Urgent Surgical Treatment of Blunt Chest Trauma Followed by Cardiac and Pericardial Injuries.

INTRODUCTION: Widespread opinion that penetrating chest injuries are more urgent, in terms of treatment and care, contributed to underestimation of the urgency of blunt chest trauma, which in most cases is treated conservatively. It remains an open question frequency when the injuries of the heart and pericardium are not timely diagnosed and surgically treated. AIM: To demonstrate the importance of well-timed surgical treatment of blunt chest trauma, when coupled with cardiac and pericardial injuries. METHODS: At the Thoracic Surgery Clinic of the University Clinical Centre Banja Luka, Bosnia and Herzego vina, during period of 10 years (01.01. 2008 - 31.01.2018.), the total of 66 patients were treated for urgent thoracotomy due to clinically and radiologically unclear findings after blunt chest trauma. In general, diagnostic examinations, apart from laboratory analysis, included radiological imaging and Multi Slice Computed Tomography (MSCT) of the chest, followed by an ultrasound of the heart in cases when sternum was injured or when pericardial tamponade was suspected. Results presented in the study where obtained from the retrospective analysis of patients data. This work presents a retrospective observational cross-sectional study, which results in the assessment of the correctness of a particular diagnostic test. STATISTICAL METHODS USED: descriptive statistics, counting measures (frequencies and percentages), central tendency measures (arithmetic mean), variability measures (standard deviation). RESULTS: Sixty six patients were treated with urgent thoracotomy after a blunt trauma of the chest due to the unclear clinical and radiological finding. In the case of 11 patients (10 men and 1 woman), presenting 16.6% of the total sample, pericardial and cardiac injuries were detected and treated intraoperatively. Further, in the case of the one patient, pericardiotomy and suturing of the right heart chamber where performed, with the creation of a pericardial window. Transthoracic echocardiogram was not used as the primary screening module, but rather as a diagnostic test for patients who had unexplained hypotension and arrhythmia. Radiographs of the chest showed cardiomegaly with or without epicardial fat pad sign suggesting a pericardial effusion. CONCLUSION: Blunt cardiac and pericardial injuries represent a serious therapeutic problem, which, if not treated properly, result in a high mortality rate. Echocardiography is the primary diagnostic method for initial detection of pericardial effusion. Pericardial fluid first accumulates posterior to the heart, when the patient is examined in the supine position. As the effusion increases, it extends laterally and with large effusions the echo-free space expands to surround the entire heart. The size of the effusion may be graded as small ( echo free spaces in diastole <10 mm, corresponding to approxymately 300 ml), moderate (10-20 mm, corresponding to 500 ml), and large ( >20 mm, corresponding to >700 ml). When the ability of the pericardium to stretch is exceeded by rapid or massive accumulation of fluid, any additional fluid causes the pressure with the pericardial sac. Early recognition, pericardiotomy with pericardial window creation and/or ventricular rupture suture remain the "gold standard" in the treatment of blunt cardiac and pericardial injuries.

Early vs. Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis - Single Center Experience.

INTRODUCTION: Laparoscopic cholecystectomy is now considered the procedure of choice that achieves a shorter recovery period after the surgery and reduction in the cost of treatment. Aim: The aim of the study is to prove which method: early or delayed laparoscopic cholecystectomy is the method of choice in the treatment of acute cholecystitis by examining: duration of hospitalization, conversion rate, duration of surgery, postoperative complications, and total cost. METHODS: The study was conducted at the University Clinical Center of Republika Srpska as a retrospective-prospective study from May 1st 2013 until December 31st 2019. Patients diagnosed with acute cholecystitis were divided into two groups: Patients designated for early laparoscopic cholecystectomy within 72 hours of admission (group A-42 patients), Patients designated for initial conservative treatment followed by a delayed interval of 6-12 weeks until surgery (group B-42 patients). RESULTS: In both groups, there were statistically significantly more female respondents. The results showed that the average cost of treatment in the early treated group was statistically significantly lower than the cost of treatment in the delayed treatment group. The patients in the early group had shorter hospitalization times (an average of 2.8 days and 5.6 days in the delayed group of patients), a smaller percentage of conversions (4.8% in the early and 16.7 in the delayed group of patients), the total cost of in the early group it was 1300.83 KM, while in the delayed group it was 1645.43 KM. CONCLUSION: Early laparoscopic cholecystectomy is a method to be preferred in surgical treatment.

Securing the base of the appendix during laparoscopic appendectomy.

In contrast to classical appendectomy where the appendiceal stump is secured by a single or double ligature, in laparoscopic appendectomy various ways of securing the stump are mentioned. Each of these methods has advantages and disadvantages. Since different possibilities exist for closing the stump, it is very important to find the optimum method for closure of the appendiceal stump, bearing in mind their simplicity, biocompatibility and price. The aim of this review article has been to present the problem of securing the base of the appendix during laparoscopic appendectomy.

Origin of the medial circumflex femoral artery--a cadaver study.

AIM: To determine the pattern of origin of medial circumflex femoral artery (MCFA), its origin distance from the midpoint of the inguinal ligament and the topographical relations of the origin, which have great significance in clinical work. METHODS: Dissections on the autopsy group of 42 thighs were performed, and anatomical relationships of MCFA was analyzed. All data were entered into a scheme of the protocol which was designed for this research containing the case number, age and sex, side, topographical-anatomical relations of MCFA, artery dimensions and variations, and the distance between the place of origin of MCFA and the midpoint of the inguinal ligament. RESULTS: Commonly, in 25 (59.5%) limbs MCFA originated from the deep femoral artery. In 14 (33.3%) limbs MCFA arose from the femoral artery (FA), in one case (2.4%) a common source of deep femoral artery (DFA) and MCFA was identified, and in two limbs MCFA was not noticed. The distance between the level of origin of MCFA and the central point of the inguinal ligament was 44.2 mm, in average, when it was emerging from FA, and 57.9 mm, in average, in cases where MCFA originated from DFA. CONCLUSION: Surgeons and radiologists should be familiar with the variations of clinically important MCFA, which is commonly involved in peripheral occlusive arterial diseases, to improve effectiveness of diagnosis and treatment of various pathological conditions in the femoral region.

[Massive hemorrhage of upper gastrointestinal tract caused by gastrointestinal stromal tumor of the stomach--case report].

INTRODUCTION: Acute bleeding from the upper gastrointestinal system is a medical emergency which is followed by high mortality rate, ranging from 6 to 15% in spite of modern diagnostic methods and treatment. Bleeding from the upper gastrointestinal system may be caused by gastrointestinal stromal tumors of the stomach, which are mainly characterized by occult bleeding, while profuse bleeding rarely occurs accompanied by hemorrhagic shock. Gastrointestinal stromal tumors of stomach are the most common mesenchimal tumors of the gastrointestinal tract. CASE REPORT: In our study we showed a 60-year-old female patient with profuse bleeding from the stomach and the clinical picture of severe hemorrhagic shock, caused by gastrointestinal stromal tumor. An ovoid junction, raised towards the lumen, covered with ulcerated mucosa in several places and followed by massive arterial bleeding was found intraoperatively, after the performed gastrotomy. Histopathological examination with immunohistochemical analysis confirmed that this was a gastrointestinal stromal tumor of the stomach. DISCUSSION: Acute bleeding from the digestive system is a sudden and serious condition of the body. Urgent esophagogastroduodenoscopy is a sensitive and specific diagnostic and therapeutic method of choice. Massive bleeding from the upper gastrointestinal tract is very rarely caused by gastrointestinal stromal tumors, whose clinical picture is very heterogeneous and depends on tumor size and location. Abundant bleeding from the tumor is an indication for urgent surgical intervention. CONCLUSION: According to the literature massive hemorrhage of the upper digestive system can rarely be caused by gastrointestinal stromal tumor of the stomach. It is shown that abundant hemorrhage of the upper digestive tract can be caused with gastric gastrointestinal stromal tumor. Surgical resection is the main form of treatment of gastrointestinal stromal tumors of the digestive system and bleeding from these tumors caused by failure of endoscopic hemostasis.