Chirurgia最新文献

Unstable pelvic ring fractures pose significant clinical challenges due to their intricate anatomy, substantial bleeding risk and frequent involvement of multiple organ systems. In the prehospital setting, early haemorrhage control with pre-peritoneal pelvic packing (PPP) and angioembolisation (AE) is critical: PPP rapidly controls venous bleeding, while AE targets arterial sources. Following initial resuscitation, timely bone repair with temporary external fixation (ExFix) and definitive bone repair, with open reduction and internal fixation (ORIF), is vital in minimising long-term complications. Hence, to coordinate these approaches from prehospital care to surgical intervention, a multidisciplinary approach is required along the trauma pathway. Advancements in trauma network systems may also offer improvements in survival and functional recovery. Therefore, this literature review critically evaluates the indications, timing and synergistic use of PPP, AE, ExFix and ORIF to optimise outcomes for patients with unstable pelvic ring fractures.

Background: Gastric cancer remains a major global health burden. Beyond oncologic outcomes, health-related quality of life (HRQoL) is increasingly recognized as a critical endpoint influenced by the reconstruction method after gastrectomy.

Methods: A prospective observational study was conducted between December 2021 and December 2024 at the Emergency County Hospital of Targu Mures, Romania, including 150 patients undergoing curative-intent gastrectomy. Patients were divided into two groups: gastroduodenal anastomosis (Billroth I, n=72) and gastrojejunal anastomosis (Billroth II/Roux-en-Y, n = 78). HRQoL was assessed using the EORTC QLQ-STO22 preoperatively and at 3 and 6 months postoperatively. Scores were linearly transformed to a 0 - 100 scale. Statistical analysis was performed with EasyMedStat

Results: The mean age was 61 years, with similar baseline characteristics. Postoperative complications occurred in 32.0% of patients, mostly grade I - II. Both groups showed deterioration in dysphagia, pain, reflux, and anxiety at 3 months, followed by partial recovery at 6 months. Reflux scores were consistently higher in the gastrojejunal group at all timepoints (baseline 26.1 vs. 17.6; 3 months 36.5 vs. 24.5; 6 months 27.2 vs. 14.7; p 0.001). Eating restrictions were also greater at 3 and 6 months.

Conclusions: Both reconstruction methods impair short-term HRQoL, with partial recovery by 6 months. Gastrojejunal reconstruction is associated with higher reflux and eating restrictions, whereas gastroduodenal reconstruction shows more favorable functional outcomes.

Background: The role of lymphadenectomy in endometrial cancer has long been debated. Once considered to have prognostic and therapeutic value, it is now evident that balancing accurate staging with procedure-related morbidity remains a challenge. Objective: This review aims to clarify the current indications for systematic lymphadenectomy in endometrial carcinoma, integrating the updated FIGO 2023 staging system, the ESGOESTRO- ESP 2025 guidelines, and the emerging role of molecular classification. Methods: We analyzed landmark randomized controlled trials, updated guideline recommendations, and the evolving paradigm of sentinel lymph node (SLN) mapping, with emphasis on risk stratification based on histology, grade, lymphovascular space invasion (LVSI), and molecular features. Results: High-level evidence demonstrated that systematic lymphadenectomy does not improve survival in early-stage disease, while significantly increasing morbidity. Current guidelines remain complex, but consistently emphasize SLN mapping as the preferred method of nodal assessment. Systematic lymphadenectomy is no longer justified as routine; it is reserved for high-intermediate and high-risk patients when SLN mapping fails, performed as side-specific dissection. In advanced disease, the surgical goal is complete cytoreduction, with selective removal of bulky or suspicious nodes; systematic lymphadenectomy must not be performed in stages III-IV. Conclusion: The paradigm has shifted from universal lymphadenectomy to a tailored, risk-adapted approach. SLN biopsy represents the new standard, reducing morbidity without compromising oncologic outcomes. Expanding access to molecular profiling, still limited in Romania, is crucial for better oncological results and alignment with European standards.

Background: Nodal status is one of the most important prognostic factors in endometrial cancer (EC), but systematic lymphadenectomy is associated with significant morbidity. Sentinel lymph node (SLN) mapping offers a less invasive alternative. However, data are limited where indocyanine green is unavailable. Methods: Between November 2019 and March 2025, 29 women with FIGO stage Iâ?"III EC were prospectively enrolled in this study. Cervical injection of methylene blue, with or without technetium-99m, was used for SLN mapping. Ultrastaging was performed routinely. In patients with high-risk disease, full pelvic and para-aortic lymphadenectomy was also performed. Detection rates, sensitivity, and negative predictive value (NPV) were calculated. Results: Overall and bilateral detection rates were 75% and 48%, respectively (methylene blue: 72% / 44%; dual tracer: 100% / 75%). Nodal metastases were identified in 9 of 29 patients (31%). Patient-level sensitivity was 71%, with an NPV of 88%. Application of the side-specific completion algorithm increased sensitivity to 86%. Side-specific sensitivity and NPV reached 100%. Lymphovascular space invasion and 50% myometrial invasion were significantly associated with nodal metastasis (p 0.05). No mapping-related complications were observed. Conclusions: SLN mapping with methylene blue, with or without technetium, combined with a side-specific completion algorithm, enables reliable nodal staging even without fluorescence imaging.

Pelvic organ prolapse (POP) and rectal prolapse (RP) frequently co-occur as manifestations of global pelvic floor dysfunction. This narrative review (January 1, 2015, to August 1, 2025) synthesizes research on the evaluation and surgical management of concurrent disease, emphasizing symptom mapping, standardized examination, and dynamic magnetic resonance defecography (DMRD) - guided phenotyping. Across retrospective series and small prospective studies, single-session, minimally invasive repair - most commonly sacrocolpopexy (Ã+- hysteropexy) with ventral rectopexy - appears feasible in well-selected patients, with perioperative morbidity similar to that in isolated procedures and consistent improvements in bulge symptoms, obstructed defecation, and quality of life. Key principles include multidisciplinary planning, nerve-sparing ventral dissection, non-overlapping meshes with complete peritonealization, and enhanced-recovery pathways. Mesh complications after rectopexy are uncommon. Across recent series, 30-day readmission rates are approximately 2-3%, and early recurrence rates are about 10% for rectal prolapse and 5-8% for apical prolapse at roughly 1-2 years; moreover, a meta-analysis of 16,471 patients found no increase in short-term complications with concomitant repair. Overall, despite encouraging outcomes, heterogeneity, selection bias, and limited follow-up constrain certainty. Higher-quality comparative and long-term studies are needed to refine indications and establish long-term effectiveness.

Introduction: The Gleason score plays a key role in risk stratification and surgical treatment selection for prostate cancer. This study evaluates the correlation between Gleason score, patient age, and tumor aggressiveness, with implications for medical practice. Methods: This retrospective study included 215 patients from Sf. Apostol Andrei Clinical Emergency Hospital of Constanta County (2023-2024) with histopathologically confirmed prostate lesions. Demographic variables (age), Gleason score (classified according to ISUP 2019), and histological grade were analyzed. Data were statistically analyzed using t tests, ANOVA, and logistic regression. While international guidelines provide a standardized framework for management, local and regional variations in healthcare access, diagnostic pathways, and patient preferences significantly influence real-world clinical practice. This study aims to describe the histopathological spectrum of prostatic lesions and evaluate the prognostic relevance of the Gleason score in surgical decision-making within the specific context of a Romanian tertiary care center. By highlighting regional particularities, such as the high burden of aggressive disease and the challenges in implementing active surveillance, our findings contribute to a more nuanced understanding of global prostate cancer care. Results: Benign prostatic hyperplasia (BPH) accounted for 42.8% of cases, PCa for 44.7%, and urothelial carcinoma for 8.4%. Among prostate cancers, 87.5% had clinically significant disease (Gleason >=7), with 29.2% high-risk (Gleason 8-10). Gleason 7 was most frequent (58.3%), predominantly 3+4. A significant correlation was observed between advanced age ( >70 years) and tumor aggressiveness (OR = 2.3; 95% CI: 1.4-3.8). Radical prostatectomy was primarily chosen for Gleason scores >=7, with higher complication rates in older patients. Conclusions: Advanced age and a high Gleason score are independent factors of tumor aggressiveness. Early surgical intervention in patients with Gleason >=7 improves oncological outcomes. Integrating histopathology with multiparametric MRI and molecular biomarkers could optimize management of these patients.

Background: Intestinal ischaemia is an abdominal emergency characterized by a drastic reduction in blood flow in the mesenteric vessels with the possible onset of necrosis of the small intestine and/or colon. Its incidence is rather rare and the diagnosis is very difficult as the clinical presentation is not specific and there are no pathognomonic laboratory tests. Methods: A retrospective study was carried out on 28 patients with intestinal infarction, including analysis of the risk factors, comorbidities, symptoms, laboratory tests and instrumental investigations, to determine the presence of eventual signs of mesenteric ischaemia secondary to vascular insufficiency. Results: Twenty-four patients (85%) underwent surgery and intestinal necrosis was found in all. Among these, a quite high mortality rate (64%) was observed. Conclusion: The retrospective study confirmed the low frequency, high mortality and diagnostic difficulty of mesenteric ischaemia in its various clinical forms. Currently, there are neither laboratory tests nor instrumental techniques that can give a certain diagnosis of acute mesenteric ischaemia in an early phase. However, strong clinical suspicion, a rapid diagnosis and an aggressive therapeutic approach could improve the clinical results and reduce its high mortality.

Background: Gastric cancer surgery requires not only oncological radicality but also functional reconstruction. Billroth I remains the most physiological method of restoring continuity, whereas Billroth II and Roux-en-Y are most frequently adopted in the oncological treatment. Nutritional and immune competence strongly influence postoperative outcomes, and the Controlling Nutritional Status (CONUT) score has emerged as a validated biomarker integrating albumin, lymphocyte count, and cholesterol in predicting complications in surgically treated patients. Methods: We conducted a prospective observational single-center study including 150 patients undergoing curative distal gastrectomy between October 2021 and December 2024. Reconstruction was performed using Billroth I (n=72) or Billroth II/Roux-en-Y (n=78). The CONUT score was assessed preoperatively (T0), early postoperatively (T1), and at three months (T2). Outcomes included CONUT evolution, postoperative complications (Clavien Dindo), length of stay, readmission, and mortality. Results: Both reconstruction groups demonstrated a significant postoperative increase in CONUT score (median 2 [1-3] at T0 to 3 [2-4] at T1, p 0.001), followed by partial recovery at three months. No differences were observed between Billroth I and Billroth II/Roux-en-Y at any timepoint. Higher CONUT values at T0, T1, and T2 independently predicted overall and major complications (OR range 1.15 1.25, p 0.05). Postoperative morbidity, mortality (3.3%), and hospital stay were similar across groups. Conclusions: The CONUT score is an independent predictor of perioperative morbidity in gastric cancer, while the choice of reconstruction method does not significantly alter immunonutritional trajectories. Serial CONUT monitoring may enhance perioperative risk stratification.

Background: Hepatic resection is a key curative option for hepatocellular carcinoma (HCC), but postoperative morbidity and early mortality remain significant concerns, especially in patients with impaired liver function. Accurate preoperative risk stratification is essential to improve outcomes. This study compares the predictive value of three liver function scores - MELD, ALBI, and Child-Pugh - for postoperative morbidity and 30-day mortality. Methods: A retrospective study was conducted on 55 patients who underwent hepatic resection for HCC between 2013 and 2024 at a single tertiary center. Preoperative MELD, ALBI, and Child-Pugh scores were calculated and analyzed in relation to postoperative complications and mortality. Diagnostic performance was assessed using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and ROC curves. Results: Postoperative morbidity occurred in 23.6% of patients, with a 30-day mortality rate of 9.1%. The ALBI score showed the highest specificity (73.8%) and NPV (81.6%) for morbidity prediction. It also demonstrated perfect sensitivity (100%) and NPV (100%) for post-hepatectomy liver failure (PHLF), with an AUC of 0.85. Patients with ALBI Grade 1 had fewer complications and shorter hospital stays. MELD showed moderate predictive value, particularly in ruling out mortality. The Child-Pugh score had the weakest performance, primarily due to low sensitivity. Conclusion: ALBI is the most accurate and objective score for identifying high-risk patients undergoing liver resection for HCC. MELD provides additional value in mortality exclusion. The limited sensitivity of Child-Pugh suggests it should be used with caution. Incorporating ALBI into preoperative assessment may enhance surgical decision-making and risk stratification.

Background: Intrahepatic anatomy remains a challenge in mini-invasive liver surgery. Augmented Reality (AR), which integrates digital information with the user's environment, can benefit liver surgery by improving tumor and vessel positioning, resection planning, and surgical training. This review highlights AR's applications in liver surgery.

Methods: Articles published from 2010-2024 on PubMed using keywords ("Augmented Reality" AND "Liver Surgery") OR ("Navigation" AND "Liver Surgery") were analyzed. 32 articles assessing AR's accuracy, safety, operative time, and training impact were included.

Results: AR in Image-Guided Surgery (IGS) combines 3D reconstructions (e.g., CT scans) with laparoscopic images, enhancing the understanding of the surgical site. AR aids in margin planning, lesion boundary setting, and accurate hemostasis. It improves oncological outcomes, reduces errors, increases accuracy, and sometimes shortens surgery time. AR also enhances surgical training by accelerating skill acquisition and reducing the learning curve. However, more data is needed to standardize AR techniques.

Conclusion: AR can significantly enhance mini-invasive liver surgery by improving precision, safety, efficiency, and training. While further research is necessary to standardize techniques, AR holds great potential for improving surgical outcomes and training quality.