[First synchronous liver resection as a part of cytoreductive surgery, peritonectomy and HIPEC in Croatia--case report]. / Prva sjnkrona resekcija jetre u sklopu citoreduktivne kirurgije, peritonektomije i HIPEC-a u hrvatskoj--prikaz bolesnice.

We present a case of a 37-year-old female, with large adenocarcinoma of transverse colon, and metastases in spleen, liver, peritoneum, greater omentum, gall bladder and right adnexa. She was transferred to our Hospital, and extensive elective cytoreductive surgery with intraabdominal hyperthermal chemotherapy (HIPEC) was performed. Couple of months later, she was operated on for a newly evidenced secondary nodus in liver segment VII, and metastasectomy was performed. Throughout entire postoperative period she was receiving cyclic chemotherapy. At this point, 2 years from the first operation, she was without evidenced recurrence of the disease. Aggressive cytoreductive surgery with multiorgan resection, peritonectomy, HIPEC and adjuvant chemotherapy which was proved to be a feasible option in some patients, with synchronous liver resection (LR) proved to be feasible and beneficial for patients with three or fewer liver metastases. This is the first liver resection included in usually performed cytoreductive surgery and HIPEC in Croatia.

[Croatian guidelines for perioperative enteral nutrition of surgical patients]. / Hrvatske smjernice za perioperativnu enteralnu prehranu kirurskih bolesnika.

Nutritional status of patients significantly affects the outcome of surgical treatment, whether it's about being obese or malnutrition with loss of muscle mass. Inadequate nutritional support in the perioperative period compromises surgical procedures even in patients who are adequately nourished. In this paper, particular attention was paid to malnourished patients, and their incidence in population hospitalized in surgical wards can be high up to 30%. Special emphasis was paid to the appropriateness of preoperative fasting and to the acceptance of new knowledge in this area of treatment. The aim of this working group was to make guidelines for perioperative nutritional support with different modalities of enteral nutrition. The development of these guidelines was attended by representatives of Croatian Medical Association: Croatian Society for Digestive Surgery, Croatian Society for Clinical Nutrition, Croatian Society of Surgery, Croatian Society for Endoscopic Surgery, Croatian Trauma Society and the Croatian Society of Anesthesiology and Intensive Care. The guidelines are designed as a set of questions that arise daily in clinical practice when preparing patients for surgery and after the surgical treatment, which relate to the assessment of nutritional status, perioperative nutritional support, duration of preoperative fasting period and the selection of food intake route. Assessment of nutritional status and the use of different modes of enteral nutrition should enter into standard protocols of diagnosis and treatment in the Croatian hospitals.

Mitochondrial myopathy associated with a novel 5522G>A mutation in the mitochondrial tRNA(Trp) gene.

We report a novel pathogenic mutation of the mitochondrial transfer RNA (tRNA) gene for tryptophan in a patient with isolated myopathy and persistently elevated creatine kinase. Muscle studies revealed ragged red fibres and decreased activity of respiratory chain complex I and cytochrome c oxidase (COX). Sequencing of the 22 mitochondrial tRNA genes revealed a mutation m.5522G>A, which alters a conserved base pairing in the D-stem of the tRNA for tryptophan. The mutation was heteroplasmic with a mutational load between 88 and 99% in COX-negative fibres. This case contributes to the genetic heterogeneity of mitochondrial diseases caused by mutations in mitochondrial tRNA genes.

Perforated ascending colon cancer presenting as colocutaneous fistula with abscess to the anterior abdominal wall at the site of a cholecystectomy scar treated with biologic mesh.

Ascending colon cancer as a colocutaneous fistula to the abdominal wall at the site of a previous postoperative scar is extremely rare. A 69 year old male presented with five day history of pain and foul smelling discharge from right subcostal scar from elective cholecystectomy performed 8 years ago. Last three days, he had fever up to 39 degrees C, with mild pain in right upper abdominal quadrant without vomiting, diarrhea, bloody stools or weight loss. Computed tomography, with peroral contrast, revealed extralumination into abdominal wall with several fistulas reaching the skin. Emergency median laparotomy found infiltrating tumor of ascending colon into abdominal wall. A right hemicolectomy and complete thickness abdominal wall excision (7 x 10 cm) was performed. The abdominal wall defect was too extensive for primary closure and two 20 x 20 cm moist gauzes were placed to cover the defect and were fixed with stitches to the skin. On second postoperative day, due to contamination, porcine dermal collagen implant was placed intraperitoneally. Such emergency presentations and therapeutic options are discussed.

[Adhesiolysis and partial resection of terminal ileum in a patient with kidney transplantation and severe sclerosing peritonitis]. / Adhezioliza i parcijalna resekcija terminalnog ileuma u bolesnice s transplantiranim bubregom i teskim sklerozirajucim peritonitisom.

A 21-year-old female patient was diagnosed with horseshoe kidney at the age of 10. She had been treated with peritoneal dialysis from 2005 to 2009, when she received kidney from a deceased donor. The posttransplant course was complicated by development of Pseudomonas aeruginosa and Candida sepsis. Reduced immunosuppression resulted in acute rejection, which demanded graphtectomy 2 months after transplantation. She restarted peritoneal dialysis for additional 2 years. In March 2011, she received her second transplant with excellent function. Nine months after the transplantation, she developed ascites, with early satiety and vomiting. MSCT revealed severe encapsulating sclerosing peritonitis. Her overall condition deteriorated, so she underwent adhesiolysis with resection of incarcerated terminal ileum. Due to acute allograft rejection, urgent graphtectomy was performed. Currently, she is receiving everolimus and dialysis successfully, with excellent overall status.

Spontaneous perforation of the small intestine, a novel manifestation of classical homocystinuria in an adult with new cystathionine beta-synthetase gene mutations.

The clinical picture of classical homocystinuria is diverse. This is the first report of an adult homocystinuric patient with non-traumatic spontaneous small bowel perforation. A 47-year old man presented with abdominal rebound tenderness, hypotension and tachycardia, anemia, and elevated markers of inflammation. Other routine laboratory tests were normal. Abdominal x-ray showed no free air. An emergency laparotomy revealed jejunal perforation in the left upper quadrant. Histologic specimen showed full-thickness nonspecific inflammation of the intestinal wall with granulocytic infiltration, hemorrhage and necrosis. Tuberculosis, actinomycosis and typhus were histologically and clinically excluded. After excluding all known possible causes of perforation, we presumed a causative relationship between homocystinuria and small bowel perforation. It could be hypothesized that connective tissue weakness in homocystinuria is a result of homocysteine interference with recombinant human fibrillin-1 fragments or cross-linking of collagen through permanent degradation of disulfide bridges and lysine amino acid residues in proteins. DNA analysis showed three detectable mutations in the cystathionine beta-synthetase gene, 1278T:c.833T>C, and two new mutations, V372G:c.1133T > G, and D520G:c.1558A > G in the aternatively spliced exon 15.

Hyperthermic intraperitoneal chemotherapy (HIPEC) and cytoreductive surgery (CS) as treatment of peritoneal carcinomatosis: preliminary results in Croatia.

The purpose of our study was to evaluate initial results following introduction of Hyperthermic Intraperitoneal Chemotherapy (HIPEC) and Cytoreductive Surgery (CS). Twenty two patients with intraperitoneal malignancy undergone cytoreductive surgery (CS) and hyperthermic intraoperative chemotherapy (HIPEC) between January of 2007 and January 2010. Nine patients had adenocarcinoma of colorectal origin, 8 patients had ovarian cancer, and 5 had pseudomyxoma peritonei. Inclusion criteria were diagnosis of peritoneal carcinomatosis based on intraoperative assessment during first operative procedure for intraabdominal malignancy or follow-up diagnostic imaging proof Excluded were patients with known malignant proliferation outside abdomen, liver metastasis and ASA score 4 and higher. All patients with pseudomyxoma peritonei diagnosis are alive, with mean follow-up time 24.8 months (range 15-35). In group of patients with adenocarcinoma from colorectal origin, 3 died, resulting in mean survival time 7.6 months (range 1-16). In group of patients with ovarian cancer, 2 died, resulting in mean survival time 13.8 months (range 0-31). Two patients died in early postoperative period. Most of the patients had some sort of mental disorder. Although HIPEC with CS improves survival, during introduction period higher morbidity and mortality could be expected.

Abdominal hernias in pregnancy.

A hernia is an area of weakness or complete disruption of the fibromuscular tissues of the body wall. In addition to the body wall, hernias can occur in the diaphragm, pelvic wall, perineum, pelvic floor, and internal abdominal viscera (hernias through omental or mesenteric defects, ligaments and folds). Surgical repair of different types of hernia is the most common general surgical procedure with more than 20 million hernioplasties performed each year. Abdominal wall hernias are not common during pregnancy. Hernias can be symptomless or have minimal symptoms, including slight discomfort or pain. Such hernias are not life-threatening and should be controlled on regular basis. After spontaneous delivery and uterine involution, they should be repaired on an elective basis. It is of utmost importance for a clinician to diagnose emergent situations, which include incarceration, strangulation and perforation caused by hernia because consultation with a surgeon and emergency operation are mandatory. There is still no consensus for irreducible hernia during pregnancy, but complications during pregnancy outweigh elective operation. Therefore, hernioplasty is recommended during pregnancy, especially in early gestation.

Radiofrequency ablation as locoregional therapy for unresectable hepatic malignancies: initial results in 24 patients with 5-years follow-up.

Radiofrequency ablation (RFA) is one treatment modality for unresectable liver metastases. Patients with hepatic malignancies (n = 24) underwent elective RFA. All tumors were ablated with a curative intent, with a margin of 1 cm, in a single session of RFA. The median diameter of tumor was 3.1 cm (range 1.7-6.9 cm). Studied patients were not candidates for resection due to multifocal hepatic disease, extrahepatic disease, proximity to major vascular structures or presence of cirrhosis with functional hepatic reserve inadequate to tolerate major hepatic resection. Complete tumor necrosis was achieved in 87.5% and tumor recurred in 3 patients (12.5%) with lesions larger than 5 cm. Distant intrahepatic recurrence was diagnosed in another 4 (16.7%). Distant metastases were found in 7 (29.2%) patients. Four of these 7 patients had also distant intrahepatic recurrence of disease. Two and 5-years survival rates were 41.7% (10 patients) and 8.3% (2 patients) respectively. RFA is safe and effective option for patients with unresectable hepatic malignancies smaller than 5 cm without distant metastatic disease. RF ablation resulted in complete tumor necrosis in 87.5% with 2 and 5-years survival rates much higher than with chemotherapy alone or only supportive therapy, when survival is measured in weeks or months. If RFA is unavailable, percutaneous ethanol injection therapy can be done but with inferior survival rates.

Colonic duplication in an adult who presented with chronic constipation attributed to hypothyroidism.

Gastrointestinal duplications are an uncommon congenital abnormality that manifest before the age of two in 80% of cases. Ileal duplication is the most common while colonic duplication, either cystic or tubular, occurs in 10%-15% of cases and remains asymptomatic and undiagnosed in most cases. Mostly occurring in pediatric patients, colonic duplication is encountered in adults in only a few cases. The most common clinical manifestations are abdominal pain and intestinal obstruction. Rarely, duplications present with signs of acute abdomen or acute bleeding. This study reports a case of colonic duplication in an adult who presented with chronic constipation. Complete diagnostic workup was made on several occasions during the previous eight year period, but no pathology was found and chronic constipation was attributed to hypothyroidism caused by long standing Hashimoto thyroiditis. Multislice CT, performed because of abdominal distension, defined colonic pathology but the definite diagnosis of duplication of the transversal colon was made at operation. The cystic duplication and the adjacent part of the ascending and transversal colon were excised en-block. This study implies that colonic duplication, though uncommon, should be included in the differential diagnosis of chronic constipation even when precipitating factors for constipation, such as hypothyroidism are present.

Endomedullary radiofrequency ablation of metastatic lesion of the right femur 5 years after primary breast carcinoma: a case report.

Metastatic tumors of the long bones usually present with severe pain refractory to analgesic therapy. Pathologic fractures of the bone may lead to the significant decrease of patient's quality of life and necessitate further surgical therapy. We present 66 year old female with metastatic left breast carcinoma (T2N0M0) diagnosed 5 years before presentation of the metastatic lesion of the right femur causing severe pain in the middle of the right upper leg. Pain persisted after palliative irradiation therapy. We performed radiofrequency ablation of the metastatic lesion of the right femur using R.I.TA. Medical System Generator. This resulted in total necrosis of the tumor mass that caused osteolysis of the internal part of the femoral cortex. First three months after RFA procedure, the pain and tenderness were absent and normal daily activities were performed without restrictions.

Gardner's syndrome: genetic testing and colonoscopy are indicated in adolescents and young adults with cranial osteomas: a case report.

We present a case of a 25-year-old female with diagnosed familial adenomatous polyposis and elevated carcinoembryonic antigen with negative family history. The suspicion of Gardner's syndrome was raised because extirpation of an osteoma of the left temporo-occipital region was made 10 years ago. Restorative procto-colectomy and ileal pouch anal anastomosis was made but histology delineated adenocarcinoma of the rectum (Dukes C stage). We conclude that cranial osteomas often precede gastrointestinal manifestations of familial adenomatous polyposis or Gardner's syndrome and such patients should be evaluated with genetic testing followed by colonoscopy if results are positive to prevent the development of colorectal carcinoma. If the diagnosis is positive all family members should be evaluated for familial adenomatous polyposis.

Is stapled hemorrhoidopexy safe for the male homosexual patient? Report of a case.

Stapled hemorrhoidopexy is becoming a widely accepted surgical treatment for third- and fourth-degree hemorrhoids because it is associated with much less postoperative pain than open hemorrhoidectomy. After the procedure, a circular line of staples is left in the anal canal; therefore, there is a risk of penile injury or condom damage during anal intercourse, which increases the risk of exposure to sexually transmitted diseases. We report the case of a male homosexual patient who engaged in anal intercourse after recovering from a stapled hemorrhoidopexy, resulting in condom damage. We did not consider this possibility and neglected to discuss the issue with the patient. With an estimated 2.5% of the general population being exclusive, male homosexuals, it is necessary to inform such patients to refrain from anal intercourse after hemorrhoidopexy, although there are no reports stating how long this restraint should last.

[Hemorrhoids--diagnosis and treatment options]. / Hemoroidi--dijagnoza i terapijske mogucnosti.

Hemorrhoids are a common condition in adult population with prevalence of about 4%. Only a third of patients with symptomatic hemorrhoids seek medical help. The annual rate of office visits for hemorrhoids is 12 for every 1000 patients in the United States. Hemorrhoids consist of connective tissue cushions surrounding direct arteriovenous communication. They can cause bleeding, pain and itching but other anorectal diseases should be ruled out. Current guidelines recommend a minimum of anoscopy and flexible sigmoidoscopy for bright-red rectal bleeding. Care depends on the extent of hemorroids. First-degree hemorrhoids can be managed with medical treatment. Surgery is reserved for patients with third and fourth-degree hemorrhoids and failure of nonoperative treatment. A new method of the stapled hemorrhoidectomy has been introduced which significantly reduces postoperative pain, hospital stay and use of analgesics with results that are equal to excisional hemorrhoidectomy.