ALPPS Procedure for the Treatment of Bilobar Multiple Liver Metastasis from Colorectal Cancer: First Case in RN Macedonia.

Introduction: ALPPS (Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy), is a recently developed procedure, first performed by HJ Schlitt in Regensburg, Germany. The technique developed two stages of hepatectomy. The ALPPS procedure has been introduced to increase the volume of future liver remnant, much more than the other technique, such as PVE (portal vein embolization). The first ALPPS in our country was introduced and performed by our team on May 15th, 2018. Results: The 60-year-old patient was previously operated on for rectal cancer in 2017 at another institution. The operation was performed with anterior resection and the patient was in long term adjuvant chemotherapy. One year after surgery, the patient has multiple bilobar liver metastases and increased tumor markers that led to instant admission to our institution for liver resection. In the first stage, we performed four metastasectomies on the left lobe with right portal vein ligation and transection on the Cantlie line. The second stage was performed after a CT evaluation on the eighth day, with significant hypertrophy on the left lobe. Pathological findings reported ten metastases on the right lobe with a diameter 1-3 cm. The patient was on the long-term chemotherapy, and after one year he had other MS in the IVa segment of the liver. We also performed a metastasectomy. The patient died 32 months after ALPPS. Conclusion: ALPPS is a safe and feasible procedure for the treatment of bilobar liver metastasis from colorectal cancer. It could provide long-term survival for patients.

The Effect of Rectus Sheath Block as a Supplement of General Anesthesia on Postoperative Analgesia in Adult Patient Undergoing Umbilical Hernia Repair.

BACKGROUND: Ultrasound guided rectus sheath block can block the ventral rami of the 7th to 12th thoracolumbar nerves by injection of local anesthetic into the space between the rectus muscle and posterior rectus sheath. The aim of this randomized double-blind study was to evaluate the analgesic effect of the bilateral ultrasound guided rectus sheath block as supplement of general anesthesia on patents undergoing elective umbilical hernia repair. METHODS: After the hospital ethics committee approval, 60 (ASA I-II) adult patients scheduled for umbilical hernia repair were included in this study. The group I (n=30) patents received only general anesthesia. In the group II (n = 30) patents after induction of general anesthesia received a bilateral ultrasound guided rectus sheath block with 40 ml of 0.25% bupivacaine. In this study we assessed demographic and clinical characteristics, pain score - VAS at rest at 2, 4, 6, 12 and 24 hours after operation and total analgesic consumption of morphine dose over 24-hours. RESULTS: There were statistically significant differences in VAS scores between the groups I and II at all postoperative time points - 2hr, 4 hr, 6 hr, 12 hr and 24 hr. (P < 0.00001). The cumulative 24 hours morphine consumption after the operation was significantly lower in the group II (mean = 3.73 ± 1. 41) than the group I (mean = 8.76 ± 2.41). This difference was statistically significant (p = 0.00076). CONCLUSION: The ultrasound guided rectus sheath block used for umbilical hernia repair could reduce postoperative pain scores and the amount of morphine consumption in 24 hours postoperative period.

Conversions in laparoscopic cholecystectomy in acute versus chronic cholecystitis.

BACKGROUND: Early laparoscopic cholecystectomy imposes itself as an option of choice for treatment of acute cholecystitis, while the rate of conversions to open procedure represents a key parameter for evaluating the outcome. AIM: The aim of this paper was to evaluate the results of the laparoscopic cholecystectomy in acute versus chronic cholecystitis through determining the conversion rate in open method, as well as to analye some predictive factors that may impact the decision to convert to open. MATERIAL AND METHODS: An analytical case control study was conducted at the University Clinic for Digestive Surgery in Skopje within a period of 27 months. The first group included 62 patients with acute cholecystitis on whom the laparoscopic cholecystectomy was performed in the period from zero to the seventh day from the onset of symptoms. The second group included 62 patients with chronic cholecystitis who underwent laparoscopic cholecystectomy. Gender, age, history of cholecystitis, the time passed from the first symptoms till laparoscopic cholecystectomy and the duration of the intervention were analysed as factors that can possibly act on conversion. RESULTS: There were no significant differences (p>0.05) between the group of patients with acute and the one with chronic cholecystitis due to conversion rate. In both groups, there was a significant difference in conversion due to the duration of the laparoscopic cholecystectomy (p<0.05), and in the group with acute cholecystitis also due to the time passed from the first symptoms till the laparoscopic intervention (p<0.01). CONCLUSION: The rate of conversions can be reduced with a prompt approach to predictive factors.