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iJurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 1

Jurnalul de chirurgie este o revist electronic, cu acces liber (OpenAccess), se adreseaz tuturor specialitilor chirurgicale i are drept obiectiveasigurarea unui mijloc de informare eficient i ncurajarea tinerilor medici icercettori n a-i publica rezultatele activitii clinice i de cercetare.

Revistele electronice cu acces liber reprezint platformele ideale pentrupublicarea rezultatelor cercetrilor ntruct articolele intr imediat ntr-un larg circuit

tiinific. Astfel, publicarea n Jurnalul de chirurgie asigur apariia rapid aarticolelor n format *.pdf i indexarea acestora i a rezumatului n IndexCopernicus,DOAJ i EBSCO Academic. Jurnalul de chirurgiepublic urmtoarele tipuri de

articole: editoriale, articole de sintez (review), articole originale, cazuri clinice, articole de tehnic i anatomiechirurgical, articole multimedia i de istorie a chirurgiei. Toate articolele sunt supuse unui proces de peer-review. Membrii colectivului de redacie asigur buna desfurare a procesului de recenzare, iar autorii trebuies respecte cerinele International Committee of Medical Journals Editors (http://www.icmje.org).

ncepnd cu 2012,Jurnalul de chirurgieapare ntr-un nou format, este patronat de Academia de tiineMedicalei, alturi de revista Chirurgiai esteagreat oficial de Societatea Romn de Chirurgie.

REDACIE

Fondator & Editor efEugen Trcoveanu

Fondator & Redactor efRadu Moldovanu

Secretar general de redacieAlin Vasilescu

Redactori

Dan AndronicIrina CruntuGabriel DimofteCristian LupacuDrago PieptuNuu Vlad

Comitet editorial naionalMonica Acalovschi (Cluj-Napoca)Nicolae Angelescu (Bucureti)Gabriel Aprodu (Iai)Mircea Beuran (Bucureti)Eugen Brtucu (Bucureti)Ioan Coman (Cluj-Napoca)Nicolae M. Constantinescu (Bucureti)Silviu Constantinoiu (Bucureti)Ctlin Copescu (Bucureti)Constantin Copotoiu (Tg. Mure)Nicolae Dnil (Iai)Corneliu Dragomirescu (Bucureti)tefan Georgescu (Iai)

Ioan Georgescu (Craiova)Cornel Iancu (Cluj-Napoca)Avram Jecu (Timioara)Fulger Lazr (Timioara)Rducu Neme (Craiova)Alexandru Nicodin (Timioara)Ion Poeat (Iai)Florian Popa (Bucureti)Irinel Popescu (Bucureti)Paul Srbu (Iai)Vasile Srbu (Constana)

Viorel Scripcariu (Iai)Valeriu urlin (Craiova)Liviu Vlad (Cluj Napoca)

Victor Tomulescu (Bucureti)Comitet editorial internaionalAlexander Beck (Ulm, Germania)Giancarlo Biliotti (Florena, Italia)Hendrick Van Damme (Lige, Belgia)Gheorghe Ghidirim (Chiinu, Rep. Moldova)Christian Gouillat (Lyon, Frana)Robrecht Van Hee (Antwerpen, Belgia)Vladimir Hotineanu (Chiinu, Rep. Moldova)Lothar Kinzl (Ulm, Germania)Liviu Lefter (Hobart, Australia)Adrian Loboniu (San Francisco, S.U.A.)Jan Lerut (Louvain, Belgia)

Christian Letoublon (Grenoble, Frana)Phillipe van der Linden (Bruxelles, Belgia)John C. Lotz (Stafford, Marea Britanie)Francoise Mornex (Lyon, Frana)Grard Pavy (Arras, Frana)Richard M. Satava (Washington, S.U.A.)Gianfranco Silecchia (Roma, Italia)Jose Schiappa (Lisabona, Portugalia)Adrian Stoica (Pasadena, S.U.A.)Paul Alan Wetter (Miami, S.U.A.)

CorectorOana Epure (Iai)

Adresa de coresponden

Prof. Dr. Eugen TRCOVEANURedaciaJurnalul de ChirurgieDepartamentul de chirurgie,Universitatea de Medicin i Farmacie Gr.T. Popa Iai Spitalul Sf. Spiridon Iai

Bd. Independentei nr. 1700111, Iai, RomaniaTel. / Fax: 0040 (0) 232 21 82 72

E-mail:[email protected]

ntreaga responsabilitate a opiniilor exprimate n articolele Jurnalului de chirurgierevine autorilor.

Republicarea sau reproducerea parial sau n ntregime a articolelor prin orice form de editare cunoscut, fr permisiuneaprealabil a redacieiJurnalului de chirurgie,este interzis. Corespondena cu privire la drepturile de a utiliza parial sauintegral articolele publicate nJurnalul de chirurgieva fi adresat redaciei:[email protected] Copyright Jurnalu l de chirurgie, Iai, 2005-2012
http://www.icmje.org/http://www.icmje.org/http://www.icmje.org/mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]://www.icmje.org/


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STANDARD DE REDACTARE

Iniializare pagin: Format A4, margini de 2,54 cm (1 inch).Pagina de titlu:

Titlul: Times New Roman, 14, aldin (bold), centrat, la un rnd; trebuie s fie ct mai scurt i elocvent pentruconinutul articolului;

Autorii: Times New Roman, 12, normal, centrat, la un rnd; vo r fi notate: prenumele i numele de familie,gradul profesional. Trebuie precizate datele de contact ale primului autor sau ale autorului desemnat ca autorcorespondent: adresa de coresponden, telefon/fax i o adres de e-mail funcional.

Apartenena autorilor:Numele instituiei trebuie precizat n conformitate cu reglementrile instituionale.Titlul prescurtat:titlu de 3-5 cuvinte, ct mai elocvent pentru articol.Pagina rezumatului:

Rezumat n englez: minim 200 cuvinte; Times New Roman, 10, la un rnd, fr aliniate i precedat de titlularticolului scris n englez, cu majuscule, urmat de cuvntul abstract (n parantez, italic). Rezumatul trebuie sfie structurat pe capitole: BACKGROUND, AIM, METHODS, RESULTS, CONCLUSIONS.Cuvintele cheie(KEY WORDS) vor fi menionate la sfritul rezumatului cu majuscule; de preferat acesteatrebuie alese din baza de date MESH (MEdical Subject Headings): www.nlm.nih.gov/mesh/MBrowser.html.Textul propriu-zis al lucrrii:Textul:Times New Roman, 12, la un rnd, structurat pe capitole: INTRODUCERE, MATERIAL SI METODA,DISCUTII, CONCLUZII.

Bibliografia: numerotat n ordinea apariiei n text; Times New Roman, 10, la un rnd, redactat dup cerineleinternaionale (http://www.nlm.nih.gov/bsd/uniform_requirements.html). Referina bibliografic trebuie sinclud TOI autorii dac sunt 6 sau mai puini. Peste 7 autori vor fi notai doar primii 3 urmai de et al.

Numele revistei va fi notat n conformitate cu prescurtrile PubMed, sau n ntregime cnd acestea nu suntdisponibile; redactarea acestuia se va face cu italice.

Formate acceptate:Articole:1. Takaori K, Raut V, Uemoto S. Clinical significance of liver ischaemia after pancreatic resection.Br J Surg. 2011; 99(4): 597-598.2. Iancu D, BartoA, Mocanu L et al. Rolul stentrii preoperatorii n chirurgia cancerului de pancreas. Jurnalul de chirurgie(Iai). 2011;7(2): 188-192.3. Diaconescu S, Barbu O, Vascu B, Moscalu C, Aprodu G, Gavrilescu S. [Hepatic and pulmonary hydatic cyst in a child]. Jurnalul dechirurgie (Iai). 2011; 7(2): 274-278.Cri:1. Whitehead WE, Schuster MM. Gastrointestinal Disorders. Behavioral and Physiological Basis for Treatment. Orlando: Academic Press;

1985. p. 213-220.2. Moldovanu R, Filip V, Vlad N. Elemente de anatomie chirurgical. Ghid pentru examenul de specialitate.Iai: Editura Tehnopress ;2010. P. 178-179.Capitole n cri i tratate:1. Meltzer PS, Kallioniemi A, Trent JM. Chromosome alterations in human solid tumors. In: Vogelstein B, Kinzler KW, editors. The geneticbasis of human cancer.New York: McGraw-Hill; 2002. p. 93-113.2. Jecu A. Patologia chirurgical a apendicelui. In : Angelescu N, editor. Tratat de patologie chirurgical vol. II. Bucureti: EdituraMedical; 2003. P. 1595-1614.Materiale electronice :1. Skandalakis JE, Colborn GL, Weidman TA et al. Skandalakis' Surgical Anatomy. New York: McGraw Hill; 2004. DVD.2. Kelly JC. Salivary Bacteria Might Reveal Pancreatic Cancer.Medscape Medical News. 2011; [available fromhttp://www.medscape.com/viewarticle/751552]

Tabelelevor fi inserate pe o pagin separat i nu vor depi o pagin; titlul tabelului va fi numerotat cu cifreromane: Times New Roman, 10, aldin, la un rnd, deasupra tabelului. Formatul tabelului trebuie s fie celacademic. Nu sunt acceptate tabelele salvate sub form de imagini.

Figurilevor fi tiprite pe o pagin separat i trimise n format *.jpg sau *.tiff. Nu sunt acceptate imaginile nformat *gif sau *png. Legenda figurilor va fi notat pe o pagin separat cu Times New Roman, 12, aldin, la unrnd i vor fi numerotate cu cifre arabe.Articolele multimedia:Filmele i prezentrile Power Point vor fi nsoite de un rezumat consistent n englez (de 300 -500 cuvinte);filmele vor fi n format *wmv, *.avi sau *.mpeg. Nu sunt acceptate filmele n format quick time. FiiereleMicrosoft Power Point (cu extensia .ppt) vor avea o dimensiune < 5Mb cu un numr de slide -uri


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Jurnalul de chirur gie(Iai) ianuarie-martie 2012; vol. 8; nr. 1

CUPRINS

EDITORIAL

UNDE SUNTEM DUP 7 ANI R. Moldovanu, E. TrcoveanuJurnalul de chirurgie(Iai) 2012; 8(1): 1-3

ARTICOLE DE SINTEZ

POSTOPERATIVE COMPLICATIONS ASSOCIATED WITH BIOMATERIALS USED INHERNIOPLASTYA. Mihilescu, D. Mihilescu, M.R. Diaconescu

Jurnalul de chirurgie(Iai) 2012; 8(1): 5-14

ARTICOLE ORIGINALE

STUDIUL PREVALENEI INFECIEI CU VIRUSUL HEPATITIC B N POPULAIA ADULT AJUDEULUI IAIGabriela Zlate, Gabriela tefnescu, Iuliana Tarai, C. Stanciu


STUDIU COMPARATIV ASUPRA IMPACTULUI FACTORILOR DE RISC CHIRURGICALI LAPACIENII CU TROMBOEMBOLISM VENOS, MODEL DE ANALIZ AL RISCULUI DE DECESIulia-Cristina Roca, Viviana Aursulesei, M. Roca, Diana Cimpoeu, M.D. Datcu

Jurnalul de chirurgie(Iai). 2012; 8(1): 23-29

CORELAII CLINICO-ECOGRAFICE N HIPERTENSIUNEA PORTALM. Melinte-Popescu, G. Blan


ACTUALITI PRIVIND TRATAMENTUL CHIRURGICAL AL OBEZITIILaura Curic, F. Bassetto, Carmen Vulpoi


EVALUAREA EFECTULUI HEMODINAMIC OCULAR INDUS DE PRESIUNEA ARTERIALSISTEMIC I PRESIUNEA DE PERFUZIE OCULAR LA PACIENII CU GLAUCOM PRIMITIV CUUNGHI DESCHIS NAINTE I DUP TRABECULOTOMIEA.R. Mousa, V. Bredeean, D. Costin


SERIE DE CAZURI

TRANSPLANTUL HEPATIC O POSIBILITATE DE TRATAMENT A CANCERULUIHEPATOCELULAR DEZVOLTAT PE CIROZ NON-VIRAL

N. Vlad, C. Ducerf, J. Baulieux, C. Gouillat, S. Mezoughi, J.Y. MabrutJurnalul de chirurgie(Iai). 2012; 8(1): 47-52

VALOAREA LIPOSTRUCTURII N RECONSTRUCIA DEFECTELOR DE PRI MOI DE LA NIVELULTERITORIULUI MAXILO-FACIALV.V. Costan, Carmen Vicol, C. Drochioi, Otilia Boiteanu, Eugenia Popescu


VALOAREA LAMBOULUI BILOBAT N RECONSTRUCIA DEFECTELOR POSTOPERATORII DUPEXTIRPAREA CARCINOAMELOR CUTANATE ALE FEEIIulia Chiscop, Eugenia Popescu, C. Mihai, V.V. Costan, D. Ferariu



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CAZURI CLINICE

TUMORA STROMAL MALIGN AGRESIV CU LOCALIZARE GASTRIC - PREZENTARE DE CAZMaria-Gabriela Aniei, D.C. Mariciuc, D.V. Scripcariu, V. Scripcariu


HERNIA HIATAL MIXT, TIP III - AFECIUNE RAR CU COMPLICAII SEVEREA.C. Munteanu, M. Munteanu, Anca Ruxanda, V. urlin


LEIOMYOSARCOMA PRESENTING AS A RECURRENT HEMATOMA OF THE DELTOID REGION. ACASE REPORTLidia Ionescu, Camelia Tama, Delia Ciobanu, D. Ferariu , Dana Clement, Anca Munteanu, R. Dnil


POSTTRAUMATIC LEFT-SIDED PORTAL HYPERTENSION MANIFESTED WITH BLEEDINGFUNDAL VARICESI. Mishin, G. Ghidirim, G. Zastavnitsky, M. Vozian


ANATOMIE I TEHNICCHIRURGICAL

LOBECTOMIA TORACOSCOPIC ASPECTE DE TEHNIC CHIRURGICALC. Bolca, M. Losano-Brotons, Jocelyn Gregoire, M. Conti, E. Frechette


TIROIDECTOMIA MINIMINVAZIV - ACTUALITII. Velicu, A. Vasilescu, N. Dnil, C. Bradea, Elena Cotea, E. Trcoveanu


ARTICOLE MULTIMEDIA

INDICATIONS ET/OU GESTES CHIRURGICAUX INHABITUELS DANS LE CANCER DU POUMONG. Pavy

Jurnalul de chirurgie(Iai). 2012; 8(1): 103

ARC PESTE TIMP

COMENTARIU LA ARTICOLULINVAGINATION APPENDICULAIRE ISOLE(S. Tzovaru, C. Vasilesco, L. Stefu -Revista de Chirurgie1937; 3-4: 272-279)

N.M. ConstantinescuJurnalul de chirurgie(Iai). 2012; 8(1): 105-110

SCRISOARE CTRE REDACIE

COMENTARIU ASUPRA NEUROLIZEI NERVULUI TIBIAL POSTERIORN.M. ConstantinescuJurnalul de chirurgie(Iai). 2012; 8(1): 111-112

RSPUNSUL AUTORULUIG. Mazilu

Jurnalul de chirurgie(Iai). 2012; 8(1):112-113.


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Jurnalul de chirurgie[Journal of Surgery](Iai) January-March 2012; vol. 8; nr. 1

TABLE OF CONTENT

EDITORIAL

JOURNALS CURRENT STATUS AFTER 7 YEARS R. Moldovanu, E. Trcoveanu


REVIEWS

POSTOPERATIVE COMPLICATIONS ASSOCIATED WITH BIOMATERIALS USED INHERNIOPLASTYA. Mihilescu, D. Mihilescu, M.R. Diaconescu


ORIGINAL PAPERS

EPIDEMIOLOGICAL STUDY OF THE HEPATITIS B VIRUS PREVALENCE IN THE COUNTY OF IAIGabriela Zlate, Gabriela tefnescu, Iuliana Tarai, C. Stanciu


COMPARATIVE STUDY ON THE IMPACT OF SURGICAL RISK FACTORS IN PATIENTS WITHVENOUS THROMBOEMBOLISM. ANALYSIS OF THE MORTALITY RISKIulia-Cristina Roca, Viviana Aursulesei, M. Roca, Diana Cimpoeu, M.D. Datcu


CLINICAL AND ULTRASOUND CORRELATIONS IN PORTAL HYPERTENSIONM. Melinte-Popescu, G. Blan


NEWS ON THE SURGICAL TREATMENT OF OBESITYLaura Curic, F. Bassetto, Carmen Vulpoi


INTRAOCULAR PERFUSION PRESSURE AS A METHOD TO ASSESS THE OCULAR CIRCULATORYIMPAIRMENT IN OPEN ANGLE GLAUCOMAA.R. Mousa, V. Bredeean, D. Costin


SERIES OF CASES

LIVER TRANSPLANTATION A PARADIGM IN THE SURGICAL TREATMENT OF

HEPATOCELLULAR CARCINOMA IN PATIENTS WITH NON-VIRAL LIVER CIRRHOSISN. Vlad, C. Ducerf, J. Baulieux, C. Gouillat, S. Mezoughi, J.Y. MabrutJurnalul de chirurgie(Iai). 2012; 8(1): 47-52

THE VALUE OF LIPOSTRUCTURE IN RECONSTRUCTION OF THE MAXILLO-FACIAL SOFT TISSUEDEFFECTSV.V. Costan, Carmen Vicol, C. Drochioi, Otilia Boiteanu, Eugenia Popescu


BILOBED FLAP IN FACIAL RECONSTRUCTION AFTER SKIN CANCER SURGERYIulia Chiscop, Eugenia Popescu, C. Mihai, V.V. Costan, D. Ferariu



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CASE REPORTS

AGGRESSIVE BEHAVIOR GASTRIC STROMAL TUMORCASE REPORTMaria-Gabriela Aniei, D.C. Mariciuc, D.V. Scripcariu, V. Scripcariu


TYPE III MIXT HIATAL HERNIA, A RARE VARIANT WITH SEVERE COMPLICATIONSA.C. Munteanu, M. Munteanu, Anca Ruxanda, V. urlinJurnalul de chirurgie(Iai). 2012; 8(1): 69-74

LEIOMYOSARCOMA PRESENTING AS A RECURRENT HEMATOMA OF THE DELTOID REGION. ACASE REPORTLidia Ionescu, Camelia Tama, Delia Ciobanu, D. Ferariu , Dana Clement, Anca Munteanu, R. Dnil


POSTTRAUMATIC LEFT-SIDED PORTAL HYPERTENSION MANIFESTED WITH BLEEDINGFUNDAL VARICESI. Mishin, G. Ghidirim, G. Zastavnitsky, M. Vozian


ANATOMY AND SURGICAL TECHNIQUE

THORACOSCOPIC LOBECTOMYTECHNICAL ASPECTSC. Bolca, M. Losano-Brotons, Jocelyn Gregoire, M. Conti, E. Frechette


MINIMALLY INVASIVE THYROIDECTOMYUP TO DATEI. Velicu, A. Vasilescu, N. Dnil, C. Bradea, Elena Cotea, E. Trcoveanu


MULTIMEDIA ARTICLES

UNUSUAL INDICATIONS AND/OR SURGICAL PROCEDURES FOR LUNG CANCERG. Pavy

Jurnalul de chirurgie(Iai). 2012; 8(1): 103

ARCH BEYOND TIME

COMMENTS ABOUT THE PAPERINVAGINATION APPENDICULAIRE ISOLE(S. Tzovaru, C. Vasilesco, L. Stefu -Revista de Chirurgie1937; 3-4: 272-279)

N.M. ConstantinescuJurnalul de chirurgie(Iai). 2012; 8(1): 105-110

LETTERS TO THE EDITOR

COMMENTS ABOUT POSTERIOR TIBIAL NERVE NEUROLYSISN.M. ConstantinescuJurnalul de chirurgie(Iai). 2012; 8(1): 111-112

AUTHORS REPLYG. Mazilu

Jurnalul de chirurgie(Iai). 2012; 8(1):112-113.


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EDITORIAL 1Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 1

Correspondence to: Dr. Radu MoldovanuDepartamentul de chirurgie, Universitatea de Medicin i Farmacie Gr.T. Popa Iai Spitalul Sf. Spiridon, IaiBd. Independenei nr.1, 700111, Iai, RomniaTel. / Fax: 0040 (0) 232 21 82 72e-mail: [email protected].

UNDE SUNTEM DUP 7 ANI

R. Moldovanu, E. TrcoveanuDepartamentul de chirurgie, Universitatea de Medicin i Farmacie Gr.T. Popa Iai

Jurnalul de chirurgiea aprut n 2005,dup succesul dezvoltrii site-uluiwww.laparosurg.ro, una dintre primele

platforme de e-learning din Romnia iprima cu profil medical, ca o dezvoltare aconceptului de e-learning / e-teaching

medical.Obiectivele principale au fost att de a

asigura un mijloc de informare i de formare(Educaie Medical Continu) la ndemntuturor rezidenilor i medicilor din diferitelespecialiti chirurgicale ct i de a-i ncurajan a-i publica experiena i rezultatelecercetrilor / activitii medicale.

Din acest motiv Jurnalul de chirurgiea mprtit ideile generoase ale liberuluischimb al informaiei tiinifice, exprimate

filozofic de Ralph Waldo Emerson nc dinsecolul XIX (Knowledge exists to beimparted) [1] i a aderat la principiulaccesului deschis att din punct de vedere alautorilor ct i din punct de vedere alcititorilor. Ca urmare, nc din anul de debutam fost acceptai i indexai n DOAJ(Directory of Open Access Journals) aUniversitii Lund, una dintre cele mai

prestigioase baze de date tiinifice destinateliberului schimb a informaiei tiinifice[2].

nc de la nceput politica editorial ainclus publicarea a apte tipuri de articole:editoriale, referate generale, articoleoriginale, cazuri clinice, articole de tehnicai anatomie chirurgical, articole multimediai de istorie a chirurgiei. Publicareaarticolelor multimedia a constituit o

prioritate naional pentru Jurnalul dechirurgie i s-a bucurat de un real succes,att din partea autorilor ct i a cititorilor.

Publicarea cazurilor clinice i a notelorde tehnic chirurgical a reprezentat o

preocupare permanent, fiind n concordancu obiectivele principale ale Jurnalului educaia medical i ncurajarea tinerilormedici de a-i publica experiena conform

principiilor you teach what you have tolearn [3] i the art of teaching is the art ofassisting discovery [4]. Aceast preocupareeditorial este oarecum n contratimp cutendina internaional a majoritiirevistelor, care au nceput fie s renune la

prezentrile de caz, fie s dezvolte revistespeciale (entry level) dedicate. Meritul

Jurnalului n formarea medical a fost dealtfel certificat, prin acreditarea acestuia dectre Colegiul Medicilor din Romnia nc

din primul an de apariie, n cadrulprogramului de Educaie Medical Continu.

Valoarea tiinific a Jurnalului a fostrecunoscut de CNCSIS n 2006 cnd

Jurnalula fost inclus n categoria C. n aniicare au urmat Jurnalul a fost acceptat iindexat n alte 3 baze de date tiinifice:IndexCopernicus, Baza de date aUniversitii Regensburg i prestigioasaEBSCO Academic. De asemenea, seregsete n fiierele a numeroase biblioteciale universitilor din ntreaga lume [5]. Carecunoatere a valorii tiinifice crescnde aJurnalului, acesta a fost inclus n categoriaB+ n 2009, categorie pe care a pstrat-o

pn n prezent (actualmente categoria B+ afost transformat n B [6]).

Pn n prezent au fost publicate nJurnal 441 articole cu o medie de 6314,29articole pe an (limite: 44-86) cu o mediande 57. Numrul articolelor publicate a avut o


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dinamicglobal ascendent (Fig. 1) dar cuevoluie diferit n funcie de tipul de articol;astfel, dac pentru notele de tehnic iarticolele multimedia evoluia a fostconstant (cte 33 de articole cu o medie de

4,71 articole anual (median de 4 irespectiv de 5) pentru referatele generale iarticolele originale tendina a fost diferit:astfel referatele generale au sczut de la 15

articole pe an la 9 (o medie de 11,14 / an(median: 12)) iar articolele originale aucrescut de aproape trei ori n ultimii ani, dela 14 articole pe an la 43 (medie de 20,43articole/an (median: 28)).Aceast dinamic

este n corelaie cu evoluia revistelormedicale internaionale i se explic prin

politica de ncurajare a cercetrii originaledar i de exigena procesului de peer-review.

Fig. 1Distribuia articolelor publicate nJurnalul de chirurgien perioada 2005-2011se remarc liniile de tendin paralele pentru numrul total de articole i articole originale i

divergent pentru referatele generale

Fig. 2Parametrii scientometrici pentruJurnalul de chirurgien perioada 2005-2011


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ARC PESTE TIMPcontinu n Jurnalul de Chirurgie!

Rubrica Arc peste timp a fostintrodus n revista Chirurgia ncepnd cunr. 2 din 2007, ca o iniiativ a redactoruluief - Prof. Dr. Irinel Popescu - n scopulfamiliarizrii chirurgilor romni cu o seriede lucrri de referin aprute de-a-lungultimpului n revista noastr.

Noua rubric se justifica prin existenaunor lucrri de real valoare publicate nurm cu 70-100 de ani, fiind n egal msur

un imbold pentru parcurgerea bibliografieiromneti dar i un prinos de recunotin

pentru marii notri naintai.n rstimpul acestor 5 ani am publicat,

comentat i actualizat 29 de articole scrise nChirurgia, cel mai vechi dintre ele datnddin 1909.

Restructurarea revistei Chirurgie nanul 2012 pentru a-i crete factorul deimpact ISI, nu mai putea permite publicareaunor lucrri la care importana tiinific eradublat de un cert factor emoional, pecarenu-l putem aprecia dect noi, romnii.

n consecin am apelat la Prof. Dr.Eugen Trcoveanu, care mi-a pus ladispoziie cu generozitate Jurnalul deChirurgie.

Sper ca tinerii notri chirurgi scontinue s se informeze i pe aceast cale,s aprecieze i s continue strdaniilenaintailor notri pentru a deveni i eiadevrai profesioniti n ale bisturiului.

Prof. Dr. N.M. Constantinescu


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REVIEW 5Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 1

Received date: 23.09.2011

Accepted date: 17.11.2011

Correspondence to: Andrei Mihilescu MD;

PhD student in General Surgery Gr.T. Popa University of Medicine and Pharmacy, Iai

First Surgical Unit, St. SpiridonHospital IaiBd. Independenei nr.1, 700111, Iai, RomaniaTel: 0040 (0) 232 24 08 22; Fax: 0040 (0) 232 21 77 81e-mail: [email protected]

POSTOPERATIVE COMPLICATIONS ASSOCIATED WITH

BIOMATERIALS USED IN HERNIOPLASTY

A. Mihilescu1, D. Mihilescu2, M.R. Diaconescu

Gr.T. Popa University of Medicine and Pharmacy, Iai

1) First Surgical Clinic, St. Spiridon Hospital, Iai2) Clinic of Orthopedic Surgery, Rehabilitation Clinical Hospital, Iai

POSTOPERATIVE COMPL ICATIONS ASSOCIATED WI TH BIOMATERIALS USED IN

HERNI OPLASTY (Abstract):Meshes of synthetic material are now being widely used to repairhernias (hernioplasty) but biomaterial-associated infections constitute a major clinical problem.

The success of surgical repair of abdominal wall defects depends on the physico-chemical

properties of biomaterials, their biocompatibility and design, preoperative handling and

conditioning of implant, surgical technique and not least, the health status of the patient. The most

common complications due to building materials are postoperative infection, seroma collection,bowel obstruction and enterocutaneous fistulas. The risk of such complications is minimized byusing composite macroporous meshes (dual layer meshes, pore size < 1 mm) whose dimensions

ensure adequate laxity without formation of folds.

KEY WORDS: BIOMATERIAL CHARACTERISCTICS; MESH POROSITY; TISSUE

INTEGRATION; POSTOPERATIVE COMPLICATIONS

SHORT TITLE: Biomaterials in hernioplasty

HOW TO CITE: Mihilescu A, Mihilescu D, Diaconescu MR.[Postoperative complications associated with biomaterialsused in hernioplasty].Jurnalul de chirurgie(Iai). 2012; 8(1): 5-14.

BACKGROUND

Ch.A.Th. Billroth, the famous surgeon

whose name is linked to the first gastric

resections with gastroduodenal/jejunal

anastomosis, ever since the late 19thcentury

intuited that by making and using an

artificial tissue with the density and

resistance comparable to those of the muscle

fascia, the secret of the radical healing of

the hernia disease would have been

discovered [1].The materialization of this desiderate

started by introducing, in 1959, the first

polymer nets, the polyethylene ones. After

this year, the range of the biomaterials used

to develop hernia meshes underwent

important changes. In an attempt to find the

best materials, new polymer fibers were

used, the least suitable ones were given up

at, multilayer composite materials start beingused and devices with special shapes and

sizes were designed. With special design and

simple actions (sutures) or with the most

complex shapes and characteristics (gastric

banding, transtumoral stents, meshes and

devices for parietal consolidation), the

products made of biomaterials are used in

surgical therapy for a high number of

diseases: incisional hernias, hernias,

neoplasm in advanced stages, morbid

obesity [2-6].

GENERAL ASPECTS OF THE

BIOMATERIAL/TISSUE

INTERACTIONS

The success of the surgical healing of

the defective abdominal wall depends on the

physico-chemical properties of biomaterials,


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6 Mihilescu A et al.Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 1

and their biocompatibility and design, on the

handling and conditioning of the implant in

the pre-surgical phase, on the surgical

technique itself, and last but not least, on the

patients health condition. To all this we

should add the capacity of the biomaterial toinhibit the development of adherences on the

adjacent side of the abdominal organs and to

answer in vivo similarly to the autologus

tissues. These last features allow good tissue

incorporation and fixation and a strong

repair without the scar reaction and without

the encapsulation problems noticed at the

current prosthesis [7-12].

The response of the organism, due to

the biomaterial / tissue interaction, is based

on a series of complex processes and it isinfluenced by a range of factors. The area

that best expresses the tolerance of the

biomaterial is the tissue / implant interface.

Figure 1 shows a diagram of the main

phenomena that constitutes the body

response to the presence of a biomaterial.

Fig. 1Scheme of the main phenomena of thebiological response to biomaterial implants

An analysis of the organism /

biomaterial relationship has in view that the

latter one has to answer a great number of

specific uses. Moreover, it has to take into

consideration the fact that the live organism

represents a complex in which proteins;

enzymes, polysaccharides or other types ofbiopolymers are represented by different

individuals. That is why the biomaterial

must have the suitable features so that it

does not disturb the natural running of the

local or general biochemical processes.

For the solving of this desiderate, a

tight collaboration is necessary between

chemists, biochemists, doctors, biologistsand pharmacists. They should work together

to develop biomaterials compatible with live

tissues, as well as to discover the

mechanisms of the biocompatibility and

biodegradability and to elaborate some

efficient methods for the shaping of the

implant/tissue systems, with the purpose of

reproducing the balance and the native

morphological and functional performance.

Anyway, all complications caused by the

consolidation material can be prevented iftheir causes are known. Therefore, the

prevention of postoperative complications

caused by the insertion of a biomaterial

implies the thorough knowledge of the

physical properties of the implanted

biomaterial, among which the surface

characteristics (dimensions and distributions

of pores, watering capacity, permeability to

fluids) are the most important.

MATERIAL CHARACTERISTICS

THAT FAVORISE POSTOPERATIVE

COMPLICATIONS

The success or the failure of a

hernioplasty depends, to a certain important

extent, on the material characteristics of the

used implant. If, by their chemical nature, all

synthetic polymers are perfectly

biocompatible materials, the differences

between their physical and morphological

properties could explain some of thecomplications associated to the prosthetic

materials.

Statistics show that, in the United

States, among all the implanted devices,

1-6% are infected pre- or post-surgery, and it

is considered that most of the infections are

nosocomial (40%). It is also considered that

the possibility of infection is higher in the

open techniques (7-18%) compared to the

laparoscopic ones (0-2%) [13-15].For the design of an advanced material

it is also necessary the exact understanding


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Biomaterials in hernioplasty 7Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 1

of the phenomena taking place at the tissue-

implant contact. Thus, from the first post-

implant moments, between the cells of the

host tissue and bacteria there is a

competition for the conquest of the

prosthesis surface. If this race is won by thehost cells, then they will attach or they will

integrate into the surface of the implant,

protecting it. The fixing capacity of the

bacteria is influenced by the reactive surface

of the implant, a characteristic which is

determined not only by the size of the pores

or of the mesh eyelets, but also by their

shape and distribution.

Data on the reaction of a foreign body

induced by the parietal consolidation

materials show that the response of theorganism appears on the surface of the yarns

that the mesh is made of. A comparative

analysis of the reaction caused by

polypropylene meshes, with different surface

characteristics (size, shape and distribution

of pores) shows that the more reduced the

reaction of a foreign body is, the smaller the

reactive mesh surface. Thus, the DynaMesh

will be better tolerated than the materials

with a reduced porosity that are

characterized by higher values of the total

surface of the yarns (Fig. 2). It is seen that

meshes with reduced FS value minimize the

reaction of a foreign body, favors the

formation of the scar tissues and gives a

higher comfort to the patient [16].

Fig. 2Surface characteristics of different

polypropylene meshes

The classification of the prostheticsmaterials according to the size of the pores,

made by Armid in 1997, allowed the

identification of 4 wide ranges of meshes

used presently in the surgical treatment of

hernias:

- Type 1 completely macroporousprosthetics (Atrium C-QUR andTrelex); the diameter of the pores is

higher than 75, a dimension that

allows the entry at the level of the

prosthetic pores of the macrophages,

fibroblasts, collagen fibres and

neoangiogenesis vessels;

- Type 2 completely microporousprosthetics: (ePTFE, Gore-Tex); they

contain pores with less than 10diameter in at least one of the 3

dimensions;- Type 3macroporous prosthetics with

multi-filaments or macroporous

elements like the PTFE (Teflon) mesh,

DacronandMersilenewoven mesh,

the mesh from woven polypropylene

filaments (SurgiproTM) or the

preshaped patches made of PTFE

(Mycro-Mesh);

- Type 4 biomaterials with sub-micronic size pores, such as:

Cellgard polypropylene meshes and

Preclude pericardial membrane.

These types of prosthetics are not

suitable for the repair of the hernia

defects, but combined with type 1

biomaterials they form composite

materials whose main characteristic

are to decrease the risk of viscero-

prosthetic adherences [17,18].

The size of the pores influences the

mechanisms for the integration of theimplant. It has been seen that, for the

polypropylene prosthetics whose eyelets

have at least 1 mm, the monofilaments of the

mesh are surrounded by granules of foreign

bodies, generating thus a normal granulation

tissue.

If the distance between monofilaments

is less than 1 mm, the incorporation of the

mesh in the neo-formation tissue is followed

by its confluence and by the formation of

scar tissues that considerably reduce thepatients comfort [16].


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The use of materials with suitable

mechanical characteristics reduces the

probability of complications due to mesh

deterioration or tearing. The prosthesis

should resist to pressures of at least 16

N/cm2 and, after implanting, it should keepunaltered its mechanical properties for long

periods. Data about the use of polypropylene

meshes with mechanical properties

(Marlex, ProleneandAtrium) showed that

if tearing occurs, it usually occurred at the

muscle fascia prosthetics junction [18].The tearing of the mesh on its margin is the

result of the decreased resistance of the

structure compared to that of the mesh. The

rate of the complications generated by these

processes can be diminished by using suturematerials similar to the material of which the

mesh is made of.

A feature that can influence the

success of a hernioplasty is the anisotropy of

the prosthetics material.

The mechanical properties of the mesh

(resistance to tearing, resistance to cutting,

elongation), generated by the mono-axial

tension on two perpendicular directions,

showed that they can have different values

on the two directions on which the tension is

applied. This behaviour will reflect into a

non-homogenous deformation of the

implant, a change of the biomechanics of the

abdominal wall and the rise of the risk of

late post-surgery complications [19].

Notwithstanding many processes

registered in the field of the biomaterials

applied in the abdominal wall repairs, the

number of post-surgery complications is

rather high, many of these (~ 20% cases)being attributed to the characteristics of the

material used for the implant.

POSTOPERATIVE COMPLICATIONS

The most frequent post-surgery

complications that can be caused by the

characteristics of the bio-materials are:

infection, seroma, intervisceral adhesion

(postsurgical adherential syndrome),

intestinal obstruction, wearing of theprosthesis due to the erosion of the cavity

viscera wall, failure of the repair caused by

the contraction of the prosthesis [20].

1) I nfection

The postsurgical infection, which can

be linked to the implantation of biomaterials(e.g. stitches and/or meshes), is caused by

bacteria infiltration and proliferation in

eyelets, interstitial spaces and pores that

characterize the implant.

Right after implantation, the surface of

the prosthesis is disputed between the hostcells in charge with the regeneration

(neoformation) and the bacteria in the

material. If the competition is gained bythe bacteria, they will form on the implant a

biofilm that will be removed/eradicated,most often, only by taking the prosthesis

out [21].

The biofilm or the bacterial plaque,

that most of the time has many species of

bacteria included in a self-excreting viscous

substance, adhere on the surface of the

implant and assures the protection of

bacteria for their proliferation. It is

considered that the eradication of the

infections, which involve microbial

microfilms, needs therapies with high doses

of antibiotics - up to 1000 higher compared

to the planktonic etiology infections caused

by planktonic bacteria [22-24].

The pathogeny of the implant

infections records:

- infiltration of bacteria at the momentof implanting or in the immediate

postoperative period (patients skinflora, pre-existing infection in the

proximity of the area of intervention,hospital environment, supporting

therapy),

- adhesion and colonization of bacteriaon the implant; they produce a self-

protective biofilm and they escape

the conventional therapy with

antibiotics and the immune response of

the patient [16].

The results of the investigations

regarding the influence of the surface

characteristics of hernia meshes on their bio-inertia in front of the microorganims attack


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shows that the pathology of the implant

infections is different according to the size

of the implanted mesh eyelets.

Thus, in the case of the type 1 meshes

(large eyelets - > 75 ) their macroporous

structure allows the rapid admission of themacrophages that destroy the bacteria, and a

quick process of fibroplasia and

angiogenesis that, being fast, does not allow

anymore the access of bacteria in interstitial

spaces.

Sometimes the postoperative infection

that appears after the use of type 1 meshes

for the repair of hernia defects is caused by

the use of the multifilament stitches for

fixing the prosthesis. These post-procedural

infections are wrongly attributed to type 1meshes.

Type 2 and 3 prostheses are similar to

the multifilament stitches and may generate

post-operative infections due to their

microporous structure.

The rate of post-procedural infections

associated to the use of type 2 and 3 meshes

is currently at a reasonable level (Smith

1971 reports the highest rate of 50% from all

the interventions where the same type of

meshes had been used, and DeBord and

Wyffels report in 1999, only 6%) [cit 17].

As for the surgeries where type 1 meshes

were used, the reported values for the post-

operative infections are a lot smaller [17].

If we refer to (postsurgical) post-

operative infections due to other causes,

when this complication appears after a

surgery where type 1 materials were used,

the most important thing is that it is not

necessary to remove the mesh. The exigentdrainage of the infected area, accompanied

by a strict monitoring of the wound was

enough to heal the complication. Unlike the

behavior of type 1 meshes, in the case of the

same complication (post-operative infection)

after procedures where type 2 and 3 meshes

were used, it is necessary: (i) to completely

remove the mesh (type 2 mesh), (ii) partial

removal (type 3 mesh).

When the eyelets or the interstitial

spaces of the material have sizes under 10 in each of the 3 structure sizes (Type 4

meshes), the bacteria of almost 1 cannot

be destroyed by large macrophages or

neutrofile granulocytes that cannot enter this

undersized pores. As a result, the

multifilament stitches and the prosthetic

materials with eyelets, interstitial spaces andpores of under 10 are an excellent location

for the bacterial proliferation and for the

development of local infections. The

complications are explained through the

possibility of quartering the small bacteria

and the impossibility of the macrophages to

enter these interstitial spaces [17].

According to the post-operative period

when the sepsis is developed, two types of

infections may appear:

- early infections they appear duringthe first 10 days from surgery;

- late infections the complicationappears several years after surgery.

Both types of infections, early and late,

can be attributed to the formation of

microbial biofilms. In the first case, the

implant is colonized by bacteria and the

treatment is not effective due to the biofilms

resilience. On a long term, the bacteria may

create a biofilm on the prosthesis material,

remaining inactive during long periods (even

years) until when a stimulus causes their

reactivation [25,26].

The clinical impact of the implant

infections is linked to the pain increase, a

higher discomfort for the patient, a longer

time for healing and recovery, a higher

morbidity and mortality rate and a longer

hospitalization at higher costs. Moreover, the

implant infections can cause the failure of

the hernia repair and they impose anadditional surgery for the removal of the

altered material [27].

The antimicrobial technology, applied

for the realization of the DualMeshPlus

meshes, materialised in a decrease of

implant infections thanks to the inhibition of

the bacterial colonization processes and to

the fact that it prevents the formation of the

initial biofilm, for at least 14 days from the

implant.

The prevention capacity of the post-operative contamination was tested on that


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particular area of the implant which

benefited of microbial inhibition treatment.

Biotests proved that the biomaterial can

achieve a substantial high activity against

both clinical and laboratory strains, isolated

from the following gram-positive and gram-negative microorganisms: methicillin-

resistant Staphylococcus aureus (MRSA),

Enterococcus faecalis resistant to

vancomicine (VRE), Escherichia coli,

Pseudomonas aeruginosa, Klebsiella

pneumoniae, Staphylococcus epidermidis,

Candida albicans, Acinetobacter baumannii

[28].

The special behaviour of DualMesh

Plus meshes is explained by the synergy of

the two anti-microbial agents: silvercarbonate and chlorhexidine. Silverscapacity of linking and destroying proteins

of the bacterial cells, causing the loss of their

biological function, is combined with the

activity of the chlorhexidine that penetrates

and disaggregates the bacterial cell wall thus

causing the elimination of the bacterial cells

content [14].

The antimicrobial therapy of Dual-

Mesh Plus prostheses has an inhibitory

effect for the early and late infections.

DeBord JR et al. monitored the short-term

evolution of 37 randomly selected patients

and they observed that Dual-Mesh Plus

hernioplasties do not seem to produce any

kind of systemic or clinical adverse reactions

[cit 25]. The same authors show, based on a

great number of cases (over 150,000

implants) monitored for a long period

(almost 10 years) that the information

regarding the hypersensitivity of the subjectsof this study to the implanted materials was

not confirmed [25].

Analyzing the data regarding the link

between the characteristics of the material

and the development of the implant related

infections we reach to following statements:

1) macroporous materials (with pores bigger

than 10 ) lead to the decrease of the post-

operative infections; 2) the use of meshes

treated with antimicrobial products eliminate

highly both the risk of early and lateinfections. [28,29].

2) Seroma

The formation of post-implant seroma

in a prosthetic biomaterial has as etiology

the inflammatory reaction of the host body(for the latest biomaterials this reaction is

neglectable), and the presence of the deadspaces between the prosthesis and the

surrounding tissue.

Admitting the importance of the

dead spaces in the formation of seromas,

K. Amid shows that, in the case of the

macroporous prosthesis (type 1 and 3), the

size of the pores of these materials allows a

rapid accumulation and fixation of the

proteins in the interstitial spaces [17]. Thus

the dead spaces between the prosthesis

and the host tissue are eliminated, and the

risk for developing a post-implant seroma is

minimal [17].

A high molecular permeability will

cause a rapid and efficient incorporation of

prosthetic material in the host tissue and

thereby filling the pores which makes

impossible the local quartering and the

bacterial proliferation, thereby decreasingthe risk of post-implant infection and the

formation of seroma. The risk of post-

operative seroma can be reduced to zero by

placing the prosthesis in a subaponeurotic or

retromuscular position thus avoiding the

direct contact of the biomaterial with the

subcutaneous adipose tissue. In addition, a

useful way to avoid seromas is using post-

operative drainage, especially useful in the

case when the surgeon used a large

prosthetic material.Due to the inadequate size of the

pores, the type 2 biomaterials/meshes lack

the optimum permeability to accumulate in

the interstices protein material and fibrin,

which results in a slow and incomplete

disappearance of the deadspaces between

the prosthesis and the host tissue where

seromas can form subsequently. When using

type 2 meshes percentages between 9.6%

(for hernia surgery) and 14.6% (for

incisional hernia surgery) were reported interms of post-procedural seroma formation.


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When correctly using the type 1 or 3 meshes,

such complications are not reported.

In most cases, seromas are solved

within 30 days without the need for

additional therapeutic gestures. Aspiration is

indicated in cases where the collectionpersists for more than 6 weeks, volume of

the seroma increases over time, clinical

symptoms appear or it is suspected of being

infected [20].

3) Adherential syndrome

The most important properties /

characteristics of the ideal prostheses for

hernia surgery are the macroporosity and the

surface texture. These characteristics favor

the infiltration of the prosthesis in the hosttissue, a process which is vital for a lasting

repair. On the other hand, an adverse side

effect of macroprosity is an increased

adhesion of the macroporous mesh to the

intestinal serous membrane when the two

surfaces come into direct contact. Currently,

all existing prosthesis (absorbable or non-

absorbable) determine viscero-prosthetic

adhesions, this process being more important

when non-absorbable meshes are used. For

this reason, it is recommended that theprosthesis notbe implanted in contact with

hollow viscera [30].

A limitation of the formation of

adhesions to the prosthesis is found with

bioabsorbable and PTFE materials.

However, neither the complete covering of

the visceral surface of the mesh with a layer

of absorbent material such as Vicryl, nor

the application of expanded PTFE patches,

does not lead to a complete resolution of

post-operative adherential syndrome. Recentexperimental studies have shown that

composite biomaterials made of types 1 and

4 meshes could prevent adhesions and they

are useful in preventing other post-implant

complications, secondary to adhesions,

namely intestinal obstruction or the

development of intestinal fistulas [17,30].

4) I ntestinal erosion and fi stulas

One of the complications attributed tothe material characteristics of the prosthesis

is the erosion of the adjacent tissues.

Prosthetic macroporous materials can

cause erosion of the tissue in direct contact

with them and so it may begin the migration

of the prosthetic material within the

gastrointestinal tract when the mesh is in

contact with the intestines. Thiscomplication is more common when the

prosthesis is in contact with segments of the

gastrointestinal tract unprotected by the

peritoneal serous membrane: distal

esophagus, rectum, bladder and any segment

of the intestinal tract that does not have a

serous membrane. However even the direct

contact between the prosthesis and intestines

that are covered by an intact serous

membrane can lead to fistula formation.

Experimental and clinical observationsup to date have shown that covering the

mesh with a layer of bioabsorbable material

which will come in contact with the intra-

abdominal organs - visceral side of the mesh

will be covered - is not an effective method

in preventing intestinal erosion or the

migration of the prosthes from the initial

point of placement [17].

Clinically it is considered that the

erosion of a hollow viscera and a fistula

formation is, most of the times, a severe late

complication with a difficult evolution and a

high mortality rate notwithstanding the

intervention [30].

5) Prosthesis contr action

The characteristics of the implant

material influence the rate and the speed of

the adhesions formation. Once formed, the

adherential tissue reduces mesh flexibility

and its ability to simulate the physiological

movements of the abdominal wall. Becauseof the immobilizationof the consolidating

material in the network of adhesions, hernia

mesh size changes and local tensions appear,

that may lead to recurrence of the

hernia defect or to the appearance of a new

one [31].

The post-implant dimensional changes

can reach high proportions depending not

only on the nature of the material, but also

on the design of the consolidation system.Thus, for the plug-type prostheses,depending on the nature of the biomaterial,


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http://www.elsevier.es/en/revistas/cirugia-espa%C3%B1ola-36/prosthetic-infection-after-hernioplasty-five-years-experience-13134935-originales-2009#7a6e58cb30706a9d8b5afc8abd0bfadf#7a6e58cb30706a9d8b5afc8abd0bfadfhttp://www.elsevier.es/en/revistas/cirugia-espa%C3%B1ola-36/prosthetic-infection-after-hernioplasty-five-years-experience-13134935-originales-2009#7a6e58cb30706a9d8b5afc8abd0bfadf#7a6e58cb30706a9d8b5afc8abd0bfadf


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ARTICOLE ORIGINALE 15Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 1

Received date: 11.09.2011Accepted date: 20.10.2011

Correspondence to: Dr. Gabriela Zlate, medic primar gastroenterologie, doctorand U.M.F. Gr.T. Popa IaiCentrul de Gastroenterologie i Hepatologie, Spitalul Clinic Judeean de Urgen Sf. Spiridon, Iai Bd. Independenei nr.1, 700111, Iai, RomniaTel: 0040 (0) 232 24 08 22; Fax: 0040 (0) 232 21 77 81e-mail: [email protected].

STUDIUL PREVALENEI INFECIEI CU VIRUSULHEPATITIC B N POPULAIA ADULT A JUDEULUI IAI

Gabriela Zlate1,2, Gabriela tefnescu1,2, Iuliana Tarai1, C. Stanciu1,2

1) Centrul de Gastroenterologie i Hepatologie,Spitalul Clinic Judeean de Urgen Sf. Spiridon Iai;

2) Universitatea de Medicin i Farmacie Gr. T. Popa Iai

EPIDEM IOLOGICAL STUDY OF THE HEPATIT I S B VIRUS PREVALENCE IN THE

COUNTY OF IAI (Abstract):AIMS: This study was aimed to evaluate the seroprevalence ofhepatitis B virus (HBV) infection in the county of Iai, Romania, the possible risk factors of HBVtransmission and to apreciate the clinical features of the infection. METHODS: A cross-sectionalepidemiological study was conducted between july 2007- june 2008 among the adult populationof county of Iai and was tried to identify the risk factors of HBV transmission. The sampleconsisted of 1200 adult subjects, registered on the list of six family physician praxis, three froman urban area and three from a rural area; it was used a questionnaire concerning the socio-demographic characteristics and potential risk factors. Serum samples were assayed for Ag HBs

by 3rd generation ELISA. The subjects found with AgHBs positive completed their evaluation forindicators of liver disease (chronic hepatitis, cirrhosis or liver cancer). RESULTS: The HBsAgprevalence in adult population of county of Iai was 5,2% (42 persons: 31 were inactive carriers, 9with chronic hepatitis, 2 with cirrhosis and none with liver cancer ). We found male sex, old age,intrafamilial exposure, serious accidents, history of acute hepatitis B, sexual risk behavior, dentaltreatment, tattooing as the major independent risk factors of HBV transmission, CONCLUSIONS:The overall HBV prevalence in the county of Iai was 5,2%, similar to other cuntries of EastEuropean region. There are risk factors implicated in HBV infection. Optimal management ofHBV infection requires lifelong routine monitoring of all patients to assess progression of liverdisease, development of hepatocellular carcinoma, need for treatment, and response to treatment.

KEY WORDS: HEPATITIS B VIRUS; INFECTION; HEPATOCELLULAR CARCINOMA;EPIDEMIOLOGY; PREVALENCE; RISK FACTORS

SHORT TITLE: Prevalence of hepatitis B virus (HBV) in Iai countyPrevalena virusului hepatitei B (VHB) n judeul Iai

HOW TO CITE: Zlate G, tefnescu G, Tarai I, Stanciu C. [Epidemiological study of the hepatitis B virus prevalence inthe county of Iai].Jurnalul de chirurgie(Iai). 2012; 8(1): 15-21.

INTRODUCERE

Infecia cu virus hepatitic B (VHB)

reprezint una din cele mai importante boliinfecioase din lume, se estimeaz c exist350 de milioane de purttori VHB pe glob[1,2].

Prevalena infeciei cu VHB variazconsiderabil, cu valori cuprinse intre 0.1% si20% , n diferite zone ale lumii, raportareadatelor exacte fiind dificil datoritnumrului mare de infecii asimptomatice,fie ele acute sau cronice [3-5]. Cronicizarea

infeciei, n special prin consecinele sale petermen lung, ciroza hepatic (CH) i

carcinomul hepatocelular (CHC) [6,7], faceca patologia legat de VHB s reprezinte oproblem de sntate public la nivelmondial.

Incidena CHC este determinat deepidemiologia factorilor si de risc [8];

pandemia prin infecia cu VHB reprezint lanivel global factorul de risc predominant.

Zonele de pe glob n care prevalenaCHC este cea mai ridicat sunt zonele cu


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16 Zlate G et al.Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 1

prevalen nalt a infeciei cu VHB,pacienii infectai cronic cu VHB prezint unrisc de 100 ori mai mare de evoluie spreCHC fa de persoanele neinfectate din

populaia generala [9,10]. Interesarea cu

precdere a vrstelor active are un impactdramatic asupra capacitii de munc asubiecilor, costul serviciilor medicalenecesitun efort financiar din partea statuluii familiei.

Clasificarea stadial a CHC adoptatn vederea aprecierii ratei de supravieuire,selectrii i optimizrii strategiilorterapeutice este Clasificarea BarcelonaClinic Liver Cancer (BCLC). Pacientii aflaiin stadiile BCLC 0 si A (doar aproximativ

25% fiind ns diagnosticai n acest stadiu)au un prognostic considerabil mai bun dectcei aflai in stadiile B, C sau D [11].

Terapia CHC trebuie adaptat stadiuluibolii, tratamentul chirurgical poate fi curativ[12] n stadiile BCLC 0-A. Rezeciachirurgical reprezint opiunea principal atratamentului curativ pentru stadiile timpuriiale CHC, este indicat n cazul pacienilor cutumori localizate i de dimensiuni mici sau

cu tumori aprute pe ficat non-cirotic.Atunci cnd rezecia nu poate fiefectuat din cauze variate (tumora nu poatefi abordat chirurgical din motive anatomice,funcia rezidual hepatic dup rezecie ar

putea fi intens afectat sau tumora estemultifocal, diseminat n ambii lobihepatici) transplantul hepatic reprezint oalternativ terapeutic [13].

Pacienii cu CHC cu extensie limitatdar cu vrsta naintat sau comorbiditi

importante de alt natur sunt selectai maiales pentru intervenii chirurgicale ablativelocalizate, ca injectarea percutan cu etanol(PEI) sau ablaiatermic prin radiofrecven(RFA), prezentnd, cel puin pe termenmediu, o evoluie postterapeuticsimilar curezecia sau transplantul hepatic.

Pentru pacienii cu CHC n stadiiavansate (BCLC B i C) care nu pot ficontrolate de terapia prin excizie local,tratamentul paliativ rmne singura opiune

terapeutic.

OBIECTIVE

Studiul a urmrit ca obiectiv principaldeterminarea prevalenei AgHBs n

populaia general a judeului Iai, iar caobiective secundare identificarea factorilorde risc pentru infecia cu virusul hepatitic B

precum i ncadrarea ntr-un stadiu de boal[14] (purttor inactiv, hepatit cronicactiv, ciroz hepatic sau hepatocarcinom)a pacienilor identificai cu Ag HBs.

MATERIAL I METOD

Studiul este unul de tip observaionaltransversal i a fost efectuat n populaiaadult din judeului Iai, n perioada iulie

2007 iunie 2008, cnd s-a desfuratProgramul naional de evaluare a strii de

sntate a populaiei. Judeul Iai are opopulaie de 826.552 persoane (2008), dincare 641.821 persoane cu vrsta peste 18 ani.Studiul a fost efectuat pe un eantion

probabilistic reprezentativ pentru populaiaadult a judeului Iai, selectnd 1.200

persoane adulte de pe listele a ase medici defamilie, cte 200 de pe lista fiecrui medic,

trei medici desfurndu-i activitatea nmediul urban i trei n mediul rural. Seleciaparticipanilor la studiu s-a fcut prin pas denumrare cu start aleatoriu: prima i a patra

persoan cu vrsta peste 18 ani care s-aprezentat la fiecare din cei 6 medici, nfiecare zi, n cadrulProgramului de evaluarea strii de sntate. Dintre acestea doar 810

persoane, cu vrsta cuprins ntre 18 i 75ani, au completat chestionarul i au efectuatinvestigaiile recomandate, rmnnd n

studiu.La prezentarea la medicul de familiepentru consultaia n cadrul Programului deevaluare a strii de sntate, stabilit ngeneral la data de natere a fiecrei

persoane, cei selecionai au completat unchestionar, datele de identificare fiindconfideniale. Toi participanii au fost deacord s completeze chestionarul i dateleobinute s fie folosite pentru prelucrristatistice. Chestionarul a fost completat n

prezena medicului de familie i a cuprinsdate socio-demografice (vrst, sex, mediu


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Prevalena VHB n judeul Iai 17Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 1

de reziden, nivel de colarizare, statutsocio-economic, date de stare civil), datedespre antecedentele medicale, activitateasexual, date privind unele practici (tatuaje,

piercing), consumul de alcool, date despre

existena unei persoane cu infecie cu VHBn familie sau n anturajul foarte apropiat.Conformprogramului de evaluare a strii desntate toate persoanele au efectuat un setde analize medicale (care a inclus itransaminazele), i li s-a determinat iAgHBs.

Determinarea AgHBs s-a realizat ntrei laboratoare de referin din Iai, folosindmetoda ELISA.

Pacienii identificai cu Ag HBs

pozitiv au fost ulterior investigai n vedereastabilirii formei clinice de boal (purttorinactiv, hepatita cronic activ, cirozahepatic sau hepatocarcinom) prin explorri

biochimice (probe hepatice), virusologice(Ag HBe, Ac anti HBe, Ac anti HD) iimagistice (ecografie abdominal).

Datele au fost centralizate n baze dedate EXCEL i prelucrate folosind

programul SPSS (Statistical Package for the

Social Sciences). n prezentarea datelor s-aufolosit intervalele de ncredere la pragul desemnificaie 95% (IC 95%), valoarea p


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Tabel IDistribuia pe grupe de vrst

Grupe vrst(ani)

70

% din subieci 2,83 20,98 18,51 15,30 19,25 11,74 11,11

Tabel II Corelaia AgHBs cu sexul i mediul de provenien

AgHBsSex Mediul de provenien

TotalBrbai Femei Urban Rural

pozitivN 22 20 20 22 42

% 5,9 4,6 6,2 4,3 5,2

negativN 352 416 305 463 768

% 96,1 95,4 93,8 95,5 94,8

TotalN 374 436 325 485 810

% 100 100 100 100 100

Tabel IIIDistribuia AgHBs pe grupe de vrst

Grupe vrst(ani) 60

Numrsubieci 1 7 6 9 17 2

Nu s-a evideniat o corelaiesemnificativ statistic cu interveniilechirurgicale (p=0,190), tratamentulinjectabil la domiciliu (p=0,466),spitalizrile frecvente (p=0,129). Persoanelecu partener cunoscut cu infecie VHB saucare au recunoscut existena bolilor cutransmitere sexual n antecedentele

personale n-au prezentat corelaiesemnificativ cu prezena AgHBs (p=0,308,respectiv p=0,636), ns corelaia s-a ntlnit

semnificativ mai frecvent la persoanele cuparteneri sexuali multipli (2=8,92; GL=1;p=0,003) cu un risc relativ de peste 3 orimai mare (RR=3,29; IC95%: 1,61 6,76).Frecventarea saloanelor de manichiur /

pedichiur i consumul crescut de alcool(p=0,123) nu au depit pragul de corelaiesemnificativ cu AgHBs, dar prezena unuitatuaj s-a asociat semnificativ cu AgHBs(2=5,37; GL=1; p=0,02), reprezentnd unrisc relativ de 4,45 ori mai mare (RR=4,45;

IC95%: 1,26 15,67). Istoricul familial deinfecie VHB sau existena unor persoane cu

infecie VHB n anturajul foarte apropiat areprezentat un factor important de risc incorelarea cu AgHBs (2=16,94; GL=2;p=0,0002).

Raportat la forma clinic de boal, dincei 42 de subieci identificai cu AgHBs

pozitiv, 31 au fost purttori inactivi, 9 auavut hepatit cronic activ i 2 subieci aufost diagnosticai cu ciroz compensat. Demenionat c, n lotul studiat nu au fostdiagnosticate cazuri de hepatocarcinom.

DISCUIIn ara noastr prevalena VHB este

mai ridicat dect in Europa occidental,Romnia plasndu-se n categoria rilor cuendemicitate intermediar. Acest studiu aanalizat prevalena AgHBs (marker alinfeciei cronice cu VHB) n populaiageneral adult din judeul Iai. Este unstudiu observaional transversal [15], simplui raional, realizat n perioada desfurrii

Programului de evaluare a strii de

sntate a populaiei, ceea ce a fcut ca


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subiecii s fie mai uor de contactat ntr-operioad limitat de timp i a asigurat o ratmare de participare [16]. Distribuia pegrupe de vrst, sex i mediu de proveniena eantionului studiat a fost asemntoare cu

structura populaiei din judeul Iai, n carepopulaia rural este majoritar. Prevalenaobinut a fost de 5,2%, valoare comparabilcu alte studii din literatura romneasc [17-20], n concordan cu prevalena ntlnit nrile din zona mediteraneean [1,20,21].Majoritatea celor cu AgHBs au avut peste40 ani, cei mai muli fiind n grupa de vrst50-59 ani; scderea prevalenei la vrste maitinere [22,23] se explic prin ameliorareacondiiilor de ngrijire medical, folosirea

materialelor sanitare de unic folosin, dari prin introducerea vaccinrii obligatoriimpotriva hepatitei virale B. Un numr maimare de brbai a prezentat AgHBs pozitiv,dar fr a se evidenia o diferensemnificativ statistic ntre brbai i femei(p=0,503) ntlnit n alte studii [22,23].Prevalena determinat a AgHBs fost maimare n mediul urban (6,2%) fa de mediulrural (4,5%), valoare ns nesemnificativ

statistic (p=0,392).Factorii de risc care se coreleaz cuinfecia cu VHB, medicali i nemedicali,variaz ca semnificaie statistic n diversestudii [24-27]. n acest studiu urmtoriifactorii de risc s-au corelat semnificativstatistic cu prezena AgHBs:

- antecedente de hepatit acut viral B(p=0,013);

- accidente grave (p=0,011) cu un riscrelativ de 3,64 ori mai mare

(RR=3,64; IC95%: 1,54 8,58);- tratamente stomatologice (p=0,045),cu un risc relativ de 1,90 ori mai mare(RR=1,90; IC95%: 1,05 3,42);

- persoanele cu parteneri sexualimultipli (2=8,92; GL=1; p=0,003) cuun risc relativ de peste 3 ori mai mare(RR=3,29; IC95%: 1,61 6,76);

- existena unui tatuaj (2=5,37; GL=1;p=0,02), cu un risc relativ de 4,45 orimai mare (RR=4,45; IC95%:

1,26 15,67);

- contact intrafamilial cu persoane cuhepatit cronic (2=16,94; GL=2;

p=0,0002) sau cu infecie cronicVHB (2=27,10; GL=2; p=0,000001).

Nu s-a identificat o corelaie

semnificativ statistic cu urmtorii factori derisc: nivel socio-economic, interveniichirurgicale, tratament injectabil ladomiciliu, spitalizri frecvente, boli cutransmitere sexual, vrsta debutului n viaasexual, parteneri sexuali infectai cu HVB,consumul de alcool, efectuarea manichiurii /

pedichiurii n saloane specializate.Istoria natural a infeciei cronice

VHB este binecunoscut: n absena terapieiantivirale o proporie important a

subiecilor infectai vor evolua spre cirozhepatic si vor deceda prin complicaiileacesteia [28], identificarea i tratareaacestora devine imperativ.

Studiul s-a bazat pe un numr limitatde subieci i este posibil s nu reflecte cuacuratee prevalena AgHBs n populaiageneral; nu a fost analizat populaia sub18 ani, iar n Romnia din 1995 esteimplementat vaccinarea obligatorie a nou-

nscuilor i sugarilor mpotriva hepatitei B,ceea ce ar putea face ca prevalena s fie maisczut dect cea determinat [29]. Deasemenea prevalena poate s varieze ndiverse regiuni i pe grupe diferite de

populaie [22,30,31]. n acelai timp, deivirusul B este un factor major n dezvoltareaCHC, n eantionul studiat nu au fostdignosticate cazuri de hepatocarcinom.Aceasta se explic prin faptul c screeningula fost realizat n populaia general, numrul

de subieci identificai cu infecie cronic cuvirus B a fost relativ mic, puini dintre eifiind n stadiul de ciroz hepatic.

Ca urmare, pentru depistarea precocea CHC la persoanele cu infecie cu VHB(esenial pentru un tratament curativ), este

justificat supravegherea celor cu risccrescut (brbaii peste 45 ani, pacienii cuciroz i cei cu istoric familial de CHC),

prin examen ecografic abdominal ideterminarea alfa-fetoproteinei (AFP) la 6

luni. Se pare c supraveghere nu este cost-eficient pentru toi subiecii cu infecie


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cronic cu VHB, unii autori recomandtotui ca purttorii inactivi s fac odeterminare a trans-aminazelor i AFP la 6luni.

CONCLUZII

n Romnia prevalena infeciei cuVHB este situat la valori intermediare,similare cu cele nregistrate n alte ri dinEuropa de Sud-Est i este mai mare la

brbaii cu vrst peste 45 de ani.O supraveghere sero-epidemio-logic

constant este esenial pentru monitorizareaprevalenei infeciei cu VHB, controlultransmiterii virusului, organizarea

programelor de tratament i prevenie,pentru a aloca ct mai judicios resurseleexistente. n acelai timp, aceast conduit

preventiv adoptat la cazurile curisc crescut pentru dezvoltarea CHC,

permite diagnosticul n stadii precoce,terapeutic utile, mbuntind semnificativ

prognosticul.

CONFLICT DE INTERESE

Autorii nu declar niciun conflict deinterese.

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ARTICOLE ORIGINALE 23Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 1

Received date: 09.11.2011Accepted date: 28.12.2011

Correspondence to: Dr. Iulia-Cristina Roca, doctorand Universitatea de Medicin i Farmacie Gr.T. Popa IaiUnitatea Primire Urgene, Spitalul Sf. Spiridon IaiBd. Independenei, nr. 1, 700111, Iai, RomniaTel: 0040 (0) 232 24 08 22; Fax: 0040 (0) 232 21 77 81e-mail: [email protected]

STUDIU COMPARATIV ASUPRA IMPACTULUI

FACTORILOR DE RISC CHIRURGICALI LA PACIENII CUTROMBOEMBOLISM VENOS, MODEL DE ANALIZ AL

RISCULUI DE DECES

Iulia-Cristina Roca1, Viviana Aursulesei2, M. Roca3,Diana Cimpoeu1, M.D. Datcu2

Universitatea de Medicin i Farmacie Gr.T. Popa Iai1) Unitatea Primire Urgene Spitalul Clinic Judeean de Urgen Sf. Spiridon Iai

2) Clinica I Medical Cardiologie ,,C.I. Negoi,Spitalul Clinic Judeean de Urgen ,,Sf. Spiridon, Iai

3) Spitalul Clinic de Pneumologie Iai

COMPARATIVE STUDY ON THE IMPACT OF SURGICAL RISK FACTORS IN

PATIENTS WITH VENOUS THROMBOEMBOLISM. ANALYSIS OF THE MORTALI TY

RISK (Abstract): BACKGROUND: Accurate and immediate diagnosis of venousthromboembolism (VTE) still remains a difficult challenge for clinicians. Without prophylaxis,the incidence of hospital-acquired VTE is approximately 10-40% among surgical patients and 40-60% following major orthopedic surgery. Pulmonary embolism (PE) is a life threatening diseaseand one of the main causes of in-hospital mortality. AIM: The purpose of this study was todetermine the relationship between surgical risk factors and VTE and in-hospital mortality in

patients with PE.METHODS: We conducted a prospective, cohort study, between January 2004and December 2010. The patients with PE, admitted in the Ist Medical Cardiology Clinic, in St.Spiridon University Hospital, Iasi were included. Different risk factors were statisticallyanalyzed to identify the independent predictors of mortality in PE. RESULTS: The cohortconsisted of 362 with EP. The mortality was 21.54% (N=78 deaths). From surgical risk factors,orthopedic surgery was most common (5.8%), followed by general surgery (2.3%) andgynecologic surgery (0.82%). Multivariate analysis showed that an obesity (OR=4.21, CI=2.08-8.53, p=0.0001), immobilization (OR=3.34, CI=1.18-9.45, p=0,023) and time between admissionand death (OR=0.77, CI=0.72-0.83, p


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24 Roca IC et al.Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 1

Americii, iar morbiditatea i mortalitateaprin embolie pulmonar, de 100000 desubieci, costurile anuale ale tratamentuluifiind de peste 1 miliard de dolari [1-3].

Conform datelor actuale, embolia

pulmonar (EP) reprezint cea mai frecventcauz de deces la pacienii spitalizai, attdin seciile de medicin intern, oncologie,ct i de chirurgie general, obstetric-ginecologie, ortopedie-traumatologie, fiinddeclarat i afeciunea cu cea mai mare ratde mortalitate prevenibil, prin diagnosticclinic i paraclinic corect efectuat, printratament rapid instituit i, n cea mai maremsur, prin recunoaterea pacienilor la risci prin utilizarea de rutin a msurilor de

profilaxie eficiente i sigure.Fr profilaxie, incidena episoadelor

de TEV survenite n spital, confirmate prinmetode obiective, este de aproximativ 10-40% la pacienii cu afeciuni medicale sausupui unor intervenii de chirurgie generali de 40-60% dup interveniile chirurgicaleortopedice majore [1-3].

Triada patogenic a trombozei venoaseprofunde i mecanismul emboliei pulmonare

au fost formulate de Virchow n 1856: stazavenoas, leziunea endoteliului venos ihipercoagulabilitatea [4].

Pacienii pot dezvolta EP, consecinacomplicaiilor spitalizrii pentru afeciunimedicale sau n perioada postoperatorie.Riscul individual pentru EP variaz, fiindrezultatul interaciunii dintre dou mari clasede factori predispozani: factorii de riscintrinseci (primari) i factorii de riscsecundari.

Conform datelor actuale, la pacieniidin seciile de chirurgie, riscul cel mai naltpentru EP apare n cazul interveniilorchirurgicale complexe sau al traumatismelor,al imobilizrii prelungite, cancerului saualtor stri de hipercoagulabilitate i n cazulantecedentelor tromboembolice.

Riscul obstetrical este asociat att cuevoluia sarcinii, ct i cu interveniileobstetricale, cu naterea vaginal/cezariana,ct i cu perioada postpartum.

Identificarea i estimarea importaneirelative a factorilor predispozani poate fi

util att n evaluarea probabilitii clinice nscop diagnostic ct i pentru deciziile ce

privesc prevenia primar.Avnd la baz aceste premise, studiul

nostru are ca obiectiv principal

caracterizarea pacienilor cu emboliepulmonar, din punct de vedere al factorilorde risc chirurgicali i adiionali, din punct devedere al impactului acestora asupraevoluiei clinice a pacienilor, precum ideterminarea unor predictori independenicare pot fi utili n evaluarea riscului demortalitate.

MATERIAL I METOD

Am realizat un studiu observaional,de cohort, de tip prospectiv. Culegereadatelor s-a efectuat dup tipul expus / non-expus la un factor de risc.

Populaia studiat a fost reprezentatde pacienii admii n Unitatea PrimireUrgene a Spitalului Clinic Judeean deUrgen ,,Sf. Spiridon i internai n ClinicaI Medical Cardiologie ,,C.I.Negoi cudiagnosticul de embolie pulmonar, n

perioada 1 ianuarie 2004 31 decembrie

2010.Constituirea lotului de studiu a urmrit

respectarea criteriilor de includere: subiecicu vrsta ntre 16 i 95 ani, diagnosticai cuembolie pulmonar (diagnosticul emboliei

pulmonare confirmat ecocardiografic,computer tomografic, scintigrafic saunecropsic) i a criteriilor de excludere:

pacieni la care nu s-a confirmat diagnosticulde embolie pulmonar sau care prezentausemne de sindrom posttrombotic la primainternare.

Protocolul studiului a cuprinssistematizarea datelor subiecilor cu embolie

pulmonar, cu realizarea foii de monitorizarestandard care a inclus: parametriidemograficii: numele i prenumele, mediulde provenien (urban, rural), sexul(masculin, feminin), vrsta; calendarulinternrii (data internrii n clinic, dataexternrii, data decesului); statusul la

externare: vindecat, ameliorat, agravat,decedat; datele privind diagnosticul deembolie pulmonar: diagnostic clinic i


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Tromboembolismul venos: analiza riscului de deces 25Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 1

paraclinic al emboliei pulmonare i cuidentificarea factorilor de risc.

Factorii de risc pentru embolie

pulmonar au fost clasificai astfel: factoride risc chirurgicali: intervenii chirurgicale

majore, intervenii de ortopedie itraumatologie, intervenii obstetric-ginecologie i factori

jurnal de chir 2012 vol 8 nr 1

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