UNLABELLED Pancreatic tumor is one with the worst prognosis of all cancers, and the tenth most frequent cancer in Europe, making the 3% of all cancers affecting both sexes. Most patients seek treatment when the disease is in its advanced stage and the level for possible resectability is low. Late presentation of the disease is responsible for the short survival period of 6 months and a five-year survival of 0.4 to 5% of patients. At the Clinic for Surgery in Tuzla during period from January 1st 1996, to January 1st 2011, a total of 127 resection surgeries were performed due to malignant tumors. The goal of this study was to show that adequate assessment of operability, proper surgical strategy and modern techniques of creating anastomoses reduces morbidity and mortality, results in fewer postoperative complications and contributes to better surgical results. In our study sample the most common place of tumor location was the head of pancreas, in 69 (59.7%) patients. Men develop this type of cancer more often than women in the ratio of 2:1, while the median age of patients was 62 years. We faced postoperative complications in 37 (29.1%) patients, pancreatic fistula being the most prevalent complication, occurring in 16 (12.6%) patients. Overall early and late postoperative mortality was observed in 12 (9.8%) patients. CONCLUSION Patients with chronic and hereditary pancreatitis are at a higher risk for developing pancreatic cancer and should be screened for the purpose of early diagnosis. The staging of pancreatic cancer has improved, with the accuracy of 85-90%. Postoperative complications, morbidity, and mortality are significantly reduced (p < 0.05) if the standardized operational procedure is applied and if modern techniques are used to create pancreaticojejunal anastomosis as the anastomosis carrying the highest risk.

The aim of the study was to define the effects of daily hospice team's activities on depression and anxiety in breast cancer patients having undergone mastectomy after three-month therapy. This prospective study included 35 patients that underwent mastectomy for breast cancer, followed by 3-month treatment at daily hospice, Tuzla University Clinical Center. Control group consisted of 35 mastectomized patients that did not visit daily hospice. Depression and anxiety were estimated by use of Zung's scale. Patients were tested initially and retested at 12 weeks. On initial testing, the mean value of depression was 59.85 +/- 6.97 in the study group and 55.65 +/- 7.91 in the control group. On three-month retesting, the level of depression was lower in the study group, with a mean value of 48.57 +/- 7.06 (P<0.0001) (steam T-test and Wilcoxon's test) and higher in the control group, with a mean value of 60.45 +/- 7.47 (P=0.0001) (steam T-test and Wilcoxon's test). On initial testing, the mean value of anxiety was 54.97 +/- 6.35 and 52.20 +/- 6.03 in the study and control group, respectively. On three-month retesting, the level of anxiety was lower in the study group, with a mean value of 43.43 +/- 5.97 (P<0.0001), showing improvement from initial testing, but was higher in the control group, with a mean value of 55.68 +/- 7.47 (P=0.0002). In conclusion, daily hospice team's treatment had favorable effects on lowering the levels of depression and anxiety in patients undergoing mastectomy for breast cancer.

Increasing gap between demand and availability of human kidneys for transplantation has forced a re-evaluation of the limits on donor age acceptability. The present study included 74 patients who underwent kidney transplantation in University Clinical Centre Tuzla. In an observational cohort study we assessed impact of donor age on post transplant renal function by analyzing following parameters: 24 hour urine output, creatinine clearance (Cr Cl) and glomerular filtration rate (GFR). Depending on donor age recipients were allocated in to two groups. Group I included patients who received renal graft from donors age up to 55 years, and Group II encountered recipients who received renal graft from donors older than 55 years. Our goal was to determine whether donor age over 55 years significantly diminishes renal graft function in first seven post transplant days. No statistically significant difference was found between Group I and II regarding 24 hour urine output. From second to fifth postoperative day creatinine clearance values were higher in the group of patients who received kidney from donors older than 55 years (47+/-19, 1 vs. 44, 4+/-20, 8). On the fifth, sixth and seventh post operative day GFR was significantly higher in patients who received renal graft from donors age up to 55 years (p<0, 0161). Our data showed no significant difference in observed variables between the two groups, thus indicating that utilization of renal grafts from donors' age > 55 years is acceptable and may considerably expand the donor pool.

The aim of this study was to evaluate the incidence, clinical data and patterns of mediastinal lymph node metastasis (pN2) in non-small-cell lung cancer patients who underwent systematic mediastinal lymph node dissection (SMLND). We retrospectively studied 140 consecutive patients [125 male and 15 female, mean ages 54.61 +/- 9.23 years (range, 21-75)], underwent SMLND and major lung resections due to non-small lung cancer (NSCLC), from January 2005 till December 2009. Preoperative clinical staging for mediastinal lymph node metastasis was negative (cN0) in all patients. SMLND was defined as a complete removal of mediastinal lymph nodes. Clinicalpathological data were compared according to the pN stage. Lymph node metastasis to the mediastinum was confirmed in 13 (9.28%) patients. In squamous cell cancer pN2 were in 8 (5.71%) cases out of 82 cases with cN0. On the other side in the adenocarcinomas pN2 were in 5 (3.57%) cases out of 48 with cN0. Unvaried analysis revealed central tumor site as predictive factor for mediastinal lymph node involvement. The upper mediastinal compartment was infiltrated in 12 (8.57%) cases, middle in 8 (5.71%) and lower in 3 (2.14%) cases. Pneumonectomy was the most performed surgical procedure in pN2 patients. We concluded that SMLND improves pTNM staging in lung cancer patients who underwent major lung resections with central location of the tumour.

Primary spontaneous pneumothorax (PSP) is a benign disease frequently found in younger and healthy-looking persons. It requires a surgical treatment in about 30-40% of cases. Video-assisted thoracoscopic surgery (VATS) has been recently introduced as a reliable alternative method to the classic thoracotomy. The aim of this paper is to establish and compare the length of surgical procedure, pain intensity, number and kind of postsurgical complications during the procedure for the patients with PNTX treated by VATS in relation to the patients with PNTX treated by thoracotomy. This is a retrospective study. The patients are divided into two groups: the first group of 50 patients treated with VATS and the second group of 50 patients treated with thoracotomy. The results obtained show a significantly shorter surgery duration in the group of the patients treated with VATS in relation to the group of patients treated by thoracotomy (p < 0.01). Video-assisted thoracoscopic surgery is characterized by a significantly low intensity of postsurgical pain in relation to thoracotomy (p < 0.001). The number and kind of postsurgical complications are similar in both target groups (p > 0.05). Only one relapse occurred in the VATS group. Video-assisted thoracoscopic surgery improves patients' life quality in relation to the thoracotomy patients. The patients return to work, or to sport activities after a very short time because of minimal sequels. That is why this method represents an obvious socio-economic interest. Today, in the era of a great video-development, VATS method is a treatment of choice for PSP.

INTRODUCTION Hepatic resection is the accepted treatment for various liver tumors. Increasing evidence suggests that two factors significantly influence outcome and successfulness of the hepatic resection in patients with HCC in cirrhosis. There are liver function recovery and the degree of inflammation during early postoperative period. OBJECTIVE Aim of this study was to determine whether probiotic use influences on liver function recovery, degree of inflammation during early postoperative period, intraoperative risk, type and frequency of intraoperative and postoperative complications, morbidity, intraoperative and early postoperative mortality and a one-year survival rate in patients who have been used probiotic, and underwent the hepatic resection due to HCC in cirrhosis. PATIENTS AND METHODS Study was conducted on 120 patients underwent the hepatic resection due to HCC in cirrhosis. This study has been done in University Clinical Centers Tuzla, Maribor and Strasbourg from October 2006 till February 2008. Patients were divided into 2 groups: 1) patients with liver cirrhosis and histologically verified HCC whom underwent liver resection surgery (segmentectomy/ bisegmenctetomy, right and left hemihepatectomy/extended hemihepatectomy) that used preoperatively and postoperatively probiotics (n = 60), 2) a control group of patients with liver cirrhosis and HCC, which did not use preoperative and postoperative probiotics (N = 60). Treatment with probiotics was conducted 3 days preoperatively and postoperatively with 7 day's oral supplementation. RESULTS This study have shown next: patients underwent to the hepatic resection due to HCC in cirrhosis who have been used preoperatively and postoperatively probiotic had liver function recovery better and faster, acute immune response better, serum level of tumor markers lower, intraoperative and postoperative complications were less frequent, and morbidity and mortality rates were lower than in those who have not been using probiotic. CONCLUSION Probiotic use may make liver function recovery better and increases immune response in early postoperative period and positively influences outcome and successfulness of the hepatic resection in patients with HCC in cirrhosis.

Background: Many efforts have been made to find diagnostic tools that would help select children with clinical signs of acute appendicitis that would need immediate appendectomy and to find tools that would reduce the numbers of negative appendectomies. Aim: We aimed to show the association between leukocyte count, level of C-reactive protein and interleukin-6 in peripheral blood on the one side and the degree of histological findings on appendix after appendectomy on the other side in children with high clinical probability for appendicitis (Alvarado score>7). Methods: We analyzed 80 patients of both genders, younger than 15 years, with Alvarado score>7, which underwent open appendectomy with subsequent histological analysis of removed appendices. We sampled 20 consecutive cases without signs of inflammation (group I), 20 cases with pathological signs of incipient inflammation (group II), 20 cases with signs of phlegmonous inflammation (group III) and 20 cases with signs of perforated appendix (group IV). Prior to appendectomy, a peripheral blood was sampled and sent for analysis of leukocyte count and C-reactive protein and interleukine-6 level. We compared values of all 3 measured parameters according to histological findings; we also used Receiver Operating Characteristics (ROC) analysis in order to evaluate diagnostic thresholds for detecting the histological signs of appendicitis. Results: The lowest values of all observed parameters were found in group of negative appendicitis while highest were observed in the group of perforated appendicitis. We have observed a significant between group differences in values of all three parameters according to the degree of histological inflammation (p<0.001). ROC analysis demonstrated that interleukine-6 had the best diagnostic performance in detecting patients with histological signs of appendicitis (AUROC=0.99; 95% CI=0.99-1.00) when compared to CRP and leukocyte count (p<0.05). There was no significant difference in diagnostic performance between CRP and leukocytes counts (p=0.35). Conclusion: Leukocyte count, CRP and interleukine-6 are very useful markers which may help in diagnostics and differentiation of phlegmonous and perforated appendicitis. In patients with high probability of appendicitis, measurement of interleukine-6 may help in better patient selection.

All conventional immunosuppressive tree drugs-protocols are based on Cyclosporine; consisting of low doses of Cyclosporine (CsA), Azathioprine (AZA) or Mycophenolate Mofetil (MMF) and Prednisolone. AZA has been used in clinical transplantation for more than 30 years and was the first immunosuppressive agent to achieve widespread use in organ transplantation. MMF was introduced in clinical practice in 1995 after several clinical trials proved that it was more efficient than AZA for prevention of acute rejection episodes. Our aim was to evaluate influence of AZA and MMF on renal graft function in early post-transplant stage. Study recruited 74 patients who underwent kidney transplantation in University Clinical Centre Tuzla. All patients received CsA and corticosteroid-based immunosuppression, as a part of triple immunosuppressive regiment, 40 patients received AZA and 34 MMF. In order to assess renal graft function, following parameters were evaluated: glomerular filtration rate GFR (ml/min) creatinine clearance (CrCl) (ml/min), 24 h urine output (ml/day), and from the serum potassium, sodium, urea and creatinine (mmol/dm3). Significantly higher average values of 24 hour urine output were recorded during first seven postoperative days in patients receiving MMF compared to those treated with AZA. Serum creatinine values showed statistically significant decrease, starting with the second postoperative day, in MMF vs. AZA group (168,7+/-70,5 vs. 119,9+/-42,6; p<0,0007). GFR was significantly higher in MMF compared to the AZA group of patients. On the first post-transplant day CrCl was higher in AZA group (24,3+/-10 vs. 17,5+/-7,3; p=0,01), next six days situation is reversed CrCl is significantly higher in the MMF group (43,7+/-15 vs. 53, 4+/-22, 8 p=0,006). MMF vs. AZA therapy was associated with protective effect against worsening of renal function in first seven post-transplant days.

Introduction: Laparoscopic cholecystectomy (LC) is a method of choice for chronic gallbladder calculus. Surgeon’s experience and sophistication of the work method itself have brought a number of advantages in comparison to open cholecystectomy (OC). Particularly, the advantage corresponds to decreased immune response of the organism on surgical stress. The aim of this study was to define the level of surgical stress through immune response of the organism on stress. Patients and Methods: One hundred patients were involved in the study, 50 of whom were treated by LC method and the other 50 by open method. The patients were of middle age group, between 47 and 57 years of age, mostly female. C-reactive protein was studied as one of the parameters of the organism’s immune response during LC and OC, and also a number of leucocytes, erythrocytes, haemoglobin and hematocrit after LC and OC procedures. C-reactive protein is a biochemical marker, as an organism’s response to stress and the aim of this study is to confirm the CRP values during surgical treatment of chronic calculus of the gallbladder through different surgical methods: conventional or open surgery and laparoscopic surgery which is considered less invasive. Number and frequency of intra-operative and post-operative complications during laparoscopic and open cholecystectomy were also compared. The erythrocytes, haemoglobin and hematocrit and leucocytes, were also determined in both groups of patients with the aim to confirm the hypothesis that the laparoscopic cholecystectomy is a less invasive method compared to the classic or open method. Results and Discussion: The results have confirmed the hypothesis that the laparoscopic cholecystectomy surgical method is less invasive and showed that the value of CRP is much less in post-operative period after LC than OC. In this way, decreased immunological response of the organism on the surgical laparoscopic procedure were confirmed in this study. Decreased value of leucocytes was determined in laparoscopic technique in the post-operative period in comparison to open technique. The number of erythrocytes, hematocrots and haemoglobin were not significantly different in the post-operative period during LC and OC. Complications such as bleeding, bile leakage, subphrenic abscess, post-operative pancreatitis, post-operative wound infection, hernias of post-operative sections and keloid were present more in OC than in LC. Conclusion: Inflammation of early protective homeostatic immune response on post-operative wound characterises the production of C-reactive protein as one of the activities of cellular and humoral mechanisms. This comparative study between laparoscopic and open cholecystectomy in light of immune response of the organism to stress, number and type of intra-operative and post-operative complications, confirmed advantages of laporascopic technique in comparison to open method.

Introduction: Renal graft function in the immediate posttransplant period is directly associated with patients hemodynamic condition during graft revascularization and early postoperative period. Our aim was to evaluate correlation between average daily value of central venous pressure (CVP) and renal perfusion, in first seven posttransplant days. Patients and methods: We recruited 74 patients, who underwent renal transplantation. We evaluated the influence of CVP and 24 h urine output on renal graft function. In order to assess the renal graft function, following parameters were evaluated: glomerular filtration rate (GFR), creatinine clearance, 24-hour urine output, and from the serum levels of K+, Na++, urea and creatinine. Results: Statistically significant positive correlation between mean values of CVP and 24 h urine output was found on the first (r=0.5422; p=0.0001) but not on the third postoperative day (r=0.1116; p=0.344). Statistically significant inverse correlation between mean values of creatinine and diuresis was found on the first (r=-0.2824; p=0.015) and third (r=-0.2976; p=0.01) postoperative day but on the seventh postoperative day a positive statistically significant correlation between these parameters was registered (r=0.4114; p=0.0001). There is a statistically significant difference between GFR and urine output on the first (r=0.2771; p= 0.017) and seventh day (r=0.4114; p=0.0001). We have not found any significant correlation between mean values of creatinine clearance and diuresis on the first posttransplant day (r=0.1760; p=0.134), but when same parameters were examined on the seventh day a positive statistical significance was found (r=0.4248; p=0.0001). Conclusion: Renal graft survival in early postoperative period is largely influenced by recipient hemodynamic condition. This study proved that 24-hour urine output directly depended on CVP level; it also proved existence of statistically significant correlation between mean values of diuresis, creatinine clearance, GFR and serum creatinine.

Resectional surgery on rectum, finishing with continued colo-rectal anastomosis by the classical manual technique, were burdened by a great number of post surgery complications of dehiscentio over 60%. If we take into reconsideration a high number of mortality 5-20% then we have valid reasons for developing modern and safer methods of surgical intervention of these patients. Two groups of 60 patients each, have been analyzed. They have been operated at the Surgical clinic University Clinical Center Tuzla because of rectum malignancy. The first group of patients where the colo-rectal anastomosis was manually operated was done between 1995-1998. In the second group of the patients being operated, colorectal continuity was done by stapler. The patients were operated in time period 2001-2002. The medium evaluation time was 20 months, for each group. All the patients were operated in elective programme, after endoscopic treatment and ph diagnosis done. The patients from the both analyzed groups were operated by the same surgeons. Preoperational procedure and postoperational observation was fullfilled according to the unified protocol. The patients with their colo-rectal continuity having been by stapler had a shorter surgery time, and less transfusion of blood. They had less ureter lesion. Also they have got a shorter hospitalization time with less number of anastomotic complications. Dehiscenc as well as bleeding. The patients with colorectal anastomosis made manually had more repeated surgeries. The patients from the manual group of the surgeries had more anastomotic relapses. The difference in the number of post operational strictures in both analyzed groups was not noticed. The patients with stapler colorectal anastomosis had no mortality. The manual group had one lethal case. The important thing that is noticed is a larger number of stapler colorectal anastomosis, not because of the illnes incidence increase but decrease of abdominoperineal rectum amputation. The patients have been safely operated from the oncologic point of wiev. They have continuing anastomosis which was not burdened with a larger number of morbidity and mortality. This was possible to do by improving surgical strategy and technique and introduction of stapler in every day surgical practice.

UNLABELLED The gallbladder cancer is the most common primary cancer of the hepatobiliary system, and ranks fifth of the cancers of the gastrointestinal system. It is accidentaly found in 1-3 % of patients with gallstone disease, and in 0,5-2,4% on postmortem exam. GOAL Show the incidence, clinical state, and suplement the diagnostic procedure of the patients with the risk factors for gallbladder cancer. Find proper surgical treatment in every stage of the disease according to Nevin-Moran system and the hystological type of the cancer. METHODS Retrospectively we evaluated all cholecystectomies in our hospital in a three year period. We established the incidence of gallbladder cancer and we tried to discover the common characteristics of this group of patients. We analized the histological type of the cancer, and the stage of the disease in correlation with clinical presentation, results of the surgical treatment , and the survival and the quality of life. RESULTS In three years we performed 2553 cholecystectomies, and in 1,7 % of patients -43 patient we discovered the cancer of gallbladder. It is 5 times more common in females. The mean age of the patients with gallbladder cancer is 65 years (55 - 82 years). The etiology of this disease is unknown. In 5 (11,6 %) patients cancer is discovered preoperatively. In 38 (88,4 %) patients it was adenocarcinoma of the gallbladder. Other morphologic types are analplastic cancer, carcinosarcoma, and "squamous cell carcinoma". In 30 patients (69,8 %) we performed cholecystectomy, and in 8 (18,6%) patients extended cholecystectomy with its components. Radical resective procedures on liver were performed in 5 (11,6%) patients. According to the localisation in 60% of cases the cancer was located in fundus, in 30% of cases in corpus,and 10% of cases in the neck of the gallbladder. No patient with stage V survived 1 year after the procedure. CONCLUSION The incidence of the gallbladder cancer in our series is in the slight increase. The quality of life and the survival are inversely correlated with the depth of the invasion and the extent of the spread of the cancer. The extensive surgical procedures in advanced stage of the disease, because of the grim prognosis, does not justify the risk of the operative treatment.

UNLABELLED The news in understanding intrahepatal anatomy, such as radiology contemporary technology making easier segmental and bisegmental access to hepatal resection. This access comprises resection of isolated anatomical segments or a sector of liver which is depends of magnitude of intrahepatal pathological process. After segmental or bisegmental resection of liver, patients were analysed in the period from 15 and 30 days after the operation. Analysis of patients from this period comprise: localisation of tumour in relation on segments, liver test and follow up, technique of resection, intraoperative stream, the period of operation, blood follow up through v. portae, blood loss and quantitative and qualitative analysis of postoperative complications. RESULTS between January 2000 and March 2005, sixty two subject were analysed that have been operated on our clinic (segmental or bisegmental resection), because of the metastatic process of liver and hepatocellular carcinoma of liver (HCC). Hospital mortality was 2.1%, with most often mortality in patients with HCC and cirrhosis of liver. High of morbidity from this period were 19,8%. Need for transfusion of blood (fresh erythrocytes) were 1,2 +/- 0,5 U. Patients with HCC had more needs from blood transfusions contrary patients without HCC; 2,9 +/- 1,4 contrary 0,7 +/- 0,28 U (p<0,05). Recidivism of malignant process in hepatal margin were 2,7%. CONCLUSION Segmental hepatal resection is very accurate technique which makes possible complete resection of tumour and in the same time preservation of healthy liver parenchyma. Segmental hepatal resection is especially useful for patients with HCC and patients with recidivism or progress of primary process.

Surgical treatment of stomach carcinoma by its specificity and takes the important place in oncological surgery. Incidence is in rise and every year about 250.000 new patients are registered. Identifying the sympotoms of disease, early diagnostics and surgical treatment improve the prognosis and results of treatment. Radical total gastrectomy (R0) and systematic lymphadenectomy (D2) represent a standard in surgical treatment of resectible stomach tumor. As for the lymphadenectomy, number of complications of surgical treatment is considerably getting higher. The objective of the paper is to show the frequency and variety of complications, the way of their treatment and results. 58 patients underwent radical total gastrectomy with lymphadenectomy in period of four years in our clinic. Sex ration is 2 : 1 in favour of men. Average age is 41.8 +/- 10.2 years. The most present abdominal complication is dehiscence of esophagojejunal anastomse 19.0% and of extraabdominal complication it is the deep vein thrombose 6.8%. Reconstruction of gastrointestinal continuity by method of Roux is the most present 55.2%. In early postoperative course 4.6% reoperations were made. Average duration of operation is 185 +/- 8.6 min. There has not been intraoperative morality. Postoperative moratily for 30 days is 10.3%, for 90 days 6.8%. Postoperative mortality and morbidity, number and different postoperative complications are statistically much higher in patients with systematic D2 and D3 lymphadenectomy (p < 0.05).