Marko Zelić

Surgical tracheostomy versus percutaneous dilational tracheostomy in patients with anterior cervical spine fixation: preliminary report

Study Design. A prospective, randomized study. Objectives. To compare the incidence of perioperative and early postoperative complications of surgical tracheostomy (ST) vs. ultrasound-guided percutaneous dilational tracheostomy (PDT) in patients with anterior cervical spine fixation (ACSF). Summary of Background Data. The patients with ACSF after acute spinal cord injury often require tracheostomy. Surgical tracheostomy is burdened with relatively high incidence of peristomal infections, and, recently, ultrasound-guided PDT is proposed in patients with ACSF. Methods. Sixteen adult patients who underwent tracheostomy after acute spinal cord injury and ACSF were analyzed. The patients were randomly assigned to two groups: eight patients (six males; age range, 24–59 years) who underwent ST and eight patients (seven males; age range, 19–47 years) who underwent ultrasound-guided PDT with dilatational forceps technique. The incidence of peri- and early postoperative complications was followed up, as well as the stoma infections and the duration of the procedure. Results. Not one patient from either group had any major perioperative complication of tracheostomy. In each group, there was one case of prolonged bleeding, which stopped spontaneously inside 24 hours. In two patients (25%) from the ST group, purulent infection of the stoma was verified during subsequent treatment at an intensive care unit. The average time of ST was 21 ± 7 minutes; the average time of ultrasound-guided PDT was 8 ± 6 minutes (P < 0.05). Conclusions. Our preliminary data demonstrate that ultrasound-guided PDT as regards to complications is at least equally safe as ST; at the same time, it is much quicker method, probably with less late infections of the stoma, which could be an important advantage in patients with ACSF.

Thoracodorsal artery as a free graft for coronary artery bypass grafting

Arterial myocardial revascularization using different arterial conduits as mammary, radial, gastroepiploic, subscapular and epigastric arteries are well documented. This report describes a preparation and use of thoracodorsal artery as a free graft for coronary artery bypass grafting. The preparation and removal of thoracodorsal artery were performed through right axilla. The artery was used as a free conduit for left anterior descending artery (LAD) in a 58-year-old female for the second revascularization. The saphenous veins, mammary arteries, right radial artery and epigastric artery were not available. The perioperative course was uneventful and we can recommend the graft as an alternative for such cases.

Fulminant Endogene Gas Gangrene in a Previously Healthy Male

Spontaneous or non-traumatic gas gangrene is a rare condition. The present report refers to a previously healthy 57-y-old male who developed gas gangrene in the left lumbar region, left flank, left scapular, inguinal and suprapubic regions. Despite surgical, intensive care treatment, and antibiotic therapy, the patient died 32 h after the onset of the first symptoms.

Influence of preoperative oral feeding on stress response after resection for colon cancer.

BACKGROUND/AIMS Preoperative management involves patients fasting from midnight on the evening prior to surgery. Fasting period is often long enough to change the metabolic condition of the patient which increases perioperative stress response. That could have a detrimental effect on clinical outcome. The aim of the present study was to investigate the possible effects of carbohydrate-rich beverage on stress response after colon resection. METHODOLOGY Randomized and double blinded study included 40 patients with colon, upper rectal or rectosigmoid cancer. Investigated group received a carbohydrate-rich beverage the day before and two hours before surgery. In the control group patients were in the standard preoperative regime: nothing by mouth from the evening prior to operation. Peripheral blood was sampled 24h before surgery, at the day of the surgery, and 6, 24 and 48h postoperatively. RESULTS Colonic resection in both groups caused a significant increase in serum interleukin 6 (IL-6) levels 6, 24 and 48h after the operation. Increase was more evident and statistically significant in the group with fasting protocol. More significant increase of interleukin 10 (IL-10) occurred in patients who received preoperative nutrition. CONCLUSIONS Smaller increase in IL-6 and higher in IL- 10 are indicators of reduced perioperative stress.

Effect of pyloric dilatation on gastric emptying after pylorus-preserving pancreaticoduodenectomy.

BACKGROUND/AIMS Pylorus-preserving pancreaticoduodenectomy (PPPD) is the standard treatment for periampullary and pancreatic head tumors. Delayed gastric emptying (DGE) is the most common (ranging from 15-45%) but not life threatening complication and impairs patient recovery and prolongs the hospital stay after PPPD. The precise pathomechanism of DGE is still unclear. The aim of this study was to evaluate whether the method of pyloric dilatation performed at the time of PPPD could improve gastric emptying. METHODOLOGY Forty patients underwent PPPD for pancreatic or periampullary lesions from January 1999 to July 2004 were included in this study. In twenty patients mechanical dilatation of the pylorus after duodenal transaction was performed (PPPD+PD group) while in other twenty PPPD was not followed with pyloric dilatation (PPPD group). The incidence of DGE as well as other complications was analyzed. Delayed gastric emptying was defined as gastric stasis requiring nasogastric intubation for more than 4 postoperative days (POD), or the inability to tolerate a regular diet on the 8th POD. RESULTS Delayed gastric emptying occurred in seven (35%) out of the 20 patients in the PPPD group, while none of the 20 patients in the PPPD+PD group developed DGE. CONCLUSIONS Pyloric dilatation reduces DGE after PPPD enabling patients to return sooner to a normal diet.

Double transection of complete duodenal circumference after blunt abdominal trauma without other intra-abdominal injuries

ZusammenfassungWir berichten über einen 20-jährigen männlichen Patienten mit isolierter duodenaler Transsektion in 2 Segmenten des Duodenums nach stumpfem Abdominaltrauma. Bei der Aufnahme wurde der Patient physikalisch untersucht, es wurden ein Abdomen-Ultraschall und eine Abdomen-Leeraufnahme durchgeführt. Die physikalische Untersuchung ergab eine diffuse Defense und ein bretthartes Abdomen mit verminderten Darmgeräuschen. Es wurden die chirurgischen Standardprozeduren durchgeführt (mediane Laparatomie, primäre Anastomose, Nasojejunaler 3-lumiger Tubus zur Ernährung und Dekompression des Magens). Bei der Exploration fanden wir zwei komplette Transsektionen des Duodenums: eine ganz Pylorus-nah und die andere zwischen dem zweiten und dritten Drittel des Duodenums. Wir führten eine primäre Anastomose beider Transsektionen mit 2-lagigen unterbrochenen Nähten durch. Vor der Entlassung wurde eine Magnetresonanzuntersuchung durchgeführt. Eine frühe Diagnose einer Ruptur des Duodenums ist wichtig. Bei der Behandlung von Patienten mit Trauma, die über einen über den Lokalbefund hinausgehenden Schmerz klagen, sollte der Mechanismus der Verletzung immer in Betracht gezogen werden.SummaryWe report a case of a 20-year-old male with isolated complete duodenal transection at two duodenal segments after blunt abdominal trauma. On admission, the patient underwent physical examination, laboratory analysis, abdominal ultrasound and plain abdominal x-ray. Physical examination revealed diffuse and rebound tenderness and extreme rigidity of the abdomen, guarding and decreased bowel sounds. Standard surgical techniques were used (median laparotomy, primary anastomosis, nasojejunal three-luminal tube for feeding and gastric decompression). At exploration, we found complete transection of the duodenum just below the pylorus and between the second and third part of the duodenum. We performed primary anastomosis of both transections with interrupted sutures in two layers. Prior to discharge magnetic resonance imaging (MRI) was performed. Early diagnosis of duodenal rupture is important. When dealing with trauma patients with pain greater than local findings, the mechanism of injury should always be taken into account.

Sudden Death After Endoscopic Retrograde Cholangiopancreatography (ERCP)—Case Report and Literature Review

AbstractThere are only a few cases found in literature regarding air embolism in endoscopic procedures, especially in connection to endoscopic retrograde cholangiopancreatography (ERCP). We are presenting a case of a 56-year-old female patient who suffered from non-Hodgkin lymphoma located in her right groin. She was also diagnosed with choledocholithiasis and underwent ERCP to remove the gallstones. Immediately after the procedure she went into sudden cardiac arrest and subsequently died, despite all of our efforts. We reviewed literature in order to identify possible causes of death because fatal outcome following an uneventful and successful procedure was not expected. It is important to bear in mind all possible complications of ERCP. Our focus during the literature search was on air embolism.

Leiomyoma of the Left Renal Vein A Report of a Case

Abstract Only a few cases of leiomyoma of the vena cava or iliac vein and, according to our knowledge, only one case of renal vein leiomyoma have been reported. We report a patient with leiomyoma of the left renal vein. Tumour resection was performed by resecting a part of the vein along with the tumour and by ligation of the vein. Left kidney drainage was established through the preserved ovarian vein. In order to establish a diagnosis, careful pathologic examination of multiple sections has to be done and because of the potentially malignant behaviour, long-term follow-up after total resection is necessary.

Early postoperative gastric enteral nutrition improves gastric emptying after non-complicated cardiac surgery

Background: Postoperative intragastric enteral feeding in cardiac surgery patients is frequently complicated by delayed gastric emptying. Objective: To evaluate how early postoperative gastric enteral nutrition affects gastric emptying in coronary artery by-pass graft (CABG) surgery patients. Methods: In this prospective, randomized study a group of 40 patients treated in the intensive care unit after CABG surgery were studied. Patients were divided in two groups: group E (20 patients: age 59±8 yr.; male 70%) and control group C (20 patients: age 58±10 yr.; male 80%), respectively. The paracetamol absorption test was used to evaluate gastric emptying. In group E gastric enteral nutrition begun 18 hours after surgery and 6 hours later this was stopped and paracetamol solution was administered. The patients in group C received only crystalloid solutions for first 24 hours. Blood samples were obtained at 0 (t 0), 15 (t+15), 30 (t+30), 60 (t+60) and 120 (t+120) min after administration of paracetamol. Results: The values of plasma paracetamol concentration (PPC) at 15 and 120 min were significantly higher in group E when compared with .group C: (t +15) 3.3±2.5 vs. 1.7±1.9 and (t+120) 5.2±2.8 vs. 3.3±1.6 (p <0.05). The PPC values at 30 and 60 min were higher, but not significantly, in group E vs. group C: (t+30) 3.7±2.0 vs. 2.9±2.7 and (t+60) 5.1±3.2 vs. 3.9±3.5 (p = NS). The area under the PPC curve was 429 ± 309 in the E group vs. 293 ± 204 in the group C (p < 0.05). Conclusion: Early postoperative gastric administration of nutritients after CABG surgery stimulates gastric emptying.

Early postoperative gastric enteral nutrition improve gastric emptying after cardiac surgery

Postoperative intragastric enteral feeding in cardiac surgery patients is frequently complicated by delayed gastric emptying. The aim of the study was to evaluate how early postoperative gastric enteral nutrition affects the gastric emptying in coronary artery by-pass graft (CABG) surgery patients.In the prospective, randomized study 40 patients treated at intensive care unit after CABG surgery were studied. Patients were divided in two groups: enteral feeding group E (20 patients: age 59±8 yr.; male 70%) and control group C (20 patients: age 58±10 yr.; male 80%), respectively. Paracetamol absorption test was used to evaluate gastric emptying. In the group E postoperative gastric supply of enteral formula begun 18 hours after surgery and after 6 hours the supply was stopped and paracetamol solution was administrated by nasogastric tube. The patients in group C for.rst 24 hours received only crystalloid solutions intravenously and paracetamol solution by nasogastric tube. Blood samples were obtained at 0 (t0), 15 (t+15), 30 (t+30), 60 (t+60) and 120 (t+120) min after administration of paracetamol.The values of plasma paracetamol concentration (PPC) at 15 and 120 min were significantly higher in group E vs. group C: (t+15) 3.3±2.5vs. 1.7±1.9 and (t+120) 5.2−2.8 vs. 3.3±1.6 (p <0.05). The PPC values at 30 and 60 min were higher, but not signi.cantly, in group E vs. group C: (t+30) 3.7±2.0 vs. 2.9±2.7 and (t+60) 5.1±3.2 vs. 3.9±3.5 (p = NS). The area under the PPC curve was 429 ± 309 in the E group vs. 293 ± 204 in the group C (p < 0.05).In conclusion an early postoperative gastric administration of nutritients after CABG surgery stimulates the gastric emptying.