Nonvenereal Sclerosing Lymphangitis of the Penis

No abstract availabl

Intermittent claudications of the hand after supracondylar humeral fracture in a 2-year old boy

Supracondylar humeral fractures (SHF) are the most common fractures associated with concomitant neurovascular injuries in children. Pink pulseless hand (PPH) labels SHF presenting without a pulse in a wellperfused hand. Management of PPH after successful SHF reduction remains controversial. Some advocate „watchful waiting”, whereas others favor early exploration. We present a case of a 2-year-old boy with PPH and intermittent claudications 6 weeks after successful SHF reduction

Thoracoscopic plication in an infant with eventration of the diaphragm

Eventracija ošita je abnormalna elevacija dijela ili cijele hemidijafragme. Može biti kongenitalna i stečena. Oboljelih je 2 do 7 na 100000 živorođenih, a češće se javlja kod dječaka. Eventracija se prezentira simptomima respiratornog ili gastrointestinalnog sustava, a dijagnoza se postavlja na temelju slikovnih radioloških pretraga. Kirurško liječenje indicirano je kod svih simptomatskih pacijenata, a cilj liječenja je ojačati tanku i oslabljenu dijafragmu plikacijom. Pristupi kirurškom liječenju su različiti. Prikazujemo osmomjesečnog dječaka kojemu je eventracija otkrivena obradom tijekom prolongiranog respiratornog infekta, a kojeg smo potom liječili torakoskopskom plikacijom s dobrim dugoročnim ishodom.Diaphragmatic eventration is an abnormal elevation of part or the entire hemidiaphragm. It can be congenital or acquired. It occurs in 2 to 7 in 100000 live births and it is more common among boys. Symptomatic eventration is presented with different respiratory or gastrointestinal symptoms. The diagnosis is based on radiological images. Surgical treatment is indicated for all symptomatic patients. The goal is to strengthen the thin and weak diaphragm by plicating the diaphragm itself. Surgical approaches may differ. We present an eight month old boy with eventration who was diagnosed during prolonged respiratory infection. Our treatment approach was thoracoscopic plication of the diaphragm with good long-term outcome

Diferencijalna dijagnostika i kliničko značenje pneumobilije ili zraka u portalnoj veni na rendgenskoj snimci abdomena

The purpose of the article is to present the differential diagnostic criteria between pneumobilia (air in the biliary system) and portal vein gas on abdominal x-ray. Differential diagnosis is essential because of its influence on patient management. Two patients are presented, one with pneumobilia and the other with portal vein gas on abdominal x-ray, with review of the relevant literature. Pneumobilia is often iatrogenic and even in cases of cholecystitis it is never a sole indication for emergency surgery. Patients with pneumobilia on abdominal x-ray can always be investigated further. On the other hand, the presence of air in portal vein is in most cases a sign of acute mesenteric ischemia. In adults with abdominal pain indicating intestinal ischemia (pain that is ‘out of proportion’ to clinical abdominal examination findings), it is an indication for emergency exploratory laparotomy. It is vital to act early when intestinal ischemia is suspected.Cilj rada je prikazati diferencijalno-dijagnostičke kriterije između pneumobilije i zraka u portalnom venskom sustavu na rendgenskoj snimci nativnog abdomena. Ti kriteriji su ključni, jer o njima ovisi daljnje postupanje s bolesnikom. Prikazane su dvije bolesnice, jedna s nalazom pneumobilije, a druga s nalazom zraka u portalnoj veni na rendgenskoj snimci nativnog abdomena, te je pretražena literatura. Pneumobilija je često jatrogena i čak u slučajevima kolecistitisa nije isključiva indikacija za hitan kirurški zahvat. Bolesnike kod kojih je nađena pneumobilija na snimci nativnog abdomena se uvijek može uputiti na daljnji dijagnostički postupak. Međutim, prisutnost zraka u portalnoj veni je u većini slučajeva znak mezenterijske ishemije. U odraslih bolesnika koji se žale na bol koja bi mogla odgovarati mezenterijskoj ishemiji (vrlo jaka bol uz mekan trbuh) zrak u portalnoj veni je indikacija za hitnu eksplorativnu laparotomiju. Od vitalne važnosti je djelovati brzo kada se sumnja na mezenterijsku ishemiju

Outpatient surgery

Podloga: Dnevna bolnica (DB) je oblik organizacije, ali i način pružanja dijagnostičko-terapijskih postupaka izvanbolničkih bolesnika uz dnevni boravak u bolnici (u trajanju do 22 sata). Dnevna bolnica može se organizirati kao organizacijski dio pojedine djelatnosti u bolnici, poliklinici i trgovačkom društvu za obavljanje zdravstvene djelatnosti. Vlada Republike Hrvatske pravilnikom propisuje minimalne uvjete za rad u Dnevnoj bolnici, a Hrvatski zavod za zdravstveno osiguranje (HZZO) ugovara kirurške postelje, plaća usluge i prati iskorištenost ugovorenih kapaciteta. Metode: Autori u ovom radu dostupnom stručnom literaturom, pravilnicima i statističkim izvješćima analiziraju brojnost i iskorištenost posteljnih kapaciteta kirurških dnevnih bolnica u javnom zdravstvenom sustavu Republike Hrvatske. Analizirano je razdoblje od 2013. Do 2014. godine. Rezultati: Od ukupno 25 219 bolničkih postelja u Hrvatskoj, u 2015. godini HZZO je ugovorio 3811 postelja dječjih bolnica (278 za potrebe opće i 33 za potrebe dječje kirurgije). U 2014. godini bolnice su imale 155 ugovorenih postelja opće i 13 postelja dječje kirurgije. U 2013. godini, bilo je 20930 dana liječenja u dnevnim bolnicama opće kirurgije i 2844 dana u dječjoj kirurgiji, a u 2014. godini bilo je 22946 dana liječenja u dnevnim bolnicama opće kirurgije i 2488 dana u dječjoj kirurgiji. Zaključak: Ukupno sudjelovanje kirurških postelja dječjih bolnica u posteljnom kapacitetu naših bolnica je niska, a popunjenost tih kapaciteta na godišnjoj razini kreće se u rasponu 5487%. Postelje dječje kirurgije u dječjim bolnicama većim se postotkom koriste nego one opće kirurgije. Zakonodavac i HZZO učestalo mijenjaju pravilnike kojima propisuju okvire rada kirurške dnevne, a bolnice teško prate te zadane okvire minimalnih uvjeta.Background: Day Hospital (DH) is a type of organization for providing diagnostic and therapeutic outpatient procedures for patients who are hospitalized and discharged within one day (within 22 hours). It can be organized in a hospital, clinic or healthcare company. The government of the Republic of Croatia prescribes minimum requirements for work on an outpatient basis, and the Croatian Health Insurance Fund (HZZO) contracts the number of surgical beds, pays for the provided services and monitors the hospital bed usage. Methods: The authors, using available literature, regulations and statistical reports, analyzed the number and hospital bed usage in surgical DH units in the public health system in Croatia for the 2013/2014 period. Results: Of 25219 hospital beds in Croatia, in 2015 HZZO contracted 3811 DH beds (278 for general surgery and 33 for pediatric surgery). In 2014 there were 155 beds for general and 13 beds for pediatric surgery. In 2013 there were 20930 days of hospitalization in general day surgery and 2844 days in pediatric day surgery. In 2014 there were 22946 days of hospitalization in general day surgery and 2488 days in pediatric day surgery. Conclusion: The percentage of surgical DH beds in overall number of surgical beds in our hospitals is low, and the utilization of capacity ranges from 54 to 87%. Pediatric day surgery beds are utilized better than general surgery. The Government and HZZO often change regulations regarding DH facilities. This makes it difficult for hospitals to maintain minimal requirements for the organization of surgical DH units

Prophylactic gonadectomy in children with mixed gonadal dysgenesis – a nine-year-old girl

Gonadna disgeneza embrionalna je anomalija gonada. Može biti čista (Turnerov sindrom) ili miješana (mozaicizam). Miješani oblik s lozom stanica u kojoj se nalazi Y spolni kromosom, sklon je pojavi gonadoblastoma u displastičnim gonadama. U takve djece indicirano je učiniti profi laktičku bilateralnu gonadektomiju, prije maligne alteracije. Stoga je važna rana dijagnoza miješane gonadne disgeneze. No djeca s gonadnom disgenezom različitih su fenotipskih osobina, katkad potpuno neupadljiva u predpubertetskoj dobi. U radu prikazujemo fenotipski neupadljivu, tek nešto nižeg rasta devetogodišnju djevojčicu s miješanom gonadnom disgenezom, kojoj smo načinili profi laktičku laparoskopsku gonadektomiju. Zaključno, miješana gonadna disgeneza može se očitovati jedino niskim rastom u djece predpubertetske dobi.Gonadal dysgenesis is an embryonal disorder of the gonads. It can be pure (Turner’s syndrome) or mixed (mosaicism). The mixed form, which also has Y chromosome, is prone to the occurrence of gonadoblastomas in dysplastic gonads. In such children, it is indicated to make prophylactic bilateral gonadectomy before malignant transformation. Therefore, early diagnosis of mixed gonadal dysgenesis is important. However, children with gonadal dysgenesis have variable phenotype. In rare cases, these children cannot be distinguished phenotypically at the pre-pubertal age from children with normal karyotype. We report on phenotypically unremarkable nine-year-old girl with short stature and mixed gonadal dysgenesis, submitted to prophylactic laparoscopic gonadectomy. In conclusion, short stature may be the only phenotypic sign of mixed gonadal dysgenesis in pre-pubertal children

Penoplasty and vacuum-assisted closure in children with Fournier’s gangrene of the penis

Fournierova gangrena (FG) penisa vrlo rijetko nastaje u djece. Liječenje započne odstranjenjem nekrotičnog tkiva i zaustavljanjem infekcije. Penoplastikom ogoljenog penisa, koja je zahtjevan i komplikacijama opterećen postupak, treba osigurati erektilnu funkciju i estetski prihvatljiv ishod. U radu se prikazuje tehnika penoplastike i primjene vakuum terapije u troje djece s FG penisa. U periodu 2000. do 2017. godine u KBC Zagreb je liječeno troje djece s FG penisa. Gangrena se razvila tijekom snažne imunosupresije zbog kemoterapija akutne limfatične leukemije, koja je krenula kao infekcija kože skrotuma, prepucija i perineuma. Nakon nekrektomije u općoj anesteziji, postavljen je i za glans fiksiran Foley urinarni kateter. Slobodni kožni presadak je uzet s lateralne strane natkoljenice u debljini 0,5 mm. Presadak je postavljan i šavovima fiksiran u nepotpunoj erekciji. Cirkularno punim opsegom obložen je prvo vazelinskom gazom, a preko nje spužvom debljine 20 mm. Preko svega je postavljena adherentna folija i vakuum cijev. Negativni tlak je održavan aparatom kontinuirano na 75 mm Hg, kako bi penis bio u produženoj erekciji. Praćena je prokrvljenost penisa kontrolom kapilarnog pulsa na eksponiranom glansu. Sustav negativnog vakuum-tlaka (VAC, engl. Vacuum Assisted Closure) odstranjen je sedmog dana. Nije bilo poslijeoperacijskih komplikacija, a puna reepitelizacija trajala je deset dana. Petnaestogodišnji pacijent je godinu dana nakon operacije i izlječenja osnovne bolesti imao bezbolnu erekciju, a masturbacijom je postigao ejakulaciju. Kako bi se minimalizirala mogućnost naknadne kontrakcije, korišteni su nešto deblji presadci. Negativni tlak od 75 mm Hg sustavno je čitavim obujmom fiksirao presadak kože unatoč konveksitetu podloge. Druga mu je funkcija održavati kavernozna tijela penisa u nepotpunoj erekciji, kako bi se slobodni kožni presadak fiksirao punom površinom. Neki su autori koristili sličnu tehniku, s jačim negativnim tlakom, no oni bilježe značajnu razinu poslijeoperacijske boli. Izostanak komplikacija, uz zadovoljavajući estetski, ali i funkcionalni ishod, ovu metodu penoplastike i vakuum-terapije promovira kao metodu izbora u djece s Fournierovom gangrenom penisa.Fournier’s gangrene (FG) of the penis rarely occurs in boys. Initial treatment consists of debridement and infection control. Penoplasty, a complex procedure burdened with complications, should ensure good erectile function and aesthetic outcome. This article presents the vacuum-assisted penoplasty procedure that was undertaken in three children with FG of the penis from 2000 to 2017 in University Hospital Centre Zagreb. FG started at the prepuce, penile skin or scrotum due to immunosuppression caused by chemotherapy for acute lymphatic leukaemia. Necrectomy of the whole penile shaft was performed in general anaesthesia, and urinary catheter was placed and fixated to the glans. A partial thickness skin graft (0.5 6 mm) was harvested from the lateral thigh, placed on the penile shaft while artificial erection was maintained (to ensure sufficient skin for later erections) and fixated with quilting sutures. The skin graft was covered by Vaseline gauzeVaseline® Petrolatum gauze, circular 20 mm thick VAC (Vacuum Assisted Closure ) sponge and adhesive film. Negative pressure was maintained at 75 mm Hg and the penis was kept in erected state. Glans capillary refill was regularly checked. Vacuum therapy was removed on the seventh postoperative day. There were no postoperative complications and full re-epithelisation occurred on postoperative day 10. The 15-year-old patient reported painless postoperative erections and achieved ejaculation with masturbation. Thicker than usual grafts were used to minimize graft contraction. Negative pressure of 75 mm Hg and complete adherence of the sponge were achieved despite the cylindrical shape of the wound bed. The function of the vacuum system was not only to fixate the graft, but to maintain the penile shaft in the state of permanent artificial erection. The pressure of 75 mm Hg was chosen because the reports in which higher pressures were used reported a higher postoperative pain levels as well. Good functional and aesthetic outcome with no complications make this procedure the method of choice for the reconstruction of penile shaft skin defects after Fournier’s gangrene in children

Aortoduodenalna fistula tri godine nakon aorto-bifemoralne premosnice: prikaz slučaja i pregled literature

Secondary aortoenteric fistulas (SAEF ) are a relatively rare but dangerous complication of aortal reconstructive surgery. We present a patient that underwent aortobifemoral bypass three years before developing the signs of aortoenteric fistula, and we reviewed the literature on the topic. Since the clinical signs are nonspecific, physicians should have a high index of suspicion for SAEF in patients who underwent aortal reconstructive surgery. The most useful diagnostic tools for stable patients are upper gastrointestinal endoscopy and computed tomography scan with contrast that can, in combination with history and clinical signs, enable accurate diagnosis in more than 90% of patients. Unstable patients with suspected aortoenteric fistula should undergo exploratory laparotomy. The treatment of choice is open surgery with graft excision, wide debridement of infected tissue, bowel repair or resection followed by an extra-anatomic bypass or in situ placement of a new graft. Early postoperative mortality remains high, around 30% in most analyses. Currently there are no guidelines for the diagnosis and management of SAEF , so individualized approach is necessary for each patient.Sekundarne aorto-enteralne fistule su rijetka ali opasna komplikacija aortne rekonstruktivne kirurgije. Prikazuje se bolesnik kod kojega su se razvili simptomi aorto-enteralne fistule tri godine nakon ugradnje aorto-bifemoralne premosnice, uz pregled literature. S obzirom na to da su klinički znaci vrlo nespecifični kod ovih bolesnika, važno je rano posumnjati na moguć razvoj sekundarne aorto-enteralne fistule kod bolesnika koji su bili podvrgnuti aortnoj rekonstruktivnoj kirurgiji. Od dijagnostičkih metoda najkorisnije su ezofagogastroduodenoskopija i kompjutorizirana tomografija s kontrastom koji, u kombinaciji s anamnezom i kliničkim znacima, omogućavaju postavljanje dijagnoze u preko 90% bolesnika. U nestabilnih bolesnika kod kojih postoji sumnja na razvoj ovoga stanja indicirana je eksplorativna laparotomija. U liječenju metoda izbora je laparotomija, ekscizija proteze, debrideman upaljenog tkiva, popravak defekta na crijevu ili resekcija zahvaćenog segmenta, te ekstraanatomska premosnica ili postavljanje nove proteze. Poslijeoperacijska smrtnost je oko 30%. Kako zasad nema smjernica za dijagnostiku i liječenje bolesnika sa sekundarnim aorto-enteralnim fistulama nužan je visoko individualizirani pristup za svakog bolesnika