A Complicated Colorectal Cancer Recurrence

SummaryThe case report demonstrates painstaking, one step at a time multitherapy for the third most common cancer and the third cause of cancer death in western countries – colorectal cancer. Multitherapeutic approach at specialized centers for the treatment of colorectal cancer is the cornerstone for reaching favorable treatment results and prognosis.

Isolated Cor Triatriatum Sinister: A Case Report

SummaryCor triatriatum sinister is a rare congenital cardiac anomaly that has been identified in 0.1% of children with congenital heart disease. It is defined as a fibromuscular membrane that divides the left atrium into two chambers: a superior (proximal) that in most cases receives drainage from the pulmonary veins and an inferior (distal) chamber that communicates with the mitral valve and the left atrium. Cor triatriatum sinister can be an isolated lesion (approximately 25% of cases), but in many cases it is associated with other congenital cardiovascular anomalies, the most common one being – atrial septal defect(3). Symptoms in patients with cor triatriatum sinister are related to obstruction of pulmonary venous drainage, pressure loading of the right side of the heart and congestive cardiac failure. Depending on the severity of the obstruction and presence of associated cardiac anomalies it can be diagnosed at any age. Diagnosis is usually achieved by echocardiography in early infancy. Elective treatment method is surgical excision of the membrane. Here we present a pediatric patient (4 months old) presenting in cardiogenic shock with a successful correction of isolated cor triatriatum sinister. To confirm diagnosis and success of surgical repair, transthoracic and transesophageal echocardiography were used.

Occipital Neuralgia Caused by an Intramuscular Lipoma. A Case Report

SummaryOccipital neuralgia is a type of chronic headache disorder in the dermatomes of the greater or lesser occipital nerve. (7) We describe here a rare case of occipital neuralgia caused by an intramuscular lipoma. A 45 year-old man presented with troublesome pain in the occipital area with 3 x 2 cm palpable mass in the right occipital region. Patient was treated by a neurologist. The X ray for cervical vertebrae and computed tomography was performed.Computed tomography revealed a mass reminding intramuscular lipoma. Surgical management was indicated. During the operation stretching of the lesser occipital nerve was detected. After resection of lipoma on postoperative follow – up, the patient reported that the pain had resolved. During the histopathological examination, lipoma was confirmed.

Subliminal Laser as Additional Therapy to Reduce Intravitreal Injection Number for the Patients with Macular Diseases

SummaryIntroductionIntravitreal injections have become one of the most performed surgical procedures in ophthalmology. There is a need to look for an effective alternative therapy for patients with anti-VEGF complications and systemic disease contraindications.Aim of the studyTo evaluate Subliminal laser effectiveness on reducing macular disease edema.Materials and methodsSubliminal laser treatment was done three times with three month intervals for patients with macular edema due to retinal diseases. On 1st, 3rd, 6th and 9th month visit the best corrected visual acuity, intraocular pressure, macular thickness and macular volume were registered.ResultsMean visual acuity before treatment was 0,52 (SD=0,31) that changed to 0,56 after the 9 month treatment (p>0,05). Mean central macular thickness from 326,12 μm reduced to 308,15 (p=0,76). Without significant difference, inner cycle volume changed from 1353,80 mm3 to 1297,57 mm3 (p=0,81) and outer cycle volume from 1179,4 mm3 to 1112,56 mm3 (p=0,51).ConclusionsSubliminal laser controls macular edema level and could be a solution for patients who cannot afford or are emotionally distressed by monthly intravitreal injections. This treatment method can be used as additional therapy to reduce the number of intravitreal injections.

Characterisation of Morphology in Musculus Semitendinosus Tendon Used for Anterior Cruciate Ligament Reconstruction: A Pilot Study

SummaryIntroductionAnterior cruciate ligament (ACL) rupture is very common in athletes. In the general population, incidence is approximately 33 per 100 000 people.Aim of the studyThe aim of the study was the evaluation of morphological changes in the musculus semitendinosus tendon used for the reconstruction of ACL to understand the quality of most common for surgery used material.Material and methodsThe materials were obtained from four ACL autologous hamstring reconstruction surgeries. The tissue was stained with hematoxyllin and eosin and with immunohistochemical (IMH) staining of PGP9.5, VEGF, collagen I and collagen III. The material was evaluated with semiquantitative method.ResultsRoutine staining showed practically unchanged tendon structure, with one exception when sclerotic blood vessels were observed in endotenon. Collagen III IMH demonstrated moderate to numerous positive collagen fibres in two cases, but in other two there were only few positive structures seen. Collagen I IMH showed few to moderate number of positive collagen fibres in all cases. In two cases, moderate number of PGP9.5 positive nerve fibres was observed and in two other cases occasional to few number of positive structures was detected. PGP 9.5 marked higher number of nerve fibres in peritenon than in endotenon. Numerous VEGF positive endotheliocytes were observed in two cases, but in two other cases VEGF positive endotheliocytes were occasional.ConclusionsTendon of musculus semitendinosus displays two patterns of distribution of tissue ischemia, neuropeptide containing innervation and collagen I and III. Collagen III is thought to be evaluated as a response of tendon to the ischemia and intensive innervation, while increase of collagen I probably is related to the relatively unchanged vascularity and innervation. The pattern of musculus semitendinosus tendon structural changes seems to be connected to the individual homeostasis in patients persisting before the usage of tendon for the reconstruction.

Literature Review of Aneurysmal Subarachnoid Hemorrhage from Incidence to Treatment Options

SummaryIntroductionAneurysmal subarachnoid haemorrhage (SAH) is associated with high mortality and morbidity. Rebleeding, cerebral vasospasm (VS) with delayed cerebral ischemia (DCI) are major complications after SAH associated with poor neurological outcome.Aim of the studyTo summarize the existing research data on the SAH from incidence, risk factors and clinical presentation to diagnostic, monitoring and treatment options after SAH.Materials and MethodsLiterature review was carried out to identify factors associated with SAH using specific keywords (aneurysmal subarachnoid haemorrhage, rebleeding, cerebral vasospasm, delayed cerebral ischemia) in the PUBMED database. In the time period from 2000 to 2019, 34 full articles were reviewed.ResultsAccording to the literature, the key risk factors for cerebral aneurysms and the SAH are hypertension, smoking, chronic alcohol abuse, family history of intracranial aneurysms in first-degree relatives and female sex. The key risk factor for early complication - rebleeding after SAH - is hypertension. The factors responsible for late complications - cerebral VS and DCI after SAH - are initially lower Glasgow coma scale and higher grades of Fisher scale, where grade IV and III predict cerebral VS in 31–37%. Furthermore, hyperglycaemic state, hyponatremia, hypotension and cerebral hypoperfusion, increased level of Troponin correlate with the incidence of cerebral VS and DCI. Although the golden standard to detect cerebral VS is digital subtraction angiography, CT angiography has become a routine examination. Transcranial doppler sonography is recommended and regional cerebral oximetry also seems to be promising. To avoid rebleeding for wide-necked, gigantic aneurysms or when SAH is combined with intraparenchymal hematoma, surgical clipping is preferred. For posterior circulation aneurisms, poor grade SAH and patients with age >70 years superior is endovascular treatment. To avoid late complications, the pharmacological method is used with Nimodipine.ConclusionsSAH is still associated with poor clinical outcome due to the development of early and late complications. The highest risk patients are those with low Glasgow coma scale and high grades of Fisher scale. Timely performed obliteration methods of the ruptured aneurysm are crucial and Nimodipine is the main agent to prevent cerebral VS and DCI.

Effectiveness of Dual Antibacterial Therapy and Effectiveness of Recommendation Criteria as a Diagnostic Tool in Children with Uncomplicated Acute Appendicitis

SummaryIntroductionAcute appendicitis (AA) – acute inflammation and infection of the appendix – is one of the most common cause for abdominal surgery in pediatrics. Appendectomy has been the gold standard since 1735, but in recent years there have been several studies that investigate antibacterial therapy for uncomplicated acute appendicitis. In 2016 new recommendations for suspected AA were implemented in emergency department setting of Children's Clinical University Hospital (CCUH).Aim of the StudyTo evaluate whether diagnostic criteria for patients with a suspected acute appendicitis is effective as a diagnostic tool and to evaluate whether dual antibacterial therapy is safe and effective as first line treatment for children with diagnosis of uncomplicated acute appendicitis in CCUH.Material and methodsA retrospective study was made in CCUH from January 2017 to December 2017. Patients aged 7 to 18 with suspected uncomplicated acute appendicitis were identified and data were collected from an internal hospital management system and patients’ medical records. Patients were divided into two groups – A and B. In group A were patients who met the criteria of uncomplicated AA, and in group B – patients who met the criteria of complicated AA. Both groups received ampicillin and metronidazole. For statistical analysis IBM SPSS Statistics 22 program was used.ResultsFrom 98 patients majority were boys (51% (n=50)) with mean age 12.6 years. As a result of antibacterial therapy clinical condition improved in 93% (n=89) of patients who were discharged without surgery. 7 patients did not improve and underwent surgery within 48 hours after admission, another 2 had elective appendectomy. There was a significant positive moderate correlation between C–reactive protein (CRP), white blood cell count (WBC), basophil granulocytes (BASO) and appendix diameter at admisson and after 48 hours of dual antibacterial therapy (r=0.31, p=0.003 vs. r=0.37, p<0.001 vs. r=0.41, p=0.017 vs. r=0.51, p=0.013). In group A (68% (n=67)) there was a significant positive moderate correlation between CRP, WBC and appendix diameter at admission and after 48 hours of dual antibacterial therapy (r=0.31, p=0.003 vs. r=0.37, p<0.001 vs. r=0.51, p=0.013). In group B (30% (n=31)) 7 patients underwent appendectomy and 2 patients received a broad spectrum antibacterial therapy prior to elective appendectomy. There is evidence of significant association between ALVARADO score (p=0.004), rebound tenderness (p<0.001), WBC (p=0.004), CRP (p<0.001) and stage in which appendicitis has progressed to.ConclusionsAntibiotic-alone treatment may be a safe and effective initial management choice in children with uncomplicated acute appendicitis. However, to fully evaluate effectiveness of antibacterial therapy and diagnostic criteria, further follow–up research is needed.A normal C–reactive protein value does not rule out uncomplicated acute appendicitis, therefore it can not act as a single marker to diagnose AA or to differentiate between complicated and uncomplicated AA.Recommendations of treatment of UCAA are acceptable for use in emergency department as they act as a unified tool that allows pediatricians and pediatric surgeons to quickly assess suspected acute appendicitis.

Large Incidental Gastrointestinal Stromal Tumor of the Stomach

SummaryGastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal (GI) tract (3). A 68-year-old male patient was referred to our hospital with complaints about feeling pressure in the thorax and heavy sweating for over 2 years. Abdominal CT showed a pathological formation approximately 21 cm × 15cm × 15 cm in size. The stomach was compressed and dislocated by the tumor. The total gastrectomy Roux modification was performed. The tumor grows from the back wall of the stomach; the tumor is not grew into the mucosa. We made a final diagnosis of an extra luminal GIST of the stomach - pT4N0M0G1R0 stage II. There was no evidence of disease recurrence six months after surgery.

A Case Report of Extracorporeal Membrane Oxygenation and Hemadsorber Therapy in Septic Patient with Multiorgan Injury

SummaryDiagnostic microbiology and management of sepsis have advanced, even though the complication of multiorgan dysfunction remains a significant cause of morbidity and mortality. An estimated incidence of sepsis in 2017 is about 48 million a year, including 11 million sepsis- related deaths, which represents 19.7% of all global deaths.(1,2) Acute respiratory distress syndrome (ARDS) is a devastating complication of sepsis, conventionally, a substantial number of patients require mechanical ventilation (MV) to avert hypoxemia and hypercapnia. However, MV per se can cause lung injury, accelerating the disease progression. The use of extracorporeal membrane oxygenation (ECMO) in the management of ARDS has grown considerably in the past decade. More recently, an increasing popularity of spontaneous breathing and awake patients undergoing ECMO is seen, as well as the use of various types of hemadsorbers for reducing pathologically increased inflammatory response.(3) The purpose of this case report is to review airway and multiorgan support management during ECMO.

Successful Extensive Multiorgan Resection of Malignant Duodenal Tumor: A Case Report

SummaryDuodenal adenocarcinoma is one of the rarest tumours of all gastrointestinal malignancies. Due to rarity and late symptoms, duodenal cancers are diagnosed in late stage, but overall survival rate is high. We present a case of locally advanced duodenal adenocarcinoma with successful surgical treatment including multiorgan resection.