Case report: successful endoscopic treatment of a large bowel perforation caused by chicken bone ingestion.

RATIONALE: Large bowel perforations by a foreign body are rarely diagnosed pre-operatively due to non-specific clinical symptoms. The safety and efficacy of foreign body removal via upper endoscopy is well-established and strongly recommended. There is far less experience of endoscopic treatment of sharp foreign bodies impacted in lower parts of gastrointestinal tract. PATIENT CONCERNS: The patient was 78-year-old female with abdominal pain and nausea. Symptoms had begun 48 hours prior to hospital admission. She had lost over 10 kg of body weight in the previous couple of months DIAGNOSIS:: A multidetector-row computed tomography (MDCT) examination of the abdomen revealed mural thickening and enhancement of the cecum with haziness and linear areas of high attenuation in the pericecal fat tissue. A colonoscopy showed, the clear presence of a sharp 5.5-cm-long chicken bone perforating the cecal wall at the antemesenteric site close to the Bauchini valve. INTERVENTIONS: A quarter of the bone that had penetrated the cecal wall was pulled out with a flexible colonoscopy using a polypectomy snare. Due to the form and length of the bone, it was withdrawn through the entire colon, using pointed end trailing. OUTCOMES: The patient was discharged three days after colonoscopy with normal laboratory results and without any pain. LESSONS: In cases where sharp foreign bodies stuck into the large bowel, it is highly advisable to try to remove them via colonoscopy, before deciding to resolve the issue through a surgical intervention.

Melanoma in the ampulla of Vater.

BACKGROUND: The most common tumors in the ampulla of Vater are adenocarcinomas. Although malignant melanoma usually occurs on the skin, it can also arise in the gastrointestinal and biliary tract. METHOD: We present a case of a 52-year-old, previously healthy man who presented with painless jaundice. RESULTS: Clinical examination revealed dilated intrahepatic and extrahepatic bile ducts and pancreatic duct due to the obstructive mass in the ampulla of Vater. The patient underwent pancreaticoduodenectomy and histopathological diagnosis of the resected tumor mass was malignant melanoma. Thorough clinical examination was preformed, but no other primary or metastatic site of melanoma could be found. In the next few months, the patient developed multiple liver metastases and died. CONCLUSION: An isolated amelanotic lesion in the ampulla of Vater can be a potential diagnostic pitfall, especially in patients who have had melanoma.

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.

The effect of analgesics and physical therapy on respiratory function after open and laparoscopic cholecystectomy.

In this study we present prospective clinical trial included 100 patients. One half of the patients underwent open cholecystectomy, whereas laparoscopic cholecystectomy was performed in the other half Spirometric parameters, arterial blood gases, acid-base balance, were determined preoperatively, and then at 6 h, 24 h, 72 h and 144 h postoperatively. The impact of physical therapy on the respiratory parameter patterns, VAS-pain score and use of tramadol were studied after cholecystectomy. Significantly lower VAS-pain score and less tramadol use, higher values and faster recovery of ventilation parameters and PaO2 were recorded after laparoscopic cholecystectomy than after open cholecystectomy (p = 0.001 for both). Physical therapy resulted in a significant improvement in the values of respiratory parameters in the open cholecystectomy group within a short time (30 min) after therapy was performed. Physical therapy failed to produce any improvement of respiratory parameters in laparoscopic cholecystectomy, whereas in open cholecystectomy group who had a favorable although transient effect, strictly limited to the short time from its application. (p = 0.005). The patients operated on by open cholecystectomy had statistically significantly more pronounced disturbances including hypoxia, hypocapnia and hyperventilation when compared to the group submitted to laparoscopic cholecystectomy. It is recommended that physical therapy be more frequently performed during the postoperative period in patients submitted to open cholecystectomy.

Effect of surgical incision on pain and respiratory function after abdominal surgery: a randomized clinical trial.

BACKGROUND/AIMS: The aim of the present study was to assess the severity of respiratory disturbances occurring after abdominal surgery and to identify surgical incisions that entail the least respiratory complications and postoperative pain. METHODOLOGY: A total of 105 patients divided into two groups were included in this randomized clinical trial. Seventy-five patients in the first group underwent upper abdominal surgery, and were operated on by use of vertical, oblique, transverse and elliptic incision. The remaining 30 patients in the second group were submitted to low abdominal surgery by use of vertical and oblique incision. Arterial blood gases and pulmonary shunt development were determined at 12 h preoperatively, and at 6 h, 72 h and 144 h postoperatively. During the postoperative course, VAS-pain score and use of tramadol were observed according to the type of surgical incision employed. RESULTS: Most severe respiratory disturbances in terms of PaO2 decrease, activating compensatory hyperventilation, pulmonary shunt increase, the highest VAS-pain score and consumption of tramadol were induced by the following upper abdominal incisions: transversal laparotomy according to Orr, elliptic periumbilical laparotomy, upper midline laparotomy, transrectal laparotomy and subcostal laparotomy. In the group of low abdominal surgery (low midline laparotomy and inguinal incision) consumption of tramadol was statistically significantly lower, but no statistically significant differences were recorded between the baseline preoperative and postoperative values of PaO2, PaCO2 and pulmonary shunt. CONCLUSIONS: All low abdominal incisions were found to entail statistically significantly less respiratory disturbances, lower VAS-pain score and lower tramadol use when compared to upper abdominal incisions. The upper abdominal incisions observed caused substantial respiratory disturbances including hypoxia, hyperventilation and pulmonary shunt increase.

Mine clearance injuries in South Croatia.

OBJECTIVE: The purpose of this retrospective study was to describe and analyze casualties in mine-clearance operations in South Croatia from 1991 to 1995. During the war in Croatia, the laying of mines by both sides was largely unplanned, without mapping or documentation, making demining, an already expensive, complicated task, even more dangerous. METHODS: The study comprised all those injured in mine-clearance operations treated at Clinical Hospital Split. The type of mines used, the mechanism of the incident, and the location and severity of injury according to the Abbreviated Injury Scale and the Injury Severity Score were analyzed. RESULTS: In a 5-year period, 160 pyrotechnicians of the Croatian Army performed demining in Southern Croatia. In 29 incidents, 53 deminers were injured. The degree of injury according to the Abbreviated Injury Scale was 2.85 +/- 0.6 and Injury Severity Score grade was 19.68 +/- 8.57. Two of the injured died. CONCLUSION: To find and remove approximately 2 million mines laid in Croatia will take at least 10 years and 2,000 to 3,000 specialized personnel. Unfortunately, the results of the study demonstrate that a significant number of deminers will suffer grave injuries or die in the process.