C-reactive protein in drainage fluid as a predictor of anastomotic leakage after elective colorectal resection.

BACKGROUND/AIM: C-reactive protein (CRP) is considered to be an indicator of postoperative complications in. abdominal surgery. The aim of this study was to determine the significance of serial measurement of CRP in drainage fluid in the detection of anastomotic leakage (AL) in patients with colorectal resection. METHODS: CRP values in serum and drainage fluid, respectively, were measured on the first, third, fifth, and seventh postoperative day (POD) in 150 patients with colorectal resection and primary anastomosis. The values obtained were compared between the groups of patient without complications of surgical treatment and those with AL. RESULTS: Clinically evident AL was observed in 15 patients--in two (4.2%) patients with left colonic surgery, and 13 (12.6%) patients with colorectal anastomosis. Mean values of CRP were higher in the patients with AL than in the patients without complications, both in serum and drainage fluid, with the most significant differences recorded on the PODs 5 and 7 (p < 0.001). Correlation analysis showed a positive correlation between serum and drainage fluid CRP levels in both groups of patients. Serum and drainage fluid CRP values on the PODs 5 and 7 are most important in the detection of AL. In 80% of patients with CRP values in the drainage fluid of 53 mg/L for the POD 5 and 42 mg/L for the POD 7 AL was observed. The method specificity was 77% for the POD 5, and 83% for the POD 7. All the patients with CRP values in drainage fluid above 108 mg/L on the POD 5 and 93 mg/L on the POD 7 had AL. CONCLUSION: Serial measurement of CRP in drainage fluid can reliably be used in the detection of AL in patients with colorectal resection. The most significant values obtained on the PODs 5 and 7 were positively correlated with the values registered in

Solitary extramedullary plasmacytoma of the duodenum and pancreas: A case report and review of the literature.

Introduction: The extramedullary plasmacytomas (EMPs) are rare tumors of plasma cell disorders which are rarely found in the duodenum. We presented a case of solitary EMPs involving the duodenum and pancreas successfully treated by surgical resection after failure of chemotherapy. Case Report: A 55-year-old female with previously diagnosed solitary EMP of the duodenum was admitted to our institution after failure of three cycles of vincristine, adriablastine, dexamethasone (VAD) chemotherapy regimen with an upper gastrointestinal obstruction. On admission computed tomography of the abdomen showed tumor in the region of the second part of duodenum and uncinate process of the pancreas with a complete duodenal obstruction. Intraoperatively a tumor formation was in the region of the second duodenal part, originated from the wall of duodenum with the total diameter of 7 x 5 cm, covering the entire circumference of duodenal wall leaded to a narrowing of duodenal lumen to the thigh gap with an upper gastrointestinal obstruction. Infiltration in the head of the pancreas and uncinate process were also found. The Whipple's procedure was performed but postoperative course was complicated by rapidly refilling chylous ascites which was resolved 4 days after the surgery. Conclusion: Each patient with gastrointestinal EMPs should be considered separately and in timely manner, thus adequate treatment could provide local disease control.

Diagnostic value of serial measurement of C-reactive protein in serum and matrix metalloproteinase-9 in drainage fluid in the detection of infectious complications and anastomotic leakage in patients with colorectal resection.

BACKGROUND/AIM: Postoperative infectious complications are one of the most important problems in surgical treatment of colorectal cancer (CRC), being present in up to 40% of patients. The aim of this paper was to establish the significance of serial measurement of C-reactive protein (CRP) in serum and matrix metalloproteinase-9 (MMP-9) in drainage fluid for the detection of infectious complications and anastomotic leakage (AL) in patients with colorectal resection. METHODS: CRP and MMP-9 values in serum and drainage fluid, respectively, were measured on the first, third, fifth, and seventh postoperative day (POD) in 150 patients with colorectal resection and primary anastomosis. The values obtained were compared between the patients without complicatons and those with surgical site and remote infections and AL. RESULTS: Surgical site infections (SSIs) were observed in 41 (27.3%), and remote infections in 10 (6.7%) patients. Clinically evident AL was observed in 15 (10/6) patients. In 82% of the patients with SSIs, serum CRP value on POD 5 exceeded 82 mg/L, with 81% specificity. AL was reported in 85% and 92% of the patients on PODs 5 and 7, respectively, with CRP values of 77 mg/L and 90 mg/L, respectively. The specificity was 77% for POD 5 and 88% for POD 7. All the patients with CRP values exceeding 139 mg/L on POD 5 had some of SSIs and/or AL. The mean values of MMP-9 were not statistically different between the group without complications (n = 99) and the group with AL (n = 15). CONCLUSION: Serial measurement of CRP is recommended for screening of infectious complications of colorectal resection. Patients with CRP values above 139 mg/L on POD 5 cannot be discharged from hospital, and require an intensive search for infectious complications, particularly AL. MMP-9 measurement in drainage fluid is not relevant in the detection of AL in patients with colorectal resection.

Giant esophageal fibrovascular polyp with clinical behaviour of inflammatory pseudotumor: a case report and the literature review.

INTRODUCTION: Esophageal fibrovascular polyps are rare, benign, intraluminal, submucosal tumor-like lesions, characterized by pedunculated masses which can demonstrate enormous growth. The most frequent symptoms are dysphagia, vomiting and weight loss. Fibrovascular polyps with long stalks can regurgitate into the airways and cause asphyxia. Esophageal inflammatory pseudotumor is extremely rare lesion accompanied with various systemic manifestations as fever, anemia and thrombocytosis. CASE REPORT: We presented a 29-year-old man complaining of a long-lasting fever and dysphagia. He was found to have huge pedunculated submucosal tumor of esophagus, surgically completely resected. Histopathological examination showed that this giant tumor, 24 x 9 x 6 cm, was a fibrovascular polyp. The postoperative course was uneventful. The preoperative fever, anemia and thrombocytosis disappeared and did not recur in the postoperative course. CONCLUSION: We reported a patient with giant esophageal pedunculated tumor with clinical manifestations of inflammatory pseudotumor and histopathological picture of fibrovascular polyp, that we have not found described in the literature before.

Parathyroidectomy for the attainment of NKF-K/DOQI™ and KDIGO recommended values for bone and mineral metabolism in dialysis patients with uncontrollable secondary hyperparathyroidism.

PURPOSE: The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI™) 2003 and Kidney Disease: Improving Global Outcomes (KDIGO) 2009 have established guidelines for the treatement of secondary hyperparathyroidism. This study evaluated the impact of parathyroidectomy to achieve recommended values for parathyroid hormone, calcium, phosphorus and CaxPO(4) product in dialysis patients with severe secondary hyperparathyroidism that is resistant to medical treatment. METHODS: This study included 43 consecutive patients who underwent parathyroidectomy for a severe form of secondary hyperparathyroidism (SHPT) that is unresponsive to medical treatment. The serum iPTH, calcium and phosphorus levels were measured prior to surgery, every morning after surgery for 5 days and on the first, sixth and eighth postoperative months. RESULTS: Following parathyroidectomy, a significant decline in iPTH values was observed in all patients; however, after the 8-month study period, only one of these patients achieved a serum iPTH concentration within the K/DOQI recommended target range. Unlike iPTH, targeting for calcium, phosphorus and CaxPO(4) at the last follow-up were 55.8%, 60.5% and 93%, respectively. These values indicated a significant improvement in comparison to preoperative percentages. In regards to the KDIGO recommended guidelines, the iPTH levels did not significantly change at the end of our study compared to preoperative values; however, calcium levels significantly declined and phosphorus levels significantly improved compared to preoperative values. CONCLUSIONS: Although the majority of patients fail to reach recommended iPTH values, parathyroidectomy remains a valuable tool to attain these NKF-K/DOQI recommendations for serum calcium, phosphorus and CaxPO(4) in dialysis patients with secondary hyperparathyroidism resistant to medical therapy. Parathyroidectomy was shown to be an inadequate intervention for achieving KDIGO recommendations.

Thyroidectomy with LigaSure.

PURPOSE: A new method for ensuring hemostasis during thyroid surgery has recently been introduced. This technique, electrothermal (LigaSure) and ultrasound blood vessel sealing, is still experimental. The aim of the present study was to evaluate the applications and efficacy of LigaSure by analyzing the duration of the surgery and the rate of complications of the surgical procedure. METHODS: A total of 23 patients who underwent the LigaSure operation (n(LS) group) were analyzed in a prospective nonrandomized/partly randomized clinical study, and were compared with patients who underwent treatment using the conventional (ligature) surgical technique. RESULTS: At our institutions, 187 patients were treated surgically for thyroid disease in 2006, and 23 of these patients were treated using LigaSure. The complication rate in the patients treated with LigaSure (n(LS): 4.3%) was lower than those who received conventional ligature surgery. However, given the small number of patients, this difference was not statistically significant (retrospective group n(1): 10.7%; nonrandomized group n(2): 9.8%; and randomized group n(3): 9.1%). The length of surgery in the LigaSure group (n(LS) = 65 ± 3 min) was significantly shorter (P < 0.001) compared with both nonrandomized (n(2) = 71 ± 6 min) and randomized (n(3) = 70 ± 4 min) patients who received a conventional ligature. CONCLUSIONS: The application of LigaSure using meticulous surgical technique provides a new option for a safe thyroidectomy. Moreover, the duration of the LigaSure procedure is significantly shorter, and there are fewer complications as compared with the classic surgical thyroidectomy technique.

The thyroid gland in works of famous old anatomists and great artists.

BACKGROUND: The thyroid gland has always been known, but its function was unclear for a long time. It has been thought to be a part of the larynx, protection of the larynx, a lubricant gland, an esthetic organ, and a buffer preventing quick afflux of blood into the head. The aim of this work is to bring out the thyroid gland in works of famous old anatomists and great artists, without valorization of its precisions and exactitudes. METHODS: The works of old anatomists and great artists are analyzed. RESULTS: There are presentations in works of anatomists such as: Rhazes, Avicenna, Mansur, Arderne, da Vinci, Vesalius, Casseri, Bidloo, Cowper, Morgagni, Haller, Gautier d'Agoty, Monro, Mascagni, Bell, Scarpa, Cloquet, Bourgery, etc. Also, there are artistic works with accentuation of thyroid gland, such as the works of: da Vinci, Botticelli, Dürer, Titian, Caravaggio, Rubens, Rembrandt, Manet, etc. CONCLUSION: Thyroid gland has been rarely presented in the works of old anatomists. Working as illustrators of anatomy, these great artists have had an invaluable importance for the development of anatomic knowledge, and some of their works are a subject of examination even in our time.

Tension pneumothorax, pneumoretroperitoneum, and subcutaneous emphysema after colonoscopic polypectomy: a case report and review of the literature.

BACKGROUND AND AIMS: Colonoscopic complications are not frequent. Cases with colon perforations without the presence of pneumoperitoneum are very rare, and those with the development of tension pneumothorax are even rarer. The aim of this article was to present a unique case of the colon perforation during colonoscopic polypectomy. CASE REPORT: We report a unique case of the colon perforation made between the two layers of the sigmoid mesocolon during colonoscopic polypectomy. The colon perforation had not been recognized during colonoscopic polypectomy, but the patient stayed at the hospital to be observed for the possible remitted bleeding after polypectomy. The colon perforation was followed by the development of the left-sided tension pneumothorax with massive mediastinum tending to move to the right, pneumoretroperitoneum, subcutaneous emphysema of the head, neck, and body, but without pneumoperitoneum. Tube drainage of the left pleural cavity was performed with release a great amount of air under pressure and then an urgent laparotomy when there was no free gas in the peritoneal cavity. After mobilizing the sigmoid colon, pneumoretroperitoneum and sigmoid colon perforation of 1.5 mm in diameter between two mesosigmoid layers were discovered. Partial sigmoidectomy was performed. A pathohistological examination verified a deepithelized area of 12 mm and a perforation of 1.5-mm diameter. The patient was dismissed as recovered 7 days after. CONCLUSION: The patient was well prepared for colonoscopy, without other general diseases, and operated on quickly after the perforation (within 2 h from the perforation), without any significant retroperitoneum contamination. These are the factors for a favorable outcome of the treatment.

[Buffon (1707-1788)].

The aim of this paper is to remember the great French naturalist Georges-Louis Leclerc, Count Buffon, as well as to point out his overall significance and work concerning medicine. Buffon's book The History of Nature, General and Particular, comprising 44 volumes, was the first systematized review of the contemporary knowledge of the history of nature, geology and anthropology, and the beginning of cosmology, palaeontology, ecology and numerous other sciences. The second volume is the most important for medicine discussing man. In its first part, Buffon presented the general knowledge concerning reproduction, nutrition, growth and development, then the formation and development of the foetus, while, in the second part, he discussed the nature of man including childhood, puberty, maturity (with an account of man), old age and death. Buffon made a valuable contribution to natural sciences and mathematics getting eternal glory as a naturalist, biologist, cosmologist and writer.

[Coexistence of Hashimoto's thyroiditis and papillary thyroidal carcinoma with papillary carcinoma of thyreoglossal duct].

BACKGROUND: Simultaneous presence of Hashimoto's thyroiditis and papillary thyroidal carcinoma in thyroidal gland with papillary carcinoma association in thyroglossal duct is quite rare. The questions like where the original site of primary process, is where metastasis is, what the cause of coexisting of these diseasesis present a diagnostic dilemma. CASE REPORT: We presented a case of a 53-year old female patient, with the diagnosis of Hashimoto's thyroiditis and symptoms of subclinical hypothyreosis and nodal changes in the right lobe of thyroidal gland, according to clinical investigation. Morphological examination of thyroidal gland, ultrasound examination and scintigraphy with technetium (Tc) confirmed the existence of nonhomogenic tissue with parenchyma nodular changes in the right lobe of thyroidal gland that weakly bonded Tc. Fine needle biopsy in nodal changes, with cytological analyses showed no evidence of atypical thyreocites. Hashimoto's thyroiditis was confirmed on the basis of the increased values of anti-microsomal antibodies, the high levels of thyreogobulin 117 ng/ml and TSH 6.29 microIU/ml. The operation near by the nodular change in the right lobe of thyroidal gland revealed pyramidal lobe spread in the thyroglossal duct. Total thyroidectomia was done with the elimination of thyroglossal duct. Final patohystological findings showed papillary carcinoma in the nodal changes pT2, N0 and in the thyroglossal duct with the presence of Hashimoto's thyroiditis in the residual parenchyme of the thyroid gland. After the surgery the whole body scintigraphy with iodine 131 (131I) did not reveal accumulation of 131I in the body, while the fixation in the neck was 1%. After that, the patient was treated with thyroxin with suppression-substitution doses. CONCLUSION: Abnormality in embrional development of thyroidal tissue might be the source of thyroidal carcinoma or the way of spreading of metastasis of primary thyroidal carcinoma from thyroid gland. The cause of this process is most probably a hereditary mutation in RET oncogenes.

[General and medical circumstances in Serbia prior to the Serbian Medical Society Foundation].

The aim of this paper is to critically summarize and present insufficiently known data on medical corps conditions within Serbia after the Second Serbian Uprising (1815) and before founding the Serbian Medical Society in 1872. By the middle of 19th century, there came the first educated doctors of medicine to Serbia, followed by the Serbian doctors from out of Serbia, and, very soon, the Serbian doctors of medicine. The first hospitals were opened shortly afterwards followed by a long process of formation of medical corps mainly due to the lack of understanding and poverty. The doctors, however, as European students, got the most important role in establishing the first professional and humanitarian associations. Proposed by Doctor Vladan Dordevic, the first Serbian Medical Society was founded in 1872, in the very same year as the German Society. At the same time, the Journal of the Serbian Medical Society (the Serbian Archives of Medicine) was launched and its first issue published in 1874. The Serbian Red Cross was founded in 1876. It was by founding of these societies that Serbia proved itself capable of keeping pace with the most developed European countries.