Richterov tip inkarcerirane obturatorne hernije: otežana dijagnostika

Obturator hernia is a rare type of abdominal hernia where herniation occurs through the obturator canal. It develops predominantly in elderly underweight women. It has unspecific early symptoms, which is the reason these hernias are usually discovered only after they have become incarcerated. Incarcerated obturator hernias are usually discovered on abdominal computed tomography (CT) scan or emergency surgery due to bowel obstruction. We present a case of an 85-year-old female patient who was admitted because of intermittent abdominal pain and vomiting. Consecutive upright abdominal x-rays failed to show bowel obstruction. Abdominal CT scan revealed a right-sided incarcerated femoral hernia that was not found during emergency surgery. After laparotomy had been performed, a Richter type of right-sided incarcerated obturator hernia was discovered with a small necrotic area on the small bowel. Bowel resection was performed and obturator hernia was closed with interrupted sutures. The patient recovered without complications. Obturator hernia, due to its rarity and unspecific early symptoms, can still be misleading even to the most experienced surgeons. Delayed diagnosis of obturator hernia can lead to bowel necrosis and perforation with significant postoperative morbidity and mortality.Obturatorna hernija je rijedak oblik abdominalne hernije gdje do hernijacije dolazi kroz obturatorni kanal. Najčešće se javlja kod starijih pothranjenih žena. Rani simptomi obturatorne hernije su nespecifični, što je razlog da se ovakve hernije prepoznaju obično nakon što se razvije inkarceracija. Inkarcerirane obturatorne hernije se najčešće prepoznaju tijekom CT trbuha ili hitnog kirurškog zahvata zbog simptoma mehaničkog ileusa. Ovdje prikazujemo slučaj 85-godišnje bolesnice koja je primljena u bolnicu zbog povremenih bolova u trbuhu praćenih povraćanjem. Uzastopne nativne RTG snimke abdomena nisu pokazale opstrukciju crijeva. Učinjen je CT trbuha gdje se prikazala desnostrana inkarcerirana femoralna kila koja, međutim, tijekom hitnog kirurškog zahvata nije nađena. Nakon što je učinjena laparotomija, pronašli smo desnostranu inkarceriranu obturatornu kilu Richterova tipa s malim područjem nekrotičnog tankog crijeva. Učinili smo segmentnu resekciju tankog crijeva. Kilni otvor je zatvoren pojedinačnim šavima. Postoperacijski oporavak bolesnice je bio uredan. Obturatorna kila, zahvaljujući niskoj incidenciji i nespecifičnim ranim simptomima, može biti zbunjujuća čak i za najiskusnijeg kirurga. Odgođena dijagnoza obturatorne kile može dovesti do nekroze i perforacije crijeva, što sa sobom nosi značajan pobol i smrtnost

Comparison of multidetector-row computed tomography and duplex Doppler ultrasonography in detecting atherosclerotic carotid plaques complicated with intraplaque hemorrhage [Usporedba višeslojne kompjuterizirane tomografije i duplex Doppler ultrazvuka u otkrivanju aterosklerotskih karotidnih plakova kompliciranih krvarenjem u plak ]

This study compared sensitivity and specificity of multidetector-row computed tomography and duplex Doppler ultrasonography in detecting atherosclerotic carotid plaques complicated with intraplaque hemorrhage. Carotid plaques from 50 patients operated for carotid artery stenosis were analyzed. Carotid endarterectomy was performed within one week of diagnostic evaluation. Results of multidetector-row computed tomography and duplex Doppler ultrasonography diagnostic evaluation were compared with results of histological analysis of the same plaque areas. American Heart Association classification of atherosclerotic plaques was applied for histological classification. Median tissue density of carotid plaques complicated with intraplaque hemorrhage was 14.7 Hounsfield units. Median tissue density of noncalcified segments of uncomplicated plaques was 54.3 Hounsfield units (p = 0.00003). The highest tissue density observed for complicated plaques was 31.8 Hounsfield units. Multidetector-row computed tomography detected plaques complicated with hemorrhage with sensitivity of 100% and specificity of 70.4%, with tissue density of 33.8 Hounsfield units as a threshold value. Duplex Doppler ultrasonography plaque analysis based on visual in-line classification showed sensitivity of 21.7% and specificity of 89.6% in detecting plaques complicated with intraplaque hemorrhage. Multidetector-row computed tomography showed a very high level of sensitivity and a moderate level of specificity in detecting atherosclerotic carotid plaques complicated with hemorrhage. Duplex Doppler ultrasonography plaque analysis based on visual in-line classification showed a low level of sensitivity and a moderate-high level of specificity in detecting atherosclerotic carotid plaques complicated with hemorrhage

Mucinozna komponenta u kolorektalnom karcinomu – utjecaj na preživljenje

AIM. Clinical significance of mucin component in colorectal cancer is still unclear. We compared clinical and pathological features of mucinous and non-mucinous colorectal cancers and assessed the impact of mucinous differentiation and other specific features of colorectal cancer on survival. PATIENTS AND METHODS. We analyzed clinical and pathological data of 271 patients who underwent surgical resection of colorectal adenocarcinoma at our Department between 1994 and 2002. RESULTS. Patients with mucinous colorectal cancer had worse overall survival, but not statistically significant (P=0.296). In a multivariate model, only tumor size, the presence of hepatic metastases, and the presence of metastases in lymph nodes, but not mucinous differentiation, were found to be significant and independent predictors of survival. CONCLUSION. The results of this study confirm the frequent observation that mucinous colorectal cancer is associated with worse prognosis compared to non-mucinous type. However, these results do not provide evidence that mucinous differentiation is independently associated with more aggressive tumor behavior. Current findings justify surgical resection of all gross tumor deposits, together with the employment of perioperative intraperitoneal chemotherapy in the treatment of patients with mucinous colorectal cancer.CILJ. Klinička važnost mucinozne komponente u kolorektalnom karcinomu još nije jasan. Usporedili smo kliničke i patološke osobine kolorektalnog karcinoma mucinoznog i nemucinoznog tipa te mjerili utjecaj diferencijacije mucina i drugih specifičnih značajka kolorektalnog karcinoma na preživljenje. BOLESNICI I METODE. Analizirali smo kliničke i patološke podatke 271 bolesnika u kojih je na našem odjelu od 1994. do 2002. kirurškim putem uklonjen kolorektalni adenokarcinom. REZULTATI. Bolesnici s mucinoznim kolorektalnim karcinomom imaju lošije sveukupno preživljenje, ali to nije statistički značajno (P=0,296). Na multivarijatnom modelu uočeno je da su samo veličina tumora, prisutnost jetrenih metastaza i prisutnost metastaza u limfnim čvorovima, a ne i mucinozna diferencijacija, značajni i nezavisni prognostički faktori preživljenja. ZAKLJUČAK. Rezultati ovog ispitivanja potvrđuju ono što se često uočava, a to je da je prognoza za mucinozni kolorektalni karcinom lošija od prognoze za nemucinozni tip raka toga sijela. Međutim, tj. rezultati ne dokazuju da je mucinozna diferencijacija nezavisno povezana s agresivnijim ponašanjem tumora. Sadašnji nalazi opravdavaju kiruršku resekciju svih okom vidljivih tumorskih depozita uz primjenu perioperativne intraperitonejske kemoterapije u liječenju bolesnika s mucinoznim kolorektalnim karcinomom

Mucinozna komponenta u kolorektalnom karcinomu – utjecaj na preživljenje

AIM. Clinical significance of mucin component in colorectal cancer is still unclear. We compared clinical and pathological features of mucinous and non-mucinous colorectal cancers and assessed the impact of mucinous differentiation and other specific features of colorectal cancer on survival. PATIENTS AND METHODS. We analyzed clinical and pathological data of 271 patients who underwent surgical resection of colorectal adenocarcinoma at our Department between 1994 and 2002. RESULTS. Patients with mucinous colorectal cancer had worse overall survival, but not statistically significant (P=0.296). In a multivariate model, only tumor size, the presence of hepatic metastases, and the presence of metastases in lymph nodes, but not mucinous differentiation, were found to be significant and independent predictors of survival. CONCLUSION. The results of this study confirm the frequent observation that mucinous colorectal cancer is associated with worse prognosis compared to non-mucinous type. However, these results do not provide evidence that mucinous differentiation is independently associated with more aggressive tumor behavior. Current findings justify surgical resection of all gross tumor deposits, together with the employment of perioperative intraperitoneal chemotherapy in the treatment of patients with mucinous colorectal cancer.CILJ. Klinička važnost mucinozne komponente u kolorektalnom karcinomu još nije jasan. Usporedili smo kliničke i patološke osobine kolorektalnog karcinoma mucinoznog i nemucinoznog tipa te mjerili utjecaj diferencijacije mucina i drugih specifičnih značajka kolorektalnog karcinoma na preživljenje. BOLESNICI I METODE. Analizirali smo kliničke i patološke podatke 271 bolesnika u kojih je na našem odjelu od 1994. do 2002. kirurškim putem uklonjen kolorektalni adenokarcinom. REZULTATI. Bolesnici s mucinoznim kolorektalnim karcinomom imaju lošije sveukupno preživljenje, ali to nije statistički značajno (P=0,296). Na multivarijatnom modelu uočeno je da su samo veličina tumora, prisutnost jetrenih metastaza i prisutnost metastaza u limfnim čvorovima, a ne i mucinozna diferencijacija, značajni i nezavisni prognostički faktori preživljenja. ZAKLJUČAK. Rezultati ovog ispitivanja potvrđuju ono što se često uočava, a to je da je prognoza za mucinozni kolorektalni karcinom lošija od prognoze za nemucinozni tip raka toga sijela. Međutim, tj. rezultati ne dokazuju da je mucinozna diferencijacija nezavisno povezana s agresivnijim ponašanjem tumora. Sadašnji nalazi opravdavaju kiruršku resekciju svih okom vidljivih tumorskih depozita uz primjenu perioperativne intraperitonejske kemoterapije u liječenju bolesnika s mucinoznim kolorektalnim karcinomom

Laparoscopic Operation of Hepatic Hydatid Cyst with Intraabdominal Dissemination – A Case Report and Literature Review

Hepatic hydatid cysts are a serious medical problem in some regions like Mediterranean region. In Croatia 25–30 new cases of hepatic hydatid cysts are recorded each year. In University Hospital Dubrava 7 patients with hepatic hydatid cysts were operated in 2008. Surgical approach recognizes open laparotomy and laparoscopy. The case and technique of laparoscopic operation of hepatic hydatid cyst in seventh segment and three disseminated intraabdominal cysts is described. Laparoscopy should be attempted even in complex cases with dissemination

Isolated Splenic Metastasis from Colon Cancer – Case Report and Literature Review

Solitary splenic metastases are very rare and sporadic. There are several explanations for this low incidence of splenic metastasis including anatomical, histological and immunological features of the spleen. In this paper we present a case of 70-year-old man with no history of previous diseases who was first operated under the diagnosis of acute abdomen revealing perforated colon tumor of splenic flexure with no metastases at that time. Left hemicolectomy was performed followed by postoperative complications demanding a subtotal colectomy and ileostomy. Primary tumor was classified as Dukes (Astler-Coller)-C2, T4N1M0. Patient was referred to oncologist and received chemotherapy (5FU, Leucovorin). 5 months later continuity of the gut was performed by ileosygmoanastomosis. 2 years after first surgical procedure, a CT scan and abdominal ultrasound, followed by needle biopsy, showed isolated metastasis in spleen, so splenectomy was performed. Pathological findings revealed sharply bordered, partially necrotic tumor inside of spleen tissue, spreading to, but not reaching splenic hilum. Histology showed low to medium differentiated adenocarcinoma tissue with desmoplastic stromal reaction. There were no protrusions of tumor cells through spleen surface. In splenic hilum 4 tumor free lymph nodes were harvested. No additional chemotherapy was conducted. The latest follow up, a year after diagnosis of metastasis showed no signs of cancer disease. Review of the literature showed that long term survival and prognosis of isolated splenic colorectal metastasis after splenectomy are rather optimistic, although these are the cases of distant metastasis. Due to small number of cases reported in literature, definitive conclusions and/or guidelines for the treatment of isolated splenic metastasis cannot be given, but splenectomy and chemotherapy are preferable in the treatment, promising long term survival at least for metachronous metastasis

Comparison of hepatoprotective effect from ischemia-reperfusion injury of remote ischemic preconditioning of the liver vs local ischemic preconditioning of the liver during human liver resections

AIM: To compare and evaluate the hepatoprotective effect of remote ischemic preconditioning (RIPC) with local ischemic preconditioning (LIPC) of the liver during human liver resections. ----- METHODS: A prospective, single-centre, randomised control trial was conducted in the Clinical Hospital "***" from April 2017 to January 2018. A total of 60 patients, who underwent liver resection due to colorectal cancer liver metastasis, were randomised to one of three study arms: 1) a RIPC group, 2) an LIPC group and 3) a control group (CG) in which no ischemic preconditioning was done before liver resection. The hepatoprotective effect was evaluated by comparing serum transaminase levels, bilirubin levels, albumin, and protein levels, coagulograms and through pathohistological analysis. The trial was registered on ClinicalTrials.gov (NCT****). ----- RESULTS: Significant differences were found in serum levels of liver transaminases and bilirubin levels between the groups, the highest level in the CG and the lowest level in the LIPC group. Levels of cholinesterase were also significantly higher in the LIPC group. Pathohistological findings graded by the Rodriguez score showed favourable changes in the LIPC and RIPC groups versus the CG. ----- CONCLUSION: Strong evidence supports the hepatoprotective effect of RIPC and LIPC preconditioning from an ischemia-reperfusion injury of the liver. Better synthetic liver function preservation in these two groups supports this conclusion

Comparison of Multidetector-Row Computed Tomography and Duplex Doppler Ultrasonography in Detecting Atherosclerotic Carotid Plaques Complicated with Intraplaque Hemorrhage

This study compared sensitivity and specificity of multidetector-row computed tomography and duplex Doppler ultrasonography in detecting atherosclerotic carotid plaques complicated with intraplaque hemorrhage. Carotid plaques from 50 patients operated for carotid artery stenosis were analyzed. Carotid endarterectomy was performed within one week of diagnostic evaluation. Results of multidetector-row computed tomography and duplex Doppler ultrasonography diagnostic evaluation were compared with results of histological analysis of the same plaque areas. American Heart Association classification of atherosclerotic plaques was applied for histological classification. Median tissue density of carotid plaques complicated with intraplaque hemorrhage was 14.7 Hounsfield units. Median tissue density of noncalcified segments of uncomplicated plaques was 54.3 Hounsfield units (p=0.00003). The highest tissue density observed for complicated plaques was 31.8 Hounsfield units. Multidetector-row computed tomography detected plaques complicated with hemorrhage with sensitivity of 100% and specificity of 70.4%, with tissue density of 33.8 Hounsfield units as a threshold value. Duplex Doppler ultrasonography plaque analysis based on visual in-line classification showed sensitivity of 21.7% and specificity of 89.6% in detecting plaques complicated with intraplaque hemorrhage. Multidetector-row computed tomography showed a very high level of sensitivity and a moderate level of specificity in detecting atherosclerotic carotid plaques complicated with hemorrhage. Duplex Doppler ultrasonography plaque analysis based on visual in-line classification showed a low level of sensitivity and a moderate-high level of specificity in detecting atherosclerotic carotid plaques complicated with hemorrhage

Laparoscopic Surgery for Large Hydatide Liver Cyst After Two Previous Laparotomies

Laparoscopic surgery for hepatic echinococcosis is a technically difficult and demanding surgical procedure even for the most experienced abdominal surgeon. Surgery is performed after the conservative treatment with albendazole for 28 days. We report a case of laparoscopic partial pericystectomy with biliostasis and omentoplasty in a patient with two previously open surgeries (laparotomies) - right subcostal laparotomy for acute inflammation of the gallbladder and right pararectal laparotomy for perforated gangrenous appendix. The patient underwent extensive laparoscopic adhesiolysis due to pronounced intra-abdominal adhesions to gain access to a large hydatid cyst with the diameter of 11 cm. Laparoscopic surgery is much less traumatic to the patient with a better cosmetic effect

Indeks ALBI kao prediktor preživljenja nakon resekcije hepatocelularnog karcinoma u bolesnika s kompenziranom cirozom jetre: usporedba s indeksima PALBI i MELD

The aim of the study was to explore predictive value of the ALBI, PALBI and MELD scores on survival in patients resected for hepatocellular carcinoma with compensated liver cirrhosis and no macrovascular infi ltration. In this retrospective study, longitudinal survival analysis was performed. We analyzed patient/tumor characteristics and MELD, ALBI and PALBI scores as liver function tests for predicting survival outcome. Survival was analyzed from the date of liver resection until death, liver transplantation, or end of follow-up. Patients were stratifi ed for age, cirrhosis etiology, presence of esophageal varices, hepatocellular carcinoma stage, microvascular invasion, histologic diff erentiation, and resection margins. We identifi ed 38 patients (alcoholic cirrhosis in 84.2% of patients) resected over an 8-year period. Median preoperative MELD score was 8, ALBI score -2.63, and PALBI score -2.38. During the follow-up period, 24 patients died. Estimated median survival time was 36 months. Microvascular invasion was observed in 33 patients. Higher ALBI score was associated with 23.1% higher relative risk of death. PALBI score was associated with 12.1% higher relative risk of death, whereas MELD score was not associated with the risk of death. In conclusion, ALBI score demonstrated signifi cant predictive capabilities for survival in patients with compensated cirrhosis resected for hepatocellular carcinoma.Cilj je bio istražiti prediktivnu vrijednost zbira ALBI, PALBI i MELD za preživljenje bolesnika s kompenziranom cirozom reseciranih zbog hepatocelularnog karcinoma bez makrovaskularne invazije. Provedena je retrospektivna longitudinalna analiza preživljenja. Testirane su karakteristike bolesnika/tumora kao i jetreni funkcijski testovi MELD, ALBI i PALBI za predviđanje preživljenja. Bolesnici su praćeni nakon resekcije jetre do smrti, transplantacije jetre odnosno do kraja vremena praćenja. Bolesnici su kategorizirani po dobi, etiologiji ciroze, prisutnosti varikoziteta jednjaka, stadiju karcinoma, mikrovaskularnoj invaziji, histološkom stadiju i resekcijskim rubovima. Identifi cirali smo 38 bolesnika (alkoholna ciroza kod 84,2% bolenika) reseciranih kroz razdoblje od 8 godina. Medijan prijeoperacijskog zbira MELD bio je 8, zbira ALBI -2,63 i zbira PALBI -2,38. Tijekom praćenja 24 bolesnika su umrla. Očekivani medijan preživljenja iznosio je 36 mjeseci. Mikrovaskularna invazija pronađena je u 33 bolesnika. Veći ALBI je bio povezan s 23,1%, a PALBI s 12,1% većim relativnim rizikom od smrtnog ishoda. MELD nije bio povezan sa smrtnim ishodom. Zbir ALBI je pokazao značajnu prediktivnu vrijednost preživljenja u skupini bolesnika s kompenziranom cirozom reseciranih zbog hepatocelularnog karcinoma