Postoperative pain management in geriatric patients after cholecystectomy and studies of glycemia and cortisol levels.

OBJECTIVE: The purpose of the study was to follow up the cortisol levels in relation to the postoperative pain intensity, its levels after treatment with opiate and non-opiate analgesics, and to monitor the relationship between the blood glucose and cortisol levels. Another goal was to optimize the postoperative analgesia of geriatric patients with the known combinations of analgesics. METHODS: The cohort comprised 28 geriatric patients undergoing laparoscopic cholecystectomy. The patients were divided according to the intensity of postoperative pain into the groups with opiate and non-opiate analgesia. Furthermore, they were divided according to their physical condition (ASA classification) into two groups, ASA 2 and ASA 3. We evaluated three values ​​of blood glucose levels, on the day before surgery, on the operative and the first postoperative days and those of cortisol on the day of surgery. RESULTS: The patients had the blood glucose levels without significant deviation during the three days of measurements. The cortisol levels increased with the intensity of postoperative pain. High levels of cortisol were observed not only in the patients, who experienced acute pain after non-optimal postoperative analgesia, but also in those treated with strong opiates in the immediate postoperative period. The patients with mild pain intensity, treated with a combination of non-opiate analgesics, had the lowest values. The role of the patient's gender in both blood glucose and cortisol levels was not observed. CONCLUSION: The cortisol levels have not corresponded so much with the assessment of acute postoperative pain as with the stress that was evoked in the patient due to hospitalization and fear of surgery. It is crucial to eliminate as much as possible all the stressors that can affect the cortisol levels and thus the blood glucose levels (Fig. 6, Ref. 25).

Importance of Different Grades of Abdominal Obesity on Testosterone Level, Erectile Dysfunction, and Clinical Coincidence.

The aim of the current study was to investigate the influence of different grades of abdominal obesity (AO) on the prevalence of testosterone deficiency syndrome (TDS), erectile dysfunction (ED), and metabolic syndrome (MetS). In a cross-sectional descriptive study, a total of 216 males underwent a complete urological, internal, and hormonal evaluation. Males were divided according to waist circumference into five groups: less than 94 cm (Grade [G] 0), 94 to 101 cm (G1), 102 to 109 cm (G2), 110 to 119 cm (G3), and more than 120 cm (G4). Incidence of ED, TDS, and MetS was compared in these groups and in participants without AO. Some degree of ED was identified in 74.7% of males with AO. In G1, there were 61% of males with ED, in G2 68%, in G3 83%, and in G4 87%. A strong correlation between testosterone (TST) level and AO was identified. Ninety-eight out of 198 (49.5%) males with AO and 1/18 (5.5%) males without AO had TDS. There were significant differences between individual groups. In the group of males with AO G4 (more than 120 cm), 87.1% had TDS. MetS was diagnosed in 105/198 (53.0%) males with AO, but in G4, 83.9% of males with AO had MetS. Males older than 40 years of age with AO have a higher incidence of ED, TDS, and MetS. Dividing males into five groups according to waist circumference seems to be reasonable. With growing AO, there were significantly more males with ED, TDS, and MetS.

Occurrence of erectile dysfunction, testosterone deficiency syndrome and metabolic syndrome in patients with abdominal obesity. Where is a sufficient level of testosterone?

AIM: The aim of this study was to determine the prevalence of erectile dysfunction (ED), testosterone deficiency syndrome (TDS), and metabolic syndrome in patients with abdominal obesity (AO) and the prevalence of morbidity at different levels of testosterone (TST). BACKGROUND: Male sex hormones play an important role in ED and variety of TDS and may have influence on the development of metabolic syndrome. The number of men with AO which constitutes a serious health risk is continuously growing. Currently, there are different views that TST levels are already insufficient, and the patient should benefit from treatment. OBJECTIVES: This study examined the association between ED, testosterone level and metabolic syndrome in men with AO. DESIGN, SETTING, AND PARTICIPANTS: The study was carried out in an outpatient urology center of Urology Clinic and Obesity Center of the Clinic of Internal Medicine. There were 167 participants­men with AO which were examined as part of preventive examination. METHODS: Hormonal, a complete urological and internal evaluation was carried out in every patient. RESULTS AND LIMITATIONS: We found some degree of ED in 73% (122/167) in men with AO. The TST levels below 14 nmol/l had of these 122 patients 84 patients (68.9%) and 49 patients (40.2%) below 10 nmol/l. In this group of patients, we found 103/167 patients (61.7%) with metabolic syndrome. When we compared TST level and morbidity, we found significantly more patients with diabetes mellitus (DM), hypertension and dyslipidemia in group with TST below 10 nmol/l. We also found difference in the levels of HDL cholesterol and triglycerides in the group of patients with TST 10­14 and over 14 nmol/l. CONCLUSION: Patients over 40 years of age with AO and ED should also be examined for TDS and metabolic syndrome. In this group of patients we found that 113/167 patients (67.6%) had total TST below 14 nmol/l, and sufficient level of TST seems to be above this level.

The application of the RT-PCR method for the staging of the prostate cancer progression.

Molecular biology seems to bring more convincing markers for the detection of prostate cancer as well as the development of metastases than immunohistochemistry. The main goal of present work was to detect the expression of prostate specific antigen (PSA) and prostate-specific membrane antigen (PSM) genes in the micrometastases by the RT-PCR to assess the progression of prostate cancer. We analyzed 50 patients: 28 patients with clinically localized or locally advanced prostate cancer who underwent radical prostatectomy, 7 patients with clinically proven metastases, 8 patients with benign prostatic hyperplasia, and 7 healthy young men. The results of RT-PCR in the first group of 28 patients varied, however, they were in good correlation with the health status of the patients. Positive results of PSA and notably for PSM were good predictors of beginning metastasing process. Seven patients with metastatic disease had positive RT-PCR results both for PSA and PSM. All of the patients with benign prostatic hyperplasia and healthy young men had negative RT-PCR results for PSA and PSM. The study showed that positive RT-PCR results for PSA and especially for PSM correlated well with the progression of the disease and negative results reflected good health status of the patients.

Pancreatic duct occlusion with acrylic glue after pancreas resection.

UNLABELLED: Postoperative complications following major pancreatic surgery are mainly due to the difficulties of performing a safe and proper anastomosis between the stomach or small bowel and the rest of the pancreas. We cannot influence the main predisposing factor of pancreatic fistula--soft pancreatic parenchyma, but we can decrease or completely block postoperative pancreatic secretion. In the last 5 years we performed 61 major pancreatic resections. There were 49 men, mean age 63 years (range 31-78) and 12 women, mean age 57 years (range 45-75). The occlusion of the main pancreatic duct was performed in 33 patients with cyanoacrylate manomer indermil (Sherwood, Davies Geck) after pancreatic resection with different types of anastomosis of their pancreatic stump. Fistula developed where glue was used only in 1 case out of 33 patients (1/33-3%) compared with 28 patients where glue was not used--fistula developed in 9 cases (9/28-32%). The difference is highly significant (p < 0.05). Only 1 out of 10 patients with pancreatic fistulation was operated later on; in 9 cases fistula closed spontaneously. Fistulo-jejunoanastomosis was performed in this patient with chronic torpid fistulation. No postoperative pancreatitis developed after blind closure of pancreatic stump. IN CONCLUSION: any decrease of pancreatic secretion from the rest of the pancreas after duodenopancreatectomy can significantly reduce the development of postoperative pancreatic fistula which can have a catastrophic influence on surgery outcome. Using glue in the pancreatic main duct is not only safe but can be an effective simple procedure in any type of pancreatic stump treatment.

The advantage of transverse laparotomy closed with continuous absorbable single-layer stitch.

The authors emphasize the advantage of transverse incisions because they provide the surgeon not only with excellent bilateral view of the operated area, but what is most important, they have significantly least negative effect on respiratory functions and the composition of blood gases, which are of major importance in patients with chronic respiratory failure. Due to the much smaller retraction forces, the incidence of postoperative dehiscences and hernias is smaller. It is an incision which interferes the least with the innervation of the abdominal wall and thus is not only less painful, but has also better healing parameters, offers excellent access to pathology from oesophagus up to sigmoid. It is an ideal incision for left open abdomen due to much less retraction of the abdominal wall and described closure is safe, simple, cheap, fast and reliable in risk, obese patients with impaired healing. The closure by a continuous, absorbable, looped double suture is not only simple, but what is most important, it is reliable and associated with minimal postoperative complications. The mean time of closure 13.6 min., supuration after 10th post-op day in 2%, none burst abdomen, 4 incisional hernias (0.8%), these are significantly better results than compared to longitudinal incisions. Authors in details describe the running Smead Jones closure technique.

Haemorrhoidectomy in outpatient practice.

OBJECTIVE: To evaluate our results of haemorrhoidectomy done as an outpatient procedure. DESIGN: Retrospective study. SETTING: University hospital Bratislava, Slovak Republic. SUBJECT: 256 patients who required haemorrhoidectomy in 1996-2001. INTERVENTIONS: Milligan-Morgan haemorrhoidectomy under local (0.5% lignocaine with adrenaline 1:200,000, 100 ml) or epidural (0.5 bupivacaine, marcain, 20 ml; or 1% lignocaine, 20 ml). MAIN OUTCOME MEASURES: Mortality, morbidity, need for admission to hospital, and acceptability to patients. RESULTS: No patient died. All patients were observed in the recovery room for 0.5-8 hours (mean 5 hours). 23 of the 256 patients (9%) developed minor complications including bleeding (n = 6), pain (n = 15), anal discharge (n = 1), and retention of urine (n = 1). 5 patients (2%) were admitted for pain or retention of urine. During the first 3 days after operation 29 patients required increased analgesia for discomfort. 223 patients (87%) were satisfied with outpatient treatment, while the remaining would have preferred to be admitted to hospital. CONCLUSION: Day case haemorrhoidectomy is a safe and effective way of reducing costs without increasing morbidity, mortality, and is acceptable to most patients.