12 research outputs found
Total parenteral nutrition in twin pregnancy after suicide attempt with corrosive
Introduction. Self-poisoning is not frequent during pregnancy. We present the successful treatment of a woman 20 weeks pregnant with twins with self-inflicted poisoning by a caustic substance. Case report. A 34-year old caucasian pregnant woman was admitted to our institution after self-inflicted poisoning with concentrated acetic acid. Initial clinical evaluation showed severe diffuse erythema of the mouth and oropharynx, a systemic inflammatory response syndrome, and dichorionic diamniotic twin pregnancy in the 20th week of gestation confirmed on abdominal ultrasound. An indirect laryngoscopic examination revealed severe generalised hyperemia of the laryngeal mucosa with corrosive changes in the pharyngeal mucosa especially of the posterior pharyngeal wall. Due to pain an urgent esophagogastroduodenoscopy could not be performed, and because of patient refusal a feeding gastrostomy or jejunostomy could not be created. The patient was given "All-in-One" total parenteral nutrition (TPN) in addition to the other supportive therapy. Gradual introduction of enteral nutrition (EN) via a nasoenteric tube placed in the second month of hospitalization failed due to severe vomiting. After almost three months of TPN, EN was however introduced; we then started with oral fluids, increasing gradually to a regular diet, and needed almost half a month to reach an adequate nutritional goal. The delivery was spontaneous at 36 weeks pregnancy and the patient gave birth to two normal healthy girls (46cm/2580gr and 48cm⁄2960gr). Conclusion. TPN can be a safe choice for providing prolonged and adequate nutritional intake even in a twin pregnancy without adverse effects on fetal growth
Splenic artery pseudoaneurysm as a complication of pancreatic pseudocyst
Introduction. Pancreatic pseudocyst presented as pseudoaneurysm of the splenic artery is a potential serious complication in patients with chronic pancreatitis. Case report. A 42-year-old male patient with a long-standing evolution of chronic pancreatitis and 8-year long evolution of pancreas pseudocyst was referred to the Military Medical Academy, Belgrade due to worsening of the general condition. At admission, the patient was cachectic, febrile, and had the increased values of amylases in urine and sedimentation (SE). After clinical and diagnostic examination: laboratory assessment, esophagogastroduodenoscopy (EGDS), ultrasonography (US), endoscopic ultrasonography (EUS), multislice computed scanner (MSCT) angiography, pseudoaneurysm was found caused by the conversion of pseudocyst on the basis of chronic pancreatitis. The patient was operated on after founding pancreatic pseudocyst, which caused erosion of the splenic artery and their mutual communication. Postoperative course was duly preceded without complications with one year follow-up. Conclusion. Angiography is the most reliable and the safest method for diagnosing hemorrhagic pseudocysts when they clinically present as pseudoaneurysms. A potentially dangerous complication in the presented case was treated surgically with excellent postoperative results
Solitary extramedullary plasmacytoma of the duodenum and pancreas: A case report and review of the literature
Introduction. The extramedullary plasmacytomas (EMPs) are rare tumors of
plasma cell disorders which are rarely found in the duodenum. We presented a
case of solitary EMPs involving the duodenum and pancreas successfully
treated by surgical resection after failure of chemotherapy. Case report. A
55-year-old female with previously diagnosed solitary EMP of the duodenum was
admitted to our institution after failure of three cycles of vincristine,
adriablastine, dexamethasone (VAD) chemotherapy regimen with an upper
gastrointestinal obstruction. On admission computed tomography of the abdomen
showed tumor in the region of the second part of duodenum and uncinate
process of the pancreas with a complete duodenal obstruction.
Intraoperatively a tumor formation was in the region of the second duodenal
part, originated from the wall of duodenum with the total diameter of 7 x 5 cm, covering the entire circumference of duodenal wall leaded to a narrowing
of duodenal lumen to the thigh gap with an upper gastrointestinal
obstruction. Infiltration in the head of the pancreas and uncinate process were also found. The Whipple’s procedure was performed but postoperative
course was complicated by rapidly refilling chylous ascites which was
resolved 4 days after the surgery. Conclusion. Each patient with
gastrointestinal EMPs should be considered separately and in timely manner,
thus adequate treatment could provide local disease control
Endovascular repair of ruptured abdominal aortic aneurysm
Introduction. Rupture of an abdominal aortic aneurysm (AAA) is a potentially
lethal state. Only half of patients with ruptured AAA reach the hospital
alive. The alternative for open reconstruction of this condition is
endovascular repair (EVAR). We presented a successful endovascular reapir of
ruptured AAA in a patient with a number of comorbidities. Case report. A
60-year-old man was admitted to our institution due to diffuse abdominal
pain with flatulence and belching. Initial abdominal ultrasonography showed
an AAA that was confirmed on multislice computed tomography scan angiography
which revealed a large retroperitoneal haematoma. Because of patient’s
comorbidites (previous surgery of laryngeal carcinoma and one-third
laryngeal stenosis, arterial hypertension and cardiomyopathy with left
ventricle ejection fraction of 30%, stenosis of the right internal carotid
artery of 80%) it was decided that endovascular repair of ruptured AAA in
local anaesthesia and analgosedation would be treatment of choice.
Endovascular grafting was achieved with aorto-bi-iliac bifurcated excluder
endoprosthesis with complete exclusion of the aneurysmal sac, without
further enlargment of haemathoma and no contrast leakage. The postoperative
course of the patient was eventless, without complications. On recall
examination 3 months after, the state of the patient was well. Conclusion.
The alternative for open reconstruction of ruptured AAA in haemodynamically
stable patients with suitable anatomy and comorbidities could be emergency
EVAR in local anesthesia. This technique could provide greater chances for
survival with lower intraoperative and postoperative morbidity and
mortality, as shown in the presented patient
Retrospective analysis of 1211 operated patients due to groin hernia with open surgical approach - single center experience
Bacground/Aim. Groin hernias are common pathology among men population. Only curative treatment is surgical reparation with various surgical procedures for groin hernia solving. The aim of this study was to evaluate the most prevalent surgical procedures and early postoperative complications after groin hernia reparation in large series of operated patients, and to assess the morphologic characteristics of groin hernias. Methods. The retrospective study included all patients with groin hernia who underwent surgical reparation from 2009 to 2012. In all patients a demographic characteristics, including gender and age, clinical characteristics and hernia type were analyzed. The surgical procedure for hernia solving and early postoperative complications were assessed. Results. The study included 1,211 patients. The male/female ratio was 1,127/84 (p < 0.001). Inguinal hernia was found in 1,195 patients (94.5% males). Femoral hernia was found in 16 patients (25% males and 75% females). Significant difference in distribution of inguinal and femoral hernia between genders was found (p < 0.001). In males right sided inguinal hernia was present in 57.6%. In females right sided inguinal hernia was present in 7 and left sided in 5 patients. Sixsten patients had bilateral inguinal hernia, all in males. There was no significant difference in side of inguinal hernia occurrence and gender. Right sided and left sided femoral hernias were present in the same percent in males. In females a higher occurrence in femoral hernia was found on the right side then on the left one (7:5) without significant difference. There were 71.1% of patients in the age group of 51–80 and 27.2% of patients in the age group of 61–70. Surgical procedures included: Lichtenstein in 51.2% of patients, nylondarn in 29.6% of patients, Bassini in 16.2% of patients, Lothaissen in 1.7% of patients, and Halsted in 1.4% of patients. Overall, postoperative complications were present in 78 (6.4%) of patients. Wound infection was the most common complication, occurred in 2.4% of patients. Conclusion. Prevalence of inguinal hernias is higher in men population, while femoral hernias are more common in females. The most affected population is at the age between 61 and 80 years. The most commonly used open surgical procedures for groin hernia reparation are Lichtenstein and nylon-darn. Both methods have low and similar incidence rates of postoperative complications
Influence of open surgical and endovascular abdominal aortic aneurysm repair on clot quality assessed by ROTEM® test
Introduction/Aim. The disturbances in hemostasis are often in open surgical
repair (OR) and endovascular repair (EVAR) of an abdominal aortic aneurysm
(AAA). These changes may influence the perioperative and early postoperative
period inducing serious complications. The aim of this study was to compare
the impact of OR and EVAR of AAA on clot quality assessed by rotational
thromboelastometry (ROTEM®) tests. Methods. The study included 40 patients
who underwent elective AAA surgery and were devided into two groups (the OR
and the EVAR group - 20 patients in each group). The ROTEM ® test was
performed in 4 points: point 1 - 10 min before starting anesthesia in both
groups; point 2 - 10 min after aortic clapming in the OR group and 10 min
after the stent-graft trunk release in the EVAR group; point 3 - 10 min after
the releasing of aortic clamp in the OR group and 10 min after stentgraft
placement and releasing the femoral clamp in the EVAR group; point 4 - one
hour after the procedure in both groups. Three ROTEM® tests were performed
as: extrinsically activated assay with tissue factor (EXTEM), intrinsically
activated test using kaolin (INTEM), and extrinsically activated test with
tissue factor and the platelet inhibitor cytochalasin D (FIBTEM). All tests
included the assessment of the maximum clot firmness (MCF) and the platelet
component of clot strength was presented as maximal clot elasticity (MCE).
Results. No significant difference in age, gender and diameter of AAA between
groups was found. The time required for the procedure was significantly
longer and loss of blood was greater in the OR group than in the EVAR group
(p < 0.001). The significant deviation of MCF values in EXTEM test was found
mainly in the point 3 (p ≤ 0.004) with significant difference between groups
(p < 0.001). A significant difference of MCF values in INTEM test between
groups was found in the points 3 and 4 (p < 0.001), which were dose-dependent
by heparin sulfate. The MCF values in FIBTEM test were more prominent in the
OR group than in the EVAR group without significant difference. The
significant changes of MCF values in the FIBTEM test were found during time
in both groups (p < 0.001). The values of MCE were lower in both groups, but
without significant changes and difference between groups (p = 0.105).
Conclusion. The disorders of hemostatic parameters assessed by ROTEM® tests
are present in both the OR and the EVAR groups being more prominent in OR of
AAA. Vigilant monitoring of hemostatic parameters evaluated by ROTEM® tests
could help in administration of the adequate and target therapy in patients
who underwent EVAR or OR of AAA
Visceral hybrid reconstruction of thoracoabdominal aortic aneurysm after open repair of type a aortic dissection by the Bentall procedure with the elephant trunk technique: A case report
Introduction. Reconstruction of chronic type B dissection and
thoracoabdominal aortic aneurysm (TAAA) remaining after the emergency
reconstruction of the ascending thoracic aorta and aortic arch for acute
type A dissection represents one of the major surgical challenges.
Complications of chronic type B dissection are aneurysmal formation and
rupture of an aortic aneurysm with a high mortality rate. We presented a
case of visceral hybrid reconstruction of TAAA secondary to chronic
dissection type B after the Bentall procedure with the elephant trunk
technique due to acute type A aortic dissection in a high-risk patient. Case
report. A 62 year-old woman was admitted to our institution for
reconstruction of Crawford type I TAAA secondary to chronic dissection. The
patient had had an acute type A aortic dissection 3 years before and
undergone reconstruction by the Bentall procedure with the elephant trunk
technique with valve replacement. On admission the patient had coronary
artery disease (myocardial infarction, two times in the past 3 years),
congestive heart disease with ejection fraction of 25% and chronic
obstructive pulmonary disease. On computed tomography (CT) of the aorta TAAA
was revealed with a maximum diameter of 93 mm in the descending thoracic
aorta secondary to chronic dissection. All the visceral arteries originated
from the true lumen with exception of the celiac artery (CA), and the end of
chronic dissection was below the origin of the superior mesenteric artery
(SMA). The patient was operated on using surgical visceral reconstruction of
the SMA, CA and the right renal artery (RRA) as the first procedure.
Postoperative course was without complications. Endovascular TAAA
reconstruction was performed as the second procedure one month later, when
the elephant trunk was used as the proximal landing zone for the endograft,
and distal landing zone was the level of origin of the RRA. Postoperatively,
the patient had no neurological deficit and renal, liver function and
functions of the other abdominal organs were normal. Control CT after 6
months showed full exclusion of the aneurysm from the systemic circulation
without endoleak and good flow through visceral anastomosis. Conclusion. In
patients with comorbidities, like in the presented case, visceral hybrid
reconstruction of chronic dissection type B with TAAA could be the treatment
of choice
Transhepatic venous access for hemodialysis: A single-centre expirience
Introduction. A percutaneous transhepatic approach has been used to place
tunneled catheters in the inferior vena cava for hemodialysis. This route
through the suprahepatic vein could be used to place a tunnelled catheter for
permanent haemodialysis without complications and with an excellent
permeability rate. Single centre expirience. From 2011 to 2020 in a Military
Medical Academy we treated 4 patients with transhepatic central venous
catheter for hemodialysis. All of them had exhausted approaches during period
of hemodialysis. Arterio-venous fistulas had been thrombosed on the arms,
thrombosis subclavian vein billateraly or superior cava veinand complications
by femoral catheters was present. Peritoneal dialysis was not possible.
Discusion. Limited number of papers descripted outcome of placement
transhepatic catheters for hemodialysis. In our expirience one patient needed
scroll catheter due hemodialysis had not well outcome, and one patient needed
thrombolysis catheter.Two of them are on hemodialysis without complications
for 300 and 1650 days. Conclusion. The transhepatic venous access under
ultrasound and radioscopic guidance is a simple and safe method. It is an
acceptable alternative for permanent haemodialysis catheters when other
venous accesses are exhausted, and when it is performed by a well-trained
team
Management of (Peri)Pancreatic Collections in Acute Pancreatitis
The development of (peri)pancreatic fluid collections are frequent local complications in acute pancreatitis. These collections are classified as early (acute peripancreatic fluid collection or acute necrotic collection) or late (walled-off necrosis or pseudocyst). The majority of pancreatic fluid collections resolve spontaneously and do not require intervention. However, infection may require intervention. Interventions may include endoscopic or percutaneous catheter drainage, or in a next step endoscopic or surgical necrosectomy, minimally invasive or open. The best timing for the first intervention is still under investigation. Whereas some use antibiotics to postpone intervention until the stage of walled-off necrosis, others drain earlier. Endoscopic drainage of (peri)pancreatic fluid collections is now the preferred approach of drainage due to reduced morbidity as compared to surgical or percutaneous drainage. However, each collection must be treated according to a tailored approach. The final treatment should take into consideration anatomic characteristics, patient preference, comorbidity profile of the patient, and physician discretion. This review summarizes the current evidence on the treatment of (peri)pancreatic fluid collections