A novel algorithm for the minimal invasive treatment of choledocholithiasis

BACKGROUND/AIMS: Laparoscopic cholecystectomy is the gold standard in choledocholithiasis treatment. Currently there is no generally accepted algorithm for choledocholithiasis treatment. A few years ago suspected or diagnosed choledocholithiasis was indication for open operation if bilious stones could not be removed with therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Today, advancements in laparoscopic equipment and operation technique render the possibility for laparoscopic treatment of choledocholithiasis. There are many different ways in which to treat choledocholithiasis, depending on the time of diagnosis. Due to the considerable variability in choledocholithiasis treatment, which depends in turn on many objective and subjective factors, we propose a unique diagnostic algorithm for the treatment of choledocholithiasis. METHODOLOGY: From January 1st until December 31st 2005, at the University Department of Surgery -Split, 131 laparoscopic cholecystectomies were performed. Thirty-three patients with suspected choledocholithiasis were treated by laparoscopic intraoperative cholangiography. After positive cholangiography, thirteen laparoscopic transcystic extractions were performed. The patients were treated in the supine position. The surgeon was positioned between the legs of the patient, the assistants on opposite sides of the patient, and the scrub nurse on the right side of the surgeon. Transcystic stone extraction was performed using a flexible choledochoscope, which was connected to the left laparoscopic monitor using Picture-in-picture system and by Nitinol tipless Dormia basket. RESULTS: The total number of operated patients includes 18 women and 15 men. The mean age of patients was 60.16 +/- 15.36. The mean length of operation was 86 +/- 21.79. Mean hospitalization length of patients with laparoscopic cholecystectomy was 2.45 +/- 1.14 days; while mean hospitalization length of patients with stone extraction was slightly longer 2.90 +/- 1.18, (p = 0.564). CONCLUSIONS: Today several different possibilities approaches exist for the treatment of choledocholithiasis and it doesn't have to be treated unconditionally using endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy before, during or after laparoscopic cholecystectomy, or by the open operation.     

Activities of endogenous antioxidant enzymes in the cerebrospinal fluid and the hippocampus after transient forebrain ischemia in rat

The activity of SOD and CAT was measured in controls and 5 h after 5, 10 and 15 min of ischemia, as well as 1 or 2 days after 10 min of ischemia in the hippocampus and in the CSF. A significant increase in total SOD activity 5 h after ischemia was caused mainly by increased CuZn-SOD activity. The highest values were measured 5 h after 5 min ischemia (by 160%) and smallest if 15 min (by 40%) of ischemia was used. In comparison to the hippocampus, the activity of SOD in CSF increased equally after all intervals of ischemia. Activities of total SOD and CuZn-SOD after 10 min of ischemia in the hippocampus were significantly increased only after 5 and 24 h of reperfusion but in CSF they were increased after all examined intervals of reperfusion. The activity of CAT was significantly increased in the hippocampus after 5 (by 260%), 10 and 15 min (by 100%) of ischemia. CAT activity in CSF was increased equally after all intervals of ischemia (by 200%). Ischemic attack causes a rapid response in hippocampal tissue as well as in the CSF, represented by an increase in the activity of endogenous antioxidant enzymes SOD and CAT.     

Multifragment fracture of the patellar apex: basket plate osteosynthesis compared with partial patellectomy

Introduction The purpose of the present study was to evaluate and compare the long-term results of operative treatment of a multifragment fracture of the inferior patellar pole by basket plate osteosynthesis and partial patellectomy. Materials and methods We retrospectively studied two groups of patients who had operative treatment of a multifragment fracture of the inferior patellar pole between 1988 and 2004. Seventy-one patients who had osteosynthesis by basket plate (Group 1) and 49 patients who had partial patellectomy (Group 2) were followed for an average of 5.3 years. The final evaluation was based on the modified Cincinnati Knee rating system test. Results The results were excellent or good in 90.1% patients of Group 1, and 73.5% patients of Group 2. Significant differences between the groups were noted with regard to knee pain, swallowing, level activity, compression pain, range of motion, muscular atrophy, muscular strength, and final patellofemoral score which confirms statistical analysis. Conclusion The stability of the osteosynthesis by basket plate allows osseous consolidation of the fracture and permits immediate mobilization and early weight bearing. Osteosynthesis by basket plate can provide better clinical results.     

Prompt Treatment of Intestinal Obstruction after Biliopancreatic Diversion can Save the Intestinal Loop

Bariatric surgery is becoming an accepted method for weight reduction. Biliopancreatic diversion is reserved for high initial BMI. With the increasing number of these procedures, the reports of complications become more important and prepare a wider range of specialties to deal with them. We report a 62-year-old woman who developed a volvulus of the biliopancreatic loop after a biliary diversion operation with a sleeve gastrectomy and antro-ileal anastomosis. Symptoms of biliopancreatic loop obstruction are rather vague, presenting with atypical abdominal pain, nausea, sometimes vomiting, preserved bowel motility, stool, and gas passage and normal upper GI X-ray. Due to the patient’s prompt reaction and straight referral to a bariatric surgeon, freeing of the loop was enough to maintain its viability. The patient’s further recovery and follow-up were uneventful. With this case, we stress the importance of an expert in such cases and a need to consider familiarizing doctors with these patients and with the peculiarities of their treatment.     

Rehabilitation medicine in countries of Central/Eastern Europe

Purpose. To describe attributes of rehabilitation medicine common to the five countries of Central Eastern Europe (CEE) and their implications for future challenges.

Methods. Critical collection and study of pertinent data on evolvement and present state of rehabilitation medicine in CEE countries by a coordinated team of rehabilitation experts from each of the relevant countries.

Results. CEE countries are similar in their need for rehabilitation medicine, its evolvement, present state and current practice. Settings largely emerged without strategic planning on the national level and lagged behind those in Central and Western Europe both in time and content.

Conclusion. The framework that evolved in all except Slovenia is not appropriate to needs. In order to meet future challenges all five CEE countries need the incorporation of inpatient, outpatient and community-based rehabilitation into one system.