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  • Author: Nikola Jankulovski x
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Aim: Clinical evaluation of the safety and effectiveness of compression anastomosis with ColonRing™ for large-bowel end-to-end anastomosis for rectal cancer and explanation of the procedure and the device itself since this device is used for the first time in our clinic.

Material and methods: In November, 2012, a team of surgeons from our clinic attended the Clinical practice workshop in Belgrade, Serbia which was organized by the World Congress of Compression Anastomosis (WCCA) and held by its President Prof. Dr. Steven Wexner from Cleveland Clinic in USA. On this workshop, all aspects of technical point of view were obtained and surgeons were certified for the technique. A total of 25 patients have been scheduled for elective colorectal surgery with subsequent compression anastomosis using ColonRing. All patients were operated for high and mid rectal cancers excluding the low rectal cancers, since those patients are usually diverted with decompressive ileostomy. Patients, who are diverted, are at higher risk of retaining the ring, after its dislodgement, in the ampulla of the rectum since they do not have natural excretion of stool via the anus. All patients were followed for anastomotic leak, anastomotic bleeding, stricture formation, device (ColonRing) handling in general and time of expulsion of the ring via anus.

Results: We used this technique for the first time in 2013 and since then a total of 25 patients underwent anterior resection of the rectum with subsequent colorectal compression anastomosis using ColonRing. Of all patients, 9 were female while 16 were male with median age of 64 years. All patients were operated for rectal cancers. The mean length of hospital stay was 7.4 days (range 5 to 9 days). None of the patients developed anastomotic bleeding or dehiscence. To date none of the patients developed anastomotic stricture, although some patients were followed for almost two years. The average day of expulsion from the body could not be calculated since despite, and although all patients were given instruction on how to check for ring expulsion, 21 of them did not report this event. Only 2 patients brought the ring to us. In two cases after 2 week of the initial operation, the ring was find and palpated on digital rectal examination, free in the ampulla of the rectum and was easily removed via the anus during the examination. Misfiring was reported in 1 patient (first patient) and reanastomosis was employed using another ColonRing, No perioperative mortality was observed in this patient population.

Conclusion: End-to end colorectal anastomosis with the ColonRing is feasible and safe procedure with fast learning curve. To date, this type of anastomosis is possible in left sided colon lesions where anastomosis is contemplated below the promontory. We find the device easy to use with high level of confidence. Further prospective studies including comparison between the ColonRing device and the conventional staplers evaluating long-term anastomotic complications (i.e., leak or stricture) are needed to evaluate the benefits and limitations of this device.


The aim of this paper was to present the strategic approach applied for improvement of quality in emergency medical services (EMS) in the Republic of Macedonia. This approach was accomplished through three stages: (I) assessment and recommendations for policies; (II) development of innovative evidence-based programmes; and (III) policy implementation. Strategic assessment of EMS was performed by applying WHO standard methodology. A survey was conducted in 2006/2007 on the national level in fifteen general hospitals, four university hospitals, and sixteen pre-hospital EMS. The overall evaluation was based on a hospital emergency department (ED) questionnaire, information on the general characteristics of the pre-hospital dispatch centre, review of ED medical records, and the patient questionnaire. The key findings of the assessment showed that EMS required extensive changes and improvements. Pre-hospital EMS was not well-developed and utilised. Hospital EDs were not organised as separate divisions ran by a head medical doctor. The diagnostic and treatment capacities were insufficient or outdated. Most of the surveyed hospitals were capable of providing essential diagnostic tests in 24 h or less. There was no follow-up of the EMS patients or an appropriate link between the hospital EDs and primary health care facilities. The main findings of the assessment, recommendations, and proposals for action served as the basis for new policies and integrated into Macedonia’s official strategy for emergency medical services 2009-2017.


Crohn's disease (CD) is a chronic inflammatory condition of the gastrointestinal tract that can give rise to strictures, inflammatory masses, fistulas, abscesses, hemorrhage, and cancer. This disease commonly affects the small bowel, colon, rectum or anus. Less commonly, it affects the stomach, esophagus and mouth. Often, the disease affects multiple areas of the gastrointestinal tract. The cause of CD is not known and there is no curative treatment. The current medical and surgical treatment is effective in controlling the disease, but even with optimal treatment, recurrences and relapses are frequent.

Various risk factors specific for the patients with conditions related to the CD can influence the outcome of the surgical treatment in the postoperative period. Those risk factors can be preoperative laboratory inflammatory markers such as WBC and CRP values, phlegmona of the anterior abdominal wall and preoperative interintestinal abscess, positive resection margins.

Here we present a case of a patient who was surgically treated as an emergent case because of the complication due to Crohn's disease. At presentation, the patient had leukocytosis, elevated CRP, anemia, low levels of total proteins, and albumin.


Aim: The aim of the study was to evaluate the effect of different grades of increased intraabdominal hypertension (IAH) on the respiratory mechanics.

Material and Methods: In this prospective observational clinical study, the influence of intaabdominal pressure (IAP) on respiratory parameters was assessed in 20 patients requiring mechanical ventilation with IAH grade I, 20 patients with IAH grade II, and 20 patients with grade III IAH. Respiratory parameters were measured and recorded by a computerized system incorporated into the mechanical ventilator.

Results: A statistical difference was noticed between IAP and the dynamic respiratory parameters among the groups. Regarding the respiratory parameters positive correlation between the IAP on one hand, and peak airway pressure and resistance on the other hand was notable: IAP increased and so did pressures and the resistance in the respiratory pathways. Also the correlation between IAP, on one hand and the compliance and peripheral saturation with oxygen on the other hand, was negative. Referring the mean pulmonary pressure there wasn’t correlation among IAP and mean pulmonary pressure in the groups.

Conclusion: IAP leads to impairment of the respiratory mechanics. An increase of the level of IAP is followed by an increase in the altering effects upon the respiratory system.


Introduction: Laparoscopic adrenalectomy has become the preferred approach for removal of the adrenal gland for the management of benign or malignant functioning or nonfunctioning adrenal masses. We aimed to present our initial experience with this procedure. In addition, we compare the clinical outcomes of laparoscopic (LA) vs. the open adrenalectomies (OA) performed at our institutions. Also we report a case of successful laparoscopic treatment of splenic artery aneurism involving laparoscopic splenectomy.

Patients and Methods: A retrospective analysis of the data of all patients who underwent adrenalectomy at three institutions, over the last 12-year period, since the laparoscopic adrenal surgery was introduced in our country. All patients were assessed regarding the demographic data, hormonal status, operative time, estimated blood loss, complications, size of the tumor, number of patients requiring blood transfusion, hospital stay and conversion to open surgery for LA.

Results: Thirty five consecutive patients, aged from 33 to 67 (average age 54 years) underwent unilateral LA adrenalectomy during the study period including 14 right and 21 left sided. The laparoscopic procedure was successfully completed in all except 4 cases, which were converted to open surgery to control bleeding from the avulsed adrenal veins. LA proved superior to OA, resulting in less estimated blood loss, shorter operating time, shorter time to resumption of oral intake, shorter postoperative hospital stay and less analgesic requirements. During the follow-up of 3 to 36 months no tumor recurrence and/or metastasis developed.

Conclusions: Our results concur with other retrospective reviews comparing laparoscopic and open adrenalectomy, demonstrating unequivocal advantages in terms of reduced length of hospital stay, blood loss, return of bowel function, functional recovery and post-operative morbidity.


Background: Ultrasound guided rectus sheath block can block the ventral rami of the 7th to 12th thoracolumbar nerves by injection of local anesthetic into the space between the rectus muscle and posterior rectus sheath. The aim of this randomized double-blind study was to evaluate the analgesic effect of the bilateral ultrasound guided rectus sheath block as supplement of general anesthesia on patents undergoing elective umbilical hernia repair.

Methods: After the hospital ethics committee approval, 60 (ASA I–II) adult patients scheduled for umbilical hernia repair were included in this study. The group I (n=30) patents received only general anesthesia. In the group II (n = 30) patents after induction of general anesthesia received a bilateral ultrasound guided rectus sheath block with 40 ml of 0.25% bupivacaine. In this study we assessed demographic and clinical characteristics, pain score - VAS at rest at 2, 4, 6, 12 and 24 hours after operation and total analgesic consumption of morphine dose over 24-hours.

Results: There were statistically significant differences in VAS scores between the groups I and II at all postoperative time points - 2hr, 4 hr, 6 hr, 12 hr and 24 hr. (P < 0.00001). The cumulative 24 hours morphine consumption after the operation was significantly lower in the group II (mean = 3.73 ± 1. 41) than the group I (mean = 8.76 ± 2.41). This difference was statistically significant (p = 0.00076).

Conclusion: The ultrasound guided rectus sheath block used for umbilical hernia repair could reduce postoperative pain scores and the amount of morphine consumption in 24 hours postoperative period.


Background: The transverses abdominals plane block (TAP) is a regional anesthesia technique that provided analgesia to the parietal peritoneum, skin and muscles of the anterior abdominal wall. The aim of this randomized double-blind study was to evaluate postoperative analgesia on patients undergoing open inguinal hernia repair under general anesthesia (GA), (GA + TAP) block preformed with ropivacaine and (GA + TAP-D) block preformed with ropivacaine and 4 mg dexamethasone.

Methods: 90 (ASA I-II) adult patients for unilateral open inguinal hernia repair were included in this study. In group I (n = 30) patents received only general anesthesia (GA). Patients in group II (n = 30) received GA and unilateral TAP block with 25 ml of 0.5% ropivacaine and the patients in group III (n = 30) received GA and unilateral TAP-D block with 25 ml of 0.5% ropivacaine + 4 mg Dexamethadsone. In this study we assessed the pain score - VAS at rest at 2, 4, 6, 12 and 24 hours after the operation and the total analgesic consumption of morphine over 24 hours.

Results: There were statistically significant differences in the VAS scores between group I, group II and group III at all postoperative time points - 2hr, 4hr, 6hr, 12hr and 24hr. (p < 0.00001). The cumulative 24 hours morphine consumption after the operation was significantly lower in group III (5.53 1.21 mg) than in group II (6.16 2.41 mg) and group I (9.26 2.41 mg). This difference is statistically significant (p < 0.00001).

Conclusion: Concerning the inguinal hernia repair we found better postoperative pain scores and 24 hours reduction of the morphine consumption in group III (GA and TAP-D block) compared with group I (GA) and group II (GA + TAP block).