Medicinsko svrdlo s protočnim hlađenjem otvorenoga tipa u koštano-zglobnoj kirurgiji [Medical drill with open type internal cooling in bone and joint surgery]

Background and aims: Drilling of the bone causes a temperature rise at the point of bone and drill contact. A temperature higher than 47°C can lead to thermal osteonecrosis. The aim of this research was to examine how stainless steel medical drill with open type cooling system affects the maximum temperature at the drilling site with drills of different degree of wear. Drill strength was also studied with regard to the changes required for the system for internal cooling. The influence of coolant on intramedullary pressure, distribution of coolant during drilling and specificity of sterilization of such drill was studied. ----- Methods and materials: For this research, through a standard 4.5 mm medical steel drill, with an electro-erosion process a channel was created. Due to the modification of the drill structure, experimental analysis of the technical properties and analysis of the finite elements was made. Afterwards, measurements of temperature increase at the point of drilling with a drill with open type internal cooling with different degree of wear were performed, also intramedullary pressure during drilling was measured. Intramedullary coolant distribution was showed with X-ray images. A study was carried out on sterilization efficiencies of drill bits with open type internal cooling system. Results: Experimental analysis of technical properties and analysis of finite elements proved that drilling modification has no effect on drill strength in clinical conditions. The maximum achieved temperatures at the drilling site with the open type internal cooling drills were less than critical regardless of the degree of wear of the drill while the temperatures of the drills without cooling were more than critical. Coolant fluid, entering the intramedullary channel, during drilling, has no effect on intramedullary pressure. During and after drilling coolant does not expand into the intramedullary channel but only remains in the bore. An open type internal cooling drill requires a prolonged cycle of sterilization cycles. ----- Conclusion: The open type internal cooling drill significantly reduces the maximum temperature at the point of bone and drill contact regardless of the degree of drill wear. Such a drill can be made of medical steel to meet standards for use in medicine and can be adequately sterilized for reuse. The coolant used during drilling does not affect the intramedullary pressure. The stainless steel medical drill with open type internal cooling is safe to use in bone and joint surgical procedures and is capable to avoid the formation of thermal osteonecrosis completely

Rectal cancer and Fournier's gangrene - current knowledge and therapeutic options

Fournier's gangrene (FG) is a rapid progressive bacterial infection that involves the subcutaneous fascia and part of the deep fascia but spares the muscle in the scrotal, perianal and perineal region. The incidence has increased dramatically, while the reported incidence of rectal cancer-induced FG is unknown but is extremely low. Pathophysiology and clinical presentation of rectal cancer-induced FG per se does not differ from the other causes. Only rectal cancer-specific symptoms before presentation can lead to the diagnosis. The diagnosis of rectal cancer-induced FG should be excluded in every patient with blood on digital rectal examination, when urogenital and dermatological causes are excluded and when fever or sepsis of unknown origin is present with perianal symptomatology. Therapeutic options are more complex than for other forms of FG. First, the causative rectal tumor should be removed. The survival of patients with rectal cancer resection is reported as 100%, while with colostomy it is 80%. The preferred method of rectal resection has not been defined. Second, oncological treatment should be administered but the timing should be adjusted to the resolution of the FG and sometimes for the healing of plastic reconstructive procedures that are commonly needed for the reconstruction of large perineal, scrotal and lower abdominal wall defects

Testicular cancer masquerading as an incarcerated inguinal hernia – A case report

An incarcerated inguinal hernia is a surgical emergency. Testicular tumors can present with scrotal swelling, hence they could easily be mistaken for a hernia. Both conditions, if left untreated, are life-threatening and lead to severe complications

Infectious gangrene as a clinical entity

Infektivne gangrene ili nekrotizirajuće infekcije mekih česti su teške infekcije potkožnog tkiva s visokim mortalitetom. Infekciji najčešće prethodi kirurški tretman ili trauma. Postoje brojne klasifikacije infektivnih gangrena, a u praksi je uobičajena mikrobiološka podjela na tip I (polimikrobni) i tip II (uzrokovan streptokokom). Klinička slika infektivne gangrene uključuje intezivnu bol u području rane, krepitacije, prisutnu sekreciju, pojavu bula i brzi razvoj septičkog šoka. Vanjski izgled rane nerijetko ne korelira s stvarnim stanjem te može biti razlogom za kasnu dijagnozu. Dijagnoza bolesti postavlja se temeljem kliničke slike, laboratorijskih nalaza, radioloških pretraga, mikrobioloških nalaza, a potvrđuje i kirurškom ekploracijom zahvaćenog područja koja je i terapijski postupak. Pojava plina u mekim tkivima je tipičan znak za nekrotizirajuće infekcije i indicira početak liječenja. Izostanak pravovremene i agresivne terapije najčešće dovodi do nepovoljnog ishoda bolesti. Liječenje se sastoji od brze i ekstenzivne kirurške ekploracije i odstranjena nekrotičnih masa, kombinirane antibiotske terapije, te potrebite simptomatske i suportivne terapije.Infectious gangrenes or necrotizing soft tissue infections are severe subcutaneous tissue infections with high mortality rates. Infections are often preceded by a surgical procedure or trauma. There are many classifications of infectious gangrenes, however the most commonly used in practice is microbiological classification into type I (polymicrobial) and type II (caused by Streptococcus). The clinical presentation of infectious gangrene includes intense pain in the wound area, crepitations, secretion, the occurrence of bullae and rapid development of septic shock. The external appearance of the wound often does not correlate with the actual condition and may be the reason for late diagnosis. The diagnosis of the disease is based on clinical features, laboratory findings, radiological examinations, microbiological results, and is confirmed by surgical exploration of the affected area which is also a therapeutic procedure. Gas formation in the soft tissues is a typical sign of necrotizing infections and indicates the beginning of treatment. Lack of timely and aggressive treatment usually leads to poor disease outcome. Optimal treatment consists of prompt and extensive surgical wound exploration and necrotic tissue removal, combined antibiotic therapy and necessary symptomatic and supportive therapy

Non-necrotising bacterial infections of the skin

Koža je barijera koja je kolonizirana apatogenim bakterijama koje ograničavaju invaziju i rast patogenih bakterija. Najčešće bakterijske infekcije kože jesu piodermije uzrokovane beta hemolitičkim streptokokom (BHS) ili zlatnim stafilokokom (SA). Impetigo je površinska infekcija kože najčešće djece predškolske dobi uzrokovana BHS ili SA. Terapijski pristup ovisi o broju i veličini kožnih promjena. Apsces kože zahtjeva inciziju, evakuaciju gnoja, a ponekad i antimikrobnu terapiju. Folikulitis, furunkul i karbunklu su infekcije folikula dlake u pravilu uzrokovane SA koje se razlikuju u opsežnosti inflamacije. Erizipel i celulitis se patohistološki razlikuju po dubini zahvaćene kože, a klinički po izgledu i morfologiji kožnih lezija. Promjenama na koži prethode sistemske manifestacije infekcije. Etiološka dijagnoza erizipela/celulitisa rijetko se uspije postaviti. Osim BHS i SA i neke druge bakterije mogu uzrokovati celulitis, ali u nekim posebnim situacijama. Dijagnoza erizipela/celulitisa postavlja se na temelju kliničke slike. No, u pravilu se ne može uočiti klinička razlika između streptokokne i stafilokokne infekcije kože. Od značaja je na vrijeme prepoznati nekrotizirajuće infekcije mekih česti koje zahtjevaju brzi kiruški tretman. Liječenje erizipela/celultiisa podrazumijeva antimikrobnu terapiju u trajanju od 10 dana, a ponekad i duže. U osoba s ponavljajućim erizipelom/celulitisom potrebno je nakon uspješno provedenog liječenja provoditi odgovarajuće preventivne mjere koju uključuju odgovarajuće higijenske mjere, liječenje popratnih čimbenika rizika, eradikaciju potencijalnog kliconoštva, a u nekim slučajevima i profilaktičku primjenu antibiotika. Celulitis orbite je ozbiljna bolest koja može izazvati ozbiljne komplikacije te ga je potrebno razlikovati od preseptalnog celulitisa koji je blaga bolest. Perianalni apsces zahtijeva neodgodivu kirušku drenažu te ponekad i antimikrobnu terapiju.The skin is a barrier colonized with apathogenic bacteria that limit the invasion and growth of pathogenic bacteria. The most common bacterial infections of the skin are pyodermas caused by Beta-hemolytic streptococcus (BHS) or Staphylococcus aureus (SA). Impetigo is a superficial skin infection caused by BHS or SA, that most commonly affects preschool children. Therapeutic approach depends on the number and size of skin changes. Skin abscess requires incision, pus drainage, and sometimes antimicrobial therapy. Folliculitis, furuncles, and carbuncles are infections of the hair follicle in general caused by SA that differ in the extensiveness of inflammation. Erysipelas and cellulitis pathohistologically differ in depth of the affected skin, and clinically in the appearance and morphology of skin lesions. Skin changes are preceded by systemic manifestations of infection. Etiological diagnosis of erysipelas/cellulitis is rarely established. Apart from BHS and SA, also some other bacteria may cause cellulitis, in some special circumstances. Diagnosis of erysipelas/cellulitis is based on clinical presentation of disease. However, streptococcal and staphylococcal skin infections cannot be clinically distinguished. It is important to timely recognize necrotizing soft tissue infections that require rapid surgical intervention. The treatment of erysipelas/cellulitis includes antimicrobial therapy lasting for 10 days, and sometimes even longer. After successful completion of treatment, in patients with recurrent erysipelas/cellulitis appropriate preventive measures need to be implemented, which include proper hygiene measures, treatment of accompanying risk factors, eradication of carriage of potential pathogens, and in some cases, prophylactic use of antibiotics. Orbital cellulitis is a serious condition that can cause severe consequences and should be distinguished from preseptal cellulitis which is a mild disease. Perianal abscess requires immediate surgical drainage and sometimes also antimicrobial therapy

Case report: Duplication of gallbladder in a newborn with gastroschisis

Gastroshiza je defekt trbušne stijenke kroz koji protrudiraju trbušni organi i često je udružena s drugim malformacijama. Najčešće se radi o crijevnim (tri četvrtine), rjeđe ju prate urološke, srčane i malformacije ekstrahepatičkog bilijarnog stabla. Duplikature žučnog mjehura u općoj populaciji su relativno rijetke i javljaju se 1 na 3000–4000. U ovom prikazu slučaja prezentirat ćemo slučaj novorođenčeta s gastroshizom udruženom s duplikaturom žučnog mjehura. Kod novorođenčeta je pronađena kompletna duplikatura žučnog mjehura s dva odvojena duktusa cistikusa (tip 2 po Boydenu). Smjernica za postupak kod duplikature žučnog mjehura u novorođenčadi s gastroshizom nema, mi smo postupili po smjernicama za duplikaturu žučnog mjehura u općoj populaciji. Duplikature žučnog mjehura udružene s gastroshizom ne zahtijevaju aktivno kirurško liječenje ako nisu simptomatske ili ako ne postoji druga malformacija bilijarnog sustava.Gastroschisis is a defect of the anterior abdominal wall through which viscera can protrude, and can be followed by additional malformations. Three quarters of the gastroschisis malformations are confined to the midgut. Other malformations are urologic and cardiac malformations and malformations of extrahepatic biliary tract. Duplication of gallbladder in general population is relatively rare, occurring once in every 3,000 to 4,000.In this case report we will present a case of an infant with gastroschisis accompanied with the duplication of gallbladder. In the newborn a complete duplication of gallbladder was found with two separate cystic ducts, i.e. type 2 by Boyden. Since the guidelines for duplication of the gallbladder associated with gastroschisis do not exist, we acted according to the guidelines for duplication of the gallbladder in the general population, i.e. nonsurgical intervention was performed on the biliary tree. Duplications of the gallbladder associated with gastroschisis do not require active surgical treatment, unless they are symptomatic or if there is other malformation of the biliary system

Probno istraživanje: ortopedska svrdla s protočnim hlađenjem otvorenog tipa - je li standardna sterilizacija dovoljna?

Bone drilling causes focal temperature rise due to metal-to-bone contact, which may result in thermal osteonecrosis. Newly constructed internally cooled medical drill of an open type decreases temperature rise at a point of metal-to-bone contact although standard sterilization of such a drill could be inadequate due to bacteria retention within the drill lumen. The aim of this pilot study was to examine the effectiveness of sterilization and to propose sterilization recommendations for internally cooled open type bone drills. Unused internally cooled medical steel bone drills were tested. Drills were contaminated with Pseudomonas aeruginosa, Bacillus sp., beta-hemolytic Streptococcus sp., Enterobacter sp. and methicillin-resistant Staphylococcus pseudintermedius and then incubated for 24 hours at 37 °C. Afterwards, drills were autoclaved for 15, 20 and 30 minutes at 132 °C and 2.6 bar. When 15-minute sterilization was used, one out of 16 drills was contaminated with Pseudomonas aeruginosa, while the other 15 drills were sterile. Extended cycle sterilization in autoclave lasting for 20 and 30 minutes resulted in 100% sterility of all drills tested. In conclusion, lumened drills should be exposed to extended sterilization times in autoclave. Minimal recommended time for sterilization of lumened drills is 20 minutes.Bušenje kosti izaziva porast temperature na mjestu kontakta metala i kosti, što može rezultirati termičkom osteonekrozom. Novokonstruirano svrdlo s unutarnjim hlađenjem otvorenog tipa smanjuje porast temperature na mjestu kontakta metala i kosti, ali standardna sterilizacija takvog svrdla može biti nedovoljna zbog zadržavanja bakterija unutar kanala svrdla. Cilj ovog probnog istraživanja bila je procjena učinkovitosti sterilizacije te prijedlog preporuka za sterilizaciju medicinskog svrdla s unutarnjim hlađenjem otvorenog tipa. Testirana su nekorištena medicinska svrdla s unutarnjim hlađenjem otvorenog tipa. Svrdla su kontaminirana sljedećim bakterijama: Pseudomonas aeruginosa, Bacillus sp., beta-hemolitički Streptococcus sp., Enterobacter sp. i meticilin-rezistentni Staphylococcus pseudintermedius. Inkubacija je trajala 24 sata na temperaturi od 37 °C. Potom su svrdla sterilizirana u autoklavu 15, 20 i 30 minuta na temperaturi od 132 °C i tlaku od 2,6 bara. Kod sterilizacije u trajanju od 15 minuta jedno od 16 korištenih svrdla bilo je kontaminirano bakterijom Pseudomonas aeruginosa, dok su ostala svrdla bila sterilna. Produženi ciklus sterilizacije u autoklavu u trajanju od 20 odnosno 30 minuta rezultirao je sterilnošću svih svrdla. U zaključku, svrdla s lumenom je potrebno sterilizirati produženim ciklusom sterilizacije. Minimalno preporučeno trajanje sterilizacije je 20 minuta

Alpha-melanotropin Peptide: Structure and Ligand–Receptor Recognition

The hydropathic profile, secondary structure, epitope and binding site of the a-melanotropin molecule were investigated. It was shown that the standard algorithm according to Kyte and Doolittle may be combined with complex methods of the secondary structure prediction to extract the information relevant for the epitope location and modeling. The binding ligand-receptor motifs of the hormone were investigated by means of the SSpro8 method. The Molecular Recognition Theory combined with an NCBInr protein database search was applied to find the possible paratope (receptor) structures for the predicted a-melanotropin epitope (ligand). The described concept constitutes a useful and simple set of procedures for deriving new biologically active peptides and antibodies and also for performing modulation of peptide-receptor interaction

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

Prva sinkrona resekcija jetre u sklopu citoreduktivne kirurgije, peritonektomije i HIPEC-a u Hrvatskoj – prikaz bolesnice [First synchronous liver resection as a part of cytoreductive surgery, peritonectomy and HIPEC in Croatia - case report]

We present a case of a 37-year-old female, with large adenocarcinoma of transverse colon, and metastases in spleen, liver, peritoneum, greater omentum, gall bladder and right adnexa. She was transferred to our Hospital, and extensive elective cytoreductive surgery with intraabdominal hyperthermal chemotherapy (HIPEC) was performed. Couple of months later, she was operated on for a newly evidenced secondary nodus in liver segment VII, and metastasectomy was performed. Throughout entire postoperative period she was receiving cyclic chemotherapy. At this point, 2 years from the first operation, she was without evidenced recurrence of the disease. Aggressive cytoreductive surgery with multiorgan resection, peritonectomy, HIPEC and adjuvant chemotherapy which was proved to be a feasible option in some patients, with synchronous liver resection (LR) proved to be feasible and beneficial for patients with three or fewer liver metastases. This is the first liver resection included in usually performed cytoreductive surgery and HIPEC in Croatia