ERCP treatment of obstructive jaundice caused by hydatid cyst in extrahepatic ducts 13 years after liver hydatid endocystectomy. A case report.

INTRODUCTION: Hydatid disease affects most commonly the liver, and complications with the rupture into the biliary tree develop in approximately one-fourth of the cases. Moreover, primary hydatid cysts of the biliary tract have been reported. PRESENTATION OF CASE: We report an extremely rare case of obstructive jaundice caused by hydatid cyst in extrahepatic ducts 13 years after liver hydatid endocystectomy treated by Endoscopic retrograde cholangiopancreatography (ERCP). A 28-year-old male patient who had undergone surgical treatment - removal of liver hydatid cyst 13 years earlier, presented with signs of obstructed jaundice, confirmed with blood tests results and magnetic resonance cholangiopancreatography (MRCP). Actually, there were no pathological changes detected in the hepatic parenchyma, but the intrahepatic and extrahepatic bile ducts were dilated. ERCP was performed and the entire hydatid material was evacuated and washed out into the gastrointestinal tract. In addition, after laparoscopic cholecystectomy, hydatid cysts were also confirmed in the gallbladder. DISCUSSION: Generally, the obstructive jaundice caused by hydatid cyst in the extrahepatic ducts can also be caused by the rupture of the liver hydatid cyst in the biliary tract, or by primary hydatid cyst in the biliary tract. The ERCP plays a key role in the diagnosis and the treatment of this pathology. CONCLUSION: The ERCP, has now become an important diagnostic and therapeutic procedure in management of primary extrahepatic hydatid cysts and of complicated liver hydatid cysts.

Celiac Disease in Kosovar Albanian Children: Evaluation of Clinical Features and Diagnosis.

BACKGROUND: Celiac disease is an immune-mediated disorder characterized by variable clinical manifestations, specific antibodies, HLA-DQ2/DQ8 haplotypes, and enteropathy. OBJECTIVES: The aim of this study was to present the clinical spectrum and patterns of celiac disease in Kosovar Albanian children. METHODS: A cross-sectional retrospective study was performed with Albanian children aged 0-18 years, treated for celiac disease in the Pediatric Clinic, University Clinical Center of Kosovo from 2005 to 2016. RESULTS: During the study period, 63 children were treated for celiac disease. The mean age at diagnosis was 5.5 years (SD ± 3.31). The mean age at celiac disease onset was 3.3 years (SD ± 2.02), while the mean delay from the first symptoms indicative of celiac disease to diagnosis was 2.2 years (SD ± 2.09). More than 70% of the patients were diagnosed in the first 7 years of life, mainly presented with gastrointestinal symptoms, while primary school children and adolescents mostly showed atypical symptoms (p<0.001). The classical form of celiac disease occurred in 78% of the cases. Sixty (95%) patients carried HLA-DQ2.5, DQ2.2 and/or HLA-DQ8 heterodimers, and only three of them tested negative. CONCLUSION: Kosovo, as the majority of developing countries, is still facing the classical form of celiac disease as the dominant mode of presentation; as a result, most children with other forms of the celiac disease remain undiagnosed. Physicians should be aware of the wide range of clinical presentations and utilize low testing thresholds in order to prevent potential long-term problems associated with untreated celiac disease.

Retained Surgical Foreign Bodies after Surgery.

The problem of retained surgical bodies (RSB) after surgery is an issue for surgeons, hospitals and the entire medical team. They have potentially harmful consequences for the patient as they can be life threatening and usually, a further operation is necessary. The incidence of RSB is between 0.3 to 1.0 per 1,000 abdominal operations, and they occur due to a lack of organisation and communication between surgical staff during the process. Typically, the RSB are surgical sponges and instruments located in the abdomen, retroperitoneum and pelvis.

Mesenteric Meckel's diverticulum or intestinal duplication cyst: A case report with review of literature.

INTRODUCTION: A Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal (GI) tract. They arise from the middle-to-distal ileum. Contrary to MD, intestinal duplication cyst (IDC) is uncommon congenital anomaly of GI, but can occur anywhere from the tongue to the anus. PRESENTATION OF CASE: Here we report an 18-year-old male who presented to the department of abdominal surgery with chronic abdominal pain, frequent vomiting and mild abdominal distension. Following radiological investigation, a laparotomy was performed with the preoperative diagnosis of a mesenteric cyst. Intraoperativelly it became apparent that the cystic mass was on the mesenteric aspect of the small bowel without intestinal communication. Resection of the cyst was performed. Histological examination of the specimen revealed the presence of gastric tissue, which resembles MD. Although, the exact diagnosis of this cystic mass is ambiguous between MD and IDC, because of similar clinical signs, their complications and presence of gastric mucosa, however surgical treatment is gold standard of both. CONCLUSION: This case report underlines the necessity of how to differentiate between MD and IDC, although, surgical management is recommended for both.

Penetrated sigmoid colon by air gun pellet could be life threatening: A case report.

INTRODUCTION: Air and paintball guns have been in existence for over 400 year. Although serious injury or death can result from the use of such guns, previous literature has not mentioned the issue of the penetration of the sigmoid colon by an air gun pellet. PRESENTATION OF CASE: We report a rare case of a 44-year-old Caucasian woman referred to abdominal surgery after an accidental small wound had occurred in the lower left abdominal quadrant that was caused by an air gun pellet. The blood and biochemical analyses were normal but the CT scan revealed the presence of a foreign body - an air gun pellet in the left iliac region of the abdomen. Clinically, during the initial 24h significant changes were not noticed. After 42h, however, pain and local tenderness in the lower left abdominal quadrant was expressed. A laparotomy revealed a retained pellet in the wall of the sigmoid colon and a small leak with colonic content with consecutive local peritonitis also occurred. The foreign body was removed and the opening edges in the colon were excised and closed with the primary suture. DISCUSSION: The hollow organs of the digestive tract, albeit very rarely penetrated by an air gun pellet, do not typically show all signs of an acute abdomen in the early posttraumatic phase. Such injuries can lead to a pronounced infection, which may cause septic shock if not appropriately treated. CONCLUSION: For correct diagnosis, a careful approach and several daily clinical observations are required.

A randomized trial of preoperative oral carbohydrates in abdominal surgery.

BACKGROUND: Carbohydrate-rich liquid drinks (CRLDs) have been recommended to attenuate insulin resistance by shortening the preoperative fasting interval. The aim of our study the effect of preoperative oral administration of CRLDs on the well-being and clinical status of patients. METHODS: A randomized, double blind, prospective study of patients undergoing open colorectal operations (CR) and open cholecyctectomy (CH) was conducted. Patients were divided into three groups: study, placebo, and control. Visual analogue scale (VAS) scores for seven parameters (thirst, hunger, anxiety, mouth dryness, nausea, weakness and sleep quality) were recorded and compared for two different time periods (up to 24 h postoperatively and from 36 to 48 h postoperatively). The Simplified Acute Physiology Score changes (SAPS)-II between the three groups were also studied. RESULTS: There were 142 patients American Society of Anesthesiology (ASA) I or II enrolled in the study (CR = 71 and CH = 71). There were no significant differences in postoperative SAPS-II scores or lengths of hospital stay (LOS) between the groups. However, in CR patients, the degree of thirst was partially improved by drinking CRLDs (P = 0.027). In CH patients, on the other hand, feelings of thirst, hunger, mouth dryness, nausea and weakness showed significant improvement (P < 0.05). CONCLUSION: Oral administration of carbohydrate-rich liquid drinks (CRLDs) improves the well-being in patients undergoing CH, but the effect is less evident in patients undergoing CR. No significant improvements were seen in clinical status or in length of hospital stay in either group. TRIAL REGISTRATION: ANZCTR.org.au: ACTRN12614000995673 (registered on 16/09/2014).

Variations of cystic duct (CD)--common hepatic duct (CHD) junction determined by ERCP.

INTRODUCTION: Cystic Duct (CD) join Common Hepatic Duct (CHD) to the right with right angle close to 75% of cases and in 25% of cases like spiral intersects the CHD from above or behind and join it to his left to form the Common Bile Duct (CBD). There are authors who describe that CD may join CHD at any level to form CBD. The importance of recognizing union of CD and CHD has significant importance for the surgeons that perform Cholecystectomy, in order to avoid injuries to the CHD or CBD. AIM OF THE STUDY: to present the variations of CD-CHD junction determined by ERCP. To recognize variations of CD-CHD junction in Albanian population used in this study. To present differences of CD-CHD junction between male and female population. METHODS AND RESULTS: Data were taken from the protocols of ERCP that has been done in UCC of Kosova - Department of Endoscopy, Clinic of Surgery. During last 2 years period we have had 398 patients in ERCP from those we have determined CD-CHD junction on 148 (37.85%) patients. 76 were Female (51.35%) and 72 male (48.65%). CD-CHD junction was identified as right junction in 117(79.05%) patients: UR in 64(43.24%), MR in 46(31.08%), LR in 7 (4.73%). Left CD-CHD junction was identified in 31 (20.95%) of patients: UL in 4(2.70%), ML 6(4.07%) and LL in 21 (14.18%) of patients. It is important to notice that Lower Left union of CD and CHD is rare or not prescribed in literature. We haven't find significant differences between male and female groups according to right or left CD-CHD junction (p<0.05). There is deference between male and female in lower CD-CHD junction (p<0.01), and there is also deference between male and female in left lower CD-CHD junction (p<0.05). CONCLUSION: We conclude that CD-CHD junction was identified as right junction in 79.05% patients and as left CD-CHD junction was identified in 20.95%. There is deference between male and female in left lower CD-CHD junction (p<0.01). We have identified LL CD-CHD junction in 14.18% of patients and that is rare or not prescribed in literature.

Correlation of serum C-reactive protein, white blood count and neutrophil percentage with histopathology findings in acute appendicitis.

BACKGROUND: Acute appendicitis is one of the most common surgical emergencies. Accurate diagnosis of acute appendicitis is based on careful history, physical examination, laboratory and imaging investigation. The aim of the study is to analyze the role of C-reactive protein (CRP), white blood count (WBC) and Neutrophil percentage (NP) in improving the accuracy of diagnosis of acute appendicitis and to compare it with the intraoperative assessment and histopathology findings. MATERIALS AND METHODS: This investigation was a prospective double blinded clinical study. The study was done on 173 patients surgically treated for acute appendicitis. The WBC, NP, and measurement of CRP were randomly collected pre-operatively from all involved patients. Macroscopic assessment was made from the operation. Appendectomy and a histopathology examination were performed on all patients. Gross description was compared with histopathology results and then correlated with CRP, WBC, and NP. RESULTS: The observational accuracy was 87,3%, as compared to histopathological accuracy which was 85.5% with a total of 173 patients that were operated on. The histopathology showed 25 (14.5%) patients had normal appendices, and 148 (85.5%) patients had acutely inflamed, gangrenous, or perforated appendicitis. 52% were male and 48% were female, with the age ranging from 5 to 59 with a median of 19.7. The gangrenous type was the most frequent (52.6%). The WBC was altered in 77.5% of the cases, NP in 72.3%, and C-reactive protein in 76.9% cases. In those with positive appendicitis, the CRP and WBC values were elevated in 126 patients (72.8%), whereas NP was higher than 75% in 117 patients (67.6%). Out of 106 patients with triple positive tests, 101 (95.2%) had appendicitis. The sensitivity, specificity, and positive predictive values of the 3 tests in combination were 95.3%, 72.2%, and 95.3%, respectively. CONCLUSION: The raised value of the CRP was directly related to the severity of inflammation (p-value <0.05). CRP monitoring enhances the diagnostic accuracy of acute appendicitis. The diagnostic accuracy of CRP is not significantly greater than WBC and NP. A combination of these three tests significantly increases the accuracy. We found that elevated serum CRP levels support the surgeon's clinical diagnosis.

Compound double ileoileal and ileocecocolic intussusception caused by lipoma of the ileum in an adult patient: A case report.

INTRODUCTION: The initial diagnosis of intussusception in adults very often can be missed and cause delayed treatment and possible serious complications. We report the case of an adult patient with complicated double ileoileal and ileocecocolic intussusception. CASE PRESENTATION: A 46-year-old Caucasian man was transferred from the gastroenterology service to the abdominal surgery service with severe abdominal pain, nausea, and vomiting. An abdominal ultrasound, barium enema, and abdominal computed tomography scan revealed an intraluminal obstruction of his ascending colon. Plain abdominal X-rays showed diffuse air-fluid levels in his small intestine. A double ileoileal and ileocecocolic intussusception was found during an emergent laparotomy. A right hemicolectomy, including resection of a long segment of his ileum, was performed. The postoperative period was complicated by acute renal failure, shock liver, and pulmonary thromboembolism. Our patient was discharged from the hospital after 30 days. An anatomical pathology examination revealed a lipoma of his ileum. CONCLUSIONS: Intussusception in adults requires early surgical resection regardless of the nature of the initial cause. Delayed treatment can cause very serious complications.

Dental identification of a decomposed body.

The dental identification of humans occurs for a number of different reasons, mainly in those cases when the body is fragmentized or disfigured and visual recognition cannot be done. The advanced step of putrefaction disables determination of identity by recognition. We report the case of an unknown man, found near Gjakova district, in 2000. The body was in advanced step of putrefaction. The identity of victim was unknown. The post mortem dental identification was done in the Institute of Forensic Medicine in Prishtina. The availability of dental records and radiographs allowed as to positively identify the body using teeth comparison method.

Symptomatic subserosal gastric lipoma successfully treated with enucleation.

Gastric lipomas are rare tumors, accounting for 2%-3% of all benign gastric tumors. They are of submucosal or extremely rare subserosal origin. Although most gastric lipomas are usually detected incidentally, they can cause abdominal pain, dyspeptic disorders, obstruction, invagination, and hemorrhages. Subserosal gastric lipomas are rarely symptomatic. There is no report on treatment of subserosal gastric lipomas in the English literature. We present a case of a 50-year-old male with symptomatic subserosal gastric lipoma which was successfully managed with removal, enucleation of lipoma, explorative gastrotomy and edge resection for histology check of gastric wall. The incidence of gastric lipoma, advanced diagnostic possibilities and their role in treatment modalities are discussed.