Single versus double stapling anastomotic technique in rectal cancer surgery.

PURPOSE: The present study was designed to investigate whether there is a difference in the anastomotic leakage rate (AL) between the single stapling (CSA) and double stapling (DSA) anastomosis techniques. METHODS: One hundred consecutive rectal cancer patients who underwent rectal resection with primary anastomosis were enrolled in this study. RESULTS: The overall rate of clinical anastomotic leakage in both groups was 7 % (7/100); 6 % (3/50) in the CSA group and 8 % (4/50) in the DSA group. The anastomotic technique did not have any significant influence on the rate of AL. All AL were seen in low anastomoses (7 cm and below). The rate of AL in patients with a diverting stoma (13 %, 3/23) was not significantly different from that of the patients without (5.2 %, 4/77) (p = 0.195). The mean length of the operation was significantly shorter in the DSA group compared to the CSA group, at 127 and 141 min, respectively (p = 0.005). There were significantly higher rates of AL in patients receiving preoperative long course radiotherapy (15.4 %, 6/39) compared with those who did not receive radiotherapy (1.63 %, 1/61) (p = 0.014). CONCLUSIONS: The CSA and DSA techniques are equally safe for the creation of a rectal anastomosis, without any significant difference in the AL rate. However, we recommend using the DSA technique because it has other definite advantages. In cases of neoadjuvant treatment and a low anastomosis, proximal diversion is recommended.

The effect of melatonin on body mass and behaviour of rats during an exposure to microwave radiation from mobile phone.

BACKGROUND: Microwave radiation (MW) produced by wireless telecommunications and a number of electrical devices used in household or in healthcare institutions may cause various disorders in human organism. On the other hand, melatonin is a potent antioxidant, immunostimulator and neuromodulator. The aim of this research was to determine body mass and behaviour changes in rats after a chronic microwave exposure, as well as to determine the effects of melatonin on body mass and behaviour in irradiated rats. METHODS: Wistar rats were divided into the four experimental groups: I group (control) - rats treated with 0,9 % saline, II group (Mel) - rats treated with melatonin (2 mg/kg), III group (MW) - rats exposed to MW radiation (4 h/day), IV group (MW+Mel) - rats, which were both exposed to MW radiation and received melatonin premedication (2 mg/kg). RESULTS: A significant body mass reduction was noted in animals exposed to MW radiation when compared to controls after 20, 40 and 60 days (p<0.001). Furthermore, body weight was significantly increased (p<0.05) in irradiated rats, which received melatonin pretreatment (MW+Mel) in comparison to irradiated group (MW) after 20 days. Microwave radiation exposed animals showed an anxiety related behaviour (agitation, irritability) after 10 days of exposure. After the radiation source removal, changes in behaviour were less noticeable. Melatonin administration to irradiated rats caused a decrease in the stress induced behaviour. CONCLUSION: Microwave radiation causes body mass decrease and anxiety related behaviour in rats, however melatonin causes a reverse of those effects on both body weight and behaviour of irradiated animals (Fig. 2, Ref. 32).

Quantitative evaluation of stromal myofibroblasts and their significance for the metastatic capacity of colorectal carcinoma.

PURPOSE: To quantify the myofibroblasts in the tumor stroma of colorectal carcinomas using immunostaining with anti smooth muscle actin (SMA) as a marker for myofibroblasts. METHODS: The study was carried out on 46 surgically resected primary colorectal adenocarcinomas from the archive of the Centre for Pathology and Forensic Medicine of the Military Medical Academy in Belgrade, from 2008-2010. All samples were analysed by the scientific software "Image J". Myofibroblasts were visualized using anti-SMA antibody and quantified in order to predict tumor capacity for invasion and metastasis. Receiver Operator Characteristic (ROC) analysis was carried out, and a score of 5.72 was suggested as the score of SMA that is significant for the clinical outcome with lymph node involvement. RESULTS: Overall, the average SMA was 7.29 (range 0.39-16.84). Further analysis showed correlation of SMA with clinical and pathological tumor characteristics, i.e. SMA was significantly higher in tumors with more advanced stage, higher histological grade, greater amount of desmoplasia, smaller amount of inflammatory infiltrate, lymph node involvement, vascular and perineural invasion and infiltrative tumor growth. CONCLUSION: Our study suggests that it is possible to define the tumor capacity for invasion and metastasis by quantifying the myofibroblasts in the tumor stroma of colorectal carcinomas. Therefore, further investigations are needed to determine targeted therapies to signaling pathways in myofibroblasts.

The clinical role of micrometastatic disease in sentinel lymph nodes in breast cancer.

PURPOSE: Complete axillary lymph node dissection (cALND) is the standard procedure in treating the patients with tumor-positive sentinel nodes (SLNs). However, approximately half of these patients have not additional metastases in their axilla and therefore do not benefit from cALND. Our aim was to examine the outcome of patients with tumor-positive SLNs without cALND. METHODS: All patients (n=591) were women with clinically T1-2N0-1M0 breast cancer. SLN marking was performed with blue dye (Patentblau V) and radiotracer (antimony sulfide marked with Tc99m). Both contrast media were applied peritumorally or periareolarly. After SLN biopsy all patients underwent breast-conserving surgery or mastectomy with or without lymph node dissection of level I and II (depending on SLN status). RESULTS: In 37 (17.84%) out of 185 patients cases SLNs contained micrometastases. In 19 of 37 cases (57.58%) cALND was performed, and in 14 (42.42%) was not. The mean and median duration of follow-up were 50.59 and 55 months, respectively (range 4-108). Two cases without cALND developed ipsilateral enlarged lymph nodes at 26 and 59 months. Biopsy showed that the enlarged nodes were tumor-free. In all other cases with micrometastases in SLNs neither axillary lymphadenopathy nor distant metastases were seen. After performing surgical treatment, all patients received adjuvant chemotherapy or hormonotherapy and radiotherapy. CONCLUSION: Patients with SLN micrometastases who had not undergone cALND showed no regional recurrence and distant metastases. ALND is not necessary for regional control in patients with micrometastatic or isolated tumor cells in SLNs. By avoiding cALND the number of complications was reduced and the quality of life was improved.

Awareness during general anaesthesia--implications of explicit intraoperative recall.

Anaesthesia awareness (AA) is postoperative recall of events experienced under general anaesthesia. Most frequently patients remember an auditory perception, the feeling of motor function lost, pain, helplessness, anxiety, panic, impending death. The prevalence of awareness in nonobstetric and noncardiac surgical cases is 0.1%-0.2%. The prevalence is higher in cardiac surgery, obstetric and major trauma cases. According to the results of many studies light anaesthesia is the most common cause of the AA. Posttraumatic stress disorder appears in 33%-56% of patients who experienced awareness during general anaesthesia. Extreme awareness experiences are very uncommon, but traumatic and can have lasting effects on patients. Several brain-function monitors based on the processed electroencephalogram or evoked potentials have been developed to assess anaesthetic depth. Measures to prevent awareness include avoidance of light anesthesia, gaining more knowledge about patient anaesthetic requirements and development of methods to detect consciousness during anesthesia.

Extralevator abdominoperineal excision for low rectal cancer: oncological outcome after five-year follow-up.

BACKGROUND: Extralevator abdominoperineal excision (ELAPE) is a surgical technique that is indicated for low rectal cancer where sphincter preservation is not possible. Compared to conventional abdominoperineal excision major advantages of ELAPE are the risk reduction of intraoperative bowel perforation and positive circumferential margin which lead to a better oncological outcome. The aim of this study was to present our results in ELAPE surgery. METHODS: From February 2011 to February 2015, 40 patients underwent surgery for low rectal cancer at the Oncology Institute of Vojvodina. The collected data included sex, age, preoperative staging, neoadjuvant treatment, operative time, rate of intraoperative bowel perforation, rate of positive circumferential resection margins, histopathological analysis, postoperative mortality, tumour, node and metastasis (TNM) classification, local recurrence (LR) rate and presence of distant metastases. RESULTS: Positive circumferential margin was found in three (7.5%) patients while eight (20%) patients had intraoperative bowel perforation. LR during follow-up was seen in seven (17.5%) patients, three of them had intraoperative bowel perforation and two patients had positive circumferential margin. The estimated five-year cumulative incidence of LR is 7%. Distant metastases occurred in 18 (45%) patients. The estimated five-year survival rate is 62%.. CONCLUSION: The study shows satisfactory five-year survival rates of 62% in a highly complex patient group treated by ELAPE procedure.

Early complications after nipple-sparing mastectomy and immediate breast reconstruction with silicone prosthesis: results of 214 procedures.

BACKGROUND AND AIMS: breast reconstruction with silicone prosthesis following nipple-sparing mastectomy has become widely accepted as a reconstruction option in women requiring mastectomy for cancer. The purpose of this study was to evaluate the incidence and some factors influencing early local complications in patients undergoing NSM with immediate implant reconstruction. MATERIAL AND METHODS: prospective study was performed on a consecutive series of 214 breast reconstructions in 205 patients. All complications during the six weeks after surgery were recorded. 42 prostheses were implanted after neoadjuvant chemotherapy, 27 patients previously had radiotherapy due to breast conserving surgery and in all other cases surgery was the pri-mary treatment for cancer. RESULTS: the overall six-week complication rate was 16% (35) and included: major skin flap necrosis (4%, 9 procedures), minor skin necrosis (3%, 7), major infection (2%, 5), minor infection (3%, 7), prolonged seroma formation (3%, 6), haematoma (1%, 2) and epidermolysis (1%, 2). In 6% (12) reconstruction procedures explantation of prosthesis was done. Neoadjuvant chemo-therapy and radiotherapy were not associated with higher rate of complications. CONCLUSION: nipple-sparing mastectomy with immediate implant reconstruction has acceptable morbidity rate in the hand of experienced oncoplastic surgeon and therefore should be considered as treatment option to women requiring mastectomy.

Surgery for patients with gastric cancer in the terminal stage of the illness - TNM stage IV.

PURPOSE: To assess any survival advantage in patients with incurable gastric cancer who had undergone resection, bypass or exploratory surgery. In nonresectable patients with pain, the effect of celiac plexus neurolysis was assessed. METHODS: We retrospectively analysed data of 330 patients, operated between 1992 and 2006. The patients were followed until death or last examination. Incurable gastric cancer was defined as TNM stage IV disease: locally advanced (LA), with solitary distant metastasis (SM) or with multiple metastases and/or peritoneal carcinomatosis (MMC). The patients were divided into these 3 groups. Their postoperative survival was calculated and compared in relation to the surgical technique used. Factors which influenced mortality and survival were identified. RESULTS: 131 patients (39.7%) had locally LA cancer, 98 (29.7%) SM, and 101 (30.6%) belonged to the MMC group. The surgical procedures included 138 (41.8%) exploratory laparotomies, 84 (25.5%) bypass procedures and 108 (32.7%) resections. Thirty-three (10%) unresectable patients with pain underwent celiac plexus neurolysis. The mean survival was 21.8 months after resections, 7 months after by-passes and 4.8 after exploratory laparotomies (p = 0.0001). It was 14.57 months (p=0.001) in the LA group, 12.53 (p = 0.005) in the SM group, and 5.2 in the MMC group. Survival was shorter in patients with preoperative weight loss of more than 20 kg (3.2 months, p <0.0001). Postoperative 30-day mortality was 23.2% after exploratory laparotomies, 23.8% after bypasses and 20.4% after resections. Increased mortality was observed in the MMC group (27.7%) and in multivisceral resections (41%, p > 0.05), while significantly increased mortality occurred in patients with weight loss of over 20 kg (32%, p=0.03). Celiac plexus neurolysis was immediately effective in 30 out of 33 (91%) patients (p=0.0001), while 3 months later it was still effective in 15 (45.5%) patients (p=0.08). CONCLUSION: Resections are suggested in the LA and SM groups, and neurolysis in all nonresected patients with pain.

Upper urothelial tumours and the Balkan nephropathy. Inference from the study of a family pedigree.

In an area heavily affected by both Balkan nephropathy (BN) and upper urothelial tumours (UUT), an outbreak of UUT (followed later by BN) affected at least four of five siblings. Their cousins developed BN in a high proportion but no one of them had any sign of UUT. It has been suggested that host factors determine the outcome of exposure to the same agent(s) responsible for both diseases.

Family history of cancer among cases of upper urothelial tumours in a Balkan nephropathy area.

The highest relative risk of developing tumours of the renal pelvis and ureters (TPU) in a general population is confined to areas where Balkan nephropathy (BN) is endemic. Whether there is a higher frequency of cancer of any site in families with TPU cases from this BN endemic part of the world was tested by a case-referent study. A group of 65 rural patients with histologically proven TPU was individually matched with the same number of their nearest neighbours, who served as controls. Comparison of age-standardized ratios revealed that over a period of 30 years family members of the cases experienced a significantly higher risk of (non-urinary) cancer deaths than family members of their pairmates.

Incidence of tumors of urinary organs in a focus of Balkan endemic nephropathy.

A prospective follow-up study which included a 25% sample of the population of Petka, a hyperendemic village located in the vicinity of Belgrade, was conducted over a 15 year period (1974 to 1988). The cohort consisted of 416 members who made up the denominator of 5,723 person-years of observation. Incidence of deaths, either from or with tumors of urinary organs, was taken as a measure of outcome. The diagnosis of tumor was based on pathohistological confirmation. Incidence density of urinary tract tumors was 1.75 per 1,000 person-years. Six individuals had upper urothelial tumors (incidence density = 1.40 per 1000 person-years of observation). These tumors occurred in 32% of the cases who had Balkan endemic nephropathy.

Relationship between weathered coal deposits and the etiology of Balkan endemic nephropathy.

Field studies in epidemiology and environmental geochemistry in areas in Yugoslavia containing villages with a high incidence of Balkan endemic nephropathy (BEN), indicate a possible relationship between the presence of low-rank coal deposits and the etiology of BEN. Preliminary results from qualitative chemical analyses of drinking water from shallow farm wells indicate the presence of soluble polar aromatic and polynuclear aromatic hydrocarbons. These compounds may be derived from weathering of low-rank coals occurring in the vicinity of the endemic villages. All of the endemic villages are in alluvial valleys of tributaries to the Danube River. All except one of the clusters of endemic villages are located in the vicinity of known Pliocene age coals. Detailed sampling of the drinking waters and the nearby coals are being undertaken to identify a possible etiologic factor.

Beta 2-microglobulinuria as a predictor of death in a population exposed to Balkan endemic nephropathy.

During the year 1974, urinary beta 2-microglobulin (beta 2mu) was measured at monthly intervals using the first-morning urine sample of randomly selected individuals from the BEN affected village of Petka (416 persons) and from the nearby situated control village of Stubica (216 persons). Initial compliance was complete; over 90% of villagers had at least 10 tests performed. beta 2mu, as assessed by radial immunodiffusion (RID), was repeatedly (at least twice) positive in 12% and 1.4% of the populations of the endemic and control villages, respectively. Over the 15 years of follow-up (1974 to 1988), none from the control village developed BEN, while many medical records of the cohort exposed to BEN contained data suggestive of BEN. Death from/with BEN was used as a measure of outcome. Incidence density of 12 was 3.3 per 1000 person/years of observation (19/5723). A single positive beta 2mu test was a sensitive predictor of BEN death (sensitivity = 89.5%). Selecting two or more positive tests as the cut-off point, the specificity and positive predictive value were considerably increased. Using the sulfosalicylic acid test for detection of significant proteinuria, a similar level of validity indices was reached only by four testings.

Beta 2-microglobulinuria in a population exposed to Balkan endemic nephropathy: inferences from repeated cross-sectional studies.

Baseline data from a study run in 1974, which comprised beta 2-microglobulinuria (beta 2mu) measurements at monthly intervals from 416 members in 112 households from the BEN affected village of Petka, were compared with the results of two subsequent, cross sectional studies. In June 1988, retesting involved 320 available persons from the same households. Another collection of 284 urine specimens took place in October 1989. Prevalence of tubular proteinuria was the same in 1988 and 1989 as it was in 1974, indicating that the level of exposure to nephrotoxic agent did not change over time. Over 94% of the individuals who were always beta 2mu negative in 1974 remained negative in 1988. By contrast, over two thirds (68.7%) of those who were positive two or more times 14 years ago, tested positive upon re-examination in 1988. Particular interest arises from the data on those initially repeatedly positive persons in whom the overt disease did not occur over time; moreover, some appeared to be unaffected in 1988 and 1989 according to our set of laboratory criteria. The results suggest occasional slow progression and even possible reversibility of tubular lesions in individuals living in the BEN affected environment.

Blue dye versus combined blue dye-radioactive tracer technique in detection of sentinel lymph node in breast cancer.

BACKGROUND: Sentinel lymph node biopsy in breast cancer can be used to select patients in which axillary lymph node dissection could be avoided. In this study we compared the value of two methods for identification of sentinel node (SN) using either only blue dye or combination of blue dye and radioactive tracer. MATERIAL AND METHODS: All patients were women with clinically T(1-2)N(0)M(0) breast cancer. They were randomized into two groups. In Group A (50 patients) SN marking was performed only with blue dye and in Group B (100 patients) combined SN marking with blue dye and radiotracer was done. We used 2 ml of blue dye Patentblau V (Byk Gulden). Radiotracer was Antimony sulfide marked with Tc 99m and of 0.3 mCy (11.1 MBq) activity. Application method of both contrasts was peritumoral. After SN biopsy all patients underwent mastectomy or conservative surgery with axillary lymph node dissection of levels I and II. RESULTS: In Group A mean of 1.7 SNs were identified (median 1, range 1-4). False-negative rate in this group was 3/17 (17.6%) with negative-predictive value 20/23 (86.9%), sensitivity 14/17 (82%), specificity 20/33 (60%) and accuracy 34/50 (68%). In Group B mean number of SNs excised per case was 1.6 (median 1, range 1-5). False-negative rate was 2/44 (4.5%), negative-predictive value 41/43 (95.3%), sensitivity 42/44 (95%), specificity 41/56 (73%) and accuracy 83/100 (83%). The combination technique was significantly superior to blue-dye alone technique for negative-predictive value (p=0.033) and overall accuracy (p=0.048). CONCLUSIONS: The prediction of axillary lymph node status in breast cancer patients using combined technique has significantly higher accuracy than marking of SN with blue dye alone and therefore should be preferred.

Attitudes of medical students in Belgrade, Yugoslavia, toward preventive medicine and epidemiology.

Medical students in Belgrade were interviewed regarding their opinions about the teaching of preventive medicine, with particular emphasis on epidemiology, at the beginning and at the end of the course. Results indicated that the course provoked no interest whatsoever in the disciplines of preventive medicine. A part of social factors influencing the motivation of students, the didactic approach to teaching and the strict division between preventive and clinical medicine were implicated as the main reasons for this lack of enthusiasm. The absence in this country of clear and generally accepted ideas regarding what a graduate student should know in order to meet optimally the health needs of the community has been assessed as the factor which obscures definition of the aims of teaching and, accordingly, the creation of purposeful syllabuses.

Psychiatric disorders and selected variables among medical students in Belgrade (Yugoslavia).

The mental health of a group of 523 medical freshmen (97% of the respective population) was assessed 1 month after enrollment. Students with psychiatric impairment (84 or 16.1%) were compared with those assessed to be mentally healthy in respect of a number of variables. Cluster, correlation, and principal component analyses revealed that psychiatric disorders were related to the result of the screening test, in a lesser degree to the test anxiety, and not at all to any of the other tested variables (separation from parents, family completeness, education of parents, number of siblings, number of employees in the family, grade point average in high school, and smoking).

Balkan nephropathy and malignant tumors.

The question of whether the cancer death risk is higher in Balkan nephropathy (BN) foci has been approached by a comparison of 25 BN endemic municipalities with the same number of the group matched ones. It came out that the total cancer mortality was considerably higher, and mortality of nonurinary cancer slightly higher in BN endemic municipalities. The absence of a significant difference for the non-urinary cancer sites the authors explain by the fact that in municipalities designated as endemic only a part of the population lived in actual BN foci. They re-evaluated data published for Bulgarian BN endemic foci and concluded that, apart of a higher total cancer mortality, there was a significantly higher (although unrecognized) risk of nonurinary deaths in BN endemic settlements.

Brick mortar exposure and chronic lymphocytic leukemia.

A case-control study of 130 patients with chronic lymphocytic leukemia (CLL) and 130 controls matched with respect to sex, age (2 years), type of residence (urban-rural) and area of residence (according to the national per capita income) was carried out. Conditional logistic regression analysis showed that, apart of four risk factors already described in the literature (work in a hazardous industry, hair dye use, family history of leukemia and exposure to electromagnetic radiation), brick mortar exposure was also significantly related to CLL.

Epidemiological evidence on Balkan nephropathy as a viral disease.

Balkan nephropathy is a chronic kidney disease of a completely unknown etiology. Most epidemiologists believe that the disease has been caused by viruses, though all attempts to prove such a relationship have been fruitless. A common feature of most of the clues offered for elucidating the role of the viruses, is that they interfere with the epidemiological evidence on BN. Therefore, a hypothesis is put forward that the disease has been caused by slow viruses transmitted by rodents which contaminate food and articles in the house. Such an explanation fits most of the existing epidemiological data.