Detection of Sarcopenia in Patients with Liver Cirrhosis Using the Bioelectrical Impedance Analysis.

Bioelectrical impedance analysis (BIA) is a body composition assessment method. We aimed to determine its accuracy in the detection of sarcopenia in patients with liver cirrhosis (LC), using skeletal muscle index (SMI) at the level of third lumbar vertebra (L3-SMI) obtained using multislice computed tomography as the reference method. Patients with LC were enrolled in the period October 2019-March 2022 and follow-ups were conducted until January 2023. Their BIA parameters were compared against L3-SMI, and BIA cut-off values were proposed using AUROC analysis. Patients underwent outcome analysis based on obtained clinical characteristics. A total of 106 patients were included. We found a fair correlation between BIA parameters with the L3-SMI. We determined cut-off values of ≤11.1 kg/m2 for BIA-SMI (Se 73%, Sp 66%, AUROC 0.737, p < 0.001) and ≤5.05° for phase angle (PA) (Se 79%, Sp 60%, AUROC 0.762, p < 0.001) in the detection of sarcopenia. The relative risk of death was 2.2 times higher in patients with skeletal muscle mass (SMM) ≤ 36.5 kg. SMM was significantly associated with outcome in Kaplan-Meier analysis. This non-invasive and simple method that showed fair performances and a very good outcome prediction could provide for the unmet need for fast and affordable detection of sarcopenia in patients with LC and should be further evaluated.

The Laparoscopic Cholecystectomy and Common Bile Duct Exploration: A Single-Step Treatment of Pediatric Cholelithiasis and Choledocholithiasis.

BACKGROUND: In recent years, complicated biliary tract diseases are increasingly diagnosed in children. Laparoscopic exploration of the common bile duct (LCBDE) followed by laparoscopic cholecystectomy has gained popularity in children. The aim of this study was to investigate the outcomes of LCBDE in children and compare them with the treatment outcomes of previously used endoscopic retrograde cholangiopancreatography (ERCP). METHODS: From January 2000 to January 2022, a total of 84 children (78.5% female) underwent laparoscopic cholecystectomy with a median follow-up of 11.4 (IQR 8, 14) years. Of these, 6 children underwent laparoscopic cholecystectomy (LC) + ERCP and 14 children underwent LCBDE for choledochiothiasis. The primary end point of the study was the success of treatment in terms of the incidence of complications, recurrence rate, and rate of reoperation. Secondary endpoints were stone characteristics, presenting symptoms, duration of surgery, and length of hospital stay. RESULTS: The majority of patients were female in both groups (83.5% vs. 85.7%), mostly overweight with a median BMI of 27.9 kg/m2 and 27.4 kg/m2, respectively. Obstructive jaundice, colicky pain, acute pancreatitis, and obstruction of the papilla were the most common symptoms in both groups. The majority of patients (68%) had one stone, whereas two or more stones were found in 32% of patients. The median diameter of the common bile duct was 9 mm in both groups. The procedure was successfully completed in all patients in the ERCP group. In the group of patients treated with LCBDE, endoscopic extraction of the stone with a Dormia basket was successfully performed in ten patients (71.4%), while in the remaining four patients (28.6%) the stones were fragmented with a laser because extraction with the Dormia basket was not possible. The median operative time was 79 min in the LCBDE group (IQR 68, 98), while it was slightly longer in the ERCP group, 85 min (IQR 74, 105) (p = 0.125). The length of hospital stay was significantly shorter in the LCBDE group (2 vs. 4 days, p = 0.011). No complications occurred in the LCBDE group, while two (40%) complications occurred in the ERCP group: pancreatitis and cholangitis (p = 0.078). During the follow-up period, no conversions, papillotomies, or recurrences were recorded in either group. CONCLUSIONS: Exploration of the common bile duct and removal of stones by LCBDE is safe and feasible in pediatric patients for the treatment of choledocholithiasis. Through this procedure, choledocholithiasis and cholelithiasis can be treated in a single procedure without papillotomy or fluoroscopy. Compared with LC + ERCP, LCBDE is associated with a shorter hospital stay. The incidence of complications was rather low but not statistically significant.

Lateral thermal damage of mesoappendix and appendiceal base during laparoscopic appendectomy in children: comparison of the harmonic scalpel (Ultracision), bipolar coagulation (LigaSure), and thermal fusion technology (MiSeal).

BACKGROUND: The aim of this study was to compare lateral thermal damage of mesoappendix and appendiceal base using three different instruments for sealing and cutting of mesoappendix. MATERIALS AND METHODS: A total number of 99 patients (54 males and 45 females) who underwent laparoscopic appendectomy because of suspected appendicitis between December 2013 and May 2015 were enrolled in the study. The patients were divided in three groups based on instrument used for sealing of mesoappendix: group 1 (Ultracision; n = 36), group 2 (LigaSure; n = 32), and group 3 (MiSeal; n = 31). Lateral thermal damage, intraoperative and postoperative complications, duration of surgery, hospital stay, and economic value were compared within groups. RESULTS: The median age of patients was 14 y (range 3-17). A histopathologic analysis revealed a positive diagnosis of appendicitis in 84 patients (85%). The median lateral thermal damage on appendiceal base using Ultracision, LigaSure, and MiSeal was 0.10 mm, 0.16 mm, and 0.10 mm respectively, and on mesoappendix, 0.08 mm, 0.13 mm, and 0.08 mm, respectively. Significantly higher thermal damage was found on mesoappendix (P = 0.015) and appendiceal base (P = 0.012) in patients treated with LigaSure than in patients from other groups. There were no statistical differences among the groups regarding intraoperative and postoperative complications (P = 0.098). No significant difference in thermal damage between appendicitis and nonappendicitis group was found (P = 0.266). CONCLUSIONS: Using of Ultracision, LigaSure, and MiSeal for sealing of mesoappendix in laparoscopic appendectomy in children is safe and useful. LigaSure produces significantly greater lateral thermal damage compared with other instruments.

The Value of Injury Severity Score and Abbreviated Injury Scale in the Management of Traumatic Injuries of Parenchymal Abdominal Organs.

The aim of this study was to investigate the influence of etiology, types of injury, levels of consciousness and the Injury Severity Score (ISS) and Abbreviated Injury Scale (AIS) values on the selection of treatment modality and survival in patients with injuries of parenchymal abdominal organs. Case records of 224 patients treated for traumatic injury of parenchymal abdominal organs from January 2003 until December 2015 were reviewed. Th e values of ISS and AIS of injury severity were calculated and compared to the values obtained according to the etiology, state of consciousness and survival. Of the 224 patients, 172 (76.8%) were treated by surgical approach and 52 (23.2%) were treated conservatively. Th e mean patient age was 40.1}18.3 years. Th ere were 97 (43.3%) polytrauma cases. Of the 224 injured patients, 143 (63.8%) were treated with transfusions of blood products. Two hundred and six (92%) patients survived. Th e mean AIS and ISS values were significantly lower in patients that survived (AIS=3; ISS=28) than in those that died (AIS=5; ISS=34) (p< 0.001). There was a statistically significant difference in AIS and ISS values between conscious (AIS=2.7; ISS=25.9) and unconscious (AIS=3.2; ISS=33) patients (p< 0.001). Of the 224 patients that did not survive, 18 (8%) were hemodynamically unstable. Survival depended on hemodynamic stability at admission; the ISS and AIS values were associated with the injuries and state of consciousness at admission. Hemodynamic stability, state of consciousness, and ISS and AIS values were the quality predictors of survival after abdominal traumatic injury.

Unusual cause of acute abdomen in a child--torsion of greater omentum: report of two cases.

INTRODUCTION: Torsion of the omentum is twisting along its long axis and a rare cause of acute abdomen. Depending on associated conditions, it is classified as primary and secondary. It may mimic different pathologies presenting as acute abdomen, most common of them being acute appendicitis. Current choice for management of omental torsion is laparoscopic surgery. CASE PRESENTATION: We present two cases of omental torsion of two boys who presented with abdominal pain, nausea and vomiting and underwent emergency laparoscopy. CONCLUSION: Omental torsion is very rare, and its diagnosis is usually made only after surgery. At laparoscopy, omental torsion is suspected when the appendix is normal and the symptoms and findings of torsion are present. Laparoscopy is a safe and effective approach for the diagnosis and management of omental torsion, with the advantages of reduced postoperative pain and hospital stay.

[Croatian guidelines for perioperative enteral nutrition of surgical patients]. / Hrvatske smjernice za perioperativnu enteralnu prehranu kirurskih bolesnika.

Nutritional status of patients significantly affects the outcome of surgical treatment, whether it's about being obese or malnutrition with loss of muscle mass. Inadequate nutritional support in the perioperative period compromises surgical procedures even in patients who are adequately nourished. In this paper, particular attention was paid to malnourished patients, and their incidence in population hospitalized in surgical wards can be high up to 30%. Special emphasis was paid to the appropriateness of preoperative fasting and to the acceptance of new knowledge in this area of treatment. The aim of this working group was to make guidelines for perioperative nutritional support with different modalities of enteral nutrition. The development of these guidelines was attended by representatives of Croatian Medical Association: Croatian Society for Digestive Surgery, Croatian Society for Clinical Nutrition, Croatian Society of Surgery, Croatian Society for Endoscopic Surgery, Croatian Trauma Society and the Croatian Society of Anesthesiology and Intensive Care. The guidelines are designed as a set of questions that arise daily in clinical practice when preparing patients for surgery and after the surgical treatment, which relate to the assessment of nutritional status, perioperative nutritional support, duration of preoperative fasting period and the selection of food intake route. Assessment of nutritional status and the use of different modes of enteral nutrition should enter into standard protocols of diagnosis and treatment in the Croatian hospitals.

Antisperm antibodies and testicular blood flow after inguinal hernia mesh repair.

BACKGROUND: Testicular flow studies after hernia mesh repair mostly showed different outcomes. The reason of infertility in some men after hernia repair is immunological factors. Aim of the study was to investigate the influence of mesh hernia repair on antisperm antibodies production and testicular blood flow and a connection among these parameters. MATERIALS AND METHODS: A prospective interventional longitudinal cohort study was made on 82 male patients without exclusion criteria who had an inguinal hernia. Patients underwent laparoscopic TAPP or open tension-free hernia repair. Vascular ultrasound and antisperm antibodies were measured in the preoperative and postoperative periods. Main outcome measures were resistive index (RI), peak systolic velocity (PSV) cm/s, and end-diastolic velocity (EDV) cm/s in testicular blood flow measurement and the quantitative value of antisperm antibodies (ASA) in serum (IU/ml). RESULTS: ASA significantly increased postoperatively only in patients who underwent open tension-free hernia repair (p < 0.001). ASA stayed in normal range in all patients except the one with postoperative complication. Friedman analysis showed significant change of the RI only on intratesticular (p < 0.001) and capsular artery level (0.02) in patients who underwent laparoscopic technique. PSV significantly changed on intratesticular (p < 0.001) and capsular artery level (p = 0.015) in the laparoscopic hernia repair. PSV showed significant change on intratesticular (p < 0.001) and testicular artery levels (p < 0.001) in the open tension-free hernia repair. EDV showed significant change only on testicular artery level (p = 0.032) in the patients who had open tension-free hernia repair. These blood flow parameters significantly increased in the early postoperative period and returned on basal value in the late postoperative period. Parameters of flow did not show any significant correlation with ASA. CONCLUSION: Mesh hernia repairs without complication caused only a transitory change in testicular blood flow and no clinical significant autoimmune reaction.

Analysis of endoloops and endostaples for closing the appendiceal stump during laparoscopic appendectomy.

PURPOSE: An inadequate closure of the appendiceal stump can lead to intra-abdominal surgical site infections. The aim of this study was to assess the efficiency of different closure techniques by focusing on the intraoperative and postoperative complications versus cost. METHODS: From June 2011 to June 2013, 333 patients from two different hospitals undergoing laparoscopic appendectomy were included in this study. The patients were divided into two groups based on the technique used for appendiceal stump closure: there were 104 patients in the stapler group and 229 in the loop group. RESULTS: Among the 333 patients who underwent laparoscopic appendectomy, there were two (0.6%) intraoperative complications and 22 (6.6%) postoperative complications. There were no significant differences between the groups with respect to the intraoperative and postoperative complications. The length of the operation was 7 min shorter when the endoloop was used (p = 0.014). The mean costs of the operation were significantly lower when the loop was used ( 554.93) compared to the stapler ( 900.70) (p = 0.000). CONCLUSIONS: There is no clinical evidence supporting the routine use of endoscopic staplers. The appendiceal stump can be secured safely with the use of endoloops in the majority of patients. Surgeons have to be more selective when choosing how to perform closure, and an endostapler should be used only in cases where it is clinically indicated.

Primary malignant fibrous histiocytoma of the spleen: recurrence eight years after splenectomy--report of a case and literature review.

Primary intraabdominal malignant mesenchymal tumors are very rare. There are just few cases of intraabdominal visceral malignant fibrous histiocytoma in the literature. We report a case of primary malignant fibrous histiocytoma of the spleen in a 57-year-old man, with a recurrence eight years after the splenectomy. After the initial surgery the patient was without complaints, and refused to receive chemotherapy or radiotherapy. Eight years after the surgery the patient reported due to general weakness and malaise when the diagnosis of disease relapse was established. Radical surgery was performed although the tumor involved large curvature of the stomach, left crus of the diaphragm, splenic flexure of the colon and tail of pancreas. Four months after the surgery patient died. To the best of our knowledge, to date, only 18 cases have been reported in the literature, describing malignant fibrous histiocytoma of the spleen.

Peutz-Jeghers syndrome complicated with intussusception: enteroscopic polyps resections through laparotomy.

Peutz-Jeghers syndrome is an autosomal dominant inherited disorder characterized by intestinal hamartomatous polyps in association with mucocutaneous pigmentations. Here we present a case of a 30-year-old woman who was hospitalized and underwent diagnostic procedures because of crampy abdominal pain. Physical examination on admission revealed pigmented spots around lips and on the oral mucosa. Multiple polyps were found in stomach, small and large intestine, with signs of initial ileo-ileal intussusception. After endoscopic removal of achievable polyps, we applied gastroscope through laparotomy and enterotomy and removed total number of 34 polyps from small bowel. The polyps were found to be mostly hamartomatous at histological examination. This procedure can provide removal of the most polyps, which are potentially premalignant, also with less complicationes than after multiple intestinal resectiones.

Predictive factors of rebleeding and mortality following endoscopic hemostasis in bleeding peptic ulcers.

BACKGROUND/AIMS: To identify predictive factors of rebleeding and mortality after endoscopic therapy in patients with high risk peptic ulcers. METHODOLOGY: Patients hospitalized due to bleeding from high-risk peptic ulcers (Forrest classes Ia, Ib, IIa and IIb) during a five-year study, received endoscopic hemostatic therapy (diluted epinephrine injection, clipping or both) in addition to proton pump inhibitors. We looked for clinical, endoscopic and laboratory parameters that had influenced rebleeding and mortality in these patients. RESULTS: Among all patients (804) with peptic ulcer bleeding, 251 high-risk ulcer pateints received endoscopic hemostasis treatment. Thirty-four of them (13.5%) experienced in-hospital rebleeding. Majority of these achieved permanent hemostasis after second endoscopic treatment, while 14 (5.6%) needed surgery. Eighteen patients died (7.2%). Among parameters studied, severe anaemia, systolic and diastolic hypotension, shock presence, low Rockall score, ulcer size and time to hemostasis were factors which predicted rebleeding. Mortality predictive factors were: severe anaemia, hypotension, shock presence, lower Rockall and physical status scores, ulcer size and Forrest class. Conclusions: Early assesment of clinical and endoscopic predictive factors of rebleeding and mortality in patients with high-risk peptic ulcer bleeding could provide optimal therapeutical measures and follow-up. It could further reduce rebleeding and mortality rates in these patients.-16 months vs. 59.5 months, IQR=37.5-68.5 months, p<0.001) and the rate of death was lower (16.7% [2/12] vs. 83.3% [5/6], p=0.006). Logistic regression showed that a shorter duration of endoscopic interval increased the rate of resectability of gastric cancer (p<0.001) and a higher rate of unresectable gastric cancer and longer duration of endoscopic interval increased death (p=0.029 and p=0.004, respectively). CONCLUSIONS: After treatment of esophageal cancer, endoscopic examination at 12-month intervals is important to lower the rate of death due to metachronous gastric cancer.

Comparison of lateral thermal damage of the human peritoneum using monopolar diathermy, Harmonic scalpel and LigaSure.

BACKGROUND: New hemostatic technologies are often employed in open and laparoscopic surgery to reduce duration of surgery and complications. Monopolar diathermy, Harmonic scalpel and LigaSure are routinely used in open and laparoscopic surgery for tissue cutting and hemostasis. We compared lateral thermal damage following in vivo application of 3 commonly used instruments. METHODS: We used monopolar diathermy, Harmonic scalpel and LigaSure to coagulate and divide the peritoneum of patients who underwent median laparotomy. After anesthesia, median supraumbilical laparotomy was performed, and the peritoneum of each patient was coagulated using different devices. Using light microscopy and morphometric imaging analysis, the width of tissue lateral thermal damage was measured from the point of the peritoneal incision. RESULTS: We included 100 patients in our study. After a peritoneal incision, the mean lateral thermal damage of monopolar diathermy, Harmonic scalpel (output power 3), Harmonic scalpel (output power 5) and LigaSure were 215.79 µm, 90.42 µm, 127.48 µm and 144.18 µm, respectively. CONCLUSION: The degree of lateral thermal spread varied by instrument type, power setting and application time. LigaSure and Harmonic scalpel were the safest and most efficient methods of tissue coagulation. Monopolar diathermy resulted in the greatest degree of thermal damage in tissues.

First Croatian transvaginal laparoscopically assisted cholecystectomies.

BACKGROUND/AIMS: The aim of this study was to determine the feasibility and technical aspects of a new endoluminal surgical procedure: transvaginal laparoscopically assisted endoscopic cholecystectomy. METHODOLOGY: Three female patients underwent transvaginal laparoscopically assisted endoscopic cholecystectomy (aged 40, 61 and 33 years). Pneumoperitoneum was created through a 5mm supraumbilical incision. Through the posterior fornix of the vagina the second 10mm trocar, laparoscope and 5mm laparoscopic grasper were introduced. The gallbladder was dissected using standard 5mm laparoscopic grasper, hook, electrocoagulation and harmonic shears introduced supraumbilically. The dissected gallbladder was removed in a specimen retrieval bag. RESULTS: Transvaginal laparoscopically assisted endoscopic cholecystectomy was feasible in all patients. No intraoperative or postoperative complications were observed and there was no need for extra-umbilical skin incisions. Total operative time ranged between 60 and 75 minutes. Median length of hospital stay was 1 day. CONCLUSIONS: This was the first clinical application of transvaginal laparoscopically assisted cholecystectomy in Croatia. The initial clinical application of this technique in 3 female patients was feasible, effective and safe when performed by experienced laparoscopic surgeons using standard laparoscopic instruments.

An unusual cause of the ileus: non-specific stenosing ulceration of the small intestine.

Non-specific ulcerations of the small intestine are very rare. The cause and pathogenesis of these lesions remain obscure. The diagnosis of primary ileal ulcer is commonly overlooked and infrequently is established intraoperatively. Here we described a case of a 73-year-old woman who was presented to the emergency surgical department with the five days history of vomiting, distension, constipation, and abdominal pain. On physical examination abdomen was mildly distended and diffusely painful on palpation. Bowel sounds were present and active. Plain abdominal x-ray film showed ileus of the small intestine. Multislice computed tomography showed stenosing process of the ileum. Patient underwent exploratory laparotomy. Approximately 60 cm from the ileocecal valve ileum was inflamed and hypertrophic with a point of obstruction. Grossly, it appeared as a small intestine carcinoma. Involved segment of ileum including the point of obstruction was resected. Pathological examination showed ulceration of the ileum. After the surgery the patient made rapid recovery and was discharged from the hospital on the tenth postoperative day.

Preperitoneal approach for femoral hernia repair.

BACKGROUND/AIMS: Although Lichtenstein's procedure is the standard procedure in surgical hernia treatment, and the role of laparoscopic hernia repair is constantly increasing, preperitoneal approach for femoral hernia repair should be equally considered. METHODOLOGY: After the horizontal incision of transversal fascia, preperitoneal space is visualized. The hernial sac is opened and its content is placed in the abdominal cavity, or if there is a need, resection is performed. Once the peritoneum is sutured, the iliopubic tract and Cooper's ligament are bridged with two or three sutures in the medial portion of the femoral ring. RESULTS: From 1998 to 2008, 94 patients were treated for femoral hernia using the preperitoneal approach. Out of 94 participants, 86 were female. Intestinal obstruction was present in 48 cases. Resection of the small intestine or omentum was performed in 40 patients. There was no perioperative mortality. We observed early postoperative complications in 4 patients. Following the procedure, there was no recurrence of the femoral hernia. CONCLUSIONS: We found that preperitoneal repair is the method of choice in surgical treatment of femoral hernia. The surgical technique is simple and feasible, while fully acknowledging the functional anatomy of the inguinofemoral region and the etiology of the condition.

Formation of adhesions at surgical meshes in a rat experimental model.

Abdominal wall hernias are surgical problem that are easily solved with laparoscopic surgery. The determining factor for the success of the operation is the right choice and use of surgical mesh as the support material. The most common complication of surgical mesh placement is the formation of adhesions. Aim of this paper is to determine whether there is a statistic difference in formation of adhesions between different surgical meshes in lab environment. Wistar rats were used as the experimental model. After the anaesthesia a 1x1 cm defect of the abdominal wall was made, but the skin was left intact. The mesh was placed directly on the internal organs. The experiment considered four different mesh types. After set time periods of one, two or four weeks the animals were sacrificed and the amount of formed adhesions were evaluated based on the modified Diamond scale. Immediately after the first week we found a statistically significant difference in the adhesion occurrence rate between compared materials. The smallest amount of adhesions was caused by polypropylen + polydoksanon mesh, and the most by polypropilen mesh. Polypropylen + polyglactin mesh showed significant reduction of adhesion formation between the tested weeks. We can conclude that polypropylen + polydoxanon meshes are superior for ventral hernia operation, because those defects are in close contact with the internal organs and it is very important to have the smallest amount of adhesions.

Laparoscopic transabdominal preperitoneal approach for inguinal hernia repair: a five-year experience at a single center.

PURPOSE: Laparoscopic hernia repair has emerged as an effective alternative method for treating inguinal hernias. It has several significant advantages over the tension-free open repair now in use. In this report we summarize our laparoscopic hernia repair results and recommendations. METHODS: The transabdominal preperitoneal (TAPP) procedures for groin hernias performed between January 2003 and January 2008 at a single center were analyzed retrospectively. Individual surgeon performances were compared to determine whether the rates of complications were related to the level of surgeon experience. RESULTS: A total of 312 TAPP procedures were reviewed, and 284 (91%) of the patients were followed retrospectively. There were 266 (85.25%) males and 46 (14.75%) females. The average age was 57.4 years. The mean length of hospital stay was 2.1 days. The mean duration of surgery was 35 min. Six (1.92%) intraoperative and seven (2.24%) postoperative complications were noted. Two recurrences occurred (0.70%). CONCLUSIONS: Laparoscopic TAPP hernia repair has proven to be an efficient method for the treatment of groin hernias at our institution. Most patients can be treated as day-cases, namely they are hospitalized for 1 day, and they demonstrate a low recurrence rate (0.70%). Such low morbidity makes TAPP an attractive method for the routine treatment of groin hernias.

Torsion of epiploic appendage mimic acute appendicitis.

Epiploic appendagitis is a rare cause of focal abdominal pain which, depending on its localisation, can mimic a variety of abdominal diseases. We report a case of 36-year-old woman who presented with a classic signs of acute appendicitis. On examination, the obese, afebrile, and had very strong right iliac fossa tenderness and guarding. The white cell count was 12.82 x 10(9)/L, and C reactive protein count was 15.13MG/DL. She underwent emergency laparoscopic procedure after the acute appendicitis diagnosis has been established. Laparoscopic exploration of the abdominal cavity showed vermiform, no inflamed, appendix and necrotic appendix epiploica of the caecum. The treatment consisted of typical laparoscopic appendectomy and laparoscopic resection of the necrotic appendix epiploica. The patient made rapid recovery and was discharged from the hospital on second day after the operation. Histological investigation of the appendix epiploica revealed gangrenous epiploic appendage.

Laparoscopic cholecystectomy in Cantonal Hospital Livno, Bosnia and Herzegovina and University Hospital Center Split, Croatia.

Cholecystectomy is the most frequently performed operation in abdominal surgery. The aim of this study was to compare the operative procedure and outcomes of the laparoscopic cholecystectomy in two hospitals, the University Hospital Center Split and the Regional Hospital in Livno. A total of 97 patients who underwent laparoscopic cholecystectomy for cholelithiasis at University Hospital Center Split and 86 patients from Regional Hospital in Livno, both groups sampled in 2005 were included in this study. Differences in patients' age, gender, operation time, total hospital stay, number of trocarsi ports, antibiotic and parenteral therapy, and complications were analyzed. There were significantly fewer men than women who underwent laparoscopic cholecystectomy in both hospitals. The mean age of the patients undergoing laparoscopic cholecystectomy at University Hospital Center Split was higher than that of the patients at Regional Hospital in Livno. The operation time was shorter at the University Hospital Center Split than that at Regional Hospital in Livno. There was a significant difference, in favor of the University Hospital Center Split, in the number of patients who received postoperative antibiotics and parenteral therapy, with fewer patients who received postoperative therapy in Split. At the Regional Hospital in Livno fewer trocars were used for laparoscopic cholecystectomy. The average hospital stay of patients undergoing laparoscopic procedures at University Hospital Center Split was shorter than that of patients at Regional Hospital in Livno. Two complications occurred in postoperative period at the University Hospital Center Split and one complication was noticed in hospital in Livno. In conclusion, there were no major complications in postoperative period. It is also encouraging to find that there was significant improvement of surgical approach and technique at the hospital in Livno during the period of time analyzed in this study.

Atypical non-small cell lung cancer presentation: inguinal lymph node metastases as the first sign of disease relapse.

A case is presented of a 67-year-old male patient with atypical non-small cell lung cancer, where inguinal lymph node metastases were the first sign of disease relapse. The patient had a long-term smoking history of 30 cigarettes per day, with no other important personal or family medical history data. Because of prolonged cough, the patient underwent diagnostic procedure, which revealed squamous cell carcinoma of the lung (stage IIIB, T3N2M0). Concomitant radiochemotherapy and consolidation chemotherapy according to PE protocol was administered. Multislice computed tomography performed upon chemotherapy completion showed almost complete tumor regression and withdrawal of mediastinal lymph node enlargement, and the patient felt well. However, in the next few months, enlarged lymph nodes appeared in both inguinal regions. Histopathologic analysis revealed metastatic lung cancer. Four months after the presentation of enlarged inguinal lymph nodes, lung cancer metastases were also diagnosed in the liver and lumbosacral spine. Despite additional treatments, the patient died four months later. Although it is well known that inguinal lymph nodes can harbor lung cancer metastases, in our patient inguinal lymph node metastases were the first sign of lung cancer relapse.