Category Archives: AMM 2015, Volume 61, Number 2

Laparoscopic Greater Curvature Plication for Morbid Obesity: Indications, Results, Perspectives

DOI: 10.1515/amma-2015-0041

Morbid obesity is an important health problem of our century. It is managed by diet, lifestyle changes and medication and surgery. Weight-loss surgery is the most effective treatment for morbid obesity, producing durable weight loss, improvement or remission of comorbid conditions and longer life. Bariatric surgery provides the best results in up to 75% of cases of severe obesity and obesity comorbidities. In the United States, over 200 000 patients benefit every year from bariatric procedures. That means there is a continuous evolving of the bariatric surgery. Bariatric surgery is metabolic surgery because it resolves or alleviates Type2 Diabetes, hyperlipidemia and hypertension. The most employed bariatric operations are Roux -en- Y gastric by-pass, adjustable gastric banding, biliopancreatic diversion and sleeve gastrectomy, each of them having shortage of long term results and safety. In the last eight years was introduced a new bariatric procedure, the gastric plication, in an effort to obtain similar weight loss with lesser complications and costs. We present our initial experience with 30 morbid obese patients who undergone laparoscopic gastric plication in our institution. The mean % Excess Weight Loss was 50% at 6 month and 65% at 12 month with important alleviation of comorbidities. The complications rate was 6.6% for major complications (but only in the first 6 cases) and 10% for minor complications.

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Low Molecular Weight Heparin versus Coumadin-Induced Skin Necrosis in a Patient with Superficial Vein Thrombosis – A Case Report

DOI: 10.1515/amma-2015-0040

Introduction: Coumadin and low molecular weight heparin (LMWH) induced skin necrosis are rare clinical conditions.
Case presentation: A 63-years-old female patient, known with hypertension and right-sided hemiparesis, had presented to the emergency departement with pain and erythema of her internal right thigh. Venous Doppler-echography showed internal safenous vein thrombosis, thus she was started on anticoagulant treatment with Dalteparin and Acenocoumarol. On the 5th day of treatment she developed plantar hematoma on her left leg, followed by the appearance of hematomas, on the lower third of her right calf and on coxofemoral regions. Therefore, we raised the suspicion of heparin or coumadin-induced cutaneous necrosis, we stopped the anticoagulation for 5 days and restarted it with the administration of Rivaroxaban, fresh frozen plasma, antibiotics and local, sterile, saline dressings. After four days the patient presented deep vein thrombosis on her left calf.
Results and Discussion: Coagulation abnormalities were suspected, but infirmed by normal values of specific laboratory tests, such as Protein C (472.2%), protein S (77.10%), lupus anticoagulant (LA1-screening 53, 5s, LA-confirmation 38,0s). Hemogram showed normal platelet values. To exclude a malignancy, abdominal CT scan was performed, which revealed a right adnexal inomogenic cystic lesion, CA-125 (6,5U/ml), requiring further gynecological investigations. For the treatment of skin lesions, the patient required necrectomy and skin graft application.
Conclusion: Particularly, considering that the patient was initially anticoagulated with LMWH and coumadins simultaneously, the etiology of her cutaneous lesions remains uncertain.

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Left Ventricular Non-compaction Cardiomyopathy – A Case Report

DOI: 10.1515/amma-2015-0039

Background: Left non-compaction cardiomyopathy (LVNC) or “spongy myocardium” is a relatively rare primary genetic cardiomyopathy, characterized by prominent wall trabeculations and intertrabecular recesses which communicate with the ventricular cavity. It appears in isolated form or coexists with other congenital heart diseases and/or systemic abnormalities.
Material and method: A 28-year-old woman was admitted with exertional dyspnoea, palpitations, non-specific chest pain and progressive fatigue on exertion. In her family history sudden cardiac-related deaths at young age are present. Cardiovascular system examination revealed tachycardia, intermittent extra beats. The rest EKG showed sinusal tachycardia (105 bpm), negative T-waves in DII, DIII, aVF, V4-V6. Consecutive 24 hours Holter EKG monitoring revealed nonsustained ventricular tachycardia, paroxysmal atrial fibrillation, isolated ventricular extrasystoles. Echocardiography showed left ventricular systolic dysfunction (LVEF:30-35%), slight LV enlargement, normal right ventricle and small left ventricle (LV) trabeculae in the apical area. Cardiac MRI demonstrated dilated LV and the presence of the trabeculations of LV walls suggestive for non-compaction cardiomyopathy. A combined treatment for heart failure and cardiac arrhythmias was initiated with good clinical results. Patient was scheduled for an implantable cardioverter defibrillator “life-saving”. Conclusions: The symptoms of heart failure and cardiac arrhythmias should be considered important in apparently healthy young patients. Besides intensive medical treatment is indicated the implantation of an ICD “life-saving” and in advanced cases heart transplantation. Even if the electrocardiographic findings are non-specific for noncompaction, a complete diagnostic evaluation is important, including sophisticated imaging techniques, a screening of first-degree relatives, and an extensive clinical, and genetic appreciation by a multidisciplinary team.

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Piggy-back Hepatic Transplant Technique and Veno-venous Bypass Without Cardiac Arrest: A Multidisciplinary Approach in Borderline T3b/T3c Renal Tumors

DOI: 10.1515/amma-2015-0038

Surgery for renal cell carcinomas with tumor thrombus extending in the Inferior Vena Cava (IVC) can be particularly challenging, especially in the retrohepatic and intraatrial situations (T3b and T3c). Classically, these tumors require the intraoperative use of cardio-pulmonary by-pass (CPB) and deep hypothermic circulatory arrest (DHCA), that can result in specific complications (stroke, platelet dysfunction), with increased postoperative morbidity rates.
In urological practice, a particular IVC preparation method is currently in use, allowing full control both upon the IVC and its tributaries. It is derived from the “piggy-back” liver transplantation technique and implies the resection of all hepatic ligaments, leaving the hepatic vascular connections intact. This procedure is joined by a form of veno-venous bypass (between the right atrium and the infrarenal IVC) that allows a constant central venous pressure (by assuring blood return), with less bleeding and without the need for CPB and DHCA (avoiding, in this way, their inherent complications). All in all, these recently-introduced procedures can offer better thrombus control, improved oncologic outcomes and smaller complication rates. We aim to present a case of borderline T3b/T3c renal tumor that was successfully treated in our university center using these techniques.

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Assesing the Knowledge, Attitudes and Eating Habits of Dietary Fibers in Tîrgu-Mureș Population

DOI: 10.1515/amma-2015-0037

Background: The aim of the study was to assess the knowledge, attitudes and eating habits upon consumption of dietary fibers in a group of people from Tirgu-Mures area.
Material and Method: We used a transversal descriptive study conducted on a group of 251 subjects from the urban area (76.4%), as well as from the rural area (23.6%), aged between 18 and 62 years, obtained using an online questionnaire consisting of 40 questions related to knowledge and attitude towards dietary fibers and estimated consumption of fiber from whole foods.
Results: In the study group, we observed that 21.28% consumed whole cereals once per week and 18% did not consume cereals at all; regarding fruit consumption 17.44% consumed 6-8 pieces/week, and 3.4% consumed over 18 pieces/week. Frequency of fast food –meals consuming:  67.68% did not  consume fast-food  meals, 25.25% ate fast food  once/week, and 1.1% consumed fast food between 8-10 times/week. Concerning the statement that fibers can prevent and/or treat colon cancer and obesity, 40% fully accepted the statement, 40% agreed, 14.29% were indifferent and 4.7% were against. From the total group of subjects, approximately 37.6% knew the meaning and classification of dietary fiber, 26.8%  knew the recommended amount of fiber to be consumed daily, and 5.9% did not check the fiber content of foods ever.
Conclusions: The inclusion of cereals and whole foods in diet is recommended in all nutrition guidelines worldwide, because of their association with a high health status, and  prevention of chronic diseases. Consumers need to understand  the benefits of whole foods, also to recognize and read the information about it on food labels.

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The Frequency of Dental Caries in Adult Patients with Gastroesophageal Reflux Disease

DOI: 10.1515/amma-2015-0036

Introduction. The aim of the study was to evaluate the frequency of dental caries in adults patients with gastroesophageal reflux disease.
Material and method. A cross-sectional study was performed between November 2013 and October 2014. All subjects who agreed to participate to the study were asked to complete a questionnaire regarding personal information, oral hygiene and dental evaluation. The individuals with complete false teeth (superior and inferior removable prosthetic devices) were excluded from the study. The study included 134 people divided in two groups, based on upper gastrointestinal endoscopy: a group with gastroesophageal reflux disease (71), and a control group (63). Dental evaluation was performed by a dentist blind to the diagnosis of the subjects. Dental caries were evaluated by applying the decayed, missing, and filled teeth index (DMFT index). The statistical significance was defined as p<0.05.
Results. From 71 subjects included in GERD group, 33 (46.48%) were males and 38 females (53.52%) with a mean age of 44.99±11.19 (42, 59.15% from urban area and 29, 40.85%, from rural area). In the control group we included 28 (44.44%) males and 35 (55.56%) females (mean age 43.84±9.48) and 29 (46.03%) subjects were from urban area and 34 (53.97%) from rural area. DMFT index in GERD group was 19.49±4.28 and in control group 18.16±4.54 (p<0.05).
Conclusions. The present study showed that there is no difference between GERD and control group, regarding the frequency of dental caries.

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Comparative Study Regarding Activity of Emergency Dental Offices in Tirgu Mures and Oradea

DOI: 10.1515/amma-2015-0035

Objective: The purpose of the study was to assess the activity of the Emergency Dental Office of UPU SMURD in Tîrgu Mures since its establishment and also to compare it with the similar unit from Oradea.
Methods: The two-year retrospective and comparative study is a statistical processing of non-personal data regarding the emergency dental services in the UPU SMURD Tîrgu Mures and UPU SMURD Oradea, involving the data collected in the same period at both emergency dental offices. Data based on the records analysis of the patients who were consulted and treated at the Emergency Dental Office in UPU SMURD Tîrgu Mure between February 1, 2012 − February 1, 2014 compared with similar data from Oradea.
Results: Assessing the number of patients presented each month − first and second year − we can see that since the establishment of the Emergency Dental Office in Tîrgu Mure (no=12780), the number of patients showed a linear increase in the first year, and in the second year the constant number of patients present in the studied unit was higher than in the other center from Oradea (no=4886).
Conclusions: The large number of patients and the nature of the cases that were present in the Emergency Dental Office in the UPU SMURD Tîrgu Mure show how necessary the set-up of this unit was.

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Bisphosphonate-Related Osteonecrosis of the Jaws: a real Challenge for Dentists

DOI: 10.1515/amma-2015-0034

Background: Osteonecrosis of the jaw is a serious complication associated with oral and intravenous bisphosphonate therapy. Its pathogenesis is not well understood and its management is difficult.The aim of ourstudy was to evaluate the awareness of dentists in Târgu Mureș on the possibilities of treating patients who are treated with bisphosphonate in dental offices.
Material and method: We carried out a questionnaire-based study among dentists in Târgu Mureș reaching important issues such as: if the patient is asked if medical history follows / followed treatment with bisphosphonates, if they made surgical treatment in these patients, if they know under what conditions can they perform this treatment, if they deem it is necessary to contact the prescriber before surgical treatment.
Results: Seventy questionnaires were returned. During the medical history most clinicians (60%) asked the patients whether they follow/followed treatment with bisphosphonates and most of them (42.85%) did not perform treatments in these patients. While 85.71% of respondents declared that they do contact the prescriber before performing surgical treatment, 48,57% were not aware under what conditions they could undergone the treatment.
Conclusions: The dentists did not seem to be well informed about this pathological entity, known only since 2003. In the absence of appropriate protocols they could not provide a high quality treatment and in these circumstances they might do more harm than good.

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Immunoexpression of Ki67 and p53 in the Dental Follicles of Impacted Teeth

DOI: 10.1515/amma-2015-0033

Aim. The purpose of this study was to evaluate the morphological aspects of dental follicles associated with impacted teeth and the immunoexpression of Ki 67 and p53, in the remaining epithelium from impacted third molars and canines. Another aspect was to identify the transformation of the remaining epithelium within the odontogenic lesions.
Material and method. We included in the study a number of 100 dental follicles, of which only 62 met the inclusion criteria. The immunohistochemical reactions were carried out in the Immunohistochemistry Lab at the Department of Histology of the University of Medicine and Pharmacy of Târgu Mureş. We counted 100 cells from the remaining epithelial islands from which we determined the percentage of labeled cells for both markers. After this all data were subjected to a statistical analysis.
Results. Out of the 62 specimens 44 were from females and 28 from males. Positive results were obtained for the two markers but not for all cases. We have also found a positive correlation regarding the immunolabeling of the two markers (p=0.002 in canines, p=0.0001 in molars). Median values for ki67 were statistically significantly higher than the values for p53 for both types of dental follicles.
Conclusions. Both markers were expressed in the remaining epithelial islands. The stronger expression of Ki67 in the follicles of impacted molars can demonstrate the
higher frequency of odontogenic cysts in this area.

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Pancreatico-Gastric Anastomosis with and without Sutures: Experimental Swine Model

DOI: 10.1515/amma-2015-0032

Objectives. The aim of our study is to identify a surgical technical that has the lowest rate of pancreatic fistulas in pancreatico-gastric anastomosis following duodenopancreatectomies. We studied pancreatico-gastric anastomosis performed with stitches compared to the ones performed without stitches.
Methods. Our experimental model is based on ten piglets, which were divided into 2 groups.  In the first group (n=5) the pancreatico-gastric anastomosis was done using double purse-string threads one passed through the gastric seromuscular layer and one through the gastric mucosa. In the second group (n=5) the pancreatico-gastric anastomosis was performed using sutures through the stomach and pancreas.
Results. Postoperative amylasemia was higher in the second group. In the first group no pancreatico-gastric fistulas were observed, whereas pancreatic necrosis was observed only at a superficial level of the pancreatic stump. In the second group, two cases had developed fistulas, both bordered by large areas of coagulation necrosis accompanied by pancreatic duct hyperplasia. Duration of the anastomosis was shorter for the first group. Conclusions.
In conclusion, the pancreatico-gastric anastomosis performed using two purse-string suture is a feasible, safe and fast process.

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