Kirurško liječenje raka želuca

Gastric cancer remains one of the commonest causes of cancer death worldwide. According to Croatian Cancer Registry, 1282 new patients with gastric cancer were reported in year 2003 in Croatia. Radical surgical resection is the only potentialy curable method of treatment of these patients. Since lymph node metastases occur during the early stages of disease, regional lymphadenectomy is recommended as a part of radical gastrectomy but there is no worldwide consensus about the extent of the lymphadenectomy needed to achive optimal results. Japanese surgeons first introduced radical D2 lymphadenectomy with distal splenopancreatectomy and achieved impressive long term survival results using this method. No western randomized trial showed better survival results after D2 lymphadenectomy compared to D1, but patients after D2 had significantly higher postoperative mortality and morbidity. European authors showed improved survival rates without increase in morbidity and mortality in patients treated by modified D2 operation – D2 extent lymphadenectomy without pancreaticosplenectomy. Our aim in this paper is to give a review of current surgical therapy of gastric cancer and to show postoperative results in patients operated for gastric cancer in our surgical department from year 2001 to 2005.Rak želuca još uvijek je jedan od najčešćih uzroka smrti od raka u cijelome svijetu. Prema podacima Hrvatskog registra za rak u Hrvatskoj je u 2003. godini zabilježeno 1282 novih bolesnika s rakom želuca. Radikalna kirurška resekcija za te je bolesnike jedina metoda liječenja s mogućnošću izlječenja. Kako se metastaze lifnih čvorova pojavljuju u ranim stadijima bolesti, u sklopu radikalne gastrektomije preporučuje se regionalna limfadenektomija, ali nije postignut konsenzus u cijelome svijetu o opsegu limfadenektomije koju je potrebno provesti da se postignu optimalni rezultati. Japanski su kirurzi prvi uveli radikalnu D2 limfadenektomiju s distalnom splenopankreoktomijom i primjenom te metode dugoročno postigli zavidne rezultate s obzirom na preživljenje. Nijedno randomizirano kliničko ispitivanje koje se provodilo na Zapadu nije pokazalo bolje rezultate preživljenja nakon provedene D2 limfadenektomije uspore|eno s D1, ali je nakon D2 u bolesnika zabilježena znatno veća stopa postoperacijske smrtnosti i obolijevanja. Europski autori su predočili bolju stopu preživljenja bez povećanog obolijevanja i smrtnosti u bolesnika liječenih modificiranim D2 zahvatom – D2 limfadenektomijom bez pankreatikosplenektomijom. U ovome radu nastojali smo dati pregled kirurških oblika liječenja raka želuca koji se danas primjenjuju te prikazati postoperativne rezultate u bolesnika koji su zbog raka želuca operirani na našem kirurškom odjelu od 2001. do 2005. godine

Kirurško liječenje raka želuca

Gastric cancer remains one of the commonest causes of cancer death worldwide. According to Croatian Cancer Registry, 1282 new patients with gastric cancer were reported in year 2003 in Croatia. Radical surgical resection is the only potentialy curable method of treatment of these patients. Since lymph node metastases occur during the early stages of disease, regional lymphadenectomy is recommended as a part of radical gastrectomy but there is no worldwide consensus about the extent of the lymphadenectomy needed to achive optimal results. Japanese surgeons first introduced radical D2 lymphadenectomy with distal splenopancreatectomy and achieved impressive long term survival results using this method. No western randomized trial showed better survival results after D2 lymphadenectomy compared to D1, but patients after D2 had significantly higher postoperative mortality and morbidity. European authors showed improved survival rates without increase in morbidity and mortality in patients treated by modified D2 operation – D2 extent lymphadenectomy without pancreaticosplenectomy. Our aim in this paper is to give a review of current surgical therapy of gastric cancer and to show postoperative results in patients operated for gastric cancer in our surgical department from year 2001 to 2005.Rak želuca još uvijek je jedan od najčešćih uzroka smrti od raka u cijelome svijetu. Prema podacima Hrvatskog registra za rak u Hrvatskoj je u 2003. godini zabilježeno 1282 novih bolesnika s rakom želuca. Radikalna kirurška resekcija za te je bolesnike jedina metoda liječenja s mogućnošću izlječenja. Kako se metastaze lifnih čvorova pojavljuju u ranim stadijima bolesti, u sklopu radikalne gastrektomije preporučuje se regionalna limfadenektomija, ali nije postignut konsenzus u cijelome svijetu o opsegu limfadenektomije koju je potrebno provesti da se postignu optimalni rezultati. Japanski su kirurzi prvi uveli radikalnu D2 limfadenektomiju s distalnom splenopankreoktomijom i primjenom te metode dugoročno postigli zavidne rezultate s obzirom na preživljenje. Nijedno randomizirano kliničko ispitivanje koje se provodilo na Zapadu nije pokazalo bolje rezultate preživljenja nakon provedene D2 limfadenektomije uspore|eno s D1, ali je nakon D2 u bolesnika zabilježena znatno veća stopa postoperacijske smrtnosti i obolijevanja. Europski autori su predočili bolju stopu preživljenja bez povećanog obolijevanja i smrtnosti u bolesnika liječenih modificiranim D2 zahvatom – D2 limfadenektomijom bez pankreatikosplenektomijom. U ovome radu nastojali smo dati pregled kirurških oblika liječenja raka želuca koji se danas primjenjuju te prikazati postoperativne rezultate u bolesnika koji su zbog raka želuca operirani na našem kirurškom odjelu od 2001. do 2005. godine

Naša iskustva u primjeni TachoSila® u hepatobilijarnoj kirurgiji

TachoSil® je proizvod koji se koristi u kirurškim granama medicine kao suportivna terapija. Naime, pripravak služi za poboljšanje hemostaze i pomaže boljem tkivnom prijanjanju tijekom operacijskog liječenja gdje se uobičajenim kirurškim tehnikama ne postiže zadovoljavajući rezultat. Promatrali smo vrijeme intraoperativne hemostaze te usporedivši ga s već dostupnim rezultatima o vremenu kod drugih načina hemostaze nedvojbeno dokazali prednosti TachoSila®. Na uzorku od deset bolesnika uz intraoperativnu uporabu TachoSila® srednje vrijeme hemostaze bilo je 4,2 min. (3,2 min.-7 min.). Pojava žučnog sadržaja na abdominalni dren uočena je kod samo jednog bolesnika nakon primjene TachoSila®. Cost/benefit omjer je u slučaju ove metode nedvojbeno na strani njene upotrebe u hepatobilijarnoj kirurgiji. Naši rezultati dobro koreliraju s onima naših kolega u svijetu

Laparoskopska apendektomija ne povećava stopu negativne apendektomije uz nižu stopu perforiranog apendicitisa - rezultati na 1899 bolesnika u KBC Zagreb

Laparoscopic appendectomy is the method of choice of many professional societies owing to its many advantages. The question arises whether surgeons urge more easily to laparoscopic exploration due to its less invasiveness, faster recovery and adequate exploration of the entire abdominal cavity than to observation in unequivocal cases. This retrospective analysis (2009-2016) included 1899 patients undergoing laparoscopic (lap) or gridiron intra-abdominal approach treated at Zagreb University Hospital Centre. The analysis included total negative appendectomy, negative-negative appendectomy (normal appendix and no other pathology found), and negative-positive appendectomy (normal appendix but another pathology found) in children (≤16 years) and adults. There was no statistically significant difference in the rates of negative appendectomy (children) – lap vs. open (p=0.24); negative appendectomy (adults) – lap vs. open (p=0.15); negative-negative appendectomy (children) – lap vs. open (p=0.36); negative-negative appendectomy (adults) – lap vs. open (p=0.21); negative-positive appendectomy (children) – lap vs. open (p=0.53); negative-positive appendectomy (adults) – lap vs. open (p=0.56); and laparoscopy group negative appendectomy in children vs. adults (p=0.56). There was a statistically significantly higher perforation rate with the open approach in total (p<0.0001), in children (p<0.0001) and in adults (p=0.02). There was no statistically significant difference between adults and children in the perforation rate with laparoscopic approach (p=0.24) and perforation rate with open approach (p=0.29). Results confirmed that there was no statistically significant difference in the rate of negative appendectomy in all subgroups. It is concluded that laparoscopic appendectomy should be offered as the method of choice in any patient population with suspicion of acute appendicitis.Laparoskopska apendektomija metoda je izbora većine stručnih društava zbog dokazanih mnogobrojnih prednosti. Pitanje je da li se u slučajevima nejasne dijagnoze kirurzi ranije odlučuju na laparoskopsku eksploraciju u odnosu na opservaciju zbog manje invazivnosti i bržeg oporavka i eksploracije cijelog abdomena. Na KBC Zagreb retrospektivno je analizirano 1899 bolesnika u razdoblju od 2009. do 2016. godine kod kojih su operacije započete izmjeničnim rezom ili laparoskopskim pristupom (lap) kod sumnje na akutni appendicitis kod djece i odraslih (stariji od 16 godina). Analizirane su: 1) ukupno negativne apendektomije, 2) negativno-negativne apendektomije (uredan apendiks i nije nađena druga patologija) i 3) negativno-pozitivne apendektomije (uredan apendiks, ali je nađena druga patologija). Nije bilo statistički značajne razlike u stopama negativne apendektomije (djeca) – lap prema izmjeničnom rezu (p=0,24); negativne apendektomije (odrasli) – lap prema izmjeničnom rezu (p=0,15); negativno-negativne apendektomije (djeca) – lap prema izmjeničnom rezu (p=0,36); negativno-negativne apendektomije (odrasli) – lap prema izmjeničnom rezu (p=0,21); negativno-pozitivne apendektomije (djeca) – lap prema izmjeničnom rezu (p=0,53); negativno-pozitivne apendektomije (odrasli) – lap prema izmjeničnom rezu (p=0,56); negativne laparoskopske apendektomije – djeca prema odraslima (p=0,56). Utvrđena je statistički značajno viša stopa perforacija izmjeničnim rezom ukupno (p<0,0001), kod djece do 16 godina (p<0,0001) i kod odraslih (p=0,02). Nije bilo statistički značajne razlike u stopi perforacije kod laparoskopskog pristupa između odrasle i dječje populacije (p=0,24) te stopi perforacije kod pristupa izmjeničnim rezom između odraslih i djece (p=0,29). Rezultati upućuju na zaključak da niti u jednoj podskupini laparoskopska apendektomija ne rezultira višom stopom negativne apendektomije, no uz niže stope perforiranog apendicitisa pa se laparoskopska apendektomija preporuča kao metoda izbora kod sumnje na akutni apendicitis kod djece i odraslih

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

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

ALPPS – new approach in the treatment of advanced liver tumors

ALPPS (engl. Associated Liver Partition and Portal Vein Ligation for Staged Hepatectomy) je inovativni operacijski zahvat koji je prvi puta predstavljen 2012. godine, a u posljednje dvije godine postao je općeprihvaćen među hepatobilijarnim kirurzima diljem svijeta te su i u našoj ustanovi dosad izvedena tri ALPPS postupka. Budući da je ALPPS relativno nova metoda koja je indicirana samo kod pažljivo odabranih bolesnika, tek se očekuju studije na većem broju bolesnika, ali prema dosadašnjim rezultatima ALPPS se pokazao kao vrlo uspješna kirurška metoda koja omogućuje resektabilnost tumora koji su dosad smatrani neresektabilnima tako da omogućuje iznenađujuće brzu i intenzivnu hipertrofiju ostatnog dijela jetre.ALPPS (Associated Liver Partition and Portal Vein Ligation for Staged Hepatectomy) is an innovative surgical procedure which was presented for the first time in 2012, and in last two years it has become widely accepted by hepatobiliary surgeons and cosequently three ALPPS procedures have been performed at our institution so far. Considering that ALPPS is a relatively new method, indicated only in carefully selected patients, we still expect studies on larger number of patients, but according to last results ALPPS has proved to be a very successful surgical method which allows resectability of tumors that were considered irresectable, by promoting surprisingly fast and intensive hypertrophy of future liver remnant

FIRST SYNCHRONOUS LIVER RESECTION AS A PART OF CYTOREDUCTIVE SURGERY, PERITONECTOMY AND HIPEC IN CROATIA – CASE REPORT

Prikazujemo slučaj tridesetsedmogodišnje bolesnice s velikim adenokarcinomom poprečnoga debelog crijeva te metastazama u slezeni, jetri, peritoneumu, velikom omentumu, žučnome mjehuru, desnom jajniku i jajovodu. Nakon premještaja bolesnice u našu Bolnicu iz vanjske ustanove provedena je opsežna citoreduktivna kirurgija s multiorganskim resekcijama i hipertermijskom intraabdominalnom kemoterapijom (HIPEC). Nekoliko mjeseci kasnije ponovo je podvrgnuta kirurškom liječenju zbog novootkrivene metastaze u 7. jetrenom segmentu i ona je ukonjena. Kemoterapijske cikluse primala je tijekom cijeloga postoperativnog perioda. Danas, dvije godine nakon prve operacije, bolesnica je subjektivno bez tegoba i bez znakova recidiva bolesti. Agresivna citoreduktivna kirurgija koja uključuje multiorganske resekcije, peritonektomiju, HIPEC dokazano je primjenjiv način liječenja u određenih skupina bolesnika s uznapredovalim abdominalnim tumorima, u sklopu čega je i sinkrona resekcija jetre. Ovo je prva sinkrona resekcija jetre u sklopu redovito provođene citoreduktivne kirurgije i HIPEC-a u Hrvatskoj.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

INGUINAL HERNIOPLASTY: DAY SURGERY OR HOSPITAL SURGERY PROCEDURE

Hernioplastika preponske kile kirurški je zahvat koji se može izvoditi u bolnici ili dnevnoj bolnici. Odabir ­bolesnika u jedan od ova dva načina liječenja nije jednostavan. Postoji više kriterija probira, no ponajprije se misli na ­sigurnost bolesnika. Ovaj rad analizira kriterije odabira te uspoređuje sigurnost bolesnika s pojavnošću komplikacija nakon operacije dviju skupina bolesnika (ukupno 590) kojima je načinjena hernioplastika preponske kile tijekom 2015. godine u KBC-u Zagreb. U prvoj je 226 (38,3%) pacijenata operiranih u dnevnoj bolnici, a u drugoj njih 364 (61,7%) bolnički liječena (69 hitno i 295 elektivno). Većina bolesnika dječje dobi (0 – 18 godina) operirana je bolnički. Bolesnici dobnih skupina 19 – 34 i 35 – 49 godina golemom su većinom operirani u jednodnevnoj kirurgiji, a stariji od 74 godine u bolničkim uvjetima. Bolesnici jednodnevne kirurgije bili su statusa ASA I ili II (samo troje bolesnika ASA III). Većina bolnički ­operiranih bolesnika bila je statusa ASA II (52,2%). ASA I bilo je 24%, ASA III 21%, a ASA IV 3% bolesnika. Lokalna anestezija bila je dominantan izbor kod pacijenata dnevne bolnice (68%), a u bolnički liječene skupine rijetko (8%). Učestalost poslijeoperacijske infekcije (2%) i boli (8%) bila je vrlo niska u obje skupine, a razlika između njih nije statistički značajna. Hematomi i seromi pojavljivali su se jednakim obrascem: vrlo rijetko i bez razlika između skupina. Recidiv se s neznatnom razlikom nešto češće pojavljivao u skupini pacijenata višednevne kirurgije. Od ukupno 226 bolesnika dnevne bolnice njih sedmero (3,0%) primljeno je na bolničko liječenje. Troje zbog mučnine, slabosti i hipotenzije, dvoje bolesnika zbog tahikardije i stenokardije, jedan zbog neurastenije, jedan zbog skrotalnog hematoma. Podjednako malen broj ranih komplikacija, recidiva i neplaniranih produžetaka liječenja bolesnika dnevne bolnice govori da su obje skupine liječene na siguran način, a probir bolesnika bio je primjeren.Inguinal hernia repair is a surgical procedure that can be done in inpatient or one-day surgery. Adequate patient selection is not a simple task. There are more than several selection criteria, but the main objective is a patient safety. This study analyzes the patient selection criteria and compares safety in the manner of postoperative complications between the two groups of patients. There were 590 patients who underwent surgical repair of inguinal hernia at the University Hospital Centre Zagreb in 2015. 226 (38.3%) of them were treated in one-day surgery, and 364 (61.7%) were treated at the main Surgical department; 69 of those had an emergent presentation. Most patients of child age (0–18) were treated at the inpatient department. ­Patients in the age groups between 19 and 39 years, as well as those between 35 and 49 were dominantly managed at the Department of one-day surgery. Those patients were mainly ASA I and ASA II (only three of them were ASA III), while hospitalized patients were mostly ASA II (52.2%). In the hospitalized, inpatient group, frequency of ASA I was 24%, ASA II 21% and ASA IV 3%. The greatest number of one-day surgery patients underwent surgery under local anesthesia (68%). In contrast, only 8% of the inpatient group had a surgery under local anesthesia. The percentage of patients with post­operative wound infection was 2%, and the incidence of pain after surgery was 8%. The results didn’t statistically differ between the groups. The recurrence rate was slightly more frequent in the inpatient group. Hematomas and seromas had the same incidence pattern; they were rarely present and without differences between the groups. 7 of 226 ambulatory patients (3%) were hospitalized. The main causes for three of them were nausea, weakness and hypotension; two patients had tachycardia and stenocardia, one patient had neurasthenia, and also one had scrotal hematoma. The hernia repair in both groups was associated with low postoperative complications, low recurrence rate, and low percentage of unplanned hospital ­admissions. Therefore it is considered that both groups were treated in a safe manner and patient selection was adequate

Kirurško liječenje preponske kile: ambulantno ili bolnički [Inguinal hernioplasty: day surgery or hospital surgery procedure]

Inguinal hernia repair is a surgical procedure that can be done in inpatient or one-day surgery. Adequate patient selection is not a simple task. There are more than several selection criteria, but the main objective is a patient safety. This study analyzes the patient selection criteria and compares safety in the manner of postoperative complications between the two groups of patients. There were 590 patients who underwent surgical repair of inguinal hernia at the University Hospital Centre Zagreb in 2015. 226 (38.3%) of them were treated in one-day surgery, and 364 (61.7%) were treated at the main Surgical department; 69 of those had an emergent presentation. Most patients of child age (0–18) were treated at the inpatient department. ­Patients in the age groups between 19 and 39 years, as well as those between 35 and 49 were dominantly managed at the Department of one-day surgery. Those patients were mainly ASA I and ASA II (only three of them were ASA III), while hospitalized patients were mostly ASA II (52.2%). In the hospitalized, inpatient group, frequency of ASA I was 24%, ASA II 21% and ASA IV 3%. The greatest number of one-day surgery patients underwent surgery under local anesthesia (68%). In contrast, only 8% of the inpatient group had a surgery under local anesthesia. The percentage of patients with post­operative wound infection was 2%, and the incidence of pain after surgery was 8%. The results didn’t statistically differ between the groups. The recurrence rate was slightly more frequent in the inpatient group. Hematomas and seromas had the same incidence pattern; they were rarely present and without differences between the groups. 7 of 226 ambulatory patients (3%) were hospitalized. The main causes for three of them were nausea, weakness and hypotension; two patients had tachycardia and stenocardia, one patient had neurasthenia, and also one had scrotal hematoma. The hernia repair in both groups was associated with low postoperative complications, low recurrence rate, and low percentage of unplanned hospital ­admissions. Therefore it is considered that both groups were treated in a safe manner and patient selection was adequate