Technique and survival after laparoscopically assisted right hemicolectomy.

BACKGROUND: The role of laparoscopic colon resection in the management of colon cancer is still controversial. In this article, the surgical strategy and techniques are described, with further consideration of the oncologically relevant aspects. METHODS: Between March 1993 and July 2003, we performed laparoscopic right hemicolectomy in 56 patients with right colon carcinoma. Average age was 74.5 years (range, 17-92). We performed a standardized surgical procedure that included mobilization from the vascularized mesenteric bridges with a window technique, transection of the ileocolic lymphovascular pedicle, and lateral and proximal mobilization of the ileocecum, ascending colon, right flexure, and proximale transversum. After enlargement of one of the trocar incisions the exteriorized colon was resected and an extracorporeal anastomosis was performed in the standard manner. RESULTS: There were no conversions to open. The mean operating time was 119 +/- 38 min, the mean length of resected colon was 27.8 +/- 4.48 cm, and the average width of the clear margins was 6.8 +/- 5.3 cm. One patient died. Lymph nodes were positive in 21 patients. The 5-year survival rate in the 48 patients who were operated on with curative intent was 75%. We have had two local recurrences. The overall 5-year mortality-free fraction was 63%. Cox multivariate analysis showed that the mortality-prognostic factors were tumor stage and length of resected colon, whereas Kaplan-Meier analysis showed that the mortality-prognostic factors were positive lymph nodes and tumor stage. CONCLUSIONS: Our results show that laparoscopic right hemicolectomy for colon cancer can be performed safely. Complications and recurrence rates are comparable to those for left-sided laparoscopic and open procedures. Therefore, we recommend this procedure as the method of choice. Laparoscopically treated patients with stage II and stage III disease have almost the same cumulative rate of survival.

Single-dose ceftriaxone versus multiple-dose cefuroxime for antimicrobial chemoprophylaxis in pleuropulmonary surgery.

The efficacy and safety of single-dose ceftriaxone and multiple-dose cefuroxime as antibiotic prophylaxis for pleuropulmonary surgery were compared in 160 patients undergoing thoracic surgery. 82 patients received a single-dose of 2 g ceftriaxone intravenous prior to surgery. Seventy-eight patients received 1.5 g of cefuroxime i.v. prior to surgery and 750 mg i.m. every 8 hours for the next 48 hours. Patients were observed daily for ten days postoperatively and monitored for signs of wound and systemic infections. Postoperative infections were studied in each treatment group. No adverse postoperative infections effects or laboratory abnormalities attributable to either drug were noted. Those results indicate that single-dose ceftriaxone was as effective and well-tolerated as a multiple-dose cefuroxime in preventing postoperative infections following pleuropulmonary surgery.

Penetrating war injuries of the heart.

Treatment of 12 penetrating heart war wounds were described. Ten wounded (83.3%) died on the spot or during transportation. Only two (16.7%) were brought to the clinic with signs of life, operated on and released from the hospital. The two wounded had not received any therapy before the arrival. The two cases described indicate the importance of a rapid transportation, adequate reanimation and the fastest possible cardiorrhaphy either by means of thoracotomy or medial sternotomy.

A war injury to the thoracic trachea.

The authors present a case of war injury to the thoracic trachea with the defect involving more than half of its circumference. After minor difficulties in establishing the right diagnosis, we passed to the surgical procedure and managed the lesion by simple suture. The patient's postoperative course at the Intensive Care Unit was uneventful. Both early and late follow-up roentgenograms, computerized tomography of the trachea and bronchoscopy showed normal findings.

War injuries to the thoracic esophagus.

OBJECTIVE: Presentation of our experience in the treatment of war injuries to the thoracic esophagus at the Split University Hospital, Croatia, during the 1991-1995 wars in Croatia and Bosnia-Herzegovina. METHODS: Retrospective analysis of clinical and surgical data on patients with war injuries to the esophagus. RESULTS: Of 2494 treated injured persons, 5 patients (0.2%) had injuries to the esophagus. We performed temporary double-exclusion of the esophagus in all our patients, followed by gastric interposition after partial esophagegtomy in three patients and simple suturing with pericardial protection of the esophagus in one patient. One of our patients died after double-exclusion due to septic complications in spite of antimicrobial chemoprophylaxis regularly performed in all injured persons. Final surgical outcome and mortality rate (20%) in our patients were quite satisfactory. CONCLUSION: Prompt transportation, appropriate diagnostic methods and an adequate surgical treatment can markedly reduce mortality and complications rate in war injuries to the thoracic esophagus.

War injuries of the lungs.

OBJECTIVE: The authors' experience in the treatment of war injuries of the lungs, gained during the war in Croatia, from August 25, 1991 until July 1, 1995, is presented. In that period, 424 patients with injuries of the lungs were treated at the Split Clinical Hospital. METHODS: The paper is a retrospective study of 424 wounded persons with lung injuries gained during the war in Croatia, processed by basic statistical analysis. RESULTS: Penetrating and nonpenetrating wounds were present in 331 (78.1%) and 93 (21.9%) patients, respectively. There were 407 (96.0%) men and 17 (4.0%) women. Explosive wounds were most frequent (n = 251; 59.2%), followed by gunshot wounds (n = 158: 37.3%) and other types of wounds in 15 (3.5%) patients only. Thoracotomy was performed in 89 (22.9%) patients, whereas conservative surgical methods (wound treatment, chest-tube drainage, appropriate fluid therapy, antimicrobial and atelectasis prophylaxis) were used in 300 (77.1%) patients. A great majority of the patients (n = 395; 93.2%) were discharged as fully recovered or in improved condition, 22 (5.2%) patients were referred to other institutions for further treatment, and seven (1.7%) wounded persons died. CONCLUSIONS: It is shown that most war wounds of the lungs can be successfully managed by 'conservative' surgical treatment.

Pentadecapeptide BPC 157 cream improves burn-wound healing and attenuates burn-gastric lesions in mice.

The effects of the gastric pentadecapeptide BPC 157 were investigated when administered topically or systemically in burned mice. This agent is known to have a beneficial effect in a variety of models of gastrointestinal lesions, as well as on wound or fracture healing. Deep partial skin thickness burns (1.5x1.5 cm) covering 20% of total body area, were induced under anesthesia on the back of mice by controlled burning and gastric lesions were assessed 1, 2, 3, 7, 14 and 21 days following injury. The first application of BPC 157 was immediately following burning, and thereafter, once daily, until 24 h before sacrifice. In the initial experiments, exposure to direct flame for 5 s, the BPC 157 was applied at 10 microg or 10 ng/kg b.w. intraperitoneally (i.p.) by injection or alternatively, topically, at the burn, as a thin layer of cream (50 microg of BPC 157 dissolved in 2 ml of distilled water was mixed with 50 g of commercial neutral cream (also used as local vehicle-control)), while silver sulfadiazine 1% cream was a standard agent acting locally. Others received no local medication: they were treated i.p. by injection of distilled water (distilled water-control) or left without any medication (control). In subsequent experiments involving deeper burns (direct flame for 7 s), BPC 157 creams (50 microg, 5 microg, 500 ng, 50 ng or 5 ng of BPC 157 dissolved in 2 ml of distilled water was mixed with 50 g of commercial neutral cream), or vehicle as a thin layer of cream, were applied topically, at the burn. Compared with untreated controls, in both experiments, in the BPC 157 cream-treated mice all parameters of burn healing were improved throughout the experiment: less edema was observed and inflammatory cell numbers decreased. Less necrosis was seen with an increased number of capillaries along with an advanced formation of dermal reticulin and collagen fibers. An increased number of preserved follicles were observed. Two weeks after injury, BPC 157 cream-treated mice completely reversed the otherwise poor re-epithelization ratio noted in the untreated control or mice treated with vehicle only. Tensiometry investigation showed an increased breaking strength and relative elongation of burned skin, while water content in burned skin decreased. This was, however, not the case with the vehicle or silver sulfadiazine. Relative to the control values, in silver sulfadiazine cream-treated mice, only collagen fiber formation was increased, in addition to a decreased inflammatory cell number. Relative to control values, BPC 157 given i.p. decreased the number of inflammatory cells, lowered water content in burned skin, and raised breaking strength and relative elongation of burned skin during tensiometry. Through the experimental period, gastric lesions were continuously noted in all thermally injured mice left without local medication and they were consistently attenuated only by BPC 157 treatments: either given i.p. (at either dose), or given locally (at either concentration). Other treatments (i.e. local treatment with silver sulfadiazine cream or neutral cream in mice subjected for 5 s to direct flame), led to only poor, if any attenuation. This stable gastric pentadecapeptide appears to be active and gives a stimulation to burn healing at the defect site. The agent may act by causing an upregulation of the growth factors, as well as influencing other local factors.

Military injuries to the popliteal vessels in Croatia.

OBJECTIVE: The paper reviews military popliteal vascular injuries in Croatia. SUMMARY BACKGROUND DATA: Popliteal vascular injuries still pose difficult problems for vascular surgeons despite improvements in resuscitation, surgical techniques and wound coverage. Popliteal vascular injuries, both arterial and venous, with a high incidence of associated musculoskeletal injuries are presented in patients with military injuries in South Croatia. METHODS: 26 wounded with popliteal vascular injuries are presented. Explosive injuries are found in 21 and associated fractures in 9 cases. In immediate repair group the time interval between trauma and surgery was 2 to 30 hours (average 9.8 hours). In the delayed repair group the interval between trauma and surgery was 11 days to 24 days. RESULTS: 21 out of 26 patients with popliteal vascular injuries had combined arterial and venous injuries; 4 patients had isolated popliteal arterial injuries, while 8 patients had other vascular injuries along with the popliteal ones; 8 amputations resulted (30.8%). CONCLUSION: Popliteal vascular injuries caused by typical military mechanism during the war in Croatia present large and extensive defects of tissues and bones, are often associated with other injuries and require more extensive surgical therapy. Evacuation of the wounded under very difficult conditions as well as considerable organization and transportation problems are characteristic for this war and greatly affect the success of vascular reconstruction. Hyperbaric oxygen therapy offers a safe noninvasive method of improving wound healing and decreasing edema formation in popliteal vascular injuries.

Penetrating thoraco-abdominal war injuries.

BACKGROUND: From April 1991 till December 1995, Split University Hospital played a major role as a third échelon war hospital during the war in Croatia and Bosnia and Herzegovina. Among 2856 treated battle casualties in general, 70 patients with penetrating thoraco-abdominal war injuries were treated at the Department of Surgery. Explosive wounds were present in 38 (54%), gunshot wounds in 32 (45%) and puncture wounds in four (5.70%) patients. METHODS: The medical data from the evacuation unit, transportation, emergency department, surgical management and follow-up were obtained and analyzed. The principle of treatment of such patients is described, with particular reference to thoracophrenolaparotomy as the most efficient diagnostic-therapeutic surgical approach. RESULTS: There were considerably more explosive wounds than gunshot and puncture wounds (ratio 38/32/4). Resource utilization analysis showed a great amount of blood products (average 1.250 ml per patient), rehydrant solutions (average 3.750 ml per patient) and seven days antimicrobial chemoprophylaxis (penicillin, gentamycin, metronidazole) used. Mean time elapsed between injury and definitive surgical repair was seven hours (range, 1 to 48 hours). Recovery on discharge was recorded in 61 (80%) and lethal outcome in nine (13%) patients. CONCLUSIONS: The treatment of respiratory insufficiency and hemorrhagic shock, and prevention of infection are the basis of the management of these injuries. Treatment success depends on emergency first-aid, quick transportation, early diagnosis, resuscitation, surgical therapy and intensive care.

Our experience with 2693 wounded treated at the Split University Hospital during the 1991-1995 period.

The authors' personal experience of 2693 wounded treated at the Split University Hospital during the 1991-1995 period is described and compared with the results reported from other recent wars worldwide. Explosive wounds were more frequent than gunshot wounds (N=1490; 55.3% vs N=988; 36.7%), and wounds due to other factors were observed in 215 (8.0%) patients. There were 2494 (92.6%) men and 99 (7.4%) women. A total of 1815 (67.4%) patients were operated on in field war hospitals, and 878 (32.6%) at the Split University Hospital. Recovery and discharge were achieved in 1527 (56.7%) and improvement with the treatment or rehabilitation continued at other institutions in 850 (31.6%) patients. In 240 (8.9%) patients, no definite opinion can yet be given. A lethal outcome was recorded in 76 (2.8%) patients. Rapid transportation from the site of wounding to medical teams was found to be of paramount importance for successful treatment. These teams were placed in field war hospitals placed as close as possible (5-15 km) to the frontline.

War injury to the liver. A case report.

We report a case of a war thoracoabdominal gunshot wound associated with severe injury to the liver and hemorrhagic shock. Immediately upon admission to the second Echelon Surgical Unit, the patient was operated on with two separate surgical approaches: right thoracotomy and subcostal laparotomy. The patient was transferred to rear hospital for recurrent postoperative hemorrhages. He was eventually transferred to our Department, where he underwent reoperation by the surgical approach through right thoracophrenolaparotomy. Liver lesion debridement and hepatic artery ligation were performed. The early and late postoperative course was normal, and the patient achieved satisfactory recovery on discharge. The case shows that the management of severe liver injuries requires special knowledge and experience from the surgeon.

Functional effects of typical lung resections for primary bronchogenic carcinoma.

In 60 patients with primary bronchogenic carcinoma undergoing surgery, pulmonary function studies were performed before, and then 10 days and 3 to 6 months after typical lung resection. Preoperative profiles showed a slight restrictive pattern without air trapping and slightly disturbed gas exchange. The restrictive pattern was not related to clinical, X-ray and endoscopy findings. The alveoloarterial oxygen gradient was smaller in the patients requiring lobectomy than in pneumonectomy patients. After surgery, the volume loss was related to the amount resected, being greater after right pneumonectomy than after left pneumonectomy, smaller after bilobectomy and the least after lobectomy. The obstructive pattern remained unchanged. Diffusion of carbon monoxide decreased significantly less than the volumes after pneumonectomy, but proportionally after lobectomy and bilobectomy. Those with increased alveoloarterial oxygen gradient or increased physiologic dead space showed a significant improvement of their gas exchange after surgery.

[Pulmonary function after decortication of the lung]. / Plucna funkcija nakon dekortikacije pluca.

From 1985 to 1994 decortication of the lung was performed in 60 patients. The indications were: specific and non-specific empyema, chronic pleural effusion, chronic pneumothorax and hemothorax. To assess the lung function, the measurements of vital capacity, forced expiratory volume and maximum breathing capacity, as well as blood gas analysis were performed preoperatively and six months after the operation. The slight improvement of lung function was seen postoperatively. Usual postoperative complications were successfully treated. Indications for decortication for the purpose of improving the lung function remain questionable.

[Our initial experience with video-assisted thoracoscopic surgery (VATS)]. / Nasa prva iskustva u videotorakoskopskoj kirurgiji (VATS).

Diagnostic and therapeutic potentials and our first two-year experience with video-assisted thoracic surgery (VATS) are reported. From May 1995 to April 1997, at the Department of Surgery, University Hospital Split, VATS approach was planned in 55 cases (recurrent pneumothorax in 23, tension pneumothorax in 1, traumatic effusion in 5, malignant metastatic lung tumor in 1, benignant lung tumor in 11, traumatic effusion in 5, suspected mediastinal lymph nodes in 4, long lasting unconfirmed pleural effusion in 9, foreign body in 1, mediastanal cyst in 1). Of these, 48 procedures (87.2%) were performed using VATS (diagnostic thoracoscopy in 12, wedge resection with or without pleural abrasion in 21, partial pleurectomy in 1, decortications in 3, mediastinal lymph nodes biopsy in 4, lung biopsy in 7). Seven patients (12.7%) underwent conventional posterolateral thoracotomy. Complications included persistent air leak in three patients, prolonged bleeding in one patient and supraventricular tachycardia in one patient. The mean duration of chest tube drainage after the procedure was 3.7 days (range 2 to 19 days), and mean hospital stay was 5.1 days (range 3 to 15 days). All patients received routine antimicrobial chemoprophylaxis with single-dose ceftriaxone 2 g intravenously immediately prior to the surgery, and average postoperative patient-controlled analgesia with buprenorphine 0.15 mg. We conclude that VATS is a very useful alternative to conventional thoracotomy in managing cases of exploration, recurrent spontaneous pneumothorax, benign pulmonary lesions, solitary pulmonary nodes, early decortications and different intrathoracic biopsies.

[Blunt heart injuries and diagnostic difficulties]. / Tupe ozljede srca i dijagnosticke teskoce.

The authors present their experiences with blunt heart injuries treated in the University Surgical Hospital in Split, Croatia. The diagnostic approach hospitalization and follow-up of these patients are described. The heart contusion was diagnosed using several repeated electrocardiographic and enzymatic tests combined with two-dimensional echocardiography. We treated 67 patients with heart contusions within two-year period. Out of them, 63 (94%) were dismissed from the hospital as cured, and 4 (6%) of them died. Results of treatment depend on the severity of injury, but also on a timely and adequate management.

[Video thoracoscopic therapy of recurrent spontaneous pneumothorax]. / Videotorakoskopsko lijecenje recidivnoga spontanog pneumotoraksa.

We report our first experience in surgical treatment of recurrent spontaneous pneumothorax using video-assisted thoracic surgery (VATS). From May 1995 to April 1998, 38 cases of recurrent spontaneous pneumothorax were treated using the VATS approach. All patients were previously treated by other methods (conservative, thoracocentesis, chest-tube drainage). We successfully managed VATS procedure in all our patients (wedge resection 28, bullectomy 1, partial pleurectomy 2, pleural abrasions 36). Complications include persistent air leak (4), prolonged bleeding (1) and supraventricular tachycardia (1). The mean duration of chest drainage was 3.9 days (range 3 to 15 days). All patients received antimicrobial chemoprophylaxis with single-dose of 2 g Ceftriaxone intravenously prior to surgery and average postoperative patient-controlled analgesia with 0.15 mg of buprenorphin. Utilisation resource analysis showed great advantage in favour of VATS procedure compared to retrospectively analysed thoracotomied patients. We conclude that VATS is very useful alternative to conventional thoracotomy in managing cases of recurrent spontaneous pneumothorax.

[Echinococcosis of the lungs]. / Ehinokokoza pluca.

The echinococcosis is the parasitic infection caused by the larval form of the echinococcus in a human or an animal organism. The infection can take part in any organ or tissue. About 20 percent of the echinococcosis of all locations are situated in the lungs. We present the results of the surgically treated lung echinococcosis. Various surgical methods of treatment were used, from the most economic ones to the most radical ones. In the last 32 years 234 patients were treated of lung echinococcosis. 224 of them were treated surgically, using the standard preoperative proceedings. Surgical methods based on the intraoperative patho-anatomic structure of the hydatid cysts were used with very sufficiently results. We preferred the economic, sparing surgical methods and used more radical ones just in a few cases. Five patients had a letel issue (2.23%), and three patients (1,34%) had a recidive of the lung echinococcosis.

[Benign tumors of the stomach]. / Benigni tumori zeluca.

The authors discuss seven cases of benign tumors of the stomach. The diagnosis was based mainly on x-ray findings. Even though in suspicious cases, a fiber gastroduodenoscopy was indicated. During surgery, three adenomat--ous polyps were found; three Leionas and one Neurnoma. The tumors were excized by gastrotomy. In two of the patients a Billroth I resection was performed. One of these two patients was operated on urgently due to serious bleeding without the aid of X-rays. This patient, a woman, withstood the operation well as did all of the remaining patient.

[Unusual diseases which may create the picture of acute appendicitis]. / Rijetka oboljenja koja mogu praviti sliku akutnog apendicitisa

Five specialy interesting cases operated under the clinical picture of acute appendicitis have been described by authors. Another completely different disease have been found during the operation, which required spread surgical treatment combined with blood transfusion even if we didn't identified the blood group. For this reason you have to pay attention while making a final diagnosis because the mistakes are very common, about 25% in out patient department while 1--3% in clinical conditions.