Bouveret's syndrome--case report

BACKGROUND

Bouveret's syndrome is a rare complication of cholecystolithiasis with gastric outlet obstruction caused by a gallstone migrating through a biliogastric or bilioduodenal fistula. Gallstone ileus is mainly treated by surgery, either enterolithotomy or gastrotomy, with some cases being treated by endoscopic extraction.

CASE REPORT

We report on an 80-year-old woman without previous episodes of biliary colic, and known cholecystolithiasis who underwent emergency surgery due to pyloric obstruction caused by a large, 7-cm stone, after failure of endoscopic treatment. The stone was removed through pylorotomy, which was closed transversely in multiple layers and patched with omentum. The patient's postoperative course was complicated by operative wound infection. She was discharged on postoperative day 22 and had no complaints at the 6-month follow-up.

Mediastinal necrosis in acute pancreatitis - case report

Ascites, pseudocyst, necrosis of the retroperitoneal fat tissue and pancreatopleural fistula with left sided pleural effusion may complicate pancreatitis. However, steatonecrosis of the mediastinum and right side pleural effusion are rather rare complications of pancreatitis. We present a case of a patient with alcohol induced pancreatitis. Chest x-ray showed right sided pleural effusion. Although high levels of amylase in pleural fluid made the diagnosis of pancreatopleural fistula most likely, necrosis of the mediastinal fat tissue with right side pleural effusion was found postmortem.

Crohn's disease and a gastrointestinal stromal tumor in an 81-year-old man--a rare coincidence

We describe an 81-year old man presenting with ileus and two rare, pathologically distinct entities: gastrointestinal stromal tumor (GIST) and Crohn's disease. Within Meckel's diverticulum a polypous tumor, 3 cm in diameter, with preserved lumen was found. In the area of the terminal ileum, coecum and colon ascendens inflamed bowel loops were fixed together with fibrous adhesions. Partial resection of the ileum with end-to-end anastomosis and right hemicolectomy with resection of the terminal ileum and end-to-end ileotransverse anastomosis were performed. Pathohistological and immunohistochemical examination revealed the polypous tumor as GIST. Changes in terminal ileum, coecum and colon ascendens were referred as Crohn's disease. Although adenocarcinoma is well known in chronic, long-standing inflammatory bowel disease, other primary intestinal tumors are rare in those patients. Furthermore, Crohn's disease can be a part of differential diagnosis of ileus, also in such an old man.

[Outcome of 268 patients with pancreatic carcinoma treated surgically]

From January 1st 1987 to December 31st 2001, 268 patients (pts) with the diagnosis of pancreatic adenocarcinoma had undergone surgery at Surgical Clinic of University Hospital Rijeka. Pts were of both sexes: 154 males (57%) and 114 females (43%). The mean age of pts at the time of operation was 66 +/- 11.4 years. 36 pts (13.4%) underwent curative resection, while 198 pts (73.9%) underwent palliative operation. At 34 pts (12.7%) explorative laparotomy and biopsy were preformed. Overall 30-days postoperative mortality was 12.3% (33 pts). 44 pts (16.4%) developed postoperative complications. Mean overall survival after surgery was 5.8 months. Pts who underwent curative resection survived significantly longer (median 24.2 months) than pts with palliative surgery (median 5.4 months). 8 pts (2.98%) survived more than two years after surgery. Lymph node involvement, distant metastases and postoperative complications were predictors of significantly worse survival.

[Transhiatal esophagectomy for carcinoma of the esophagus--our ten years experience]

During the past 10 years, at University Surgical Clinic Rijeka, 107 patients underwent operation for carcinoma of the esophagus and cardia. Transhiatal esophagectomy was performed in 29 patients; in 28 of them an esophagogastrostomy was performed, and in one patient a pharingogastrostomy. Of the 29 patients, there were 24 men (82.8 %) and 5 women (17.2 %), with an average age of 60.7 years. Histologically, 26 lesions (89.7 %) were squamous cell carcinomas, and 3 (10.3 %) were adenocarcinomas. According to the prognostic stage as defined by the UICC, 15 patients (51.7 %) were stage II A, and 14 (48.3 %) stage III. The lesion was located in the cervical esophagus in two, the thoracic esophagus in thirteen and the lower esophagus in fourteen patients. Six patients died, for a hospital mortality rate of 20.7 %; the most common cause of death was respiratory failure. Pulmonary complications occurred in 14 patients (48.3 %). Anastomotic leak with all clinical manifestations occurred in one patient, while in two patients the radiological diagnosis of anastomotic leakage was made without clinical manifestations. Five patients (17.2 %) developed anastomotic stenosis, which was satisfactory treated by endoscopic dilatation. Mean survival after surgery was 21 months. One-year survival was 65.5 %, two and three-year survival was 37.9 and 17.2 % respectively. Younger patients and patients with lower stage of disease survived significantly longer (p < 0.05).

[Portasystemic shunt--our twenty years experience]

OBJECTIVE

It was the aim of this study to demonstrate our experiences over twenty years with portasystemic shunt surgery in patients with chronic liver disease and variceal bleeding.

PATIENTS AND METHODS

From January 1 st, 1980 to December 31 st, 2000 we performed 90 portasystemic shunt operations (PSO). The patients were divided in two groups. The patients of the first group were operated upon between 1980-1988 (n = 58), patients of the second group (n = 32) between 1988-1998. Both groups did not differ in age, gender and cause of hepatic disease. In the first group the most performed type of shunt was the portacaval shunt, in group II the splenorenal shunt.

RESULTS

We observed an improved early and late mortality rate, encephalopathy rate and reduction of recurrent variceal bleeding in the second group: the early mortality rate decreased from 16 to 9 % (p < 0.01), the late mortality rate from 35 to 6 % (p < 0.05), the encephalopathy rate from 43 to 12 % and the variceal rebleeding rate from 10 to 6 %.

CONCLUSION

Selective shunts, such as the distal splenorenal shunt are significantly superior to the standard (end-to-side or side-to-side) portasystemic shunt. In countries where acute treatment of recurrent variceal hemorrhage with sclerotherapy is not available in remote areas or in countries where transplantation procedures are in the very beginning and where TIPPS operations are too expensive, portasystemic shunt operations are the only possibility to save the patients life when sclerotherapy fails.

[Upper gastrointestinal bleeding - Review of our ten years results]

Acute upper gastrointestinal bleeding (UGIB) is a common reason for emergency hospitalisation. Early upper gastrointestinal endoscopy is the corner stone of management; the alternative option for achieving primary hemostasis is emergency surgery. The aim of this study was to analyse the frequency of UGIB in the last 10 years and to present our surgical results. We observed 5 955 bleeding patients (68.4 % male and 31.6 % female) with a mean age of 57.7 inverted question mark 15.8 years. The most frequent causes of bleeding were gastric and duodenal ulcers (61 %) followed by gastroduodenal erosions (15.4 %) and varicous veins (5.7 %). Indications for emergency surgery were massive UGIB or rebleeding after active endoscopic treatment. On operation, gastric and duodenal ulcers were responsible for massive UGIB in 86.4 % cases. Overall hospital mortality rate during 10 years was 13.2 % and depended on age and concomitant diseases. In total 5.9 % of operated patients were rebleeding. Those with rebleeding underwent a second operation and showed a statistically higher mortality rate (35.7 % vs 11.8 %) compared to those surgical patients without rebleeding; p < 0.001. The mortality rate after vagotomy and pyloroplasty was 13.2 % (14/106) and did not differ significantly from that after gastric resection (15.2 %; 9/59).

Wound healing of animal and human body sport and traffic accident injuries using low-level laser therapy treatment: a randomized clinical study of seventy-four patients with control group

BACKGROUND AND OBJECTIVE

The main objective of current animal and clinical studies was to assess the efficacy of low level laser therapy (LLLT) on wound healing in rabbits and humans.

STUDY DESIGN/MATERIALS AND METHODS

In the initial part of our research we conducted a randomized controlled animal study, where we evaluated the effects of laser irradiation on the healing of surgical wounds on rabbits. The manner of the application of LLLT on the human body are analogous to those of similar physiologic structure in animal tissue, therefore, this study was continued on humans. Clinical study was performed on 74 patients with injuries to the following anatomic locations: ankle and knee, bilaterally, Achilles tendon; epicondylus; shoulder; wrist; interphalangeal joints of hands, unilaterally. All patients had had surgical procedure prior to LLLT. Two types of laser devices were used: infrared diode laser (GaAlAs) 830 nm continuous wave for treatment of trigger points (TPs) and HeNe 632.8 nm combined with diode laser 904-nm pulsed wave for scanning procedure. Both were applied as monotherapy during current clinical study. The results were observed and measured according to the following clinical parameters: redness, heat, pain, swelling and loss of function, and finally postponed to statistical analysis via chi2 test.

RESULTS

After comparing the healing process between two groups of patients, we obtained the following results: wound healing was significantly accelerated (25%-35%) in the group of patients treated with LLLT. Pain relief and functional recovery of patients treated with LLLT were significantly improved comparing to untreated patients.

CONCLUSION

In addition to accelerated wound healing, the main advantages of LLLT for postoperative sport- and traffic-related injuries include prevention of side effects of drugs, significantly accelerated functional recovery, earlier return to work, training and sport competition compared to the control group of patients, and cost benefit.

Intra-pancreatic rupture of the bile duct

Injury of the bile duct after blunt trauma is rare but injury and rupture of the intrapancreatic portion of the bile duct is extremely rare. Injury is very difficult to recognize even if explorative laparotomy is done. Elevation of the liver tests, especially gamma GT and alkaline phosphatase, is very often the first sign of injury. When jaundice occurs the diagnostic procedures of ultrasound (US), computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP) must be done. If there is no sign of great injury to the head of the pancreas we have to perform normal biliary flow. Here we report a rare case of intrapancreatic rupture of the common bile duct without high degree of pancreatic injury after blunt injury. Cholecystectomy and choledochojejunostomy were performed.

Organization and activity of the health service in the Croatian province of Lika in the first year of the war

The aim of this report is to present the various aspects of the reorganization of the health service in the Croatian province of Lika during the first year, 1991-1992, of the war in Croatia. In the former Socialist Republic of Yugoslavia, the health service was completely in the hands of the state, and Croatia was not able to transform it in the first year of its independence. The paper documents the personnel, supplies, and equipment that the health service of Lika had at its disposal in the first year of the war, the division of the health service into the stationary and front-line medical corps, and the evacuation protocols developed to transfer surgical patients to the rear-area hospital. The response of the health service allowed for rapid and successful patient treatment, emphasized by the fact that the usual time elapsed between wounding and delivery of the patient to the operating table was less than 30 minutes. All surgeries, with the exception of those involving severe craniocerebral injuries, were performed in the war hospitals of Lika. After stabilization of their postoperative condition, generally within 30 minutes, patients were evacuated to the rear-area hospital in Rijeka, with artificial respiration. The distance by road from the war hospitals in Otocac and Gospić to the reararea hospital in Rijeka was 120 and 170 km, respectively. Collectively, the results of our work demonstrate that a nonmilitary health service can be transformed successfully and efficiently into a war medical service. Yet, we believe that this is possible only under the extreme conditions of a defensive war.