Albanian Journal of Trauma and Emergency Surgery

71-75

Authors: Rifat Latifi; Agron Dogjani

Postsurgical gastro-intestinal or intestinal-intestinal anastomotic leaks while not frequent, are the most feared complications for any anastomoses performed in the gastrointestinal tract (GIT) by general surgeons. This is particularly important in the upper GIT, such as gastro esophageal anastomosis, where leaks can lead to severe sepsis and septic shock, need for re-operation, or stent placement. For this short review we will address post-operative leaks following esophagectomy and sleeve gastrectomy as the most frequent bariatric procedure today. The factors and causes responsible for Upper Gastro-Intestinal Anastomosis, as they relate to patient, surgeon or technique will be reviewed. Moreover, the diagnosis and current management will be examined.

84 - 90

Authors: Astrit Mustafaj, Evisa Zhapa, Francesco Saverio Grossi

Background: Laparoscopic or robotic assisted prostatectomy has become common world wide. However, to our knowledge, laparoscopic radical prostatectomy has not been reported in Albania. Objective: To analyze the early perioperative and oncologic results obtained with the extraperitoneal laparoscopic prostatectomy (ELRP). Patients and Method: A retrospective study of all the patients operated at Salus Hospital Tirana, Albania. All data were collected and evaluated retrospectively on the basis of thorough clinical and pathological examination. For data management and statistical analysis, all variables pre-, intra- and perioperative data were collected in a spreadsheet. Results: In the 4-year period ( outline the period), 25 patients underwent the ELRP procedure. The average age of patients was 65 year-old and the PSA of 17.5 ng/dl. The total surgery time was 168 minutes on average. Only one patient was transfused after surgery, and limfocele was present in 2 patients. No other complications occured. Pathological examination revealed pT2 and pT3 cancers in 72% (18/25) and 25% (6/25) of patients, respectively. One patient had regional lymph nodes infiltration. The incidence of positive surgical margins and biochemical relapse rate was 16 % (4/25) and 32 % (8/25), respectively. Conclusion: The ELRP technique is safe and effective procedure in the treatment of prostate cancer, with low morbidity.

99-104

Authors: Kastriot Haxhirexha, Agron Dogjani, Lutfi Zylbehari, Ferizate Dika – Haxhirexha

Background: Appendicitis is the one of the most common emergency abdominal operation in children. It is estimated that appendicitis is diagnosed in about 2 % of children who present to emergency department because of acute abdominal pain1. Timely diagnosis and appendectomy can prevent abscess formation, perforation as well as reducing early and late postoperative complication. Methods: This study is a retrospective review of all children diagnosed with acute appendicitis in our emergency department between January 2015 – 2018. We have compared the clinical features and the results of examinations between two group of patients - those who were diagnosed correctly and have been operated, and those who were misdiagnosed and operated later respectively more than 24 hours after initial control. Results: This study includes fifty-nine children less than sixteen years old, admitted in our clinic and operated due to acute appendicitis. Fifty three (89.9%) of them were hospitalized after the first control, whereas the remining six (10.1 %) were discharged home after the initial control. The misdiagnosed patients were returned in our department less than twenty hours after the first control. Compared with the patients in which the diagnosis was made correctly the misdiagnosed patients in general had lower levels of leukocytes, CRP and temperature. Conclusion: The diagnosis of appendicitis in children can be very difficult because of the atypical features. According to our experience and the data from other studies, still there is not a single test or combination of clinical and laboratory examinations, able to discriminate children with and without acute appendicitis with a high percentage of accuracy.

113-117

Authors: Astrit Mustafaj, Evisa Zhapa, Francesco Saverio Grossi

Introduction: The most commonly used treatment modality for urethral strictures is the direct visual internal urethrotomy method according Sachse cold knife, but with low long-term success rate. Alternative method after failure is isurethroplasty with preputial flap or Buccal mucosa. The aim of this presentation is to report the efficacy of the Internal Urethrotomy with Holmium Laser (Sachse laser). Material and methods: We report three cases of urethral stenosis after trauma which treated with Internal Urethrotomy with Holmium Laser (Sachse laser) after failure of multiple treatments with Sachse cold knife. We evaluated and compared the uroflowmetry parameters before and after Sachse laser. Results: The average of uroflowmetry parameters before incision were: Q max 4.5 ml/sec, Q med 3 ml/sec. Voided Volume 323 cc, while after incision with Sachse laser were: Q max 30 ml/sec, Q med 12 ml/sec. Voided Volume 363 cc.No patients relapsed during follow-up time from 3 to 24 months. Conclusion: Even though these are only a few cases, we think that Sachse laser is a valid alternative after unsuccessful Sachse cold knife and before Urethroplasty, even in patients with urethral stricture after trauma.

126-135

Authors: Phillip Lindholm, Patrick Young, Walter Reed

Acute cholangitis is an infection of the biliary system that typically results from obstruction. Common causes include choledocholithiasis, strictures, foreign bodies (such as biliary stents) parasitic worms (e.g. ascarids) and compression from an external structure. Obstruction allows for higher bacterial concentrations and bacterial proliferation. With biliary stasis and increases in intraductal pressure, bacteria migrate into the venous and lymphatic systems with subsequent bacteremia. The rate of gallstone development is 3-4 % annually in those >60 years old with up to a 15% overall prevalence in the US. In the US, 85% of ascending cholangitis cases are a consequence of choledocholithiasis. The gram-negative bacteria E coli, Klebsiella, Pseudomonas and Enterobacter are the most commonly identified pathogens. Anaerobes are less common. Ascending cholangitis is classically diagnosed by the presence of Charcot’s triad – fever, right upper quadrant pain and jaundice. Though very specific, the presence of Charcot’s triad is only 26% sensitive and thus its absence does not rule out the diagnosis. All patients with suspected ascending cholangitis should undergo appropriate fluid resuscitation, be given broad spectrum antibiotics to cover the likely enteric pathogens, and closely monitored for worsening in their clinical condition. Once initial assessment is complete and resuscitative efforts begun, imaging is often helpful in confirming the diagnosis of ascending cholangitis. After the diagnosis has been confirmed, ERCP and biliary drainage is indicated.

142-149

Authors: F. Gradica, L. Lisha, Dh. Argjiri, A. Cani, F. Kokici, F. S. Gradica, V. Rexha, D. Lala, D. Xhemalaj; Y. Vata; L. Shpataraku; A.Vyshka

Background: Radical surgical resection of lung cancer with or without adjuvant treatment is still a prerequisite for cure. Advances in operative and postoperative care led to a decline in complications and mortality rates during the last decades. In spite of different additional modes of treatment, survival is still poor. The aim of study: To examine the operative mortality and morbidity after lung cancer surgery and to identify factors associated with an adverse outcome. Material and methods: The study comprised 968 consecutive patients referred to University Hospital of Lung Disease, “Shefqet Ndroqi” Tirana, Albania, for lung carcinoma, during a 13-years period (January 2004-December 2017). All patients underwent routine laboratory examinations spirometry and preoperative CT- scan of the thorax and upper abdomen. PET-CT, EBUS–EUS, Mediastinotomy or Mediastinoscopy wasn’t performed as routine. Results: Of 968 patients, 690 (70.5%) were male and 278 (28.7%) female. Mean age 65.5±9.4 years (range 15 - 87 years). Lobectomy was the most used surgical modality in 566 (58.5%) patients, meanwhile pneumonectomy was performed in 112 (11.6%) of patients. Minor complications during surgery occurred in 45 (11.7%) of patients. Continuous air leakage was the most complication after surgery in 25.3%, followed by lung atelectasis in 21.3% and cardiovascular complications in 17%. Conclusion: our results show low mortality and morbidity after lung cancer surgery. However, patients with reduced lung capacity, older age and those undergoing pneumonectomy should be treated with great care.

163-173

Authors: Skender Veliu, Jasmina Kröpfl, Dominika Vrbnjak

Introduction: Treatment of acute and chronic wounds are a major challenge. In modern medicine, numerous approaches to wound healing are known. One of them is the use of epidermal autologous grafts. The purpose of this article is to present the use of automated epidermal harvesting system (CELLUTOMETM Epidermal Harvesting System; KCI, an Acelity company, San Antonio, TX, USA) in General Hospital dr. Jože Potrč Ptuj, Slovenija. Case presentation: Treatment of a patient with a chronic wound after ruptured varicose veins on the right shin, a patient with a chronic wound after crash injury and a patient with nonhealing postoperative wound using CELLUTOMETM Epidermal Harvesting System are described. Conclusion: Our results showed the positive effects of epidermal autologous grafts on the healing process of various types of wounds and confirmed the advantages of this system for the production of epidermal autologous grafts.

182-188

Authors: Alfred Ibrahimi, Saimir Kuci, Ervin Bejko, Stavri Llazo, Jonela Burimi, Esmerilda Bulku, Edvin Prifti, Andi Kacani

Pyrexia is a protective physiologic response of the body against external and internal aggression. Temperature control is safe in and effective in septic shock but remain controversial in sepsis. Treating pyrexia to reduce oxygen consumption appears to have beneficial in cardiac arrest, low cardiac output and acute brain injury. Multiple therapeutic options are available for managing pyrexia, with precise targeted temperature management. Notably, the use of pharmacotherapy versus surface cooling has not been shown to be advantageous. When these two-therapy failed to control the extra-corporal method of cooling should be started. Renal replacement therapies are not typically indicated for temperature control but, in patients requiring renal support, they contribute to heat loss and participate in pyrexia control. Renal replacement therapies may represent a confounding factor in comparative trials on temperature control.

11 -13

Authors: Edvin Selmani, Fatmir Brahimi, Leard Duraj

The concept of damage control surgery was first described for the purpose of treating medically unstable patients with abdominal trauma. The purpose of such surgery is rapid control of hemorrhage and contamination, not definitive repair of injuries. The goal is to improve survival of patients with the potentially lethal triad of hypothermia, acidosis and coagulopathy. Definitive repair of injuries and abdominal closure are not performed at the time of initial laparotomy. Rather, the abdominal wound is left open, a dressing is placed, and the patient is transported to the intensive care unit for continued resuscitation. This includes optimization of hemodynamic condition, respiratory support, warming, and correction of coagulopathy. Following successful resuscitation, when the patient is medically stable, a return to the operating room is scheduled for repair of injuries and abdominal closure.

21 - 26

Authors: Agron Dogjani, Engjellushe Jonuzi, Shkelzen Osmanaj, Fadil Gradica, Rustem Celami, Rifat Latifi

Background: In the last decade, the risk of terrorist attacks has increased largely almost worldwide. In this setting, disaster response personnel must understand the unique physiopathology of injuries associated with explosions and must be prepared to assess and treat the people injured in such tragedies. The ammunition explosion in Gërdec, Vora, just 13 miles from the capital of Albania, Tirana, confronted our country with a real human tragedy with severe casualties. The striking force of the two consecutive explosions resulted in two consecutive earthquakes with respectively an amplitude of 9.2 and 2.5 on the Richter scale. Objective: To explain the classification of explosives and in connection with it to identify the major types of explosive and blast injuries, and the management options in the cases of explosions and blast injuries. Material & Methods: Efforts to dismantle Albania’s stockpiles of obsolete munitions took a catastrophic turn on March 15th, when a series of explosions occurred as crews were clearing out a storage depot in Gërdec, on 15th of March 2008, at 12:15 AM hours. Gërdec is located 10 km northwest of the capital of Albania, Tirana; near the national highway Tirana-Durres and at a distance of 3-4 km in air line from National Airport. Data presented here were collected from the patients’ files in our Trauma UHC and from the official reports from the different governmental offices. Conclusion: The explosive and blast injuries now present a true modern epidemic disease that threaten the very survival of the free world. A thorough understanding of detonation and blast dynamics by the treating teams is required to better correlate the injury patterns presented. This is also critical for revision of current multiple casualty protocols. It is up to the medical establishment to prepare suitable protocols, coordinate manpower and secure medical resources to successfully handle such events.

31-35

Authors: Altin Habazaj, Holta Tafa, Donika Bardhi, Hasan Hafizi

Background: Physiological research on dyspnea has provided some information on how sex differences in lung and airway size can influence the experience of dyspnea during exercise; however, there is still a knowledge gap with regard to sex-related differences in other respiratory symptoms, including cough and sputum production. Objective: The objective of this analysis was to assess sex related differences in reported objective symptoms using data from the population-based Burden of Obstructive Lung Disease (BOLD) study in Albania. Method: Males and females with impaired lung function may experience the same symptoms but perceive and/or report them differently. In this analysis were included 997 responders who had completed the core questionnaire, which included data on respiratory symptoms using the following questions: “Do you usually cough when you don’t have a cold?” and “Do you usually bring up phlegm from your chest, or do you usually have phlegm in your chest that is difficult to bring up when you don’t have a cold. Chronic was defined as three months or more per year. Data used were drawn from the final report for Albania provided by BOLD team. Results: Overall, male gender was associated with increased odds for reported chronic cough at any group age [Total: 14.7 (2.3) vs. 6.6 (0.9)]. This difference is very much reduced in the group age 70+ years old [25.8 (8.2) vs. 21.3 (6.8)]. In the contrary when we used the estimated population prevalence of chronic cough by pack-years and gender, female gender was associated with increased odds for reported chronic cough especially in the 10+ pack-years groups [50.4 (11.0) vs. 12.2 (8.3) in 10-20 pack-years and 29.0 (5.5) vs. 26.0 (3.3) 20+ pack-years] indicating a increased smoking susceptibility of female gender. In contrast, female gender was associated with decreased odds for reported phlegm. Even for the same pack-years of smoking, female gender is associated with decreased odds for reported chronic phlegm [0 vs. 7.1 (8.6) in 10-20 pack-years group; 0 vs. 15.4 (3.0) in 20+ pack-years group]. Conclusions: Physicians need to recognize that although a female may not report chronic sputum or phlegm production and a male may not report chronic cough, a diagnosis of Chronic Obstructive Pulmonary Disease should still be considered as symptoms often are the first step to a diagnosis of underlying airway disease.

41-51

Authors: Lutfi Zylbeari, Sihana Ahmeti Lika, Nasir Behxheti, Mirlind Behxheti, Zamira Bexheti, Jetmire Jakupi- Alimani, Hanife Ahmeti, Ferizate Dika Haxhirexha, Ledia Kaci, Kastriot Haxhirexha

Background: Homocystinuria is a rare autosomal recessive disease complicated by early and aggressive occlusive arterial disease. This may be related to the grossly increased homocysteine concentrations seen in this disease. More recently, milder hyperhomocysteinemia has been proposed as an independent risk factor for coronary artery disease. Cardiovascular disease (CVD) is among the diseases with multiple contributing factors, hence making it difficult to pinpoint a particular factor alone. The main factor that is of relevance to this study is homocysteine. Coronary artery disease is the narrowing or blockage of the arteries and vessels that supply oxygen and nutrients to the heart (1, 2). CVD is the major cause of morbidity and mortality worldwide. Obesity, HTA, Diabetes mellitus, hypercholesterolemia, and smoking have been recognized as major risk factors for CVD. Aim: Aim of this paper is to examine concentrations of Hcyt and lipid profiles in patients with CVD and positive personal history for CVD, comparing them with the control group composed of healthy individuals. Our study aimed to verify the role of Homocysteine as a new independent risk factor on the onset of early atherosclerosis and atheromatous processes in coronary arteries in patients with CVD. Materials and methods: The results obtained represent the average value earned once every three months in the 3 year period. 5ccm serum with a few heparin spots was sent to the Clinical Laboratory of the University Clinic of Skopje. Results: The results obtained from patients with CVD and control groups are presented in the following text, where a statistically significant difference was observed for p <0.0001 between the parameters obtained by patients with CVD compared to the control group. Concentrations of homocysteine and lipids in patients with CVD compared to the control group showed statistically significant difference with p<0.0001, expected results, and verified in many other multicentric studies. These facts show that raised Hcyt has more impact on the onset of CVD. When Hcy levels are in the blood, the activity of the cystathionine-synthetase enzyme is raised. It is believed that this enzyme plays a vital role in the metabolism of Hcyt. In recent years a lot of studies have been made on the effect of hyperhomocysteinemia and its impact on the onset of coronary and all have verified that hyperhomocysteinemia is a significant parameter for the onset of early atherosclerosis of coronary and CVD(6,7,8). Conclusions: In the above-mentioned cases, it is recommended substitutive therapy with folic acid, pyridoxine, vitamin B12, vitamin E and other antioxidants which are found that have an effect on the prevention of premature atherosclerosis in patients with CVD and raised Hcyt: acute myocardial infarction, CARB, angina pectoris. PTCA, Stenting, and prevention of stroke.

57-60

Authors: Leon Kaza, Senad Halluni, Rustem Celami, Zef Delia

Cezarean Hysterectomy refers to emergency peripartum hysterectomy - EPH, which is performed as a life saving procedure in cases of continual obstetric hemorrhage secondary to uterine atony, uterine rupture, placental disorders, fibroids, and lacerations during cesarean section - CS or vaginal parturition. Emergency peripartum hysterectomy - EPH, although rare in modern obstetrics, remains a lifesaving procedure in cases of severe hemorrhage. In contemporary obstetrics, overall incidence of severe postpartum hemorrhage was reported to occur in 6.7/1,000 deliveries worldwide. It is one of the leading causes of maternal mortality and morbidity and represents the most challenging complication that an obstetrician will face. The incidence of peripartum hysterectomy in the literature is reported as 0.24, 0.77, 2.3, and 5.09 per 1,000 deliveries by many authors mentioning a few; Sakse et al., Whiteman et al., Bai et al., and Zeteroglu et al., respectively. Nevertheless, there is a lack of Albanian data on EPH. To our knowledge, there is no Portuguese information on postpartum hemorrhage and EPH, which does not mean that we do not have suc obstetrical complication and therefore such emergency intervention. This paper’s intention is to bring awareness of such catastrophic obstetrical complication especially in young primigavida and primipara women.