Browsing by Author "Doklestić, Krstina (37861226800)"

Introduction Gallstone ileus is a complete or partial mechanical bowel obstruction due to gallstone impaction in the bowel lumen and most commonly occurs after stones migrate through the cholecys-toenteric fistula. Case outline We present a patient with signs of gallstone ileus after stone migration through the chole-cystoduodenal fistula into the duodenum with hematemesis as the first symptom. Conservative treatment had been started, to which the patient initially responded well. On the eighth day from the onset of the disease, the condition worsened. Signs of the Rigler triad were identified on computed tomography and magnetic resonance imaging of the abdomen. Enterolithotomy was successfully performed by the open surgical method. Postoperative recovery was orderly, without any biliary problems. Conclusion Physical examination, upper endoscopy, and radiological diagnostic procedures are com-plementary and necessary in monitoring the dynamics of stone movement and deciding on when to perform surgery. © 2022, Serbia Medical Society. All rights reserved.

Introduction: Endometriosis is a benign condition affecting females of reproductive age. Although intestinal endometriosis is common, it is rarely manifested as an acute bowel obstruction secondary to ileal endometriosis. Enteric endometriosis should be considered as a differential diagnosis when assessing females of reproductive age with acute small bowel obstruction. Case Outline: A 41-year-old woman presented with symptoms and signs of an acute small bowel obstruction requiring emergency surgery. A small bowel resection was performed with end-to-end anastomosis. Histological examination demonstrated endometriosis with fibrosis and stricture of the ileal segment. This case is important to report as it highlights the diagnostic difficulty this particular condition presents to an emergency surgeon. Conclusion: In the differential diagnosis, endometriosis should be taken into consideration when assessing females of reproductive age who present with abdominal pain and small bowel obstruction. © 2012, Serbia Medical Society. All rights reserved.

Background: The objective of our study was to determine the serum concentrations of protein S100B and neuron specific enolase (NSE) as well as their ability and accuracy in the prediction of early neurological outcome after a traumatic brain injury. Methods: A total of 130 polytraumatized patients with the associated traumatic brain injuries were included in this prospective cohort study. Serum protein S100B and NSE levels were measured at 6, 24, 48 and 72 hours after the injury. Early neurological outcome was scored by Glasgow Outcome Scale (GOS) on day 14 after the brain injury. Results: The protein S100B concentrations were maximal at 6 hours after the injury, which was followed by an abrupt fall, and subsequently slower release in the following two days with continual and significantly increased values (p<0.0001) in patients with poor outcome. Secondary increase in protein S100B at 72 hours was recorded in patients with lethal outcome (GOS 1). Dynamics of NSE changes was characterized by a secondary increase in concentrations at 72 hours after the injury in patients with poor outcome. Conclusion: Both markers have good predictive ability for poor neurological outcome, although NSE provides better discriminative potential at 72 hours after the brain injury, while protein S100B has better discriminative potential for mortality prediction. © by Branislava Stefanović 2017.

Background: The objective of our study was to determine the serum concentrations of protein S100B and neuron specific enolase (NSE) as well as their ability and accuracy in the prediction of early neurological outcome after a traumatic brain injury. Methods: A total of 130 polytraumatized patients with the associated traumatic brain injuries were included in this prospective cohort study. Serum protein S100B and NSE levels were measured at 6, 24, 48 and 72 hours after the injury. Early neurological outcome was scored by Glasgow Outcome Scale (GOS) on day 14 after the brain injury. Results: The protein S100B concentrations were maximal at 6 hours after the injury, which was followed by an abrupt fall, and subsequently slower release in the following two days with continual and significantly increased values (p<0.0001) in patients with poor outcome. Secondary increase in protein S100B at 72 hours was recorded in patients with lethal outcome (GOS 1). Dynamics of NSE changes was characterized by a secondary increase in concentrations at 72 hours after the injury in patients with poor outcome. Conclusion: Both markers have good predictive ability for poor neurological outcome, although NSE provides better discriminative potential at 72 hours after the brain injury, while protein S100B has better discriminative potential for mortality prediction. © by Branislava Stefanović 2017.

Background/Aims: Liver resections are still one of the most challenging operations. The aim of this study was to analyze the efficiency and safety of the intrahepatic Glissonean pedicle approach vs. classical Hilar dissection in major hepatectomies. Methodology: Thirty-four patients were assigned to the Glissonean approach (GA, n=34), while the Hilar dissection were assessed as historical control, matched for the age, gender, comorbidities and Child-Pugh score (HD, n=34). Results: The GA was associated with significantly shorter surgery duration (191.18±41.10 vs. 246.62± 56.55), transection time (38.94±14.56 vs. 56.32±19.40) and ischemic duration (26.03±11.27 vs. 41.18±12.80) than HD (p<0.001 for all). The amount of blood loss was significantly lower in GA (245.59±169.39 vs. 344.71±166.25; p=0.018). The amount of blood transfusion was significantly lower in GA during surgery (322.86±102.07 vs. 414.76±135.48) as well as postoperatively than HD (246.67±5.77 vs. 336.67±120.55) (p=0.038 and p=0.026. respectively). Conclusions: Major hepatectomy can be performed more easily using the Glissonean pedicle approach than by hilar dissection. En-masse transection of pedicles, as well as hepatic veins, using endo-GIA vascular stapler could be performed safely. Liver surgeons should know the Glissonean pedicle approach. © H.G.E. Update Medical Publishing S.A.

Introduction/Objective The development of acute insulin resistance after surgery intervention is associated with the type and magnitude of operation and tissue injury. The aim of our study was to compare insulin sensitivity assessed by homeostatic model assessment of insulin resistance (HOMA-IR) and C-reactive protein (CRP) before and after laparoscopic and open cholecystectomy during seven days follow-up. Methods In total, 92 patients were divided into two groups: laparoscopic cholecystectomy (Group 1) (n = 61) and open cholecystectomy (Group 2) (n = 31). Glucose, insulin and CRP levels were measured at day 0 and at postoperative days one, three and seven. Glucose, insulin and CRP were determined using commercial assay on Roche Cobas 6000 automated analyzer (Roche Diagnostics, Manheim, Germany). Results There was no statistical difference between studied groups concerning age (p = 0.626), body mass index (p = 0.548), glucose (p = 0.947), insulin (p = 0.212), HOMA-IR (p = 0.390) and CRP (p = 0.546) at day 0. At day one, higher values of CRP were found in group 2 compared with group 1 (p = 0.046). At day three, significantly higher values of glucose and HOMA-IR were found in group 2 compared with group 1 (p = 0.025, p = 0.036, respectively). Conclusion Increase in CRP precedes deterioration of insulin sensitivity measured by HOMA-IR after cholecystectomy. Impairment of insulin sensitivity was more pronounced at postoperative day three in group with open cholecystectomy. On the basis of our results, laparoscopic cholecystectomy induced less impairment in insulin sensitivity and lower inflammatory response. © 2023, Serbia Medical Society. All rights reserved.

Introduction Isolated jejunal perforation (IJP) without any associated injuries is rare in blunt abdominal trauma (BAT). It most commonly occurs in decelerating trauma. Diagnosis of traumatic intestinal perforation may be difficult in the first hours after injury so unrecognized “missing” intestinal injuries incidences are as high as 24%. Unrecognized traumatic bowel perforation without adequate treatment leads to the intestinal leakage into the peritoneal cavity, leading to secondary peritonitis and potentially lethal complications. Case outline We presented the case of a 43-year-old woman injured in a road traffic accident. She was admitted to emergency surgery after diagnostic procedures according to the protocol for trauma. Initial examination, and body computed tomography (CT) revealed orthopedic injuries. Daily monitoring and follow-up examinations were done, she did not complain of any discomfort nor pain in the abdomen, and there were no signs of abdominal injury. Two days after trauma, follow-up abdominal CT revealed highly suspected jejunum perforation, still without signs of pneumoperitoneum. Laparotomy was performed and diagnosis of IJP was confirmed. Bowel perforation was surgically closed in two layers, followed by drainage of septic collections, abdominal saline lavage and primary abdominal closure. The patient was discharged on the seventh postoperative day without complications. Conclusion In the case of BAT due to severe traumatic force in patient with nonspecific clinical signs of abdominal trauma on initial clinical and radiological examination, follow-up in a short period is necessary, to detect hidden jejunal perforation. Surgery is a life-saving for those patients and treatment of these injuries usually require simple operative procedures. © 2021, Serbia Medical Society. All rights reserved.

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. © 2017, Institut za Vojnomedicinske Naucne Informacije/Documentaciju. All rights reserved.

Introduction Trichobezoars presents a rare form of bezoar made of swallowed hair, with clinical manifesta-tion of gastric or intestinal obstruction, gastric ulceration, bleeding, and perforation. It is predominantly found in emotionally disturbed or mentally retarded youngsters, who eating their own hair which is clini-cally known as trichophagia. Patients often deny eating their own hair which makes diagnosis difficult. Case report We present a case of acute gastric outlet obstruction caused by a giant gastric trichobezoar made of a long thin hair, in a 20-year young female. Although patient had a long history of trichophagia, she did not think her behavior was unusual and she had not been treated before. Following the initial diagnostic procedures, exploratory laparotomy was indicated. After anterior gastrotomy was performed, a massive stomach-shaped trichobezoar was removed. Postoperatively, the patient had a psychiatric consult exam. She recovered well and was discharged without complications. She was referred for further psychiatric follow-up. Conclusion Trichobezoars are non-digestible collections that usually accumulates in stomach and can extend to small bowel, causing mechanical injury such as hollow viscus obstruction. Patients with acute gastric obstruction caused by a giant trichobezoar require urgent removal of the trichobezoar, to preserve the stomach and avoid further, catastrophic consequences. © 2023, Serbia Medical Society. All rights reserved.

Background/Aim. Presepsin (soluble CD14-subtype) is a fragment of CD14 produced in response to bacterial infections and a novel biomarker of pneumonia, sepsis and septic shock. The aim of this study was to compare sensitivity and specificity of persepsin, soluble CD14-subtype (sCD14-ST) with other biomarkers: procalcitonine (PCT), C-reactive protein (CRP) and leukocyte count (Le) in mechanically ventilated injured patients, as a marker of pneumonia, sepsis and septic shock. Methods. The prospective study was undertaken in trauma and surgery intensive care unit of the Emergency Center, the Clinical Center of Serbia from January to April 2013. The study included 39 trauma patients requiring mechanical ventilation, and who developed one of the following inclusion criteria: Systemic Inflammatory Response Syndrome (SIRS), ventilator associated pneumonia (VAP), sepsis and/or septic shock. On admission Acute Physiology and Chronic Health Evaluation II (APACHE II) Score and Injury Severity Score (ISS) were calculated. Seventy-two measurements of four biomarkers (presepsin, PCT, CRP and Le) were performed in 39 patients at the moments of diagnosis of SIRS, VAP, sepsis and/or septic shock (21 when SIRS diagnosis was established, 21 after the diagnosis of VAP, 18 at the moment of diagnosis of sepsis and the remaining 12 measurements were conducted while diagnosing the septic shock). The Sequential Organ Failure Assessment (SOFA) score was calculated at these points as well. Results. Patients were mainly severely injured (mean ISS = 24.2) and had moderately severe medical condition at admission (mean Apache II score, 14.5). Presepsin concentration significantly differed among all the four groups, except between sepsis and septic shock. The strongest positive correlation of presepsin evinced with PCT (r = 0.741, p < 0.001). The sCD14-ST indicated better performance in diagnosis of both VAP (AUC = 0.909) and sepsis (AUC = 0.899), compared to PCT (AUCs: 0.863, 0.885, respectively), CRP (AUCs: 0.703, 0.677, respectively) and Le (AUCs: 0.668, 0.700, respectively). Conclusion. This study revealed that sCD14-ST is a reliable biomarker for distinguishing sepsis severity. It also showed a good correlation with the infection development as well as worsening in injured patients. © 2018, Routledge. All rights reserved.

Introduction Despite the fact that treatment of liver injuries has dramatically evolved, severe liver traumas in polytraumatic patients still have a significant morbidity and mortality. Objective The purpose of this study was to determine the options for surgical management of severe liver trauma as well as the outcome. Methods In this retrospective study 70 polytraumatic patients with severe (American Association for the Surgery of Trauma [AAST] grade III–V) blunt liver injuries were operated on at the Clinic for Emergency Surgery. Results Mean age of patients was 48.26±16.80 years; 82.8% of patients were male. Road traffic accident was the leading cause of trauma, seen in 63 patients (90.0%). Primary repair was performed in 36 patients (51.4%), while damage control with perihepatic packing was done in 34 (48.6%). Complications related to the liver occurred in 14 patients (20.0%). Liver related mortality was 17.1%. Non-survivors had a significantly higher AAST grade (p=0.0001), higher aspartate aminotransferase level (p=0.01), lower hemoglobin level (p=0.0001), associated brain injury (p=0.0001), perioperative complications (p=0.001) and higher transfusion score (p=0.0001). The most common cause of mortality in the “early period” was uncontrolled bleeding, in the “late period” mortality was caused by sepsis and acute respiratory distress syndrome. Conclusion Patients with high-grade liver trauma who present with hemorrhagic shock and associated severe injury should be managed operatively. Mortality from liver trauma is high for patients with higher AAST grade of injury, associated brain injury and massive transfusion score. © 2015, Serbia Medical Society. All rights reserved.

Introduction Hemangioma is the most frequent benign solid tumor of the liver. It is well known that a giant liver hemangioma carries the risk of spontaneous rupture, followed by hemoperitoneum and hemorrhagic shock with possible fatal outcome. Case Outline This is a case report of the spontaneous rupture of a giant cavernous hemangioma of the liver in an 85-year old patient. The patient was presented with abdominal pain and hemorrhagic shock. Emergency ultrasonography and computed tomography of the abdomen showed a heterogeneous ruptured solid tumor of the right liver lobe, multiple cysts in the left lobe and massive hemoperitoneum. The patient was successfully managed by immediate exploratory laparotomy, surgical enucleation of the hemangioma under intermittent inflow vascular occlusion, temporary perihepatic packing and planned second look relaparotomy. Conclusion Immediate surgical procedure is indicated mandatory in unstable patients with a ruptured giant hemangioma of the liver. Surgical enucleation under intermittent inflow vascular occlusion and temporary perihepatic packing could be a life-saving procedure in those patients.

Background/Aims: In this study we analyzed our experience of suprahilar-posterior intrahepatic Glissonian pedicle approach using an endo-GIA vascular stapling device for the pedicle and hepatic vein division. Methodology: Sixty-eight 68 major and 102 minor liver resections were performed. The hilar extrahepatic structures remain intact, and during parenchyma dissection by CUSA, the whole right or left or the appropriate segmental pedicle was isolated intrahepatically and then transected using a stapler device. Results: The minor liver resections was associated with significantly shorter surgery duration (95.1+31.1 vs. 186.6± 56.5) and transection time (35.9+14.5 vs. 65.3±17.2) than major hepatectomies (p<0.001 for all). The mean blood loss was 255.6+129.9 mL in minor resection and 385.7+200.1 mL in major resection (p = 0.003). The mean blood transfusion requirement was 300.8+99.5 mL for the patients with minor hepatectomy and 450.9+89.6 mL for those with major liver resection [p - 0.067). There was no significant difference in morbidity and mortality between the groups [p = 0.989; p = 0.920). Major as well as minor liver resection were a superior oncologic operation with no significant difference in the 3-year overall survival rates. Conclusions: Liver transection using CUSA with suprahilar endo-GIA stapling of Glisson's pedicle, as well as major hepatic veins represents an effective and safe surgical procedure. © H.G.E. Update Medical Publishing S.A.

Background: Severe liver injury in trauma patients still accounts for significant morbidity and mortality. Operative techniques in liver trauma are some of the most challenging. They include the broad and complex area, from damage control to liver resection. Material and method: This is a retrospective study of 121 trauma patients with hepatic trauma American Association for Surgery of Trauma (AAST) grade III-V who have undergone surgery. Indications for surgery include refractory hypotension not responding to resuscitation due to uncontrolled hemorrhage from liver trauma; massive hemoperitonem on Focused assessment by ultrasound for trauma (FAST) and/or Diagnostic peritoneal lavage (DPL) as well as Multislice Computed Tomography (MSCT) findings of the severe liver injury and major vascular injuries with active bleeding. Results: Non-survivors have significantly higher AAST grade of liver injury and higher Injury Severity Score (ISS) (p=0.000; p=0.0001). Non-survivors have significant hypotension on arrival and lower Glasgow Coma Scale (GCS) on admission (p=0.000; p=0.0001). Definitive hepatic repair was performed in 62(51.2%) patient. Damage Control, liver packing and planned re-laparotomy after 48h were used in 59(48.8%). There was no statistically significant difference in terms of the surgical approach. There was significant difference in the amount of red blood cells (RBC) transfusion in the first 24h between survivors and non-survivors (p=0.001). Overall mortality rate was 33.1%. Regarding complications non-survivors had significantly prolonged bleeding and higher rate of Acute respiratory distress syndrome (ARDS) (p=0.0001; p=0.0001), while survivors had significantly higher rate of pleural effusion (p=0.0001). Conclusion: All efforts in the treatment of severe liver injuries should be directed to the rapid and effective control of bleeding, because uncontrollable hemorrhage is the cause of early death and it requires massive blood transfusion, all of which contributes to the late fatal complication. © 2015 Doklestić et al.

Background/Aims: Liver resection is a demanding procedure due to the risk of massive blood loss. Different instruments for liver transection are available today. The aim of this randomized clinical trial was to analyze the efficacy of three different parenchyma transection techniques of liver resection. Methodology: A total of 60 non-cirrhotic patients undergoing hepatectomy were randomly selected for clamp crushing technique (CRUSH), ultrasonic dissection (CUSA) or bipolar device (LigaSure), n=20 in each group. All patients had liver resection under low central venous pressure anaesthesia (CVP), with ischemic preconditioning and intermittent inflow occlusion. Primary endpoints were surgery duration, transection duration, cumulative pedicle clamping time, intraoperative blood loss and blood transfusion. Secondary endpoints included the postoperative liver injury, postoperative morbidity and mortality. Results: Overall surgery duration was 295 vs. 270 vs. 240min for LigaSure, CUSA and Clamp Crushing Technique, respectively. The transection duration was 85 vs. 52.5 vs. 40 minutes, respectively. These three different resection techniques of non-cirrhotic liver produced similar outcome in terms of intraoperative blood loss, blood transfusion, postoperative complications and mortality. Conclusions: The Clump Crushing Technique, CUSA and Liga Sure are equally safe for resection of non-cirrhotic liver. Liver resections can be performed safely if the entire concept is well designed and the choice of dissection device does not affect the outcome of hepatectomy. © H.G.E. Update Medical Publishing S.A.

Introduction/Objective Acute pancreatitis (AP) is a relatively common disease which in most patients has favorable course. However, in approximately 20% patients, the course of the disease is more severe with high mortality (40–50%). The evaluation of disease severity is now primarily based on protocols that includes clinical, laboratory, and radiographic diagnostic procedures, APACHE II score, Ranson score, CT index, and CT necrosis score. Key cells in the immunopathogenesis of AP are T-lymphocytes, and recent studies indicate the role of Th2 and their effector cytokines: interleukin (IL)-4 and interleukin (IL)-5. The purpose of our study was to determine the potential clinical value of IL-4 and IL-5 as biochemical markers for predicting development of severe, necrotizing form of acute pancreatitis with systemic complication such as systemic inflammatory response syndrome (SIRS). Methods This prospective study included 240 patients hospitalized at The Clinic for Emergency Surgery of Clinical Center of Serbia as AP. Levels of IL-4 and IL-5 in serum were detected using commercial Bender Med Systems (BMS716FF) kits. Results IL-4 and IL-5 were statistically significant increased on the second day of hospitalization with maximum values on the third day. In patients with severe AP complicated with necrosis and/or sepsis values were rising all through the seventh day. Conclusion Levels of IL-4 and IL-5 in peripheral blood correlate with SIRS, Ranson score and clinical outcome in AP patients, therefore these cytokines are potential early biomarkers of disease progression and related complications. © 2021, Serbia Medical Society. All rights reserved.

OBJECTIVE: Rescuing severe trauma cases is extremely demanding. The present study purposed to analyze the efficiency of trauma management at Emergency Centre, University Clinical Centre of Serbia, Belgrade, included outcome within 28 days. METHODS: This retrospective study involved 131 intensive care unit trauma cases with total Injury Severity Score ≥16, in terms of administrating the two strategies: (i) definitive surgical repair and (ii) damage control laparotomy. RESULTS: The damage control laparotomy cases revealed statistically higher Injury Severity Score and APACHE II scores, significant brain dysfunction, and hemorrhagic shock on arrival (p<0.001). In addition, the damage control laparotomy had a higher rate of respiratory complications, multiple organ deficiency syndrome, and surgical wound complications (p=0.017, <0.001, and 0.004, respectively), with more days on mechanical ventilation (p=0.003). Overall mortality was 29.8%. Although higher early mortality within ≤24 h in the damage control laparotomy (p=0.021) had been observed, no difference between groups (p=0.172) after the 4th day of hospitalization was detected. CONCLUSIONS: Trauma patients have a high mortality rate in the 1st hours after the incident. Compelling evidence linking host and pathogen factors, such as mitochondrial apoptosis pathways, appears to correlate with loss of organ dysfunction, both cytopathologically and histopathologically. Adequate selection of patients necessitating damage control laparotomy, allowed by the World Society of Emergency Surgery, abdominopelvic trauma classifications, and improvements in resuscitation, may improve the results of severe trauma treatment. © 2022 Associacao Medica Brasileira. All rights reserved.