Darko Zdravkovic

Importance of revealing a rare case of breast cancer in a female to male transsexual after bilateral mastectomy

The incidence of breast carcinoma following prophylactic mastectomy is probably less than 2%. We present a 43-year-old female to male transsexual who developed breast cancer 1 year after bilateral nipple- sparing subcutaneous mastectomy as part of female to male gender reassignment surgery. In addition to gender reassignment surgery, total abdominal hysterectomy with bilateral salpingo-oophorectomy (to avoid the patient from entering menopause and to eliminate any subsequent risk of iatrogenic endometrial carcinoma), colpocleisys, metoidioplasty, phalloplasty, urethroplasty together with scrotoplasty/placement of testicular prosthesis and perineoplasty were also performed. Before the sex change surgery, the following diagnostic procedures were performed: breast ultrasound and mammography (which were normal), lung radiography (also normal) together with abdominal ultrasound examination, biochemical analysis of the blood and hormonal status.According to medical literature, in the last 50 years only three papers have been published with four cases of breast cancer in transsexual female to male patients. All hormonal pathways included in this complex hormonal and surgical procedure of transgender surgery have important implications for women undergoing prophylactic mastectomy because of a high risk of possible breast cancer.

Echocardiographic study of early left ventricular remodeling in highly trained preadolescent footballers.

Almost all the studies of athletes heart have been carried out on adult and older adolescent players; hence the limited data on the cardiac response to exercise in the beginning of the active sports career in the youngest athletes. The study was designed to examine the physiological limits of left ventricle (LV) cavity size and wall thickness in elite footballers at the preadolescent age, it the beginning of the active sports career. Ninety-four highly trained male footballers (mean aged 12.85±0.84) competing in the Serbian Football League and 47 age-matched healthy male controls, aged 12-14, were enrolled in the study. All the echocardiographic findings were adjusted to BSA(-0.5), while left ventricle mass (LVM) was additionally adjusted to BSA(-1.5). Reference ranges were defined as values of 5-95th centile according to the mean values in both groups. The proportions of the footballers with LV dimensions outside expected ranges were additionally noted. The data indicate significant increases in absolute values of LV dimensions, aortic root size and left atrium (p<0.001) in preadolescent professional footballers compared with the values expected for age-matched controls, whereas there are no differences in absolute values of ventricular septal and posterior wall thickness, LV wall thickness and LVM (p>0.05). Upon body-size adjustments, significant increases were observed in all echocardiographic parameters (p<0.001). Our data indicate an early cardiac remodeling, already apparent in pre-adolescence, even after a short period of training.

Lesion of the femoral nerve caused by a hydatid cyst of the right psoas muscle

INTRODUCTION Hydatidosis is a human disease caused by the larval form of Echinococcus granulosus. All organs in the human body may be affected by hydatid disease, but excluding liver and lungs, all other organs are considered as uncommon locations. Hydatid disease located in the psoas muscle is uncommon. CASE OUTLINE The authors present a 36-year-old male living in endemic areas of Serbia, admitted due to pain and weakness of the right thigh and weight loss. Duration of symptoms was one year. CT and MRI revealed a big cystic mass (20 cm long) in the right psoas muscle. Neurological investigation showed a loss of function of the right femoral nerve. Serology for Echinococcosis was negative. Surgery was indicated and performed by median laparotomy. Total excision of the cyst was done. Pathohystology confirmed the nature of the cyst. Three years after operation the patient was without any signs of disease relapse. CONCLUSION Echinococcal disease of the psoas has been very rarely reported, sometimes associated with paraspinal disease and often with vertebral involvement. Cystic or complex retroperitoneal tumour, pyogenic abscess of the psoas and even tuberculosis should be considered in the differential diagnosis. Treatment of choice is surgery. The greatest danger for the patient is dissemination and anaphylactic reaction. Also, compression of adjacent organs may produce significant morbidity.

Early Dumping Syndrome and Reflux Esophagitis Prevention with Pouch Reconstruction

BACKGROUND Total gastrectomy causes numerous disorders, such as reflux esophagitis, dumping syndrome, malabsorption, and malnutrition. To minimize the consequences, different variants of reconstruction are performed. The aim of our study is the comparison of two reconstructive methods: the standard Roux-en-Y and a new modality of pouch interposition, preduodenal-pouch interposition. This study aims to investigate the advantage of bile reflux prevention and to reduce symptoms of dumping syndrome after 3- and 6-mo follow-up. MATERIALS AND METHODS A total of 60 patients were divided in two groups: (A) 30 patients with Roux-en-Y reconstruction, and (B) 30 patients with the preduodenal-pouch (PDP) type of reconstruction. Endoscopic examination and endoluminal jejunal limb pressure measurements were performed. Scintigraphic measurements of half-emptying time were performed to evaluate meal elimination in the context of reflux esophagitis and early dumping syndrome. The Japan Society of Gastrointestinal Surgery has provided guidelines with which to classify the symptoms of early dumping syndrome. Patients were followed up for periods of 3 and 6 mo after the surgery. RESULTS Our study groups did not differ with regard to the level of reflux esophagitis (P = 0.688). Average values of pressure at 10 and 15 cm below the esophago-jejunal junction were significantly lower in the PDP group (P < 0.001). Elimination of the test meal between two groups was not significant (P = 0.222). Evaluation of early dumping syndrome symptoms revealed a significant reduction among PDP patients after 3 and 6 mo. CONCLUSION Our study showed significant superiority of the new pouch reconstruction over the standard Roux-en-Y approach in the treatment of early dumping syndrome.

Comparison of Functional Recovery is Crucial for Implementing ERAS.

We read with great interest the paper by Kummer et al. [1] on the ERAS protocol and comparison on functional recovery, published online in May 2016 in World Journal of Surgery. First of all, we wish to offer our gratitude and to congratulate the authors for their efforts in further development of treatment of patients submitted to right or left colectomies. This was a retrospective analysis which included 223 consecutive and unselected patients that underwent elective colonic resection and were included in a prospective ERAS database. The authors wanted to compare compliance with the ERAS protocol and outcomes after right versus left colectomy, bowel recovery, complications, and hospital stay. We have some concerns which are mostly in reference to postoperative complications, first and foremost the time of their acknowledgement, distribution between the two groups, and their treatment, and also the administration of epidural analgesia. We feel that a more indicating comparison of functional recovery with application of the ERAS pathway could have been achieved by creating two groups with the equal number of patients [2]. It has been stated in this study that severe complications were present in 12% of right and 7% of left colectomies group. We feel that it might have been important to point out how many of these patients with severe complications were treated for malignant disease. In our clinical experience, it is important to state the macroscopic characteristics of the tumor, which can influence the conversion rate, therefore prolonging the time of operation, and potentially delaying functional recovery. Also, it is important to state the age distribution within the group of patients with postoperative complications. In our experience, anastomotic leakage is a complication which can, often enough, first be verified with the presence of abdominal drainage. In reference to that, we think it is important to point out how was the anastomotic leakage diagnosed, as well as the exact postoperative day it was established. Furthermore, we feel that the information on how many of patients with anastomotic leakage were treated for malignant disease can be considered an important one [3]. As far as postoperative ileus is concerned, various studies have shown a variety of different definitions of postoperative ileus. In this study, it was diagnosed by the necessity of nasogastric tube placement. We would have liked to come across the information as to how many of patients with postoperative ileus were submitted to operation due to malignant disease. Also, it has been stated that postoperative ileus was present in 24% of patients with right colectomies, but with no reference as to how many of these patients were treated for carcinoma of the colon. Also, signaling out the group of patients who were submitted to open colorectal surgery could provide a much more valid insight, and shed light on the controversy of epidural analgesia application in colorectal surgery [4, 5].

Early Left Ventricular Systolic and Diastolic Dysfunction in Patients with Newly Diagnosed Obstructive Sleep Apnoea and Normal Left Ventricular Ejection Fraction

The aim of the study was to evaluate whether obstructive sleep apnea (OSA) contributes directly to left ventricular (LV) diastolic and regional systolic dysfunction in newly diagnosed OSA with normal left ventricle ejection fraction. Methods. 125 consecutive patients were prospectively enrolled in the study. Control group consisted of 78 asymptomatic age-matched healthy subjects who did not have any cardiovascular and respiratory diseases. All patients had undergone overnight polysomnography and standard transthoracic and tissue Doppler imaging echocardiogram. Results. The E/A ratio and the peak E wave at mitral flow were significantly lower and the peak A wave at mitral flow was significantly higher in OSA patients compared with control subjects. Left ventricle isovolumetric relaxation time (IVRT) and mitral valve flow propagation (MVFP) were significantly longer in OSA patients than in controls. Tissue Doppler derived S′ amplitude of lateral part at mitral valve (S′Lm) and E′ wave amplitudes both at the lateral (E′Lm) and septal parts of the mitral valve (E′Sm) were significantly lower in OSA patients compared to controls. Conclusion. Newly diagnosed OSA patients with normal global LV function have significantly impaired diastolic function and regional longitudinal systolic function. OSA is independently associated with these changes in LV function.

Biliobronchial fistula due to hydatidosis of the liver and choledocholithiasis

INTRODUCTION Biliobronchial fistula (BBF) is an abnormal communication between the biliary system and bronchial tree due to trauma, hemiheptectomy benign biliary stricture with cholangitis and necrotic hepatic infections such as hydatid disease. Intratoracic rupture of a hydatis cyst of the liver is a rare but severe complication with an incidence about 1% and mortality rate about 10%. CASE REPORT A 50-year-old male patient presented with cough, episodes of biliary expectoration and haemoptysis followed with fever, fatigue and dyspnea. The diagnosis was set by echosonography, Chest x-ray finding, CT scan, bronchoscope aspirates while bronchography did not show results. The surgery was done through right subcostal laparotomy. A hydatid cyst was found in the right liver lobe its diameter being 10 cm, fixed with diaphragm. Intraoperative cholangiography revealed choledocholithiasis (two calculi), dilatation of bile ducts and communication of right hepatic duct with the irregular liver cavity as well as with the bronchi of the right lower pulmonary lobe. Cholecystectomy, choledocholitotomy with drainage lavage of bile ducts pericystectomy and cyst evacuation was performed, followed by diaphragm necrosectomy. The postoperative period and control cholangiography through T drain were normal. DISCUSSION The surgical treatment has five goals: to treat the liver cyst, secure free biliary drainage, perform hepatodiaphragmatic disconection, solve intratoracic lesion and restore the diaphragm. We believe these goals could be achieved through abdominal approach except for irreversible bronchiectasis, intratoracal collection and chronic pulmonary sepsis. CONCLUSION In any case, a surgery still remains the treatment of choice in cases of echinococcosis. Most cases can be solved by laparotomy.

Surgery indeed has an important role in long-term outcome in patients with pancreatic head cancer.

We read with interest the article by Petermann et al. [1] in the August 2013 issue of World Journal of Surgery. First of all, we would like to congratulate the authors for their very interesting article. In this retrospective study 101 pancreatic head resections due to pancreatic ductal adenocarcinoma were analyzed. The authors wanted to assess the impact of postoperative complications, stratified by severity, on long-term survival of patients after pancreatic head resection for ductal adenocarcinoma. However, we have several concerns about their conclusions. First, the authors concluded that surgery is not associated with severe postoperative complications. Surgery is the cornestone in the treatment of pancreatic cancer. Pancreaticoduodenectomy (PD) is the standard surgical treatment of pancreas head cancer. Using an optimal pancreatic reconstruction technique is thought to be a major prophylactic measure to minimize the risk of PD-related complications. Also, there are many possibilities of type of reconstruction as well as many possibilities for pancreaticojejunostomies (PJA): (1) layer with or without telescope, (2) layer, end-to-end, end-to-side, ‘‘duct to mucosa,’’ ‘‘Blumgart‘s’’ anastomosis, etc. [2]. Further, we don’t agree with authors’ conclusion that surgery is not associated with severe postoperative complications. They did not mention what kind of reconstructions were performed In accordance with this we could state following facts. Delayed gastric emptying (DGE) occurs dominantly after pylorus-preserving pancreaticoduodenectomy (PPPD) and remains a leading cause of PPPD postoperative complications. Delayed gastric emptying was probably exacerbated by some intra-abdominal complications, such as an anastomotic leak or an abscess. Problems could also be caused by the surgical procedure itself, namely injury to the nerve of Latarjet. In one study the incidence of DGE was significantly reduced in the pyloric ring resection group compared to controls, without an increase in dumping syndrome [3]. Most pancreatic fistulas (PF) can be managed nonoperatively, but a significant number of grade C PF do require reoperative surgical intervention. Risk factors for pancreatic fistula are well recognized and include a soft pancreatic parenchyma, small main pancreatic duct caliber, and a distal pancreatic resection (vs PD) [4]. Type of anastomosis is also very important regarding this problem. For example, there is a statistically significant decrease in fistula rate in the invagination group—PJA with invagination compared to other types of anastomoses [5]. Patients with postoperative hemorrhage often have underlying complications such as pancreatic fistula that require urgent surgical treatment. Pancreatic enzymes in combination with infection can cause erosion of the gastroduodenal artery or splenic artery stump, resulting in significant bleeding requiring immediate treatment. D. Zdravkovic (&) D. Bilanovic T. Randjelovic S. Dikic Surgery, Faculty of Medicine, University of Belgrade, Belgrade, Serbia e-mail: drdarkozdravkovic@gmail.com

Obstructive jaundice and cholangitis caused by an arterial ring of the proper hepatic artery around the common bile duct

Summary Background Many different benign and malignant diseases can cause obstruction of the extrahepatic biliary duct. One of the more serious complications of biliary obstruction is cholangitis leading to emergency decompression. Anatomic variations are frequent in this region; however, it has rarely been reported that the extrahepatic bile duct is compressed by the arterial vessels. Case Report We present the case of a 68-year-old woman who was admitted through the emergency department of our hospital with jaundice, abdominal pain and fever. Biochemical analyses of liver function showed increased value of AST (113 IU/L) and AST (128 IU/L). Total bilirubin was 5.88 mg/dl, conjugated bilirubin was 3.00 mg/dl, and alkaline phosphatase was 393 IU/L. We performed abdominal ultrasound (US), magnetic resonance cholangiopancreatography (MRCP), and computed tomography (CT) imaging. Multislice CT angiography showed that the arterial ring of the common hepatic artery around the common bile duct (CBD) originated from the superior mesenteric artery. Cholecystectomy and intraoperative cholangiography were performed, as well as decompression and lavage of the biliary tree. Escherichia coli was identified from bile. Dissection of the hepatoduodenal ligament confirmed that the proper hepatic artery made a vascular ring around the CBD. Finally, a T tube was placed into the CBD. During 5 years of follow-up the patient has been without recurrent episodes of jaundice. In such cases dissection of the proper hepatic artery from the common hepatic duct is the treatment of choice. Conclusions If there are signs of cholangitis decompression and lavage of the biliary tree with “T”, drainage should be performed. Vascular malformations should be considered as a possible cause of extrahepatic biliary obstruction. CT angiography may be helpful in identifying these malformations.

Acute appendicitis in a femoral hernia

INTRODUCTION Acute appendicitis in a femoral hernia is an uncommon condition that can be serious. Complications are more frequent if the diagnosis is delayed and surgery is not performed on time. CASE REPORT We present a 71-year-old man with a painful swollen mass. The patient presented with fatigue and loss of appetite, while body temperature was normal. The abdomen was not painful, and peristaltic was normal. All laboratory findings were normal. After anamnesis and physical examination, the presumed diagnosis was incarcerated femoral hernia and the patient was sent to the operating room. Intraoperative findings revealed an incarcerated femoral hernia within a phlegmonous inflammated appendix. Appendectomy and McVay hernioplastics were done. The postoperative course was without complications. CONCLUSION It is very important to bear in mind that right femoral hernia with signs of incarceration and inflammation may contain an acutely inflamed appendix. Delayed diagnosis and misdiagnosis cause greater morbidity and mortality.