Emergency department sternotomy - report of a case with indications and technique overview

The Emergency Department thoracotomy and Emergency Department sternotomy are solutions of the last resort for traumatic cardiorespiratory arrest. Time is the most important factor in terms of survival and sparing potential neurological damage, therefore surgery should not be delayed as it can be done in an emergency room, intensive care unit or in the operating room. We will present a case of a 45-year-old man with a knife stab in his chest and cardiorespiratory arrest during transport in ambulance. Upon arrival at the Emergency Department, sternotomy was performed followed by decompressive pericardiotomy and cardiorrhaphy with successful and uneventful recovery. We will discuss the indications, necessary equipment and surgical technique

Reuse of single-use surgical equipment - Survey on current practice and attitudes in Croatia

Aims: To gain an insight into current practice and attitudes regarding the reuse of single-use surgical equipment among surgeons and surgical residents in Croatia. Methods: During May 2020, an online survey was shared among Croatian surgeons and surgical residents via email link. The survey included 10 questions seeking information on respondents’ current positions at their departments, real-life practice about reusing single-use instruments, personal attitudes and knowledge about the current law frame. Results: The majority of 53 participants reused single-use surgical equipment in their practice (92.5%). More than half of them reused many single-use devices such as harmonic scalpels, bipolar dissectors, staplers, single-use trocars, graspers, and scissors. The participants had divided opinions on safety issues, personal support of such practice and the necessity of disclosing to patients. However, the majority was inclined towards the use of new instruments if they found themselves with patients on the operating table (75.5%). Very few participants were aware of the current legal regulations and the law changes that would take effect in the near future (5.6%). Conclusion: Current practice shows widespread reuse of single-use surgical equipment in Croatia despite the concerns of the involved surgeons. It seems that they recognize the potential safety and ethical issues, but at the same time, they are not well informed about the legal regulations of the practice which is alarming and calls for further education and preparation for the upcoming legal changes

Posttraumatic clostridial necrotizing fasciitis of the head and neck with descending necrotizing mediastinitis treated by video-assisted thoracoscopic surgery - report of a case

Background: Necrotizing fasciitis of the head and neck with subsequent descending necrotizing mediastinitis is a highly lethal condition. The clostridial origin has a particularly aggressive course. Case presentation: Herein we present a case of a 22-year-old male with clostridial necrotizing fasciitis of the head and neck complicated with descending necrotizing mediastinitis after a traumatic scalp wound. Three days after having sutured the wound at the Emergency Department, the patient became septic with marked cellulitis of the head and neck soft tissue. Urgent surgical wound debridement of necrotic tissue along with transcervical drainage of the upper mediastinum was performed. The patient was ventilator dependent, receiving vasoactive support and empiric broad-spectrum antibiotic therapy. Left-sided pleural effusion and CT signs of infection descent into the middle and lower mediastinum mandated further surgical intervention. A video-assisted thoracoscopic surgical approach was used to drain and debride the affected mediastinal and pleural spaces leading to a gradual stabilization of the patient followed by being transferred to the Surgical Department. Microbiological analysis revealed Clostridium perfringens as an infective agent. Further recovery was uneventful and the patient was dismissed on postoperative day 24. Conclusion: Posttraumatic clostridial gas gangrene of the head and neck is a fulminant and life-threatening infection. It requires urgent clinical and radiological assessment. Treatment should be multidisciplinary based. The invasiveness and extent of surgery should be tailored for individual patients. Video-assisted thoracoscopic surgery technique is a safe and appealing approach to all mediastinal compartments. It offers less invasiveness, superior visibility and equal efficiency in terms of tissue debridement and mediastinal as well as pleural drainage

High-volume post-obstructive choleresis (biliary hyperproduction) with acute kidney injury after choledochotomy, gallstones extraction, and T-tube drainage, successfully treated with octreotide - Report of a case

Only several cases of postprocedural choleresis (biliary hyperproduction) were reported, and guidance on management is scarce, although an application of octreotide was anecdotally described. We herein present a rare post-obstructive choleresis complicated with acute kidney injury due to dehydration, successfully treated with an off-label application of octreotide. A 58-year-old female, following cholecystectomy and choledochotomy with numerous stones extraction, developed excessive bile loss via a T-tube complicated with acute kidney injury. Despite aggressive fluid replacement, the patient continued to deteriorate, prompting a trial of subcutaneous octreotide 0.1 mg three times per day over five days. Therapy yielded a rapid decline in bile production with improved diuresis and normalizing kidney function. The patient was discharged with a ligated T-tube, which we removed a month later. The followup was unremarkable, with normalized laboratory findings and symptom-free. Early use of octreotide could help resolve complicated biliary hyperproduction; however, further research is required to determine the risks and benefits of such an approach

Utjecaj COVID-19 pandemije na bolesnike s novootkrivenim kolorektalnim karcinomom u Općoj bolnici Zadar

Kolorektalni karcinom je jedna od najučestalijih zloćudnih bolesti u Republici Hrvatskoj.1 Ako se otkrije u ranom, odnosno lokaliziranom stadiju bolesti, petogodišnje preživljenje iznosi oko 90%.5 Iznimno je važno dijagnosticirati bolest u što ranijem stadiju radi boljeg ishoda liječenja. Stoga je odlukom Vlade Republike Hrvatske 2007. godine usvojen Nacionalni program ranog otkrivanja raka debelog crijeva.1 Pojava pandemije koronavirusne bolesti dovela je do izazova u funkcioniranju zdravstvenog sustava diljem svjeta, pa tako i programa ranog otkrivanja raka debelog crijeva.3 Za vrijeme Covid-19 pandemije zabilježen je smanjen broj obavljenih kolonoskopija i odaziv na program ranog otkrivanja raka debelog crijeva. Cilj ovog istraživanja je retrospektivno otvrditi utjecaj COVID-19 pandemije na bolesnike s novootkrivenim kolorektalnim karcinomom u razdoblju od 01.04.2020. do 30.09.2021. (za vrijeme COVID-19 pandemije) u odnosu na razdoblje od 01.04.2018. do 30.09.2019. (vrijeme prije COVID-19 pandemije) u Općoj bolnici Zadar. Glavni cilj istraživanja bio je odrediti vrstu operacije primarnog tumora (elektivne i hitne operacije) prije i za vrijeme COVID-19 pandemije. U našem istraživanju uspjeli smo dokazati hipotezu da će u COVID-19 pandemiji biti povećan udio hitnih operacijskih zahvata u odnosu na elektivne, što se može povezati sa smanjenim brojem preventivnih pregleda u sekundarnim zdravstvenim ustanovama, odnosno smanjenim odazivom na program za rano otkrivanje raka debelog crijeva

Zbrinjavanje bolesnika s masivnim krvarenjem u Općoj bolnici Zadar

Zbrinjavanje politraumatiziranih bolesnika i bolesnika s hemoragijskim šokom predstavlja stručni i organizacijski izazov za osoblje hitnih službi. Preživljavanje takvih bolesnika ovisiti će o brzoj dijagnostici, kirurškoj kontroli krvarenja i agresivnoj nadoknadi volumena krvnim pripravcima. U našem radu prikazali smo slijed postupaka zbrinjavanja bolesnika s masivnim krvarenjem, uz primjenu protokola masivne transfuzije, čime se ubrzava doprema odgovarajuće vrste i količine krvnih pripravaka, uz istovremeno smanjenje potencijalnih nuspojava. No, uvođenje takvoga protokola u praksu zahtijeva značajne organizacijske napore, te dodatnu edukaciju osoblja koje sudjeluje u zbrinjavanju ozlijeđenih bolesnika. Svi navedeni postupci prilagođeni su organizaciji, ustroju i uvjetima u Općoj bolnici Zadar, a prilog su kvalitetnijem zbrinjavanju politraumatiziranih bolesnika, kao i drugih bolesnika u hemoragijskom šoku, poput bolesnika s obilnim gastrointestinalnim krvarenjem, opstetricijskim, ginekološkim i općenito masivnim perioperacijskim krvarenjem

COMPARISON OF NEW VERSUS REUSED HARMONIC SCALPEL PERFORMANCE, TECHNICAL SAFETY AND LATERAL THERMAL DAMAGE IN LAPAROSCOPIC APPENDECTOMY IN PATIENTS WITH ACUTE APPENDICITIS

Cilj istraživanja: Usporediti postranično termičko oštećenje tkiva crvuljka i klinički ishod laparoskopske apendektomije uporabom novog u odnosu na resterilizirani harmonični skalpel. Ispitanici i metode: Ukupno 100 bolesnika s akutnom upalom crvuljka koji su podvrgnuti laparoskopskoj apendektomiji je uključeno u randomizirani klinički pokus u dvije bolnice. Pomoću računalnog generatora slučajnih brojeva bolesnici su raspoređeni u dvije skupine: u prvoj je korišten novi, a u drugoj resterilizirani harmonični skalpel. Unutar grupa uspoređeni su rezultati patohistološkog mjerenja postraničnog termičkog oštećenja baze i mezenteriola crvuljka, brzina rezanja baze crvuljka, trajanje operacijskog zahvata, subjektivna ocjena funkcionalnosti uređaja, duljina boravka u bolnici i komplikacije. Rezultati: Medijan postraničnog termičkog oštećenja baze crvuljka u prvoj skupini (N=49) iznosio je 0,2 mm (IQR 0,1 - 0,2), u drugoj skupini (N=51), 0,1 mm (IQR 0,1 - 0,3) (P=0,644), dok je na mezenteriolu crvuljka u obje skupine postranično termičko oštećenje iznosilo 0,1 mm (IQR 0,1 - 0,2) (P=0,418). Medijan vremena potrebnog za transekciju baze u obje skupine bio je osam sekundi (IQR 7 - 9) (P=0,776). Medijan trajanja operacije također je bio usporediv među skupinama (22 min, IQR 20 - 30 naspram 25 min, IQR 21 - 35; P=0,233). Zabilježene su dvije poslijeoperacijske komplikacije u prvoj i jedna u drugoj skupini, što nije bilo statistički značajno (4% naspram 2%; P=0,536). Subjektivne ocjene kirurških instrumenta nisu bile statistički različite između skupina ni u jednoj promatranoj kategoriji. Zaključak: Rezultati naše studije podupiru ponovnu uporabu harmoničnih skalpela, posebno kad ekonomska ograničenja mogu otežati pristup minimalno invazivnoj kirurgiji širem krugu bolesnika. Rezultati dobiveni na laparoskopskoj apendektomiji ne mogu se izravno preslikati na druge, zahtjevnije kirurške zahvate.Background: The aim of this study was to compare lateral thermal damage of the appendix and clinical outcomes after laparoscopic appendectomy using new versus reused harmonic scalpels. Methods: A total of 100 consecutive patients with acute appendicitis who underwent laparoscopic appendectomy were enrolled in the two-center, randomized clinical trial. Using a computer random number generator, patients were allocated to new or reused groups. Histopathological measurement of lateral thermal damage of the appendiceal base and mesoappendix, speed of transection of the appendiceal base, duration of surgery, subjective rating of device functionality, length of stay, and complications were compared within groups. Results: The median lateral thermal damage on the appendiceal base in the new group (N=49) was 0.2 mm (IQR 0.1-0.2) and 0.1 mm (IQR 0.1-0.3) in the reused group (N=51) (P=0.644), while on the mesoappendix for both groups, thermal damage was 0.1 mm (IQR 0.1-0.2) (P=0.418). The median time required for base transection in both groups was eight seconds (IQR 7-9) (P=0.776). The median duration of surgery was also comparable between the groups (22 min, IQR 20-30 vs 25 min, IQR 21-35; P=0.233). Two postoperative complications in the new group and one in the reused group were recorded (4% vs 2%; P=0.536). Surgeons' subjective assessment of the instrument did not reveal significant differences between the groups in all of the investigated categories. Conclusions: The results of our study support the reuse of harmonic scalpels especially in the settings where economic constraints might hamper access to minimally invasive surgery to a larger number of patients. The results obtained on laparoscopic appendectomy might not be reproducible to other more demanding surgical procedures

COMPARISON OF NEW VERSUS REUSED HARMONIC SCALPEL PERFORMANCE, TECHNICAL SAFETY AND LATERAL THERMAL DAMAGE IN LAPAROSCOPIC APPENDECTOMY IN PATIENTS WITH ACUTE APPENDICITIS

Cilj istraživanja: Usporediti postranično termičko oštećenje tkiva crvuljka i klinički ishod laparoskopske apendektomije uporabom novog u odnosu na resterilizirani harmonični skalpel. Ispitanici i metode: Ukupno 100 bolesnika s akutnom upalom crvuljka koji su podvrgnuti laparoskopskoj apendektomiji je uključeno u randomizirani klinički pokus u dvije bolnice. Pomoću računalnog generatora slučajnih brojeva bolesnici su raspoređeni u dvije skupine: u prvoj je korišten novi, a u drugoj resterilizirani harmonični skalpel. Unutar grupa uspoređeni su rezultati patohistološkog mjerenja postraničnog termičkog oštećenja baze i mezenteriola crvuljka, brzina rezanja baze crvuljka, trajanje operacijskog zahvata, subjektivna ocjena funkcionalnosti uređaja, duljina boravka u bolnici i komplikacije. Rezultati: Medijan postraničnog termičkog oštećenja baze crvuljka u prvoj skupini (N=49) iznosio je 0,2 mm (IQR 0,1 - 0,2), u drugoj skupini (N=51), 0,1 mm (IQR 0,1 - 0,3) (P=0,644), dok je na mezenteriolu crvuljka u obje skupine postranično termičko oštećenje iznosilo 0,1 mm (IQR 0,1 - 0,2) (P=0,418). Medijan vremena potrebnog za transekciju baze u obje skupine bio je osam sekundi (IQR 7 - 9) (P=0,776). Medijan trajanja operacije također je bio usporediv među skupinama (22 min, IQR 20 - 30 naspram 25 min, IQR 21 - 35; P=0,233). Zabilježene su dvije poslijeoperacijske komplikacije u prvoj i jedna u drugoj skupini, što nije bilo statistički značajno (4% naspram 2%; P=0,536). Subjektivne ocjene kirurških instrumenta nisu bile statistički različite između skupina ni u jednoj promatranoj kategoriji. Zaključak: Rezultati naše studije podupiru ponovnu uporabu harmoničnih skalpela, posebno kad ekonomska ograničenja mogu otežati pristup minimalno invazivnoj kirurgiji širem krugu bolesnika. Rezultati dobiveni na laparoskopskoj apendektomiji ne mogu se izravno preslikati na druge, zahtjevnije kirurške zahvate.Background: The aim of this study was to compare lateral thermal damage of the appendix and clinical outcomes after laparoscopic appendectomy using new versus reused harmonic scalpels. Methods: A total of 100 consecutive patients with acute appendicitis who underwent laparoscopic appendectomy were enrolled in the two-center, randomized clinical trial. Using a computer random number generator, patients were allocated to new or reused groups. Histopathological measurement of lateral thermal damage of the appendiceal base and mesoappendix, speed of transection of the appendiceal base, duration of surgery, subjective rating of device functionality, length of stay, and complications were compared within groups. Results: The median lateral thermal damage on the appendiceal base in the new group (N=49) was 0.2 mm (IQR 0.1-0.2) and 0.1 mm (IQR 0.1-0.3) in the reused group (N=51) (P=0.644), while on the mesoappendix for both groups, thermal damage was 0.1 mm (IQR 0.1-0.2) (P=0.418). The median time required for base transection in both groups was eight seconds (IQR 7-9) (P=0.776). The median duration of surgery was also comparable between the groups (22 min, IQR 20-30 vs 25 min, IQR 21-35; P=0.233). Two postoperative complications in the new group and one in the reused group were recorded (4% vs 2%; P=0.536). Surgeons' subjective assessment of the instrument did not reveal significant differences between the groups in all of the investigated categories. Conclusions: The results of our study support the reuse of harmonic scalpels especially in the settings where economic constraints might hamper access to minimally invasive surgery to a larger number of patients. The results obtained on laparoscopic appendectomy might not be reproducible to other more demanding surgical procedures

Negative-pressure in treatment of persistent post-traumatic subcutaneous emphysema with respiratory failure: Case report and literature review

Subcutaneous emphysema may aggravate traumatic pneumothorax treatment, especially when mechanical ventilation is required. Expectative management usually suffices, but when respiratory function is impaired surgical treatment might be indicated. Historically relevant methods are blowhole incisions and placement of various drains, often with related wound complications. Since the first report of negative pressure wound therapy for the treatment of severe subcutaneous emphysema in 2009, only few publications on use of commercially available sets were published. We report on patient injured in a motor vehicle accident who had serial rib fractures and bilateral pneumothorax managed initially in another hospital. Due to respiratory deterioration, haemodynamic instability and renal failure patient was transferred to our Intensive Care Unit. Massive and persistent subcutaneous emphysema despite adequate thoracic drainage with respiratory deterioration and potentially injurious mechanical ventilation with high airway pressures was the indication for active surgical treatment. Negative-pressure wound therapy dressing was applied on typical blowhole incisions which resulted in swift emphysema regression and respiratory improvement. Negative pressure wound therapy for decompression of severe subcutaneous emphysema represents simple, effective and relatively unknown technique that deserves wider attention