[Peripheral Primitive Neuroectodermal Tumor of the Small Bowel Mesentery - Report of a Case].

INTRODUCTION: Primitive neuroectodermal tumor or Ewing's sarcoma is a tumor of undifferentiated small round cells that arise from the soft tissues, and is believed to be of neural origin. It occurs most often in children, followed by adolescents and young adults. CASE OUTLINE: A case of a 24-year-old patient with ulcerostenosans Ewing's sarcoma of the initial part of the small intestine is presented in our paper. Reviewing the literature and using as an example the case of a female patient with signs of sideropenic anemia caused by primitive neuroectodermal tumor of the small intestine, an attempt was made to clarify the etiology, clinical presentation, diagnosis and therapy with the aim of its rapid detection and treatment. CONCLUSION: Mesenteric primitive neuroectodermal tumor is a rare neoplasm in adults, while it usually occurs in children and young adults. Surgical resection of the lesions with the application of chemotherapy is the main form of treatment of patients suffering from this disease.

[Streptococcus bovis endocarditis as a sign of colon cancer: case report].

INTRODUCTION: Streptococcus bovis is labeled in the literature as a cause of bacteremia and endocarditis, which are often associated with gastrointestinal malignancy. CASE OUTLINE: In our paper we present a patient with endocarditis induced by Streptococcus bovis who was also, after completed cardiologic examination and treatment, diagnosed colon cancer in situ by targeted endoscopy. Owing to the timely diagnosis, and after successful cardiologic surgery with implantation of an artificial aortic valve, patient underwent surgery of the colon, and is now asymptomatic and in good health. CONCLUSION: Complete and detailed endoscopic examination of the colon must be done in patients with endocarditis caused by Streptococcus bovis, even if the patient is asymptomatic. By following these recommendations, it is possible to detect precancerosis or cancer at an early stage and save the patient's life.

[Surgical anatomy of the initial segment of the lateral circumflex femoral artery].

INTRODUCTION: The lateral circumflex femoral artery usually originates from the lateral side of the initial part of the deep femoral artery, or less frequently from the femoral artery. If it is a branch of the femoral artery, it arises directly above the point of origin of the deep femoral artery. The aim of this study was to determine the origin of the lateral circumflex femoral artery, its origin distance from the midpoint of the inguinal ligament and the topographical relations of the origin, which have a great significance in clinical work. MATERIAL AND METHODS: A dissection was performed on the autopsy group of 42 thighs, followed by the analysis of anatomical relationships of the lateral circumflex femoral artery. All data were entered into the custom-made protocol, which contained the case number, age and sex, side, topographical-anatomical relations of the lateral circumflex femoral artery, artery dimensions and variations, and the distance between the place of origin of the lateral circumflex femoral artery and the midpoint of the inguinal ligament. RESULTS: In our study, the lateral circumflex femoral artery most frequently originated from the deep femoral artery, i.e. in 78.6% of cases. In 19.0% of limbs, it originated from the femoral artery, and in one case (2.4%) from a common stem of the deep femoral artery and the lateral circumflex femoral artery, coming from the femoral artery. CONCLUSION: In clinical practice, it is of great importance to know the origin variations of the lateral circumflex femoral artery while planning and performing various surgical and invasive diagnostic procedures in the inguino-femoral region.

Origin of the medial circumflex femoral artery--a cadaver study.

AIM: To determine the pattern of origin of medial circumflex femoral artery (MCFA), its origin distance from the midpoint of the inguinal ligament and the topographical relations of the origin, which have great significance in clinical work. METHODS: Dissections on the autopsy group of 42 thighs were performed, and anatomical relationships of MCFA was analyzed. All data were entered into a scheme of the protocol which was designed for this research containing the case number, age and sex, side, topographical-anatomical relations of MCFA, artery dimensions and variations, and the distance between the place of origin of MCFA and the midpoint of the inguinal ligament. RESULTS: Commonly, in 25 (59.5%) limbs MCFA originated from the deep femoral artery. In 14 (33.3%) limbs MCFA arose from the femoral artery (FA), in one case (2.4%) a common source of deep femoral artery (DFA) and MCFA was identified, and in two limbs MCFA was not noticed. The distance between the level of origin of MCFA and the central point of the inguinal ligament was 44.2 mm, in average, when it was emerging from FA, and 57.9 mm, in average, in cases where MCFA originated from DFA. CONCLUSION: Surgeons and radiologists should be familiar with the variations of clinically important MCFA, which is commonly involved in peripheral occlusive arterial diseases, to improve effectiveness of diagnosis and treatment of various pathological conditions in the femoral region.

Preoperative evaluation in the era of laparoscopic surgery.

To confirm the importance of preoperative evaluation of a patient's health state, to reduce perioperative morbidity and mortality after laparoscopic surgery. A total number of 1,070 patients were selected into groups based on a type of intervention, gender, ASA and NYHA classification. The most common laparoscopic procedure that was performed was cholecystectomy in 920 (86%) patients. Cardiovascular disease had been presented in 952 (89%) patients, 1006 (94 %) of patients were ASA class I- III, while 1049 (98%) patients were NYHA class I and II. Frequency of lethal outcome was 0.1% due to postoperative thromboembolic complications. A lower mortality rate is a result of prescribed protocol and adequate preoperative examination.

Laparoscopic body-tail pancreatic resection for insulinoma.

INTRODUCTION: Insulinomas are the most common endocrine tumours of the pancreas. They are more frequent in females, and they are commonly less than 2 cm in diameter. If conservative treatment of typical clinical symptoms fails, detailed diagnostic procedures are necessary and surgical treatment is indicated.The aim of this report was to emphasize the need of pancreatic resection when insulinoma is poorly visualized during surgery and when it is not possible to perform intraoperative ultrasonography. CASE OUTLINE: A 27-year-old female patient suffered from hypoglycaemic episodes during physical efforts and fasting periods. After examination, diagnostic procedures and preoperative preparation, laparoscopic surgery was performed. The tumour was less than 10 mm in diameter, and it could not be visualized during laparoscopic exploration. The body and the tail of the pancreas were mobilized using ultrasound scissors and the resection was performed by two Endo GIA staplers. The surgical specimen was removed in an endo-bag. The postoperative course was without complications and the glycemic level was normalized. Macroscopic examination of the resected specimen showed a solitary, poorly demarcated, dark grey lesion, 0.8 cm in diameter, with a solid consistence in comparison with the surrounding gland tissue. Histological examination showed a poorly demarcated, subcapsular tissue in this area, consisting of uniform, irregular, cubic and short cylindrical cells, organized in clusters with pseudoglandular and "zellballen" formations. CONCLUSION: In case when the insulinoma is so small in size that it cannot be visualized during operation, pancreas resection is a surgical procedure of choice. Laparoscopic surgery is preferred because of less postoperative complications and faster recovery.

Intraoperative air testing of colorectal anastomoses.

INTRODUCTION: Intraoperative anastomotic air testing of stapled colorectal anastomosis is performed by filling the pelvis with saline solution and insufflating the rectum with air through a sigmoidoscope. The presence of air bubbles indicates anastomotic leaks which are resolved during surgery. OBJECTIVE: The aim of this prospective, randomized study was to perform a comparative analysis regarding the number of anastomotic dehiscences in patients checked by air leak testing and in the control group without air testing. METHODS: After stapled colorectal anastomosis was performed, patients were randomized into two groups of 30 patients. The first group patients underwent intraoperative anastomotic air testing, whereas in the control group this procedure was not performed. The two groups were matched for age, sex, diagnosis and surgical procedure. RESULTS: Intraoperative air tests were positive in seven cases and anastomotic defects were repaired. After surgery, there were three clinical leaks in this group of patients. In the control group, there were six leaks (Unilateral Fischer's exact test, p = 0.24). The incidence of colorectal anastomotic dehiscences in the study group was lower than in the control group by 50%. However, this finding was not statistically significant in our sample. CONCLUSION: In our opinion, intraoperative air testing of colorectal anastomosis is a good method for prevention of anastomotic dehiscence.

Adenomyomatosis of the gallbladder--case report.

Adenomyomatosis of the gallbladder is a benign, mostly asymptomatic condition of an unknown aetiology. Hyperplastic changes in the gallbladder wall cause an overgrowth of the mucosa, thickening of the muscular wall, and formation of intramural diverticula or sinus tracts termed Rokitansky-Aschoff sinuses. Adenomyomatosis is divided on general, segmental and localised. Ultrasound examination, computerized tomography and magnetic resonance are used in diagnostic procedure. The importance of the disease lies in the fact that it can cause recurrent right upper quadrant pain so it must be concerned in resolving pain cause. This paper was aimed at explaining the aetiology of the disease, its clinical manifestation, making diagnosis and therapy in order to make its diagnosis and treatment possible.

[Thoracoabdominal teratoma--rare location].

INTRODUCTION: Teratomas are tumours derived from pluripotent germ cells. They appear most frequently on ovaries. However, other locations are also possible: testicles, retroperitoneum, stomach, neck, and bottom of the mouth cavity. It is not very common to find teratomas in two different body cavities. CASE REPORT: A 51-year-old patient visited her doctor complaining of an intensive pain which suddenly appeared in her low back. The computed tomography scan of the abdomen was performed, which revealed cystic formation, 12.5 x 18 cm in size, with remarkable capsule visualization. It had paraaortic, subdiaphragmatic, retropancreatic and suprarenal left localisation with signs of compression and pancreatic dislocation. The cystic formation had a septated appearance filled with clear fluid in all its parts except at the bottom, where it was dense. The intra-operative finding was left retroperitoneal mass placed above the left kidney, dislocating surrounding structures and their infiltration could not be excluded for sure. A tumour mass passed through the diaphragmatic hiatus and continued in the left thoracic space. The cyst was only drained and the fenestration was performed. Three months later, the second operation was performed--splenectomy, left suprarenaladenectomy, left nephrectomy, aortic deliberalisation, the left diaphragmatic crus was opened and tumour mass was completely removed from the thoracic space. The histological examination showed mature teratoma with morphological characterisations of the skin, so the definite diagnosis was dermoid cyst. CONCLUSION: The patient presented with thoracoabdominal teratoma. Although without malignant transformation, the teratoma required splenectomy, supraadrenalectomy and nefrectomy due to its position and size.

[Complications in laparoscopic surgery].

The development of technology and improvement of laparoscopic equipment enhanced expansion laparoscopic surgeries. Various operations performed using classical operative approach are nowadays done laparoscopic technique. The expansion of the repertoire, the performance of most complicated surgical procedures and increase in the number of laparoscopic interventions result in the increased number of intraoperative and postoperative complications. They occur due to the basic disease that is the cause of surgery and surgical procedure, but also due to other factors. We cannot influence the very disease - it is the reason for surgical treatment. However, we can make some changes in approach concerning the laparoscopic technique, which can considerably influence possible development of complications. This involves a different approach to the operative field, but also to very surgery. In laparoscopic surgery such approach causes specific intraoperative and postoperative complications. These complications are mainly caused by technical factors, such as the quality of the equipment, instruments and human factors, such as inexperience, insufficient education and excessive self-assurance. To decrease the frequency of intraoperative and postoperative complications in laparoscopic operations we require perfect equipment and instruments, education in a referent institution, but also everyday training with laparascopic equipment and experimental animals.

Harmonic Scalpel hemorrhoidectomy: a painless procedure?

Since the surgical treatment of hemorrhoidal disease has been characterized by intense postoperative pain, recent studies have tried to modify the standard Milligan-Morgans technique. The up-to-date literature, in the experience of authors, has confirmed that the new method of Harmonic Scalpel hemorrhoidectomy reduces postoperative pain. The aim of our study was to statistically evaluate, based on our experience, the efficacy of this surgical approach in terms of reducing postoperative pain and establishing a stable hemostasis. Seventy-seven (77) patients suffering from hemorrhoidal disease, stage III and IV, underwent surgery in our clinic during the last five years. The postoperative pain was determined using the visual analog scale on the 1st, 2nd and 7th postoperative days. Patients were divided into two groups in regard to the surgical procedure applied. The data were statistically processed using the Statistica 7.0 software. We concluded that Harmonic Scalpel hemorrhoidectomy, due to less thermal damage, statistically significantly reduced postoperative pain with better hemostasis, compared with Milligan-Morgan's method of treating hemorrhoidal disease.

[A case of choledochal cyst complicated by biliary peritonitis].

INTRODUCTION: Choledochal cyst is a rare congenital malformation of the extrahepatic bile ducts. Its incidence varies among different populations, but it is highest in North East Asia. It is most frequent in childhood, and very rare in adults. CASE REPORT: A 7-year-old boy was admitted to the hospital with severe abdominal pain under the right rib margin. He presented with constant nausea, occasional jaundice and high coloured urine. The following day the boy underwent ultrasound examination and computer tomography (CT). A choledochal cyst was found, and a CT-controlled puncture of the cyst was performed. An Xray was taken by injecting contrast medium through the drain. A small leakage into the abdominal cavity was observed with subsequent peritonitis. The general condition of the child deteriorated and a decision was made to operate immediately. An upper medial laparotomy was performed. A cystic formation was noted in the hepatoduodenal ligament of 90 x 70 mm in dimension. The cyst was completely removed and a hepaticojejunal anastomosis was performed The child tolerated the surgery well and recovered quickly. DISCUSSION: Cystic dilation of the common bile duct, known as choledochal cyst, is related to a rare malformation of this region. The exact mechanism of cyst formation remains unknown. Choledochal cysts usually present in the early childhood, with higher frequency in females. The diagnosis is easily made, especially with the use of ultrasound and computed tomography. The treatment is usually surgical, and complete resection of the cyst with hepatico-jejunal anastomosis is the therapy of choice. CONCLUSION: One year later, ultrasound examination and specific dynamic tests (HIDA) showed normal liver function, and good anastomosis.