Adrenocorticotropic Hormone (ACTH) and Cortisol Monitoring as Stress Markers During Laparoscopic Cholecystectomy: Standard and Low Intraabdominal Pressure and Open Cholecystectomy.

INTRODUCTION: In this study we wanted to examine the hormonal responses due to stress exposure during laparoscopic cholecystectomy with standard (12-15 mm / Hg) (LCSP) and low (6-8 mm / Hg) (LCLP) intraabdominal pressure and open cholecystectomy (OC), with particular emphasis on stress hormone responses. AIM: Determination of adrenocorticotropic hormone (ACTH) and cortisol stress hormones before and after laparoscopic cholecystectomy with standard and low insufflation pressure, determination of ACTH and cortisol values before and after open cholecystectomy and comparison of ACTH and cortisol values between the patient sub-groups. METHODS: In a prospective study conducted between July 2016 and February 2018, we involved 110 patients which were divided into two groups: 70 patients with laparoscopic cholecystectomy (LC) and 40 patients with open cholecystectomy (OC). The first group of patients was further divided into two subgroups of 35 patients, (subgroup LC with standard and subgroup LC with low intraabdominal pressure). All patients met the preset inclusion and exclusion criteria of the study. There were no statistically significant differences in the demographic characteristics of patients between the investigated groups. The stress hormones determined were adrenocorticotropic hormone (ACTH) and cortisol. RESULTS: During the first, second and seventh day postoperative day (POD),ACTH values were significantly lower (p <0.0001) in LCLP than in LCSP and OC groups. This was also the case for comparison in LCSP and OC groups. By comparing LC and OC groups during first, the second and seventh POD, there was a significant difference (p <0.0001) in the ACTH levels. The concentration of this hormone was higher in the OC group in all three cases. The first, second and seventh POD were also statistically significant (p <0.0001) in cortisol values and between LC and OC groups there was an increase in cortisol levels in patients operated by open method. There was also a significant difference (p <0.0001) in cortisol values measured between LCLP and LCSP groups in the investigated days. Cortisol levels were higher in patients in the LCSP group. CONCLUSION: During open and laparoscopic cholecystectomy the response of the body to stress increased. The stress response of the organism during laparoscopic cholecystectomy was less than during open cholecystectomy. The stress response of the organism during laparoscopic cholecystectomy with low insufflation pressure ( 6-8mmHg) was less than during laparoscopic cholecystectomy with standard insufflation pressure (12-15mmHg).

A rare case of primary rectal adenocarcinoma metastatic to the breast.

Primary rectal adenocarcinoma metastatic to the breast is an exceedingly rare event. Its management differs from that of primary breast cancer, as illustrated by this case. A 63-year-old woman presented with a breast lump 30 months after abdominoperineal resection for rectal adenocarcinoma, stage T3N1M0 (stage III), followed by standard postoperative radiochemotherapy. The patient underwent a mammography and ultrasonography. A CT scan of the abdomen showed metastatic disease. An excisional biopsy of the breast lump was performed; morphological features were identical to the original rectal cancer. Immunohistochemical results were negative for estrogen and progesterone receptors and gross cystic disease fluid protein-15, and intensity positive for cytokeratin 20 and carcinoembryonic antigen. The patient died after treatment with palliative chemotherapy. Metastatic disease from rectal carcinoma to the breast is a marker for disseminated metastatic spread with poor prognosis.

Transumbilical single-port laparoscopic cholecystectomy.

Surgery of the gallbladder has evolved tremendously over the last century. Laparoscopic cholecystectomy is the gold standard for gallbladder removal and the most common laparoscopic procedure worldwide. In recent times, innovative techniques of natural orifice transluminal endoscopic surgery (NOTES) and transumbilical single-port (TUSP) or single-incision laparoscopic surgery (SILS), have been applied in gallbladder removal as a step towards even more less-invasive procedures. We report a 49-year-old woman with calculosis which were submitted to a single-port transumbilical laparoscopic cholecystectomy, first time done on the Surgical Clinic of Tuzla, and first time in Bosnia and Herzegovina.

Quality of life in patients after laparoscopic and open cholecystectomy.

BACKGROUND/AIM: The aim of this study was to establish Gastrointestinal Life Quality Index scores of patients before and after laparoscopic and open cholecystectomy comparing scores after both operations. SETTINGS AND DESIGN: The 120 patients were involved in this prospective study, 51 male and 69 female, 59 of patients were underwent by laparoscopic method and rest of them, 61, by open method on Surgery Clinic on Clinical university center in Tuzla in period from February 2006 to October 2006, chosen by consecutive method. This study evaluates patients life quality according to score of Gastrointestinal Life Quality Index. METHODS: Patients have been tested two weeks before the operation and in two, five and ten weeks of post-operative period. Except from Gastrointestinal Life Quality Index total score, established scores,a parts of life quality are: symptoms, physical function, emotional and mental status and also social activities. STATISTICAL ANALYSIS USED: For analysis of achieved results, SPSS (Statistical Package for Social Sciences, V 10.01) program with statistical parameters was used: average values and standard deviation. Out of statistical tests, we used Chi-square test and Student t-test. Values p < 0,05 have been accepted as statisticaly significant. RESULTS: The results of the study confirm a working hypothesis that patients life quality after two and five weeks of postoperative period is significantly better (p < 0.05) in laparoscopic method group versus open method group. Also, in domains Gastrointestinal Life Quality Index symptoms, physical function, emotional and menthal status and social activities results are significantly better (p < 0.05) in the laparoscopic cholecystectomy group than in open method cholecystectomy group. Ten weeks of post-operative period, results showed that these two groups have no difference in life quality in total score, also in domain score. CONCLUSION: This comparative study between laparoscopic and open cholecystectomy according to patients life quality aspects confirms advantages of laparoscopic technique in comparison to open cholecystectomy method.

Rate of complications and conversions after laparoscopic and open cholecystectomy.

BACKGROUND AND OBJECTIVES: Although many advantages of laparoscopic method in regard to open one have been already proved, both surgical methods may cause a certain number of complications. The goal of the study is to answer the question: Is Laparoscopic Cholecystectomy (LC) safer and more satisfactory method than open cholecystectomy (OC) concerning number, type and seriousness of complications? DESIGN AND SETTING: Prospective, the research includes all patients in Bihac Cantonal Hospital during 2007, who had cholecystectomy, laparoscopic or open, because of the gallbladder calculosus. METHODS: The study has included 476 patients who had cholecystectomy and who satisfied standards for this study. Of the total number of patients, 293 of them had laparoscopic cholecystectomy and 183 open cholecystectomy. Total number of complications is established for each group of patients. RESULTS: The study has shown that there were more complications in patients operated by open method than in those operated by laparoscopic cholecystectomy (p < 0.0001). Intraoperative bleeding was found in 1.63% of patients with open and 0.68% with laparoscopic cholecystectomy. Postoperative collection in abdomen were found in 2.18% of patients with open and 1.02% with laparoscopic method. The most common complications for open cholecystectomy were: infection (2.73%), hematoma in the wound (2.73%) and urine retention (2.18%). CONCLUSION: It can be concluded that LC and OC are comparable procedures for the treatment of gall stone disease in terms of complications, results of this study demonstrate that LC is essentially a safe procedure with low complicatins, morbidity and mortality rate.

Laparoscopic appendectomy in Bosnia and Herzegovina: the state of laparoscopic procedure in the treatment of acute appendicitis.

BACKGROUND: Laparoscopic appendectomy (LA) has recently become a standard procedure in the treatment of acute appendicitis, as it has been shown to be advantageous over open appendectomy. Since laparoscopic appendectomy was recently introduced in Bosnia and Herzegovina, we evaluated the practice of this procedure in the treatment of acute appendicitis. METHODS: An audit was carried out through a written questionnaire sent to 16 different medical hospitals in Bosnia and Herzegovina. The questionnaire examined the use of laparoscopic appendectomy since the period of its introduction to the end of 2007, including operative time, hospital stay, morbidity and mortality rates, conversion rate and the reasons for the conversion and laparoscopic technique. RESULTS: The response rate from the questionnaire was 37.5%, but only three institutions (18.75%) perform LA. The mean interval from introduction of laparoscopic surgery to inception of LA was 5 years. In period from inception of LA to the end of 2007, 243 appendectomies were done by laparoscopic approach. Correct diagnosis were made in 229/243 cases. Mean hospital stay was 2.2 +/- 0.4 days. Postoperative complications were observed in 13/243 patients. The most frequent complications were intrabdominal abscess (4/13), wound infection (4/13) and intrabdominal bleeding (2/13). Nine conversions from LA into open procedure were done, two due to technical reasons (equipment malfunction), two due to mesoappendix bleeding and five due to periapendicular block or retrocecal position. Conversions and postoperative complications were observed only at the start of the introduction of this procedure. CONCLUSION: Only three institutions in Bosnia and Herzegovina, with small surgical teams, routinely perform laparoscopic appendectomy. Thus, there is a need for systemic education of surgical teams across the country. Laparoscopic appendectomy could be the first operation in the acquisition of laparoscopic skills.

Hem-o-lok plastic clips in securing of the base of the appendix during laparoscopic appendectomy.

BACKGROUND: During laparoscopic appendectomy (LA), the standard technique in securing of the base of the appendix is by endoloop ligatures. However, application of the endoloop demands dexterity and a short training, while hem-o-lok clips may be more advantageous to use due to their simplicity of application and low cost. The objective of this study was to evaluate the technical feasibility and eventual advantages of this way of securing of the base of the appendix. PATIENTS AND METHODS: Prospective study was conducted in the period from August 2006 to August 2008. The patients were divided into two groups; in the first group the base of the appendix was secured by double endoloop ligatures, while in the second group it was done by double nonabsorbable hem-o-lok clips. The data collected included age, gender, operative time, hospital stay, costs, and intra- and postoperative complications. RESULTS: There was no difference in hospital stay between the two groups of patients; mean operative time was 47.1 ± 6.7 min in the first group where the base was secured by endoloop ligatures, and was 38.7 ± 5.0 min in the group where the base was secured by hem-o-lok clips. The cost of the three hem-o-lok clips was 76.9, and that of the three endoloop ligatures was 88.5. In hem-o-lok group of patients, one intraoperative complication was observed, involving bleeding of mesoappendix. There were no postoperative complications in either group of patients. CONCLUSION: The simplicity of application, shorter time of operation, and lower cost of hem-o-lok clips are advantages of this way of securing of the base of the appendix in relation to the standard endoloop procedure.