Impact of timing on surgical outcome in patients with cauda equina syndrome caused by lumbar disc herniation.

Aim To analyze the relationship between timing of surgery and outcome in patients with cauda equina syndrome caused by lumbar disc herniation. Methods A retrospective, non-randomized clinical study included 25 consecutive patients with cauda equina syndrome (CES) caused by lumbar disc herniation. All patients were operated within 24 hours after hospitalization at the Department of Neurosurgery, Cantonal Hospital Zenica, Bosnia and Herzegovina, between January 2000 and December 2010. All patients were evaluated before surgery on the basis of complete history, neurological examination and neuroimaging evaluations using CT (computed tomography)and MRI (magnetic resonance imaging). Results Statistically significant difference between preoperative and postoperative bladder (p=0.05) and bowel (p=0.05) function was found. A significant number of patients had bladder and bowel recovery after surgery, nine (36%) and 11 (44%), respectively. Significant recovery of muscle strength was noted with complete recovery(5/5) in 12 (48%) and partial recovery in 13 (52%) patients. Complete sensory recovery was noted in 16 (64%), incomplete in four (16%), and in five (20%) patients there were no changes. Most commonly, patients with complete sensory recovery were operated within 48 hours of symptom onset. In most patients early surgery was associated with better outcome. Conclusion This research showed that early decompression correlated with better outcome. Patients with cauda equina syndrome must be cleared for surgery in optimal conditions and, if it possible within optimal timing for recovery (within 48 hours).

Evaluation of the surgical treatment of diabetic foot.

AIM: To examine two modalities of surgical treatment of diabetic foot based on two different approaches, classical and multidisciplinary. METHODS: A retrospective-prospective study including 120 consecutive patients with diabetic foot treated in the Department of Surgery, General Hospital Tesanj in the period 1999-2006. Since 2003 a new multidisciplinary approach to the treatment of diabetic foot based on a more conservative approach has been introduced. Two groups of patients were analyzed according to two treatment approaches: the first group included patients treated with classical method (in the period 1999-2002), and the second group included patients treated with multidisciplinary approach (in period 2003- 2006). An age distribution, gender, local changes in the extremities, results of microbiological analysis of wound swabs, and modalities of surgical treatment of diabetic foot were analyzed. RESULTS: Duration of the disease (p=0.24), the level of blood glucose (p=0.52) and glycosylated hemoglobin (p=0.10) had no statistically significant effect to the outcome of the treatment of diabetic foot, while the level of hematocrit (p less than 0.006), fibrinogen (p less than 0.003), cholesterol (p less than 0.000001), and the absence of a pulse in the peripheral arteries (p less than 0.000002), and the outcome of surgical treatment of diabetic foot had the influence to the outcome of the treatment of diabetic foot with statistical significance. CONCLUSION: Aggressive and appropriate medical and surgical treatment according to a grade of disease could improve the outcome and reduce the morbidity and mortality of diabetic foot. The results of this study showed the importance of proper diabetes treatment, prevention of complications and a multidisciplinary approach to the treatment of diabetic foot.

Quality of life for tobacco smokers in relation to their socioeconomic status.

AIM: To analyze differences in quality of life between smokers and non-smokers in relation to socioeconomic factors. METHODS: This study was conducted on a sample of 600 respondents equally divided in two groups, smokers (300) and non-smokers (300). Former smokers were excluded. The study included both sexes equally further distributed into age groups: 19-34, 35- 49, 50-64 and 65-70 years. A questionnaire SF-36 to test the quality of life (36 questions measuring eight dimensions of quality of life) and questionnaire EuroQoL to examine the socioeconomic status was used. For the assessment of a given factor impact multivariant and univariant analyses of variance were used. RESULTS: A significant difference in the quality of life between smokers and non-smokers according to the gender was found, but only at the subscales of physical functioning and bodily pain (p=0.000). An analysis of individual dimensions of quality of life in relation to marital status of smokers and non-smokers showed significant differences on the subscales of physical functioning (p=0.032), vitality (p=0.0430) and mental health (p=0.016). An analysis of life quality in relation to smoking status of respondents and the average monthly income showed that the average scores on all subscales were higher in non-smokers compared to smokers (p=0.000) and they were increased with the average monthly income. CONCLUSION: The results of this study prove that there are significant differences in quality of life according to the smoking status. Also the socioeconomic factors which include age, gender, the surrounding, marital status, employment, total monthly income and level of education are of great influence on the quality of life with significant differences in relation to smoking status.

Tumor necrosis factor-alpha serum level in assessment of disease activity in inflammatory bowel diseases.

AIM: To investigate an influence of the concentration of proinflammatory cytokines tumor necrosis factor-alpha (TNF-α) in serum on the activity of inflammatory bowel disease (IBD). METHODS: The IBD patients of both genders (n=60) were divided in two equal groups, ulcerative colitis (UC) and Crohn's disease (CD). Based on the result of activity index each group was subdivided in two subgroups: active and inactive phase of the disease. Age and gender matched apparently healthy individuals (n=30) involved in the control group. Serum TNF-α concentration was determined by enzyme linked immune-adsorbent assay (ELISA). RESULTS: The significant difference (Mann-Whitney Test) in serum TNF-α level was found between healthy controls 28.86 pg/ml (28.74 - 29.19 pg/ml) and CD patients (29.47 pg/ml (29.1 - 29.77 pg/ml) (p less than 0.05) and UC patients 29.34 pg/ml (29.14 - 29.71 pg/ ml) (p less than 0.05) respectively. Serum TNF-α level in patients with CD was higher compared to serum TNF-α level in patients with UC, but the difference was not significant (p more than 0,05). There were no significant difference in serum TNF-α concentrations either in CD or UC patients related to the phase of disease activity: active CD 29.53 pg/ml (29.20 - 29.90 pg/ml) vs inactive CD 29.26 pg/ml (29.15 - 29.53 pg/ml); active UC 29.53 pg/ml (29.32 - 29.85 pg/ ml) vs inactive UC 29.26 pg/ml (29.10 - 29.63 pg/ml). CONCLUSIONS: Since there were no differences in serum TNF-α concentrations related to the disease activity we consider that TNF-α is not an adequate serum biomarker for an assessment of the disease activity in patients with IBD.

Bile duct injury during laparoscopic cholecystectomy: risk of procedure or professional negligence?

Laparoscopic cholecystectomy introduced in the late eighties has now become the gold standard and has taken the place of conventional cholecystectomy. Bile duct injury during cholecystectomy is an iatrogenic, but rare catastrophe associated with significant morbidity and mortality. The incidence of bile duct injuries during laparoscopic cholecystectomy is 0.1-0.42%. We have presented a patient who underwent laparoscopic cholecystectomy which got complicated with bile duct injury grade four. The complication was recognized three weeks later. A remediation of complications was performed in a reference center with full involvement of the primary surgeon.

Retrocaecal appendix position--findings during the clasic appendectomy.

INTRODUCTION: Appendicitis is one of the most common diseases that require urgent surgical intervention. Due to its position, the inflamed appendix can cause many complications in abdominal cavity. Most of these complications are based on the anatomical position of the appendix. According to world literature over 65% of the anatomical positions of appendix is retrocaecal position, followed paracaecal and then the other positions of the appendix in different percentages. GOAL: The main goal of this research is to shown that anatomical retrocaecal position of the appendix can lead to prolonged hospitalization and more often occurrence of appendicitis complications. MATERIAL AND METHODS: The research is based on patients who had appendectomy during 2009 at the Cantonal Hospital Zenica and General Hospital Tesanj. The study included approximately 400 respondents and the method of research was of retrospective, descriptive and analytical type. RESULTS AND DISCUSSION: According to the results of this research we can conclude that in our country is not devoted enough attention to the anatomic position of the appendix and that we are not using enough diagnostic methods such as ultrasound and CT in determining the anatomic position to help determine the course of the disease. CONCLUSIONS: Retrocaecal appendix position according to the obtained data from this study did not cause many complications in classical appendectomy but this can be attributed to insufficient observation of the anatomical position of the appendix.

Intrahepatic transposition of bile ducts.

Objective. To describe the intrahepatic bile duct transposition (anatomical variation occurring in intrahepatic ducts) and to determine the frequency of this variation. Material and Methods. The researches were performed randomly on 100 livers of adults, both sexes. Main research methods were anatomical macrodissection. As a criterion for determination of variations in some parts of bile tree, we used the classification of Segmentatio hepatis according to Couinaud (1957) according to Terminologia Anatomica, Thieme Stuugart: Federative Committee on Anatomical Terminology, 1988. Results. Intrahepatic transposition of bile ducts was found in two cases (2%), out of total examined cases (100): right-left transposition (right segmental bile duct, originating from the segment VIII, joins the left liver duct-ductus hepaticus sinister) and left-right intrahepatic transposition (left segmental bile duct originating from the segment IV ends in right liver duct-ductus hepaticus dexter). Conclusion. Safety and success in liver transplantation to great extent depends on knowledge of anatomy and some common embryological anomalies in bile tree. Variations in bile tree were found in 24-43% of cases, out of which 1-22% are the variations of intrahepatic bile ducts. Therefore, good knowledge on ductal anatomy enables good planning, safe performance of therapeutic and operative procedures, and decreases the risk of intraoperative and postoperative complications.

[Variations in position and place of formation of appendix vermiformis found in the course of open appendectomy]. / Varijacije polozaja i mjesta nastanka appendix vermiformis utvrdene tokom klasicne apendektomije.

This paper describes variations of the appendix vermiformis, found in the course of open appendectomy. Investigations involved surgeries performed in 2008 year in the Regional Hospital TeSanj. Variations in the site of formation and position of appendix vermiformis were established. Dominantly, appendix vermiformis is placed in the pelvic position in 57.71% of cases. In the smallest number of cases (2), or 3.07% lateral (paracecal) position was found. Variations of position of ostium appendicis vermiformis were registered as well. Two types of ostium appendicis vermiformis were found: dorso-medial wall of intestinum caecum below ostium ileocaecale (35.39%), dorso-lateral medial wall of intestinum caecum (30.7%) and lower pole of intestinum caecum (64.61%). Results of this research indicate very large variability of appendix vermiformis anatomy, which together with other factors (age, sex, phase in which is patient at the moment of examination) form a clinical picture of the acute appendicitis.