[Show abstract][Hide abstract] ABSTRACT: Laparoscopic cholecystectomy is a surgical procedure of choice for benign gallbladder diseases. In about 1-2% of cases histopathological examination demonstrate incidental gallbladder cancer (GBCA). We report a case of a 61 year old woman who developed port site metastases after laparoscopic cholecystectomy for adenocarcinoma of the gallbladder. Metastases appeared on all four port sites. Review of literature regarding incidental GBCA an port site metastases was also performed. We conclude that the retrieval bag should be routinely used in laparoscopic cholecystectomy; the procedure should be performed with minimal trauma; in cases of incidental GB carcinoma, full thickness excision of the abdominal wall of the port sites demands additional studies; additional liver bed excision and local lymphadenectomy for T1b carcinoma are yet to be considered.
[Show abstract][Hide abstract] ABSTRACT: Single-incision laparoscopic cholecystectomy is a relatively new minimally invasive surgical technique in treatment of benign gallbladder diseases. It is considered a bridge technique between conventional laparoscopic cholecystectomy (LC) and NOTES. We are presenting our initial experiences in SILC (single-incision laparoscopic cholecystectomy). Seventeen patients underwent SILC (11 women and 6 men) with an average age of 43 years. Mean BMI score was 29,4 kg/m2. The mean operative time was 93,5 minutes. There were conversions to conventional LC in two cases (11,6%). Average pain score measured on visual-analogue scale (VAS) 8 h after the operation was 2,00. All patients expressed satisfaction with achieved cosmetic effect. We conclude that SILC is safe and feasible procedure, with excellent cosmetic effect, but further prospective studies are required before SILC can be generally accepted.
[Show abstract][Hide abstract] ABSTRACT: Gastric adenomyoma is a rare, hamartomatous tumor localized most frequently in the gastric antrum. Review of the available literature shows only sporadic reports or smaller series.
We presented a 72-year-old woman admitted due to epigastric pain with dyspeptic difficulties. Biochemical parameters and tumor markers were within the referential limits. Diagnostic procedures (upper endoscopy, endoscopic ultrasonography and computerized tomography) revealed an intramural tumor prominence with intact mucosa on the posterior wall of gastric antrum, not accessible for biopsy. Surgical treatment was performed with total extirpation of the tumor. Histopathological examination verified adenomyoma with focal low grade epithelial dysplasia. Cytologic immunophenotype was consistent with smooth muscle stromal and epithelial tumor (CK7 and CK20 ++ immunophenotype). Stromal component revealed low proliferative index (Ki-67 protein immunoexpression level 3%), and p53 less than 0.1% in both epithelial and stromal components. Following the operation, the patient remained in good condition.
Uncertain malignant potential of the gastric adenomyoma in the presented case indicates that timely diagnostics with adequate surgical treatment is crucial for an adequate treatment.
[Show abstract][Hide abstract] ABSTRACT: The aim of our study was to demonstrate clinical manifestations and diagnostic methods of splenic echinococcosis and suggest surgical approach.
The study involved 20 patients of previously diagnosed spleen echinococcosis. A diagnosis was made for each patient, based on medical history, biochemical and serological tests, physical examination and abdominal ultrasonography. All the patients received a CT scan of the abdomen. These patients had undergone the following surgery procedures: total splenectomy 13 (60%), and spleen-preserving surgery 7 (35%) patients. Histological examination confirmed the spleen echinoccocosis in all the patients.
Nonspecific left upper abdominal pain was present in 10 (50%) cases, while 5 (25%) patients presented with the right upper abdominal pain with dyspepsia and five patients (25%) were asymptomatic. Postoperative complications developed in 2/13 (15.4 %) patients who underwent total splenectomy, while there were no complications after spleen-preserving surgery.
Spleen-preserving surgery should be undertaken if possible in patients with spleen echinococcosis, and total splenectomy is reserved for the patients with large cysts located centrally or near the hilus.
[Show abstract][Hide abstract] ABSTRACT: The liver actinomycosis is a rare disease associated with complex differentiation from the liver metastases or hepatocellular carcinoma.
A 50-year-old immunocompetent female patient was admitted to the Surgical Department in an exhausted condition, with dyspnea, significant weight loss and intermittent fever in the recent two months. Diagnostic procedures that followed, including abdominal ultrasound and computed tomography led us to the diagnosis of metastatic liver disease of unknown etiology with pleural and pericardial effusion. Intraoperatively, the presence of liver pseudotumor without malignancy in the liver was confirmed. Histological examination confirmed the diagnosis of liver actinomycosis. Prolonged treatment with high dose penicillin was performed and all signs and symptoms resolved completely without further problems. The control abdominal ultrasond finding was normal.
Liver actinomycosis has a nonspecific presentation, often mimicking liver tumor. A timely diagnosis as well as a combined surgical and antibiotic therapy is necessary in the treatment of patients with primary disease and prevention of complications.
[Show abstract][Hide abstract] ABSTRACT: To estimate the characteristics of Color Doppler findings and the results of hepatic radionuclide angiography (HRA) in secondary Hodgkin's hepatic lymphoma.
The research included patients with a diagnosis of Hodgkin's lymphoma with metastatic focal lesions in the liver and controls. Morphologic characteristics of focal liver lesions and hemodynamic parameters were examined by pulsed and Color Doppler in the portal, hepatic and splenic veins were examined. Hepatic perfusion index (HPI) estimated by HRA was calculated.
In the majority of patients, hepatomegaly was observed. Lesions were mostly hypoechoic and mixed, solitary or multiple. Some of the patients presented with dilated splenic veins and hepatofugal blood flow. A pulse wave was registered in the centre and at the margins of lymphoma. The average velocity of the pulse wave was higher at the margins (P > 0.05). A continuous venous wave was found only at the margins of lymphoma. There was no linear correlation between lymphoma size and velocity of pulse and continuous wave (r = 390, P < 0.01). HPI was significantly lower in patients with lymphomas than in controls (P < 0.05), pointing out increased arterial perfusion in comparison to portal perfusion.
Color Doppler ultrasonography is a sensitive method for the detection of neovascularization in Hodgkin's hepatic lymphoma and estimation of its intensity. Hepatic radionuclide angiography can additionally help in the assessment of vascularisation of liver lesions.
World Journal of Gastroenterology 07/2009; 15(26):3269-75. DOI:10.3748/wjg.15.3269 · 2.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine risk factors for pulmonary embolism and estimate effects and benefits of prophylaxis.
We included 78 patients who died subsequently to a pulmonary embolism after major abdominal surgery from 1985 to 2003. A first, retrospective analysis involved 41 patients who underwent elective surgery between 1985 and 1990 without receiving any prophylaxis. In the prospectively evaluated subgroup, 37 patients undergoing major surgery between 1991 and 2003 were enrolled: all of them had received a prophylaxis consisting in low-molecular weight heparin, given subcutaneously at a dose of 2850 IU AXa/0.3 mL (body weight < 50 kg) or 5700 IU AXa/0.6 mL (body weight > or = 50 kg).
A higher incidence of thromboembolism (43.9% and 46.34% in the two groups, respectively) was found in older patients (> 60 years). The incidence of pulmonary embolism after major abdominal surgery in patients who had received the prophylaxis was significantly lower compared to the subjects with the same condition who had not received any prophylaxis (P < 0.001, OR = 2.825; 95% CI, 1.811-4.408). Furthermore, the incidence of pulmonary embolism after colorectal cancer surgery was significantly higher compared to incidence of pulmonary embolism after other abdominal surgical procedures. Finally, the incidence of pulmonary embolism after colorectal cancer surgery among the patients who had received the prophylaxis (11/4316, 0.26%) was significantly lower compared to subjects undergoing a surgical procedure for the same indication but without prophylaxis (10/1562, 0.64%) (P < 0.05, OR = 2.522; 95% CI, 1.069-5.949).
Prophylaxis with low molecular weight heparin is highly recommended during the preoperative period in patients with diagnosis of colorectal cancer due to high risk of pulmonary embolism after elective surgery.
World Journal of Gastroenterology 01/2009; 15(3):344-8. · 2.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Dietary fat and its relation to obesity has been a controversial issue for many years. Experimental data shows that most, though not all animals, which consume a high fat diet, will become obese. However, the effect of fatty acids on animal obesity has not been studied in detail. In order to evaluate the effects of low versus high fat diet on serum phospholipids fatty acids composition a 4-wk study was conducted on male Wister rats. The rats were fed low-fat (10% energy) and high-fat (46% energy) foods containing constant proportions of fatty acids. Control group C was fed a standard laboratory diet (polyunsaturated/ saturated (P/S) fatty ratio 1.3), group M was fed a standard laboratory diet supplemented with margarine (P/S ratio 0.95), and the diet of the SL group was additionally supplemented with a sunflower oil-lard (1:1) mixture (P/S ratio 1.3). All lipid supplemented hyperenergetic diets caused an increase in the average daily energy intake. Both the final and the daily body weight gain were significantly higher in M and SL groups than in group C. Additionally, serum triglyceride levels, LDL-cholesterol and total cholesterol were also significantly higher in M and SL groups when compared to the control group. Serum phospholipids fatty acids varied in response to total dietary fat. A significant decrease in saturated fatty acids (SFA) content (16:0 and 18:0) and an increase in monounsaturated fatty acid (MUFA) content (18:1, n-9) was found in the M group when compared to both C and SL groups. In the SL group, SFA content (18:0) was higher and MUFA content (18:1, n-9) was lower than in group C. Polyunsaturated fatty acids (PUFA) content showed an increase in both experimental groups. The PUFA/SFA ratio was higher in the M group than in the C and SL groups. Our study suggests that the amount of dietary fat has a greater influence on obesity than the effects of the type of fat consumed. However, depending on the type of fat present in the diet the differences were observed in the composition of serum PL fatty acid suggesting that both total fat and individual fatty acids have to be considered when reaching conclusions about the effect of dietary fat and obesity in animals.
[Show abstract][Hide abstract] ABSTRACT: The phenomenon now known as haemobilia was first recorded in XVII century by well known anatomist from Cambridge, Francis Glisson and his description was published in Anatomia Hepatis in 1654. Until today etiology, clinical presentation and management are clearly defined. Haemobilia is a rare clinical condition that has to be considered in differential diagnosis of upper gastrointestinal bleeding. In Western countries, the leading cause of haemobilia is hepatic trauma with bleeding from an intrahepatic branch of the hepatic artery into a biliary duct (mostly iatrogenic in origin, e.g. needle biopsy of the liver or percutaneous cholangiography). Less common causes include hepatic neoplasm; rupture of a hepatic artery aneurysm, hepatic abscess, choledocholithiasis and in the Orient, additional causes include ductal parasitism by Ascaris lumbricoides and Oriental cholangiohepatitis. Clinical presentation of heamobilia includes one symptom and two signs (Quinke triad): a. upper abdominal pain, b. upper gastrointestinal bleeding and c. jaundice. The complications of haemobilia are uncommon and include pancreatitis, cholecystitis and cholangitis. Investigation of haemobilia depends on clinical presentation. For patients with upper gastrointestinal bleeding oesophagogastroduodenoscopy is the first investigation choice. The presence of blood clot at the papilla of Vater clearly indicates the bleeding from biliary tree. Other investigations include CT and angiography. The management of haemobilia is directed at stopping bleeding and relieving biliary obstruction. Today, transarterial embolization is the golden standard in the management of heamobilia and if it fails further management is surgical.
[Show abstract][Hide abstract] ABSTRACT: The prognosis of patients with acute pancreatitis is still uncertain regardless of modern therapeutic procedures. It is even more emphasized if the acute pancreatitis is followed by psychic disorders.
The aim of the study was to provide an overview of the incidence of certain psychosomatic disorders in patients with acute pancreatitis and evaluate priority therapeutic procedures.
In this study, we analysed 16 patients with psychosomatic disorders followed by the episode of acute pancreatitis among 202 patients that were hospitalized in the period from 1993 until 2000. The diagnosis was based on anamnesis, clinical and laboratory findings and diagnostic procedures such as X-ray, US, CT and MRI.
Among 16 patients with psychosomatic disorders followed by acute pancreatitis, 13 (81.25%) patients were operated on and 3 (18.75%) patients were medically treated. 6 patients experienced hallucinations, 5 memory deficiency, 16 disorientation and 14 confabulation.
Psychosomatic disorders in patients with acute pancreatitis require complex medical treatment. Due to the already mentioned complications, the management of these conditions is very difficult and with uncertain results.
Srpski arhiv za celokupno lekarstvo 01/2007; 135(7-8):414-8. DOI:10.2298/SARH0708414S · 0.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To review and discuss the current strategies and controversies in the surgical management of colorectal cancer liver metastases.
An analysis of indications, contraindications and scoring systems and concepts for expanding the indications for resection are discussed. The findings and discussion are related to our own experience, especially with radiofrequency assisted liver resection for colorectal cancer liver metastases.
Resection is the only management strategy that can potentially cure the patient. Certain controversies still exist, such as contraindications for surgery, timing of treatment of synchronous metastases, significance of extra-hepatic disease etc. Strategies that can improve respectability are discussed. Parenchyma oriented, tissue sparing surgery facilitates reresection should it become necessary.
The management of colorectal cancer liver metastases is still a confusing issue for general oncologists and general surgeons. A multidisciplinary approach that tailors the management strategy to the individual patient is the only option that provides optimal results for patients with advanced disease.
[Show abstract][Hide abstract] ABSTRACT: Traditionally, the operation of hernia is considered as a clean operation due to expected, low incidence of infection, on the spot of surgical work (SSI). The incidence of SSI in hernia surgery is more frequent then it is assumed. The important risk factors for SSI are the following: type of hernia (inguinal, incisional), operative approach (open - laparoscopic), usage of the prosthetic material and drainage. Comparing to inguinal hernia repair, incisional hernia repair, is more frequently followed by the infection. The laparoscopic operations are followed with the lower incidence of SSI then in the case of open operations. The usage of the mesh does not increase the incidence of SSI, although the consequences of the mesh infection may be severe. A type I of the prosthesis is more resistant to the infection then prosthesis II and III. The mesh infection (type I) never involves its body but it is present around sutures and bended edges. The mesh infection Type II involves entire prosthesis while in the case of Type III it is present in its peripheral part. In the case of SSI, a prosthesis Type I is possible to be saved, while prosthesis Type II must be removed completely; and the same is for the Type III (the partial removal is rarely suggested). The defect that remained after excision of non-resorptive prosthesis is a long-term and very complicated surgical problem. In regard to the position of the mesh, SSI is more common if the mesh is placed subcutaneously then in the case of sub-aponeurotic premuscular, pre-aponeurotic retromuscular or pre-peritoneal mesh placemen. If the infection is present the nontension techniques using non-resorptive prosthetic implants are not recommended. The presence of drainage and its duration increases the incidence of SSI. It is more common for incisional hernioplasty then for inguinal hernia repair. If there is an indication for drainage it should be as short as possible. The cause of SSI for elective operations are bacteria's that arrives from the skin, while in the case of opening of various organs dominant bacteria's originate from them. The superficial infection does not lead to the recurrence, while it is very possible in the case for deep infection. There are no prospective studies that justify the usage of antibiotic prophylaxes in hernia surgery. The antibiotic prophylaxis is indicated for the clean operations when placing the implants and when severe complication is expected. The appearance of SSI increases the price of treatment and may lead to the recurrence.
[Show abstract][Hide abstract] ABSTRACT: After the introduction of prosthetic material in hernia surgery the fundamental changes in operative strategy occurred. This is because the coverage of myopectineal orifitium with non-absorbable prosthesis decreases the incidence of recurrences. Because of the appearance of lateral re-recurrences after the classical Rives procedure, we modified the operative technique. The modified Rives technique consists of the following: always polypropilen mesh 15x10 cm; creation of the new internal inguinal ring between Poupart's ligament and mesh; no lateral notching the mesh and anchoring mesh 2-3 cm from the medial, inferior, lateral and superior edge. During the period January 2001-December 2003, 34 cases of recurrent hernias were operated on 7th dept. of I Surgical Clinic of CCS. The recurrences were managed by classical (10/34) or modified Rives technique through direct inguinal approach (22/34), less frequently Lichtenstein procedure (1/34) and McVay (1/34) technique. Among 10 patients with recurrent inguinal hernias managed by classical Rives technique 2 re-recurrences appeared (indirect and interstitial) and 2 cases of infection (immediately after the operation or 7 months after the operation), and in the group of 22 cases with recurrent inguinal hernias managed by modified Rives technique the aim complications didn't appear. Using the modified Rives technique we managed the primary hernias in 56 cases without recurrences and infections. The modified Rives technique, because of the way of mesh fixation (all around), no lateral notching of mesh and remaining hem in all directions secures abdominal wall protection 2-3 cm from the line of fixation and prevents any movement of the mesh. This procedure enables management of all inguinal hernias regardless to their size and full protection of the medial, femoral and lateral inguinal triangle. The modified Rives technique is the technique of choice for big multiple defects (giant inguino-scrotal and re-recurrences), especially among patients with increased intra-abdominal pressure when other techniques may be insufficient because of mesh protrusion.
[Show abstract][Hide abstract] ABSTRACT: In solving inguinal hernias, surgeons today have in front of them many variations of different operative procedures (both tensional and non-tensional techniques). They are performed through operative or endoscope approach. Classical tension techniques present the operation of choice for smaller indirect, direct or femoral hernias among younger patients while non/tensional techniques are the best solution for all types of inguinal hernia among older patients with big destruction of transversal fascia and the best solution for most of recurrent hernias. Positioning of mesh with non-tensional techniques can be completed on different levels, with big hernias where the biggest part of transversal fascia of miopectineal orifitium is destroyed it is anatomically the most useful to place the mesh in preperitoneal space. Rives technique is the base of that concept and it presents one of good solutions in that kind of situations. In the period January 2001 until december 2002 using different operative techniques the authors treated 99 inguinal hernias of which 78 were primary and 21 recurrent hernias. Rives technique was performed in 46 cases (46.5%) among which 26 cases were primary inguinoscrotal hernias (3 patients IIIA, 22 patients IIIB, 1 patient IIIC, according to Nyhus classification) and 20 cases were recurrent hernias (6 patients IVA, 11 IVB, 3 IVD). Complications after Rives technique were the following: 1 recurrence (2.17%), 1 ischemic orchitis (2.17%) and 1 scrotal hematoma (2.17%). Infections and chronic pain were not present. The follow up was from 30 days to 2 years. Authors have shown that Rives technique is reliable solution for primary indirect, direct and femoral hernias with big hernial defect (especially for big, so called "giant" inquinoscrotal hernias) and for all types of recurrent hernias. The advantage of the technique is an easy performance without some previous special training because of the fact that dissection and preparation is the same as for the tension techniques. With small amount of prosthetic material all weak points of miopectineal orifitium are closed. The real risks of this technique are ischemic orchitis and chronis neuralgia in treatment of recurrent hernias and the presence of polypropylene mesh in Bogras space.