[LAPAROSCOPIC PARTIAL PERICYSTECTOMY OF SPLENIC HYDATID CYST - A CASE REPORT]

Echinococcal cyst of the spleen is usually a result of infection with the parasite Echinococcus granulosus. The spleen is the third most frequent localization of echinococcus after liver and lungs. Partial laparoscopic pericystectomy can be done without the loss of blood and scattering of scolexes with spleen preservation and conservation of its immune function. We present the patient with a large (1 8 x 16 x 12 cm) echinococcal cyst of the spleen that compressed the surrounding organs (stomach, transverse colon, pancreas and left kidney), and prevented normal passage causing vomiting after every meal. In this patient, PAIR procedure (puncture, aspiration, injection, reaspiration) and conservative treatment was attempted on several occasions without success. Finally, laparoscopic partial pericystectomy was performed, evacuating the contents of the cyst. The surgery lasted 120 minutes. Postoperatively the patient was without complications. Hospitalization lasted five days. Six months later, the patient is without problems. These echinococcus cysts of the spleen cannot be solved using PAIR technique and conservative treatment. Laparoscopic partial pericystectomy is a better solution than open surgery due to less trauma to the patient, especially in elderly people.

Laparoscopic surgery for large hydatide liver cyst after two previous laparotomies

Laparoscopic surgery for hepatic echinococcosis is a technically difficult and demanding surgical procedure even for the most experienced abdominal surgeon. Surgery is performed after the conservative treatment with albendazole for 28 days. We report a case of laparoscopic partial pericystectomy with biliostasis and omentoplasty in a patient with two previously open surgeries (laparotomies)--right subcostal laparotomy for acute inflammation of the gallbladder and right pararectal laparotomy for perforated gangrenous appendix. The patient underwent extensive laparoscopic adhesiolysis due to pronounced intra-abdominal adhesions to gain access to a large hydatid cyst with the diameter of 11 cm. Laparoscopic surgery is much less traumatic to the patient with a better cosmetic effect.

Emergency surgery for large bowel obstruction caused by cancer

There are several options for surgical treatment of large bowel obstruction caused by cancer, depending on location of obstruction, intraoperative local findings (perforation, peritonitis, bowel dilatation proximal to obstruction) and patients' condition. Resection and anastomosis as one stage surgery would be prefered procedure. Anastomotic leakage, on the other hand, highly elevates risk of mortality and mobidity. The most important question is whether to, in resectable cases, perform primary resection with anastomosis or not. This study was retrospective and included 40 patients that have undergone emergency surgery for large bowel obstruction caused by cancer. According to whether resection and anastomosis was made at initial surgery or not, patients were grouped in group A (N = 18) and group B (N = 21), respectively. We have analysed the type of surgical procedure, days of hospitalization, mortality, anastomotic leakeage, wound infection and other postoperative complications. Our results show that there is no major difference in mortality and morbidity in these two groups, suggesting that for selected patients primary resection and anastomosis is a safe option of tratment with acceptable risk. Since there are no strict guidelines or scorring system which would point the tratment option the decision about the choice of procedure still remains the burden of surgeon and depends on its experience and subspeciality. Our experience recomends primary resection and anastomosis except in cases of bowel perforation on tumor site, in cases of extreme dilatation and atony of bowel proximal to obstruction site and severe hypoproteinemia and anemia.

Liver abscess as a therapeutic and diagnostic challenge

Liver abscess still represents a significant clinical entity with mortality rates of up to 10%. Traditional treatment of liver abscesses is open surgical treatment. Recently, percutaneous and laparoscopic drainage has been increasingly used. Still, in spite of these relatively novel techniques and improved imaging, liver abscess can sometimes be difficult to diagnose or treat. Here we present two cases of chronic liver abscess treated at our department. First patient was twice hospitalized in other hospitals without reaching definitive diagnosis. He was admitted at our department because of clinical presentation of sepsis, and definitive diagnosis of liver abscess was established only during open surgery. Second patient was admitted after laparoscopic drainage and repeated percutaneous drainage had failed to resolve his symptoms. In both cases, liver segment resection led to complete healing. These cases indicate that chronic liver abscess can still present a diagnostic and therapeutic challenge.

Mechanical bowel preparation in colorectal surgery

The aim of this study was to assess the use of mechanical bowel preparation (MBP) and antimicrobial prophylaxis in elective colorectal surgery regarding still existing controversies. A prospective study of 85 patients undergoing elective colon and rectal surgery during 2 years period was performed, divided in two groups. Group A (N = 46) with patients who underwent mechanical bowel preparation, and group B (N = 39) patients without mechanical bowel preparation. We analysed: gender, age, preoperative difficulties, diagnostic colonoscopy, tumor localization, operation performed, pathohystological findings, Dukes classification, number of lymphonodes inspected, liver metastasis, other organ infiltrations, mean time of surgery, length of hospital stay, postoperative complications and mortality. Demographic characteristics, pathohystological findings, the site of malignancy, and type of surgical procedure did not significantly differentiate the two groups. The only significance revealed in mean time of surgery (138/178 minutes) in favor of patients with MBP (p = 0.017). Mechanical bowel preparation (MBP) for elective colorectal surgery is not advantageous. It does not influence radicalism of the procedure, does not decrease neither postoperative complications, nor hospital mortality.

Prognostic factors of local recurrence and survival after curative rectal cancer surgery: a single institution experience

The aim of our study is to evaluate the importance of prognostic factors, both tumor-related and therapy related, and their impact on local recurrence rate of rectal carcinoma. It is also important to evaluate impact of chemoradiotherapy (CRT) on local recurrence rate and survival. We used the data of 514 patients with rectal carcinoma treated at Clinic of surgery at University Hospital Centre in Osijek, during the period from 2000 to 2007. Routine follow-up was carried out until March of 2012 or death. Median life expectancy for all patients who underwent surgery was 98 months. 47% of patients with resection without residual tumor (R0) did not develop local recurrence after median of observation of 90 months. 5-year survival rate for patients with R0 resection was 76.4%. The patients who had preoperative serum levels of carcinoembryonic antigen (CEA) within the normal range (< 5 microg/mL) had a significantly better prognosis with 5-year survival of 75.8%, than patients with elevated levels who had 5-year survival of 46.5%. Tumor stage had great influence on survival and was defined by UICC TNM (International Union against Cancer, Tumor Node Metastases) classification, 7th edition. 5-year survival rate was (93.5% for stage I, 87.4% for stage II, 58.2% for stage III, 8.1% for stage IV). Patients with low grade differentiation tumors had 5-year survival rate of 73.5%, and those with high-grade had 38.2%. We have found that preoperative CRT significantly reduces the rate of local recurrence (5.3% vs. 14.1%), but patients who were treated with preoperative CRT did not appear to benefit significantly in terms of their long-term prognosis, because there was no difference in overall survival between the patients who received preoperative radiochemotherapy and those who did not receive it (66.2% vs. 67.8%). It was found that the R-classification, anatomical extent of tumor described by the TNM classification of the UICC, tumor grade, and preoperative CEA serum level were prognostic factors that influenced survival.

Surgical treatment of liver echinococcosis--open or laparoscopic surgery?

Human echinococcosis remains a significant medical issue in endemic areas. Hydatid cysts can rupture, which is the most severe complication of echinococcosis as it can cause anaphylactic reaction and seeding of secondary cysts. Traditionally, hydatid cysts were evacuated by open surgical procedure in order to remove the entire cyst or by unroofing method, with evacuation of the cyst content. Recently, an increasing number of such operations are performed using laparoscopic approach. This study was prospectively conducted in a 5-year period, from 2004-2008. Altogether, 25 surgically treated patients were included in this study. Clinical examination, specific serological test, abdominal ultrasound and computed tomography were used for establishing diagnosis. Open surgery was initially performed in 17 patients and laparoscopic in 8. Three of those 8 patients required conversion to open surgery. Open pericystectomy was performed in 11 patients and laparoscopic pericystectomy in 3 patients. Open partial pericystectomy according to Papadimitriou was performed in 9 patients with hydatid cyst and laparoscopic partial pericistectomy in 2 patients. Our experience indicates that in the case of liver hydatid cyst disease, laparoscopic exploration, and if possible, laparoscopic pericystectomy or partial pericystectomy, should be performed in selected patients.

[Laparoscopic versus open appendectomy: our experience and literature review]

AIM

The controversy of the choice between open and laparoscopic appendectomy still remains. The benefits as well as disadvantages of laparoscopy are well known.

METHODS

We designed a prospective 3-year clinical study (January 1, 2008-December 31,2010) with 123 patients operated on for acute appendicitis. They were prospectively divided into laparoscopic appendectomy (LA) group with 42 results and open appendectomy (OA) group with 81 results. The following parameters were analyzed: age, sex, preoperative leukocyte count, C-reactive protein (CRP) value, preoperative ultrasound finding (US), analgesic administration and histopathologic finding. The length of the operation, length of hospitalization (LOS) and complications were compared between the two groups, along with personal postoperative satisfaction estimated by telephone survey after discharge from the hospital.

RESULTS

In 90% of cases, histopathology was positive for inflammation. CRP was determined in 42 (34%) patients preoperatively, with a mean value of 59; positive histopathology finding was recorded in 31 (74%) patients with increased preoperative CRP. US was performed in 68 (55%) patients; positive US was consistent with histopathology in 44 (65%) cases. The mean time of LA/ OA was 75/72 minutes. The only statistical difference was found for LOS: 4 versus 6 days (p < 0.01).

CONCLUSION

LA and OA are comparable for the number of complications. The slight benefit of LA offers the surgeon free hand in decision when dealing with acute appendicitis needing urgent operation.

[Stercoral rectosigmoid colonic perforation with fecal peritonitis]

Chronic constipation can lead to fecal impaction and catastrophic complication such as colonic obstruction, perforation and fecal peritonitis. A case is reported of stercoral perforation of the rectosigmoid with pneumoperitoneum and fecal peritonitis. The patient was admitted for the signs of acute abdomen with pneumoperitoneum diagnosed on native radiological imaging.

Cystic echinococcosis of lung and heart coupled with repeated echinococcosis of brain--a case report

Echinococcosis is rarely encountered as a cystic brain disease. In this article we are presenting a case of a young woman repeatedly operated due to echinococcosis of lung, heart and brain. Recurrent brain ecchinococcosis developed despite preoperative and postoperative albendazol therapy after first and combined therapy with albendazol and praziquantel after the second brain surgery. The mechanism of recurrence remains unclear (primary infestation, dissemination after spontaneous or intraoperative cyst rupture or new infestation).

[Laparoscopic partial pericystectomy of hepatic hydatid cysts --Papadimitriou operation: a case report]

Operative treatment of hepatic hydatid cyst is technically demanding procedure. The method of choice is conservative treatment with Albendazolum followed by surgery. Open laparotomy or laparoscopic operation can be performed. We prefere laparoscopic exploration followed by laparoscopic total pericystectomy or laparoscopic partial pericystectomy. If laparoscopic operation is not possible due to technical reasons and patient safety, conversion to an open operation should be done, followed by total or partial pericystectomy. The case and our detailed technique of laparoscopic partial pericystectomy with biliostasis and omentoplasty is described. Laparoscopic operation is equally safe for the patient, yet with minor trauma and better aesthetic effect.

Laparoscopic repair of perforated peptic duodenal ulcer

Although prevalence of peptic ulcer is decreasing, the number of peptic ulcer perforations appears to be unchanged. This complication of peptic ulcer is traditionally surgically treated. In recent years, a number of papers have been published where the authors managed perforated duodenal peptic ulcer in selected patients using laparoscopic approach. Laparoscopic treatment of perforated duodenal ulcer has been described as safe and advantageous compared to open technique but advantages are still not clear due to small number of cases in published studies. Based on these recommendations we decided to establish our own protocol for laparoscopic treatment of perforated peptic duodenal ulcer. In this prospective study we evaluated the first 10 patients in whom we performed laparoscopic repair of perforated duodenal ulcer. There were no conversions to open procedure and no early postoperative complications. The patients were contacted by phone a year after the operation, and all were satisfied with the operation and the appearance of postoperative scars. We regard laparoscopic repair of selected patients with perforated duodenal ulcer as a safe and preferable treatment.

Isolated splenic metastasis from colon cancer--case report and literature review

Solitary splenic metastases are very rare and sporadic. There are several explanations for this low incidence of splenic metastasis including anatomical, histological and immunological features of the spleen. In this paper we present a case of 70-year-old man with no history of previous diseases who was first operated under the diagnosis of acute abdomen revealing perforated colon tumor of splenic flexure with no metastases at that time. Left hemicolectomy was performed followed by postoperative complications demanding a subtotal colectomy and ileostomy. Primary tumor was classified as Dukes (Astler-Coller)-C2, T4NIMO. Patient was referred to oncologist and received chemotherapy (5FU, Leucovorin). 5 months later continuity of the gut was performed by ileosygmoanastomosis. 2 years after first surgical procedure, a CT scan and abdominal ultrasound, followed by needle biopsy, showed isolated metastasis in spleen, so splenectomy was performed. Pathological findings revealed sharply bordered, partially necrotic tumor inside of spleen tissue, spreading to, but not reaching splenic hilum. Histology showed low to medium differentiated adenocarcinoma tissue with desmoplastic stromal reaction. There were no protrusions of tumor cells through spleen surface. In splenic hilum 4 tumor free lymph nodes were harvested. No additional chemotherapy was conducted. The latest follow up, a year after diagnosis of metastasis showed no signs of cancer disease. Review of the literature showed that long term survival and prognosis of isolated splenic colorectal metastasis after splenectomy are rather optimistic, although these are the cases of distant metastasis. Due to small number of cases reported in literature, definitive conclusions and/or guidelines for the treatment of isolated splenic metastasis cannot be given, but splenectomy and chemotherapy are preferable in the treatment, promising long term survival at least for metachronous metastasis.

Homocystinuria, a possible solution of the Akhenaten's mystery

Pharaoh Amenophis IV (Amenhotep IV), also known as Akhenaten, is the most mysterious person in Egyptian history and he still remains the object of academic argues. This revolutionary king introduced a new concept in Egyptian religion and arts. It is still unexplained if images of him and his family were just an artistic outbreak from old Egyptian canon or an excellent paleopathological study. Several pathologic conditions were proposed to explain his appearance but neither is completely acceptable. We propose a different disease that he could have suffered of homocystinuria--lack of cysthationine-synthase. Our conclusion is that in comparison with up to date most convincing theory, that he was suffering of Marfan syndrome, our theory equally well explains his physical appearance but is better in explaining affecting and unaffecting of his relatives. This is the only theory about Akhenaten's disease that could be checked in the near future.

Laparoscopic operation of hepatic hydatid cyst with intraabdominal dissemination--a case report and literature review

Hepatic hydatid cysts are a serious medical problem in some regions like Mediterranean region. In Croatia 25-30 new cases of hepatic hydatid cysts are recorded each year In University Hospital Dubrava 7 patients with hepatic hydatid cysts were operated in 2008. Surgical approach recognizes open laparotomy and laparoscopy. The case and technique of laparoscopic operation of hepatic hydatid cyst in seventh segment and three disseminated intraabdominal cysts is described. Laparoscopy should be attempted even in complex cases with dissemination.

[Necrotizing fasciitis of the upper leg--case report and review of the literature]

Necrotizing fasciitis is an uncommon but serious infection of skin, subcutaneous fat and fascia, characterised by rapidly spreading inflammation and associated with considerable morbidity and mortality. A 42-year-old man, with necrotizing fasciitis of the right upper leg, was hospitalized and treated by surgical debridement, along with intravenous administration of antibiotics, fluid resuscitation, correction of acidosis and electrolyte abnormalities. Four debridements were performed over four days. The patient developed septic shock with early stage of multiple organ failure, requiring one week in intensive care unit (ICU). Split-thickness skin grafts were placed on the fourth day after admission to the hospital. The patient was released to home care on the 21st day after admission, fully recovered. Necrotizing fasciitis is a life threatening infectious entity that requires rapid diagnosis, urgent extensive surgical debridement and tissue coverage as soon as possible to prevent secondary infections. ICU measures including intravenous antibiotics are often necessary, along with surgical treatment.

Laparoscopic treatment of iatrogenic endoscopic sigmoid colon perforation: a case report and literature review

Iatrogenic colon injury during a colonoscopy procedure is rare. The controversy exists when the surgical treatment of such lesions is concerned: operative or conservative. This case report is in favor of the operative endoscopic approach, with a literature review. An 80-year-old male sustained an iatrogenic endoscopic sigmoid colon perforation. Laparoscopic suturing was done within 5 hours after the perforation, with no complications after 4 months of follow-up.

[Laparoscopic transgastric cystogastrostomy of pancreatic pseudocyst: a case report]

Pancreatic pseudocyst is one of the most common complications of acute pancreatitis. Symptomatic or complicated pseudocysts require treatment. The basic principle of pseudocyst treatment is its drainage. The best method is internal drainage by establishing communication between pseudocyst and stomach or small intestine. With advances in endoscopic technology it is now possible to drain pseudocyst efficently in neighboring stomach or duodenum, however the surgical internal drainage of pancreatic pseudocysts that has been carried out as open operation for decades, remains the criterion standard against which all other therapies are measured. In recent years, several methods of laparoscopic internal drainage of pancreatic pseudocysts have been published. Initial results are encouraging, although the number of patients operated using these methods is still small and there is no clear evidence that laparoscopic internal drainage is beneficial for the patients. In this case report we present our first case of laparoscopic internal drainage of pancreatic pseudocyst. The pseudocyst developed as a complication of acute pancreatitis. Laparoscopic internal drainage with cholecystectomy was carried out on 4th of April, 2005. The patient recovered without complications and during first year of follow-up no recurrence of pseudocyst was observed.

Surgical treatment of liver echinococcosis--the role of laparoscopy

BACKGROUND

The surgical approach to liver echinococcosis is still a controversial issue. This study shows our results of surgical treatment of liver hydatid cysts during a 5-year period.

METHODS

A prospective study of 21 patients operated on in a 5-year period (1999-2003), in Dubrava University Hospital in Zagreb, Croatia, with hepatic hydatid cyst. All patients were pre-operatively treated with albendazole. In 12 patients, total pericystectomy without opening the cyst cavity was performed, 9 open and 3 laparoscopic. In the other 9 patients, partial pericystectomy was done, 6 open and 3 laparoscopic.

RESULTS

There was no mortality after 5-65 months follow-up, but in 1 patient, in the open partial pericystectomy group, recurrence of the disease occurred after 3 years. When a laparoscopic procedure was done, there were no complications or recurrence. The median operative duration for open surgery was 100.0 min (range 60.0-210.0), and for laparoscopic surgery 67.5 min (range 60.0-120.0). The median length of hospitalisation for open surgery was 8.0 days (range 7.0-14.0), and for laparoscopic surgery 5.0 days (range 4.0-7.0).

CONCLUSION

Total pericystectomy without opening the cyst cavity, preceded by pre-operative albendazole therapy is the method of choice for hepatic hydatid cyst treatment. Despite the small group of patients, our first results show laparoscopic total pericystectomy without opening the cyst cavity, in the treatment of hepatic hydatid cyst, as a good alternative to open surgery in selected patients.

[Laparoscopic surgery in acute abdominal trauma]

In the past few years, laparoscopy has been increasingly used in patients with acute abdominal trauma. This metod in experienced hands enables direct eye visualisation of abdominal cavity, ensures accurate and early diagnosis and leads to prompt decision on the therapy. Reviewing the literature, laparoscopy in acute abdominal trauma is a safe and accurate procedure to yield diagnosis, enable laparoscopic interventions and help avoid unnecessary laparotomy. In acute abdominal trauma, laparoscopy is mostly used as a diagnostic method, not so often as a therapeutic method, but an expanding range of therapeutic interventions is available. We show our early results with diagnostic and therapeutic laparoscopy from January 1st 2003 to March 31st 2004, stressing therapeutic laparoscopy. We performed 79 laparoscopic explorations in patients with diagnosis of acute abdomen. 7 of them were explored because of acute abdominal trauma. In 3 patients there was no need for intervention after laparoscopic exploration, in 1 patient we electrocoagulates smaller bleeding from the spleen and in other 3 patients we made conversion to open surgery procedure, because of III-IV grade liver or spleen injury. In our group we didn't have injuries of any other internal abdominal organs. Laparoscopic treatment of acute abdominal trauma with spleen or liver injury is applicable in I-III grade liver injury and I-II grade spleen injury, while in greater injuries it is necessary to make conversion to laparotomy.

[Blast injury to the spleen and pancreas after a non-penetrating gunshot wound--result after 12 years]

The spleen is the most frequently injured organ in adults who sustain blunt abdominal trauma. The aim is to report on a patient with non-penetrating gunshot traumatic injury to the spleen and pancreas, and to evaluate the result after 12 years A soldier with gunshot wound of the left lateral abdominal wall was admitted to the Military Hospital in Mostar in the year 1993. The patient was hemodynamically unstable and underwent emergency surgery. On wound exploration, there was no abdominal penetration. Because of hemodynamic instability, we decided to perform emergency laparotomy and abdominal exploration. The spleen and distal pancreas were shattered. Splenectomy and hemostasis were performed. The peritoneum was closed and the abdominal wall wound healed secondarily. The patient was in good condition postoperatively. Now, after 12 years, the patient is free from any sequel of the war injury. Blast injury to the spleen can result from non-penetrating abdominal gunshot wounds despite the absence of injury to the peritoneum. In war conditions, the diagnosis and indications are usually based on clinical findings only because special investigations, including ultrasound and CT are not readily available. The management of splenic injury has been rapidly modified over the last decade, with ever more emphasis on splenic salvage and nonoperative management, however, these procedures cannot be performed in war conditions. War injuries to the spleen are life threatening and emergency open splenectomy is the only solution.

[Laparoscopic treatment of acute cholecystitis]

Acute cholecystitis has been considered a contraindication for laparoscopic cholecystectomy after its affirmation as the golden standard for treatment of chronic cholecystitis. However, over time it has been proven that acute cholecystitis could also be managed laparoscopically, although it was technically demanding procedure, burdened with relatively high conversion rates. In this study we present our series of 26 patients, urgently admitted for acute cholecystitis. They are presented with clinical findings typical for acute cholecystitis. The diagnosis was determined using ultrasound examination, and confirmed postoperatively by pathohistological findings. In all 26 cases we managed to perform laparoscopic cholecystectomy, there were no conversion. Mean operative time was 73 +/- 21 minutes. Postoperatively, we haven't recorded any significant complications. Mean hospital stay was 4.8 +/- 2.5 days. Even though laparoscopic treatment of acute cholecystitis is technically more demanding and lengthier procedure than laparoscopic treatment of chronic cholecystitis, we consider acute cholecystitis to be a laparoscopically manageable disease. During the operation, tissue edema and hyperemia presented main technical challenge. They presented a significantly greater problem if the symptoms lasted for more than 3 days prior to operation. Therefore we suggest that laparoscopic cholecystectomy should be carried out in the first 72 hours after the onset of symptoms, since any further delay will lead to development of tissue hyperemia and edema, thus making the operation technically more demanding.

Improving comprehension of informed consent

OBJECTIVE

To explore the way the doctor-patient communication process may be improved by adopting the patients' conversational style in the development of written materials for surgical patients.

METHODS

Written information prepared by doctors, specialists in abdominal surgery, was tested for comprehension on patients undergoing cholecystectomy, using the standard Cloze test procedure. At the same time, the patients were asked to describe in their own words all they knew about their illness and the treatment. The collected 150 patient narratives were analyzed, and a typical narrative for each educational level was selected based on average SMOG score, word count and sentence length. The patient-worded information was then tested for comprehension on new patients, selected from primary health care, using the same Cloze procedure as with doctor-developed information. Patient profile of best lay communicators was defined using also sociodemographic characteristics, and reported information seeking and decision making preferences.

RESULTS

Only 50% of patients completed Cloze test, of which over 40% showed poor comprehension. Analysis of transcribed narratives collected from 150 patients showed increasing complexity of style by educational level (average SMOG score 7, 8, and 9; sentence length 11, 13, and 15 words; for low, medium, and high educational level, respectively). Cloze tests based on typical narratives, and tested on primary care patients, indicated to the style best understood by all. Dominant characteristics of patients producing a narrative of similar style to the best-understood narrative were observed: medium educational level, women over 60, urban workers, interviewed after surgery, informed by specialist at ultrasound, knowledge about illness from 1 to 10 years, learned most about illness from lay people, those who wanted more information in both oral and written form, and preferred active role in decision making.

CONCLUSION

Analysis of patient profiles with typical narratives that were best understood by other patients shows where to look for lay experts in doctor-patient communication.

PRACTICE IMPLICATIONS

Obtained findings indicate to the importance of patient participation in developing informed consent information, and to the possible method for improving comprehension of educational patient materials in general.

Small bowel injuries in penetrating abdominal trauma during war: ten-year follow-up findings

BACKGROUND

Injuries of the small intestine are common in penetrating abdominal trauma. This article presents 10-year follow-up results for 23 patients with penetrating small bowel injuries who were treated in Nova Gradiska City Hospital during the 1991-1992 war in Croatia. The early hospital mortality rate was 13% (three deaths), and good results were found for 16 (84%) of 19 patients after 10 years.

METHODS

The hospital charts of 23 patients who sustained small bowel injuries during an 8-month period were reviewed. Of 20 patients who survived, 19 came for an examination and interview 10 years after injury. The following criteria were used: existence of an abdominal wall defect or hernia, bowel passage problems, and reoperations attributable to the small bowel injury.

RESULTS

Early results revealed adhesive peritonitis and ileus for three patients demanding early reoperation (13%) and a hospital mortality rate of 13% (three deaths, mainly attributable to multiple injuries). Ten years after injury, 16 patients had no problems, whereas 3 reported occasional abdominal pain.

CONCLUSION

Penetrating abdominal injuries in war demand urgent diagnostic procedures and, in almost all cases, urgent laparotomy. In cases with no evidence of abdominal penetration and cases involving multiple injuries, an aggressive approach reduces the risk of missing small bowel injuries. Use of established principles for surgical management of small bowel injuries yields good results and low incidences of late complications and difficulties.

Small bowel injuries in penetrating abdominal trauma during war: ten-year follow-up findings

BACKGROUND

Injuries of the small intestine are common in penetrating abdominal trauma. This article presents 10-year follow-up results for 23 patients with penetrating small bowel injuries who were treated in Nova Gradiska City Hospital during the 1991-1992 war in Croatia. The early hospital mortality rate was 13% (three deaths), and good results were found for 16 (84%) of 19 patients after 10 years.

METHODS

The hospital charts of 23 patients who sustained small bowel injuries during an 8-month period were reviewed. Of 20 patients who survived, 19 came for an examination and interview 10 years after injury. The following criteria were used: existence of an abdominal wall defect or hernia, bowel passage problems, and reoperations attributable to the small bowel injury.

RESULTS

Early results revealed adhesive peritonitis and ileus for three patients demanding early reoperation (13%) and a hospital mortality rate of 13% (three deaths, mainly attributable to multiple injuries). Ten years after injury, 16 patients had no problems, whereas 3 reported occasional abdominal pain.

CONCLUSION

Penetrating abdominal injuries in war demand urgent diagnostic procedures and, in almost all cases, urgent laparotomy. In cases with no evidence of abdominal penetration and cases involving multiple injuries, an aggressive approach reduces the risk of missing small bowel injuries. Use of established principles for surgical management of small bowel injuries yields good results and low incidences of late complications and difficulties.

[Laparoscopic repair of a cholecystoduodenal fistula--a case report]

Although cholecystoduodenal fistula is traditionally considered a contraindication for laparoscopic cholecystectomy, literature search reveals reports of cholecystoduodenal fistulae successfully repaired laparoscopically, regardless whether cholecystoduodenal fistula was diagnosed before or during operation. Here we present a case of preoperatively diagnosed and confirmed cholecystoduodenal fistula that was successfully repaired during elective laparoscopic cholecystectomy using an Endo-GIA 35 stapling device. Thus we side with the growing number of surgeons who do not consider cholecystoduodenal fistula to be a contraindication for laparoscopic cholecystectomy.

Common bile duct obstruction caused by the hydatid daughter cysts

Echinococcosis is a human parasitary disease. In 2002, 29 new cases of liver echinococcosis were recorded in Croatia. Liver is the most common site of hydatid cysts. Nine patients with echinoccocal liver disease were operated in our department in 2002. Here we present a case where a patient with verified hydatid cyst in the left liver lobe developed high fever, jaundice, nausea, vomiting and pain in the upper abdomen. The symptoms were initially ascribed to the acute cholangitis. After unsuccessful antibiotic treatment, computerized tomography and endoscopic retrograde cholangiopancreatography (ERCP) were performed, demonstrating daughter cysts in the common bile duct. During ERCP, papilotomy was made and daughter cysts were extracted. Hydatid cyst was surgically removed, and a communication between the cyst and left hepatic duct was noted during surgery. Pericystectomy, choledochotomy, removal of remaining daughter cysts from the common bile duct, and sutures of left hepatic duct were performed. The patient recovered fully after the surgery. One of the possible complications of the liver hydatid cysts is the communication between cyst and the biliary tree. Such communications are usually asymptomatic, but symptoms can also mimic acute cholangitis and jaundice, which may lead to the misdiagnosis of the patient's condition.

War injuries of colon and rectum--results after 10 years

The aim of our study is to evaluate results of treating war injuries of colon and rectum, after 10 years. During the war in Croatia, 21 wounded, with colon (19) and rectum (2) injuries, were treated in the Department of Surgery at Nova Gradiska General Hospital from August 1991 to April 1992. Bullet wounds accounted for 57% of the injuries. All patients had other associated injuries. Primary repair and proximal derivation was possible in 2 cases (9.5%), while primary resection with intraperitoneal anastomosis was performed in 3 (14.3%) patients. In 2 (9.5%) patients sustained intraperitoneal and extraperitoneal rectal penetrating injury rectum was resected and closed performing temporary sigmoidostomy. When multiple perforations or crush injury of the colon were found, in 8 (38.1%) injured persons resection of the involved segment was combined with proximal end colostomy and aboral mucous fistula. Exteriorization of injured segment of the colon and creating colostomy incorporating the injured colon as the stoma was performed in 6 (28.5%) wounded patients. Four of the wounded (19.0%) died two of them during the operative procedure due to hemorrhagic shock. One injured died after eight days due to pulmonary embolism, and one patient died after thirty days due to sepsis. Reoperation was necessary in two (9.5%) injured due to bowel obstruction four days following initial surgery because of adhesions. Three (14.3%) of the injured had wound infection, one of them died 30 days after injury due to sepsis, and two (9.5%) consequently developed ventral hernia that was operated after 4 and 5 years respectively. Four (19.0%) of the injured are still occasionally experiencing occasional abdominal pain.

Craniocerebral war missile injuries: clinical and radiological study

In this study we reviewed the initial clinical and radiological management and early outcomes of 176 consecutive patients from the war in Croatia.

Spine and spinal cord war injuries during the war in Croatia

OBJECTIVE

The present report summarizes the experience of an evacuation hospital in southern Croatia in treating 96 patients with spine and spinal cord war injuries.

METHODS

A retrospective review was done for 96 wounded persons (86 soldiers, 10 civilians) with spinal cord injuries from August 1991 through December 1995. The ages ranged from 15 to 59 years (mean, 28.3 years for soldiers, 38.5 years for civilians). Diagnostic procedures were plain radiography, computed tomography, and computed tomographic myelography. However, in most cases a more conservative surgical approach was used.

RESULTS

The highest rates of admittance were recorded in 1992 (N = 38) and 1993 (N = 47). The lumbar spine was injured in 55% of the patients, the cervical and thoracic spines in 17.7%. All injuries were caused by projectiles from automatic rifles and sniper fire (51%) and from fragments of explosive devices (49%). Blast injury of the spinal cord was found in 10 patients. The most frequent complications caused by the fragments were wound infection, urinary tract infection, decubitus, and pneumonia. Four patients (4.2%) died in the hospital, and 43.0% of patients survived but were severely handicapped.

CONCLUSION

Careful clinical examination combined with modern diagnostic imaging and use of broad-spectrum antibiotics reduced the need for surgical intervention in patients with spinal cord injuries.

Orbitocranial war injuries: report of 14 cases

OBJECTIVE

In this study, we review the initial clinical and radiological management and early outcomes of 14 patients with orbitocranial war injuries treated at the University Hospital Split between 1991 and 1995.

METHODS

This investigation involves 14 patients (13 soldiers and 1 civilian) with orbitocranial war injuries. The mean patient age was 31 years (range, 23-54 years). The penetrating object was a metal shrapnel fragment in 8 patients and a bullet in 6 patients. The results of clinical and radiological management were retrospectively analyzed.

RESULTS

The mean time from the moment of wounding to hospital admission was 6 hours (range, 1-30 hours). The mean Glasgow Coma Scale score was 8 (range, 3-14). Craniotomy was the basic neurosurgical procedure, and three patients were treated with simple scalp wound debridement and closure. Osteoplastic operations of the orbital bones were performed in 13 patients. Enucleation/evisceration was performed in 6 patients (42.8%). At discharge, the mean Glasgow Outcome Scale score was 13, and 1 patient died in the hospital. Blindness (including amaurosis and anophthalmus) was present in nine eyes (8 patients), light-perception positivity and projection positivity were present in four eyes, and visual acuity was at 0.1 in 1 patient.

CONCLUSION

An early multidisciplinary therapeutic approach and computed tomography as a diagnostic procedure are necessary for a good result in the treatment of orbitocranial war injuries.

Early intracranial infections after brain missile injuries--the role of computer tomography in diagnosis and treatment

During the war in Croatia, from August 1991 until December 1994, 138 soldiers were treated at the Split University Hospital for different brain injuries inflicted by missiles. Nine of these 138 patients developed intracranial infection. This retrospective study reports on the outcome of these 9 intracranial infections caused by penetrating missile head injuries. In case of clinically suspected infection, computerized tomography scan was obtained at two time points during the course of infection in the same patient. Scans were obtained with and without contrast media, 7 to 14 days after the injury and the 4 weeks later. The role of computerized tomography in the detection and follow-up of various intracranial infections and long-term consequences were evaluated.