Gastric tube ulcer perforating the pericardium after subtotal esophagectomy.

Subtotal esophagectomy with retrosternal transposition of the gastric tube to the neck was performed in a 62-year-old patient with squamous cell carcinoma of the proximal third of the esophagus. He developed a salivatory fistula in the early postoperative period that healed spontaneously. Five months later, the patient developed partial stenosis of the esophagogastric anastomosis which required recervicotomy and excision, after numerous failed dilatation attempts. Eighteen months later, the patient presented to the hospital for severe pain in the upper abdomen. Clinical work-up revealed pericardial perforation by the gastric tube ulcer necessitating emergent surgery and gastric tube removal. We present a patient who developed both early and late complications of subtotal esophagectomy with gastric tube transposition as well as a review of the literature.

Successful use of activated recombinant factor VII in life threatening bleeding after thoracic surgery.

We present three patients in whom life-threatening haemorrhage following lung resection was successfully managed using activated recombinant factor VII (NovoSeven). In one case, activated recombinant factor VII was the only therapy administered to manage bleeding, and in the two remaining cases, activated recombinant factor VII was administered after patients failed to respond to conventional therapy. All patients demonstrated effective haemostasis and improved coagulation parameters as a result of treatment with activated recombinant factor VII. Our experience with the clinical use of rFVIIa suggests that this agent may provide effective hemostasis following lifethreatening postoperative bleeding after major thoracic surgery. Despite these favorable results, randomized, placebo - controlled trials are needed to identify optimal treatment strategy, patient selection, and safety of treatment in patients with massive bleeding following major thoracic surgery.

Influence of oral hygiene on oral health of recruits and professionals in the Croatian Army.

OBJECTIVES: Good oral health of soldiers would decrease the number of urgent dental interventions and absences from training and the battlefield and would improve the security of the whole formation. This study shows the habits for maintaining oral health and the oral status of the examined population in the Croatian Army. METHODS: The data were obtained from examinations and questionnaires of 912 Croatian soldiers, 650 of whom were recruits and 262 professional soldiers of the Croatian Army land forces. RESULTS: The results showed that the oral health of the examined population was mostly bad, as a consequence of inadequate prevention of illnesses of the oral cavity associated with insufficient oral hygiene. The most common disease was dental caries (5.84 carious teeth per recruit and 2.71 per professional). Only 14 (1.53%) of 912 examinees had completely healthy teeth. Only one-third of the examinees had no bleeding when tested with a periodontal probe. Acute pain of odontogenic origin was present for 23.5% of examinees. Such oral health makes most of the soldiers unreliable for peace operations that would last >6 months, because it lowers their combat readiness. CONCLUSION: Oral hygiene and oral health are poor. Consequently, combat readiness is low because of the need for frequent dental interventions, which could further lead to absence from the field and appointed tasks. The results emphasize the need for obligatory regular check-ups to improve oral health in the Croatian Army.

[Impact of dental emergencies on combat readiness in Croatian Army]. / Utjecaj hitnih stomatoloskih stanja na borbenu spremnost pripadnika Hrvatske vojske.

AIM: The potential of dental emergencies to reduce combat readiness is a major concern of military planners. Dental fitness classification is the primary measure of a soldier's dental readiness. METHODS: The teeth and mouth of 400 soldiers, 200 of them recruits and 200 active duty military personnel, were prospectively examined. According to oral status, the subjects were divided into three classes: class 1, requiring no dental treatment or reevaluation within 12 months; class 2, oral condition not expected to result in dental emergency within 12 months, if not treated or followed up; and class 3, subjects requiring dental treatment to correct both their dental and oral health condition, which is likely to cause dental emergency during a 12-month period. RESULTS: The survey designated 18% of study subjects to class 1, 15.5% to class 2, and 66.% to class 3. Group 3 subjects had a considerably reduced combat readiness, because they may have needed treatment for some dental emergencies at any moment. CONCLUSION: It is concluded that recruits generally have inappropriate dental status when they present for military service. Although they have free dental care (except for prosthetics and orthodontics), professional soldiers also have rather poor dental status, which can reduce the possibility of providing due care for dental emergencies, thus adversely affecting their combat readiness.

[Anesthesia and perioperative management of patients with resection for esophageal carcinoma]. / Anestezija i perioperacijski postupak u resekcijskoj kirurgiji karcinoma jednjaka.

The current approach to the anesthetic procedure and postoperative intensive therapy after esophageal resection for esophageal carcinoma, as well as characteristic perioperative pathophysiological events are presented. The contributory factors of severe postsurgical morbidity are considered too. Esophagectomy is an extented procedure which includes laparotomy, thoracotomy and often cervicotomy, and carries a great surgical stress with a huge fluid shift. It is mostly performed in the aged population with a certain co-morbidity: malnutrition, compromized immune status, respiratory and cardiovascular diseases. Standardization of esophageal resection and reconstructive techniques together with the optimal perioperative management significantly reduce operative mortality. Preoperatively, the patients' nutritive, respiratory and cardiac status should be improved. Intraoperatively, beside adequate depth of anesthesia which enables the optimal metabolic response to surgical stress, the invasive hemodynamic monitoring with insertion of pulmonary artery catheter is of great importance. The aim is to ensure adequate tissue perfusion and oxygenation avoiding pulmonary overhydration at the same time. Postoperatively, important role has epidural analgesia, allowing proper breathing and coughing and routine usage of fiberbronchoscopy for clearance of pulmonary secretion. After resection there are several conditions which contribute to cough and swallow disturbances: bilateral vagotomy, the absence of upper and lower esophageal sphincters, transient aperistalsis of the substitute, sometimes a transient vocal cord paresis. All of these make patients prone to regurgitation and aspiration of duodenal and gastric juice. Currently, the pulmonary complications are the leading problems after this procedure, so their prevention and early treatment are the key tasks for the clinicians.

[Role of transthoracic echocardiography in evaluation of cardiac risk in thoracic surgery]. / Uloga transtorakalne ehokardiografije u procjeni kardijalnog rizika u torakokirurskog bolesnika.

BACKGROUND AND OBJECTIVE: It is not precisely defined which group of non-cardiac surgery patients should undergo transthoracic echocardiography in preoperative preparation. This study was prospectively performed to find out whether the routine use of echocardiography is justified in patients scheduled for lung resection, and to assess its role in cardiac risk evaluation. METHODS: Patients classified as ASA III who were identified as having minor or intermediate predictors of cardiac risk were included in the study. Based on this triage, 130 patients underwent transthoracic echocardiography. RESULTS: Intermediate index of increased perioperative cardiovascular risk was recorded in 36.2% and low index in 63.8% of patients. Preoperative anesthesiologic examination revealed some form of cardiac arrhythmia in 28.5%, symptoms of coronary disease in 25.4%; hypertension in 52.3%, and chronic obstructive pulmonary disease in 16.9% of patients. Transthoracic echocardiography showed the ejection fraction of 60% in 86.9% and of 40%-49% in only one patient. Left ventricular contractility was preserved in 96.2% of patients. Diastolic relaxation was weakened in 42.3% of patients. Mild mitral insufficiency was found in 29.2%; aortic stenosis in 1.5%, mild aortic insufficiency in 2.3%, mild pulmonary hypertension in 70.8%, and severe pulmonary hypertension in only 1.5% of patients. Pulmonectomy was performed in 26.9%, lobectomy in 62.3% and segmental tumor resection in 10.8% of patients. Only 26.2% of patients had peri- and postoperative complications: tachyarrhythmia and atrial fibrillation with rapid ventricular answer in 16.2%, hypotension 1.5%; hypertension in 2.3% and hypertension and arrhythmia in 1.5% of patients. Three (2.3%) patients died. None of our patients had Goldman's score higher than 25; according to Detsky index our patients belonged to 0-15 point group, class I, with the foreseen risk %. CONCLUSIONS: Transthoracic echocardiography is not justified in the routine preoperative preparation of thoracosurgical patients classified as ASA III with clinically minor and intermediate indexes of increased cardiovascular risk. It should be done in selected patients, primarily those that have history data and clinical picture consistent with major indices of an increased cardiovascular risk.