Isolated splenic metastasis from colorectal carcinoma in a high risk patient: a case report.

Isolated splenic metastasis arising from a colorectal carcinoma is a rare finding. We report a case of 74-year-old man with a medical history of diabetes type II and paroxysmal atrial fibrillation, who underwent a right hemicolectomy for an adenocarcinoma of caecum in August 2004. In June 2007 the patient was diagnosed with high grade aortic valve stenosis as well as long segment stenosis of the first obtuse marginal branch of left coronary artery. He was suggested aortic valve replacement with coronary artery bypass grafting but he refused the surgery. In October 2007 the patient underwent alpha 18FDG - PET scanning, due to increasing values of CEA serum level, which showed a 5 cm big isolated hypermetabolic lesion in the spleen. Due to operative risk, splenectomy was refused by surgeons. The patient underwent a chemotherapy with capecitabine in total of 8 cycles before his CEA level began to rise and MSCT showed a progression in size of splenic metastasis. The patients condition was reevaluated by a team of experts and splenectomy was performed in September 2008. In May 2009 during the postoperative follow up, MSCT scanning revealed enlarged lymph nodes in celiac region and hepatic lesion suspicious of metastasis and the patient was admitted for further chemotherapy treatment. There is still no standardized treatment for this condition due to small number of cases reported in literature. Splenectomy followed by chemotherapy seems to be an optimal treatment but still no final conclusions can be made.

Post-intubation long-segment tracheal stenosis of the posterior wall: a case report and review of the literature.

Tracheal stenosis, a well-known complication of endotracheal intubation and artificial ventilation, is most likely to occur in critically ill patients requiring prolonged mechanical ventilation. Although a rare complication, and despite technological improvements and better patient care in intensive care units, tracheal stenosis still constitutes a serious clinical problem which can also develop after a short period of mechanical ventilation. In this article, we present a very rare case report of a patient who developed a long-segment tracheal stenosis localized at the posterior wall after a relatively short period of endotracheal intubation with a high-volume, low-pressure cuffed endotracheal tube, and a review of the literature.

[Characteristics of war wound infection]. / Osobitosti infekcije ratne ozljede.

War wounds are the most complex type of non-targeted injuries due to uncontrolled tissue damage of varied and multifold localizations, exposing sterile body areas to contamination with a huge amount of bacteria. Wound contamination is caused by both the host microflora and exogenous agents from the environment (bullets, cloth fragments, dust, dirt, water) due to destruction of the host protective barriers. War wounds are the consequence of destructive effects of various types of projectiles, which result in massive tissue devitalization, hematomas, and compromised circulation with tissue ischemia or anoxia. This environment is highly favorable for proliferation of bacteria and their invasion in the surrounding tissue over a relatively short period of time. War wounds are associated with a high risk of local and systemic infection. The infection will develop unless a timely combined treatment is undertaken, including surgical intervention within 6 hours of wounding and antibiotic therapy administered immediately or at latest in 3 hours of wound infliction. Time is a crucial factor in this type of targeted combined treatment consisting of surgical debridement, appropriate empirical antimicrobial therapy, and specific antitetanic prophylaxis. Apart from exposure factors, there are a number of predisposing factors that favor the development of polymicrobial aerobic-anaerobic infection. These are shock, pain, blood loss, hypoxia, hematomas, type and amount of traumatized tissue, age, and comorbidity factors in the wounded. The determinants that define the spectrum of etiologic agents in contaminated war wounds are: wound type, body region involved, time interval between wounding and primary surgical treatment, climate factors, season, geographical area, hygienic conditions, and patient habits. The etiologic agents of infection include gram-positive aerobic cocci, i. e. Staphylococcus spp, Streptococcus spp and Enterococcus spp, which belong to the physiological flora of the human skin and mucosa; gram-negative facultative aerobic rods; members of the family Enterobacteriacea (Escherichia coil, Proteus mirabilis, Klebsiella pneumoniae, Enterobacter cloacae), which predominate in the physiological flora of the intestines, transitory flora of the skin and environment; gram-negative bacteria, i. e. Pseudomonas aeruginosa, Serratia marcescens, Acinetobacter calcoaceticus - A. baumanii complex; environmental bacteria associated with humid environment and dust; anaerobic gram-positive sporogeneous rods Clostridium spp, gram-negative asporogeneous rods Bacteroides spp and gram-positive anaerobic cocci; Peptostreptococcus spp and Peptococcus spp. The latter usually colonize the intestine, primarily the colon, and the skin, while clostridium spores are also found in the environment. Early empirical antibiotic therapy is used instead of standard antibiotic prophylaxis. Empirical antimicrobial therapy is administered to prevent the development of systemic infection, gas gangrene, necrotizing infection of soft tissue, intoxication and death. The choice of antibiotics is determined by the presumed infective agents and localization of the wound. It is used in all types of war wounds over 5-7-10 days. The characteristics of antibiotics used in war wounds are the following: broad spectrum of activity, ability to penetrate deep into the tissue, low toxicity, long half-life, easy storage and application, and cost effectiveness. The use of antibiotics is not a substitution for surgical treatment. The expected incidence of infection, according to literature data, is 35%-40%. If the time elapsed until surgical debridement exceeds 12 hours, or the administration of antibiotics exceeds 6 hours of wound infliction, primary infection of the war wound occurs (early infection) in more than 50% of cases. The keys for the prevention of infection are prompt and thorough surgical exploration of the wound, administration of antibiotics and antitetanic prophylaxis, awareness of the probable pathogens with respect to localization of the wound, and optimal choice of antibiotics and length of their administration.

[Iatrogenic injury of the brachiocephalic arterial trunk and its branches--case report]. / Jatrogena ozljeda brahiocefalicnog arterijskog stabla i njegovih ogranaka: prikaz slucaja.

Iatrogenic vascular traumas are increasing and their proportion exceeds 40% of all vascular injuries. We report on a rare case of iatrogenic injury of the brachiocephalic arterial trunk during surgical intervention due to postirradiation arteriopathy, which was successfully treated with a silver prosthesis graft. A 58-year-old male underwent surgery for metastases of papillary carcinoma of the thyroid gland, located in lymph nodes adjacent to the right common carotid artery and right subclavian artery. During the surgery, there was an intraoperative injury of the brachiocephalic arterial trunk that included spontaneous rupture and tear of the subclavian and common carotid artery, as the result of extreme fragility of the arterial wall, probably due to the previous irradiation therapy. Emergency sternotomy and clavicle resection were followed by blood flow reconstruction by use of an Y prosthesis that was applied for terminoterminal anastomosis between the brachiocephalic trunk to common carotid artery and subclavian artery. The authors concluded that irradiation therapy may lead to progressive arteriopathy in affected arteries.

Comparison of postoperative hepatic function between laparoscopic and open cholecystectomy.

OBJECTIVE: In this prospective study, we evaluated the effects of pneumoperitoneum on hepatic function during laparoscopic (LC) and open cholecystectomy (OC). SUBJECTS AND METHODS: One hundred patients who underwent LC (n = 50) or OC (n = 50) were included in the study. The groups were similar in age, sex, weight and height. Following liver function tests (total bilirubin; gamma-glutamyltransferase, GGT; alkaline phosphatase, ALP), aspartate aminotransferase (AST), alanine aminotransferase (ALT) and lactate dehydrogenase (LDH) were obtained preoperatively and at 24 and 48 h postoperatively. Similar anesthesiologic protocol was used for both LC and OC. During LC, the intra-abdominal pressure was maintained within the conventional range of 12-14 mm Hg. RESULTS: Total bilirubin, ALP, GGT and LDH levels remained unchanged from baseline in both groups without significant difference between them. A higher number of patients had increased values of ALT (26/50 vs. 5/50) and AST (23/50 vs. 6/50) in LC compared to OC group. Although the difference was statistically significant (p < 0.000 for ALT and p = 0.0004 for AST) the increased level decreased at 48 compared to 24 h. CONCLUSION: The results indicate that LC is associated with transient elevation of ALT and AST. The disturbances in the function of the liver after LC are self-limited and not associated with any morbidity in patients with a normal liver function.