Potential New Approaches in Predicting Adverse Cardiac Events One Month after Major Vascular Surgery.

OBJECTIVE: The aim of our study was to find the best model with sufficient power to improve the risk stratification in major vascular surgery patients during the first 30 days after this procedure. The discriminatory power of 4 biomarkers (troponin I [TnI], N-terminal prohormone of brain natriuretic peptide [NT-proBNP], creatine kinase-MB isoenzyme [CK-MB], high-sensitivity C-reactive protein [hs-CRP]) was tested as well as 2 risk assessment models and 13 different combinations of them. SUBJECTS AND METHODS: The study included 122 patients (77% men, 23% women) with an average age of 67.03 ± 4.5 years. An aortobifemoral bypass was performed in 6.56% of the patients, a femoropopliteal bypass in 18.85%, and 49.18% received open surgical reconstruction of the carotid arteries. A total of 25.41% of the patients were given an aortobi-iliac bypass. RESULTS: During the first 30 days, 13 patients (10.7%) had 17 cardiac complications. The most common complication was the new onset of atrial fibrillation (35.3%). During the first 10 days, 10 patients had 1 complication and 2 patients had 2 cardiac events, while 1 patient had 3 complications. By comparing combinations of scores and markers, it was shown that revised cardiac risk index (RCRI) + Vascular Portsmouth Physiological and Operative Severity Score (V-POSSUM) + hsTnI and RCRI + V-POSSUM + hsTnI + NT-proBNP with 100% sensitivity, > 80% specificity had the best discriminatory ability (AUC 0.924 and 0.933, respectively; p < 0.001 for both models) for cardiac complications during the 30 days after surgery. CONCLUSION: Combinations of traditional preoperative risk factors and scores can enhance the assessment of major adverse cardiac events (MACE) in patients preparing for large vascular surgery. Using only one risk score in these patients seems to be underperforming in preoperative risk assessment.

[VATS THYMECTOMY IN MYASTHENIA GRAVIS TREATMENT--A CASE REPORT]. / VATS TIMEKTOMIJA U LIJECENJU MIASTENIJE GRAVIS--PRIKAZ BOLESNICE.

Myasthenia gravis (MG) is a chronic autoimmune disease characterized by weakness of skeletal muscles, specifically ocular. Relationship between the thymus gland and MG is not fully understood yet. Thymectomy is recommended for individuals with thymoma, but should be considered in all patients under 60 years of age with generalized MG in cases with no thymomatous tissue. We report a 27-year-old female patient with ocular type myasthenia gravis and radiological findings of anterior mediastinal mass, treated by VATS thymectomy. The intervention was carried out by 3-portal right-sided thoracoscopic approach. Single-lung ventilation and carbon-dioxide insufflation provided working space, and harmonic scalpel was used for the dissection and ligation. The patient's postoperative course was uncomplicated and the patient was discharged on the third postoperative day. The aim of our case report is to stress the importance of VATS technique in faster recovery and better cosmetic effect than in sternotomy procedures.

Improved staging using intraoperative ultrasound for mediastinal lymphadenectomy in non-small lung cancer surgery.

BACKGROUND: Extent of lymph node involvement in patients with non-small cell lung cancer (NSCLC) is the cornerstone of staging and influences both multimodality treatment and final outcome. The aim of this study was to investigate accuracy and characteristics of intraoperative ultrasound guided systematic mediastinal nodal dissection in patients with resected NSCLC. METHODS: From January 2008 to June 2013, 244 patients undergoing intraoperative surgical staging after radical surgery for NSCLC were included in prospective study. The patients were divided in two groups according to systematic mediastinal nodal dissection: 124 patients in intraoperative ultrasound nodal dissection guided group and 120 in standard nodal dissection group. The lymph nodes were mapped by their number and station and histopathologic evaluation was performed. RESULTS: Operating time was prolonged for 10 min in patients with ultrasound guided mediastinal nodal dissection, but number and stations of evaluated lymph nodes were significantly higher (p < 0.001) in the same group. Skip nodal metastases were found in 24% of patients without N1 nodal involvement. Twelve (10%) patients were upstaged using US guided mediastinal lymphadenectomy. In US guided group 5-year survival rate was 59% and in the group of standard systematic mediastinal lymphadenectomy 43% (p = 0.001) Standard staging system seemed to be improved in ultrasound guided mediastinal lymphadenectomy patients. Complication rate showed no difference between analyzed groups. CONCLUSION: Higher number and location of analyzed mediastinal nodal stations in patients with resected NSCLC using ultrasound is suggested to be of great oncological significance. Our results indicate that intraoperative ultrasound may have important staging implications.

[Surgical treatment of tibial nonunion after wounding by high velocity missile and external fixators: a case report].

INTRODUCTION: The missiles of modern firearms can cause severe fractures of the extremity. High velocity missile fractures of the tibia are characterized by massive tissue destruction and primary contamination with polymorphic bacteria. Treatment of these fractures is often complicated by delayed healing, poor position healing, nonhealing and bone tissue infection. CASE OUTLINE: We present the management of tibial nonunion after wounding by high velocity missile and primary treatment by external fixation in a 25-year-old patient. The patient was primarily treated with external fixation and reconstructive operations of the soft tissue without union of the fracture. Seven months after injury we placed a compression-distraction external fixator type Mitkovic and started with compression and distraction in the fracture focus after osteotomy of the fibula and autospongioplasty. We recorded satisfactory fracture healing and good functional outcome. CONCLUSION: Contamination and devitalization of the soft-tissue envelope increase the risk of infection and nonunion in fractures after wounding by high velocity missile. The use of the compression-distraction external fixator type Mitkovic may be an effective method in nonunions of the tibia after this kind of injury.

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.

Increasing of malignant pleural mesothelioma: burning issue in Split-Dalmatian County, Croatia.

Asbestos-related diseases are one of the burning public health issues worldwide. The incidence and the epidemiological patterns of malignant pleural mesothelioma in Split-Dalmatian County, where a large part of Croatian industry related to asbestos processing and use have been situated were assessed in this study. The history of asbestos-related issues and development of current legislation in Croatia was also discussed briefly. Data on the incidence were collected retrospectively from the medical records of patients with malignant pleural mesothelioma treated at Department of Pulmonary Diseases University Hospital Split during the 2000-2007 period. A total of 137 new cases was recorded with the mean incidence of 3.55/100,000 and the trend was increasing over years compared with 1992-1995 period in the same county when the mean incidence was 1.7/100,000. Men accounted for 85.4% of all cases. The mean age of patients was 64.9 +/- 15.4 years. The majority of patients were occupationally exposed to asbestos (85.4%), 8.8% had environmental exposure, and 2.2% had domestic exposure. The type of household exposition was in 5.8% of patients. More than half of the cases were exposed to asbestos 31-40 years. The mean length of exposure was 28.87 +/- 15.63 years. The incidence of malignant pleural mesothelioma in Split-Dalmatian County has been obviously increasing due to the predominantly occupational exposure and it is reasonable to assume that it will remain high in the next two-three decades and to be a reason for concern and fear among the general population.

Advantages of the spared surgical treatment of the spleen injuries in the clinical conditions.

BACKGROUND/AIMS: Aim of this study was to compare clinical, biochemical and hematological parameters of the patients after posttraumatic splenectomy, posttraumatic spleen preservation and auto transplantation and the control group of the patients. METHODOLOGY: The study included data on 169 patients treated at the University Surgery Department, University Hospital Split, from 1998 till 2006. There were 127 male, and 42 female patients, mean age was 40,3 years (range 15-74), 137 of the patients underwent surgery and 32 were treated without operation. A group of 29 patients, who underwent inguinal hernia repair, was the control group. RESULTS: Reduction in postoperative morbidity, hospital stays and blood products administration are achieved if the spleen is preserved. The values of Howell-Jolly bodies, CH50 complement particles, IgM antibodies, lymphocytes and monocites are reduced if the spleen is not preserved. CONCLUSION: No operative treatment and spleen preserving surgical procedures are superior to the splenectomy in the spleen trauma treatment. Splenectomy should be avoided whenever is possible.

Skip mediastinal nodal metastases in the IIIa/N2 non-small cell lung cancer.

INTRODUCTION: To study the incidence and characteristics of mediastinal nodal metastases without N1 nodal metastases (skip N2 metastases) in patients with resected pIII/A/N2 non-small cell lung cancer. METHODS: A total of 323 non-small cell lung cancer patients who underwent radical surgical resection with a systematic mediastinal nodal dissection in 4-year period (2000-2003) were retrospectively reviewed. The 85 patients (26%) at stage IIIA/N2 (pN2+) were grouped according to their skip metastases status. Patient data were statistically analyzed. RESULTS: Skip N2 metastases were found in 21 patients (25%) without N1 nodal involvement. The postoperative survival for skip N2 disease was almost the same as that for pN2 disease with N1 nodal involvement. The incidence of N2 metastases seemed to be more frequent in adenocarcinoma patients (p < 0.005), but skip N2 metastases were significantly higher (p < 0.001) in squamous cell carcinoma patients. Although skip metastases involved more often upper mediastinal lymph nodes and one station level, the difference was not found statistically significant (p < 0.227). Complication rate showed no difference between analyzed groups of patients. CONCLUSIONS: Sample mediastinal lymphadenectomy may not be appropriate in surgery for non-small cell lung cancer because skip metastases were found in 25% of patients without N1 nodal involvement.