Living unrelated donor kidney transplantation--a fourteen-year experience.

BACKGROUND: In countries without a national organization for retrieval and distribution of organs of the deceased donors, problem of organ shortage is still not resolved. In order to increase the number of kidney transplantations we started with the program of living unrelated - spousal donors. The aim of this study was to compare treatment outcome and renal graft function in patients receiving the graft from spousal and those receiving ghe graft from living related donors. METHOD: We retrospectively identified 14 patients who received renal allograft from spousal donors between 1996 and 2009 (group I). The control group consisted of 14 patients who got graft from related donor retrieved from the database and matched than with respect to sex, age, kidney disease, immunological and viral pretransplant status, the initial method of the end stage renal disease treatment and ABO compatibility. In the follow-up period of 41 +/- 38 months we recorded immunosuppressive therapy, surgical complications, episodes of acute rejection, CMV infection and graft function, assessed by serum creatinine levels at the beginning and in the end of the follow-up period. All patients had pretransplant negative cross-match. In ABO incompatible patients pretransplant isoagglutinine titer was zero. RESULTS: The patients with a spousal donor had worse HLA matching. There were no significant differences between the groups in surgical, infective, immunological complications and graft function. Two patients from the group I returned to hemodialysis after 82 and 22 months due to serious comorbidities. CONCLUSION: In spite of the worse HLA matching, graft survival and function of renal grafts from spousal donors were as good as those retrieved from related donors.

[Detection of free cancer cells in peritoneal cavity in patients surgically treated for gastric adenocarcinoma].

BACKGROUND/AIM: Peritoneal metastasis is a leading cause of therapeutic failure after an operative treatment of patients with gastric adenocarcinoma. Free cancer cells might induce or indicate an early peritoneal seeding with a subsequent peritoneal metastasis. The aim of this study was to determine the frequency of the presence of free cancer cells in the peritoneal cavity in the patients surgically treated for gastric adenocarcinoma, and its relation to certain clinical, operative and pathohistological paramethers. METHODS: Inside a period from April 2000, and April 2004, the total of 100 patients underwent intraoperative peritoneal lavage for cytological examination. Immediately after the laparotomy, 200 ml physiologic saline, heated to 37 degrees C, was introduced into the abdominal cavity, mannualy dispersed and collected from the region around the gastric tumor and the pouch of Douglas. The nucleated cell layer was smeared on four glass slides for every patient and dyed with May-Grünwald-Giemsa stain. The cytological findings were defined as positive or negative according to the presence of cancer cells. The frequency of positive cytological findings was compared to the location and the diameter of the cancer, pathohistological type of carcinoma, pathohistological stage of the disease, lymph node and the liver and/or peritoneal metastases and the type of surgical procedure. RESULTS: Free cancer cells were found in 24 (24%) of the patients, while in 76 (76%) of them cytological findings were negative. A statistically highly significant difference (p < or = 0.001) in the frequency of positive cytological finding was found between the groups of patients with and without cancer invasion of serosa, with cancer diameters > 5 cm and < or = 5 cm, in the stage of disease I, II and III, IV, with macroscopically present and without metastases, with re section and D2 lymphadenectomy and palliative procedure. Free cancer cells were statistically more frequently (p < or = 0.05) detected in the patients with lymph nodes metastases comparing to the patients with out lymph nodes involvement. The results of the univariate analysis showed that the cancer diameter > 5 cm, tumor invasion of serosa, pathohistological stage of the disease III and IV and macroscopically visible metastases were the most important risk factors for the free cancer cells detection. CONCLUSION: Peritoneal lavage cytology was shown to be a useful tool for the detection of the group of patients with greatest risk of peritoneal dissemination. The frequency of positive cytological findings was highly associated with the diameter of the tumor and the cancer invasion of serosa. Cytological examination of peritoneal lavage fluid improved the accuracy of staging and selection of patients who might have benefit from neoadjuvant chemotherapy.

[Indirect blast rupture of the pancreas with a primary unperforated blast injury of the duodenum].

BACKGROUND: To present a patient with an indirect blast rupture of the head of pancreas, as well as with a blast contusion of the duodenum following abdominal gunshot injury. CASE REPORT: A patient with the abdominal gunshot injury was submitted to the management of the injury of the liver, gaster and the right kidney in the field hospital. The revealed rupture of the head of the pancreas and the contusion of the duodenum were managed applying the method of Whipple. CONCLUSION: Indirect blast injuries require extensive surgical interventions, especially under war conditions.

[Tertiary blast injury to the intestines].

BACKGROUND: To present the first case of the tertiary blast injury to the intestine, and the tertiary blast injury in general. CASE REPORT: A parachutist of the Army of Serbia and Montenegro was injured when descended from the 1 200m height by parachute which did not expand. The force of stroke to the ground, caused the reactive transfer of energy and the subsequent blast injury to the intestine. After 24 hours, the secondary perforation of the small intestine, contusioned by the blast, developed which was the indication of explorative laparotomy. The resectioned small intestine showed the histologic characteristics of a blast injury, so the tertiary blast injury was diagnosed on the basis of these and of the mechanism of the injury. CONCLUSION: Tertiary blast injuries fall into the group of indirect blast injuries. The only difference between indirect injuries as compared to direct ones, is in the manner of inflicting, otherwise the traumatic mechanisms are alike, and include the transfer of the energy of stroke through the tissue of different density.

[Prolonged survival of a female patient with total pelvic exenteration].

BACKGROUND: To present a female patient who lived 5 years after total pelvic exenteration (TPE). CASE REPORT: The female patient underwent TPE due to retrovesicovaginal fistula as a consequence of locoregional irradiation after the operation for the malignoma of the vaginal part of the uterus. In the formation of Bricker conduit, the ureter antireflux was achieved by the application of the "tobacco sack muff" made of the intestines around the ureter. By the use of this technique, the occurrence of pyelonephritis, as the leading cause of death in such patients, was prevented. CONCLUSION: TPE is a hope for significantly prolonged survival of patients with advanced pelvic malignomas, or with a postirradiatiation fistula.

[Gangrene of the right colon after blast injury caused by abdominal gunshot wounds].

AIM: To present a patient with an indirect secondary non-perforating blast injury of the right colon following abdominal gunshot injury, which led to necrosis and the right colon gangrene, and was surgically managed. CASE REPORT: A 26-year-old male was shot in the abdomen by four projectiles causing the secondary indirect blast injury of the right colon that turned into gangrene after 24 hours. Two days after admission, laparotomy was performed, but the primary anastomosis was not done because of the stomach and pancreatic injury, and the resection of the colon with terminal ileostomy was done instead. Three months later, the reconstruction of the colon was performed using ileocolotransverso-terminolatetral anastomosis. CONCLUSION: Secondary blast injuries should be anticipated in gunshot injuries, and could be expected to any organs, particularly the air filled ones.

[Extended ankle and foot fasciotomy as an enhancement to the surgical treatment of patients with prolonged ischemia of the lower extremities].

AIM: To present the technique and efficacy of extended ankle and foot fasciotomy, as a surgical limb-salvage procedure associated with the successful revascularization after the gold interval. METHOD: A retrospective review of six patients at the age of 16- 79 years (mean 39) in the period from 1996 to 2003, treated with the extended ankle and foot fasciotomy. There were four males undergoing the delayed treatment of war injuries to the lower extremity, and two females with atherosclerotic occlusive disease (a. illiacae dex and a. poplitealis dex.). The average ishemic time in the wounded patients was 22 hours (range, 14-30 hours), and ischemic time in occlusive disease (range, 48-72 hours). Clinical signs, indications, surgical access and the technique of extended ankle and foot fasciotomy was reported. RESULTS: The obtained results were classified as early and late. There was no cases with lethal outcome. Incisional wounds closed 15 days after the intervention, using secondary suture or skin transplant sec. Thiersch. The satisfactory functional results were achieved in 4 of the patients, 1 had a small edema, while amputation was performed in 1 patient. CONCLUSION: In cases of prolonged foot ischemia with edema and paresthesia in the toes, extended ankle and foot fasciotomy should be performed as a surgical limb-salvage procedure.

[External transluminal drainage of the pancreatic duct due to fistula caused by post biopsy pancreatic necrosis].

BACKGROUND: Pancreatic fistulas are not frequent after the needle biopsy of the pancreatic head. The aim was to present a patient with this type of fistula who was managed using the surgical method never previously applied in our surgical practice. CASE REPORT: In our patient, pancreatic fistula appeared at the site of the needle biopsies due to the development of the necrosis. Since the conservative treatment with octreotide and the total parenteral nutrition were without result, we turned to the surgical treatment by placing a silicone prosthesis along the pancreatic duct into the duodenum, next through the Roux-en-Y flexure to provide the external drainage of a pancreatic juice. Postoperatively, applying the conservative treatment, pancreatic fistula disappeared, and a silicone prosthesis was removed three weeks later. CONCLUSION: The described surgical procedure can be successful i managing fistulas which occur after the pancreatic necrosis.

[Acute leg compartment syndrome after exertion].

A case of a 22-year old soldier, with a history of pain in the leg during heavy exercise, which desisted at rest, was presented. One day before admission, the patient had felt an extreme exertion-induced pain in his right leg which had not lessenned at rest. At the same time, the patient noticed persistent severe leg edema. On physical examination, the intracompartmental pressure was 62 mmHg (> 30 mmHg). The patient was urgently operated on, and fasciotomy according to Mubarak was used. At second surgery, the debridement of the muscles of the posterior group of the leg, and the evacuation of hemathoma from the anterior and lateral group of the right leg muscles were perfomed. Postoperative recovery was uneventful. Fasciotomy wounds were closed within 14 days of the surgery. The complete physical treatment was done. Follow-up examinations 1, 3, and 6 months afterwards were satisfactory. The soldier completed his compulsory military service without any sequelae. Laboratory results were normal. Overlooked, unrecognized or surgically untreated compartment syndrome can cause severe damage, including even the loss of the extremity.

[War, traffic and iatrogenic injuries of D3 duodenal segment]. / Ratna, saobracajna i jatrogena povreda D3 segmenta duodenuma.

BACKGROUND: Injuries of the duodenum at the level of aortomesenteric clamp (segment D3) are with a high incidence of death due to the development of fistula and peritonitis. In three successfully managed cases, we applied the biliary surgery method. CASE REPORTS: All three cases were with the injuries of D3 duodenal segment. The first patient suffered from the blast perforation of duodenum at the level of the aortomesenteric clamp which occurred at the 7th day after the injury. The second patient suffered from the duodenal injury caused in a traffic accident. The third patient suffered from an iatrogenic injury at the beginning of D3 duodenal segment inflicted during ureterolithotomy. The described surgical procedure included basically the suture to narrow the site of the injury, then lateroterminal anastomosis with the Roux-en-Y jejunal flexure and, finally, the placement of a silicone prosthesis starting from the duodenum through the site of injury and the Roux-en-Y out. Octreotide and the total parenteral nutrition were administered to the patients postoperatively. CONCLUSION: The use of the releasing silicone prosthesis in all three patients provided the repair of the site of the injury with anastomosed Reux-en-Y jejunum.