Potential use of Doppler perfusion index in detection of occult liver metastases from colorectal cancer.

Many clinical and preclinical studies demonstrated that measurements of liver hemodynamic [Doppler perfusion index (DPI)] may be used to accurately diagnose and predict liver metastases from primary colorectal cancer in a research setting. However, Doppler measurements have some serious limitations when applied to general population. Ultrasound is very operator-dependent, and requires skilled examiners. Also, many conditions may limit the use of Doppler ultrasound and ultrasound in general, such as the presence of air in digestive tract, cardiac arrhythmias, vascular anomalies, obesity and other conditions. Therefore, in spite of the results from clinical studies, its value may be limited in everyday practice. On the contrary, scientific research of the DPI in detection of liver metastases is of great importance, since current research speaks strongly for the presence of systemic vasoactive substance responsible for observed hemodynamic changes. Identification of such a systemic vasoactive substance may lead to the development of a simple and reproducible laboratory test that may reliably identify the presence of occult liver metastases and therefore increase the success of adjuvant chemotherapy through better selection of patients. Further research in this subject is therefore of great importance.

[Laparoscopic transgastric cystogastrostomy of pancreatic pseudocyst: a case report]. / Laparoskopska transgastricna cistogastrostomija pseudociste gusterace: prikaz bolesnika.

Pancreatic pseudocyst is one of the most common complications of acute pancreatitis. Symptomatic or complicated pseudocysts require treatment. The basic principle of pseudocyst treatment is its drainage. The best method is internal drainage by establishing communication between pseudocyst and stomach or small intestine. With advances in endoscopic technology it is now possible to drain pseudocyst efficently in neighboring stomach or duodenum, however the surgical internal drainage of pancreatic pseudocysts that has been carried out as open operation for decades, remains the criterion standard against which all other therapies are measured. In recent years, several methods of laparoscopic internal drainage of pancreatic pseudocysts have been published. Initial results are encouraging, although the number of patients operated using these methods is still small and there is no clear evidence that laparoscopic internal drainage is beneficial for the patients. In this case report we present our first case of laparoscopic internal drainage of pancreatic pseudocyst. The pseudocyst developed as a complication of acute pancreatitis. Laparoscopic internal drainage with cholecystectomy was carried out on 4th of April, 2005. The patient recovered without complications and during first year of follow-up no recurrence of pseudocyst was observed.

[Laparoscopic surgery in acute abdominal trauma]. / Laparoskopska kirurgija kod akutne ozljede trbuha.

In the past few years, laparoscopy has been increasingly used in patients with acute abdominal trauma. This metod in experienced hands enables direct eye visualisation of abdominal cavity, ensures accurate and early diagnosis and leads to prompt decision on the therapy. Reviewing the literature, laparoscopy in acute abdominal trauma is a safe and accurate procedure to yield diagnosis, enable laparoscopic interventions and help avoid unnecessary laparotomy. In acute abdominal trauma, laparoscopy is mostly used as a diagnostic method, not so often as a therapeutic method, but an expanding range of therapeutic interventions is available. We show our early results with diagnostic and therapeutic laparoscopy from January 1st 2003 to March 31st 2004, stressing therapeutic laparoscopy. We performed 79 laparoscopic explorations in patients with diagnosis of acute abdomen. 7 of them were explored because of acute abdominal trauma. In 3 patients there was no need for intervention after laparoscopic exploration, in 1 patient we electrocoagulates smaller bleeding from the spleen and in other 3 patients we made conversion to open surgery procedure, because of III-IV grade liver or spleen injury. In our group we didn't have injuries of any other internal abdominal organs. Laparoscopic treatment of acute abdominal trauma with spleen or liver injury is applicable in I-III grade liver injury and I-II grade spleen injury, while in greater injuries it is necessary to make conversion to laparotomy.

[Blast injury to the spleen and pancreas after a non-penetrating gunshot wound--result after 12 years]. / Ratna ozljeda slezene i gusterace nastala bocnim udarnim valom metka--rezultat nakon 12 godina.

The spleen is the most frequently injured organ in adults who sustain blunt abdominal trauma. The aim is to report on a patient with non-penetrating gunshot traumatic injury to the spleen and pancreas, and to evaluate the result after 12 years A soldier with gunshot wound of the left lateral abdominal wall was admitted to the Military Hospital in Mostar in the year 1993. The patient was hemodynamically unstable and underwent emergency surgery. On wound exploration, there was no abdominal penetration. Because of hemodynamic instability, we decided to perform emergency laparotomy and abdominal exploration. The spleen and distal pancreas were shattered. Splenectomy and hemostasis were performed. The peritoneum was closed and the abdominal wall wound healed secondarily. The patient was in good condition postoperatively. Now, after 12 years, the patient is free from any sequel of the war injury. Blast injury to the spleen can result from non-penetrating abdominal gunshot wounds despite the absence of injury to the peritoneum. In war conditions, the diagnosis and indications are usually based on clinical findings only because special investigations, including ultrasound and CT are not readily available. The management of splenic injury has been rapidly modified over the last decade, with ever more emphasis on splenic salvage and nonoperative management, however, these procedures cannot be performed in war conditions. War injuries to the spleen are life threatening and emergency open splenectomy is the only solution.

[Laparoscopic treatment of acute cholecystitis]. / Laparoskopsko lijecenje akutnog kolecistitisa.

Acute cholecystitis has been considered a contraindication for laparoscopic cholecystectomy after its affirmation as the golden standard for treatment of chronic cholecystitis. However, over time it has been proven that acute cholecystitis could also be managed laparoscopically, although it was technically demanding procedure, burdened with relatively high conversion rates. In this study we present our series of 26 patients, urgently admitted for acute cholecystitis. They are presented with clinical findings typical for acute cholecystitis. The diagnosis was determined using ultrasound examination, and confirmed postoperatively by pathohistological findings. In all 26 cases we managed to perform laparoscopic cholecystectomy, there were no conversion. Mean operative time was 73 +/- 21 minutes. Postoperatively, we haven't recorded any significant complications. Mean hospital stay was 4.8 +/- 2.5 days. Even though laparoscopic treatment of acute cholecystitis is technically more demanding and lengthier procedure than laparoscopic treatment of chronic cholecystitis, we consider acute cholecystitis to be a laparoscopically manageable disease. During the operation, tissue edema and hyperemia presented main technical challenge. They presented a significantly greater problem if the symptoms lasted for more than 3 days prior to operation. Therefore we suggest that laparoscopic cholecystectomy should be carried out in the first 72 hours after the onset of symptoms, since any further delay will lead to development of tissue hyperemia and edema, thus making the operation technically more demanding.

Altered iron metabolism, transferrin receptor 1 and ferritin in patients with colon cancer.

In this study, the level and distribution of transferrin receptor 1 (TfR1) and ferritin in colorectal carcinoma and in normal colon epithelium has been determined relative to the tumor stage and iron status of patients using immunohistochemical staining methods. While the majority of carcinoma patients were anemic, no relationship between the level of colon tissue ferritin and TfR1 and the systemic parameters of iron metabolism was evident. Furthermore, no association between ferritin content and the grade of colorectal carcinoma was observed. However, a relationship between the expression of TfR1 and the grade of colorectal carcinoma was observed. In this case high expression of TfR1 was found in colorectal carcinoma samples of Dukes A or B grade, and well differentiated colorectal carcinoma cells. In comparison, weak or no expression of TfR1 was observed in carcinoma samples of Dukes C or D grade with poorly differentiated cells and in carcinoma samples that had lymph node infiltration and distant metastasis.

Oxidative stress markers after laparoscopic and open cholecystectomy.

BACKGROUND: Surgical injury is associated with oxidative stress, often due to ischemia/reperfusion injury. During laparoscopy, increased intra-abdominal pressure caused by pneumoperitoneum may cause splanchnic ischemia followed by reperfusion due to deflation. We measured several markers of oxidative stress in patients undergoing laparoscopic cholecystectomy (LC) versus open cholecystectomy (OC) to find if these surgical procedures result in different patterns of oxidative stress. METHODS: This prospective study enrolled 43 patients with symptomatic cholelithiasis, of whom 21 underwent open, and 22 laparoscopic, cholecystectomy. Twenty healthy adults comprised the control group. Total antioxidant status (TAS), superoxide dismutase (SOD), endogenous peroxide level (POX), oxidized low density lipoprotein (oLDL) autoantibodies (oLAb), and neopterin were measured preoperatively and on postoperative days 1, 3, and 7. RESULTS: POX values decreased significantly on postoperative day 1 in the OC (P<0.01), but not in the LC, group. On postoperative day 7, POX values were higher than preoperatively in both groups (P<0.01) with no difference between the LC and OC groups. Significant postoperative elevations of oLAb and neopterin levels were observed only on postoperative day 7 in the OC group. There were no changes of oLAb and neopterin levels in the LC group. TAS and SOD levels did not change after either LC or OC. CONCLUSION: Cholecystectomy, either open or laparoscopic, caused only moderate oxidative stress. Open cholecystectomy caused changes of oLAb and neopterin, suggesting more severe oxidative stress, and a possible role of reactive oxygen species in the healing of the laparotomic wound.

[Laparoscopic repair of a cholecystoduodenal fistula--a case report]. / Laparoskopsko zbrinjavanje kolecistoduodenalne fistule--prikaz slucaja.

Although cholecystoduodenal fistula is traditionally considered a contraindication for laparoscopic cholecystectomy, literature search reveals reports of cholecystoduodenal fistulae successfully repaired laparoscopically, regardless whether cholecystoduodenal fistula was diagnosed before or during operation. Here we present a case of preoperatively diagnosed and confirmed cholecystoduodenal fistula that was successfully repaired during elective laparoscopic cholecystectomy using an Endo-GIA 35 stapling device. Thus we side with the growing number of surgeons who do not consider cholecystoduodenal fistula to be a contraindication for laparoscopic cholecystectomy.

Common bile duct obstruction caused by the hydatid daughter cysts.

Echinococcosis is a human parasitary disease. In 2002, 29 new cases of liver echinococcosis were recorded in Croatia. Liver is the most common site of hydatid cysts. Nine patients with echinoccocal liver disease were operated in our department in 2002. Here we present a case where a patient with verified hydatid cyst in the left liver lobe developed high fever, jaundice, nausea, vomiting and pain in the upper abdomen. The symptoms were initially ascribed to the acute cholangitis. After unsuccessful antibiotic treatment, computerized tomography and endoscopic retrograde cholangiopancreatography (ERCP) were performed, demonstrating daughter cysts in the common bile duct. During ERCP, papilotomy was made and daughter cysts were extracted. Hydatid cyst was surgically removed, and a communication between the cyst and left hepatic duct was noted during surgery. Pericystectomy, choledochotomy, removal of remaining daughter cysts from the common bile duct, and sutures of left hepatic duct were performed. The patient recovered fully after the surgery. One of the possible complications of the liver hydatid cysts is the communication between cyst and the biliary tree. Such communications are usually asymptomatic, but symptoms can also mimic acute cholangitis and jaundice, which may lead to the misdiagnosis of the patient's condition.

Effect of cyclosporine in a murine model of experimental colitis.

The use of immunosuppressive therapy may be associated with significant toxicity. The aim of this study was to investigate the effect of cyclosporine A (CsA) in murine model of experimental colitis. Experimental colitis was induced in NMRI mice using an enema of 0.2% solution of dinitrofluorobenzene, combined with skin sensitization. After inducing colitis, experimental groups of animals were treated with CsA (1, 3, 5, 10, 25, 50 mg/kg/day) intraperitoneally (i.p.) or intracolonically (i.c.), and control groups were treated with phosphate-buffered saline intraperitoneally or intracolonically, respectively. Colonic inflammatory changes were assessed using a histopathologic score of 0-30, and pooled whole blood samples were processed with monoclonal antibodies for cyclosporine concentration. In addition, two groups of animals with experimental colitis were treated intraperitoneally or intracolonically with 3 mg/kg/day of CsA, and the colons were also taken for immunohistochemistry for CD25. CsA diminished the extent of colitis in groups treated with 3, 5, 10, or 25 mg/kg intraperitoneally or intracolonically, and in groups treated with 1 and 50 mg/kg intracolonically (P < 0.05). The effect of intracolonic application of CsA was not related to whole blood cyclosporine concentrations. In addition, the effect of CsA at 3 mg/kg, applied intraperitoneally or intracolonically was, in part, expressed in decreasing the numbers of CD25+ cells within colonic mucosa/submucosa (P < 0.05). In conclusions, the results of this study indicate the possibility of intracolonic application of cyclosporine in order to widen the therapeutic window for effective, but possibly toxic drug, such as cyclosporine.