Successful Associating Liver Partition and Portal Vein Ligation after Unsuccessful Double TACE Procedure Complicated with Sepsis and Pancreatitis

The associating liver partition and portal vein ligation (ALPPS) is a novel procedure with increasing number of scientific and clinical studies, and by now, it showed to be efficient and safe procedure in selected group of patients. Here we present the first case of ALPPS done after double TACE procedure in a 64-years-old female patient with extensive hepatocellular carcinoma of the right liver lobe. The procedure was successful and liver remnant showed significant 90% hypertrophy which proves that ALPPS sometimes can be performed after palliative procedures in liver malignancies.

[Rupture of the spleen and acute pancreatitis after ESWL therapy: a rare complication]

INTRODUCTION

ESWL is a safe and efficient method in the therapy of urolithiasis which, however, is not free of complications.

CASE REPORT

ESWL was performed in a 54-year-old patient with a stone of 18 mm in size located in one of the upper calyces of the left kidney. Several hours after the ambulatory ESWL treatment the patient was admitted to the emergency room with strong pain in the left lumbar region and the upper abdomen. During examination low blood pressure, tachycardia and low Hb levels were found. Ultrasound and CAT scans revealed a subcapsular rupture of the spleen. Surgery was indicated, and a laparotomy with splenectomy was performed. Ten days after surgery the patient developed acute pancreatitis which was treated conservatively with success.

CONCLUSIONS

Although ESWL is a safe method in the treatment of urinary stones with a relatively small number of complications, rare complications like ruptures of the spleen have to be considered. Special attention should be given to patients with kidney stones in the left upper calyces, pathological growth of the spleen, and accompanying diseases such as chronic heart failure or hypertension. In such patients ESWL should not be performed on an outpatient basis.

Benign mesenchymal liver hamartoma in an adult male: a case report and review of the literature

Mesenchymal hamartoma of the liver is an uncommon benign lesion seen almost exclusively in children younger than two years of age. The first case was reported in 1903, and until now fewer than 200 cases have been reported. A 38-year-old male complaining of dull subcostal pain lasting for almost 10 months was found on abdominal ultrasound to have a focal lesion of the liver. He was referred to our Unit where imaging procedures (ultrasound and computed tomography) revealed a solid lesion, 8 centimeters in diameter, located in the IVb and V segments of the liver. There were no clear margins between the lesion and the gallbladder wall. Alpha-fetoprotein and carcinoembryonic antigen were within normal limits and carbohydrate antigen 19-9 was minimally elevated. There was no evidence of metastatic disease. Ultrasound-guided biopsy of the lesion was done and pathology report of a biopsy specimen suggested that the tumor was probably a benign mesenchymal hamartoma. The patient underwent a formal bi-segmentectomy (IVb and V segments) with cholecystectomy. Definitive pathology report confirmed the diagnosis of a benign mesenchymal hamartoma.

Organization and work of the war hospital in Tomislavgrad during the war in Bosnia and Herzegovina from 1992 to 1995

The work of the War Hospital in Tomislavgrad during the war in Bosnia and Herzegovina from 1992 to 1995 is described. The War Hospital in Tomislavgrad was one of the first medical institutions organized in Bosnia and Herzegovina, with the intention of providing surgical treatment and care to soldiers, local civilians, and refugees who found shelter in this part of the country. It was located on the main communication route connecting Bosnia and Herzegovina and the south part of Croatia. During the 4-year period, 23,191 examinations, of which 8,341 were first-time examinations, and 1,547 surgical operations were performed. The hospital provided a high level of surgical and anesthesiology service in an area where none existed before the war. All patients were treated regardless of their nationality or religion, thus mitigating the consequences of the war.

[Anastomosis of the colon using the Valtrac biofragmentable ring]

Since January 1995, Valtrac biofragmentary ring for compressive anastomosis of the colon has been employed in Croatia. This study comprises experience in four Croatian hospitals in which 244 anastomoses of the colon with Valtrac biofragmentary ring were performed in the four-year period (1995-1998). The average age of the patients was 64.7 years. One hundred and eighty-seven of them (76.64%) were operated for colon cancer, 15 (6.1%) for Crohn's disease, eight (3.3%) for rectal cancer, and 34 for other diseases. One hundred and nineteen anastomoses were made between small intestine and colon, and 125 end-to-end of the colon. Valtrac BAR 28 mm in diameter was most frequently used (41.8%), and 34 mm in diameter least often (8.6%). Sixteen patients had complications related to anastomosis. One had obstruction which required repeated surgery, and 15 (6.15%) dehiscence of the anastomosis, of which 12 were reoperated. In the postoperative course six patients (2.46%) died due to the sequelae of dehiscence. Compressive anastomoses with Valtrac biofragmentary ring should be considered equal to manual and stapler methods when choosing the technique of colon anastomosis.

Quantitative tissue carcinoembryonic antigen (T CEA) assay as a screening test for severe dysplasia in colorectal adenomas

Relationship between the serum (S CEA) and the tissue (T CEA) carcinoembryonic antigen concentrations with regard to the degree of dysplasia in colorectal adenomas was investigated. Our study included 56 single or multiple colorectal adenomas in 46 patients. The measurements of T CEA concentrations were performed using the quantitative CEA-EIA method (Abbott) modified for wet tissue, obtained from heads of the adenomas. As a control point the mucosa near adenoma and the rectal mucosa were used. Our results suggest that the T CEA concentrations from the head of the adenoma demonstrate a highly significant difference between mild and severe dysplasia (P < 0.001), between mild dysplasia and invasive adenocarcinoma (P < 0.001) and a significant difference between mild and moderate dysplasia (P < 0.05). On the other hand, the S CEA concentrations corresponding to these cases showed no such differences. In conclusion, we suggest the quantitative measurement of T CEA concentrations as a screening test for severe dysplasia in colorectal adenomas.

[Laparoscopic cholecystectomy in a child with sickle cell disease]

Laparoscopic cholecystectomy has become the procedure of choice for the removal of the diseased gallbladder in children. Its use in small children and infants is rare. At the Department of Pediatric Surgery of the Medical faculty in Zagreb five children underwent laparoscopic cholecystectomy. One of them was a five year old boy with sickle cell disease and cholelithiasis. Before the advent of laparoscopy, few children with sickle cell disease and cholelithiasis underwent cholecystectomy, because of the high morbidity associated with open cholecystectomy. The authors use the case to present details of the operative procedure of laparoscopic cholecystectomy in small children and infants. Laparoscopic cholecystectomy is the procedure of choice in the management of cholelithiasis in small children and infants, especially those with sickle cell disease.