Customized alloplastic cranioplasty of large bone defects by 3D-printed prefabricated mold template after posttraumatic decompressive craniectomy: A technical note.

Background: Manufacturing of customized three-dimensional (3D)-printed cranioplastic implant after decompressive craniectomy has been introduced to overcome the difficulties of intraoperative implant molding. The authors present and discuss the technique, which consists of the prefabrication of silicone implant mold using additive manufacturing, also known as 3D printing, and polymethyl methacrylate (PMMA) implant casting. Methods: To reconstruct a large bone defect sustained after decompressive craniectomy due to traumatic brain injury (TBI), a 3D-printed prefabricated mold template was used to create a customized PMMA implant for cranial vault repair in five consecutive patients. Results: A superb restoration of the symmetrical contours and curvature of the cranium was achieved in all patients. The outcome was clinically and cosmetically favorable in all of them. Conclusion: Customized alloplastic cranioplasty using 3D-printed prefabricated mold for casting PMMA implant is easy to perform technique for the restoration of cranial vault after a decompressive craniectomy following moderate-to-severe TBI. It is a valuable and modern technique to advance manufacturing of personalized prefabricated cranioplastic implants used for the reconstruction of large skull defects having complex geometry. It is a safe and cost-effective procedure having an excellent cosmetic outcome, which may considerably decrease expenses and time needed for cranial reconstructive surgery.

Combined Microsurgical, Endoscopic and Neuronavigation Assisted Transseptal- Transsphenoidal Resection of Pituitary Tumors.

OBJECTIVE: To describe the technical nuances of multimodal transseptal-transsphenoid surgery for pituitary tumors using a combination of microneurosurgery, neuroendoscopy, and electromagnetic neuronavigation. MATERIALS AND METHODS: A transnasal approach to the sella is performed endoscopically and widely exposed by an otolaryngologic surgeon. Surgery is next performed by the neurosurgeon with microscope and neuronavigation for microsurgical resection of pituitary tumors. Neuroendoscope is also used at the end of surgery to confirm tumor resection and inspect operative site. During surgery, the patient's head, angle and height of the microscope, and position of the table are repositionable to allow for multiple angle views. Abdominal fat harvested prior to the procedure is used to ensure cerebrospinal fluid seal. RESULTS: The senior author (KIA) has used the combined approach with 84 consecutive patients. Radical resection was achieved in 66 patients, subtotal in 11, and partial in 7. There were no perioperative complications. Six patients experienced postoperative transient diabetes insipidus. The pituitary gland and stalk were preserved in all cases. Visual symptoms were improved in 78% and endocrinological symptoms in 56% of cases. CONCLUSION: This combined approach is safe and effective. It increases the efficacy and radicality of surgical resection, helps to preserve the pituitary gland, and improves and resolves preoperatively altered patient hormonal function and impaired vision. It also reduces complications, provides less postoperative pain and discomfort, reduces the surgery time, and enables a shorter hospital-stay.

CSF-Related Complications After Intradural Spinal Tumor Surgery: Utility of an Autologous Fat Graft.

OBJECT: The incidence of cerebrospinal fluid (CSF)-related complications after intradural spinal tumor (IST) surgery is high and reported in up to 18% of patients. However, no efficient way to prevent those complications has been reported so far. Treating these complications may require prolonged bed rest, re-exploration, external lumbar drain, use of antibiotics, and possible precipitation of other complications. To alleviate the risk of CSF-related complications, we prospectively adopted the intraoperative use of autologous fat grafting after IST surgery. METHODS: This is a perspective analysis of 37 cases (out of 40 cases series) that a prospective use of abdominal fat autograft was applied during dural closure. After the tumor was resected and the dura closed, we used the Valsalva maneuver to ensure watertight closure. CSF leak was prevented with the enforcement of suture with a fat autograft as necessary. In addition a thin layer of fat tissue was then placed over the dura to obliterate any dead space. Fibrin glue was then applied over the graft. Filling the dead space with the fat graft prevented a low-pressure space in which CSF could pool and form a pseudomeningocele. RESULTS: After adopting the fat autograft technique, we did not observe any post-surgery CSF-related complications in any of these patients. CONCLUSIONS: The prospective use of autologous fat grafting can ensure watertight dural closure and obliterate the dead space created during surgical exposure and bone removal. This technique significantly reduces, and may completely eliminate, postoperative CSF-related complications in patients with ISTs.

Management and prognosis of primary cerebral melanocytic tumors. A case report and systematic review.

Primary melanocytic cerebral tumors form a spectrum of different lesions that range from benign to extremely malignant, such as an intracranial melanoma. This article points out some characteristics of primary melanocytic cerebral tumors and discusses their management and prognosis, based on a systematic literature review and a case of primary cerebral malignant melanoma.Because the biological characteristics of primary melanocytic cerebral tumors remain unclear, it appears that total surgical resection of the tumor followed by oncologic treatment is the mainstay of the management. The prognosis still depends on the degree of malignancy.

Thoracic epidural analgesia for radical cystectomy improves bowel function even in traditional perioperative care: a retrospective study in eighty-five patients.

Radical cystectomy is associated with significant morbidity and mortality due to complex surgery and comorbidities associated with advanced age of patients. In contrast to the surgery, which is clearly the procedure of choice for patients with invasive bladder cancer, the opti- mal anesthesiologic method is still under debate. Therefore, we retrospectively analyzed 85 patients having undergone radical cystectomy at our institution, either under combined epidural-general anesthesia (CEGA) or opioid based general anesthesia (GA). The intraoperative blood loss was significantly lower in CEGA group (497.37 ± 354.13) than in GA group (742.31 ± 403.69; p = 0.006), due to induced hypotension. Consequently, blood transfusion requirements were lower in CEGA group (107.20 ± 263.92) than in GA group (388.18 ± 321.32; p = 0.001). The incidence of postoperative ileus was also lower in CEGA group (p = 0.024). There was no difference in analgesic efficacy, but a trend towards lower incidence of venous thrombosis and infection was noticed. The results of our study suggest that epidural anesthesia might have specific advantages in patients undergoing radical cystectomy.

[Perioperative disorders of mental functions]. / Perioperacijski poremecaji mentalnih funkcija.

Mental disorders are characterized by disturbances of thought, perception, affect and behavior, which occur as a result of brain damage. Recognizing and treating these conditions is necessary not only for psychiatrists but for all physicians. Disorder of mental function is one of the most common associated conditions in intensive care unit (ICU) patients. However, disturbances of mental function often remain unrecognized. In ICU patients, different types of mental function disorders may develop. They range from sleep disorders, severe depression, anxiety, posttraumatic stress disorder (PTSD) to cognitive disorders including delirium. The causes of mental dysfunction in ICU patients can be divided into environmental and medical. Cognitive disorders are related to mental processes such as learning ability, memory, perception and problem solving. Cognitive disorders are usually not prominent in the early postoperative period and in many cases are discovered after hospital discharge because of difficulties in performing everyday activities at home or at work. The etiology of postoperative cognitive impairment is unclear. Older age, previous presence of cognitive dysfunction, severity of disease, and polypharmacy with more than four drugs are some of the risk factors identified. Delirium is a multifactorial disorder. It is an acute confusional state characterized by alteration of consciousness with reduced ability to focus, sustain, or shift attention. It is considered as the most common form of mental distress in ICU patients. Nearly 30% of all hospitalized patients pass through deliriant phase during their hospital stay. Delirium can last for several days to several weeks. Almost always it ends with complete withdrawal of psychopathological symptoms. Sometimes it can evolve into a chronic brain syndrome (dementia). The causes are often multifactorial and require a number of measures to ease the symptoms. Delirious patient is at risk of complications of immobility and confusion, leading to a high prevalence of irreversible functional decline. An interdisciplinary approach to delirium should also include family or other caregivers. In the diagnosis of delirium, several tests are used to complement clinical assessment. Among the most commonly used are the Confusion Assessment Method (CAM-ICU) and Clinical Dementia Rating (CDR) test. Depression is a common disorder among patients treated at ICU and occurs due to the impact of the disease on the body and the quality of life, independence, employment and other aspects of life. Depression can interfere with the speed of recovery, affects the postoperative quality of life, and in a certain number of patients may lead to suicidal thoughts and intentions. Phobias and generalized anxiety are the most common anxiety disorders. Generalized anxiety disorder is characterized by strong, excessive anxiety and worry about everyday life events. PTSD is delayed and/or protracted response to a stressful event or situation, extremely threatening or catastrophic nature, which is outside the common experience of people and would hit or traumatize almost all people. Treatment of delirium and other disorders is causal. The causes of psychosis are often multifactorial and require a number of measures to ease symptoms. The primary objective of prevention is appropriate therapy and correction of potential imbalances possibly underlying disturbances, stabilization of vital functions as well as early return to daily activities. Doctors and other medical staff must be aware of the importance and consequences of behavioral and emotional disorders in critically ill patients. Additional research is needed to discover the ways to prevent and/ or reduce the frequency and severity of the consequences and treatment of cognitive and emotional disorders.

The effect of spinal versus general anesthesia on postoperative pain and analgesic requirements in patients undergoing peripheral vascular surgery.

The optimal anesthetic technique for peripheral vascular surgery remains controversial. The purpose of this study was to evaluate the effect of spinal versus general anesthesia on postoperative pain, analgesic requirements and postoperative comfort in patients undergoing peripheral vascular surgery. A total of 40 patients scheduled for peripheral vascular surgery were randomly assigned to two groups of 20 patients each to receive general anesthesia (GA) or spinal anesthesia (SA). In GA group, anesthesia was induced using thiopental and fentanyl. Vecuronium was used for muscle relaxation. Anaesthesia was maintained with isoflurane and nitrous oxide. In the SA group, hyperbaric 0.5% bupivacaine was injected into the subarachnoid space. Postoperative pain was assessed for 24 hours by a visual analog scale during three assessment periods: 0-4, 4-12 and 12-24 h as well as analgesic requirements. Patients were also asked to assess their postoperative state as satisfactory or unsatisfactory with regard to the pain, side effects and postoperative nausea and vomiting. Visual analogue scale (VAS) pain score was significantly lower in the group SA compared with group GA. This effect was mainly due to the lower pain score during the first study period. The patients received general anesthesia also reported a significantly higher rate of unsatisfactory postoperative comfort than those receiving spinal anesthesia. We conclude that spinal anesthesia is superior to general anesthesia when considering patients' satisfaction, side effects and early postoperative analgesic management.

[Laparoscopic cholecystectomy in patients with ventriculoperitoneal shunt]. / Laparoskopsko odstranjenje zucnog mjehura u bolesnika s ventrikuloperitonealnim kateterom.

Because of development of laparoscopic surgery and by knowing of its pathophysiological effects on organism, indications for laparoscopic surgery have become more extensive, so this method is today used for therapeutic and diagnostic procedures. Although ventriculoperitoneal shunt is not normally considered a contraindication for laparoscopic surgery, pneumoperitoneum is described as a cause of raised intracranial pressure. Since 1992 when the first laparoscopic cholecystectomy was done at the University Department of Surgery of Sveti Duh Clinical Hospital in Zagreb, three patients with implanted ventriculoperitoneal shunt were managed successfully laparoscopically. In all three patients, there were no complications during and after the surgery. In this paper we present our experience of three cases and short review of the literature.

Morphometric characteristics of thyroid cartilage in people of Eastern Croatia.

The aim of this research was to describe thyroid cartilage morphometry in the population of Eastern Slavonia in detail. The research was carried out on 68 samples of adult thyroid cartilages. There was statistically significant difference between all analysed parameters in male and female samples, except for the distance between the superior horns tips. All parameters had greater values in men, except for the thyroid angle, which was greater in women. There was significant correlation between most of the measured parameters. The strongest correlation was noticed in the distance between the horns at all measured levels and between the pairs of parameters measured for the left and right side respectively. The difference of our results in comparison to the results obtained by other researchers is probably caused by the fact that the measurements were taken on the samples obtained from different populations.