Influence of Prognostic Factors for Recurrence of Adenocarcinoma of the Stomach.

INTRODUCTION: Gastric cancer is the second most important neoplasm in the world. Surgical resection is the treatment of choice for gastric cancer, and recognized by the International Union against Cancer (International Union Against Cancer - UICC) TNM classification of the parameters of the tumor and lymph node. Prognostic factors related to characteristics of the tumor by histopathologic findings have an impact on the planning of the operation. According to the results of most studies it is possible to predict survival and recurrence based on histological type and TNM classification of tumors on the one hand and the surgical procedure on the other. AIM: The aim of the research was to analyze prognostic factors that influenced the frequency of recurrence in gastric surgery patients. PATIENTS AND METHODS: The five year study covered a population of 100 treated patients of adenocarcinoma of the stomach at the Department of Surgery, University Clinical Center Tuzla. The first group were characteristics of tumors in patients with gastric adenocarcinoma. Lymphadenectomy and splenectomy, types of surgery were the second group of prognostic factors. RESULTS: Histological type and TNM stage of tumor as prognostic factors had a significant impact on local tumor recurrence. The type of surgery had no statistically significant value for tumor recurrence (p = 0.7520). CONCLUSION: Statistical analysis of prognostic factors related to histopathologic characteristics of tumors and the type of surgery gave the results that had an impact on recurrence in gastric surgery patients. The most important prognostic factors were TNM stage of tumor and histological type of tumor that influenced the incidence of recurrence.

Pancreatic injury in blunt abdominal trauma.

INTRODUCTION: Pancreatic injuries are not common after blunt and penetrating trauma, but can be challenging to diagnose and manage. CASE REPORT: Twenty-three year old man, injured during a fall from a motorcycle two days earlier, was admitted to Department of Surgery, University Clinical Centre Tuzla because of suspicion of pancreatic trauma. Immediately after hospitalization, patient underwent laboratory and radiological tests that revealed the existence of pancreatic trauma, so we opted for urgent surgical treatment. Surgery and early postoperative course were normal and the patient was discharged on the ninth postoperative day. CONCLUSION: Proper diagnosis and well-selected surgical treatment significantly increases the chances for recovery of these patients.

Preoperative Hypoalbuminemia as a Predictor of Severe Postoperative Complications in Patients Undergoing Whipple Pancreatoduodenectomy.

Background: Pancreaticoduodenectomy (PD) known as Whipple procedure is still one of the most complex abdominal surgeries used for treatment of periampullary tumors. PD is often followed with postoperative complications (pancreatic, biliar or intestinal fistula, haemorrhage, intraabdominal abscess, delayed gastric empting. Severe postoperative complications (SPC) can be reason for reoperation and reason of bad outcome of treatment and life treathening condition. Objective: To investigate predicitive value of preoperative hypoalbuminemia for severe postoperative complications (SPC) in patients who have undergone Whipple pancreaticoduodenetomy (PD). However, no similiar study has been ever reported from our country until now. Methods: In this retrospective-prospective study, 100 patients who have had Whipple pancreaticoduodenectomy for malignant periampullary tumors at the Department for Surgery of University Clinic Center Tuzla, Bosnia and Herzegovina were enrolled, from january of 2009 to decembre of 2021. All patients were preoperatively analysed according to serum albumine levels and presensce of hypolabuminemia (serum albumine levels <32g/l). Serum albumine biochemical test were done 1-2 days preoperatively. Clavien Dindo classification was used for determination patients with SPC. Patients who did not have SPC belonged to (I-II) Clavien Dindo group of patients while those who had SPC belonged to( III-V) Clavien Dindo group of patients. Results: Out of 100 patients who have undergone pancreaticoduodenetomy, in 55 (55%) patients postoperative complications were noticed. Mortality rate was 18 (18%) and reoperation has been done in 20 cases (20%). SPC were noticed in 19 patients and most often were: delayed gastric emptying (20%), pancreatic fistula (13%) and intraabdominal collections (9%). Hypoalbuminemic patients had a significantly higher rate of severe postoperative complications ( p<0.05). Using hypoalbuminemia-SPC correlation analaysis, there is confirmed statistically significant correlation between hypoalbuminemia and SPC (ρ= 0.236; p<0.05). Conclusion: Preoperative hypoalbuminemia can be used as predictor and prognostic factor for severe postoperative complications after Whipple pancreaticoduodenectomy. Identification and optimization of serum albumin level prior to Whipple pancreatoduodenectomy may improve surgical outcomes.

Urine amylase level after Whipple resection might be a predictive factor of postoperative complications.

The association between urine amylase levels and the development of postoperative complications after Whipple resection is still unknown. Aim of this study was to determine the prognostic value of urine amylase levels for postoperative complications in patients who underwent Whipple resection. In this retrospective cohort study, we analyzed amylase levels in urine, serum and drains in 52 patients who underwent Whipple resection preoperatively and on Postoperative Day 1 (POD1) after the intervention. Patients were followed up for 3 months to assess their predictive value for postoperative complications. In patients with complications, urine amylase levels were significantly higher on POD1 than before resection (198.89 ± 28.41 vs. 53.70 ± 7.44, p=0.000). Considering the sensitivity and specificity of the urine amylase level on POD1, an area under the ROC curve of 0.918 was obtained (p<0.001, 95% CI: 0.894-0.942). Patients with urine amylase levels ³140.00 U/L had significantly higher risks of postoperative pancreatic fistula (POPF) grade C (definition of POPF done according to the ISGP) (RR:20.26; 95% CI: 1.18-347.07; p=0.038), readmission to hospital (RR: 6.61; 95% CI: 1.53-28.58; p=0.011), reoperation (RR: 5.67; 95% CI: 1.27-25.27; p=0.023), and mortality (RR:17.00; 95% CI: 2.33-123.80; p=0.005) than patients with urine amylase levels <140.00 U/L. Urine amylase levels on POD1 displayed strong and significant positive correlations with serum amylase levels (r=0.92, p=0.001) and amylase levels in drains (r=0.86, p=0.002). We can conclude that urine amylase levels on POD1 have good prognostic value for postoperative complications after Whipple resection and might be used as an additional predictive risk factor.

Surgical treatment and complications of treating pancreatic tumor.

UNLABELLED: Pancreatic tumor is one with the worst prognosis of all cancers, and the tenth most frequent cancer in Europe, making the 3% of all cancers affecting both sexes. Most patients seek treatment when the disease is in its advanced stage and the level for possible resectability is low. Late presentation of the disease is responsible for the short survival period of 6 months and a five-year survival of 0.4 to 5% of patients. At the Clinic for Surgery in Tuzla during period from January 1st 1996, to January 1st 2011, a total of 127 resection surgeries were performed due to malignant tumors. The goal of this study was to show that adequate assessment of operability, proper surgical strategy and modern techniques of creating anastomoses reduces morbidity and mortality, results in fewer postoperative complications and contributes to better surgical results. In our study sample the most common place of tumor location was the head of pancreas, in 69 (59.7%) patients. Men develop this type of cancer more often than women in the ratio of 2:1, while the median age of patients was 62 years. We faced postoperative complications in 37 (29.1%) patients, pancreatic fistula being the most prevalent complication, occurring in 16 (12.6%) patients. Overall early and late postoperative mortality was observed in 12 (9.8%) patients. CONCLUSION: Patients with chronic and hereditary pancreatitis are at a higher risk for developing pancreatic cancer and should be screened for the purpose of early diagnosis. The staging of pancreatic cancer has improved, with the accuracy of 85-90%. Postoperative complications, morbidity, and mortality are significantly reduced (p < 0.05) if the standardized operational procedure is applied and if modern techniques are used to create pancreaticojejunal anastomosis as the anastomosis carrying the highest risk.

Effect of probiotics on liver function after surgery resection for malignancy in the liver cirrhotic.

INTRODUCTION: Hepatic resection is the accepted treatment for various liver tumors. Increasing evidence suggests that two factors significantly influence outcome and successfulness of the hepatic resection in patients with HCC in cirrhosis. There are liver function recovery and the degree of inflammation during early postoperative period. OBJECTIVE: Aim of this study was to determine whether probiotic use influences on liver function recovery, degree of inflammation during early postoperative period, intraoperative risk, type and frequency of intraoperative and postoperative complications, morbidity, intraoperative and early postoperative mortality and a one-year survival rate in patients who have been used probiotic, and underwent the hepatic resection due to HCC in cirrhosis. PATIENTS AND METHODS: Study was conducted on 120 patients underwent the hepatic resection due to HCC in cirrhosis. This study has been done in University Clinical Centers Tuzla, Maribor and Strasbourg from October 2006 till February 2008. Patients were divided into 2 groups: 1) patients with liver cirrhosis and histologically verified HCC whom underwent liver resection surgery (segmentectomy/ bisegmenctetomy, right and left hemihepatectomy/extended hemihepatectomy) that used preoperatively and postoperatively probiotics (n = 60), 2) a control group of patients with liver cirrhosis and HCC, which did not use preoperative and postoperative probiotics (N = 60). Treatment with probiotics was conducted 3 days preoperatively and postoperatively with 7 day's oral supplementation. RESULTS: This study have shown next: patients underwent to the hepatic resection due to HCC in cirrhosis who have been used preoperatively and postoperatively probiotic had liver function recovery better and faster, acute immune response better, serum level of tumor markers lower, intraoperative and postoperative complications were less frequent, and morbidity and mortality rates were lower than in those who have not been using probiotic. CONCLUSION: Probiotic use may make liver function recovery better and increases immune response in early postoperative period and positively influences outcome and successfulness of the hepatic resection in patients with HCC in cirrhosis.

[Complications of laparoscopic cholecystectomy first and last procedures]. / Ukupne komplikacije laparoskopske holecistektomije prvih i poslijednjih 200 procedura.

BACKGROUND: The aim of this study were evaluated intraoperative and postoperative complication, and reasons for conversions among first 200 and last 200 procedures inside about 2 000 where we performed laparoscopic cholecystectomy in our clinic. MATERIAL AND METHODS: Retrospective-prospective we analised overall complication rate, operative time and reasons for conversions in first and last 200 procedures where we performed laparoscopic cholecystectomy. We use the USA technique for operation with three troacars. Demografic dates about patients, intraoperative finding and hospital statistic was the same in both groups. RESULTS: In the first group we have 8 (4%) intraoperative complications and 12 (4.8%) postoperative complications, the average operative time was 77.8 (+/- 12.01) minutes, and the number of conversions was 10 (5%). In first group we had two cases with intraopertive bleeding (1%), two cases with common bile duct injury (1%), three cases with adhesions (1.5%) and one cases of negative effects of resorption of CO2. In the second group we have 5 (2.5%) intraoperative complications, and 8 (4%) postoperative complications, the average operative time was 56.8 (+/- 12.03) minutes, and we done 5 (2.5%) conversions. The most important postoperative complications were: postoperative pancreatitis, deep veins thrombosis and postoperative abscess collection in both groups. We had statistically significant difference between first and last 200 procedures LC. Hospital stay were 3.10 (+/- 1.06) days for first, and 2.90 (+/- 67.09) days for second group. CONCLUSIONS: Analyses of our results after first and last 200 patients showed lower rate of complications, conversions and reoperations in the second group. Our results we explain with better surgery technique, more experience of surgeons and better surgery equipment.

[Analysis the efficacy of preoperative biliary stent placement in patients with malignant obstructions of distal choledochus]. / Analiza efikasnosti preoperativnog plasiranja bilijarnog stenta u pacijenata sa malignim opstrukcijama distalnog holedohusa.

BACKGROUND: In a very short time, malignant obstructions of distal choledochus cause a lot of damage to the liver function that may result in serious intra operative and postoperative complications and consequent high hospital mortality. Contradictory results with respect to the recovery of the liver function and origin of intra operative and postoperative complications lead us believe in the necessity of the evaluation of the preoperative placement of billiar stent in these patients, knowing that these patients see the doctor in the advanced stage of the disease with the relatively high level of the liver function damage. The goal of this research was a quantitative and qualitative analysis of intra operative and postoperative complications as well as high hospital mortality in both groups of subjects so that through this kind and scope of complications and mortality rate we could indirectly reach the conclusion relating to efficiency of the billiar stent placement. Another goal of the research was the analysis of liver tests before the operation and ten days after the operation with both groups of subjects so that, based upon the speed of their normalization, the conclusion could be reached in relation to the speed and level of the liver function recovery after the performed pancreatoduodenectomy. RESULTS: The subjects from the first group had more expressed symptoms of jaundice and high temperature and fever whereas in respect to the other presented symptoms there was no statistically significant difference. Preoperative values of ALT and AST values and the total values of bilirubin and C-reactive protein were statistically significantly higher in the first group of subjects (p<0.05). Contrary to that, ALP and GGT enzymes value were higher but there was no statistically significant difference between the compared groups. After the operation the normalization of all mentioned parameters of the liver function occurs in both groups of subjects but ALT, AST, ALP and GGT enzymes values and total bilirubin values in the first group of subjects were closer to the reference values. Based upon these data we can conclude that the liver function recovery also was better and faster. By analyzing intra operative complications no statistically significant difference was found between the compared groups. The total ratio of postoperative complications was 32 %, compared to 40 %, which is not a statistically significant difference. With respect to fistula and infections there were no statistically significant differences. Other postoperative complications in both groups were almost equally present and are not statistically significant. CONCLUSION: Better liver function recovery in the first group of subjects and the equal ratio of complications in both group of subjects, justifies the application of preoperative placement of billiar stent under our conditions.

[Segmental and bisegmental resections of liver in a treatment of malignant neoplasms]. / Segmentalne i bisegmentalne resekcije jetre u tretmanu malignih neoplazmi.

UNLABELLED: The news in understanding intrahepatal anatomy, such as radiology contemporary technology making easier segmental and bisegmental access to hepatal resection. This access comprises resection of isolated anatomical segments or a sector of liver which is depends of magnitude of intrahepatal pathological process. After segmental or bisegmental resection of liver, patients were analysed in the period from 15 and 30 days after the operation. Analysis of patients from this period comprise: localisation of tumour in relation on segments, liver test and follow up, technique of resection, intraoperative stream, the period of operation, blood follow up through v. portae, blood loss and quantitative and qualitative analysis of postoperative complications. RESULTS: between January 2000 and March 2005, sixty two subject were analysed that have been operated on our clinic (segmental or bisegmental resection), because of the metastatic process of liver and hepatocellular carcinoma of liver (HCC). Hospital mortality was 2.1%, with most often mortality in patients with HCC and cirrhosis of liver. High of morbidity from this period were 19,8%. Need for transfusion of blood (fresh erythrocytes) were 1,2 +/- 0,5 U. Patients with HCC had more needs from blood transfusions contrary patients without HCC; 2,9 +/- 1,4 contrary 0,7 +/- 0,28 U (p<0,05). Recidivism of malignant process in hepatal margin were 2,7%. CONCLUSION: Segmental hepatal resection is very accurate technique which makes possible complete resection of tumour and in the same time preservation of healthy liver parenchyma. Segmental hepatal resection is especially useful for patients with HCC and patients with recidivism or progress of primary process.

[Operative treatment of acute pancreatitis]. / Operativno lijecenje akutnog pankreatitisa.

Most attacks of acute pancreatitis are self limiting, and the patients recover completely within days or weeks. In a few cases, however, the course is severe, with development of organ failure (single or multiple) and local complications such as necrosis, abscesses, and pseudocist. Between 01.01.2001-01.06.2004, 286 cases of acute pancreatitis were treated in our clinic. The purpose of this study is to represent indication for operative treatment of acute pancreatitis and its complications, according to the Atlanta classification. According to our date, the most frequent cause are changes on biliary tract. Of these 286 patients, 247 suffered from a mild or moderate type of acute pancreatitis and responded fully to medical treatment (215 patients) or to biliary tract surgery (32 patients). The hospital mortality of this group of patients was 2.4%. Surgery was indicated when the patients developed signs of an acute abdomen (9 patients), pancreatic pseudocyst (7 patients), progressiv icterus (2 patients), infection of pancreatic necrosis (10 patients), and pancreatic abscess (7 patients). Four patients with pancreatic necrosis were stable, and they had conservative treatment. The most difficult decision in the management of these patients is whether surgery is required and which of the complementary approaches to necrosectomy and drainage is appropriate. The hospital mortality of patients with severe acute pancreatitis was 28.2%. Multiple organ failure was the predominant cause of death.