Mihailo Bezmarevic

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.

An aortoduodenal fistula as a complication of immunoglobulin G4-related disease.

Most primary aortoduodenal fistulas occur in the presence of an aortic aneurysm, which can be part of immunoglobulin G4 (IgG4)-related sclerosing disease. We present a case who underwent endovascular grafting of an aortoduodenal fistula associated with a high serum IgG4 level. A 56-year-old male underwent urgent endovascular reconstruction of an aortoduodenal fistula. The patient received antibiotics and other supportive therapy, and the postoperative course was uneventful, however, elevated levels of serum IgG, IgG4 and C-reactive protein were noted, which normalized after the introduction of steroid therapy. Control computed tomography angiography showed no endoleaks. The primary aortoduodenal fistula may have been associated with IgG4-related sclerosing disease as a possible complication of IgG4-related inflammatory aortic aneurysm. Endovascular grafting of a primary aortoduodenal fistula is an effective and minimally invasive alternative to standard surgical repair.

Interventional Treatment of Abdominal Compartment Syndrome during Severe Acute Pancreatitis: Current Status and Historical Perspective

Abdominal compartment syndrome (ACS) in patients with severe acute pancreatitis (SAP) is a marker of severe disease. It occurs as combination of inflammation of retroperitoneum, visceral edema, ascites, acute peripancreatic fluid collections, paralytic ileus, and aggressive fluid resuscitation. The frequency of ACS in SAP may be rising due to more aggressive fluid resuscitation, a trend towards conservative treatment, and attempts to use a minimally invasive approach. There remains uncertainty about the most appropriate surgical technique for the treatment of ACS in SAP. Some unresolved questions remain including medical treatment, indications, timing, and interventional techniques. This review will focus on interventional treatment of this serious condition. First line therapy is conservative treatment aiming to decrease IAP and to restore organ dysfunction. If nonoperative measures are not effective, early abdominal decompression is mandatory. Midline laparostomy seems to be method of choice. Since it carries significant morbidity we need randomized studies to establish firm advantages over other described techniques. After ACS resolves efforts should be made to achieve early primary fascia closure. Additional data are necessary to resolve uncertainties regarding ideal timing and indication for operative 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.

Endovascular repair of ruptured abdominal aortic aneurysm

Introduction. Rupture of an abdominal aortic aneurysm (AAA) is a potentially lethal state. Only half of patients with ruptured AAA reach the hospital alive. The alternative for open reconstruction of this condition is endovascular repair (EVAR). We presented a successful endovascular reapir of ruptured AAA in a patient with a number of comorbidities. Case report. A 60-year-old man was admitted to our institution due to diffuse abdominal pain with flatulence and belching. Initial abdominal ultrasonography showed an AAA that was confirmed on multislice computed tomography scan angiography which revealed a large retroperitoneal haematoma. Because of patient’s comorbidites (previous surgery of laryngeal carcinoma and one-third laryngeal stenosis, arterial hypertension and cardiomyopathy with left ventricle ejection fraction of 30%, stenosis of the right internal carotid artery of 80%) it was decided that endovascular repair of ruptured AAA in local anaesthesia and analgosedation would be treatment of choice. Endovascular grafting was achieved with aorto-bi-iliac bifurcated excluder endoprosthesis with complete exclusion of the aneurysmal sac, without further enlargment of haemathoma and no contrast leakage. The postoperative course of the patient was eventless, without complications. On recall examination 3 months after, the state of the patient was well. Conclusion. The alternative for open reconstruction of ruptured AAA in haemodynamically stable patients with suitable anatomy and comorbidities could be emergency EVAR in local anesthesia. This technique could provide greater chances for survival with lower intraoperative and postoperative morbidity and mortality, as shown in the presented patient.

Endovascular repair of mycotic aneurysm of the descending thoracic aorta: diagnostic and therapeutic dilemmas-two case reports with 1-year follow-up.

A mycotic aneurysm of the thoracic aorta is a rare diagnosis with high mortality. We present two cases of endovascular reconstruction of mycotic descending thoracic aorta. Specific or nonspecific bacterial or other infectious agent in serial samples of blood, urine, cerebrospinal fluid, and pleural puncture was not detected in the first case, but we found in sputum sample Mycobacterium tuberculosis in the second patient. We empirically began by administering broad-spectrum intravenous antibiotics in the first case, with preoperative antibiotic prophylaxis and antituberculotic drugs therapy in the second case, and continued with the same medication for 4 months after endovascular repair. Control computed tomographic scans 6 months after reconstruction showed no endoleak in both patients. Repair of mycotic descending thoracic aortic aneurysms by endoluminal stent graft is reasonable alternative to open surgical intervention. A broad-spectrum antibiotic therapy has a high significance in the treatment of patients with mycotic aneurysm.

Nutritional Support of Patients with the Abdominal Compartment Syndrome during Severe Acute Pancreatitis

Copyright ©2016 Bezmarevic M. This is an open access article distributed under the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Volume 1 : Issue 1 Article Ref. #: 1000POJ1105 Nutritional Support of Patients With the Abdominal Compartment Syndrome During Severe Acute Pancreatitis

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

Commentary: What Is the Appropriate Treatment of Immunoglobulin G4-Related Vascular Lesions?:

Since immunoglobulin G4-related disease (IgG4-RD) was first reported with regard to autoimmune pancreatitis, this entity has been expanded to other organs, such as the retroperitoneum, biliary tract, salivary gland, kidney, and lung. Irrespective of the organ of origin, IgG4-RD shows common clinical and pathological features. A frequent occurrence in adult male patients, IgG4-RD is characterized by elevated serum IgG4 level and steroid sensitivity. Diffuse lymphocytic IgG4-positive plasma cell infiltration, irregular fibrosis, and phlebitis are the most common pathological features. Due to severe and possibly lethal complications, it is right to say that blood vessel involvement represents a particular form of IgG4-RD. For vascular lesions in this entity, the pathological changes in large to medium size arteries occur mainly in the adventitia, but the media and intima can be involved also. The aorta is affected most often. Inflammatory changes lead to damage of the aortic wall, directly contributing to aneurysm development or dissection. Also, retroperitoneal inflammation (fibrosis) can extend into the periaortic tissues, including the adventitia, with IgG4-positive plasma cell infiltration causing chronic periaortitis. The main feature in IgG4-RD affecting the aorta is periaortitis, but true aortitis affecting the media is most likely responsible for aneurysm development. The term ‘‘IgG4-related aortitis/periaortitis’’ was advocated in the recent consensus conference on nomenclature. An arterial lesion in IgG4-RD could be associated with aneurysms or not. On the other hand, the existence of fibrotic, inflammatory, and thickened tissue around the arteries decreases the possibility of their rupture. In comparison between non-IgG4 inflammatory abdominal aortic aneurysm (IAAA) and IgG4 IAAA, Kasashima et al. reported that aneurysmal rupture in IgG4 IAAA was less frequent than that in nonIgG4 IAAA (0% vs. 30%). Actually, there are only a few cases reported in the literature of complete or contained aneurysm rupture in IgG4-RD, but only one case with ruptured aorta due to periaortitis, as Kasashima et al. report in this issue of the JEVT. These cases have reported IAAA rupture in two of them, one with dissection of the ascending aorta, one IgG4-IAAA contained rupture, and one case with ruptured visceral artery. In these patients, two of them died, including the current case by Kasashima et al. The patient reported by Qian et al. had no follow-up presented. Five of these patients underwent surgery, three of them with an open surgical repair (OSR) and two with endovascular aneurysm