Estimation of the relative liver perfusion using two methods of radionuclide angiography in the patients with hemodynamic disorders in the portal system.

The aim of this study is the assessment of the relative arterial and venous contribution to the total liver blood flow (hepatic perfusion index-HPI), with two methods (S1 and S2), and estimation of their value. With this correction, HPI nonsignificantly increases (p>0.05) in all the groups of patients, with a very high correlation between the HPI (S1) and HPI (S2) values (p<0.01). In comparison to the portal perfusion in controls, values were significantly (p<0.01) lower in chronic active hepatitis and liver cirrhosis and differed between themselves (p<0.01). In the groups of cirrhotic patients with esophageal varices, sclerosated esophageal varices, recanalized umbilical vein, portal thrombosis and cavernous portal vein, portal perfusion was lower (p<0.01) than in controls, chronic active hepatitis and liver cirrhosis without collaterals. Both angioscintigraphic methods are useful for the estimation of the disturbances in the portal system. Because of the more exact estimation of the liver perfusion, S2 is recommended.

[Surgery of abdominal aorta with horseshoe kidney]. / Hirurski zahvati na aorti abdominalis kod bolesnika s potkovicastim bubregom.

Seventy one surgical procedures on abdominal aorta in patients with horseshoe kidney have been reported in literature until 1980. Bergan reviewed 30 operations of abdominal aortic aneurysms (AAA) in these patients until 1974. Of them 3 AAA were ruptured. Gutowitz noticed 57 surgically treated AAA in patients with horseshoe kidney until 1984. Over the period from 1991 to 1996 thirty nine new cases were reported , including 2 ruptured AAA. The surgery of the abdominal aorta in patients with horseshoe kidney is associated with the following major problems: -reservation of anomalous (aberrant) renal arteries; reservation of the kidney excretory system; approach to the abdominal aorta (especially in patients with AAA) and graft placement The aim of the paper is the presentation of 5 new patients operated for abdominal aorta with horseshoe kidney. Over the last 12 years (January 1, 1984 to December 31, 1996) at the Centre of Vascular Surgery of the Institute of Cardiovascular Diseases of the Clinical Centre of Serbia, 5 patients with horseshoe kidney underwent surgery of the abdominal aorta. There were 4 male and one female patients whose average age was 57.8 years (50-70). Patient 1. A 50-year-old male patient was admitted to the hospital for disabling claudication discomforts (Fontan stadium IlI) and with significantly decreased Ankle-Brachial indexes (ABI). The translumbal aortography showed aorto-iliac occlusive disease and horseshoe kidney with two normal and one anomalous renal artery originating from infrarenal aorta (Crawford type II). Intravenous pyelography and retrograde urography showed two separated ureters. The aorto-bifemoral (AFF) bypass with Dacron graft was done with end-to-end (TT) proximal anastomosis just under the anomalous renal artery. The graft was placed behind the isthmus. During a 12-year follow-up renal failure, renovascular hypertension and graft occlusion were not observed. Patient 2. A 53-year-old male patient was admitted to the hospital for symptomatic AAA. Two years before admission the patient underwent coronary artery bypass grafting. The Duplex scan ultrasonography and translumbal aortography showed an infrarenal AAA, aneurysm of the right iliac artery and horseshoe kidney with two normal and one anomalous renal artery originating from the left iliac artery (Crawford type III). Intravenous pyelography and retrograde urography showed two separated ureters. After partial aneurysmectomy, the flow was restaured using bifurcated Dacron graft placed behind the isthmus. The right limb of the bifurcated graft was anastomosed with the common femoral artery and the left limb with left iliac artery just above the origin of the anomalous renal artery. The first day after operation thrombosis of the left common femoral artery with leg ischaemia was observed. (That artery was cannulated for ECC during coronary artery bypass grafting 2 years ago). The revascularisation of the left leg was done with femoro-femoral cross over bypass. During a 11-year follow-up period, the graft was patent and renal failure or revascular hypertension were not observed. Patient 3. A 66-year-old male patient was admitted to the hospital for rest pain (Fontan stadium III) and significantly decreased ABI. The patient had diabetes mellitus and myocardial infarction two months before admission. Translumbar aortography showed an aorto-iliac occlusive disease associated with horseshoe kidney with 5 anomalous renal arteries. (Crawford type III). Due to high risk, the axillo-bifemoral (AxFF) extra-anatomic bypass graft was performed. Five years after the operation the patient died due to new myocardial infarction. During the follow-up period the graft was patent and there were no signs of renal failure and renovascular hypertension. Patient 4. A 50-year old male patient was admitted to the hospital for high asymptomatic AAA. The diagnosis was established by Duplex scan and translumbal aortography. The large infrarenal AAA (transverse diameter 7 cm) associated with horseshoe kidney with two normal renal arteries (Crawford type I) were found. Intravenous pyelography and retrograde urogrpahy showed two separated ureters. After partial aneurysmectomy the tubular Dacron graft was placed behind the isthmus. During a 15-month follow-up the graft was patent and there were no signs of renal failure and renovascular hypertension. Patient 5. A 70-year-old female patient was admitted to the hospital for large asymptomatic AAA. The Duplex ultrasonography, CT scan, NMR and translumbal aortography showed an infrarenal AAA, aneurysms of the both common iliac arteries, aneurysm of the left hypergastric artery and horseshoe kidney with two normal and two anomalous renal arteries. One of the anomalous renal arteries originated from AAA, and the other from the left common iliac artery (Crawford type II). Intravenous pyelography and retrograde urography showed two separated ureters. After partial aneurysmectomy the flow was restaured using bifurcated Dacron graft placed behind the isthmus. The right limb of the graft was anastomosed (TT) with bifurcation of the common iliac artery and the left limb with the distal part of the common iliac artery (end-to-side) just above the origin of the second anomalous renal artery. The first anomalous renal artery that originated from AAA was removed from the aneurysm wall and anastomosed with graft using Carrel patch technique. During a 9-month follow-up the graft was patent and there were no signs of renovascular hypertension and renal failure. The horseshoe kidney is a rare anomaly of the urinary system. The incidence of this anomaly is from 1:1600 to 1:400 In 95% of cases the kidneys are connected with the lower poles, while in 5% with the upper poles In most cases, the isthmus structure is parenchimatous structure, and rarely it consists of the connective tissue. Usually the isthmus is located in front of the abdominal aorta and inferior vena cava, and very rarely behind them In two thirds of patients anomalous vascularization is present There are two classifications of anomalous vascularization: Papin's and Crawford's. According to Papin's classification, based on the number of renal arteries, there are three types of horseshoe kidney vascularization: Papin I (20%): There are two normal renal arteries only. (One of our 5 patients); Papin II (66%): There are 3-5 renal arteries. (Four of our 5 patients); Papin III (14%): There are more than 5 renal arteries. The Crawford's classification based on the origin of renal arteries, is of greater surgical importance than Papin's. According to it there are also three types of vascularization: Crawford I: There are two renal arteries with normal origin. (One of our 5 patients); Crawford II: Besides two normal, there are 1-3 anomalous renal arteries originating from the infrarenal aorta or iliac arteries (Three of our 5 patients); Crawford III: All renal arteries have an anomalous origin. (One of our 5 patients). The patients with horseshoe kidney can also have two separated, or one connected excretory urinary systems. All our 5 patients had two separated ureters. There is no specific clinical manifestation of the horseshoe kidney. Urinary infection or calculosis are very frequent as are in other urinary anomalies. The diagnosis of horseshoe kidney is established by Dupplex ultrasonography, CT scan, NMR, radionuclide scintigraphy and angiography. Very often the diagnosis is established occasionally during the examination of aneurysmal and occlusive diseases of the abdominal aorta. In cases of AAA or AIO associated with horseshoe kidney preoperative vascularization and condition of the excretory system should be established. Besides standard translumbar aortography selective renovasography is often neccessary. In some cases the intraoperative angiography or arterial identification, with metallic probe must be done. All renal arteries are "terminal" without significant anastomosis on the side of the kidney. Therefor its preservation is neccessary. There are three ways. The first is the location of anastomosis (3 of our patients). The second is an AxFF bypass, but only in patients with AIO (One of our patients and in the third reimplantation of the renal artery using Carrel patch technique was performed (One of our patients). The Isthmus of the kidney aggravates aortic preparation especially in patients with AAA. Sometimes isthmectomy is neccessary. In such cases there is danger of urinary fistula. Therefor many authors suggest the left extraperitoneal approach to abdominal aorta. In our patients, the transperitoneal approach was used, isthmectomy was not neccessary and graft was placed behind the isthmus. The operation of the abdominal aorta in patients with horseshoe kidney can be difficult due to anomalous renal arteries, anomalous excretory urinary system and is Ehmus. In these patients a more precise preoperative diagnosis is neccessary.

Study of portacaval shunt effectiveness in rats.

BACKGROUND/AIMS: This is a report of a study designed to confirm the presence and determine the effectiveness of portacaval shunts. MATERIAL AND METHODS: Color Doppler ultrasonography of the portal system, as a superior diagnostic procedure, was performed in experimental animals. RESULTS: Presence of shunt is indicated by initial loss of body mass in such animals (p < 0.01) as well as by increased ammonia concentration (p < 0.01). CONCLUSIONS: Surgical technique of end-to-side portacaval anastomosis, originally described in 1961 and modified in 1963, has been used as a model of hepatic insufficiency in rats. Color Doppler ultrasonography of the portal system was performed to confirm PCS efficacy. Blood flow in PCS was confirmed in all operated animals. Blood flow in the portal vein was phased and respiratory dependent, slightly decreased. Portacaval shunt had typical mixed blood flow of turbulent character. Blood flow in VCI was increased due to PCS. No comparable data for this model in rats were available. Body mass of animals with PCS significantly decreases during the first two weeks, by 15-18% (p < 0.01), to be followed by statistically significant increase (p < 0.01). Ammonia concentrations, obtained at the beginning of the second postoperative week, were significantly higher than in control group, probably as a consequence of complete diversion of portal blood, rich with ammonia, into systemic circulation and of decreased liver capacity for ammonia uptake.

[Localised adenomyomatosis of the gall bladder]. / Lokalizovana adenomiomatoza zucne kese.

Adenomyomatosis of the gall bladder is a rare benign disease in which hypertrophic mucosa makes deep sinuses into hypetrophic muscular layer making, the so called Rokitansky-Aschoff's sinuses. It appears as a localised, segmental or diffuse form of the disease. Localised adnomyomatosis leads to the formation of "tumorous" lesions. Two patients, a 44-year old man and a 67-year old woman in whom "tumorous" lesions of the gall bladder were diagnosed preoperatively, are presented. Both patients were operated on. Cholecystectomy was carried out. "Tumorous" changes were, in fact, a localised form of adenomyomatosis, what was histologically confirmed.

[Leiomyosarcoma of the duodenum (case report)]. / Lejomiosarkom duodenuma (prikaz bolesnika).

Leiomyosarcomas of the duodenum are rare tumors, usually presented with gastrointestinal bleeding and/or symptoms of duodenal obstruction, rarely with obstructive jaundice. If successfully removed, these tumors have better prognosis than carcinomas of duodenum or head of the pancreas. A 62 year old man in whom leiomyosarcoma of the duodenum was successfully removed by cephalic duodenopancreatectomy (Whipple's procedure) is presented.

The evaluation of tumor markers levels in determination of surgical procedure in patients with gallbladder carcinoma.

In purpose of early diagnosis of gallbladder carcinoma, the serum levels of tumor markers CA 72-4, CA 19-9, CEA, AFP, Ferritin and beta HCG were determined in 124 patients with benign and malign diseases of gallbladder, before and 10 days after the operation. The most important clinical significance have CA 72-4 and CA 19-9, which are increased in Ca in situ and carcinoma of the first stage. These early stages of carcinoma cannot be diagnostified by preoperative echotomography, but radical operation is possible with recover by all means. These two tumor markers should be attended in risk group of patients for rising gallbladder carcinoma: calculosis and polyposis. The rest of tumor markers are increased in progressive carcinoma with infiltration of surrounding tissue and metastases.

[The effect of propranolol on portal hypertension]. / Uticaj propranolola na pritisak u sistemu portne vene.

The review of literature on propranolol (Inderal) pharmacological action on the portal vein pressure is reported in this article. The patients with liver cirrhosis and esophagogastric varices have 25-33% risk of initial bleeding, risk more than 70% of variceal re-bleeding and associated mortality over 50% in each episode. The use of nonselective beta adrenergic blockers according to previous data, descreases portal vein pressure and mostly prevents the initial bleeding. In the prevention of esophageal re-bleeding, nonselective beta adrenergic blockers (Inderal) are recommended in patients with relatively good liver function (Child's A and Child's B), while in liver failure with great ascites (Child's C) no beneficial effect is expected.

[Epidermoid cyst of the spleen]. / Epidermoidna cista slezine.

A 33-year old woman with 6 x 6 cm splenic cyst of the lower pole of a moderately enlarged spleen, found during ultrasonographic examination for epigastric and left subcostal abdominal pain, is presented. At operation the spleen of 900 grams with a subcapsular cyst in pedunculated extension of the lower splenic pole, ie. accessory lobe, was removed. No other abdominal disease was found. Postoperative recovery was uneventful. Pathohistological examination revealed a cyst, 6 cm in diameter, with whitish wall filled with dark-red turbid fluid containing yellow flocules. The wall of the cyst consisted of the fibrous connective tissue with sclerotic and hyaline changes. The cyst was entirely lined by the stratified squamous epithelium, in some areas flattened, transformed into endothelium. Diagnosis of a very rare splenic epidermoid cyst in the "accessory lobe" of the lower pole, was confirmed.

Splenic vein thrombosis. Diagnosed with Doppler ultrasonography.

The case of a 31-year-old pregnant woman with an isolated splenic vein thrombosis, diagnosed with Doppler ultrasonography is presented. Routine ultrasound examination in the fourth month of the pregnancy revealed massive splenomegaly of unknown origin. Doppler ultrasonography subsequently revealed splenic venous thrombosis with absence of blood flow. Noteworthy gastric varices were present at the endoscopic examination. On splenectomy, a spleen weighing 2,600 was removed, and numerous venous collaterals were found in the perigastric region. The postoperative course was satisfactory, pregnancy evolved normally, and a healthy female baby was delivered at term. The patient remained in excellent health with normal clinical and laboratory data.

[Accessory spleen causing recurrent idiopathic thrombocytopenic purpura (case report)]. / Akcesorne slezine kao uzrok recidiva idiopatske trombocitopenijske pupure (prikaz bolesnice).

Idiopathic thrombocytopenic purpura is an autoimmune disease in which macrophages of reticuloendothelial system, mainly in the spleen, remove platelets covered by autoantibodies from circulation. By removing the spleen 60-80% of patients are cured. Partial remission is achieved in 10-20% of cases. Recurrence of idiopathic thrombocytopenic purpura in a splenectomized patient achieving complete remission, may be caused by hypertrophy of one or more of the retained accessory spleens. We describe a 41-year-old wonam in whom splenectomy for idiopathic thrombocytopenic purpura was performed 10 years ago. After quick and full remission which lasted almost 10 years, a full reccurrence of the disease with severe thrombocytopenia and haemorhagic syndrome appeared. With ultrasonography, computed tomography and scintigraphy accessory spleens in the splenic fossa were found. Removal of 3 accessory spleens, 21 gram of weight, led to quick and full remission of the disease. A number of platelets stayed over 200 x 10(9)/l with no additional treatment.

[Echotomography of malignant tumors of the liver]. / Ehotomografska slika malignih tumora u jetri.

The echotomographic primary liver carcinoma can be hyperechogenic and hypoechogenic, or both. In metastasis, in addition to the pattern of primary carcinoma end-lesion changes are also visible, or liver parenchyma can be diffusely heterogeneous. The echotomographic findings of primary and secondary liver tumours cannot be differentiated. The origin of metastasis in the liver cannot be established by echotomography. However, a typical echotomographic picture can be obtained in some carcinoma (colon carcinoma).

Retroperitoneal biloma secondary to operative common bile duct injury.

Encapsulated collections of bile ("biloma") may be a sequela of liver trauma, operative injury or disease. Such collections may be intrahepatic or extrahepatic and usually in the supramesocolic compartment of the abdomen. This is a report of a retroperitoneal biloma, an entity that has been reported only twice to date but this is the first secondary to an operative common bile duct lesion. Evacuation of the biloma and reconstruction of the associated biliary stricture were successfully carried out. The patient remains symptom free with normal clinical and laboratory data more than 14 months after surgery.

[Surgical treatment of aneurysms of the femoral artery]. / Operativno lecenje aneurizmi femoralnih arterija.

The authors have presented the importance and technics of operative treatment of femoral aneurysms as the only correct method of treatment aiming at prevention of complications which are the consequence of the natural course of the disease. The majority of current operative technics involve total or partial resection of an aneurysm and reconstructive operative approach (graft interposition, bypass) aiming at establishment of the arterial continuity. In the same time the authors have emphasized the importance of echosonographic diagnostical procedure which has even some advantages over angiography, especially in cases with normal central recanalization of the clot.

[Injury of the left hepatic vein by a large hepatic echinococcal cyst]. / Ostecenje leve hepaticke vene velikom ehinokokusnom cistom jetr.

While different sorts of affection of the biliary tree by the hydatide cysts of the liver are frequent (20-30%), vascular complications are rare. That is why serious peroperative bleedings are usually caused by surgical mistakes. Bleeding caused by hydatide cyst itself is very rare, sudden, abundant, dramatic and usually lethal on the operative table. We present a 76-years-old man in whom during the operation of a huge hydatide liver cyst, sudden and abundant bleeding from the defect (2 x 0.5 cm) of the left hepatic vein caused by the cyst itself, appeared. The bleeding was successfully solved by direct suture of the defect. Three months later hepatitis B viral infection manifested apparently after numerous blood and plasma transfusions during surgery, and patient died in hepato-renal syndrome.

[Biliary mucinous cystadenocarcinoma of the liver]. / Bilijarni mucinozni cistadenokarcinom jetre.

Biliary mucinous cystadenocarcinoma is an extremely rare tumour. Less than 50 cases have been reported. It is usually a multilocular cystic tumour covered with mucous producing epithelium, with papillary excrescences containing mucinous mass arising from bile ducts. The size of the tumour varies from 3.5 to 25 cm in diameter. It is more frequent in women. The majority of patients belong to the middle age population. We present a 63-year-old man who had been suffering from an epigastric and right subcostal pain of unknown aetiology for over 35 years. During the last 10 years he suffered from multiple attacks of cholangitis with high temperature, rigor, chills, pain and obstructive jaundice. Five years ago he had the attack of pancreatitis with retroperitoneal fatty necrosis for which he was operated on in another institution and cholecystectomy and pancreatic necrectomy were carried out. The attacks of cholangitis continued they were more serious and more frequent until June 1987, when the "cyst" in the left lobe of the liver, dilated bile ducts and "polyps" in the common bile duct were diagnosed by ultrasonography. During the operation advanced biliary cirrhosis, portal hypertension, splenomegaly, very dilated common bile duct full of jelly and the "cyst" in the liver filled with jelly, were found. The removal of the jelly and choledochojejunostomy resulted in temporary relief. Two months later he was reoperated for recurrent obstructive jaundice during which left lobectomy, partial excision of the cyst and cystojejunostomy between the rest of the cyst and another Roux-en-Y jejunal limb, were carried out.(ABSTRACT TRUNCATED AT 250 WORDS)

[Diffuse adenomyomatosis of the gallbladder]. / Difuzna adenomiomatoza zucne kesice.

Adenomyomatosis is a rare benign proliferative disease of the gallbladder characterized by epithelial proliferation and formation of mucosal pouches through the thickened muscular layer of gall bladder wall. It appears in three different types: diffuse, segmental and localised adenomyomatosis. Diffuse type is the rarest. Etiology is unknown. Patients sometimes feel a dull pain in the upper right abdominal quadrant. Preoperative diagnosis is based on cholecystography and ultrasonography. Cholecystectomy is a method of treatment. Diagnosis is confirmed on histology. Very rarely, adenomyomatosis seems to bee a premalignant condition. We present four patients treated during the last two years, a woman and three men, 27-41 years old (average 37 years). All these patients had a dull pain in the right subcostal region, approximately 6 months before the diagnosis was established. One patient had chronic alcoholic pancreatitis with dilated pancreatic duct. Diagnosis of diffuse adenomyomatosis was made preoperatively on ultrasonography in all patients. Cholecystectomy was carried out Diagnosis was confirmed on histology. There was no carcinoma. In a patient with chronic pancreatitis Wirsungojejunostomy (Puestow) and choledochojejunostomy were also carried out.

[Mixed colon tumour: leiomyoma-haemangioma]. / Miksni tumor kolona: lejomiom-hemangiom

Leiomyoma and heamangioma of the colon are extremely rare tumours. Only 27 cases were published in world literature up to 1954. A few new were published after that period. We describe a 46-year-old man with 3-months-history of occlusive symptoms in whom during the operation for complete colon obstruction mixed colon tumour (leiomyoma-haemangioma) was found, 10 cm distal to hepatic flexure. The tumour was of intraluminal pedunculated type", 7 cm in maximal diameter. Four enlarged, firm lymph nodes in the mesocolon close to the tumour were found. Right colectomy was carried out as the most resonable procedure. Histopathology showed leiomyoma of the colon with massive fibrous tissue, degeneration, bleeding of the tumour and many dilated blood vessels, so that its pedunculated part resembled a haemangioma. No sign of malignancy was found. The recovery of the patient was normal, and he stayed symptom-free, with normal small bowel function, clinical and laboratory data.

[Tuberculosis of the lymph nodes and spleen preceding Hodgkin's disease]. / Tuberkuloza limfnih zlezda i slezine koja je prethodila Hodgkinovoj bolesti.

Tuberculosis of the lymph nodes is not rare today. However tuberculosis of the spleen has been very rare even in the past when many patients had suffered from tuberculosis. The appearance of Hodgkin's disease following tuberculosis is an extremely rare condition. It has thought that deficiency of cellular immunity was responsible for both tuberculosis and malignancy. We present a 44-year-old man in whom lymph node and spleen tuberculosis antedated the clinical onset of Hodgkin's disease for three years. The patient was successfully treated with tuberculostatics until he developed Hodgkin's disease; he was treated according to MOPP protocol. Six years after the onset of disease nodular lesion of the spleen was detected and splenectomy was carried out. The enlarged spleen, g in weight, was removed with tuberculoma in the lower pole, 4 cm in diameter. The tuberculostatic therapy for a year followed splenectomy. The patient stayed symptom-free, with no sign of tuberculosis. He is in the remission stage of Hodgkin's disease with normal clinical and laboratory data.