Traumatic penile fracture with bilateral corporeal rupture

A 24-year-old man with no urological history presented to the emergency room for rapid onset severe penile pain, tenderness, swelling, and ecchymosis during vaginal sexual intercourse. Clinical examination was suggestive of penile fracture with a high suspicion of bilateral corporeal involvement. Urethrography excluded an injury to the corpus spongiosum. Surgical exploration confirmed the bilateral laceration of the corpora and tunica albuginea which was repaired with absorbable sutures. Penile fractures are true urological emergencies whose surgical treatment must not be delayed to prevent long-term sequelae. Bilateral corporal rupture represents only 2-10% percent of penile fractures and usually involves the urethra, especially when the lacerations are situated ventrally.

UTERINE RUPTURE DURING PREGNANCY – CASE REPORT

Uterine rupture is a life-threatening complication in pregnancy with no specific signs and symptoms, that requires fast diagnosis and surgical treatment. The main risk factors for uterine rupture are previous caesarean section deliveries and myomectomies, which can lead to improper uterine wall healing. We report a case of a 37-year-old secundigravida in 29 weeks of pregnancy, with prior caesarian delivery that was admitted in our ward for altered general status and abdominal pain. The patient underwent emergency laparotomy during which we found a massive 3500ml hemoperitoneum, 1000 g dead fetus and a rupture in the posterolateral uterine wall. The uterine scar from the previous caesarian section was intact. Uterine rupture is a complication with a growing incidence in past years that is very difficult to predict, which can occur at any time during pregnancy, especially during labour, but also in the second or early third trimester. Fast diagnosis and proper management is imperious because of the catastrophic outcomes uterine rupture is associated with.

THE ROLE OF ULTRASOUND IN PREVENTING THE LIFE-THREATENING EMERGENCIES ASSOCIATED WITH REPEATED CESAREAN SECTION

Ultrasonographic evaluation of the hysterorrhaphy scar is an extremely important element in current obstetrical practice, especially in patients who still want a future pregnancy. The purpose of our study was to evaluate the ultrasound findings of the cesarean scar in the third trimester of pregnancy that can reduce the life-threatening emergencies caused by repeated cesarean section such as uterine rupture of abnormal placental adhesions. We conducted a prospective study that included patients who gave birth by caesarean section and presented at a subsequent pregnancy to be monitored during pregnancy. The study was realized during 2016-2020at the Bucur Maternity Hospital, 'Saint John', Bucharest. A number of 57 patients were included in the analyzed group. A number of 12 pregnant women (21%) monitored both in weeks 30-34 and intraoperatively presented contractions and areas of dehiscence, while 30 (52.6%) pregnant women showed neither contractions nor areas of dehiscence. Women with contractions had an average scar thickness measured in the third trimester of 3.81 mm (SD 1.62, CI: [3.32; 4.30]), and those without contractions a thickness of 4.58 mm (SD 1.25, CI: [3.78; 5.37]. Intraoperatively we identified 3 cases with incomplete uterine rupture. Those cases were previously diagnosed with hysterorraphy scar between 0.15-0.5 cm. The repeated ultrasound evaluation of the cesarean scar is a good predictive factor for the intraoperative quality of the cesarean scar. With the third trimester ultrasound measurement of the uterine scar thickness, the uterine rupture may be avoided.

A RARE FORM OF PRESENTATION OF A SMALL INTESTINE GIST IN THE EMERGENCY DEPARTMENT

Gastro-intestinal stromal tumors are a form of mesenchymal tumors most commonly located in the gastro-intestinal tract, as the name suggests. The symptoms that might occur can be abdominal pain or discomfort, early satiety, bloating, jaundice, fatigue, hematemesis or melena. Most of GISTs (>95%) are positive for the KIT protein. Surgery remains the only curative treatment for GIST amenable for resection. High risk tumors can receive adjuvant or neoadjuvant treatment with Imatinib Mesylate, a tyrosin-kinase inhibitor. We present the case of a 59-years old patient that presented with rectal bleeding and abdominal diffuse pain. Blood tests shows leukocytosis and moderate anemia. CT scan describes an expansive, polycyclic process projected at the limit between the mesogastric region and the left flank, in close contact with the small intestine without any clear demarcation line between them and at the superior pole of the tumor, located in an enteral loop, a band of hyperdensity with net contour. Intraoperative, an extraluminal jejunal tumor was found, located at 15 cm from the duodeno-jejunal flexure, with intraluminal active bleeding, which lead us to suspect a GIST based on the macroscopic aspect. We performed segmental enterectomy of 10 cm of the small intestine containing the tumor with entero-enteral anastomosis end to end. The histopathological and immunohistochemistry examinations correlated with the macroscopic aspect have confirmed the diagnosis of GIST.

Endometriosis of the Rectus Abdominis Muscle: A Rare Cause of Emergency Department Visit; Case Report

Introduction: Endometriosis affects approximately 10% of the reproductive age woman. Although the most common affected sites are ovaries, sacrouterine ligament, rectovaginal septum, and pelvic peritoneum, it can be located in any organ. Endometriosis of rectus abdominal muscle independent from the cesarean section incision is extremely rare. Case Presentation: A 31-years-old female was admitted to the emergency department with periodical abdominal pain and distension complaints. Ultrasonography and computed tomography revealed a heterogeneous mass in the rectus abdominis muscle. Surgical excision was performed. Histopathologic examination showed endometrial tissue with glandular and stromal elements within the muscularis propria. Conclusion: Endometriosis should be kept in mind in the differential diagnosis of atypical pain and mass of the abdominal wall in the emergency settings.

THE STOMA REVERSAL AFTER HARTMANN PROCEDURE IN PATIENTS WITH COLORECTAL CANCER OPERATED IN EMERGENCY

The Hartmann procedure still has an important place in the surgical therapy of complicated colorectal cancers. The morbidity rate can be very high and many patients never undergo the stoma reversal. We conducted a retrospective study on 431 patients with colorectal cancer operated in the second clinic of General Surgery of the Clinical Emergency County Hospital Galati between 2008-2017. 42,53 % of the patients with Hartmann operation had a stoma reversal after a medium period of 5,7 months. The 5-years survival rate in patients with stoma reversal was 4,9 %. The reversal rate in our study is similar to those found in the literature in recent studies, that report percentages of 23,3 %-55,17 %. In our study, the medium period between the emergency Hartmann procedure and the reversal of the stoma was 5,7 months, which is also similar to the data in the literature. We found a 5-years survival rate of 4,9 % in patients with Hartmann reversal, much lower than others’ results. Many stomas initially intended to be temporary, may not be reversed. It is important to optimize the timing of stoma closure. A period of approximately 6 months between the initial operation and the reversal seem to be adequate.

IS LAPAROSCOPIC SURGERY BECOMING THE FIRST CHOICE IN TREATMENT OF PERFORATED PEPTIC ULCER?

Perforated peptic ulcer (PPU), a significant complication of peptic ulcer disease, has proven to be associated with high rates of mortality and morbidity and to this day, it remains a clear indication of emergency surgery. Whilst open repair remains a feasible treatment option for this complication, the development of laparoscopic surgery has brought along new perspectives, by revealing the benefits and drawbacks of this procedure and therefore raising the question whether it should be the first choice in treatment of a PPU. A literature search was performed using PubMed, Web of Science and Scopus, with the selection of relevant articles from the last 15 years. By comparing the two surgical approaches, conventional and laparoscopic, we aimed to identify the reasons laparoscopy is gaining ground as a mean of treatment of a PPU. Outcomes such as hospital stay, complication rates, use of postoperative analgesics and visual analogue scale favored laparoscopy. The most heterogeneous result was dictated by the operation time, which seems to correlate with multiple factors, a major one being the learning curve and skills this procedure requires. In addition, a significant number of papers had developed patient inclusion and exclusion criteria, which impacted the results of outcomes like morbidity and mortality. There is a lot of evidence that points to laparoscopy becoming the preferred method of treatment of a PPU, however further research is needed in order to reach a consensus.

APPENDECTOMY IN THE TIMES OF COVID-19: COMPARATIVE STUDY OF TWO GROUPS OF PATIENTS BETWEEN SIMILAR PERIODS OF TIME - 2019 VS 2020

Acute pathology of the cecal appendix - appendicitis, is a condition that does not take into account the pandemic period. The aim of this study is to retrospectively analyze the relationship of care for two groups of patients who underwent appendectomy in COVID-19 period and one year before, same period of time, in emergency hospital service. We performed a retrospective analysis on the patients admitted in our surgery center by comparing two groups for each period analysed: group A, for the period March-May 2019 and group B for the period March-May 2020 (corresponding to COVID-19 pandemic). We compared the groups analysing features that prove the change in age, incidence, grade (severity) of appendicitis, delay of surgery, length of surgery, postoperative complications and hospitalization time. CT scan was made for each patient. In the group B, PCR COVID-19 testing was made (all patients were negative for COVID-19). Our study consisted of 52 patients, group A-32 patients (61.53%) and group B-22 patients (38.47%). The Covid-19 pandemic influenced the incidence of appendicitis and we noted a delayed presentation which led to more complicated appendicitis than same period of the previous year. The impact also was noted on length of surgery, due to use of PPE (personal protective equipment) and also modified anatomy of the region related to inflammation. The severity of appendicitis was higher in the COVID-19 period when compared to 2019 similar period of time. Further research is required to draw more conclusions on this period.

POLITRAUMA DURING COVID-19 PANDEMIC: AN INCREASING INCIDENCE OF DOMESTIC VIOLENCE

The Covid-19 pandemic changed certain social habits and practices. The pandemic also changed the profile of polytrauma patients who presented in the emergency room. The etiology of polytraumas has undergone changes in the context of social distancing. While road accidents, falls and physical assaults, including gunshot trauma on the streets have decreased, we are confronting with an alarming increase in domestic violence. We analyzed the etiology of polytraumas from a period of 3 months that overlapped with the pandemic and compared it with the similar periods of the previous 3 years. We found an increase of about 4 times the incidence of physical aggression through domestic violence.