Subarachnoid morphine, bupivacaine and fentanyl as part of combined spinal-epidural analgesia for low anterior resection. A prospective, randomised, double-blind clinical trial.

This study was designed to compare the efficacy of subarachnoid morphine alone or in combination with bupivacaine and fentanyl for combined spinal-epidural analgesia in colorectal surgery. This is a prospective, randomised, double-blind clinical trial. Sixty patients undergoing low anterior resection were assigned to one of three groups: subarachnoid morphine, bupivacaine and fentanyl, subarachnoid morphine and bupivacaine or subarachnoid morphine only. Epidural catheter placement and subarachnoid injection were done via a combined spinal-epidural Epistar needle at L2-3. The epidural catheter was used for scheduled intraoperative bupivacaine and intermittent postoperative bupivacaine and morphine administration. Intraoperative epidural bupivacaine, intraoperative intravenous fentanyl use, time to first analgesia request, postoperative visual analogue scale pain scores, tramadol requirements and side-effects were recorded for 72 hours. Postoperative analgesia was comparable in all groups. Intraoperative fentanyl and bupivacaine consumption was lowest in the morphine, bupivacaine and fentanyl group. Time to first analgesia request was longer in the morphine, bupivacaine and fentanyl compared to the morphine group (P = 0.009). Tramadol use was lower in the morphine and bupivacaine group compared to morphine, bupivacaine and fentanyl (P = 0.017) on postoperative day two. There were no significant adverse effects. All patients ambulated the morning after surgery. The addition of bupivacaine and fentanyl to subarachnoid morphine did not confer any advantage on postoperative visual analogue scale scores and tramadol use, but lowered the need for additional intraoperative intravenous fentanyl and epidural bupivacaine and prolonged the time to first analgesia request.

Gastrojejunocolic fistula as a complication of Billroth II gastrectomy: a case report.

Gastrojejunocolic fistula is a late, severe complication of a stomal ulcer, which develops as a result of inadequate resection of the stomach or incomplete vagotomy. It is uncommon and in our century is reported only sporadically in medical literature The authors report a case of benign gastrojejunocolic fistula, diagnosed by barium based contrast radiography, which demonstrated reflux of contrast from the transverse colon to the stomach and jejunum via a fistulous tract. Therapy of the gastrojejunal fistula is always radical and comprises en bloc resection of the fistula and revision of gastrectomy, partial resection of the jejunum and the colon, which is involved in the fistula, and restoration of continuity of the digestive tract by gastrojejunostomy, jejunojejunostomy and colocolostomy. If trunkal vagotomy has not previously been completed, it is advisable to perform it nonetheless.

Granular cell tumor of the common hepatic duct presenting as cholangiocarcinoma and acute acalculous cholecystitis.

Granular cell tumors (GCT) are rare benign tumors. Less than 1% of GCTs involve the extrahepatic biliary tree. Most researches favour a Schwann cell origin. Patient, caucasion, female, 31-year-old presented with 4 month history of painless jaundice and pruritus. US and CT revealed dilatation of intrahepatic biliary tree and surgery was performed. Firm tumor mass was found above the conjunction of cystic duct and common hepatic duct (CHD) that caused obstruction and gallblader empyema. The patient underwent radical surgical procedure because Klatskin tumor was clinically suspected. Patohystology and immunohistochemistry confirmed granular cell tumor. Eight years after surgery the patient is wellbeing without symptoms. To our knowledge 69 cases of GCT of the extrahepatic biliary tree have been reported and none of the acute acalculous cholecystitis case acompanied by GCT of CHD. Granular cell tumors are rarely diagnosed preoperatively. Wide resection offers the best chance for cure.

Fragmentation of axillary fibrofatty tissue during dissection facilitates preservation of the intercostobrachial nerve and the lateral thoracic vein.

The preservation of neurovascular elements passing through the axillary fibrofatty tissue (the intercostobrachial nerve and the lateral thoracic vein) could be techniqually demanding if an en bloc axillary dissection is performed in the conventional way. In this paper we describe a surgical technique for more successful preservation of these elements, by which fragmentation of the axillary fibrofatty tissue is planned and performed "in advance". The techniques of axillary sampling biopsies, where lymphatic vessels are always divided, have shown that cutting of the lymph routes does not increase the risk of local regional recurrence. After adopting and applying this technique in a series of 22 consecutive dissections, the nerve was spared in 22 patients (100%) (compared to an earlier series where the nerve was spared in 53 of 65 patients (81.5%)), while the vein was spared in 21 patients (95%) (earlier 22 of 65 patients (34%)).

Short-segment jejunoplasty: the option treatment in the management of benign esophageal stricture.

A non-dilatable benign stricture of the esophagus is a problem for the patient and always a challenge for the surgeon. The present study is intended to provide some details of surgical technique and the physiological concept that constitutes the basis for patient selection for short-segment jejunoplasty. In this study, out of 98 patients, 91 had complex stricture of the lower, and seven of the cervical esophagus. The main cause of stenosis in 60 patients (61.2%) was gastroesophageal reflux, in 34 (34.7%) post-corrosive damage, and in three (3.0%) it was other causes. All patients were treated by three methods of jejunoplasty: group I (n=54 patients) short-segment of the jejunum; group II (n=37 pts) Roux-en-Y double tract; and group III (n=7 patients) short jejunal segment on the long vascular pedicle. Intraoperative complications occurred in 17 (17.34%) of the patients. An anastomotic leak occurred only in three (3.29%) in group I and II, and 1/98 patients (1.02%) died from mediastinitis. Follow-up of functional results for up to 36 months (average 18 months) was available in 77/97 (79.3%) hospital survivors. Fifty-seven (74%) patients are satisfied with their ability to take food, postoperative reflux was completely denied by 72 (93.5%) patients. Postvagotomy diarrhea was transient and gradually subsided over the course of the first 6 months.

Visceral metastases of melanoma-single institution experience an analysis of 15 cases.

Authors analysed 15 cases with visceral metastasis of melanoma. In eight cases the primary was unknown but in seven cases the data about primary was known. From 15 patients 10 were male and 5 female. All metastases were in abdominal cavity (liver-3, abdominal lymph nodes-4. stomach-2, bowel-4, omentum-1, spleen-1, oesophagus-1, adrenal-2 cases. In one case metastatic deposit was in brain and in one case i the vertebral body. In 6 cases visceral metastases were in more than one location.

[Initial diagnosis of intra-abdominal hemorrhage caused by isolated splenic injury in blunt abdominal trauma]. / Inicijalna dijagnostika intraabdominalnog krvavljenja uzrokovano izolovanom povredom slezine kod tupe abdominalne traume.

Diagnosis of intraabdominal bleeding caused by spleen injury must be performed in the shortest possible period of time, with little risk for the patient, and with high preciseness. By its simple performance, high preciseness and little risk for the patient, DPL imposes as the predominant method in initial diagnostic of intraabdominal bleeding. Control and monitoring of lavage may duly signalize degree of bleeding. Preciseness of this diagnostic in our series ranges up to 93.3%. DPL method is especially important in a combined neurotrauma. Ultrasonography is a sovereign method in diagnostic of bleeding source as well as in monitoring of bleeding that from the very beginning does not require urgent surgical intervention. Its importance is in monitoring both intrasplenic and subcapsulary hematomas. It is not appliable in disturbed and haemodynamically unstable patients. It is in particular important in children where a maximum conservative attitude with respect to operative treatment has been assumed. CT takes the leading place with respect to preciseness of bleeding area, and the combined thoracoabdominal trauma. Preciseness of CT in our series comes up to 96.6%, but can be applied only in haemodynamically stable patients. Same as US of abdomen so the CT of abdomen represents a prominent method in monitoring of both intrasplenic and subcapsular hematomas, which do not require urgent surgical intervention.

[Mediastinitis caused by tonsillitis ]. / Medijastinitis kao posledica tonzilitisa.

We report case of 50-year-old female with mediastinitis due to tonsillitis. Mediastinitis was diagnosed after five days according to clinical signs, radiological examination and computerized tomography scan. The patient underwent mediastinal drainage through a cervical incision and bilateral thoracic drainage because of bilateral pleural empyema. Initial broad-spectrum antibiotic therapy was replaced with imipenem, amicacin and vancomycin after the bacteriological investigation revealed susceptibility to isolated acinetobacter spp, staphylococcus spp coagulase-negative, enterococcus and staphylococcus. After 46 days of hospitalization patient went home.

[Mediastinitis--diagnosis and therapy]. / Medijastinitis-dijagnostika i lecenje.

Mediastinitis is serious, life-threating infection. Desceding necrotizing mediastinitis is a form of mediastinitis with mortality rate of 40%. It develops as a complication of odontogenic and deep cervical infection. Early diagnosis and therapy are the most important issues. Computed tomographic scan is suggested if odontogenic infection is complicated with dyspnea. Mediastinitis is usually polymicrobial infection. Transcervical mediastinal drainage and intravenous antibiotic therapy are suggested. In some [figure: see text] cases aggressive mediastinal drainage by thoracotomy approach is performed.

[Surgical treatment of cardial carcinoma]. / Hirursko lecenje karcinoma kardije.

In the period from 1970 to 1996, in the Departmenf of Esophagogastric Surgery, Belgrade, Yugoslavia 562 have been operated with curative intent due to cardiac carcinoma. Since 1970 until 1985, in 182 patients a distal esophagectomy and proximal gastrectomy followed by eosphagogastro anastomosis had been performed. In the period between 1982 and 1996, a distal esophagectomy with total gastrectomy and radical or extended radical dissection and intrathoracic esophagojejuno anastomosis in 380 patients (192 hand sewn 3/0 interrupted sutures and 188 spapled anastomosis) had been performed. In our opinion for the majority of patients with advanced cardiac carcinoma distal esophagectomy and total gastrectomy, via the left thoracoabdominal approach, with D2 pancreas preserving splenectomy and dissection of lymph nodes in stations 16a1 and 16a2 is a surgical therapy of choice. Overall complications of such a procedure not differ in type and number from those after standard total gastrectomy and D2 dissection.

[Surgical strategy in the treatment of primary lymphoma of the stomach]. / Hirurska strategija u lecenju primarnog limfoma zeluca.

Primary gastric lymphoma has been traditionally accounted for only 1-7% of all malignancies of the stomach. During the period 1980-1996 in Department of Esophagogastric Surgery of University Surgical Hospital in Belgrade 41 patients have been operated due to primary gastric lymphoma. Radical surgery is the only therapeutic procedure in more then 45% of patients. It is also a safe procedure with specific complication rate less then 22%, and specific mortality rate less then 5%. In our experience, total gastrectomy with systematic lymphadenectomy is a therapy of choice in most patients with primary gastric lymphoma.

[Leiomyoma of the esophagus. Case report]. / Leomiom jednjaka. Prikaz bolesnika.

Of all oesophageal tumours benign tumours account for less than 10%, of which 4% are leiomyomas. These tumours are most frequently asymptomatic, mostly localized in the lower oesophageal third. The most frequent symptoms, if any, are the following: dysphagia, unspecific retrostemal pain, heartburn, and occasionally, weight loss. Tumour enucleation is a therapy of choice in patients with oesophageal leiomyoma. In case of successful surgical removal, the prognosis is good and complains are practically eliminated. A male patient, aged 53, with paroxysmal tachycardia, in whom transhiatal enucleation was carried out in order to remove a large oesophageal leiomyoma after which cardiac complains were eliminated, is reported.

[Paraesophageal hiatal hernia of the diaphragm]. / Paraezofagealne hernije hijatusa dijafragme.

Paraesophageal hernia (type II hiatal hernia) accounts for less than 5-10% of all herniation through the esophageal hiatus. Anatomically, it is distinguished from the more common sliding variety (type I hiatal hernia) by the position of the gastroesophageal junction. The management of paraesophageal hiatal hernia is influenced by the tendency of the herniated stomach to develop volvulus, which potentiates life-threatening complications that include complete gastric obstruction, bleeding, infarction and perforation. In a cases with gastroesophageal reflux one of the antireflux procedures had to be done. In the Institute of Digestive Diseases, in the 16 years period from 1980-1996, 37 patients had treated of paraesophageal hernia. Authors discuss their management strategies, especially the using of antireflux procedures.

Gastric foveolar hyperplasia in patients with cancer of the intact stomach.

The incidence of gastric foveolar hyperplasia, a reliable histological marker of bile reflux into the stomach, was evaluated in patients with cancer of the intact stomach. Lesions classified as foveolar hyperplasia were found in 17 of 32 gastric cancer patients and in seven of 30 controls. This difference was statistically significant (p < 0.02). Differences in the incidence of foveolar hyperplasia according to sex, tumor site, attendant chronic atrophic gastritis, and alcohol consumption were not significant, which lends support to the association of gastric cancer with duodenogastric reflux.

Acquired benign esophagorespiratory fistula: report of 16 consecutive cases.

Sixteen cases of acquired benign esophagorespiratory fistula were treated in a 20-year period. A delay in diagnosis was usual, and most patients were first seen with a pulmonary infection already developed. Contrast esophageal x-ray studies established the diagnosis in all patients. There were seven esophagotracheal and nine esophagobronchial fistulas. A fistula between the esophageal diverticulum and a bronchus considered to be of inflammatory origin developed in 7 patients. A fistula as the consequence of trauma developed in 9 patients, and these fistulas were situated at a higher level of the respiratory tree. All patients underwent surgical treatment; in 12 it was definitive, and in 4 temporary gastrostomy was performed to improve nutrition before definite repair. The definitive repair consisted of eventual diverticulectomy, division of the fistula, and suture of both esophageal and respiratory defects. Two patients required esophageal resection and later reconstruction with colon interposition. One patient died, creating an operative mortality of 8.3% in the definitive-repair group. The remaining 11 patients had a gratifying long-term result. There were two deaths in the gastrostomy group due to an extremely poor condition of patients and debilitating pulmonary infection. Early diagnosis of this rare condition is necessary if severe pulmonary complications are to be avoided. Early direct repair gives excellent results.