[Diagnostic value of diffusion weighted imaging in assessment of malignant focal liver lesions].

INTRODUCTION: The study was designed to determine if there was a difference between apparent diffusion coefficient (ADC) values using diffusion weighted imaging (DWI) MRI technique between different malignant focal liver lesions. PATIENTS AND METHODS: The study included 63 patients with focal hepatic lesions: fourteen patients (22.2%) with hepatocellular carcinoma (HCC), 16 patients (25.4%) with hepatic metastatic colorectal tumors, 17 patients (26.9%) with cavernous haemangioma and 16 patients (25.4%) with hepatic cysts. MRI was performed with 1.5T scanner, using EPI sequence with ADC values being determined for all lesions based on three b values. RESULTS: ADC values were statistically different among the groups (F = 70.7, p < 0.01): HCC patients 1.11 +/- 0.29 x 10(-3) s/mm2, metastatic tumours 2.18 +/- 0.15 x 10(-3) s/mm2, haemangioma 2.22 +/- 0.32 x 10(-3) s/mm, cysts 3.08 +/- 0.03 x 10(-3) s/mm2. Furthermore, there was statistically significant difference between benign lesions (haemangiom and cysts, 2.36 +/- 0.43 x 10(-3) s/mm2), and malignant diseases (HCC and secondary tumors, 1.52 +/- 0.58 x 10(-3) s/mm2), t = 5,6, p < 0.01. CONCLUSION: DWI technique could be helpful in defining the focal liver lesions.

[Magnetic resonance cholangiopancreatography: diagnostic significance in malignant diseases of bile and pancreatic ducts].

Magnetic resonance cholangiopancreatography (MR CP) is a relatively new, noninvasive method in patients with pancreaticobiliary diseases, which is comparable to invasive endoscopic retrograde cholangiopancreatography (ERCP). One of the most common indications for MRCP is malignant obstruction of the bile and pancreatic ducts. Standard imaging protocol includes routine abdominal study followed by a sequence for MRCP adapted to each of the patients and site of the malignant process. MRCP is a simple to perform, does not exposure the patients to radiation, requires no anesthesia, is less operator dependent and allows better visualization of ducts proximal to an obstruction. Thus, during one examination only, it is possible to assess not only pancreaticobiliary system but also abdominal structures, which increases diagnostic value of MR and is therefore, optimal method in evaluation of these patients.

[Treatment of gastrointestinal hemorrhage manifestation induced by nonsteroidal anti-inflammatory agents]].

INTRODUCTION: The risk of upper gastrointestinal tract bleeding in the patients taking NSAID estimates 1% per year. Bleeding stops spontaneously in approximately 80% of all cases. Persistent and repeated bleeding (expecialy during the initial hospitalization) still represent the serious clinical problem. In this group of patients, mortality rate is between 6-10%, which in the USA counts 10-20000 patients per year. AIM OF THE STUDY: The purpose of this review is to update the current knowledge of the use of different therapeutic strategies in patients with NSAID induced upper gastrointestinal bleeding. RESULTS: Proton pump inhibitors (PPI) therapy is effective as a prevention of NSAID induced acidopeptic lesions, and also represents the first and best therapeutic option for the treatment of complications, such as upper gastrointestinal bleeding. In the last three decades use of early flexibile (diagnostic and therapeutic) endoscopy, agressive acidosupression (PPIs), and surgical treatment in restrictive indications, resulted in decreasing of the mortality rates from 25-35% to 6-10%. When PPIs and flexible endoscopy are not sufficient in the control of upper gastrointestinal bleeding, use of systemic hemostatic drugs could be taken into consideration. CONCLUSION: Multidisciplinary approach, precise diagnostic and therapeutic critearia would probably result in better outcome of patients with active upper gastrointestinal bleeding.

[Diagnosis of pericardial cysts: significance of cardiac magnetic resonance and literature review].

Pericardial cysts are uncommon and caused by an incomplete coalescence of fetal lacunae forming the pericardium. The paper presents two cases of pericardial cyst and literature review. The first is a case of a female patient with progressive dispnoa and spherical mass located in the right cardiophrenic angle on a chest x-ray. A pericardial cyst with low signal intensity was noted on T1w, high signal intensity on T2w in TSE (turbo spin echo) sequence on magnetic resonance images (MRI) which was suggestive of serous content. The patient underwent pericardial puncture and was thereafter free of symptoms. Histologic study of the cyst confirmed hydatid cyst diagnosis. Another patient is with echocardiographic evidence of cystic formation which was confirmed on MRI, with high signal intensity on SSFP (steady state free precession) sequence. The cyst was without septa and without communication with pericardial space. Since there were no significant hemodynamic changes, the patient is on regular follow up.

[Gastrointestinal stromal tumors (GIST) of the stomach as a cause of upper gastrointestinal bleeding].

Gastrointestinal stromal tumors (GIST) is the most common mesenchymal tumor of the gastrointestinal tract. GIST is currently defined as a gastrointestinal tract mesenchymal tumor containing spindle cells (less commonly epitheloid cells or rarely both) and showing CD 117 (c-kit protein) positivity in more than 95% of cases. Although they may arise throughout the gut, the commonest site are stomach (60-70%), small intestine (20-30%), colorectum (5%) and esophagus (up to 5%). Rarely, GISTs develop in the retroperitoneum, omentum or mesentery. GIST originates from the intestinal cell of Cajal (ICC). ICCs are located in and around the myenteric plexus and are thought to function as intestinal pacemaker cells. Historicaly, GIST were often misclassified as leiomyomas or leiomyosarcomas. Subsequently, it has been determined that GISTs have distinct ultrastructural features and immunophenotypical markers compared with smooth muscle and smooth muscle tumors. GIST predominantly occur in middle aged and older patients, with no significant difference in the sex incidence. Data from the recent population study suggest an incidence of about 10-22 cases per million persons per year. Clinical presentation of GIST varies widely, and depends on tumor size and location. GISTs that caused symptoms tended to be larger with an average size of 6cm versus 2cm for asymptomatic GISTs. Symptoms are most commonly related to mass effect or bleeding. GISTs can grow very large before producing symptoms. Commonest symptom of gastric GIST is manifest or occult bleeding. Abudant, life-threateting bleeding that require urgent surgery is rare. For patient with primary, localized, nonmetastatic GIST, complete surgical resection represents the only chance for cure. Lymhadenectomy is not necessary, because lymph node metastasis is very rare. The 5 year survival rate in patients with resected primary GISTs ranges from 48-65%. Conventional chemotherapy and radiation therapy is ineffective in the treatment of GIST. Imatinib mesilate (a tyrosine kinase inhibitor) was confirmed to be effective against metastatic or unresectable GISTs.

[Systemic hemostatic drugs].

Understanding the haemostatic changes is crucial in developing strategies for the management of haemorrhage syndroma. In recent years, the revised model of coagulation ("cell based" model) provided a much more authentic description of the coagulation process. Pharmacological intervention, especially desmopresin, antifibrinolytics (synthetics and nature) and increasingly recombinant activated factor VII are being used in prevention and therapeutically to control bleeding of variety etiologies. Skillfull surgery combined with blood saving methods and careful management of blood coagulation will all help in sucessfull haemorrhage prevention and treatment, and reduce unnecessary blood loss and transfusion requirements and its attendant risks. Among the all avalaible tests, the use of thromboelastography has allowed for more detailed dynamic assessment of the various steps of hemostasis.

[Iatrogenic perforations of the esophagus and hypopharynx--5 year experience at the Center for Esophageal Surgery]. / Jatrogene perforacije jednjaka i hipofarinksa--petogodisnje iskustvo Centra za hirurgiju jednjaka.

Iatrogenic perforations of the esophagus and hypopharynx are important problem, due to diagnostic difficulties, controversies about adequate treatment, and high morbidity and mortality rate. Incidence of iatrogenic perforations is from 50 to 75% of all perforations. In the period from April 1999. to April 2004, 15 patients with iatrogenic perforation of the esophagus and hypopharynx were treated at the Department of esophageal surgery, First University Surgical Hospital in Belgrade. In majority of patients iatrogenic perforation occured during endoscopic interventional procedure (endoscopic removal of ingested foreign body--10 pts, endotracheal intubation--2 pts, intraoperative iatrogenic perforation--2 pts, pneumatic dilatation--1 pt). Surgical treatment was performed in 12 (80%) pts and 3 (20%) pts were treated conservatively. Surgical approach was cervicoabdominal, thoracoabdominal and cervicothoracoabdominal in 9.1 and 2 pts, respectively. Among 12 operated pts, primary repair of the esophagus was performed in 5 pts, and esophageal resection or exclusion in 7 pts. Overall mortality rate was 13.3% (2 pts), in surgical group 8.3% (1 pt) and in conservatively treated group 33.3% (1 pt). Iatrogenic perforations of the esophagus and hypopharynx are diagnostic and therapeutic problem. Awareness of the possibility of esophageal perforation during instrumental manipulations and early diagnosis is essential for successful, individually adapted, and in most cases surgical, treatment.

[Surgical treatment of cardial carcinoma]. / Hirursko lecenje karcinoma kardije.

In the period from 1970 to 1996, in the Departmenf of Esophagogastric Surgery, Belgrade, Yugoslavia 562 have been operated with curative intent due to cardiac carcinoma. Since 1970 until 1985, in 182 patients a distal esophagectomy and proximal gastrectomy followed by eosphagogastro anastomosis had been performed. In the period between 1982 and 1996, a distal esophagectomy with total gastrectomy and radical or extended radical dissection and intrathoracic esophagojejuno anastomosis in 380 patients (192 hand sewn 3/0 interrupted sutures and 188 spapled anastomosis) had been performed. In our opinion for the majority of patients with advanced cardiac carcinoma distal esophagectomy and total gastrectomy, via the left thoracoabdominal approach, with D2 pancreas preserving splenectomy and dissection of lymph nodes in stations 16a1 and 16a2 is a surgical therapy of choice. Overall complications of such a procedure not differ in type and number from those after standard total gastrectomy and D2 dissection.

[Surgical strategy in the treatment of primary lymphoma of the stomach]. / Hirurska strategija u lecenju primarnog limfoma zeluca.

Primary gastric lymphoma has been traditionally accounted for only 1-7% of all malignancies of the stomach. During the period 1980-1996 in Department of Esophagogastric Surgery of University Surgical Hospital in Belgrade 41 patients have been operated due to primary gastric lymphoma. Radical surgery is the only therapeutic procedure in more then 45% of patients. It is also a safe procedure with specific complication rate less then 22%, and specific mortality rate less then 5%. In our experience, total gastrectomy with systematic lymphadenectomy is a therapy of choice in most patients with primary gastric lymphoma.

[Reconstruction of the hypopharynx and cervical esophagus using a free jejunal graft]. / Rekonstrukcija hipofarinksa i cervikalnog jednjaka slobodnim jejunalnim transplantatom.

Extensive malignant tumors of the hypopharynx and cervical esophagus continue to challenge surgeons in respect to both type and extent of resection as well as type of reconstruction. In the period between November 1st, 1996 and November 1st, 1998, at our Department, five patients have been operated due to squamocellular carcinoma of the hypopharynx using a free jejunal graft reconstruction method. The first free jejunal graft operation due to hypopharyngeal carcinoma, at the same time the first operation of this kind ever done in our Country, was performed on November 13th, 1998. There were 4 female and one male patient, average age 47.75 years. Disfagia for solid foods was a leading symptom in all patients (mean duration of 3.5 months) and was always accompanied with weight loss (average of 8 kg for two months). In all patients barium swallow, endoscopy, CT as well as intraoperative endoscopy was performed. Radical surgical procedure was always accompanied with the bilateral modified lympf node neck dissection. As a arterial donor vessel superior thyroid artery was used in all patients. As a venous drainage in three patients a external jugular vein was used and in two facial vein. Reconstruction using a free jejunal graft of approximately 25 cm long was performed in all patients creating upper, oropharingeal, anastomosis end to side and distal, esophageal, end to end (in only one patients side to end) using 3/0 apsorbable sutures. Mean duration of the operation was six hours. The postoperative course in all patients was uneventful. On the 9th postoperative day gastrografin and three days later barium swallow radiography was performed as a standard control study. Regular check ups were done on three, six, nine months, year and two years. On all controls all patients were symptom free and feeling well. It is our opinion that in the patients with isolated carcinoma of the hypopharynx due to low morbidity and mortality rate, free jejunal graft method is the surgical procedure of choice.

Paraoesophageal hernia repair with and without concomitant fundoplication.

There is currently no consensus as to whether an antireflux procedure should accompany surgical repair of paraoesophageal hernia. Forty consecutive patients with paraoesophageal hernia were studied. Surgery routinely included transabdominal hernia reduction, excision of the sac and crural repair. The addition of fundoplication was based on the presence of preoperative endoscopic evidence of oesophagitis. Twenty-three patients without endoscopic oesophagitis had no antireflux procedure whereas 17 with oesophagitis underwent concomitant antireflux surgery. Thirty-six patients were followed for 1-7 years. Patients without endoscopic oesophagitis had no postoperative reflux problems. All patients with oesophagitis who underwent fundoplication were improved or cured of reflux. The selection of patients for antireflux repair can satisfactorily be based on preoperative endoscopic findings.

Gastric foveolar hyperplasia in patients with cancer of the intact stomach.

The incidence of gastric foveolar hyperplasia, a reliable histological marker of bile reflux into the stomach, was evaluated in patients with cancer of the intact stomach. Lesions classified as foveolar hyperplasia were found in 17 of 32 gastric cancer patients and in seven of 30 controls. This difference was statistically significant (p < 0.02). Differences in the incidence of foveolar hyperplasia according to sex, tumor site, attendant chronic atrophic gastritis, and alcohol consumption were not significant, which lends support to the association of gastric cancer with duodenogastric reflux.

[Complications in esophagojejunal anastomosis]. / Komplikacije pri izvodenju ezofagojejuno anastomoza.

In the period between January 1, 1982 until December 31 1993, in the Center for Esophageal Surgery, Institute for Digestive Disease - 1 st Surgical clinic in Belgrade, 345 esophago-jejuno anastomosis (EJA) were performed. In 326 pt's EJA, with the Roux-en-Y reconstruction with the segment of the small intestine, was performed after a total gastrectomy due to a malignant disease of stomach or cardia and in 7 due to an extensive corrosive changes of the stomach. In 12 pt's a resection of the distal esophagus due to an undilatable stricture and the reconstruction with the short segment of the small intestine (Merendino) was performed. In all 345 pt's a terminolaternal EJA was performed. In 149 pt's EJA was done mechanically by staplers (e.g., the EEA instrument) and in 196 an interrupted two layer suture was performed. In 326 pt's (operated due to a malignant disease) complications occurred in 29 of them (8.89%) while in the group of patients with benignant disease only in 2 pt's or 10.52%. A dehiscention of EJA occurred only in the group of pt's with malignant disease. Comparing the way of performing EJA a higher percentage of anastomotic leaks was found in the group of hand sewn anastomosis (18/8.16%) while in the group with a stapler performed anastomosis anastomotic leak was found only in 7 pt's (4.69%). In two pt's where a stapler anastomosis was performed there was a hemorrhage from the anastomosis during the operation, and in 8 pt's or 5.36% an unsuccessful anastomosis using a stapler was performed. Overall mortality was 6.66% or 23 pt's. Due to anastomotic leak 13 pt's died (3.76%). In 5 pt's 4 to 14 months after the operation a stenosis of anastomosis developed on EJA that severely compromised EJA and needed further medical treatment. None of the pt's was reoperated.

Venous thromboprophylaxis in oesophageal cancer surgery.

In a retrospective study of 127 patients who underwent resection for oesophageal cancer without anticoagulant thromboprophylaxis, the incidence of clinically established postoperative deep vein thrombosis (DVT) was 1.6 per cent. In a prospective study the Sue-Ling DVT risk factor index was calculated for 53 consecutive patients with oesophageal cancer; the mean (s.d.) value was -4.4(3.5). For 29 patients who underwent resection the following policy of thromboprophylaxis was applied. Patients undergoing transthoracic oesophagectomy with risk score > -4 (four patients) and those undergoing transhiatal resection with risk score > -1 (four) received both anticoagulant and mechanical thromboprophylaxis; the remaining 21 patients received only mechanical thromboprophylaxis. No patient developed DVT after operation. There were no haemorrhagic complications in the group undergoing anticoagulant thromboprophylaxis. The selective approach, based on the Sue-Ling risk factor index and type of operation, spared 72 per cent of the patients operated on from undergoing anticoagulant thromboprophylaxis and produced favourable results in this small series.