[A rare case of an acute abdomen patient with gangrene of the colon as a complication of systemic lupus erythematosus]. / Zriedkavá náhla brusná príhoda - gangréna kolonu ako komplikácia systémového lupus erythematosus.

The authors present a case report of a 39-year-old woman with acute abdomen - a comorbid patient with systemic lupus erythematosus, chronic renal insufficiency as a complication of lupus nephritis, included in a haemodialysis programme. The patient had also undergone transplantation of the left kidney in the past. She was initially admitted to the Department of Traumatology for a total endoprosthesis procedure due to bionecrosis of the head of the thigh bone. Postoperatively, the patients condition was complicated by gangrene of the colon confirmed by CT scan and during the operation. The patient was operated on - subtotal colectomy, terminal ileostomy and left-sided ovariectomy was performed. The postoperative course was complicated by perforation of the jejunum which was sutured. The patient was admitted to ICU and, after recovery, to our surgical department. Because of the metabolic disturbance she was treated in the internal medicine department. After 60 days she was discharged in a good condition, walking and with full per os realimentation.Key words: lupus erythematosus gangrene of the colon acute abdomen.

A pilot study on peak systolic velocity monitoring of fetal anemia after administration of chemotherapy during pregnancy.

OBJECTIVES: To monitor fetal anemia during administration of chemotherapy to the fetus's mother. STUDY DESIGN: Between 2007 and 2012 six patients with malignancy diagnosed during pregnancy were included in our prospective study. For evaluation of fetal anemia, peak systolic velocimetry (PSV) of the middle cerebral artery is considered the best method. The patients were repeatedly examined one day before and on the third day after the administration of chemotherapy. At least three measurements were performed and the highest value was used as appropriate. Multiples of the median (MoM) were calculated using the website http://www.perinatology.com/calculators/MCA.htm. When the MoM reached 1.29, moderate anemia was diagnosed. RESULTS: The women's average age was 30 years. The average gestational age at diagnosis was 20.7 weeks of pregnancy. Borderline fetal anemia was detected in only in one patient. After delivery newborns were examined by standard pediatric evaluation and blood count was provided. There was no evidence of any newborn anemia. CONCLUSIONS: Chemotherapy administered during pregnancy is becoming more frequent due to increasing knowledge and data on such cases. Close monitoring of the fetus should be performed in specialized centers. For detection of chemotherapy-induced anemia, PSV measurement should be employed.

Use of intraabdominal VAC (Vacuum Assisted Closure) lowers mortality and morbidity in patients with open abdomen.

OBJECTIVE: Authors compare two groups of patients with open abdomen. The objective is to compare and evaluate two treatment modalities, namely Kern laparostomy and vacuum-assisted closure in terms of mortality, closure of abdominal wound, and fistula management, all these stratified by BMI and CRP. BACKGROUND: Open abdomen can be considered a "patient salvage technique", used in patients with abdominal sepsis, as well as in patients with abdominal compartment syndrome, and in damage control surgery. Various management techniques are known, of which Kern laparostomy is most widely used. Newer techniques using negative pressure have emerged, still waiting for their wider acceptance and use. The authors present their study, in which they compare Kern laparostomy and intraabdominal VAC in patients with open abdomen. MATERIAL AND METHODS: Study consists of 44 patients treated at the authors´ clinics, while group KERN consisted of patients managed by Kern laparostomy, and group VAC was managed by intraabdominal VAC. The groups were compared in terms of mortality, abdominal closure, appearance of enteroatmospheric fistulas, primary closure of fistulas, and possibility of diversion of enteral contents. All outputs were stratified by CRP (C-reactive protein) and BMI (Body Mass Index). RESULTS: In VAC group, a significant decrease in mortality was seen, as well as significantly higher closure of abdominal wall, and significantly higher possibility of diversion of enteral content from fistulas. No statistically significant findings were observed in stratification with CRP and BMI. CONCLUSION: Intraabdominal VAC offers patients lower morbidity and mortality and should be defined as a treatment of choice in patients with open abdomen (Tab. 4, Fig. 3, Ref. 15).

Laparoscopic splenectomy in pregnancy - from contraindication to golden standard.

Laparoscopy has been holding its strong position within visceral surgery for decades. For several diagnoses, laparoscopy became the method of first choice. Laparoscopic splenectomy is a standardized procedure in patients indicated mostly due to haematological disorders. Apart from bleeding disorders, pregnancy used to be recognized as a contraindication to laparoscopic surgery. Splenic cysts are extremely rare during pregnancy; only seven cases have been described in literature. The authors had to deal with a patient treated and observed by haematologist for haemorrhagic splenic cyst and hypersplenism. Because of her low compliance, the patient did not undergo splenectomy in the past. Due to the gradual progression of disease and furthermore because of her pregnancy, the question of splenectomy became semi-urgent. The patient underwent laparoscopic splenectomy in second trimester, while not only the surgery alone, but also her early postoperative period and remaining pregnancy passed off uneventful. The authors suggest that even in pregnancy, the patients suffering from serious haematological disorders necessitating splenectomy could safely benefit from the advantages of laparoscopic approach, which also in these cases could become a gold standard (Fig. 2, Ref. 13).

Intra-abdominal hypertension and acute pancreatitis.

Intra-abdominal hypertension (IAH) contributes to organ dysfunction and leads to the development of the abdominal compartment syndrome (ACS). IAH and ACS are relatively frequent findings in patiens with severe acute pancreatitis (SAP) and are associated with deterioration in organ functions. The most affected are cardiovascular, respiratory and renal functions. The incidence of IAH in patients with SAP is approximately 60-80%. There is an accumulating evidence in human and animal studies that changes of perfusion, particularly to the microvasculature, are crucial events in the progression of acute pancreatitis (AP). The perfusion of the small and large intestine is impaired due to reduced arterial pressure, increased vascular resistence and diminished portal blood flow. Bacterial translocation has been described in patients with ACS, and this may apply to patients with SAP. Approximately 30-40% of SAP patients develop ACS because of pancreatic (retroperitoneal) inflammation, peripancreatic tissue edema, formation of fluid collections or abdominal distension. Surgical debridement was the preferred treatment to control necrotizing pancreatitis in the past. However, the management of necrotizing pancreatitis has changed over the last decade. The main objective of this article is to describe the association between IAH and AP and to emphasize this situation in clinical praxis as well (Fig. 1, Ref. 38).

[Diverticulum of the greater curvature of the stomach as a cause of anaemia]. / Divertikul velkej kurvatúry zalúdka ako prícina anemizácie.

Gastric diverticula represent a rare pathological condition. They are usually asymptomatic and are often found only by accident during radiologic or endoscopic examination, or during autopsy. Their incidence is low and evenly distributed between men and women. Gastric diverticula are most frequently located on the posterior wall of the cardia and on the lesser curvature of the stomach. The authors present a case study of a 58-year-old patient with severe sideropenic anaemia, a marked weight loss and non-specific dyspeptic symptoms. The suspicion of a diverticulum was raised by a gastroenterologist during gastrofibroscopy and confirmed by a radiologist following a dynamic CT examination of the stomach. The diverticulum had an atypical location beneath the cardia on the greater curvature. The patient was indicated for surgery. During conventional laparotomy, resection of the diverticulum was performed using a linear stapler. The postoperative course was uneventful. Histology confirmed a false diverticulum. The patient is doing well, is asymptomatic, has put on 7 kg since the operation and her blood count is normal.

Rare conditions of gastrointestinal bleeding.

The aim of this paper is to analyze and discuss an infrequent topic, i. e. rare conditions of gastrointestinal bleeding.Bleeding from gastrointestinal system is a common cause of acute abdomen and the most frequent causes are generally known.Clinicians, first of all emergency medicine staff, surgeons and internists (gastroenterology specialists), general practitioners, or less frequently other specialists, sometimes meet with less common causes of acute or chronic bleeding from gastrointestinal organs. It is quite important to be aware of the possibility the bleeding being caused by some rare condition, which is not so often met in medical practice, because of their great diagnostic and therapeutic problem. The low index of expectation of such a rare etiological unit could be the reason why destiny of such patients can be extremely problematic and why clinicians may fail at management of these patients (Fig. 4, Ref. 8).

[Cholecystoduodenal fistule as a consequence of calculouse cholecystitis in a female elderly patient]. / Cholecystoduodenálna fistula ako dôsledok kalkulóznej cholecystitídy pacientky vysokého veku (Kazuistika).

Bilioenteric fistules are fairly rare, cholecystoduodenal fistules are the commonest type, accounting for 70-80% of cases. Cholecystoduodenal fistules usually occur as a consequence of cholecystolithiasis and cholecystitis. Their symptomatology is atypical and fistules are frequently detected during surgery. Preoperative diagnostic procedures include visualization methods, such as US, CT, MRI, resp.ERCP. Both conventional laparotomy, as well as laparoscopy may be used in the treatment of the disease. Each of the methods has its pros and cons. The authors present a case review of a 85-year old female patient with a cholecystoduodenal fistule, diagnosed prior to the surgical procedure. Conventional laparotomy was elected as a method of treatment and the outcome was successful.

Rectal prolapse.

It is not so much the diagnosis that offers the surgeon a wide range of opportunities in the technical solutions of rectal prolapse. Currently there are at least 130 different techniques used in the surgical treatment of rectal prolapse and in fact none of these procedures has been shown most effective for any one patient. In this study, our intent is to describe the experiences of the authors with the treatment of rectal prolapse, to estimate the actual level of expertise of the surgeons in treatment of rectal prolapse, and to describe in which way to proceed in the future (Tab. 4, Fig. 3, Ref. 27). Full Text (Free, PDF) www.bmj.sk.

Specific aspects of acute pancreatitis.

Acute pancreatitis (AP) is still a disease with a significant mortality rate, mainly concerning the severe forms of this disease. Mortality in acute pancreatitis has 2 peaks. The first peak is caused by systemic inflammatory response syndrome (SIRS), which takes place in the first week of the disease. Sepsis is responsible for a second peak. It begins 1 to 3 weeks after the onset of acute pancreatitis and is caused by pancreatic superinfection. Sepsis as a result of infected pancreatic necrosis is the most serious complication in late phase of severe acute pancreatitis (SAP) and contributes to the high mortality rate of this disease. This complication is thought to be a result of the bacterial translocation from the gastrointestinal tract. The damage of the microvessels and the subsequent onset of systemic cascade reactions plays also an important role during acute pancreatitis. Recent experimental data suggest also the role of nervous system in etiopathogenesis of acute pancreatitis. We assume that the diagnostic and treatment strategy can not improve without a thorough knowledge of the physiology and patophysiology of acute pancreatitis. Therefore the aim of this paper is to highlight certain specific situations of high importance that are activated in the human organism during acute pancreatitis (Ref. 100).

Diagnosis and management of local and locoregional recurrence of colorectal carcinoma.

All intraabdominal forms of recurrence of colorectal carcinoma, other than metastases in the liver, are considered a locoregional treatment failure. Maximum frequency of local recurrence of CRC occurs in the first two years following the initial potentially curative resection. Intensive follow-up in this period is therefore reasonable. It should be based on case history, clinical examination and examination of tumor markers (particularly CEA). Other examinations are indicated only for patients with abnormal findings or during normal annual check-ups. The salvage surgery for CRC recurrence covers a large scale of surgical performances from limited local resections up to extensive surgery including pelvic exenteration and peritonectomy. The potentially curative resection (R0 and R1) of colorectal carcinoma is a sole confirmed factor that has a direct positive influence on the overall survival of patients (Fig. 5, Ref. 21).

Gastrointestinal stromal tumors.

In the last 3 years 9 patients with gastrointestinal stromal tumors (GIST) underwent surgery at our department. All cases were with very atypical process. From these patients 3 interesting cases are described in more details. A 75-years-old woman with gastroscopically verified endoluminal tumour in the proximal third of stomach, 6x7 cm, 76-years-old man with a large endoluminal tumour in D2-D3 part of the duodenum, 4x4 cm, and 62-years-old man with verified extraluminal tumour by CT examination in the middle part of stomach. In all cases, gastrointestinal stromal tumour was histologically confirmed. Work is well photo-documented pre-surgically with endoscopic and CT-findings and during surgery: individual steps during the removal of these tumours. In assessment of the size and number of mitoses, tumours belonged to a group with highly malignant potential. Patients are regularly checked in 3-months intervals and also examination by positron emission tomography was performed--it seems to have the best demonstrability of possible relapse. All three patients live and are subjectively and objectively without significant problems (Tab. 5, Fig. 5, Ref. 7). Full Text (Free, PDF) www.bmj.sk.

[Short bowel syndrome and limits of small intestinal resections]. / Short bowel syndróm a limity resekcnej chirurgie tenkého creva.

Short bowel syndrome (SBS) is a malabsorption syndrome resulting from anatomical or functional loss of a significantly long small intestinal segment. A loss over 80% of the small intestinal length is associated with increased urgency for supportive parenteral nutrition and results in reduced overall survival of the patients. The ileocaecal valve (valvula Bauhini) loss results in bacterial contamination of the small intestine, affecting tolerability of the oral, ev. enteral nutrition. The authors present a case review of a 27-year-old patient with repetitive small intestinal resections. The last procedure included the Bauhini valve and, finally, the patient has only 70 cm of the jejunum preserved.

[Biliary ileus--potential complication of cholecystolithiasis]. / Biliárny ileus-- nad'alej reálna komplikácia cholecystolitiázy.

Biliary ileus is a rare complication of cholecystolithiasis. The condition occurs predominantly in the elderly with incidence rates of 1-4%, according to the literature data. Most commonly, it develops as a complication of cholelithiasis which remained untreated or was managed conservatively, or as a complication of a gallbladder decubitus necrosis. The condition results in a cholecysto-duodenal fistula. In this case, the cholecystolithiasis is latent or is clinically manifested in a third of the patients. A total of 1560 cholecystectomies (1345 L-CHE and 215 conventional CHE) were performed in our clinic during a five-year period. Biliary ileus was an indication for operation only in two subjects, during the studied period. In the both cases, the diagnosis was established intraoperatively, although upon re-examination of the visualization modalities views (upright native abdominal views, CT scans) the authors concluded that the primary cause of the ileus could have already been identified, based on the above views.

Is local excision due to rectal carcinoma a safe operation?

Though the treatment of patients with polypoid lesions of rectum is most frequently based on endoscopic approach, there are many cases that cannot be solved endoscopically and therefore must be treated by surgeons. In the past there were several possibilities of how to operate. In reachable localisations even local operation could be performed, however with varying measures of local recurrences and survival. The aim of this article is to draw attention to the complex topic of local excisions for rectal neoplasms and at the same time to analyse the review of indication criteria and evaluate the drawbacks of this operative method in our conditions (Tab. 3, Fig. 1, Ref 14).

Conditions responsible for small bowel resection.

The authors deal with the problems of surgery of small intestine. They analyze causes leading to small bowel resection, including small intestinal obstructions, tumors, diverticles, Crohn's disease and traumas of small intestine, in a group of patients operated at Ist Department of Surgery, University Hospital, Commenius University, Bratislava, during the last 30 years. Authors also discuss the problems of short bowel syndrome (SBS) as the consequence of an extensive small bowel resection, reporting the surgical approach to its therapy. (Tab. 1., Ref. 5.)

Iatrogenic esophageal perforation--diagnosis and therapy.

The diagnosis and therapy of iatrogenic esophageal perforation in a group of patients treated for this condition. During the period of 1994-2002 twelve patients suffered iatrogenic esophageal perforation with a mortality rate of 33.3%. The therapeutical approach consisted of either primary repair of the perforation, drainage of the mediastinum and pleural cavity or inserting a stent. (Ref. 6.).

Transoral application of EEA stapler after subtotal oesophagectomy.

OBJECTIVE: To describe a new transoral technique of cervical oesophagogastric and oesophagojejunal anastomoses using the EEA stapler. DESIGN: Prospective clinical study. SETTING: University Hospital, Bratislava, Slovakia. SUBJECTS: Two patients with squamous cell carcinoma of the middle and distal third of the oesophagus. INTERVENTIONS: Transhiatal subtotal oesophagectomy without thoracotomy, and cervical oesophageal anastomosis by transoral EEA stapling. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: Transoral stapling was successful in both patients with no anastomotic leaks. The patients were discharged on the 14th and 21st postoperative days, respectively. CONCLUSIONS: Transoral stapling of the cervical anastomosis gave good results in two patients. More development and evaluation are needed.

[Reconstruction of the gastrointestinal tract after esophagogastrectomy]. / Rekonstrukcia gastrointestinálneho traktu po ezofágogastrektómii.

The authors deal with the problems of reconstruction of gastrointestinal continuity after esophagectomy. They present the advantages of the stomach which is an especially good mediastinal as well as retrosternal substituent. One case of restoration of gastrointestinal continuity after both esophagectomy and gastrectomy by a jejunal loop with anastomosis on the neck is also presented.

[Systemic amyloidosis as a cause of so-called atherosclerotic hemorrhagic complications]. / Systémová amyloidóza ako prícina tzv. aterosklerotických krvácavých komplikácií.

BACKGROUND: A survey of the pathogenesis, diagnostics and treatment of amyloidosis is presented, illustrated by long-term clinical experience with the treatment of 28 patients with primary amyloidosis, 4 patients with familial and 7 patients with secondary amyloidosis. METHODS AND RESULTS: To all patients combined treatment of glucocorticosteroids and cytostatics was administered. For primary amyloidosis methylprednisolone, vincristine (oncovine), cyclosphosphamide, alkeran, chlorethylnitrosourea (MOCCA), and in secondary amyloidosis cyclophosphamide, vincristine, prednisone (CVP). In all patients, this treatment was combined with dimethylsulphoxide treatment (DMSO) administered in intravenous infusion (5 g/100 ml saline) for 3-5 days before the start of cytostatic therapy. In primary amyloidosis the median of survival was 48 months, in secondary amyloidosis the median survival was 72 months. CONCLUSIONS: The authors emphasise the need of an early diagnosis and start of comprehensive therapy completed in recent years successfully with immunomodulatory therapy using hydrolytic enzymes (WOBE MUGOS).