Acute pancreatitis in the Zabok General Hospital.

Acute pancreatitis is an acute disease of the pancreas due to the organ autodigestion. The disease is still burdened with numerous complications and quite frequently with lethal outcome, in spite of the sophisticated diagnostic and therapeutic methods currently available. The disease has a benign course in a majority of patients (80%), however, in the remaining 20% it assumes a malignant course with the development of massive necroses of the pancreatic and peripancreatic tissues, infection, hemorrhage, and endogenous intoxication with lesions of the lungs, kidneys, heart and liver. The biliary tract disease plays the major role in the etiology of acute pancreatitis (80%), followed by alcoholism (10% to 15%). This differs from the experience acquired at the Zabok General Hospital, where an almost identical incidence of biliary and ethylic etiology was recorded. Other, less common causes include post-traumatic, postoperative, infective and hormonal (hyperparathyroidism) etiology. In some cases, the cause of acute pancreatitis remains unknown. The disease shows a female predominance, which results from the higher prevalence of cholelithiasis in women than in men. Anatomically, there are two main forms of acute pancreatitis, interstitial or edematous form, and hemorrhagic necrotizing form. The interstitial or edematous form of acute pancreatitis is characterized by edema (exudation) of the pancreatic interstitium. The hemorrhagic necrotizing form of acute pancreatitis is characterized by autodigestion of a minor or major portion of the pancreas and peripancreatic tissues. The diagnosis of acute pancreatitis may initially pose a considerable problem. Decision on the mode of treatment should primarily be based on the clinical picture and supported by relevant laboratory parameters and other diagnostic procedures (ultrasonography, computed tomography). Conservative therapy is indicated for the edematous form of acute pancreatitis, whereas operative treatment is as a rule used for the necrotizing form of acute pancreatitis. Secondary bacterial contamination of the necrotic foci with the development of septic complications occurs in more than 50% of patients with the necrotizing form of acute pancreatitis, and is an absolute indication for surgical intervention. The modes of treatment used in 57 patients admitted for acute pancreatitis during the 1996-1999 period are described. Cholelithiasis was the cause of acute pancreatitis in 28 (49.1%), and alcoholism in 29 (50.9%) patients. Conservative treatment was used in 41 (72%) patients. Sixteen (28%) patients underwent operative treatment. Explorative laparotomy and drainage were performed in four patients, and explorative laparotomy, necrectomy, sequestrectomy and drainage with two or more drains in 11 patients. Cholecystectomy and T drainage along with necrectomy and drainage were performed in one patient. There were 12 (21%) patients with the most severe form of acute pancreatitis. Nine of these patients were operated on (necrectomy drainage) between day 6 and 10 of the disease. Two of these patients had to be reoperated on within a month, due to necrosis and abscess recurrence. Three of the 12 patients with the severe form of acute pancreatitis received conservative therapy. Fifteen patients were operated on 8-10 weeks after acute pancreatitis had subsided. Pseudocysts developed in three patients. These patients were operated on 6-8 weeks from the onset of disease, with internal drainage via isolated small intestine flexure performed in all of these patients. The mean duration of intensive care unit stay for all patients with acute pancreatitis was 20.6 days. Four of 57 patients hospitalized for acute pancreatitis died. The mortality rate in the group of patients with the severe form of acute pancreatitis (n = 12) was 33%. Complications developed in 50% of operatively treated patients.

[Contribution to the nomenclature of variations of the cystic artery]. / Ein Beitrag zur Nomenklatur der Variationen der Arteria cystica.

INTRODUCTION: Safe procedures for laparoscopic cholecystectomy demand good knowledge of the anatomy of the terminal part of the cystic artery and its variations, and also precise dissection in and around the hepatobiliary triangle. METHOD: Good laparoscopic visualisation enables recognition of the variation of the cystic artery. Our observations are based on 1000 cholecystectomies. RESULTS: We have described and named variations of the terminal part of the cystic artery. Group I comprises the five variations of the cystic artery within the hepatobiliary triangle: (a) "normal" position; (b) frontal cystic artery; (c) backside; (d) multiple; (e) short cystic artery that arises from an aberrant right hepatic artery. Group II consists of variations of the cystic artery that approach--the gallbladder beyond the hepatobiliary triangle: (a) "low-lying"; (b) transhepatic; (c) "recurrent" cystic artery. CONCLUSION: Our classification is simple and easy to memorize and will considerably facilitate safe laparoscopic cholecystectomy.

Gastrointestinal pseudo-obstruction: report of a patient with postoperative pseudo-obstruction.

Postoperative pseudo-obstruction is a rare state of protracted gastrointestinal paresis that may progress to paralysis without the presence of obstructive lesions. Pseudo-obstruction is usually, but not exclusively, associated with an abdominal operative procedure (laparotomy), however, it may occasionally occur following extra-abdominal operations. As differentiated from the usual, 'physiologic'postoperative paresis, pseudo-obstruction persists for more than 7 days. The pathogenesis of postoperative pseudo-obstruction is complex and as yet partially unknown. Whereas the 'physiologic' postoperative gastrointestinal paresis includes short-term functional cholinergic depression of the visceral organs, in pseudo-obstruction focal lesions in the region of Auerbach's plexus, manifesting as visceral neuromyopathy, are involved. That is why the 'physiologic' postoperative paresis never transforms into paralytic ileus, while in pseudo-obstruction such a risk is potentially involved. The treatment for pseudo-obstruction is as a rule conservative. Surgical treatment (cecostomy) is rarely required. Colonoscopic decompresive suction is usually enough to eliminate the risk of colon rupture due to extensive distention by fast growing meteorism. A patient with postoperative pseudo-obstruction is presented.

Laparoscopic visualization of the cystic artery anatomy.

Uncontrolled bleeding from the cystic artery and its branches is a serious problem that may increase the risk of intraoperative lesions to vital vascular and biliary structures. On laparoscopic visualization anatomic relations are seen differently than during conventional surgery, so proper knowledge of the hepatobiliary triangle anatomic structures under the conditions of laparoscopic visualization is required. We present an original classification of the anatomic variations of the cystic artery into two main groups based on our experience with 200 laparoscopic cholecystectomies, with due consideration of the known anatomicotopographic relations. Group I designates a cystic artery situated within the hepatobiliary triangle on laparoscopic visualization. This group included three types: (1) normally lying cystic artery, found in 147 (73.5%) patients; (2) most common cystic artery variation, manifesting as its doubling, present in 31 (15.5%) patients; and (3) the cystic artery originating from the aberrant right hepatic artery, observed in 11 (5.5%) patients. Group II designates a cystic artery that could not be found within the hepatobiliary triangle on laparoscopic dissection. This group included two types of variation: (1) cystic artery originating from the gastroduodenal artery, found in nine (4. 5%) patients; and (2) cystic artery originating from the left hepatic artery, recorded in two (1%) patients.

Aging and surgery.

Among other things, current science and civilization have enabled us to live longer than ever before. This, in turn, has resulted in a greater proportion of elderly people (aged > or = 65). In Croatia, elderly people accounted for 6.2% of the general population in 1971, and 11.6% in 1991. The greater proportion of the elderly results in increased demands placed upon the health care system, including surgical treatment. Due to the advances in medicine and medical technology, old age itself is not a contraindication for surgical treatment anymore. However, elderly people are more vulnerable to surgical trauma, thus being exposed to a higher surgical risk than young patients. Surgical risk is additionally increased by concomitant diseases typical for old age. Therefore, surgical treatment in the elderly requires strict indications. During the 1993-1998 period, 585 elective and 286 emergency operations in elderly patients were performed at the General Hospital in Zabok. In patients under the age of 65, postoperative mortality was 1.7% after elective and 4.5% after emergency procedures, while in elderly patients the respective figures were 5.6% and 12.0%. This clearly indicates the high level of surgical risk in elderly patients requiring emergency operations.

Biliary duct reoperations.

Conventional operations for cholelithiasis are rarely associated with postoperative complications. However, when the complications do occur, they are frequently life threatening and require reoperation. These reoperations are associated with a considerably higher risk than primary procedures, and require maximal caution and experience from the surgeon. Reoperations are performed in anatomically altered conditions, and in a patient psychically and physically exhausted and in fear from repeat procedure. Therefore, it is of utmost importance for each primary operation including conventional procedure for cholelithiasis to be carried out at a high professional level, using all technologic achievements available that facilitate and improve the surgeon's work safety. In this way, the need of undesired and hazardous reoperations is minimized. The rate of and indications for reoperation in 530 patients operated on by the conventional procedure for cholelithiasis during the 1994-1999 period are presented.

A contribution to the casuistics of choledochal cysts.

Choledochal cyst is a rare cystic anomaly of bile ducts, primarily affecting the choledochus. The etiology of the disease is unknown, while the symptoms predominated by cholangitis usually occur by the age of thirty. The complications of untreated disease include septic complications, biliary cirrhosis, formation of concrements in cystically dilated bile ducts, and a potential risk of cholangiocarcinoma. Two patients with choledochal cysts type III and IV are presented. The patient with type III choledochal cyst underwent radical treatment, whereas in the patient with type IV choledochal cyst only a palliative procedure could be used. Both patients were men older than 40, and were free from the disease associated sequels for two and five years after the surgery.

Ethical considerations in contemporary medicine.

Numerous benefits brought along by the impressive technological progress of the contemporary world are also accompanied by potential hazards of dehumanization of life. As neither medicine has been skipped over by the technological progress, there is a risk for the physician to become dependent on it rather than master it. Therefore, there is the risk of deprivation of medical ethics norms, ever more frequently transforming the patient's position of the subject of medical activities into the position of an object. This pending risk is especially present in surgery, a medical discipline characterized by the highest technological and technical differentiation. If the surgeon is to preserve high ethical standards in his work, he should strictly follow the basic medical ethics norm, that proclaim full respect of the patient's will, forbid doing harm to the patient, and point to equity and compassion on providing medical aid. These ethical norms should be respected not only on performing surgical procedures, but also on making indications for the procedure. The future development of medicine and surgery, with a substantial impact of new, technical and technological advances, will open new, presently unknown ethical issues. All this will require through sociophilosophical and humane-ethical considerations in order to preserve the basic medical ethics norms warranting humaneness and ethics of medicine.

Papers published by members of the Croatian Academy of Medical Sciences, registered in international bibliographic data bases in the period 1986-1990.

Scientific productivity of the CAMS members was analyzed according to the number of papers published in periodicals covered by international Medline and Science Citation Index data bases from 1986 to 1990. Results showed the mean scientific productivity per CAMS member, and the relationship between scientific productivity and age, field of medicine or respective biomedical discipline. The pattern of scientific productivity was also found to change, when analyzed according to Medline or SCI data bases in separate.

["Stress" ulcer - acute ulcerous and erosive lesions in the gastroduodenal mucosa]. / "Stress" ulkus - akutne ulkusne i erozivne lizije sluznice zeluca i dvanaesnika.

Acute gastroduodenal mucosal lesions are observed following shock, sepsis, trauma, bat also after the ingestion of certain substances (alcohol) and in the course of severe, chronic medical illness. The so-called cushing ulcus should probably be separated from the clinical syndrome of stress ulcer. We must also exclude without any discussion reactivated chronic duodenal or ventricular ulcers with their complications, often manifested after serious trauma or illness. Digestive complaints are absent from the history of illness. The earliest manifest sign is in most cases severe gastrointestinal haemorrhage. It appears that the presence of Hydrogen ions in gastric contents and mucosal ischaemia are required for stress ulcer to develop, in which process damage to the "mucosal barrier" is also instrumental. The basic diagnostics is endoscopy. Angiography is only indicated in patients where endoscopy has failed. Conservative therapy brings haemorrhage under control in most cases. Surgery is indicated only if conservative therapy has proved inadequate to control bleeding or in cases of free perforation. Optimal surgical treatment remains a matter of discussion since no surgical method, except total gastrectomy, can protect the patient from recurrent haemorrhage.

[Correlation of gastroscopic, pathohistologic, cytologic and cytochemical analysis of ulcer lesions and other pathologic changes in the gastric mucosa. Preliminary study]. / Korelacija gastroskopskih, patohistoloskih, citoloskih i citokemijskih analiza kod ulkusnih lezija i ostalih patoloskih promjena sluznice zeluca -- preliminarni izvestaj.

This paper concerns our first experience of correlation analysis between the gastroscopic, pathohystologic, cytologic and cytochemical findings of different organic gastric lesion on gastroscopy. The authors' experience is based on 78 patients in whom 450 biopsies were performed. For an adequate analysis, 135 samples of pathohystologic anc cytological examinations were useful and only 80 samples for cytochemical analysis. From these examinations it is possible to conclude that the cytochemical reactions of the group of patients with inflammatory lesions and intestinal metaplasia showed changes in the level of enzyme aminopolypeptidase together with the presence of acid mucopolysacharides. In the group of patients with lesions showing an ulcer, carcinoma or suspect malignancies, the changes occured in the composition of enzymes such as acid phosphatase, DNP Diaphoresis and nonspecific esterases. With such combined examinations the percentage of correct diagnoses was increased in comparison with conventional method of gastroscopy and biopsy.