Multiple esophageal leiomyomas: a case report

Background: Primary intramural benign tumors of the esophagus are rare. Leiomyomas are the most common benign esophageal neoplasms. Multiple esophageal leiomyomas are very rare, with only a few reports on more than ten coexisting lesions. Case study: A male patient presented with progressing dysphagia and a tumor of the esophageal wall, over 10 cm in length, confirmed by magnetic resonance imaging and endoscopic ultrasound examination. There were no changes of the esophageal mucosa. Multiple fine needle aspirations were performed with inconclusive finding. Surgical exploration through right thoracotomy revealed multiple extramucosal tumors from 5 to 25 millimeters in size. A total of 16 tumors were removed by enucleation without opening the esophageal mucosa. Postoperative period was uneventful. Conclusion: Exact preoperative diagnosis of esophageal submucosal tumors may be difficult to establish without open biopsy. Removal by enucleation is the treatment of choice

Uniportalna video-potpomognuta torakalna operacija plućnog hamartoma: prikaz slučaja

Pulmonary hamartoma is the most common benign tumor of the lung. It accounts for 77% of all benign lung tumors but less than 1% of all lung tumors. Malignant alteration is ­extremely rare. Surgical removal is therapy of choice. Uniportal video-assisted thoracic surgery is an easy-to-learn variant of video-assisted thoracic surgery. The approach is very similar to classic thora-cotomy. Instruments for both classic and video-assisted thoracic surgery can be combined. A case is presented of a 44-year-old female patient with pulmonary hamartoma treated by uniportal video-assisted ­thoracic surgery as a new method used for the first time at our department.Hamartom pluća je najčešći benigni tumor pluća. Predstavlja 77% svih dobroćudnih tumora pluća, ali manje od 1% svih plućnih tumora. Maligna alteracija je izrazito rijetka. Metoda izbora za liječenje hamartoma pluća je kirurška ekstirpacija. Uniportalna video-potpomognuta torakalna kirurgija je varijanta video-potpomognute torakalne kirurgije koja se brže svladava te omogućava kombiniranje postojećih klasičnih torakokirurških instrumenata i instrumenata za video-potpomognutu torakalnu kirurgiji. Prikazuje se slučaj bolesnice u dobi od 44 godine s hamartomom pluća koja je operirana metodom uniportalne video-potpomognute torakalne kirurgije, prvi put primijenjene u našoj klinici

Menstrual cycle related pneumothorax: case report and review of the literature

Background: Catamenial pneumothorax is the most common form of thoracic endometriosis syndrome. It occurs around the beginning of a menstrual cycle. Although the mechanism of catamenial pneumothorax is not definitely clear, endometriosis plays an important role in it. Video-assisted thoracic surgery is standard procedure for the treatment of recurrent pneumothorax in general. Case study: We report on a case of catamenial pneumothorax in women with a history of recurring spontaneous pneumotoraces associated with diaphragmatic endometrial implants who is involved in the IVF procedure. Conclusion: Combination of video-assisted thoracoscopic surgery (VATS) and gonadotropinreleasing-hormone analogue gives the best results, to reduce the risk of pneumothorax to recur. Treatment of catamenial pneumothorax is complex and should include thoracic surgeon and gynecologist as soon as the diagnosis is definitive

Ruptura maternice u trećem trimestru nakon prethodne miomektomije

Rupture of gravid uterus is surgical emergency causing maternal and fetal morbidity and mortality. The risk of uterine rupture is associated with uterine scars caused by previous cesarean section, myomectomy, hysteroscopic procedures, and curettage. We report a case of a 40-year-old woman in 31st week of gestation with spontaneous uterine rupture. It was her third pregnancy. She had two healthy children from previous pregnancies. Her symptoms were abdominal pain, vomiting and pain in the right shoulder lasting for 12 hours prior to admission. Ultrasound examination at admission revealed a dead fetus in the abdomen and free fluid in the abdominal cavity. She had previously undergone laparoscopic myomectomy. After myomectomy, she had one successful vaginal delivery. Every abdominal pain in pregnant woman with uterine scar should be carefully and promptly examined to exclude uterine rupture before further diagnostic procedures. This early time frame is essential for survival of the fetus and sometimes even of the mother. Uterine rupture represents indication for immediate cesarean section and it should be performed within 25 minutes of the first signs of uterine rupture. As shown in the case presented, one successful vaginal delivery after myomectomy is no guarantee for future pregnancies.Ruptura maternice je akutno stanje u porodništvu koje može voditi do majčine i/ili fetalne smrti. Rizik za rupturu maternice povezan je s ožiljkom na maternici uzrokovanim prethodnim carskim rezom, miomektomijom, histeroskopskim zahvatom ili kiretažom. Prikazuje se 40-godišnja trudnica u 31. tjednu trudnoće koja je imala spontanu rupturu maternice. Ovo je bila treća trudnoća ove bolesnice koja je iz ranijih trudnoća rodila dvoje zdrave djece. Simptomi su bili praćeni bolovima u trbuhu, povraćanjem i bolovima u desnom ramenu koji su trajali 12 sati. Ultrazvučnim pregledom kod prijma je nađen mrtav plod u trbušnoj šupljini uz slobodnu tekućinu u abdomenu. Prethodno je bolesnica jedanput imala laparoskopsku miomektomiju. Nakon miomektomije je vaginalno rodila. Svakoj boli u trbuhu kod trudnice s ožiljkom na maternici treba pristupiti pažljivo i hitno pregledati te obraditi kako bi se isključila ruptura maternice prije daljnjih dijagnostičkih postupaka. Ovo rano vrijeme prepoznavanja je ključno za preživljavanje fetusa, a ponekad i majke. Ruptura maternice je indikacija za hitni carski rez koji treba učiniti unutar 25 minuta od prvih znakova rupture maternice. Čak niti jedan uspješan porod nakon stanja poslije miomektomije ne jamči da će ožiljak izdržati drugu trudnoću

Ishod trudnoće uz gestacijski dijabetes u usporedbi s indeksom tjelesne mase

Gestational diabetes involves disorder of glucose metabolism first diagnosed in pregnancy. Obese women undoubtedly have more often complications in reproductive age, such as fertility difficulties, spontaneous and recurrent miscarriages, premature births, and various obstetric and surgical complications related to the course of pregnancy, delivery and puerperium. Children of obese pregnant women are more likely to develop obesity in childhood and adulthood. We analyzed the outcome of 51 pregnancies in obese pregnant women and 50 pregnant women with normal body mass index. All women in both groups were diagnosed with gestational diabetes by the IADPSG criteria. We analyzed gestational age at delivery and mode of delivery, gestational weight gain, presence of concomitant diagnosis of gestational or chronic hypertension, difference in birth weight, and prevalence of hypertrophic newborns. There was no significant difference in gestational age at pregnancy termination and in the mode of delivery. There was a significant difference in gestational weight gain, number of pregnant women with hypertension, neonatal birth weight and number of hypertrophic children. Based on the data presented, we conclude that obesity is an unfavorable factor for pregnancy outcome. It also influences birth weight and fetal hypertrophy, as well as gestational weight gain.Gestacijski dijabetes podrazumijeva poremećaj metabolizma glukoze koji se prvi puta dijagnosticira u trudnoći, a njegova incidencija je u porastu. Pretile žene nedvojbeno imaju češće probleme i komplikacije u reproduktivnim godinama, što podrazumijeva teškoće pri zanošenju, spontane i habitualne pobačaje, prijevremene porođaje i različite opstetričke i kirurške komplikacije vezane za tijek trudnoće, porođaja i babinja. Djeca iz takvih trudnoća češće razvijaju pretilost u djetinjstvu kao i u odrasloj dobi. S obzirom na navedeno analizirali smo ishod trudnoća u 51 pretile trudnice i 50 trudnica s urednim indeksom tjelesne mase, pri čemu su sve trudnice (u objema skupinama) imale dijagnozu gestacijskog dijabetesa prema kriterijima IADPSG. Analizirali smo gestacijsku dob, način dovršenja trudnoće, prirast na težini trudnica, prisutnost istodobnih dijagnoza gestacijske ili kronične hipertenzije, razliku u težini novorođenčadi te učestalost hipertrofične novorođenčadi. Rezultati su pokazali da ne postoji statistički značajna razlika u gestacijskoj dobi kad je završena trudnoća niti u načinu dovršenja porođaja. Utvrđena je statistički značajna razlika u dobivenim kilogramima tijekom trudnoće, broju trudnica s hipertenzijom, porođajnoj masi novorođenčadi i broju hipertrofične djece. U zaključku, pretilost u trudnoći s gestacijskim dijabetesom je nepovoljan čimbenik za ishod trudnoće, porođajnu masu i prekomjeran rast novorođenčadi, kao i za prirast tjelesne mase trudnice tijekom trudnoće

Adenoidni cistični karcinom distalne traheje: prikaz slučaja

Primary malignant tumors of the trachea are very rare with the incidence of less than two per million people per year, and only ten percent of them are adenoid cystic carcinomas. Eighty percent of all tracheal tumors are malignant. Diagnosis is usually late because the symptoms mimic other conditions such as asthma. Clinical picture may sometimes be dramatic when airway is almost closed and emergency recanalization is necessary. Diagnosis is made by chest computed tomography scan or magnetic resonance imaging. Definitive treatment is surgical resection alone or followed by radiation therapy or radiation therapy alone. Radical resection is only accomplished in about half of all cases because of the submucosal tumor growth and limited length of tracheal resection. The role of adjuvant radiation therapy in negative resection margin cases is not clear but all patients with positive resection margin benefit from radiation therapy. We present a case of a 43-year-old patient with primary adenoid cystic carcinoma of distal trachea treated by emergency bronchoscopic recanalization and resection of the tracheal tumor with end-to-end anastomosis.Primarni maligni tumori traheje su iznimno rijetki s incidencijom manjom od dva slučaja na milijun stanovnika u jednoj godini, a adenoidni cistični karcinom čini samo deset posto. Osamdeset posto svih tumora traheje je maligno. Dijagnoza se obično postavlja kasno, jer su početni simptomi slični astmi. Ponekad je klinička slika dramatična kada dođe do opstrukcije dišnog puta i potrebe za hitnom rekanalizacijom. Dijagnoza se potvrđuje kompjutorskom tomografijom prsišta ili magnetnom rezonancom. Definitivno liječenje je resekcija tumora sama ili uz adjuvantnu radioterapiju, ili radioterapija sama. Radikalna resekcija se postiže samo u oko polovice svih slučajeva zbog submukoznog rasta tumora i ograničene duljine resekcije traheje. Uloga adjuvantne radioterapije u slučajevima s negativnim resekcijskim rubom je nejasna, dok svi bolesnici s pozitivnim resekcijskim rubom imaju koristi od adjuvantne radioterapije. Prikazujemo slučaj 43-godišnjeg bolesnika s adenoidnim cističnim karcinomom distalnog dijela traheje koji je liječen bronhoskopskom rekanalizacijom i resekcijom traheje s terminoterminalnom anastomozom

Je li povećanje incidencije OASIS-a pokazatelj lošije opstetričke skrbi?

In the era of new molecular, epigenetic and proteomic discoveries, birth canal injuries seem like outdated discussion. A vast increase in the incidence of obstetric anal sphincter injuries (OASIS) has been recorded in the last two decades despite advantages in modern medicine and new obstetric methods. This increase might be attributed to the new classification of perineal injury but also to the new imaging methods, including endoanal sonography, which earlier identifies injuries that previously were considered to be occult and actually underwent unrecognized, and which should have been recognized immediately postpartum. OASIS are third and fourth degree perineal injuries that occur during delivery. The reported incidence of OASIS varies from 0.1% to 10.9%. It is well known that third and fourth degree perineal injuries occur more often in primiparae, and in cases of macrosomic newborn, dorsoposterior position of fetal head and shoulder dystocia. The protective role of episiotomy is controversial. Birth canal injury during delivery can happen to any parturient woman. It is important for obstetricians to have this in mind at every delivery. Repercussions of OASIS are serious and can persist for life. They include emotional, psychological, social, physical and sexual disturbances. Therefore, it is very important to recognize the risk factors, diagnose the injury on time and treat it properly by a multidisciplinary team. Accordingly, it can be concluded that the increased incidence of OASIS is a result of better recognition of the risk factors, reduced rates of unrecognized sphincter injuries, adoption of the new classification and better postpartum imagining methods for detection of occult injuries.U eri novih molekularnih, epigenetičkih i proteomskih otkrića porođajne ozljede izgledaju kao zastarjela tema za raspravu. U posljednja dva desetljeća zabilježen je porast ozljeda analnog sfinktera tijekom porođaja unatoč napretcima moderne medicine i novim porođajnim metodama. Ovo povećanje moglo bi se pripisati novoj klasifikaciji perinealnih ozljeda, ali i novim slikovnim metodama uključujući endoanalnu sonografiju koja kvalificira ozljede za koje se smatra da su prije bile okultne, zapravo neprepoznate, a trebale su biti prepoznate odmah nakon porođaja. U opstetričke ozljede analnog sfinktera se ubrajaju treći i četvrti stupanj razdora međice tijekom porođaja. Učestalost ovih ozljeda varira od 0,1% do 10,9%. Poznato je da je razdor međice trećeg i četvrtog stupnja češći u prvorotkinja te u slučajevima makrosomnog novorođenčeta, dorsoposteriornom položaju fetalne glavice i kod distocije ramena. Zaštitna uloga epiziotomije je proturječna. Ozljeda porođajnog kanala se može dogoditi kod bilo koje žene u porođaju, što porodničar uvijek mora imati na umu. Razdori međice trećeg i četvrtog stupnja mogu imati ozbiljne dalekosežne posljedice koje uključuju emocionalne, psihološke, socijalne, fizičke i seksualne poremećaje. Stoga je vrlo važno prepoznati čimbenike rizika, dijagnosticirati ozljedu na vrijeme i zbrinuti ju na odgovarajući način uz multidisciplinarni pristup. Uza sve navedeno može se zaključiti da je povećana učestalost OASIS-a rezultat boljeg prepoznavanja čimbenika rizika, smanjene stope neprepoznate ozljede sfinktera, uvođenja nove klasifikacije i boljih slikovnih metoda koje postpartalno mogu otkriti okultne ozljede

Adenoidni cistični karcinom distalne traheje: prikaz slučaja

Primary malignant tumors of the trachea are very rare with the incidence of less than two per million people per year, and only ten percent of them are adenoid cystic carcinomas. Eighty percent of all tracheal tumors are malignant. Diagnosis is usually late because the symptoms mimic other conditions such as asthma. Clinical picture may sometimes be dramatic when airway is almost closed and emergency recanalization is necessary. Diagnosis is made by chest computed tomography scan or magnetic resonance imaging. Definitive treatment is surgical resection alone or followed by radiation therapy or radiation therapy alone. Radical resection is only accomplished in about half of all cases because of the submucosal tumor growth and limited length of tracheal resection. The role of adjuvant radiation therapy in negative resection margin cases is not clear but all patients with positive resection margin benefit from radiation therapy. We present a case of a 43-year-old patient with primary adenoid cystic carcinoma of distal trachea treated by emergency bronchoscopic recanalization and resection of the tracheal tumor with end-to-end anastomosis.Primarni maligni tumori traheje su iznimno rijetki s incidencijom manjom od dva slučaja na milijun stanovnika u jednoj godini, a adenoidni cistični karcinom čini samo deset posto. Osamdeset posto svih tumora traheje je maligno. Dijagnoza se obično postavlja kasno, jer su početni simptomi slični astmi. Ponekad je klinička slika dramatična kada dođe do opstrukcije dišnog puta i potrebe za hitnom rekanalizacijom. Dijagnoza se potvrđuje kompjutorskom tomografijom prsišta ili magnetnom rezonancom. Definitivno liječenje je resekcija tumora sama ili uz adjuvantnu radioterapiju, ili radioterapija sama. Radikalna resekcija se postiže samo u oko polovice svih slučajeva zbog submukoznog rasta tumora i ograničene duljine resekcije traheje. Uloga adjuvantne radioterapije u slučajevima s negativnim resekcijskim rubom je nejasna, dok svi bolesnici s pozitivnim resekcijskim rubom imaju koristi od adjuvantne radioterapije. Prikazujemo slučaj 43-godišnjeg bolesnika s adenoidnim cističnim karcinomom distalnog dijela traheje koji je liječen bronhoskopskom rekanalizacijom i resekcijom traheje s terminoterminalnom anastomozom

Epiduralna analgezija u porodništvu - proturječja

Labor pain is one of the most severe pains. Labor is a complex and individual process with varying maternal requesting analgesia. Labor analgesia must be safe and accompanied by minimal amount of unwanted consequences for both the mother and the child, as well as for the delivery procedure. Epidural analgesia is the treatment that best meets these demands. According to the American Congress of Obstetrics and Gynecology and American Society of Anesthesiologists, mother’s demand is a reason enough for the introduction of epidural analgesia in labor, providing that no contraindications exist. The application of analgesics should not cease at the end of the second stage of labor, but it is recommended that lower concentration analgesics be then applied. Based on the latest studies, it can be claimed that epidural analgesia can be applied during the major part of the first and second stage of labor. According to previous investigations, there is no definitive conclusion about the incidence of instrumental delivery, duration of second stage of labor, time of epidural analgesia initiation, and long term outcomes for the newborn. Cooperation of obstetric and anesthesiology personnel, as well as appropriate technical equipment significantly decrease the need of instrumental completion of a delivery, as well as other complications encountered in the application of epidural analgesia. Our hospital offers 24/7 epidural analgesia service. The majority of pregnant women in our hospital were aware of the advantages of epidural analgesia for labor, however, only a small proportion of them used it, mainly because of inadequate level of information.Bol kod porođaja smatra se jednom od najjačih boli. Porođaj je složen i individualan proces s različitim željama žena za analgezijom. Analgezija u porođaju mora biti sigurna i s minimalnim neželjenim posljedicama za majku, dijete i za tijek porođaja. Tim uvjetima najbolje udovoljava epiduralna analgezija (EA). Prema American College of Obstetrics and Gynecology i American Society of Anesthesiologists za primjenu EA u porođaju dovoljna je želja rodilje ako ne postoji kontraindikacija. Davanje analgetika ne treba prestati na kraju drugog porođajnog doba, ali se tada preporučuju niske koncentracije lokalnog anestetika te dodavanje adjuvansa. Novije studije ukazuju na to da se EA može primijeniti u najvećem dijelu prvog i drugog porođajnog doba. Bez obzira na dosadašnja iskustva i istraživanja ne postoji slaganje oko učestalosti instrumentalnog dovršenja porođaja, trajanja drugog porođajnog doba uz EA i vremena uvođenja EA te dugoročnog utjecaja na dijete. Dobra suradnja opstetričkog i anesteziološkog osoblja i dobra tehnička opremljenost znatno smanjuju potrebu za instrumentalnim dovršenjem porođaja, kao i druge komplikacije EA. Naša bolnica nudi EA za olakšani porođaj tijekom 24 sata. Većina trudnica je svjesna prednosti primjene EA za vaginalni porođaj, međutim, samo mali broj trudnica iskoristi tu mogućnost, uglavnom zbog nedovoljne obaviještenosti o toj metodi

Epiduralna analgezija u porodništvu - proturječja

Labor pain is one of the most severe pains. Labor is a complex and individual process with varying maternal requesting analgesia. Labor analgesia must be safe and accompanied by minimal amount of unwanted consequences for both the mother and the child, as well as for the delivery procedure. Epidural analgesia is the treatment that best meets these demands. According to the American Congress of Obstetrics and Gynecology and American Society of Anesthesiologists, mother’s demand is a reason enough for the introduction of epidural analgesia in labor, providing that no contraindications exist. The application of analgesics should not cease at the end of the second stage of labor, but it is recommended that lower concentration analgesics be then applied. Based on the latest studies, it can be claimed that epidural analgesia can be applied during the major part of the first and second stage of labor. According to previous investigations, there is no definitive conclusion about the incidence of instrumental delivery, duration of second stage of labor, time of epidural analgesia initiation, and long term outcomes for the newborn. Cooperation of obstetric and anesthesiology personnel, as well as appropriate technical equipment significantly decrease the need of instrumental completion of a delivery, as well as other complications encountered in the application of epidural analgesia. Our hospital offers 24/7 epidural analgesia service. The majority of pregnant women in our hospital were aware of the advantages of epidural analgesia for labor, however, only a small proportion of them used it, mainly because of inadequate level of information.Bol kod porođaja smatra se jednom od najjačih boli. Porođaj je složen i individualan proces s različitim željama žena za analgezijom. Analgezija u porođaju mora biti sigurna i s minimalnim neželjenim posljedicama za majku, dijete i za tijek porođaja. Tim uvjetima najbolje udovoljava epiduralna analgezija (EA). Prema American College of Obstetrics and Gynecology i American Society of Anesthesiologists za primjenu EA u porođaju dovoljna je želja rodilje ako ne postoji kontraindikacija. Davanje analgetika ne treba prestati na kraju drugog porođajnog doba, ali se tada preporučuju niske koncentracije lokalnog anestetika te dodavanje adjuvansa. Novije studije ukazuju na to da se EA može primijeniti u najvećem dijelu prvog i drugog porođajnog doba. Bez obzira na dosadašnja iskustva i istraživanja ne postoji slaganje oko učestalosti instrumentalnog dovršenja porođaja, trajanja drugog porođajnog doba uz EA i vremena uvođenja EA te dugoročnog utjecaja na dijete. Dobra suradnja opstetričkog i anesteziološkog osoblja i dobra tehnička opremljenost znatno smanjuju potrebu za instrumentalnim dovršenjem porođaja, kao i druge komplikacije EA. Naša bolnica nudi EA za olakšani porođaj tijekom 24 sata. Većina trudnica je svjesna prednosti primjene EA za vaginalni porođaj, međutim, samo mali broj trudnica iskoristi tu mogućnost, uglavnom zbog nedovoljne obaviještenosti o toj metodi