Publications by authors named "Milos Bjelovic"

35 Publications

Impact of neoadjuvant therapy followed by laparoscopic radical gastrectomy with D2 lymph node dissection in Western population: A multi-institutional propensity score-matched study.

J Surg Oncol 2021 Aug 25. Epub 2021 Aug 25.

Department of Public Health, University of Naples Federico II, Naples, Italy.

Background And Objectives: In the setting of a minimally invasive approach, we aimed to compare short and long-term postoperative outcomes of patients treated with neoadjuvant therapy (NAT) + surgery or upfront surgery in Western population.

Methods: All consecutive patients from six Italian and one Serbian center with locally advanced gastric cancer who had undergone laparoscopic gastrectomy with D2 lymph node dissection were selected between 2005 and 2019. After propensity score-matching, postoperative morbidity and oncologic outcomes were investigated.

Results: After matching, 97 patients were allocated in each cohort with a mean age of 69.4 and 70.5 years. The two groups showed no difference in operative details except for a higher conversion rate in the NAT group (p = 0.038). The overall postoperative complications rate significantly differed between NAT + surgery (38.1%) and US (21.6%) group (p = 0.019). NAT was found to be related to a higher risk of postoperative morbidity in patients older than 60 years old (p = 0.013) but not in patients younger (p = 0.620). Conversely, no difference in overall survival (p = 0.41) and disease-free-survival (p = 0.34) was found between groups.

Conclusions: NAT appears to be related to a higher postoperative complication rate and equivalent oncological outcomes when compared with surgery alone. However, poor short-term outcomes are more evident in patients over 60 years old receiving NAT.
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http://dx.doi.org/10.1002/jso.26657DOI Listing
August 2021

Author Correction: Preparation and modeling of three-layered PCL/PLGA/PCL fibrous scaffolds for prolonged drug release.

Sci Rep 2021 Aug 2;11(1):16028. Epub 2021 Aug 2.

Bioengineering Research and Development Center BioIRC Kragujevac, Prvoslava Stojanovica 6, Kragujevac, 34000, Serbia.

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http://dx.doi.org/10.1038/s41598-021-95377-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8329292PMC
August 2021

The impact of EAES Fellowship Programme: a five-year review and evaluation.

Surg Endosc 2021 Jun 8. Epub 2021 Jun 8.

Department of General Surgery, Linköping University Hospital, 581 85, Linköping, Sweden.

Background: The European Association of Endoscopic Surgery (EAES) fellowship programme was established in 2014, allowing nine surgeons annually to obtain experience and skills in minimally invasive surgery (MIS) from specialist centres across the Europe and United States. It aligns with the strategic focus of EAES Education and Training Committee on enabling Learning Mobility opportunities. To assess the impact of the programme, a survey was conducted aiming to evaluate the experience and impact of the programme and receive feedback for improvements.

Methods: A survey using a 5-point Likert scale was used to evaluate clinical, education and research experience. The impact on acquisition of new technical skills, change in clinical practice and ongoing collaboration with the host institute was assessed. The fellows selected between 2014 and 2018 were included. Ratings were analysed in percentage; thematic analysis was applied to the free-text feedbacks using qualitative analysis.

Results: All the fellows had good access to observing in operating theatres and 70.6% were able to assist. 91.2% participated in educational activities and 23.5% were able to contribute through teaching. 44.1% participated in research activities and 41.2% became an author/co-author of a publication from the host. 97.1% of fellows stated that their operative competency had increased, 94.3% gained new surgical skills and 85.7% was able to introduce new techniques in their hospitals. 74.29% agreed that the clinical experience led to a change in their practices. The most commonly suggested improvements were setting realistic target in clinical and research areas, increasing fellowship duration, and maximising theatre assisting opportunities. Nevertheless, 100% of fellows would recommend the fellowship to their peers.

Conclusion: EAES fellowship programme has shown a positive impact on acquiring and adopting new MIS techniques. To further refine the programme, an individualised approach should be adopted to set achievable learning objectives in clinical skills, education and research.
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http://dx.doi.org/10.1007/s00464-021-08525-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8186018PMC
June 2021

Laparoscopic gastrectomy for stage II and III advanced gastric cancer: long‑term follow‑up data from a Western multicenter retrospective study.

Surg Endosc 2021 Apr 20. Epub 2021 Apr 20.

Department of General Surgery and Specialty, School of Medicine University, Federico II of Naples, Naples, Italy.

Introduction: There has been an increasing interest for the laparoscopic treatment of early gastric cancer, especially among Eastern surgeons. However, the oncological effectiveness of Laparoscopic Gastrectomy (LG) for Advanced Gastric Cancer (AGC) remains a subject of debate, especially in Western countries where limited reports have been published. The aim of this paper is to retrospectively analyze short- and long-term results of LG for AGC in a real-life Western practice.

Materials And Methods: All consecutive cases of LG with D2 lymphadenectomy for AGC performed from January 2005 to December 2019 at seven different surgical departments were analyzed retrospectively. The primary outcome was diseases-free survival (DFS). Secondary outcomes were overall survival (OS), number of retrieved lymph nodes, postoperative morbidity and conversion rate.

Results: A total of 366 patients with stage II and III AGC underwent either total or subtotal LG. The mean number of harvested lymph nodes was 25 ± 14. The mean hospital stay was 13 ± 10 days and overall postoperative morbidity rate 27.32%, with severe complications (grade ≥ III) accounting for 9.29%. The median follow-up was 36 ± 16 months during which 90 deaths occurred, all due to disease progression. The DFS and OS probability was equal to 0.85 (95% CI 0.81-0.89) and 0.94 (95% CI 0.92-0.97) at 1 year, 0.62 (95% CI 0.55-0.69) and 0.63 (95% CI 0.56-0.71) at 5 years, respectively.

Conclusion: Our study has led us to conclude that LG for AGC is feasible and safe in the general practice of Western institutions when performed by trained surgeons.
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http://dx.doi.org/10.1007/s00464-021-08505-yDOI Listing
April 2021

Laparoscopic enucleation of Frantz's tumor of the pancreas: Case report and literature review.

Ann Med Surg (Lond) 2021 Apr 14;64:102221. Epub 2021 Mar 14.

Clinical Center of Serbia, University Hospital for Digestive Surgery, Department for Minimally Invasive Upper Digestive Surgery, Belgrade, Serbia.

Introduction: Frantz's tumor of the pancreas is a rare phenomenon, and it accounts for 1-3% of all neoplasms of the pancreas. Its percentage is much higher in younger persons, especially in younger women, as compared to the rest of the population.

Presentation Of Case: The present study describes a 32-year-old female patient in whom a preoperative imaging diagnosis confirmed a mass in the junction of the pancreas' body and tail. Based on the anamnesis, the preoperative diagnosis, and the patient's general status, the decision was made to performed laparoscopic enucleation of the pancreatic tumor. The operation and postoperative recovery passed without complications. Definitive histopathological and immunohistochemical findings confirmed a solid pseudopapillary neoplasm of the pancreas.

Discussion: Depending on the localization and the size of the tumor, surgical options range from typical and atypical resections of the pancreas to minimally invasive surgical procedures, such as local excision and enucleation. Laparoscopic procedures have a comparative advantage in cases of enucleation and resection of the pancreas. The low frequency of recidivation and a favorable prognosis, even after repeated surgery, are additional reasons for favoring the laparoscopic approach over the classical surgical approach.

Conclusion: A minimally invasive surgical approach should be applied whenever the dimensions and the localization of the tumor permit it, bearing in mind all the benefits and advantages that this surgical technique offers.
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http://dx.doi.org/10.1016/j.amsu.2021.102221DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7995482PMC
April 2021

Non-active implantable device treating acid reflux with a new dynamic treatment approach: 1-year results : RefluxStop™ device; a new method in acid reflux surgery obtaining CE mark.

BMC Surg 2020 Jul 20;20(1):159. Epub 2020 Jul 20.

Inventor of RefluxStop™, Seehof 4b, 6072, Sachseln, Switzerland.

Background: RefluxStop™ is an implantable, non-active, single use device used in the laparoscopic treatment of GERD. RefluxStop™ aims to block the movement of the LES up into the thorax and keep the angle of His in its original, anatomically correct position. This new device restores normal anatomy, leaving the food passageway unaffected.

Methods: In a prospective, single arm, multicentric clinical investigation analyzing safety and effectiveness of the RefluxStop™ device to treat GERD, 50 subjects with chronic GERD were operated using a standardized surgical technique between December 2016 and September 2017. They were followed up for 1 year (CE-mark investigation 6-months). Primary safety outcome was prevalence of serious adverse events related to the device, and primary effectiveness outcome reduction of GERD symptoms based on GERD-HRQL score. Secondary outcomes were prevalence of adverse events other than serious adverse events, reduction of total acid exposure time in 24-h pH monitoring, and reduction in average daily PPI usage and subject satisfaction.

Results: There were no serious adverse events related to the device. Average GERD-HRQL total score at 1 year improved 86% from baseline (p < 0.001). 24-h pH monitoring compared to baseline showed a mean reduction percentage of overall time with pH < 4 from 16.35 to 0.80% at the 6-month visit (p < 0.001), with 98% of subjects showing normal 24-h pH. At 1 year: No new cases of dysphagia were recorded, present in 2 subjects, which existed already at baseline. Regular daily PPI usage occurred in all 50 subjects at baseline. At 1-year follow-up, only 1 subject took regular daily PPIs due to a too low placement of the device thereby prohibiting its function. None or minimal occasional episodes of regurgitation occurred in 97.8% of evaluable subjects. Gas bloating disappeared in 30 subjects and improved in 7 subjects.

Conclusion: The new principle of RefluxStop™ is safe and effective to treat GERD according to investigation results. At 1-year follow-up, both the GERD-HRQL score and 24-h pH monitoring results indicate success for the new treatment principle. In addition, with the dynamic treatment for acid reflux, which avoids compressing the food passageway, prevalence of dysphagia and gas bloating are significantly reduced.

Trial Registration: ClinicalTrials.gov , NCT02759094 . Registered 3 May, 2016.
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http://dx.doi.org/10.1186/s12893-020-00794-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7370422PMC
July 2020

Preparation and modeling of three-layered PCL/PLGA/PCL fibrous scaffolds for prolonged drug release.

Sci Rep 2020 07 7;10(1):11126. Epub 2020 Jul 7.

Bioengineering Research and Development Center BioIRC Kragujevac, Prvoslava Stojanovica 6, Kragujevac, 34000, Serbia.

The authors present the preparation procedure and a computational model of a three-layered fibrous scaffold for prolonged drug release. The scaffold, produced by emulsion/sequential electrospinning, consists of a poly(D,L-lactic-co-glycolic acid) (PLGA) fiber layer sandwiched between two poly(ε-caprolactone) (PCL) layers. Experimental results of drug release rates from the scaffold are compared with the results of the recently introduced computational finite element (FE) models for diffusive drug release from nanofibers to the three-dimensional (3D) surrounding medium. Two different FE models are used: (1) a 3D discretized continuum and fibers represented by a simple radial one-dimensional (1D) finite elements, and (2) a 3D continuum discretized by composite smeared finite elements (CSFEs) containing the fiber smeared and surrounding domains. Both models include the effects of polymer degradation and hydrophobicity (as partitioning) of the drug at the fiber/surrounding interface. The CSFE model includes a volumetric fraction of fibers and diameter distribution, and is additionally enhanced by using correction function to improve the accuracy of the model. The computational results are validated on Rhodamine B (fluorescent drug l) and other hydrophilic drugs. Agreement with experimental results proves that numerical models can serve as efficient tools for drug release to the surrounding porous medium or biological tissue. It is demonstrated that the introduced three-layered scaffold delays the drug release process and can be used for the time-controlled release of drugs in postoperative therapy.
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http://dx.doi.org/10.1038/s41598-020-68117-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7341868PMC
July 2020

Laparoscopic Management of Initially Unrecognized Splenic Hydatid Cysts: A Case Report and Review of the Literature.

Medicina (Kaunas) 2019 Dec 3;55(12). Epub 2019 Dec 3.

Clinical Centre of Serbia, Clinic for Digestive Surgery, 11000 Belgrade, Serbia.

We present a case report that demonstrates diagnostic and intraoperative challenges in the laparoscopic management of initially unrecognized splenic hydatid disease. A male patient, aged 44, was admitted to our department with a big unilocular splenic cyst, radiologically (ultrasonography, computed tomography) characterized as a simple cyst. Serological tests for anti-Echonococcus antibody were negative, and chests X-ray findings were unremarkable, so laparoscopic cyst fenestration with omentoplasty was planned. The intraoperative finding did not correspond to a simple splenic cyst. Hydatid daughter cysts were recognized after the careful opening of the cyst wall. The operation was completed without shifting to open procedures. Laparoscopic partial pericystectomy with omentoplasty is a safe and effective surgical procedure for the management of splenic hydatid disease.
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http://dx.doi.org/10.3390/medicina55120771DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6956320PMC
December 2019

A Prospective, Randomized, Phase III Study to Evaluate the Efficacy and Safety of Fibrin Sealant Grifols as an Adjunct to Hemostasis as Compared to Cellulose Sheets in Hepatic Surgery Resections.

J Gastrointest Surg 2018 11 2;22(11):1939-1949. Epub 2018 Jul 2.

Bioscience Research Group, Grifols, Barcelona, Spain.

Background: Local hemostatic agents have a role in limiting bleeding complications associated with liver resection.

Methods: In this randomized, phase III study, we compared the efficacy and safety of Fibrin Sealant Grifols (FS Grifols) with oxidized cellulose sheets (Surgicel®) as adjuncts to hemostasis during hepatic resections. The primary efficacy endpoint was the proportion of patients achieving hemostasis at target bleeding sites (TBS) within 4 min (T) of treatment application. Secondary efficacy variables were time to hemostasis (TTH) at a later time point if re-bleeding occurs and cumulative proportion of patients achieving hemostasis by time points T, T, T, T, and T.

Results: The rate of hemostasis by T was 92.8% in the FS Grifols group (n = 163) and 80.5% in the Surgicel® group (n = 162) (p = 0.01). The mean TTH was significantly shorter (p < 0.001) in the FS Grifols group (2.8 ± 0.14 vs. 3.8 ± 0.24 min). The rate of hemostasis by T, T, and T was higher and statistically superior in the FS Grifols group compared to Surgicel®. No substantial differences in adverse events (AE) were noted between treatment groups. The most common AEs were procedural pain (36.2 vs. 37.7%), nausea (20.9 vs. 23.5%), and hypotension (14.1 vs 6.2%).

Conclusions: FS Grifols was safe and well tolerated as a local hemostatic agent during liver resection surgeries. Overall, data demonstrate that the hemostatic efficacy of FS Grifols is superior to Surgicel® and support the use of FS Grifols as an effective local hemostatic agent in these surgical procedures.
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http://dx.doi.org/10.1007/s11605-018-3852-4DOI Listing
November 2018

Open Surgical Treatment of Secondary Aortoesophageal and Aortobronchial Fistula after Thoracic Endovascular Aortic Repair and Esophagocoloplasty in a Second Procedure.

Ann Vasc Surg 2017 Oct 11;44:417.e11-417.e16. Epub 2017 May 11.

Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia.

Aortoesophageal (AEF) and aortobronchial fistula (ABF) after thoracic endovascular aortic repair (TEVAR) are rare complications with catastrophic consequences without treatment. In this case report, we presented a patient with AEF and ABF after TEVAR successfully treated with endograft explantation and replaced by Dacron graft followed by esophagectomy and left principal bronchus repairing. We report a patient with AEF and ABF after TEVAR who was evaluated due to dysphagia and chest pain followed by hematemesis and hemoptysis. Endoscopic examination revealed lesion of the esophageal wall with chronic abscess formation and stent-graft protrusion into the cavity. Patient was operated on with extracorporeal circulation. AEF and ABF were confirmed intraoperatively. Endograft was explanted and in situ reconstruction of thoracic aorta was carried out with tubular Dacron 22-mm prosthesis wrapped with omental flap. After aortic reconstruction, esophageal mucosal stripping was performed with cervical esophagostomy, pyloromyotomy, and Stamm-Kader gastrostomy for nutrition. In addition, omentoplasty of the defect in the left principal bronchus was performed. To re-establish peroral food intake esophagocoloplasty was carried out 8 months after previous surgery utilizing transversosplenic segment of the colon and retrosternal route. In very selective cases, stent-graft explantation and in situ reconstruction with Dacron graft covered by omental flap followed by esophagectomy and bronchus repairing permit adequate debridement reducing the risk of mediastinitis and graft infection and allow a safe esophageal reconstruction in a second procedure.
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http://dx.doi.org/10.1016/j.avsg.2017.01.019DOI Listing
October 2017

The Burden of Gastroesophageal Reflux Disease on Patients' Daily Lives: A Cross-Sectional Study Conducted in a Primary Care Setting in Serbia.

Srp Arh Celok Lek 2015 Nov-Dec;143(11-12):676-80

Introduction: Recent data from the studies conducted in the Western countries have proved that patients with gastroesophageal reflux disease have significantly impaired health-related quality of life compared to general population.

Objective: The study is aimed at evaluating the burden of reflux symptoms on patients'health-related quality of life.

Methods: The study involved 1,593 patients with diagnosed gastroesophageal reflux disease.The Serbian version of a generic self-administered Centers for Disease Control and Prevention questionnaire was used. Statistical analyses included descriptive statistics, Pearson chi-square test and a multiple regression model.

Results: Among all participants, 43.9% reported fair or poor health. Mean value of unhealthy days during the past 30 days was 10.4 days, physically unhealthy days 6.4 days, mentally unhealthy days 5.3 days and activity limitation days 4.3 days. Furthermore, 24.8% participants reported having ≥ 14 unhealthy days, 14.9% had 14 physically unhealthy days, 11.8% reported 14 mentally unhealthy days, and 9.4% had ≥ 14 activity limitation days.

Conclusion: This study addressed complex relationships between reflux symptoms and patients'impaired everyday lives.
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http://dx.doi.org/10.2298/sarh1512676bDOI Listing
March 2016

Minimally Invasive Esophagectomy for Cancer: Single Center Experience after 44 Consecutive Cases.

Srp Arh Celok Lek 2015 Jul-Aug;143(7-8):410-5

Introduction: At the Department of Minimally Invasive Upper Digestive Surgery of the Hospital for Digestive Surgery in Belgrade, hybrid minimally invasive esophagectomy (hMIE) has been a standard of care for patients with resectable esophageal cancer since 2009. As a next and final step in the change management, from January 2015 we utilized total minimally invasive esophagectomy (tMIE) as a standard of care.

Objective: The aim of the study was to report initial experiences in hMIE (laparoscopic approach) for cancer and analyze surgical technique, major morbidity and 30-day mortality.

Methods: A retrospective cohort study included 44 patients who underwent elective hMIE for esophageal cancer at the Department for Minimally Invasive Upper Digestive Surgery, Hospital for Digestive Surgery, Clinical Center of Serbia in Belgrade from April 2009 to December 2014.

Results: There were 16 (36%) middle thoracic esophagus tumors and 28 (64%) tumors of distal thoracic esophagus. Mean duration of the operation was 319 minutes (approximately five hours and 20 minutes). The average blood loss was 173.6 ml. A total of 12 (27%) of patients had postoperative complications and mean intensive care unit stay was 2.8 days. Mean hospital stay after surgery was 16 days. The average number of harvested lymph nodes during surgery was 31.9. The overall 30-day mortality rate within 30 days after surgery was 2%.

Conclusion: As long as MIE is an oncological equivalent to open esophagectomy (OE), better relation between cost savings and potentially increased effectiveness will make MIE the preferred approach in high-volume esophageal centers that are experienced in minimally invasive procedures.
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http://dx.doi.org/10.2298/sarh1508410bDOI Listing
December 2015

Efficacy of long-acting somatostatin analogs in recurrent variceal bleeding in a patient with pre-hepatic portal vein thrombosis.

Vojnosanit Pregl 2015 Mar;72(3):283-6

Introduction: Bleeding from esophageal varices is a serious medical problem because of the risk of recurrent bleeding and high mortality rate (17-54%). Gastroesophageal varices develop in 50% of cirrhotic patients with portal hypertension, but can also develop in other pre- or post-hepatic causes of portal hypertension.

Case Report: We reported a 48-year-old female patient with portal hy- pertension caused by mesenterial vein thrombosis due to congenital thrombophilia. The patient was hospitalized several times be- cause of recurrent gastroesophageal bleeding. Thrombosis of portal, lienal and mesenteric veins was diagnosed using multislice computed tomography (MSCT) angiography. Sclerotherapy and/or variceal ligation could not be used due to variceal size and distribution. Beta blockers were ineffective. Balloon tamponade and octreotide were used in each massive bleeding episode. Carvedilol therapy was introduced but rebleeding occured. Surgical treatment was considered a high risk procedure due to massive thrombosis of mesenterial veins, patient's general condition and high risk of postoperative thrombotic events. Thus, long-acting somatostatin analogue--Sandostatin LAR was initiated at a dose of 30 mg im/month. The patient responded to the therapy well and variceal bleeding did not occur for the following 3 months. After 3 months another episode of gastric variceal hemorrhage occurred and surgical treatment was reconsidered. Total gastrectomy was performed in order to prevent repeated bleeding from large gastric varices and the patient recovered successfully, and after 1 year is symptom-free. Conclusion. Long-lasting somatostatin analogue was used for the first time in treatment of gastroesophageal variceal hemorrhage in the patient with prehepatic portal hypertension. It was effective as temporary therapeutic option allowing the improvement of the patients general condition and adequate planning of elective surgical procedure. Futher reports are needed in order to compare efficacy in treatment of patients with variceal bleeding, where poor outcome is expected.
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http://dx.doi.org/10.2298/vsp1503283aDOI Listing
March 2015

The use of autologous fascia lata graft in the laparoscopic reinforcement of large hiatal defect: initial observations of the surgical technique.

BMC Surg 2015 Mar 11;15:22. Epub 2015 Mar 11.

Department of Plastic Surgery, Special Hospital Banjica, Belgrade, Serbia.

Background: Even though there is no consensus, many authors believe that in the cases of large hiatal defects, structurally altered crura and/or absence of peritoneal lining, a crural reinforcement should be performed. Reinforcement could be performed with different techniques and different type of mesh, either synthetic or biologic. The disadvantages of mesh repair include the possibility of serious complications and increased costs especially in the usage of composite or biologic mesh.

Methods: The study includes 10 cases of reinforced primary suture line of the pillars with autologous fascia lata, in elective laparoscopic repair of the giant PEH with a large hiatal defect and friable crura. After intraopreative confirmation of the large hiatal defect (hiatal surface area of more than 8 cm²) and friable crura, an autologous fascia lata graft was harvested in the usual manner and placed in on-lay fashion to reinforce the pillar suture line. We analyzed surgical technique, complications, and initial follow-up of the patients.

Results: Average hiatal surface area (HSA) in our series was 10.6 cm² (range 8.1 to 14.4 cm²). The average duration of operation was 203.9 min/3.4 hours (range 160-250 min). Except for a mild hematoma in the harvesting region that resolved spontaneously, there were no procedure related complications and 30 days mortality rate was zero. The average postoperative length of stay was 6.5 days (5-8 days). Out of 10 patients, 5 completed the annual follow-up visit, while 8 completed a 6- month follow-up visit. So far there is no hernia recurrence and/or problems with swallowing function. However, one patient has felt a mild discomfort in the harvested region that does not influence normal daily activities.

Conclusions: Autologous fascia lata graft hiatal reinforcement represents a technically feasible, easy, and available option for the on-lay reinforcement of large hiatal defects with friable crura in the laparoscopic repair of giant PEHs.
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http://dx.doi.org/10.1186/s12893-015-0008-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4359456PMC
March 2015

Laparoscopic repair of hiatal hernias: experience after 200 consecutive cases.

Srp Arh Celok Lek 2014 Jul-Aug;142(7-8):424-30

Introduction: Repair of hiatal hernias has been performed traditionally via open laparotomy or thoracotomy. Since first laparoscopic hiatal hernia repair in 1992, this method had a growing popularity and today it is the standard approach in experienced centers specialized for minimally invasive surgery.

Objective: In the current study we present our experience after 200 consecutive laparoscopic hiatal hernia repairs.

Methods: A retrospective cohort study included 200 patients who underwent elective laparoscopic hiatal hernia repair at the Department for Minimally Invasive Upper Digestive Surgery, Clinic for Digestive Surgery, Clinical Center of Serbia in Belgrade from April 2004 to December 2013.

Results: Hiatal hernia types included 108(54%) patients with type 1, 30 (15%) with type III, 62 (31%) with giant paraesophageal hernia, while 27 (13.5%) patients presented with a chronic gastric volvulus. There were a total of 154 (77%) Nissen fundoplications. In 26 (13%) cases Nissen procedure was combined with esophageal lengthening procedure (Collis-Nissen), and in 17 (8.5%) Toupet fundoplications was performed. Primary retroesophageal crural repair was performed in 164 (82%) cases, Cleveland Clinic Foundation suture modification in 27 (13.5%), 4 (2%) patients underwent synthetic mesh hiatoplasty, 1 (0.5%) primary repair reinforced with pledgets, and 4 (2%) autologous fascia lata graft reinforcement. Poor result with anatomic and symptomatic recurrence (indication for revisional surgery) was detected in 5 patients (2.7%).

Conclusion: Based on the result analysis, we found that laparoscopic hiatal hernia repair was a technically challenging but feasible technique, associated with good to excellent postoperative outcomes comparable to the best open surgery series.
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October 2015

Does the computed tomography perfusion imaging improve the diagnostic accuracy in the response evaluation of esophageal carcinoma to the neoadjuvant chemoradiotherapy? Preliminary study.

J BUON 2014 Jan-Mar;19(1):237-44

Unit of Digestive Radiology (First Surgery University Clinic), Center of Radiology and MR, Clinical Center of Serbia, Belgrade, Serbia.

Purpose: To estimate whether the computed tomography (CT) perfusion imaging could be useful to predict the pathological complete response (pCR) of esophageal cancer to the neoadjuvant chemoradiotherapy (NACRT).

Methods: Twenty-seven patients with the advanced squamous cell esophageal carcinoma, who were treated with concomitant CRT (CIS/5-FU/LV and 45-50 Gy total radiation dose), were re-evaluated using CT examination, which included the low-dose CT perfusion study. CT perfusion series were analysed using the deconvolution-based CT perfusion software (Perfusion 3.0, GE), and color parametric maps of the blood flow (BF), blood volume (BV), mean transit time (MTT), and permeability surface area product (PS) were displayed. All patients were operated and histopathological analysis of the resected esophagus considered the gold standard for pathologic complete response (pCR).

Results: BFpost-NACRT, BVpost-NACRT, and PSpost-NACRT were significantly lower, and MTTpost-NACRT significantly higher in the pCR group. Mean (±SD), or median perfusion parameter values in the pCRs (11 patients) vs non-pCRs (16 patients) were: BFpost-NACRT- 21.4±5.0 vs 86.0±29 ml/min/100 g (p<0.001), BVpost-NACRT- 1.3 vs 3.9 ml/100 g (p<0.001), MTTpost-NACRT- 5.5 vs 3.7 s (p=0.018), and PSpost-NACRT- 5.9 vs 9.8 ml/min/100 g (p=0.006). ROC analysis revealed that BFpost- NACRT (AUC=1.000), BVpost-NACRT (AUC=0.932), MTTpost-NACRT (AUC=0.801), and PSpost-NACRT (AUC=0.844) could predict the pCR (p<0.01), while maximal esophageal wall thickness could not (AUC=0.676, p=0.126). If we set a cut-off value of BFpost-NACRT<30.0 ml/min/100 g, pCR was predicted with sensitivity and specificity of 100%.

Conclusion: CT perfusion imaging enables accurate prediction of pCR of esophageal carcinoma to neoadjuvant chemoradiotherapy.
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May 2014

[Laparoscopic myotomy in achalasia cardia treatment: experience after 36 operations].

Srp Arh Celok Lek 2013 Jul-Aug;141(7-8):475-81

School of Medicine, University of Belgrade, Belgrade, Serbia; Center for Esophageal Surgery, First Surgical Clinic, Clinical Center of Serbia, Belgrade, Serbia.

Introduction: Laparoscopic Heller-Dor operation, a standard method in the treatment of achalasia, has been performed at the Center for Esophageal Surgery of the First Surgical Clinic since April 2006.

Objective: The aim of this study was to present this surgical procedure and initial experiences after 36 consecutive laparoscopic Heller-Dor operations.

Methods: This partly retrospective, partly prospective study presented our results after laparoscopic Heller-Dor operation (presentation of the treatment method). We performed a standard anterior esophagocardioymiotomy, without releasing the posterior aspect of the cardia, and anterior partial fundoplication. The type and severity of symptoms and their duration were evaluated based on questionnaires fulfilled by patients. The diagnosis was made based on radiological, endoscopic and manometric findings. Laparoscopic surgery as the method of treatment was evaluated based on the duration of surgery, intra- and postoperative complications, time interval until the initiation of oral feeding, length of hospital stay, need for additional therapeutic measures after the operation and effect of surgery on the severity of symptoms.

Results: Preopereratively, dysphagia was the predominant symptom in all patients, while regurgitation was much lower (44%). The average duration of operation was 127 minutes. Postoperative hospitalization lasted on the average 5.7 days. From 36 treated patients, 34 (94.4%) considered that the effect of treatment was good or excellent. Postoperative dysphagia was present in two patients (5.6%) and was successfully solved by balloon dilatation.

Conclusion: Laparoscopic Heller-Dor operation is an effective and safe surgical procedure in resolving symptoms of achalasia and today presents the method of the first choice in the treatment of this disease.
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November 2015

Primary inflammatory myofibroblastic tumor of the stomach in an adult woman: a case report and review of the literature.

World J Surg Oncol 2013 Feb 4;11:35. Epub 2013 Feb 4.

University of Belgrade, Belgrade, Serbia.

Inflammatory myofibroblastic tumor has been defined as a histologically distinctive lesion with uncertain behaviour. The term inflammatory myofibroblastic tumor more commonly referred to as "pseudostumor ", denotes a pseudosarcomatous inflammatory lesion that contains spindle cells, myofibroblasts, plasma cells, lymphocytes and histiocytes. It exhibits a variable biological behavior that ranges from frequently benign lesions to more aggressive variants. Inflammatory myofibroblastic tumor mostly occurs in the soft tissue of children and young adults, and the lungs are the most commonly affected site, but it has been recognized that any anatomic localization can be involved. Inflammatory myofibroblastic tumors in adults are very rare, especially in the stomach. We present a case of a 43-year old woman with primary inflammatory myofibiroblastic tumor in the stomach and a review of the literature.
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http://dx.doi.org/10.1186/1477-7819-11-35DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3570320PMC
February 2013

PFA-100 test in the detection of platelet dysfunction and monitoring DDAVP in a patient with liver cirrhosis undergoing inguinal hernia repair.

Srp Arh Celok Lek 2012 Nov-Dec;140(11-12):782-5

Clinic of Digestive Surgery, Clinical Center of Serbia, Belgrade, Serbia.

Introduction: Hemostatic abnormalities in liver cirrhosis are complex and multifactorial and may predispose to prolonged hemorrhage following invasive procedures. Due to increased perioperative bleeding risks, patients with cirrhosis should undergo elective surgery after making medical preparations. It has been shown that 1-deamino-8-D-arginine vasopressin (DDAVP), desmopressin, can be used as a safe and effective remedy in preventing and treating bleeding in cirrhotics. However, there is still scarce information of adequate test(s) for assessing effects of DDAVP in platelet dysfunction. The use of platelet function analyzer-100 (PFA-100) allows more reliable assessment of impaired primary hemostasis as well as follow-up of hemostatic changes induced by DDAVP effects.

Case Outline: In a 49-year-old male with ethylic liver cirrhosis and prolonged bleeding time scheduled for elective left side inguinal hernia repair, we carried out PFA-100 testing to investigate the patients platelet functional status. Results were affirmative for the presence of platelet functional problems. By standard coagulation tests the patient was also identified as having secondary hemostasis. Preoperatively, PFA-100 was used to test the patient's response to a standard dose of DDAVP, which was favorable. The patient was operated after medical preparations with DDAVP and vitamin K. Neither bleeding complications nor side effects of DDAVP were recorded in the perioperative period.

Conclusion: The PFA-100 is a simple and reliable test for the assessment of primary hemostasis as well as in monitoring of DDAVP therapy.
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March 2013

[Carcinoid syndrome in neuroendocrine tumors--not easy to recognize].

Authors:
Bjelović Milos

Acta Chir Iugosl 2013 ;60(3):13-6

Neuroendocrine tumors (NET) are solid potentially malignant tumors originated from the diffuse neuroendocrine system. They could origin in many organs, with highest prevalence in lungs, small intestine and rectum. Characteristics of NET are slow growth, non-specific clinical presentation causing diagnostic problems. Thus, in majority of patients diagnosis is established in the metastatic phase of the disease. Hopefully, there are new and very potent treatment options capable to successfully control the disease. Clinical presentation cause local tumor growth or para-neoplastic syndrome. Secretory active tumors produce peptides or hormones causing different clinical syndromes. In most cases NET cause carcinoid syndrome. It is often misinterpreted, because similar symptoms are present in more prevalent disorders. Symptoms are not specific and include flashing, diarrhea, abdominal pain, right heart disease, bronchoconstriction ... and to establish the right diagnosis medical doctor have to think about NET as a possibility. Thus, it is very important to recognize symptoms and signs of the carcinoid syndrome, and distinguish them from other gastrointestinal disorders. Early diagnosis and treatment have significant impact in control of the disease, and overall treatment results.
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http://dx.doi.org/10.2298/aci1303013bDOI Listing
October 2015

[Neuroendocrine tumors of gastrointestinal tract: the paradigm that lasts].

Acta Chir Iugosl 2013 ;60(1):39-45

Historically, the tumors that were morphologically different and clinically less agressive than the more common gastrointestinal adenocarcinomas were clasified under carcinoid tumors. However, the development of molecular biology tehniques revealed the heterogeneity of these tumors on cellular and subcellular level and ther different biological behaviour. Neuroendocrine tumors of gastrointestinal tract originated from neuroendocrine cells scaterred across the gastrointestinal mucosa. As a result these tumors were capable of secreting many different neurotransmiters, which may or may not be biologically active. The incidence of gastrointestinal NETs has been incresing over the last 2 to 3 decades. Patients often presented with vague, nonspecific symptoms which resulted in delayed diagnosis and adequate treatment. In this article, we discuss the nature of gastrointestinal NETs, clinical presentation, treatment options and prognosis.
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http://dx.doi.org/10.2298/aci1301039bDOI Listing
October 2015

Magnetic resonance imaging features of multiple duodenal lipomas: a rare cause of intestinal obstruction.

Jpn J Radiol 2012 Oct 4;30(8):676-9. Epub 2012 Jul 4.

Center for Radiology and Magnetic Resonance Imaging, Clinical Center of Serbia, Pasterova 2, 11000 Belgrade, Serbia.

A 65-year-old man was evaluated because of vomiting and epigastric pain. The patient underwent upper gastrointestinal endoscopy and endoscopic ultrasound examination and was found to have multiple polypoid lesions in the D1 and D2 portions of the duodenum, causing almost complete obstruction of the duodenal lumen. The lesions were hyperintense on T1-weighted and intermediately intense on T2-weighted images, with a drop in signal on T1- and T2-weighted fat-suppressed images, consistent with a diagnosis of duodenal lipomas. Pathohistological examination confirmed the diagnosis of duodenal lipomas.
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http://dx.doi.org/10.1007/s11604-012-0098-zDOI Listing
October 2012

Bloodless esophageal replacement in children with corrosive esophageal strictures--report of two cases.

Acta Chir Iugosl 2011 ;58(3):63-71

Clinic for Digestive Disease, First Surgical Clinic, Clinical Center of Serbia, Belgrade.

Background: Esophageal replacement is major procedure with high risk for perioperative allogeneic blood transfusion (ABT), especially in pediatric patients due to nutritive deficiency, anemia, small body weight and blood volume. Autologous blood policy is particularly important in female children.

Methods: We present treatment strategy with the aim of avoiding ABT, that have been applied in two female pediatric patients with caustic stricture of thoracic esophagus. The patients were 7 and 8 years old, with body weight 34 and 23.5 kg, respectively. Protocol was based on the stimulation of haematopoetic system with erythropoietin, iron therapy and preoperative autologous blood donation (PABD). In the first patient, with a history of previous retrosternal bypass esophagocoloplasty and extraction of necrotic colonic graft, delayed reconstruction--transhiatal subtotal esophagectomy and gastric pull-up with cervical anastomosis were performed. In the second patient, repeated ineffective dilatations of esophageal stricture were reason for retrosternal left colon interposiotion and exclusion of native esophagus.

Results: No adverse events were attributed to preoperative blood donation period. No allogenic blood products were used during perioperative period. Both patients had uneventful postoperative course.

Conclusion: In specialized institutions for esophageal surgery, PABD with administration of erythropoietin and iron therapy, enable bloodless esophageal replacement, even in children.
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March 2012

Decompressive tube jejunogastrostomy after esophagectomy for carcinoma.

Hepatogastroenterology 2011 Jul-Aug;58(109):1220-3

Department of Esophagogastric Surgery, University of Belgrade, Belgrade, Serbia.

Background/aims: Gastric distension after esophagectomy and reconstruction with gastric conduit can promote both pulmonary complications and conduit ischaemia. The aim of this paper is to present a method of retrograde transjejunal decompression, with special emphasis on surgical technique and specific technique-related complications.

Methodology: In the period from January 2005 to December 2008 we prospectively evaluated 95 patients who underwent esophagectomy for carcinoma. In all of these patients decompressive jejunogastrostomy was employed.

Results: There was no peritonitis or re-operation due to the decompressive tube placement, the most common complication that occurred was cellulitis and it was present in 7 patients. Decompressive tube was usefull in preventing postoperative gastric conduit distension. No patient complained of discomfort due to the jejunogastric tube placement. Postoperative pneumonia developed in 8 patients (8.4%).

Conclusions: We believe that the usage of jejunogastric tube decompression during the open esophagectomy is a safe, simple and useful technique, which improves postoperative recovery, and possibly reduces respiratory complications.
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http://dx.doi.org/10.5754/hge11077DOI Listing
January 2012

Minimally invasive surgery in the treatment of gastric cancer.

Acta Chir Iugosl 2011 ;58(4):37-40

Faculty of Medicine, University of Belgrade, Serbia.

Unlike benign pathology, progress of laparoscopy in performing cancer surgery has been slow because of fear of safety and oncological adequacy. However, the initial fear has been replaced by optimism as the results from a numerous studies have shown equivalent if not superior results to open surgery. Laparoscopic gastrectomy is safe and oncologic adequate, but time consuming and technically demanding procedure. Laparoscopic surgery has gained wide acceptance in the treatment of early gastric cancer, especially of the distal stomach. The use of laparoscopic surgery for the treatment of advanced gastric cancer remains controversial. Another open question that need complete evaluation is cost-effectiveness analysis of minimally invasive and open approach.
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May 2012

Minimally invasive esophagectomy in the treatment of esophageal cancer.

Acta Chir Iugosl 2011 ;58(4):27-30

Faculty of Medicine, University of Belgrade, Serbia.

In the Western countries, the incidence of esophaeal carcinoma is 3-6 cases per 100,000 persons. g Despite tremendous success of other therapeutic options, surgical treatment still represents the best therapeutic option whenever possible. For the long period, debate has centered on which of the a vailable surgical procedures is superior-transhiatal or transthoracic esophagectomy. Minimally invasive esophagectomy (MIE) could offer both minimally invasive approach and proper mediastinal lymph node dissection. Minimally invasive esophagectomy is safe and adequate, but time consuming and technically demanding procedure. It is procedure reserved for the surgeons experienced in open esophagectomy for cancer, and specially trained in advanced minimally invasive procedures. Even in that case, learning curve is steep.
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May 2012

[Clinicopathological characteristics of Barrett's carcinoma, cardia carcinoma type II and distal gastric carcinoma: influence of observed parameters on the five-year postoperative survival of patients].

Srp Arh Celok Lek 2009 May-Jun;137(5-6):249-54

Unlabelled: INTRODUCTION In the past two decades, the increased frequency of distal esophageal adenocarcinoma, esophagogastric junction and proximal gastric adenocarcinoma has been observed. The vast majority of these tumours are diagnosed in advanced stages, when the prognosis is poorer than in other gastric cancers.

Objective: The aim of our study was to analyze the demographic and clinicopathological characteristics of patients operated on for Barrett's, cardia and distal gastric adenocarcinomas, as well as to study the influence of manifestations of each cancerogenetic indication on the studied clinicopathological parameters and to analyze the 5-year survival rate of patients surgically treated for cardia adenocarcinoma in relation to the patients operated on for distal gastric adenocarcinoma.

Methods: We analyzed gender and age, tumour type, depth of tumour invasion, involvement of blood and lymph vessels in 66 patients surgically treated at the Centre for Oesophageal Surgery of the Institute for Digestive Diseases of the Belgrade Clinical Centre.

Results: Except for significant differences in the depth of tumour invasion during surgery, there were no other statistically significant differences between the studied groups of patients. In the patients operated on for Barrett's and cardia cancers, the tumours invaded more deeply the wall layers, i.e. they were significantly more invasive than the distal gastric tumour. The lymph node involvement was present in 87.5% of patients with Barrett's cancer, in 80% with cardia cancer and in 87% with distal gastric cancer. The 3-year survival rate of patients operated on for cardia cancer was 47.4% and the 5-year survival rate was 31.6%, while the 3-year survival rate of patients operated on for distal gastric cancer was 46.2% and the 5-year survival rate was 34.6%. These differences were not statistically significant (Wilcoxon 0.036; p = 0.85). Singly, the patients' gender, cancer type and the degree of tumour differentiation had no influence on the length of patients' postsurgical survival rate.

Conclusion: At the time of diagnosis cardia cancer and cancers developed at the location of the Barrett's oesophagus, developed significant deeper per continuitatem than gastric cancer. There were no other differences in regard to the analyzed clinicopathological parameters among the tumours of these three locations, and there was no difference between the 3-year and 5-year survival rate between the patients operated on for gastric cancer and cardia cancer. Each studied clinicopathological parameter had no influence on the illness course.
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http://dx.doi.org/10.2298/sarh0906249jDOI Listing
August 2009

[The use of recombinant activated factor VII in the treatment of gastrointestinal bleeding following acetylsalicylic acid therapy in a surgical patient].

Srp Arh Celok Lek 2008 Sep;136 Suppl 3:240-5

Introduction: Gastrointestinal bleeding is the most important complication associated with acetylsalicylic acid therapy. Patients with preexisting haemostatic disorders are at the higher risk and may experience life-threatening hemorrhagic syndrome. Platelet transfusions and desmopressin administration commonly successfully arrest bleeding. However, in clinical situations with profound bleeding and haemorrhagic shock, these therapeutic approaches may fail.

Case Outline: We report a 24-year old female patient with previously undetected acquired platelet dysfunction, who underwent reconstructive surgical intervention. On the 20th postoperative day, acetylsalicylic acid was introduced due to reactive thrombocytosis (platelet count 1480x10(9)/L) with daily dose of 100 mg tablets. On the 12th day of the acetylsalicylic acid treatment, massive gastrointestinal bleeding with haemorrhagic shock suddenly occurred. Attempts to control massive haemorrhage by resuscitation, blood products and haemostatics (desmopressin, tranexamic acid) failed. Two bolus doses of recombinant activated factor VII (rFVIIa) (100 microg/kg and 60 microg/kg respectively) in 90 minutes interval were given. Bleeding was successfully controlled with no requirements for further haemoproducts and haemostatic remedies treatment.

Conclusion: This case demonstrates that the use of rFVIIa may be a specific treatment option in patients suffering from severe gastrointestinal bleeding associated with acetylsalicylic acid treatment.
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http://dx.doi.org/10.2298/sarh08s3240vDOI Listing
September 2008

Primary esophageal diffuse large B-cell lymphoma: report of a case.

Surg Today 2008 9;38(7):647-50. Epub 2008 Jul 9.

Department of Esophagogastric Surgery, First Surgical University Hospital, Institute of Digestive Diseases, Koste Todorovica 6, Belgrade, Serbia.

Primary esophageal lymphoma is very rare, with fewer than 25 cases documented in the English-language literature. We report a case of primary diffuse large B-cell lymphoma of the esophagus in a 42-year-old woman. Barium esophagogram revealed almost complete esophageal obstruction at the level of the cervical esophagus, and flexible endoscopy showed a circumferential submucosal tumor covered with intact mucosa. Neck magnetic resonance imaging (MRI) showed a wide cervical mass circumferentially encompassing the lumen of the cervical esophagus. Biopsies taken with multiple forceps during flexible and rigid esophagoscopy were nondiagnostic. Finally, external esophageal wall biopsies taken during neck exploration provided information that helped us establish the diagnosis. Pathohistological findings confirmed non-Hodgkin's lymphoma of the diffuse large B-cell type. The patient was treated with combined immunochemotherapy, consisting of rituximab plus cyclophosphamide, vincristine, adriablastin, and prednisone (CHOP), followed by irradiation. A complete response was achieved, and 3 years after diagnosis and treatment the patient was disease-free.
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http://dx.doi.org/10.1007/s00595-007-3690-6DOI Listing
December 2008

Insulin-like growth factor-I in wound healing of rat skin.

Regul Pept 2008 Oct 25;150(1-3):7-13. Epub 2008 May 25.

Institute for Medical Research, University of Belgrade, Belgrade, Serbia.

Growth factors play an important role in orchestrating and enabling the cellular responses required for successful wound healing. In the present study, rat surgical incision was used to investigate insulin-like growth factor-I (IGF-I) expression in skin cells as well as its systemic and cutaneous tissue concentrations during acute phase of wound healing. Thirty two animals were sacrificed at days 2, 3, 5 and 9 after surgery. Eight animals were used as control. Tissue expression of IGF-I in both incisional and periincisional skin areas, as well as in skin of control unwounded animals was determined by immunohistochemistry. Serum and tissue concentrations of IGF-I were measured using RIA. Immunohistochemical analysis revealed enhanced IGF-I immunostaining in the incisional area at day 2 post-wounding. Presence of IGF-I immunoreactivity in the epidermis, as well as in dermal fibroblasts and monocytes within perivascular inflammatory infiltrate suggests its local synthesis. Although serum levels of IGF-I were not altered during wound healing, their tissue contents in the incisional area were significantly increased compared with periincisional area at days 2 and 3 after injury, as well as compared with skin content of unwounded control rats in all examined time points. Obtained results support a paracrine role of IGF-I during the acute phase of wound healing by primary intention in the rat.
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http://dx.doi.org/10.1016/j.regpep.2008.05.006DOI Listing
October 2008
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