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Laparoscopic sleeve gastrectomy is a relatively simple procedure, but the complications can quickly become life-threating. The aim of this study was to investigate based on our experience when is best to follow a conservative protocol in postoperative bleeding after sleeve gastrectomy. The study is retrospective, we identified a number of 150 cases of sleeve gastrectomy, of which 18 has postoperative bleeding. A conservative approach with close observation (ultrasound, CT, Hb levels) was practiced in 10 cases and no surgical intervention was required. The recommendations are as follows: The first and obvious recommendation is to stop anticoagulants. The perigastric drainage should drain, if Hb levels go down an nothing is coming through the drain consider other sources of bleed or try to reopen the blocked drain. A blood cloth developed around the bleeder may maintain the active bleed due to local fibrinolysis, in these cases, one should take into consideration guided drainage (ultrasound/CT) and monitor Hb levels afterward. The presence of a small perigastric collection without clinical manifestation should be left as such. Take into consideration reintervention if: signs of hypovolemia are present (tachycardia, hypotension, profuse sweating), Hb below 7g/dL. The patient's clinical state should always play an important role in decision making. [ABSTRACT FROM AUTHOR]

Up to 20% of the patients with gallstones have bile duct stones which are asymptomatic in 50% of the cases. The study aimed to evaluate the role of choledocoscopy with regards to extracting main bile duct stones. We conducted a retrospective study (January 2003 - December 2018). The group comprised 2 309 which had a laparoscopic cholecystectomy. Laparoscopic choledocoscopy was practiced in 32 cases. Of the 32 patients with complete clearance, none had residual CBDS at a 1- year postop. Transcystic approach: The ideal approach in our opinion. Shortest hospital stays (mean 3 days) comparable to LC. It was feasible in only 7 patients. All of the patients had transcystic drain which was removed after 10 days. Mean OR time 105 min. Transcholedocal approach: Technically demanding. Primary ductal closure was practiced in 5 patients. Ductal closure with transcystic drain in 9 patients. A total of 14 patients had a T-tube. Longer OR time (mean 170 min). Conversion to open surgery was realized in 4 cases. Cause: difficult dissection in the porta hepatis. LCBDE for CBDS previously documented or discovered during LC is safe and feasible. The technique is technically demanding, requires advanced laparoscopic skills. Patient selection is very important. The transcystic approach for LCBDE when possible is optimal. [ABSTRACT FROM AUTHOR]

Gastric stump cancer (GSC) is an entity described in the literature as early as the 1920s. Along the years the clinicopathological characteristic had changed. At the moment, there are no wellestablished guidelines regarding the optimal treatment. We conducted a literature review of the studies published from 2014 to 2019 using the PubMed database. After searching the PubMed database for the keywords: "gastric remnant cancer" AND "stump" AND "neoplasm" we identified 167 articles. Of these, 25 studies were considered relevant. GSC develops after 2 years from the primary intervention for malignancy and after 20 years for benign lesions. The development mechanisms vary depending on the type of primary gastric lesions. GSC is considered a unique clinicopathological entity. The pattern of lymphatic drainage is different in comparison to primary gastric neoplasm. Thus, an important negative prognostic factor is considered to be the N group of TNM staging. More studies are required to improve the understanding of development mechanisms and evolution of this pathology. Survival after gastric cancer has increased and it is possible to observe an increased percentage of patients who achieve the 5-year survival interval after surgery. Currently, there are no guidelines to select the optimal treatment with regards to surgery or chemotherapy as pathology is rare and studies which investigate the evolution and prognosis lack a significant cohort of patients. Therefore, the existent data is not substantial enough to elaborate guidelines that would define a standard surgical treatment. [ABSTRACT FROM AUTHOR]

An increasing interest exits towards the use of antibiotics in the treatment of uncomplicated acute appendicitis. For a long period of time, surgery was the only treatment for acute appendicitis. Due to recent research in the etiology of acute appendicitis which seems to be driven by intraluminal bacterial proliferation, new data suggests that for non-perforated appendicitis confirmed with the help of CT, antibiotics may play a central role in the treatment. As relapse rates amount in some cases to only 5% after antibiotic treatment, a discussion is required regarding the risks of interval appendectomy and its use. The debate regarding the optimal antibiotic course is on-going as some surgeons advocate for amoxicillin/clavulanic while others, due to acquired resistance recommend ertapenem. Selective antibiotic treatment for selected forms of acute appendicitis, uncomplicated without perforation is safe and has a relatively low complication rate. However, certain mentions must be made: surgery must not be delayed if failure of antibiotics exists as it can lead to higher rates of peritonitis. Close clinical surveillance is of utmost importance. [ABSTRACT FROM AUTHOR]

Neuroendocrine tumors represent a varied group of neoplasms which have the potential to produce and secrete a wide range of hormones along with other vasoactive substances. The care of these patients involves several specialties including: surgery, oncology, radiotherapy, interventional radiology and nuclear oncology. Despite this large number of options there is currently no consensus on the optimal sequence of these treatment resources for metastatic patients. We present the case of a 24 year women who was diagnosed with a gastric tumor (could not be biopsied) by imagistics and liver metastasis. A Pean resection with metastasectomy was done. The histopathology study revealed that the gastric tumor was benign ectopic pancreas tissue and the metastases were actually of neuroendocrine origin. A somatostatin receptor scintigraphy (OctreoScan) was done which revealed the primary tumor in the ileal mesentery which was resected in a secondary intervention. The patient was started on long acting sandostatin with no recurrence. [ABSTRACT FROM AUTHOR]

Sexual dysfunction following surgery for rectal cancer may be frequent and often severe. The aim of the present study is to evaluate the postoperative incidence of this complication and its severity. The current study is a retrospective study in which consecutive patients with rectal tumors, regardless of location (upper, middle or lower) were enrolled during a 1 year period in the General Surgery Clinic of the Emergency Clinical Hospital Prof. Dr. Agrippa Ionescu, Hospital, Bucharest. The patient files, paraclinical investigations, operative protocols and histopathological bulletins were reviewed and data regarding age, gender, date of diagnosis, medical treatment administered including neoadjuvant therapy and reinterventions were collected. The IIEF-5 type questionnaires were used to assess sexual function at 6 months. We identified a number of 30 patients with a median age of 60 years. All the patients were operated via open approach. Total mesorectal resection (TME) was practiced in 18 cases. Mean period follow-up was 10 months. Perioperative mortality was 0. There was no recurrence 1 year after surgery. Ten patients benefited from neoadjuvant radiotherapy. Rate of erectile dysfunction was 80%. Rate of ejaculation dysfunction was 70%. Patients operated for rectal cancer via open approach showed severe sexual dysfunctions (SD). These complications affect the patient's quality of life and needs a multidisiplinary approach towards a better understanding of this problem by both the medical staff and the patient. [ABSTRACT FROM AUTHOR]

Crohn's Disease is a dilemma from a surgical point of view. The nature of the pathology increases the technical complexity of surgical interventions, their morbidity and the incidence of reintervention. In this context, the advantages of minimally invasive surgery such as reduced hospitalization, fewer adhesions, the low incidence of wound complications, the faster return to normal intestinal function are of particular importance to these patients. This pathology that requires interventions in an elective context may in most cases be initially approached laparoscopically. Observatory sheets, operative protocols, and in some cases video recordings, were reviewed retrospectively over a period of 20 years (January 1997 - January 2017), bearing in mind indications, contraindications, difficulties and complications encountered. The literature on the minimal invasive approach to the treatment of Crohn's disease has also been reviewed by accessing medical databases (SCOPUS, PUBMED). The mean age of the study group was 40 years with female sex predominance. The main surgical indication was abdominal algic syndrome and intestinal transit disorders. For all patients, the diagnosis resulted from laparoscopy surgery - by macroscopic appearance of intestinal lesions and lymphatic tissue biopsy, with the clear majority of patients presenting mesenteric adenopathies during inflammatory attacks. The intestinal transit resumed on average on day 2 postoperatively and the duration of hospitalization was on average of 4 days. There were no intraoperative or postoperative incidents. Mortality was 0. Laparoscopic surgery combines many benefits for the patient with Crohn's disease, all of which eventually lead to a lower cost of care and a less hostile abdomen in the case of other interventions. These patients, through the anti-inflammatory treatment (steroids), fragile tissues, and abdominal adhesions complicate laparoscopic surgery - so it should only be attempted by experienced surgeons. [ABSTRACT FROM AUTHOR]

We present the case of patient SS aged 44 who had undergone bariatric surgery (BMI=44 kg/m2) -- a laparoscopic sleeve gastrectomy. Five days after surgery he presented to the emergency room with clinical symptoms suggestive of peritonitis. Abdominal radiography identified pneumoperitoneum. Ultrasound examination showed the existence of peritoneal fluid in small quantity. Biological analysis of the blood showed leukocytosis and inflammatory syndrome. Laparoscopic emergency surgery was undertaken - when the optic trocar was introduced -- minimum pneumoperitoneum was eliminated. The laparoscopic exploration of the peritoneal cavity showed cloudy peritoneal fluid in a minimum quantity and a small fistula which corresponded to a failded mechanical suture clip. Lavage and aspiration were practiced profusely (5L), multiple peritoneal drainage and installation of a nasogastric tube under laparoscopic control. The postoperative evolution was favorable with bowel movements being regained and progressive removal of the drainage tubes. The patient was discharged on postoperative day 7 after reoperation. Laparoscopic approach can be used successfully in reinterventions after bariatric surgery [ABSTRACT FROM AUTHOR]

Robotic surgery appeared in the Romanian health system in 2008 with the purchase of the first two surgical robots. One of them belonged to "Dan Setlacec" Center of General Surgery and Liver Transplantation - Fundeni and the second to Floreasca Emergency Clinical Hospital. Funding was provided by the Ministry of Health special program. Since the first year of operation by the robotic system, the Fundeni Center has performed about 200 interventions. A key objective of the program was to identify the interventions that are cost efficient, i.e., around 9,000 RON for each surgical intervention. Subsequently, another 7 robotic systems were put into operation, out of which three are in urology and four in general surgery. Given the high cost of consumables and post-warranty maintenance, the operation of these robotic systems could only be done through the national health system, or private sector. The operation of the program allowed for an annual limited number of cases, and since 2013 the program funding has ceased. During this period, a significant experience was gained using robotic surgery in general surgery, urology and gynecology as well. [ABSTRACT FROM AUTHOR]

Based on a case operated in our clinic the paper discusses the various applications of robotic surgery in the surgical treatment of the hepatic hydatid cyst. We present the case of a 29-year-old patient who presented to our clinic with chronic abdominal pain (8 months) localized in the right upper quadrant, without irradiation and showing no other accompanying phenomena. The patient was hospitalized and after clinical and laboratory investigations we confirmed the diagnosis of hepatic multilocular hydatid cyst located in the V, VI and VIII segments. Surgery was performed under general anesthesia and with the help of the STANDARD da Vinci robotic system equipped with four arms. The parasite was intactivated, a partial pericystectomy was done and the remaining cavity was drained. The patient's postoperative evolution was favorable and she was discharged in the 8th postoperative day. The 8 month follow-up showed no complications or pathological changes. In conclusion, robotic surgery can be successfully used in the treatment of the hepatic hydatid cyst. [ABSTRACT FROM AUTHOR]

We present the case of patient SC aged 44 years who underwent surgery 5 years prior to the presentation to our clinic for a tumor in the head of the pancreas, the operation than consisted of a cephalic duodenopancretectomy which was followed by a number of complications. On admission the patient had abdominal pain in the right flank, giant median postoperative eventration and a external "a la Witzel" biliary drainage tube. Abdominal ultrasound revealed the presence of a interhepaticodiaphragmatic collection that measured 4.6 / 3 cm. A cholangiography was done which showed biliary tract opacification of the left lobe with the full stop of the contrast in the distal left main hepatic duct without intrahepatic biliary dilatation. Surgery was undertaken under total anesthesia -the intraoperative diagnosis consisted of: almost complete stenosis of the biliojejunostomy. After the adhesions were cut, the bilio-jejunostomy was redone using the left hepatic duct in a terminal-lateral anastomosis. The collection was drained and the abdominal defect was corrected. The patient maintained a favorable external biliary drainage of about 200 ml per day so in the 5-th postoperative day the drainage was clamped without any complications. Conclusions: 1. Duodenopancreatectomy should be reserved for average / high volume surgical centers. 2. During the intervention the steps to achieve the biliary-digestive anastomosis should be respected thoroughly 3. Fast reoperation may increase the chance of survival of the patient. [ABSTRACT FROM AUTHOR]

After more than 20 years from the beginning of laparoscopic surgery, laparoscopic cholecystectomy still holds a conversion rate of 5.1 % in the specialty literature. We have conducted a retrospective study based on the experience of the clinical unit of General Surgery within "Prof. Dr. A. Ionescu" Emergency Clinical Hospital, between 1997 and 2013. A number of 2,309 laparoscopic cholecystectomies were performed. The average age of the group was 47.3 years. Conversion was performed to a number of 58 patients (2.51%), out of which 74.13% women (no. = 43) and 26% men (no. 15). The average age of the patients to whom the conversion was performed was 57. Conversion to open cholecystectomy was more frequent in patients over 60 (no. 38). The main preoperative diagnosis in converted patients was acute lithiasic cholecystitis. Laparoscopic cholecystectomy is a safe method with optimal results, being considered the "gold standard" in the treatment of bladder lithiasis. Conversion to open surgery is an expression of the surgeon's experience and wisdom. [ABSTRACT FROM AUTHOR]