Darko Mirkovic

Correlation between procalcitonin and intra-abdominal pressure and their role in prediction of the severity of acute pancreatitis.

BACKGROUND/AIMS Early assessment of disease severity and vigilant patient monitoring are key factors for adequate treatment of acute pancreatitis (AP). The aim of this study was to determine the correlation of procalcitonin (PCT) serum concentrations and intra-abdominal pressure (IAP) as prognostic markers in early stages of AP. METHODS This prospective observational study included 51 patients, of which 29 had severe AP (SAP). Patients were evaluated with the Acute Physiology And Chronic Health Evaluation (APACHE II) score, C-reactive protein (CRP) and PCT serum concentrations and IAP at 24 h from admission. PCT was measured three times in the 1st week of disease and three times afterward, while IAP was measured daily. PCT and IAP values correlated with each other, and also compared with APACHE II score and CRP values. RESULTS PCT, IAP, CRP values and APACHE II score at 24 h after hospital admission were significantly elevated in patients with SAP. There was significant correlation between PCT and IAP values measured at 24 h of admission, and between maximal PCT and IAP values. Sensitivity/specificity for predicting AP severity at 24 h after admission was 89%/69% for APACHE II score, 75%/86% for CRP, 86%/63% for PCT and 75%/77% for IAP. CONCLUSIONS Increased IAP was accompanied by increased PCT serum concentration in patients with AP. PCT and IAP can both be used as early markers of AP severity.

Decompressive laparotomy with temporary abdominal closure versus percutaneous puncture with placement of abdominal catheter in patients with abdominal compartment syndrome during acute pancreatitis: background and design of multicenter, randomised, controlled study

BackgroundDevelopment of abdominal compartment syndrome (ACS) in patients with severe acute pancreatitis (SAP) has a strong impact on the course of disease. Number of patients with this complication increases during the years due more aggressive fluid resuscitation, much bigger proportion of patients who is treated conservatively or by minimal invasive approach, and efforts to delay open surgery. There have not been standard recommendations for a surgical or some other interventional treatment of patients who develop ACS during the SAP. The aim of DECOMPRESS study was to compare decompresive laparotomy with temporary abdominal closure and percutaneus puncture with placement of abdominal catheter in these patients.MethodsOne hundred patients with ACS will be randomly allocated to two groups: I) decompresive laparotomy with temporary abdominal closure or II) percutaneus puncture with placement of abdominal catheter. Patients will be recruited from five hospitals in Belgrade during two years period. The primary endpoint is the mortality rate within hospitalization. Secondary endpoints are time interval between intervention and resolving of organ failure and multi organ dysfunction syndrome, incidence of infectious complications and duration of hospital and ICU stay. A total sample size of 100 patients was calculated to demonstrate that decompresive laparotomy with temporary abdominal closure can reduce mortality rate from 60% to 40% with 80% power at 5% alfa.ConclusionDECOMPRESS study is designed to reveal a reduction in mortality and major morbidity by using decompresive laparotomy with temporary abdominal closure in comparison with percutaneus puncture with placement of abdominal catheter in patients with ACS during SAP.Trial registrationClinicalTrials.gov Identifier: NTC00793715

Magnetic resonance imaging in the evaluation of uterus didelphys with obstructed hemivagina and renal agenesis: a case report

Uterus didelphys with obstructed hemivagina and ipsilateral renal agenesis usually presents after menarche with progressive abdominal pain during menses secondary to hematocolpos. Initially, the anomaly remains unrecognized, while patients most frequently referred to surgeons for assistance. The method of choice for diagnosis is magnetic resonance imaging. A greater awareness of the syndrome of uterus didelphys, obstructed hemivagina and ipsilateral renal agenesis should lead to its prompt diagnosis, allowing for early and appropriate surgical treatment as well as decreased long-term morbidity. Transvaginal excision of the septum is the appropriate mode of treatment.

[Intra-abdominal hypertension and abdominal compartment syndrome].

Abdominalni kompartment sindrom je stanje udruženo sa visokim morbiditetom i mortalitetom. Identifikacija i brižljivo pracenje bolesnika sa rizikom, ukljucujuci i merenje IAP treba da bude rutina, kako bi se izbegle neželjene posledice ovoga stanja. Posto ne postoje detaljni protokoli koji govore o tacnim vrednostima IAP pri kojima treba pravovremeno reagovati adekvatnom terapijom i terapijskim procedurama, neophodno je svakog bolesnika sa ovim stanjem individualno posmatrati i ukljuciti u naucnoistraživacke studije. Shodno utvrđenim vrednostima i znacima za ACS, formiranje protokola za lecenje AP i njegova primena omogucice poboljsanje u smanjivanju morbiditeta i mortaliteta kod AP.

Portosystemic shunt in the treatment of portal hypertension

Hirurgija santova u dekompresiji portnog sistema tehnicki se tokom vremena znacajno menjala. U toku evolucije lecenja izgubila je primat u tretmanu portne hipertenzije. Do devedestih godina proslog veka hirurgija gotovo da nije imala alternativu, ali pojavom novih lekova, endoskopske sklerozacije, TIPS i transplantacije jetre izbor za hirurgiju je znatno sužen. U profilaksi prvog variksnog krvarenja sant hirurgija nije indikovana zato sto je tesko sa apsolutnom sigurnoscu odrediti bolesnika koji ima visok rizik od krvarenja iz variksa, ocuvanu funkciju jetre tako da bez rizika može podneti sant. Bolesnik sa dobrom funkcijom jetre (A i B klasa po CTP klasifikaciji) kandidat je za sant hirurgiju, a samo u izuzetnim slucajevima i bolesnik sa ozbiljnim ostecenjem jetre. Selektivni sant je opcija koja obezbeđuje dobru variksnu dekompresiju i zadovoljavajuce održavanje funkcije jetre. Rezultati kod ovog santa umnogome zavise od vestine hirurga. Kod urgentnih krvarenja iz variksa prvo treba pokusati sa primenom lekova i skleroterapijom, a u slucaju neuspeha neophodno je primeniti sant hirurgiju, pri cemu se mora voditi racuna o opstem stanju bolesnika kako bi se iskoristilo optimalno vreme. Sant može poslužiti kao odlican dugorocni most do transplantacije jetre za bolesnike sa ocuvanom hepaticnom rezervom. Primena santova u dekompresiji portnog sistema jos uvek igra važnu ulogu u tretmanu pažljivo selektovanih bolesnika sa variksnim krvarenjem koji u buducnosti nece biti u prilici da im se uradi transplantacija jetre.

Mesoatrial shunt in Budd-Chiari syndrome

BACKGROUND Budd-Chiari syndrome (BCS) represents partial or total occlusion of the hepatic veins with or without simultaneous obstruction of vena cava inferior (VCI). The symptoms of BCS are abdominal pain, hepatomegaly, ascites, varices of the abdominal wall, sometimes bleeding from the upper part of gastointestinal tract (GIT), lower limbs swelling and jaundice. Primary BSC is a relatively rare condition occuring in one per 100,000 of the population worldwide. CASE REPORT A male patient, 25-year-old, facing tooth postextraction complications, was presented with acute BCS. On admission, physical examination revealed pale-grayish complexion, more pronounced veins over the thorax and abdomen, ascites, enlarged liver rising 8 cm below the right costal arch and having a minor pleural effusion by the right side. The patient was submitted to Doppler sonography and computed tomography (CT) that verified the right leg deep veins thrombosis, as well as the presence of a thrombus in the intrahepatic portion of the VCI. Multislice computed tomography (MSCT) showed occlusion of hepatic veins (Budd-Chiari syndrome) and thrombosis of the VCI in the retrohepatic part 6 cm long. Also, increased values of transaminases and gamma GT and reduced values of albumines and serum ferrum were registered. Molecular examination revealed Factor V Leiden mutation--heterozygote. After preoperative preparations a mesocaval shunt was made using Gore-Tex ring graft of 12 mm. Intraoperatively, the blue enlarged liver was found with almost black zones of tense capsule. After a graft making, liver congestion decreased followed by the change of colour and volume. Within postoperative course metabolic and synthetic liver functions were obvious. CONCLUSION In patients with BCS medicamentous treatment does not yield adequate results, but even causes worsening of general condition. Surgical therapy in the presented patient was performed timely regarding the stage of the disease due to which irreversible liver changes were prevented while decompression of the portal system provided time overbridging up to liver transplantation.

Long-term outcome of a modified balloon dilatation in the treatment of patients with achalasia.

BACKGROUND/AIM Balloon dilatation is a standard approach to the initial achalasia treatment. Modified dilatation is also applied to rise efficacy and to lower complications. METHODS A total of 57 patients were analysed within a median follow-up of 8.2 years. No premedication was used, dilatation was performed up to the pain treshold, while introduction and positioning of a dilatator was done in combination of endoscopic and radiological control. Dilatation effect was estimated by both Kim Symptom Scoring and objective parameters: body weight rise and radiological scintigraphic findings. RESULTS Excellent and good results were obtained in 50 (88%) of the patients, while in 7 (12%) of the patients surgery was performed. There was no difference in dilatation efficacy regarding sex of the patients, but the results were better in the patients above 40 years. Duration of symptoms, body weight loss, esophageal lumen width do not indicate the definitive dilatation outcome. Esophageal scintigraphy and body weight increase were in a direct correlation with the effect of dilatation measured with the Kim Symptom Scoring. After the one to two repeated dilatations the efficacy increased from 74% to 88% justifying the repetition of dilatation. In 2 (3.57%) of the patients, that is in 2.65% of the totally dilated patients, perforation was recorded. There was no lethal outcome of dilatation, and the other complications were not clinically significant. CONCLUSION Modified balloon dilatation can be recommended for initial method in achalasia treatment due to high efficacy, easy performance in daily hospital while complications are in standard range.

Delayed bleeding due to hydatid cyst rupture one month after blunt liver trauma

Reference A 55-year old male was admitted to our hospital with haemorhagic shock. He had injured his right hip in a fall during syncope. month earlier, the patient accidentally fell in the bathroom and eported trauma to the right upper quadrant region but had not ought medical attention. Since then he had progressive weakness ith intermittent abdominal pain. On admission blood pressure was 80/50 mmHg, heart rate 20 beats/min, haematocrit 24% and haemoglobin of 8.6 g/dL. A omputed tomography (CT) scan showed two liver cysts; one howed high-density fluid collection, suspicious for blood conent. Furthermore, a lesion of the right hepatic vein (RHV, Fig. 1), yst rupture and free fluid in the peritoneal cavity was evident Figs. 1 and 2). CT findings were confirmed at urgent laparotomy. resh and coagulated dark-brown blood was found in the ruptured

Colorectal anastomosis dehiscence following radical surgical operation for rectal carcinoma

UNLABELLED BACKGROUND/AIM. Colorectal cancer (CRC) is one of the biggest health problems of modern humanity, especially in highly developed countries. In Serbia about 3,200 patients suffer from CRC, out of whom about 1,100 patients suffer from rectal cancer (RC), while about 2,100 patients suffer from other colon segments cancer. The aim of the study was to show the incidence genesis of one of the possible early postoperative complications regarding dehiscence of the colorectal anastomosis (CRA) with a group of patients suffering from RC and operated by using sphincter-saving procedures, in the period from 1993 to 2007, and then to compare the incidence genesis of these complications with those in the published series of the reporting colorectal institutions. METHODS The research included 242 patients radically operated on for RC in a 15-year period using some of sphincter-saving procedures following by a careful analysis of the symptoms of subclinical dehyscencias not solved with the reintervention as well as of the clinically evidented dehyscencias mostly solved by reoperation. RESULTS With 22 (9.1%) patients in the first 10 postoperative days there were early postoperative symptoms of CRA dehiscence. In 6 (2.47%) of the patients there were subclinical signs of raised body temperature, less quantity of feces content, and after the conservative treatment they ended in spontaneous process of rehabilitation. In 16 (6.61%) patients there was clinically evidented anastomosis dehiscence followed by abundant drainage of feces content, signs of local peritonitis, pelvic sepsis, so we had to undertake surgical intervention. CONCLUSION. Comparing the results of a few tenths of published studies with our results we proved that performing and operative technique of colorectal anastomosis in the patients suffered and radically surgically treated for RC, is quite adequate with the operative technique in reporting world institutions that are engaged in surgical treatment of RC.