Dvostruko slijepa randomizirana studija o učinkovitosti topičke primjene 2% lidokaina u liječenju simptomatskih hemoroida [Double blinded randomized clinical trial of the efficacy of topical 2% lidocaine for the treatment of symptomatic hemorrhoids]

Hemorrhoids are the most common ailment affecting the male gender. This condition affects 38.93% of the general population and is even more common in middle aged individuals with higher social-economic status. It is estimated that at least half this population is affected by hemorrhoids at least once in their lifetime. Topical hemorrhoid therapy is the most frequently prescribed first line treatment by the general practitioner and is the most common type of therapy sought by the patient in the beginning stages. There have been no documented randomized clinical studies that observed the quality and success of using perianal lidocaine as treatment and therefore this method is based on empirical findings without any quality clinical proof. We can state that the topical treatment of hemorrhoids is not a medically founded pharmacologic practice, but rather, remains an empirically based treatment without proof of effectiveness. In the American Gastroenterological Association guidelines for diagnosing and treating hemorrhoids, under the topical treatment section, the following is stated: Over the counter topical and suppository products have become more present in the empirical treatment of symptoms associated with hemorrhoids, without any information supporting their use. The goal of this study is to conduct a randomized clinical study on the effectiveness of using local lidocaine compared with a placebo in reducing hemorrhoid symptoms. The main goal is to determine the effectiveness of topical lidocaine use in patients with symptomatic hemorrhoids who, due to this ailment, have changes in the degree of disease and changes/increase in symptoms (pain, itch, bleeding, swelling and comfort are subjective symptoms which we observed and objectified using the validated analogue Corrects scale) The results of this study show that lidocaine, when used as a topical treatment has the identical effect on symptoms using the Corrects scale on days 1,3 and 7 after application as the placebo. If we stratify the individual symptoms such as pail, itch, swelling, bleeding and comfort, we see that lidocaine when compared with the placebo is not effective in reducing hemorrhoid symptoms. Furthermore, there is no significant difference in the general patients’ health status nor on the subjective decrease in symptoms between the two groups at 1,3 and 7 days after topical application. In both groups there was no noted improvement in the degree of disease and therefore we can conclude that neither lidocaine nor the placebo can influence the morphologic changes in hemorrhoid tissue

Hyperthermic Intraperitoneal Chemotherapy (HIPEC) and Cytoreductive Surgery (CS) as Treatment of Peritoneal Carcinomatosis: Preliminary Results in Croatia

The purpose of our study was to evaluate initial results following introduction of Hyperthermic Intraperitoneal Chemotherapy (HIPEC) and Cytoreductive Surgery (CS). Twenty two patients with intraperitoneal malignancy undergone cytoreductive surgery (CS) and hyperthermic intraoperative chemotherapy (HIPEC) between January of 2007 and January 2010. Nine patients had adenocarcinoma of colorectal origin, 8 patients had ovarian cancer, and 5 had pseudomyxoma peritonei. Inclusion criteria were diagnosis of peritoneal carcinomatosis based on intraoperative assessment during first operative procedure for intraabdominal malignancy or follow-up diagnostic imaging proof. Excluded were patients with known malignant proliferation outside abdomen, liver metastasis and ASA score 4 and higher. All patients with pseudomyxoma peritonei diagnosis are alive, with mean follow-up time 24.8 months (range 15–35). In group of patients with adenocarcinoma from colorectal origin, 3 died, resulting in mean survival time 7.6 months (range 1–16). In group of patients with ovarian cancer, 2 died, resulting in mean survival time 13.8 months (range 0–31). Two patients died in early postoperative period. Most of the patients had some sort of mental disorder. Although HIPEC with CS improves survival, during introduction period higher morbidity and mortality could be expected

Hyperthermic Intraperitoneal Chemotherapy (HIPEC) and Cytoreductive Surgery (CS) as Treatment of Peritoneal Carcinomatosis: Preliminary Results in Croatia

The purpose of our study was to evaluate initial results following introduction of Hyperthermic Intraperitoneal Chemotherapy (HIPEC) and Cytoreductive Surgery (CS). Twenty two patients with intraperitoneal malignancy undergone cytoreductive surgery (CS) and hyperthermic intraoperative chemotherapy (HIPEC) between January of 2007 and January 2010. Nine patients had adenocarcinoma of colorectal origin, 8 patients had ovarian cancer, and 5 had pseudomyxoma peritonei. Inclusion criteria were diagnosis of peritoneal carcinomatosis based on intraoperative assessment during first operative procedure for intraabdominal malignancy or follow-up diagnostic imaging proof. Excluded were patients with known malignant proliferation outside abdomen, liver metastasis and ASA score 4 and higher. All patients with pseudomyxoma peritonei diagnosis are alive, with mean follow-up time 24.8 months (range 15–35). In group of patients with adenocarcinoma from colorectal origin, 3 died, resulting in mean survival time 7.6 months (range 1–16). In group of patients with ovarian cancer, 2 died, resulting in mean survival time 13.8 months (range 0–31). Two patients died in early postoperative period. Most of the patients had some sort of mental disorder. Although HIPEC with CS improves survival, during introduction period higher morbidity and mortality could be expected

Upotreba staplera u onkološkoj kirurgiji rektuma povećava incidenciju niskih anteriornih resekcija: 11 godina iskustva (1996.-2006.)

Pozadina Niski karcinomi rektuma predstavljaju teškoću u izvođenju niske/ultraniske anastomoze. Staplerske tehnike anastomoze sve se više koriste, kako zbog brzine izvođenja, tako i zbog tehnički jednostavnijeg izvođenja niske anastomoze. Cilj istraživanja je utvrditi je li upotreba staplera povećala udio kontinuitetnih resekcija rektuma zbog karcinoma u KBC-u Zagreb. Metode U razdoblju od 11 godina (1996.−2006.) svi pacijenti s rektalnim karcinomom na Zavodu za abdominalnu kirurgiju bili su uključeni u istraživanje. Stapleri su u rektalnoj kirurgiji bili korišteni tijekom cijelog istraživačkog razdoblja, a kontinuirano i trajno nakon 2000. godine. Rezultati Operirano je 413 pacijenata i izvedeno 149 niskih anteriornih resekcija, 156 Milesovih operacija i preostalih operacija (Hartmann i palijativne). Tijekom godina broj operacija se stalno povećavao s povećanjem učestalosti niskih anteriornih resekcija rektuma. Učestalost Milesove operacije ostala je nepromijenjena s vrijednošću od oko 40%. Zaključci Uspostava kontinuiteta nakon resekcija rektuma značajno poboljšava kvalitetu života uz jednaku onkološku sigurnost ako je tehnički izvediva u usporedbi s abdominoperinealnom resekcijom rektuma. Konstantnom upotrebom staplera u onkološkoj rektalnoj kirurgiji postoji povećana učestalost niskih anteriornih resekcija rektuma. Nažalost, učestalost Milesove operacije ostaje nepromijenjena

Radiofrequency ablation as locoregional therapy for unresectable hepatic malignancies: initial results in 24 patients with 5-years follow-up

Radiofrequency ablation (RFA) is one treatment modality for unresectable liver metastases. Patients with hepatic malignancies (n = 24) underwent elective RFA. All tumors were ablated with a curative intent, with a margin of 1 cm, in a single session of RFA. The median diameter of tumor was 3.1 cm (range 1.7-6.9 cm). Studied patients were not candidates for resection due to multifocal hepatic disease, extrahepatic disease, proximity to major vascular structures or presence of cirrhosis with functional hepatic reserve inadequate to tolerate major hepatic resection. Complete tumor necrosis was achieved in 87.5% and tumor recurred in 3 patients (12.5%) with lesions larger than 5 cm. Distant intrahepatic recurrence was diagnosed in another 4 (16.7%). Distant metastases were found in 7 (29.2%) patients. Four of these 7 patients had also distant intrahepatic recurrence of disease. Two and 5-years survival rates were 41.7% (10 patients) and 8.3% (2 patients) respectively. RFA is safe and effective option for patients with unresectable hepatic malignancies smaller than 5 cm without distant metastatic disease. RF ablation resulted in complete tumor necrosis in 87.5% with 2 and 5-years survival rates much higher than with chemotherapy alone or only supportive therapy, when survival is measured in weeks or months. If RFA is unavailable, percutaneous ethanol injection therapy can be done but with inferior survival rates

Perforated Ascending Colon Cancer Presenting as Colocutaneous Fistula with Abscess to the Anterior Abdominal Wall at the Site of a Cholecystectomy Scar Treated with Biologic Mesh

Ascending colon cancer as a colocutaneous fistula to the abdominal wall at the site of a previous postoperative scar is extremely rare. A 69 year old male presented with five day history of pain and foul smelling discharge from right subcostal scar from elective cholecystectomy performed 8 years ago. Last three days, he had fever up to 39°C, with mild pain in right upper abdominal quadrant without vomiting, diarrhea, bloody stools or weight loss. Computed tomography, with peroral contrast, revealed extralumination into abdominal wall with several fistulas reaching the skin. Emergency median laparotomy found infiltrating tumor of ascending colon into abdominal wall. A right hemicolectomy and complete thickness abdominal wall excision (7´10 cm) was performed. The abdominal wall defect was too extensive for primary closure and two 20 x 20 cm moist gauzes were placed to cover the defect and were fixed with stitches to the skin. On second postoperative day, due to contamination, porcine dermal collagen implant was placed intraperitoneally. Such emergency presentations and therapeutic options are discussed

Upotreba staplera u onkološkoj kirurgiji rektuma povećava incidenciju niskih anteriornih resekcija: 11 godina iskustva (1996.-2006.)

Pozadina Niski karcinomi rektuma predstavljaju teškoću u izvođenju niske/ultraniske anastomoze. Staplerske tehnike anastomoze sve se više koriste, kako zbog brzine izvođenja, tako i zbog tehnički jednostavnijeg izvođenja niske anastomoze. Cilj istraživanja je utvrditi je li upotreba staplera povećala udio kontinuitetnih resekcija rektuma zbog karcinoma u KBC-u Zagreb. Metode U razdoblju od 11 godina (1996.−2006.) svi pacijenti s rektalnim karcinomom na Zavodu za abdominalnu kirurgiju bili su uključeni u istraživanje. Stapleri su u rektalnoj kirurgiji bili korišteni tijekom cijelog istraživačkog razdoblja, a kontinuirano i trajno nakon 2000. godine. Rezultati Operirano je 413 pacijenata i izvedeno 149 niskih anteriornih resekcija, 156 Milesovih operacija i preostalih operacija (Hartmann i palijativne). Tijekom godina broj operacija se stalno povećavao s povećanjem učestalosti niskih anteriornih resekcija rektuma. Učestalost Milesove operacije ostala je nepromijenjena s vrijednošću od oko 40%. Zaključci Uspostava kontinuiteta nakon resekcija rektuma značajno poboljšava kvalitetu života uz jednaku onkološku sigurnost ako je tehnički izvediva u usporedbi s abdominoperinealnom resekcijom rektuma. Konstantnom upotrebom staplera u onkološkoj rektalnoj kirurgiji postoji povećana učestalost niskih anteriornih resekcija rektuma. Nažalost, učestalost Milesove operacije ostaje nepromijenjena

ADHESIOLYSIS AND PARTIAL RESECTION OF TERMINAL ILEUM IN A PATIENT WITH KIDNEY TRANSPLANTATION AND SEVERE SCLEROSING PERITONITIS

Sada dvadesetjednogodišnja bolesnica od 2001. godine zna da ima potkovasti bubreg. Od travnja 2005. godine se liječi peritonejskom dijalizom. U lipnju 2009. učinjena je transplantacija bubrega s umrle osobe, ali je dva mjeseca kasnije bilo neophodno učiniti graftektomiju zbog teške gljivične infekcije uz razvoj akutnog odbacivanja presatka. Bolesnica je vraćena na peritonejsku dijalizu. U ožujku 2011. učinjena je druga transplantacija uz dobru funkciju presatka. Devet mjeseci kasnije dolazi do razvoja ascitesa uz difuzne bolove u abdomenu. MSCT-om se verificira opsežni skleroziraju i peritonitis uz dilataciju terminalnog ileuma do 9 cm, a distalnije od distenzije nađeno je 25-30 cm terminalnog ileuma u bloku. Unatoč parenteralnoj prehrani stanje bolesnice se pogoršavalo te se u travnju 2012. godine pristupilo kirurškom zahvatu. Medijanom laparotomijom nađe se tanko crijevo prekriveno vrstom fibroznom pločom uz opsežne priraslice. Učini se opsežna adhezioliza s lateralnih strana u području retroperitoneuma prema sagitalnoj liniji. Presiječe se ileum ispred opisanog bloka otprilike 25-30 cm od ileocekalne valvule, a potom se presiječe i transverzum i formira laterolateralna anastomoza terminalnog ileuma i transverzuma produženim šavom u dva sloja. Postavi se abdominalni dren. Postoperativni tijek se komplicira febrilitetom pa se osam dana nakon prvog kirurškog zahvata učini eksplorativna relaparotomija i evakuira sadržaj iz apscesne šupljine. Bolesnica je liječena antibioticima širokog spektra, a zbog zatajivanja funkcije presatka i hemodijalizom. Nakon mjesec dana bolesnica ponovno postaje febrilna, MSCT-om se postavi sumnja na apsces, ali se eksplorativnom laparotomijom ne nađe kolekcija u abdomenu. Ponovno očitanje MSCT-a pokazalo je da se radi o edematoznom transplantiranom bubregu. Učini se graftektomija. Bolesnica se dobro oporavila i nastavila liječenje hemodijalizom u matičnom centru.A 21-year-old female patient was diagnosed with horseshoe kidney at the age of 10. She had been treated with peritoneal dialysis from 2005 to 2009, when she received kidney from a deceased donor. The posttransplant course was complicated by development of Pseudomonas aeruginosa and Candida sepsis. Reduced immunosuppression resulted in acute rejection, which demanded graphtectomy 2 months after transplantation. She restarted peritoneal dialysis for additional 2 years. In March 2011, she received her second transplant with excellent function. Nine months after the transplantation, she developed ascites, with early satiety and vomiting. MSCT revealed severe encapsulating sclerosing peritonitis. Her overall condition deteriorated, so she underwent adhesiolysis with resection of incarcerated terminal ileum. Due to acute allograft rejection, urgent graphtectomy was performed. Currently, she is receiving everolimus and dialysis successfully, with excellent overall status

Spontaneous Perforation of the Small Intestine, a Novel Manifestation of Classical Homocystinuria in an Adult with New Cystathionine b-synthetase Gene Mutations

The clinical picture of classical homocystinuria is diverse. This is the first report of an adult homocystinuric patient with non-traumatic spontaneous small bowel perforation. A 47-year old man presented with abdominal rebound tenderness, hypotension and tachycardia, anemia, and elevated markers of inflammation. Other routine laboratory tests were normal. Abdominal x-ray showed no free air. An emergency laparotomy revealed jejunal perforation in the left upper quadrant. Histologic specimen showed full-thickness nonspecific inflammation of the intestinal wall with granulocytic infiltration, hemorrhage and necrosis. Tuberculosis, actinomycosis and typhus were histologically and clinically excluded. After excluding all known possible causes of perforation, we presumed a causative relationship between homocystinuria and small bowel perforation. It could be hypothesized that connective tissue weakness in homocystinuria is a result of homocysteine interference with recombinant human fibrillin-1 fragments or cross-linking of collagen through permanent degradation of disulfide bridges and lysine amino acid residues in proteins. DNA analysis showed three detectable mutations in the cystathionine beta-synthetase gene, 1278T:c.833T>C, and two new mutations, V372G:c.1133T>G, and D520G:c.1558A>G in the alternatively spliced exon 15

Surgical treatment of perihilar cholangiocarcinoma: 10-year experience at a single institution

Background: Our study evaluates surgical outcomes of patients treated for perihilar cholangiocarcinoma in a single institution and demonstrates postoperative (90 days) morbidity and mortality rates and potential prognostic factors associated with complications. Methods: Medical records of all patients with a diagnosis of perihilar cholangiocarcinoma (pCC) between 2007 and 2017 who underwent a surgical procedure at the University hospital centre Zagreb, were retrospectively evaluated. Statistical analysis to determine predictors of postoperative mortality was performed using the Chi-square test and Fisher exact probability test where appropriate. Results: Out of 52 surgically treated patients, 43 underwent radical and 9 palliative procedures. Hilar resection and hilar resection along with right hepatectomy were the most commonly performed procedures in 34 radically treated patients. Overall morbidity and mortality rates were 46% and 5.7%, respectively. Significantly higher morbidity rate was observed in a group of patient with untreated preoperative jaundice and in those aged 70 and over. Conclusion: Current guidelines favor extension of radicality in treatment of pCC by performing left or right hepatectomy in addition to hilar resection. This may increase R0 resection rates and prolong disease free survival. Our experience shows similar mortality/morbidity rates as reported in other centers and confirms that in selected patients, concomitant hepatectomy for perihilar pCC is a safe and feasible surgical strategy