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Open access

Svetozar Antovic, Aleksandar Mitevski, Aleksandar Karagozov, Biljana Kuzmanovska and Nikola Jankulovski


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.

Open access

Fimka Tozija and Nikola Jankulovski


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.

Open access

Svetozar Antovic, Nikola Jankulovski and Sinisa Stojanovski


Introduction. One of the most important factors for prognosis in patients with colorectal cancer (CRC), especially the 5-year survival is the status of regional lymph nodes (RLN). Threfore, today’s recommendations for systematic lymphadenectomy in CRC operations are very important. For correct staging and accepted by all international recommendations, at least 12 LN must be analyzed microscopically. The sentinel lymph node (SLN) is the first lymph node that drains lymph from the tumor and thus represents a LN that has the greatest chance to be the bearer of metastatic disease. Tests to locate the SLN in CRC have started recently and so far there is no consensus on the method for its localization or its significance. The main aim of this study was to improve the tracing of SLN by using radioactive colloid. The secondary aims were to investigate the accuracy, sensitivity and rate of method’s identification. Especially important for the analysis is the significance of SLN and its correlation with other RLN.

Methods. The study is performed at the University Clinic for Digestive Surgery from January 2013 and is still ongoing. A day before the surgery endoscopically around the tumor is injected radioactive colloid with Technetium 99 (Sentiscint Tc 99m Mediradiofarma Ltd) in the amount of 4 ml, which corresponds to 4 mCi (mill curie). Immediately after that, at the Institute of Pathophysiology using a Gamma camera (Mediso DHV nucline spirit), the distribution of the colloid is monitored, which as expected is mostly accumulated in the first LN, that is the genuine sentinel lymph node, thus making lymphatic mapping that is important for identifying possible aberrant drainage. On the day of surgery at 8:00 am, a rerecording with the Gamma camera is made that shows the late distribution of contrast. All patients are operated with standard surgical technique by making resection with systematic lymphadenectomy. Promptly after removing the preparation a Gamma detector probe (Europrobe) is used to determine the radioactivity of the lymph pool and it finds the right SLN which has the highest radioactivity and it is separately sent for complete pathohistological analysis. At the Institute of Pathology all lymph nodes are first treated standardly with HE and then with immunohistochemical method.

Results. So far the study includes 10 patients, 6 men and 4 women, mean age 63 years (59-77). Until now the identification rate is 100%, which means that SLN has been found in all procedures. Only in 2 patients two sentinel lymph nodes have been revealed while the in the remaining only 1, average 1.2. At PH analysis, an average of 14.2 lymph nodes have been isolated (6-25). Only in one patient false negative 1 SLN has been revealed. The number of patients with real negative SLN is 2, which means the SLN is negative and also all the other lymph nodes. The total number of patients with real positive SLN is 7, which means SLN is positive and also some of the other lymph nodes. Therefore the accuracy of the procedure is 90%. The sensitivity of the procedure in our study that is still ongoing, is 87.5%. Up to now there have been no micrometastases detected in these 10 patients with immunohistochemical methods and because of it the up staging for now is 0%. In 2 patients the SLN is the only positive lymph node of all examined LN. In none of the patients aberrant lymphatic drainage has been discovered.

Conclusions. From the results obtained so far in this study, it can be concluded that the identification of the SLN with this method is possible; the accuracy and sensitivity are high and we expect them to be even higher, which is our motive to continue with the study and to analyze minimum 30 patients. We think this would be the highest number of discovered SLN by a surgeon and an institution and we believe it to be sufficient validation of the method.

Open access

Vladimir Joksimović, Nikola Jankulovski, Svetozar Antović, Marija Joksimović and Ljubinka Mančeva


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.

Open access

Biljana Kuzmanovska, Marija Donevska Tolevska, Andrijan Kartalov, Marija Jovanovski Srceva, Mirjana Shosholcheva and Nikola Jankulovski


Introduction. As a N-methyl-D-aspartate receptors antagonist, magnesium may play a role in prevention of pain. The aim of this study was to assess the effects of single dose magnesium sulfate preoperatively on postoperative pain scores, discomfort and quality of sleep.

Methods. Forty patients scheduled for elective laparoscopic cholecystectomy were randomized in two groups. Group A received 20 mg/kg magnesium sulfate after the anesthesia induction, prior to surgical incision, and Group B was the control group. Assessment was made for pain at rest in both groups according to VAS (0-10), analgesic consumption, discomfort and quality of sleep during first 48 hours postoperatively.

Resultѕ. Compared to control group, magnesium-treated patients had lower postoperative pain at rest according to VAS score (p< 0.05) and consumed less analgesic drugs during the first 48 hours (p<0.05). The magnesium-treated group experienced less discomfort during the first and the second postoperative day. The magnesium-treated group reported no changes in sleeping pattern compared to preoperative sleeping pattern, while the control group showed an increase in insomnia during the first and the second postoperative night, compared to that preoperatively.

Conclusion. Perioperative use of magnesium sulfate as an adjuvant to general anesthesia is associated with lower postoperative pain, less analgesic consumption, less discomfort and better sleep in the postoperative period.

Open access

Aleksandra Gavrilovska-Brzanov, Zorka Nikolova, Nikola Jankulovski, Mirjana Sosolceva, Gordana Taleska, Maja Mojsova-Mijovska, Marija Jovanovski-Srceva, Darko Angusev, Darko Sazdov and Nikola Brzanov


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.

Open access

Andrijan Kartalov, Nikola Jankulovski, Biljana Kuzmanovska, Milka Zdravkovska, Mirjana Shosholcheva, Marija Tolevska, Filip Naumovski, Marija Srceva, Aleksandra Panovska Petrusheva, Rexhep Selmani and Atanas Sivevski


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.

Open access

Zivko Popov, Nikola Jankulovski, Oliver Stankov, Sotir Stavridis, Skender Saidi, Marjan Kuzmanoski, Igor Chipurovski, Sasho Banev, Branka Krstevska, Ognen Ivanovski and Chedomir Dimitrovski


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.

Open access

Andrijan Kartalov, Nikola Jankulovski, Biljana Kuzmanovska, Milka Zdravkovska, Mirjana Shosholcheva, Tatjana Spirovska, Aleksandra Panovska Petrusheva, Marija Tolevska, Marija Srceva, Vesna Durnev, Gjorgji Jota, Redzep Selmani and Atanas Sivevski


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).