Albanian Journal of Trauma and Emergency Surgery <p>Albanian<em><strong> Journal of Trauma and Emergency Surgery</strong></em>&nbsp;<strong><em>(AJTES)</em></strong> is the official publication of the Albanian Society for Trauma and Emergency Surgery (ASTES) that comes out two times a year. <em><strong>AJTES</strong></em>&nbsp;is an open access, peer reviewed journal that aims to promote interest, knowledge, and quality of care in emergency and trauma surgery. Under the editorship of Asc. <em>Prof. Agron Dogjani MD, PhD</em>, FACS, FISS,&nbsp;&nbsp;<em><strong>Albanian Journal of Trauma and Emergency Surgery</strong></em>&nbsp;<strong><em>(AJTES)</em></strong> <em>&nbsp;</em>provides an in-depth, national and international forum for the most authoritative information on major clinical problems in the fields of trauma and emergency surgery, surgical education, and not only...&nbsp; Contributions are reviewed and selected by a group of distinguished surgeons from across Albania and worldwide as well who make up the Editorial Board.&nbsp;</p> <p><strong><em>Online ISSN</em></strong>:&nbsp;2616-4922</p> <p><strong><em>Print ISSN</em></strong>:&nbsp;2521-8778</p> Albanian Society for Trauma and Emergency Surgery (ASTES). en-US Albanian Journal of Trauma and Emergency Surgery 2521-8778 <p>Submission of a manuscript implies that the submitted work has not been published before (except as part of a thesis or report, or abstract); that it is not under consideration for publication elsewhere; that its publication has been approved by all co-authors. If and when the manuscript is accepted for publication, the author(s) still hold the copyright and retain publishing rights without restrictions. Authors or others are allowed to multiply article as long as not for commercial purposes. For the new invention, authors are suggested to manage its patent before published.&nbsp;The license type is&nbsp;<a href=""><span class="cc-license-identifier">(CC BY-NC 4.0)</span></a></p> Time and Season Incidence of Complicated Colorectal Cancer <p>Colorectal cancer complications are seldom analyzed for occurrence through day and night, working days and weekends, as well as throughout seasons. We hypothesized that information and analysis of high/low complicated colon cancer incidence in the above mentioned terms can improve our preparedness and manage better the resources for superior outcomes. Therefore we performed a retrospective study/2010 – 2018/ of 165 patients with complicated colorectal cancer operated on emergently or urgently in the Second Clinic of General and Thoracic Surgery, University Hospital St George, Plovdiv, Medical University Plovdiv, Bulgaria.</p> Iordanov I. Uzunova V. Uchikov P. Podnov L. Sakakushev A. Sakakushev B. ##submission.copyrightStatement## 2020-01-20 2020-01-20 4 1 10.32391/ajtes.v4i1.76 Control of Hemorrhage in Liver Trauma <p>Background: Control of hemorrhage in major liver trauma constitutes an ongoing surgical challenge even in nowadays, as surgeons often face difficult situations in its management. The goal of this study was to analyze our experience in the control of hemorrhage in major liver trauma. Materials and methods: Our study was performed prospectively covering a period of time from January 2009 till December 2012. 173 patients with liver trauma were included in our study. Results: Temporary haemostasis maneuvers in the setting of urgent laparotomy consisted of: bimanual compression 13 patients (15.3%), Pringle maneuver 23 patients (27%), perihepatic packing 10 patients (11,8%), Foley catheter balloon tamponade 2 patients (2.4%), intrahepatic tamponade in penetrating trauma 4 patients (4.7%). Definitive haemostasis methods used in urgent laparotomy were: electro-coagulation of the liver injury 12 patients (14.1%), haemostasis and biliostasis followed by hepatic closure 41 patients (48.2%), haemostasis and biliostasis without hepatic closure 6 patients (7.1%), tamponade with a pedicled vascularized omental flap (pedicled omentum hepatorrhaphy) 7 patients (8.2%), anatomic liver resection 1 patient (1.2%), nonanatomic/atypical liver resection 7 patients (8.2%), right hepatic artery ligation 1 patient (1.2%). Surgical techniques in preplanned laparotomies consisted of: left hepatectomy 1 patient (16.6%), right hepatectomy 1 patient (16,6%), nonanatomic/atypical liver resections 4 patients (66.7%). The success of treatment was significantly related to the grade of liver injury (z= 5.2912, p=&lt;0.00001), other concomitant abdominal organ injuries (z=4.0743, p=0.00005), amount of blood transfusion received (p=0.03207), and age (p=0.04944). Overall mortality rate was 13%. Conclusion: Perihepatic packing and performing the surgical intervention in two sessions has significantly improved survival rates in major liver trauma from our experience.</p> Skender Buci Dorina Shtjefni Arben Gjata Gjovalin Bushi Sonja Saraçi Butorac ##submission.copyrightStatement## 2020-01-10 2020-01-10 4 1 10.32391/ajtes.v4i1.78 Efficacity of Ventilator strategy in A.R.D.S (Acute Respiratory Distress Syndrome). <p><strong>Background:</strong> ARDS is defined as pulmonary inflammatory process characterized by increased capillary permeability associated with acute severe hypoxemia and bilateral&nbsp; infiltrates on the chest radiograph. Chlinical manifestations of ARDS is associated with a reduction of &nbsp;functional residual capacity and &nbsp;static compliance of the respiratory system.Recently,after experimental models and physiological studies have just established the principles to understand&nbsp; the potential beneficial effects &nbsp;of PEEP and reduction in mortality to 22%. The benefit of PEEP has been demonstrated in terms of preventing cyclic opening and collapsing alveoli in acute respiratory distress syndrome patients (ARDS).</p> <p><strong>Aim of study: </strong>To determine &nbsp;the appropriate PEEP level in-patients with ARDS.</p> <p><strong>Objective: </strong>By using optimal PEEP:to realize the maximal alveolar recruitment.To avoid the decrease of oxygen delivery (DO2) as result of an unfavourable reduction in cardiac output.</p> <p><strong>Material and methods:</strong>Retrospectiv study of 120 patients which only 63 of them are included in study with age 18-70 years old.(2012-2014 )<strong>&nbsp; </strong>The entry criteria were clinically (severe dyspnoea, tachypnea, cyanosis); PaO2/FiO2 &lt;200mmHG, the presence of bilateral chest infiltrates. The exclusion criteria were: aged &lt; 18 yrs, COPD in history of diseases, heart attack; PEEP was set the level that provided the greatest improvement in oxygenation. The optimal PEEP came as a result of gradual increase of PEEP from 2-5 cmH2O every 6 hours, depended on gas analyses. The right PEEP level is the PEEP allowing the highest PaO2 value without causing hemodynamic compromise.</p> <p><strong>Results: </strong>During this study we conclude that the gradual increase of PEEP improves significantly arterial oxygen tension (PaO2). Per value of PEEP 9.6-15.8, CI 95% is 145.9-191.8. The &nbsp;Pearson test &nbsp;with a significant correlation coefficient of level 0.995 and significance level 0.000 shows also a very important result. It was considered significant statistically the value of P≤ 0.05.&nbsp; Also &nbsp;the value of Chi ² of PaO<sub>2</sub> and of PEEP, has resulted significant in 0.950 with P &lt; 0.001.</p> <p><strong>Conclusion: </strong>Mechanical ventilation using optimal PEEP increases the value of PaO2. As a matter of fact 88% of cases with PaO2 &gt; 220 mmHg survive. The role of PEEP in clinical practice is still debated but, in selected categories of patients with a careful monitoring, it may play an important role in improving outcome.</p> Alma Cani Fadil Gradica Fahri Kokiçi Loreta Agolli ##submission.copyrightStatement## 2020-01-20 2020-01-20 4 1 10.32391/ajtes.v4i1.83 Safety in Road Comunication and Role of Pre –Hospital Emergency Service <p>Traffic accidents are leading cause of death in the most productive age group - 20-45 years of age. 20 - 50 milion people in the world are left with injuries and disability caused by traffic accidents.</p> <p>Half of those who loose their life in traffic accidents are active participants - pedestrians, bicycle and motorcycle drivers. Unless preventive measure are taken, it is expected that by year 2030, traffic accidents with be the 7<sup>-th</sup> leading cause of death in the world. Large number of traffic accidents is caused by a variety of factors and the result is a relatively large number of victims left with disability and material loss. This number can be lowered with proper laws and practices.</p> Isuf Bajrami ##submission.copyrightStatement## 2020-01-20 2020-01-20 4 1 10.32391/ajtes.v4i1.79 Parent’s Experiences from the Treatment of their Children at the Physic Children’s Surgery Clinic in Skopje. <p><strong><em>Background:</em></strong> The respect of the needs and wishes of the patients is in the focus of the human health system. The experience of the parents in terms of child’s health care may be used as an indicator of quality of the health care.</p> <p><strong><em>Material and methods</em></strong><em>:</em> The research is a quantitative analytical cross-sectional study. In accordance with the inclusion and exclusion criteria, simple random sample of 207 parents / guardians is covered, whose children in the period of three months, had been hospitalized in the hospital department JZUU Pediatric Surgery Clinic in Skopje.It was used a two parted questionnaire. The first part is a standardized questionnaire (Parent Experience of Pediatric Care - PECP), and the second part concerns the general socio-demographic data of the parent/guardian. Statistical evaluation was performed using appropriate statistical programs <strong>(</strong><em>Statistics for Windows 7,0 and SPSS 17.0).</em></p> <p><strong><em>Results:&nbsp;</em></strong>In accordance with the age of the parents, the survey respondents were divided into two groups: a) age ≤ 33 years - 107 (51.69%) and b) age&gt; 33 years - 100 (48.31%).Significant independent predictor of parental satisfaction from the receipt of their child to the clinic research confirms the age of the parent under / over 33 years due to 4.1% of the change in satisfaction (R2 = 0,041). Parents generally believe that their children's room of the clinic is "good", without significant difference between parental satisfaction from both age groups (Mann-Whitney U Test Z = -0,9613 p = 0,3364). Significant independent predictor of parental satisfaction from the room of their child improves the health status after treatment due to 6% of the change in satisfaction (R2 = 0,060). Parents generally believe that testing and treatment of their children in the clinic was "very good" and an independent significant predictor is to improve the health status after the treatment - 7,8% (R2 = 0,078).</p> <p><strong><em>Conclusions:</em></strong> Regardless of the generally good parental satisfaction about health care for their children, it is necessary to continuously monitor the status of the clinic in order to consider the possible deficiencies and needs of intervention.</p> M. Trajchevska A. Lleshi S. Gjoshev A. Trajchevski ##submission.copyrightStatement## 2020-01-20 2020-01-20 4 1 10.32391/ajtes.v4i1.88 Pediatric Blunt Renal Trauma. A Single Institution’s 20 Years Experience with Surgically Treated Patients. <p><em><strong>Background: </strong></em>Kidney is the most common site of genitourinary trauma. 50% of all urinary injuries is kidney.Kidney is also affected in 8-12% of all blunt and penetrating trauma to abdomen. 80-90% of renal injury is caused by blunt injury GY. Children,&nbsp; compared to adults, have&nbsp; at a higher risk of renal injury from blunt trauma due to a variety of anatomic factors including decreased perirenal fat, weaker abdominal muscles, and a less ossified thoracic cage. While there are strong trends toward non-operative management of blunt renal trauma, there are no explicit guidelines for high grade injuries. Organ preservation in children is always a primary goal with solid organ injury.</p> <p><em><strong>Aim of the work:&nbsp;</strong></em>The aim of the retrospective study is to show the specificity of kidney injury in children as well as the specificity of surgical treatment.</p> <p><em><strong>Material and Methods</strong>:</em> All 19 patients under the age of 18 who were admitted to Clinic for Pediatic surgery in Sarajevo with a diagnosis of renal trauma were retrospectively reviewed .The Echo an CT were used to identify patients with a renal injury. The time period examined was between January 1, 1999- 2019. Inclusion criteria were either a diagnosis of renal trauma or a diagnosis of blunt abdominal trauma and hematuria. Exclusion criterion was death due to an additional traumatic injury. The mechanism of injury (fall, car accident , assault) injury grade (I-V), the presence of hematuria, and demographic data to include age, weight, and sex, were recorded and reviewed.&nbsp; In addition, amount of blood product required, hematocrit nadir prior to transfusion to assist in ascertaining whether transfusion was necessary, surgical interventions performed, and hospital length of stay were also retrospectively analyzed. Due to the low sample size we used descriptive as opposed to inferential statistics in our analysis.</p> <p><em><strong>Result:</strong></em> Demographics include male to female ratio of 13:6 and the average age of patients was 11.9 + 4.6 years. Of the nineteen patients who underwent review, eleven (57,89%) children presented with a grade III renal injury, five&nbsp; with a grade IV injury and three with&nbsp; grade V injury. Six patients presented with gross hematuria and 3 with microscopic hematuria. Only four patients (22%) required blood transfusions, with the average hematocrit nadir being 31 + 5.3% (24.8-37.8). One of the two patients transfused had a concomitant grade IV splenic laceration with a hematocrit nadir of 24.8% and clinical symptoms consistent with shock.</p> <p><em><strong>Conclusions:</strong></em>The specificity of the child's anatomy is an aggravating prognostic factor (the kidney is larger in relation to the body cavity than in adults, less protected against the ribs, the muscles of the body and the lower abdomen, the less developed peritoneal and retroperitoneal fatty tissue).It is recommended to initiate conservative treatment (leaching, infusion solution, monitoring) and possibly delayed surgical treatment.Indications for early surgicaly treatment are reserved only for patients with bleeding (absolute) and extravasation (relative).If it is necessary surgical treatment sould be&nbsp; maximally preserve kidney tissue.</p> Kenan Karavdić ##submission.copyrightStatement## 2020-01-19 2020-01-19 4 1 10.32391/ajtes.v4i1.87 Anesthesia and Perioperative Management of Hepatic Metastases to CRC Patients in Liver Resection. Our Experience. <p><em><strong>Background:</strong></em> The patients with colorectal adenocarcinoma very often developed hepatic metastases. Resection of them still remains the best treatment of disease. Hepatectomy carried about 20% mortality rate. The most important intraoperative factor is major hemorrhage and hypotension and postoperatively the main reasons are hemorrhage, coagulopathy, renal failure, pulmonary, and cardiac disturbance till biliary fistula and liver failure.&nbsp; Anesthesia and perioperative management have resulted in diminished value of mortality and morbidity at the same time.</p> <p><strong><em>Aim:</em> </strong>The aim of this study is to submit our experience in anesthesia and perioperative management in liver resection of hepatic metastases in CRC patients.</p> <p><strong><em>Material and Methods:</em></strong> In that retrospective study we enrolled 6 patients ASAII- III, from January to July 2019. All patients treated for liver malignancy diagnosis after colorectal carcinoma in elective surgery and received general anesthesia with fentanyl 1-2μg/kg/h, profolol 4.0μg/kg/min via target controlled infusion and vecuronium 0.001mg/kg/min and sevofluran 2%. All patients are monitored with continuous central venous pressure(CVP).&nbsp; We recorded mean artery pressure (MAP), heart rate (HR), CVP, amount of transfusion, incidence of complications and discharge from intensive care and hospital.</p> <p><strong><em>Results:</em></strong> Female/male report was 66,6% vs. 33.4%. The ages of patients were 53-72 years with a mean ± SD age of 65.1 ± 9.5 years. CVP was 0-5. Amount of blood was 2.5 unite during intervention. Average of days in intensive care was 3.83. Renal compromised was 3%. Ascites and edema was 50%. &nbsp;All patients were discharged home after 14.66 days.</p> <p><strong><em>Conclusion:</em></strong> Optimizing hemodynamic and fluid administration and reduced the administration of blood therapy using low CVP (0-5).</p> Majlinda Naço Suzana Mukaj Monika Belba Haxhire Gani Nertila Kodra Eden Naço ##submission.copyrightStatement## 2020-01-20 2020-01-20 4 1 10.32391/ajtes.v4i1.81 Imaging Pregnant Patients in Different Acute Medical Non-Traumatic Emergencies. A Literature Review. <p>Radiologists should suggest what kind of imaging is best suited for a pregnant patient presenting with an acute condition. The type of imaging study is planned in close consultation with the clinical team. Ultrasonography (US) should always be the initial modality for evaluation of a pregnant patient, especially in abdominal emergencies. In other conditions like suspected pulmonary embolism or neurological emergencies ultrasound doesn’t help, so using other diagnostic modalities like CT and MRI will be necessary. A recurring debate in many radiology practices is the concern of radiologists about performing an examination that exposes a fetus to radiation. This literature review aims to identify an optimal imaging strategy for the accurate detection of different acute medical non-traumatic emergencies in pregnant patients.</p> Behar Tocilla ##submission.copyrightStatement## 2020-01-20 2020-01-20 4 1 10.32391/ajtes.v4i1.85 Treatment of Unstable Trochanteric / Subtrocanteric Fractures with PFN, First Cases in University Hospital of Trauma & American Hospital. Results and Complications. <p><strong><em>Aims and objectives:</em></strong> This study was done to evaluate the functional and radiographic outcome of PFN in treatment of proximal femoral fracture and more common technical, mechanical complications and intraoperative difficulties during the implant implementation.</p> <p><strong><em>Materials &amp; Methods:</em></strong> We conducted a retrospective study with ten cases of proximal femoral fractures treated between September 2017 and September 2018, which were accepted at the Department of Orthopedics, the University Hospital of Trauma and the American Hospital in Tirana. Fractures are classified according to classification AO and Boyd-Griffin. The age range of patients taking the study was 20-90 years. Ten cases were followed at regular intervals and the final assessment was made at the end of the 6 month period. In the result, functional clinical assessment according to Harris hip score was done .</p> <p><strong><em>Results</em></strong><em>:</em> In our study,mean age was 66 y.o, 7 male and 3 females. Mean of hospitalization time 6 days, mean operation time 120 min. In our study at 6 months follow up, union was achieved in 9 cases, open reduction was performed in 3 cases (10 cases). Technical and mechanical complications were noted in one case. Reoperation rate was 10 % (one case). According Harris hip scoring system excellent results were seen 40&nbsp;&nbsp; % of cases (4 cases), good results in 50 % cases (5 cases),&nbsp; and poor results in 10% cases (1 case).</p> <p><strong><em>Conclusions</em></strong><em>:</em> In our study, in spite of low experience in proximal femoral nailing in cases with unstable trochanteric / subtrocanteric fractures, it was found that PFN is an attractive implant and suitable for proximal femoral fractures and its use in unstable trochanteric / subtrocanteric fractures is very encouraging. This study has also shown that this device can safely be used by an average surgeon to handle common but sometimes tough fractures. Operation is technically not difficult, but gradual learning and great patience is needed to make this method really minimal invasive.</p> Ledian Fezollari Gjergj Caushi Vilson Ruci Artid Duni Agron Dogjani Edvin Selmani Zamir Demiraj Guido Bassi ##submission.copyrightStatement## 2020-01-20 2020-01-20 4 1 10.32391/ajtes.v4i1.86 A very rare complication of an Abdominal Aortic Aneurysm: Primary Aortoduodenal Fistula without gastrointestinal bleeding. <p>An abdominal aortic aneurism (AAA) is an enlargement of the lower part of the aorta that extends through the abdominal area.The diameter of the aneurismatic vessel is represented by 3 cm or more in either anterior – posterior , or transverse planes.</p> <p>The developpement of Abdominal aortic aneurysm (AAA) is a complex, multifactorial process involving destructive remodeling of aortic wall connective tissue. Four interrelated factors involved in this process include: (1) chronic inflammation associated with neovascularization and increased proinflammatory cytokine production, (2) increased and dysregulated production of matrix-degrading proteinases, (3) destruction of structural matrix proteins, and (4) decreased medial smooth muscle cell (SMC) presence, resulting in impaired connective tissue repair. This understanding has developed from a characterization of human AAA tissue, as well as the use of different animal models that replicate human disease.</p> <p>The&nbsp; mortality of ruptured AAA is set between 40 – 70% in patients that manage to arrive alive in the emergency room,&nbsp; and that of 90% in overall patients confirmed with rAAA in the autopsy results.</p> <p>A ruptured abdominal aortic aneurysm (rAAA) represents a disruption of a dilated aortic wall that leads to blood outside the aortic wall.</p> Sokol Xhepa Ervin Bejko Denis Kosovrasti Marsela Sopiqoti Stavri Llazo Astrit Xhemali Frenki Vila Eliona Xhelili ##submission.copyrightStatement## 2020-01-20 2020-01-20 4 1 10.32391/ajtes.v4i1.80 Unconjugated Hyperbilirubinemia after Open Heart Surgery <p>The occurrence of hyperbilirubinaemia after heart surgery using cardiopulmonary bypass or post-operative heart failure is fairly common. Mechanism of hyperbilirubinemiais still not completely clarified, and there are so few specific therapies available for acute hepatobiliary injury. Post-operative mortality well correlates with increasing total bilirubin values, particularly for bilirubin-associate acute kidney tubular necrosis. The difficulty to reduce mortality is partially a consequence of not completely understood physiopathology. It is obvious that long-lasting CPB plays an important role, in association with hemodilution, hypotension, ischemia-reperfusion, and increasing hematic level of endogenous catecholamine with reduction of hepatic blood flow. Case report. A 68 years old man with severe mitral valve regurgitation and pulmonary hypertension and low EF 30%. Mitral valve replacement and tricuspid anuloplastic was performed. Due to low cardiac output syndrome severe hyperbilirubiemeia was seen (24 mg/dl. and unconjugated fraction 16mg/dl) days after. Phenobarbital (luminal) was started 15 mg/kg daily. Two days later the level decreased until 8 mg/dl with normalization of conjugation/unconjugation ratio.Postoperative hyperbilirubinemia is a multifactorial process caused by both impaired liver function of bilirubin transport. In case of elevated level of unconjugated fraction we suggest to use Luminal as alternative for decreasing unconjugated fraction.</p> Alfred Ibrahimi Saimir Kuci Ervin Bejko Stavri Llazo Jehona Neziraj Jacob Zeitani Edvin Prifti ##submission.copyrightStatement## 2020-01-20 2020-01-20 4 1 10.32391/ajtes.v4i1.84 Surgical treatment of mechanical complications following acute myocardial infarction. A Case Series. <p><strong>Background: </strong>Acute myocardial infarction can result in ischemic, mechanical, arrhythmic, embolic or inflammatory complications. Despite high operative mortality, the lack of an effective and immediate medical alternative makes the surgery repair the mainstay of current management for these patients. Novel surgical approaches are presented to manage these complications.</p> <p><strong>Main body: </strong>Mechanical complications presented at the Department of Cardiac Surgery-Tirana University Medical Centre consisted in nine cases during the period January 2008-June 2018: two anterolateral papillary muscle rupture cases (22%), one posteromedial papillary muscle rupture case (11%), two ventricular septal rupture cases (22%),&nbsp; one free ventricle wall rupture case (11%),&nbsp; three chordae tendineae rupture cases (33%), four out of nine patients (44,5%) underwent concomitant CABG intervention. Intra operator mortality is estimated 11% (one out of nine cases). The Department of Cardiac Surgery-Tirana University Medical Centre is limited only in open surgery techniques for repair the post myocardial infarction mechanical complications. To our personal view key reasons for these results are conditioned from lack of medical devices, trained stuff, reliable short and long outcome data from alternative procedures in order to incorporate thus in our daily practice. Further studies should be undertaken not only to create a precise image of the situation, but also to evaluate the results of the possible changes.&nbsp;</p> <p><strong>Key words: </strong>Acute myocardial infarction, mechanical complications, papillary muscle rupture, ventricular septal rupture, free ventricle wall rupture, CABG intervention.</p> Jorgjia Bucaj Edvin Prifti ##submission.copyrightStatement## 2020-01-20 2020-01-20 4 1 10.32391/ajtes.v4i1.63