The MIDCAB surgery - minimally invasive alternative to the open-heart surgery in one-vessel disease

Introduction: Minimally invasive direct coronary artery bypass (MIDCAB) is an established surgical procedure for revascularisation of the coronary arteries. MIDCAB has been mainly used in patients with proximal stenosis of the left anterior descending artery (LAD). The MIDCAB technique with approach through the left anterior small thoracotomy resulted in effective LIMA(left internal mam­mary artery)-to-LAD grafting. The MIDCAB technique carries a very low rate of complications and restenosis. By avoiding sternotomy and cardiopulmonary bypass it is less invasive than conventional bypass surgery. It reduces surgical trauma and gives a satisfying cosmetic effect.Materials and Methods: A case report of a 64-year-old man with single-vessel coronary artery disease, angina pectoris class III NYHA, hypertension class III, hyperlipidemia, left ventricular hypertrophy who was admitted to the Department of Cardiac Surgery, complaining of breathlessness, chest pain and fatigue during physical effort. The symptoms relieved after 5-10 minutes rest. The patient under­went Coronary angiography which shows chronic total occlusion of LAD and an unsuccessful attempt for percutaneous coronary intervention (PCI) in the past. The patient was considered as suitable for MIDCAB surgery in planned order.Results: The patient tolerated the operation with stable haemodynamics. The blood flow in the LAD was restored with LIMA-to-LAD graft and the positive result was proven by flowmetry in the oper­ation theatre. The patient was extubated on the 3rd postoperative hour. No rhythm and conduction disorders were registered.Conclusion: MIDCAB surgery is a suitable alternative to the conventional open-heart bypass sur­gery. It is not only applicable in isolated lesions of the LAD but also with the Hybrid concepts (MID­CAB and PCI) it is of growing interest in serving older patients with significant comorbidities. Over­all, MIDCAB surgery is associated with few perioperative complications, psychological and surgical trauma and with high graft patency rates in the mid-term and long-term course

Fulminant clostridiosis in ulcerative colitis

Introduction: Ulcerative colitis is an inflammatory bowel disease of the colon. It presents itself with ulcers and pus, damaged mucosa and a continual course. It usually starts from the rectum and affects other parts of the colon. The histological findings include chronic inflammation of the mucosa, poly­morphonuclear neutrophilic infiltration of the crypts of the colon, presence of crypt abscesses and disturbance of mucosal glands structure. Clostridium difficile is a bacterium which causes colitis by producing toxins that further damage the lining of the colon. These conditions have several forms-acute, sub-chronic, chronic and fulminant. The latter leads to toxic megacolon.Materials and Methods: A 15-year-old girl was hospitalized due to hematemesis and diarrhoea. Her skin was pale, her face and limbs were oedemic. Blood analysis and microbiology tests, radiographies, CT and MRI scans, sonography, esophagogastroduodenoscopy and colonoscopy were all performed. The results showed various laboratory index deviations, anaemic syndrome, hypoproteinaemia, hy­poalbuminemia, mushy stool mixed with mucus, but no blood. However, only a few days later the pa­tient started bleeding, blood clots and colon mucous were also observed. The bleeding would go on for two days and another colonoscopy was performed while blood infusions were ongoing. On both oc­casions histological samples were taken. The final diagnosis was fulminant clostridiosis in ulcerative colitis. An unanimous decision for colostomy was taken and carried out. An ileostoma was then cre­ated and the surgical intervention was terminated.Results: Her post-operative period was about a month long. There were complications such as epilep­tic seizures, hypovolemic shock, ascites and pleural effusion. Another bleeding did not occur. Thera­py for both ulcerative colitis and clostridium difficile infection was appointed.Conclusion: Fulminant ulcerative colitis is a serious condition with high mortality rates by itself, let alone being complicated by clostridium difficile. Histological remission is what is mandatory for a bowel transplant to be placed

Biological treatment of Crohn`s disease

Introduction: Crohn`s disease (CD) is a chronic relapsing inflammatory bowel disease (IBD). It is characterized by a transmural granulomatous inflammation which can affect any part of the gastro­intestinal tract. CD most commonly affects the ileum, colon or both. Despite biological treatment being associated with an improved health-related quality of life, patients still report impediment on daily activities during both flares and remissions.Materials and Methods: A case of a 41-year-old man with a history of IBD affecting pars duodeni, the small intestine and the colon (A3L3B2) is presented. Manifestations related to the disease such as ab­dominal pain and diarrhea appeared in 2015.Virtual colonoscopy and the biopsy from the ascend­ing and transverse colon indicated typical development for Crohn`s disease. Due to the progression of CD, a therapy with Adalimumab (HUMIRA) was started. Symptoms such as coughing, sweating and subfebrile temperature appeared in 2017 - eight months after the biological treatment. The control endoscopic examinations indicated an impact on the upper gastrointestinal tract.Results: Biological therapy with Adalimumab (HUMIRA) was started. Eight months later the patient presented with respiratory symptoms. Mantoux and Interferon-Gamma Release Assays (IGRAs) re­sults were negative excluding latent tuberculosis (LTBI). The results of chest X-ray imaging were nor­mal. Therapy with Esomeprazole and antihistamines was started.Conclusion: Crohn`s disease affecting both the upper and lower gastrointestinal tract indicates pro­gression. Biological treatment is associated with an improved health-related lifestyle and all patients who are candidates should be studied to detect a possible LTBI, given that they constitute one of the groups at highest risk of developing tuberculosis