COMPARISON OF C-REACTIVE PROTEIN LEVELS IN SERUM AND PERITONEAL FLUID IN EARLY DIAGNOSIS OF ANASTOMOTIC LEAKAGE AFTER COLORECTAL SURGERY.

In colorectal surgery, anastomotic leakage is a serious complication, leading to higher postoperative morbidity and mortality. The aim of this study was to evaluate the accuracy of serum and intraperitoneal C-reactive protein (CRP) in early diagnostics of anastomotic leakage on the first four postoperative days after colorectal surgery. From January to October 2019, fifty-nine patients with colorectal carcinoma were operated on, with formation of primary anastomosis. Anastomotic leakage was diagnosed in eight patients. Comparing the levels of serum and intraperitoneal CRP, our study showed that serum CRP was a better predictor of anastomotic leakage. Serum CRP levels lower than 121 mg/L on postoperative day 4 were predictive of good healing of anastomosis.

COMPARATIVE RADIOLOGICAL DIAGNOSTICS OF ACUTE TRIANGULAR FIBROCARTILAGE COMPLEX INJURIES.

The aim was to analyze patients with clinical diagnosis of triangular fibrocartilage complex (TFCC) lesion using standard x-ray, ultrasound, conventional magnetic resonance imaging (MRI) and MR arthrography (MRA); to evaluate the accuracy of MRA compared with MRI in the diagnosis of this lesion; and to evaluate ultrasound as a method of diagnosing TFCC lesion. We analyzed 72 patients (46 female and 26 male; age range, 22-61 years; mean age 37 years; 50 right and 22 left wrists) with suspected TFCC lesion with clinical examination, standard x-rays, and ultrasound. We confirmed patients with traumatic TFCC injury on MRI and MRA. Ultrasound found 13 lesions in 72 patients with suspected TFCC lesions. Conventional MRI found 66 and MRA 68 TFCC lesions. Ultrasound is useful for visualizing intra-articular effusion, soft tissue, bone surface, and for early detection of occult fractures. MRI is a better diagnostic modality, fully able to visualize the TFCC cartilage and ligaments. MRA is consistently and accurately able to visualize structural abnormalities of TFCC.

Validation of a clinical score in predicting pancreatic fistula after pancreaticoduodenectomy.

BACKGROUND: Postoperative pancreatic fistula (POPF) is one of the most severe complications after cephalic pancreaticoduodenectomy, with mortality as high as 30%. Risk scores may help predict the risk of POPF. Multiple external validations substantially improve generalized clinical acceptability of a scoring system. AIM: The aim of this study was to externally validate previously described fistula risk score in the prediction of clinically relevant POPF. METHODS: All patients who underwent pancreaticoduodenectomy for any indication during a 5-year period were prospectively analyzed. A total of 132 patients were analyzed. RESULTS: Of the 132 patients, 44 (33.3%) developed pancreatic fistula, including 12.9% biochemical leaks, 7.6% grade B fistula, and 12.9% grade C fistula. Cut-off point of 4.5 was determined to best separate patients who developed clinically relevant POPF with area under curve of 78% (p = .00003). Sensitivity and specificity for the prediction of clinically relevant POPF with the cut-off value of 4.5 was 70.4 and 74.3%, respectively. Positive predictive value with cut-off value 4.5 was 57.8%, and negative predictive value was 83.4%. CONCLUSION: Fistula risk score identified low risk patients with false negative rate of 16.6%. Further external validation studies on large cohorts of patients and with wide case-mix may enable additional refinements of the score model.

DISCHARGE AFTER ELECTIVE UNCOMPLICATED LAPAROSCOPIC CHOLECYSTECTOMY: CAN THE POSTOPERATIVE STAY BE REDUCED?

- The aim of the study was to reevaluate the safety and feasibility of discharge 24 h after elective uncomplicated laparoscopic cholecystectomy. Since the introduction of laparoscopic cholecystectomy in our hospital, the minimum postoperative stay was considered to be two days based on surgeons' experience. The study included 337 operations performed by 21 surgeons during 2016 in the Sestre milosrdnice University Hospital Centre. Conversion to open technique and cases of acute cholecystitis were excluded, while 15 patients had insufficient postoperative data. The mean length of stay was 2.38 (range 1 to 6) postoperative days, median two postoperative days. Serious complications involving suspected drain bile leakage and postoperative hemorrhage occurred in two (0.59%) patients, both in the first 24 h following surgery. One patient required emergency laparotomy on the first postoperative day. Readmission rate was 1.2%. The postoperative minor complication rate was 42 of 337 (12.46%); these included wound infections, urinary tract infections, symptoms included in postcholecystectomy syndrome, etc. The onset of these complications was mostly after postoperative day 3. The data obtained suggest that discharge on the first postoperative day after elective uncomplicated laparoscopic cholecystectomy should be considered safe and can be practiced in our hospital.

Sensitivity and Specificity of Fenyö-Lindberg and Teicher Scores in the Diagnosis of Acute Appendicitis in Women

The aim of the study was to assess diagnostic accuracy (sensitivity and specificity) of Fenyö-Lindberg and Teicher scores for distinguishing patients that need immediate surgical treatment from the others, in a female population from an urban setting. The study prospectively included 130 female patients admitted to the emergency department with abdominal pain indicating acute appendicitis. The scores and parameters of validity were calculated and compared to definitive diagnosis. For Fenyö-Lindberg score of -17 or less, 84.5% sensitivity, 55.6% specificity, 87.9% positive predictive value (PPV) and 48.4% negative predictive value (NPV) were recorded. For cut-off value greater or equal to -2, there was 59.2% sensitivity, 77.8% specificity, 91% PPV and 33.3% NPV. The Receiver Operating Characteristic (ROC) curve analysis of Fenyö-Lindberg score showed that the best single cut-off value for discriminating acute appendicitis in the study population was -15. For Teicher score, values greater than -3 yielded 89.3% sensitivity and 22.2% specificity, 81.4% PPV and 35.3% NPV. In conclusion, Fenyö-Lindberg score could be used as an additional tool to exclude appendicitis and avoid unnecessary appendectomies. Teicher score may help in recognizing patients with appendicitis. None of the two scores can indicate or decline appendectomy in all cases. Scoring systems may be useful for pointing to important clinical signs and symptoms in specific subpopulations.

[LAPAROSCOPIC PARTIAL PERICYSTECTOMY OF SPLENIC HYDATID CYST - A CASE REPORT]. / LAPAROSKOPSKA PARCIJALNA PERICISTEKTOMIJA EHINOKOKNE CISTE SLEZENE - PRIKAZ BOLESNICE.

Echinococcal cyst of the spleen is usually a result of infection with the parasite Echinococcus granulosus. The spleen is the third most frequent localization of echinococcus after liver and lungs. Partial laparoscopic pericystectomy can be done without the loss of blood and scattering of scolexes with spleen preservation and conservation of its immune function. We present the patient with a large (1 8 x 16 x 12 cm) echinococcal cyst of the spleen that compressed the surrounding organs (stomach, transverse colon, pancreas and left kidney), and prevented normal passage causing vomiting after every meal. In this patient, PAIR procedure (puncture, aspiration, injection, reaspiration) and conservative treatment was attempted on several occasions without success. Finally, laparoscopic partial pericystectomy was performed, evacuating the contents of the cyst. The surgery lasted 120 minutes. Postoperatively the patient was without complications. Hospitalization lasted five days. Six months later, the patient is without problems. These echinococcus cysts of the spleen cannot be solved using PAIR technique and conservative treatment. Laparoscopic partial pericystectomy is a better solution than open surgery due to less trauma to the patient, especially in elderly people.

Low-dose dexamethasone with levobupivacaine improves analgesia after supraclavicular brachial plexus blockade.

PURPOSE: We conducted ultrasound-guided single-shot supraclavicular blockade and investigated the analgesic effect of dexamethasone added to levobupivacaine. The aim of this study was to determine whether the addition of low-dose dexamethasone to levobupivacaine would prolong the duration of analgesia sufficiently to avoid additional intravenous analgesic use for the first 24 hours postoperatively. METHODS: This randomised controlled study assessed 70 patients undergoing upper-extremity surgery. Patients were eligible if there 18 years or over with American Society of Anaesthesiologists (ASA) physical status I, II or III. Patients were randomly assigned to receive 25 ml 0.5% levobupivacaine plus four milligrams dexamethasone (group 1) or 25 ml 0.5% levobupivacaine plus one millilitre saline (group 2). Pain scores, analgesic consumption and time estimation at which they perceived that sensory and motor blockade started and resolved were recorded. RESULTS: Duration of sensory (1,260 min. in group 1 vs 600 min. in group 2) and motor (1,200 min. in group 1 vs 700 min. in group 2) blockade were significantly longer in group 1 (P < 0.05). Postoperative pain levels in group 1 were significantly lower (P < 0.05) at all investigation times. Analgesia consumption was significantly lower (P < 0.05) in group 1; at six and 12 hours, no patient required additional analgesia, and at 24 hours, only two patients compared with 17 in the levobupivacaine group required additional analgesia. CONCLUSION: Using single-shot low-dose dexamethasone in a mixture with levobupivacaine results in prolonged analgesia duration and less analgesic use compared with levobupivacaine alone.

Laparoscopic surgery for large hydatide liver cyst after two previous laparotomies.

Laparoscopic surgery for hepatic echinococcosis is a technically difficult and demanding surgical procedure even for the most experienced abdominal surgeon. Surgery is performed after the conservative treatment with albendazole for 28 days. We report a case of laparoscopic partial pericystectomy with biliostasis and omentoplasty in a patient with two previously open surgeries (laparotomies)--right subcostal laparotomy for acute inflammation of the gallbladder and right pararectal laparotomy for perforated gangrenous appendix. The patient underwent extensive laparoscopic adhesiolysis due to pronounced intra-abdominal adhesions to gain access to a large hydatid cyst with the diameter of 11 cm. Laparoscopic surgery is much less traumatic to the patient with a better cosmetic effect.

Awareness, attitudes, and perceptions of Croatian-based orthopedic and trauma surgeons toward scientific manuscripts, publishing internationally and medical writing. Results of an online questionnaire.

The objective of this survey was to identify the importance placed by Croatian-based surgeons on writing scientific manuscripts and publishing them internationally, as well as their awareness of and attitudes toward medical writing. A link to an online survey was sent to 327 Croatian-based orthopedic and trauma surgeons. The electronic questionnaire consisted of rating scales, multiple choice questions and free text reply boxes. A total of 61 surgeons based in Croatia replied to the survey, yielding a response rate of 19% (61/327). The survey results indicate that surgeons in Croatia are active in both research and the writing of manuscripts. There is also a high level of interest among them to publish internationally in English to further their careers. While 68% (38/56) of respondents initially claimed to know about medical writing, further questioning on the subject revealed a reduced level of familiarity with the concept. Only 19% (11/58) of respondents had ever engaged the services of a medical writer and they were generally satisfied with the work done across the three areas of language, editing and scientific knowledge. Medical writers are advised to increase awareness of their services among Croatian-based orthopedic and trauma surgeons who may well have a need for their expertise.

Mangled extremity--case report, literature review and borderline cases guidelines proposal.

Treatment of a mangled lower extremity represents a major challenge. The decision whether to amputate or attempt reconstruction is currently based upon surgical evaluation. The aim of this paper is to propose a new approach to surgical evaluation based on scoring systems, local clinical status of the patient as well as comorbidities, mechanism of trauma and hospital resources. Available literature regarding this topic was evaluated and a case of patient with mangled extremity is presented. Based on current literature guidelines and evidence-based medicine, management for borderline cases is proposed to aid clinical decision making in these situations. We describe a 44-year old male patient who presented with mangled lower left leg. Despite a borderline Mangled Extremity Severity Score (MESS), due to the overall health status of the patient and local clinical status with preserved plantar sensitivity and satisfactory capillary perfusion, reconstruction was attempted. After 6 months of treatment, all wounds healed completely with no pain, and satisfactory motor and sensory function was achieved. In conclusion, the treatment of mangled extremity treatment should be based on evidence based literature along with a clinical evaluation of every individual patient. Scores are helpful, but should not be taken as the sole indication for amputation.

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.

Experimental shortening of the radius in the treatment of Kienböck's disease.

AIM: The aim of the research was to determine the smallest amount of loading on the lunate bone obtained by gradually shortening the radius in different ulnar variants as the potential treatment of Kienböck's disease. METHODS: The research was conducted on anatomic preparations of 20 upper extremities using only the distal part of the forearm and hand, placing them in exactly defined positions. A Fuji Prescale film was inserted in the open radiocarpal joint to measure pressure after compressing axially by changing the length of forearm in four stages by the gradual shortening of the radius. RESULTS: The greatest reduction of average pressure on the lunatum achieved by shortening the radius depended on ulnar variant. In ulnar variant 0, the greatest reduction of average pressure on lunatum was achieved by shortening the radius for 3 mm (24% reduction). For ulnar variant -1, the greatest reduction of average pressure on lunatum was achieved by shortening the radius for 2 mm (37% reduction). For ulnar variants -2, -3 and +1, the greatest reduction of average pressure on lunatum was achieved by shortening the radius for 3 mm (5%, 75% and 9% respectively). CONCLUSIONS: The pressure distribution in the distal radiocarpal joint is vital for healing, and shortening of the radius relieves the pressure on the lunate bone. The exact type of surgery and the amount of radial osteotomy depends on preoperative ulnar variant.

Operative versus non-operative management of blunt pancreatic trauma in children: Systematic review and meta-analysis.

AIM: Blunt abdominal trauma is the major cause of abdominal injury in children. No clear guidelines exist for the initial management of blunt pancreatic trauma in children. The aim of this study was to perform a systematic review and meta-analysis of initially non-operative versus initially operative treatment in children with blunt pancreatic injury. METHODS: Studies including children (<18 years) with blunt pancreatic injuries published in any language after year 1990 were included. Total of 849 studies were identified by searching PubMed, Scopus, CINAHL and Cochrane Database. After review, 42 studies met inclusion criteria and were included in this systematic review. There were 1754 patients, of whom 1095 were initially managed non-operatively (NOM), and 659 operatively (OM). Primary outcome was non-operative management success rate, and secondary outcomes were mortality, complications (including specifically pseudocysts and pancreatic fistulas), percent of patients and days on total parenteral nutrition (TPN), length of hospital stay and readmissions. RESULTS: There was no difference in mortality between NOM and OM groups. The incidence of pseudocysts was significantly higher in NOM group compared to OM (P<0.001), especially for AAST grade III or higher (P<0.00001). Overall incidence of pancreatic fistulas was significantly lower for NOM group (p = 0.02) but no difference was observed for AAST grades III or higher (p = 0.49). There was no difference in the length of hospital stay (P = 0.31). Duration of total parenteral nutrition was not different for all AAST grades (P = 0.35), but was significantly shorter for OM group for AAST grades III and higher (p = 0.0001). There was no overall difference in readmissions (P = 0.94). Overall success rate of initial non-operative treatment was 87%. CONCLUSIONS: Most patients with pancreatic trauma can initially be treated non-operatively, while early surgical treatment may benefit patients with lesions of the main pancreatic duct. ERCP offers both highly accurate diagnosis and potential treatment of ductal injuries.

Retrorenal fat predicts grade C pancreatic fistula after pancreaticoduodenectomy.

BACKGROUND: Pancreatic fistula after pancreaticoduodenectomy is one of the most severe complications with mortality rates as high as 45%, and the prediction of most severe form of fistula (grade C) is crucial for successful management of patients who are to undergo cephalic pancreatoduodenectomy. It has been found that the amount of abdominal fat may predict grade C postoperative pancreatic fistula. In this study, we analysed the value of retrorenal fat thickness in the prediction of grade C pancreatic fistula. METHODS: A total of 140 patients who underwent pancreaticoduodenectomy were retrospectively analysed. Retrorenal fat thickness and intra-abdominal fat, expressed as total fat area, visceral fat area and subcutaneous fat area, were determined from computed tomography slices using the known range of attenuation values (-190 to -30). Blood loss, operating time, pancreatic texture and main pancreatic duct diameter as well as body mass index were also analysed. RESULTS: Retrorenal fat thickness (P = 0.0004), duct diameter (P = 0.0008), subcutaneous fat area (P = 0.023) and total fat area (P = 0.014) were found to be significant predictors of grade C pancreatic fistula. CONCLUSION: Although retrorenal fat tissue thickness may seem robust, it is a simple measure that can be used to predict the most severe grade of pancreatic fistula after pancreaticoduodenectomy.

Anterior rectus sheath in inguinal hernia repair: preliminary study.

Inguinal hernia repair using the anterior rectus sheath flap represents a tension-free repair with potential advantages (no foreign material or tension on the suture line). The aim of this research was to evaluate the method of inguinal hernia repair using the anterior rectus sheath and to compare it with tension-free mesh repair (modified Lichtenstein repair). In total, 62 patients were evaluated. Each patient's age, gender, type of hernia, total operating-room time, the length of postoperative hospital stay, and the recurrence-free period were recorded, as well as the total number of postoperatively administered doses of analgesics, and analyzed using the Mann-Whitney test. No difference in age (p = .08), postoperative hospital stay (p = 0.810), or postoperative use of analgesics (p = .116) was observed between two groups. Total operating-room time was significantly longer in patients undergoing mesh repair (median 80 min, range 45-150) compared to anterior rectus sheath repair (median 65 min, range 45-125) (p = .049). No complications or recurrences were noted in either group. Thus, this study showed good results using the anterior rectus sheath repair for primary, uncomplicated inguinal hernias, comparable to mesh repair.

[Lymphedema of the penis and scrotum: surgical treatment and reconstruction]. / Limfedem penisa i skrotuma: kirursko lijecenje i rekonstrukcija.

Penile and scrotal lymphedema causes significant functional, cosmetic and psychological problems. We present two patients with penoscrotal lymphedema successfully treated with wide radical excision of the lymphedematous tissue and reconstruction with skin flaps and split thickness grafts. No complications occurred postoperatively. Good cosmetic results and functionality are preserved 8 and 15 years after the surgery, with no recurrences.

Quality of life changes after inguinal hernia repair using anterior rectus sheath--a preliminary study.

Chronic pain is the most serious long-term complication after groin hernia repair. The aim of this preliminary research was to assess the quality of life before and after standard tension-free mesh repair and new method of tension-free inguinal hernia repair using anterior rectus sheath. Total of 62 patients were evaluated. Anterior rectus sheath method was performed in 29 patients and in 33 patients standard mesh repair was used (Lichtenstein repair). Quality of life was assessed before and after the surgery using short-form SF-36 questionnaire (QualityMetric Inc.), adjusted for Croatian language. There were statistically significant improvements in bodily pain and general health scores in both groups. Patients operated using mesh technique also demonstrated statistically significant improvements in social functioning and emotional role. Similarly, patients in whom inguinal hernia was repaired using anterior rectus sheath had significantly better postoperative scores for physical functioning and role physical scores. Quality of life assessment demonstrated good ability to differentiate between several independent aspects of quality of life. Anterior rectus sheath repair significantly improved quality of life and was shown to be similar to mesh repair in the aspect of physical functioning.

Minimal number of lymph nodes that need to be examined for adequate staging of colorectal cancer--factors influencing lymph node harvest.

BACKGROUND/AIMS: Accurate assessment of lymphatic node status is an essential component in staging of colorectal cancer and determining the need for adjuvant treatment. The risk of understaging nodal status decreases by increasing the number of examined lymph nodes. Several recommendations have been published for the minimum number of lymphatic nodes that need to be harvested for accurate nodal staging with minimal chance of error, ranging from 6 to 17 lymph nodes. However, the number of harvested lymph nodes is very variable, and this variability is poorly understood. The aim of this study was to determine factors associated with the number of retrieved lymph nodes in patients with colorectal cancer. METHODOLOGY: Clinical and histological characteristics of 177 patients operated for colorectal cancer were analyzed. RESULTS: In multiple regression analysis, male gender, better tumor differentiation and greater tumor size, as well as the presence of acute inflammation were determined as significant independent predictors of the increased number of resected and examined lymph nodes. CONCLUSIONS: The determination of the minimum number of lymph nodes required for accurate nodal staging of patients with colorectal cancer needs to be individualized.

Postoperative infections in colorectal cancer patients.

BACKGROUND/AIMS: Colorectal surgery is associated with some of the highest rates of infective complications, and especially surgical site infections. It has recently been reported that postoperative infection in colorectal cancer surgery increases the risk of recurrence. The aim of this study was to analyze factors associated with the occurrence of postoperative infections in patients with colorectal cancer. METHODOLOGY: A total of 81 patients operated for colorectal cancer was included. Patients' characteristics and postoperative course were recorded and analyzed. RESULTS: Patients with tumors located in the rectum had significantly higher rate of postoperative infectious complications compared to patients with tumors located in the colon (p=0.002). In a logistic regression model, among all evaluated predictors, only preoperative hemoglobin concentration was found to be an independent significant predictor of postoperative infection (p=0.01). CONCLUSIONS: Preoperative anemia was found to be significant independent predictor of postoperative infection. Meticulous surgical technique with minimal blood loss is an important means of reduction of postoperative infections in colorectal surgery.

Analysis of scores in diagnosis of acute appendicitis in women.

Acute appendicitis is a common surgical condition that requires prompt diagnosis. Besides modern imaging techniques, scoring systems, based on clinical signs and symptoms and routine laboratory assessments, have been used as a diagnostic aid. However, differences in sensitivities and specificities were observed if the scores were applied to various populations and clinical settings. The purpose of this paper is to assess validity of three scores (modified Alvarado score, Ohmann score and Eskelinen score) for diagnosis of acute appendicitis in women. 126 female patients admitted for suspicion of acute appendicitis in a tertiary hospital emergency department were analyzed prospectively. Modified Alvarado score, Ohmann score and Eskelinen score were calculated at admission and compared to final diagnosis. All patients with modified Alvarado score 7 or more had acute appendicitis (100% specificity) and it can be used to determine the need for immediate appendectomy. Values of Ohmann score greater than 6 resulted in 0.9% rate of overlooked appendicitis. Besides obvious educational role, scores may help to determine the group of patients who require immediate appendectomy, therefore expediting treatment and avoid unnecessary observation or more lengthy diagnostic procedures that require highly educated and skilled senior staff: No single score may be used alone to dictate or decline surgery. Different cut-off points may also be considered for different subpopulations.