Miroslav Mitrovic

[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.

Portosystemic shunt in the treatment of portal hypertension

Hirurgija santova u dekompresiji portnog sistema tehnicki se tokom vremena znacajno menjala. U toku evolucije lecenja izgubila je primat u tretmanu portne hipertenzije. Do devedestih godina proslog veka hirurgija gotovo da nije imala alternativu, ali pojavom novih lekova, endoskopske sklerozacije, TIPS i transplantacije jetre izbor za hirurgiju je znatno sužen. U profilaksi prvog variksnog krvarenja sant hirurgija nije indikovana zato sto je tesko sa apsolutnom sigurnoscu odrediti bolesnika koji ima visok rizik od krvarenja iz variksa, ocuvanu funkciju jetre tako da bez rizika može podneti sant. Bolesnik sa dobrom funkcijom jetre (A i B klasa po CTP klasifikaciji) kandidat je za sant hirurgiju, a samo u izuzetnim slucajevima i bolesnik sa ozbiljnim ostecenjem jetre. Selektivni sant je opcija koja obezbeđuje dobru variksnu dekompresiju i zadovoljavajuce održavanje funkcije jetre. Rezultati kod ovog santa umnogome zavise od vestine hirurga. Kod urgentnih krvarenja iz variksa prvo treba pokusati sa primenom lekova i skleroterapijom, a u slucaju neuspeha neophodno je primeniti sant hirurgiju, pri cemu se mora voditi racuna o opstem stanju bolesnika kako bi se iskoristilo optimalno vreme. Sant može poslužiti kao odlican dugorocni most do transplantacije jetre za bolesnike sa ocuvanom hepaticnom rezervom. Primena santova u dekompresiji portnog sistema jos uvek igra važnu ulogu u tretmanu pažljivo selektovanih bolesnika sa variksnim krvarenjem koji u buducnosti nece biti u prilici da im se uradi transplantacija jetre.

Mesoatrial shunt in Budd-Chiari syndrome

BACKGROUND Budd-Chiari syndrome (BCS) represents partial or total occlusion of the hepatic veins with or without simultaneous obstruction of vena cava inferior (VCI). The symptoms of BCS are abdominal pain, hepatomegaly, ascites, varices of the abdominal wall, sometimes bleeding from the upper part of gastointestinal tract (GIT), lower limbs swelling and jaundice. Primary BSC is a relatively rare condition occuring in one per 100,000 of the population worldwide. CASE REPORT A male patient, 25-year-old, facing tooth postextraction complications, was presented with acute BCS. On admission, physical examination revealed pale-grayish complexion, more pronounced veins over the thorax and abdomen, ascites, enlarged liver rising 8 cm below the right costal arch and having a minor pleural effusion by the right side. The patient was submitted to Doppler sonography and computed tomography (CT) that verified the right leg deep veins thrombosis, as well as the presence of a thrombus in the intrahepatic portion of the VCI. Multislice computed tomography (MSCT) showed occlusion of hepatic veins (Budd-Chiari syndrome) and thrombosis of the VCI in the retrohepatic part 6 cm long. Also, increased values of transaminases and gamma GT and reduced values of albumines and serum ferrum were registered. Molecular examination revealed Factor V Leiden mutation--heterozygote. After preoperative preparations a mesocaval shunt was made using Gore-Tex ring graft of 12 mm. Intraoperatively, the blue enlarged liver was found with almost black zones of tense capsule. After a graft making, liver congestion decreased followed by the change of colour and volume. Within postoperative course metabolic and synthetic liver functions were obvious. CONCLUSION In patients with BCS medicamentous treatment does not yield adequate results, but even causes worsening of general condition. Surgical therapy in the presented patient was performed timely regarding the stage of the disease due to which irreversible liver changes were prevented while decompression of the portal system provided time overbridging up to liver transplantation.