C-reactive protein as an early predictor for anastomotic leakage in elective abdominal surgery.

BACKGROUND: Anastomotic leakage (AL) represents a serious complication after abdominal surgery. Therefore, it is important to detect it early before it becomes clinically apparent. The predictive value of C-reactive protein (CRP) as a marker of infective postoperative complications, particularly in the form of anastomotic leakage, has been investigated by several authors with promising results. The aim of this study was to evaluate the diagnostic accuracy of C-reactive protein in predicting anastomotic leakage. METHODS: The serum CRP level, white blood cell (WBC) count, and body temperature (BT) of 156 patients who underwent elective abdominal surgery with primary anastomosis were monitored daily until postoperative day (POD) 7. We recorded all postoperative complications and analyzed the data. Diagnostic accuracy of CRP with regard to development of AL was assessed by receiver operating characteristic curve analysis. RESULTS: Fifteen patients (9.6 %) developed anastomotic leakage. CRP was significantly higher every day during the first 7 postoperative days in patients who developed AL compared with those patients who did not develop complications, whereas the WBC count and BT were not. A CRP cutoff value of 135 mg/l on POD 3 yielded a sensitivity of 73 %, a specificity of 73 %, and a negative predictive value of 95.4 % for the detection of AL. CONCLUSIONS: According to our results, values of CRP less than 135 mg/l on POD 3 may contribute to a safe discharge from hospital. Patients with CRP values higher than 135 mg/l on POD 3 require prolonged hospitalization and an intensive search for infective complications, particularly AL.

Early prediction of symptomatic hypocalcemia after total thyroidectomy.

BACKGROUND: Hypocalcemia is the most common postoperative complication after total thyroidectomy. The aim of this prospective study was to determine biochemical parameters in the early postoperative period that could identify patients with significantly increased risk of symptomatic hypocalcemia development. METHODS: The study included 100 individuals undergoing total thyroidectomy from January to May 2009. In all patients PTH, calcium, inorganic phosphate, magnesium, and albumin levels were measured immediately preoperatively, 30 minutes postoperatively and every morning for the following five days. RESULTS: Clinically significant hypocalcemia was observed in 19% of all cases. Fall of the iPTH values by more than 88% from preoperative values, 30 min after completion of the surgery, showed 100% sensitivity and 100% specificity for the occurrence of symptomatic hypocalcemia. CONCLUSIONS: According to our results immediate postoperative measurement of the iPTH may be considered as a useful method to predict with high certainty which patients will need calcium supplementation, and to separate them from patients who can be safely and early discharged.

The histological diagnosis of dysplastic and neoplastic lesions in inflammatory bowel disease: a pathological perspective.

Patients with inflammatory bowel disease (IBD), both ulcerative colitis (UC) and Crohn's disease (CD), are at an increased risk for developing colorectal carcinoma (CRC). The accurate diagnosis of dysplasia in biopsies taken during periodic surveillance of long-standing IBD patients is most important in prevention of UC and CD related cancer. Distinction of low from high grade IBD-related dysplasia and differential diagnosis between IBD-related dysplasia and dysplasia in sporadic adenoma as well as distinction from pseudodysplastic lesions in inflammatory pseudopolyps or reparative lesions is often very subtle and difficult and demands expertise of second experienced gastrointestinal pathologist. Although surveillance colonoscopy with multiple biopsies does not reduce the cancer mortality, it offers a reasonable chance of detecting precancer and performed prophylactic colectomy. Novel methods of detecting dysplasia are continuously being evaluated, including chromoscopy and molecular biology markers. In the future, one may expect, from these new markers to detect the dysplasia in IBD patients before development of histological evidence of neoplastic changes.

[Papillary carcinoma of the thyroid in intrathoracic goiter]. / Papilarni tireoidni karcinom u intratoraksnoj strumi.

Intrathoracic goiter (more than 80% of tissue in the thoracic cavity) represents very rare clinical entity (less than 1% of total number of thyroid gland surgical procedures). Cancer incidence in these goiter is 0-5%. The aim of this article is to present a case report of intrathoracic thyroid papillary carcinoma with multiple compressive syndrome and review of compressive intrathoracic syndrome of thyroid etiology. In our patient we have found: tracheal and oesophageal deviation and compression, superior vena cava syndrome, downhill varices, chylothorax, pericardial effusion, compress of the left a. subclavia, unilateral lesion of recurrent and phrenic nerve, and brachial plexopathy. This was a unique case with multiple compressive syndrome between 3000 patients surgically treated for all kinds of thyroid diseases. Intrathoracic goiter can cause all the known symptoms and syndromes of intrathoracic compression with possibility of rapid deterioration and fatal end.

[Papillary microcarcinoma of the thyroid and secondary hyperparathyroidism in a patient on hemodialysis]. / Papilarni mikrokarcinom stitaste zlezde i sekundarni hiperparatireoidizam kod bolesnika na hemodijalizi.

Association between non-medullary thyroid carcinoma and secondary hyperparathyroidism have been rarely reported in patients with renal failure. A few cases of micropapillary thyroid carcinoma have been reported in patients before and after renal transplantation. We present a case of incidental detection of thyroid carcinoma at the time of parathyroidectomy in patient on dialysis after cadaver renal transplantation.

[Early complications in surgical treatment of thyroid diseases: analysis of 2100 patients]. / Rane komplikacije operativnog lecenja oboljenja stitaste zlezde: analiza 2100 bolesnika.

Thyroid gland surgery today is not saddled with high incidence of main complications. Miscellaneous surgical institutions with different surgical approach, operative technique and radicality have published reports with great discrepancy in incidence of complications, analyzing them with different methods of diagnosis and result evaluation. In the same way it is well known that higher latitude of operative procedure gave better control of thyroid diseases, but it can be accompanied with more complications. All of that motivate us to analyze complications of operative treatment in our patients under well known criteria, with hypothesis that higher radicality of operative procedure do not increase incidence of complications, and that this incidence is in correlations with results published in world literature. Aim of this nonrandomized study was to analyze results of operative treatment for huge number of consecutively operated patients in our teaching hospital, to analyze and compare results according to group of diseases and operative procedures, and to compare final results with results published in the world literature. Complications of operative treatment were analyzed retrospectively for period 1988-1997 (Group I) and prospectively in period 1998-2002 (Group II). Operations were performed by 20 surgeons and 20 young surgeons during their education. We have analyzed only complications during first 30 days after operation. In Group I there was 1425 patients with 1451 operations (192 thyroid malignancies, 247 hyperthyreosis, 98 reoperations, 13% thyroidectomies and 14.8% lobectomies), with complication rate of 14.3%. Most common complication was recurrent laryngeal nerve injury in 9.3% patients or 6.3% according to number of exposed nerves (nerve at risk), then postoperative hypocalcemia with rate of 4.7% (persistent in 1.3%). In Group II in 675 patients there was 687 operations (96 thyroid malignancies, 111 hyperthyreosis, 35 reoperations, 36.6% thyreoidectomies and 25% lobectomies), with complication rate of 10.7%. Most common postoperative complication was hypocalcemia with 5% rate (persistent in 0.7%), then recurrent laryngeal nerve injury in 4.4% patients or 2.9% according to number of exposed nerves. Incidence of recurrent laryngeal nerve injury in Group II is less frequent than in Group I, highly statistically significant (p < 0.01), while for other complications there is no statistically significant difference. Totally for both groups there was 0.7% tracheotomies, postoperative bleeding in 1.1% of patients, wound hemathoma in 0.5%. wound infections in 0.9%, pneumonia in 0.5%, mortality 0.5% and most common cause of death (8/11) was problem with respiration, Airway obstruction. In Group II complications were less frequent in total thyroidectomies in relation to lobectomy with contra lateral subtotal lobectomy. In both groups and totally incidence of complications was higher in reoperations, in patients with more extensive operative procedure, in malignant diseases and hyperthyreosis. In thyroid gland surgery more extensive operative treatment with improved operative technique (micro dissection, recurrent laryngeal nerve visualization and parathyroid gland preservation), in our teaching hospital, do not have influence on incidence of postoperative complications, even recurrent laryngeal nerve injury was significantly less frequent. This results are in correlation with published results of similar hospitals around the world.

Intrathoracic goiter: analysis of 21 cases.

UNLABELLED: Goiters are classified into: the cervical, retrosternal, substernal and intrathoracic. The aim of research is to analysis of intrathoracic goiters (ITG) which include goiters with more than 80% of tissue in the thoracic cavity and intrathoracic thyroid choristomas. METHODS: In prospective non-randomized study were analyzed 21 consecutive patients operated on for intrathoracic non-toxic benign goiters from 1987-98. Fourteen patients with intrathoracic goiters (more than 80% of tissue in the thoracic cavity) and seven patients with intratoracic choristomas were operated. Two groups of ITG were observed according to the expressed symptomatology and surgical approach and complications of operative treatment were compared to the complications of operative treatment of 986 non-ITG non-toxic benign goiters. RESULTS: ITG represented 1.1% of the whole number of operatively treated thyroid diseases. One third of patients were asymptomatic. Commonly observed symptoms were dispnea, stridor and dysphagia and there was no significant difference in appearance of these symptoms between the two groups of ITG. In 19% of patients correct preoperative diagnosis wasn't assessed. Cervical approach with sternothomy was used in 11 patients, cervical approach with right thoracotomy in seven, right thoracotomy only in two, and cervical approach only in one patient. Thoracic approach was used in 95% of cases and there was no significant difference between the two groups of ITG. Concerning the operative complications, in two patients transient vocal cord paresis and in one patient postoperative bleeding were verified. There was no statistically significant deference in frequency of operative complications between ITG and non-ITG. CONCLUSIONS: ITG are rare, but might present a difficult diagnostic and complex surgical problem. Common clinical presentation and identical surgical approach in operative treatment justify the common review of the two groups of intrathoracic goiters. With adequate and timely performed surgical approach, in specialized institutions, frequency of complications in operative treatment of ITG is not higher if compared to operative treatment of non-ITG.

[Cystic mesothelioma of the greater omentum]. / Cisticni mezoteliom velikog omentuma.

Peritoneal cystic mesothelioma is very rare clinical entity, and only a few cases situated on the greater omentum are described. The authors here presented two cases of the greater omentum cystic mesothelioma that were diagnosed in 260,000 adult patients hospitalized for the first time, during the fifteen year period. Cystic tumor of 30 cm in diameter was found in a 78 years old male patient, and the second one was 35 cm in diameter in female patient 56 years old. Symptomatology was not characteristic. Peritoneal pseudocyst or parasitic, lymphogen, urogenital, enteric or dermoid cyst origin was preoperatively excluded, and correct diagnosis was established upon the operative findings and immuno-histochemical investigations. In both cases keratin and vimentin were clearly positive in tumor cells, but other markers were negative (EMA, Actin, S-100, NSE, chromogranin and sinoptophysin). Cystic mesothelioma was not infiltrative and surgical treatment was simple and successful.

[Adhesive ileus caused by a peritoneal reaction to starch]. / Adhezivnih ileus izazvan reakcijom peritoneuma na skrob.

Peritoneal reaction caused by glove powder is not so rare in surgical practice. We have presented a case report of a patient who was operated on due to the adhesive bowel obstruction, two years after the total gastrectomy for gastric cancer. Changes found on the peritoneal surface were similar to carcinomatous dissemination, but intraoperative frozen section analysis showed granulomatous lesions caused by foreign bodies. Nature of these changes was confirmed by PAS smear and polarization microscopy. Clarification of the peritoneal changes during relaparotomy is possible only with careful microscopic analysis of these granulomas.

[Total intravenous anesthesia using remifentanil and propofol with midazolam co-induction in laparoscopic surgery of the gallbladder]. / TIVA remifentanilom i propofolom uz koindukciju midazolamom za laparoskopske operacije zucne kese.

We investigated effects of total intravenous anesthesia (TIVA) with propofol and remifentanil (in two parallel continuous infusions), on 28 ASA I-II patients undergoing laparoscopic cholecystectomy. All patients received midazolame (0.05 mg/kg b.w.), and 90 sec thereafter, remifentanil (0.5 g/kg b.w.). Computer controlled intravenous infusion of propofol started at dose of 6 mg/kg/h (by Graseby 3400 Syringe Pump). Muscle relaxation was achieved by rocuronium (0.6 mg/kg b.w.). After endotracheal intubation, rate of propofol was decreased on 3 mg/kg/h and started with another infusion of remifentanil (0.5 ug/kg/min). Before (T0) and after induction (T1), after start of surgery (T2), and at the end of surgery (T3), we evaluated: systolic, diastolic, and medial arterial blood pressure (SAP, DAP, MAP), heart rate (HR), peripheral saturation of O2 (O2Sat), and capnometry (ETCO2), by Datex-Engstrome AS/3 Monitore. It was followed side effects of anaesthesia, early and complete recovery rate, and frequency of nausea and vomiting in postoperative period. Results showed haemodynamic stability of patients after induction in anaesthesia (defined as decreasing of MAP 20%, compared with preinduction values). During investigation (T0-T3), results of 0.2Sat and ETCO2 were excellent (0.60 +/- 2 and 5.1 +/- 2.4 min). There wasonly one case of postoperative nausea and vomiting, and no significant side effects of anaesthesia. TIVA remifentanil-propofol and co-induction with midazolame makes possible haemodynamic stability of patients after induction in anaesthesia, good oxygenation during surgery, fast early and complete recovery, and avoiding of side effects of anaesthesia and postoperative nausea and vomiting. We concluded that it is a good choice of anaesthesia for laparoscopic cholecystectomy.

[Mesothelial cyst and cystic mesothelioma of the greater omentum:case report and literature review]. / Mezotelna cista i cisticni mezoteliom velikog omentuma: prikaz slucaja i pregled literature.

Mesothelial cysts and cystic mesotheliomas of the greater omentum are very rare clinical entities. About 30 cases of mesothelial cysts and only 4 cases of cystic mesotheliomas were described in the world literature so far. Over 13 years period (1987-2000), between 15,000 laparotomised adult patients, we have diagnosed one case of mesothelial cyst and one of cystic mesothelioma only. Mesothelial cyst, 7 cm in diameter, covered by regular mesothelial cells, was found accidently during gaster cancer surgery. In a 78 years old man, 30 cm in diameter cystic mesothelioma was diagnosed with immunohistochemical studies, necessarily for differentiation between cystic mesothelioma and other peritoneal cysts. Due to possible aggressive course at the diseases and tendency to recurrency, a complete surgical excision and log term follow-up are necessary.

Tympanometric findings in cleft palate patients: influence of age and cleft type.

Tympanometry was analysed according to cleft type with respect to age in 239 cleft palate patients (57 with bilateral cleft lip and palate (BCLP)), 122 with unilateral cleft lip and palate (UCLP) and 60 with isolated cleft palate (ICP). The frequency of type B tympanograms was 46.5 per cent in the BCLP group, 50.6 per cent in the UCLP group and 58.3 per cent in the ICP group. Type A tympanograms were more frequently observed in older patients (median age 11 years) in comparison to type B (median age five years; p < 0.001) and type C (median age six years; p < 0.001). The total sample showed an age-related decrease in the frequency of type B tympanograms (rs = -0.3942; p < 0.001). The frequency of type A tympanograms increased significantly with age (rs = 0.4263; p < 0.001), whereas type C was not correlated with age. In the UCLP group, the frequency of type B tympanograms decreased with age (rs = -0.4430; p < 0.001), the decrease being faster than in the BCLP group (rs = -0.3186; p = 0.001) and the ICP group (rs = -0.3378; p < 0.0001)). Type B tympanograms had the highest correlation with a hearing loss of 21-40 dB at mean hearing level at speech frequencies (MHLSF) (rs = 0.4574; p < 0.001), a lower correlation with a hearing loss of 11-20 dB (rs = 0.2184; p = 0.02) and the lowest correlation with hearing loss above 40 dB. At the ages of one to three, the frequency of type B is higher in UCLP patients than in the BCLP and ICP groups, decreasing at seven to 12, increasing again at 13 to 15, and thereafter showing a continuous decrease. In the BCLP group, the frequency of type B increased significantly at the ages of four to six and then decreased continuously from seven to 18. In ICP patients, the changes in the frequency of type B with age are not significant until the age of 15; at the age of seven, it is higher than in the BCLP and ICP groups. The type C tympanogram is not typically found in cleft palate patients and its frequency is not correlated with age. It can be presumed that each type of cleft lip and palate, due to its characteristic conditions in the epipharynx, will favour a different mode of pathophysiological development of middle-ear disease.

Early angiogenic capabilities of the transposed omental flap after omentomyelopexy.

Abundant in blood and lymph vessels, capable to adhere to the surface of every lesion, with capillary overgrowing in 4-6 hours, omentum represents almost very suitable organ for revascularization of the ishaemic nervous tissue. Angiographic study of the omentum, especially of the surgically developed omental flap have been rarely performed in clinical practice. The aim of this study was evaluate the angiographic features of the omental flaps after omentomyelopexy. Omentomyelopexy based on the left gastroepiploic vessels was performed in 100 patients of different levels spinal cord injuries. In order to study the omental flap's vascularization, selective angiography of the splenic artery was performed in three patients at the 10th postoperative day. In one patient, angiographic finding showed the establishment of anastomosis between omental flap's arteries and vertebral and spinal artery and in that way, almost incredible angiogenic capabilities of omentum have been proved. Besides confirmation of vitality and good vascularization of the extraperitonealy transposed omental flap, an extraordinary angiogenic capabilities of the omentum have been proved as early as at the 10th postoperative day. To our best knowledge the angiographic findings of this kind have not been published so far.

[Complications in omentopexy and personal experience with 100 omentomyelopexies]. / Komplikacije omentopeksija i nase iskustvo sa 100 omentomijelopeksija.

Abdominal and general complications of omentomyelopexies are seldom seen, and were mostly presented as the case reports. The aim of this study was to present in a comprehensive analysis of the data acquired from literature the reported omentopexy complications, and to compare them with our own results of the application of the omental flap with left gastroepiploic blood vessels. Prospective clinical research included the first 100 operated patients with injuries on different spinal cord levels. In all patients the omental flap was prepared by our original surgical technique and led to the site of the spinal cord lesion. In 6 of our patients we noticed seven complications and those were: three iatrogenic pneumothoraxes, two lesions of the spleen (without splenectomy), one pneumonia and one mild infection of the laparotomy wound. Prevalence of the complications related to the abdominal act of omentomyelopexy of 7% was significantly lower than in those presented in the literature with other right gastroepiploic artery omentopexies (20-79%). In our patients complications occurred earlier, lasted shorter and had no permanent implications for the patients' health. By using the omental flap with left gastroepiploic blood vessels it was possible to perform effective, relatively simple and safe omentomyelopexy for the injuries on all levels of the spinal cord. Such a mode of omental flap preparation with left gastroepiploic blood vessels could be applied for other omentopexies as well.

[Premalignant and malignant changes in idiopathic inflammatory bowel disease]. / Premaligne i maligne promene u idiopatskim zapaljenskim crevnim bolestima.

It is well known that patients with long-standing inflammatory bowel disease (IBD), ulcerative colitis (UC) or Crohn's disease(CD) are at increased risk for developing colorectal cancer (CC). Before adenocarcinoma develops, the intestinal epithelium progress through a premalignant phase of dysplasia, which can be identified via mucosal biopsy and routine tissue histology. Surveillance colonoscopy and prophylactic colectomy for dysplasia or asymptomatic cancer is advised as a method of reducing cancer-related mortality. Many physicians suggests that surveillance for extensive colitis should begin after 8 to 10 years of disease, and surveillance for left-sided colitis should begin after 15-20 years. Colonoscopy is recommended with frequent biopsies, at least every 10 cm in all four quadrants, and with biopsy of any suspicious lesion. The emerging field of colon cancer genetics has identified several important tumor markers that have potential to improve sensitivity for detection of early neoplasia.

[Surgical treatment of Crohn disease of the small intestine]. / Hirursko lecenje Kronove bolesti tankog creva.

The evolution of the surgical treatment of Crohn's disease has three attainable aims: to be minimal, safe and therefore timely. Conservative surgery is increasingly the trend in surgical treatment of small-bowel Crohn's disease. Patients with Crohn's disease are managed non-surgically until complications of the disease or failure to thrive or significant side effects of medication occur, and then--at this point--surgery usually occurs. Once a complication has developed, it is not recommended to wait for this to become further complicated. Resectional surgery and strictureplasty for Crohn's disease of the small bowel are today methods of choice. Laparoscopic intestinal surgery is going to be of a great significance. Abdominal surgery for Crohn's disease is not curative and forms only part of a lifetime management of the patient.

Mastoid pneumatization and aging in children with Pierre-Robin syndrome and in the cleft palate population out of syndrome.

We examined the characteristics of mastoid pneumatization in the Pierre-Robin syndrome (PRS) and non-PRS cleft palate population in relation to age. There were 14 patients with PRS (median age, 5 years), 7 patients with bilateral cleft lip-palates (BCLP: median age, 6 years), 29 patients with unilateral cleft lip-palates (UCLP: median age, 6 years) and 15 patients with isolated cleft palates (ICP: median age, 7 years). All had secretory otitis and ventilation tubes inserted. Pneumatization was assessed by standard computerized planimetric methods. Temporal bone (Schüller view) X-rays were obtained. Areas of bone pneumatization were outlined and measured separately for each ear. The median pneumatized area of the mastoid (MBP) in PRS patients (6.73 cm2) was significantly lower than in non-PRS cleft patients (7.29 cm2). It was also lower than in UCLP (7.35 cm2; P = 0.01) and ICP (7.19 cm2; P = 0.02). MBP did not change significantly with age in PRS (Spearman rs = 0.11) and BCLP (Spearman rs = 0.11), but did increase significantly in the ICP group (Spearman rs = 0.23; P = 0.04). Cubic regression showed the best fit in the BCLP (r2 = 0.61; P = 0.01) and ICP (r2 = 0.10; P = 0.05). It was not significant for PRS (r2 = 0.132) or UCLP (r2 = 0.049). We concluded that pneumatization in all cases increases with age, but it is statistically significant only in ICP. PRS patients have a lower area of mastoid air-cell size than the non-PRS cleft palate population. The extent of mastoid pneumatization in PRS patients does not correlate with age because of the negative influence of the mandibular hypoplasia and glossoptosis present.