Transanal hemorrhoid dearterialization is a safe and effective outpatient procedure for the treatment of hemorrhoidal disease. / Desarterialización hemorroidal transanal, un procedimiento seguro y eficaz para el tratamiento ambulatorio de la enfermedad hemorroidal.

INTRODUCTION: This prospective, observational study evaluated transanal dearterialization (THD) efficacy and safety in grade 2-4 hemorrhoids (HD). METHODS: THD was performed under sedation-locoregional anesthesia in 402 outpatients. Patients had follow-up evaluation 3 days, 2 weeks, 1, 6 and 12 months postoperatively. Postoperative complications and recurrence of symptoms at 12 months were analyzed. The relationship between the learning curve and the number of postoperative complications was studied. RESULTS: Mean patient age was 46.4 (range 20-85) years. A total of 268 patients (66.6%) were male. Sixteen patients (4.0%) had grade 2 HD, 210 (52.2%) had grade 3 and 176 (43.8%) had grade 4 HD. Surgery lasted 23 (17-34) min. A total of 67 patients had complications: bleeding in 10 patients (2.5%), hemorrhoidal thromboses in 10 (2.5%), perianal fistulas in 5 (1.2%), fissures in 14 (3.5%), urinary retention in 3 (0.8%), residual prolapse in 19 (4.7%), severe anal pain in 3 (0.8%), and perianal abscess in 3 patients (0.8%). Recurrent HD occurred in 6.3% (1/16) of grade 2 HD patients, 5.8% (12/210) of grade 3 patients and 9.7% (17/176) of grade 4 patients. Twelve months after THD, bleeding was controlled in 363 patients (90.5%), prolapse was controlled in 391 (97.3%) and pain markedly improved in 390 patients (97%). CONCLUSION: THD appears safe and effective for grade 2-4 HD, and the number of complications decreased with increasing surgeon experience. THD advantages include mild pain, fast recovery, early return to daily activities and low incidence of complications.

Ambulatory phlebectomy under tumescent local anesthesia in a kidney-transplant patient.

INTRODUCTION: Tumescent local anesthesia (TLA) is widely used for ambulatory surgery. Patients with transplanted or gans are on immunosuppressive therapy and with risk for organ rejection or severe infection. CASE REPORT: Saphe nectomy with phlebectomy on the left leg under TLA was performed in a patient with kidney transplantation per formed four years ago. A combination of 35 mg of 1% prilocaine-hydrochloride, 5 mL of 8.4% sodium bicarbonate and 500 microg of epinephrine in 460 mL of normal saline was used for TLA. Overall 750 mL of the solution was used. The patient had satisfactory postoperative analgesia and was discharged home on the same day. Blood levels of urea, cre atinine, estimated glomerular filtration rate (eGFR) and ta crolimus concentration, measured preoperatively and on the second postoperative day, were in a regular range. Prilocaine blood concentrations determined on the 4th, 10th and 16th postoperative hours, were below toxic levels. CONCLUSION: TLA in a kidney-transplanted patient performed for saphe nectomy with phlebectomy proved to be a safe and reliable anesthesia method.

[Surgical treatment of varicose vein using the tumescent technique of local anesthesia].

BACKGROUND/AIM: Tumescent local anesthesia (TLA) is a technique for local and regional anesthesia of the skin and the subcutaneous tissue, using infiltration of large amounts of a diluted solution of local anesthetic. This technique is applied in plastic surgery, liposuction as well as in dermatology for the entire series of dermatocosmetic procedures. The purpose of this study was to determine efficiency of surgical treatment of varicose vein using TLA as an alternative method to a conventional treatment for varicose vein. METHODS: Seventy-two patients with varicose vein were enrolled in the study. All of them were operated on applying TLA, from April 2008 to November 2009. TLA solution consisted of local anesthetics was used. TLA solutions used were: 1% prilocaine-chloride with adrenaline supplement, and 2% lidocaine-chloride and adrenaline in concentration of 0.1%-0.4%. RESULTS: Out of 72 patients, we stripped great saphenous vein from 60 patient and did varicectomy as well as ligation of insufficiently perforating veins. In 12 patients we did partial varicectomy and ligation of perforating veins. There were not any patients with the need for continued surgery, as well as bringing patient to the general anesthesia due to pain during the surgery. One patient came for postoperative opening wound in the groin, one for infection of the wound and one for the formation of seroma in the groin. There were not any allergic reactions or systemic complications in the operations as well as postoperative period. Postoperatively, all the patients were treated with compressive elastic bandage during the period of 6 weeks as well as anticoagulation prophylaxis in the duration of 5 days. CONCLUSION: Surgery of varicose veins with implementation of TLA is easy and safe method with very low percentage of complications and unwanted effects. It is a good alternative method to classic surgery of varicose veins. The economic aspect is a very important component because the cost of this method is significantly lower than that of a classical surgical treatment of varicose veins.

Desarterialización hemorroidal transanal, un procedimiento seguro y eficaz para el tratamiento ambulatorio de la enfermedad hemorroidal / Transanal hemorrhoid dearterialization is a safe and effective outpatient procedure for the treatment of hemorrhoidal disease

INTRODUCCIÓN: El objetivo de este estudio fue evaluar la eficacia y seguridad de la desarterialización hemorroidal transanal (THD) para hemorroides (HD) de grado II-IV. MÉTODOS: Estudio observacional prospectivo de una serie de 402 pacientes a los que se les realizó una THD en régimen de cirugía ambulatoria con analgosedación y anestesia locorregional. Se visitó a los pacientes a los 3 días; 2 semanas, 1, 6 y 12 meses después de la cirugía. Se analizaron las complicaciones postoperatorias y la recurrencia de síntomas a a los 12 meses. Se estudió la relación entre la curva de aprendizaje y el número de complicaciones postoperatoria. RESULTADOS: La media de edad de los pacientes era 46,4 años (rango: 20-85); 268 pacientes (66,6%) eran hombres; 16 pacientes (4,0%) presentaban HD de grado II; 210 (52,2%), HD de grado III y 176 (43,8%), HD de grado IV. La cirugía duró 23 (17-34) min. Hubo complicaciones postoperatorias en 67 pacientes: hemorragia en 10 pacientes (2,5%), trombosis hemorroidal en 10 (2,5%), fístula perianal en 5 (1,2%), fisura en 14 (3,5%), retención urinaria en 3 (0,8%), prolapso residual en 19 (4,7%), dolor anal intenso en 3 (0,8%) y absceso perianal en 3 pacientes (0,8%). La enfermedad hemorroidal recidivó en el 6,3% (1/16) de los pacientes con HD de grado II, en el 5,8% (12/210) de los pacientes con HD de grado III y en el 9,7% (17/176) de los pacientes con HD de grado IV. Doce meses después de la THD, la hemorragia se había solucionado en 363 pacientes (90,5%), el prolapso en 391 (97,3%) y el dolor mejoró significativamente en 390 pacientes (97%). CONCLUSIÓN: La THD es un método seguro y eficaz para las hemorroides de los grados II-IV. Se caracteriza por dolor moderado, recuperación rápida, pronto retorno a las actividades de la vida diaria y baja incidencia de complicaciones

INTRODUCTION: This prospective, observational study evaluated transanal dearterialization (THD) efficacy and safety in grade 2-4 hemorrhoids (HD). METHODS: THD was performed under sedation-locoregional anesthesia in 402 outpatients. Patients had follow-up evaluation 3 days, 2 weeks, 1, 6 and 12 months postoperatively. Postoperative complications and recurrence of symptoms at 12 months were analyzed. The relationship between the learning curve and the number of postoperative complications was studied. RESULTS: Mean patient age was 46.4 (range 20-85) years. A total of 268 patients (66.6%) were male. Sixteen patients (4.0%) had grade 2 HD, 210 (52.2%) had grade 3 and 176 (43.8%) had grade 4 HD. Surgery lasted 23 (17-34) min. A total of 67 patients had complications: bleeding in 10 patients (2.5%), hemorrhoidal thromboses in 10 (2.5%), perianal fistulas in 5 (1.2%), fissures in 14 (3.5%), urinary retention in 3 (0.8%), residual prolapse in 19 (4.7%), severe anal pain in 3 (0.8%), and perianal abscess in 3 patients (0.8%). Recurrent HD occurred in 6.3% (1/ 16) of grade 2 HD patients, 5.8% (12/210) of grade 3 patients and 9.7% (17/176) of grade 4 patients. Twelve months after THD, bleeding was controlled in 363 patients (90.5%), prolapse was controlled in 391 (97.3%) and pain markedly improved in 390 patients (97%). CONCLUSION: THD appears safe and effective for grade 2-4 HD, and the number of complications decreased with increasing surgeon experience. THD advantages include mild pain, fast recovery, early return to daily activities and low incidence of complications

[Using vacuum in the treatment of surgical wounds complications].

BACKGROUND/AIM: Using vacuum in medicine has been known from long ago, however, it has not been used for the treatment of wounds. The first experiments in this field were performed by Wagner Fleischmann, University of Ulm, Ulm, West Germany, in 1993. The aim of this study was to present our clinical experience with the treatment of surgical wounds complications in vascular patients by the use of controled vacuum. METHOD: In a period October 2006 - December 2009 a total of 18 patients with infection and surgical wound dehiscence were treated by the use of vacuum. Vacuum was applied to wounds by placing a polyurethane sponge on them and by fixing a polyurethane foil and a sponge to the surrounding healthy skin so to completely airtight wounds. Over a foil vacuum of--150 mmHg was applied for a 5-day period, and on the day 6 a foil and a sponge were removed. RESULTS: In all the 18 wounds treated by the use of vacuum secondary wound closing was achieved with no complications and with a significantly shortened time period treatment. Wound infections were healed using this method and only in 2 patients antibiotics were used at the same time. CONCLUSION: The use of vacuum in the treatment of operative wounds complications is an easy and reliable method contributing significantly to wounds better healing.

[Subcutaneous paratibial fasciotomy in the treatment of chronic venous ulcer].

BACKGROUND/AIM: Chronic venous ulcer (CVU), a disease of high incidence, is one of the most serious chronic venous insufficiency complications. It has been estimated that there are 1%-2% of adults with CVU deriving a high social significance. The aim of this study was to, using the clinical experience, determine the influence of subcutaneous paratibial fasciotomy (SPF) on the course and the treatment outcome of CVU. METHODS: From February 2006 to September 2009 SPF was applied in a group of 43 patients treated for CVU along with other standard methods of treatment, and its influence on the course of ulcus cruris was followed up regarding the control group of another 43 patients treated with standard methods with no paratibial fasciotomy. RESULTS: In the group of patients treated with SPF there was a significantly better clinical course of ulcus cruris closing as compared with the group of patients in which this method was not applied. In the group with paratibial fasaciotomy there was no Thiersch skin transplant rejection recorded nor ulcus recurrence within a 6-month after-surgery period, while in the control group there was Thiersch skeen transplant rejection in 11 patients, and ulcus recurrence in 9 patients within the same period. CONCLUSION: SPF is a useful method with a favorable influence on better clinical course of ulcus cruris closing, reducing recurrence rate and improving local microcirculation in the affected region. Operation act itself is safe, requires no specific equipment nor special training of the team of surgeons, thus being applicable to the majority of patients with ulcus cruris indicated for surgery.

Living unrelated donor kidney transplantation--a fourteen-year experience.

BACKGROUND: In countries without a national organization for retrieval and distribution of organs of the deceased donors, problem of organ shortage is still not resolved. In order to increase the number of kidney transplantations we started with the program of living unrelated - spousal donors. The aim of this study was to compare treatment outcome and renal graft function in patients receiving the graft from spousal and those receiving ghe graft from living related donors. METHOD: We retrospectively identified 14 patients who received renal allograft from spousal donors between 1996 and 2009 (group I). The control group consisted of 14 patients who got graft from related donor retrieved from the database and matched than with respect to sex, age, kidney disease, immunological and viral pretransplant status, the initial method of the end stage renal disease treatment and ABO compatibility. In the follow-up period of 41 +/- 38 months we recorded immunosuppressive therapy, surgical complications, episodes of acute rejection, CMV infection and graft function, assessed by serum creatinine levels at the beginning and in the end of the follow-up period. All patients had pretransplant negative cross-match. In ABO incompatible patients pretransplant isoagglutinine titer was zero. RESULTS: The patients with a spousal donor had worse HLA matching. There were no significant differences between the groups in surgical, infective, immunological complications and graft function. Two patients from the group I returned to hemodialysis after 82 and 22 months due to serious comorbidities. CONCLUSION: In spite of the worse HLA matching, graft survival and function of renal grafts from spousal donors were as good as those retrieved from related donors.

[Abdominal aortic aneurysm--rupture of the anterior wall].

INTRODUCTION: An aneurysm is a focal dilatation of an artery (aorta), involving an increase in diameter of at least 50% as compared to the expected normal diameter (over 3 cm). Abdominal aortic aneurysms (AAA) cause thousands of deaths every year, many of which can be prevented with timely diagnosis and treatment. AAA can be asymptomatic for many years, but in one third of patients whose aneurysm ruptured, the mortality rate is 90%. In the past, palpation of the abdomen was the preferred method for identifyng AAA. However, diagnostic imaging techniques, such as ultrasonography and computed tomography are more accurate and offer opportunities for early detection of AAA. CASE REPORT: This paper is a case report of an 83-year-old female patient. She was admitted due to severe pain in the abdomen. We already knew about the AAA (from her medical history). After using all available diagnostic procedures, rupture or disection of the AAA were not comfirmed. The patient underwent emergency surgery. During the operation, rupture of the anterior wall of the aneurysm was found. The anterior wall was filled with parietal thrombus, which hermetically closed the perforation. The patient was successfully operated and recovered. CONCLUSION: The aim of this case report was to point out that our diagnostic procedures failed to confirm the rupture of AAA. We decided to apply surgical treatment, based on medical experience, clinical findings, ultrasonography and computed tomography and during operation rupture of AAA was confirmed Patients with an already diagnosed AAA, or patients with clinical picture of rupture or dissection, are in urgent need for surgery, no matter what diagnostic tools are being used.

[Use of presternal catheters for peritoneal dialysis in obese patients].

INTRODUCTION: Patients with terminal kidney failure represent an important socio-medical problem not only in our country, but also in most countries of the world. There are three options of treatment: transplantation, hemodialysis and peritoneal dialysis. Each of them has advantages and disadvantages. CASE REPORT: This is a case report of an extremely obese woman on peritoneal dialysis. Due to obesity, we decided to use a presternal catheter. We wished to report our dilemmas, opinions and experiences associated with this problem, as well as opinions from avaliable medical literature.

[Anastomotic aneurysm in forearm AV fistula for hemodialysis access--a late complication].

This case report describes the treatment of arteriovenous aneurysm and late vascular complications of native arteriovenous fistula (AVF) in a patient with end-stage renal disease. Aneurysm resection was performed and a new vascular access was created at the original site. 8-month follow-up revealed that this treatment was highly successful.

[Takayasu arteritis].

INTRODUCTION: Giovanni Battista Mlorgani reported the first case with Takayasu arteritis (TA) in 1761. The disease affects the aortic arch and large blood vessels. It is found in every race and in every age-group, predominantly in female population aged 20-40 years. There are four types of TA: type I affects blood vessels of aortic arch: Type II is syndrome of middle aorta (thoracal and abdominal aorta); Type III affects aortic arch and abdominal aorta; Type IV affects pulmonary artery. CLINICAL MANIFESTATIONS: TA has three phases: 1. weakness, fever, anemia, loss of appetite: 2. inflammation of blood vessels; 3. symptoms of stenosis and occlusive lesions. Pathoanatomical disorder includes inflammation of all three layers of blood vessels. CASE REPORT: This is a case report of a 41-year-old woman with TA. She suffered from chest pain, fatigue and pain in both legs, predominatly in the right. Clinical presentation of the disease varies whereas development of TA is unpredictable. Angiography is an important method in diagnosis of the disease and in planning surgical treatment. In our patient five arterial stenoses were established by angiography. ECHO Color Doppler angiography may be useful. Diagnostic criteria include: age under 40 years, occlusion of the right and left subclavian artery and nine minor criteria. Corticosteroid and antiinflammatory therapy is indicated. One third of patients needs surgery. DISCUSSION AND CONCLUSION: In our opinion surgical treatment should be delayed until acute phase is over. Surgical treatment in our patient included: aortobifemoral bypass and left carotid-axillary bypass grafting. Some patients need multiple surgical treatments, like our patient. They also need post-surgical controls.

[Jejuno-jejunal intussusception in adults secondary to submucosal leiomyoma].

INTRODUCTION: Intussusception is the invagionation of a segment of the intestine into itself. It is a serous condition that most commonly affects infants and children, but can also occur in adults. Intussusception in adults is usually caused by tumors, benign or malignant. Early diagnosis is essential to avoid treatment delays, which can increase morbidity and mortality. In older patinets and adolescents the diagnosis can be complicated due to lower incidence and variable subacute symptoms. CASE REPORT: We report a rare case of a 27-year-old patient with increasing abdominal discomfort over several weeks. The patient experienced increasing colics, recurrent vomiting, dehydration and weight loss. Finally he was transferred to the surgical ward of our hospital. Intussusception of the small bowel was diagnosed by CT examination. Laparotomy revealed a jejunojejunal intussusception caused by a small bowel tumor. CONCLUSION: The tumor in the jejunum, almost completely obstructed the intestinal lumen and it was resected and bowel continuity was restored. Histopathological examination revealed a submucosal leiomyoma of the jejunum.