Inflammatory Malignant Fibrous Histiocytoma of the Retroperitoneum

The authors present a case of inflammatory malignant fibrous histiocytoma located in the left retroperitoneum. The tumor was resected enblock with kidney and suprarenal gland. During the resection the system of retractors called the pillars of Kocman was used which allowed wide exposure of the abdominal cavity. The tumor measured 23x17x10cm with the left kidney and suprarenal incorporated. The tumor was centrally pseudocystic made of xanthomatous cells, foamy cells and rare giant cells with storiform formations and infiltrated with neutrophills. Imunohistochemically, the tumor cells were vimentin and CD 68 positive and CD 20, CD3, EMA, S-100, HMB 45, CD 34 and CD 1a negative. Neutrophills were CD 15 positive

Inflammatory Malignant Fibrous Histiocytoma of the Retroperitoneum

The authors present a case of inflammatory malignant fibrous histiocytoma located in the left retroperitoneum. The tumor was resected enblock with kidney and suprarenal gland. During the resection the system of retractors called the pillars of Kocman was used which allowed wide exposure of the abdominal cavity. The tumor measured 23x17x10cm with the left kidney and suprarenal incorporated. The tumor was centrally pseudocystic made of xanthomatous cells, foamy cells and rare giant cells with storiform formations and infiltrated with neutrophills. Imunohistochemically, the tumor cells were vimentin and CD 68 positive and CD 20, CD3, EMA, S-100, HMB 45, CD 34 and CD 1a negative. Neutrophills were CD 15 positive

Paragangliom karotidnog tjelešca koji je imitirao sliku peritonzilarnog apscesa - prikaz slučaja

Paragangliomi su neuroendokrini tumori koji se u području glave i vrata javljaju kao glomus tumori karotidnog tjelešca, timpanični, jugularni ili vagalni glomus tumori. Ovi tumori u području glave i vrata uglavnom ne izlučuju katekolamine, već daju različite kliničke slike, ovisno o lokaciji. Paragangliomi karotidnog tjelešca najčešće se prezentiraju kao bezbolne spororastuće lateralne tvorbe vrata. Najčešće budu dijagnosticirani u dobnoj skupini od trideset do pedeset godina. Prikazati ćemo slučaj četrdesetpetogodišnje bolesnice koja se javila u našu kliniku radi grlobolje s peritonzilarnom i parafaringealnom oteklinom desno uz hipertrofične tonzile i hiperemiju ždrijela. Po učinjenoj inciziji prednjeg nepčanog luka došlo je do krvarenja koje nije odgovorilo na lokalne mjere, te je hemostaza i daljnje liječenje apscesa zahtijevalo opću anesteziju. Tijekom perioperativne pripreme, operativni plan je promijenjen po pristizanju nalaza neuroradiološke obrade koji su pokazali tvorbu dimenzija 4.5 cm × 3 cm × 6 cm, što obliterira desni parafaringealni prostor i potiskuje orofarinks kontralateralno te odgovara paragangliomu karotidnog tjelešca. Učinjena je hemostaza bez daljnjih incizija tvorbe, koja je najprije bila pod sumnjom za peritonzilarni, a zatim i parafaringealni apsces. Kod bolesnice je potom učinjena dodatna dijagnostička obrada, te je na daljnje liječenje upućena vaskularnom kirurgu. Pregledom relevantnih znanstvenih baza podataka nismo našli ovakvu prezentaciju paraganglioma karotidnog tjelešca. Ovim prikazom slučaja i pregledom literature želimo podsjetiti na paragangliom karotidnog tjelešca kao moguću diferencijalnu dijagnozu peritonzilarnog ili parafaringealnog apscesa kako bi se izbjeglo moguće fatalno krvarenje kao ishod operativnog liječenja apscesa

CAROTID ENDARTERECTOMY IN PATIENTS WITH ANTIAGGREGATION THERAPY

Nakon karotidne endarterektomije ponekad dolazi do krvarenja koje može potaknuti antiagreacijska terapija. Prednosti antiagregacijske terapije su manja učestalost tromboza i povoljan učinak kod koronarnih bolesnika. Tijekom karotidne endarterektomije kod bolesnika s antiagregacijskom terapijom smo lokalno aplicirali TachoSil spužvu. Pregledali smo radove na PubMed-u koji obrađuju karotidnu endarterektomiju, antiagregacijsku terapiju i postoperacijsko krvarenje. Kod 24 operiranih bolesnika s antiagregacijskom terapijom i intraoperacijskom primjenom TachoSil-a nije bilo postoperacijskih krvarenja. Pregled literature je pokazao da antiagregacijska terapija ipak u nekim okolnostima povećava vjerojatnost postoperacijskog krvarenja. Također, usprkos novim smjernicama značajan broj kirurga prekida antiagregacijsku terapiju prije karotidne endarterektomije. Zaključujemo da je karotidnu endarterektomiju u lokalnoj anesteziji moguće učiniti i bez prekida antiagregacijske terapije, a da pritom nema porasta učestalosti postoperacijskih krvarenja ili hematoma.Carotid endarterectomy is a common way of surgical treatment of extracranial carotid artery disease caused by atherosclerosis. Patients are often operated on under local anesthesia with intraoperative application of heparin. Postoperative bleeding occurs in up to 8% of cases, and up to 4.7% of patients need reoperation due to bleeding. TachoSil is a medical sponge consisting of collagen with added human coagulation factors (fi brinogen and thrombin). In contact with water, blood or bodily fl uids, it forms a clot that adheres to the surface. The hypothesis and aim of our study was to show that TachoSil could be topically administered during surgery on carotid arteries in order to prevent minor bleeding, without causing any local signs of infl ammation or infection. The study included a prospective series of consecutive patients that underwent surgery for extracranial carotid stenosis with concomitant antiplatelet therapy at Department of Vascular Surgery, Merkur University Hospital in Zagreb. All patients received antiplatelet therapy with aspirin or aspirin and clopidogrel until the day before surgery. From April 2, 2012 to February 8, 2013, a total of 24 patients with extracranial carotid artery stenosis were operated on, along with receiving antiplatelet therapy. All patients received 100 mg of acetylsalicylic acid and/or 75 mg of clopidogrel until one day prior to surgery. Patients had been treated with antiplatelet drugs for at least six months prior to carotid endarterectomy. Four patients had been on dual antiplatelet therapy (aspirin 100 mg and clopidogrel 75 mg) because of percutaneous transluminal angioplasty (PTA) and a stent placed in pelvic arteries or superfi cial femoral artery. Due to speech disturbances following clamping of carotid arteries in two study patients a temporary intraluminal shunt was created. These two patients underwent longitudinal arteriotomy and longitudinal endarterectomy. Arteriotomy was closed by direct suture without a patch. Following arteriotomy and partial conversion of heparin with protamine, six patients needed additional individual sutures. Then, protamine was added again to up to the full dose of conversion (50 mg). In 19 patients, only one TachoSil medical sponge (9.5 cm x 4.8 cm) was placed, whereas in fi ve patients two sponges were placed. None of the patients (24 of them operated on between April 2, 2012 and February 8, 2013) with TachoSil placed intraoperatively had any signs of postoperative wound infection. Carotid artery stenosis is a very common disease the incidence of which increases proportionally with age of the population observed. Bleeding is a relatively common and significant complication following surgical treatment, particularly in case of arterial bleeding. Bleeding and other complications in the neck can be very serious and challenging for surgical treatment. With the present guidelines for the administration of clopidogrel in the evening before surgery, in some circumstances an increased incidence of postoperative hemorrhage or prolonged duration of surgery can be expected. Intraoperative use of hemostatics may reduce the postoperative bleeding complications. Intraoperative application of TachoSil does not increase the rate of postoperative complications such as infection and delayed healing. TachoSil may reduce the rate of postoperative complications in carotid surgery

Ozljeda vertebralne arterije u bolesnika s prijelomom C4 kralješka

Vertebral artery injuries due to cervical spine trauma, although rarely described in the literature, are relatively common. While most of them will remain asymptomatic, a small percentage of patients may suffer life threatening complications. We report a case of the right vertebral artery injury in a patient with fracture of C4 vertebra, successfully treated with endovascular approach. A 78-year-old male patient was hospitalized for cervical spine injury caused by falling off the tractor. Radiological assessment revealed fracture of C4 vertebra with proximal two-thirds of C4 body dislocated five millimeters dorsally. Significant swelling of soft prevertebral tissues distally of C2 segment was also present. During emergency surgery using standard anterior approach for cervical spine, excessive bleeding started from the injured right vertebral artery. Bleeding was stopped by tamponade with oxidized regenerated cellulose sheet and C4-C5 anterior fixation; then partial reduction of displacement was done. Fifteen days later, after angiography, endovascular repair of the right vertebral artery was performed using percutaneous stent graft. Follow up computed tomography scan angiography showed valid stent patency without contrast extravasation. In cases of cervical spine trauma, surgeon should always be prepared to manage injury of vertebral artery. Bleeding can primarily be stopped by hemostatic packing, and definitive repair can be successfully achieved by endovascular approach using percutaneous stent graft.Oštećenja vertebralnih arterija, iako se rijetko navode u literaturi, relativno su učestale u bolesnika s ozljedom vratne kralježnice. Iako će većina bolesnika ostati asimptomatska, njihov mali postotak može zadobiti životno ugrožavajuće komplikacije. U ovom članku opisujemo ozljedu desne vertebralne arterije kod bolesnika s prijelomom C4 kralješka, koja je uspješno zbrinuta endovaskularnim pristupom. Muškarac u dobi od 78 godina hospitaliziran je zbog ozljede vratne kralježnice koju je zadobio pri padu s traktora. Radiološkom dijagnostičkom obradom potvrđen je prijelom C4 kralješka s dorzalnom dislokacijom tijela istog kralješka za 5 mm. Pritom je bila vidljiva i značajna oteklina prevertebralnih mekih tkiva distalno od C2 segmenta. Tijekom hitnog operacijskog zahvata u kojem je korišten standardni prednji pristup na vratnu kralježnicu došlo je do masivnog krvarenja iz ozlijeđene desne vertebralne arterije. Krvarenje je zaustavljeno pomoću tamponade vaticom od oksidirane regenerirane celuloze, uz prednju fiksaciju segmenta C4-C5 i parcijalnu repoziciju. Petnaest dana kasnije, nakon angiografije, učinjena je endovaskularna sanacija oštećenja desne vertebralne arterije, uz perkutano umetanje stent grafta. Kontrolno oslikavanje kompjutoriziranom tomografijom pokazalo je dobru prohodnost stenta, bez ekstravazacije kontrasta. Kirurg mora uvijek biti svjestan mogućeg oštećenja vertebralne arterije kod bolesnika s ozljedom vratne kralježnice. Krvarenje se može primarno zaustaviti hemostatskom tamponadom, a konačna se sanacija oštećenja može učiniti endovaskularnim pristupom, korištenjem perkutanog stent grafta

Awareness, Attitudes, and Perceptions of Croatian-Based Orthopedic and Trauma Surgeons toward Scientific Manuscripts, Publishing Internationally and Medical Writing. Results of an Online Questionnaire

The objective of this survey was to identify the importance placed by Croatian-based surgeons on writing scientific manuscripts and publishing them internationally, as well as their awareness of and attitudes toward medical writing. A link to an online survey was sent to 327 Croatian-based orthopedic and trauma surgeons. The electronic questionnaire consisted of rating scales, multiple choice questions and free text reply boxes. A total of 61 surgeons based in Croatia replied to the survey, yielding a response rate of 19% (61/327). The survey results indicate that surgeons in Croatia are active in both research and the writing of manuscripts. There is also a high level of interest among them to publish internationally in English to further their careers. While 68% (38/56) of respondents initially claimed to know about medical writing, further questioning on the subject revealed a reduced level of familiarity with the concept. Only 19% (11/58) of respondents had ever engaged the services of a medical writer and they were generally satisfied with the work done across the three areas of language, editing and scientific knowledge. Medical writers are advised to increase awareness of their services among Croatian-based orthopedic and trauma surgeons who may well have a need for their expertise

MRI Study of the ACL in Children and Adolescents

Reconstruction of the ACL (anterior cruciate ligament) requires precise anatomical placement of the tendon graft. Anatomic variations may increase/decrease risk of the ACL rupture. Twenty-eight children with clinical, MRI and arthroscopic verified ACL ruptures were compared with match case control group. MRI was done one to 12 months after trauma. The thresholds values for identifying the ACL rupture were set; ACL angle 0°, and the PCL angle <115°. RESULTS: There was no significant difference of tibial attachment for the ACL and measured parameters of the femur. The ACL angle (p<0.001), the Blumensat angle (p=0.001), and the PCL angle (p<0.001) were significantly different. Each of the patients in group with a torn ACL had at least one parameter positive. DISCUSSION: ACL angle, Blumensat angle and PCL angle might help to diagnose ruptured ACL. Pediatric patients with the ruptured ACL show no difference in notch width or the tibial roof inclination angle as compared with pediatric patients without ACL rupture

Mangled Extremity – Case Report, Literature Review and Borderline Cases Guidelines Proposal

Treatment of a mangled lower extremity represents a major challenge. The decision whether to amputate or attempt reconstruction is currently based upon surgical evaluation. The aim of this paper is to propose a new approach to surgical evaluation based on scoring systems, local clinical status of the patient as well as comorbidities, mechanism of trauma and hospital resources. Available literature regarding this topic was evaluated and a case of patient with mangled extremity is presented. Based on current literature guidelines and evidence-based medicine, management for borderline cases is proposed to aid clinical decision making in these situations. We describe a 44-year old male patient who presented with mangled lower left leg. Despite a borderline Mangled Extremity Severity Score (MESS), due to the overall health status of the patient and local clinical status with preserved plantar sensitivity and satisfactory capillary perfusion, reconstruction was attempted. After 6 months of treatment, all wounds healed completely with no pain, and satisfactory motor and sensory function was achieved. In conclusion, the treatment of mangled extremity treatment should be based on evidence based literature along with a clinical evaluation of every individual patient. Scores are helpful, but should not be taken as the sole indication for amputation