Ljiljana Jeremic

Diagnostic Importance of Pulse Oximetry in the Determination of the Stage of Chronic Arterial Insufficiency of Lower Extremities

INTRODUCTION Chronic arterial insufficiency (CAI) of lower extremities is important socio-economical and healthcare problem, due to its high incidence of morbidity, disability and mortality. OBJECTIVE The aim of our work was to determine the diagnostic importance of pulse oximetry in the early detection of stage of lower extremities CAI based on peripheral arterial oxygen saturation of haemoglobin (SpO2). METHODS Prospectively, we analyzed a group of 50 patients, admitted at the Vascular Department of Surgical Clinic in Nis during the period from September 2006 to October 2007, with evident symptoms and signs of different stages of lower extremities CAI verified by ultrasonography. In patients with lower extremity disorder of tissue arterial capillaries, SpO2 was determined by pulse oximetry. RESULTS Using pulse oximetry, depending on the of stage of lower extremities CAI, we revealed a considerable difference in the stages of functional ischemia SpO2: Fontaine I - 95.33 +/- 1.41%, Fontaine IIa - 92.14 +/- 2.27% and Fontaine IIb - 79.67 +/- 2.73%; in stage critical ischemia SpO2: Fontaine III - 62.54 +/- 4.39% and Fontaine IV - 47.67 +/- 6.16%. In 3 patients with gangrenous foot and fingers SpO2 was immeasurable and progressive decrease in SpO2 of arterial capillaries (p < 0.01 between stages). CONCLUSION Due to the reliability and simplicity of pulse oximetry it can be a routinely used diagnostic device for patients with early determined stage of lower extremities CAI.

Double giant chronic bilomas with late presentation: 9 years after cholecystectomy.

Dear Editor, We have the intention to report of a 68-year-old man with very late presentation of two well-encapsulated giant bilomas. They occurred 9 years after open cholecystectomy, performed for an acute calculous cholecystitis. Early and late postoperative course was absolutely uneventful. Nine years later, few days before actual admission, he felt unclear symptoms of abdominal pressure and discomfort. Clinical examination and ultrasonography (US) showed large cystic masses in the right and left part of the abdomen. Computed tomography (CT) density values were 16 Hounsfield units (HU). At first, we suspected on the extrapancreatic pseudocysts. However, the pancreas was normal on the CT. At magnetic resonance imaging (MR), lesions were heterogeneously intense (T1) and homogenously hyperintense on the T2-weighted images (Figs. 1 and 2). Magnetic resonance cholangiopancreatography (MRCP) showed a normal biliary tree, with no strictures or stones and without any communication. Analysis of percutaneous needle aspirate showed clear bile with no cellular structures and bilirubin concentration of 680 mcm/L. The bilomas measured in total 5.2 L of the stagnant bile. The smaller one (16.3×10.7 cm) was located in the right part of the abdomen, into the subhepatic space and right paracolic gutter. The bigger one (22.7×11.2 cm) occupied left subphrenic space with propagation into the left paracolic gutter. Because of the failure of percutaneous drainage (incomplete drainage of the left biloma despite of the two repositioning of the drainage catheter), the patient was operated on, with simple surgical drainage. Surgical exploration and intraoperative cholangiography showed a normal biliary tree. The patient remains symptom-free with normal clinical and laboratory data more than 12 months after surgery. A biloma is a well-demarcated, encapsulated or not, bile collection outside the biliary tree caused by iatrogenic, traumatic, and spontaneous injury of the biliary tree [1–6]. It usually arises a few days or weeks after the injury [2, 3, 7]. Slow leakage of uninfected bile may be asymptomatic for a long time. The main curiosity in our case report is the fact that the patient was asymptomatic for 9 years after the cholecystectomy. We believe that biloma occurred from lowproducing bile leakage as a complication of cholecystectomy. Our opinion is based on the fact that stagnant bile was firmly captured inside a 5-mm-thick fibrous capsule biloma. Also, the bilomas might be a result of typical spontaneous rupture of the biliary tree during the long period of the 9 years after operation [2, 6]. The size and location of bilomas depend on the cause of the biliary rupture, the site and the rate of the bile leakage, and the reabsorption capacity of the peritoneum [3, 10]. The maximal reported diameter of the biloma was 40 cm containing 5,700 mL of bile [3]. Most extrahepatic bilomas are located on the right. However, bilomas may be found in the left upper quadrant or bilaterally [2, 10]. Retroperitoneal localization of the biloma is very rare [7], with the possibility of the abdominal wall bile staining [8] or biliscrotum formation [9]. The diagnosis is established on the clinical history, biloma location, US, CT, and MRCP findings. The USguided percutaneous needle aspiration with a chemical analysis definitely confirms the diagnosis of biloma. Although the asymptomatic patients may be treated conservatively, the appropriate treatment for most of the Langenbecks Arch Surg (2008) 393:617–618 DOI 10.1007/s00423-007-0270-6

Safety of simultaneous colon and liver resection for colorectal liver metastases

BACKGROUND/AIM Surgical strategy for the treatment of resectable synchronous hepatic metastases of colorectal cancer (CRC) remains controversial. The aim of this study was to assess safety of simultaneous colon and liver rese cions and the direct effects of this type of treatment upon morbidity and mortality of the patients with synchronus hepatic metastases of CRC. METHODS Intraoperative and postoperative data of 31 patients with simultaneous liver and colorectal resection were compared with the data of 51 patients who had undergone colon and hepatic resection in the staging setting. Analized were demographic data, number of metastases, type of the liver resection, operation time, intraoperative blood loss, percentage of postoperative complications, morbidity and mortality and lenght of hospitalisation. RESULTS In the group of the patients operated simultaneously 5 hepatectomies, 3 sectionectomies, 2 trisegmentectomies, 3 bisegmentectomy, 6 segmentectomies, and 12 metastasectomies were combined with colon resection. In this group operation time (280 vs. 330 minutes) and in traoperative blood loss (450 vs. 820 ml) were lower than those in the two staged operation group. Postoperative complication rate was lower in the simultaneous group (19.35%o) than in the two-staged operation group (19.60%), without statistical significance. There was no hospital mortality in both groups. The patients having simultaneous resection required fewer days in the hospital (median 10.2 days) than the patients undergone operation in the two stage (18.34 days). CONCLUSION By avoiding a second laparotomy, overall operation time, blood loss, hospital stay and complication rate are reduced with no change in hospital mortality, so simultaneous colon and hepatic resection performed by the competent surgeons are safe and efficient for the treatment of synchronous colorectal liver metastases.

Histopathologic differentiation as a prognostic factor in patients with carcinoma of the hepatopancreatic ampulla of Vater

Objective Periampullary carcinomas are a group of neoplasms with variable histopathology that originate from the anatomical junction of different epithelial types including the bile duct, pancreatic duct, and duodenal mucosa. This study was performed to determine whether the histopathologic type of these tumors should be considered an independent prognostic factor. Methods We analyzed the specimen histopathology of 37 patients who underwent radical cephalic pancreatoduodenectomy for carcinoma of the ampulla of Vater during a 5-year period. We excluded patients with other tumors with an indication for Whipple’s procedure and those in whom R0 resection was not achieved. Results The carcinomas of the hepatopancreatic ampulla were intestinal in 23 (62%) patients, pancreatobiliary in 13 (35%), and mixed type in 1 (3%). The analysis demonstrated significantly more advanced local tumor spread, a more aggressive lymph node metastasizing pattern, and more frequent lymphatic and perineural invasion in patients with pancreatobiliary than intestinal and mixed type tumors. Conclusion Pancreatobiliary type of ampullary carcinoma is associated with a poorer prognosis than intestinal and mixed types because of its more aggressive behavior. Histopathology should be regarded as an independent predictor of survival and may have therapeutic and prognostic implications for patients.

Necrotizing soft tissue infection in pregnancy

Introduction Necrotizing soft tissue infection (NSTI) is a life-threatening condition, characterized by widely spread necrosis of skin, subcutaneous fat, fascia and muscles. Treatment involves surgical debridement and broad-spectrum antimicrobial therapy. Mortality is still high due to diagnostic delays. NSTI is rare in general population, there are even less literature data of this condition in pregnancy. Timely diagnosis and therapy is crucial for outcome of these patients. Clinicians should have in mind NSTI in patients with perianal infections, especially in cases where immunosuppressive role of pregnancy is present. Case outline We present a case of a 21-year-old pregnant woman with NSTI spreading from perianal region. The patient was admitted to hospital in the 31st week of otherwise healthy twin pregnancy one day after incision of perianal abscess. At admission she was examined by a gynecologist; vital signs were stable, laboratory results showed the presence of infection. She was referred for another surgical procedure and broad-spectrum antibiotics were prescribed. The next morning the patient complained of intense abdominal pain. Clinical exam revealed only discrete redness of the skin tender on palpation, crepitating. She was immediately referred to surgery. Intraoperative findings revealed massive soft tissue infection spreading up to the chest wall. Wide skin incisions and debridement were performed. The patient developed septic shock and after initial resuscitation gynecologist confirmed intrauterine death of twins and indicated labor induction. Over the next few days the patient’s general condition improved. On several occasions the wounds were aggressively debrided under general anesthesia, which left the patient with large abdominal wall defect. Twenty-three days after the initial operation, the defect was reconstructed with partial-thickness skin grafts, providing satisfactory results. Conclusion Diagnosis and outcome of NSTI are challenging for many reasons. Course of the disease is rapid and hidden. Chances of survival depend on early recognition and prompt treatment.