Chronic venous insufficiency is a condition caused by dysfunction of the venous valves, which hinders venous blood return and increases hydrostatic pressure. This can lead to the appearance of telangiectasia, varicose veins, hyperpigmentation, eczema, lipodermatosclerosis, and in more severe cases, venous ulcers. Long-term chronic venous insufficiency can lead to a rare complication - subcutaneous ossification, which was first described by Lippman in 1957. Dystrophic calcification, which occurs in chronic venous insufficiency, causes deposition of calcium in the subcutaneous tissue, which can interfere with ulcer healing and contribute to the development of heterotopic ossification. Heterotopic ossification is an abnormal formation of bones in the extraskeletal tissue, which most often occurs after trauma, orthopaedic procedures or in neurological disorders. Although the exact mechanism of heterotopic ossification development in chronic venous insufficiency is not fully elucidated, research indicates that inflammatory processes and increased activity of alkaline phosphatase can lead to calcium accumulation, leading to the formation of bone structures. In patients with venous insufficiency, calcifications most often appear as phleboliths, with a characteristic appearance on X-rays. Histologically, heterotopic ossification shows a zonal bone structure with a peripheral area of ossification, while in later stages it resembles a normal bone structure. Treatment includes surgical removal as the optimal method, while conservative treatments such as sodium thiosulfate and etidronate can be used to slow the progression of calcifications.

Objective: To determine the prevalence of positive non-sentinel nodes (non-SLN) after axillary dissection for positive sentinel lymph node (SLN) and the relationship between occurrence of positive non-SLNs and penetration of the sentinel's capsule by malignant cells, as well as grade and molecular subtype of the breast cancer. Methods: An analysis was performed of a total of 77 patients with a positive SLN from a fiveyear period. Patients were categorized according to the following criteria: positivity of non-SLN, invasion of SLN capsule, tumour grade, T stage and molecular subtype. Results: In over 65% of patients, non-SLN were negative for metastases despite a positive SLN. A statistically significant correlation was observed between SLN capsule penetration and positive non-SLN metastases (p < 0.001). It was also observed that non-SLN metastases are more commonly positive in patients with a high tumour grade, high T stage, and HER2-positive and triple-negative tumours. Conclusion: Non-SLN metastases are generally found in patients with SLN capsule penetration by malignant cells, in those with poorly differentiated tumours (high grade), and in those with high T stage, as well as in triple-negative and HER2-positive tumours. Based on these findings, such patients should undergo axillary dissection due to an increased risk of non-SLN metastases.

Cilj: Prikazati slučaj pacijentice s akutnim abdominalnim bolom i Bouveretovim sindromom kao rijetkom komplikacijom kolecistolitijaze. Prikaz slučaja: Osamdesetogodišnja pacijentica primljena je u hitnu medicinsku službu zbog bolova u epigastriju i gornjem abdomenu uz povraćanje tamnog sadržaja koji traju unazad tri dana. Posljednja stolica pacijentice bila je uredna, uredne diureze i pacijentica je bila afebrilna. U laboratorijskim nalazima vrijednosti upalnih parametara bile su neznatno povišene. Učinjen je ultrazvuk abdomena koji je pokazao skvrčeni žučnjak s kamencima. Nativna snimka abdomena nije pokazala znakove pneumoperitoneuma i ileusa. Pacijentici je ordinirana ulkusna terapija s naglaskom da se javi na kontrolni pregled ako se stanje pogorša. Dva dana nakon prijama pacijentici se stanje pogoršalo te dolazi u gastroenterološku ambulantu, gdje joj je učinjena ezofagogastroduodenoskopija (EGDS) koja je pokazala tamnozeleni sadržaj u lumenu jednjaka i želuca te zaglavljen velik kamenac u pilorusu, zbog čega je pacijentica hospitalizirana. Drugog dana hospitalizacije pacijentici se ponovio EGDS s neuspješnim ishodom. Trećeg dana hospitalizacije pacijentici je neuspješno učinjena hitna eksplorativna laparoskopija i operativni zahvat se konvertirao u desnu subkostalnu laparotomiju, te je gastrotomijom ekstrahiran žučni kamenac. Pacijentici je dalje učinjena gastroenteroanastomoza i enteroenteralna anastomoza po metodi Braun, uveden je dren subhepatalno i rana je zašivena po slojevima. Postoperativni tijek kompliciran je infekcijom operacijske rane. Pacijentica je otpuštena dvadesetdrugog postoperativnog dana te nije imala bilijarnih smetnji u sljedećih šest mjeseci praćenja. Zaključak: Uzrok akutnog abdominalnog bola nerijetko može biti i komplikacija kolecistolitijaze. U rijetkim slučajevima kolecistolitijaza se može komplicirati žučnim kamencem prisutnim izvan žučnjaka koji migirira kroz biliogastričnu ili bilioduodenalnu fistulu s opstrukcijom pilorusa (Bouveretov sindrom), što predstavlja životno ugrožavajuće stanje uz smrtnost od 12 % do 30 %.

BACKGROUND: The aim of this paper was to compare laparoscopic and classic appendectomy over a ten-year period to the complications and recovery rate of patients. METHODS: In the period from the beginning of 2007 to the end of 2016, a total of 1480 patients with laparoscopic approach and 1220 patients with classic approach (including 65 patients converted to open appendectomy - 2.4%) were operated at Clinical Hospital Center Rijeka, Croatia. 43% (1161 patients) of the total number of patients were female and the remaining were men (1539 patients, 57%). RESULTS: Out of 1480 patients with laparoscopic approach, 212 (14%) had peritonitis due to perforated appendicitis, compared to 193 (16%) among 1220 patients with classic approach. Among the laparoscopic appendectomies there were 242 (16%) gangrenous appendicitis without perforation, and 220 (18%) among the classic appendectomies. Other patients had acute phlegmonous appendicitis. Postoperative wound infection was the most common complication in 83 (5.6%) patients operated by laparoscopic approach and in 105 (8.6%) of classic operated patients. Postoperative hematoma of the wound had 25 (2%) of the classic operated patients versus 4 patients (0.2%) operated by laparoscopic approach. Douglas abscess had 92 (7.5%) of the classic operated patients, and 42 (2.8%) of the patients operated by laparoscopic surgery. The average duration of hospitalization in laparoscopic operated patients was two days, in the classic operated three days. CONCLUSIONS: Laparoscopic appendectomy is a less invasive operation with shorter recovery time, minor complications, and faster early onset of per of nutrition and return to everyday life.

Akutni apendicitis jedan je od najčešćih uzroka razloga indiciranja neopstetričkog operativnog zahvata u trudnica. Iako se može prezentirati klasičnom kliničkom slikom, u trudnoći je zbog fizioloških i anatomskih promjena atipična slika češća. To čini dijagnozu ovog stanja kompliciranom te ona zahtijeva osim kliničkog pregleda i daljnje pretrage. One uključuju diferencijalnu krvnu sliku i CRP te slikovne pretrage. Činjenica da leukocitoza u trudnoći ne predstavlja patologiju te da CRP može pokazivati tendenciju rasta potvrđuje da ove metode nisu pretjerano uspješne. Od slikovnih pretraga najbolja se pokazala magnetska rezonancija, ali je njezina dostupnost ograničena. Liječenje se provodi kirurški, pri čemu postoje različiti pristupi. Iako postoje brojni radovi koji preferiraju otvorenu nad laparoskopskom apendektomijom, novija istraživanja pokazuju kako nema značajnih rizika za majku i fetus kod korištenja laparoskopskog pristupa. U novije se doba spominje i konzervativni način liječenja antibioticima, ali zbog mogućih komplikacija on se izbjegava, osim u slučajevima nedostupne kirurške skrbi. Akutni apendicitis je stanje koje treba brzo riješiti kako bi se izbjegle komplikacije koje u nekim slučajevima mogu izazvati značajne posljedice za majku i dijete. U članku je prikazan cjelovit pristup trudnici s apendicitisom uz korištenje najnovije literature.

Aims: To investigate the expression of metallothioneins (MTs) and free zinc content in gallbladderassociated with cholecystolithiasis. Study Design: Gallbladder tissue samples were obtained from patients, subjected to laparoscopic cholecystectomy, owing to the cholecystolithiasis, verified by hematological examination and by ultrasonography. Operations were performed in clinical stable phase of gallstone disease. Place and Duration of Study: Department of Surgery, Clinical Hospital Center, Departments of Physiology and Immunology and Department of Pathology, Medical Faculty, University of Rijeka, between June 2011 and June 2012. Methodology: In 25 collected gallbladders the degree of inflammation was classified as subacute (SA) or chronic cholecystitis (CC), according to the standard pathohistological analysis and intensity of NF-B expression. The tissue expression of MT-I/II isoforms and free zinc content werevisualized by immunohistochemistry, using the monoclonal anti-MT I+II antibodies and zinc fluorophore-Zinquin. The cell-based staining quantification was performed by Cell F v3.1 software. Results: The data have shown that in 20 patients out of 25 patients the gallstones induced the CC with upregulation of NF-B in gallbladder epithelium, as well as that high inflammation was followed by overexpression MTs and accumulation of Zn. in 15 and 12 out of 20 patients, respectively. Furthermore, histomorphometric analysis revealed that the average grey values for MT I/II in CC arose from 49.8 +/- 3.3 (in SC) to 195.4 +/- 15.5 (in epithelial cells) and from 62.3 +/- 21.0 to 194.8 +/- 20.1 (in stromal cells) (P<0.01). Similarly, average values for zinc ions increased from 25.6+/-7.4 (in SC) to 118.8 +/- 5.7 (in epithelial cells). Besides, in areas of high inflammation several CD3+cells were found in contact with MT+ epithelial, endothelial and monocyte-like cells. Conclusion: The data point to high local activation of MT/zinc network in chronic cholecystitis associated by gallstones, emphasizing its regulatory functions in inflammatory environment.

The investigation of the cardiac veins have been neglected for decades because of the great importance of the coronary arteries in the pathogenesis of coronary heart disease. Advances in modern medicine and the introduction of innovative diagnostic and therapeutic procedures have led to the alternative routes to the access of the damaged heart, where the cardiac veins play an important role. Before the application of the new imaging methods for cardiac vessels, only dissection of the hearts were used. Now, with the help of these new diagnostic methods, the different classifications of cardiac veins was present. Most cardiac veins drain into the right atrium. The coronary sinus and its tributaries and the anterior cardiac veins have an important role in collecting and returning blood from the heart has. These veins constitute the greater cardiac venous system, while smaller cardiac venous system consists of the Thebesian vessels. They are the subject of an ongoing research in order to adapt to the different needs of myocardial drainage depending on the age and changes in various heart diseases. Variations of cardiac veins are common. The knowledge of cardiac vein variations and anastomoses have become important for understanding and interpretation of the heart vein images during performing diagnostic and therapeutic procedures.

Objective: The objective of this study is to show the incidence and characteristics of chronic groin pain after inguinal hernia repair using different types of prolene mesh. Methods: The study was undertaken at the Department of Surgery, Clinical Hospital Centre Rijeka, and included 180 patients who had undergone inguinal hernia repair six to eight months prior to examination. Inguinal canal plasty had been done in 90 patients using a small-pored prolene mesh and in 90 patients using a large-pored prolene mesh. Every patient had undergone the Lichtenstein technique and preservation of inguinal nerves. Patients who felt pain were invited to complete a pain quality assessment scale (PQAS) with 20 items scored on a 0 to 10 numeric rating scale. Results: In the group of patients who had undergone inguinal canal plasty using a small-pored prolene mesh, 16 (18%) of the 90 patients had chronic postoperative groin pain. In the group of patients (90 patients) that had undergone inguinal canal plasty using a large-pored prolene mesh, none expressed chronic postoperative groin pain. The Pain Quality Assessment Scale is divided into three sub-scales. The first sub-scale evaluates paroxysmal pain. The mean value on this sub-scale was 2.56, which pertains to mild pain. The second sub-scale examines superficial pain, which had a mean value of 2.08, and the third subscale evaluates deep pain, which had a mean value of 1.89. All values pertained to mild pain. Conclusion: Using small-pored mesh for inguinal hernia repair increases the incidence of postoperative groin pain.

The aim was to analyze our results and complications in laparoscopic-assisted placement of the Tenckhoff catheter for peritoneal dialysis in comparison with results reported in the literature. Fifty patients were included in this retrospective analysis. From January 2000 to November 2010, they underwent laparoscopic-assisted placement of catheter for peritonea dialysis at the University Department of Surgery, Rijeka University Hospital Center. The results of this approach, early and late postoperative complications, conversions to open technique, and reoperation rate were analyzed. The complications that occurred within the first 4 weeks were considered as early complications. In 23 patients, 29 complications were recorded. There were 18 early complications, of which 2 acute peritonitis, 2 ileus, 4 bleeding, 4 catheter infection, 3 fluid leakage, 2 catheter malpositioning and 1 genital edema. There were 11 late complications, of which 5 acute peritonitis, 1 recurrent peritonitis, 1 bleeding, 1 catheter infection, 1 catheter malpositioning, 1 fluid leakage and 1 port site hernia. There were no deaths after surgery or any complications disabling the implementation of peritonea dialysis. In patients with end-stage renal disease, laparoscopic-assisted placement of catheter for peritoneal dialysis is a safe and appropriate method of treatment

BACKGROUND/AIMS:This study is an analysis of the large series of laparoscopic cholecystectomies and compare our results with those reported in the literature concerning complications.METHODOLOGY:From December 1993 to September 2010, 10,317 patients with gallstone disease underwent laparoscopic cholecystectomy. Previously operated patients were also included in the study. We analyzed the successfulness of the results, intraoperative and postoperative complications, conversions in open cholecystectomy, mortality and reoperation rate.RESULTS:We registered 23.28% complications. Intraoperative complications were bleeding in 9.84%, gallbladder perforation in 8.63%, stone loss in 1.37%, common bile duct injury in 0.24% and injury of intraabdominal organs in 0.07% of cases. Postoperative complications were bleeding in 1.12%, wound infection in 0.59%, bile leakage in 0.5%, incisional umbilical hernias in 0.37%, subhepatal collection in 0.33%, residual gallstones in choledocus in 0.09%, urine retention in 0.08% and biliary peritonitis in 0.01% of patients. Conversion to open cholecystectomy was necessary in 2.13%. Reoperation was performed in 0.27%. The mortality rate was 0.019%.CONCLUSIONS:Our results on large number of patients are similar to other series in the newer literature but the rate of complications should be decreased. The incidence of complications decreases with growing laparoscopic experience.

Background and purpose: The incidence of gastric cancer decreases but despite declining, it still remains the second cause of death of all malignancies worldwide. Morphometric methods are independent prognostic variables in various cancers and there have been encouraging results in using it for estimating the prognosis of gastric cancer. Aim of this study was to evaluate the influence of nuclear area (morphometric method), on the survival of patients with intestinal type of gastric cancer. Materialsandmethods: Seventy-four patients who had undergone gastric resections for adenocarcinoma of the stomach in the University Hospital Center, Rijeka, Croatia, were analyzed in this study. None had received pre-operative radiotherapy or chemotherapy. Age, gender, tumor size, tumor depth into the stomach wall (T-category) presence or absence of metastases to regional lymph nodes (N-category) or distant organs (M-category) and nuclear area of tumor cells were estimated. All patients were followed up for at least 36 months or to death. Results: Univariate analysis showed that gender (P = 0.009), nuclear area (P = 0.017), TNM (P = 0.001) and size of the tumor (P = 0.024) have influence on the survival. Patients age at the time of diagnosis showed no influence on the survival in univariate analysis (P = 0.089). In multivariate analysis only TNM (P = 0.048) and size of the tumor (P = 0.020) are independent prognostic factors for planning further therapy. Conclusions: According to our results, reliable prognostic factors in patients with intestinal type of gastric cancer are still TNM and size of the tumor; nuclear area showed no influence on the outcome of the disease.

Colorectal cancer is the second most common malignant disease in developed countries, with about one million new cases worldwide every year, accompanied with high mortality rate. We examined the survival rate and recurrence (occurrence of distant metastases and/or local recurrence) of patients with colorectal cancer in Primorsko-Goranska and Istarska County who received adjuvant chemotherapy, compared to those who did not in the period since 1980. until 1999. This study involves 483 patients with colorectal cancer stages II and III of Primorsko-Goranska and Istarska County, which were underwent curative resections of colorectal cancer at the Clinical Hospital Centre Rijeka, and then treated with chemotherapy (288) or without Chemotherapy (195). We analyzed the five year survival rate and the recurrence of malignant disease in the adjuvant treatment group in comparison with not treated group with chemotherapy, depending on the stage of disease, degree of histological differentiation, patient age and location of cancer (colon or rectum). After follow-up of 60 months died 44.79% (129/288) of patients who received chemotherapy and 53.33% (104/195) of patients who did not receive chemotherapy. The relative risk of death (from any cause) in chemotherapy-treated group versus the group without chemotherapy was 0.82 (p < 0.008). Recurrence of malignant disease in the chemotherapy group was 38.54% (111/288), and in the group without chemotherapy was 46.15% (90/195). The relative risk of recurrence of malignant disease in the chemotherapy group versus the group without chemotherapy was 0.78 (p < 0.001). There was no difference in treatment efficacy regard to the localization of the tumor, but there were differences in efficiency with respect to disease stage, grade and age. Chemotherapy with 5-fluorouracil and leukovorin ameliorate the survival and reduces recurrence and distant metastases in patients with colorectal cancer stages II and III.

Perforin-(P-) related characteristics of cytotoxic T lymphocytes and natural killer cells were investigated in peripheral blood of patients subjected to open (OC; n = 23) or laparoscopic cholecystectomy (LC; n = 21) and healthy controls (n = 20). Blood samples were obtained preoperatively and 24 hours after the surgeries, and the data were correlated with the intensity of cholestasis and concomitant inflammation, determined by functional hepatic tests. Postoperative differences were found to be minimal: OC decreased only the percentage of CD56(+) cells, while LC decreased the fraction of CD8(+)P(+) cells and augmented the mean fluorescence intensity of P in CD56 cells. Patients elected for OC had, however, higher preoperative numbers of total P(+), CD3(+)P(+), and CD4(+)P(+) cells than patients elected for LC and healthy controls, while both groups of patients, preoperatively, had lower fraction of CD16(+)P(+) and CD56(+)P(+) cells. These changes were in high correlation with blood concentrations of CRP, AP, and ALT, emphasizing the link between the preoperative cholestasis and inflammation and P-dependent cytotoxic mechanisms.

BACKGROUND:Bouveret's syndrome is a rare complication of cholecystolithiasis with gastric outlet obstruction caused by a gallstone migrating through a biliogastric or bilioduodenal fistula. Gallstone ileus is mainly treated by surgery, either enterolithotomy or gastrotomy, with some cases being treated by endoscopic extraction.CASE REPORT:We report on an 80-year-old woman without previous episodes of biliary colic, and known cholecystolithiasis who underwent emergency surgery due to pyloric obstruction caused by a large, 7-cm stone, after failure of endoscopic treatment. The stone was removed through pylorotomy, which was closed transversely in multiple layers and patched with omentum. The patient's postoperative course was complicated by operative wound infection. She was discharged on postoperative day 22 and had no complaints at the 6-month follow-up.