Ranson releva: 312 pacienti cu 0- 2 puncte; 13 pacienti 3 - 4 puncte; 1 pacient cu 6 puncte; 1 pacient cu 7 puncte. Scorul Imrie: 263 pacienti cu O puncte; 45 cu 1 punct; 14 cu 2 puncte; 3 cu 3 puncte si 2 cu 4 puncte. Scala G1asgow Modificata: 139 pacienti cu O puncte; 146 cu 1 punct; 26 cu 2 puncte; 12 cu 3 puncte; 3 cu 4 puncte; 1 pacient cu 5 puncte. Scorul AP ACRE II: 164 pacienti O - 4; 119 pacienti cu 5 - 9; 38 pacienti cu 10 - 14 si 6 pacienti cu 15 - 19. Primele trei scoruri au aratat mortalitati ceva mai mari ca in literatura. Concatenarea cu APACRE II aduce concordanta cu studii similare.

 CONCLUZII. Ranson, Imrie si Glasgow reprezinta scoruri statice. Scorul APACHE II, prin numarul mare de parametri si dinamica sa, reflecta cel mai bine starea pacientului.

 THE PREDICTIVE VALUE OF VARIOUS SCORES (RANSON, IMRIE, MODIFIED GLASGOW AND APACHE II IN ACUTE PANCREATITIS (A.P.)

FL. POPA, V. STRAMBU, V. CONSTANTIN, C. IORGA, R. JITIANU, N. COSTINAS, B. SOCEA, T. POPESCU, P. TONU, C. PUSCU Surgery Clinic, 'Sf. Pantelimon' Emergency Hospital, Bucharest

 AIM. The comparison of the predictive va1ue of Ranson, Imrie, Modified G1asgow and AP ACRE II.

 MATERIALS AND METHOD. We calcu1ated the 4 scores in 327 patients with A.P ..

 RESULTS. For the Ranson score the results were: 312 patients scored O - 2 points, 13 patients scored 3 - 4 points, 1 patient scored 6 points and 1 patient scored 7 points. For the Imrie score the results were: 263 patients scored O points, 45 scored 1 point, 14 scored 2 points, 3 scored 3 points and 2 scored 4 points. For the Modified G1asgow: 139 patients scored O points, 146 scored 1 point, 26 scored 2 points, 12 scored 3 points, 3 scored 4 points and 1 scored 5 points. For the APACRE II score: 164 patients scored 0- 4 points, 119 scored 5 - 9 points, 38 scored 10 - 14 points, and 6 scored 15  19 points. In our lot, the first 3 scores showed higher morta1ity than reported in the 1iterature. The AP ACRE score correlated best with the pub1ished 1iterature.

 CONCLUSIONS. The Ranson, Imrie and Modified G1asgow are fairly static. The APACHE II score is dynamic and, by taking into account many parameters, best corre1ates with the patient' s status.

 PANCREATITA ACUTA NECROTICO-HEMORAGICA (PANH) CU HEMOPERITONEU - PREZENTARE DE CAZ

FL. POPA, V. STRAMBU, C. BALALAU, J. MOTOFEI, O. CARSTEA, R. PETRE Clinica Chirurgie, Spitalul Clinic de Urgenta 'Sf. Pantelimon', Bucuresti

 OBIECTIVE. Prezentarea unui caz de PANH, barbat de 52 ani cu evolutie grevata de hemoperitoneu.

 MATERIAL SI METODA. Analiza clinico-imagistica, tipul si momentul interventiilor, evolutia in timp.

 REZULTATE. Pacientul se prezinta cu semne clinice de PANH. Dupa evaluarea paraclinica si imagistica in urgenta pacientul prezinta scor APACHE II 10, respectiv scor Ranson 3. Se instituie tratament antibiotic, antisecretor, de supleere hidro-electrolitica. In ziua 12 starea bolnavului se agraveaza, prezentand soc hipovolemic. Intraoperator se descopera hemoperitoneu masiv (1,5 1 sange si cheaguri), dintr-un hematom subcapsular eclatat in peritoneu. Hemostaza in situ, lavaj, drenaj al lojei pancreatice. Evolutie favorabila de 28 zile, cu control imagistic seriat. Din ziua 7 postoperator pacientul prezinta subfebrilitate. Controalele imagistice pun in evidenta formarea de sechestre pancreatice cefalo corporeale. In ziua 28 postoperator se intervine constatandu-se supuratie cefalocorporeala cu sechestru pancreatic 10/4/4 cm care se evacueaza. Evolutie favorabila cu extemare la 29 zile.

 CONCLUZII. Cazul este prezentat datorita hemoperitoneului masiv, care dicteaza momentul interventiei primare si necorelarii scorurilor cu evolutia clinica.

CASE REPORT: NECROTIZING-HEMORRHAGIC PANCREATITIS (NHP) WITH HEMOPERITONEUM

FL. POPA, V. STRAMBU, c. BALALAU, 1. MOTOFEI, O. CARSTEA, R. PETRE Surgery Clinic, 'Sf. Pantelimon' Emergency Hospital, Bucharest

AIM. We present a 52 year-old male with NRP with Remoperitoneum.

MATERIALS AND METHOD. The Clinical, Paraclinical and Imagistic analysis, type of surgeries and the outcome.

RESULTS. The patients, a 52 year-old male, presented with classic signs and symptoms ofNHP. After E.R. evaluation, based on imaging and labs, the patient is evaluated as being AP ACRE II score 10 and Ranson score 3. Volume and electrolyte replacement, as well as antibiotic and antisecretory treatment were initiated. The patient underwent surgery and was found to have massive hemoperitoneum (1.5 liters fresh and clotted blood), from a subcapsular hematoma. Re underwent in-situ hemostasis, and drainage of the pancreatic fossa. Patient improved, and was followed by serial CT and ultrasound for 28 days. Starting on day 7 postop, he developed low-grade fever and the imaging revealed abscess formation in the head and body of the pancreas. On the 28th day postop, he underwent the second surgery, drainage of head and body abscess (10/4/4 cm). The patient was discharged home 29 days after re-intervention.

 CONCLUSIONS. This case is interesting because of the life threatening hemoperitoneum, requiring early intervention and the fact that the scores did not correlate with the severity ofthe case.

PSEUDOCHIST GIGANT DE PANCREAS - PREZENTARE DE CAZ  

 FL. POPA, C. BALALAU, A. CUIBAC, T. POPESCU, R. GURITA Spitalul Clinic de Urgenta 'Sf. Pantelimon', Bucuresti

 CUVINTE CHEIE: pseudochist acut, pancreatita, colecistostoma, perichistogastroanastomoza

 INTRODUCERE. Notiunea de pseudochist acut de pancreas incearca sa defineasca o complicatie precoce a pancreatitei acute, care nu este nici un abces nici un pseudochist real la distanta de episodul acut. Aceasta lucrare aduce inca un caz in sprijinul acestei definitii, cu particularitatea data de dimensiune si evolutie.

MATERIAL SI METODA. Lucrarea urmareste aparitia si evolutia unei complicatii rare a pancreatitei acute, respectiv pseudochistul acut de pancreas, la o bolnava internata pentru pancreatita acuta necrotico hemoragica de etiologie neprecizata, pentru care se intervine chirurgical practicandu-se colecistostoma cu decapsulare pancreatica si drenaj multiplu, urmata la 6 saptamani de reinterventie cu perichistogastroanastomoza si colecistectomie cu controlul imagistic intraoperator a C.B.P ..

REZULTATE. Dificultatea cazului a constat in alegerea atitudinii terapeutice, stiut fiind faptul ca un drenaj extern precoce va duce la o fistula pancreatica externa permanenta, iar efectuarea unei anastomoze perichistoodigestive este extrem de riscanta.

 CONCLUZII. In ciuda caracterului acut al acestei complicatii, aceasta este in general bine tolerata de pacient, transformarea intr-un abces pancreatic fiind rara. Dimensiunile mari pot duce la complicatii prin compresie extrinseca in intervalul 'clasic' de maturare, precipitand astfel actul operator.

EVOLUTIA PANCREA TITELOR ACUTE (P.A.) GRAVE IN FUNCTIE DE GESTURILE CHIRURGICALE EFECTUATE SI MOMENTUL OPERATOR

 V. STRAMBU, C. IORGA, C. MOCULESCU, A. CUIBAC, A. CIUDIN,  M. PADURARU, C. MARINESCU, M. CALIN, R. GURITA, P. RADU, FL. POPA Clinica Chirurgie, Spitalul Clinic de Urgenta 'Sf. Pantelimon' Bucuresti

 OBIECTIVE. Evolutia P.A. grave, in functie de gesturile chirurgicale efectuate si de momentul operator.

 MATERIAL SI METODA. Studiul unui lot de 107 pacienti cu P.A. la care s-au practicat, in functie de etiologia afectiunii: colecistectomie, colecistostomie sau alt tip de drenaj biliar, decapsularea pancreatica, lavajul si drenajul lojei pancreatice.

 REZULTATE. 82 de pacienti au avut P.A. de etiologie litiazica, 10 pacienti etiologie etanolica si 15 pacienti de alte etiologii. Pentru etiologia litiazica predomina colecistectomia (31 de cazuri) si/sau drenajul biliar extern (17 cazuri). Rata deceselor = 11 % (7 cazuri). Pentru etiologia etanolica sau alte etiologii predomina: decapsularea cu drenajul si lavajul lojei pancreatice (mortalitate 20%, respectiv 11,8%). Statistic este semnificativa doar corelarea colecistectomiei cu rata mortalitatii (p<0,005). Majoritatea deceselor au survenit la pacientii operati in primele 7 zile de la internare (p<0,003).

 CONCLUZII. In afara colecistectomiei, restul gesturilor chirurgicale nu isi justifica valoarea. Mortalitatea crescuta la pacientii operati in primele 7 zile sustine atitudinea de expectativa chirurgicala 'armata'.

THE CORRELATION BETWEEN THE SURGICAL OPTION AND THE TIMING OF SURGERY WITH THE OUTCOME IN SEVERE ACUTE PANCREATITIS (A.P.)

 V. STRAMBU, C. IORGA, C. MOCULESCU, A. CUIBAC, A. CIUDIN, M. PADURARU, C. MARINESCU, M. CALIN, R. GURITA, P. RADU, FL. POPA Surgery Clinic, 'Sf. Pantelimon' Emergency Clinic Hospital, Bucharest

 . AIM. To evaluate the correlation between the surgical option and the timing of surgery in A.P.

 MATERIAL AND METHOD. We studied 107 patients presenting with AP: which underwent various surgical interventions, according to the etiology: cholecystectomy, cholecystostomy OI' other type of billiary drainage, pancreatic fossa decapsulation, the lavage and drainage of the pancreatic fossa.

RESULTS. Out of 107 patients, 87 patients had billiary etiology, 10 patients had a1coholic etiology and 15 had other etiologies. Among the billiary etiology, the most frequent procedure was Cholecystectomy (31 cases), with/or External Billiary Drainage (17 cases), mortality rate 11 %. For the a1coholic and other etiologies, the procedure was: decapsulation, lavage and drainage of the pancreatic fossa. The mortality rate was 20 % and 11.8%. The statistic analysis correlates the colecystectomy with mortality (p <0.005). The majority of deaths were in aH operated patients within 7 days of admis sion (p<0.003).

CONCLUSIONS. Only the Cholecystectomy, significantly influences the outcome. The expectant approach may be a better choice.

PSEUDOCHIST GIGANT DE PANCREAS CU PLEUREZIE - PREZENTARE DE CAZ

V. STRAMBU, 1. MOTOFEI, O. CARSTEA, C. UDRISTE, S. STOIAN, FL. POPA Clinica Chirurgie, Spitalul Clinic de Urgenta 'se. Pantelimon' Bucuresti

SCOP Prezentarea unui caz de pseudochist gigant de pancreas la pacient de 52 de ani, insotit de pleurezie dreapta.

 MATERIAL SI METODA. Analiza clinica, biologica, imagistica a cazului si sanctionarea chirurgicala.

 REZULTATE. Barbat de 52 ani care se interneaza prin transfer dintr-un serviciu pneumologic, pentru pleurezie inchis tata dreapta. Examenul clinic si imagistic releva formatiune tumorala la nivelul hipocondrului si flancului stang de 15,4/11,4/16 cm (C.T. ) impingand stomacul, ridicand hemidiafragmul stang cu 10 cm, deplasand mediastinul catre dreapta cu pleurezie postero-bazala dreapta. Toracocenteza: lichid xantocrom, cu amilaze = 4084U/L si LDH = 4563U/L. Dupa echilibrare volemica si corectarea tarelor se intervine chirurgical. Se practica perichistoojejunostomie pe ansa Y a la Roux. Postoperator prezinta episod de H.D.S. a 6-a zi, remis la tratament medical. Se extemeaza vindecat chirurgical la 15 zile postoperator.

 CONCLUZII. Cazul prezinta interes prin: lipsa unui episod de pancreatita certificat medical, prezenta pleureziei controlaterale de cauza pancreatica si complicatia hemoragica digestiva.

CASE REPORT: PLEURAL EFFUSION ASSOCIATED WITH A GIANT PANCREA TIC PSEUDOCYST

 V. STRAMBU, I. MOTOFEI, O. CARSTEA, C. UDRISTE, S. STOIAN, FL. POPA Surgery Clinic, 'Sf. Pantelimon' Emergency Clinic Hospital, Bucharest

 AIM. Case of a 52 year-old patient with a gigantic pancreatic pseudocyst associated with right sided pleural effusion.

 MATERIAL AND METHODS. Analysis from a clinical, biological and imagistic point ofview and the surgical approach.

 RESULTS. A 52 year-old male was transferred from a pulmonary clinic, for a right-sided pleural effusion. The physical exam, the ultrasound and the C.T. revealed a left upper quadrant and left flank tumor of 15.4/11.4/16 cm which was displacing the stomach, elevating the left hemidiafragm and displaceing the mediastinum with pleural effusion in the right base, posterior1y. The thoracenthesis revealed xanthochromic, fluid with amylase level = 4084 U/L and LDH = 4535 UlL. After volume replacement and transfusion, the cyst was drained surgically with a jejunostomy en Y a la Roux. On the 6th day postop, he had an episode of upper GI bleeding. The patient was discharged an the l5th day post.

 CONCLUSIONS. This case is interesting thraugh: 1. No documented prior pancreatitis. 2. Pleural effusion in the opposite side 3. The hemorrhagic complication in a patient with diminished reserves.