Fluoroscopic iliosacral screw placement made safe.

AIM: Unstable posterior pelvic ring injuries should be stabilised successfully by percutaneous iliosacral screwing. The intervention takes place under intraoperative fluoroscopic guidance. The inlet and outlet views are crucial and are performed by tilting the image intensifier. Safely interpreting fluoroscopic views can be challenging in certain clinical scenarios. We demonstrated on a series of patients howpreoperative CT scans can be used to anticipate the appropriate intraoperative inlet and outlet fluoroscopic views and positioning of the patient on the operating table, thereby avoiding possible operating table obstacles. MATERIALS AND METHODS: We analysed at random 30 pelvic CT scans from patients of different ages and both sexes, utilising the sagittal reconstructions. Inlet and outlet angle measurements were calculated on the scans to determine the appropriate intraoperative inlet and outlet views. RESULTS: The analysed CT scans showed an average inlet view of 22.3° (range 10.4°-39.8°) and an average outlet view of 42.3° (range 31.5°-53.1°). Sex and age had no influence on results. The calculated required free space under the operating table for unobstructed tilting of the C-arm was a minimum of 145cm. CONCLUSION: The significant anatomic variations of the posterior pelvic ring have been well documented in the literature. The angles required to obtain appropriate intraoperative inlet and outlet views are not perpendicular and differ greatly from traditional settings, which directed the beam 45° caudally and 45° cranially. The fluoroscopic beam would need to be angled differently in each patient to obtain ideal cardinal views that ultimately assist in safe iliosacral screw placement. To avoid collision of the C-arm with the operating table, it is essential to provide secure free space under the operating table of at least 145cm.

Definition of polytrauma: Discussion on the objective definition based on quantitative estimation of multiply injured patients during wartime.

AIM: There is a clear lack of consensus on a validated definition of the term "polytrauma". This study presents and classifies the extent of injuries during wartime in Croatia using the Revised Trauma Score and Injury Severity Score (TRISS) and compares the scores with a clinical estimation based on subjective assessments of polytraumatised and non-polytraumatised patients. METHODS: We analysed the data from 426 war victims who sustained multiple injuries and were managed at Osijek University Hospital from September 1st 1991 to December 31st 1991. The victims were divided into polytraumatised (n=149) and multitraumatised (n=277) patients according to the initial clinical estimation of the extent of injury. Patients classified as monotraumatised were excluded from this study. The assessment was based on the following definition of polytrauma: simultaneous injury of two or more body regions or anatomical systems with at least one injury being life-threatening. All data were scored retrospectively using TRISS methodology. RESULTS: Two patients classified as polytraumatised had an ISS of less than 16, and one patient classified as multitraumatised had an ISS of more than 16. The difference between the actual (29.5%) and expected (40.44%) postoperative mortality in the polytraumatised group was statistically significant (p=0.0016), whereas in the multitraumatised group, the difference between the actual (3.2%) and expected (3.04%) postoperative mortality was not significant (p=0.6103). CONCLUSIONS: The data show that clinical and subjective assessment of polytraumatised patients can be useful in the management of such cases and can be tested retrospectively using TRISS methodology.

Prognostic significance of specific injury patterns in casualties of traffic-related accidents.

AIM: Fatal triad and ipsilateral dyad are patterns of pedestrian injuries related to significant mortality in traffic-related accidents. The aim of this research was to investigate the correlation between specific injury patterns and fatal outcome in other participants of traffic-related accidents. METHODS: This was a retrospective study of traffic-related accidents in the broader area of the city of Osijek in a five-year period from 1995 to 1999. Autopsy results from the Institute of Pathology and Forensic Medicine of the Clinical Hospital Centre Osijek were analysed of individuals who died after their accident. The total severity of injuries was measured using the ISS. Logistic regression analysis was used for assessing the correlation between specific injury patterns and an early outcome from the severe injury. RESULTS: There were 213 individuals included in the study: 72 pedestrians and 141 other participants (drivers, assistant drivers, passengers, cyclists and motorcyclists). A total of129 individuals died on the spot and 84 died in the hospital during the first 48h. Femoral and pelvic fracture, fatal triad and both variants of ipsilateral dyad were related to higher ISS values. Ipsilateral fracture of upper and lower extremities (ipsilateral dyad 1) was associated with a 4.59 times higher risk of an immediate fatal outcome in the total sample. In pedestrians, the risk was 5.99 higher, and in other participants, the risk was 4.11 times higher. CONCLUSION: Specific skeletal injuries and injury patterns are a significant indicator for total injury severity and related poor prognosis for all participants of traffic-related injuries, not only for pedestrians. In this study, the ipsilateral fracture of upper and lower extremity was related to the largest total severity of injuries and the poorest prognosis.

Immediate fatal outcome vs. fatal outcome within the first 48 hours following a severe traffic trauma--analysis of the possible effect of alcohol intoxication on the outcome.

UNLABELLED: This paper is a retrospective analysis of data on 278 persons with fatal outcomes in traffic accidents in Osjecko--baranjska County, Croatia, during a five-year period. The observed sample of casualties was divided according to the time of fatal outcome into three groups: immediately deceased (139 or 50.0%), deceased within the first 48 hours (84 or 30.2%) and deceased after 48 hours (55 or 19.8%). A comparison of data was made for the first two groups of casualties, based on the level of alcohol intoxication, and an analysis of the possible influence of alcohol intoxication on an early outcome of severe trauma, which was defined as immediate fatal outcome and fatal outcome within the first 48 hours following the trauma. Casualties from the group of immediately deceased had a significantly higher average blood alcohol level than casualties from the group of persons deceased within the first 48 hours (shown through arithmetic mean of 0.81 g/kg vs. 0.33 g/kg, p =0.000). A binary logistic regression analysis showed that every increase in blood alcohol level by 1 g/kg also increased the odds of an immediate fatal outcome by 1.92 times (p=0.004). CONCLUSION: Beside increased risks of traffic accidents, the collected data showed that alcohol intoxication of accident participants also increases their chances of an immediate fatal outcome.

[Stercoral rectosigmoid colonic perforation with fecal peritonitis]. / Sterkoralna perforacija rektosigmoidnog kolona s fekalnim peritonitisom.

Chronic constipation can lead to fecal impaction and catastrophic complication such as colonic obstruction, perforation and fecal peritonitis. A case is reported of stercoral perforation of the rectosigmoid with pneumoperitoneum and fecal peritonitis. The patient was admitted for the signs of acute abdomen with pneumoperitoneum diagnosed on native radiological imaging.

Mechanical bowel preparation in colorectal surgery.

The aim of this study was to assess the use of mechanical bowel preparation (MBP) and antimicrobial prophylaxis in elective colorectal surgery regarding still existing controversies. A prospective study of 85 patients undergoing elective colon and rectal surgery during 2 years period was performed, divided in two groups. Group A (N = 46) with patients who underwent mechanical bowel preparation, and group B (N = 39) patients without mechanical bowel preparation. We analysed: gender, age, preoperative difficulties, diagnostic colonoscopy, tumor localization, operation performed, pathohystological findings, Dukes classification, number of lymphonodes inspected, liver metastasis, other organ infiltrations, mean time of surgery, length of hospital stay, postoperative complications and mortality. Demographic characteristics, pathohystological findings, the site of malignancy, and type of surgical procedure did not significantly differentiate the two groups. The only significance revealed in mean time of surgery (138/178 minutes) in favor of patients with MBP (p = 0.017). Mechanical bowel preparation (MBP) for elective colorectal surgery is not advantageous. It does not influence radicalism of the procedure, does not decrease neither postoperative complications, nor hospital mortality.

[Laparoscopic versus open appendectomy: our experience and literature review]. / Laparoskopska ili otvorena apendektomija: nasa iskustva i pregled literature.

AIM: The controversy of the choice between open and laparoscopic appendectomy still remains. The benefits as well as disadvantages of laparoscopy are well known. METHODS: We designed a prospective 3-year clinical study (January 1, 2008-December 31,2010) with 123 patients operated on for acute appendicitis. They were prospectively divided into laparoscopic appendectomy (LA) group with 42 results and open appendectomy (OA) group with 81 results. The following parameters were analyzed: age, sex, preoperative leukocyte count, C-reactive protein (CRP) value, preoperative ultrasound finding (US), analgesic administration and histopathologic finding. The length of the operation, length of hospitalization (LOS) and complications were compared between the two groups, along with personal postoperative satisfaction estimated by telephone survey after discharge from the hospital. RESULTS: In 90% of cases, histopathology was positive for inflammation. CRP was determined in 42 (34%) patients preoperatively, with a mean value of 59; positive histopathology finding was recorded in 31 (74%) patients with increased preoperative CRP. US was performed in 68 (55%) patients; positive US was consistent with histopathology in 44 (65%) cases. The mean time of LA/ OA was 75/72 minutes. The only statistical difference was found for LOS: 4 versus 6 days (p < 0.01). CONCLUSION: LA and OA are comparable for the number of complications. The slight benefit of LA offers the surgeon free hand in decision when dealing with acute appendicitis needing urgent operation.

[Laparoscopic partial pericystectomy of hepatic hydatid cysts --Papadimitriou operation: a case report]. / Laparoskopska parcijalna pericistektomija ehinokokne ciste jetre po papadimitriouu: prikaz bolesnika.

Operative treatment of hepatic hydatid cyst is technically demanding procedure. The method of choice is conservative treatment with Albendazolum followed by surgery. Open laparotomy or laparoscopic operation can be performed. We prefere laparoscopic exploration followed by laparoscopic total pericystectomy or laparoscopic partial pericystectomy. If laparoscopic operation is not possible due to technical reasons and patient safety, conversion to an open operation should be done, followed by total or partial pericystectomy. The case and our detailed technique of laparoscopic partial pericystectomy with biliostasis and omentoplasty is described. Laparoscopic operation is equally safe for the patient, yet with minor trauma and better aesthetic effect.

[Laparoscopic diagnosis and desincarceration of inguinal Richter hernia: a case report]. / Laparoskopska dijagnoza i dezinkarceracija ingvinalne Richterove hernije-prikaz bolesnika.

In the cases of incarcerated Richter hernia the diagnosis is difficult especially for obese patients. Laparoscopic diagnostics and desincarceration, can be combined with mini laparotomy in lieu of bowel resection and open hernioplasty, or conversion to classic laparotomy and open hernioplasty. Here is presented a case of incarcerated Richter inguinal hernia managed through the combination of laparoscopy, mini laparotomy for segmental bowel resection and open hernioplasty.

Laparoscopic operation of hepatic hydatid cyst with intraabdominal dissemination--a case report and literature review.

Hepatic hydatid cysts are a serious medical problem in some regions like Mediterranean region. In Croatia 25-30 new cases of hepatic hydatid cysts are recorded each year In University Hospital Dubrava 7 patients with hepatic hydatid cysts were operated in 2008. Surgical approach recognizes open laparotomy and laparoscopy. The case and technique of laparoscopic operation of hepatic hydatid cyst in seventh segment and three disseminated intraabdominal cysts is described. Laparoscopy should be attempted even in complex cases with dissemination.

Laparoscopic treatment of iatrogenic endoscopic sigmoid colon perforation: a case report and literature review.

Iatrogenic colon injury during a colonoscopy procedure is rare. The controversy exists when the surgical treatment of such lesions is concerned: operative or conservative. This case report is in favor of the operative endoscopic approach, with a literature review. An 80-year-old male sustained an iatrogenic endoscopic sigmoid colon perforation. Laparoscopic suturing was done within 5 hours after the perforation, with no complications after 4 months of follow-up.

Small bowel injuries in penetrating abdominal trauma during war: ten-year follow-up findings.

BACKGROUND: Injuries of the small intestine are common in penetrating abdominal trauma. This article presents 10-year follow-up results for 23 patients with penetrating small bowel injuries who were treated in Nova Gradiska City Hospital during the 1991-1992 war in Croatia. The early hospital mortality rate was 13% (three deaths), and good results were found for 16 (84%) of 19 patients after 10 years. METHODS: The hospital charts of 23 patients who sustained small bowel injuries during an 8-month period were reviewed. Of 20 patients who survived, 19 came for an examination and interview 10 years after injury. The following criteria were used: existence of an abdominal wall defect or hernia, bowel passage problems, and reoperations attributable to the small bowel injury. RESULTS: Early results revealed adhesive peritonitis and ileus for three patients demanding early reoperation (13%) and a hospital mortality rate of 13% (three deaths, mainly attributable to multiple injuries). Ten years after injury, 16 patients had no problems, whereas 3 reported occasional abdominal pain. CONCLUSION: Penetrating abdominal injuries in war demand urgent diagnostic procedures and, in almost all cases, urgent laparotomy. In cases with no evidence of abdominal penetration and cases involving multiple injuries, an aggressive approach reduces the risk of missing small bowel injuries. Use of established principles for surgical management of small bowel injuries yields good results and low incidences of late complications and difficulties.