Treatment of anastomotic leak after Ivor Lewis esophagectomy.

INTRODUCTION: Anastomotic leak (AL) is one of the most serious surgical complications after esophagectomy. Endoscopic, radiological and surgical methods are used in the treatment of AL. The aim of this study was to retrospectively evaluate our therapeutic procedures and results of AL treatment after Ivor Lewis esophagectomy (ILE). METHODS: Retrospective audit of all ILEs performed in the years 20052019. Evaluation of AL treatment results according to Esophagectomy Complication Consensus Group (ECCG) classification and according to the primary therapeutic procedure with a focus on the treatment with esophageal stent. RESULTS: Out of 817 patients with ILE, AL was detected in 80 patients (9.8%): ECCG type I 33 (41%), type II 23 (29%) and type III 24 (30%) patients. Some 33 patients (41%) were treated conservatively. Esophageal stents were used in 39 patients (49%), of which 18 (23%) had concomitant percutaneous drainage and 17 (21%) were reoperated. Reoperation without a stent insertion was performed in 7 patients (9%). Esophageal diversion with cervical esophagostomy was performed in a total of 16 patients (20%). Esophageal stent treatment was successful in 24/39 patients (62%). Airway fistula occurred in 4 patients treated with stent (10%). Endoscopic vacuum therapy was successfully used in three patients after stent failure. Eight patients (10%) died as a result of AL. Mortality of AL type I, II and III was 0%, 4% and 29%. CONCLUSION: Successful treatment of AL requires an individual and multidisciplinary approach. The primary effort should aim to preserve anastomosis using endoscopic and radiological methods. In case of insufficient clinical effect, we recommend not to hesitate with reoperation. If primary therapy fails, the life-saving procedure is a cervical esophagostomy.

Measurement of intact parathormone during operation for primary hyperparathyroidism.

In this prospective study, the role of the intact parathormone (iPHT) levels for the verification of pathologic parathyroid tissue removal during parathyroidectomy, was analyzed in 441 patients diagnosed with primary hyperparathyroidism. The level of intact parathormone was obtained before the initial incision (baseline level) and 10 minutes after the pathologic parathyroid gland removal (control value). In 80 % of cases, the decrease of intact parathormone was more than 50 % of the baseline level. The comparison of preoperative and postoperative intact parathormone levels can also be used as marker of parathyroid hyperplasia or persistent hyperparathyroidism. This method is necessary mainly for performance of focused, miniinvasive approaches as well as in reoperations. This method is of significant benefit in cases of negative preoperative examination methods. The determination of intact parathormone level increases the success of parathyroidectomy (Ref. 26).

[Ruptures of the diaphragm]. / Ruptury bránice.

INTRODUCTION: The diaphragm is a flat muscle that divides the thoracic and abdominal cavities, and it is one of the most important muscles involved in respiration. Traumas of the diaphragm include its rupture caused by an external force, resulting in blunt or penetrating injuries. Diaphragmatic rupture is associated with the risk of a prolapse (i.e. not a typical hernia) of abdominal organs into the pleural cavity. The rupture may occur due to a blunt injury of the chest or abdomen, or due to penetrating injuries (gunshots, stab wounds, foreign bodies) in the lower part of the chest and epigastrium. Ruptures never heal spontaneously and always require suture of the diaphragmatic defect. Most acute rupture cases are managed using laparotomy; thoracotomy is preferred for lately recognised ruptures to facilitate the removal of adhesions in the thoracic cavity developed between the diaphragmatic defect and a lung. Thirty one patients with diaphragmatic rupture were operated at the 3rd Department of Surgery of the 1st Faculty of Medicine, Charles University and University Hospital Motol between 2006 and 2016. Acute rupture was present in 60% of the cases and chronic in 40%. Right-sided rupture was found in 20% and left-sided in 80%. CONCLUSION: The authors describe surgical treatment of diaphragmatic ruptures. They recommend an early surgical treatment if diaphragmatic rupture is recognized. Generally, the prognosis of the patients depends on availability of professional health care; ideally, these patients should be treated at specialised traumacentres with specialists for abdominal and thoracic surgery. The authors advise against establishing injudicious thoracic drainage in cases where diaphragmatic rupture with herniation of abdominal organs into the thorax may be present.Key words: polytrauma - acute rupture of diaphragm - chronic rupture - suture - patch.

[Development of tracheal resection technique - our experience]. / Vývoj techniky resekcí trachey - nase zkusenosti.

INTRODUCTION: Tracheal resections are very frequent interventions on the trachea in general. In borderline cases where the tracheal resection length is too high, the situation can be resolved by inserting a stent or Montgomerys T cannula. Tracheal stenoses are of benign origin in 94%, and malignant in 6% of cases. We present a summary of tracheal resection interventions for the last 21 years. METHOD: 235 tracheal resections were performed at the authors institution in 1993-2013. In total 221 benign stenosis cases (85 % developed after tracheostomy, 15% developed after intubation) and 14 malignant cases were treated. The patients were divided into two groups: A resection in years 19932002 and B - resection in years 20032013. The comparison of these two time periods is presented with focus on surgical procedures development and recommendations based on experienced complications. RESULTS: Restenosis (early or late) is the most common complication during the process of tracheal resection treatment. Tiny fistulas in the suture can be diagnosed easily by minor air leaking and are treated conservatively without intervention. Fortunately, suture insufficiency is relatively rare. In some cases the restenoses can be resected or treated by stent application or by Montgomerys T-cannula application. Complications were observed in 2% of the treated patients, which is a number presented also by international studies. CONCLUSION: Tracheal resection is definitely an optimal solution for patients suffering from tracheal stenosis. As presented in our study, in the hands of experienced thoracic surgeons tracheal resections is a safe and final solution of tracheal stenosis. KEY WORDS: trachea - stenosis resection.

[The first lung re-transplantation in the Czech Republic]. / První retransplantace plic v Ceské republice.

Nowadays, lung re-transplantation is an acceptable method of treatment in patients with graft failure after lung transplantation. During the 15-year duration of the lung transplant program in the Czech Republic, the first re-transplantation was performed on 1. 8. 2012. This article presents the case report of a female patient with lymphangioleiomyomatosis who underwent single lung transplantation on the left side on 4. 10. 1998. Over 12 years, based on bronchiolitis obliterans syndrome, she developed chronic respiratory insufficiency again. The patient was re-listed on the waiting list and on 1. 8. 2012, successful single-lung transplantation on the right side was performed.Key words: lung re-transplantation bronchiolitis obliterans syndrome organ allocation.

Postoperative rectal anastomotic complications.

Colorectal cancer represents the most common tumour of the gastrointestinal tract and the second most common tumour in men as well as women. The trend of increasing incidence of colorectal cancer is alerting. We undertook a retrospective study on 588 patients with rectal cancer and operated by rectal resection with anastomosis between the years 2002-2012. In our sample, we observed 54 (9.2 %) cases of anastomosis insufficiencies requiring reoperation. Out of 54 insufficient anastomoses, 36 (66 %) were in the lower two thirds of the rectum and only 18 (34 %) in the oral one. Although we have observed similar occurrences of anastomosis insufficiency in both groups - classical vs. staple suture (9.5 % and 9.0 %, respectively), the majority of stapler anastomoses (94 %) were made in the aboral part of the rectum. However, we can state that a majority of authors prefer the staple anastomosis as the one with lowest risk, mainly in the distal region of anastomosis. The high ligation of inferior mesenteric artery was performed in 182 (31 %) patients; out of these, we observed anastomosis insufficiency in 12 cases (22 %), which is exactly similar to that in the group of patients without high ligation of the inferior mesenteric artery. We did not observe the use of antibiotics in therapeutical doses as a positive factor for anastomosis insufficiencies, and neither was oncological therapy observed as a risk factor. In our group of patients we agreed that age, level of anastomosis and corticosteroids are high-risk factors. The purpose of these reports, is for the sake of future to share and reference our experiences with cases of rectal and rectosigmoideal resection over the last 11 years. We consider it important to reference our results, especially the risk factors regarding the healing of rectal anastomosis, because anastomotic healing is a surgical problem with potentially deadly consequences for patients (Tab. 4, Ref. 24).

[Informed consent]. / Informovaný souhlas.

Unless it is necessary to provide immediate assistance to a patient who, due to his state of health, is unable to give consent, every medical treatment must be performed with an voluntary consent from the patient. The patient must be informed, in advance, about the purpose and nature of the treatment, its consequences and risks. If the patient refuses the proposed treatment he must be notified about the possible harmful effects of this decision for his health (life) and the patient must sign a written refusal of the medical treatment - commonly known as revers. In case the patient refuses both the treatment and the signature, then the refusal must be signed by a witness. Informed consent may be oral; its written form is obligatorily dictated by law only in exceptional cases. Every health service provider is solely responsible for deciding which treatments will require written consents. The refusal form, revers, must always be written. The European courts have been emphasising that the most significant thing is the dialogue between the doctor and the patient, not the signed document. The patient must be informed by a relevant doctor about the treatment he is about to undergo not by a nurse or a doctor who will not be performing it. It is questionable whether it would not be better to substitute a written consent for an audio or audio-visual recording showing the interaction between the doctor and the patient, or his family. Anyone is allowed to express a future wish for situations when he will not be able to agree or disagree with the offered health services (that means previously expressed wishes - living will). The law will determine the formalities of such a document. Previously expressed wish should be respected unequivocally, although, its fulfillment must not lead to active cause of death. The rule is that human free will gives way to the protection of his life.

[Right to privacy]. / Právo na ochranu soukromí

The protection of personal information of patients and compulsory secrecy of the medical staff are very up-to-date issues, and to breach the laws means facing high sanctions. It is necessary for a doctor to know to whom he can disclose information. If the doctor does not obtain permission from the patient then he may provide information to the police only with permission from the court. The only exception is the case when the doctor acts according to the legal duty to report information about the time and place of provided medical treatment to a person who is being searched after by the police. The most common cases of breaching the compulsory secrecy are interactions during ward rounds with other co-patients and giving information over the phone to persons whose identity cannot be verified. In the event of a patient running away from the health facility and if there is a suspicion that his life may be threatened, the doctor is obliged to inform the Police of CR and a significant other who is entitled to obtain information and is recorded in the medical documentation, if there is one and it is possible to contact them.

[Lege artis]. / Lege artis.

It is a common legal practice that a court will ask an expert to testify whether a doctor behaved "lege artis". However, this term is misleading and it was substituted by the law about health services for the term adequate level of expertise. Its definition is based on a proposal by the Czech Medical Chamber and it was confirmed by the Czech Constitutional Court. It is important to pay attention to the specific conditions and objective possibilities in the situation when evaluating the work of doctors. Sometimes, there may be issues concerning incompetent expert evidence, when the evidence does not account for the conditions and possibilities of the specific situations and it is, rather, an expression of subjective opinions of the author. The system of selection of experts (judge advocates) from the medical field is treated vaguely by the Czech law and, thus, assigning responsibility for making a faulty judgement has been insufficient so far. A new law concerning court experts (judge advocates) is currently in preparation.

[Working under supervision]. / Práce pod odborným dohledem.

A graduate from a medical school who has obtained only, so called, adequate competence/ expertise must work under a supervision of a doctor who has the relevant specialised competence certification in order for the graduate to obtain this specialised competence as well. It is recommended to determine in writing which activities the doctor in training can perform alone during that time, which need to be supervised by the responsible doctor, and which treatment he is not yet prepared to perform at all. The head doctor or the head of the clinic is responsible for ensuring a full-time supervision of the doctor trainee by a certified specialist. If the trainee has obtained a certificate of completion of the basic level training of the relevant specialised module then he can serve during emergency hours under the condition that the presence of a specialised doctor is ensured to be within 20 minutes if needed. The head doctor, the head of the clinic or the specialised medical supervisor have no universal responsibility for any possible misconduct of the trainee. Everyone is responsible for his own conduct. The responsibility of the head doctor and the head of the clinic may be relevant if they did not fulfil the duties of being a supervising doctor. The responsibility may also be relevant if the supervising was neglected. Responsibility for the trainee may arise if he did not respect the orders from the supervisor or if the misconduct was such that it would be unacceptable even for a doctor without the relevant professional competence. If it is the case that the misconduct happens despite the supervising being absolutely correct, and under the conditions that the misconduct was unavoidable, the supervising attested professional doctor cannot be responsible for the consequences. Manual misconduct during a surgery is usually regarded to be accepted risk not violation of the rules of medical science.

[Smoking and postoperative complications]. / Kourení a pooperacní komplikace.

INTRODUCTION: Smoking has a negative impact on the outcome of surgical procedures. Smoking leads to higher risk of postoperative complications and it delays wound healing. MATERIALS AND METHODS: We observed pulmonary complications, wound healing complications, and the length of the postoperative hospitalization period of 877 patients admitted for elective surgery.. Patients were divided according to their smoking status in to 3 groups: the current smokers were 32% (279/877), the former smokers 31% (274/877) and the non-smokers 37% (324/877). RESULTS: Pulmonary complications occurred more frequently in the smoking group (3.9%) compared to the non-smoking group (0.9%), p<0,001. The incidence of wound infections was 7.5% in the smoking group compared to 4.6% in the non-smoking group. Wound dehiscence occurred in 3.6% patients in the smoking group, respectively 2.8% in the non-smoking group, without statistical significance. The number of postoperative hospitalisation days was 3 days for both smokers and non-smokers, but it decreased inversely to number of smoke-free days before the surgery for those who stopped smoking: those abstinent for 31-90 days were hospitalized for 7.0 days, those abstinent for 91-183 were hospitalized for 5.5 days, and for those abstinent over 184 days the postoperative hospitalization was, again, 3 days. Among the current smokers, 93% preferred to stay smoke-free after the surgery. CONCLUSIONS: Our results support better surgery outcomes for non-smokers. However, our sample was not large enough to assess the impact of the number of preoperative smoke-free days. An elective surgery seems to be an unused occasion to motivate smokers to stop smoking, preferably, as soon as possible before the surgery date.

Impact of MDR1 genetic polymorphisms on postoperative piritramide analgesia.

OBJECTIVES: The aim of prospective study was to evaluate the therapeutic efficacy of piritramide in patients after removal of parathyroid glands in relation to MDR1 genotype. In the treatment of moderate acute postoperative pain, piritramide plays a major role. It is difficult to predict its optimal therapeutic efficacy and tolerability in individual patients. METHODS: We compared the effect of piritramide in 56 patients after surgical removal of parathyroid glands in a prospective study. We evaluated pain intensity, pain difference and sum of pain difference (SPID) using visual analogue scale (VAS in mm) and adverse effects in the relationship with the MDR1 - polymorphism of G2677T/A. RESULTS: In the wild-type group (2677GG), there was maximal pain difference of 30.6 ± 24.9 and SPID of 209.33 ± 95.80 while in genotype 2677TT and 2677GT, the corresponding values were 19.5 ± 25.5 and 147.07 ± 91.38, respectively. In group of patients with wild type of 2677GG genotype, there was 80 % of responders with more than 50 % reduction in VAS as compared to baseline while in group with carriers of 2677T allele, there are only 39 % of responders present (χ² = 5. 83; p = 0.016). Furthermore, the total consumption of piritramide was lower in comparison with the variant-allele carrying group (p = 0.008). The total incidence of adverse drug reactions was observed in 40 % of patients with wild type of 2677GG genotype when compared to 83% in the group carrying the variant allele (χ² = 7.92; p = 0.005). Significantly more patients in the wild-type group were satisfied with postoperative pain treatment in comparison to the variant allele group (χ² = 6. 49; p = 0.0109). CONCLUSION: We observed a better analgesic effect of piritramide and a decreased incidence of side effects in the wild-type genotype (2677GG) group, when compared with variant-allele carrying patients (Tab. 2, Fig. 1, Ref. 7).

Tramadol efficacy in patients with postoperative pain in relation to CYP2D6 and MDR1 polymorphisms.

OBJECTIVES: The aim of our study was to evaluate impact of CYP2D6 and MDR1 polymorphisms on the analgesic efficacy of tramadol in patients after a knee arthroscopy. BACKGROUND: Pharmacokinetics of tramadol and its metabolites is stereoselective and displays high interindividual variability correlating with polymorphic CYP2D6 in the population. Available data provide controversial results regarding the analgesic efficacy of tramadol in subjects with different CYP2D6 genotypes. METHODS: Pain intensity was assessed using visual analogue scale at 2 and 24 hours after the knee arthroscopy in 156 patients. Polymorphisms CYP2D6*3,*4,*5,*6, and gene duplication and C3435T in MDR1 gene were analyzed by PCR - RFLP. RESULTS: Mean VAS2h value in the whole study group was 44.0 ± 16.5 mm. Mean pain difference, was lowest in the UM group and highest in the PM group. The pain difference varied significantly among the CYP2D6 subgroups (F = 4.29; p = 0.006) with significant differences between homEM vs hetEM, homEM vs PM, and UM vs PM subgroups. There were no significant differences among MDR1 subgroups with regards of pain difference. Mean tramadol consumption was 2.47 ± 1.17 mg/kg during the 24 h period. There were no significant differences in the drug consumption, reporting of adverse reactions, need for rescue analgesic medication or verbal description of pain among the CYP2D6 or MDR1 genotype subgroups. CONCLUSION: CYP2D6 plays a significant role in tramadol analgesic efficacy. The non-opioid analgesia in PMs was associated with better subjective pain relief in patients after a knee arthroscopy (Tab. 3, Ref. 18).

[Timeline trends in surgery of bronchogenic carcinoma]. / Casové trendy chirurgické terapie bronchogenního karcinomu.

BACKGROUND: The aim of our study was to determine how patient preoperative status and outcomes of resection have changed over last 12 years. MATERIAL AND METHODS: This retrospective study of prospective database included 1412 patients operated from January 1,1998 through December 31,2009. Patient characteristics and outcomes were compared for two time periods (1998-2003 and 2004-2009). RESULTS: We performed 985 lobectomies with 30-days mortality 1.8% and 300 pneumonectomies with 30-days mortality 5.7%. Median of survival of all 1412 patients was 4.3 year and 5-year survival was 45%. The percentage of female patients, lobectomies and adenocarcinoma increased over time, as well as age of our patients. Outcome improved over time, with significant decrease in 30-days mortality after pneumonectomy (8.2% vs. 2.3%, p = 0.029). The overall 3-year survival improved in patients with III. stage (30 % vs. 40%, p = 0.012). CONCLUSION: Our study identified time trends which are in-line with increased incidence of lung cancer among women and with improvement of preoperative evaluation, preoperative and postoperative care

Risk factor analysis for early mortality and morbidity following pneumonectomy for non-small cell lung cancer.

OBJECTIVES: The purpose of this report is to analyze factors affecting morbidity and mortality following pneumonectomy for non-small cell lung cancer (NSCLC). METHODS: We reviewed our institutional experience with all consecutive patients undergoing pneumonectomy for NSCLC from 1998 to 2010. Patients were analyzed with regard to hospital mortality and morbidity and long-term outcome. RESULTS: There were 310 patients following pneumonectomy. Overall 30-day mortality rate was 5.5 %. Chronic obstructive pulmonary disease, induction therapy, smoking habits and obesity had no statistical influence on short-term outcome. Coronary artery disease and respiratory failure were identified as risk factors for increased 30-day mortality (p<0.01). Right pneumonectomy and presence of respiratory failure with mechanical ventilation increases the incidence of bronchopleural fistula (p<0.01). CONCLUSIONS: Patients with right pneumonectomies are at increased risk. Coronary artery disease and respiratory failure adversely affect morbidity and mortality after this procedure (Tab. 3, Ref. 19). Full Text in free PDF www.bmj.sk.

Time trend in the surgical therapy of lung cancer.

BACKGROUND: The purpose of our study was to clarify results of surgery for non-small cell lung cancer (NSCLC) and its time trends. METHODS: We retrospectively reviewed our prospective database of patients who underwent surgery for NSCLC between 1998 and 2009 in our institution. Patients were divided into two equal 6-year periods according to the year of surgery (1998-2003 and 2004-2009). RESULTS: One thousand, four hundred and twelve patients underwent operation for NSCLC. We performed 985 lobectomies with 30-days mortality of 1.8 % and 300 pneumonectomies with 30-days mortality of 5.7 %. Median of survival of all 1412 patients was 4.3 year and 5-year survival was 45 %. The percentage of female patients, lobectomies and adenocarcinomas increased over time, as well as the age of our patients. Outcome improved over time, with significant decrease in a 30-days mortality after pneumonectomy (8.2 % vs 2.3 %, p=0.029). The overall 3-year survival improved in patients with stage III (30 % vs 40 %, p=0.012). CONCLUSION: Outcomes of lung resection for NSCLC improved over time despite a worsening of some elements of preoperative status. The shift in histological distribution was associated with an increasing proportion of patients with stage I, a lower operative mortality and better 3- and 5-year survival. These trends are due to improvement of preoperative evaluation, preoperative and postoperative care (Tab. 1, Fig. 2, Ref. 9). Full Text in free PDF www.bmj.sk.

[Lung transplantation]. / Transplantace plic.

Lung transplantation is an effective life-saving therapy for the treatment of a variety of end-stage lung diseases. However, the application of lung transplantation is hindered by multiple factors such as the shortage of organ donors, early graft failure, infection, and chronic graft dysfunction. A novel strategy for donor lung preservation--ex-vivo lung perfusion (EVLP)--that keeps the organ at physiological protective conditions, has shown great promise to increase lung utilization by reassessing, treating, and repairing injured donor lungs prior to transplantation. Infections are a major cause of early morbidity and mortality after lung transplantation. Because of the potential association of infections such as respiratory viral infections and gram-negative bacterial infections with bronchiolitis obliterans syndrome, prompt attention to these pathogens is critical. Despite marked improvements in early survival, long-term outcome after lung transplantation is still threatened by bronchiolitis obliterans syndrome. The program of lung transplantation in Czech Republic was started in University Hospital Motol in Prague in 1997. Nowadays in Czech Republic is performed about 20 transplants every year with results comparable to other advanced centers. Until September 2011, 175 transplants were carried out in Czech Republic.

[Esophageal perforation]. / Perforace jícnu.

OBJECTIVE: Evaluation of patients with acute esophageal perforations with single institution experience. MATERIAL AND METHODS: The authors evaluate the set of 64 consecutive patients with esophageal perforation treated in our department between January 2000 and December 2010. In all patients were before decision making performed CT scans and X-ray examination with contrast agent administration. For selected patients was also accompanied upper endoscopy. Excluded were patients with malignant tracheoesophageal fistula and patients with perforation of malignant stenosis treated with palliative intent. RESULTS: The mean age was 62 years (range 24-90), of which one third (34.4%) were aged 70 years or more. We received the iatrogenic perforation in 45 (70%) patients, less than one quarter (n = 15; 23%) consisted of spontaneous perforation, in three patients we have failed to determine the cause of perforation (5%) and one patient experienced perforation during removal of foreign body. Perforation of the thoracic esophagus in 41 patients, in 20 (31%) cases in the upper and middle third and 21 (33%) in the distal third of the thoracic esophagus. Cervical perforation was noted in 14 patients (22%) and abdominal of the 9 patients (14%). 92% of patients were treated surgically (n = 59). 43% (n = 27) were treated by primary suture of the perforation, esophageal resection with primary reconstruction was performed in 4 patients, esophagectomy with terminal esophagostomy and nutritional jejunostomy in 7 patients, 4 patients were treated by surgical drainage and only 7 patients, we introduced endless lavage. In 9 cases we have resected affected portion of esophagus with stapler closure in the chest. Conservative management of esophageal perforation we proceeded in 5 patients in whom a stent was introduced and the perforation successfully healed. Overall mortality in our set of patients is 23.4%. CONCLUSION: Conservative procedure in carefully selected patients could be an alternative to radical and inherently surgical procedures. Published results and our little experience are encouraging, but this topic is still under study.

The role of diclofenac and piritramide in the management of acute postoperative pain in hernioplasty.

OBJECTIVES: The aim of the study was to compare the effects of diclofenac and piritramide in acute postoperative pain after hernioplasty. BACKGROUND: In the treatment of moderate acute postoperative pain, non-steroidal anti-inflammatory drugs and opioids play the major role. The data on safety and effect of analgesia based on opioid and non-opioid drugs are still a controversial topic. METHODS: We compared the first-line treatment effects of diclofenac and piritramide in 105 patients after hernioplasty in a retrospective manner. The subsequent therapy combined piritramide with diclofenac. We evaluated the intensity of pain and its relief using a visual analogue scale (VAS). We also evaluated the necessity of application of other analgesics. RESULTS: One hour after the application of the first analgesic dose, we observed complete pain relief in 39.5% of patients treated with piritramide and in 19.4% of patients treated with diclofenac (chi2=5.17; p=0.02). After the use of piritramide, the pain relief (3.84 +/- 1.27 mm) was significantly higher than after diclofenac (3.34 +/- 0.77 mm). Another injection was needed in 76% and 54% of patients subjected to first-line treatment based on diclofenac and piritramide, respectively. CONCLUSION: We observed that the first-line analgesic treatment based on piritramide was more effective when compared to that based on diclofenac (Tab. 3, Ref. 3). Full Text in free PDF www.bmj.sk.