Biomedical subjects

Mladen Stulhofer

Publications and source records attributed to Mladen Stulhofer.

3 recordsLinked to original sources

PubMed2003

[Laparoscopic cholecystectomy--accessory bile ducts].

INTRODUCTION: Modern medical technology (ultrasonography, intraoperative radiologic contrast methods, ERC, CT and NMR) help in performing laparoscopic cholecystectomy and operative procedures on bile ducts. The safe performance of these operative procedures requires good knowledge of clinical anatomy. In spite of excellent laparoscopic visualization, perioperative lesions of vascular structures or extrahepatic (especially accessory) bile ducts during laparoscopic cholecystectomy are a frequent cause of intra- and postoperative complications. Therefore, we wish to point to the potential risk of running into accessory bile ducts on dissection within or around the cystohepatic triangle, which may entail some overlooked and untreated lesions. PATIENTS AND METHOD: Accessory bile ducts originate from the liver parenchyma and may enter a large bile duct or gallbladder at any location, or can directly enter the intestine. The accessory bile ducts encountered on cholecystectomy or bile duct procedure call for special attention. We found accessory bile ducts in 13 (0.52%) patients during the procedure of laparoscopic cholecystectomy. There are three groups of 'risky' accessory bile ducts that can be encountered during laparoscopic cholecystectomy. Group I includes accessory bile ducts encountered on gallbladder removal from its support: 1) Luschka's subvesical accessory bile duct was found in six (46.1%) patients. A lesion to these ducts was intraoperatively observed in three (23.1%) patients, whereas in another three (23.1%) patients it was only detected and treated on reoperation; 2) the hepatocystic bile duct enters gallbladder directly from liver parenchyma, in the area of the gallbladder lobe. A hepatocystic accessory bile duct was identified during one (7.7%) laparoscopic cholecystectomy, when the duct lumen was observed on the gallbladder removal from the lobe, and another one (7.7%) was only identified on reoperation. Group II comprises accessory bile ducts encountered during dissection in the cystohepatic triangle, between the two hepatovesical plicae: 1) the hepatocystic accessory bile duct runs from liver parenchyma into the cystic duct within the cystohepatic triangle. Bile leak from a bile duct approaching the cystic duct immediately below the clip was observed on reoperation in one (7.7%) patient; 2) the hepatohepatic accessory bile duct drains a part of the liver and runs into the common hepatic duct within the cystohepatic triangle. During one (7.7%) dissection, another delicate bile duct originating from liver parenchyma was detected upon cystic duct clipping. Bile leak from a bile duct running into the common bile duct before entering the properly occluded cystic duct was observed on one (7.7%) reoperation; 3) anastomotic accessory bile ducts connect cystic duct with the common hepatic duct, or connect gallbladder, which has its own cystic duct, with the common hepatic duct or right hepatic duct. In our laparoscopic practice, we did not encounter this type of accessory bile ducts. Group III includes accessory bile ducts observed in the laparoscopic operative field, beyond the cystohepatic triangle, during cholecystectomy and bile duct procedures: 1) the hepatocystic accessory bile duct leaves liver parenchyma and enters the gallbladder at various sites. Stumps of two such accessory bile ducts (15.4%) were detected on reoperation. One entered the gallbladder below the cystic duct entry, and the other approached the gallbladder from above. RESULTS: Reoperation following laparoscopic cholecystectomy was required in 15 (0.6%) patients. In eight (53.3%) of these, the reason for reoperation was untreated lesion of accessory bile duct in eight (53.3%), other untreated minor lesions of the cystic duct in five (33.3%), and lesions of the hepatocystic duct in two (13.3%) patients. Out of the eight patients reoperated on for untreated lesion of accessory bile duct, reoperation was indicated by external biliary secretion by drain for more than 7 days in three (37.5%), and by the development of biliary peritonitis with the symptom of pain in five (62.5%) patients. Right-sided shoulder pain and elevated body temperature were recorded in two (40.0%) patients each, whereas abdominal distension with pronounced local defense and hyperbilirubinemia were observed in four (80.0%) patients each. A combination of these symptoms was present in the majority of patients. The prevalence of symptoms was consistent with literature reports. Of the eight patients reoperated on for lesions of accessory bile ducts, the lesion was managed by repeat laparoscopy procedure in five (62.5%) and by laparotomy in three (37.5%) patients. There was no mortality. CONCLUSION: Besides technical skill and experience, good knowledge of the clinical anatomy of accessory bile ducts is required to reduce the incidence of postoperative biliary secretion. Based on our own experience, lesions to accessory bile ducts are the most common cause of postoperative complications.

Bile Ducts↗

PubMed2002

[Mesenteric cysts].

INTRODUCTION: Mesenteric cysts and cystic mesenteric tumors are very rare abdominal growths. They may be localized all over the mesentery, from duodenum to rectum, however, they are mostly found in the ileum and right colon mesentery. There are several classifications of these formations, among which the one based on histopathologic features including 6 groups has been most commonly used: 1) cysts of lymphatic origin--lymphatic (hilar cysts) and lymphangiomas; 2) cysts of mesothelial origin--benign or malignant mesothelial cysts; 3) enteric cysts; 4) cysts of urogenital origin; 5) dermoid cysts; and 6) pseudocysts--infectious or traumatic etiology. PATIENTS AND METHODS: Two adult female patients treated at the Department of Surgery, Zabok General Hospital, are presented. The diagnosis of mesenteric cyst was based on explorative laparotomy indicated for a cystic abdominal growth and characteristic palpatory finding, US and CT findings. In both patients, the cysts were successfully treated by total cystectomy. Pathohistologic findings pointed to lymphatic cysts. Control US finding at 3 months postoperatively was normal in both patients. DISCUSSION: Cystic lymphangioma mostly occurs in the first decade of life, with a female predominance. It is usually accompanied by acute abdominal symptomatology. Lymphatic cysts occur later in life (1:100,000 in adults and 1:20,000 in children), also show female predominance, and as a rule are asymptomatic. A mesenteric cyst, especially lymphatic, should be suspected in the presence of painless abdominal tumor, with occasionally painful abdominal pressure, normal laboratory findings, and good general condition in a female patient. In symptomatic cases, acute or chronic abdominal pain is the most common feature, whereas other symptomatology depends on the localization, size and consequential abdominal organ compression (intestinal obstruction, hydronephrosis, lower extremity lymphedema). The term of cystic mesenteric tumor is mostly used to refer to cystic lymphangiomas and lymphatic cysts. In the former, smooth muscle tissue is found, with endothelial lining towards the cavity. The wall of hilar mesenteric cysts does not contain smooth muscle tissue, however, they also show endothelial lining towards the cavity. Exact differentiation between these two entities is necessary for the disease prognosis. Lymphangiomas are prone to recurrence and infiltrating growth. The diagnosis should be made by use of all standard methods of abdominal tumor diagnosis, with ultrasonography (US) and computed tomography (CT), and especially nuclear magnetic resonance providing most information of the growth size and localization. Total cystectomy is the therapeutic method of choice. Open method has been preferred, although reports on successful cystectomy by the laparoscopic method have already appeared in the literature. CONCLUSION: Intraoperative differentiation between lymphatic cyst and lymphangioma is of utmost importance, and can only be achieved by pathohistologic examination of the cyst wall. If intraoperative biopsy cannot be performed or the finding is uncertain, each cyst should be extirpated in toto due to the above mentioned risk associated with cystic lymphangioma.

Adult↗

PubMed2002

[Views on health, disease and human life].

We should not conceptualize health as a normal biological state. The WHO definition, equating health with physical, psychological, and social satisfaction is not adequate. Health should be defined as a life situation unaffected by pain, injuries, physical, and/or psychological dysfunctions. Most of the time we are only partially healthy, just as we are only partially free (J.J. Rousseau). Both health and illness should be comprehended as normal biological states, which are constantly interchanging. Individual variations are the consequences of a complex interaction of genetic and environmental factors. These variations are the source of our individuality, talents, and specific skills. Genetic mutations, as is well known, can lead to a range of diseases, which modern molecular medicine is trying to prevent or treat with success. The sense of pain is an important defense mechanism that has evolved in many species, including ours. It is an alarm system indicating problems and pathogenic developments. The sense of pain is of huge importance in maintaining health. There is yet another important phenomenon in human life--the addiction syndrome. As well researched, addiction is related to specific brain receptors. In some individuals these receptors are extremely sensitive to psychoactive substances, such as alcohol, nicotine, and recrational drugs, leading to addiction. In contemporary societies, the symptoms of addiction can also be related to the more extreme forms of professional and sports ambitions. Contemporary medical science has succeeded in prolonging human life. The costs, however, have also risen due to the aging population. This fact is not only an economic or a social, but also a political problem. Human aging should not be viewed only as a process of wearing the biological machine off, but primarily as a gradual loss of genetic control over life functions.

Aging↗