Miodrag Radunovic

Clinical outcome in patients with hilar malignant strictures type II Bismuth-Corlette treated by minimally invasive unilateral versus bilateral endoscopic biliary drainage

BACKGROUND Stenting of malignant hilar strictures remains a standard endoscopic treatment in patients with unresectable tumors. The aim of this two-center prospective study was to compare unilateral versus bilateral drainage in hilar malignant stenosis Bismuth-Corlette type II. METHODS During a 3-year period, a total of 49 patients with hilar tumors (Bismuth-Corlette type II) were referred for endoscopic treatment, following the criteria of unresectability. Ultrasound, computed tomography scan and magnetic resonance cholangiopancreatography (MRCP) were previously performed in all patients in order to facilitate endoscopic retrograde cholangiopancreatography (ERCP). The stricture was first passed by the hydrophilic guide-wire and then contrast medium was injected. Mechanical bile duct dilation was performed, followed by plastic stent placement only in the liver lobe which was previously opacified. The procedures were performed under conscious sedation. The patients were followed up for the next 12 months with a stent exchange every 3 months. Primary outcome was assessed by patient survival in the first 12 months after the procedure. RESULTS All 49 patients were treated with ERCP while 39 (79.59%) had successful stent placement. Among these, 32 had hilar cholangiocarcinoma (82%) and 7 (18%) had gallbladder cancer. Two groups of patients had Bismuth II strictures: A, 21 patients (54%) with unilateral contrast injection and drainage, and B, 18 (46%) with bilateral contrast injection and drainage. A total of 57 plastic stents were used (10 Fr, 89%; 11.5 Fr, 11%). Group B showed a lower bilirubin level 7 days after the procedure (P=0.008). Early complications were cholangitis (3 patients, 2 in group A and 1 in group B) and acute pancreatitis (2 patients, 1 each in A and B) with no statistical difference between the groups. Late complications were stent migration (5 patients, 1 in A and 4 in B) and stent clogging (6 patients, 2 in A and 4 in B) showing a significant difference between the groups (P<0.01). The first stent replacement after 3 months was successful in 87% of patients (four died due to disease progression and one due to cardiopulmonary insufficiency) showing no statistical difference between the groups. At 6 months follow-up, 72% patients survived, with no statistical difference between the groups. A final follow-up (12 months) showed the survival rate of 18% (4 patients from group A and 3 from group B) (P>0.05). CONCLUSIONS A minimally invasive approach, based on the criterion that every bile duct being opacified needs to be drained, is associated with a lower incidence of early complications. Considering that the clinical outcome measured by bilirubin level was lower in patients with bilateral drainage 7 days after the procedure, we assumed that drainage of 50% or more of the liver volume leads to sufficient drainage effectiveness.

Smallpox as actual biothreat: lessons learned from its outbreak in ex-Yugoslavia in 1972

Variola (smallpox) virus is classified as class A of potential biological weapons, due to its microbiological, genetic, antigenic and epidemiological characteristics. The potential danger is more real because vaccination against smallpox has stopped since disease eradication in 1979. That is why we want to share our unique, rich experience and acquired knowledge in the fight against this highly contagious and deadly disease during the smallpox outbreak in ex-Yugoslavia in 1972. It was the largest postwar outbreak in Europe when there were officially registered 175 ill patients, 35 of them with lethal outcome. This outbreak was specific by the time of its occurrence, the affected territory, dimensions and some epidemiological characteristics, but also by the well-organized, synchronized and efficient reaction of the competent state services in the fight against it.

Preoperative misdiagnosed gastrointestinal stromal tumor surgical “transferred” into gastric duplication cyst

Introduction. Gastrointestinal duplications are rare congenital anomalies, especially in the adult population which can occur along the entire gastrointestinal tract. The rarest among them are gastric duplications, making up 2–8% of all gastrointestinal duplications. Unusual embryonic malformations can be found even in the adult population and should always be considered in the differential diagnosis of thoraco-abdominal tumors. Unclear findings during preoperative diagnostic procedures are the reason for presenting the case. Case report. We present a 33 years old female, with tumorous lesion in the stomach wall, which had the endoscopic ultrasound features of gastrointestinal stromal tumor. During surgery, it was determined that the lesion was actually a cystic formation with gelatin content and histological examination confirmed the diagnosis of gastric duplication cyst. Conclusion. Preoperative diagnosis of gastric duplication cyst has always been a challenge for clinicians, since its morphological appearance may vary. That is the reason why these anomalies are often misdiagnosed as solid tumorous lesions by imaging methods and even by the most superior ones, and set up the surgery as a part of diagnostic algorithm.

Complications of Laparoscopic Cholecystectomy: Our Experience from a Retrospective Analysis.

AIM: The aim of this study was to evaluate the intraoperative and postoperative complications of laparoscopic cholecystectomy, as well as the frequency of conversions. MATERIAL AND METHODS: Medical records of 740 patients who had laparoscopic cholecystectomy were analysed retrospectively. We evaluated patients for the presence of potential risk factors that could predict the development of complications such as age, gender, body mass index, white blood cell count and C-reactive protein (CRP), gallbladder ultrasonographic findings, and pathohistological analysis of removed gallbladders. The correlation between these risk factors was also analysed. RESULTS: There were 97 (13.1%) intraoperative complications (IOC). Iatrogenic perforations of a gallbladder were the most common complication - 39 patients (5.27%). Among the postoperative complications (POC), the most common ones were bleeding from abdominal cavity 27 (3.64%), biliary duct leaks 14 (1.89%), and infection of the surgical wound 7 patients (0.94%). There were 29 conversions (3.91%). The presence of more than one complication was more common in males (OR = 2.95, CI 95%, 1.42-4.23, p < 0.001). An especially high incidence of complications was noted in patients with elevated white blood cell count (OR = 3.98, CI 95% 1.68-16.92, p < 0.01), and CRP (OR = 2.42, CI 95% 1.23-12.54, p < 0.01). The increased incidence of complications was noted in patients with ultrasonographic finding of gallbladder empyema and increased thickness of the gallbladder wall > 3 mm (OR = 4.63, CI 95% 1.56-17.33, p < 0.001), as well as in patients with acute cholecystitis that was confirmed by pathohistological analysis (OR = 1.75, CI 95% 2.39-16.46, p < 0.001). CONCLUSION: Adopting laparoscopic cholecystectomy as a new technique for treatment of cholelithiasis, introduced a new spectrum of complications. Major biliary and vascular complications are life threatening, while minor complications cause patient discomfort and prolongation of the hospital stay. It is important recognising IOC complications during the surgery so they are taken care of in a timely manner during the surgical intervention. Conversion should not be considered a complication.