Large-cell neuroendocrine carcinoma of the ampulla of Vater.

Large-cell neuroendocrine carcinoma is a high-grade neuroendocrine carcinoma, originally described in the lung. The tumor rarely occurs in extrapulmonary sites like the gastrointestinal tract, and only few examples have been described in the ampulla of Vater. A new case of large-cell neuroendocrine carcinoma of the ampulla of Vater in a 60-year-old man is reported. After pancreatoduodenectomy, macroscopic examination revealed ulcerated tumor in the region of the ampulla of Vater. Microscopically, the tumor exhibited organoid, predominantly nested growth pattern, consisting of large, polygonal cells with pleomorphic nuclei. Average number of mitoses was 36 per 10 high-power fields. Small and large areas of necrosis were identified. Immunohistochemically, the tumor cells were positive for synaptophysin, chromogranin A, PGP 9.5, neuron-specific enolase, pancytokeratin, CK8 and somatostatin and negative for CK7, CK20, S-100, TTF-1, HMB-45, CD117, E-cadherin and regulatory peptides. Ki-67 proliferative index was 41%. Histone deacetylase (HDAC) analysis showed almost identical results for HDAC1, HDAC2 and HDAC3--60, 60.3 and 61%, respectively. Two months after surgery, liver metastases occurred, confirming highly aggressive behavior of large-cell neuroendocrine carcinoma.

TiO2 P-25 anatase rapid precipitation from water by use of struvite formation.

UV(360nm) irradiation of TiO(2) P-25 nanoparticle in water suspension is used for photocatalytic mineralization of pollutants or inactivation of microorganisms. Removal of TiO(2) particles from large volumes of water following photocatalytic process is problematic due to their nano-size. So far no chemical methods are available for TiO(2) rapid precipitation while filtration or centrifugation is not feasible because of high cost and limited performance. In the present study TiO(2) was rapidly precipitated from water suspension by formation of the mineral struvite. Addition of Mg, P, and NH(4)(+) at stochiometric rates of 1:1:1 at pH>8.3 resulted in TiO(2) entrapment into struvite formed flocs and rapid precipitation. Struvite sludge formed and precipitated was observed under HSEM revealing TiO(2) entrapment into struvite mineral.

Enhanced suppression of hormonal and metabolic responses to stress by application of combined spinal-epidural and general anaesthesia compared with combined spinal general anaesthesia during colorectal surgery.

The aim of the study was to determine the impact of combined spinal-epidural and general anesthesia (CSEGA) on the suppression of the hormonal and metabolic response to surgical stress and to compare it with the technique of combined spinal and general anesthesia (CSGA). Sixteen patients referred for elective colorectal surgery randomly divided into two groups on the basis of anesthesia (CSEGA and CSGA). Mean arterial blood pressure, heart rate, haemoglobin saturation, serum glucose, serum cortisol and urinary catecholamines (adrenaline, noradrenaline and dopamine) were determined at four distinct peri-operative time points. During the peri-operative period the overall haemodynamic and respiratory functions in patients that received CSEGA were superior compared to those in patients that received CSGA. Biochemical analysis revealed that in the sera of patients that received CSEGA the concentration of both glucose and cortisol was elevated to a lesser degree than that observed in the sera of patients that received CSGA. Furthermore, a significant reduction in post-operative urinary catecholamine (adrenaline and noradrenaline) excretion was apparent in the CSEGA group. We conclude that CSEGA is a more suitable form of combined anaesthesia for colorectal surgery with a clear advantage of a blunted surgery-mediated neuro-endocrine stress response.

Granular cell tumor of the common hepatic duct presenting as cholangiocarcinoma and acute acalculous cholecystitis.

Granular cell tumors (GCT) are rare benign tumors. Less than 1% of GCTs involve the extrahepatic biliary tree. Most researches favour a Schwann cell origin. Patient, caucasion, female, 31-year-old presented with 4 month history of painless jaundice and pruritus. US and CT revealed dilatation of intrahepatic biliary tree and surgery was performed. Firm tumor mass was found above the conjunction of cystic duct and common hepatic duct (CHD) that caused obstruction and gallblader empyema. The patient underwent radical surgical procedure because Klatskin tumor was clinically suspected. Patohystology and immunohistochemistry confirmed granular cell tumor. Eight years after surgery the patient is wellbeing without symptoms. To our knowledge 69 cases of GCT of the extrahepatic biliary tree have been reported and none of the acute acalculous cholecystitis case acompanied by GCT of CHD. Granular cell tumors are rarely diagnosed preoperatively. Wide resection offers the best chance for cure.

Short-segment jejunoplasty: the option treatment in the management of benign esophageal stricture.

A non-dilatable benign stricture of the esophagus is a problem for the patient and always a challenge for the surgeon. The present study is intended to provide some details of surgical technique and the physiological concept that constitutes the basis for patient selection for short-segment jejunoplasty. In this study, out of 98 patients, 91 had complex stricture of the lower, and seven of the cervical esophagus. The main cause of stenosis in 60 patients (61.2%) was gastroesophageal reflux, in 34 (34.7%) post-corrosive damage, and in three (3.0%) it was other causes. All patients were treated by three methods of jejunoplasty: group I (n=54 patients) short-segment of the jejunum; group II (n=37 pts) Roux-en-Y double tract; and group III (n=7 patients) short jejunal segment on the long vascular pedicle. Intraoperative complications occurred in 17 (17.34%) of the patients. An anastomotic leak occurred only in three (3.29%) in group I and II, and 1/98 patients (1.02%) died from mediastinitis. Follow-up of functional results for up to 36 months (average 18 months) was available in 77/97 (79.3%) hospital survivors. Fifty-seven (74%) patients are satisfied with their ability to take food, postoperative reflux was completely denied by 72 (93.5%) patients. Postvagotomy diarrhea was transient and gradually subsided over the course of the first 6 months.

[Splenic artery aneurysms].

Although the third most frequent aneurysm in the abdomen, after aneurysms of the aorta and iliac arteries, and most frequent aneurisms of visceral arteries, splenic artery aneurysms are rare, but not very rare. Thanks to the new imaging techniques, first of all ultrasonography, they have been discovered with increasing frequency. We present a series of 9 splenic artery aneurysms. Seven patients were female and two male of average age 49 years (ranging from 28 to 75 years). The majority of afected women were multiparae, with average 3 children (ranging from 1 to 6). One patient had a subacute rupture, and 2 had ruptures into the splenic vein causing portal hypertension. The spleen was enlarged in 7 out of 9 patients. The average size of aneurysms was 3,2 cm (ranging from 2 to 8 cm). The preoperative diagnosis of splenic artery aneurysm was established in 6 patients while in 3 patients aneurism was accidentally found during other operations, during splenectomy in 2, and during the excision of a retroperitoneal tumour in 1 patient. Aneurysmectomy was carried out in 7 patients, while a ligation of the incoming and outcoming wessels was performed in 2 patients with arteriovenous fistula. Splenectomy was performed in 6 patients, while pancreatic tail resection, cholecystectomy and excision of the retroperitoneal tumor were performed in 3 patients. Additional resection of the abdominal aortic aneurysm with reconstruction of aortoiliac segment was performed in 2 patients. There were no mortality and the postoperative recovery was uneventful in all patients.

[Retrohepatic veins of the posterior section of the right hepatic lobe--terminology and surgical significance].

Three main hepatic veins: right, middle and left are constant, but there is a variable number of retrohepatic vessels called accessory or minor hepatic veins. The most important of them are veins reffered to as middle right hepatic vein (MRHV) draining segment VII and inferior right hepatic vein (IRHV) draining segment VI. The incidence of large MRHV and IRHV reaching or exceeding a caliber of 5mm, their arrangement in the liver and drainage territories were investigated in our collection of 142 injection-corrosion specimens of the liver. In 1/5 of the cases with large IRHV this vein drains small part of segment VI, sometimes its insignificant marginal part so it couldn't be used for segment VI preservation when it is necessary. A precise knowledge of the vein anatomy of right posterior sector of the liver and its vein drainage territories is very important during complex dissections of the retrohepatic areas, resections and preservation liver parenchima.

Visceral metastases of melanoma-single institution experience an analysis of 15 cases.

Authors analysed 15 cases with visceral metastasis of melanoma. In eight cases the primary was unknown but in seven cases the data about primary was known. From 15 patients 10 were male and 5 female. All metastases were in abdominal cavity (liver-3, abdominal lymph nodes-4. stomach-2, bowel-4, omentum-1, spleen-1, oesophagus-1, adrenal-2 cases. In one case metastatic deposit was in brain and in one case i the vertebral body. In 6 cases visceral metastases were in more than one location.

[Initial diagnosis of intra-abdominal hemorrhage caused by isolated splenic injury in blunt abdominal trauma]. / Inicijalna dijagnostika intraabdominalnog krvavljenja uzrokovano izolovanom povredom slezine kod tupe abdominalne traume.

Diagnosis of intraabdominal bleeding caused by spleen injury must be performed in the shortest possible period of time, with little risk for the patient, and with high preciseness. By its simple performance, high preciseness and little risk for the patient, DPL imposes as the predominant method in initial diagnostic of intraabdominal bleeding. Control and monitoring of lavage may duly signalize degree of bleeding. Preciseness of this diagnostic in our series ranges up to 93.3%. DPL method is especially important in a combined neurotrauma. Ultrasonography is a sovereign method in diagnostic of bleeding source as well as in monitoring of bleeding that from the very beginning does not require urgent surgical intervention. Its importance is in monitoring both intrasplenic and subcapsulary hematomas. It is not appliable in disturbed and haemodynamically unstable patients. It is in particular important in children where a maximum conservative attitude with respect to operative treatment has been assumed. CT takes the leading place with respect to preciseness of bleeding area, and the combined thoracoabdominal trauma. Preciseness of CT in our series comes up to 96.6%, but can be applied only in haemodynamically stable patients. Same as US of abdomen so the CT of abdomen represents a prominent method in monitoring of both intrasplenic and subcapsular hematomas, which do not require urgent surgical intervention.

[Treatment of severe anemia and gastrointestinal tract hemorrhage in a Jehovah's Witness]. / Tretman Jehovinog svedoka sa teskom anemijom i krvarenjem iz gastrointestinalnog trakta.

This case report discribes the treatment of 67-year-old Jehovah's Witness with severe anemia and gastrointestinal haemorrhage from gastric leiomyoma and peptic ulcer. Minimal invasive surgery with meticulous hemostasis, controlled hypotension, hyperoxic normovolemia and normotermia were main principles. Minimal blood samples for necessary laboratory parameters and noninvasive onitoring were ways to decrease iatrogenic blood loss. The operative and postoperative period were uneventful and well tolerated. The patient was discharged home after eighteen days and well in follow up period.

[Esophagus preserving surgery--eversion and mucosal stripping]. / Postedna hirurgija jednjaka--everzioni i mukozni stripping.

The eversional stripping and esophageal mucosal stripping methods as standard procedures in the preserving esophageal surgery are presented in this paper. These procedures have indication limit and results are excellent in selected risk dependent group of patients. This review describes technique, indications and advantages of these techniques in comparision with conventional finger esophageal dissection.

Cystadenomas of the pancreas.

Cystadenomas of the pancreas are rare tumors. They represent about 10% of the pancreatic cystic masses. Several hundred cases seem to have been reported so far. These tumors appear as serous and mucinous. Over 13 years period (1983-1996) we treated 22 patients for cystadenoma of the pancreas. All patients were women. There were 6 serous and 16 mucinous cystadenomas. The average age in the serous group was 31 years (ranging from 23 to 42 years) and 43 years (ranging 17-64) in mucinous group. Two patients had tumor in the head, 20 others in the tail and body of the pancreas. The diameter of these tumors varied from 3.5 to 17.0 cm (average 9.6 cm). The leading symptoms were epigastric or left subcostal pain in 19 patients, palpable mass in 10, weight loss in 5, vomiting in 5, and melena in one patient. Tumor was accidentally found in a women undergoing abdominal operation for enteric fistula after hysterectomy. Serum amylase was moderately elevated in two patients. Diagnosis of pancreatic cystadenoma was proposed preoperatively in 16 patients (72.7%). In other cases, diagnoses of pancreatic cysts in 5 patients or hydatid cyst in 1 patient were made. An ideal operative removal (excision) was done in 7 patients, both excision of the tumor and splenectomy in 2, while distal pancreatectomy and splenectomy were carried out in 13 others. There was no mortality. One female patient developed left subphrenic abscess and left pleural effusion which were successfully treated by drainage and thoracocenthesis. One patient developed transient pancreatic fistula. All patients have been under close follow-up from 6 months to 13 years and all stayed symptom free so far.

[Sutures in biliopancreatic surgery]. / Sav u biliopankreaticnoj hirurgiji.

The most important element of surgical intervention is quality of the surgical stitch, meaning of surgical anastomosis. The importance of resorptive surgical stitch in the surgery of hepato-biliary system has been painted out, so that a possibility of delayed stricture and calculus's can be avoided. Principals of the reconstruction of extrahepatic biliary system have been shown together with the types of surgical suture material in the bilio-pancreatic surgery. Review of 486 bilio and pancreaticoenteric derivations or reconstructions in the period from 1989 until 1993 on the First Surgical Clinic is presented. A comparative study has been made comparing postoperative complications due to an anastomotic leak and the mortality in the groups of patients with the reconstruction of benign biliary strictures (119 pt's) and cephalic duodenopancreatectomy (44 pt's) with the other results from the world-wide instructions reported in the literature. In the group with benign biliary strictures temporary bile leakage reached 3.8% and operative mortality was 0.8%. In the group with Whipple operation 11.3% pt's had pancreatic, 4.5% pt's had biliary leakage and operative mortality was 4.5%. We can conclude that our results match the worldwide results concerning this problem.

[Cavernous hemangioma of the liver]. / Kavernozni hemangiomi jetre.

Over the last six years 8 patients with cavernous haemangioma of the liver were operated in our institute, of whom 7 women and 1 man, aged from 32 to 77 years average, 19.6 years. In two patients double haemangiomas of the liver were removed. So the number of resected haemangiomas was 10. The size of these haemangiomas was 2, 2, 3, 3.5, 6, 6, 6, 6, 6.5 and 16 cm respectively, average 5.7 cm. Diagnosis was established by ultrasonography, computed tomography, blood pool 99m-technetium-scintigraphy, laparoscopy and selective angiography. Indications for the operation were: palpable tumour and pain in 2 patients; suspected liver metastases secondary to colon cancer 7 years after right colectomy; suspicion to primary haematoma of the liver and suspicion to secondary liver tumour in a patient with a big tumour of the left ovary. Incidental ultrasonic finding of the liver tumour occurred in a patient with obstructive jaundice. In a female with Bartter's syndrome ultrasonography and explorative surgery were carried out in order to reveal endocrine tumour (reninoma), as well as an occasional finding during cholecystectomy. Various operative techniques were performed in these 5 patients: 3 left lobectomies, 1 segmentectomy of the V and the VI liver segments, and 3 atypical resections. The only postoperative complication in our series was a mild superficial variceal thrombophlebitis of the leg in one female patient which disappeared on conservative treatment. These 5 patients have been followed-up from 1 to 48 months (average 18 months), and were symptom-free, except the patient with Bartter's syndrome who stayed on treatment.

[Biliary ileus]. / Bilijarni ileus.

In the period 1946-1987 at the former Second Surgical Clinic of the Medical Faculty in Belgrade 25 patients with a biliary ileus were Surgically treated, 20 females (80%), and 5 males (20%), aged from 53 to 87 years, (mean 67 years). Six patients were decade, 7 in 7th, 9 in 8th, and 3 in 9th decade. In only 8 patients biliary calculosis had been confirmed earlier. Preoperative troubles in the Bowel Passage lasted 1-7 days, (mean 3 days), mostly as in incomplete gut occlusion. Preoperative diagnosis of the biliary ileus, using x-ray, was exact only in 3 cases (12%), while other remaining patients underwent Surgery diagnosed as ileus of the small bowel or acute abdomen. In 7 patients a stone obstructed the jejunum, in 6 ones its widpart and in 10 cases the terminal ileum. In 23 patients an enterotomy distally to the obstruction with an expulsion-extraction was done, in one patient a partial resection of the gut and in another patient a manual stone expulsion into the colon, with no enterotomy, was carried out, and after operation the stone was removed from the rectum. The Bilio-digestive fistula was never treated either the surgery itself, or later. Complications arised in 13 patients: wound infection in 11, deep thrombophlebitis in one and a pneumonia in two patients. An average hospitalization was 27 days, and all patients Survived.