C-reactive protein as an early predictor for anastomotic leakage in elective abdominal surgery.

BACKGROUND: Anastomotic leakage (AL) represents a serious complication after abdominal surgery. Therefore, it is important to detect it early before it becomes clinically apparent. The predictive value of C-reactive protein (CRP) as a marker of infective postoperative complications, particularly in the form of anastomotic leakage, has been investigated by several authors with promising results. The aim of this study was to evaluate the diagnostic accuracy of C-reactive protein in predicting anastomotic leakage. METHODS: The serum CRP level, white blood cell (WBC) count, and body temperature (BT) of 156 patients who underwent elective abdominal surgery with primary anastomosis were monitored daily until postoperative day (POD) 7. We recorded all postoperative complications and analyzed the data. Diagnostic accuracy of CRP with regard to development of AL was assessed by receiver operating characteristic curve analysis. RESULTS: Fifteen patients (9.6 %) developed anastomotic leakage. CRP was significantly higher every day during the first 7 postoperative days in patients who developed AL compared with those patients who did not develop complications, whereas the WBC count and BT were not. A CRP cutoff value of 135 mg/l on POD 3 yielded a sensitivity of 73 %, a specificity of 73 %, and a negative predictive value of 95.4 % for the detection of AL. CONCLUSIONS: According to our results, values of CRP less than 135 mg/l on POD 3 may contribute to a safe discharge from hospital. Patients with CRP values higher than 135 mg/l on POD 3 require prolonged hospitalization and an intensive search for infective complications, particularly AL.

Early prediction of symptomatic hypocalcemia after total thyroidectomy.

BACKGROUND: Hypocalcemia is the most common postoperative complication after total thyroidectomy. The aim of this prospective study was to determine biochemical parameters in the early postoperative period that could identify patients with significantly increased risk of symptomatic hypocalcemia development. METHODS: The study included 100 individuals undergoing total thyroidectomy from January to May 2009. In all patients PTH, calcium, inorganic phosphate, magnesium, and albumin levels were measured immediately preoperatively, 30 minutes postoperatively and every morning for the following five days. RESULTS: Clinically significant hypocalcemia was observed in 19% of all cases. Fall of the iPTH values by more than 88% from preoperative values, 30 min after completion of the surgery, showed 100% sensitivity and 100% specificity for the occurrence of symptomatic hypocalcemia. CONCLUSIONS: According to our results immediate postoperative measurement of the iPTH may be considered as a useful method to predict with high certainty which patients will need calcium supplementation, and to separate them from patients who can be safely and early discharged.

Lipid-bound sialic acid, prostaglandin E and histamine in head and neck cancer.

Blood concentration of lipid-bound sialic acid (LBSA), prostaglandin E (PGE) and histamine were determined in 37 patients with carcinoma of hypopharynx and larynx (supraglottic and glottic), in 12 non-cancer patients and in 10 healthy subjects. The concentration of LBSA was significantly increased in 94.4% cancer patients preoperatively and fell to somewhat lower levels within 1 month after tumour resection. In patients with complete tumour resection and no tumour recurrences within 2 years, it steadily decreased thereafter, reaching normal levels within 6-24 months after surgery, whereas in patients with tumour recurrences or incomplete tumour resection it rose again within 6 months after tumour resection. Similarly, the concentration of PGE was significantly increased in about two thirds of cancer patients (67.6%) preoperatively, dropped significantly within 1 month after tumour resection and rose again in patients with tumour recurrences. Preoperative histamine concentration was decreased in 24.3% of cancer patients and postoperatively it rose both in patients with or without tumour recurrences.

Prognostic significance of plasma prostaglandin E concentration in patients with head and neck cancer.

Plasma prostaglandin E (PGE) levels were determined by radioimmunoassay in 53 patients with various stages (II, III, and IV) of hypopharyngeal and laryngeal squamous cell carcinoma, in 12 non-cancer patients and in 10 healthy volunteers. The mean PGE concentration was somewhat higher in non-cancer patients (mean +/- SD = 34.6 +/- 5.37 pg/ml) than in healthy subjects (28.1 +/- 4.96 pg/ml). In spite of a high data variability, the mean preoperative PGE levels in cancer patients were proportional to the stage of the disease and higher than in non-cancer patients (41.2 +/- 19.7 pg/ml, 52.8 +/- 26.7 pg/ml and 82.0 +/- 34.9 pg/ml in stages II, III and IV respectively). The mean plasma PGE concentration significantly decreased for all tumour stages 15-30 days after surgical removal of the tumour, but rose again in some patients within 6-18 months after surgery. The incidence of tumour recurrences 6 and 18 months after surgery was significantly higher in patients with an increased preoperative PGE level (greater than 43.3 pg/ml) than in those patients with a PGE level within the normal range (less than 43.3 pg/ml). The mortality was also higher in the former group, but the difference did not reach the level of significance. Similarly, the mean preoperative and most postoperative concentrations of PGE were significantly higher in patients in whom tumour recurred within 18 months than in tumour-free patients.

Discriminant analysis of pre- and intraoperatively detected prognostic factors influencing lymph node involvement in patients with colorectal carcinoma.

BACKGROUND/AIMS: The aim of this study was to establish whether, and to what extent, pre- and intraoperatively detected characteristics (demographic, anamnestic and laboratory data) and tumor characteristics can be used in the assessment of regional lymph node involvement in patients with colorectal carcinoma. The assessment also included the number of lymph nodes involved in patients with positive lymph nodes. Considering that the number of obtained lymph nodes widely varies in resected specimens, assessment parameters also included the percentage of the involved lymph nodes within the total population of lymph nodes. METHODOLOGY: From 1992-1993, 46 patients with carcinoma of the rectum and sigmoid colon were studied, with a total number of 736 lymph nodes evaluated. Out of the total number of lymph nodes, 577 (78.4%) were benign and 159 (21.6%), malignant. Data were analyzed by multi-variant statistical methods, namely: discriminant analysis and multiple regression with the aid of SPSS/PC+ software. RESULTS: For this patient group, we evaluated the following potentially predictive factors for lymph node involvement: age; serum hemoglobin, albumin and alkaline phosphatase levels; weight loss; and the primary tumor localization characteristics: histologic type, macroscopic growth pattern and depth of tumor invasion of the bowel wall. We found that there was no difference in the prediction of regional lymph node involvement between analysis of the aforementioned parameters and analysis of the isolated discriminators only. CONCLUSION: A predictability likelihood of 83.78% greatly surpasses the acceptable error tolerance level of 5%. Correlation of demographic, anamnestic and laboratory data about the patient and the characteristics of the primary tumor cannot be used in distinguishing malignant lymph nodes from benign ones. These data cannot be the basis for exact intraoperative staging and thus cannot be significant criteria for decision-making about operative treatment modalities.

Hearing levels and age in cleft palate patients.

Tonal audiometry was used to compare hearing levels in patients with bilateral cleft lip and palate (BCLP) (57 patients). unilateral cleft lip and palate (UCLP) (124 patients) and isolated cleft palate (ICP) (62 patients), and according to age groups. Patients with isolated cleft palate showed greater improvement in hearing level with age than patients with UCLP and BCLP; as adults they showed the lowest frequency of ears with hearing level of less than 40 dB, and the highest frequency of ears with hearing levels of 11-20 dB. Patients with BCLP had a higher frequency of ears with a hearing level of 21-40 dB during early childhood and adult age than patients with ICP. Patients with UCLP and BCLP showed a slower decrease with age in the frequency of ears with hearing loss than patients with ICP; the hearing level in patients with UCLP and BCLP improved only in groups with hearing levels of 21-40 dB, while those with hearing levels above 40 dB showed no significant improvement with age.

Morphological changes of stria vascularis in congenital hearing impairment due to membranous labyrinth underdevelopment.

Congenital malformations of the inner ear may involve either the bone and membranous labyrinth or the membranous labyrinth alone. The same labyrinth structures can be affected with an acquired disease, toxaemia or viral labyrinthitis, for instance, with the same or very similar histologic findings. So far, there have been no studies examining the possible morphological changes of stria vascularis in different diseases with sensorineural anomalies. We examined the temporal bones of 16 patients, from whom audiograms and history data on hearing impairments present at birth or later were obtained previously. When malformation of the membranous labyrinth was caused by a congenital anomaly, three groups of typical changes of stria vascularis were observed: i) pseudocystic formation which replaced the strial tissue, with dark-stained deposits: ii) accumulation of endothelial cells or irregularly shaped cells in the basal coil of the cochlea: and iii) atrophy of the stria vascularis tissue in all coils. These findings may prove important for accurate diagnostic procedures.

Tympanometric findings in cleft palate patients: influence of age and cleft type.

Tympanometry was analysed according to cleft type with respect to age in 239 cleft palate patients (57 with bilateral cleft lip and palate (BCLP)), 122 with unilateral cleft lip and palate (UCLP) and 60 with isolated cleft palate (ICP). The frequency of type B tympanograms was 46.5 per cent in the BCLP group, 50.6 per cent in the UCLP group and 58.3 per cent in the ICP group. Type A tympanograms were more frequently observed in older patients (median age 11 years) in comparison to type B (median age five years; p < 0.001) and type C (median age six years; p < 0.001). The total sample showed an age-related decrease in the frequency of type B tympanograms (rs = -0.3942; p < 0.001). The frequency of type A tympanograms increased significantly with age (rs = 0.4263; p < 0.001), whereas type C was not correlated with age. In the UCLP group, the frequency of type B tympanograms decreased with age (rs = -0.4430; p < 0.001), the decrease being faster than in the BCLP group (rs = -0.3186; p = 0.001) and the ICP group (rs = -0.3378; p < 0.0001)). Type B tympanograms had the highest correlation with a hearing loss of 21-40 dB at mean hearing level at speech frequencies (MHLSF) (rs = 0.4574; p < 0.001), a lower correlation with a hearing loss of 11-20 dB (rs = 0.2184; p = 0.02) and the lowest correlation with hearing loss above 40 dB. At the ages of one to three, the frequency of type B is higher in UCLP patients than in the BCLP and ICP groups, decreasing at seven to 12, increasing again at 13 to 15, and thereafter showing a continuous decrease. In the BCLP group, the frequency of type B increased significantly at the ages of four to six and then decreased continuously from seven to 18. In ICP patients, the changes in the frequency of type B with age are not significant until the age of 15; at the age of seven, it is higher than in the BCLP and ICP groups. The type C tympanogram is not typically found in cleft palate patients and its frequency is not correlated with age. It can be presumed that each type of cleft lip and palate, due to its characteristic conditions in the epipharynx, will favour a different mode of pathophysiological development of middle-ear disease.

Pierre Robin syndrome: characteristics of hearing loss, effect of age on hearing level and possibilities in therapy planning.

Hearing loss was studied in 22 patients with Pierre Robin syndrome (PRS) aged three to 12 years (median 5.0 years). The results were compared to those obtained in 62 patients with isolated cleft palate (ICP) aged one to 27 years (median 5.5 years). Hearing loss was more frequently found in PRS (73.3 per cent) than in ICP (58.1 per cent) patients (p = 0.02). PRS patients had more ears with moderate (21-40 dB) and severe (> 40 dB) hearing loss, disturbing their social contact, with no tendency to normalization with age (Spearman r = 0.065). In contrast to PRS, ICP patients showed a significant tendency to hearing level normalization with ageing (Spearman r = -0.453; p = 0.001). Planigraphs of temporal bones showed inadequately developed pneumatization of the mastoid bone in all PRS patients and in most ICP patients. No malformation of the inner or middle ear was found in either group. PRS patients have a significantly higher risk of conductive hearing loss than those with ICP. Use of tympanostomy (ventilation) tubes is therapy of choice in patients with Pierre Robin syndrome, and it should be introduced as early as possible, even at the same time as palatoplasty.

[The site for esophageal transection in the treatment of hemorrhage from dilated esophageal veins]. / Mesto transekcije jednjaka u lecenju krvavljenja iz prosirenih vena jednjaka.

Esophageal stapler transection was performed in 15 patients with bleeding from the dilated esophageal veins in the period 1984-1988. In 7 patients operated on as urgent cases due to prolonged uncontrolled bleeding, the mortality was high--71.4%, contrary to the group of electively operated patients in whom the mortality was 12.5% with a low postoperative morbidity and successful prevention of repeated bleedings.

[Mesothelial cyst and cystic mesothelioma of the greater omentum:case report and literature review]. / Mezotelna cista i cisticni mezoteliom velikog omentuma: prikaz slucaja i pregled literature.

Mesothelial cysts and cystic mesotheliomas of the greater omentum are very rare clinical entities. About 30 cases of mesothelial cysts and only 4 cases of cystic mesotheliomas were described in the world literature so far. Over 13 years period (1987-2000), between 15,000 laparotomised adult patients, we have diagnosed one case of mesothelial cyst and one of cystic mesothelioma only. Mesothelial cyst, 7 cm in diameter, covered by regular mesothelial cells, was found accidently during gaster cancer surgery. In a 78 years old man, 30 cm in diameter cystic mesothelioma was diagnosed with immunohistochemical studies, necessarily for differentiation between cystic mesothelioma and other peritoneal cysts. Due to possible aggressive course at the diseases and tendency to recurrency, a complete surgical excision and log term follow-up are necessary.

[Cystic mesothelioma of the greater omentum]. / Cisticni mezoteliom velikog omentuma.

Peritoneal cystic mesothelioma is very rare clinical entity, and only a few cases situated on the greater omentum are described. The authors here presented two cases of the greater omentum cystic mesothelioma that were diagnosed in 260,000 adult patients hospitalized for the first time, during the fifteen year period. Cystic tumor of 30 cm in diameter was found in a 78 years old male patient, and the second one was 35 cm in diameter in female patient 56 years old. Symptomatology was not characteristic. Peritoneal pseudocyst or parasitic, lymphogen, urogenital, enteric or dermoid cyst origin was preoperatively excluded, and correct diagnosis was established upon the operative findings and immuno-histochemical investigations. In both cases keratin and vimentin were clearly positive in tumor cells, but other markers were negative (EMA, Actin, S-100, NSE, chromogranin and sinoptophysin). Cystic mesothelioma was not infiltrative and surgical treatment was simple and successful.

Intrathoracic goiter: analysis of 21 cases.

UNLABELLED: Goiters are classified into: the cervical, retrosternal, substernal and intrathoracic. The aim of research is to analysis of intrathoracic goiters (ITG) which include goiters with more than 80% of tissue in the thoracic cavity and intrathoracic thyroid choristomas. METHODS: In prospective non-randomized study were analyzed 21 consecutive patients operated on for intrathoracic non-toxic benign goiters from 1987-98. Fourteen patients with intrathoracic goiters (more than 80% of tissue in the thoracic cavity) and seven patients with intratoracic choristomas were operated. Two groups of ITG were observed according to the expressed symptomatology and surgical approach and complications of operative treatment were compared to the complications of operative treatment of 986 non-ITG non-toxic benign goiters. RESULTS: ITG represented 1.1% of the whole number of operatively treated thyroid diseases. One third of patients were asymptomatic. Commonly observed symptoms were dispnea, stridor and dysphagia and there was no significant difference in appearance of these symptoms between the two groups of ITG. In 19% of patients correct preoperative diagnosis wasn't assessed. Cervical approach with sternothomy was used in 11 patients, cervical approach with right thoracotomy in seven, right thoracotomy only in two, and cervical approach only in one patient. Thoracic approach was used in 95% of cases and there was no significant difference between the two groups of ITG. Concerning the operative complications, in two patients transient vocal cord paresis and in one patient postoperative bleeding were verified. There was no statistically significant deference in frequency of operative complications between ITG and non-ITG. CONCLUSIONS: ITG are rare, but might present a difficult diagnostic and complex surgical problem. Common clinical presentation and identical surgical approach in operative treatment justify the common review of the two groups of intrathoracic goiters. With adequate and timely performed surgical approach, in specialized institutions, frequency of complications in operative treatment of ITG is not higher if compared to operative treatment of non-ITG.

[Abdominal war injuries]. / Ratne povrede abdomena.

In the period of July 1, 1991-December 31, 1992, 4292 wounded were treated in the Military Medical Academy (MMA) in Belgrade. Out of 410 (9.6%) wounded with abdominal war injuries, 156 (38%) received the primary treatment in MMA and the remainder in other hospitals. One fifth of the wounded with abdominal injuries suffered combined injuries of more organs and 82.7% of the cases had multiple injuries of one organ or combined injury of two or more abdominal organs. Wounding caused by explosive devices prevailed (61.5%), and the most frequently injured organs were small intestine in 40% and colon in 30.7% of the cases. Reoperation due to complications was performed in 7% of the wounded primarily managed in MMA and 33.8% of there primarily managed in other hospitals. Total mortality due to the abdominal war injuries was 10.9%, while mortality in patients primarily managed in MMA amounted to 4.5% compared to 14.9% of those operated on in other hospitals.

[Comparative analysis of sutured and stapled colorectal anastomoses]. / Komparativna analiza savnih i stapler kolorektalnih anastomoza.

In the period of 1987-1993 at the Clinic of General and Vascular Surgery, Military Medical Academy, 364 colorectal anastomoses were performed; the group I was composed of 167 patients with sutured anastomoses, and 197 patients with stapled anastomoses were in the group II. More than half of patients were over 60, and ratio between males and females was 2:1. The reason for resection in almost 90% of the patients was adenocarcinoma of the rectum of which in 40% of the patients the process advanced up to stages C and D by Dukes. Pathologic process in the group I was localized in the lower two thirds of the rectum in 24.6% of the patients, while the percentage in the group II was tripled--76.1%. Surgical wound complications were most frequent in both groups (14.3%:9.6%), and complications associated with anastomosis were less frequent in the stapler group. Clinically clear anastomosis dehiscence appeared in 11.4% of the group I and in 10.7% of the group II. Total mortality was 3.3% (Group I 3.6%, group II 3.0%). By comparative analysis of early complications after resection of the rectum with sutured or stapled colorectal anastomosis, it is concluded that the introduction of staplers in colorectal surgery facilitated the easier accomplishment of larger number of low-lying colorectal or coloanal anastomoses, which are safer and followed by fewer complications, and with equal oncological disease control.

[Complications in omentopexy and personal experience with 100 omentomyelopexies]. / Komplikacije omentopeksija i nase iskustvo sa 100 omentomijelopeksija.

Abdominal and general complications of omentomyelopexies are seldom seen, and were mostly presented as the case reports. The aim of this study was to present in a comprehensive analysis of the data acquired from literature the reported omentopexy complications, and to compare them with our own results of the application of the omental flap with left gastroepiploic blood vessels. Prospective clinical research included the first 100 operated patients with injuries on different spinal cord levels. In all patients the omental flap was prepared by our original surgical technique and led to the site of the spinal cord lesion. In 6 of our patients we noticed seven complications and those were: three iatrogenic pneumothoraxes, two lesions of the spleen (without splenectomy), one pneumonia and one mild infection of the laparotomy wound. Prevalence of the complications related to the abdominal act of omentomyelopexy of 7% was significantly lower than in those presented in the literature with other right gastroepiploic artery omentopexies (20-79%). In our patients complications occurred earlier, lasted shorter and had no permanent implications for the patients' health. By using the omental flap with left gastroepiploic blood vessels it was possible to perform effective, relatively simple and safe omentomyelopexy for the injuries on all levels of the spinal cord. Such a mode of omental flap preparation with left gastroepiploic blood vessels could be applied for other omentopexies as well.

New surgical technique of omental pedicle graft preparation for omentomyelopexy.

Omental pedicle graft with left gastroepiploic vessels is very rarely used extraabdominally and all existing techniques of graft mobilization and lengthening are related to the graft with right gastroepiploic vessels. The aim of this research was to present the new surgical preparation technique of the omental graft based on the left gastroepiploic vessels for omentomyelopexy. First 100 patients, with injuries of spinal cord on different levels, were included in this prospective clinical study. In all these cases we performed omentomyelopexy with omental pedicle graft based on the new surgical technique of omental mobilization and lengthening. The results revealed that the way of preparation of omental pedicle graft depended on the level of the spinal cord lesion: in most cases for the lesions of cervical spinal cord the omental grafts had to be lengthened, for the midthoracic lesions omental graft was prepared without lengthening, while for the thoracolumbar lesions, only a part of omentum for graft was mostly used. The new surgical technique for preparation of omental pedicle graft for omentomyelopexy enabled the application of one of three possibilities for omentum lengthening. It depended on the type of omental vascularization, based on our own original classification and not on the level of spinal cord lesion. The preparation of omental pedicled graft with the left gastroepiploic vessels enabled the omentomyelopexy regardless of the level of spinal cord injury.

Hearing levels in Pierre Robin syndrome.

Hearing was tested in 18 patients with Pierre Robin syndrome (PRS). These results were compared with those obtained for 243 patients with either cleft lip or cleft palate, or both. None of the PRS group patients had middle ear or inner ear malformations, or sensorineural hearing loss in speech frequencies. Hearing loss in PRS is usually conductive, bilateral, and more frequent in PRS patients (30 ears or 83.33%) than in patients who do not have PRS (290 ears or 59.67%). A significantly higher (p < .01) mean of hearing loss for air conduction in speech frequencies (MHLSF = 24.5 dB) was found in PRS patients than in patients without PRS (MHLSF = 17.8 dB). The ears of the PRS patients with hearing loss were examined, revealing middle ear effusion. In all cases, hearing was restored to a normal level through suction and the use of ventilation tubes.

[Adhesive ileus caused by a peritoneal reaction to starch]. / Adhezivnih ileus izazvan reakcijom peritoneuma na skrob.

Peritoneal reaction caused by glove powder is not so rare in surgical practice. We have presented a case report of a patient who was operated on due to the adhesive bowel obstruction, two years after the total gastrectomy for gastric cancer. Changes found on the peritoneal surface were similar to carcinomatous dissemination, but intraoperative frozen section analysis showed granulomatous lesions caused by foreign bodies. Nature of these changes was confirmed by PAS smear and polarization microscopy. Clarification of the peritoneal changes during relaparotomy is possible only with careful microscopic analysis of these granulomas.

Mastoid pneumatization and aging in children with Pierre-Robin syndrome and in the cleft palate population out of syndrome.

We examined the characteristics of mastoid pneumatization in the Pierre-Robin syndrome (PRS) and non-PRS cleft palate population in relation to age. There were 14 patients with PRS (median age, 5 years), 7 patients with bilateral cleft lip-palates (BCLP: median age, 6 years), 29 patients with unilateral cleft lip-palates (UCLP: median age, 6 years) and 15 patients with isolated cleft palates (ICP: median age, 7 years). All had secretory otitis and ventilation tubes inserted. Pneumatization was assessed by standard computerized planimetric methods. Temporal bone (Schüller view) X-rays were obtained. Areas of bone pneumatization were outlined and measured separately for each ear. The median pneumatized area of the mastoid (MBP) in PRS patients (6.73 cm2) was significantly lower than in non-PRS cleft patients (7.29 cm2). It was also lower than in UCLP (7.35 cm2; P = 0.01) and ICP (7.19 cm2; P = 0.02). MBP did not change significantly with age in PRS (Spearman rs = 0.11) and BCLP (Spearman rs = 0.11), but did increase significantly in the ICP group (Spearman rs = 0.23; P = 0.04). Cubic regression showed the best fit in the BCLP (r2 = 0.61; P = 0.01) and ICP (r2 = 0.10; P = 0.05). It was not significant for PRS (r2 = 0.132) or UCLP (r2 = 0.049). We concluded that pneumatization in all cases increases with age, but it is statistically significant only in ICP. PRS patients have a lower area of mastoid air-cell size than the non-PRS cleft palate population. The extent of mastoid pneumatization in PRS patients does not correlate with age because of the negative influence of the mandibular hypoplasia and glossoptosis present.