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

Kirurgija raka debelog crijeva s obzirom na razlike u prognozi između desnostranih i lijevostranih tumora

Human colon is derived from the embryological midgut and hindgut resulting in the developement of the right and left colon respectively. Right-sided and left-sided colon cancers are not differentiated only based on the embryological origin, anatomical position and clinical manifestations, but there are also numerous studies which prove that heterogeneous genotype features exsist in right and left-sided colon cancers,with distinguishing types of chromosome and microsatellite instability and gene expression patterns. Accumulating evidence suggests that gut microbiota, which differs in right and left colon, also plays an important role in the development of colon cancer. Although the systemic oncologic treatment has changed recently for disseminated left and right colon cancer, the current surgical treatment of both cancer locations for stages I-III follows the same principles of radical surgical oncology and should be executed in the same manner.Ljudsko debelo crijevo nastaje iz embriološkog srednjeg i stražnjeg crijeva, odakle se formira desno- i lijevostrano debelo crijevo. Desno- i lijevostrani zloćudni tumori debelog crijeva ne razlikuju se samo prema embrionalnom podrijetlu, anatomoskoj lokalizaciji i kliničkim manifestacijama, nego i prema heterogenim genotipskim značajkama, s različitim vrstama kromosomskih i mikrosatelitskih nestabilnosti te različitim uzrocima ekspresije gena, što je i dokazano brojnim studijama. Sve veći broj istraživanja sugerira da i crijevna mikrobiota, koja je različita u desnom i lijevom debelom crijevu, također igra značajnu ulogu u razvoju zloćudnih tumora debelog crijeva. Iako se sistemno onkološko liječenje za metastatski prošireni karcinom debelog crijeva nedavno promijenilo, ovisno da li je primarna lokalizacija desno- ili lijevostrani karcinom debelog crijeva, sadašnje kirurško liječenje za stadije I-III slijedi principe radikalnog onkološkog liječenja i trebalo bi biti isto za obje lokacije karcinoma debelog crijeva

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

Liječenje polipa žučnoga mjehura: prijedlog optimalne strategije

Polypoid lesions of the gallbladder can be divided into benign and malignant lesions. Benign polypoid lesions of the gallbladder are divided into tumors and pseudotumors. Pseudotumors make up the majority of polypoid lesions of the gallbladder. They can occur in the form of polyps, hyperplasia or other miscellaneous lesions. Adenomas are the most common benign neoplasms of the gallbladder. Ultrasound has been demonstrated to be significantly better in detecting polypoid lesions of the gallbladder as compared with computed tomography and cholecystography. Recommendations for an optimal strategy in the management of gallbladder polyps are presented. Generally, no treatment is required in a young patient with very small gallbladder polyps, who is completely free from symptoms. In patients with unequivocal recurrent biliary colic, elective cholecystotomy is warranted, especially in case of coexistence of stones and polyps. Cholecystectomy is also indicated in patients with gallbladder polyps greater than 10 mm, irrespective of symptomatology. In patients with gallbladder polypoid lesions smaller than 10 mm, cholecystectomy is only indicated if complicating factors are present, e.g., age ³ 50 and coexistence of gallstones. If a gallbladder polyp is smaller than 10 mm and if complicating factors are absent, the “watch-and-wait” strategy seems to be recommendable.Polipoidne lezije žučnoga mjehura mogu se podijeliti u benigne i maligne. Benigne polipoidne lezije dijele se na prave tumore i pseudotumore. Pseudotumori čine većinu polipoidnih lezija žučnoga mjehura, a mogu se očitovati kao polipi, hiperplazija ili druge različite lezije. Adenomi predstavljaju najčešće benigne neoplazme žučnoga mjehura. Pokazalo se da je ultrazvuk značajno bolji u otkrivanju polipoidnih lezija žučnoga mjehura u usporedbi s kompjutoriziranom tomografijom i kolecistografijom. U ovom su radu prikazane preporuke za optimalnu strategiju praćenja i obrade polipa žučnoga mjehura. Općenito, u mladog bolesnika s polipima žučnoga mjehura manjim od 10 mm i bez simptoma nije potrebna nikakva terapija. U bolesnika s jasnim kolikama elektivna kolecistektomija je opravdana, poglavito ako su uz polipe prisutni i žučni kamenci. Kolecistektomija je također indicirana u bolesnika s polipima većim od 10 mm, bez obzira na simptomatologiju. U bolesnika s polipima manjim od 10 mm kolecistektomija je indicirana samo ako se radi o bolesnicima starijim od 50 godina i/ili ako su istodobno prisutni i žučni kamenci. Kad su polipi žučnoga mjehura manji od 10 mm i ako se radi o bolesnicima mlađim od 50 godina u kojih nije moguće dokazati žučne kamence, preporučujemo strategiju ‘pratiti i čekati’

Gigantski liposarkom mezenterija miješanog tipa

Primary mesenteric liposarcomas are very rare, especially when they are of mixed histologic pattern. Patient prognosis is based upon the most aggressive histologic type of liposarcoma. A case is reported of a 77-year-old man with a history of slowly increasing abdominal volume over 3 years. The diagnosis of giant intra-abdominal mass suspect of liposarcoma was confirmed by computed tomography and ultrasound scans. The patient underwent resection of 24 tumor masses weighing together 23.5 kg. The microscopic diagnosis was mixed-type liposarcoma of the mesentery. Although this type of tumor is rare, tumor tissue should be thoroughly collected and analyzed on histologic examination to reach definitive diagnosis. Recognition of the underappreciated subtype of liposarcoma is important for proper prognosis and treatment of the patient. According to our knowledge, this is the largest size of mixed-type mesenteric liposarcoma described in the English literature.Primarni liposarkomi mezenterija su rijetki, osobito ako su miješanog histološkog izgleda. Prognoza pacijenta ovisi o najagresivnijem histološkom tipu liposarkoma. Prikazujemo slučaj 77. godišnjeg muškarca s anamnezom spororastućeg volumena abdomena tijekom 3 godine. Dijagnoza ogromne intra-abdominalne mase suspektne na liposarkom potvrđena je CT-om i ultrazvukom. Pacijentu su resecirane 24 tumorske mase koje su zajedno težile 23.5 kg. Histološka dijagnoza je bila miješani tip liposarkoma mezenterija. Iako je ovaj tip tumora rijedak, tumorsko tkivo treba pomno preuzeti i pregledati histološki kako bi se postavila ispravna zaključna dijagnoza. Pronalazak nepovoljnog tipa liposarkoma je važan zbog točne prognoze i daljnjeg liječenja pacijenta. Prema našim saznanjima, ovo je najveći opisani liposarkom mezenterija miješanog tipa u engleskoj literaturi

Gigantski liposarkom mezenterija miješanog tipa

Primary mesenteric liposarcomas are very rare, especially when they are of mixed histologic pattern. Patient prognosis is based upon the most aggressive histologic type of liposarcoma. A case is reported of a 77-year-old man with a history of slowly increasing abdominal volume over 3 years. The diagnosis of giant intra-abdominal mass suspect of liposarcoma was confirmed by computed tomography and ultrasound scans. The patient underwent resection of 24 tumor masses weighing together 23.5 kg. The microscopic diagnosis was mixed-type liposarcoma of the mesentery. Although this type of tumor is rare, tumor tissue should be thoroughly collected and analyzed on histologic examination to reach definitive diagnosis. Recognition of the underappreciated subtype of liposarcoma is important for proper prognosis and treatment of the patient. According to our knowledge, this is the largest size of mixed-type mesenteric liposarcoma described in the English literature.Primarni liposarkomi mezenterija su rijetki, osobito ako su miješanog histološkog izgleda. Prognoza pacijenta ovisi o najagresivnijem histološkom tipu liposarkoma. Prikazujemo slučaj 77. godišnjeg muškarca s anamnezom spororastućeg volumena abdomena tijekom 3 godine. Dijagnoza ogromne intra-abdominalne mase suspektne na liposarkom potvrđena je CT-om i ultrazvukom. Pacijentu su resecirane 24 tumorske mase koje su zajedno težile 23.5 kg. Histološka dijagnoza je bila miješani tip liposarkoma mezenterija. Iako je ovaj tip tumora rijedak, tumorsko tkivo treba pomno preuzeti i pregledati histološki kako bi se postavila ispravna zaključna dijagnoza. Pronalazak nepovoljnog tipa liposarkoma je važan zbog točne prognoze i daljnjeg liječenja pacijenta. Prema našim saznanjima, ovo je najveći opisani liposarkom mezenterija miješanog tipa u engleskoj literaturi

After 40 Years Gossypiboma Caused Spleen Abscess

We report a case of spleen abscess cased by foreign body (gossypiboma) after 40 years. After physical examination, laboratory, ultrasonography and CT findings with diagnosis of acute abdomen, 73 years old woman had undergone laparatomy. Operation revealed intraabdominal spleen abscess. Capsulotomy and drainage of the collection was performed before splenectomy. Histological examination showed foreign body material surrounded by chronic inflammation, foreign body-type multinucleated giant cells, extravasated red blood cells and fibroblastic proliferation. From anamnesis we found that woman was operated only once during a life with diagnosis of extrauterine pregnancy, 40 years ago. Spleen abscess caused by gossypiboma after 40 years was never described before. However, diagnosis like this is very well known but rarely published because medical-legal implication. Education, professionalism and cooperation of all persons involved in surgical procedure are very important to prevent accidentally mistakes

Sekundarna arterijsko-enterična fistula: prikaz slučaja i pregled literature

Arterio-enteric fistula is a rare, but potentially deadly cause of gastrointestinal bleeding. The disease occurs in two forms: primary as a result of atherosclerotic aortic aneurysm, aortitis, trauma, radiation, tumor invasion or penetrating ulcer, and secondary as a consequence of surgical aortal reconstruction. The clinical manifestation is mostly gastrointestinal bleeding, rarely back pain, fever and sepsis. Computed tomography with contrast medium is the most suitable diagnostic test, however, the diagnosis frequently requires explorative laparotomy. A case is presented of secondary arterio-enteric fistula, found two years after surgical treatment of chronic pancreatitis with pseudocystojejunostomy, which clinically manifested with gastrointestinal bleeding. Although there was strong suspicion of arterio-enteric fistula, the diagnosis was not verified by routine workup, but only on explorative laparotomy.Arterijsko-enterična fistula je rijedak, ali potencijalno smrtonosan uzrok krvarenja iz probavnog sustava. Bolest se javlja u dva oblika: kao primarna, nastala kao rezultat aterosklerotski promijenjene aneurizme aorte, aortitisa, traume, zračenja, invazije tumora ili penetrirajućeg ulkusa, te kao sekundarna, odnosno posljedica kirurške rekonstrukcije aorte. Klinički se najčešće manifestira u vidu krvarenja iz probavnog sustava, rjeđe bolovima u leđima, vrućicom i sepsom. Najprikladniji dijagnostički test je kompjutorizirana tomografija, no sama dijagnoza se često postavlja tek eksploracijskom laparotomijom. Prikazuje se slučaj sekundarne arterijsko-enterične fistule nađene dvije godine nakon kirurškog liječenja kroničnog pankreatitisa pseudocistojejunostomijom, koja se klinički manifestirala gastrointestinalnim krvarenjem. Iako je postojala velika sumnja na arterijsko-enteričnu fistulu dijagnoza se nije mogla potvrditi standardnim dijagnostičkim postupcima, nego tek na eksploracijskoj laparotomiji

Vaskularna hibridna dvorana – operacijaska dvorana budućnosti

The last two decades have seen a paradigm shift in the treatment of vascular related diseases from once traditional open surgical repairs to the entire vascular tree being amenable to percutaneous interventions. Neither the classic operating room nor the conventional angiography suite is optimal for both open surgery and endovascular procedures. Important issues for the vascular hybrid operating room include quality of the imaging equipment, radiation burden, ease of use of the equipment, need for specially trained personnel, ergonomics, ability to perform both open and percutaneous procedures, sterile environments, as well as quality and efficiency of patient care. The most important feature of working in a dedicated hybrid vascular suite should be the ability to attain best treatment of vascular patients. Whether the interventional radiologist or the vascular surgeon uses the facilities is of less importance. Establishment of an endovascular operating room suite has the benefit of a sterile environment, and the possibility of performing hybrid procedures and conversions when necessary. Moreover, angiography immediately before treatment gives contemporary anatomical information, and after treatment provides quality control. Consequently, better quality and service can be provided to the individual patient. These changes in the treatment of vascular disease require that a new type of vascular specialist, named ‘vascular hybrid surgeon’, trained to perform both endovascular and open surgical procedures in this highly complex patient group.U posljednja dva desetljeća primjećuje se pomak u liječenju vaskularnih bolesti od tradicionalno otvorenih kirurških zahvata prema perkutanoj intervenciji cijelog vaskularnog stabla. Niti klasične operativne dvorane, a niti konvencionalne angio dvorane nisu optimalne za izvođenje otvorene operacije ili za endovaskularne zahvate. Glavne značajke vaskularne hibridne operativne dvorane obuhvaćaju kvalitetnu opremu za snimanje, radijacijski štit, opremu za jednostavnu upotrebu, potrebu za dobro izučenim kadrom, ergonomičnost, mogućnost odvijanja otvorenih i perkutanih zahvata, sterilnu okolinu, kao i kvalitetu i učinkovitost bolesničke skrbi. Najznačajnija značajka rada u hibridnoj vaskularnoj operacijskoj dvorani trebala bi biti mogućnost pružanja najbolje operacije bolesniku s krvožilnom bolešću. Manje je važno tko će opremu upotrebljavati, intervencijski radiolog ili vaskularni kirurg. Uspostava jedne endovaskularne operativne dvorane ima prednost sterilne okoline, mogućnost izvođenja hibridnih zahvata, te ako je potrebno i konverzije. Također, angiografija učinjena neposredno prije operativnog zahvata pruža točnije anatomske informacije, a nakon zahvata pruža bolju kontrolu kvalitete. Posljedično, bolja kvaliteta i usluga može se ponuditi svakom pojedinačnom bolesniku. Takve promjene u liječenju bolesnika s bolešću krvnih žila zahtijevaju i novi profil vaskularnog kirurga nazvan “vaskularni hibridni kirurg” koji mora biti osposobljen u izvođenju endovaskularnih, ali i otvorenih operativnih zahvata kod iznimno složene skupine bolesnika