Vladimir Djukic

Letter to the Editor: Stenting in Palliation of Unresectable Esophageal Cancer

Dear Editor, We read with great care and interest the article on stenting in palliation of unresectable esophageal cancer by Wlodarczyk and Kuzdzal [1] in the June 2018 issue of World Journal of Surgery. First of all, we wish to congratulate the authors on this scientific report and on their dedication to better understanding of this very significant disease and its treatment modalities, especially in the cases of advanced stages. This was a retrospective study with prospective data collection, which included 442 patients who underwent esophageal stenting procedure. The authors wanted to evaluate the safety and efficacy of stenting in patients with esophageal squamous cell carcinoma and carcinoma of the esophagogastric junction, complications, re-interventions and survival after the treatment. Our concerns are in regards to the exact stage of the esophageal cancer and its possible resectability. According to Ajani et al. [2], patients with esophageal cancer can be divided into two groups: locoregional cancer (stages I–III) and metastatic cancer (stage IV). Patients with locoregional cancer must be treated surgically, unless there are severe comorbidities that present major risk factors for complications and mortality of anesthesia and surgery. We think that it would have been very useful if Wlodarczyk and Kuzdzal had stated in their study the exact cancer stage of the patients that underwent palliative esophageal stenting. In their study on 2626 patients over the age of 65 (Surveillance, Epidemiology, and End Results—SEER), Smith et al. [3] showed that in patients with advanced locoregional disease (T3-T4aN0 or T1-4aN1), the best results are obtained combining preoperative chemotherapy and surgery. Thus, we think that it would be very interesting if the authors stated the exact stage and what were the main criteria for non-resectability. According to European Society of Gastrointestinal Endoscopy (ESGE) clinical guidelines [4], brachytherapy can be used in addition to palliative stenting in esophageal cancer patients. Brachytherapy may provide better quality of life and survival rate [4]. We feel that additional data on brachytherapy, if it was considered as a therapeutic modality at all in the study by Wlodarczyk and Kuzdzal, could give useful guidelines in treating patients with advanced esophageal cancer. Wlodarczyk and Kuzdzal stated that they performed double stenting (synchronous stenting of airway and esophagus) in patients with unresectable esophageal cancer that had involved airway. Shin et al. [5], in their study on 61 patients with esophagorespiratory fistulas, placed with success SEMS in 51 patients, while only 10 patients needed double stenting. They managed to seal off the fistula in 49 patients, while only 10 (16%) needed a concomitant airway stent. According to clinical guidelines [4], esophageal stenting is recommended as the best treatment for sealing esophagorespiratory fistulas (tracheoesophageal or bronchoesophageal). Also, application of double stenting can be considered in cases when fistula occlusion is not accomplished by esophageal stenting alone [4]. We hope that these additional data would give more accurate directives in treating patients with advanced-stage esophageal cancer, in order to define the best approach and therapeutic strategy. & Vladimir Resanovic vladaresan@gmail.com

Influence of IL-6, TNF-α and hs-CRP on Insulin Sensitivity in Patients after Laparoscopic Cholecystectomy or Open Hernia Repair

Summary The aim of this study was to investigate the influence of IL-6, TNF-α and hs-CRP on insulin sensitivity during postoperative follow-up in patients with laparoscopic cholecystectomy (LC) or open hernia repair (OHR). 65 patients were studied: after laparoscopic cholecystectomy (LC; n=40) or open hernia repair (OHR; n=25). Glucose, insulin, hs-CRP, IL-6 and TNF-a were determined at day 0 (before the operation) and at days 1, 3 and 7 (after the operation). There were no difference between LC and OHR groups concerning age, BMI, glucose, insulin, hs-CRP, IL-6 and TNF-α at day 0. hs-CRP increased at day 1, 3 and 7 vs. day 0 (p<0.0005), without difference between groups (p=0.561). IL-6 increased at day 1 and day 3 vs. day 0 (p<0.005). IL-6 was higher at day 1 in OHR group in comparison with LC group (p=0.044). There were no differences in TNF-a levels between LC and OHR groups (p=0.056). There was increase of HOMA-IR at day 1, 3 and 7 vs. day 0 (p<0.0005) in both groups. Significantly higher increase of HOMA-IR was in OHR group compared with LC group at day 1 (p=0.045). There was a positive correlation between hs-CRP and HOMA-IR (r=0.46; p=0.025) and between IL-6 and HOMA-IR at day 1 in OHR group (r=0.44; p=0.030). Significantly higher HOMA-IR was found in OHR group compared with LC. Positive correlation between hs-CRP and IL-6 with HOMA-IR in OHR group at day 1, indicate possible influence of this mediators on impairment of insulin sensitivity.

Challenges and advances in the care of injuries in the Republic of Serbia

There are many problems that trauma care system in Serbia is facing today. Few of them are: 1) Lack of categorization of trauma centers; 2) Diversity in managing of trauma patients among institutions; 3) There is no trauma management training, 4) Inappropriate cooperation between pre hospital trauma care and hospital trauma care; 5) There is no standard in managing of trauma patients as well as procedures. To improve trauma care quality throughout the country we must learn from the experiences of other countries. The aim of this paper was to report representative data about organization, management, stuff and equipment of ambulance and emergency services in Serbia. We analyzed 12 out of 138 parameters we obtained from the relevant institutions.

Izazovi u unapređenju zbrinjavanja povređenih u Republici Srbiji

There are many problems that trauma care system in Serbia is facing today. Few of them are: 1) Lack of categorization of trauma centers; 2) Diversity in managing of trauma patients among institutions; 3) There is no trauma management training, 4) Inappropriate cooperation between pre hospital trauma care and hospital trauma care; 5) There is no standard in managing of trauma patients as well as procedures. To improve trauma care quality throughout the country we must learn from the experiences of other countries. The aim of this paper was to report representative data about organization, management, stuff and equipment of ambulance and emergency services in Serbia. We analyzed 12 out of 138 parameters we obtained from the relevant institutions.

Previdi u zbrinjavanju teško povređenih

Question of missed injuries is more offen a question of human errors: task execution errors, procedural errors, communication errors, decision errors and noncompliance. Missed injuries are those which are not identified in the first three days of hospitalization. This theme is not popular among physicians. Literature data mention percent from 3 - 29% missed injuries overall. The underlying causes errors are: false attributin, false negative prediction and false lebeling. False attribution involves a tendency to incorrectly link a clinical observation with an arroneous cause. This tendency also ignores one of the fundamental principles of the management of traumatic injury: that the index of suspicion should proceed on the basis of assumed wors resonable case scenario. Weaknesses of traumasistems: high patients volume, high-risk patients, long hours, changing set of resources, and problems sush bad admission planing, defficite anamnesis, defficite diagnostic procedures, bad communication, improvisation etc.