Suvremeno kirurško liječenje raka rektuma

Surgical treatment is a method of choice in treating patients with resectable primary form of rectal cancer. An important step in treatment is the multidisciplinary approach from different medical specialties in the fields of radiology, gastroenterology, oncology and surgery. In recent years, several minimally invasive surgical procedures have been developed that improve postoperative recovery while still preserving oncological principles, such as laparoscopic low anterior resection, transanal total mesorectal excision and robotic surgery. Surgical and oncological principles that must be respected in all cases are wide resection of the tumor with histologically free resection margins and the use of total mesorectal excision with anal sphincter preservation and preservation of the continuity of the intestine whenever possible.Kirurgija je metoda izbora u liječenju bolesnika s resektabilnim rakom rektuma. Važan korak u liječenju je multidisciplinarni pristup različitih medicinskih specijalnosti iz područja radiologije, gastroenterologije, onkologije i kirurgije. U posljednjih nekoliko godina razvijeno je nekoliko minimalno invazivnih kirurških postupaka s ciljem poboljšanja postoperativnog oporavka uz očuvanje svih onkoloških principa, kao što su laparoskopske niske prednje resekcije, transanalne totalne mezorektalne resekcije i robotske operacije. Kirurška i onkološka načela koja se moraju poštivati u svim slučajevima su široka resekcija tumora s histološki slobodnim resekcijskim rubovima i totalna mezorektalna ekscizija s očuvanjem analnog sfinktera kao i očuvanje kontinuiteta crijeva kad god je to moguće

Otpust iz bolnice nakon elektivne nekomplicirane laparoskopske kolecistektomije: može li se skratiti poslijeoperacijski boravak u bolnici?

The aim of the study was to reevaluate the safety and feasibility of discharge 24 h after elective uncomplicated laparoscopic cholecystectomy. Since the introduction of laparoscopic cholecystectomy in our hospital, the minimum postoperative stay was considered to be two days based on surgeons’ experience. The study included 337 operations performed by 21 surgeons during 2016 in the Sestre milosrdnice University Hospital Centre. Conversion to open technique and cases of acute cholecystitis were excluded, while 15 patients had insufficient postoperative data. The mean length of stay was 2.38 (range 1 to 6) postoperative days, median two postoperative days. Serious complications involving suspected drain bile leakage and postoperative hemorrhage occurred in two (0.59%) patients, both in the first 24 h following surgery. One patient required emergency laparotomy on the first postoperative day. Readmission rate was 1.2%. The postoperative minor complication rate was 42 of 337 (12.46%); these included wound infections, urinary tract infections, symptoms included in postcholecystectomy syndrome, etc. The onset of these complications was mostly after postoperative day 3. The data obtained suggest that discharge on the first postoperative day after elective uncomplicated laparoscopic cholecystectomy should be considered safe and can be practiced in our hospital.Cilj studije bio je reevaluirati sigurnost i izvodljivost otpusta bolesnika u prva 24 sata nakon elektivnih laparoskopskih kolecistektomija. Od uvođenja laparoskopske metode u našoj ustanovi, prema iskustvu kirurga smatralo se kako je minimalni poslijeoperacijski boravak 2 dana. Studija je obuhvatila 337 operacija koje je proveo 21 kirurg u 2016. godini u KBC “Sestre milosrdnice”. Isključeni su slučajevi konverzije u otvorene operacije kao i slučajevi akutnog kolecistitisa. Kod 15 bolesnika nije bilo dovoljno podataka o poslijeoperacijskom tijeku. Prosjek poslijeoperacijskog boravka bio je 2,38 (1 do 6) dana, medijan je bio 2 dana. Ozbiljne komplikacije u vidu suspektnog curenja žuči i poslijeoperacijskog krvarenja pojavile su se kod dvoje (0,59%) bolesnika; oba slučaja dogodila su se unutar 24 sata od operacije. Kod jednog bolesnika indicirana je hitna reoperacija prvog poslijeoperacijskog dana. Stopa ponovnog prijma u bolnicu bila je 1,2%. Manje poslijeoperacijske komplikacije dogodile su se kod 42 (12,46% operiranih) bolesnika; ove komplikacije uključivale su infekcije rane, uroinfekcije, simptome postkolecistektomijskog sindroma itd. Ove komplikacije događale su se uglavnom nakon 3. poslijeoperacijskog dana. Prikupljeni podaci ukazuju na to da se otpust prvog poslijeoperacijskog dana nakon elektivne nekomplicirane laparoskopske kolecistektomije može smatrati sigurnim i provoditi tu praksu u našoj ustanovi

Usporedba vrijednosti serumskog i intraperitonealnog C-reaktivnog proteina u ranoj dijagnostici dehiscencije anastomoze nakon kirurgije debeloga crijeva

In colorectal surgery, anastomotic leakage is a serious complication, leading to higher postoperative morbidity and mortality. The aim of this study was to evaluate the accuracy of serum and intraperitoneal C-reactive protein (CRP) in early diagnostics of anastomotic leakage on the first four postoperative days after colorectal surgery. From January to October 2019, fifty-nine patients with colorectal carcinoma were operated on, with formation of primary anastomosis. Anastomotic leakage was diagnosed in eight patients. Comparing the levels of serum and intraperitoneal CRP, our study showed that serum CRP was a better predictor of anastomotic leakage. Serum CRP levels lower than 121 mg/L on postoperative day 4 were predictive of good healing of anastomosis.U kirurgiji debelog crijeva dehiscencija crijevne anastomoze je ozbiljna komplikacija koja dovodi do povećanja pobola i smrtnosti nakon operativnog zahvata. Cilj ove studije bio je utvrditi točnost serumskog i intraperitonealnog C-reaktivnog proteina u ranoj dijagnostici dehiscencije crijevne anastomoze u prva četiri poslijeoperacijska dana nakon operacije debelog crijeva. Od siječnja do kolovoza 2019. godine operirano je 59 bolesnika s rakom debelog crijeva uz uspostavu primarne crijevne anastomoze. Kod osam bolesnika dijagnosticirana je dehiscencija crijevne anastomoze. Uspoređujući vrijednosti serumskog i intraperitonealnog C-reaktivnog proteina naša studija je pokazala da je serumski C-reaktivni protein bolji biljeg u predviđanju dehiscencije crijevne anastomoze. Vrijednosti serumskog C-reaktivnog proteina manje od 121 mg/L četvrtog poslijeoperacijskog dana pokazatelj su dobrog cijeljenja anastomoze

Attenuation of systemic inflammatory stress response after preoperative analgesia with clonidine compared to levobupivacaine-a randomised clinical trial

Background and purpose: Use of analgetics before the pain stimulus (preventive analgesia) obstruct development of neuroplastic changes in central nervous system, and reduces pain. Furthermore, preventive analgesia can block harmful central nervous system response and inflammation as an early consequence of operation as well. Investigation hypothesis is that preoperative central clonidine will reduce systemic inflammatory stress response better than levobupivacaine. Materials and methods:. Patients were allocated to three groups, according to preoperative epidural use of 5 μg/kg clonidine (n=17), 0.25% levobupivacaine (n=12) or saline as control group (n=13). Before operation, 1 h after the beginning, 1 h, 6 h, 12 h and 24 h after the operation following parameters were analyzed: procalcitonin (PCT), interleukine-6 (IL-6), C-reactive protein (CRP) and lactate. Results: There were no significant differences between groups in age, gender, body mass index and operation time. We demonstrated significant reduction in PCT, IL-6, CRP and lactate levels in preoperative clonidine group, compared to preoperative levobupivacaine group and controle group. Conclusion. These results support importance of clonidine central effect on pain pathways and systemic inflammatory stress response blockade

Prädiktoren zur Gewichtsbestimmung bei Neugeborenen

Recent observations that there is a secular variation in newborn weight and length call for their continuous assessment, as well as evaluating factors that influence them. The influence of maternal age, weight and height, as well as the number of previous deliveries, abortions and the number of cigarettes smoked per day on newborn weight and length was examined. Data were collected from 181 healthy pregnant women from Zagreb, Croatia, who delivered healthy newborns in term. Multiple regression, correlation coefficients and variance analysis were performed to assess the significance of tested variables on observed fetal features. Maternal age has no significant influence on birth weight, even though mothers younger than 20 and older than 30 tend to have lighter children. Both the numbers of previous deliveries and abortions showed no significant correlation to newborn weight. The number of cigarettes smoked per day during pregnancy and maternal pre-pregnancy weight were found to have significant correlation to newborn weight and length. Maternal height correlated significantly with newborn weight and length, but when multiple regression was performed, controlling for other parameters, no significant influence on newborn weight was found. These results indicate that smoking cessation and im-provement in maternal nutritional status (expressed as body weight) are the two modifiable factors that play a significant role in the reduction of low birth weight children, and thus the reduction of perinatal mortality.Novija zapažanja da postoje sekularna odstupanja u težini i duljini novorođenčadi zahtijevaju stalnu provjeru, kao i vrijednosti koje na njih utječu.Stoga se ispitivao utjecaj majčine dobi, težine i visine, kao i broj prijašnjih poroda, abortusa te broj popušenih cigareta na dan, na težinu i duljinu novorođene djece.Podaci su prikupljani od 181 zdrave trudnice iz Zagreba, Hrvatske, koje su rodile zdravu novorođenčad u terminu.Izvedene su regresijska analiza, korelacija koeficijenata i analiza varijance kako bi se utvrdila značajnost provjeravanih varijabli na opažanim karakteristikama fetusa.Majčina dob ne utječe značajno na težinu novorođenog djeteta, premda su majke mlađe od dvadeset godina i starije od 30 sklone rađanju djece s manjom porođajnom težinom.Broj prijašnjih poroda kao i prekida trudnoće nije značajno povezan s težinom novorođenčeta. Međutim, broj dnevno popušenih cigareta tijekom trudnoće te težina majki prije trudnoće bile su značajno korelirane s težinom i duljinom novorođenog djeteta.Visina majki također je bila značajno povezana s težinom i duljinom djeteta, ali nakon regresijske analize, kontrolom ostalih parametara, nije zamijećen značajan utjecaj na djetetovu težinu.Ovi nalazi pokazuju da su prestanak pušenja i poboljšanje majčine prehrane (izražene u tjelesnoj težini) dva modificirajuća faktora koji imaju važnu ulogu u smanjivanju broja djece s niskom porođajnom tjelesnom težinom te tako smanjuju i perinatalni mortalitet.Jüngsten Beobachtungen zufolge gibt es unter Neugeborenen außerordentlich große Schwankungen in Körpergewicht und Größe. Dies wie auch die Umstände, die dazu führen, erfordern eine ständige Kontrolle. Die vorliegende Untersuchung galt daher den Auswirkungen, die das Alter der Mutter, deren Körpergewicht und Größe, die Zahl der früheren Geburten und Abtreibungen, die Zahl der pro Tag gerauchten Zigaretten auf das Körpergewicht und die Größe von Neugeborenen haben. Die ermittelten Angaben stammen von 181 Schwangeren aus Zagreb, Kroatien, die innerhalb des Geburtstermins gesunde Babys zur Welt brachten. Es wurden eine Regressionsanalyse, eine Koeffizienten-Korrelation und eine Varianzanalyse angewandt, um die Auswirkung der geprüften Variablen auf die an den Föten beobachteten Charakteristiken zu untersuchen. Das Gewicht des Neugeborenen wird nur unwesentlich durch das Alter der Mutter beeinflußt, auch wenn Frauen unter 20 sowie Frauen über 30 Jahren dazu neigen, Kinder mit geringerem Körpergewicht zu gebären. Ebensowenig steht die Zahl früherer Geburten und Schwangerschaftsabbrüche in einem wesentlichen Zusammenhang mit dem Körpergewicht des Neugeborenen. Dafür erwies sich jedoch, daß die tägliche Zahl der während der Schwangerschaft gerauchten Zigaretten sowie das Körpergewicht der Mutter vor der Schwangerschaft in wesentlichem Bezug zu Körpergewicht und Größe des Neugeborenen stehen. Dasselbe gilt für die Körpergröße der Mutter, doch konnte – nach angewandter Regressionsanalyse und einer Kontrolle der übrigen Parameter – kein ausschlaggebender Einfluß auf das Körpergewicht des Säuglings nachgewiesen werden. Diese Angaben zeigen, daß die Einstellung des Rauchens und eine verbesserte Ernährungsweise der Mutter (ausgedrückt im Körpergewicht) zwei modifizierende Faktoren darstellen, die nachhaltig dazu beitragen können, die Zahl der untergewichtigen Neugeborenen und somit das Ausmaß der Säuglingssterblichkeit einzudämmen

Analysis of Scores in Diagnosis of Acute Appendicitis in Women

Acute appendicitis is a common surgical condition that requires prompt diagnosis. Besides modern imaging techniques, scoring systems, based on clinical signs and symptoms and routine laboratory assessments, have been used as a diagnostic aid. However, differences in sensitivities and specificities were observed if the scores were applied to various populations and clinical settings. The purpose of this paper is to assess validity of three scores (modified Alvarado score, Ohmann score and Eskelinen score) for diagnosis of acute appendicitis in women. 126 female patients admitted for suspicion of acute appendicitis in a tertiary hospital emergency department were analyzed prospectively. Modified Alvarado score, Ohmann score and Eskelinen score were calculated at admission and compared to final diagnosis. All patients with modified Alvarado score 7 or more had acute appendicitis (100% specificity) and it can be used to determine the need for immediate appendectomy. Values of Ohmann score greater than 6 resulted in 0.9% rate of overlooked appendicitis. Besides obvious educational role, scores may help to determine the group of patients who require immediate appendectomy, therefore expediting treatment and avoid unnecessary observation or more lengthy diagnostic procedures that require highly educated and skilled senior staff. No single score may be used alone to dictate or decline surgery. Different cut-off points may also be considered for different subpopulations

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

Uloga fotodinamske terapije u liječenju karcinoma probavnog sustava

The discovery that particular substances can cause photosensitivity is attributed to Oscar Raab, however, the modern era of photodynamic therapy was established by Dr. T.J. Dougherty from Buffalo Memorial Institute. He was the first to report that a systemically injected porphyrin (hematoporphyrin), when activated by red light, caused complete eradication of transplanted experimental tumors. He also was the first to demonstrate the preferential accumulation of the photosensitizer in malignant cells. The first clinical application of photodynamic therapy was in 1980 at the Tokyo Medical College in a patient with a small upper bronchial squamous cell tumor, treated at bronchoscopy with photodynamic therapy using a laser as the light source. The tumor was completely eradicated. Simultaneously, a case of large obstructing esophageal cancer similarly treated with photodynamic therapy with good relief of dysphagia and prolonged survival was reported. The current state-of-the-art and results recorded in the clinical use of photodynamic therapy in the management of gastrointestinal malignancies are presented.Otkriće da određene tvari mogu uzrokovati fotosenzitivnost pripisuje se Oscaru Raabu, međutim, ocem moderne ere fotodinamske terapije smatra se T. J. Dougherty s Instituta Buffalo Memorial. On je naime prvi objavio da sistemski dan porfirin (hematoporfirin), kada se aktivira crvenom svjetlošću, uzrokuje potpuno uništenje transplantiranog eksperimentalnog tumora. Također je prvi otkrio i objavio da fotosenzibilizirajuće tvari imaju sklonost nakupljanju u malignim stanicama. Prvi slučaj kliničke primjene fotodinamske terapije učinjen je na Tokyo Medical Collegeu 1980. godine. Bolesnik s malim skvamoznim tumorom gornjeg bronha bio je bronhoskopski podvrgnut fotodinamskoj terapiji, pri čemu se kao izvor svjetlosti rabio laser, a rezultat je bio potpuna eradikacija tumora. Istodobno je objavljen slučaj kliničke primjene fotodinamske terapije kao palijacijske metode u bolesnika s velikim karcinomom jednjaka, što je dovelo do uklanjanja disfagije te produžilo bolesnikov život. Ovaj rad prikazuje dosadašnje spoznaje i rezultate kliničke primjene fotodinamske terapije u liječenju malignih bolesti probavnog sustava

Complications, Pain Control, and Patient Recovery After Local Versus General Anesthesia for Open Inguinal Hernia Repair in Adults—Systematic Review and Meta-analysis

The purpose of this systematic review is to provide an ‘‘up-to-date’’ evidence-based guideline and clarify the possible benefits as well as drawbacks of local anesthesia (LA) and general anesthesia (GA) in open inguinal hernia surgery in adults. Study method comprised randomized controlled trials. Primary outcome measures were complications, pain control, and patient recovery. Secondary outcome measures were patient satisfaction and hernia recurrence. A total of 14 randomized controlled trials contributed to the study. A total of 1677 patients were analyzed, with 953 in the LA group and 724 in the GA group. Complications were statistically less frequent in the LA group compared with the GA group [odds ratio (OR), 0.31; 95% confidence interval (95% CI), 0.15, 0.64). Supplemental intraoperative analgesia had a statistical significance in the LA group, with an OR of 28.93 (95% CI, 7.86, 106.47). Postoperative pain was statistically significantly lower in the LA group [standardized eman difference (SMD), -1.06; 95% CI, -1.64, -0.48)]. Length of stay was shorter for patients who underwent operation under LA compared with those receiving GA (OR, -1.21; 95% CI, -2.08, -0.33]). Time to full mobility was shorter in the LA group, without statistical significance (OR, 3.04; 95% CI, 0.19, 47.90), whereas measuring in SMD showed significance in comparison with GA (SMD, -1.74; 95% CI, -2.34, -1.14). Hernia recurrence was not noted. Patient satisfaction was greater in the LA group (SMD, 0.65; 95% CI, 0.15, 1.15). Compared with GA, LA showed superiority in terms of complications, postoperative pain, length of stay, time to full mobility, and patient satisfaction. Therefore, it appears to be a more appropriate anesthetic technique for open inguinal hernia repair in adults