Clinical value of immunoscintigraphy in the rectal carcinomas: immunoscintigraphy of rectal carcinomas.

BACKGROUND/AIM: The aim of this study was to evaluate the clinical reliability of the immunoscintigraphy with radiolabeled monoclonal antibodies for the detection of metastases and recurrences of rectal carcinomas. METHODOLOGY: A total of 65 patients underwent immunoscintigraphy with radiolabeled monoclonal antibodies. Indication for that examination was suspicious rectal cancer or suspicious rectal cancer recurrence and/or metastases. RESULTS: The method proved to have 92.7% sensitivity, specificity 83.3%, positive predictive value 90.5%, negative predictive value 87.0% and accuracy 89.2%. There was a statistically significant relationship between immunoscintigraphy findings and rectoscopy findings (rs=0.415, p=0.013), as well as significant relationship between immunoscintigraphy findings and US findings (rs=0.332, p=0.001). Tumor marker levels were in positive correlation with findings of immunoscintigraphy (rs=0.845, p=0.001), especially raised CEA level (rs=0.816, p=0.004). Patients with higher CA19-9 level had higher Duke's stage (p=0.025). CONCLUSIONS: We can conclude that immunoscintigraphy can be helpful in the detection of metastases and recurrences of colon carcinomas.

Scintigraphic detection of colon carcinomas with iodinated monoclonal antibodies.

PURPOSE: The aim of this study was to evaluate the clinical reliability of the immunoscintigraphy with iodinated monoclonal antibodies for the detection of metastases and recurrences of colon carcinomas. METHODS: A total of 45 patients with colon carcinoma was investigated with gamma camera, after intravenous application of iodinated monoclonal antibodies. RESULTS: The sensitivity of the method was 90%, specificity 86%, positive predictive value 93%, negative predictive value 80% and accuracy 87%. There was statistically significant relationship between immunoscintigraphic and ultrasonographic (US) findings (p=0.005). Also, there was significant relationship between immunoscintigraphy and Dukes stage (p=0.019). Tumor marker levels were not significantly correlated with immunoscintigraphic findings (p<0.05). Significant difference was noted in patients with positive findings for malignancy on US and immunoscintigraphic findings (p=0.006), i.e. patients with positive findings for malignancy had more frequently immunoscintigraphic findings of malignancy. Correlation with other diagnostic procedures (rectoscopy, colonoscopy, CT) did not show significant correlations. CONCLUSION: We conclude that immunoscintigraphy can be helpful in the detection of metastases and recurrences of colon carcinomas.

Epidural analgesia and liver resection: postoperative coagulation disorders and epidural catheter removal.

BACKGROUND: The aim of this study was to quantify the duration and severity of postoperative coagulopathy in order to establish the optimal time for epidural catheter removal. METHODS: In a 2-year retrospective study, 140 consecutive patients underwent major liver resection. RESULTS: Epidural catheters were present in 123 patients (87.9%). Resections were: 33 (26.8%) right hepatectomy (with or without left metastasectomy), 9 (7.3%) left hemihepatectomy (with or without right metastasectomy), 37 (30.1%) trisectionectomy (extended hemihepatectomy) and 44 (35.8%) non-anatomical metastasectomy. Surgery was quantified by segments resected (4 [range: 1-7]). Vascular inflow occlusion was used in 65.6%. Ischaemic time was 26.5 min (range: 0-104 min). Platelet count fell postoperatively and was lowest on day 2 (205±72 10(9) L(-1)). There was a significant increase in prothrombin time, activated partial thromboplastin time and International Normalised Ratio (INR) postoperatively, peaking on day 2 (21.5±5.6 s, 37.9±5.8 s and 1.9±0.5, respectively). Changes persisted beyond day 6. Epidural catheters were removed on day 5 (1-11), with a protocol criterion of INR <1.2. Actual INR on day 5 was 1.49±0.36. CONCLUSION: Despite this, no epidural or spinal haematoma was recorded.

Determination of culprit lesion in patients undergoing elective percutaneous coronary intervention by myocardial perfusion imaging.

UNLABELLED: The aim of this study was to determine and localize culprit lesion by myocardial perfusion imaging (MPI) in cases of angiographically detected coronary narrowing >or= 75% of at least one coronary artery. MATERIAL AND METHODS: One hundred and thirty-two (132) patients with angiographically detected significant coronary narrowing (>or= 75% luminal stenosis of at least one major coronary artery) were studied. All the patients submitted MPI (99m)Tc-MIBI, with pharmacologic dipyridamole stress protocol with concomitant low level bicycle exercise 50W (DipyEX). We measured relative uptake (99m)Tc-MIBI for each myocardial segment using short-axis myocardial tomogram study. A 5-point scoring system was used to assess the difference between uptake degree in stress and rest studies for the same segments, and we created two indices: Sum reversibility score (SRS), Index of sum reversibility score (ISRS). RESULTS: A total of 396 vascular territories (2244 segments) were analyzed before elective percutaneous coronary intervention (ePCI). Overall sensitivity, specificity and accuracy using SRS were 90.2%, 87.5%, and 89.4%, with a positive predictive value of 94.1%. Overall sensitivity, specificity, and accuracy using ISRS were 94.4%, 90.6%, 93.2% and the positive predictive value was 95.7%. CONCLUSION: DipyEX MPI with the two indices created, SRS and ISRS, significantly improves sensitivity, specificity and accuracy in the determination and localization of culprit lesions in patients undergoing elective PCI.

Successful outcome after a technically challenging liver transplant during pregnancy.

Little is known about the implications of liver transplantation (OLT) during pregnancy. We report the case of a 26-year-old woman with cryptogenic familial biliary cirrhosis that decompensated rapidly. OLT was performed using the donor iliac vein for a retrogastric portal vein conduit to the superior mesenteric vein and the donor iliac artery for an infrarenal aortic conduit. During the latter anastomosis, a viable fetus was noticed. Both donor and recipient were cytomegalovirus positive. Postoperative ultrasound revealed a 13.5-week-old viable fetus. The patient received tacrolimus, azathioprine, and prednisolone. The pregnancy progressed normally with the vaginal delivery of a healthy male infant after 36 weeks gestation. Nineteen months later, both the mother and child were well. This case demonstrated that even technically difficult OLT during pregnancy can have a successful outcome, raising the question of whether transplant patients of childbearing age should be routinely tested for pregnancy.

Diagnostic value of ocular melanoma immunoscintigraphy.

PURPOSE: To estimate the diagnostic value of ocular immunoscintigraphy (ISG) in the differentiation of melanoma from other ocular tumors or lesions. PATIENTS AND METHODS: ISG was performed in 27 patients. Twenty-four patients were suspected of having ocular melanoma and 3 patients had previous eye enucleation for melanoma and were without recurrent disease. Monoclonal antibody (MoAb) 225.28S was administered intravenously and the patient's head was imaged with gamma camera after 5 minutes and after 5 hours collecting 500.00 counts per image. RESULTS: The diagnosis of malignant melanoma was established by clinical examination in 12 patients (10 of them were subjected to enucleation and histopathological confirmation). ISG was positive in 10 out of 12 patients (sensitivity 83%). Two patients with operated melanoma had negative scintigraphic result. Fifteen patients with non melanoma lesions had negative findings except one patient with haemangioma who had positive ISG. The specificity of ISG was 93%. CONCLUSION: ISG is a sensitive and specific diagnostic method for ocular melanoma. The reliability of the results depends on proper acquisition of data and interpretation of images, including comparison of both eyes and early and late images with contrast enhancement.

Fatal haemothorax following large-bore percutaneous cannulation before liver transplantation.

Percutaneous bypass catheters are routinely used for veno-venous bypass (VVBP) during orthotopic liver transplantation (OLT). The recognized risks include bleeding, injury of vascular and nerve structures and lymphatic leakage. We describe a case where there were difficulties during catheterization and the patient suffered a cardiac arrest on commencing VVBP. Post-mortem examination revealed the bypass catheter tip in the pleural space and a large right haemothorax. Possible mechanisms of vascular perforation and preventative measures are discussed.

[Combined spinal-epidural anaesthesia for urgent Hartmann's procedure].

A 46- year old patient without previous history of general anaesthesia was admitted for urgent Hartman's procedure. The suspected tumor of sigmoid colon caused the obstructive ileus with extreme abdominal distension and threatened colon perforation. After induction of anaesthesia and adequate muscle relaxation it appeared that endotrh ileus because of possible regurgitation and aspiration.

[Enteral nutrition and surgical patient]. / Enteralna ishrana i hirurski bolesnik.

Enteral nutrition can be applicated alone or in combination with parenteral nutrition. Enteral feeding should be applicated as early as possible in preoperative preparation or in postoperative period in respect of contraindications and everyday evaluation of patients. Immunomodulatory substances like arginine, 3-omega-fat acids, ribonucleic acid and glutamine are incorporated in "ready to use" solution for enteral feeding. Enteral feedings oral or via tubes are safe if some precautions are taken: like sitting position and control of feeding tubes position. Use of jejunostomy and promotility agents improved enteral feeding after major abdominal surgery and acute pancreatitis. Enteral feeding and immunonutrition improved postoperative course in reduction of hospital stay, incidence of postoperative complications especially infections. The aim of this review article is to validate pro and con for enteral nutrition in preoperative and postoperative course.

[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.

[Epidural analgesia in total gastrectomy--combination of bupivacaine with ketamine or fentanyl]. / Epiduralna analgezija za totalnu gastrektomiju--kombinacija bupivakaina sa ketaminom ili fentanilom.

The effects of intraoperative epidural administration of ketamine added to bupivacaine were compared with fentanyl added to bupivacaine in patients undergoing total gastrectomy. Prospective, randomized, double blind study was designed to compare: group F: 20 patients (pts) receiving 20 ml of 0.125% bupivacaine and 50 ug of fentanyl and group K: 20 pts in whom 20 ml of 0.125% bupivacaine was combined with 50 mg of ketamine. Pts received an epidural injection through peridural catheter introduced through either T7-8 or T8-9 interspinous space. Non invasive arterial blood pressure, heart rate and ECG were recorded every 5 mins. We measured supplementary fentanyl requirement, ephedrine consumption, first postoperative complain on pain, tracheal extubation time. The groups were comparable with regard to patients characteristics, operation and anaesthesia related factors. There were no difference between groups in mean intraoperative fentanyl requirements (F vs. K = 118.5 (122.5) ug vs. 122.5(122.5)ug) (p n > 0.05), in the duration of epidural pain relief (F vs. K = 393.72 (98.75)min vs.403.63 (111.41)min, in the tracheal extubation time (F vs.K = 52.31 (50.4) vs.46.75 (48.35) min), postoperative sedation score (F vs.K = 1.26 (0.73) vs.1.11 (0.32)) (p > 0.05). Significantly higher systolic blood pressure was measured in group K comparing with group F in 20, 75, 105, 120, 150 min (p > 0.05). Statistically significant more ephedrine was applied in F group (F vs.K = 0.88(1.76)ml vs.0.05(0.23)ml) (p > 0.05). There were no statistically significant differences between groups in heart rate during the operation. None of the pts complained of bad dreams or awakeness during operation. Both fentanyl and ketamine added to bupivacaine and given as a bolus provided good intraoperative analgesia in combination with general anaesthesia, minimal sensorimotor disturbance and early tracheal extubation. In our study fentanyl added to bupivacaine caused higher incidence of hypotension than ketamine added to bupivacaine.

[Importance of oximetry parameters in the detection of hypoxia in the early phase of septic shock]. / Znacaj odnosa oksimetrijskih parametara u otkrivanju hipoksije u ranoj fazi septicnog soka.

The routinely monitored variables in shock stages include: arterial pressure, heart rate, central venous pressure, pulmonary artery wedge pressure and cardiac index. With vigorous therapy it is possible to bring these values back into the normal range in both survivors and nonsurvivors. The therapeutic goal in septic shock stages is to maximize the values of cardiac index, O2 delivery (DO2) and O2 consumption (CO2). The aim of this study is to determine the relationship between O2 delivery and O2 consumption as an early sign of hypoxia. Fifteen patients with septic shock were treated in order to maximize the value of CI, DO2 and VO2. We compared the levels of these parameters between the survivors and nonsurvivors and found no significant differences after 24 hours. High levels of DO2 and VO2 do not exclude tissue hypoxia in the early stage of septic shock.

[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.

[Advantages and disadvantages of esophagogastroplasty in reconstruction of malignant and benign esophageal stenosis]. / Prednosti i nedostaci ezofagogastroplastike u rekonstrukciji malignih i benignih stenoza jednjaka.

Advantageous morphology, sufficient blood supply and good tissue quality predispose use of stomach for ideal substitute in subtotal and total esophagoplasty. Additional advantages are one act surgery and possibility of single anastomosis formation. In an eighteen years' time, since 1976., two hundred nine (209) patients were operated with use of esophagogastroplasty for malignancies and benign diseases of esophagus and hyphopharinx. The esophagogastric anastomosis is most common reconstructive procedure for esophageal and hyphopharingeal malignancies. Anastomosis on pharyngeal level was made in 13 pts., on cervical esophagus level in 168 pts. and on thoracic esophagus level in the rest of 28 pts. Overall postoperative morbidity was 25,36%. Most common complication was anastomotic dehiscence (18,66%), transplant necrosis occurred in 2% of pts., whereas stenosis of the anastomosis was observed in 4,78% of pts. Overall intrahospital mortality was 14,38%, while specific mortality (anastomotic dehiscence and/or transplant necrosis) was 10,04% (21 pts.), whereas nonspecific mortality (predominantly lung insufficiency) was 4,78% (10 pts.). Anastomotic dehiscence is major disadvantage of this method.

Salivary gland scintigraphy in patients with primary Sjögren's syndrome.

Methodology, interpretation and results of salivary gland scintigraphy in 33 patients with primary Sjögren's syndrome (pSs) are presented. Patients were divided in two groups: 14 patients with isolated pSs and 19 patients with pSs and extraglandulary manifestations. There was no correlation between scintigraphic findings and duration of disease, and between scintigraphic findings and presence of recurrent swelling of parotid glands. The damage of salivary glands, detected by scintigraphy, was more marked in patients with pSs and extraglandulary manifestations than in patients with isolated pSs.