Mario Zovak

Comparison of Surgical Treatments of Gallstone Ileus: Preliminary Report

Gallstone ileus is an uncommon cause of small bowel obstruction, accounting for only 1% to 4% of all intestinal obstructions. In the group of patients over 65 years of age, gallstones cause about 25% of all non-strangulated obstructions of the small bowel. Gallstone ileus is burdened with high mortality rate, ranging from 12% to 18%, and most patients are of advanced age, with many other concomitant diseases that may increase the operative risk. The purpose of this study was to compare the two investigated surgical procedures: treatment of intestinal obstruction alone or combined with urgent cholecystectomy and fistula repair. Analysis of 30 patients undergoing operation for gallstone ileus at the Clinical Hospital “Sestre milosrdnice” between 1985 and 2001 is presented. Patients were treated either for ileus alone (group 1, 11 patients) or as one-stage procedure with urgent fistula closure (group 2, 19 patients). Operating time was significantly longer for the one-stage procedure. Complications occurred in 3 of 11 patients (27.3%) from group 1 and in 11 of 18 patients (61.1%) from group 2 (one tailed, p = 0.043). One patient in group 1 died and two patients in group 2 died. Urgent fistula repair was significantly associated with the occurrence of complications (odds ratio [OR] 12.1, 95% confidence internal [95% CI] 1.2–121.5). Simple enterotomy should be the procedure of choice for patients with gallstone ileus. The one-stage procedure including urgent fistula repair should be reserved only for highly selected patients with absolute indications.

Pancreatic surgery: evolution and current tailored approach

Surgical resection of pancreatic cancer offers the only chance for prolonged survival. Pancretic resections are technically challenging, and are accompanied by a substantial risk for postoperative complications, the most significant complication being a pancreatic fistula. Risk factors for development of pancreatic leakage are now well known, and several prophylactic pharmacological measures, as well as technical interventions have been suggested in prevention of pancreatic fistula. With better postoperative care and improved radiological interventions, most frequently complications can be managed conservatively. This review also attempts to address some of the controversies related to optimal management of the pancreatic remnant after pancreaticoduodenectomy.

Papillary renal cell‐like carcinoma in a retroperitoneal teratoma

We report a case of somatic type malignancy with papillary renal cell carcinoma differentiation arising in a retroperitoneal mixed germ cell tumor. The patient was a 36‐year‐old man with a synchronous mediastinal teratoma. The somatic type malignancy in the retroperitoneal tumor was composed of papillary structures covered by atypical epithelial cells with eosinophilic cytoplasm, prominent nucleoli and pseudostratified nuclei. Papillary cores contained numerous aggregates of foamy macrophages, typical of type I papillary renal cell carcinomas. The immunohistochemical profile was consistent with papillary renal cell carcinoma, including positive reactions for cytokeratin 7 and alpha‐methyl acyl CoA racemase. There was no somatic type malignancy component in the synchronous mediastinal teratoma. Both the retroperitoneal and the mediastinal tumor showed gains of 12p and chromosome 17 material. There was no c‐MET mutation in the somatic type malignancy. To our knowledge, this is the first report of a somatic type malignancy with features of papillary renal cell carcinoma arising in a germ cell tumor. It is important not to confuse such a retroperitoneal tumor with a conventional papillary renal cell carcinoma, because presence of other malignant histologies within the germ cell tumor may warrant different treatment. In such cases, the presence of isochromosome 12p can be helpful to the diagnosis.

Lack of prognostic significance of connexin-43 labeling in a series of 46 gastrointestinal stromal tumors

Background Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors with variable malignant potential. Connexin-43 (C×43) is the commonest gap-junction protein and has been frequently investigated in oncology. Our aim was to establish the immunohistochemical expression of C×43 in relation to GIST location, size, Ki67 index, tumor grade and follow-up. Materials and methods The study included postoperative samples of 46 patients treated for GIST in the 1999–2010 time frame. Complete clinical workup was available for 38 patients (82.6%); total surgical resection was carried out in 32 (84.2%) patients, while 13 (34.2%) patients underwent chemotherapy. Median follow-up was 40.7 months (range, 1-134). Results The calculated incidence of GIST in our setting was 11.5 per million. C×43 was expressed in 43/46 (93.5%) GIST cases, with a significant difference between stomach- and small intestine-derived tumors (p=0.006). Ki67 was 10% on average (range, 1–22) and was not correlated with tumor location (p=0.194). C×43 did not show significance with regard to tumor size (p=0.264) or higher tumor grade (p=0.658), as opposed to Ki67, which significantly correlated with both (p=0.0048 and p<0.001, respectively). C×43 and Ki67 were not significantly correlated (p=0.708). Ki67 correlated with time to recurrence (p=0.022). Ki67 >11% was taken as the indication to start imatinib chemotherapy (sensitivity 61.5%, specificity 92.0%, p=0.022). Ten (66.7%) of 15 patients with long-term (>5 years) follow-up were in remission. Conclusion C×43 was frequently expressed in GISTs regardless of tumor site. However, no significant relationships to histopathological parameters suggestive for prognosis were found. Further investigations might clarify the roles of C×43 in GIST oncogenesis.

Significance of surgery for prognosis of gist in cohort from transitional healthcare settings

OBJECTIVE Despite significant improvement in survival of gastrointestinal stromal tumors (GIST) due to use of tyrosine kinase inhibitors, surgery still represents the important part of clinical management. The aim of our study was to retrospectively analyze prognosis of GIST depending on the success of surgical treatments and utilization of chemotherapy in transitional country with relatively limited resources. METHODS cohort of consecutive patients operated for GIST in tertiary medical center, within time frame 1999-2012. RESULTS 54 patients, in age range 20-85 years (63.3 ± 14.7), male to female ratio 28 (51.9%):26 (48.1%), respectively. Complete excision with clean resection margins (R0) was obtained in 44 (81.5%)of total patients i.e. 44/47 (93.6%) of localized GISTs. Mean follow up was 3.9 ± 3.3 years and 19 patients (35.2%) received imatinib. Rate of overall survival was 40 (74.1%), disease-free survival 31 (57.4%) and 20 (37.0%) experienced recidivism. Follow-up parameters showed significant difference in connection with utilization of imatinib, completeness of resection and existence of metastatic disease (all p < 0.05). ROC analyzes revealed critical value of Ki-67 > 9% as significant predictor of long-term mortality; sensitivity 64.3% [95%CI = 35.1-87.2]; specificity 75.0% [58.8-87.3]; (AUC = 0.693; p = 0.049). CONCLUSION Rate of complete resections in studied sample of patients from transitional background was overall peer comparable with reports from the developed countries. On the other hand, relatively dominant prognostic position of surgical treatments might be consequence of limited utilization of adjuvant treatment with tyrosine kinase inhibitors.

Retroperitoneal cystic lesion: an unusual first manifestation of metastatic testicular cancer

Retroperitoneal and intraabdominal cystic lesions are rare entities, and pose diagnostic and therapeutic challenge. All those lesions should be managed case by case, based on previous medical history, diagnostic imaging features and eventually percutaneous cytological analysis. In case of uncertain preoperative diagnosis, malignancy should always be ruled out with surgical removal or biopsy.

Bleeding Peptic Ulcer – Tertiary Center Experience: Epidemiology, Treatment and Prognosis

The aim of this study was to demonstrate epidemiological, clinical and endoscopic characteristics of acute upper gastrointestinal bleeding (UGIB) with special reference to peptic ulcer bleeding (PUB). The study included 2198 consecutive patients referred to our emergency department due to acute UGIB from January 2008 to December 2012. All patients underwent urgent upper GI endoscopy within 24 hours of admission, and 842 patients diagnosed with PUB were enrolled and prospectively followed-up. The cumulative incidence of UGIB was 126/100,000 in the 5-year period. Two out of five patients had a bleeding peptic ulcer; in total, 440 (52.3%) had bleeding gastric ulcer, 356 (42.3%) had bleeding duodenal ulcer, 17 (2%) had both bleeding gastric and duodenal ulcers, and 29 (3.5%) patients had bleeding ulcers on gastroenteric anastomoses. PUB was more common in men. The mean patient age was 65.9 years. The majority of patients (57%) with PUB were taking agents that attenuate the cytoprotective function of gastric and duodenal mucosa. Rebleeding occurred in 77 (9.7%) patients and 47 (5.9%) patients required surgical intervention. The 30-day morality was 5.2% and 10% of patients died from uncontrolled bleeding and concomitant diseases. In conclusion, PUB is the main cause of UGIB, characterized by a significant rebleeding rate and mortality.

Osjetljivost i specifičnost Fenyö-Lindbergova i Teicherova sustava bodovanja u dijagnostici akutne upale crvuljka u žena

The aim of the study was to assess diagnostic accuracy (sensitivity and specificity) of Fenyö-Lindberg and Teicher scores for distinguishing patients that need immediate surgical treatment from the others, in a female population from an urban setting. The study prospectively included 130 female patients admitted to the emergency department with abdominal pain indicating acute appendicitis. The scores and parameters of validity were calculated and compared to definitive diagnosis. For Fenyö-Lindberg score of -17 or less, 84.5% sensitivity, 55.6% specificity, 87.9% positive predictive value (PPV) and 48.4% negative predictive value (NPV) were recorded. For cut-off value greater or equal to -2, there was 59.2% sensitivity, 77.8% specificity, 91% PPV and 33.3% NPV. The Receiver Operating Characteristic (ROC) curve analysis of Fenyö-Lindberg score showed that the best single cut-off value for discriminating acute appendicitis in the study population was -15. For Teicher score, values greater than -3 yielded 89.3% sensitivity and 22.2% specificity, 81.4% PPV and 35.3% NPV. In conclusion, Fenyö-Lindberg score could be used as an additional tool to exclude appendicitis and avoid unnecessary appendectomies. Teicher score may help in recognizing patients with appendicitis. None of the two scores can indicate or decline appendectomy in all cases. Scoring systems may be useful for pointing to important clinical signs and symptoms in specific subpopulations.

Familial adenomatous polyposis in three generations of a single family: a case study.

Background: Familial adenomatous polyposis (FAP) is an autosomal dominantly inherited syndrome characterized by the development of numerous polyps in the colon and rectum. If left untreated, the affected patients inevitably develop colon cancer by the age of 40 years. A resection of the colon (colectomy) or of the colon and rectum (proctocolectomy) is needed to minimize the risk of cancer. Case Presentation: We report a case of FAP through three generations of a single family, in which the grandmother and granddaughter underwent total colectomy with ileoanal anastomosis and did not develop colon cancer, while the son underwent subtotal colectomy with ileorectal anastomosis and developed recurrent rectal cancer. Data regarding timely surgery, surveillance, and chemoprevention are discussed. Conclusion: The FAP phenotype determines the type of treatment. In severe polyposis, proctocolectomy with ileoanal anastomosis seems to be the optimal method for minimizing the risk of cancer development. This case report advocates complete rectal removal, especially in cases of poor patient compliance with colonoscopic surveillance.

The Emergence and Ozone Treatment Studies of Living Cells

Most processes in biomedicine can hardly be addressed within some physicists’ reductionist views. More appropriate is the emergence approach, the process of complex pattern formations from simpler rules, that was introduced by biologists, and that has a natural place within bio-complexity. There is nothing that commands the system to form an emergent pattern, but instead the interactions of each part, to its immediate surroundings, causes a complex process which leads to some form of order. One such emergent process in re-balancing of tissue cells is the high-frequency bio oxidative treatment. Ozone therapy is a well established alternative and complementary treatment in most mainland EU countries and The European Cooperation of Medical Ozone Societies publishes guidelines on medical indications and contraindications of ozone and hosts expert training seminars. Here we describe the accumulated know-how on the use of feeble active flux of ozone in the cell healing and briefly discuss several tested ozone treatments in dentistry and medicine (herpes, muscle recovery, injury recovery etc.).