Endoskopinis ūminės storosios žarnos obstrukcijos gydymas

Kęstutis Adamonis, Dainius Pavalkis, Žilvinas Saladžinskas, Algimantas TamelisKMU Gastroenterologijos klinika, KMU Chirurgijos klinika Šiuolaikis virškinimo trakto piktybinės obstrukcijos gydymas vis labiau tampa minimaliai invazinis. Ligoniai, sergantys storosios žarnos vėžiu, komplikuotu obstrukcija, į gydymo įstaigas patenka skubos tvarka, neretai sunkios būklės, ir nėra idealūs kandidatai chirurginei operacijai. Šiuolaikinėje medicinos literatūroje gausėja mokslinių straipsnių apie sėkmingą ir saugų endoskopiniu būdu įkišamų savaime išsiplečiančių metalinių stentų naudojimą proktologijoje. Nors stentai ir yra brangūs, tačiau proktologinis stentavimas yra rentabili procedūra, leidžianti ligoniams, sergantiems storosios žarnos vėžiu, komplikuotu ūminė storosios žarnos obstrukcija, išvengti neatidėliotinos operacijos, o esant nerezektabiliam vėžiui, – kolostomos. Straipsnyje aprašomas KMU Chirurgijos klinikoje atliktas pirmasis Lietuvoje sėkmingas endoskopinis ūminės žarnų obstrukcijos gydymas stentuojant žarnyną. Prasminiai žodžiai: žarnyno obstrukcija, kolorektinis vėžys, endoskopija, stentavimas. Acute colonic obstruction: endoscopical management Kęstutis Adamonis, Dainius Pavalkis, Žilvinas Saladžinskas, Algimantas Tamelis Management of malignant gastrointestinal obstruction presents a significant challenge. Most patients are in a profoundly decompensated state due to underlying malignancy and are not ideal candidates for invasive surgical procedures. In recent years, self-expandable metal stents have emerged as an effective and safe, less invasive alternative for the treatment of malignant intestinal obstruction. Although stents are expensive, the procedure appears to be cost-effective, since emergency surgery can be avoided in patients with acute bowel obstruction, and in those with advanced disease no resection of the colon is necessary. Here we report a retrospective analysis of a first self-expandable metal stent placed for colorectal obstruction at Kaunas Medical University Hospital, as well as review the literature published on self-expandable metal stent placement. Our first data confirm self-expandable metal stent efficacy in palliation of malignant intestinal obstruction. Keywords: intestinal obstruction, colorectal cancer, endoscopy, endoluminal stenting

Laparoskopinė storosios žarnos chirurgija: pirmoji patirtis Lietuvoje

Gintarė Valeikaitė1, Juozas Stanaitis2, Nerijus Kaselis3, Eligijus Poškus4, Kęstutis Strupas4, Dainius Pavalkis11 Kauno medicinos universiteto klinikų Chirurgijos klinika;2 Vilniaus universiteto Bendrosios ir plastinės chirurgijos, ortopedijos ir traumatologijos klinika;3 Klaipėdos apskrities ligoninės Chirurgijos skyrius;4 Vilniaus universiteto ligoninės Santariškių klinikų Pilvo chirurgijos centras,Santariškių g. 2, LT-08661 VilniusEl paštas: [email protected] Įvadas Šio straipsnio tikslas – įvertinti pirmąją laparoskopinės storosios žarnos chirurgijos praktiką Lietuvoje ir supažindinti su pasauline patirtimi. Metodai Sudarytas klausimynas išsiųstas keturiems pagrindiniams Lietuvos centrams, kuriuose atliekamos storosios žarnos laparoskopinės operacijos. Išnagrinėti 56 atliktų operacijų duomenys. Trisdešimt šeši (64,3%) pacientai buvo operuoti nuo vėžio: penkiolika – nuo riestinės, vienuolika – tiesiosios, keturi – kylančiosios, trys – aklosios, du – skersinės ir vienas – nusileidžiančiosios žarnos vėžio. Nuo nepiktybinių storosios ir tiesiosios žarnos ligų operuota dvidešimt (35,7%) pacientų: aštuoni – nuo divertikuliozės, aštuoni – tiesiosios žarnos iškritimo, keturi – pailgėjusios riestinės žarnos. Vidutinis moterų amžius – 64,9 metų, vyrų – 59,7 metų. Rezultatai Buvo atlikta septyniolika aukštų priekinių tiesiosios žarnos rezekcijų, vidutinė operacijos trukmė (VOT) – 203,9 min., penkiolika dešinių hemikolektomijų, VOT – 212 min., devynios kairios hemikolektomijos, VOT – 221,4 min., šešios riestinės žarnos rezekcijos, VOT – 194 min., trys riestinės ir tiesiosios žarnos rezekcijos, VOT – 220 min, aštuonios rektopeksijos, VOT – 179,5 min., viena tiesiosios žarnos ekstirpacija, VOT – 255 min. Visos žarnų jungtys buvo padarytos intrakorporaliniu būdu, išskyrus dešinę hemikolektomiją, kai jungtis padaroma išorėje per minilaparotominį pjūvį dešinėje pilvo sienos pusėje. Konversijos priežastys dviem atvejais buvo kraujavimas iš pasaito ir dviem atvejais – peraugęs į gretimus organus navikas. Vidutiniškai prieš operaciją ligoniai gulėjo 3,2 dienos, po operacijos – 8,3 dienos. Išvada Laparoskopinis metodas toliau vertinamas atliekant perspektyvųjį nacio nalinį tyrimą. Reikšminiai žodžiai: laparoskopija, storoji žarna, chirurgija First experience in laparoscopic colorectal surgery in Lithuania Gintarė Valeikaitė1, Juozas Stanaitis2, Nerijus Kaselis3, Eligijus Poškus4, Kęstutis Strupas4, Dainius Pavalkis11 Kaunas University of Medicine, Clinic of Surgery;2 Vilnius University Clinic of General, Plastic Surgery, Orthopedic and Traumatology;3 Klaipėda City Hospital;4 Vilnius University Hospital Santariškių Klinikos, Centre of Abdominal Surgery,Santariškių 2, LT-08661 Vilnius, LithuaniaE-mail: [email protected] Objective To evaluate the first experience in laparoscopic colorectal surgery in Lithuania and to review the worldwild accepted practice. Methods A questionnaire was sent to four major centers performing laparoscopic colorectal surgery in Lithuania. Analysis of obtained data showed that 56 laparoscopic operations were performed. For colorectal cancer were operated 36 patients (64.3%): 11 for rectal, 15 for sigmoid, 4 for ascending colon, 3 for ceacal, 2 for transversal and 1 for descending colon cancer. For benign colorectal disease – 20 (35.7%): 8 for diverticular disease, 8 for rectal prolapse, 4 for constipation caused by sigmoid elongation. The mean age of males was 59.7 and of females – 64.9 years. Results There were performed 15 laparoscopic left hemicolectomies (the mean operative time (MOT) 212 min), 17 laparoscopic high rectal resections (MOT 203.9 min), 9 laparoscopic right hemicolectomies (MOT 221.4 min), 6 sigmoid resections (MOT 194 min), 3 sigmoid and rectal resections (MOT 220 min), 8 laparoscopic rectopexies (MOT 179.5 min) and one laparoscopic abdominoperineal resection, operative time 255 min. All the anastomoses were intracorporeal, except right hemicolectomies and sigmoid resections. The reasons for conversion were bleeding from mesenterium in 2 cases and advanced tumours in 2 cases. The mean preoperative stay was 3.2 and postoperative stay 8.3 days. Conclusions There could not be clear conclusions, and the laparoscopic method is being further evaluated by a prospective national trial. Key words: laparoscopic colorectal surger

Schizophrenia – time to commit to policy change

Schizophrenia is recognised as one of the most complex and profound mental health conditions, steeped in both myth and reality. Efforts needs to be multifaceted, including policy development, treatment guidance and scientific innovation, with all stakeholders working together to ensure meaningful progress. This report delves into the unique needs of people with schizophrenia, exploring supportive measures for their well-being, practical and attainable recommendations for change. The message to all nations, policy makers, payers and healthcare professionals is clear: strive for excellence, but most importantly – start somewhere

Predictors of post-operative mortality following treatment for non-ruptured abdominal aortic aneurysm

The aim of this prospective study of patients undergoing repair of non-ruptured abdominal aortic aneurysm between 1999 and 2003 was to evaluate and compare risk factors for mortality after surgery, to determine a complex of informative factors for lethal outcome, and to define patient risk groups. Logistic regression analysis revealed a complex of informative factors, including female gender, previous myocardial infarction, age greater than 75 years, and clinical course of abdominal aortic aneurysm as important indicators for lethal outcome. A risk score model identified low-, moderate- and high-risk groups with mortality rates of 2.9%, 8.0% and 44.4%, respectively

The impact of age on post-operative outcomes of colorectal cancer patients undergoing surgical treatment

BACKGROUND: the purpose of study was to evaluate the impact of age on outcomes in colorectal cancer surgery. METHODS: patients on hospital database treated for colorectal cancer during the period 1995 – 2002 were divided into two groups: Group 1 – patients of 75 years or older (n = 154), and Group 2 – those younger than 75 years (n = 532). RESULTS: In Group 1, for colon cancers, proximal tumors were significantly more common (23% vs. 13.5%, p < 0.05), complicated cases were more frequent (46 % vs. 33%, p = 0.002), bowel obstruction more common at presentation (40% vs. 26.5%, p = 0.001), and more frequent emergency surgery required (24% vs. 14%, p = 0.003). Postoperative overall morbidity was higher in the elderly group, but with no differences in surgical complications rate. Overall 5 year survival was 39% vs. 55% (p = 0.0006) and cancer related 5 year survival was 44% vs. 62% (p = 0.0006). Multivariate Cox analysis showed that age was not an independent risk factor for postoperative mortality. CONCLUSION: Preoperative complications and co-morbidities, more advanced disease, and higher postoperative nonsurgical complication rates adversely affect postoperative outcomes after surgery for colorectal cancer in the elderly

Microvessel density as new prognostic marker after radiotherapy in rectal cancer

<p>Abstract</p> <p>Background</p> <p>The extent of angiogenesis is an important prognostic factor for colorectal carcinoma, however, there are few studies concerning changes in angiogenesis with radiotherapy (RTX). Our aim was to investigate changes in tumor angiogenesis influenced by radiotherapy to assess the prognostic value of angiogenesis the microvessel density (MVD) in overall survival after radiotherapy.</p> <p>Methods</p> <p>Tumor specimens were taken from 101 patients resected for rectal cancer. The patients were divided into three groups according to the treatment they received before surgery (not treated, a short course, or long course of RTX). Tumor specimens were paraffin-embedded and immunohistochemistry was performed with primary antibody against CD-34 to count MVD.</p> <p>Results</p> <p>MVD was significantly lower in the group of patients treated with a long course of RTX (p <0.025). The mean MVD for the long RTX group was 134.8; for the short RTX group – 192.5; and for those not treated with RTX – 193.0. There were no significant statistical correlations between MVD and age, sex, grade of tumor differentiation (G) and tumor size (T) in those untreated with RTX. In long RTX group we found a significant prognostic rate for MVD when the density cut off was near 130 with 92.3% sensitivity and 64.7% specificity. When the MVD was lower than a cut off of 130, the survival period significantly increased (p = 0.001), the mortality rate is significantly higher if the MVD is higher than 130 (microvessel/mm²) (1953.047; p = 0.002), if the histological grade is moderate/poor (127.407; p = 0.013), if the tumor is T3/T4 (111.618; p = 0.014), and if the patient is male (17.92; p = 0.034) adjusted by other variable in model.</p> <p>Conclusion</p> <p>Our results show that a long course of radiotherapy significantly decreased angiogenesis in rectal cancer tissue. MVD was found to be a favourable marker for tumor behaviour during RTX and a predictor of overall survival after long course of RTX. Further investigations are now needed to determine the changes in angiogenesis during a shorter course of RTX.</p

Anesthesia for ambulatory anorectal surgery

The prevalence of minor anorectal diseases is 4–5% of adult Western population. Operations are performed on ambulatory or 24-hour stay basis. Requirements for ambulatory anesthesia are: rapid onset and recovery, ability to provide quick adjustments during maintenance, lack of intraoperative and postoperative side effects, and cost-effectiveness. Anorectal surgery requires deep levels of anesthesia. The aim is achieved with 1) regional blocks alone or in combination with monitored anesthesia care or 2) deep general anesthesia, usually with muscle relaxants and tracheal intubation. Modern general anesthetics provide smooth, quickly adjustable anesthesia and are a good choice for ambulatory surgery. Popular regional methods are: spinal anesthesia, caudal blockade, posterior perineal blockade and local anesthesia. The trend in regional anesthesia is lowering the dose of local anesthetic, providing selective segmental block. Adjuvants potentiating analgesia are recommended. Postoperative period may be complicated by: 1) severe pain, 2) urinary retention due to common nerve supply, and 3) surgical bleeding. Complications may lead to hospital admission. In conclusion, novel general anesthetics are recommended for ambulatory anorectal surgery. Further studies to determine an optimal dose and method are needed in the group of regional anesthesia

Comparison of two different methods of analgesia. Postoperative course after colorectal cancer surgery

Background. The purpose of our study is to compare two methods of postoperative analgesia in colorectal cancer patients after resectional operations, and to evaluate advantages and limitations of each method on the postoperative course of these patients. Methods. One hundred patients scheduled to undergo elective colorectal cancer surgery were randomized into two groups; after general anesthesia, one group received epidural analgesia (n=50) and the second one \u96 intramuscular pethidine analgesia (n=50). Visual analogue scale at rest and on coughing was used to compare intensiveness of pain between the two groups during the day of surgery and first three postoperative days. Patients\u92 mood and self-satisfaction were evaluated using self-assessment manikin scale. Side effects of both analgesia techniques were registered. All complications and postoperative hospital stay were also evaluated. Results. Visual analogue scale pain scores at rest and on coughing were significantly better in epidural analgesia group as compared to systemic intramuscular pethidine analgesia group (p<0.05). Additional analgesics were needed for 10 (20%) and 28 (56%) patients respectively to keep visual analogue scale pain scores below 5. Adverse effects such as profound sedation, nausea and vomiting were more frequent in systemic intramuscular pethidine group, but pruritus \u96 very uncommon to compare with epidural analgesia group (p<0.05). There were no significant differences between the two groups in respect to complications and postoperative hospital stay. Conclusions. Epidural analgesia has demonstrated significantly better effectiveness than intramuscular pethidine analgesia after colorectal cancer surgery with fewer adverse events. Self-assessment manikin scores showed better self-satisfaction in patients of epidural analgesia group as compared to patients in systemic pethidine group