Gastric tube ulcer perforating the pericardium after subtotal esophagectomy [Perforacija ulkusa želučanog supstituta u perikard nakon subtotalne ezofagektomije]

Subtotal esophagectomy with retrosternal transposition of the gastric tube to the neck was performed in a 62-year-old patient with squamous cell carcinoma of the proximal third of the esophagus. He developed a salivatory fistula in the early postoperative period that healed spontaneously. Five months later, the patient developed partial stenosis of the esophagogastric anastomosis which required recervicotomy and excision, after numerous failed dilatation attempts. Eighteen months later, the patient presented to the hospital for severe pain in the upper abdomen. Clinical work-up revealed pericardial perforation by the gastric tube ulcer necessitating emergent surgery and gastric tube removal. We present a patient who developed both early and late complications of subtotal esophagectomy with gastric tube transposition as well as a review of the literature

Orijentacija i asimetrija fasetnih zglobova: povezanost s ubrzanom degeneracijom stabilizacijskih struktura u donjoj slabinskoj kralježnici

The influence of facet orientation and tropism on the process of spinal degeneration has been extensively studied during the last few decades, but there are still many controversies and conflicting results in this field of research. The biomechanical cause of accelerated degeneration of stabilizing structures in lower lumbar spine lies within the combination of several factors, but two most important ones are compressive load and more coronal facet orientation that offers less resistance against torsional loading. Axial rotation of lower lumbar spine is undoubtedly associated with higher strain in disc annulus, and enhanced range of secondary rotational movements may be even more significant for the progression of annular degeneration. Accordingly, more pronounced facet tropism could be having part in faster progression of disc degeneration in lower lumbar spine, as indicated by a number of recent studies. More sagittal facet orientation in patients with a higher facet osteoarthritis score at lower lumbar segments is very likely related to arthritic remodeling commonly seen in other synovial joints. There is also a possibility that it could be associated with the adaptation to partial loss of lumbar lordosis, as both coincide with advanced age.Utjecaj orijentacije i asimetrije fasetnih zglobova na progresiju degenerativnih promjena kralježnice bio je predmetom mnogih istraživanja provedenih u zadnjih nekoliko desetljeća, no rezultati studija su još uvijek proturječni. Biomehanički uzrok ubrzane degeneracije stabilizacijskih struktura donje slabinske kralježnice je složen, no najvažniji čimbenici su kompresivno opterećenje i više frontalna orijentacija fasetnih zglobova koja pruža manji otpor sili rotacije. Aksijalna rotacija donje slabinske kralježnice je nesumnjivo povezana sa znatnim opterećenjem prstena diska te se čini da bi povećani opseg sekundarnih rotacijskih pokreta mogao biti još značajniji za progresiju degenerativnih promjena fibroznog prstena. Sukladno tome, više izražena asimetrija fasetnih zglobova mogla bi imati određenu ulogu u bržoj progresiji degeneracije diska u donjoj slabinskoj kralježnici, na što ukazuju i mnoga novija istraživanja. Više sagitalna orijentacija fasetnih zglobova u bolesnika s jače izraženim osteoartritisom fasetnih zglobova je najvjerojatnije povezana s degenerativnim remodeliranjem koje se često može vidjeti i u drugim sinovijalnim zglobovima. Također postoji mogućnost da je povezana i s adaptacijom na djelomični gubitak fiziološke slabinske lordoze, jer obje pojave koincidiraju s poodmaklom životnom dobi

Paravertebral blockade as indication, not as anesthesia choice – two case reports

Background and purpose. We present two case reports of patients with ASA IV status, scheduled for surgery due to a malignant process. They were contraindicated for general anesthesia so we decided to perform paravertebral blockade. Patients and Methods: Case 1. A 84-year-old female patient was scheduled for operation because of amalignant process in the left axillary region. She was an ASA IV patient with a suspected malignant process in the lung, bilateral tumor of suprarenal glands, hypothyreosis, and chronic renal insufficiency. ChestX-ray showed decompensated heart. Case 2. A 69-year-old male patient was scheduled for operation of malignant melanoma on the back. He was an ASA IV patient with implanted cardiac electrostimulator, liver cirrhosis, and obstructive lung disease. Chest X-ray showed decompensated heart. Paravertebral space was identified with ultrasound using 8 Hz linear transducer probe. Additionally, needle position was confirmed with neurostimulation. When muscle contraction persisted at 0.4 mA, an anesthetic was applied in levels of Th1, Th2, and Th3 (5 ml per level); in first case, a mixture of 7.5 ml 0.5% levobupivacaine [Chirocaine®, Abbott Laboratories] and 7.5 ml 2% lydocain [Lidocaine®, Belupo], and in second case, 15 ml 0.5% levobupivacaine. Results: Sensory blockade occurred after 15minutes in the first case, and after 20 minutes in the second case. The surgery was without complications. In the first case, sensory blockade lasted for 4.5 h after block was administered, which is 3h after surgery, and 12 h after blockade or 10 h after surgery in the second case. Conclusion: At 24h postoperative interview, both patients were very satisfiedwith the anesthesiology treatment, and no complications occurred

Clinical and Patohistological Factors Affecting the 5 Year Survival Rate in a Population of Croatian Women with Invasive Ductal Breast Carcinoma

Breast carinoma falls into a heterogeneous group of diseases which can be determined by various prognostic factors. The identification of clinical and histopathologic factors is of great value in predicting the progression of tumor growth and survival outcome. Due to a high degree of cell proliferation in breast tumors and high genetic instability of these tumors, as a consequence of defective DNA repair mechanisms, chemotherapy as a treatment option often renders very successful results. During our scientific study of the expression of genes responsible for mismatch repair of DNA in cells of invasive ductal carcinoma we also compared the patient survival rate with the major prognostic factors. This study included 108 patients who were surgically treated for invasive breast cancer at the Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital »Dubrava«. The overall survival rate was compared to factors such as initial tumor stage, regional lymph node involvement and distant metastasis. The overall five year survival rate of our patients was 78,7%. Patients without the presence of distant metastasis, a lower rate of local lymph node involvement and a lower tumor stage statistically had a longer overall survival period. It is important that physicians recognize the various clinico- pathohistological factors in patients with breast carcinoma. This study confirms that this prognostic factors determine the type of treatment required and most important, the patient overall survival period

Expression of Genes Responsible for the Repair of Mispaired Bases of the DNA (MLH1) in Invasive Ductal Breast Carcinoma

Breast cancer is a heterogeneous group of diseases determined and distinguished by cellular type, gene expression and clinical signs and symptoms. Identification of histological and biological markers is of great value in predicting the progression of tumor growth and anticipating the expected response to various treatment options. Due to a high degree of cell proliferation in breast tumors and high genetic instability of these tumors, as a consequence of defective DNA repair mechanisms, chemotherapy as a treatment option often renders very successful results. During our scientific research we wanted to determine the involvement of the genetic polymorphisms of DNA mismatch repair system (MLH1 gene) and the subsequent development of breast carcinoma. This study included 108 patients who were surgically treated for inva- sive breast cancer at the Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital »Dubrava«. The expression of the MLH1 gene was determined by immunohistochemical methods. The results showed that 82.9% of tumor cells expressed the MLH1 gene. Analysis of survival rate for patients with invasive ductal breast cancer showed a statistically significant (p=0.043) correlation with the expression of MLH1 genes. The overall five year survival rate of our patients was 78.7%. These results indicate that there is a possible involvement of MLH1 gene in the progression and development of breast cancer

Perioperative Management with Glucose Solution and Insulin

The objective of this study was to analyze how preoperative glucose treatment influences the blood glucose level as a measured exponent of surgical stress and to establish the best postoperative replacement considering glucose solutions and insulin. This prospective clinical trial involved 208 non-diabetic patients with normal glucose tolerance, who underwent major surgical procedures and needed 24 hours ICU monitoring postoperatively. Patients were randomly given 5% glucose solution (1000 mL) one day before surgery or after overnight fasting. Group A and group B were randomized to be given 5 different kinds of postoperative replacement with cristalloids and insulin. None of the patients from group A or group B were given glucose solutions during surgical procedures. Blood glucose levels were measured 14 times from the preoperative period until 24 hours after admission to the ICU and the main outcome measure was blood glucose level. All patients had a statistically significant increase in blood glucose levels in comparison to basal levels (p<0.05) in all measurements. All data were processed with descriptive statistics, chi-square test, parametric ANOVA test and ANOVA test with repeated measure, non parametric Kruskal-Wallis test and Mann-Whitney U-test. Statistically significant change was accepted with p<0.05. Preoperative glucose infusion decreased metabolic and endocrine response only during surgery; the smallest increase of postoperative blood glucose level was noticed after administering postoperative non-glucose crystalloid solutions; there is no clinical evidence that one specific postoperative replacement is better than the other; there is no clinical evidence that postoperative use of insulin can decrease or attenuate surgical induced insulin resistance

RECONSTRUCTING THE LIFE OF AN UNKNOWN MAN – INTERDISCIPLINARY APPROACH

U radu se prikazuje mogućnost i važnost interdisciplinarnog pristupa analizi bioarheološkog materijala humanog podrijetla. prikazuju se podatci dobiveni različitim aspektima biološke antropologije iz otvorenog groba i obradom prisutnih posmrtnih ostataka, dajući priču osobe, muškarca. Primarna antropološka identifi kacija, koja uključuje spol, dob u trenutku smrti i visinu, zajedno s analizom patoloških promjena na kostima i razvijenosti mišićno-koštanih hvatišta, uvijek nam daje obilje podataka, koji su iznimno važni u antropologiji, ali otvaraju i nove vidike arheolozima te povjesničarima. Analiza stabilnih izotopa 13C, 15N, 18O dala je uvid u moguću migraciju osobe, kemijski opis regije u kojoj je istraživani muškarac proveo rano djetinjstvo, kao i obilježja područja gdje je boravio posljednjih godina života. Pomoću višeslojne tomografi je (CT) skeniranja lubanje i uz korištenje računalne tehnike za rekonstrukciju mekotkivnih struktura lica dobiven je prikaz lica analizirane osobe. Općenito, takva je rekonstrukcija korisna u forenzičkom aspektu, a može koristiti, kao u prikazanom slučaju, i za vizualizaciju stvaranja morfološko - antropoloških pokazatelja.The remains of a tomb were discovered below the foundations of the Roman church of “Majka Bozja Gorska” in Lobor in 2002. It was a vaulted tomb carved from a single stone. The narthex of ancient Christian and pre-roman churches often served as the resting place of religious, secular and noble dignitaries, who were credited for founding the church at the time. By anthropological methods, the age, gender, height, pathological changes, tendon and ligament hinges and degree of development were able to be analysed. The stable isotopes of Carbon-13, Nitrogen-15 and Oxygen-18 were analysed and expressed a

Quality of Life after the Sweedish Adjustable Gastric Band Procedure

The term »quality of life« usually describes factors that have an impact on living conditions within the society or on an individual. Generally, the term quality of life refers to the level of the welfare of individuals or group of people. Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health and as such is one of the most common pathological conditions of modern society. Almost 10–25% of adult population in Europe, 1/3 population in the USA and 20% of population in Croatia are affected by obesity5,6. In this prospective study we included 30 patients who underwent Sweedish adjustable gastric band procedure (SAGB) (Johnson & Johnson) procedures without complications during the first year of the postoperative period. Body mass index (BMI) was in female patients 40,52174 kg/m2 and in male patients 46,71429 kg/m2. Prior to the surgical procedures 13 patients (43.33%) experienced worse health conditions. Health conditions were equl in 17 patients. The treatment was ineffective in 5 patients (16.67%). In 5 patients health conditions were equal. 6 patients (20%) had good quality of life, 11 patients (36.67%) very good and only 3 patients (10%) had excellent quality of life after the procedure. We noticed body weight reduction in all patients. The quality of life was improved in all patients, except for one 28 years old woman. Body weight loss and quality of life after the procedure are in positive correlation which means that significant body weight loss leads to improved quality of life. Our conclusion is that SAGB is a quality method in obesity treatment which improves quality of life

Immediate Breast Reconstruction in Relation to Women’s Age

A modern approach to breast cancer treatment after mastectomy includes immediate breast reconstruction (performed simultaneously with the mastectomy). The understanding of factors that influence women’s decisions and appreciation of their satisfaction is as important as the knowledge of medical efficiency of the selected treatment. The influence of women’s age on opinion making for immediate breast reconstruction was researched in a monocentric prospective study (N=102). Methods included questionnaires, interviews and medical documentation reviews. Women comply breast reconstruction with silicone implants and autologous tissue equally. Analyzing age distribution it is evident that women age 35–50 and older than 65 would agree to reconstruction with silicone implants more often. This can be explained by the fact that younger women expect to have better shaped breasts after reconstruction then prior to the same, while older women tend to avoid breast reconstruction using muscle flaps because they are more demanding and also require longer hospitalization

Primjena paravertebralnog bloka za postavljanje gastrostome kod visoko rizičnih bolesnika s karcinomom jednjaka – dva prikaza slučaja

Here we present two cases of gastrostomy insertion via laparotomy in patients with malignant esophageal disease. Patients were ASA (American Society of Anesthesiologists) physical status III and IV. The patients presented as very high risk for general anesthesia, so we decided to use unilateral left sided paravertebral block (PVB) on four thoracic levels along with contralateral local infiltration at the gastrostomy insertion site. We present two cases, one of them a 57-year-old male ASA III patient scheduled for a gastrostomy procedure due to esophageal cancer with infiltration of the trachea. We also present a case of a 59-year-old male patient, ASA IV status, scheduled for the same procedure due to advanced esophageal cancer with a fistula between the left main bronchus and the esophagus and metastases in the left lung. The paravertebral space was identified with the use of an 8 Hertz (Hz) linear ultrasound probe and a nerve stimulator. Paravertebral block was successfully used for insertion of a gastrostomy, thereby enabling adequate anesthesia and perioperative analgesia without hemodynamic or respiratory complications.Prikazujemo dva slučaja postavljanja gastrostome laparotomijskim putem kod bolesnika s malignom bolesti jednjaka. Bolesnici su prema Američkom anesteziološkom društvu (American Society of Anesthesiologists, ASA) klasificirani kao ASA status III i IV. Zbog vrlo visokog rizika za primjenu opće anestezije prikazanim bolesnicima odlučili smo primijeniti prsni paravertebralni blok na četiri razine s nasuprotnom lokalnom infiltracijom mjesta postavljanja gastrostome. Prikazujemo dva slučaja; jedan je bio 57-godišnji ASA III bolesnik predviđen za postavljanje gastrostome zbog karcinoma jednjaka s infiltracijom traheje. Također prikazujemo 59-godišnjeg ASA IV bolesnika predviđenog za isti zahvat zbog uznapredovalog karcinoma jednjaka s fistulom između glavnog lijevog bronha i jednjaka uz metastaze na lijevom plućnom krilu. Paravertebralni prostor je identificiran primjenom ultrazvučne linearne sonde od 8 Hertza (Hz). Paravertebralni blok je uspješno primijenjen za postavljanje gastrostome omogućavajući time zadovoljavajuću anesteziju i perioperacijsku analgeziju bez hemodinamskih i respiracijskih komplikacija