Spleen cystic echinococcosis: clinical manifestations and treatment.

AIM: The aim of our study was to demonstrate clinical manifestations and diagnostic methods of splenic echinococcosis and suggest surgical approach. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Study of molecular and granular layer of dentate gyrus of female rats neonatally treated with estrogen.

The proliferation of hippocampal dentate gyrus granule cells was investigated using (3)H-thymidine incorporation in control and estrogen-treated rats. Newborn 3-day old female Wistar rats were treated with a single dose of 1 mg of estradiol and 30 microCi (3)H-thymidine, and were sacrificed when 10 days old. The total number of neurons and the number of labeled granule cells in the granular layer and its subdivisions of both suprapyramidal and infrapyramidal limbs were analyzed using a stereological method. In both limbs, the total number of neurons as well as the total number of labeled granule cells in the granular layer were significantly increased in treated rats compared to corresponding controls. The thicknesses of the molecular and the granular layers and their subdivisions of both suprapyramidal and infrapyramidal limbs were analyzed using a stereological method. In treated female rats the molecular layer (ML) in both limbs was significantly decreased, and the granular layer (GL) was significantly increased in suprapyramidal limb. However, in the infrapyramidal limb an increased number of labeled cells in treated animals were significant in all particular zones of the granular layer. In the suprapyramidal limb's granular layer a significant increase in labeled cells was observed in subgranular zone (SGZ). Our results suggest a differential effect of estradiol on thicknesses of the ML and the GL, and dentate gyrus granule cells proliferation through the early rat life.

Detection of gastrointestinal and abdominal infections by 99mTc-antigranulocyte antibodies.

BACKGROUND/AIMS: The aim of the study was detection of abdominal infections by 99mTc- antigranulocyte antibodies. METHODOLOGY: Total of 36 patients with clinical suspicion on abdominal or gastrointestinal infections was investigated. RESULTS: There were 23 true positive (TP) findings (one pulmonary abscess, 2 subhepatic abscesses after surgery, 2 perianal fistula, 2 chronic and 4 acute appendicitis, 5 abdominal and 3 pelvic abscesses, 3 M. Crohn, one ulcerative colitis), 9 true negative (TN) (3 tumors of the coecum, 2 tumors of papilla Wateri, 2 gastric carcinoma, 2 colon carcinoma), and 4 false negative (FN) (2 abscesses subphrenic and 2 enterocolic fistula). False positive (FP) findings were not observed. The smallest lesion found was 19x18 mm. SPECT increased the number of TP findings from 17 to 23. Fifteen of 23 infectious of inflammatory lesions could be detected in the early scan. Sensitivity was 85%, specificity 100%, positive predictive value 100%, negative predictive value 69% and accuracy 89%. CONCLUSION: According to the present results, scintigraphy with 99mTc antigranulocyte antibodies is a useful method for detection and assessment of exact localization abdominal infections, which is very important for the prompt and appropriate therapy.

Color Doppler sonography and angioscintigraphy in hepatic Hodgkin's lymphoma.

AIM: To estimate the characteristics of Color Doppler findings and the results of hepatic radionuclide angiography (HRA) in secondary Hodgkin's hepatic lymphoma. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Perioperative myocardial ischemia in coronary artery disease patients undergoing abdominal nonvascular surgery.

BACKGROUND: The incidence of perioperative myocardial ischemia (PMI) is the highest in patients who have coronary artery disease, and it is the best predictor of intrahospital morbidity and mortality. OBJECTIVE: To identify predictors of PMI in patients who have coronary artery disease and are undergoing abdominal nonvascular surgery. METHODS: A prospective, observational, clinical study of 111 consecutive patients with angiographically verified coronary artery disease, scheduled for open abdominal nonvascular surgery, was conducted. Patients received general anesthesia and were monitored by continuous electrocardiogram during surgery and immediately postsurgery (72 h period) in the intensive care unit at the University Clinical Center (Belgrade, Serbia). All of the patients had 12-lead electrocardiography immediately after the surgery, on postoperative days 1, 2 and 7, and one day before discharge from hospital. The patients were monitored until the 30th postoperative day. RESULTS: A total of 24 predictors for PMI were analyzed. The Pearson's chi(2) test and a binomial logistic regression model were used for statistical analysis. A significant difference in the incidence of PMI was found in the coronary artery disease patients with an associated risk factor (14 of 24 risk factors) compared with those without the risk factor. In particular, a highly significant difference in the incidence of PMI was found in coronary artery disease patients with angina pectoris, compared with those without angina pectoris. CONCLUSION: Using the multivariate logistic regression analysis, angina pectoris was an independent predictor of PMI.

A study of pulmonary embolism after abdominal surgery in patients undergoing prophylaxis.

AIM: To determine risk factors for pulmonary embolism and estimate effects and benefits of prophylaxis. METHODS: 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). RESULTS: 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). CONCLUSION: 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.

[Serous microcystic adenoma of the head of the pancreas causing an obstructive jaundice].

BACKGROUND: Serous microcystic adenoma is a rare benign tumor of the exocrine pancreas originating from the ductal system and composed of a large number of small cysts covered by cuboid cells, filled with clear serous fluid and separated with fibrocolagenous stroma. Most frequently it appears in women in 7th and 8th decades, in the distal pancreas. It shows a very low malignant potential. In 2/3 of patients symptoms are uncharacteristic and in 1/3 they are absent When localised within the head of the pancreas it rarely causes an obstructive jaundice. CASE REPORT: We presented a 61-year-old female patient who for months had had mild and nonspecific abdominal symptoms developing to progressive obstructive jaundice. At surgery we revealed a rather large policystic mass of the head of the pancreas causing not only obstructive jaundice but also a venous stasis by compression and dislocation of the portomesenteric vein. The tumor was removed with pylorus preserving cephalic duodenopancreatectomy (Whipple's procedure modified by Longmire-Traverso). Histology confirmed serous microcystic adenoma of the pancreas. The postoperative recovery was uneventful and preoperative symptoms disappeared. CONCLUSION: Although very rare, serous microcystic adenoma might appear within the head of the pancreas and has to be taken into consideration in differential diagnosis of cystic lesions of the head of the pancreas. Very rarely the tumour might cause obstructive jaundice. Surgical resection, which might be demanding, leads to complete recovery.

Cystic lymphangioma of the pancreas.

Lymphangioma of the pancreas is an extremely rare benign tumour of lymphatic origin, with fewer than 60 published cases. Histologically, it is polycystic, with the cysts separated by thin septa and lined with endothelial cells. Though congenital, it can affect all age groups, and occurs more frequently in females. Patients usually present with epigastric pain and an associated palpable mass. Complete excision is curative, even though, depending on the tumour location, surgery may be simple or involve extensive pancreatic resection and anastomoses. The authors present a 49-year-old woman in whom a polycystic septated mass, 35 mm multiply 35 mm in size, was discovered by ultrasonography (US) in the body of the pancreas during investigations for epigastric pain and nausea. At surgery, a well circumscribed polycystic tumor was completely excised, with preservation of the pancreatic duct. The postoperative recovery was uneventful. Histology confirmed a microcystic lymphangioma of the pancreas. Immunohistochemistry showed cystic endothelial cells reactivity to factor VIII-RA (++), CD31 (+++) and CD34 (-). Postoperatively, abdominal pain disappeared and the patient remained symptom free for 12 mo until now. Although extremely rare, lymphangioma of the pancreas should be taken into consideration as a differential diagnosis of a pancreatic cystic lesion, especially in women.

[Disseminated subcutaneous fat necrosis and elbow joint arthritis as a complication of pancreatitis].

BACKGROUND: Intraabdominal fat necrosis of the retroperitoneum, mesenthery and omentum is a frequent complication of acute pancreatitis. Very rarely, during the disease multiple aseptic subcutaneous fat necrosis, polyarthritis, polyserositis, vasculitis, subcutaneous nodi and eosinophylia, isolated or in combination, may appear. They are known as "pancreatic disease syndrome". CASE REPORT: We presented a female patient, 43-year-old, in whom in the course of acute interstitial biliary pancreatitis had occur red multiple localized aseptic necrosis of subcutaneous fat tissue of extremities appeared mostly around the talocrural and wrist joints requiring multiple incision, as well as aseptic elbow joints arthritis requiring puncture of one elbow joint. The symptoms were followed by a prolonged febrility that settled within several weeks. CONCLUSION: Localized disseminated fat necrosis around joints, arthritis of major joints, alone or with some of other symptoms of the "pancreatic disease syndrome" have to be considered as a probable sign of pancreatitis, even in the abscence of major abdominal symptoms.

[The use of recombinant activated factor VII to control haemorrhage following exenteration and massive transfusion in coagulopathic patients].

INTRODUCTION: Exentheresis pelvis totalis due to locally advanced pelvic malignancies is an extensive surgical procedure. The operation is commonly associated with anticipated perioperative haemorrhage requiring a large volume of haemoproducts. Sometimes, the intervention can result in unexpected massive and uncontrolled haemorrhage that is frequently a combination of surgical and coagulopathic bleeding. Attempts to arrest massive bleeding by conventional means may fail. CASES OUTLINE: We describe our experience in the use of recombinant activated factor VII (rFVIIa) in three previously hemostatically competent patients who underwent exentheresis in order to control massive bleeding resulting from dilution coagulopathy in the operating theatre, as well as in the treatment of postoperative bleeding associated with consumptive coagulopathy. Of these, two massively transfused patients developed dilution coagulopathy in the operative theatre, which was poorly responsive to conventional management. In both cases, a single dose of rFVIIa (70 microg/kg and 60 microg/kg respectively) was given. Prompt clinical response was achieved and operations were successfully finished. In the third case, the patient developed consumptive coagulopathy on the first day after surgical procedure that was treated with conventional therapy. On the second postoperative day the patient became anuric and experienced severe intraabdominal bleeding. The bleeding was successfully controlled with rFVIIa in a single dose of 70 microg/kg. CONCLUSION: RFVIIa can be a treatment option in patients suffering from intractable coagulopathic bleeding when standard therapy has failed.

Hemodynamic and cardiovascular problems during modified hyperthermic intraperitoneal perioperative chemotherapy.

BACKGROUND/AIMS: Cytoreductive surgery and hyperthermic intraperitoneal perioperative chemotherapy (HIPEC) significantly improves patients survival with peritoneal carcinomatosis especially in low-grade tumor e.g. ovarian and appendiceal adenocarcinoma, peritoneal pseudomyxoma and grade I gastric and colorectal cancer. METHODOLOGY: During a period of nine years, hemodynamic and cardiac functions combined with urinary output during hyperthermic intraoperative intraperitoneal chemotherapy were prospectively measured in 60 patients. RESULTS: Statistically significant hemodynamic and cardiac parameters were characterized by an increased heart rate and cardiac output as well as decreased systemic vascular resistance associated with an increased body temperature and decreased effective circulating volume. The tendency of urinary output was to decrease as the therapy progressed. CONCLUSIONS: HIPEC induces a hyperdynamic circulatory state requiring increased intravenous fluid administration, which avoids changes because of increased intra-abdominal pressure. Documented by normal blood pressure and adequate urinary output hemodynamic and intravenous fluids, titrated to frequent urinary output determination, can achieve cardiac stability.

Bulk agent Plantago ovata after Milligan-Morgan hemorrhoidectomy with Ligasure.

The aim of this study was to determine usefulness of the bulk agent Plantago ovata in reducing postoperative pain and tenesmus after open hemorrhoidectomy (Milligan-Morgan with Ligasure). Ninety-eight patients were randomized into two groups of 49 patients each. In both groups Milligan-Morgan open hemorrhoidectomy with Ligasure was performed. The first group received postoperatively two sachets daily of 3.26 g of the bulk agent, Plantago ovata, for 20 days. The control group was treated postoperatively with glycerin oil. There was no statistically significant difference in age, gender distribution and hemorrhoid grading, between the two groups. The pain score after first defecation (p < 0.001) and after 10 days (p < 0.01) and the global pain score (p < 0.001) was statistically significantly lower in the group treated with Plantago ovata, while there was no statistically significant difference in the pain level after 20 days (p > 0.05). The hospital stay was statistically significantly shorter in the group receiving Plantago ovata (2.6 +/- 0.6 vs 3.9 +/- 0.7 days, p < 0.001). The incidence of tenesmus was higher in the control group (40.8% vs 10.2%, p < 0.01). Treating patients with Plantago ovata after open hemorrhoidectomy, reduces pain, tenesmus rate and shortens postoperative hospital stay.

[Protective ventilation strategy in the acute respiratory distress syndrome]. / Protektivna strategija ventilacije u sindromu akutnog respiratornog distresa.

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) contribute to progressive hypoxemia in critically ill patients. It has been proved that conventional mechanical ventilation with physiological respiratory volume contributes to further lung damage. In this respect, application of protective ventilatory strategy--pulmonary ventilation with limited volume and pressure can avoid mentioned consequences. The aim of this paper is to discuss mechanims by which elements contained in protective mechanical ventilation of patients with ALI/ARDS prevent further progrssive lung injury, to argue the effects of positive end--expiratory pressure and present insturctions for its application.