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Organizing committee

Președinte conferință Conf. Univ. Dr. Mihai ROMAN – ULB Sibiu

Vicepreședinte Conf. Univ. Dr. Adrian HASEGAN – ULB Sibiu

Main organizers

Prof. Univ. Dr. Silviu MORAR– ULB Sibiu

Prof. Univ. Dr. Nicolae GRIGORE – ULB Sibiu

Conf. Univ. Dr. Radu CHICEA– ULB Sibiu

Conf. Univ. Dr. Dan BRATU – ULB Sibiu

Conf. Univ. Dr. Radu FLEACĂ – ULB Sibiu

Conf. Univ. Dr. Horațiu DURA – ULB Sibiu

Conf. Univ. Dr. Ciprian TĂNĂSESCU – ULB Sibiu

Conf. Univ. Adrian BOICEAN – ULB Sibiu

Șef lucrări Dr. Adrian TEODORU – ULB Sibiu

Șef lucrări Dr. Claudiu HELGIU – ULB Sibiu

Șef lucrări Dr. Cosmin MOHOR– ULB Sibiu

Șef lucrări Dr. Calin MOHOR – ULB Sibiu

Șef lucrări Dr. Adrian CRISTIAN – ULB Sibiu

Șef lucrări Dr. Ramona COCA – ULB Sibiu

Șef lucrări Dr. Dan CRETU – ULB Sibiu

Asist. Univ. Dr. Denisa TĂNĂSESCU – ULB Sibiu

Asist. Univ. Paula NITA – ULB Sibiu

Asist. Univ. Dr. Alin MIHETIU – ULB Sibiu

Scientific Committee

Prof. Univ. Dr. Calin GUET – Viena

Prof. Dr. Marius MOGA – UMF Brașov

Prof. Univ. Dr. Silviu MORAR – ULB Sibiu

Prof. Dr. Diana BULGARU ILIESIU – UMF Iasi

Prof. Dr. Dan PERJU DUMBRAVA – UMF Cluj

Prof. Univ. Dr. Marius MOGA – UniTBv

Prof. Univ. Dr. Claudia GHERMAN – UMF Cluj-Napoca

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Prof. Univ. Dr. Nicolae GRIGORE – ULB Sibiu

Prof. Univ. Dr. Alin CUMPANAS – UMF Timișoara

Conf. Univ. dr. Costin Vlad ANASTASIU – UniTBv

Conf. Univ. Dr. Dan BRATU – ULB Sibiu

Conf. Univ. Dr. Adrian BOICEAN – ULB Sibiu

Conf. Univ. Dr. Radu CHICEA – ULB Sibiu

Conf. Univ. Dr. Horațiu DURA – ULB Sibiu

Conf. Univ. Dr. Radu FLEACA – ULB Sibiu

Conf. Univ. Dr. Adrian HASEGAN – ULB Sibiu

Conf. Univ. Dr. Mihai ROMAN – ULB Sibiu

Conf. Univ. Dr. Ciprian TĂNĂSESCU – ULB Sibiu

Conf. Univ. Dr. Dragoș ȘERBAN – UMF Bucuresti

Conf. Univ. Dr. Călin CHIBELEAN – UMF Mureș

Șef. Lucrări Dr. Octav RUSSU – UMF Mures

Șef. Lucrări Dr. Gabriel SMARANDACHE – UMF Bucuresti

Șef. Lucrări Dr. Tudor BADESCU – ULB Sibiu

Șef. Lucrări Dr. Ramona COCA – ULB Sibiu

Șef. Lucrări Dr. Adrian CRISTIAN – ULB Sibiu

Șef. Lucrări Dr. Claudiu HELGIU – ULB Sibiu

Șef. Lucrări Dr. Calin MOHOR – ULB Sibiu

Șef. Lucrări Dr. Cosmin MOHOR – ULB Sibiu

Șef. Lucrări Dr. Dragoș POPESCU – ULB Sibiu

Șef. Lucrări Dr. Adrian TEODORU – ULB Sibiu

Asist. Univ. Dr. Bogdan BOCEA – ULB Sibiu

Dr. Marius ANTONESCU – Hospital du Jura Elveția

Dr. Doru MOGA – Spitalul Militar Sibiu

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VESICOVAGINAL FISTULA - LAPAROSCOPIC APPROACH

Adrian Haşegan1,2, I. Mihai1,2, V. Pirvut, I. Sava, A. Marica, I. Osoianu, N. Grigore1,2

1Urology Clinic, 2Faculty of Medicine Sibiu

Introduction

The vesico-vaginal fistula is an abnormal fistula tract that extends between the bladder and the

vagina that allows involuntary continuous or intermittent evacuation of urine into the vaginal arch.

In addition to the medical implications, they often have a profound effect on the patient's emotional

well-being. Vesico-vaginal fistula is a complication observed in urologic and gynecologic surgery.

The rate of post abdominal hysterectomy is estimated between 0.5% and 1%, with the vaginal hysterectomy

rate being between 1.7% and 13% higher.

In the literature, they are described several techniques of treatment of vesico-vaginal fistula, including

transabdominal, transvaginal, laparoscopic and robotic approach

Material and Methods In this video we will present the technique of the laparoscopic approach.

Results

The bladder catheter was maintained for 7 days postoperatively.

The results were favorable with healing per primam

Operating time - 45 minutes.

Duration of hospitalization - 4 days.

There were no intraoperative lesions of the ureters.

Conclusion

Iatrogenic vesico-vaginal fistulas are rare but possible, undesirable complications of gynecological

operations.

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LAPAROSCOPIC RETROPERITONEAL SURGERY OF ADRENAL GLAND

THROUGH PRONE POSITION

I. Mihai1,2, V. Pirvut, I. Sava, A. Marica1, I. Osoianu, N. Grigore1,2, A. Haşegan1,2

1Urology Clinic, 2Faculty of Medicine Sibiu

Introduction

Laparoscopic adrenalectomy is the treatment of choice in adrenal tumor pathology.

Material and method

The movie presents experience of Urology Clinic Sibiu in retroperitoneal laparoscopic treatment through

prone position of adrenal tumors, performed at 20 patients with adrenal pathology.

Results

Retroperitoneal posterior approch to 20 p.

Patient in ventral decubitus position. Retroperitoneal access through an incision of 1.5 cm from the tip of

twelfth rib with digital dissection to create workingspace. Trocar position under digital control, one at the top

of twelfth rib and one in costomuscular angle (3 trocars).

Loss of blood: 80 ml.

Mean operative time: 90 min without intraoperative incidents.

Medium hospitalization period was two days.

All patients had subcutaneous emphysema which has been resolved spontaneously within 24 hours.

Early mobilization with resumption of bowel activity in the first postoperative day.

Hospital discharge at day two.

Conclusions

Laparoscopic retroperitoneal adrenalectomy through prone position is superior to laparoscopic

transperitoneal surgery and open surgery.

Avoiding pneumoperitoneum, minimize dissection, minor parietal trauma, small incisions lead to lower

postoperative pain, reduced recovery period of convalescence and quick socio-professional integration.

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LASER PERCUTANEOUS NEPHROLITHOTOMY IN THE TREATMENT OF

KIDNEY STONE

A. Haşegan1,2, I. Mihai1,2, V. Pirvut, I. Sava, A. Marica1, I. Osoianu, N. Grigore1,2

1Urology Clinic, 2Faculty of Medicine Sibiu

Introduction

The kidney stones has an increasing incidence in developed countries with high risk of recurrence. It is

associated with urinary tract infection, renal excretory malformations and metabolic disorders.

Treatment options are: extracorporeal lithotripsy (ESWL), percutaneous nephrolitotomy (PCNL mini-

PCNL), retrograde intrarenal surgery and open surgery.

Percutaneous nephrolithotomy (PCNL) is a feasible treatment option for the stones between 1-2 cm and the

treatment of choice for renal stones larger than 2 cm.

Material and method

Between 2019 -2021, in the Sibiu Urology Clinic, 54 patients with renal lithiasis were diagnosed and

subjected to percutaneous nephrolithotomy (PCNL) using laser fragmentation.

All patients were evaluated by computed tomography (uroCT) with lithiasis protocol prior to the procedure.

Each patient was evaluated for lithiasis location, stone number and size, BMI, operating time, stone-free rate,

intra and perioperative complications.

The average age was 46 years (23-78), the average value of the body mass index (BMI) was 29.5 kg / m2,

and the average size of the stones was 2.8 cm.

Results

Staghorn calculus were present in 10 patients. The average operating time was 40.8 minutes, the average

radiation exposure being 30 seconds. The mean decrease of hemoglobin was 1 g / dl.

The stone-free rate was 93.7%. Three pacients had complications according to the Clavien-Dindo I

classification (2 p -persistent haematuria on nehrostomy catheter, 1p- persistent urinary fistulae).

There were no injuries to the abdominal organs.

Conclusions

During laser lithotripsy, the use of high energy leads to a greater loss of stone mass and is an important

variable when using a fragmentation approach. Low energy results in smaller fragments and, together with

high frequencies, results in submillimeter fragments. Laser lithotripsy improves fragmentation efficiency by

reducing retropulsion at a higher stone-free rate.

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LAPAROSCOPIC PYELOPLASTY FOR URETERO-PELVIC JUNCTION

OBSTRUCTION

A. Haşegan1,2, I. Mihai1,2, V. Pirvut, I. Sava, A. Marica1, I. Osoianu, N. Grigore1,2

1Urology Clinic, 2Faculty of Medicine Sibiu

Introduction

Uretero-pelvic junction obstruction-UPJO is the impairment of urinary transport from the renal pelvis to the

proximal ureter, due to intrinsic or extrinsic obstruction at this level → different grades of hydronephrosis.

Material and method

The movie presents experience of Urology Clinic Sibiu in laparoscopic retroperitoneal approach tehnique

treatment of UPJO.

Results

The patient is usually positioned in the flank position with the use of flexion and elevation of the kidney rest.

To enter the retroperitoneum, a retroperitoneal working space can be created using finger blunt dissection or

with balloon dilation.

After CO2 pneumoretroperitoneum, three or four laparoscopic ports are used to perform the laparoscopic

pyeloplasty.

The ureter is usually identified early in the procedure, below the lower pole of the kidney as it lies above the

psoas.

The renal pelvis is first transected circumferentially above the UPJ and the proximal ureter is spatulated

The apex of this lateral, spatulated aspect of the proximal ureter is brought to the inferior border of the renal

pelvis, and the medial side of the ureter is brought to the superior aspect

The anastomosis is then performed with fine interrupted or running absorbable sutures, placed full thickness

through the ureteral and renal pelvic walls, in a watertight manner over an internal ureteral stent, which is

left indwelling.

Conclusion

Open pyeloplasty and the laparoscopic approach have similar functional results, with estetic and recovery

advantages for laparoscopic techniques.

Retroperitoneoscopic dismembered pyeloplasty is superior to transperitoneal approach in terms of

postoperative ileus, postoperative analgesic medication and hospital stay.

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TREATMENT OF LATE MAJOR COMPLICATIONS AFTER PROSTATE

SURGERY. ARTIFICIAL URINARY SPHINCTER. PENILE PROSTHESIS

Calin Chibelean1 1Faculty of General Medicine, University of Medicine, Pharmacy, Sciences and Technology, Tirgu Mures,

Romania

The discovery and wide use of PSA has led to early diagnosis of localized or locally advanced prostate

cancer, including in young patients. This has led to a significant increase in the number of radical

prostatectomies (open retropubic, laparoscopic or robotic assisted). These are performed by a growing

number of urologists, each of whom need a variable learning curve. On the other hand, a number of cases are

understaged preoperatively or are operated in locally advanced stages. Unfortunately, as a result of these

operations, some of these patients suffer an impairment of both the urinary and the erectile function.

The correction of acquired functional deficits can be achieved through physical rehabilitation sessions and

pharmacological treatment. However, medical devices are frequently necessary in order to correct or

compensate of such deficits.

For severe forms of urinary incontinence or erectile dysfunction, the treatment of choice is the use of

prosthetic devices that can restore an acceptable quality of life.

The rate of complications and reoperation in the case of these medical devices is relatively high.

Nevertheless, due to the high level of satisfaction of recipient patients, these devices have an increasing

acceptability and popularity.

Therefore, there is a real need to cover such pathologies which have occured following surgical operations

carried out for justified oncological reasons.

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CASE STUDY: MEDICO-SURGICAL APPROACH IN CORNEAL WOUND

Georgiana Olteanu1, Adrian Teodoru1

1University "Lucian Blaga" of Sibiu, Sibiu,

Introduction

Corneal wounds are medical and surgical emergencies with potentially serious functional and morphological

consequences.

Case Presentation

This paper presents the case of the patient M. I., aged 79 years with non-penetrating corneal trauma. After

exploring the wound, surgical treatment is instituted in order to suture the corneal flaps resulted from the

trauma. The repair of the corneal wounds is made with separate 10.0 non-absorbable surgical suture, with

buried knots.

Discussions

The particularity of the case consists in the associated diseases of the patient, the locomotor disability

preventing the specific examination at the biomicroscope.

Conclusions

Following the surgical and medical treatment, the morphological integrity of the cornea was restored with

partial restoration of the visual function.

Keyword: emergencies, impenetrate corneal wound, surgical treatment.

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COLON INVAGINATION IN ADULT. CASE PRESENTATION

Alin Mihetiu1, Dan Bratu1 1University Lucian Blaga of Sibiu.Second Surgical Department Emergency County Hospital of Sibiu, Sibiu,

Romania

Introduction:

Colon invagination is the telescoping of a segment of the intestine in the distal segment. It is a more common

condition in children, being rare in adults. It has as a trigger the existence of a tumor, usually malignant.

Case presentation

We present the case of an 84-year-old patient who has abdominal pain, abdominal distension, absence of

intestinal transit for 3 days.

Rectal cough reveals a well-defined, non-hemorrhagic rectal tumor formation.

Abdominal tomography shows sigmoid-rectal invagination and a rectal tumor formation with a diameter of 5

cm with lipoma characters.

Surgery is performed, transanal excision of the formation, subumbilical midline exploratory laparotomy that

highlights sigmoid-rectal invagination for about 20 cm. Devagination and colopexy are practiced. The

evolution was favorable.

Discussions

Colon invagination in adults represents less than 5% of total invaginations. Approximately 90% of adult

invaginations have as a triggering cause a tumor formation that acts as a starting point for invagination. The

diagnosis is imaging, the treatment can be by enema, colonoscopy, laparoscopic or by open surgery.

Conclusions

Rare disease, colonic invagination has as a common cause a tumor formation usually malignant. The

symptoms are nonspecific and the diagnosis is made either by tomography or can be an intraoperative

surprise.

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GASTRIC DEVASCULARIZATION, HEMOSTASIS SOLUTION IN A PATIENT WITH

GASTRIC STRESS ULCERS IN THE CONTEXT OF COVID 19

Dan Bratu1, Alin Mihetiu1 1University Lucian Blaga of Sibiu.Second Surgical Department Emergency County Hospital of Sibiu, Sibiu,

Romania

Introduction:

Stress gastric ulcer is a hemorrhagic ulceration located more frequently in the bottom and gastric body, but

can affect the entire surface of the stomach.

They occur frequently after shock, sepsis and trauma, being more common in patients with chronic diseases.

Case presentation

We present the case of an intubated elderly patient with septic condition through Klebsiella multidrug

resistant with severe form SARS COV2 infection, patient with upper digestive hemorrhage, with

hemodynamic instability and severe anemia. Upper digestive endoscopy reveals multiple gastric ulcers on

the entire mucosal surface. Attempts of endoscopic or conservative hemostasis have been ineffective. a total

gastrectomy is decided by a loco-regional hemostasis intervention practicing gastric devascularization and

vagotomy. The patient no longer shows postoperative signs of upper digestive hemorrhage and anemia but

dies at 5 days postoperatively due to respiratory failure.

Discussions

The technique presented is not one currently used today due to the good results obtained by endoscopic

treatment. It is used only in extreme situations where the patient's condition does not allow other therapeutic

solutions. Its efficiency is good, for stress ulcers being reported only 9% cases of reactivation of bleeding.

Conclusion

Gastric devascularization can be last resort solution in diffuse hemorrhages that cannot be controlled by other

surgical or non-surgical methods.

Keywords: stress ulcers, devascularization, vagotomy

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INGUINAL HERNIA SURGERY-MESH VS NONMESH, LAPAROSCOPIC VS OPEN

SURGERY

Dan Bratu1, Alin Mihetiu1 1University Lucian Blaga of Sibiu, Sibiu, Romania,

Introduction:

Inguinal hernias are a common pathology that requires 20 million surgeries annually. The condition has been

a permanent concern over time, entering a new era with the advent of tension free procedures, textile

allografts and laparoscopy.

Discussions

Tissue procedures are the basis on which it has been repeatedly tried to solve this condition. The Bassini

procedure, Shouldice, and more recently Desarda use in a somewhat similar way the local tissues for the

restoration and strengthening of the posterior wall of the inguinal canal. The Lichtenstein variant, the most

used technique nowadays, uses a textile mesh to replace the fascia transversalis. The low recurrence rate and

the fact that it is easily reproducible make it a preferred technique, but it is engraved with the risk of local

infection, chronic pain or mesh rejection. The benefits of laparoscopy occur especially in the case of a hernia

with bilateral localization, recurrences after open surgery treatment, but involve a longer duration of surgery

and higher costs.

Conclusions

Defining the best surgical procedure in the treatment of inguinal hernia is still difficult. However, there is a

clear tendency towards mesh repair, and it remains to be discussed whether the approach should be open or

laparoscopic.

Keywords: inguinal hernia, mesh, laparoscopy

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MENISCAL LESIONS ASSOCIATED WITH ACL INJURIES

Mihai Roman1,2, Radu Fleaca1,2, Cosmin Mohor1,2, Tiberiu Bataga3, Octav Marius Russu3

1University "Lucian Blaga" of Sibiu,

2Clinical County Hospital Sibiu,

3Faculty of General Medicine, University of Medicine, Pharmacy, Sciences and Technology, Tîrgu Mureș,

Romania,

Meniscal tears are frequently associated with ACL injuries. Injury to either the ACL or the meniscus

will increase the risk of osteoarthritis in the affected knee and the risk is higher in combined injuries even

after successful ACL reconstruction.

Surgery should be performed as soon as possible in order to minimise secondary damage. The

general rule in this combined lesions is to operate them in one surgical session.

Treatment of meniscal tears has evolved over the past 30 years from total or partial meniscectomy to

more focus on meniscal preservation like leaving the tear in situ or repair. Our goal should be to preserve as

much functioning meniscus as possible in order to reduce the risk of future osteoarthritis and to improve

stability of the knee.

Short, stable tears are often best treated with “masterly neglect.” Meniscal suture should be

performed whenever it possible. Meniscectomy should be performed only as the last solution.

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ENDOVASCULAR THERAPY OR INTERVENTIONAL TREATMENT IN PERIPHERAL

ARTERIAL DISEASE – CASE REPORT

Stoia Oana1,2, Andrei Filip1, Raluca Daria Mitea1,2, Ioan Cornel Bitea1,3

1SCJU, Sibiu, 2LB University, Sibiu, 3CVASIC, Sibiu,

Peripheral arterial disease of the lower limbs through the main causative factor, atherosclerosis, is a

pathology that requires complex investigations, due to the increased risk of developing major cardiovascular

events. Critical ischemia of a lower limb is defined as the presence of ischemic pain, which may or may not

be associated with tissue damage, and is a marker for generalized, severe atherosclerosis with a 3-fold

increased risk of myocardial infarction, stroke, or of vascular death compared to patients with heart

failure.(1)

Starting from these premises, we present the case of an 81-year-old patient, known to have a moderate form

of hypertension, diabetic with insulin requirements, who presents for pain in the right lower limb, at rest,

accompanied by paresthesia, with accentuation in the last 2 days.

Following clinical and paraclinical investigations, was highlighted bilateral low ABI, conduction disorder

(AV block grade II, Mobitz 1, with Wenchebach periods, then AV block grade II, Mobitz 2:1), degenerative

mitral and aortic valvulopathy, with preserved systolic function; without significant changes in laboratory

analyzes.

Due to intense pain in the lower limbs, Wifl classification (increased risk of amputation) and

electrocardiographic changes, which could contraindicate bypass surgery with general anesthesia, it was

decided to perform angioplasty by approaching occlusion of the superficial femoral artery (highlighted by

angioCT) by retrograde approach, with repeated balloon angioplasties, then stent implantation, with good

angiographic result.

The patient was discharged in an improved general condition, without pain in the lower limb, with optimal

therapy with double antiplatelet, statins and hypotensive, and recommendation of pacemaker implantation.

ESC guidelines state that attempting to revascularize these patients as often as possible.(1) To date, only one

randomized study (Bypass versus Angioplasty in Severe Ischemia of the Leg) has compared endovascular

therapy with conventional surgical treatment in these critically ill patients of the lower limbs, and after 2

years of follow-up there were no significant differences in terms of survival without limb amputation.(2)

1. Guide to the European Society of Cardiology (ESC) for the diagnosis and treatment of Peripheral

Arterial Disease, in collaboration with the European Society of Vascular Surgery (ESVS) - Romanian

Journal of Cardiology | Vol 28, No. 1, 2018, pp.57-127.

2. Adam DJ, Beard JD, Cleveland T, Bell J, Bradbury AW, Forbes JF, Fowkes FG, Gillepsie I,

Ruckley CV, Raab G, Storkey H. Bypass versus angioplasty in severe ischaemia of the leg (BASIL):

multicenter, randomized controlled trial. Lancet 2005; 366: 1925–1934.

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WHEN ELECTROCARDIOGRAMS MAKE THE DIFFERENCE IN THE THERAPEUTIC

STRATEGY

Stoia Oana1,2, Paula Anderco2, Ioan Cornel Bitea1,3

1SCJU Sibiu, Sibiu,

2LB University, Sibiu, Romania,

3CVASIC, Sibiu, Romania

Introduction: It is very well known that, out of all cardiovascular diseases, obstructive coronary disease

stands out as one of the leading causes of morbidity and mortality in developed and middle-developed

countries. Performing coronary angiography provides unique information about the presence and severity of

this disease, representing the gold standard for diagnosing these patients. In 1982, Wellens described that

patients with electrocardiogram findings, who were admitted for unstable pectoral angina, were at high risk

for myocardial infarction. Due to the critical anterior descending artery stenosis, patients with Wellens

Syndrome usually require intensive therapy and may suffer cardiac arrest or anterior myocardial infarction.

Case presentation: We present the case of a 71-year-old patient, documented with an old myocardial

infarction, with drug-active stent positioned in the anterior descending artery, and correctly administered

drug-therapy hypertension at home. He showed up at the hospital for typical angina pain, with an onset of

one week and with recent aggravation, accompanied by minimal effort dyspnoea. The EKG highlighted the

necrosis Q-wave in the antero-septal territory, with a negative tendency of the T-wave. Echocardiography

detected preserved systolic function, aortic valvulopathy, without significant kinetic disorders in the mid-

basal interventricular sept and apex. Due to the dynamic myocardial cytolysis markers and

echocardiography, we decided to also re-evaluate the EKG with the correct positioning of the electrodes,

which detected ST-T segment elevation with biphasic T-waves in V2-V4, which correspond to Wellens

Syndrome. Coronary angiography was also performed due to the chest pain not subsiding after the

administration of maximum optimal treatment, which detected sub-occlusive stenosis in the mid-proximal

anterior descending artery, requiring the implantation of a pharmacological stent, with good angiographic

result.

Conclusions: The patient was discharged with a clearly improved general condition, without additional chest

pain, with recommendations, including maximum treatment with antiplatelet agents, statins, conversion

enzyme inhibitors, beta-blockers and diuretics. The most important aspect of acute myocardial infarction

treatment is to perform angiography as soon as possible and, if mandatory, myocardial revascularization, to

reduce the risk of acute and late complications. In conclusion, it is crucial for clinicians to recognize Wellens

pattern early in order to better manage patients with coronary disease and gain successful results.

Keywords: angiography, electrocardiogram, Wellens syndrome

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OPEN FEMURAL SHAFT FRACTURE AFTER CLOSE RANGE SHOOTING:

CHALLENGES IN TREATMENT, COMPLICATIONS AND EVOLUTION. CASE

PRESENTATION.

Mitu Nicoleta Anamaria1, Popa Raoul1, Sopon Mircea1

1Scju Sibiu, Sibiu,

Introduction:

Fractures of the femoral shaft are found especially after traffic or work accidents.

These fractures are observed at all ages, with some predilection for the young adult.

The common feature of these fractures is the appearance of a state of shock, with a significant decrease in

Hb.

Presentation of a clinical case in a patient with open fracture of the femoral shaft, by shooting and bone

defect, in which we will present the treatment steps followed.

Case presentation:

This presentation considers the case of a 38-year-old patient who presented to our service following a work

accident by self-shooting, injury, in the right thigh, presenting an open fracture classified after Gustilo-

Anderson type III B, of the femoral shaft with bone loss and skin defect.

Discussions:

The presentation of this case aims to emphasize the choice of the right treatment, but also the appropriate

operating time for repairing defects, both skin and bone, to obtain the best result.

At the presentation of the patient, it was decided the emergency surgery which consisted in: washing the

bruised wounds, debridement of the tissue, application of a drain tube to discharge secretions, secondary

suture and repair of skin defect, fixing the fracture site with an external fixator. The subsequent evolution

was difficult with an enterococcal infection which treated with antibiotic therapy after the antimbiogram.

After about one month, it turns into surgical form osteosyntesis with long Gamma neil.

The evolution was slowly in recuperation with a good fuctional for patient.

Clinical and radiological follow-up of the patient allowed the observation of callus formation.

Conclusion:

It is very important for the patient, to follow rigorously, the protocols for the treatment of open fractures of

the femur with a shot wound, because the risk of infection is high with a subsequent evolution towards

osteitis and the lack of cosolidation of the fracture focus.

As a peculiarity of the case, the lack of neurovascular damage is underlined, which determined a favorable

evolution of the case.

Keywords: open fracture, bone defect, infection, nail.

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TOTAL KNEE ARTHROPLASTY AFTER TIBIAL PLATEAU MALUNION

Alexandru Florin Diconi2, Radu Sorin Fleaca1,2, Mihai Dan Roman1,2

1University "Lucian Blaga" of Sibiu, 2Clinical County Hospital Sibiu,

Introduction:

Radiological evidence of post-traumatic osteoarthritis (PTOA) after tibial plateau fractures is common, but

end-stage arthritis which requires total knee arthroplasty (TKA) is more rare.

Fractures of the tibial plateau may affect knee alignment, stability, and motion. Early detection and

appropriate treatment of these fractures are critical for minimising patient disability and reducing the risk of

late complications: knee stiffness, knee instability, angular deformities, late collapse, malunion, osteo-

arthrosis.

Case presentation:

We present the case of a 55-year-old woman who, after suffering a fracture of the left medial tibial plateau,

was operated one year before admission in our department. We performed (ORIF) of the postero-medial

tibial plateau with two screws and cemented TKA with tibial revision component.

Discussions:

Total knee arthroplasty (TKA) used as treatment for a fracture/malunuion of the tibial plateau is a rare

indication. It is very important to use the appropriate surgical technique and to chose the correct implant in

oder to obtain the best outcome.

Conclusions:

There are various methods of treatment in tibial plateau malunions/fractures. However, when clasic operative

treatment fails, total knee arthroplasty is the method of choice.

Keywords: malunion, TKA, tibial plateau fracture

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MULTIDISCIPLINARY APPROACH AND TIMING IN CHRONIC OSTEOMYELITIS

Mihai Maslina1

1Scju Sibiu, Sibiu,

Introduction

Reconstruction of diaphyseal bone and skin defects after chronic osteomyelitis represents a major clinical

challenge. Several approaches are used in order to achieve the main objective: to regenerate bone loss and

function restoral. The most commonly used methods are the vascularised fibula autograft and the Ilizarov

bone transfer technique. Recently, Masquelet proposed a procedure combining induced membranes and

cancellous autografts.

Objectives

The aim of the report is to choose the right treatment and timing for repairing both skin and bone defects

after chronic osteomyelitis in order to obtain the best outcome.

Materials and methods

This paper presents a case of a 41 years old patient known with chronic osteomyelitis of the right tibia from

the age of 25 years. At that time he was treated for tibial lengthening with the Ilizarov tehnique. Local

infection supervened after one and a half year. At the age of 38 years, he suffered a car accident with fracture

of the right tibia at the site of chronical osteomyelitis, treated with intramedullary nail in another Orthopaedic

centre. Following this, local osteomyelitis has reappeared. The patient was local treated for two and a half

years but the result was not succesfull.

Results and disscutions

At admission in the Orthopaedic Traumatology Department of Sibiu County Hospital, the pacient presented

with a productive fistula at the site of osteomyelitis. We decided to remove the intramedullary nail, to

eliminate the osseous sequestrum and to fill the osseous defect with bone cement loaded with gentamicin and

vancomyin. Postoperative evolution was made difficlut due to a tegumentary defect of 2 square centimetres.

After 3 months, a mixt team of plastic and orthopaedic surgeons performed the intervention: the bone cement

removal, filling of the osseous defect with spongious graft from iliac crest and fixing the tegumentary defect

with gastrocnemian pedunculated flap and free flap skin graft, with primary wound healing.

Conclusions

The Masquelet tehnique provides a good alternative for the challenging problem of the bone loss in chronic

ostemyelitis

Concomitant surgical procedures (bone grafting and plastic surgery) turned out to be a good choice.

Keywords: osteomyelitis, Masquelet, bone grafting, muscular fla

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PERCUTANEOUS DRAINAGE OF THE PANCREATIC PSEUDOCYST

Faur Mihai1, Sabau Dan1, Tanasescu Ciprian1, Sabau Alexandru1, Mohor Calin1

1Spitalul Clinic Județean De Urgenta Sibiu, Sibiu, ROMANIA

The pancreatic pseudocyst represents the main complication that occurred 3-6 weeks after an outbreak of

acute or chronic pancreatitis represented by a collection containing pancreatic enzymes without their own

epithelial wall.

In the paper we present the drainage of the mini-invasive pancreatic pseudocyst by incision in the right

lumbar area, in the case of a 53-year-old patient known to have a history of multiple cardiac defects,

pancreatic pseudocyst discovered approximately 6 months ago for which the patient underwent conservative

treatment, and who had 5 resuscitated cardio-respiratory arrests in evolution.

Dsicussions: The imaging tracking in evolution by CT examinations of the pancreatic pseudocysts showed

that 40% of them with a diameter below 6 cm regress spontaneously if there is no communication with the

pancreatic duct. Late regression is all the more likely as the pseudocyst is smaller.

Conclusions: The type of pancreatic cystic lesion decisively determines the strategy and the operative

tactics, and the errors of therapeutic conduct can have severe effects on the prognosis, including the vital

one.

Keywords: pancreatic pseudocyst, percutaneous drainage, resuscitated cardio-respiratory arrests

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ABCESSED PNEUMONIA, FISTULIZED IN THE MUSCLE OF THE FOREAR

THORACIC WALL

Calin Mohor1,2, Doris Pirvu2, Jamal Barazi2, Stefan Bancila3

1 Faculty of Medicine - Lucian Blaga University Sibiu, SIBIU, ROMANIA, 2Departament of General Surgery

I- Emergency Clinical County Hospital Sibiu, SIBIU, ROMANIA, 3Departament of General Surgery I

GENERAL THORACIC WARD- Emergency Clinical County Hospital Sibiu, SIBIU, ROMANIA

ABCESSED PNEUMONIA, FISTULIZED IN THE MUSCLE OF THE THORACIC WALL

Lung abscess develops more frequently in people with immunosuppressive pathology (diabetes, HIV

infection, malnutrition or neoplasia). The most common lung abscesses are caused by anaerobic germs and

Streptococcus species, but in recent years there has been an increase in the frequency of lung abscesses

caused by Klebsiella pneumoniae. The clinical picture in a patient with lung abscess may be influenced by

associated comorbidities or nutritional status.

We present the case of a 68-year-old patient, recently diagnosed with medium lobe pneumonia (Klebsiella

pneumoniae) abscessed at the level of the chest wall (pectoral region), known with DM II, hypertension.

Following imaging investigations (chest CT / soft tissue ultrasound) she is diagnosed with: medium lobe

pneumonia, abscessed at the level of the Vth intercostal muscle and the pectoral muscles, with parieto-

pulmonary bronchial fistula.

The patient required a complex medical and surgical treatment with multiple surgeries (1- excision of the

large and small right pectoral muscle, filling of the pleuro-pulmonary fistula medium lobe with breast fat,

pleural and subcutaneous drainage and secretion collection from postoperative wound, 2- Resection of

antero-lateral costal arches (Vth-VIth) straight in block with the intercostal muscle, 3- installation of vaccum

therapy at the parietal thoracic wall, 4- reconstruction of the thoracic wall with rotated muscle flap (large

pectoral muscles). superinfected with multidrug-resistant Acinetobacter baumanii prolonging hospitalization.

Conclusion: Thoracic wall infections require a multidisciplinary team (infectious disease, general / thoracic

surgeon and plastic surgeon) due to staged treatment (resection of devitalized tissues, wound sterilization and

reconstruction of the chest wall.

The peculiarity of the case is the ongoing evolution of pneumonia with abscess and fistula in the muscles of

the chest wall.

Keywords: abscessed pneumonia, chest wall resection / reconstruction, Klebsiella, Acinetobacter, chest wall

infection

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CASE PRESENTATION: TRAUMATIC DISRUPTION OF THE PUBIC SYMPHYSIS,

POSSIBLE OUTCOMES

Popa Alexandru Darius2 Bocea Bogdan Axente1,2, Fleaca Radu1,2, Roman Mihai Dan1,2

1Scjus, Sibiu, Romania

2 Clinical County Hospital Sibiu

Introduction:

Disruption of the anterior pelvis ring occurs secondary to high energy trauma and is associated with life

threatening pathologies: haemorrhage, neurological deficits, genitourinary and bowel injuries. This are to be

surgically addressed immediately. But choosing the correct treatment isn ’t always the best thing for the

patient.

Case presentation:

Male patient, 47 years old, motorcyclist, victim of a traffic accident. At admission in the emergency room he

presents: pelvis pain, external rotation of the inferior limbs; extreme pain on active and passive movements

of the inferior limbs, macroscopic hematuria, rectorrhagia, right forearm pain and open soft tissue injury on

the right wrist area. The patient is conscious and responsive but he is actively bleeding. X-ray and CT-scan

reveal a pubic symphysis disjunction; open book fracture.

Discussion:

The active bleeding must be stopped: the rectal and urinary bladder haemorrhage are the first to be

addressed. Next, the open book lesions must be reduced as soon as possible. the external fixator is usually

the option of choice in a emergency setting. ORIF performed simultaneously with the urinary tract surgery

may ba associated with a high risc of infection.

Conclusion:

Managing pelvic ring injuries associated with genitourinary injuries may be challenging. Damage control

strategy must be used in order to reduce the complication rate and obtain the best results.

Keywords: pelvic ring, pubic symphysis diastasis, damage control

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PLACENTA PERCRETA – CASE REPORT

Dr. Olimpiu Muresan, Dr. Anisoara Batir, Dr. Tia-Maria Manta 1Scju Sibiu, Sibiu, Romania

Introduction: Placenta percreta is a very rare condition, which consists in the abnormal placing of the

placenta on the inferior segment of the uterus, penetrating the myometrium and also, most frequently,

invading the walls of the bladder. Although it’s incidence is low, it has a very high morbidity and mortality.

Placenta percreta is one of the most serious complications of placenta previa and is frequently associated

with severe obstetric hemorrhage usually necessitating hysterectomy.

Case presentation: We are presenting the case of a 17-year-old woman, with a 25 week pregnancy who

came at the hospital presenting adominal pain. The ultrasound exam showed a malformed fetus and an

abnormal insertion of the placenta without any strict delimitation within the uterus walls. After a surgical,

urological, internal and cardiological consultation, the patient is diagnosed with acute surgical abdomen.

Following the aggravation of her condition, with hemodynamic decompensation, an exploratory laparotomy

has been decided, followed by a caesarean section, a total hysterectomy and ultimately, the insertion of

ureteral stents and cystorrhaphy. Postoperatively, the patient’s condition has improved, followed by a full

recovery.

Discutions: We chose to draw our attention to this particular case because of the young age of the patient

who had to undergo a total hysterectomy with important repercussions on her life.

Conclusions: As we can see, this condition, called placenta percreta, most frequently puts the patients in

serious situations, leading them to infertility and, sometimes, even death. A fast diagnosis and intervention

are required, most often this cases representing real life-threatening emergencies.

Keywords: placenta percreta, myometrium, laparotomy, hysterectomy, cystorrhaphy

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LATE ILEAL FISTULA AFTER LEFT HEMICOLECTOMY FOR SPLENIC ANGLE

COLIC NEOPLASM

Andrei Moisin1, Bianca Olaru1, Popa Adriana1, Ciprian Tanasescu1,2

1Sibiu County Emergency Clinical Hospital, Sibiu, Romania, 2“Lucian Blaga” University of Sibiu, Surgical

Clinical Department, Sibiu, Romania

Introduction: Colorectal cancer is the third most common cancer and the fourth leading cause of cancer

death. Most cases are detected in Western countries, with its incidence increasing from year to year. Both

genetic and environmental factors play an important role in the etiology of this neoplasm. The incidence of

new cases and mortality has steadily decreased in recent years, with the exception of young adults (under

50), possibly linked to increased cancer screening and better treatment modalities. About 5% of all colorectal

cancers are attributed to two inherited syndromes, familial adenomatous polyposis and Lynch syndrome.

Case presentation: We present a 60-year-old patient, known in a personal pathological history with

hypertension, chronic ischemic heart disease, left ventricular failure NYHA III, acute renal failure, dialysis

15 years ago, in treatment at home with Tenaxium and Metoprolol, colonic neoplasm of splenic flexure for

which left hemicolectomy was performed with colorectal anastomosis TL (June 2021), blocked evisceration

one month after hemicolectomy, for which secondary suture was performed. The patient is hospitalized in

our service for the superinfected abdominal wound with minimal dehiscence at the periumbilical level, from

where liquid with dirty appearance and fetid smell is evacuated, local pain, asthenia, fatigue. The patient was

investigated clinically, biochemically and paraclinically, being diagnosed with late ileal fistula with

externalization to the skin. Wound toilet and sterile dressings are practiced daily and then the installation of a

colostomy bag, with the slow favorable evolution of the patient.

Discussions: Management of enterocutaneous fistula is one of the most prolonged and difficult problems in

colorectal surgery with substantial morbidity and mortality rates. Most (up to 90%) are iatrogenic or, more

precisely, postoperative or postprocedural. About half of these are thought to be caused by anastomotic

leakage or dehiscence and about half by accidental enterotomy. The other 10-25% are considered

spontaneous and include fistulas from inflammatory bowel disease, neoplasia, radiation enteritis or

mesenteric ischemia, pancreatitis or other intra-abdominal infections. Cancer, chemotherapy and radiation

reduce the likelihood of spontaneous closure of the fistula.

Conclusions: Ileal fistula remains a complex problem, which must be treated using a careful and

interdisciplinary approach. In addition to the primary management of sepsis, conservative treatment remains

the main treatment, including the combination of wound management, nutritional support and social support.

Surgical treatment must be carefully planned and used in cases where conservative treatment fails.

Keywords: late ileal fistula. Splenic angle neoplasm, left hemicolectomy

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MODERN BIOPSY METHODS IN THE DIAGNOSIS OF BREAST CANCER

Andrei Moisin1, Carmen Popa3, Ciprian Tanasescu1,2

1Departament of General Surgery I - Sibiu County Emergency Clinical Hospital, Sibiu, Romania,

2“Lucian Blaga” University of Sibiu, Surgical Clinical Department, Sibiu, Romania,

3Departament of Radiology - Sibiu County Emergency Clinical Hospital, Sibiu, Romania

Introduction:

Breast cancer is the most common form of malignant tumor in females, its frequency is constantly increasing

and is the second cause, after lung cancer in terms of mortality in women. Incidence rates of breast cancer

increase sharply with age, becoming substantial before the age of 50. Due to this worsening trend, additional

efforts have been made to achieve lower mortality through early detection and early treatment of breast

cancer. The investigation of any breast abnormality must involve a "triple" evaluation by clinical, imaging

and cytological examination.

In the framework of the paper, we make a synthesis of the specialized literature and an update of the data

related to modern methods of breast biopsy, being an integrated part in the diagnosis of breast cancer.

The cytological or histological diagnosis of a palpable / non-palpable mass can be obtained by surgical

biopsy, or minimally invasive, by percutaneous biopsy. The latter is less expensive, faster and better borne

by the patient. The addition of modern imaging methods (ultrasound / MRI) in percutaneous needle biopsy,

has led to an increase in the sensitivity and specificity of the method up to 99% with a much lower

complication rate than classical surgical biopsy.

Conclusions: The minimally invasive breast biopsy, guided by imaging methods, is gaining more and more

ground in front of the classic surgical one.

Keywords: minimally invasive biopsy, imaging guidance, breast cancer.

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PREGNANCY AND COVID 19 INFECTION: AN OVERVIEW OF SYSTEMATIC REVIEWS

ABOUT IMPACT OF COVID 19 IN PREGNANCY

Georgeta Gînfălean1, MD Paula Luncaşu1

1Scju Sibiu, Sibiu, Romania

There are few data about the negative impact of COVID to pregnancy even if is almost 2 years from

discovering the virus that lead us to a pandemic crises. Medical fields has already experience with other

coronaviruses e.g. Severe Acute Respiratory Syndrome (SARS) and Middle Eastern Respiratory Syndrome

situation which has led us to consider pregnancies in a vulnerable position in front of COVID 19 infection.

The aim of this article is to review the literature regarding SARS- CoV 2 infection in pregnancy, its

physiological changes regarding the immune sistem, respiratory sistem, cadiovascular sistem and

coagulation, and to identify the maternal and perinatal outcomes of pregnancies affected by SARS-CoV-2

infection.

This systematic review was carried out by searching studies in PubMed, Medline, ScienceDirect and

National Center for Biotechnology Information databases. The inclusion criteria were: English language, full

text, COVID 19 in pregnant women. The literature search was not limited by the study design or the

publication date. The searched terms were: Covid 19, SARS-CoV 2, pregnancy, coronaviruses in pregnancy.

Nowadays is a global effort to concretize the impact of COVID infection in pregnancy, maternal and fetal

outcomes, including the indirect consequences witch affect the maternal health, decreased access to

reproductive health system, increased mental health stain and increased socioeconomic deprivation.

In these new pandemic situation is hard to elaborate some conclusions, but in big line we can say that women

will experience mild or asymptomatic disease with no lasting consequences, even if however, some centers

have seen increased rates of ICU admission, and the need for mechanical ventilation in pregnant women.

Keywords: COVID 19, SARS-CoV 2, coronavirus, pregnancy, infection.

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SIGNET RING CELL CARCINOMA: KRUKENBERG TUMOR OR PRIMARY OVARIAN

SIGNET RING CELL CARCINOMA? A CASE REPORT STUDY

MD Ilonco Coracioni1, MD Marian-Valeriu Codru1, MD Paula Luncaşu1

1Scju Sibiu, Sibiu, Romania

Signet ring cell carcinoma (SRCC) of the ovary is most commonly metastatic from a primary lesion. The

distinction between a primary ovarian mucinous carcinoma with signet ring cell and the metastatic form may

be difficult and has to include a variety of clinical, pathologic and morphologic features. Frequently signet

ring cell are found in the stomach or appendix, which has to be rigorous exanimated in cases with ovarian

signet ring cell carcinoma.

We present a case of primary SRCC of the ovary in a 51 year old woman presenting with two ovarian masses

sized 200/140/100mm respectively 160/120/100 mm. Total hysterectomy with bilateral salpingo-

oophorectomy, omentectomy and appendectomy were performed. Upon histological examination, mucinous

carcinoma composed predominantly of signet ring cell was observed in both tumors. The result of

immunohistochemical examination included diffuse positivity for cytokeratin CK7 and CK20, the tumor was

negative for P53. A preoperative computed tomography (CT) scan of the abdomen did not reveal any

suspicious extraovarian lesions.

Based on the histological and clinic-radiological examinations, this case was diagnosed as a primary ovarian

SRCC.

Keywords: ovary, signet ring cell carcinoma, mucinous carcinoma, Krukenberg tumor

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BIMALLEOLAR FRACTURE TREATMENT - A RETROSPECTIVE STUDY OF

INPATIENTS FROM SIBIU COUNTY EMERGENCY CLINICAL HOSPITAL IN 2020

Gelu Cristian Mărginean1, Dan Mihai Roman1,2, Radu Sorin Fleacă1,2, Marius Ioan Popescu1, Alexis

Vasilis Sacarelis1

11. Sibiu County Emergency Clinical Hospital., Sibiu, Romania, 22. Lucian Blaga University, Sibiu, Romania

Introduction:

Traumatic pathology in general and bimalleolar fractures in particular increased in number and in complexity

in the last century. This is caused by multiple factors.

Objectives:

ORIF is the Gold Standard for displaced bimalleolar fractures. The aim of this study was to evaluate the

results after surgical management of bimalleolar fractures.

Materials and methods:

We retrospectively evaluated 34 patients with closed bimalleolar fractures, treated in our department in 2020.

The data were collected from the Patient Observation Sheets and were processed by mathematical and

statistical methods.

Results:

In this study, 34 patients were involved, representing 3.92% of the total number of patients treated in our

department in 2020. There where 22 women (64.7%) and 12 men (34.3%). The patients age was between 24

and 83 years. They were divided into 4 age groups. 64.7%of the patients were from urban environment.

82.35% (28 patients) were treated surgically by ORIF.

Conclusions:

The studied group was non-homogeneous, with a predominance of females

The majority of the farctures occured in Group III (50-64 years)

The majority of patients hospitalized with this pathology received surgical treatment (82.35% of cases).

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RECTAL AMPUTATION FOR LOWER RECTAL CANCER, AN ALTERNATIVE

BETWEEN ONCOLOGICAL SAFETY AND PATIENT COMFORT

Dan Gheorghe Cretu1,2, Gabriel Mester2, Ramona Corsatea2, Fabian Igor2

1Faculty Of Medicine - Lucian Blaga University Sibiu, Sibiu, Romania,

2Departament Of General Surgery I - Emergency Clinic Hospital Sibiu, Sibiu, Romania

Rectal amputation consists of removing the rectum in its entirety, including the entire anorectal sphincter,

removing the distal sigmoid, and performing a definitive terminal colostomy. In 1908 Milles codified the

monobloc technique of organ and tissue amputation, describing the combined abdominal and perineal

approach with a single operating team for rectal cancer.

Clinical case: Patient G.E. 64 years old, diagnosed preoperatively with endoscopic anorectal

adenocarcinoma, radiotherapy (June 2021) is hospitalized in the Surgery Department I (September 2021) in

order to perform surgical treatment. It is decided to perform rectal amputation, given the low location, 3 cm

from external anal orifice, and on the posterior rectal wall, being known for early metastasis in the perirectal

tissues that in some situations can’t be removed to achieve a complete oncological resection. We consider

that in this situation the amputation of the rectum with colostomy ensures a better oncological safety.

Conclusions: Rectal amputation in lower tumors located and when the invaded perirectal tissues cannot be

excised, is the solution of choice ensuring a better oncological safety and an increased effectiveness of the

adjuvant treatment.

Keywords: rectal amputation, terminal colostomy, oncological safety

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LAPAROSCOPIC SUBTOTAL CHOLECYSTECTOMY, A SURGICAL ALTERNATIVE

TO REDUCE THE COMPLICATIONS OF DIFFICULT CHOLECYSTECTOMIES

Dan Gheorghe Cretu1,2, Gabriel Mester2, Ramona Corsatea2, Razvan Neagoe-Lepadatu2, Adriana Ioana Popa2

1Faculty Of Medicine - Lucian Blaga University Sibiu, Sibiu, Romania,

2Departament Of General Surgery I - Emergency Clinic Hospital Sibiu, Sibiu, Romania

Subtotal cholecystectomy is a procedure that removes portions of the gallbladder when structure of the Calot

triangle cannot be safety identified in difficult gallbladders.

Methods: This perspective study include all subtotal laparoscopic cholecystectomy performed in Sibiu

Country Emergency Hospital between 2018-2021.

Results: 8 Laparoscopic subtotal cholecystectomy without cystic duct ligation we performed in 6 men and 2

women, medium age 68 years median operating time was 90 min. One temporary bile leak resolved

spontaneously on day 14

Conclusion: Laparoscopic subtotal cholecystectomy without cyst duct ligation is an alternative to open

conversion when dissection of Calot’s triangle is hazardous. Bile leaks are predictable and readily managed

Keywords: subtotal cholecystectomy, gallbladder, bile leaks

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POST-COVID BILATERAL COXOFEMURAL SEPTIC ARTHRITIS

Costin Ghica1

1Sibiu County Emergency Clinical Hospital, România

Post-Covid bilateral coxofemoral septic arthritis

Mihai Dan Roman (1,2), Costin Ghica (2), Mircea Ciprian Sopon (2), Radu Sorin Fleaca (1,2)

1 - University “Lucian Blaga” of Sibiu

2 - Clinical County Hospital Sibiu

Introduction:

The increased prevalence of Sars-Cov-2 infections has led to immune-mediated consequences triggered by

this infection.

There are studies showing that infection with the Sars-Cov-2 virus, which usually presents respiratory

symptoms, can have in the short or long term various other manifestations and sequelae. One of the

complications of Covid-19 infection is arthritis.

Objectives:

Presentation of a particular case of post-Covid-19 destructive arthritis, at the level of the coxo-femoral joints,

occurred 4 months after infection with Sars-Cov-2.

Materials and methods:

We report a 53-year-old woman hospitalised 4 months ago to treat the Covid-19 infection.

She is currently complaining of walking difficulties, pain in both hips. Diagnosis of post-Covid bilateral

coxo-femoral destructive arthritis was sustained by imaging studies (destructive coxo-femoral changes on X-

Rays and CT scan) and biological investigations (increased inflammatory markers).

Differential diagnosis of Aseptic Necrosis of the Femoral Head and bilateral coxarthrosis was made.

Staphylococcus aureus and Staphylococcus capitis on pharyngeal exudate and hemocultures were identified

and appropriate antibiotic treatment was initiated.

Results:

Bone biopsy revealed small fragments of bone tissue and fragments of fibro-conjunctive tissue with slight

nonspecific inflammatory infiltration.

Total bilateral hip prosthesis is planned after normalisation of inflammatory parameters.

Conclusion:

The latest evidence shows that Sars-Cov-2 infection can lead to immunosuppression, which, in certain

patients, may favor septic arthritis with destructive changes of the joint. Additional attention should be paid

to clinical, laboratory data and symptoms that occur after an episode of Covid-19 infection as specific

medication can cause inflammatory changes in the joints.

Keywords: Sars-Cov-2, Covid-19, arthritis, inflammatory parameters, complications.

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SINGLETON PREGNANCY OUTCOMES AFTER IN VITRO FERTILIZATION – A

RETROSPECTIVE STUDY

Vladia-Maria Panța, Iulian-Florin Ispasoiu 1Spitalul Clinic Județean De Urgenta Sibiu, Sibiu, Romania

THE OBJECTIVE OF THE STUDY: An increased risk of adverse conditions related to in vitro

fertilization (IVF) pregnancies has been repeatedly reported. Our study aimed to summarize outcome

differences between pregnancies after IVF and after spontaneous conception (SC).

MATERIALS AND METHODS: A retrospective study was carried out. The study population consisted of

100 women in singleton pregnancies (50 IVF and 50 SC) who delivered at 38-40 weeks of gestation at the

Department of Obstetrics and Gynecology, Emergency Hospital Sibiu, between January 2020 - January

2021. Controls were initially matched by age and parity and drawn from the group of deliveries following

each IVF delivery. Collected data included maternal characteristics, incidence of pregnancy complications,

time and mode of delivery, and neonatal outcome at delivery. The relative risk of pregnancy-related

complications and adverse pregnancy outcomes in the IVF cohort in comparison with the SC cohort was

quantified using BMI SPSS statistical program.

RESULTS: In our study 50 IVF pregnancies were compared with 50 control pregnancies after elaborate

matching of maternal characteristics. The cohort of IVF singletons experienced a higher risk of small for

gestational age and low birthweight. Analysis showed that patients who conceived by IVF had a significantly

higher risk for gestational diabetes mellitus and pregnancy-induced hypertension. IVF mothers were at

increased risk of placenta previa, placental abruption and cesarean section. The risk of pre-eclampsia was

borderline. Maternal education, ethnicity and marital status had no effect on the magnitude of the risk

estimates.

CONCLUSION: The increased risk of pregnancy-related complications and adverse pregnancy outcomes

was observed in the cohort group of IVF singletons in comparison with the cohort of spontaneously

conceived singletons. The relative risk estimates grew with maternal age but were not influenced by the

maternal education, ethnicity and marital status.

KEYWORDS: in vitro fertilization, singleton pregnancy, adverse pregnancy outcomes, small for gestational

age, low birthweight

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UNICORNUATE UTERUS WITH NON-COMMUNICATING CAVITARY

RUDIMENTARY HORN – A CASE REPORT

Iulian-Florin Ispășoiu, Vladia-Maria Panța, Adam-Elisei Iuga1 1Obstetrics and Gynecology Department, Emergency Hospital Sibiu, Sibiu, Romania

INTRODUCTION: Unicornuate uterus is a form of uterine anomaly which arise from failure of

development and fusion of the Mullerian ducts, and accounts for about 2.4-13% of all Mullerian anomalies.

Unicornuate uterus with functioning non-communicating rudimentary horns are susceptible to many

gynaecologic and obstetric complications such as hematometra, endometriosis and ectopic pregnancy and

thus surgical resection is usually recommended.

CASE REPORT: We report a case of a unicornuate right uterus with rudimentary non-communicating

(functional) cavitary left horn in a 46-year-old female who was diagnosed with right ovarian cyst. She was

presented to our center with abdominal pain. She had no remarkable medical and surgical histories. Excision

of the left ovary and the rudimentary horn with right adnexectomy was performed and an uneventful

recovery followed.

DISCUSSION: These anomalies are usually diagnosed in the second decade of life, because they tend to

remain asymptomatic until adolescence and their initial symptoms may vary. Patients present with symptoms

such as dysmenorrhea, infertility and chronic or acute abdominal pain. Our patient had no renal

abnormalities despite approximately 38% of patients having coexisting renal abnormalities. Unilateral renal

agenesis is most commonly found; this is always ipsilateral with the rudimentary horn. Whenever diagnosed,

surgical excision (preferably laparoscopic) of the functional non-communicating rudimentary horn is

recommended.

CONCLUSION: Laparoscopic amputation of a functional rudimentary horn is considered the basic and

traditional surgical option for women with hemiuterus. A detailed diagnostic evaluation should be performed

to avoid misdiagnoses of other anomalies with blind hemicavity, which may be treated by hysteroscopy.

Laparoscopic surgery with minimally invasive approach could be an essential tool to treat these cases,

achieving optimal results with low postsurgical pain and a short hospital stay.

Keywords: rudimentary horn, unicornuate uterus, uterus anomaly, laparoscopy

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EARLY PRIMARY ABDOMINAL ECTOPIC PREGNANCY - A CASE REPORT

Iulian-Florin Ispășoiu, Vladia-Maria Panța, Ioana-Silvia Bela1 1Spitalul Clinic Județean De Urgenta Sibiu, Sibiu, Romania

INTRODUCTION: Abdominal pregnancy is a rare type of ectopic pregnancies associated with a high

mortality rate. Symptoms are not specific and usually resemble the other types of ectopic pregnancies.

Medical management is used in cases where a potentially lethal hemorrhage can be anticipated. Nowadays,

laparoscopic surgery has become the most common choice especially in cases diagnosed during the first

trimester.

CASE REPORT: A 18-year-old woman consulted for a pelvic pain and menstruation delay. She had a

stable hemodynamic status and hypogastric tenderness during deep abdominal palpation. Pelvic

ultrasonography revealed a gestational sac next to the right adnexa of 1.2/2 cm. Laparoscopic exploration

was performed finding normal fallopian tubes and ovaries with a 2 cm mass on the posterior site of the left

broad ligament. Resection of ectopic pregnancy was successfully performed and patient was discharged the

next day with no postoperative complications.

DISCUSSION: To date, there is no therapeutic protocol that has been established and there are no predictive

criteria of success concerning medical management for ectopic pregnancy. Surgery is the most common

choice in the therapeutic management of ectopic abdominal pregnancy. Laparotomy was preferred to the

laparoscopic surgery because of the high risk of perioperative hemorrhage which can be uncontrollable from

the implantation site. Nowadays, laparoscopic surgery should be the first measure if the abdominal

pregnancy is diagnosed at an early stage (< 12 weeks) or if the implantation site allows a non-hemorrhagic

surgical excision. As it is not uncommon to diagnose EAP for the first time at laparotomy or laparoscopy

performed for tubal ectopic pregnancy, it may have an impact on the clinician–patient relationship as patients

might find it difficult to accept the diagnosis and the management option offered.

CONCLUSION: Laparoscopic management of abdominal pregnancies is an encouraging choice to

laparotomy. Given the benefits of operative laparoscopy and increasing use of this modality for treatment, an

initial laparoscopic approach may be appropriate to evaluate the size of the EAP, the organs to which it is

attached and relative vascularity, to decide further management. Teamwork, a multidisciplinary approach

and expert opinion cannot be overemphasised to ensure successful management of these cases.

Keywords: abdominal ectopic pregnancy, risk factors, mortality, laparoscopy

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TIBIOTALOCALCANEAL ARTHRODESIS WITH MORSELLIZED GRAFT AND NAIL

Raoul Popa1, Mitu Nicoleta Anamaria1, Sopon Ciprian Mircea1

1Scjus, Sibiu,

Study objective: Arthrodesis is the surgical process of uniting the joints into one. The procedure is usually

performed to treat arthrosis at level of the foot and ankle, in this case, the tibioastragalocalcanean joint. We

want to present the difficulties we faced and the result of the surgery.

Materials and methods: Case report of a 62-year-old female with open fracture Gustilo-Anderson type 3B

and tibiotalar dislocation. The pacient presented at the hospital after 5 days sence traumatism occurred. We

decided to practice talus, tibial and fibular malleolus osteosinthesis. Following that, the evolution of the

patient was favorable, but after 6 months the evolution was unfavorable. She developed a massive arthrosis

that affected the soft tissue and bone structure showing a plantar deformity. The patient is known with talus

aseptic necrosis.

Result: Rx and CT at the level of the affected area revealed advanced degenerative changes of tibiotalar

arthrosis. After evaluating the advanced stage of bone necrosis and tibiotalar arthrosis combined with the

pain, it was decided that surgery was mandatory. Removal of the osteosynthesis material and prepare the

pacient for arthrodesis. During surgry, curettage was performed at the level of the level of the astragal bone,

followed by preparation of the tibial surface. To perform arthrodesis, we insert the morsellized graft inti the

pseudoarthrosis outbreak. After applying the graft, a nail with screw was placed retrograd to block the joint

and maintain the graft. In addition to rigid fastening, adequate reinforcement of an arthrodesis is also

dependent on the presence of a suistable blood intake. The major inconvenience of an arthrodesis is the

limitation pf the limb or body region mobility concerned. No immediate complication were encountered.

Conclusions: Tibiotalocalcaneal arthrodesis is a safe and effective technique with satisfactory clinical result,

even though more studies are needed to determine the optimum surgical treatment for this rare disease.

Keywords: tibiotalocalcaneal, arhrosis, nail, bone necrosis

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VACUUM- ASSISTED CLOSURE THERAPY (VAC) - RESCUE SOLUTION AGAINST

BILATERAL THIGH AMPUTATION IN A PATIENT WITH SEVERE VENOUS ULCERS

Mihetiu Alin1, Radu Alexandru Damsa, Victoria Gira, Dan Bratu, Alexandru Sabau, Sanda Simon 1University Lucian Blaga Of Sibiu, Sibiu,

Introduction:

Chronic venous insufficiency can progress to severe ulcers of the lower limbs that through local trophic and

infectious complications can impose amputation of the affected limb.

A solution to this type of evolution is VAC therapy (Vacuum- Assisted Closure Therapy).

Case report

We present the case of a 57-year-old patient who presents in sepsis with bilateral leg ulcers, with skin,

fascial, muscular and tendon necrosis.

Surgery is performed by performing necrectomy, debridement, and local dressings, under which the

evolution is favorable.

VAC therapy is instituted for 3 weeks, under which the evolution is spectacular allowing the installation of

skin autograft.

The evolution was favorable.

Discussions

The most common cause of lower limb ulcers is neglected venous insufficiency.This type of condition in

complicated form with ulceration affects between 0.11 and 0.18% of the population.

The treatment is a complex one and involves local compression methods to ensure a better venous return,

specific local dressings or surgery with the interruption of the venous communicators by ligation,

sclerotherapy or stripping.

VAC therapy by using a negative pressure, removes local edema and determines a better vascular intake,

which determines the decrease of the risk of local superinfection. In this way, the elements necessary for a

local tissue granulation are fulfilled.

Conclusions

VAC therapy is a non-invasive method that can significantly accelerate the healing process by preventing

progression to local complications that can lead to amputation of the affected limb.

Keywords: venous ulcers, VAC therapy, limb salvation

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GASTRIC DEVASCULARIZATION, HEMOSTASIS SOLUTION IN A PATIENT WITH

GASTRIC STRESS ULCERS IN THE CONTEXT OF COVID 19

Mihetiu Alin1, Dan Bratu1

1University Lucian Blaga Of Sibiu.Second Surgical Department Emergency County Hospital of Sibiu, Sibiu,

Romania

Introduction:

Stress gastric ulcer is a hemorrhagic ulceration located more frequently in the bottom and gastric body, but

can affect the entire surface of the stomach.

They occur frequently after shock, sepsis and trauma, being more common in patients with chronic diseases.

Case presentation

We present the case of an intubated elderly patient with septic condition through Klebsiella multidrug

resistant with severe form SARS COV2 infection, patient with upper digestive hemorrhage, with

hemodynamic instability and severe anemia. Upper digestive endoscopy reveals multiple gastric ulcers on

the entire mucosal surface. Attempts of endoscopic or conservative hemostasis have been ineffective. a total

gastrectomy is decided by a loco-regional hemostasis intervention practicing gastric devascularization and

vagotomy. The patient no longer shows postoperative signs of upper digestive hemorrhage and anemia but

dies at 5 days postoperatively due to respiratory failure.

Discussions

The technique presented is not one currently used today due to the good results obtained by endoscopic

treatment. It is used only in extreme situations where the patient's condition does not allow other therapeutic

solutions. Its efficiency is good, for stress ulcers being reported only 9% cases of reactivation of bleeding.

Conclusion

Gastric devascularization can be last resort solution in diffuse hemorrhages that cannot be controlled by other

surgical or non-surgical methods.

Keywords: stress ulcers, devascularization, vagotomy

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MORPHOMETRIC ANALYSIS OF MENISCI AND TIBIAL PLATEAU AT THE KNEE

JOINT IN ADULTS

Cosmin Mohor1, Mihai Roman1, Radu Sorin Fleaca1, Calin Mohor1, Nicolas Ion1 1Scjus, Sibiu, Romania

Background: Analyzing the synovial joints present in the human body we can say that the knee joint is the

largest. The menisci represent an anatomical fibrocartilaginous structure that only partially covers an

articular surface, compared to the articular discs, which cover the entire surface. At the level of the proximal

tibial epiphysis there are two articular surfaces separated by an intercondylar eminence that make up the

tibial plateau. The purpose of this presentation is to form a database on the menisci in the knee joint as well

as the variation of the dimensions of the tibial plateau for the young adult.

Methods: A batch of 10 bodies was selected for this study. Measurements were performed and 20 menisci

(10 right and 10 left) as well as the corresponding tibial plateaus were analyzed. The measurements were

performed with special equipment in special laboratory conditions.

Results: Important dimensional differences could be observed especially at the width of the lateral meniscus

compared to the medial meniscus, with areas of observable thickness at the level of the middle third of both

menisci. The obtained results classify the tibial plateaus according to sex.

Conclusions: Knowing the morphometry of joint components is very important in addressing the multiple

pathologies present in the knee, both traumatic and degenerative.

Keywords: Meniscus, tibial plateau, width, thickness

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TREATMENT OF TIBIAL PLATE PSEUDARTHROSIS BY TOTAL KNEE

ARTHROPLASTY WITH REVISION TIBIAL COMPONENT

Ion Nicolas1, Radu Sorin Fleaca1, Cosmin Mohor1, Mihai Roman1, Alexandru Diconi1 1Scjus, Sibiu, Romania

Introduction:

Pseudarthrosis of the tibial plateau is a rare condition.

Objectives:

Case presentation of a Total Knee Artrhoplasty (TKA) in case of a pseudarthrosis secondary to a untreated

tibial plateau fracture.

Material and method:

Patient G.E. 55-year-old, urban, professional textile handler, known with a history of Parkinson's disease and

depression.

The patient suffered a tibial plateau fracture 9 month ago but, for unknown reasons, she opted for no medical

treatment until she was admitted in our department. TKA with a tibial revision component was performed

Results:

The patient's postoperative recovery was favourable, with no signs of local or general inflammation. ROM

resumed almost completely and she was ligamentary stable at 3 month follow-up.

Conclusions:

Pseudarthrosis after tibial plateau fracture is a rare condition and is usually treated by t reduction of the

malunited fragment and osteosynthesis. Performing tTKA with tibial revision component plus double

augmentation on the internal tibial plateau is the treatment of choice if the local bone stock is compromised.

Keywords: pseudarthrosis, tibial plateau fracture, TKA, revision

39

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THE ADVANTAGES OF THE IPOM TECHNIQUE IN THE SURGICAL TREATMENT

OF UMBILICAL HERNIA

Bindea Alina-Cristina1

1Facultatea De Medicina Victor Papilian, Sibiu,

THE ADVANTAGES OF THE IPOM TECHNIQUE IN THE SURGICAL TREATMENT OF

UMBILICAL HERNIA

Autor: Bindea Alina-Cristina

Scientific coordinator: Conf. Dr. Ciprian Tănăsescu

Introduction: The European Hernia Society defines umbilical hernia as the protrusion of the abdominal

viscera, with or without a "hernia sac" through congenitally determined orifices. These are the second most

common type of hernia in adults, after inguinal hernia and about 6% -14% of all abdominal wall hernias in

adults. Surgical treatment of umbilical hernia can be performed by open surgery or by laparoscopic

approach. Laparoscopic surgery can be associated with the IPOM technique, a technique dating back to the

early 1990s. The technique involves placing a prosthetic material directly on the peritoneum overlapping the

hernia defect and leaving an additional 5 cm margin, using laparoscopic cannulas. The mesh used must

induce a fast and adequate fixation to the abdominal wall, and may also allow an overlap of 2 or more

meshes in case of major defects.

Case prezentation: We present the case of a 77-year-old patient, known in a personal pathological history

with hypertension gr. III, CIC, FiA which presents on the Surgery I section for an uncomplicated umbilical

pseudotumor formation, local sensitivity, asthenia and fatigue, symptomatology with onset of approximately

5 years, accentuated in the last 48 hours. At the local examination, a pseudotumor formation is detected at

the umbilical level, of approximately 5/6 cm, reducible by taxi, expansive to cough and exertion,

uncomplicated, slightly sensitive to palpation. After an adequate preoperative preparation, surgery is

performed on 25.08.21 in the AG with IOT and the surgical treatment of recurrent umbilical hernia is

performed by laparoscopic alloplastic procedure IPOM.

Discussions: The advantages and disadvantages of the IPOM technique compared to the classical procedure

are described.

Conclusions: The small number of possible complications and the rapid recovery of patients benefiting from

the IPOM procedure.

Keywords: Umbilical hernia, IPOM, laparoscopy.

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THE SURGICAL APPROACH OF THE INTRADURAL EXTRAMEDULLARY TUMORS

LOCATED IN THE ANTERIOR COMPARTMENT

MD, PhD Claudiu Matei1, MD Sofia Nistor1, MD, PhD Dan Filip1, MD Iulia Dancu1, MD, PhD Oana

Muntiu1, MD, PhD Ciprian Sofariu2, MD, PhD Ioana Matacuta2, MD Ioana Andreea Crisan2, MD, PhD

Adrian Hasegan3

1Polisano MedLife Hospital, Sibiu, Romania,

2Pediatric Clinical Hospital Sibiu, Sibiu, Romania,

3Sibiu County Clinical Emergency Hospital, Sibiu, Romania

Introduction

Extramedullary tumors are rare lesions of the nervous system, accounting for 3% of all central nervous

system tumors and 4% of spinal tumors. A recent epidemiological study estimates the incidence of these

lesions at 0.74 -1.5 per 100,000 people. Most of these tumors are meningiomas (25-46%), followed by

tumors developed from the spinal nerves (33.9%) and ependymomas, developed from the filum terminale

(5.6-6.8%); other lesions such as neurenteric cysts, arachnoid cysts, cavernous dermoid cysts,

mealnocytomas, hemangiopericytomas, metastases are also cited. Intradural extramedullary tumors

developed from the nerve sheath are represented by schwannomas, neurofibromas or malignant nerve sheath

tumors. Thoracic spinal cord lesions are rare, because the most common locations involved, are cervical and

lumbar. These tumors are usually located laterally or posterolaterally, very rarely these lesions are situated in

the anterior intradural compartment. The surgical approach of intradural extramedullary tumors located in

the anterior compartment is difficult and burdened by technical aspects, which significantly influence the

prognosis of these cases.

Case report

This paper is based on the case of an 8-year-old patient admitted to our service in September 2021,

presenting at admission, spastic paraplegia installed 9 days before hospitalization, urinary retention and

exteroceptive and myoarthrokinetic hypesthesia. Imaging investigations revealed an intradural

extramedullary spinal tumor at the T10-T11 level, located in the anterior compartment. The surgery was

performed with the patient under general TIVA anesthesia, with continuous intraoperative

neurophysiological monitoring, with patient in a prone position, and the operating table rotated to the

opposite side; a T10 and T11 laminectomy was performed with a left unilateral partial arthrectomy T10-T11,

mobilization of the spinal cord by traction on the dentate ligament. A complete tumor resection was

performed, certified by postoperative imaging studies. The clinical evolution was spectacular with the

progressive neurological improvement and the patient was walking on discharge from the hospital.

Conclusions

In order to obtain the best possible prognosis, in the case of spinal cord tumors located in the anterior

compartment, timely diagnosis and early surgery are mandatory. The approach of these tumors represents a

surgical challenge, for which both, the appropriate technical equipment and an important microsurgical

experience are necessary.

Keywords: spinal tumors, paraplegia, intraoperative neurophysiological monitoring, laminectomy

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CASE PRESENTATION: GIANT, COMPRESSIVE, NONTOXIC MULTINODULAR

GOITER WITH DYSPNEA

Castilia Dobra1, Mihai Faur1, Ioan Bombea1, Razvan Neagoe1

1Clinical Emergency Hospital Sibiu County,

2Surgery I Clinic,

Introduction: Nontoxic multinodular goiter is a disease of the thyroid gland characterized by the presence of

thyroid nodules without biochemical abnormalities of the thyroid gland. Increasing age, less iodine intake

and exposure to external irradiation are the usual causative factors. Generally, nodular goiters are more

common in women than in men. It is reported that the frequency of the nodular goiter is up to 5% at

nonendemic regions and 15% at endemic regions.

Case presentation: We present you the case of a 76 year old woman, known with multinodular goiter for

about 30 years. She presented with a painful tumor formation developed in the anterior neck, dyspnea and

dysphagia for solids. Computed tomography scan of the neck showed a gross enlargement of the thyroid

gland across both sides of the neck, causing mechanical compression of the trachea. A thyroid hormone

profile confirmed the euthyroid status of the patient during routine preoperative tests. The ENT doctor

established the diagnosis of recurential palsy and raised the issues of the high risk of prolonged intubation

and therefore the necessity of performing tracheostomy. The patient underwent uneventful tracheal

intubation. Intraoperatively we found a huge multinodular goiter, especially in the right lobe. Under general

anaesthesia we managed to perform a total thyroidectomy, which required an enormous effort, because of the

adhesion between the tumor formation and trachea. Fortunately, the woman was extubated immediately after

the surgical procedure and she didn’t required tracheostomy. The histopathology report revealead no atypia.

The postoperative recovery was favourable and the patient was discharged in 3 days after the operation.

Discutions: Multinodular goiters usually grow slowly and may cause mechanical compression of the trachea

and esophagus, causing dyspnea and dysphagia respectively. The total thyroidectomy is strongly

recommended for multinodular goiters as it is rapid, reliable and removes any coexisting malignancy.

Conclusions: Surgery for voluminous goiter is challenging and one should be careful about difficult

intubation, altered anatomy and adhesions to the surrounding structures. The operative challenge was the

huge size of the gland and its adherence to vital structures. To improve the outcome of such operations the

multinodular goitres must be timely diagnosed and treated.

Keywords: total thyroidectomy, dyspnea, dysphagia, multinodular goiter.

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TOTAL HIP ARTHROPLASTY REVISION, POST INFECTED PRIMARY CEMENTED

PROSTHESIS CASE REPORT

Istrate Victor1

1SCJU Sibiu, Sibiu, Romania

Total Hip Arthroplasty Revision, Post Infected Primary Cemented Prosthesis: Case report

Teodor Lucian Stanciu, Victor Alexandru Istrate, Nicolas Catalin Ion

Clinical Emergency Hospital of Sibiu, Sibiu, Romania

Introduction:

Hip arthroplasty is a surgical intervention in which the damaged hip joint is replaced with an artificial

implant called hip prosthesis. Irreversible damage of the joint may appear as a result of arthrosis, a fracture

or even other causes (pathological, traumatic). As a result of the intervention, the pain goes away, and the

patient may recover the mobility of the hip, resuming his day to day activities. Revision of total hip

arthroplasty means the change of one or all the damaged joint components. It is considered to be a very

difficult and long intervention which requires complex equipment, appropriate instrumentation, a wide range

of revision prostheses, a surgical team with experience and a prolonged recovery. A good settlement in any

case impose the presence of three basic principles: the restoration of the osseous capital, the reestablishment

of the rotational center of the hip and ensuring primary stability of the implant.

Materials and methods:

Case report of a 50-year-old morbidly obese male patient who had undergone total hip arthroplasty about 2

years before due to a bilateral femoral head necrosis. As a result of a local infection the implant was removed

and 16 months later a revision was performed.

Conclusions:

Although total hip arthroplasty became more and more successful in the recent years, a good portion of the

cases evolve towards revision. Related comorbidities, especially the increased degree of obesity represents a

major factor in determining the intra and postoperative evolution. In this particular case the patient lost

approximately 15 kg before the intervention facilitating its success. At discharge, the patient did not report

any more pain at the hip level, while regaining almost full mobility

Keywords: Total hip arthroplasty, revision, complications, morbid obesity

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SARCINA LA TERMEN IN UTERULU DIDELF

Dr. Valentin Voiasciuc1, Dr. Livia Georgiana Matei1, Dr. Cristina Chirila1

1Spitalul Clinic Județean de Urgenta Sibiu, Sibiu, Romania

Introducere: Uterul didelf apare in urma absentei fuziunii ductelor mulleriene, aceasta fiind o anomalie

caracterizatata prin prezenta a doua coarne uterine, fiecare cu cavitate endometriala si col uterin propriu.

Sarcina se dezvolta in unul dintre cele doua cornuri uterine, uterul dublu (didelf) avand cel mai bun

prognostic reproductiv dintre toate malformatiile uterine majore.

Materiale si metode: Prezentam cazul unei paciente in varsta de 23 de ani, primipara, cu

amenoree anamnestica de 39 saptamani si 2 zile, fara patologii asociate, nedispensarizata,

care se prezinta in clinica obstetrica ginecologie cu contractii uterine dureroase.

Rezultate: In timpul examenului ecografic efectuat la internare se vizualizeaza uterul dublu continand in

interior un fat viu cu parametrii ecografici in limite fiziologice. Se decide terminarea nasterii prin operatie

cezariana. Intraoperator se evidentiaza uterul didelf din care se extrage un fat viu de sex masculin normal

dezvoltat.

Concluzii: In ciuda faptului ca reprezinta o anomalie structurala, uterul didelf permite

dezvoltarea in conditii fiziologice a unei sarcini la termen, lipsita de complicatii pre si intraoperator.

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LARGE MULTILOCULATED DERMOID CYST, LAPAROSCOPICALLY

CONSERVATIVE APPROACH WITH PARTIAL PRESERVATION OF THE RIGHT

OVARY

Dr. Dragos Popescu1, Dr. Razvan-ioan Stanescu1

1Spitalul Clinic Județean de Urgenta Sibiu, Sibiu, Romania

Dermoid cysts or mature cystic teratoma, are common and often occur in women of childbearing age. We

present the case of a patient with primary sterility, with large multiloculated dermoid cyst on the right ovary

and left ovarian functional cyst, partial preservation of the right ovary is achieved, through laparoscopic

intervention, given the age and desire of patient to procreate.

Keys: Dermoid cysts, sterility, laparoscopy

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UTERINE FIBROMYOMA - THE CAUSE OF PRIMARY STERILITY, FAVORABLY

RESOLVED AFTER MYOMECTOMY

Dr. Dragos Popescu1, Dr. Ioana Gherman1 1Spitalul Clinic Județean De Urgenta Sibiu, Sibiu, Romania

Uterine fibroids are the most common benign tumor that develops in the muscular layer of the uterus. About

40% of women over the age of 35 are diagnosed with this condition. We present 2 cases of patiens with

primary sterility, with intramural fibromatous, performing multiple myomectomy. After 15 months post-

myomectomy, they get pregnant spontaneously, the evolution being favorable until term, ending by cesarean

section without complications.

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INCIDENCE OF EXTREME PREMATURITY IN THE OBSTETRICS-GYNECOLOGY

CLINIC SIBIU

Dr. Popescu Dragos1, Ioana Gherman1

1Spitalul Clinic Județean De Urgenta Sibiu, Sibiu, Romania

Premature birth is an obstetric issue of great importance. It complicates about 5 - 12% of pregnancies and is

the leading cause of mortality and perinatal morbidity worldwide. In this study, we analyze the incidence of

extreme prematurity at births in the Obstetrics-Gynecology Clinic, Sibiu, between 25-28 gestational weeks.

The study is based on certain criteria: dermographic, clinical, paraclinical and therapeutic.

Keywords: premature birth, perinatal morbidity, therapy

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COMMON MISTAKES IN THE MANAGMENT OF PERIPROSTHETIC JOINT

INFECTIONS

Dr. Rares-Mircea Birlutiu1, Dr. Victoria Birlutiu2

1Foisor Orthopaedics Clinical Hospital Bucharest, “Lucian Blaga” University of Sibiu, Romania.,

Bucharest, Romania, 2“Lucian Blaga” University of Sibiu, Emergency County Clinical Hospital Sibiu,

Department of Infectious Diseases, Romania., Sibiu, Romania

Objectives:

Prosthetic joint infections (PJIs) represent major cause of healthcare expenditure and morbidity. PJI remain

the most common and feared arthroplasty complication. A rapid and correct diagnosis of infection is

mandatory for a correct therapeutical management. Errors in the management of PJI can compromise the

management success. Our goal is to describe common errors in the diagnosis and management of PJI, and to

help surgeons avoid them.

Materials and methods:

We analyzed common diagnostic and treatment errors based on a hypothetical case.

Results:

Diagnostic pitfalls or errors include the incorrect use of serum inflammatory, incomplete evaluation of the

synovial fluid, and unadjusted microbiological procedures for the detection of biofilm-related infections.

Insufficient surgical management and an inadequate antibiotic treatment are other reasons for treatment

failure.

Conclusion:

The rate of infection eradication is improved by the existence of adapted protocols for managing biofilm

infections and the new diagnostic methods, still without having a 100% certainty that we have eradicated it.

Well-equipped treatment centers for diagnosis and multidisciplinary teams (orthopedic surgeon, infection

diseases specialist, and clinical microbiologist) are mandatory to offer the chance of a periprosthetic joint

infection well-management. To be aware of the possible difficulties in the management of periprosthetic

joint infections can improve diagnosis and treatment results.

Keywords: periprosthetic joint infection; common errors; diagnosis; treatment.

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AN UNUSUAL PREECLAMPSIA IN A PREGNANT WOMAN WITH COVID-19

INFECTION

MD Ph.D Georgeta Gînfălean1, MD Irma Pljakić1 1Spitalul Județean De Urgență Sibiu, Sibiu, Romania

Georgeta Gînfălean, MD, Ph.D, Lecturer,‘Victor Papilian’ Faculty of Medicine, Obstetrics and Gynecology

Department, Emergency Hospital of Sibiu

Irma Pljakić MD, Resident, Obstetrics and Gynecology Department, Emergency Hospital of Sibiu

Key words: Preeclampsia, COVID-19, Hypertension.

Introduction: Pregnancy-induced hypertension is defined as new onset elevation of blood pressure (140/90

mmHg or higher) without proteinuria after 20 weeks gestation. Preeclampsia is a pregnancy complication

characterized by high blood pressure and signs of damage to another organ system, most often the liver and

kidneys. This clinical case report is meant to highlight the course of the disease and the importance of

multidisciplinary management.

Case report: A 24-year old woman, gravida 1, para 1, at 37 weeks of gestation was admitted to the

Infectious Disease department with confirmed COVID-19 infection, presenting asthenia, fatigue, nausea,

vomiting and cough, blood pressure(BP) was normal. The patient did not report any history of medical or

pregnancy related problems. The diagnosis: Acute viral pneumonia; Acute respiratory failure; Inflammatory

syndrome. Treatment was initiated. Four days later, high BP(180/112mmHg) and headache were reported.

Cardiology consult led to intitiating antihypertensive therapy. Next day patient presented difficulty

cooperating, stupor, temporal/spatial disorientation, palpebral and lower limbs edema, proteinuria(11g/24h.

As a neurological exam was performed, preeclampsia suspicion conducted the patient’s transfer to the

Obstetrics and Gynecology department. Ultrasound with Doppler examination were normal. Given that

during the transfer the patient developed a seizure, adding to the high levels of TGO, TGP and LDH, the case

was interpreted as “severe preeclampsia complicated with eclamptic seizure”. Cesarean section was

performed, delivering a baby with a birth weight of 2660g, Apgar score 9, under normal conditions. With

intensive monitoring and multidisciplinary management, the patient's condition improved and she was

discharged from the hospital on day 14 from admission.

Discussions: Most recent studies found that the odds of developing severe preeclampsia, eclampsia and

HELLP syndrome were significantly higher among pregnant women with COVID-19 infection. However,

differentiating between preeclampsia and COVID-19 in pregnancy can be challenging. PLGF is a placental-

related angiogenic marker considered highly specific for preeclampsia and could be useful to test.

Conclusion: As COVID-19 infection triggered term preeclampsia in a patient without history of pregnancy

induced hypertension, early diagnosis of preeclampsia is crucial for the appropriate management that will

decrease the progression to severe preeclampsia and eclampsia, and as a result, reduce maternal and fetal

morbidity and mortality.

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ADENOMYOSIS AND INFERTILITY. CASE REPORT

Ispasoiu Iulian Florin1, Vladia PAnta1, Ioana Bela1, Elisei Iuga1, Corina Alina Ispasoiu2

1Scju Sibiu, Sibiu, Romania, 2Gynmed, Sibiu, Romania

Introduction: Adenomyosis is an important clinical challenge in obstetrics and gynecology. Symptoms of

adenomyosis typically include menorrhagia, pelvic pain and dysmenorrhea. In addition, adenomyosis

enhances the risk of obstetric complications, impair the IVF outcomes [1].

Case Report: We present a case of a 35 years old woman with 3 years primary infertility secondary to

adenomyosis. In the past she underwent a laparoscopy which revealed pelvic adhesions, left hydrosalpinx

and no signs of endometriosis. The sperm count was normal. Menstrual cycles were regular. The basic

hormonal status was normal. The vaginal ultrasound revealed enlarged uterus with focal adenomyosis of the

anterior wall, irregular endometrium, normal ovaries. Hysteroscopy revealed a slightly distorted uterine

cavity and endometrial defects on the anterior wall. Due to the uterine pathology, we proposed to the couple

an IVF procedure with freeze-all strategy followed by a medical treatment for adenomyosis. For IVF an

antagonist protocol was used. We collected 29 oocytes, 15 were fertilized and 4 good quality blastocysts

were frozen. Afterwards medical menopause was induced with GnRH analog for 12 months. The embryo

transfer was performed with 2 thawed embryos and a single pregnancy was confirmed. The pregnancy was

complicated by several episodes of imminent abortion and fetal growth restriction (under 5th percentile). The

delivery was performed by cesarean section at 37 weeks of pregnancy and a healthy boy of 2450 g, Apgar 10

was delivered.

Discussions: The prevalence of adenomyosis fluctuates between 5 and 70%. Fertility could be disturbed by

various mechanisms: abnormal utero-tubal transport and disruption of endometrial function [2], anatomical

distortion and hyperactivity of the myometrium. Ultrasound is the first-line imaging tool in the infertile

patient. Hhysteroscopy can be a valuable diagnostic tool for visualization of the uterine cavity. Pelvic MRI is

the reference standard for the noninvasive detection of the adenomyosis in patients with infertility [2]. Endo-

myometrial resection is effective in patients with the disease limited to the endo-myometrial junction but

contraindicated in patients who desire pregnancy. Nonsteroidal anti-inflammatory drugs and oral

contraceptives have negative impact on fertility [3]. GnRH analogues have been used to induce a constant

hypoestrogenic state [4]. There are still very few data on their impact on future fertility. Progestins have an

antiproliferative and anti-inflammatory effect.

Conclusion: There is no specific treatment for adenomyotic patients who wish to preserve fertility. Thus, it

is of great importance to explore new, more effective strategies in women with infertility due to

adenomyosis.

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RH ALLOIMMUNIZATION WITH HIGH ANTIBODIES TITER BUT WITHOUT FETAL

IMPAIRMENT.

CASE REPORT

Ispasoiu Iulian Florin1, Vladia Panta1, Ioana Bela1, Elisei Iuga1, Corina Alina Ispasoiu2

1Scju Sibiu, Sibiu, Romania, 2Gynmed, Sibiu, Romania

Introduction: Rh alloimmunization occurs when maternal immune system is sensitized to Rh erythrocyte

surface antigens. Once produced, maternal Rh immunoglobulin G antibodies persist for life and may cross

freely from the placenta to the fetal circulation, resulting in a fetal hemolytic anemia.

Case Report: This study presents a case of a Rh alloimmunization with high levels of antibodies but with no

fetal impairment. A 32 years old pregnant woman known with Rh alloimmunization from her first pregnancy

was referred to our center. At admission she had a titer of Rh antibodies of 1:128. Antibodies levels and fetal

well-being were monitored monthly. At 31th week of pregnancy the antibodies level raised to 1:2048. The

fetal ultrasound revealed no signs of fetal hydrops. The MCA peak systolic velocity was 42.5 cm/s. The

patient was monitored weekly by ultrasound, Doppler and antibodies titer. All the tests were normal. At 35

weeks of pregnancy the titer rose again at 1:2048 but no signs of fetal distress. The patient was monitored

twice a week until 37+4 weeks of pregnancy when she delivered by cesarean section. At birth the newborn

had a hemoglobin level of 11.9g/l, no jaundice. After 2 hours it developed jaundice and the Hb level 9.1g/l,

probably due to antibodies passage during the delivery. The newborn received blood transfusion with Hb

level of 13.7 g/l afterwards but no exchange transfusion was needed.

Discussions: The most common cause of Rh incompatibility is exposure of a Rh negative mother to Rh-

positive fetal blood during pregnancy or delivery[1]. Women with titers higher than 1:4 should be considered

Rh alloimmunized. The probability of subsequent affected Rh D-incompatible fetus is more than 80%[2]

Fetal ultrasound has an essential role. Sonographic findings include ascites, pleural and pericardial effusions,

edema, polyhydramnios, increased placental thickness.

Peak systolic velocity in the middle cerebral artery(MCA) is used to detect fetal anemia[2]. Generally, a

value of 1.5 MoM is considered critical.

Cordocentesis is the best approach in diagnosing of fetal anemia and acidosis. When fetal hematocrit is less

than 30%, intrauterine fetal transfusion is mandatory.

In determining the optimal delivery time, gestational age, severity of fetal anemia, and fetal lung maturity

should all be considered.

Neonatal outcome is complicated by the need of transfusions. Long-term studies have revealed normal

neurologic outcomes in more than 90% of cases[3].

Conclusion: Although it is a life-threatening disorder, Rh alloimmunization when managed correctly can

lead to favorable outcome.

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Ovarian Fibroma - Case Report

Manta Tia-Maria1

1Spitalul Judetean De Urgenta Sibiu, Sibiu, Romania

Radu Chicea, Olimpiu Muresan, Tia-Maria Manta, Anisoara Batir

„Lucian Blaga University of Sibiu, Emergency County Clinical Hospital of Sibiu”

Ovarian fibromas are solid tumors that belong to sex-cord stromal cell tumors of the ovary and comprise

spindle shape fibroblastic cells and abundant collagen. They are the most common benign solid tumors of the

ovary, accounting for 1–4 % of all ovarian tumors. Ovarian fibroma is often difficult to diagnose

preoperatively and usually misdiagnosed as uterine myoma, because of the solid nature of the mass on

clinical examination, and the ultrasound similarities between the two anomalies. They are seldom bilateral,

and their masses vary in size from microscopic to extremely large ones. Although infrequently diagnosed

prior to the age of 30, they can occur in any age group; however, the average age of diagnosis is the latter

half of the fifth decade of life. It rarely occurs in prepubertal age group . About 10–15 % of large ovarian

fibroma can be associated with ascites due to escape of large amount of fluid from the edematous surface.

Furthermore, 1 % of ovarian fibromas can present with Meigs syndrome, a condition which refers to triad of

benign ovarian tumor, ascites, and pleural effusion (usually unilateral and right sided). In the minority of

patients with ovarian fibroma, the serum level of CA125 is raised, which may lead to misdiagnosis of a

malignant ovarian tumor. The standard of treatment for ovarian fibroma is surgical removal. In all post-

menopausal women and those who have completed their family, total abdominal hysterectomy is the

treatment of choice; however, owing to benign nature of the disease, a fertility-preserving surgery with

unilateral salpingo-oophorectomy in young premenopausal women can be contemplated.

Keywords: ovarian fibroma, fibroblastic, Meigs syndrome, treatment, hysterectomy.

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THE SURGICAL APPROACH OF THE INTRADURAL EXTRAMEDULLARY TUMORS

LOCATED IN THE ANTERIOR COMPARTMENT

MD, PhD Claudiu Matei1, MD Sofia Nistor1, MD, PhD Dan Filip1, MD Iulia Dancu1, MD, PhD Oana

Muntiu1, MD, PhD Ciprian Sofariu2, MD, PhD Ioana Matacuta2, MD Ioana Andreea Crisan2, MD, PhD

Adrian Hasegan3

1Polisano MedLife Hospital, Sibiu, Romania, 2Pediatric Clinical Hospital Sibiu, Sibiu, Romania, 3Sibiu

County Clinical Emergency Hospital, Sibiu, Romania

Introduction

Extramedullary tumors are rare lesions of the nervous system, accounting for 3% of all central nervous

system tumors and 4% of spinal tumors. A recent epidemiological study estimates the incidence of these

lesions at 0.74 -1.5 per 100,000 people. Most of these tumors are meningiomas (25-46%), followed by

tumors developed from the spinal nerves (33.9%) and ependymomas, developed from the filum terminale

(5.6-6.8%); other lesions such as neurenteric cysts, arachnoid cysts, cavernous dermoid cysts,

mealnocytomas, hemangiopericytomas, metastases are also cited. Intradural extramedullary tumors

developed from the nerve sheath are represented by schwannomas, neurofibromas or malignant nerve sheath

tumors. Thoracic spinal cord lesions are rare, because the most common locations involved, are cervical and

lumbar. These tumors are usually located laterally or posterolaterally, very rarely these lesions are situated in

the anterior intradural compartment. The surgical approach of intradural extramedullary tumors located in

the anterior compartment is difficult and burdened by technical aspects, which significantly influence the

prognosis of these cases.

Case report

This paper is based on the case of an 8-year-old patient admitted to our service in September 2021,

presenting at admission, spastic paraplegia installed 9 days before hospitalization, urinary retention and

exteroceptive and myoarthrokinetic hypesthesia. Imaging investigations revealed an intradural

extramedullary spinal tumor at the T10-T11 level, located in the anterior compartment. The surgery was

performed with the patient under general TIVA anesthesia, with continuous intraoperative

neurophysiological monitoring, with patient in a prone position, and the operating table rotated to the

opposite side; a T10 and T11 laminectomy was performed with a left unilateral partial arthrectomy T10-T11,

mobilization of the spinal cord by traction on the dentate ligament. A complete tumor resection was

performed, certified by postoperative imaging studies. The clinical evolution was spectacular with the

progressive neurological improvement and the patient was walking on discharge from the hospital.

Conclusions

In order to obtain the best possible prognosis, in the case of spinal cord tumors located in the anterior

compartment, timely diagnosis and early surgery are mandatory. The approach of these tumors represents a

surgical challenge, for which both, the appropriate technical equipment and an important microsurgical

experience are necessary.

Keywords: spinal tumors, paraplegia, intraoperative neurophysiological monitoring, laminectomy

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HYDROPS FETALIS

Dr. Nicoleta Popa1, Dr. Radu Chicea1, Dr. Mirela Popa1, Dr. Diana Lodromanean1, Dr. Ricarda Maris1

1Sp Cl Jud Sibiu, Sibiu, Romania

Hydrops fetalis is a very serious condition in the fetus reffering to abnormal and excessive accumulation of

fluid with at least two of the following:

-Edema (free fluid beneath the skin, more than 5 mm)

-Ascites (free fluid in abdomen)

-Pleural effusion (fluid in the pleural cavity)

-Pericardial effusion (fluid in the pericardial sac)

In addition, hydrops fetalis is frequently associated with polyhydramnios and a thickened placenta (>6 cm).

Hydrops fetalis can have multiple etiology, each one of them developing severe condition of the fetuses. It

has been divided in two categories, immune, when the mother`s immune system causes breakdown of the

fetuses red blood cells, and non-immune hydrops fetalis caused by the fetuses incapacity to manage fluids

due to various genetic disorders or virus infections.

The incidence of immune hydrops fetalis has significantly decreased along with MCA Doppler studies and Ig

anti D, while the incidence of non-immune hydrops fetalis is increasing.

Case report

We described the case of a 23 year old VG IV P 31 weeks pregnant woman that came to the hospital after

being reffered to by a private practice due to ultrasound abnormalities.

Ultrasound revealed that the fetus presents voluminous ascites and nuchal edema.

After admitting the mother, laboratory results reveal that this is a classic case of Rh incompatibility, the

mother`s antibodies value was 1/ 1024.

Conclusions

Immune hydrops fetalis is a severe condition that requires emergency treatment for mother and newborn

although regular check-out and precise control of the pregnancy should discover early the etiology and

severity of the case.

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VOLUMINOUS OVARIAN CYST IN A FULL TERM PREGNANCY - CASE REPORT

Dr. Nicoleta Popa1, Dr. Radu Chicea1, Dr. Mirela Popa1, Dr. Georgeta Ginfalean1, Dr. Diana Lodromanean1,

Dr. Ricarda Maris1

1Sp Cl Jud Sibiu, Sibiu, Romania

Ovarian masses are a common discovery in Gynecology, most of them being cysts, among them functional

cysts are a very frequent discovery.

The incidence of ovarian cyst is somewhere between 5% and 15%, depending on demographic areas.

The exact mechanism of ovarian cyst is still unknown. Angiogenesis is an essential factor in the two phases

of the ovarian cycle, and also participates in various pathological ovarian processes like the follicular cyst,

PCOS, and ovarian tumors.

The incidence of ovarian cyst in pregnancy is approximately 1 in 1000 cases and they require extra care.

Case report

We described the case of a 33 year old first time pregnant woman, 40 gestational weeks, that presented

herself to the hospital with uterine contractions 10` apart, pain in the lower abdomen, breech presentation

and a voluminous ovarian cyst.

The patient was admitted and due to the sizes of the cyst and the breech presentation we decided to perform a

C-section. Both mother and child were stable. Due to the volume of the ovarian cyst and the fact that there

was no healthy ovarian tissues, in the same surgical procedure we performed adnexectomy on the right side.

The removed adnexa has been sent to histopathological exam, the final diagnose being mucinous

cystadenoma.

Conclusions

Symptoms of ovarian cysts in pregnant women are similar to not pregnant women, such as abdominal pain.

An important aspect is still the size and ultrasound aspect of the cyst, that determines the attitude in

pregnancy and in labor.

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SINDROMUL PRES - REVIEW DE LITERATURĂ ȘI MINISERIE DE CAZURI

Radu Chicea1, Lebădă Codruța1

1Universitatea Lucian Blaga din Sibiu, Romania, Sibiu,

Sindromul PRES (Posterior reversible encephalopathy syndrome) este o entitate clinico-radiologică descrisă

pentru prima dată de Hinchey în 1996.

Sindromul de encefalopatie reversibilă posterioară (PRES) este un sindrom clinico-radiologic caracterizat

prin cefalee, convulsii, stare mentală modificată și pierderi vizuale și caracterizat prin edem vasogen de

substanță albă care afectează predominant lobii occipitali și parietali posteriori ai creierului. Acest sindrom

clinic este din ce în ce mai recunoscut datorită îmbunătățirii și disponibilității imaginii cerebrale, în special

imagistică prin rezonanță magnetică (RMN).

Diagnosticul este sugerat clinic și confirmat imagistic, fără să existe un consens general valabil cu privire la

criteriile de diagnostic. Manifestările clinice sunt reprezentate de tulburări ale stării de conștiență, activitate

critică, cefalee, tulburări vizuale, greață/vărsături și semne neurologice de focar. Imagistic este prezent edem

bilateral simetric în mod tipic în substanța albă din lobii occipitali și parietal posterior. În 95% din cazuri

edemul vasogen este localizat în regiunile occipitale și parietale, probabil legat de teritoriul de distribuție a

arterei cerebrale posterioare.

Cauza apariției este hipertensiunea arterială severă care afectează autoreglarea cerebrală. HTA necontrolată

duce la hiperperfuzie și distrucția vaselor cerebrale rezultând astfel extravazare de proteine și fluide în

interstițiu cauzând edem vasogen.

Prezentam o miniserie de 5 cazuri de sindrom PRES descoperite in Clinica Obstetrica Ginecologie Sibiu, cu

evoluție clinică bună și remisie completă

Cuvinte cheie: PRES, Eclampsie, IRM

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SARCINĂ MOLARĂ CU LOCALIZARE RARĂ

PREZENTARE DE CAZ

Radu Chicea1, Lebădă Codruța1

1Universitatea Lucian Blaga din Sibiu, Romania, Sibiu,

Boala trofoblastică gestațională (GTD) constă în sarcina molară, coriocarcinom, tumoare trofoblastică a

locului placentar și tumoare epitelioidă trofoblastică. Deoarece majoritatea cazurilor de GTD apar în uter,

sarcina molară ectopică este extrem de rară, cel mai frecvent cu localizare tubară. Diagnosticul preoperator al

sarcinii molare ectopice este dificil, iar literatura de specialitate descrie un singur caz cu diagnostic

preoperator. Evaluarea literaturii identifică 26 de articole care raportează 31 de cazuri de sarcină molară

ectopică și 3 articole care mentionează sarcină cervicală molară.

Prezentăm un caz de sarcină molară cervicală la o pacientă de 38 de ani, cu uter cicatricial. Internată ca avort

incomplet efectuat, se practică chiuretaj uterin cu hemoragie importantă ce necesită sutura arterelor cervico-

vaginale. Valorile Beta HCG 40.000 UI sugereaza o sarcină molară confirmată apoi histopatologic.

Ecografia evidentiaza o formatiune tumorală cervicala voluminoasa cu diametrul de 8 cm, intens

vascularizata la nivelul colului si pericervical.

Se administrează Methotrexat – doză unică – 50mg/m2, cu terapie de salvare cu Leucovorin. Pacienta

dezvoltă o stare septică cu Klebsiella pneumonie corectată cu antibiotice.

La 7 săptămâni pentru hemoragie importantă - se practică CT abdominal care evidențiază formațiunea

tumorală în progresie dimensională cu vascularizație intensă.

Se decide tratament chirurgical de urgenta in scop vital matern – histerectomie totală cu păstrarea anexelor –

relativ facil - cu păstrarea planurilor anatomice de delimitare ale colului uterin și evoluție ulterioară bună

spre vindecare

Concluzii: Sarcina ectopică cervicală rămâne o provocare majoră în domeniul sarcinii incipiente. Succesul

tratamentului conservator depinde în principal de diagnosticul precoce, cazurile de sarcina cervicala

presupun abordarea unor multiple posibilitati de tratament, conservator si chirurgical.

Cuvinte cheie: sarcină molară cervicală, tratament chirugical

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TRATAMENTUL CU METHOTREXAT IN SARCINA ECTOPICĂ CERVICALĂ

Radu Chicea1, Lebădă Codruța1

1Universitatea Lucian Blaga din Sibiu, Romania, Sibiu,

Introducere Sarcina cervicală reprezintă un tip rar de sarcină ectopică, care pune în pericol viața bolnavei.

Incidența sarcinii cervicale variază între 1: 1000 și 1: 18000 sarcini și a fost descrisă pentru prima dată de

Rubin. În ultimii ani, numărul sarcinilor cervicale crește din cauza numărului tot mai mare de nașteri prin

operației cezariană și a fertilizări in vitro. Deși sunt considerate rare, acestea reprezintă o amenințare majoră

datorită riscului de hemoragii majore care pun viața în pericol. Au fost imaginate o multitudine de metode de

tratament, de la histerectomie până la cele conservatoare.

Metodă și rezultate: Descriem o serie de 5 cazuri de sarcină ectopică cervicală la 4 paciente cu uter cicatricial

și una nulipară fără antecedente obstetricale care a fost tratate cu succes cu metotrexat initial in doza unica cu

Methotrexat 10mg/Kg corp inițial sistemic asociat cu incă o doză similară intramniotic, ghidat ecografic,

transvaginal. Sângerarea vaginală a fost prezentă timp de 3-5 luni cu evacuarea completă a resurilor

placentare și mentinerea funcției reproductive.

Concluzii: În ciuda problemelor care pot apărea în tratamentul cu metotrexat, este încă de departe, cel mai

ieftin și cel mai eficient tratament al sarcinilor cervicale. Dacă este necesar, procedura poate fi combinată cu

alte proceduri chirurgicale minim invazive care duc la rezultate satisfăcătoare.

Cuvinte cheie: sarcină cervicală, sarcină ectopică, metotrexat

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CONSERVATIVE LAPAROSCOPIC TREATMENT FOR AN OVARIAN ECTOPIC

PREGNANCY IN A 25-YEAR-OLD WOMAN

Radu Chicea1, Andrei Neagu2

1Universitatea Lucian Blaga din Sibiu, Romania, 2Emergency County Clinical Hospital of Sibiu, Sibiu,

Ectopic pregnancy occurs in 1–2% of pregnancies, is defined as a pregnancy that occurs outside of the

uterine cavity and is an important health problem and accounts for 10% of all maternal mortality. Ovarian

pregnancy is a very rare variety of ectopic pregnancy, constitutes 0.5% to 1.0% of all ectopic pregnancies

and the incidence varies from 1 in 7000 to 1 in 40000.

Although the incidence of ovarian ectopic pregnancy is low, there is a high risk of severe complications

(hemorrhagic shock) if it’s not identified and treated in time.

The symptoms mimic those of ectopic tubal pregnancy and can be difficult to differentiate only on the basis

of the ultrasound image and on the clinical and paraclinical examination. The laparoscopic management is

most often required for the diagnosis.

The primary risk factors associated with the development of an ovarian pregnancy are the use of intrauterine

contraceptive device (IUCD), ovulatory drugs, assisted reproductive techniques such as in vitro fertilization,

and embryo transfer.

We present the case of a 25-year-old female who accused left lower abdominal pain, vaginal bleeding and a

positive pregnancy test. Transvaginal sonography identified a gestational sac in the very proximity of the left

ovary. Laparoscopy was performed and we discovered a purple tumor, 3.5/3 cm, with intense vascular

drawing, situated on the left ovary.

The management of an ovarian pregnancy includes medical and surgical options (laparotomy or

laparoscopy). Historically, the treatment for an ovarian pregnancy was oophorectomy; however, the current

trend is to perform an ovarian cystectomy. If medical treatment is an option, methotrexate therapy could also

be attempted. However, ovarian ectopic pregnancy in an unstable patient is a medical emergency that

requires prompt surgical intervention.

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DEZLIPIREA PREMATURĂ DE PLACENTĂ NORMAL INSERATĂ – PREZENTARE DE

CAZ

Radu Chicea1

1University "Lucian Blaga" of Sibiu, Sibiu,

Dezlipirea prematură de placentă normal inserată (DPPNI) reprezintă o patologie obstetricală extrem de

severă care are consecințe grave atât asupra fătului cât și a mamei. Dezlipirea prematură de placentă normal

inserată complică 1% din nașteri, iar în ultimi ani s-a înregistrat un trend ascendent al acesteia. Aproximativ

o treime din sângerările apărute antepartum sunt date de aceasta.

Scopul acestei lucrări este de a expune un caz de dezlipire prematură de placentă normal inserată din

patologia obstetrică a Clinicii de Obstetrică și Ginecologie din Sibiu.

Prezentăm cazul unei paciente în vârstă de 19 ani, care este adusă în serviciul de urgență al Clinicii de

Obstetrică și Ginecologie Sibiu de către serviciul de ambulanță.

La momentul prezentării în clinica noastră, gravida era în stare comatoasă, inconștientă, fără să răspundă la

stimuli dureroși. În urma efectuării examenului obstetrical s-a decelat hipertonie uterină cu sângerare

moderată și persistentă pe cale vaginală. S-a efectuat examen ecografic în urma căruia s-a evidențiat o

sarcină cu parametrii biometriei fetale corespunzători la 35 săptămâni de gestație, cu făt mort antepartum în

prezentație craniană. Retroplacentar s-a evidențiat o imagine inomogenă, hipoecogenă cu dimensiuni de

aproximativ 60mm / 70 mm, cu aspect sugestiv pentru hematom retroplacentar.

S-a intervenit chirurgical, s-a practicat operație cezariană segmento transversală în scop vital matern.

Intraoperator a fost confirmat diagnosticul de dezlipire prematură de placentă normal inserată. S-a reușit

prezervarea uterului și implicit a funcției reproductive a pacientei.

În concluzie, prognosticul matern și fetal este influențat de timpul scurs de la debutul simptomatologiei până

la momentul prezentării gravidei la spital, precum și de precocitatea stabilirii diagnosticul.

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ELECTROCHIRURGIA LEZIUNILOR OVARIENE - ASPECTE HISTOLOGICE

Radu Chicea1, Codruta Lebada 1University "Lucian Blaga" of Sibiu, Sibiu, Romania

Introducere

Chirurgia leziunilor ovariene presupune aproape întotdeauna realizarea hemostazei prin coagulare bipolară

sau monopolară. Pe lângă realizarea hemostazei, zonele de imediată vecinătate, prin efectul termic suferă

distrucții care în final se soldează cu reducere semnificativă a rezervei ovariene.

Material și metodă: Efectul coagulării tesutului ovarian a fost evaluat pentru 6 paciente în perimenopauza

operate pentru patologie uterină cu ovare indemne la care s-a practicat histetrectomie totala cu anexectomie

bilaterală. Au fost utilizate puteri progresiv crescânde pentru un ovar: 30-60-90 watts pentru 4 sec si aceiați

putere de 30 Watts pentru 4-6-8 sec pentru al doilea ovar. Adâncimea coagulării – monopolare a fost de 8

mm. Ovarul a fost prelucrat la anatomie patologică cu coloratie hematoxilină-eoazină iar volumul distructiei

calculat cu formula: πR2 * D

Rezultate La aceeași energie, leziunile ovariene cresc lent în timp, la aceeași durată, distrucțiile tisulare sunt

mai extinse cu creșterea energiei.

Concluzii / Discuții: Sunt preferabile energiile scăzute, pentru a reduce extensia distrucției tisulare, numărul

de puncte de găurire trebuie calculat în funcție de setările dispozitivului. Electrocoagularea după chirurgia

laparoscopică a chisturilor ovariene este asociată cu o reducere semnificativă a rezervei ovariene, care este

parțial o consecință a reducerii parenchimului ovarian și a numărului de foliculi ovarieni și parțial afectării

sistemului vascular.

Cuvinte cheie: electrocoagulare, rezerva ovariană

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TRATAMENTUL CHIRURGICAL AL PROLAPSULUI DE BONT VAGINAL –

COLPOSACROPEXIA ABDOMINALĂ

Radu Chicea1

1University "Lucian Blaga" of Sibiu, Sibiu,

Patologia planșeului pelvin este o afecțiune întâlnită frecvent la femeile din întreaga lume. Această se

caracterizează în primul rând prin scăderea calității vieții.

Tratamentul chirurgical al tulburărilor de statică pelvină este extrem de ofertant incluzând numeroase

tehnici chirurgicale atât conservatoare cât și radicale.

În aplicarea acestor tehnici este necesară cunoașterea anatomiei planșeului pelvin și a structurilor de

rezistență implicate în susținerea acestuia.

De-a lungul timpului, tratamentul tulburărilor de statică pelvină a stârnit numeroase controverse mai ales în

cazurile pacientelor tinere unde prezervarea funcției sexuale este importantă. În Statele Unite ale Americii

prolapsul organelor pelvine reprezintă una dintre principalele cauze de histerectomie.

Scopul acestei lucrări este de a expune tehnica chirurgicală utilizată în tratarea prolapsului de bont

vaginal posthisterectomie totala cu anexectomie bilaterală abdominală.

Tehnica a fost aplicată în cazul unei paciente în vârstă de 60 de ani care prezintă în antecedente histerectomie

totala cu anexectomie bilaterală realizată pe cale abdominală realizată în urma cu 18 ani pentru patologie

benignă. Prolapsul de bont vaginal a apărut la 10 ani postoperator. Tehnica operatorie constă în fixarea

bontului vaginal la promontoriu cu ajutorul unei bandelete de polipropilen.

Colposacropexia are o rată scăzută a mortalității și recidivelor, asigurând în același timp suspensia eficientă a

bontului vaginal. Tehnica este complexă, iar curba de învățare este lungă acest lucru făcând ca ea sa fie

utilizată de un număr restrâns de chirurgic.

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AN OPTION FOR DISTAL ARTERIOVENOUS FISTULA

Helgiu Claudiu1, dr Helgiu Alina2

1Ulb Sibiu, Sibiu, România, 2Sibiu, County Emergency Hospital,

The objective of the study: Forearm basilic vein used for distal arteriovenous fistula creation.

Materials and Methods: The retrospective study at 24 patients whith anastomosis between basilic vein and

cubital or radial artery.

Results: In the first 30 postoperative days, 3 cases of thrombosis led to loss of vascular access were

observed. After initiating the puncture procedure for CHD (chronic hemodialysis), there occurred the

thrombosis of the vein without transposition. The mortality rate was zero. Out of the 24 cases, vein

transposition was performed on the anterior part of the forearm in 11 cases. There were no cases of distal

ischemia.

Conclusions: The 3 case of thrombosis occured in the first 30 postoperative days appeared when the vein

transposition was performed in the same operative time with arteriovenous anastomosis, and the vein

diameter was less than 3 mm. One patient was diabetic with obesity. Basilic vein represents a good solution

for distal AVF and the transposition in the same operative time with anastomosis is indicated when the vein

diameter is greater the 3 mm.

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HAND ISCHEMIA INDUCED BY ARTERIOVENOUS FISTULA (HIIAVF) FOR

DIABETIC PACIENT

CASE REPORT

Helgiu Claudiu1, dr Helgiu Alina2

1Ulb Sibiu, Sibiu, 2Emergency County Hospital Sibiu,

Introduction: Diabetic patients represent the majority of End Stage Renal Disease (ESRD). For this

patients, the Arteriovenous Fistula (AVF) is a real challenge in terms of creation and also in terms of

maintenance of AVF function, despite distal ischemia induced by proximal AVF. Rapid surgical solution for

hand ischemia was ligation of AVF.

Case presentation: We present a clinical case in wich Dril procedure preserve the AVF and solve hand

ischemia.

Discussions: Surgical sollutions for correction of Vascular Access Induced Hand Ischemia (VAIHI) are:

AFV ligation, vein banding, distal inflow (RUDI) and Dril procedure (Distal Revascularisation and Interval

Ligation.

Conclusions: In our case, using DRIL procedure correct hand ischemia and preserve vascular access When

Distal inflow arteries are not suitable.

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FATAL DOG ATTACK ON HUMAN FROM A MEDICO-LEGAL PERSPECTIVE

Ioana Carstoc1, Horatiu Dura1

1University "Lucian Blaga" of Sibiu,

The paper presents the case of an adult male found dead in the vicinity of an animal farm, with multiple

traumatic injuries on the body and limbs. Autopsy revealed lesions consistent for both ante mortem and

postmortem canine bite. Identifying the cause and circumstances of death encounters many difficulties and

has multiple implications. Sometimes the victim himself precipitates dog’s attack by a certain provocative

behaviour, sometimes the dogs brutally attack the victim. Identification of the dogs (stray dogs or sheepdogs)

can bring legal consequences for sheepdog’s owner if the dog’s attack took place outside the property. The

movement of the victim during the attack or the disarticulation and movement of the anatomical parts of the

body after death make the forensic diagnosis difficult.

Keywords: dog attack, bite mark, autopsy, forensic pathology

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ANEMIC SYNDROME DUE TO A GIANT HIATAL HERNIA WITH GASTRIC

VOLVULUS – A CASE REPORT

Adrian Popentiu1

1Spitalul Militar Sibiu, Sibiu, ROMANIA

Keywords: anemic syndrome, gastric volvulus, hiatal hernia

Introduction:

We are presenting a case of chronic gastric volvulus within a hiatal hernia, resulting in a severe anemia as a

singular clinical symptome. In the first part, we show some literature data concerning the chronic gastric

volvulus and its complications.

Presentation:

The definition of a gastric (or any other organ) volvulus is of a abnormal rotation, with more than 180

degrees. The real incidence is not known, since many of these conditions remain undiagnosed. For the

chronic gastric volvulus, one of the frequent consequences is a minor, persistant upper gastrointestinal tract

hemorrhage. If this events is recurrent, it lcan lead to a anemic syndrome, of various degree. The literature

review underlines the diagnostic and treatment challenges encounterd, and also the treatment options.

The case report realtes to a patient with gastric volvulus within a large hiatal hernia, complicated by a severe

anemic syndrome. We present the clinical history, the imaging of this case, and we also demonstrate the

technique of surgical treatment we have chosen.

Discussions:

The peculiarity of this case results from the lack of gastrointestinal symptoms, the first sign being the result

of the severe anemic syndrome. After the surgical treatment, the anemia was corrected, and at the follow up

the results were also very satisfactory

Conclusion:

Depending on the clinical form, the gastric volvulus associated with a hiatal hernia can present in a multitude

of forms. The treatment of choice is the surgical one, in order to prevent further complications.

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DEEP INGUINAL ABSCESSES AFTER LAPAROSCOPIC INGUINAL HERNIA

INTERVENTIONS

Adrian Popentiu1

1„ Dr. Alexandru Augustin” Emergency Military Hospital Sibiu, Sibiu, ROMANIA

Aim:

This paper is reviewing in its first part the literature concerning some complications after laparoscopic cure

of inguinal hernias, with emphasis on the septic ones. We are underlining the risk factor, as well as the

multiple treatment options.

In the second part two case reports are presented, in order to illustrate the presented data.

Material and methods / Case reports

Since the introduction of laparoscopic interventions for inguinal hernia repair, the mesh infections dropped

even more in incidence, compared with the open approach. The total incidence of such events after the

laparoscopic cure is under 1%, in large series reported.

The abscesses can manifest with early onset, in the first 30 postoperative days, or late, up to years after the

initial surgical event. For treatment, there are more options, ranging from antibiotic treatment, to

percutaneous drainage, up to excision of the infected mesh.

The case reports present a superficial collection, simply drained under local anesthesia, and a large pelvic

abscess after bi-lateral hernia repair, treated in a more invasive way, by extraction of both meshes and

drainage.

Results:

In our center, the incidence of septic complications is similar with the other reports from the literature. We

try to adapt the extent of the intervention to the general status of the patient and the severity of the infection.

Both presented cases had good long distance results, as proved by late re-evaluations.

Conclusion:

Deep inguinal abscess after the laparoscopic cure of inguinal hernia is a rare complication, but plausible in

large series, or at the beginning of the learning curve. This event benefits from a range of increasingly

invasive interventions, depending on the case.

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OVARIAN CYSTADENOCARCINOMA - CASE REPORT

Cimpean Tulea Andreea Alexandra1, Dr. Popescu Dragos, Dr. Codru Marian Valeriu 1Scjus, Sibiu, Romania

Epithelial neoplasms of the ovary account for 60% of all ovarian tumors and 40% of benign tumors. They

classify as benign, borderline, or malignant tumors.

These tumors are generally asymptomatic at early stages, causing symptoms only after reaching enormous

dimensions, and consequently are diagnosed late in low- and middle-income countries.

Ovarian cancer has few subjective symptoms, so approximately 40%–50% of cases have already reached

stage III or IV by the time of diagnosis.

Mucinous ovarian tumors account for 15% all ovarian neoplasms, of which giant variants rarely occur.

Ovarian carcinomas are a heterogeneous group of neoplasms and are traditionally subclassified based on

type and degree of differentiation.

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THERAPEUTIC ATTITUDE IN ADVANCED SIGMOID NEOPLASM TO A YOUNG

PATIENT

Dr Calin-Ilie Mohor1,3, Dr Cosmin Mohor2,3

1Departament of General Surgery I- Emergency Clinical County Hospital Sibiu, Sibiu, Romania, 2Departament Of Orthopedic Surgery I- Emergency Clinical County Hospital Sibiu, Sibiu, Romania,

3Faculty Of Medicine - Lucian Blaga University Sibiu, Sibiu, Romania

As a frequency, colon cancer is the third oncological disease in Romania, after lung and breast cancer and in

second place, after lung cancer in terms of mortality, according from the National Institute of Statistics,

centralized during 2019.

Stage I colorectal cancers involve only the inner layers of the colon or rectum. The prognosis is very good,

the cure rate being over 90%. Stage II cancer has a larger growth and spread of the tumor through the wall of

the colon or rectum in adjacent structures. Stage III colorectal cancers show the spread of cancer to the local

lymph nodes. Stage IV (metastatic) colorectal cancer has metastasized to other organs or lymph nodes, far

from the initial tumor formation.

I present the case of a 49-year-old patient with no known personal pathological history who presents in our

service for abdominal pain, accelerated intestinal insanity for feces, rectal bleeding, asthenia, fatigue.

Following the investigations, the diagnosis of recto-sigmoid neoplasm is established (Colonoscopy: which

establishes the diagnosis of recto-sigmoid tumor, voluminous, partially stenotic).

Surgical intervention in AG + IOT, performing exploratory laparotomy that highlights manies secondary

determinations in the liver in both lobes, a tumor formation in the upper rectal and lower sigmoid colon, for

which it is decided and practiced recto-sigmoid resection and sigmoid) Hartman operation with left flank

terminal colostoma, large amount of ascites, viscerolysis, lavage, drainage.

The peculiarity of the case is the advanced sigmoid neoplasm in a young patient, without other

comorbidities.

Conclusion: The surgery has a palliative purpose.

Keywords: recto-sigmoid neoplasm, colonoscopy, secondary determinations.

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WHIPPLE CYPHALIC DUODENOPANCREATECTOMY IN THE VATERIAN

AMPULOMA APPEARED IN A PATIENT OPERATED BACKGROUND FOR OVARIAN

NEOPLASM

Dr Calin Mohor1,3, Dr Cosmin Mohor2,3

1Departament of General Surgery I - Emergency Clinical Hospital Sibiu, SIBIU, Romania,

2Departament of Orthopedic Surgery - Emergency Clinical Hospital Sibiu, SIBIU, Romania,

3Faculty of Medicine -Lucian Blaga University Sibiu, SIBIU, Romania

Ampullary carcinoma is a rare malignancy that develops in the Vater ampulla.

It represents approximately 0.2% of the total neoplasms of the gastrointestinal tract and approximately 7% of

the periampullary carcinomas. The surgical standard is represented by the pancreaticoduodenal resection

(Whipple procedure) which involves resection of the gastric antrum, duodenum, first portion of the jejunum,

gallbladder and distal portion of the common bile duct, head and neck of the pancreas and adjacent lymph

nodes. The surgery is extremely extensive, which is why secondary morbidity and mortality are also

significant. The 5-year survival rate is between 20 and 61%.

I present the case of a 56-year-old patient, operated on 7 years ago for STD I B ovarian neoplasm, for whom

a total hysterectomy was performed with salpingo - bilateral oophorectomy, total lymphadenectomy, total

omentectomy.

THE PATIENT PERFORMED ANALYSIS, CT ABD-PELVIN: intrahepatic and extrahepatic cholestasis,

vesicular hydrops, lithiasis VB, CBP dilatation along the entire path with decalibration at the level of an

iodophilic tissue component located at the ampullary level, adenopathy underlying the hepatic hilum.

ERCP - advances with the duodenoscope to the level of DII, visualizes the tumor-transformed papilla, performs

sphincterotomy and mounts a bile stent.

Following the investigations, the diagnosis of mechanical jaundice, vaterian ampuloma is established, Bladder

Hydrops, Bladder Lithiasis;

After performing in the multidisciplinary team the paraclinical examinations, the AG + IOT was performed,

practicing prolonged right subcostal laparotomy, left subcostal, mobilization of the right colic angle and

sectioning of the gastro-colic ligament, duodeno-pancreatic detachment, stomach section, isthmus section.

pancreatic, release of the pancreatic head and excision piece, jejunum section, excision of paraaortic lymph

nodes, hepatic hilum, cholecystectomy is performed, choledochal-jejunal anastomosis is continued, gastro-

jejunal and pancreatico-gastric, cholecystectomy, lavage, hemost control drainage, parietorafia in anatomical

layers, suture to the skin, SNG assembly, sterile dressing, the pieces are sent for Histopathological

examination.

The peculiarity of the case is represented by a patient operated on with an ovarian tumor with a survival of

7years after the intervention, the patient considered cured-cancer survivor and the appearance of a new

neoplasm at the level of Vater's blister.

Conclusion The patient operated in the antecedents with a stageIB ovarian tumor for which a radical

intervention was performed with a survival of over 7years, considered surgically cured with the appearance of

a tumor at the level of Vater's ampoule for which a radical intervention was performed with evolution favorite

Keywords: ovarian neoplasm, blister, jaundice.

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WHIPPLE-TYPHALUS DUODENOPANCREATECTOMY IN PANCREAS HEAD

TUMOR APPEARED IN A PATIENT OPERATED BACKGROUND FOR BLADDER

NEOPLASM

Dr Calin-Ilie Mohor1,2, Dr Cosmin Mohor2,3

1Emergency Clinical Hospital Sibiu-Departament Of General Surgery I, Sibiu, Romania , 2Faculty Of

Medicine -Lucian Blaga University Sibiu, Sibiu, Romania , 3Departament Of Orthopedic Surgery I-

Emergency Clinical County Hospital Sibiu, Sibiu, Romania

Pancreatic cancer is the fourth leading cause of cancer death in Europe and the sixth largest in the world. It is

one of the deadliest neoplasms, causing about450,000 deaths in2020.

Despite advances in the detection and treatment of pancreatic cancer, the 5year survival rate is 9%.I present

the case of a 60year-old patient, operated 8years ago for an infiltrative bladder tumor for which total

cystectomy, bilateral ilio-obturator lymph-dissection and neo-bladder replacement of the ileal loop Studer

type with bilateral ureteral reimplantation were performed direct.Abdomino-pelvic CT center that highlights

tissue damage heterogeneous 40/46mm, diffusely delimited, located on the projection area of the head of the

pancreas with extension at the level of the papilla, with sudden decalibration of the distal choledochus that

appears dilated upstream of up to17mm;dilation of the Wirsung canal up to10mm along its entire length;

atrophy of the pancreatic parenchyma at the body level. Bilateral cortical cysts. Partially necrotic adeopathy,

heterogeneous iodophilic23/14mm retropancreatic. Due to the complexity of the case, the patient is referred

to the Sibiu County Clinical Hospital.

After performing in the multidisciplinary team the paraclinical examinations (EDS-. Duodenal bulb with

narrowed lumen by compression (possibly extrinsic), with normal-looking mucosa. : suspicion of duodenal

invasion. peripheral and central neo-formation vessels (do not puncture due to increased risk of bleeding,

vesicular hydrops).After a medical training, and adequate preoperative training, surgery is performed, in the

AG-IOT performing exploratory laparotomy that highlights a large tumor in the process uncinate and

pancreatic head of about 10/10cm, hard, retro-pancreatic lymphadenopathy, multiple epiplono-parietal

adhesions, epliplono-enteral, entero-enteral, for which is decided and practiced cephalic

duodenopancreatectomy type Whipple (cephalic pancreatic resection, gastric resection antral, duodenal

resection, cholecystectomy, resection of the first jejunal loop, with choledocho-jejuno-anastomosis TL,

implantation of the pancreas in the stomach through the posterior wall and gastro-entero-anastomosis TL,

regional lymphadenectomy, viscerolysis, lavage, multiple drainage, parietal anatomy, parietal band Aid .The

peculiarity of the case is represented by a patient operated on with a malignant bladder tumor with a survival

of 8 years after the operation, a patient considered cured-cancer survivor and the appearance of a new

neoplasm in the pancreas.

Conclusion Patient operated in theantecedents with an advanced stage bladder tumor for which a radical

intervention with a survival of over 5 years was practiced, considered surgically cured with the appearance of

a pancreatic tumor for which a radical intervention with favorable evolution was

performed.

Keywords: pancreatic tumor, bladder tumor, duodenopancreatectomy.

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TUMOR RECURRENCE DURING ANASTOMOSIS AFTER CECO-ASCENDANT

NEOPLASM OPERATION

Dr Calin Mohor1,3, Dr Cosmin Mohor2,3

1Departament of General Surgery I - Emergency Clinical Hospital Sibiu, SIBIU, Romania, 2Departament of

Orthopedic Surgery - Emergency Clinical Hospital Sibiu, SIBIU, Romania, 3Faculty of Medicine -Lucian

Blaga University Sibiu, SIBIU, Romania

Colon cancer is a type of cancer whose starting point is in the colon, an important segment of the digestive

tract.

Colon cancer generally affects older adults, although the disease can occur at any age. Initially, the disease

manifests as a small, non-cancerous polyp (benign) on the inner wall of the colon. Over time, some of these

polyps become colon cancers.

I present the case of a cancer patient, aged 55, operated in 2015 for operated with a colon neoplasm for

which a right hemicolectomy was performed, AD type II ADO, Prostate neoplasm with sacral metastasis-

diagnosed 2020, is presented for diffuse abdominal pain , nausea, alternating stools constipation-diarrhea,

asthenia, fatigue, sclero-skin pallor, anemia.

The patient performs EDI that highlights: at 20 cm from OAE sessile polyp, at 80 cm from the anal margin,

ileo-colic anastomosis (quasi-abnormal appearance), at 20 cm, on the ileal slope, vegetative formation that

partially obstructs the lumen, preventing the passage of the colonoscope. . Conclusion Ileal tumor,

descending colon polyp.

Following clinical and paraclinical investigations, the diagnosis of ileal tumor is made and surgery is

performed in AG-IOT, performing an exploratory laparotomy that highlights a voluminous ileal tumor of 15

/ 8cm and another ileal tumor formation of 7 / 5cm that invades the ileal loops. mesentery, transverse colon

and transverse mesocolon, mesenteric lymphadenopathy for which wide ileal resection and transverse colon

resection with terminal ileostomy, viscerolysis, double drainage, massive lavage, parietoraphia, dressing are

decided and practiced.

The peculiarity of the case is represented by a patient operated on for a history of operated colon neoplasm

(right hemicolectomy) with a survival of 6 years from the intervention and the appearance of a new neoplasm

at the ileal level.

CONCLUSION: Cancer patients diagnosed with this disease who receive the optimal treatments associated

with appropriate palliative care benefit from a superior quality of life and a better prognosis of the disease.

Keywords: right hemicolectomy, neoplasm, lymphadenopathy, ileum.

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ECTOPIC PREGNANCY

David Tatiana 1Spitalul Clinic Județean de Urgență din Sibiu, Sibiu, Romania

Introduction: Ectopic pregnancy is a pregnancy that develops outside the uterine cavity. ~ 40% of ectopic

pregnancies are in women aged 20-29 years, 90% of ectopic pregnancies develop in the fallopian tube (tubal

pregnancy). As the ectopic pregnancy progresses it most frequently appears: - pelvic-abdominal pain, - mild

or heavy vaginal bleeding.

Case presentation: The 24-year-old patient, who affirmatively aborted spontaneously at 7 weeks with B-

hCG values in decreasing dynamics, presents for pelvic-abdominal pain and vaginal bleeding in small

amounts, symptoms that began one day with a weak positive pregnancy test . Laboratory tests that are within

normal limits were performed. Ultrasound examination was performed the diagnosis of: Suspicion of right

ectopic pregnancy was established.

Discussions: Under general anesthesia with airway prosthesis, is decided and performed exploratory

laparoscopy, intraoperatively is found the left dilated fallopian tube to the ampullary region. It is decided and

practiced: Laparectopic left salpingectomy. The postoperative evolution is favorable with antibiotic,

anticoagulant, analgesic treatment. The patient is discharged on the 3rd postoperative day with good general

condition and re-evaluation in the outpatient department with the HPE result.

Conclusions: The case presented notes the importance of establishing an early diagnosis of ectopic

pregnancy that improves the vital prognosis with decreasing maternal mortality rate.

Keywords: ectopic pregnancy, vaginal bleeding, pelvic-abdominal pain.

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MALFORMATIE FETALA: LAPAROSCHIZIS

Badescu Tudor Mihai1

1Scju Sibiu, Sibiu,

An omphalocele is caused by an opening (defect) in the middle of the abdominal wall at the umbilicus. The

skin, muscle, and fibrous tissue are missing. The intestines spill (herniate) out through the opening and are

covered by a thin sac. The umbilical cord is in the center of the defect.

An omphalocele commonly occurs along with other birth defects (such as heart defects and kidney defects )

and with specific genetic syndromes (such as Down syndrome , trisomy 18 , trisomy 13 , and Beckwith-

Wiedemann syndrome).

Gastroschisis also is an abnormal opening of the abdominal wall. Gastroschisis refers to an extra-abdominal

herniation (evisceration) of fetal or neonatal bowel loops (and occasionally portions of the stomach and or

liver) into the amniotic cavity through a para-umbilical anterior abdominal wall defect.

The estimated incidence is at around 1-6 per 10,000 live births.

The herniated content is towards the right side of the umbilical cord in most cases; color Doppler may be

useful to locate the cord in relation to the herniation. This causes the fetal abdominal circumference to be

smaller than expected for gestation age. The herniated bowel often appears free-floating rather than

contained. The herniated bowel wall can be thickened due to edema.

There can be either accompanying oligohydramnios or polyhydramnios as ancillary sonographic features.

There can be an intra-uterine mortality rate of 10-15%. The condition of the bowel at birth is the single most

important prognostic factor.

Before birth, because the intestines are not covered by a sac, they may be damaged by exposure to amniotic

fluid, which causes inflammation. The inflammation irritates the intestine, which can result in complications

such as problems with movements of the digestive system, scar tissue, and intestinal obstruction .

There are several complications which can mainly involve the bowel and include: in utero bowel obstruction,

in utero bowel perforation, peritonitis: meconium peritonitis, motility dysfunction, necrotizing enterocolitis,

short-gut syndrome, fistula formation, neonatal gastro-esophageal reflux: especially following repair.

Both omphalocele and gastroschisis are usually diagnosed before birth with routine prenatal ultrasonography

. If not, the defects are very obvious as soon as the infant is delivered.

Surgery is required to replace the intestines in the abdomen and close the opening. If possible, surgery to

repair the defect is done soon after birth.

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PREECLAMPSIA - CASE REPORT

Badescu Tudor Mihai1

1Scju Sibiu, Sibiu,

Hypertensive disorders of pregnancy affect up to 10% of pregnancies worldwide, which includes the 3%–5%

of all pregnancies complicated by preeclampsia. Preeclampsia is a pregnancy-specific condition of increased

blood pressure accompanied by proteinuria, edema, or both.

Preeclampsia is defined as new onset hypertension after 20 weeks gestation with evidence of maternal organ

or uteroplacental dysfunction or proteinuria.

The incidence of preeclampsia has been reported as ranging from 2.5% to 7%.

Despite its prevalence, the risk factors that have been identified lack accuracy in predicting its onset and

preventative therapies only moderately reduce a woman’s risk of preeclampsia.

Risk factors for the development of preeclampsia include young maternal age, previous preeclampsia, twin

pregnancy, chronic hypertension, diabetes mellitus, and hydatidiform mole. Vasospasm is considered central

to the pathologic changes of preeclampsia, and the data suggest that this process is triggered by an imbalance

between prostacyclin (prostaglandin I2) and thromboxane Ax, biologically active metabolites of arachidonic

acid.

Preeclampsia is a major cause of maternal morbidity and is associated with adverse foetal outcomes

including intra-uterine growth restriction, preterm birth, placental abruption, foetal distress, and foetal death

in utero. At present, national guidelines for foetal surveillance in preeclamptic pregnancies are inconsistent,

due to a lack of evidence detailing the most appropriate assessment modalities as well as the timing and

frequency at which assessments should be conducted.

Preeclampsia has a wide clinical spectrum ranging from mild to severe forms and, potentially, eclampsia

with symptoms occurring primarily with severe disease. Preventive strategies under investigation include

calcium supplementation and low-dose aspirin supplementation. Prenatal screening, monitoring, and

management of preeclampsia are presented.

Current management of the foetus in preeclampsia involves timely delivery and prevention of adverse effects

of prematurity with antenatal corticosteroids and/or magnesium sulphate depending on gestation.

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ARTIfiCIAL INTELLIGENCE IN ORTHOPEDIC SURGERY: CURRENT STATE AND

FUTURE PERSPECTIVE

Tiberiu BĂȚAGĂ1, Pal Fodor1, Marton Denes1, Denis Pasc1, Flaviu Moldovan1, Giuseppe Cammaleri1,

Solyom Arpad1

1University of Medicine, Pharmacy, Science and Technology “George Emil Palade” Tg-Mures

AI techniques have made great improvements in every stepof the medical imaging pathway, from acquisition

and reconstruction to analysis and interpretation.By incorporating information from the patient’s medical

records(including symptoms, laboratory results, and physica lexamination findings), AI identifies the most

appropriate patient-specific imaging examination and determines the most appropriate protocol.

Robotic surgeries are considered “minimally invasive” — meaning practitioners replace large incisions with

a series of quarter-inch incisions and utilize miniaturized surgical instruments.

A surgeon controls the machine’s arms from a seat at a computer console near the operating table. This

allows the surgeon to successfully perform surgeries in tight spaces and reduces the margin for error.

Numerous applications in orthopaedics have already been demonstrated, and these applications will increase

in quantity and impact as AI continues to grow as a key healthcare technology.

The limitations of AI are existing.

First, the use of AI is limited by the high capital cost, the time needed for its use (both in preparation and

intra-operatively), the variable reliability of AI technologies, and the absence of long-term follow-up studies

Second, there are ethical considerations regarding the use of ML in orthopedic surgery. Furthermore, in cases

of misdiagnosis or maloperation, it is unclear whether the doctor or the robot should be held responsible.

Despite its pitfalls and potential shortcomings, ML provides a unique ability to create meaningful change.

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CONSERVATIVE SURGERY IN CERVICAL CANCER STAGE I: NOVEL

OPPORTUNITIES AND SAFETY DATA

Marius MOGA1, Oana Dimienescu1, Sabina Ioana Bădilă1, Stela Casap1, Mircea Hogea2

1Facultatea de Medicină, Univ. Transilvania din Brașov, Brasov, 2Clinica Chirurgie I - Facultatea de

Medicină, Univ. Transilvania din Brașov,

The objective of the study: Cervical cancer represents the fourth most common type of cancer of cancer

among women pacients worldwide. It is documented tham approximately half a million women are

diagnosed annually with cervical cancer, and over 300.000 women die annually due to this pathology. The

human papilloma virus (HPV) with its high-risk subtypes represent the major cause for cervical cancer

apparition. Due to the advances in screening and early diagnosis have lowered its mortality, and the need for

childbearing in early-stages of cervical cancer has given a great importance to more conservatives procedures

such as cervical conization, cervix amputation and trachelectomy wich can highly decrease cervical cancer

mortality and offer improved chances in fertility.

Materials and methods: We selected the studies from Google Academic and PubMed databases and

reviewed recent articles from literature, aiming to evaluate the safety data and the opportunities after

conservative treatment in stage I cervical cancer. Our research included all the publications during the period

of January 2018 to May 2021 using the following Medical Subject Headings (MeSH): cerclage,

trachelectomy, cervix cancer, pelvic lymphadenectomy, conservative, FIGO stage I.

Results: Reviewing literature concerning the optimal treatment show that conservative methods have almost

the same results as radical surgery (such as radical hysterectomy and lymphadenectomy as described by

Wertheim and radical trachelectomy) referring to cervical cancer recurrency but they offer significantly

improved fertility and chance of childbearing. This attitude is preferred in cases of cervical cancer in fertile

aged patients and in the early stage of cancer.

Conclusions: Due to actual screening methods and early-stage diagnosis in cervical cancer, the therapeutic

attitude has shifted towards conservative surgery for preservation of fertility in reproductive-aged women

when the cervical cancer is diagnosed in stages that permit this therapeutic conduct.

Keywords: cervix, cancer, conservative, cerclage, trachelectomy, cervical amputation.

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SPONTANEOUS OSTEONECROSIS OF THE KNEE (SONK/SPONK) /SUBCHONDRAL

INSUFFICIENCY FRACTURE OF THE KNEE (SIF/SIFK) – WHAT WE KNOW? A

LITERATURE REVIEW

Octav RUSSU1,2, Andrei Marian Feier1,2, Paul-Gabriel Borodi2, Andrea Pasquini3,4, Tudor Sorin Pop1,2

1Faculty of General Medicine, University of Medicine, Pharmacy, Sciences and Technology, 540139 Tirgu

Mures, Romania,

2Department of Orthopaedics and Traumatology, Clinical County Hospital, 540139 Tirgu Mures, Romania, 3"Victor Babes" University of Medicine and Pharmacy, 300014 Timisoara, Romania,

4Center for Modeling Biological Systems and Data Analysis, Department of Functional Sciences, "Victor

Babes" University of Medicine and Pharmacy, 300041, Timisoara, Romania,

Background:

Spontaneous osteonecrosis of the knee (SONK), recently renamed as subchondral insufficiency fracture of

the knee is now considered as a distinct clinical condition that is a common cause of acute, unilateral knee

pain and swelling. SONK is considered the most common form of osteonecrosis of the knee with an higher

prevalence in patients over 50 years old.

Purpose:

The aim of this study was to provide a concise review of the literature and report state of the art diagnosis

and treatment guidelines of SONK.

Methods:

The reasearch was conducted using PubMed and Cochrane databases filtering articles until September 2021.

The key words used were: spontaneous osteonecrosis of the knee, subchondral insufficiency fracture, knee

osteonecrosis. Softwares such as STATA (versions 12.0 and 6.0), IBM SPSS (versions 20.0 and 16.0), R

Foundation for Statistical Computing were used for data recording and processing.

Results:

Female gender is most commonly affected with the medial femoral condyle (94%) reported as most

commonly affected. A common history of osteoporosis or osteopenia has been observed with frequent

symptoms such as focal tenderness of the medical femoral condyle.

The gold standard for the diagnosis of SONK was MRI which reported bone marrow edema (%),

subchondral crescent linear focus on T1 (%). Bone scintigraphy may also be used but it has a lower

sensitivity (%) compared to MRI. Conservative treatments are reserved for small lesions (size<3.5 cm

squared). They imply protected weight bearing, lateral widge insoles, NSAIDs, bisphosphonates and

prostaglandins I2. Surgical treatment is used for larger lesions (size<3.5 cm squared of 50% of the femoral

condyle). They include diagnostic and therapeutic arthroscopy, core decompression, bone grafting and

osteochondral autologous transplant. In case of advanced stages of the disease, high tibial osteotomy (HTO),

used in younger and active patients, unicompartimental knee arthroplasty (UKA) or total knee arthroplasty

(TKA) can be considered.

Conclusions:

Gender plays a role in the incidence of medial femoral condyle SONK. Small-sized lesions are considered

reponsive to conservative treatment. Metaanalyses on the topic could further detail treatment protocols and

guidelines.

Keywords: spontaneous osteonecrosis of the knee, subchondral insufficiency fracture, knee osteonecrosis,

knee joint, humans

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THE ADVANTAGES OF MINIMALLY INVASIVE SURGERY IN THE SURGICAL

TREATMENT OF INGUINAL HERNIA

Ciprian Tănăsescu1

1Universitatea Lucian Blaga din Sibiu, Romania, Sibiu,

Inguinal hernia consists in the exit of the abdominal viscera from the peritoneal cavity, wrapped in the

peritoneal serosa, through a point of weak anatomical resistance located at the level of the inguinal canal.

Surgery for inguinal hernia is one of the most common interventions in a surgery department.

In this paper we will present the advantages of minimally invasive surgery in the treatment of inguinal

hernia, as evidenced by the use of the modified Lichtenstein procedure, applied to the Proctoven Clinic case

study.

We consider that the ambulatory Lichtenstein procedure, with a hospitalization of maximum 3 hours, is an

extremely feasible procedure, very well accepted by patients, with good results in the short and long term.

Keywords: inguinal hernia, minimally invasive treatment, Lichtenstein

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ELECTROCUTION - A PUBLIC HEALTH ISSUE IN SIBIU COUNTY?

Elena Topircean1, 2, Adrian Cristian1, 2, Oprinca-Muja Alexandra2, Silviu Morar1, 2

1University "Lucian Blaga" of Sibiu, Sibiu,

2Sibiu Clinical Emergency County Hospital - Forensic Department of Sibiu County,

Even though the incidence of electrocutions has been steadily decreasing in absolute terms, electricity still

kills a few hundred people every year, globally.

We conducted a retrospective study of all deaths caused by electrocution, recorded in the casuistry of the

Forensic Department of Sibiu County, between the years 2000 and 2020. We focused on identifying the

number of deaths caused by exposure to electricity, analyzing their epidemiological characteristics,

stipulating the type of electrocution and, last but not least, correlating it with alcohol consumption. Out of the

total of 7221 autopsies performed and analised, in 80 cases (1.11%) we identified electrocution as a primary

cause of death, out of which 2 cases were suicides and 78 cases were accidental. Out of the 78 cases reported

as accidental, we identified 12 domestic accidents, 17 work related accidents, 24 deaths caused by lightning

and 25 cases of unspecified electrocution accidents. Our retrospective study found a higher prevalence of

males (67 cases - 83.75%), with a slight tendency to decline in the past few years for both genders. The

analysis of the other epidemiological coordinates revealed a higher number of cases in the age group 30-39

years (25 cases), an approximately equal distribution of cases in rural and urban areas (52.5% urban and

47.5% rural) and a higher frequency in summer (45 cases - 56.25%). The blood alcohol level could be

determined in 74 cases, and the presence of ethanol in the bloodstream was identified in 23 cases (31.08%).

The study identified the people who are at high risk, who can benefit from a preventive approach in order to

reduce the risk of death by electrocution.

Keywords: forensic pathology, forensic autopsy, electrocution

80

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STEINERT MYOTONIC DYSTROPHY ASOCIATED WITH CATARACT AND

MACULAR HOLE

Popa Paul1, Teodoru Adrian1

1Scju Sibiu, Sibiu, România

Steinert myotonic dystrophy asociated with cataract and macular hole

Authors- Teodoru Adrian, Popa Paul-Vlad

Introduction

The paper describes the asociation of different ocular manifestations with Steinert myotonic dystrophy.

Materials and methods

We present the case of a 40 year old patient that has been diagnosed at the age of 20 with Steinert myotonic

dystrophy. After investigations several ocular diseases that are asociated with this genetic syndrome are

discovered.

Results and conclusions

Steinert myotonic dystrophy is a rare genetic multisystemic syndrome wich affects the striated muscles. The

role of ophtalmologists is to identify and treat the different ocular manifestations which can apear along with

this disease.

Keywords: Steinert myotonic dystrophy, cataract, macular hole

81

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PRELIMINARY STUDY ON INTRAOPERATIVE PARAMETERS IN

PHACOEMULSIFICATION

Diana Suditu1, Adrian Teodoru 1University "Lucian Blaga" of Sibiu, Sibiu,

Introduction

Cataract is the opacification of the lens and is currently solved exclusively surgically. The surgery consists in

the extraction of the opacified lens using phacoemulsification. The device generates ultrasounds,

fragmenting the nucleus of the opacified lens.

Materials and methods

In the study were included 18 patients operated in the Arcada Clinic from Sibiu. The paper analyzed the

following parameters: case time, U/S total time, phaco time, average phaco time, torsional time, aspiration

time, estimated fluid time recorded during phacoemulsification.

Results

We correlated the parameters recorded during the phacoemulsification process with the postoperative

functional results for each patient in the studied group.

Conclusions

There are correlations between cataract morphology, intraoperative parameters used and postoperative

functional results.

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ARTHROSCOPIC EVALUATION OF MENISCAL TEARS

Radu Fleaca1, Mihai Roman1, Tiberiu Bățagă2, Octav Russu2, Cosmin Mohor1 1Universitatea Lucian Blaga din Sibiu, Romania,

2Universitatea de Medicina, Farmacie, Stiinte si Tehnologie Tg. Mures,

Introduction

Meniscal lesions are frequent among professional and recreational athletes, but also in general population. A

meniscal rupture is one of the most common cause for knee arthroscopic procedures. To decide how to

approach a meniscal lesion one should understand the anatomy of the lesion. Starting point for treatment

decision making include the ability to identify and describe a meniscal lesion

Discussions

There are differences between the medial and lateral meniscus in shape and insertion. Each meniscus has

three segments: anterior horn, pars intermedia and posterior horn and also an anterior and a posterior root.

There are three zones with different vascularization therefore with different capabilities for healing. The

localization of a lesion is more frequent in pars intermedia for the lateral meniscus and in the posterior horn

for the medial meniscus. To describe a meniscal lesion one should identify the localization, anatomy of the

lesion, if it’s complete or partial, if it is traumatic or degenerative. The primary meniscal lesions are

classified according with the anatomy in vertical longitudinal, oblique, radial, horizontal, complex. Each of

these types can evolve in different other more complex anatomical types. The vertical longitudinal lesion

evolves from superior to inferior face, parallel with the peripheral insertion. This type can be partial or

incomplete and it is easy to miss on a superficial inspection. The Bucket handle tear is a large longitudinal

flap dislocated to the notch with anterior and posterior insertions. The vertical flap tear is a longitudinal tear

with a rupture of one end thru the inner margin. The oblique lesion extends oblique from the free margin to

the periphery. The radial lesion extends perpendicular to the periphery in vertical plane. The posterior root

lesion may be complete and incomplete lesions and are very easy to miss during arthroscopy and even on

MRI. The horizontal cleavage extends to the periphery but in a horizontal plane. The flap lesion classic

described is a horizontal lesion with rupture of one margin, but I found more flaps that are developed from

vertical lesions. A stable meniscal lesion is a longitudinal rupture less than 15 mm that cannot be dislocated

with the prober. The meniscal cyst is associated usually with a horizontal lesion developed from the

peripheral rim as a balloon. Is located more frequent in pars intermedia for the lateral meniscus and in

posteromedial part of medial meniscus. The degenerative meniscal lesions are associated with cartilage

lesions, have no exact description, may be fibrilar or complex.

Conclusion

Understanding the anatomy and biomechanical properties of the meniscal lesions represent the first major

step to performing an adequate treatment of these injuries.

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RETROSPECTIVE STUDY OF DEATHS DUE TO PHYSICAL AGENTS IN THE

CASUISTRY OF THE FORENSIC DEPARTMENT OF SIBIU COUNTY, 2011-2020

Silviu Morar1,2, Elena Topîrcean1,2, Adrian Cristian1,2

1University "Lucian Blaga" of Sibiu,

2Clinical Emergency County Hospital Sibiu, Forensic Department of Sibiu County

Deaths due to physical agents are an important category of avoidable deaths; specific preventive measures

can help reduce their incidence.

Our study aimed to identify the vulnerable population, with the highest risks of presenting a death caused by

physical agents. Thus, we conducted a retrospective observational study on the casuistry of the Forensic

Departament of Sibiu County, during 2011-2020, which had as main objectives: identifying the number of

deaths caused by physical agents, the evolution of these deaths over the analyzed period, their

epidemiological characteristics and the values of blood alcohol level. We analyzed the data recorded in

forensic autopsy reports and toxicological analysis bulletins.

Out of the total of 3489 forensic autopsies analyzed, 2020 were violent deaths (57.89%), and 94 (2.69%)

were due to physical agents, with an undulatory evolution during the studied period. Such deaths occurred

mainly in males (75 cases, 79.78%), in the elderly - over 60 years (44 cases, 46.80%), in rural areas (54

cases, 57.44%), having as more common causes burns and hypothermia. These deaths occurred in similar

proportions at home (especially burns) and in public places (especially hypothermia). Alcohol consumption

is an important risk factor; we identified blood alcohol levels between 0.01-2.00 g‰ in about one third of

cases (28 cases, 29.79%).

Based on these data, we were able to identify the characteristics of people at risk (males, from rural areas,

over 60 years old, with acute alcohol consumption), to whom specific prophylactic measures can be

addressed in order to reduce the incidence of these deaths.

Keywords: forensic pathology, forensic autopsy, physical agents, avoidable deaths

84

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EPIDEMIOLOGICAL CHARACTERISTICS OF HYPOTHERMIA-RELATED DEATHS,

FORENSIC DEPARTMENT OF SIBIU COUNTY, 2000-2020

Adrian Cristian1,2, Elena Topîrcean1,2, Alexandra Oprinca-Muja2, Silviu Morar1,2

1University "Lucian Blaga" of Sibiu,

2Sibiu Clinical Emergency County Hospital - Forensic Department of Sibiu County,

Hypothermia represents the lowering of human body core temperature, and it can be therapeutic,

spontaneous, iatrogenic, and, last but not least, accidental, through prolonged exposure to cold. A study that

investigated all deaths from 43 countries across five continents discovered that hypothermia was the primary

cause of death for approximately 5 million people each year.

Given the reported global data on this matter, we conducted a retrospective longitudinal study on all deaths

which occurred between 2000 and 2020, recorded in the casuistry of the Forensic Department of Sibiu

County, with the primary goals of identifying the number of hypothermia-related death cases out of the total

number of violent deaths, determining the number of cases with a high value of ethanol in the bloodstream,

epidemiological characteristics, as well as their evolution in time. From a total of 4052 violent deaths, 52 had

hypothermia as their primary cause of death, with a mortality spike of 6 deaths secondary to exposure to cold

in the year 2007. The analysis of the epidemiological coordinates revealed the prelavence of males (41

cases), from rural areas (32 cases), age groups between 60 and 69 years (15 cases), in the months of January

(14 cases) and February (13 cases). Regarding the presence of acute alcohol consumption, it turned out that

alcohol was found in the bloodstream in a number of 27 out of 52 cases of hypothermia.

This study of hypothermia-related deaths provided important information on the identification of people at

risk, to whom specific prophylactic measures should be addressed, which would reduce the number of such

avoidable deaths.

Keywords: forensic pathology, forensic autopsy, hypothermia

85

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"DIABETIC FOOT" - A DIFICULTE COMPLICATION OF DIABETES

Denisa Tanasescu1

1Universitatea Lucian Blaga din Sibiu, Romania, Sibiu,

Diabetes is a chronic condition of the pancreas, a heterogeneous syndrome, from an etiological, pathogenic,

clinical and therapeutic point of view characterized by chronic hyperglycemia, caused by decreased insulin

resistance and / or reduced insulin sensitivity (insulin resistance) of various tissues, mainly muscular, adipose

and hepatic.

The prevalence of diabetes has increased dramatically in recent decades, especially in developing countries,

reaching the height of a real epidemic. Age is the most important factor influencing the prevalence of type 2

diabetes. Almost every epidemiological study shows an increase in the prevalence of carbohydrate

metabolism disorders, up to a certain age, followed by a plateau and then a decrease. The aim of this paper is

to develop a diagnosis and treatment of diabetes and its formidable complication "diabetic foot", based on

data from the literature.

Keywords: diabetes, diabetic foot.

86

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SARCINA LA TERMEN LA O GRAVIDA CU UTER DIDELF

Valentin Voiasciuc1, Livia-Giorgiana Matei, Cristina Chirila 1University "Lucian Blaga" of Sibiu,

2Emergency County Clinical Hospital of Sibiu,

Introducere: Uterul didelf apare in urma absentei fuziunii ductelor mulleriene, aceasta fiind o anomalie

caracterizatata prin prezenta a doua coarne uterine, fiecare cu cavitate endometriala si col uterin propriu.

Sarcina se dezvolta in unul dintre cele doua cornuri uterine, uterul dublu (didelf) avand cel mai bun

prognostic reproductiv dintre toate malformatiile uterine majore.

Materiale si metode: Prezentam cazul unei gravide in varsta de 23 de ani, primipara, cu

amenoree anamnestica de 39 saptamani si 2 zile, fara patologii asociate, diagnosticata cu uter didelf,care se

prezinta in clinica obstetrica ginecologie cu contractii uterine dureroase.

Rezultate: Se decide terminarea nasterii prin operatie cezariana. Intraoperator se evidentiaza uterul didelf

din care se extrage un fat viu de sex masculin, cu caracteristici macroscopice fiziologice.

Concluzii: In ciuda faptului ca reprezinta o anomalie structurala, uterul didelf permite

dezvoltarea in conditii fiziologice a unei sarcini la termen.

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FORENSIC ANTHROPOLOGY: AN IDENTIFICATION PROCESS

Flavia Negru1, Flavia Sandoiu2

1Forensic Medicine Department of Sibiu County

2Forensic Medicine Department of Bihor County

Examining unidentified human remains in a high decomposition state represents an arduous task for any

medical examiner’s office. Forensic anthropology cases challenge the medical examiner not only to establish

an accurate biological profile (sex, age, stature, ancestry), but also to provide a broader view upon the events

surrounding the moment of death. Our aim is to illustrate the approaching steps and the methods applied to

solve a forensic anthropology case and also to point out the challenges and limitations we faced during the

process. In December 2019 skeletal remains were located and recovered on a pasture field in Bihor County

(Romania). The Medical Examiner’s Office was requested to perform an osteological examination in order to

establish the biological profile of the remains and thus a positive identification. Furthermore, particular

attention was demanded for estimating the post-mortem interval and establishing the cause of death. Based

on methods already described in the scientific literature, we conclude that the remains belong to a Caucasian

male individual, aged between 22 – 35 years old, with a stature between 167.3 cm and 176.3 cm, who

probably died in the time frame 11th - 23rd of October 2019. The absence of traumatic marks on the

available bones suggests that the cause of death was most likely pathological (i.e., non-traumatic).

Keywords: forensic anthropology, skeletal remains, biological profile

88

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UTILITY OF OCULAR ULTRASONOGRAPHY IN DAILY PRACTICE

Maria-Emilia CERGHEDEAN FLOREA1, Adrian Teodoru1, Corina Tudor1, Andrada Feiereisz1

1University "Lucian Blaga" of Sibiu,

INTRODUCTION

Ocular ultrasound, also known as ocular echography, “echo,” or a B-scan, is a quick, non-invasive test

routinely used in clinical practice to assess the structural integrity of the eye, useful especially in cases where

direct visualization of the ocular structures is not possible (cornea or lens opacity).

CASE PRESENTATION

We present several cases in which the use of ocular ultrasound brought additional information. The most

common pathologies are vitreous hemorrhage, retinal detachment, posterior vitreous detachment, ocular

trauma or intraocular tumors.

DISCUSSIONS

The paper aims to raise awareness of the importance of using eye ultrasound in ophthalmological practice, its

utility and the benefits it brings in completing the diagnosis.

CONCLUSIONS

US has the advantage of being widely available, noninvasive, quick, and cost-effective. It is a useful imaging

method in establishing ophthalmological diagnosis and also further medical or surgical treatment

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CURRENT APPLICATIONS OF OPTICAL COHERENCE TOMOGRAPHY (OCT) IN

OPHTHALMOLOGY

Maria-Emilia CERGHEDEAN FLOREA1, Adrian Teodoru1, Corina Tudor1, Andrada Feiereisz1

1University "Lucian Blaga" of Sibiu

INTRODUCTION

OCT is a non-contact, topographic, biomicroscopic device that provides high resolution, cross-sectional

digital images of ocular structures in vivo and in real time.

CASE PRESENTATION

We present several cases encountered in the usual ophthalmological practice in whom the usefulness of OCT

is extremely important. Age-related macular degeneration is a chronic ophthalmological disease. Macular

thickness, before and after the treatment, is an important parameter for the follow up of this disease. It is also

useful in other types of retinal pathologies such as the macular hole, diabetic retinopathy or the assessment of

progression in glaucoma.

DISCUSSION

The paper highlights the advantages of using OCT in daily practice and presents the importance of OCT in

establishing the diagnosis, but also in the follow-up of various ophthalmological pathologies.

CONCLUSIONS

Optical coherence tomography (OCT) has revolutionized the clinical practice of Ophthalmology. It allows to

establish early diagnosis in glaucoma and the rate of progression. It also allows the quantification of various

macular changes, early detected in the morphology of the retinal nerve fiber layer.

90

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BREAST CANCER IN MEN WITH OCULAR COMPLICATIONS

Maria-Emilia CERGHEDEAN FLOREA1, Adrian Teodoru1, Tudor Corina1

1University "Lucian Blaga" of Sibiu,

INTRODUCTION

Breast cancer is the most common neoplastic disorder diagnosed in women. In contrast, breast cancer in men

(MBC) is rare and accounts for less than 1% of total neoplastic cases.

CASE PRESENTATION

We present the case of a 65 year old patient who presents to the ophthalmologist accusing pain, unilateral

exophthalmia and limitation of eye movements. The patient has a history of invasive breast cancer. On the

ophthalmological examination, BCVA RE = 1fc LE=0.9 fc, PIO RE = 28 mmHg LE = 43 mmHg. OS-

exophthalmos associated with deviation of the eyeball down and out, diplopia, eyelid edema. Cranial CT-

fronto-ethmoidal tumor mass with left orbital extension and left frontal extension.

DISCUSSIONS

The paper presents ocular complications that appeared as a consequence of secondary determinations in

breast neoplasia in men.

CONCLUSIONS

Ocular and orbital metastasis from breast cancer is usually preceded by metastasis to other organs. It can

cause secondary glaucoma due to various mechanisms, elevated intraocular pressure (IOP) being one of the

most common manifestations in these cases. The management of secondary glaucoma due to ocular and

orbital tumors depends on both tumor characteristics and glaucoma related factors.

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THERAPEUTIC MANAGEMENT OF NON-PENETRATING OCULAR TRAUMA

ALEKANDRA ABDULRAHMAN1, Adrian Teodoru 1University "Lucian Blaga" of Sibiu,

INTRODUCTION

Non-penetrating ocular trauma are relatively common injuries found in ophthalmology clinics and

emergency medical services and their etiology could be a variety of violent external agents. They require a

careful and urgent eye examination, an evaluation of the eye lesions produced to achieve an optimal

therapeutic approach.

OBJECTIVES

The aim of the paper is to study the diagnostic methods, the clinical evolution of contusive traumas from the

admission to hospital until discharge, ocular structures most often affected, most common complications of

ocular contusions, and the therapeutic management.

METHODS:

A review of the current literature and a retrospective study of clinical evolution, diagnosis and therapeutic

management of non-perforating eye injuries was performed. The medical records of 26 from 60 patients

treated for ocular trauma at Sibiu County Emergency Hospital, Ophthalmology Department, during January

2016 to February 2020 were reviewed. All these patients suffered contusive injuries on a closed globe

according to the Birmingham Eye Trauma Terminology System classification.

RESULTS:

The most common mechanism of injury was contusion of the eyeball and the orbit (53.9%) by contact with a

contorting object (30%), followed by aggression by physical force. Among the complications following the

trauma, secondary glaucoma is found in 23% (N = 6) of cases, followed by indirect post-traumatic cataract

(15.3%). At hospital admission, 43% of the 32 traumatized eyes had an AV = 1 or 0.5, compared to

discharge where the percentage increases to 81%, which shows a favorable intrahospital evolution.

CONCLUSION:

Non-penetrating ocular trauma, can be a cause of unilateral blindness, with major complications: glaucoma

and cataracts. Etiology may differ depending on settings. Trauma is more likely to occur in men on 40y age.

Strategies for prevention of ocular trauma require knowledge of the cause or mechanism of injuries, which

may allow a more appropriate targeting of resources to prevent such injuries.

KEYWORDS: ocular trauma, closed globe, nonpenetrating, eye contusion, blindness.

92

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PARTICULARITIES AND DIFFICULTIES IN DIAGNOSIS OF DEATH FROM

MECHANICAL ASPHYXIA

Ioana Carstoc1, Horatiu Dura1

1University "Lucian Blaga" of Sibiu,

Mechanical asphyxia represents a class of sudden deaths that includes: positional asphyxia, traumatic

asphyxia, and physical restraint. In these cases, the death occurs as a result of the victim’s inability to breathe

normally, either due to mechanical compression of the chest or neck, or due to the long-time fixation of the

body in a certain position. Victim’s endurance is significantly impaired by somatic (respiratory,

cardiovascular) or neurological co-morbidities, also by the existence of predisposing factors (obesity, alcohol

or drug use, fatigue). Diagnostic criteria for positional asphyxia are mainly circumstantial (a position that

interfere with normal pulmonary ventilation, victim’s inability to extricate from the fatal position, evidence

that the victim deliberately place himself/herself in that position, exclusion of other unnatural causes of

death). Complementary to the on-site findings, the autopsy, and histopathological and toxicological tests

contribute to a reasonable degree of certainty of the death cause. The paper highlights the difficulties of the

diagnosis in a case of positional asphyxia.

Keywords: positional asphyxia, physical restraint, death scene, forensic pathology

93

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THE FATAL IMPACT OF PREMORBID CONDITIONS IN THE EVOLUTION OF NON-

SEVERE MECHANICAL TRAUMAS

Ioana Carstoc1, Horatiu Dura1

1University "Lucian Blaga" of Sibiu,

The ways in which traumatic injuries lead to death are very varied, being determined by the diversity of

thanatogenerator chains, which, in turn, are influenced by trauma (type, topography, intensity), individual

biological terrain (age, organ damages), and clinical management (promptness and accuracy of diagnosis and

treatment). This diversity has both medical and legal implications leading to different legal classifications of

the deed of the perpetrator of the trauma. The diversity of thanatogenerator chains and the importance of

establishing them require both a thorough knowledge of the notions of forensic medicine and the notions of

clinical medicine, as well as a critical analysis of each case, taking into account not only the data obtained

after the autopsy, but also the entire medical history of the case. We present the case of an elderly man, in

whom the death occurred as a result of complications (piarthrosis with toxic-septic state and digestive

hemorrhage) occurred in the evolution of a non-severe knee trauma, in a person with multiple organ damages

(liver cirrhosis, diabetes, mycardofibrosis, aortic valve prosthesis, cardiostimulation).

Keywords: traumatic injuries, comorbidities, premorbid background

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PHYSICAL AGGRESSION OR FALL FROM A HEIGHT? A CASE PRESENTATION

Ioana Carstoc1, Horatiu Dura1

1University "Lucian Blaga" of Sibiu,

Forensic pathologists are sometimes faced with a challenge when it comes to determining the legal

framework for violent deaths. The correct differentiation of the mechanisms for producing traumatic injuries

(hitting, falling, compression) leads to the legal classification of the deed (accident, suicide, hetero

aggression) and to the consequent criminal consequences. The omission of some seemingly insignificant

details can lead to an erroneous legal classification. Sometimes, the type of lesion mechanism and the impact

of lesions produced by this mechanism on thanatogenesis is difficult to establish. We present a case that

raised problems of differential diagnosis between injuries caused by falling from a height, injuries caused by

repeated hitting against bodies during this fall and injuries caused by hetero aggression.

Keywords: fall from height, physical aggression, forensic pathology.

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A

Abdulrahman,

Alekandra

76 Alexandru-Florin,

Diconi

7

Adrian, Popentiu 38, 28 Alin, Mihetiu 14, 13

Adrian, Teodoru 50 Alina, Helgiu 61, 60

Adriana, Popa 34 Alina-Cristina,

Bindea

11

Alexandra,

Oprinca-Muja

70 Anderco, Paula 37

Alexandru, Sabau 18 Andreea

Alexandra,

Cimpean Tulea

36

Alexandru Darius,

Popa

19 Arpad, Solyom 86

B

Bancila, Stefan 16 Bela, Ioana-Silvia 30

Barazi, Jamal 16 Birlutiu, Rares-

Mircea

17

Bataga, Tiberiu 89 Birlutiu, Victoria 17

Batir, Anisoara 8 Bitea, Ioan Cornel 9, 37

Bădilă, Sabina

Ioana

78 Bombea, Ioan 87

Bățagă, Tiberiu 91 Borodi, Paul-

Gabriel

83

Bățagă, Tiberiu 86 Bratu, Dan 4, 88, 3, 14, 13

Bela, Ioana 20, 21

C

Calin, Mohor 18 Claudiu, Helgiu 61, 60

Cammaleri,

Giuseppe

86 Codru, Marian-

Valeriu

48

Carstoc, Ioana 82, 81, 79, 80 Codruța, Lebădă 65, 64, 63

Casap, Stela 78 Codruța, Lebădă 62

Cerghedean

Florea, Maria-

Emilia

73, 72, 74 Coracioni, Ilonco 48

Chicea, Radu 57, 58, 62, 65, 64,

68, 93, 33, 92, 63

Corina, Tudor 74

Chirila, Cristina 59 Corsatea, Ramona 22, 23

Chirila, Cristina 85 Cretu, Dan

Gheorghe

22, 23

Ciprian, Tanasescu 18 Crisan, Ioana

Andreea

53, 54

Ciprian Mircea,

Sopon

55 Cristian, Adrian 70, 69, 71

96

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D

Damsa, Radu

Alexandru

14 Diconi, Alexandru

Florin

90

Dan, Sabau 18 Dimienescu, Oana 78

Dancu, Iulia 53, 54 Dobra, Castilia 87

Denes, Marton 86 Dragos, Popescu 44, 36

Diconi, Alexandru 24 Dura, Horatiu 82, 81, 79, 80

F

Faur, Mihai 87 Fleaca, Radu 89, 91

Feier, Andrei

Marian

83 Fleaca, Radu Sorin 90, 25

Feiereisz, Andrada 73, 72 Fleaca, Radu Sorin 24

Filip, Andrei 9 Fleacă, Radu Sorin 52

Filip, Dan 53, 54 Fodor, Pal 86

G

Gherman, Ioana 43, 44 Gira, Victoria 14

Ghica, Costin 32 Gînfălean,

Georgeta

49, 47

Ginfalean,

Georgeta

58

H

Hasegan, Adrian 53, 54 Hogea, Mircea 78

I

Igor, Fabian 22 Ispășoiu, Iulian-

Florin

31

Ion, Nicolas 25 Iuga, Adam-Elisei 31

Ispasoiu, Corina

Alina

20, 21 Iuga, Elisei 20, 21

Ispasoiu, Iulian-

Florin

29 Iulian Florin,

Ispasoiu

20, 21

Ispășoiu, Iulian-

Florin

30

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L

Lebada, Codruta 33 Luncaşu, Paula 49, 48

Lodromanean,

Diana

57, 58

M

Manta, Tia-Maria 8 Mitea, Raluca

Daria

9

Marian Valeriu,

Codru

36 Moga, Marius 78

Maris, Ricarda 57, 58 Mohor, Calin 25

Maslina, Mihai 6, 5 Mohor, Cosmin 89, 25, 24, 91

Matacuta, Ioana 53, 54 Mohor, Calin 16, 27, 39

Matei, Claudiu 53, 54 Mohor, Calin-Ilie 40, 26

Matei, Livia

Georgiana

59 Mohor, Cosmin 40, 27, 26, 39

Matei, Livia-

Giorgiana

85 Moisin, Andrei 35

Mărginean, Gelu

Cristian

52 Moisin, Andrei 34

Mester, Gabriel 22, 23 Moldovan, Flaviu 86

Mihai, Faur 18 Morar, Silviu 70, 69, 71

Mihetiu, Alin 4, 88, 3 Muntiu, Oana 53, 54

Mircea, Sopon 56 Muresan, Olimpiu 8

N

Neagoe, Razvan 87 Nicolas, Ion 24

Neagoe-Lepadatu,

Razvan

23 Nicoleta

Anamaria, Mitu

56, 55

Neagu, Andrei 68 Nistor, Sofia 53, 54

Negru, Flavia 84

O

Oana, Stoia 9, 37 Olteanu,

Georgiana

75

Olaru, Bianca 34 Oprinca-Muja,

Alexandra

71

P

Panta, Vladia 21 Popa, Carmen 35

Panta, Vladia 20 Popa, Mirela 58

Panța, Vladia-

Maria

29, 31, 30 Popa, Mirela 57

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Pasc, Denis 86 Popa, Nicoleta 57

Pasquini, Andrea 83 Popa, Nicoleta 58

Paul, Popa 50 Popa, Raoul 55

Pirvu, Doris 16 Popa, Adriana

Ioana

23

Pljakić, Irma 47 Popescu, Dragos 45, 43

Pop, Tudor Sorin 83 Popescu, Marius

Ioan

52

R

Raoul, Popa 56 Russu, Octav 91

Roman, Mihai 89, 25, 24, 91 Russu, Octav

Marius

89

Roman, Mihai Dan 90 Russu, Octav 83

Roman, Dan Mihai 52

S

Sabau, Alexandru 14 Sofariu, Ciprian 53, 54

Sacarelis, Alexis

Vasilis

52 Stanescu, Razvan-

Ioan

45

Sandoiu, Flavia 84 Suditu, Diana 77

Simon, Sanda 14

T

Tanasescu, Ciprian 34, 35 Topircean, Elena 70

Tanasescu, Denisa 67 Topîrcean, Elena 71

Tatiana, David 46 Topîrcean, Elena 69

Tănăsescu, Ciprian 66 Tudor, Corina 73, 72

Teodoru, Adrian 75, 77, 73, 72, 74,

76

Tudor Mihai,

Badescu

41, 42

Tia-Maria, Manta 15

V

Victor, Istrate 51 Voiasciuc,

Valentin

59, 85