[Traumatic rupture of the right hemidiaphragm].

The right hemidiaphragm rupture, caused by blunt force, occurs rarely and often is overlooked because of immediate management of life-threatening injuries. Our paper presents 31-year-old female patient, admitted as emergency case due to traffic accident injuries. Physical examination revealed diminished respiratory mobility of the right hemothorax, along with the impaired respiratory sound to the right infrascapular aspect, diffuse painful sensitivity of the abdomen and limited mobility of the lower extremities. X-ray examination of the chest verified the tight hemidiaphragm elevation without any signs of bone structure fractures and hydro-pneumothorax. Computerized tomography of the abdomen and small pelvis showed the rupture of the right diaphragmatic cupola with the prolaps of the right hepatic lobe, sacral fracture and fracture of both ischial rami. The surgery verified the rupture of the right hemidiaphragm in transversal direction of about 10 cm long, with partial prolaps of liver to the right hemithorax. Surgical intervention included the insertion of thoracic drain and liver mobilization by severing the falciform ligament. The operation was completed by interrupted sutures of the right hemidiaphragm and hematomas in the retroperitoneum were incised. Postoperative course was uneventful, and oral nutrition was initiated on day 4. The patient was discharged 18 days after the surgery. Preoperative diagnostics, attentive intraoperative examination and early surgical treatment significantly reduce morbidity and mortality of patients with traumatic diaphragmatic rupture.

[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.

[Schwannoma of the gallbladder]. / Svanom zucne kesice.

Schwanomas of the biliary tract are very rare with about 55 reported cases. Schwanomas of the gallbladder are the rarest, probably with less then ten reported cases. We reported a 61 old woman in whom we did a cholecystectomy for a tumor of gallbladder 6.5 x 9 cm in diameter with a central softness which showed a histologic appearance of schwanoma. Ten years after surgery the patient is symptom-free and with no signs of recurrency.

[Recurrence of immunologic thrombocytopenic purpura due to hypertrophy of retained accessory spleens]. / Recidiv imunoloske trombocitopenijske purpure zbog hipertrofije zaostalih akcesornih slezina.

Idiopathic thrombocytopenic purpura is an autoimmune disease in which macrophages of reticuloendothelial system, mainly in the spleen, remove platelets covered by autoantibodies from circulation. By removing the spleen 60-80% of patients are cured. Partial remission is achieved in 10-20% cases. Very few patients do not react on splenectomy. Recurrency of idiopathic thrombocytopenic purpura in a splenectomized patient after already achieved complete remission, may be caused by hypertrophy of one or more of the retained accessory spleens. We present 3 patients, 41, 23 and 44 year old, in whom splenectomy for ITP had been performed 10, 3 and 11 years earlier. After full remission which lasted 10, 2.5 and 10.5 years a full recurrency of ITP took place with signs of severe thrombocytopenia and haemorrhagic syndrome. Using ultrasonography, computed tomography and scintigraphy accessory spleen/s, were discovered. By their removal, a full remission was achieved in all 3 patients, but full favorable effect appeared approximately three months after surgery during which period additional steroid therapy was necessary.

[Non-functioning tumor of the islets of Langerhans]. / Nefunkcionalni tumor Langerhansovih ostrvaca.

About 15% of tumors of Langerhans, islets do not cause any hormone induced syndrome although they sintetise and secrete one or more regulatory peptides. These tumors are most frequently localised in the head and tail of the pancreas. They are usually greater then 5 cm. In diameter and present with pain, jaundice, palpable mass and malaise, rarely with variceal bleeding due to compression of the splenic vein. About 50% of the tumors present with symptoms caused by metastases. We present a 51 year old women in whom during the investigation for paraumbilical pain, predominantly on the left side a tumor of the tail of the pancreas was discovered and subsequently surgically removed. Standard histology showed a neuroendocrine tumor. Immunohistochemistry showed generalised immunoreactivity with antibodies against chromographin A, neuron specific enolasa and glucagon in more then 95% of cells. Somatostatatin was coexpressed in more then 5% of cells, PP in rare scattered cells. No reactivity was found for the other hormone markers. Ten years after surgery the patient has no signs of tumor recurrency.

[Cholecystitis associated with milk of calcium] ]. / Holecistitis zbog kalcijumovog mleka.

Milk of calcium cholecystitis is a rare disease predominantely of adults. The term designates a pathologic accumulation of calcium carbonate in the gallbladder, much rarer in the common bile duct as well. The patient may be symptom-free. If present the symptoms may be very mild or as an acute biliary pain, transient jaundice and mild attack of pancreatitis. Calcium in the bile may be liquid or it may form a paste-like mass. Both may be seen on a plain X-ray of the abdomen. The stone or stones of calcium carbonate may be formed so that they may cause an obstruction of the gallbladder outflow tract or cystic duct or pass into the common bile duct or into the duodenum. [figure: see text] We present a 71 year old male who was admitted for inguinal hernia repair but in whom a mild hiperbilirubinaemia was found and then on ultrasonography a gallbladder stone was diagnosed. We performed a hernia repair as well as cholecystectomy and operative cholangiography which turn to be normal. Within an almost normal gallbladder a gray-whitesh paste-like mass was found composed of calcium carbonate. The postoperative recovery was uneventful and serum bilirubin become normal. Histology of gallbladder showed chronic nonspecific cholecystitis.

[Solid and cystic-papillary tumor of the pancreas]. / Solidni i cisticni-papilarni tumor pankreasa.

Solid and cystic-papillary tumour of the pancreas is a rare neoplasm. About 420 cases seem to have been reported as yet. It appears almost exclusively in young women, although it may appear in males in all ages. This is a tumour of benign or low malignant potential with vary rare invasion of surrounding tissues and organs. Metastases of the tumour are rare. Local recurrence after surgical excision is also rare. About 50% of patients have no symptoms. The others may have upper abdominal pain or palpable abdominal mass. Complications such as rupture, bleeding or secondary infection, are rare. The average size of the tumour is cca 10 cm in diameter. The tumour is more frequent in the body and tail of the pancreas. New imaging techniques make diagnosis of the tumour very easy, but exact diagnosis is based on histological findings. Surgical excision is the treatment of choice. We report on a 23-year-old woman with a two-year history of upper abdominal pain and occasional fever, in whom ultrasonographic and CT scan examinations revealed a well defined mass of 5 cm in diameter. The mass was excised with limited resection of the pancreas along with removal of the spleen which was adherent to the mass so that it could not have been saved. Histological findings established a solid and cystic-papillary neoplasm of the pancreas. The recovery was uneventful. The patient was symptom-free, with normal clinical findings and laboratory results.

[Vascular changes in the ocular fundus in patients with coronary artery disease]. / Vaskularne promene fundusa oka u bolesnika sa koronarnom arterijskom bolescu.

Confrontation of coronary arteriography, i.e. the exact invasive diagnostic method and the direct method of gaining an insight into the blood vessels of the fundus of the eye by the "in vivo" method was aimed at elucidating the fact to which extent the atherosclerotic changes in these two vessel systems were confronted. Changes in the blood vessels of the fundus, ECG changes and some of the risk factors were investigated in 52 patients who had undergone coronary arteriography. Changes in the sense of stenosing atherosclerosis of changed arteries were found in 38 patients and in 26 (68.4%) of them atherosclerotic changes in the fundus of the eye were also observed, while in 31 (81.5%) cases ECG changes were registered pointing to compromised coronary circulation. In 14 cases coronary arteriography showed the absence of atherosclerotic changes, while the positive finding obtained by ophthalmoscopy was confirmed only in one of them (7.1%). According to the results obtained, it was pointed out that the study of the fundus of the eye in addition to electrocardiogram and the existence of risk factors may serve as a reliable method in practice for the verification of atherosclerotic degree in general and ischaemic heart disease in particular in the framework of the atherosclerotic process.