Therapy of Umbilical Hernia during Laparoscopic Cholecystectomy

The aim of this study is to show our experience with umbilical hernia herniorrhaphy and laparoscopic cholecys- tectomy, both in the same act. During last 10 years we operated 89 patients with cholecystitis and pre-existing umbilical hernia. In 61 of them we performed standard laparoscopic cholecystectomy and additional sutures of abdominal wall, and in 28 patients we performed in the same act laparoscopic cholecystectomy and herniorrhaphy of umbilical hernia. We observed incidence of postoperative herniation, and compared patients recovery after herniorrhaphy combined with laparoscopic cholecystectomy in the same act, and patients after standard laparoscopic cholecystectomy and additional sutures of abdominal wall. Patients, who had in the same time umbilical hernia herniorrhaphy and laparoscopic chole- cystectomy, shown better postoperative recovery and lower incidence of postoperative umbilical hernias then patients with standard laparoscopic cholecystectomy and additional abdominal wall sutures

Effects of diclofenac, L-NAME, L-Arginine, and pentadecapeptide BPC 157 on gastrointestinal, liver, and brain lesions, failed anastomosis, and intestinal adaptation deterioration in 24 hour-short-bowel rats

Stable gastric pentadecapeptide BPC 157 was previously used to ameliorate wound healing following major surgery and counteract diclofenac toxicity. To resolve the increasing early risks following major massive small bowel resectioning surgery, diclofenac combined with nitric oxide (NO) system blockade was used, suggesting therapy with BPC 157 and the nitric oxide synthase (NOS substrate) L-arginine, is efficacious. Immediately after anastomosis creation, short-bowel rats were untreated or administered intraperitoneal diclofenac (12 mg/kg), BPC 157 (10 μg/kg or 10 ng/kg), L-NG-nitroarginine methyl ester (L-NAME, 5 mg/kg), L-arginine (100 mg/kg) alone or combined, and assessed 24 h later. Short-bowel rats exhibited poor anastomosis healing, failed intestine adaptation, and gastrointestinal, liver, and brain lesions, which worsened with diclofenac. This was gradually ameliorated by immediate therapy with BPC 157 and L-arginine. Contrastingly, NOS-blocker L-NAME induced further aggravation and lesions gradually worsened. Specifically, rats with surgery alone exhibited mild stomach/duodenum lesions, considerable liver lesions, and severe cerebral/hippocampal lesions while those also administered diclofenac showed widespread severe lesions in the gastrointestinal tract, liver, cerebellar nuclear/Purkinje cells, and cerebrum/hippocampus. Rats subjected to surgery, diclofenac, and L-NAME exhibited the mentioned lesions, worsening anastomosis, and macro/microscopical necrosis. Thus, rats subjected to surgery alone showed evidence of deterioration. Furtheremore, rats subjected to surgery and administered diclofenac showed worse symptoms, than the rats subjected to surgery alone did. Rats subjected to surgery combined with diclofenac and L-NAME showed the worst deterioration. Rats subjected to surgery exhibited habitual adaptation of the remaining small intestine, which was markedly reversed in rats subjected to surgery and diclofenac, and those with surgery, diclofenac, and L-NAME. BPC 157 completely ameliorated symptoms in massive intestinal resection-, massive intestinal resection plus diclofenac-, and massive intestinal resection plus diclofenac plus L-NAME-treated short bowel rats that presented with cyclooxygenase (COX)-NO-system inhibition. L-arginine ameliorated only L-NAME-induced aggravation of symptoms in rats subjected to massive intestinal resection and administered diclofenac plus L-NAME

BILE STONE ILEUS WITH CHOLECYSTODUODENAL FISTULA – BOUVERET’S SYNDROME

U prikazu kliničkog slučaja riječ je o visokorizičnom kardijalnom sedamdesetjednogodišnjem bolesniku, koji je primljen u hitnoj službi sa simptomima visoke temperature, kontinuiranim povraćanjem i bolovima u epigastriju i pod desnim rebrenim lukom. Kompjuteriziranom tomografijom pronađena je patološka komunikacija žučnog mjehura s dvanaesnikom te veći žučni kamen koji opstruira silazni dio dvanaesnika ispred donjeg koljena. Bolesnik je podvrgnut uspješnom kirurškom liječenju.This is a case report of a 71-year-old man, who presented to emergency department with elevated temperature, vomiting and epigastric pain. Computed tomography of the abdomen revealed a large fistulous tract extending from the gallbladder to the duodenal bulb, as well as a large calculus obstructing the second part of the duodenum. The patient subsequently underwent successful surgical therapy

Kako terapijski postupiti kod ciste koledokusa?

We report a case of biliary cyst type II which, independently of its a priori benign nature, caused numerous complications such as recurrent cholangitis and pancreatitis, as well as subsequent hepatic fibrosis and the potential danger of choledochocele perforation. Although they are benign, biliary/choledochal cysts can cause numerous disorders such as cholestasis, leading to cholangitis and pancreatitis and biliary sepsis, and due to chronic inflammation of the biliary system even cholangiocarcinogenesis. Our findings showed that sometimes this type of biliary cyst (according to the available literature the rarest and most benign type), as well as type I cyst, should undergo timely radical excision. In our patient, timely choledochocele resection would have certainly contributed to the reduction of subsequent complications, as well as to obviating repeated invasive diagnostic and surgical procedures.Opisan je slučaj bilijarne ciste tip II. koja je u naše bolesnice usprkos svojoj a priori dobroćudnoj naravi bila uzrokom brojnih komplikacija poput ponavljajućih kolangitisa i pankreatitisa s posljedičnom jetrenom cirozom te potencijalnom opasnošću od perforacije koledohocele. Usprkos svojoj dobroćudnoj naravi bilijarne/koledohalne ciste mogu uzrokovati mnogobrojne poremećaje poput kolestaze s kolangitisom, pankreatitisom i bilijarnom sepsom, a s obzirom na kroničnu upalu bilijarnog sustava mogu pogodovati i nastanku kolangiokarcinoma. Iz primjera naše bolesnice može se zaključiti kako u određenom broju slučajeva čak i ovaj tip bilijarne ciste (prema dostupnoj literaturi najmanje zastupljen i najbenigniji tip) treba razmotriti s kirurškog aspekta, jednako kao i bilijarnu cistu tip I. Naime, pravodobna resekcija odnosno ekscizija bilijarne ciste u naše bolesnice svakako bi smanjila gore spomenute komplikacije, a isto tako i opetovane invazivne dijagnostičke i kirurške zahvate kojima je bolesnica bila višestruko podvrgnuta

Spontana heterotopična, ektopična cervikalna i ektopična tubarna trudnoća - uvijek prisutna dijagnostička poteškoća: prikaz triju slučajeva

The incidence of heterotopic/ectopic pregnancy in recent times has increased partly due to the increase in assisted reproductive technologies, whereas such medical cases and cervical pregnancy in particular are extremely rare with spontaneous conception. We report on three patients referred to our department in one week: one patient each with spontaneous heterotopic pregnancy, cervical pregnancy and tubal pregnancy. All of them had conceived spontaneously and were properly diagnosed and treated, however, additional care is needed in diagnosing and managing the potentially fatal consequences of ectopic pregnancy if not recognized early and managed properly, despite its low incidence.Incidencija heterotopičnih/ektopičnih trudnoća se u posljednje vrijeme povećava između ostalog i zbog sve veće upotrebe metoda pomognute oplodnje, ali ovi slučajevi, a naročito cervikalna trudnoća, iznimno su rijetki u spontanim zanošenjima. Prikazujemo tri bolesnice koje su se javile u našu Kliniku u tjedan dana: bolesnica sa spontanom heterotopičnom trudnoćom, druga s cervikalnom i treća s tubarnom trudnoćom. Sve su spontano zanijele, pravodobno dijagnosticirane i izliječene, ali naglašavamo da je osobita pozornost potrebna u dijagnozi i liječenju potencijalno fatalnih posljedica izvanmaterničnih trudnoća ako nisu prepoznate i liječene dovoljno rano, unatoč tako iznimno rijetkoj pojavnosti

PYOGENIC LIVER ABSCESS CAUSED BY KLEBSIELLA PNEUMONIAE

Piogeni apsces jetre uzrokovan bakterijom Klebsiella pneumoniae najčešće se nalazi u jugoistočnoj Aziji, dok u Europi kao uzročnici piogenog jetrenog apscesa prednjače Escherichia coli, Streptococcus spp. ili Staphylococcus spp. U slučaju neuspjele ultrazvučno kontrolirane aspiracije apscesa, indicirano je operacijsko liječenje. U radu je prikazan klinički slučaj piogenog apscesa jetre uzrokovanog bakterijom Klebsiella pneumoniae liječenog kirurškom drenažom. Šezdesetogodišnji bolesnik premješten je u našu ustanovu iz Klinike za infektivne bolesti u Zagrebu; septičan, bolnog trbuha s verificiranim jetrenim apscesom, koji nije reagirao na provedenu antibiotsku terapiju. Nakon prijma učinjena je dodatna laboratorijska i višeslojna kompjutorska tomografija (MultiSlice Computed Tomography – MSCT) kojom je potvrđena početna dijagnoza. S obzirom na lokalizaciju apscesa koja je tehnički onemogućavala ultrazvučno kontroliranu punkciju i drenažu apscesa, nakon adekvatne prijeoperacijske pripreme pristupilo se kirurškom zahvatu. Učinjena je laparotomija, incizija i drenaža jetrenog apscesa. Mikrobiološki pregled aspirata apscesa potvrdio je Klebsiella pneumoniae kao uzročnika jetrenog apscesaPyogenic liver abscess caused by Klebsiella pneumoniae is usually found in Southeast Asia, while in Europe Escherichia coli, Streptococcus or Staphylococcus are most common. In case of a failed ultrasound controlled abscess, aspiration surgical treatment is indicated. This paper reports the clinical case of pyogenic liver abscess caused by Klebsiella pneumoniae, which was treated by operative drainage. A 60-year-old patient was transferred to our institution from the University Hospital for Infectious Diseases with septic temperature, abdominal pain and finding of Klebsiella pneumoniae liver abscess (resistant to antibiotic therapy). Additional laboratory tests and abdominal MSCT scan confirmed the initial diagnosis. The localization of abscesses technically prevented ultrasound-controlled abscess aspiration and drainage; after appropriate preparation, operative liver abscess incision and drainage were performed. Microbiological examination of the abscess sample revealed Klebsiella pneumoniae as the cause of liver abscess

BILE STONE ILEUS WITH CHOLECYSTODUODENAL FISTULA – BOUVERET’S SYNDROME

U prikazu kliničkog slučaja riječ je o visokorizičnom kardijalnom sedamdesetjednogodišnjem bolesniku, koji je primljen u hitnoj službi sa simptomima visoke temperature, kontinuiranim povraćanjem i bolovima u epigastriju i pod desnim rebrenim lukom. Kompjuteriziranom tomografijom pronađena je patološka komunikacija žučnog mjehura s dvanaesnikom te veći žučni kamen koji opstruira silazni dio dvanaesnika ispred donjeg koljena. Bolesnik je podvrgnut uspješnom kirurškom liječenju.This is a case report of a 71-year-old man, who presented to emergency department with elevated temperature, vomiting and epigastric pain. Computed tomography of the abdomen revealed a large fistulous tract extending from the gallbladder to the duodenal bulb, as well as a large calculus obstructing the second part of the duodenum. The patient subsequently underwent successful surgical therapy

What is the Right Therapeutic Approach to Biliary Choledochal Cyst?

We report a case of biliary cyst type II which, independently of its a priori benign nature, caused numerous complications such as recurrent cholangitis and pancreatitis, as well as subsequent hepatic fibrosis and the potential danger of choledochocele perforation. Although they are benign, biliary/choledochal cysts can cause numerous disorders such as cholestasis, leading to cholangitis and pancreatitis and biliary sepsis, and due to chronic inflammation of the biliary system even cholangiocarcinogenesis. Our findings showed that sometimes this type of biliary cyst (according to the available literature the rarest and most benign type), as well as type I cyst, should undergo timely radical excision. In our patient, timely choledochocele resection would have certainly contributed to the reduction of subsequent complications, as well as to obviating repeated invasive diagnostic and surgical procedures