Jasminka Peršec

Postoperative pain and systemic inflammatory stress response after preoperative analgesia with clonidine or levobupivacaine: a randomized controlled trial.

ZusammenfassungZIEL DER STUDIE: Mit einer adäquaten perioperativen Schmerzkontrolle kann man zentrale und periphere Entzündungsreaktion auf eine Operation sowie das Ergebnis von Operationen kontrollieren. Der Einsatz von Analgetika vor dem Schmerzreiz (Präventive Analgesie) verhindert die Entwicklung von neuroplastischen Veränderungen im ZNS und vermindert den Schmerz. Wir untersuchten die Hypothese, ob eine präoperative epidurale oder intrathekale Gabe von Clonidin den postoperativen Schmerz und die postoperative systemische Entzündungs-Stress-Reaktion besser vermindert als Levobupivacain. METHODEN: In einer kontrollierten, randomisierten Studie wurden 42 Patienten vor einer kolorektalen Resektion in 3 Gruppen geteilt: Gruppe 1 (n = 17) erhielt präoperativ epidural 5 µg/kg Clonidin, Gruppe 2 (n = 12) 2,5 mg/ml Levobupivacain und Gruppe 3 als Kontrolle (n = 13) Kochsalz. Die folgenden Parameter wurden vor der Operation, 1 h nach Operationsbeginn, 1 h, 6 h, 12 h und 24 h nach der Operation erhoben: Procalcitonin (PCT), Interleukin-6 (IL-6) und postoperatives Schmerzniveau. ERGEBNISSE: Alter, Geschlecht, BMI, Körperoberfläche und Operationsdauer der Gruppen waren nicht signifikant unterschiedlich. Gruppe 1 (Clonidingruppe) hatte signifikant (p < 0,05) niedrigere PCT und IL-6 Werte im Vergleich zu beiden anderen Gruppen. Auch das postoperative Schmerzniveau in Ruhe und bei Bewegung war in Gruppe 1 vor allem 1 h nach der Operation signifikant (p < 0,05) niedriger (VAS = 0,82 und 1,18) im Vergleich zu Gruppe 2 (VAS = 5,25 und 6,67) und auch zu Gruppe 3 (VAS = 7,08 und 8,31). SCHLUSSFOLGERUNG: Unsere Ergebnisse unterstützen die Bedeutung des zentralen Effekts von Clonidin auf die Schmerzbahnen und auf die Blockade der systemischen Entzündungs-Stress-Reaktion.SummaryAIM: With adequate control of perioperative pain it is possible to control central and peripheral inflammatory responses to surgery and influence patient outcomes. Use of analgesics before the pain stimulus (preventive analgesia) obstructs development of neuroplastic changes in the central nervous system and reduces pain. Our investigation hypothesis is that preoperative central (epidural or intrathecal) clonidine will reduce postoperative pain and the systemic inflammatory stress response more effectively than levobupivacaine. DESIGN: Randomized controlled study. METHODS: Forty-two patients undergoing colorectal resection surgery were allocated into three groups receiving a preoperative epidural dose of (i) clonidine 5 µg/kg (n = 17), (ii) levobupivacaine 2.5 mg/ml (n = 12) or (iii) saline as a control group (n = 13). Procalcitonin, interleukin-6 and pain levels were assessed before operation, 1 h after starting, and then at 1, 6, 12 and 24 h after operation. RESULTS: There were no significant differences between the groups of patients in age, sex, body-mass index, body surface area and operation time. We demonstrated significant reduction (P < 0.05) in levels of procalcitonin and interleukin-6 in the preoperative clonidine group compared with the preoperative levobupivacaine and control groups. Postoperative pain levels at rest and on movement were significantly lower (P < 0.05) in the clonidine group, especially 1 h after surgery (VAS 0.82 and 1.18), than in the levobupivacaine group (VAS 5.25 and 6.67) and the control group (VAS 7.08 and 8.31). CONCLUSION: These results support the importance of the central effect of clonidine on pain pathways and blockade of the systemic inflammatory stress response.

Effect of bispectral index monitoring on extubation time and analgesic consumption in abdominal surgery: a randomised clinical trial

PRINCIPLES The aim of this study was to investigate the effect of bispectral index (BIS) monitoring on intra-operative anaesthesia consumption and extubation time. DESIGN Randomised controlled study. METHODS The study included 45 patients undergoing major abdominal surgery under general anaesthesia in a six month period (February - July 2011), aged 18 years or older, and classified as ASA (American Society of Anaesthesiologists) physical status II or III. Patients were randomly assigned to receive BIS-guided anaesthesia or routine anaesthesia care as a non BIS-guided group. At the induction of anaesthesia, and during the operation the following parameters were continuously recorded: BIS level, heart rate (HR), systolic blood pressure (sBP), end-tidal CO2 (etCO2).Operation time and time to extubation were also recorded. On the first post-operative day all patients were visited and interviewed about intra-operative recall. RESULTS BIS levels in the non BIS-guided group were significantly lower from 30 minutes further to the end of the operation, compared to the BIS-guided group (p <0.05). Time to extubation was significantly shorter in the BIS-guided group (17.5 min vs. 75 min, p <0.001). There were no statistically significant differences in the required amounts of anaesthetics. In the post-operative interview, none of the patients reported an episode of intra-operative awareness. CONCLUSION Guiding anaesthesia according to BIS level will result in significantly faster recovery after anaesthesia. The investigation was registered on ClinicalTrials.gov (NCT01470898).

Penile injury and effect on male sexual function

Penile injury is common as an emergency and should be accurately diagnosed and treated. We analysed 22 patients with penile injury admitted to the emergency unit of Dubrava University Hospital during a 4‐year period. According to the American Association for the Surgery of Trauma five‐grade classification of penile injuries, there were 14 grade I, 6 grade II and 2 grade III cases. Diagnosis was mainly based on clinical and ultrasonography findings, and in some cases on cavernosography. Nineteen patients underwent immediate surgery and three patients received conservative therapy. On outpatient follow up, sexual function was assessed by use of the 5‐item International Index of Erectile Function (IIEF‐5) test at 3 and 12 months of injury. At 3‐month follow up, moderate, mild and no erectile dysfunction was recorded in 5, 6 and 11 patients respectively (mean IIEF‐5: 19.62). At 12‐month follow up, mild erectile dysfunction was found in only one patient (IIEF‐5: 20), whereas all other patients were free from erectile dysfunction (mean IIEF‐5: 23.75). The 12‐month follow up yielded a higher statistical difference (P < 0.001) when compared with 3‐month follow up. Study results indicated that appropriate treatment of penile injuries resulted in complete recovery of sexual function within 12 months.

Metastatic prostate cancer in an asymptomatic patient with an initial prostate-specific antigen (PSA) serum concentration of 21,380 ng/ml.

Background: Prostate cancer is the second most common cause of cancer death in men, being responsible for approximately 13% of all cancer deaths. Due to the high specificity for prostate tissue, prostate-specific antigen (PSA) is the primary serum tumor marker for prostate cancer. To our knowledge, in published data, the highest reported PSA level on initial presentation was 5,666 ng/ml. Case Report: We present a 64-year-old Caucasian man with no specific urologic or pain symptoms and with an initial PSA serum value of 21,380 ng/ml. Initial laboratory studies showed chronic anemia and elevated alkaline phosphatase, most likely from bone marrow infiltration due to metastatic disease. Prostate biopsies diagnosed an adenocarcinoma of the prostate (Gleason score 9). Computed tomography (CT) showed multiple liver metastases with retroperitoneal lymph nodes of up to 1 cm. The prostate was moderately enlarged (estimated weight 35 g). Both kidneys were normal (no hydronephrosis present). A bone scintigraphy demonstrated diffuse osseous metastasis. Treatment was initiated with bilateral subcapsular orchiectomy and bicalutamide therapy in an effort to create total androgen blockade. After 3 months of follow-up, the serum concentration of PSA was 29 ng/ml. Conclusion: This case presents an asymptomatic prostate cancer patient with bone and liver metastasis, enlarged retroperitoneal lymph nodes and the highest PSA level published to date.

Xanthogranulomatous epididymitis: clinical report and immunohistochemical analysis

ZusammenfassungDie xanthogranulomatöse Epididymitis (XE) ist ein seltener nicht-neoplastischer Prozess mit Zerstörung von Gewebe, welches durch eine eindrucksvolle zelluläre Infiltration mit schaumigen Makrophagen, dichten Lymphozyten und Plasmazellen ersetzt wird. Wir berichten über einen 72-jährigen Mann mit der klinischen Anamnese einer inadäquat behandelten arteriellen Hypertonie, der bei uns mit einer seit 10 Tagen bestehenden schmerzhaften Tumormasse rechts im Bereich des Skrotums vorstellig wurde. Bei der physikalischen Untersuchung wurde ein Eiter sezernierendes, hyperämisiertes und ödematöses Skrotum bei normaler Körpertemperatur festgestellt. Die Tumormarker für maligne Hodenerkrankungen waren negativ. Die Ultraschalluntersuchung (US) des rechten Hodens zeigte ein ödematös geschichtetes Skrotum sowie ein heterogenes Areal mit schlecht definierter Abgrenzung im Hoden und Nebenhoden. Es bestand eine minimale Hydrocele, der rechte Funikulus hatte einen normalen Durchmesser ohne Ödem oder andere pathologische Formationen. Die Progression der klinischen Befunde, der US und auch der Farb-US zusammen mit den negativen Tumormarkern ergaben letztlich die Indikation zur chirurgischen Sanierung. Es wurde eine Orchiepididymektomie rechts nach entsprechender präoperativer Therapie durchgeführt. Die Histologie bestätigte die Diagnose einer XE.SummaryXanthogranulomatous epididymitis is an uncommon non-neoplastic process with destruction of tissue and replacement by striking cellular infiltration of foamy macrophages, dense lymphocytes and plasma cells. We report on a 72-year-old man with a clinical history of inadequately treated arterial hypertension, who presented with a right scrotal mass associated with right scrotal pain for 10 days. Physical examination revealed pyogenic discharge from the hyperemic and edematous scrotum, with normal body temperature. Testicular tumor markers were normal. Ultrasonography (US) of the right testis showed edematous scrotal layers and a heterogeneous area of poorly defined margins within the testis and epididymis. There was minimal hydrocele, and the right funiculus was of normal diameter with no edema or pathologic formation. The progression of clinical findings, inflammatory parameters, US and color Doppler US findings with negative testicular tumor markers indicated surgical treatment. After preoperative treatment, right orchiepididymectomy was performed. Histology confirmed the diagnosis of xanthogranulomatous epididymitis.

A combination of levobupivacaine and lidocaine for paravertebral block in breast cancer patients undergoing quadrantectomy causes greater hemodynamic oscillations than levobupivacaine alone

Aim To test for differences in hemodynamic and analgesic properties in patients with breast cancer undergoing quadrantectomy with paravertebral block (PVB) induced with a solution of either one or two local anesthetics. Method A prospective, single-center, randomized, double-blinded, controlled trial was conducted from June 2014 until September 2015. A total of 85 women with breast cancer were assigned to receive PVB with either 0.5% levobupivacaine (n = 42) or 0.5% levobupivacaine with 2% lidocaine (n = 43). Hemodynamic variables of interest included intraoperative stroke volume variation (SVV), mean arterial pressure, heart rate, cardiac output, episodes of hypotension, use of crystalloids, and use of inotropes. Analgesic variables of interest were time to block onset, duration of analgesia, and postoperative serial pain assessment using a visual analogue scale. Results Although the use of 0.5% levobupivacaine with 2% lidocaine solution for PVB decreased the mean time-to-block onset (14 minutes; P < 0.001), it also caused significantly higher SVV values over the 60 minutes of monitoring (mean difference: 4.33; P < 0.001). Furthermore, the patients who received 0.5% levobupivacaine with 2% lidocaine experienced shorter mean duration of analgesia (105 minutes; P = 0.006) and more episodes of hypotension (17.5%; P = 0.048) and received more intraoperative crystalloids (mean volume: 550 mL; P < 0.001). Conclusion The use of 0.5% levobupivacaine in comparison with 0.5% levobupivacaine with 2% lidocaine solution for PVB had a longer time-to-block onset, but it also reduced hemodynamic disturbances and prolonged the analgesic effect. Registration No.: NTC02004834

Primjena paravertebralnog bloka za postavljanje gastrostome kod visoko rizičnih bolesnika s karcinomom jednjaka – dva prikaza slučaja

Here we present two cases of gastrostomy insertion via laparotomy in patients with malignant esophageal disease. Patients were ASA (American Society of Anesthesiologists) physical status III and IV. The patients presented as very high risk for general anesthesia, so we decided to use unilateral left sided paravertebral block (PVB) on four thoracic levels along with contralateral local infiltration at the gastrostomy insertion site. We present two cases, one of them a 57-year-old male ASA III patient scheduled for a gastrostomy procedure due to esophageal cancer with infiltration of the trachea. We also present a case of a 59-year-old male patient, ASA IV status, scheduled for the same procedure due to advanced esophageal cancer with a fistula between the left main bronchus and the esophagus and metastases in the left lung. The paravertebral space was identified with the use of an 8 Hertz (Hz) linear ultrasound probe and a nerve stimulator. Paravertebral block was successfully used for insertion of a gastrostomy, thereby enabling adequate anesthesia and perioperative analgesia without hemodynamic or respiratory complications.

Median Raphe Cyst – Clinical Report and Immunohistochemical Analysis

Cysts of the median raphe are very rare. We describe a 20-year-old man with an asymptomatic nodule on the ventral surface of the penis. The nodule was surgically removed under local anaesthesia, and send to histological and immunohistochemical analisys. Immunohistologicaly epithelial cells apeared Cytokeratin-7 (CK7), Epithelial membrane antigen (EMA) positive and anti-S100 protein (S100), Cytokeratin-20 (CK20), smooth muscle actin (SMA) and carcinoembryonic antigen (CEA) negative. Hystological and immunohystochemical findings indicate median raphe cyst.

A Definite and Less Invasive Treatment with a Monarc Transobturator Sling after Several Failed Operations for Urinary Incontinence in Women

Stress urinary incontinence (SUI), defined as a leakage of small amounts of urine during physical movement (coughing, sneezing, exercising), is a common problem in women of all ages. The epidemiologic data showed that incontinence increases in prevalence during young adult life (20–30%), with a broad peak around middle age (30–40%), and then a steady increase in elderly women (30–50%) [1]. SUI is the most common form of transurethral urinary incontinence in women (49%) and especially predominates in young and middle-aged women [1]. The most common reason is weakness of the pelvic floor muscles caused by a variety of etiologies such as pregnancy, childbirth or menopause. There is strong evidence to support the causal role of obesity and urinary incontinence [1]. The treatment of this disorder is even more non-uniformed: there have been about 100 operations proposed for it. The Burch procedure has become probably the most popular even though its success rate is about 80%, and the results may be not durable [2–4]. Recently, some minimally invasive procedures to treat SUI have been proposed. Based on the Integral Theory as described by Petros and Ulmsten [5], these procedures tend to restore the defective connection between the urethra and the vagina and thereby reinforce the suburethral hammock. Although it is effective and easy to perform [6–10], retropubic placement of suburethral tension-free vaginal tape (TVT) for the treatment of SUI can be associated with bowel, vascular, nerve and bladder injury [11–15]. Such complications appear to be related to the unique upward vaginal passage of metallic sling trocars through the retropubic space. Newel slings eliminate the upward approach, but still require routine cystoscopy to confirm an intact bladder and urethra. A new tension-free suburethral sling addresses these shortcomings using an innovative transobturator route [16, 17].