Comparative Analysis of Transradial and Transfemoral Arterial Approach When Performing Diagnostic Coronary Angiography.

Background: The transfemoral (TF) arterial approach is still the most commonly used approach for performing diagnostic coronary angiography in most centers in the world as well as in Bosnia and Herzegovina. Recently, the transradial (TR) arterial approach has gained more and more supporters among interventional cardiologists. Objective: The aim of the study was to compare the duration of the procedure, the amount of delivered ionizing radiation, the amount of applied contrast agent, the frequency of procedural complications and patient comfort during coronary angiography performed via TR and TF arterial approach. Methods: The total sample of 240 respondents was divided into two groups in such a way that the first group consisted of 121 respondents who underwent coronary angiography using TR arterial approach, and the second group consisted of 119 respondents who underwent coronary angiography using TF arterial approach. The Mann-Whitney U test was used to verify the research objective. Results: The obtained research results showed that the duration of coronary angiography and the amount of radiation was greater when using TR arterial approach compared to TF approach. There is no statistically significant difference in relation to the amount of applied contrast medium and the frequency of complications between the two approaches. Periprocedural and postprocedural comfort was better in patents who underwent TR approach. Conclusion: The findings of this study show that diagnostic coronary angiography performed via the TR arterial approach is as safe for the patient as diagnostic coronary angiography performed via the TF arterial approach. With both approaches, there is no significant difference in the amount of contrast agent used nor in the frequency of complications. Procedure duration and radiation exposure are shorter when TF arterial approach i used, while patient comfort is better when the TR arterial approach is used.

Guidelines for Editing Biomedical Journals: Recommended by Academy of Medical Sciences of Bosnia and Herzegovina.

BACKGROUND: Enormous number of medical journals published around the globe requires standardization of editing practice. OBJECTIVE: The aim of this article was to enlist main principles of editing biomedical scientific journals adopted at annual meeting of Academy of Medical Sciences of Bosnia & Herzegovina (AMSB&H). METHODS: The evidence for writing this Guideline was systematically searched for during September 2020 in the PUBMED and GOOGLE SCHOLAR databases. The inclusion criteria were: original studies, systematic reviews, invited expert opinions, guidelines and editorials. The exclusion criteria were narrative reviews and uninvited opinion articles. The retrieved evidence was analyzed by members of the AMSB&H, then discussed at 2020 annual meeting of the AMSB&H and adopted by nominal group technique. RESULTS: In total 14 recommendations were made, based on A to C class of evidence. The editors should educate potential authors and instruct them how to structure their manuscript, how to write every segment of the manuscript, and take care about correct use of statistical tests. Plagiarism detection softwares should be used regularly, and statistical and technical editing should be rigorous and thorough. International standards of reporting specific types of studies should be followed, and principles of ethical and responsible behavior of editors, reviewers and authors should be published on the journal's web site. The editors should insist on registration of clinical studies before submission, and check whether non-essential personal information is removed from the articles; when essential personal information has to be included, an article should not be published without signed informed consent by the patient to whom these information relate. CONCLUSIONS: Principles of editing biomedical scientific journals recommended in this guideline should serve as one of the means of improving medical journals' quality.

Balkan Clinical Research Registry: Established by Academy of Medical Sciences of Bosnia and Herzegovina.

BACKGROUND: From 2013 the World Medical Association's Declaration of Helsinki explicitly requires pre-registration of a study involving human subjects. The registration gives a chance for improvement of design and avoidance of bias. OBJECTIVE: The aim of this article was to describe process of bearing decision to create regional registry of clinical studies for Balkan countries. METHODS: After finding relevant studies about research registries and designing the concept and structure of future regional registry an article was published in IJBH journal. The article was than used as basis for discussion at 2020 meeting of Academy of Medical Sciences of Bosnia and Herzegovina (AMSBH), and final decision was made by the Academy to create the research registry. RESULTS: Regional registry of clinical studies will be under the auspices of AMSBH and web-based, with the option of online registration of new studies. The data required to be entered in the moment of registration relate to key elements of research plan: topic, variables, sample, type of the study and the study population. After applying for registration of a clinical study, the authors will soon receive the review made by the AMSBH expert committee. The application could be accepted, rejected or returned for major or minor revision. After an application is accepted, it will be deposited in the searchable database and given the registration number. CONCLUSION: The AMSBH's decision to create the regional registry of clinical studies will satisfy needs of researchers from Balkan countries in the first place, who share cultural and lingual similarities. It will also help with increasing standards of clinical research in the region.

Activation and Repassivation of Stainless Steels in Artificial Brines as a Function of pH.

When planning oil wells with stainless steel components, two possible reasons for depassivation have to be considered-chemical depassivation caused by acidizing jobs and mechanical depassivation caused by various tools and hard particles. The study explores conditions causing chemical activation of investigated steels and circumstances under which repassivation occurs after activation. The main focus of the study is to determine, how quickly various steels can repassivate under different conditions and to find pH values where repassivation will occur after depassivation. The investigated steels were ferritic (martensitic or bainitic) in the cases of 13Cr, 13Cr6Ni2Mo, and 17Cr4Ni2Mo, austenitic in the case of 17Cr12Ni2Mo, and duplex (austenitic and ferritic) in the case of 22Cr5Ni3Mo. Potentiodynamic experiments were employed to obtain electrochemical properties of investigated steels, followed by immersion tests to find ultimate conditions, where the steels still retain their passivity. After obtaining this information, scratch tests were performed to study the repassivation kinetics. It was found that repassivation times are similar for nearly all investigated steels independent of their chemical composition and microstructure.

Comparison of Results Classical and Eversion Carotid Endarterectomy.

INTRODUCTION: Atherosclerosis blood vessels, be it on extra-cranial or intra-cranial circulation, the most common cause of incidents such as cerebro-vascular insult (ICV). Carotid endarterectomy (CEA) is a preventive operation to reduce the risk of stroke and it can be performed by eversion carotid endarterectomy (E-CEA) or a classical carotid endarterectomy (C-CEA). The aim of this study was to investigate the influence of the used techniques in basic perioperative results and the incidence of postoperative complications. MATERIALS AND METHODS: It was retrospective-prospective study that involved 173 patients, with carotid stenosis, who underwent CEA, in the period of time December 2013 till December 2016. Subjects were divided into two groups in respect of technique: 90 patients were treated with E-CEA and 83 patients were treated with C-CEA. RESULTS: Between two groups revealed a significant difference in favor of the patients from group E-CEA in the length of the surgery (92.56 ± 29.11 min. vs. 104.04 ± 18.01 min., P = 0.000), the time of clamping the carotid arteries (11.83 ± 1.81 min. vs. 23.69 ± 5:39 min., p = 0.000), the amount of post-operative drainage (25.33 ± 24.67 ml. vs. 36.14 ± 14:32 ml., p = 0.001), time spent in the intensive care unit (± 25.43 vs. 13:51 hours 34.54 ± 35.81 hours, p = 0.000), and the length of stay (4.60 ± 0.90 days vs. 5:42 ± 1.80 days, p = 0.001). In the patients of the group E-CEA, fewer number of individual postoperative complications without statistical significance: ICV (2.2% vs. 4.8%, p = 0.351), cardiac arrhythmia (2.2% vs. 4.8%, p = 0.351), transitory ischaemic attack (TIA) and cognitive disorder (2.2% vs. 7.2%, p = 0.117), mortality (1.1% vs. 1.2%, p = 0.954); and the total number of postoperative complications was significantly less in the same patients (7.77% vs. 18.7%, p = 0.042). CONCLUSION: The results of this study clearly indicate that operating techniques affects the specified monitored outcomes of vascular treatment of carotid arteries in favor of E-CEA technique. It would be ideally that the conclusions of this study contribute to broader use of E-CEA in treatment of carotid stenosis.

Surgical coronary revascularization on-pump versus off-pump in patients with stenosis of the main tree of the left coronary artery and carotid stenosis.

OBJECTIVE: The aim of this study was to show perioperative complications of CABG procedure with and without cardiopulmonary bypass (CPB) in patients with combined coronary and carotid disease. PATIENTS AND METHODS: This retrospective survey included patients with left main stenosis greater than 50% and carotid stenosis over 50%, who had undergone CABG without carotid endarterectomy at the BH Heart Centre, from May 2009 to May 2014. The patients were divided into two groups according to the surgical method used. Group A consisted of 50 patients who underwent surgery without CPB and the second group of 50 patients with CPB, conformed according to gender, ejection fraction values, EuroSCORE and the number of bypass grafts performed. RESULTS: Analysis of the basic results indicates significant differences between the groups in the time spent on a respirator or time in the ICU, the amount of postoperative bleeding or compensated blood, as well as subsequent complications. The overall incidence of neurological complications showed a difference in the observed groups. CONCLUSION: With ever easier technical performance, complete planned revascularization and the quality of performed grafts, the conditions have been created for a comparative analysis. According to the results we can say that CABG without CPB has a number of advantages over the other method, in patients with the combined disease.

Time of Occurrence and Duration of Atrial Fibrillation Following Coronary Artery Bypass Grafting.

INTRODUCTION: Dilatation of the left atrium and left ventricular diastolic dysfunction (DDLV) according to recent studies has significance in the occurrence of postoperative atrial fibrillation (AF), stroke and death. Authors of some studies found no relationship between these parameters and atrial fibrillation. OBJECTIVE: this study is to determine the time of occurrence and duration of atrial fibrillation in patients after surgical revascularization (CABG) due to the presence of left ventricular diastolic dysfunction and left atrium dilatation and identify the most significant predictors of incident AF. METHODS: Prospective study included 116 patients undergoing surgical myocardial revascularization followed from admission to discharge. The study was conducted at the Special Hospital "Heart Center BH" Tuzla for a period of one year (March 2011/2012 g.). For all patients was performed preoperative ultrasound examination, especially parameters of diastolic function of the left ventricle and left atrium volume index (LAVi), as the best parameter sized left atrium, and the postoperative occurrence of certain AF and day occurrence, duration in hours, the number of attacks. To assess whether an event occurred or not was used logistic regression, and the effect of time on the event of interest is analyzed by Cox 's regression hazard parallel. RESULTS: 75.9 % of patients had DDLV, and 91.4 % were hypertensives, 12.9 % from the previous stroke (ICV) and 42.2 % diabetics (DM), 14 % with COPD. The average age of patients was 61.41 ± 4.69 years. In both groups was 32.8 % women and 67.2 % men. LAVi preoperative values were significantly higher as DDLV greater degree. In patients with DDLV and higher values LAVi risk of AF is higher, the greater the length of AF and significantly higher number of attacks FA. Early occurrence of atrial fibrillation and its longer duration in function with increasing LAVi a marked increase in the value LAVi have the greatest hazard for the early appearance of atrial fibrillation. As a result of analysis of the most significant predictors of AF are DDLV and LAVi. CONCLUSION: Postoperative atrial fibrillation occurs earlier and lasts longer in patients with DDLV and elevated left atrial volume index especially LAV > 36ml/m(2). LAVi has the best explanation of the function of hazard occurrence of atrial fibrillation after CABG.

Importance of Full-Length Scan of Arterial Grafts in Coronary Artery Bypass Grafting.

Cardiac ischemia after coronary artery bypass grafting is often caused by graft occlusion. Short- and long-term graft patency is related to the quality of the surgical technique during harvesting and anastomosis. Transit time flow measurement is a recognized technique for the quality control of grafts but may not rule out structural abnormalities in the conduits, which can cause graft occlusion. This article reports on two cases of suspected intra-arterial dissection of the left internal mammary artery despite satisfactory flow measurements. Routine ultrasound scanning of arterial conduits is helpful in distinguishing dissection and hematoma in the graft conduits.

Operative treatment of combined aortic stenosis and coronary artery disease.

INTRODUCTION: The aortic valve replacement is a standard operating procedure in patients with severe aortic stenosis. Structure of patients undergoing surgery ranges from young population with isolated mitral valvular disease to the elderly population, which is in addition to the underlying disease additionally burdened with comorbidity. One of the most commonly present factors that further complicate the surgery is coronary heart disease that occurs in, almost, one third of patients with aortic stenosis. The aim is to compare the results of surgery for aortic valve replacement with or without coronary artery bypass graft (CABG). PATIENTS AND METHODS: From August 2008 to January 2013 in our center operated on 120 patients for aortic stenosis. Of this number, 75 were men and 45 women. The average age was 63.37 years (16-78). Isolated aortic valve replacement was performed in 89 patients and in 31 patients underwent aortic valve replacement and coronary bypass surgery. Implanted 89 biological and 31 mechanical valves. RESULTS: Patients with associated aortic stenosis and coronary artery disease were more expressed symptomatic symptoms preoperatively to patients with isolated aortic stenosis who were on average younger age. Intra-hospital morbidity and mortality was more pronounced in the group of patients with concomitant aortic valve replacement and coronary bypass surgery. Morbidity was recorded in 17 patients (14.3%) in both groups, while the mortality rate in both groups was 12 patients (10.1%). CONCLUSION: Evaluation of preoperative risk factors and comorbidity in patients with aortic stenosis and coronary artery disease contributes to a significant reduction in intraoperative and postoperative complications. Also, early diagnosis of associated coronary artery disease and aortic stenosis contributes to timely decision for surgery thus avoiding subsequent ischaemic changes and myocardial damage.

Surgical treatment of left ventricular pseudoaneurysm.

INTRODUCTION: Left ventricular pseudoaneurysm is a rare condition because in most instances ventricular free-wall rupture leads to fatal pericardial tamponade. Rupture of the free wall of the left ventricle is a catastrophic complication of myocardial infarction, occurring in approximately 4% of patients with infarcts, resulting in immediate collapse of the patient and electromechanical dissociation. In rare cases the rupture is contained by pericardial and fibrous tissue, and the result is a pseudoaneurysm. The left ventricular pseudoaneurysm contains only pericardial and fibrous elements in its wall-no myocardial tissue. Because such aneurysms have a strong tendency to rupture, this disorder may lead to death if it is left surgically untreated. CASE REPORT: In this case report, we present a patient who underwent successful repair of a left ventricular pseudoaneurysm, which followed a myocardial infarction that was caused by occlusion of the left circumflex coronary artery. Although repair of left ventricular pseudoaneurysm is still a surgical challenge, it can be performed with acceptable results in most patients.

Surgical treatment of left ventricular pseudoaneurysm.

INTRODUCTION: Left ventricular pseudoaneurysm is a rare condition because in most instances ventricular free-wall rupture leads to fatal pericardial tamponade. Rupture of the free wall of the left ventricle is a cata-strophic complication of myocardial infarction, occurring in approximately 4% of pa-tients with infarcts, resulting in immediate collapse of the patient and electromechanical dissociation. In rare cases the rupture is contained by pericardial and fibrous tissue, and the result is a pseudoaneurysm. The left ventricular pseudoaneurysm contains only pericardial and fibrous elements in its wall-no myocardial tissue. Because such aneurysms have a strong tendency to rupture, this disorder may lead to death if it is left surgically untreated. CASE REPORT: In this case report, we present a patient who underwent successful repair of a left ventricular pseudoaneurysm, which followed a myocardial infarction that was caused by occlusion of the left circumflex coronary artery. Although repair of left ventricular pseudoaneurysm is still a surgical challenge, it can be performed with acceptable results in most patients.

Surgical revascularization in elderly patients with and without cardiopulmonary bypass.

UNLABELLED: The number of patients undergoing coronary artery bypass grafting (coronary artery bypass grafting-CABG) older than 70 years is increasing. Cardiac surgeons are investigate applicability of alternative and less invasive methods such as surgery without the use of cardiopulmonary bypass (CPB). The aim of this study was to compare the peri- and postoperative results of CABG in elderly patients operated with and without CPB. PATIENTS AND METHODS: The study included subjects older than 70 years, who underwent coronary bypass surgery at the BH Heart Center Tuzla in the period from August 2008 to August 2010, divided into two groups. Group A consisted of 50 patients operated without CPB, group B 50 patients operated with CPB, adjusted by sex, left ventricular ejection fraction values, EuroSCORE, and the number of bypass grafts was made. RESULTS: In the group treated without the use CPB there were significantly lower values of the time-duration of mechanical ventilation, length of stay in the Intensive Care Unit (ICU), the amount of postoperative bleeding and blood recovered, the length of hospital stay, levels of serum creatinine, C-reactive protein and creatine kinase MB fraction. CONCLUSION: CABG without the use of CPB has a number of advantages over the method with CPB in elderly patients, which is evident from the lower values of renal and inflammatory parameters and markers of myocardial lesion, less time spent on a ventilator, shorter length of stay in the ICU and total hospitalization time, less postoperative bleeding and blood transfusion.

Comparison of transperitoneal and retroperitoneal approach in aorto iliac occlusive disease.

INTRODUCTION: Despite the fact that the transperitoneal approach (TP) is most widely accepted approach to the aortic surgery because it is simple, fast, and provides good exposure of the abdominal cavity and vascular structures, lately have been increasingly advocated as an alternative retroperitoneal (RP) approach in order to avoid entering peritoneal sac, achieving lower physiological trauma and faster establishment of gastrointestinal function. OBJECTIVE: The aim of this study was to compare the basic peri and postoperative results of TP and RP approaches in the surgical treatment of AIOD. PATIENTS AND METHODS: The study included 114 patients with aortoiliac occlusive disease (AIOD) that underwent surgical treatment at the Department of Vascular Surgery, Clinical Center University of Sarajevo from January 2010 until December 2012 year. In view of the surgical technique used subjects were divided into two groups. Group A consisted of 57 patients on who had been used RP approach, and group B 57 subjects with TP used approach. RESULTS: In patients from group A were observed significantly lower values: the length of operation (201.66 +/- 43.9 minute vs. 267.36 +/- 47.57 min, p < 0.001), amount of postoperative drainage (56.14 +/- 55.5 ml versus 130.71 +/- 92.34 ml, p < 0.001), length of stay in the intensive care unit (ICU) (1.10 +/- 0.36 days versus 2.46 +/- 1.25 days, p < 0.001), time required for the restoration of gastrointestinal motility (4.38 +/- 5.59 versus 1.05 days +/- 1.19 days, p < 0.001), length of hospitalization (9.26 +/- 1, 95 +/- 11 days versus 1.96 days, p < 0.001), costs of hospitalization (2394.98 +/- BAM 346.67 versus 2933.72 +/- 428.10 BAM, p < 0.001). Analysis of the incidence of postoperative complications (8 vs. 7 complication complications, p > 0.05) and mortality (3 versus 3, p > 0.05) showed no statistically significant difference between the analyzed groups. CONCLUSION: RP approach in vascular reconstructive surgery in AIOD offers better postoperative results when compared to TP approach.

Bloodless off pump coronary artery bypass grafting treatment of choice for Jehova's witness patients.

Jehovah's witnesses (JW) belong to a religious group refusing to accept blood transfusion Surgical treatment remains a challenge in this subset of patients. From 1945, JW introduced a ban on accepting blood transfusions, even in life-threatening situations while autologous blood must also be refused if it is predeposited-thus excluding preoperative autodonation. However, autologous blood is acceptable if it is not separated from the patients' circulation at any time. The invasive nature of coronary artery bypass grafting (CABG), the associated decrease of body temperature and the use of cardiopulmonary bypass (CPB) are major reasons for increased blood loss and high incidence for blood transfusions during and after this procedures. Allogenic blood transfusions are often given and considered necessary in such operations, in spite of increased mortality, morbidity and major adverse outcomes resulting from transfusion. Reduction in the use of blood products should therefore be a general desire for every patient due to the associated risk factors. The evolution of less invasive cardiac surgical approaches, such as CABG without CPB (OPCAB) may contribute to a further reduction of blood transfusion and although these minimally invasive techniques may benefit every patient, they might be particularly valuable for JW. In this report, we present our initial experience in JW patient undergoing OPCAB and the way to use patient blood management for improved surgical outcome in such patient.

Frequency of superficial and deep vein thrombosis in patients with variations of superficial veins of lower extremities.

UNLABELLED: Anatomical variations of veins often play a crucial role in formation of thrombotic changes in superficial and deep veins of lower extremities. THE AIM of this study was to determine the frequency of the dominant type of the lower extremity superficial veins, and to determine the eventual influence of such variations to the formation of superficial and deep vein thrombosis (DVT). MATERIAL AND METHODS: The sample used in this study consisted of 180 patients subjected to ascedent contrast phlebography of lower extremities. The total sample was divided into following groups: patients with and without variations of the lower extremity superficial veins. RESULTS AND DISCUSSION: Dominant type of the superficial veins (without variation) consisted of 97 patients (53.89%), while the rest of 83 patients showed some kind of anatomical variation (46.11%). The most frequent variation was the duplicated form ofv. saphena magna in 53.85%, while this procentage in women was 57.89%. Most frequent variations of duplicated v. saphena magna were: simple duplicated form, closed loop form, branching form and combined form. Topographical variation of saphenopopliteal junction besides fossa poplitea in the group of men showed procentage of 53.85%, while in the group of women that value accounted 63.16%. CONCLUSION: The percentage of varicose veins was more frequent in men and women without variations, but deep vein DVT showed higher frequency in patients with anatomical variations of superficial veins of lower extremities.

Aorto-caval fistula as a complication of ruptured infrarenal aortic aneurysm.

We present a case of 71 year old man operated in our clinic for ruptured abdominal aneurysm complicated with aorto-caval fistula, which was revealed during the surgery and successfully repaired by direct sutures within the aorta. This is the first record of the aorto-caval fistula that was so far noticed in our clinic. Urgent surgery and repair of the defect conneting aorta and vena cava by direct sutures within the aorta followed by ruptured aneurysm repair with tube graft is only way of treatment. Despite its infrequent occurrence, aorto-caval fistula should always be considered in any case of ruptured abdominal aneurysm.

Coronary bypass grafting without use of cardiopulmonary bypass for dextrocardia.

Dextrocardia is a condition in which the heart is pointed toward the right side of the chest instead of normally pointing to the left. The rate of atherosclerotic heart disease in subjects with this condition is similar to that of the general population. We present a patient with situs inversus totalis with dextrocardia who underwent coronary artery bypass grafting without use of cardiopulmonary bypass (OPCAB). A 74-year-old man who was known to have dextrocardia with situs inversus was admitted to the hospital because of angina. Coronary angiography was performed and showed ostial occlusion of the left anterior descendng artery (LAD) unsuitable for percutaneous coronary interventions but collatereralised from the right coronary artery. Patient underwent OPCAB under general anestesia. Right internal mammary artery was anastomosed to LAD on the beating heart with the surgeon standing on the right side of the patient. The patient's post-operative course was uneventful, and he was discharged on the 6th postoperative day in good condition. Performing OPCAB surgery is not technically more demanding, and present no unusual challenge on patients with dextrocardia.

Minimally invasive repair of the mitral valve: technological and clinical developments.

The present article will review new technology in the invasive approach to mitral valvular disease. Mitral valve pathology continues to present an important challenge to the cardiac surgeon and interventionalist. From the early days of closed mitral valvular commisurotomy, a number of new approaches to this valve have been developed. Mitral stenosis was previously approached through a minimally invasive beating heart surgical approach, but may now be treated with either catheter-based or open surgical techniques. Regurgitation, which has become the leading pathology of the mitral valve in the developed world, may be approached through traditional cardiac surgery or through catheter-based techniques. New imaging techniques and device innovation will cause drastic changes in therapy for mitral valvular disease in the foreseeable future.

Calcified right atrial and pulmonary artery mass after ventriculoatrial shunt insertion.

Insertion of ventriculoatrial (VA) shunts is an effective method of draining cerebrospinal fluid from the cerebral ventricle to the right atrium and significantly improves the survival of patients with hydrocephalus. Some patients who received a VA shunt subsequently developed complications, including thrombus formation around the intracardiac end of the catheter and thromboembolism. The relative rarity of complications and the long latency between shunt insertion and the development of symptoms in VA shunt recipients may result in misdiagnosis or delayed diagnosis. The case presented suggests that such patients may require routine echocardiography at regular intervals. Otherwise, the indwelling foreign body may become the source of a life-threatening thrombotic mass, if not recognised and treated appropriately.

Ruptured aneurysm of the noncoronary sinus of valsalva into the right atrium.

Sinus of Valsalva (SV) aneurysm is rare cardiac lesion with variable clinical presentation. We presented a case of a 41-year-old female who was admitted to our Center because of severe heart failure and a signs of ruptured aneurysm of the SV into the right atrium. Transthoracic echocardiography confirmed communication between noncoronary SV and right atrium measuring 12 mm in diameter, tricuspid insufficiency, biatrial dilatation and preserved left ventricular function. Urgent heart catheterization showed normal coronary arteries. Surgical repair with patch repair of the ruptured aneurysm was performed. Control echocardiography showed no communication with regression in tricuspid insufficiency. Eight days after surgery the patient was discharged home in good condition with no symptoms. Rupture of SV aneurysm may produce serious hemodynamic instability with heart failure or sudden death. Our experience supports the concept that early diagnosis and surgical treatment can save lives for most of the patients.