Miroslav Stojanovic

Primary colorectal lymphoma: An overview

Lymphomas represent common hematological malignancies with increasing incidence in recent years. The major site of extranodal non-Hodgkin lymphoma is the gastrointestinal tract. Involvement of the large intestine is rare in comparison to the stomach or small bowel. The disease appears later in life, predominantly in the male population. Complaints are nonspecific, requiring a high index of suspicion in order to establish the diagnosis. The treatment varies from chemotherapy alone to multimodal therapies combining surgery, chemotherapy and radiotherapy. The small number of patients with various histological subtypes and different stage at presentation results in unclear protocol for the treatment of primary colorectal lymphoma. The purpose of this paper is to review current data on primary lymphoma of the colon and rectum while analyzing reported case series and published material on the subject.

The effect of ursodeoxycholic acid on oxidative stress level and DNase activity in rat liver after bile duct ligation

Accumulation of hydrophobic bile acids (BAs) during cholestasis plays an important role in apoptosis initiation as well as oxidative stress increase in liver cells. Ursodeoxycholic acid (UDCA) acts as a protector in BA-induced cell injury.The aim of the study was to evaluate the effect of UDCA on oxidative stress level and DNase I and II activity caused by liver injury in bile duct ligation (BDL) rats.Wistar rats were divided in four groups: group 1, control (sham-operated); group 2, sham-operated and injected with UDCA (30 mg/kg); group 3,animals with BDL; and group 4,UDCA-treatedcholestatic rats. Animals were sacrificed after 9 days. Malondialdehyde (MDA; lipid peroxidation end-product) level and protein-molecule oxidative modification (carbonyl group content) significantly increased in BDL rat liver. Catalase (CAT) activity in liver tissue was found to be decreased in BDL rats. In addition, xanthine oxidase (XO) activity, which is thought to be one of the key enzymes producing reactive oxygen species, was found to be increased in the cholestatic group. The apoptotic effect in cholestasis was probably triggered by the increased activation of DNase I and II. The protective effect of UDCA on liver tissue damage in BDL rats, in comparison to cholestatic liver, were 1) decrease of MDA levels, 2) increased CAT activity, 3) reduced XO activity, and 4) effect on terminal apoptotic reaction, shown as a decrease in DNase I and II activity.Therefore, UDCA may be useful in the preservation of liver function in cholestasis treatment.

Primary colorectal lymphomas

BACKGROUND/AIM Colorectal lymphoma is a rare tumor representing 1.4% of human lymphomas, 10-20% of gastrointestinal lymphomas, namely 0.2-0.6% of all malignancies in the colon. The aim of this study was to review clinical characteristics of primary colorectal lymphoma and overall survival. METHODS A detailed analysis of 16 surgically treated patients included patients age, symptoms and signs, tumor site, type of surgery, histopathologic findings, diagnosis of the disease, disease stage, type of surgery related to the degreee of emergency (elective or urgent), applied adjuvant therapy, patient follow-up and treatment outcomes. Survival was expressed by the Kaplan-Meier curve, while the difference in survival among the two groups by the Log-rank test. RESULTS The all patients were on an average followed-up for a median of 29 months (range 2-60 months), while those with chemotherapy 48 months (range 4-60 months). An overall mean survival time was 38.65 months. CONCLUSION Primary colorectal lymphoma is a rare malignant tumor of the large bowel. Therapy usually involves resection of the affected colon or rectum and regional lymphovascular structures, followed by adjuvant therapy. Survival period is short and, therefore, timely diagnosis is crucial in early disease stages when the probability of cure is high.

Diagnostic Importance of Pulse Oximetry in the Determination of the Stage of Chronic Arterial Insufficiency of Lower Extremities

INTRODUCTION Chronic arterial insufficiency (CAI) of lower extremities is important socio-economical and healthcare problem, due to its high incidence of morbidity, disability and mortality. OBJECTIVE The aim of our work was to determine the diagnostic importance of pulse oximetry in the early detection of stage of lower extremities CAI based on peripheral arterial oxygen saturation of haemoglobin (SpO2). METHODS Prospectively, we analyzed a group of 50 patients, admitted at the Vascular Department of Surgical Clinic in Nis during the period from September 2006 to October 2007, with evident symptoms and signs of different stages of lower extremities CAI verified by ultrasonography. In patients with lower extremity disorder of tissue arterial capillaries, SpO2 was determined by pulse oximetry. RESULTS Using pulse oximetry, depending on the of stage of lower extremities CAI, we revealed a considerable difference in the stages of functional ischemia SpO2: Fontaine I - 95.33 +/- 1.41%, Fontaine IIa - 92.14 +/- 2.27% and Fontaine IIb - 79.67 +/- 2.73%; in stage critical ischemia SpO2: Fontaine III - 62.54 +/- 4.39% and Fontaine IV - 47.67 +/- 6.16%. In 3 patients with gangrenous foot and fingers SpO2 was immeasurable and progressive decrease in SpO2 of arterial capillaries (p < 0.01 between stages). CONCLUSION Due to the reliability and simplicity of pulse oximetry it can be a routinely used diagnostic device for patients with early determined stage of lower extremities CAI.

Three cases of death caused by shots from blank cartridge.

The authors describe 3 cases of lethal injuries caused by 7.62 mm blank cartridge shots from military automatic rifle of domestic origin (AK 47, 7.62 mm). In 1 case, the cartridge was fired from a weapon that had been leaned on the head, with subsequent destruction of brain, and in other 2 cases, the weapon had been leaned on the chests, which led to destruction of heart parts. The injuries were caused by the action of striking wave of gunpowder explosion, the air blast type. The cases demonstrate that the gas pressure from the exploding propellant of blank cartridge is powerful enough to penetrate the thoracic wall and the skull.

Case of rectal angioleiomyoma in a female patient.

Angioleiomyoma represents a benign stromal tumor, which usually occurs in the subcutaneous tissue of the extremities, although its occurrence in the gastrointestinal tract is very rare. A case of rectal angioleiomyoma in a 40 year-old female patient is described here. Six months earlier, the patient suffered from periodical prolapse of an oval tumor from the anus, along with difficulties in bowel movement. A transanal extirpation of the tumor was performed. This is the first reported case in the English literature of a patient presenting with prolapsed angioleiomyoma of the rectum. During the immediate postoperative period, as well as 6 mo later, the patient had an unremarkable postoperative recovery.

Double giant chronic bilomas with late presentation: 9 years after cholecystectomy.

Dear Editor, We have the intention to report of a 68-year-old man with very late presentation of two well-encapsulated giant bilomas. They occurred 9 years after open cholecystectomy, performed for an acute calculous cholecystitis. Early and late postoperative course was absolutely uneventful. Nine years later, few days before actual admission, he felt unclear symptoms of abdominal pressure and discomfort. Clinical examination and ultrasonography (US) showed large cystic masses in the right and left part of the abdomen. Computed tomography (CT) density values were 16 Hounsfield units (HU). At first, we suspected on the extrapancreatic pseudocysts. However, the pancreas was normal on the CT. At magnetic resonance imaging (MR), lesions were heterogeneously intense (T1) and homogenously hyperintense on the T2-weighted images (Figs. 1 and 2). Magnetic resonance cholangiopancreatography (MRCP) showed a normal biliary tree, with no strictures or stones and without any communication. Analysis of percutaneous needle aspirate showed clear bile with no cellular structures and bilirubin concentration of 680 mcm/L. The bilomas measured in total 5.2 L of the stagnant bile. The smaller one (16.3×10.7 cm) was located in the right part of the abdomen, into the subhepatic space and right paracolic gutter. The bigger one (22.7×11.2 cm) occupied left subphrenic space with propagation into the left paracolic gutter. Because of the failure of percutaneous drainage (incomplete drainage of the left biloma despite of the two repositioning of the drainage catheter), the patient was operated on, with simple surgical drainage. Surgical exploration and intraoperative cholangiography showed a normal biliary tree. The patient remains symptom-free with normal clinical and laboratory data more than 12 months after surgery. A biloma is a well-demarcated, encapsulated or not, bile collection outside the biliary tree caused by iatrogenic, traumatic, and spontaneous injury of the biliary tree [1–6]. It usually arises a few days or weeks after the injury [2, 3, 7]. Slow leakage of uninfected bile may be asymptomatic for a long time. The main curiosity in our case report is the fact that the patient was asymptomatic for 9 years after the cholecystectomy. We believe that biloma occurred from lowproducing bile leakage as a complication of cholecystectomy. Our opinion is based on the fact that stagnant bile was firmly captured inside a 5-mm-thick fibrous capsule biloma. Also, the bilomas might be a result of typical spontaneous rupture of the biliary tree during the long period of the 9 years after operation [2, 6]. The size and location of bilomas depend on the cause of the biliary rupture, the site and the rate of the bile leakage, and the reabsorption capacity of the peritoneum [3, 10]. The maximal reported diameter of the biloma was 40 cm containing 5,700 mL of bile [3]. Most extrahepatic bilomas are located on the right. However, bilomas may be found in the left upper quadrant or bilaterally [2, 10]. Retroperitoneal localization of the biloma is very rare [7], with the possibility of the abdominal wall bile staining [8] or biliscrotum formation [9]. The diagnosis is established on the clinical history, biloma location, US, CT, and MRCP findings. The USguided percutaneous needle aspiration with a chemical analysis definitely confirms the diagnosis of biloma. Although the asymptomatic patients may be treated conservatively, the appropriate treatment for most of the Langenbecks Arch Surg (2008) 393:617–618 DOI 10.1007/s00423-007-0270-6

Giant primary retroperitoneal myxoid leiomyoma: A case report

INTRODUCTION Leiomyomas are benign smooth muscle tumors that usually arise from the uterus. CASE REPORT We present a patient with a 6-month history of vague abdominal discomfort, occasional nausea, vomiting and urinary incontinence. On examination, there was an extremely large firm unpainfull palpable abdominal mass. Laboratory investigation revealed mild leukocytosis and blood creatinine elevation. Abdominopelvic ultrasonography and computed tomography revealed a massive well bordered, encapsulated intraabdominal tumor, extending from the pelvis to epigastrium and almost completely fulfilling the pelvic and abdominal cavity. At laparotomy, tumor arising from the retroperitoneum was excised in toto. Histopathological examination disclosed that the tumor was composed mainly of smooth muscle cells and very rare fibrous connective tissue elements with myxomatous alteration and with no mitotic activity. The negative results of numerous additional parameters analyzed (pancytokeratin, epithelial membrane antigen, S100 protein, CD68, CD34, desmin, aktin) ruled out different origin of a tumor. One year after resection the patient had no complaints and no radiological evidence of tumor recurrence. CONCLUSION Considering current limitations in radiological diagnosis, in toto resection of these tumors is necessary to rule out malignancy.

The role of duodenogastric reflux in formation of precarcinogenic gastric lesions--an experimental study.

INTRODUCTION Duodenogastric reflux, commonly encountered as an aftermath of gastroenteroanastomosis, with or without gastric resection (Billroth I, Billroth II), vagotomy and pyloroplastic surgery, is known to cause inflammatory-dystrophic-metaplastic lesions of gastric mucosa. Our objective was to determine the effects of surgery-induced duodenogastric reflux on the development of precarcinogenic lesions or carcinoma in correlation with the reflux duration. MATERIAL AND METHODS The experiment was performed on three groups of Wistar rats with 1) Billroth II-induced reflux surgery, 2) resection of the Rouxr-en-Y type reconstruction, and 3) control group with no resection. The aim of the experiment was to study the effects ofduodenogastric reflux on the rat gastric mucosa in correlation with two different types of gastroenteroanastomosis 8, 16 and 24 weeks after the surgery. RESULTS In Billroth II group, hyperplastic changes were observed as early as in week 16. Statistically significant results were recorded in week 24, with 6.7% of metaplastic alterations, including dysplasia of all three degrees, dominantly severe dysplasia in 66.67%, early carcinoma in 20% and gastric carcinoma in 6.67%. In the Roux-en-Y group, gastric mucosa remained predominantly normal (60%), with somewhat increased frequency ofgastritis and dysplasia in week 24. In the control group, the finding of normal gastric mucosa was constant. CONCLUSION The experiment confirms that direct contact of duodenal juice with gastric mucosa associated with Billroth II resection causes precarcinogenic lesions. Development of adenocarcinoma caused solely by duodenogastric reflux, excluding a carcinogenic agent is possible 20 weeks after the experiment--earlier than suggested by previous researchers.

Safety of simultaneous colon and liver resection for colorectal liver metastases

BACKGROUND/AIM Surgical strategy for the treatment of resectable synchronous hepatic metastases of colorectal cancer (CRC) remains controversial. The aim of this study was to assess safety of simultaneous colon and liver rese cions and the direct effects of this type of treatment upon morbidity and mortality of the patients with synchronus hepatic metastases of CRC. METHODS Intraoperative and postoperative data of 31 patients with simultaneous liver and colorectal resection were compared with the data of 51 patients who had undergone colon and hepatic resection in the staging setting. Analized were demographic data, number of metastases, type of the liver resection, operation time, intraoperative blood loss, percentage of postoperative complications, morbidity and mortality and lenght of hospitalisation. RESULTS In the group of the patients operated simultaneously 5 hepatectomies, 3 sectionectomies, 2 trisegmentectomies, 3 bisegmentectomy, 6 segmentectomies, and 12 metastasectomies were combined with colon resection. In this group operation time (280 vs. 330 minutes) and in traoperative blood loss (450 vs. 820 ml) were lower than those in the two staged operation group. Postoperative complication rate was lower in the simultaneous group (19.35%o) than in the two-staged operation group (19.60%), without statistical significance. There was no hospital mortality in both groups. The patients having simultaneous resection required fewer days in the hospital (median 10.2 days) than the patients undergone operation in the two stage (18.34 days). CONCLUSION By avoiding a second laparotomy, overall operation time, blood loss, hospital stay and complication rate are reduced with no change in hospital mortality, so simultaneous colon and hepatic resection performed by the competent surgeons are safe and efficient for the treatment of synchronous colorectal liver metastases.