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Peripancreatic lymph node tuberculosis is a rare disease with a difficult diagnosis. The case of a 61-year-old patient who was admitted because of intermittent dull pain in upper abdomen lasting 3-4 months followed by nausea, loss of appetite and body weight. The applied diagnostic procedures indicate a change in the head of the pancreas. The method of choice for establishing a definitive histopathological diagnosis is the biopsy of the lesion. Biopsy changes can be done using U.S., CT, Endo U.S. and laparoscopy. Surgery is a last resort only to establish a definitive histopathological diagnosis.

Radiofrequency (RF)-assisted resection techniques are associated with minimal blood loss providing safe hemostasis of the transected liver 1-3 parenchyma. Different RF-assisted liver resection techniques have been developed. The presented RF technique is the sequentional coagulate-cut liver resection technique (“The Belgrade technique”) and the difference from other techniques is the way the electrode is used. A coagulate-cut liver resection cycle can be described as a process of creating a 30-mm long and 6-8 mm wide cylinder of coagulated and desiccated liver tissue by applying RF energy through the non-insulated tip of the electrode inserted into the liver parenchyma and then dividing the coagulated tissue by surgical scalpel or scissors. From January 2001 to January 2014, 830 RF-assisted liver resections were performed for various indications at the HPB unit of the Clinic for Digestive Surgery, Clinical center of Serbia, Belgrade. Among 830 liver resections, 470 resections were performed in 383 patients with colorectal cancer liver metastasis. Sixty-six patients experienced repeated liver resection ranging from a second to a fifth resection. The majority of patients had bi-lobar spread of the disease before the first liver resection was performed. No difference was found in the postoperative morbidity between the patients after the first, the second and the third liver resection (F=0.168; p=0.846). 90-days mortality was 5.7% after the repeated liver resections and 2.5% in patients with one liver resection (X2=2.278; 4,13 p=0.165). Single HPB unit experience has demonstrated that RF-assisted liver resection technique is feasible, safe and effective procedure in the management of patients with CRC liver metastasis.

The presence of benign and/or malignant liver lesions is not easy to determine, especially differentiated. Preoperative diagnosis has to include more procedures for correlation of data in order to establish the correct diagnosis and proper treatment. The case of a 72-year-old female patient who was admitted because of the appearance of persistent dull pain under right rib cage. Ultrasound and CT findings verify the presence of two changes in the right liver, various radiographic characteristics. One change was good, other cystic. The presence of easily elevated tumor markers (AFP) in favor of hepatocellular carcinoma. The nature of other types of cystic changes was not clear. Intraoperatively and histologically confirmed to be a simultaneous presence of hepatocellular carcinoma and hydatid cysts in the right lobe of the liver. Surgical treatment is the only solution for the simultaneous treatment of both changes in the liver.

INTRODUCTION: Central venous catheter (CVC) placement is an unavoidable part of the everyday medical practice. At the same time CVC application is associated with high risk of development of central line-associated bloodstream infections (CLABSIs). These infections are cause of icreased morbidity and mortality rates as well as higer costs of the inpatient treatment2. Risk factors for onset of CLABSIs include duration of catheterization, length of hospital stay before catheterization, anatomic site of placement, CVC placement at the intensive care units (ICU), parenteral nutrition (PN) and ommisions diring CVC placement, use and care. CLABSI incidence rates vary depending on distribution of different risk factors associated with CVC and patient him/herself. The most significant causative organisms of CLABSIs are coagulase-negative Staphylococcocae, Staphylococcus aureus (S.aures), Enterococcus spp. i Candida spp. CLABSIs prevention measures include compliance with the rules of the aseptic technique upon placement, use and care of CVCs, which, based on the study results, may enable prevention of 65% to 70% of cases of CLABSIs. METHODS: A prospective cohort study included 200 patients hospitalized at the intensive care and therapy units of the CCS Clinic of Digestive Surgery in the period November 30th, 2006-November 31st, 2007 in whom CVC was placed for more than 48 hours. All the data necessary for the study were obtained based on the review of the case histories and they were recorded into the individual questionnaires for each patient. The questionnarire included patient information (age, gender, underlying disease, presence of other infections), information related to diagnostic and therapeutic procedures to which the patient was exposed. The incidence of CRBSIs in ICU patients, Institute of Digestive Diseases, CCS over the study period was 10.08 per 1,000 catheter-days. During the study CLABSI more often present in the females. Additionally, application of albumin and amino acids, ICU stay longer that 7 days and CVC application longer than 15 days, significantly more often present in patients with CRBSIs than in the group of patients without CRBSIs. Independent factors for development of CRBSI are gender, administration of albumin and amino acids. The most common microorganisms isolated from hemocultures and CVC were S. aureus and Klebsiella spp., with 31,8% of isolates each. Statistically significant difference was evidenced in frequency of resistance of S. aureus isolates to methicillin in the group of patients with CRBSI in comparison to the group of patients without CLABSIs. CLABSIs prevention measurs include compliance with the rules of the aseptic technique upon placement, use and care of CVCs.

Uvod: Ehinokokoza predstavlja znacajan zdravstveni problem u endemskim podrucjima, ali zbog migracije ljudi, ovo postaje briga citavog covecanstva. Ehinokokoza najcesce zahvata jetru. Na osnovu ultrasonografskog izgleda, ehinokokusne ciste su klasifikovane u pet tipova. Međutim, razlicite ciste imaju razlicit klinicki tok, sa razlicitim terapijskim implikacijama. Stoga je Svetska zdravstvena organizacija 2003, dala novu podelu uzimajuci u obzir i morfoloske i klinicke karakteristike ehinokokusnih cisti, sa preporukom da naucnici sirom sveta koriste ove podelu u cilju da se njihovi podaci mogu upoređivati. Cilj: Cilj ove deskriptivne studije je prezentacija rezultat pregleda pacijenata pregledanih zbog ehinokokoze jetre tokom jedne godine. Metod: Ova studija je ukljucila 52 pacijenta ispitivanih i lecenih zbog ehinokokusne ciste jetre u Klinici za digestivnu hirurgiju, Klinickog centra Srbije u Beogradu podvrgnutih ehosonografskom pregledu abdomena. Analizirani su podaci o polu i uzrastu pacijenata, njihovi simptomi (abdominalni bol, mucnina, povracanje, povisena telesna tempretaura) i prisustvo solitarnih ili multiplih cista jetre. Prikazani su podaci o segmentnoj lokalizaciji i tipu ehinokokusnih cista jetre. Rezultati: U studiju je ukljuceno 16 muskaraca i 36 žena prosecne starosti 53,15+/-17,51 godina (najmanje 17; najvise 78). Bol u trbuhu je imalo 69,2% pacijenata, mucninu 23,1%, povracanje 15,4% i povisenu telesnu temperaturu 3,8% pacijenata. Solitarna ehinokokoza jetre je nađena kod 69,2% pacijenata. Kod 19,2% pacijenata je identifikovana Gharbi I cista, kod 29,8% Gharbi II, Gharbi III kod 33,7%, Gharbi IV kod 15,4%, a Gharbi V tip ciste je identifikovana kod 1,9% pacijenata. Vecina cisti je identifikovano u IV, VII i III segmentu jetre (34,6%, 23,1% i 11,5%). Zakljucak: Ova deskriprivna studija je analizirala, pored demografskih karakteristika i tipa i ucestalosti tegoba, rezultate ehosonografskog ispitivanja i primenu standardizovane klasifikacije ehinokokusnih cisti jetre radi doprinosa znanju o karakteristikama ehinokokusnih cisti jetre u nasem podrucju. Ovo je, takodje, koristan prikaz dijagnostickih standarda za ovo oboljenje.

The authors describe their own experience with chemoembolization as a palliation in the treatment of non resectable hepatocellular carcinoma. Material/Methods: During period of 64 months procedure was performed in 41 patients with non resectable hepatocellular carcinoma. The combination of Lipiodol and chemotherapeutic agents were applied in a. hepatica propria and its branches via transfemorally placed catheter. Stages of neoplasms were defined by Okuda method. Results: The majority of tumors (30) were classified as Grade I. Liver cirrhosis was present in 36 patients, and abnormal levels of alpha-fetoprotein were found in 68% of cases. Each of twenty nine patients had more than one chemoembolization therapy, therefore, a total of 85 treatments were carried out. CT scanning perfomed one month following the procedure revealed more than 75% of Lipiodol retention in 42% of cases, and over 90% of neoplasm necrosis was recorded in 90% of cases, while all treated patients manifested lower levels of alpha - fetoprotein. All patients survived during three and six months, respectively, while the survival rate was 68% after 18 months. No letal outcome was reported during procedure, and morbidity in relation to total number of interventions was 19%. Conclusion : Achieved effects of this relatively safe procedure in our series do not differ significantly from those in the literature.

INTRODUCTION: Nosocomial infections (NI) are significant medical problem in the countries worldwide. NI significance reflects in higher morbidity and mortality rates, and moreover, NIs add to longer stay and higher treatment costs. Based on data obtained from underdeveloped and developing countries, over 20% of hospitalized patients acquire some of NIs, while that proportion is 5% in developed countries. OBJECTIVE: a) to establish the frequency of noosocomial infections at the Clinic of Digestive System Diseases, b) determine the NI incidence in accord with anatomic localizations, c) evaluate the percentage prevalence of NI causes according to anatomic localizations, and d) review the problem of resistance of NI causative agents. MATERIAL AND METHODS: The study of NI incidence was calculated by Center for Diseases and Prevention (CDC) methodology. Sampling, cultivation, isolation, identification and sensitivity tests of cauosative agents to antimicrobial drugs, obtained from patient's material, were carried out by standard microbiological methods in Microbiological laboratory of the Emergency Center, Clinical Center of Serbia. All infections in patients hospitalized at the Clinic of Digestive System Surgery in 2007 were recorded. Data available from medical documentation as well as data obtained from interviews of medical personnel were analyzed. RESULTS: The incidence rates of patients with NI ranged from 1.7-3.4 per 1000 hospital days. Out of a total number of recorded nosocomial infections, surgical site infections accounted for 69%, blood infections 23% and urinary tract infections 6.8%. The most frequent causative agents of surgical site infections in the last year were as follows: Pseudomonas spp (19%), followed by Staphylococcus aureus and Klebsiella spp - (18%), Acinetobacter spp. (13%), and Enterococcus spp (8%). Forty percent (40%) of all blood infections verified by laboratory tests in 2007 was caused by coagulase negative Staphylococcus spp (CNS), followed by Acinetobacter spp (18%), Enterococcus spp (11%), and Staphylococcus aureus (7%). The most frequent causative agents of urinary infections were: Escherichia coli (35%) and Enterococcus spp (29%). Over 80% of Staphylococcus aureus isolates were resistant to Methicillin (MRSA) and enterobacteria produced by beta lactamase were recorded (ESBL). CONCLUSION: Enforcement of epidemiological surveillance of nosocomial infections contributes to insight of severity of NI problem, recognition of resistance of causative agents to antibiotics and recommendation of specific preventive measures related to these infections.

Magnetic resonance cholangiopancreatography (MR CP) is a relatively new, noninvasive method in patients with pancreaticobiliary diseases, which is comparable to invasive endoscopic retrograde cholangiopancreatography (ERCP). One of the most common indications for MRCP is malignant obstruction of the bile and pancreatic ducts. Standard imaging protocol includes routine abdominal study followed by a sequence for MRCP adapted to each of the patients and site of the malignant process. MRCP is a simple to perform, does not exposure the patients to radiation, requires no anesthesia, is less operator dependent and allows better visualization of ducts proximal to an obstruction. Thus, during one examination only, it is possible to assess not only pancreaticobiliary system but also abdominal structures, which increases diagnostic value of MR and is therefore, optimal method in evaluation of these patients. .

Background: The primary objective of the analysis was to compare duration of survival in patients who received bevacizumab plus 5FU/LV, irinotecan or oxaliplatin based chemotherapy with the survival rate in a combined control groups of patients who received the same protocols alone, without bevacizumab. Methods: Pooling of the data from the several studies allows evaluation of efficacy end points with greater statistical power to detect real differences between the groups of patients who were and were not treated with bevacizumab. The 10 studies have to be used for analysis were well designed, prospective trials conducted in patients with metastatic colorectal adenocarcinoma. Results: The median duration of survival was 18/12/11 months median duration of progression free survival was 8.8/7/6.7 months and response rate was 34/14/12% in the 5-FU/LV/bevacizumab group, 5-FU/LV CI group, and bolus 5-FU/LV group, respectively. Difference in OS for patients who received bevacizumab with 5-FU/LV in comparison to 5-FU/LV alone is up to 7 months. The median duration of survival for bevacizumab plus irinotecan-based chemotherapy was 20 months, median duration of progression free survival was 11 months and response rate was 45%. Difference in OS, PFS and RR for patients who received bevacizumab plus irinotecan-based chemotherapy in comparison to irinotecan-based chemotherapy alone is up to 5 months, 4.5 months and 10%. For oxaliplatinbased protocols tumor response was 43-53%, overall survival was 16.4-19.4 months and the median progression free survival was 8-9 months. The median duration of survival was 26 months (benefit is up to 10 months), median duration of progression free survival was 19 months (benefit is up to 10 months) and response rate was 59% (benefit is up to 16%) were achieved for bevacizumab plus FOLFOX4 (oxaliplatin/ inf.5FU/LV). Conclusions: Addition of bevacizumab to 5-FU/LV, irinotecan or oxaliplatin-based chemotherapy provided significantly and clinically meaningful improvement in overall survival, disease-free survival and response rate compared with 5-FU/LV, irinotecan or oxaliplatin- based chemotherapy alone in patients with metastatic CRC.

It is retrospective analysis of all percutaneous billiary dranage types used in 600 patients with obstructive icterus in last 10 years. The procedure techniques is analyzed. It had positive therapeutical result in about 75% cases. The most frequent complication are showed. The most corresponding percutaneous derivation algorithm is discussed. As initial method is suggested the usage of externo-internal derivation which, in dependence of the procedure, continue by internal derivation-catheteral endoprosthesys or metallic stent. The covered metallic stents usage is suggested as method of choice in metallic endoprosthesys application.

Invagination is specific form of bowel obstruction that is seen in 1-4 children per 1000 births, usually in the period from 3 to 12 months of age. In 90-95 % reason for invagination in unknown so we called this forms idiopathic. In 5-10% invagination is caused by specific leading point. The aim of this retrospective study was to determinate prognostic valye of used biochemical tests (hemograms, glucosa, electrolites ( levels of Na+, K+ , Ca+ and Cl-) and to prove bad influence of existing "leading point" in therapy of invagination (weather it will be surgical or hydrostatic desinvagination). Methods: We analyzed 65 patients with invagination. We divided all our patients into 2 groups: first group consisted patients with idiopathic forms of invagination, and the other one were patients with invagination caused by specific leading point. Results proved that leading point in invagination has great implications on clinical presentation, laboratory results, diagnostic and therapeutic procedure, and finally in prognosis. .

Introduction. The dilemma whether to use the mesh or non mesh technique in the management of umbilical, epigastric and small incisional hernia is slowly fading away. The open preperitoneal "flat mesh" technique performed as ambulatory surgery may be one of the solutions. The Aim. The aim of this retrospective study is to present the results of open preperitoneal "flat mesh" technique in the management of umbilical, epigastric and small incisional hernia within Material and methods. This study included 34 patients (11 of them with umbilical, 13 with epigastric and 8 of them with small incisional hernia) operated by one surgeon in the period January 2004 - January 2006. Results. The median operative time was 52 minutes for umbilical hernia?s, 43 minutes for epgastric and 54 minutes for incisional hernia?s. The ambulatory surgery was performed at 91% of patients. The median hospitalization was 4h for patients with umbilical hernia?s, 3,7h for patients with epigastric and, 7,7h for patients with small incisional hernia. The follow up is 10,5 months. Apart of one superficial infection other complications were absent. Conclusion. The open preperitoneal "flat mesh" technique performed in local anesthesia as an ambulatory surgery provides good results in the management of umbilical, epigastric and small incisional hernia.

Three main hepatic veins: right, middle and left are constant, but there is a variable number of retrohepatic vessels called accessory or minor hepatic veins. The most important of them are veins reffered to as middle right hepatic vein (MRHV) draining segment VII and inferior right hepatic vein (IRHV) draining segment VI. The incidence of large MRHV and IRHV reaching or exceeding a caliber of 5mm, their arrangement in the liver and drainage territories were investigated in our collection of 142 injection-corrosion specimens of the liver. In 1/5 of the cases with large IRHV this vein drains small part of segment VI, sometimes its insignificant marginal part so it couldn?t be used for segment VI preservation when it is necessary. A precise knowledge of the vein anatomy of right posterior sector of the liver and its vein drainage territories is very important during complex dissections of the retrohepatic areas, resections and preservation liver parenchima.

The ankle fractures continue to be a topical issue in orthopedic surgery. X-ray diagnostics, but primarily also other modern diagnostic procedures such as CT, MRI, and arthroscopy enable detection of not only fractures but also osteocartilaginous fractures and soft-tissue ligamentary lesions, which are frequent causes of pain and instability of the ankle. The key segment is the posterio-lateral segment and tibio-fibular syndesmosis whose integrity is sometimes only surgically establishable. In the ankle treatment, stable fixation - since recently by means of resorptive osteofixation materials - and early rehabilitation of the operated ankle are aimed at. The open and pylon fractures, as the most severe forms of ankle fractures, are treated by external fixation with minimum internal fixation (hybrid fixation) of the ankle with conversion of the rigid into a dynamic (articulated) external fixator enabling movement and nutrition of the damaged articular cartilage.

The anterior cruciate ligament or ACL (ligamentum cruciatum anterius) is often injured, either alone or within complex ligament injuries of the knee. Therefore, the knowledge of detailed anatomic (macro- and micro-morphological) characteristics of this ligament is of key importance in therapy. The anatomy, structure, insertions, vascularization and innervations of the anterior cruciate ligament of the knee are described from the aspect of modern treatment and rehabilitation methods.

Traditionally, the operation of hernia is considered as a clean operation due to expected, low incidence of infection, on the spot of surgical work (SSI). The incidence of SSI in hernia surgery is more frequent then it is assumed. The important risk factors for SSI are the following: type of hernia (inguinal, incisional), operative approach (open - laparoscopic), usage of the prosthetic material and drainage. Comparing to inguinal hernia repair, incisional hernia repair, is more frequently followed by the infection. The laparoscopic operations are followed with the lower incidence of SSI then in the case of open operation. The usage of the mesh does not increase the incidence of SSI, although the consequences of the mesh infection may be severe. A type I of the prosthesis is more resistant to the infection then prosthesis II and III. The mesh infection (type I) never involves its body but it is present around sutures and bended edges. The mesh infection Type II involves entire prosthesis while in the case of Type III it is present in its peripheral part. In the case of SSI, a prosthesis Type I is possible to be saved, while prosthesis Type II must be removed completely; and the same is for the Type III (the partial removal is rarely suggested). The defect that remained after excision of non-resorptive prosthesis is a long-term and very complicated surgical problem. In regard to the position of the mesh, SSI is more common if the mesh is placed subcutaneously then in the case of sub-aponeurotic peri-muscular, pre-aponeurotic retromuscular or pre-peritoneal mesh placemen. If the infection is present the non-tension techniques using non-resorptive prosthetic implants are not recommended. the presence of drainage and its duration increases the incidence of SSI. It is more common for incisional hernioplasty then for inguinal hernia repair. If there is an indication for drainage it should be as short as possible. The cause of SSI for elective operations are bacteria?s that arrives from the skin, while in the case of opening of various organs dominant bacteria?s originate from them. The superficial infection does not lead to the recurrence, while it is very possible in the case for deep infection. There are no prospective studies that justify the usage of antibiotic prophylaxes in hernia surgery. The antibiotic prophylaxis in hernia surgery. The antibiotic prophylaxis is indicated for the clean operations when placing the implants and when severe complication is expected. The appearance of SSI increases the price of treatment and may lead to the recurrence.

Acute pancreatitis is illness with unpredictable outcome. In some patients course of illness is progressive and leading to multiple organ dysfunction syndrome often resulting with lethal outcome. During last decade the treatment protocols have changed. Basic patophysiologic mechanisms leading to progression of the illness, as well as, contemporary diagnostic and treatment possibilities that can prevent occurrence of severe consequences and improve outcome are presented.

After the introduction of prosthetic material in hernia surgery the fundamental changes in operative strategy occurred. This is because the coverage of miopectineal orifitium with non-absorbable prosthesis decreases the incidence of recurrences. Because of the appearance of lateral re-recurrences after the classical Rives procedure, we modified the operative technique. The modified Rives technique consists of the following: always polypropilen mesh 15x10cm; creation of the new internal inguinal ring between Poupart's ligament and mesh; no lateral notching the mesh and anchoring mesh 2-3cm from the medial, inferior, lateral and superior edge. During the period January 2001 - December 2003, 34 cases of recurrent hernias were operated on 7th dept. of I Surgical Clinic of CCS. The recurrences were managed by classical (10/34) or modified Rives technique through direct inguinal approach (22/34), less frequently Lichtenstein procedure (1/34) and McVay (1/34) technique. Among 10 patients with recurrent inguinal hernias managed by classical Rives technique 2 re-recurrences appeared (indirect and interstitial) and 2 cases of infection (immediately after the operation or 7 months after the operation), and in the group of 22 cases with recurrent inguinal hernias managed by modified Rives technique the aim complications didn't appear. Using the modified Rives technique we managed the primary hernias in 56 cases without recurrences and infections. The modified Rives technique, because of the way of mesh fixation (all around), no lateral notching of mesh and remaining hem in all directions secures abdominal wall protection 2-3cm from the line of fixation and prevents any movement of the mesh. This procedure enables management of all inguinal hernias regardless to their size and full protection of the medial, femoral and lateral inguinal triangle. The modified Rives technique is the technique of choice for big multiple defects (giant inguino-scrotal and re-recurrences), especially among patients with increased infra-abdominal pressure when other techniques may be insufficient because of mesh protrusion.

In solving inguinal hernias, surgeons today have in front of them many variations of different operative procedures (both tensional and nontensional techniques). They are performed through operative or endoscope approach. Classical tension techniques present the operation of choice for smaller indirect, direct or femoral hernias among younger patients while non/tensional techniques are the best solution for all types of inguinal herniar among older patients with big destruction of transversal fascia and the best solution for most of recurrent hernias. Positioning of mesh with nontensional techniques can be completed on different levels. with big hernias where the biggest part of transversal fascia of miopectineal orifitium is destroyed it is anatomically the most useful to place the mesh in preperitoneal space. Rives technique is the base of that concept and it presents one of good solutions in that kind of situations. In the period January 2001 until December 2002 using different operative techniques the authors treated 99 inquinal hernias of which 78 were primary and 21 recurrent hernias. Rives technique was performed in 46 cases (46.5%) among which 26 cases were primary inguinoscrotal hernias (3 patients IIIA, 22 patients IIIB, 1 patient IIIC, according to Nyhus classification) and 20 cases were recurrent hernias (6 patients IVA, 11 IVB, 3 IVD). Complications after Rives technique were the following: 1 recurrence (2,17%), 1 ischemic orchitis (2,17%) and 1 scrotal hematoma (2,17%). Infections and chronic pain were not present. The follow up was from 30 days to 2 years. Authors have shown that Rives technique is reliable solution for primary indirect, direct and femoral hernias with big hernial defect (especially for big, so called "giant" inquinoscrotal hernias) and for all types of recurrent hernias. The advantage of the technque is an easy performace without some previous special training because of the fact that dissection and preparation is the same as for the tension techniques. With small amount of prosthetic material all weak points of miopectineal orifitium are closed. The real risks of this technique are ischemic orchitis and chronis neuralgia in treatment of recurrent hernias and the presence of polypropylene mesh in Bogras space.

The authors present a short overview of the development of elective splenic resections. Past and present indications are presented. Contemporary hemostatic technique for elective splenic resection are discussed. An original new technique for transsegmental partial splenic resection using RF generator (Radionic Cool Tip) without any additional hemostatic procedures is presented. This technique is inovative and when use properly it is a practically zero blood loss technique. A patient with transsegmental splenic resection using RF generator is presented. Further clinical application of the technique is necessary.

The surgical management of splenic disorders has changed considerably over past few years. The increased use of laparoscopic approach for general surgical problems has prompted surgeons to investigate feasibility of laparoscopic splenectomy. However, some unique anatomical features of disordered spleen may limit the application of laparoscopic techniques for this procedure. In this article we analyzed indications for laparoscopic a surgery of the spleen, some surgical particularities of laparoscopic splenectomy, as well as the techniques to accomplish this procedure.

The authors report on a patient presenting with subarachnoid hemorrhage that was caused by a rupture of an spinal combined arteriovenous malformation at cervicothoracic junction. The patient was a 30-year-old female, who had exhibited an abrupt onset of severe low neck and occipital pain with radiation into shoulders and vomiting. Neurological examination revealed severe meningism without motor or sensory deficit. Digital subtraction angiography did not demonstrate any intracranial source of bleeding, whereas spinal angiography revealed a spinal arteriovenous malformation at cervicothoracic junction. Endovascular treatment of the malformation was considered for this patient. Occipital and neck pain with radiation into shoulders and severe meningism are clues pointing to a spinal origin of the haemorrhage.

Congenital pseudoarthrosis (CPT) of the lower leg is still a considerable therapeutic problem. There are many surgical and other procedures to manage pseudoarthrosis, but the results are not always satisfactory, unfortunately, and are accompanied by a big number of complications, even limb amputation in some cases. The most complicated surgical procedure is transplantation of the autogenous free microvascular fibula coil which has had the best results momentarily. We are showing a case of a 2.5- year old patient with congenital pseudoarthrosis of the lower leg previously treated unsuccessfully by a conventional surgical method. This is at the same time the first case of such operative treatment of CPT in the territory of Serbia and Montenegro as well as former Yugoslavia. The patient was operated in October 1992.

We report a case of heparin-induced thrombocytopenia thrombosis (HITT) syndrome in a patient prophylactically treated with low molecular weight heparin. A 66-year-old men underwent radiofrequency-assisted partial liver resection for colorectal carcinoma liver metastases a year-and-ahalf after he had been operated for rectal cancer. In the postoperative period, patient was prophilactically treated with reviparin sodium. On the 8th postoperative day, the platelet count decreased by more than 50% without clinical signs of thrombosis. HITT syndrome was suspected on the 19th postoperative day, after iliacofemoropopliteal thrombosis had developed, and related diagnosis was supported by the strongly positive particle gel agglutination technique immunoassay. Heparin was withdrawn and alternative anticoagulant, danaparoid sodium, was introduced in therapeutic doses. Despite delayed recognition, favorable clinical outcome was achieved. HITT syndrome should be considered with priority among the possible causes of thrombocytopenia in a surgical patient on heparin.

INTRODUCTION: The results of numerous studies carried out over the last two decades have indicated that Acinetobacter spp. represents an increasingly important cause of intrahospital infections (IHI). The aim of the study was to determine potential differences in distribution of individual risk factors between the group of patients in whom multiresistant Acinetobacter spp. was isolated and the group of patients in whom it was not. MATERIAL AND METHODS: A prospective cohort study of 64 patients hospitalized with recorded IHI at the University Hospital for Digestive Surgery, Clinical Center of Serbia in the period between January and July 2011. The subjects were divided into two groups: patients with IHI in whom multiresistant Acinetobacter spp. was isolated from the biological material samples, and those with IHI without the presence of Acinetobacter spp. RESULTS: Univariate data analysis indicated presence of statistically significant difference in distribution of certain types of surgeries (esophageal, pancreatic and hepatobiliary) among the two groups of subjects, distribution of CVC placement, application of mechanical ventilation and nasogastric tube placement, length of stay in ICU, lethal outcomes and administration of third generation cephalosporins. The results of multivariate analysis indicated that length of hospitalization in ICU (> 7 days), CVC, mechanical ventilation, esophageal, pancreatic and hepatobiliary surgeries as well as administration of third generation cephalosporins are independent risk factors for colonization and infection of patients with Acinetobacter spp. CONCLUSION: Colonized or infected patients with Acinetobacter spp. play a major role in contamination of hands of the medical staff in the course of care and treatment, while inadequate hand hygiene of the staff leads to cross transmission of the causative organism to infection-free patients. Selective antibiotic pressure, particularly administration of quinolones and broad-spectrum cephalosporins, favor onset of multiresistant species of Acinetobacter spp., and therefore appropriate prophylaxis and treatment represent basic preventive measures against the onset and spreading of the causative organisms.

INTRODUCTION: The study was designed to determine if there was a difference between apparent diffusion coefficient (ADC) values using diffusion weighted imaging (DWI) MRI technique between different malignant focal liver lesions. PATIENTS AND METHODS: The study included 63 patients with focal hepatic lesions: fourteen patients (22.2%) with hepatocellular carcinoma (HCC), 16 patients (25.4%) with hepatic metastatic colorectal tumors, 17 patients (26.9%) with cavernous haemangioma and 16 patients (25.4%) with hepatic cysts. MRI was performed with 1.5T scanner, using EPI sequence with ADC values being determined for all lesions based on three b values. RESULTS: ADC values were statistically different among the groups (F = 70.7, p < 0.01): HCC patients 1.11 +/- 0.29 x 10(-3) s/mm2, metastatic tumours 2.18 +/- 0.15 x 10(-3) s/mm2, haemangioma 2.22 +/- 0.32 x 10(-3) s/mm, cysts 3.08 +/- 0.03 x 10(-3) s/mm2. Furthermore, there was statistically significant difference between benign lesions (haemangiom and cysts, 2.36 +/- 0.43 x 10(-3) s/mm2), and malignant diseases (HCC and secondary tumors, 1.52 +/- 0.58 x 10(-3) s/mm2), t = 5,6, p < 0.01. CONCLUSION: DWI technique could be helpful in defining the focal liver lesions.

Transcatheter antitumor therapy very quickly accepted during the last decade and their importance in the treatment of oncology patients will be increasing. By improvement of new targeted agents, which can be given intraarterial or systemic, efficiency of transcatheteric therapeutic approaches can be drastically increased. Numerous clinical trials (study phase I / II / III) relating to the synergy of two antitumor therapeutic approaches are already in progress. Preliminary results of these trials are already very encouraging. Further improvement in the development of specific therapeutics antitumor drugs and systemic applications will be a big step in the quest for medication against malignant tumors.

During operations of the aneurysms showing anatomical details is the means that leads to the aim, and it is not only a purpose in itself. Data on details that the surgeons come across during their work and which sometimes represent difficulties during interpretations of angiographic findings and planning operations, as well as the intraoperative orientations and identifications of the elements . Frequency of occurrence of such anatomical details and anomalies may be completely different from the one that autopsy series show. Knowledge of this makes the work of surgeons easier and gives a necessary feeling of confidence during operations. Thus, we decided to conduct a clinical, morphological study based on angiographic and surgical analyses of the explored segments of the Wilson circle. The study included 344 patients from the Institute for Neurosurgery, during the period of 2 years; the patients had complete angiographic diagnosing and operative exploration. Our findings confirm differences in localization of aneurysms according to sex. Aneurysms on the front communicant complex are to a great extent associated with anomalies of the front part of the Wilson circle.

The discovery of the appearance of a serious disease, and the necessity for diagnostics, treatment and rehabilitation, particularly when malignity is involved, represents exceptionally stressful news for the patient and his family. Most often this is a task for the physician. In this paper the authors consider the meaning of bad news in unexpected life events which significantly disturb the individual psycho-social balance of the patient, as well as the family dynamics and structure. It presents a review of available literature on the subject of the definition of so-called "bad news", the development of approaches in announcement, and current practical approaches and models which assist physicians in helping suffering patients in professional and humane ways. It points out inadequacies in the education of physicians for this kind of task, and the variety of approaches. With the aim of improving the education of physicians, and especially clinicians in surgical fields, the authors recommend a number of educational programs: education in the area of psychological and psychiatric aspects of learning of a serious disease, including acute reactions such as depressive states, reactive psychotic states, consumption of alcohol, etc.; education in the area of the family life cycle, and the effect of the disease as an unexpected life crisis on the family dynamic; education in the area of fundamental principles of psycho and pharmaco-therapy, as well as the provision of support to the patient and his family; training in the skills of announcing bad news to the patient and his family through the explanatory presentation of the case and supervised simulation of sessions. .

The phenomenon now known as haemobilia was first recorded in XVII century by well known anatomist from Cambridge, Francis Glisson and his description was published in Anatomia Hepatis in 1654. Until today etiology, clinical presentation and management are clearly defined. Haemobilia is a rare clinical condition that has to be considered in differential diagnosis of upper gastrointestinal bleeding. In Western countries, the leading cause of haemobilia is hepatic trauma with bleeding from an intrahepatic branch of the hepatic artery into a biliary duct (mostly iatrogenic in origin, e.g. needle biopsy of the liver or percutaneous cholangiography). Less common causes include hepatic neoplasm; rupture of a hepatic artery aneurysm, hepatic abscess, choledocholithiasis and in the Orient, additional causes include ductal parasitism by Ascaris lumbricoides and Oriental cholangiohepatitis. Clinical presentation of heamobilia includes one symptom and two signs (Quinke triad): a. upper abdominal pain, b. upper gastrointestinal bleeding and c. jaundice. The complications of haemobilia are uncommon and include pancreatitis, cholecystitis and cholangitis. Investigation of haemobilia depends on clinical presentation. For patients with upper gastrointestinal bleeding oesophagogastroduodenoscopy is the first investigation choice. The presence of blood clot at the papilla of Vater clearly indicates the bleeding from biliary tree. Other investigations include CT and angiography. The management of haemobilia isdirected at stopping bleeding and relieving biliary obstruction. Today, transarterial embolization is the golden standard in the management of heamobilia and if it fails further management is surgical.

Only 20 - 30% of patients with gallstones have symptoms and the probability of a patient with silent gallstones developing biliary-related pain is 1- 2% while the risk of developing a serious complication (e.g. empyema, perforation, peritonitis etc.) is less than 0.1% per year. Imaging techniques are important in establishing the diagnosis and evaluating the patient. Laparoscopic cholecystectomy (LC) is the golden standard for the management of symptomatic gallstones and there are two surgical treatment options: early cholecystectomy (same hospital admission) and interval (delayed) cholecystectomy (6-8 weeks after resolution of acute attack). Early LC has medical and socioeconomic advantages over interval LC. LC can be undertaken for the majority of patients with AC and in some high risk groups the postoperative mortality can even be reduced. LC in AC is associated with longer operating time, a higher rate of conversion and bile damage. Early diagnosis and early operation can prevent the development of complications associated with AC.

Fibrin tissue adhesive (FTA) is an agent developed for achieving better hemostasis and adhesion of living tissue. FTA appears to have no tissue toxicity, promotes a firm seal in seconds to minutes, is reabsorbed in days to weeks following application, and appears to promote local tissue growth and repair. It can be used in various surgical procedures. It has been used preoperatively, perioperatively and postoperatively in abdominal surgical procedures. There were no side effects. Improvement of surgical hemostasis was obvious in all patients. Anastomotic leakages were closed in a shorter time without surgical intervention. Sero-lymphatic drainage after surgical procedures that include extensive lymph node dissections was less. Use of FTA in treatment of fistula in ano was successful. The data would indicate that use of FTA may be a good alternative in solving various conditions in every day clinical practice, although a bigger randomized series, and longer follow up is needed.