Dusica Stamenkovic

Correlation between procalcitonin and intra-abdominal pressure and their role in prediction of the severity of acute pancreatitis.

BACKGROUND/AIMS Early assessment of disease severity and vigilant patient monitoring are key factors for adequate treatment of acute pancreatitis (AP). The aim of this study was to determine the correlation of procalcitonin (PCT) serum concentrations and intra-abdominal pressure (IAP) as prognostic markers in early stages of AP. METHODS This prospective observational study included 51 patients, of which 29 had severe AP (SAP). Patients were evaluated with the Acute Physiology And Chronic Health Evaluation (APACHE II) score, C-reactive protein (CRP) and PCT serum concentrations and IAP at 24 h from admission. PCT was measured three times in the 1st week of disease and three times afterward, while IAP was measured daily. PCT and IAP values correlated with each other, and also compared with APACHE II score and CRP values. RESULTS PCT, IAP, CRP values and APACHE II score at 24 h after hospital admission were significantly elevated in patients with SAP. There was significant correlation between PCT and IAP values measured at 24 h of admission, and between maximal PCT and IAP values. Sensitivity/specificity for predicting AP severity at 24 h after admission was 89%/69% for APACHE II score, 75%/86% for CRP, 86%/63% for PCT and 75%/77% for IAP. CONCLUSIONS Increased IAP was accompanied by increased PCT serum concentration in patients with AP. PCT and IAP can both be used as early markers of AP severity.

Short ileal segment for orthotopic neobladder: A feasibility study

Objectives:  The objective of this study was to present the construction of a neobladder with a modified pouch technique using 25–35 cm of terminal ileum.

Desarterialización hemorroidal transanal, un procedimiento seguro y eficaz para el tratamiento ambulatorio de la enfermedad hemorroidal

INTRODUCTION This prospective, observational study evaluated transanal dearterialization (THD) efficacy and safety in grade 2-4 hemorrhoids (HD). METHODS THD was performed under sedation-locoregional anesthesia in 402 outpatients. Patients had follow-up evaluation 3 days, 2 weeks, 1, 6 and 12 months postoperatively. Postoperative complications and recurrence of symptoms at 12 months were analyzed. The relationship between the learning curve and the number of postoperative complications was studied. RESULTS Mean patient age was 46.4 (range 20-85) years. A total of 268 patients (66.6%) were male. Sixteen patients (4.0%) had grade 2 HD, 210 (52.2%) had grade 3 and 176 (43.8%) had grade 4 HD. Surgery lasted 23 (17-34) min. A total of 67 patients had complications: bleeding in 10 patients (2.5%), hemorrhoidal thromboses in 10 (2.5%), perianal fistulas in 5 (1.2%), fissures in 14 (3.5%), urinary retention in 3 (0.8%), residual prolapse in 19 (4.7%), severe anal pain in 3 (0.8%), and perianal abscess in 3 patients (0.8%). Recurrent HD occurred in 6.3% (1/16) of grade 2 HD patients, 5.8% (12/210) of grade 3 patients and 9.7% (17/176) of grade 4 patients. Twelve months after THD, bleeding was controlled in 363 patients (90.5%), prolapse was controlled in 391 (97.3%) and pain markedly improved in 390 patients (97%). CONCLUSION THD appears safe and effective for grade 2-4 HD, and the number of complications decreased with increasing surgeon experience. THD advantages include mild pain, fast recovery, early return to daily activities and low incidence of complications.

Combined Spinal Epidural Anesthesia and Analgesia

In principle, the combination of two different administration of anesthesia routes on the same patient improves effectiveness and reduces side effects (Stevens and Edwards, 1999) [B]: Spinal anesthesia provides fast and reliable segmental anesthesia with minimal risk for toxicity, while epidural anesthesia provides perioperative anesthesia (alone or in combination with general anesthesia), followed by excellent analgesia in the postoperative period (Cook, 2000;Rawal et al., 2000) [A]. Moreover, Combined Spinal Epidural (CSE) anesthesia reduces the potential for problems, such as the somewhat unpredictable level of blockade after spinal anesthesia, and the problems of missed segments, incomplete motor block, poor sacral spread and local anesthetic toxicity that can occur with epidural anesthesia (Cook, 2000) [A]. At the present time, CSE anesthesia is widely used in orthopedic, urologic and gynecologic surgery. Major CSE anesthesia benefits are the need for low doses of medications, low incidence of motor blockade, adequate sensory block, the ability to extend the area of blockade if the surgical field needs to be extended, and excellent analgesia (Rawal et al., 1997) [A]. However, use of CSE anesthesia or analgesia also introduces the potential for complications, such as technical failure, altered spread of epidural drugs in patients who also had a lumbar puncture, and altered spread of subarachnoid medications due to the effects of the epidural injection.

Utilization of Parenteral Morphine by Application of ATC/DDD Methodology: Retrospective Study in the Referral Teaching Hospital

Background Few studies analyzed the pattern of opioid analgesic utilization in hospital settings. The aim of this study was to determine the consumption pattern of parenteral morphine in patients hospitalized in the Serbian referral teaching hospital and to correlate it with utilization at the national and international level. Methods In retrospective study, the required data were extracted from medical records of surgical patients who received parenteral morphine in the 5-year period, from 2011 to 2015. We used the Anatomical Therapeutic Chemical Classification/Defined Daily Doses (DDD) international system for consumption evaluation. Results While the number of performed surgical procedures in our hospital steadily increased from 2011 to 2015, the number of inpatient bed-days decreased from 2012. However, the consumption of parenteral morphine varied and was not more than 0.867 DDD/100 bed-days in the observed period. Conclusion Based on the available data, parenteral morphine consumption in our hospital was lower compared with international data. The low level of morphine use in the hospital was in accordance with national data, and compared with other countries, morphine consumption applied for medical indications in Serbia was low. Adequate legal provision to ensure the availability of opioids, better education and training of medical personnel, as well as multidisciplinary approach should enable more rational and individual pain management in the future, not only within the hospitals.

Metamizole Utilization and Expenditure During 6-Year Period: Serbia vs. Croatia

Background: Metamizole is a medication with analgesic, antipyretic, spasmolytic, and weak anti-inflammatory effects. The aim of our study was to evaluate a six-year trend in the utilization and expenditure of metamizole in comparison to other group of licensed non-opioid analgesics in Serbia and Croatia, in order to rationalize its use and prescribing in these countries. Methods: The data of metamizole vs. all other non-opioid analgesics utilization and expenditure in Serbia and Croatia was analyzed according to the WHO methodology and expressed as defined daily doses per 1,000 inhabitants per day (DDD/1,000 inhabitants/per day) and total costs, respectively, during the 6-year period from 2010 to 2015. Results: In the observed period, utilization of metamizole was 3.31 fold higher in Serbia than in Croatia (median in Serbia was 2.238 vs. 0.675 in Croatia DDD/1,000 inhabitants/per day/per year). Expenditure of metamizole in the same period was 5.29-fold higher in Serbia than in Croatia (median in Serbia was 1,738,192.51 €/per year vs. 328,355.03 €/per year in Croatia). Conclusion: Utilization and expenditure of non-opioid analgesics, including metamizole, in Serbia was significantly higher comparing with Croatia.Further research is needed to determine whether the current analgesic consumption in Serbia meets the needs of the patient. The benefits of metamizole should be weighed against the risk of metamizole-induced adverse effects. Until then, its prescribing should be based on indications and the appropriate duration of therapy.

Urodynamic characteristics of the modified orthotopic ileal neobladder

BACKGROUND/AIM Radical cystectomy is the method of choice in management of muscle invasive, organ-confined tumors of the bladder (T2-T4, N0-Nx). The most frequent continent orthotopic urinary diversion after radical cystectomy is the ileal neobladder. A modified technique consists of using a shorter segment of the terminal ileum than the standard technique, around 30 cm. The aim of this study was to determine the urodynamic characteristics of the orthotopic ileal neobladder created by a modified technique. METHODS In this prospective clinical study we analyzed the urodynamic parameters of 24 patients who had underwent radical cystectomy with orthotopic urinary diversion by ileal neobladder created using a modified technique. In all the patients we performed invasive and noninvasive urodynamic investigations 12 months after the operation. The urethral pressure profile parameters analyzed were maximal urethral pressure, maximal urethral closure pressure and the functional urethral profile length. RESULTS The average age of the patients was 63 (49-73) years, 90% were males and 10% were females. The median length of the shorter segment of the terminal ileum was 28 (range 22-35) cm. Prior to enterocystometry and uroflowmetry postvoid residual (PVR) urine was measured by a urethral catheter. The median PVR was 16.7 (0-140) mL. The median enterocystometric capacity was 396 (range 372-532) mL. The median end filling pouch pressure was 27.6 (range 20-70) cmH2O. The median maximal flow of urine was 22.1 (range 9.7-39.5) mL/s and the average flow of urine was 9.61 (range 3.6-17.6) mL/s. Flow time in the analyzed group was 47.5 (range 22-119) s. The median maximal urethral pressure was 54 (range 12-101) cmH2O, maximal urethral closure pressure 36.6 (range 6-91) cmH2O. Functional urethral profile length was 14.9 (range 4-37) mm. CONCLUSION An ileal orthotopic pouch created by a modified technique using a shorter segment of the terminal ileum after 12 months presents with urodynamic characteristics similar to the native bladder.