Stipislav Jadrijević

Fibrin Glue-Antibiotic Mixture in the Treatment of Anal Fistulae: Experience with 69 Cases

Background/Aims: To investigate the potential value of the use of the fibrin glue-antibiotic mixture in the treatment of anal fistulae. Materials and Methods: This study included 69 patients with idiopathic nonspecific anal fistulae. Patients with IBD (inflammatory bowel disease), TBC, actinomycosis, and cancer were excluded from the study. The microbiological analysis of the discharge of the fistula was done routinely. If there was any doubt about vertical classification of the fistulous tract MR of anal canal was necessary. As regards the vertical disposition, 39 fistulae were classified as intersphincteric and 30 as transsphincteric, and as to the length of the fistulous tract, 24 fistulas had tracts ≤3.5 cm long, and 45 fistulas had tracts >3.5 cm long. All fistulae were first treated with the lavage of the fistulous tract with antibiotic solution until a sterile microbiological finding was obtained. This was followed by electrocoagulation of the fistulous tract with a special probe for the eradication of granulomatous tissue. Finally the fibrin glue-antibiotic mixture (Tisseel, Immuno Ltd., Vienna, Austria) was applied. Results: After a follow-up of 18–36 months (median 28) 18 patients (26%) had a recurrence; among these, intersphincteric fistula recurred in 9 patients (23%) and transsphincteric also in 9 (30%). Regarding the length of the fistulous tract, a fistula with a ≤3.5 cm long tract recurred in 13 patients (54%) and a fistula with a >3.5 cm long tract in 5 (11%). Conclusion: The analysis showed that the success of the treatment of anal fistulae with fibrin glue-antibiotic mixture was independent of the vertical disposition of the fistula, and was dependent on the length of the fistulous tract. Surgical treatment remains a golden standard for simple fistulae with a tract ≤3.5 cm. Anal fistulae with a longer tract usually present a more complex problem and are often more difficult to treat surgically, the use of the fibrin glue-antibiotic complex proved to be a feasible method for those cases. It is a safe, cheap, reproducible, pain-free procedure, which eliminates the possibility of anal incontinence and can be performed under local anesthesia.

Osteogenic effect of a gastric pentadecapeptide, BPC-157, on the healing of segmental bone defect in rabbits: a comparison with bone marrow and autologous cortical bone implantation

Gastrectomy often results in increased likelihood of osteoporosis, metabolic aberration, and risk of fracture, and there is a need for a gastric peptide with osteogenic activity. A novel stomach pentadecapeptide, BPC-157, improves wound and fracture healing in rats in addition to having an angiogenic effect. Therefore, in the present study, using a segmental osteoperiosteal bone defect (0.8 cm, in the middle of the left radius) that remained incompletely healed in all control rabbits for 6 weeks (assessed in 2 week intervals), pentadecapeptide BPC-157 was further studied (either percutaneously given locally [10 microg/kg body weight] into the bone defect, or applied intramuscularly [intermittently, at postoperative days 7, 9, 14, and 16 at 10 microg/kg body weight] or continuously [once per day, postoperative days 7-21 at 10 microg or 10 ng/kg body weight]). For comparison, rabbits percutaneously received locally autologous bone marrow (2 mL, postoperative day 7). As standard treatment, immediately after its formation, the bone defect was filled with an autologous cortical graft. Saline-treated (2 mL intramuscularly [i.m.] and 2 mL locally into the bone defect), injured animals were used as controls. Pentadecapeptide BPC-157 significantly improved the healing of segmental bone defects. For instance, upon radiographic assessment, the callus surface, microphotodensitometry, quantitative histomorphometry (10 microg/kg body weight i.m. for 14 days), or quantitative histomorphometry (10 ng/kg body weight i.m. for 14 days) the effect of pentadecapeptide BPC-157 was shown to correspond to improvement after local application of bone marrow or autologous cortical graft. Moreover, a comparison of the number of animals with unhealed defects (all controls) or healed defects (complete bony continuity across the defect site) showed that besides pentadecapeptide intramuscular application for 14 days (i.e., local application of bone marrow or autologous cortical graft), also following other pentadecapeptide BPC-157 regimens (local application, or intermittent intramuscular administration), the number of animals with healed defect was increased. Hopefully, in the light of the suggested stomach significance for bone homeostasis, the possible relevance of this pentadecapeptide BPC-157 effect (local or intramuscular effectiveness, lack of unwanted effects) could be a basis for methods of choice in the future management of healing impairment in humans, and requires further investigation.

Pentadecapeptide BPC 157, Cimetidine, Ranitidine, Bromocriptine, and Atropine Effect in Cysteamine Lesions in Totally Gastrectromized Rats (A Model for Cytoprotective Studies)

A superior effectiveness in various lesionassays was noted for the novel pentadecapeptide BPC 157,originated from human gastric juice protein (BPC) andclaimed to be a cytoprotective agent. From this viewpoint, as a previously untreatedexperimental improvement to create an acid-freeenvironmental for cytoprotection studies, totalgastrectomy was done 24 hr before the ulcerogenicprocedure. In the absence of stomach and gastric acid, the damagingeffects of cysteamine (400 mg/kg subcutaneously, death24 hr thereafter), to date thought to be an acid-relatedduodenal ulcerogen, and the BPC 157 cytoprotective effect (10 mug or 10 ng/kg intraperitoneally)were further challenged. BPC 157 was compared withreference agents [cimetidine (50), ranitidine (10),omeprazole (10), bromocriptine (10) and atropine (10) (mg/kg intraperitoneally, 1 hr beforecysteamine] known to be also cytoprotective. In naiverats, with intact stomach, all of them showed a strongbeneficial effect. Interestingly, in gastrectomizedanimals, the application of BPC 157 or the referenceagents before cysteamine significantly prevented theotherwise severe duodenal lesion development noted inthe control gastrectomized cysteamine rats. In groups without cysteamine, no lesions were noted(laparotomy, gastrectomy only, 24 or 48 hr postsurgicalperiod), nor was lesion potentiation seen incysteamine-treated laparotomized animals. In summary,these findings -- equal damaging effect ofcysteamine and equal protection of pentadecapeptide BPC157 and reference agents in gastrectomized and rats withintact stomach -- seem to be particularly relevantfor a cytoprotective viewpoint. Without a stomach,the cysteamine damaging effect was convincingly definedas an essential gastric acid-independent injury(analogous to ethanol gastric lesions). Likewise, a high “cytoprotective capacity,”apparently acid independent, common for all testedagents (novel pentadecapeptide BPC 157, cimetidine,ranitidine, omeprazole and atropine) could be clearlystressed.

Long-Term Survival After Living-Donor Liver Transplantation for Unresectable Colorectal Metastases to the Liver: Case Report

We present a case of long-term survival of a patient who underwent living-donor liver transplantation for unresectable liver metastases of colon cancer. Two years after left hemicolectomy and subsequent to repeated liver resections, this patient presented with unresectable metastatic disease confined to the liver. She was offered a living-donor liver transplantation, and her husband agreed to be the donor. Five years after transplant, she was alive and recurrence free.

Living Donor Liver Transplantation for Unresectable Liver Metastases From Solid Pseudo-Papillary Tumor of the Pancreas: A Case Report

Solid pseudo-papillary tumors (SPT) are rare primary tumors of the pancreas that primarily affect young women. They are of borderline malignancy, and, unlike other pancreatic malignancies, the prognosis after resection is quite good. However, metastatic disease does occur; the liver is the most common site of tumor dissemination. Herein we have reported a case of a 20-year-old woman who presented with multiple, bilateral liver metastases at 3 years after distal pancreatectomy for SPT of the body and tail of the pancreas. The patient underwent living donor liver transplantation (LDLT) and is alive and disease-free at 24 months after surgery. In this report, we discuss the treatment of liver metastases from SPT, with an emphasis on the possible role of orthotopic liver transplantation (OLT).

Right hepatectomy due to portal vein thrombosis in vasculobiliary injury following laparoscopic cholecystectomy: a case report

IntroductionVasculobiliary injury composed of bile duct, portal vein and hepatic artery injury is a rare, but the most severe, complication after cholecystectomy that may require hepatectomy or even urgent liver transplantation.Case presentationWe present a case of a 36-year-old Caucasian woman with a biliary sepsis and a large right liver lobe abscess due to an extreme vasculobiliary injury after laparoscopic cholecystectomy. Bismuth type IV biliary duct injury, portal vein thrombosis and injury of right hepatic artery were identified, resulting in life-threatening septic episodes. Right hepatectomy with Roux-en-Y hepaticojejunostomy and reconstruction of her portal vein with a vein allograft were performed. She fully recovered and remained well during 3 years of follow-up.ConclusionsAlthough rare, the impact of vasculobiliary injuries after cholecystectomy highlights the need for constant alertness and prompt management in order to minimize the risk of the routine operative procedure. Hepatectomy with biliary and vascular reconstruction should be considered early in the management of vasculobiliary injury to avoid the development of life-threatening consequences.