Lithuanian Surgery <p>Founded in 1993. Publishes scientific surgical articles written by Lithuanian and foreign authors.</p> Vilniaus universiteto leidykla / Vilnius University Press lt-LT Lithuanian Surgery 1392-0995 <p>Please read the Copyright Notice in&nbsp;<a href="">Journal Policy</a>.&nbsp;</p> Editorial Board and Table of Contents <div>[text in Lithuanian]</div> Lietuvos chirurgija T. 17 ##submission.copyrightStatement## 2018-12-03 2018-12-03 17 3-4 199 206 Origins of neurosurgery in the beginning of the XIXth century in Vilnius clinics <p>[full article and abstract in Lithuanian; abstract in English]</p> <p><strong>Objectives</strong></p> <p>Before the end of the XIXth century neurosurgical operations were rarely performed in European university clinics and city hospitals. The development of neurosurgery was not possible without major medical discoveries: anaesthetics and antiseptics, effective haemostasis and atraumatic surgical techniques. The aim of this work is to discover the origins of neurosurgery, to determine what type of surgical operations of the nervous system were performed in the beginning of the XIXth century in Vilnius.</p> <p><strong>Material and methods</strong></p> <p>We analyzed doctoral theses devoted for neurosurgery and defended in Imperial university of Vilnius during 1803–1832.</p> <p><strong>Results</strong></p> <p>Five theses (out of 26) were included into analysis: dissertation on brain commotion, external head injuries, trepanation, encephalocele and brain fungus, and the ligation of the common carotid artery. Evaluating patients with external head injuries, University professors and students performed primitive neurological examination and estimated signs of brain compression.</p> <p>Dizziness, somnolence and stupor, stertorous breathing, headache and weakness of voluntary movements were evaluated, taking the side of hemiplegia as one of the most important signs. If the patient presented with head trauma which caused brain compression, but no external head injuries and signs of skull fractures were observed, then the side of limbs paralysis was evaluated and trepanation performed contralaterally to paralysis. Post mortem examinations of the deceased patients in Vilnius Surgery clinic were performed to confirm the clinical diagnosis.</p> <p><strong>Conclusions</strong></p> <p>The origin of neurosurgery in Vilnius goes back to the beginning of the 19th century. Trepanation, evacuation of epidural or subdural hematomas, ligation of the common carotid artery and excision or ligation of the surface head tumors were performed in Vilnius Surgery clinic.</p> Eglė Sakalauskaitė-Juodeikienė Robertas Kvaščevičius Dalius Jatužis ##submission.copyrightStatement## 2018-12-03 2018-12-03 17 3-4 207 223 10.15388/LietChirur.2018.3-4.12045 Methods of adipose tissue distribution measurement by ultrasound: systematic review <p>[full article and abstract in Lithuanian; abstract in English]</p> <p><strong>Background / objective</strong></p> <p>The aim of this systematic literature review is to provide a complete overview of ultrasound techniques used for measuring subcutaneous adipose tissue and visceral adipose tissue and distinguish the most appropriate ultrasound technique used for obese patients.</p> <p><strong>Methods</strong></p> <p>The search of the publications was performed using PubMed, Current Contents and Cochrane Library databases. All publications with emphasis on ultrasound measurements of adipose tissue and it’s comparison to computed tomography or magnetic resonance imaging and published before December 1, 2017 were reviewed.</p> <p><strong>Results</strong></p> <p>17 studies which examined adipose tissue distribution by ultrasound measurements were included in our analysis. A total number of 1 085 patients were evaluated in the included studies. Studies which compared and validated ultrasound measurements with computed tomography and magnetic resonance imaging confirmed slightly inconsistent accuracy for visceral adipose tissue (r = 0.63–0.94) and for subcutaneous adipose tissue (r = 0.33–0.96). Six studies have studied the obese and morbidly obese population (BMI ≥30 kg/m2). In these studies the correlation coefficient between computed tomography and ultrasound was very strong for visceral adipose tissue (r = 0.823) and subcutaneous adipose tissue (r = 0.745). In the morbidly obese group, the reliability of the measurements was excellent (r = 0.94).</p> <p><strong>Conclusions</strong></p> <p>Ultrasound is a relatively inexpensive, non-invasive and available tool which can be used for estimating adiposity in large scale population surveys. We recommend modified Stolk method for the measurement of adipose tissue distribution in obese patients.</p> Bronius Buckus Gintautas Brimas Gintautas Brimas ##submission.copyrightStatement## 2018-12-03 2018-12-03 17 3-4 224 233 10.15388/LietChirur.2018.3-4.12046 Short-term results of preventive ileostomy closure <p>[full article and abstract in Lithuanian; abstract in English]</p> <p><strong>Introduction</strong>. Preventive ileostomy is most often performed to prevent leakage through low rectal anastomosis. This procedure is most commonly performed during surgery of low rectal cancer.</p> <p><strong>The aim</strong>. To review short-term results of preventive ileostomy closure.</p> <p>Method. Retrospective analysis of data about patients operated for ileostomy closure at Coloproctology Section of the Surgery Department of the Lithuanian University of Health Sciences Kaunas Clinics between 2015 and 2017 was carried out. Age, characteristics of complications, number of days of hospitalization, application of neoadjuvant treatment before surgery, time span until ileostomy closure surgery, resection type, type of anastomosis, duration of surgery and postoperative period were analysed. Statistical data analysis was performed using Microsoft Excel software.</p> <p><strong>Results</strong>. The data of 64 patients were analysed: 34 men (53.12%) and 30 women (46.87%). These patients underwent surgery for rectal, sigmoid tumours and also for perforated diverticulitis. Patients’ mean age 64±3.1 years. Neoadjuvant treatment before surgery was applied to 16 patients (25%). For all patients, anastomotic leak test was performed before their preventive ileostomy closure surgery. Preventive ileostomy closure surgery took place on average after 5.17±0.95 months. Mean duration of hospitalization was 5.7±0.74 days. Mean duration of the surgery was 75.93±8.57 min. During surgery, segment resection was performed on 38 patients (59.37%). The following anastomoses were formed: “end-to-end” – 20 (52.63%), “end-to-side” – 13 (34.21%) and “side-to-side” – 5 (13.16%). After preventive ileostomy closure surgery early complications affected 7 patients (10.94%). Haemorrhage from anastomosis site was present in 2 (3.12%) patients. For one of them “end-to-side” anastomosis was performed. Another patient underwent marginal resection surgery. Arrhythmia occurred in 2 patients (3.12%). 2 patients (3.12%) developed symptoms of ileus. One of them underwent marginal resection, whereas the other one had “end-to-end” anastomosis. After marginal resection, abdominal wall abscess formed in 1 patient (1.58%). There was no re-operations.</p> <p><strong>Conclusions</strong></p> <p>1. Most often, during preventive ileostomy closure surgery segment resection is performed. 2. Mean time before ileostomy closure was 5 months. 3. Complications in the postoperative period were more frequent after segment resection. 4. End-to-end anastomosis is associated with few complications during the postoperative period.</p> Matas Pažusis Rūta Maželytė Žilvinas Saladžinskas ##submission.copyrightStatement## 2018-12-03 2018-12-03 17 3-4 234 237 10.15388/LietChirur.2018.3-4.12047 Laryngeal palpation in thyroid surgery: practical recommendations for method integration into daily clinical practice according to comprehensive literature review and prospective cohort study results <p>[full article and abstract in Lithuanian; abstract in English]</p> <p>The incidence of thyroid surgery is steadily increasing. Recurrent laryngeal nerve injury is one of the most serious postoperative complications related to thyroid surgery, because it impairs patients’ quality of life, causes voice changes, or even respiratory dysfunction in case of bilateral nerve injury. To reduce the nerve injury rate various modern intraoperative techniques are used. One of the most effective strategies to avoid bilateral nerve injury is intraoperative neuromonitoring technique. This method effectively evaluates nerve function but is associated with increased costs. Laryngeal palpation may be a cheap alternative. However, it is not clear if this method is enough specific and sensitive. Therefore, to summarise method sensitivity, specificity, and clinical value we comprehensively reviewed current literature and presented the results of our prospective cohort study. According to various authors, laryngeal palpation method sensitivity and specificity for nerve injury detection varies between 33–100% and 92–100%, respectively. Our study showed similar results – laryngeal palpation is highly sensitive (100%) and specific (96.6%) method for intraoperative nerve function evaluation.</p> <p>After summarising current evidence, we suggested recommendation for method application in daily clinical practice: 1. Recurrent laryngeal nerve should be always identified during thyroid surgery. 2. Intraoperative neurostimulation is indicated in all cases when thyroidectomy is planned. If intraoperative neuromonitoring is not available, laryngeal palpation should be the method of choice. 3. In case of thyroidectomy intraoperative neurostimulation should be performed after first lobe mobilization to avoid bilateral nerve injury.</p> Andrius Rybakovas Andrius Matulevičius Viktorija Belogorceva Virgilijus Beiša Kęstutis Strupas ##submission.copyrightStatement## 2018-12-03 2018-12-03 17 3-4 238 249 10.15388/LietChirur.2018.3-4.12048 Ovarian Dysgerminoma with Metastases in Supraclavicular Lymph Nodes Diagnosed in a 16-year-old Girl: Clinical Case and Literature Review <p>[full article, abstract in English; abstract in Lithuanian]</p> <p><strong>Background</strong></p> <p>Tumors of children reproductive system are rare, the most frequent among them is ovarian tumor. The most frequent histological type of ovarian tumor in girls and adolescents is germ cell tumor, with dysgerminoma being the most frequent of all. Symptoms are very non-specific, this is why these tumors are often diagnosed late. Dysgerminoma is a malignant tumor, thus if not treated, it may be potentially lethal.</p> <p><strong>Case report</strong></p> <p>We present a 16-year old patient, who has come to Vilnius University Hospital Santaros Klinikos, Children’s unit, due to a sudden emergence of a growth above the left clavicle. The girl did not have any other specific complaints. Huge hard growth was founded during palpation of the abdomen. After the cancer marker test (alfa-fetoprotein – 1,9 kU/L, beta-human chorionic gonadotropin – 1231.0 U/L; lactate dehydrogenase – 2721.0 U/L; Ca125 – 665.8 kU/L), pelvic ultrasound examination, computed tomography and histological evaluation of the supraclavicular mass, dysgerminoma of the right ovary FIGO stage IV was diagnosed. The patient was treated with laparotomic oophorectomy and chemotherapy before and after surgery. Treatment was successful as 100% of tumor cells necrosis was achieved.</p> <p><strong>Conclusions</strong></p> <p>Girls and adolescents should be suspect to ovarian masses if they complains about abdominal pain, a growth in the abdominal area, disruptions of menstrual cycle or signs of premature puberty. Early diagnosis and treatment of ovarian dysgerminoma have a very good recovery rate in girls and adolescent.</p> Diana Maldžiūtė Vilma Rukauskaitė Kęstutis Trainavičius ##submission.copyrightStatement## 2018-12-03 2018-12-03 17 3-4 250 255 10.15388/LietChirur.2018.3-4.12049 A Case Report of Intraoperatively Diagnosed Cholangiocarcinoma after Unsuccessful Conservative Treatment of ERCP Complicated with Hemorrhage <p>[full article, abstract in English; abstract in Lithuanian]</p> <p><strong>Background</strong></p> <p>Cholangiocarcinoma is a malignant tumor arising from the epithelium of the bile ducts. Most of these tumors are adenocarcinomas [1]. Intrahepatic cholangiocarcinoma accounts for 10% of all cholangiocarcinomas, hilar cholangiocarcinoma for 25%, and extrahepatic cholangiocarcinoma for 65% [2, 3]. Cholangiocarcinoma can develop in any part of the extrahepatic duct, occurring in 50–75% of reported cases in the upper third of the duct including the hepatic hilum, in 10–25% in the middle third, and in 10–20% in the lower third [4–6]. Approximately 95% of cases show extrahepatic obstruction at the time of diagnosis [7]. In a meta-analysis of 21 prospective trials, the rate of hemorrhage as a complication of ERCP was 1.3% (95% CI, 1.2%–1.5%) with 70% of the bleeding episodes classified as mild [8]. Hemorrhagic complications may be immediate or delayed, with recognition of occurring up to 2 weeks after the procedure. The risk of severe hemorrhage (ie, requiring &gt;5 units of blood, surgery or angiography) is estimated to occur in fewer than1 per 1 000 sphincterotomies [9]. Despite new and advanced diagnostic methods, sometimes this type of tumor is finally diagnosed from pathological findings on excised tissue.</p> <p><strong>Case report</strong></p> <p>We present one case with cholangiocarcinoma diagnosed after surgical treatment of hemorrhage as post procedural complication from ERCP. With MRCP intraluminal stenosis of the upper part of common bile duct has been noticed and suspicious presence of substrate with consecutive dilatation of the upper billiary tract. ERCP was performed and sphincterotomy have been made without evacuation of any intraluminal substrate from common bile duct. Insufficient ERCP cholangiography was made and biopsy of the part with stenosis could not be taken due to permanent bleeding from performed sphincterotomy.</p> <p>Despite all attempts for conservative treatment of the hemorrhage, patient was still with permanent decreases of hemoglobin levels and with persistent hemorrhagic anemia. With decision from medical council the patient has been transferred to the Department of abdominal surgery for further immediate surgical treatment.</p> <p><strong>Conclusion</strong></p> <p>Patient with extrahepatic bile duct carcinoma initially diagnosed as a calculus in the common bile duct. Looking back, the patient had symptoms which differential diagnosis for bile duct cholangiocarcinoma should be established. Clinical symptoms such as right hypochondrium pain, itchy skin, vomiting and diarrhea. The laboratory findings showed constantly elevated bilirubin and liver enzymes also elevated tumor markers as CA19-9 and CEA. Hemorrhage that occurs after ERCP sphincterotomy and attempt for biopsy could not been controlled with conservative measures. Patient with consequently caused hemorrhagic anemia has been transferred for surgical treatment, which stopped the bleeding, made final diagnosis and treatment of proximal stenosis of common bile duct.</p> Gordana Bozinovska Beaka Biljana Prgova Veljanovska Milka Zdravkovska Blagica Burova ##submission.copyrightStatement## 2018-12-03 2018-12-03 17 3-4 256 263 10.15388/LietChirur.2018.3-4.12050 Author Guidelines <p>[text in English and Lithuanian]</p> Lietuvos chirurgija T. 17 ##submission.copyrightStatement## 2018-12-03 2018-12-03 17 3-4 264 270 Sepsis – infection related life-threatening organ dysfunction <div> <p>[full article and abstract in Lithuanian; abstract in English]</p> <p>Sepsis is associated with poor outcome of infection especially if not recognized early and not treated promptly. Early confirmed diagnosis, timely and adequate treatment is essential in order to overcome sepsis. Novel medical studies have clarified the pathophysiology of sepsis, but clinicians and researchers still struggle to define diagnostic criteria of sepsis while searching for simple and more specific criteria. The Third International Consensus Definitions for Sepsis and Septic Shock was published in 2016; the main difference from the previous definition is shifting focus to early recognition of organ dysfunction caused by infection. By agreement of experts it is advised to abandon terms of systemic inflammatory response syndrome and severe sepsis. Local infection may lead to sepsis when dysregulated host response to local infection causes organ dysfunction. Septic shock is defined as sepsis-induced hypotension persisting despite adequate fluid resuscitation and requiring use of vasopressors to maintain optimal mean blood pressure as well as confirming hyperlactatemia. The renewed diagnostic criteria of sepsis proposed by physicians and researchers from different specialities is a step forward in promoting new epidemiological and clinical studies, initiatives for better identifying and treating sepsis.</p> </div> Saulius Vosylius Milda Nekrašienė ##submission.copyrightStatement## 2018-11-04 2018-11-04 17 3-4 9 16 10.15388/LietChirur.2018.1-2.11736 Endoscopic elimination of foreign body from the upper gastrointestinal tract in Republican Vilnius university hospital: 25 years’ experience <p>[full article and abstract in Lithuanian; abstract in English]</p> <div> <p>Foreign body and food bolius impaction in the upper gastrointestinal tract is a common clinical situation in emergency departments throughout the world. The majority of foreign bodies will pass through the gastrointestinal tract and naturally go out with the stool, but in about 1/5 of cases the foreign bodies must be removed. The impaction of a foreign body in the upper gastrointestinal tract is the second leading cause of urgent endoscopy after bleeding. The aim of this retrospective descriptive study is to review a quarter-century (25 years) experience of removal foreign bodies from the upper gastrointestinal tract by flexible endoscopic approach in Republican Vilnius University Hospital (RVUL). We conclude that the endoscopic removal of foreign bodies by a qualified specialist is an effective and safe method with a great success rate of the procedure using an endoscope with accessories: loop, basket and forceps, which significantly reduces the length of hospitalization and requirement of surgery.</p> </div> Edvinas Kildušis Aurelijus Grigaliūnas Laura Žilevičė ##submission.copyrightStatement## 2018-11-04 2018-11-04 17 3-4 17 24 10.15388/LietChirur.2018.1-2.11737