Zlatibor Loncar

Letter to the Editor: Stenting in Palliation of Unresectable Esophageal Cancer

Dear Editor, We read with great care and interest the article on stenting in palliation of unresectable esophageal cancer by Wlodarczyk and Kuzdzal [1] in the June 2018 issue of World Journal of Surgery. First of all, we wish to congratulate the authors on this scientific report and on their dedication to better understanding of this very significant disease and its treatment modalities, especially in the cases of advanced stages. This was a retrospective study with prospective data collection, which included 442 patients who underwent esophageal stenting procedure. The authors wanted to evaluate the safety and efficacy of stenting in patients with esophageal squamous cell carcinoma and carcinoma of the esophagogastric junction, complications, re-interventions and survival after the treatment. Our concerns are in regards to the exact stage of the esophageal cancer and its possible resectability. According to Ajani et al. [2], patients with esophageal cancer can be divided into two groups: locoregional cancer (stages I–III) and metastatic cancer (stage IV). Patients with locoregional cancer must be treated surgically, unless there are severe comorbidities that present major risk factors for complications and mortality of anesthesia and surgery. We think that it would have been very useful if Wlodarczyk and Kuzdzal had stated in their study the exact cancer stage of the patients that underwent palliative esophageal stenting. In their study on 2626 patients over the age of 65 (Surveillance, Epidemiology, and End Results—SEER), Smith et al. [3] showed that in patients with advanced locoregional disease (T3-T4aN0 or T1-4aN1), the best results are obtained combining preoperative chemotherapy and surgery. Thus, we think that it would be very interesting if the authors stated the exact stage and what were the main criteria for non-resectability. According to European Society of Gastrointestinal Endoscopy (ESGE) clinical guidelines [4], brachytherapy can be used in addition to palliative stenting in esophageal cancer patients. Brachytherapy may provide better quality of life and survival rate [4]. We feel that additional data on brachytherapy, if it was considered as a therapeutic modality at all in the study by Wlodarczyk and Kuzdzal, could give useful guidelines in treating patients with advanced esophageal cancer. Wlodarczyk and Kuzdzal stated that they performed double stenting (synchronous stenting of airway and esophagus) in patients with unresectable esophageal cancer that had involved airway. Shin et al. [5], in their study on 61 patients with esophagorespiratory fistulas, placed with success SEMS in 51 patients, while only 10 patients needed double stenting. They managed to seal off the fistula in 49 patients, while only 10 (16%) needed a concomitant airway stent. According to clinical guidelines [4], esophageal stenting is recommended as the best treatment for sealing esophagorespiratory fistulas (tracheoesophageal or bronchoesophageal). Also, application of double stenting can be considered in cases when fistula occlusion is not accomplished by esophageal stenting alone [4]. We hope that these additional data would give more accurate directives in treating patients with advanced-stage esophageal cancer, in order to define the best approach and therapeutic strategy. & Vladimir Resanovic vladaresan@gmail.com

Which Patients Require Extended Thromboprophylaxis After Colectomy? Modeling Risk and Assessing Indications for Post-discharge Pharmacoprophylaxis

Dear Editor, We devoted great amount of attention to reading the paper by Beal et al. [1] on the need for extended thromboprophylaxis after colectomy published online in January 2018 in World Journal of Surgery. First of all, we would like to offer our congratulations and acknowledgement for the tremendous amount of work that has been put in by the authors. This was a study in which the authors utilized the American College of Surgeons National Surgical Quality Improvent Project database, and the study included 77,823 patients. The authors wanted to assess the risk factors for post-discharge venous thromboembolism after colectomy and to establish the guidelines for post-discharge pharmacoprophylaxis. Our concerns are in regards to the exact stage of the cancer, precise location and its possible influence to the deep vein thrombosis and pulmonary embolism. Moghadamyeghaneh et al. [2] in their study on 116,029 patients showed that stage 4 cancer had association with deep vein thrombosis. Alcalay et al. [3] conducted another study on venous thromboembolism in patients with colorectal cancer, which included 68,142 patients. The results showed that incidence of venous thromboembolism had increased significantly with advancing stage. In the same study results showed that the exact hystological type also influenced on thromboembolism, and that rectosigmoid cancer had been associated with significantly lower incidence comparing with neoplasm of ascending, transverse and descending colon. According to Choi et al. [4], significant predictors of venous tromboembolism were advanced stage and comorbidities. Furthermore, in the study by Clouston et al. [5], it was stated that the development of deep vein thrombosis had been significantly associated with positive lymph nodes. Thus we think that it would be very useful for clinical practice to determine more profound risk factors for deep vein thrombosis and venous thromboembolism regarding the exact cancer location, its more precise stage and hystological type. Asymptomatic preoperative deep below knee vein thrombosis can lead to venous thromboembolism. Clouston et al. [5] in their multicentre prospective study screened colorectal cancer patients in order to detect the presence of deep vein thrombosis. The results showed that around 8% of patients with colorectal cancer have had asymptomatic preoperative deep vein thrombosis located below knee proven by bilateral full leg duplex venous ultrasound. According to this study, preoperative D-dimer might offer a valuable predictive method for early detection of patients with increased risk of postoperative deep vein thrombosis. We feel that this also should be taken into account when assessing patients with colorectal cancer for extended prophylaxis against venous thromboembolism. There is no doubt that extended thromboprophylaxis after colectomy is beneficial in selected cases. We tend to believe that some additional data mentioned before (exact cancer stage, its location and hi type, as well as early detection of preoperative below knee deep vein thrombosis) could lead to better detection of patients with increased risk of venous thromboembolism and therefore need for extended thromboprophylaxis. & V. Resanovic vladaresan@gmail.com

Magnets ingestion as a rare cause of ileus in adults: A case report

Introduction. Magnetic foreign bodies are harmless when ingested as a single object. However, if numerous of individual magnets are ingested at certain intervals, one after the other, they may attract each other through the bowel wall and cause severe bowel damage. Case report. We reported a case of a man, age 21, who swallowed 2 very small magnets, presented with clinical and radiographic signs of acute bowel obstruction and intestinal fistula. The cause of obstruction was detected during laparotomy. At laparotomy, one magnet was found in the proximal jejunum and the other in the distal ileum, strongly attracting each other followed by small bowel twisting around this point of rotation, causing a complete small bowel obstruction with strangulation and jejuno-ileal fistula. The intestinal segments were devolvulated and both intestine perforations were primarily sutured. The patient recovered successfully after the surgery and was discharged 5 days after the laparotomy. Conclusion. Patients who ingested magnetic objects must be seriously considered and emergency laparotomy should be performed to prevent serious gastrointestinal complications.

Coagulopathy in trauma

Trauma is still a leading cause of morbidity and mortality in the contemporary community, particularly in population younger than 40 years of age. Recent studies have offered new knowledge on the central role of coagulopathy in traumatized people. Massive hemorrhage is a cause of death in severely traumatized people in 40% of cases, and the control of bleeding is a special challenge in the developed and verified coagulopathy. After severe trauma, massive hemorrhage is very often the consequence of associated surgical and coagulopathic bleeding. Massive blood loss diminishes the capacity of coagulation system, resulting in coagulopathy even in patients whose hemostasis before the injury has been within physiological limits.

Veštačka stimulacija nervus-a frenikus-a nakon povrede

The phrenic nerve is a nerve that originates in the neck (C3-C5) and passes down between the lung and heart to reach the diaphragm. It controls the diaphragm which is the primary muscle involved in breathing. Injuries of the phrenic nerve can occur after trauma such as falls, blunt trauma, after penetrating injuries or in car accidents, iatrogenic nerve injury during surgery in the neck and chest. Phrenic nerve pacing (PNP), or “diaphragm pacing”, is the application of rhythmic electrical impulses to the diaphragm, resulting in respiration for patients who would be otherwise dependent on a mechanical ventilator. Phrenic nerve stimulators are indicated for selected patients with partial or complete respiratory insufficiency” and “can be only effective if the patient has an intact phrenic nerve and diaphragm, which means in patients with spinal cord injuries, central sleep apnea and in patients with lesion of central nervous system. In contrast, trauma below C2 usually does not allow pacing, because the cell bodies of the phrenic nerves are damaged. This kind of treatment can lead to a significant improvement in the quality of life of ventilator-dependent quadriplegic individuals. It can improve pulmonary function and reduce the incidence of pulmonary infections. In addition, it improves quality of speech and olfaction which leads to much better quality of life and higher rates of social participation. We would like to demonstrate a case of a nineteen years old patient that was admitted to the ER department in Clinical Center of Serbia as an emergency case with penetrating wound injury after a gunshot wound to the neck. Data from the literature, which have been also confirmed with our individual experience suggest that the phrenic nerve pacing begins in cases that there is no recovery of nerve not earlier than three and no later than six months after the injury when the results are the most appropriate. Most patients with diaphragmatic pacemakers continue to need tracheostomies and mechanical ventilators as a back-up to their pacemakers. It is important to note that diaphragmatic pace makers only improve inspiratory function and do not target expiratory functions such as coughing and clearing secretions. Finally, the extremely high cost of the device itself, with modest results of the implementation of the device, gives a basis to observe it with great criticism, especially in countries with lower economic status.

Radio-guided parathyroidectomy for recurrent renal hyperparathyroidism caused by graft hyperplasia

Radio-guided surgery offers several advantages in treatment of primary hyperparathyroidism. It is considered less helpful in renal hyperparathyroidism, but it could be of great advantage in the treatment of persistent or recurrent secondary hyperparathyroidism. One of the surgical options for symptomatic renal hyperparathyroidism is total parathyroidectomy with autotransplantation of hyperplastic parathyroid tissue in forearm muscles or sternocleidomastoid muscle. Recurrence can occur and is most likely caused by graft hyperplasia. In this report we present the case of 54-year-old woman with recurrent renal hyperparathyroidism caused by hyperplasia of the graft in sternocleidomastoid muscle. Unfortunately no sutures or clips were placed at initial surgery to identify the location of the parathyroid tissue. The preoperative assessment consisting of 99mTc-sestamibi scintigraphy identified a parathyroid tissue in the in the middle third of sternocleidomastoid muscle. The patient underwent a radio-guided neck re-exploration that allowed a rapid localization and excision of the hyperplastic graft.

Injuries of the pancreas

Background: In spite of significant progress in diagnostics and surgery for pancreatic injuries in the last few decades, there have still been professional controversies about its management. Aim: Retrospective analysis of patients with pancreatic injuries, treated at the Clinic for Urgent Surgery of the Emergency Center, Clinical Center of Serbia (2003-2013), highlighting the relevant diagnostic and therapeutical aspects of the pancreatic injuries, present dilemmas, as well as review of post-operative complications and mortality. Methods: Statistical analysis. Results: In the abovementioned period, 60 patients with pancreatic injuries were treated. More than 50% of patients were managed by lesion suture and drainage. A total percentage of complications was 32.6% and an overall mortality was 18%. Conclusion: Management of pancreatic injuries might present a serious professional problem, even if managed by qualified and experienced teams in highly specialized (“high volume”) centers.