Gallstone ileus is an uncommon cause of small bowel obstruction, accounting for only 1% to 4% of all intestinal obstructions. In the group of patients over 65 years of age, gallstones cause about 25% ...of all non‐strangulated obstructions of the small bowel. Gallstone ileus is burdened with high mortality rate, ranging from 12% to 18%, and most patients are of advanced age, with many other concomitant diseases that may increase the operative risk. The purpose of this study was to compare the two investigated surgical procedures: treatment of intestinal obstruction alone or combined with urgent cholecystectomy and fistula repair. Analysis of 30 patients undergoing operation for gallstone ileus at the Clinical Hospital “Sestre milosrdnice” between 1985 and 2001 is presented. Patients were treated either for ileus alone (group 1, 11 patients) or as one‐stage procedure with urgent fistula closure (group 2, 19 patients). Operating time was significantly longer for the one‐stage procedure. Complications occurred in 3 of 11 patients (27.3%) from group 1 and in 11 of 18 patients (61.1%) from group 2 (one tailed, p = 0.043). One patient in group 1 died and two patients in group 2 died. Urgent fistula repair was significantly associated with the occurrence of complications (odds ratio OR 12.1, 95% confidence internal 95% CI 1.2–121.5). Simple enterotomy should be the procedure of choice for patients with gallstone ileus. The one‐stage procedure including urgent fistula repair should be reserved only for highly selected patients with absolute indications.
Between January 1st 1990 and December 31st 1999, 24 patients affected by Klatskin tumor underwent operation in our department of surgery. According to Bismuth's classification, there were 0 (0%) type ...I, 5 (21%) type II, 6 (25%) type IIIa, 4 (17%) type IIIb and 9 (37%) type IV tumors. Five patients (21%) were treated by curative resection (group I) while in 14 patients (58%) palliative surgical procedure was performed (group II). In 5 cases (21%) the extension of malignancy did not allowed any procedure (group III). Curative resection for malignant tumors of the hepatic duct bifurcation included wide tumor excision and bile duct resection at the liver hilum (with wedge hepatic resection in one patient) and creation of biliary-enteric anastomosis. Palliative surgical procedure included stent insertion. Jaundice was completely relieved in all patients undergoing resection, since 3 patients (21%) after stenting hadn't satisfactory biliary drainage. There was 1 (20%) perioperative death in the group 1, while in group 2, 5 patients (36%) died postoperatively. In this series, the mean postoperative survival of all patients was 16 months. The mean postoperative survival of patients undergoing localized tumor resection with curative intent was 38 months, in contrast to 10 months for those undergoing operative stent insertion. in addition, only 1 patient from group III, in whom only exploratory surgery were performed survived 7 months, while other 4 patients died in the hospital. This retrospective review suggests that aggressive surgical treatment could improve survival and quality of life in patients suffering from Klatskin tumor.
Between January 1st 1990 and December 31st 1999, 24 patients affected by Klatskin tumor underwent operation in our department of surgery. According to Bismuth’s classification, there were 0 (0%) type ...I, 5 (21%) type II, 6 (25%) type IIIa, 4 (17%) type IIIb and 9 (37%) type IV tumors. Five patients (21%) were treated by curative resection (group I) while in 14 patients (58%) palliative surgical procedure was performed (group II). In 5 cases (21%) the extension of malignancy did not allowed any procedure (group III). Curative resection for malignant tumors of the hepatic duct bifurcation included wide tumor excision and bile duct resection at the liver hilum (with »wedge« hepatic resection in one patient) and creation of biliary-enteric anastomosis. Palliative surgical procedure included stent insertion. Jaundice was completely relieved in all patients undergoing resection, since 3 patients (21%) after stenting hadn’t satisfactory biliary drainage. There was 1 (20%) perioperative death in the group 1, while in group 2, 5 patients (36%) died postoperatively. In this series, the mean postoperative survival of all patients was 16 months. The mean postoperative survival of patients undergoing localized tumor resection with curative intent was 38 months, in contrast to 10 months for those undergoing operative stent insertion. In addition, only 1 patient from group III, in whom only exploratory surgery were performed survived 7 months, while other 4 patients died in the hospital. This retrospective review suggests that aggressive surgical treatment could improve survival and quality of life in patients suffering from Klatskin tumor.
Ozljeda glavnog žučovoda jedna je od najtežih komplikacija kolecistektomije. Nekoliko je multicentričnih studija pokazalo kako su ove ozljede češće kod laparoskopske negoli kod otvorene ...kolecistektomije. Tijekom sedmogodišnjeg razdoblja, od siječnja 1995. do prosinca 2001. godine, na Klinici za kirurgiju Kliničke bolnice "Sestre milosrdnice" u Zagrebu izvedena je kolecistektomija u 4528 bolesnika. Laparoskopska kolecistektomija učinjena je u 2657 (58%) bolesnika. Ozljeda glavnog žučovoda zabilježena je u 15 (0,33%) bolesnika. Ozljeda glavnog žučovoda nastala je u troje (0,16%) operiranih bolesnika metodom otvorene kolecistektomije. Djelomično presijecanje glavnog žučovoda nastupilo je kod dvoje bolesnika, a potpuno presijecanje kod jednog bolesnika. U skupini bolesnika kod kojih je učinjena laparoskopska kolecistektomija do ozljeda glavnog žučovoda došlo je u 12 (0,45%) operiranih: potpuno presijecanje glavnog žučovoda u petero, djelomično presijecanje u troje, ozljeda metalnom kopčom također u troje te suženje glavnog žučovoda bez intraoperacijski vidljive ozljede u jednog bolesnika i to u kasnom poslijeoperacijskom razdoblju. Svi bolesnici s jatrogenom ozljedom glavnog žučovoda koja je nastala nakon otvorene ili laparoskopske kolecistektomije liječeni su kirurški. Koledokojejuno-anastomoza po Rouxu izvedena je u devetoro bolesnika a kod šestoro bolesnika napravljena je rekonstrukcija glavnog žučovoda pomoću terminoterminalne anastomoze i uvođenjem T cjevčice. Suženje anastomoze nastupilo je u kasnom poslijeoperacijskom razdoblju u petoro bolesnika. Zato je kod njih izvedena sekundarna rekonstrukcija žučnog kontinuiteta pomoću koledokojejuno-anastomoze po Roux-u.
Otkriće da određene tvari mogu uzrokovati fotosenzitivnost pripisuje se Oscaru Raabu, međutim, ocem moderne ere fotodinamske terapije smatra se T. J. Dougherty s Instituta Buffalo Memorial. On je ...naime prvi objavio da sistemski dan porfirin (hematoporfirin), kada se aktivira crvenom svjetlošću, uzrokuje potpuno uništenje transplantiranog eksperimentalnog tumora. Također je prvi otkrio i objavio da fotosenzibilizirajuće tvari imaju sklonost nakupljanju u malignim stanicama. Prvi slučaj kliničke primjene fotodinamske terapije učinjen je na Tokyo Medical Collegeu 1980. godine. Bolesnik s malim skvamoznim tumorom gornjeg bronha bio je bronhoskopski podvrgnut fotodinamskoj terapiji, pri čemu se kao izvor svjetlosti rabio laser, a rezultat je bio potpuna eradikacija tumora. Istodobno je objavljen slučaj kliničke primjene fotodinamske terapije kao palijacijske metode u bolesnika s velikim karcinomom jednjaka, što je dovelo do uklanjanja disfagije te produžilo bolesnikov život. Ovaj rad prikazuje dosadašnje spoznaje i rezultate kliničke primjene fotodinamske terapije u liječenju malignih bolesti probavnog sustava.
Opisana je laparoskopsko-endoskopska operacija perforiranog želučanog vrijeda s biopsijom želučane sluznice i aplikacijom velikog omentuma u otvor perforacije. Kombinacija endoskopskog i ...laparoskopskog postupka daje dobar uvid u prohodnost pilorusa i dvanaesnika. Intraperitonejska biopsija sluznice antruma i želučanog korpusa omogućuje konačnu histološku dijagnozu te daje potvrdu moguće prisutnosti Helicobacter pylori. Uz brzi poslijeoperacijski oporavak bolesnika, laparoskopski pristup perforiranom vrijedu omogućava zadovoljavajuću irigaciju i drenažu abdomena.
