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Open access

Norbert Sławeta and Stanisław Głuszek

Thyroid resection procedures are the most common endocrine surgery procedures in Poland; an estimated 25 000 procedures are performed annually. Long term patient outcomes are rarely analyzed.

The aim of the study was to assess effect of complicated thyroid burgery procedur es on personal and Professional life of patients.

Material and methods.

Follow-up of patients with complications was conducted according to a predetermined protocol involving survey and biochemistry.

Results.

Unilateral and bilateral vocal cord paralysis accounted for 69% and 8% of complications, respectively. The complications resolved unilaterally in 58% of patients with bilateral vocal cord paralysis. Persistent hypoparathyroidism accounted for 26% of cases of postoperative hypoparathyroidism. Following thyroid resection procedures all patients received supplementation of thyroid hormones and were monitored by an endocrinologist until their follow-up examination. Eighty eight percent patients with vocal cord paralysis were treated at an outpatient department of laryngology and/or speech therapy. Physical therapy resulted in improvement irrespective of final nature of the complications. Vocal cord paralysis or both complications concurrently result in marked prolongation of absence from work and resulted in disability pension in 15% of professionally active patients.

Low level of adaptation to diseas e was found in 19% patients in the study group, while low score on Satisfaction with Life Scale (SWLS) was found in 17% patients in the study group, irrespective of the type of complication.

Conclusions.

Acceptance of complications after thyroid surgical procedures is difficult for patients and worsens their life satisfaction in the long term follow-up and adversely modifies their professional and personal life.

In the long term perspective, persistent hypoparathyroidism is more burdensome for patients than recurrent laryngeal nerve injury. Chronic deficit of innervations does not require chronic substitution or specialist therapy that are necessary in the persistent hypoparathyroidism.

Open access

Krzysztof Bartosz and Stanisław Głuszek

Need Assessment for Gastroscopy in Patients with Gall-Stones

Cholelithiasis (gall-stones) occurs in 13% of the Polish population. Patients affected with gall-stones notify non-specific symptoms caused by pathology of the upper segment of the digestive track which coexists with gall-stones.

The aim of the study was to analyze the risk of occurrence of pathological changes, within the part of the digestive track in patients affected with gall-stones, to assess the correlation between data of medical histories of patients and results of gastroscopy based diagnosis; to devise tactics of alterations to the planned measures in case a clinically significant disease has been diagnosed.

Material and methods. The study group comprised 615 patients, qualified for cholecystectomy, with symptomatic gall-stones, verified by an ultrasound diagnosis. After being interviewed and examined, all the patients were subjected to gastroscopy, and when necessary biopsy was performed. The statistical analysis was performed using an multifactorial analysis (Pearson's correlation coefficient for categorical variables).

Results. Among 615 patients, the subjects in the study, we found 183 ones (29.7%) with a normal upper digestive tract, we found pathology of the upper digestive system in 70.3% cases (432 patients). Serious pathology resulting in changing the planned treatment was found in 83 patients (13.5%): among those four ones had gastric carcinoma, sixty-three ones suffering from chronic peptic ulcer disease (gastric or/and duodenal), twelve patients were affected with hemorrhagic gastritis, four patients had GERD C and D. In a group of 83 patients cholocystectomy was postponed and the diagnosed disease was treated. Four patients were operated on because of gastric cancer, with intention of cure.

Conclusions. 1. Routine gastroscopy performed before cholecystectomy is justified. The percentage of abnormalities diagnosed during gastroscopy proved the above mentioned thesis. 2. Medical histories and an object examination do not allow to state explicitly that there is another disease of the upper part of the digestive system which coexists with gall-stones. In case of diagnosing the other pathology it is necessary to take into consideration an alteration of tactics of management: to delay an operation and treat the other disease which has been diagnosed.

Open access

Jarosław Matykiewicz and Stanisław Głuszek

Spontaneous Rupture of the Spleen - A Rare Case

The study presented two cases of spontaneous rupture of the spleen. Both patients were treated at the Department of General, Oncological, and Endocrinological Surgery. The first patient underwent splenectomy. The postoperative course was uneventful. The second patient was subject to pharmacological treatment because of non-acceptance to surgical intervention. The patient died during the following hospitalization. Both patients received oral anticoagulants, due to atrial fibrillation and an implanted heart valve. History of previous trauma was absent. The study presented a detailed description of the clinical course of splenic rupture.

Open access

Stanisław Głuszek and Dorota Kozieł

Abstract

Acute pancreatitis (AP) is a significant clinical problem. There have been no prospective epidemiological data on AP in Poland. The aim of this study is to estimate prevalence, etiology and severity of acute pancreatitis in the Świętokrzyskie Voivodeship population, involving risk factors of this disease.

Material and methods. In 2011 prospective observation was conducted in all departments of surgery of the Świętokrzyskie Voivodeship. The inclusion criterion of the study, a definite diagnosis of AP, was met in 1044 hospitalized patients. According to our assumption that repeated hospitalization is considered as a new case if occurred more than 60 days after the previous one, 1004 patients were included in the further analysis.

Results. The incidence rate was 99.96/100,000. Incidence rate among woman was 72/100,000 and incidence among men was 130.24/100,000 (p < 0.05). Median age of AP patients was 53 years. Median age among woman (65 years) was significantly (p < 0.005) higher than among man (47 years). Incidence rate for the first episode was 79.7/100,000 citizens. Main causes of AP included cholelithiasis (30.1%), alcohol (24.1%), coexisting cholelithiasis and alcohol abuse (2.9%), pancreatic cancer (1%), AP after ERCP (0.7%). Basing on modified Atlanta criteria, severe AP was diagnosed in 7%, moderate in 12.3%, and mild in 80.7% of patients. Mean duration of hospitalization of patients with severe AP was 14.8, moderate - 16,7, mild - 7.1 days. Mortality rate for AP was 3.9%. Mean age of deceased women was 74 years and was significantly higher than in the group of men (61 years). Mortality rate in severe AP was 52.9% and was significantly (p < 0.05) higher than mortality in moderate (no deaths) or mild AP (0.2%).

Conclusions. Incidence rate of AP in the Świętokrzyskie Voivodeship population is among the highest in Poland. Our study indicates that new Atlanta classification, that differentiates between moderate and severe AP, needs to be implemented to the clinical practice, since the latter carries high mortality in severe cases.

Open access

Jarosław Matykiewicz, Stanisław Głuszek and Sławomir Szafran

The Influence of Anti-Platelet and Antithrombotic Treatment on the Clinical Course of Bleeding into the Lumen of Alimentary Tract Upper Segment

The most frequently used drugs which may cause bleeding into the lumen of alimentary tract include: acetylsalicylic acid (ASA), ticlopidine/clopidogrel and acenocoumarol.

The aim of the study was to analyze the frequency of the occurrence of bleeding into the lumen of alimentary tract upper segment (gopp) in patients taking anti-platelet drugs and oral anticoagulants, treated at the surgical department.

Material and methods. The study covered a group of 164 patients treated at the Clinical Surgery Department of the Provincial Hospital in Kielce over the years 2006-2009. They were consecutive patients admitted to hospital with the initial diagnosis of bleeding into the lumen of gopp. The diagnosis was made on the basis of medical history, clinical examination and additional investigation. In all patients within 24-48 hours after the admission endoscopy of gopp was performed.

Results. 164 patients with symptoms of bleeding into the lumen of gopp were treated. Among them there were 94 men (57%) as well as 70 women (43%). The average age was 61.8 years (from 23 to 91 years). In this group 24.4% (40/164) patients took drugs influencing coagulation system (acetylsalicylic acid, clopidogrel and/or acenocoumarol). In the subgroup taking the drugs mentioned above were 21 men (52.5%) and 19 women (47.5%). The average age was 73.6 years (from 48 to 91 years). Among patients taking drugs influencing hemostasis system 23 patients took ASA preparations, ticlopidine/clopidogrel - 5 patients and acenocoumarol - 12 patients. 8 patients took more than one drug, most frequently ASA and ticlopidine/clopidogrel, 1 patient took three drugs. 6 deaths were reported in the group taking drugs. Mortality rate was 15% (6/40). Among the deceased patients significantly lower (p<0.001) concentration of hemoglobin at the admission can be noticed (average concentration of Hb reached 6.1 g/dl) as well as non-interchangeably higher (p=0.13) average age of patients (average age of the deceased patients was 77.2 years). All the deceased patients were admitted to hospital with hypovolaemic shock. Results were statistically analyzed by the use of the test for comparison of two proportions and the t-Student test for the difference in expected values.

Conclusions. Bleeding into the lumen of gopp induces considerable mortality, especially in patients with low hemoglobin concentration and hypotension at the admission to hospital. During the treatment of a patient with bleeding into the lumen of gopp a compromise between the risk of cardiovascular complications and the risk of death due to bleeding should be searched for.

Open access

Norbert Sławeta, Stanisław Głuszek and Jacek Heciak

Clinical and metabolic consequences of complicated thyroid resection procedures are rarely an object of complex analysis, and teams participating in treatment may have a very limited knowledge of them.

The aim of the study was to assess clinical and metabolic consequences of complicated thyroid surgical procedures.

Material and methods. In the years 2002-2007, 756 patients underwent surgery due to non-neoplastic thyroid diseases. Sixty-nine (9.1%) patients experienced complications manifesting as vocal cord paralysis and/or hypoparathyroidism. Follow-up examination was conducted in a group of 42 persons, which amounted to 61% of patients who experienced complications following thyroid surgical procedures. Follow-up examination, comprising assessment of morphotic blood elements, electrolyte, lipid and parathormone blood concentrations, thyroid hormone activity, respiratory function, vocal cord mobility, bone mineralization and ultrasound examination of the pocket left after thyroid resection, was conducted after the mean period of 43 months following surgery.

Results. In the analyzed group, no significant differences in plasma electrolyte content were found (sodium, potassium, magnesium, calcium and phosphorus ions). In the group of patients with chronic hypoparathyroidism, no hypophosphatemia was observed, and there were no reports of concomitant nephrolithiasis or cataract. Increased cholesterol concentration was observed in the group of patients with chronic hypoparathyroidism and without hypoparathyroidism (p = 0.07). In 35% of patients with chronic vocal cord paralysis, abnormal results of spirometry tests were obtained. In the group of patients with chronic hypoparathyroidism, densitometry examination revealed higher T-score values compared with patients with transient hypoparathyroidism and vocal cord paralysis (p = 0.07). No bone mineralization disorders manifesting as pathological fractures were noted.

Conclusions. The knowledge of clinical and metabolic consequences of complicated thyroid surgical procedures, due to their complexity, may be very limited among the members of both surgical teams and teams involved in management of complications. Development of a complication following thyroid surgery may be associated with significant homeostasis disorders, especially as regards calcium-phosphate metabolism, the skeletal system and the respiratory system.

Such disorders can manifest long after the disease onset, only properly intensified and long-term management allows limitation of their extent.

Open access

Dorota Kozieł, Jarosław Matykiewicz and Stanisław Głuszek

Gastrointestinal Bleeding in Patients Aged 85 Years and Older

The aging of the population is associated with the increased risk of chronic diseases, and greater consumption of drugs used in their treatment, which may lead towards gastrointestinal bleeding.

The aim of the study was to analyze the reasons, treatment results, complications and mortality connected with gastrointestinal bleeding in patients aged 85 years and older.

Material and methods. The study comprised the retrospective analysis of 84 patients, aged between 85 and 97 years admitted to the Department of General Surgery with diagnosis of gastrointestinal bleeding, during the period between 2005 and 2010. The results were compared to a younger control group of 151 patients (mean age-53 years) with gastrointestinal bleeding, admitted to the department during the same period. Diagnosis was based on the history, physical examination, endoscopy, morphology and biochemical lab results. Analysis considered the therapeutic method used, treatment results, complications and hospital mortality. The endoscopic picture and risk of recurrent bleeding in patients with upper gastrointestinal hemorrhage was evaluated by means of the clinical Forrest scale. Results were subject to statistical analysis.

Results. Most of the gastrointestinal bleeding cases considering patients aged 85 years and older concerned the upper gastrointestinal tract (41.67%). Thirty (35.71%) patients were on drugs affecting the coagulation system. On admission, the average hemoglobin concentration level in the elderly was comparable to results observed in case of the control group. Considering patients aged 85+, drugs affecting the coagulation system were used statistically more frequently, as compared to younger patients. Recurrence of bleeding was observed in 10 (11.9%) study group patients.

Overall mortality due to gastrointestinal bleeding in elderly patients amounted to 20.24% and was statistically higher, as compared to the control group- 7.2%.

Conclusions. Treatment results in case of gastrointestinal bleeding in the elderly patients (above 85 years) are burdened with a higher mortality rate. Different diagnostic and therapeutic methods should be applied in case of elderly patients (above 85 years), in order to increase their chance of survival. The problem of aging is an epidemiological phenomenon and gastrointestinal bleeding will become an increasing problem, needing to be solved in everyday clinical practice.

Open access

Stanisław Głuszek, Maria Korczak, Marta Kot, Jarosław Matykiewicz and Dorota Kozieł

Digestive System Fistula - A Problem Still Relevant Today

Digestive system fistula originates most frequently as a complication after surgical procedures, less often occurs in the course of inflammatory diseases, but it can also result from neoplasm and injuries.

The aim of the study was to analyze the causes and retrospectively assess the perioperative procedures as well as the results of digestive system fistula treatment.

Material and methods. Own experience in digestive system fistula treatment was presented. The subject group consisted of 32 patients treated at the General Surgery, Oncology and Endocrinology Clinical Department between 01.05.2005 and 30.04.2010 due to different digestive tract diseases. The causes of the occurrence of digestive system fistula, methods and results of treatment were analyzed.

Results. The analysis covered 32 patients with digestive system fistula, among them 15 men and 17 women. Average age for men was 57 years (20-78), and for women 61 years (24-88). In 11 patients idiopathic fistula causally connected with primary inflammatory disease (7 cases) and with neoplasm (4 cases) was diagnosed, in 19 patients fistula was the result of complications after surgery, in 2 - after abdominal cavity injury. Recovery from fistula was achieved in 23 patients (72%) with the use of individually planned conservative therapy (TPN, EN, antibiotics, drainage, and others) and surgery, depending on the needs of individual patient. 5 patients (16%) died, whereas in 4 left (12%) recovery wasn't achieved (fistula in palliative patients, with advanced stages of neoplasm - bronchoesophageal fistula, the recurrence of uterine carcinoma).

Conclusions. Recently the results of digestive system fistula treatment showed an improvement which manifests itself in mortality decrease and shortening of fistula healing time. Yet, digestive system fistula as a serious complication still poses a very difficult surgical problem.

Open access

Stanisław Głuszek, Łukasz Nawacki, Jarosław Matykiewicz, Marta Kot and Jakub Kuchinka

Abstract

Acute pancreatitis (AP) develops as a result of the imbalance of the mechanisms inhibiting the activity of enzymes in the pancreatic cells, which causes their autoactivation in the pancreas. The incidence of AP ranges from 10 up to 100 cases per 100,000 population per year in different parts of the world. The overall mortality rate for acute pancreatitis is 10-15%. The mortality rate in patients diagnosed with the severe form of acute pancreatitis is up to 30-40%.

Material and methods. The study included 10 patients treated due to acute pancreatitis in two surgical departments run by one of the authors (S.G.) in the years 2004-2014, who developed a serious complication in the form of haemorrhage into the inflammatory tumour/pancreatic cyst or an adjacent organ. Haemorrhage was diagnosed based on the clinical picture, most often a sudden drop in blood pressure, peritonitis symptoms and imaging findings – abdominal ultrasound and abdominal computed tomography. Therapeutic methods included conservative treatment, endovascular embolisation and, in the absence of efficacy of the above mentioned methods, surgical treatment. Patients age and gender, the etiological factor, comorbidities, Atlanta Classification, treatment outcomes and mortality rate were assessed.

Results. Alcohol was the most common etiological factor in the investigated AP cases. The patients received conservative treatment, interventional radiology treatment (endovascular embolisation) or surgical treatment. In the study group, 6 patients required surgical treatment, 3 patients received invasive radiology treatment, and conservative treatment was used in one patient. The mortality rate in the study group was 30%.

Conclusions. Haemorrhages into the inflammatory cisterns or adjacent organs (stomach, transverse colon mesentery) secondary to AP are the most severe complications, which are difficult to manage. The successful use of interventional radiology methods to inhibit and prevent the recurrence of bleeding in some of the patients is a significant milestone.

Open access

Stanisław Głuszek, Jarosław Matykiewicz, Dorota Kozieł, Dariusz Klimer, Iwona Wawrzycka and Aleksandra Ogonowska

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) is the most important non-surgical procedure in serious pancreatic and biliary diseases, still burdened with the risk of severe complications. The objective of the study was to distinguish factors which could increase the risk of occurrence of ERCP complication in the form of pancreatitis.

Material and methods. The study included 452 patients who had undergone ERCP. Patients’ records were retrospectively analyzed from the aspect of demographic data, indications for the procedure, type and course of the procedure, type and severity of complications, width of the common bile duct (CBD), concomitant diseases and administered medicines which might increase the risk of complications.

Results. In 35 patients (7.7%) a complication occurred in the form of pancreatitis (AP). A severe course was confirmed in 11 patients (31%). Cholelithiasis constituted approximately 2/3 of indications for ERCP. AP after ERCP was significantly more often observed in the group of patients aged under 40 (22.9% vs 8.6%; p<0.05). Narrow biliary ducts (3-8 mm) were the factor increasing the frequency of development of AP (25.9% vs 45%; p<0.05). Death occurred in 5 patients (1.1%), including 4 patients (0.96%) in the group without complications, and in 1 patient (2.85%) with complicated AP.

Conclusions. ERCP is a very valuable procedure in clinical treatment; however, it is burdened with the risk of complications, such as AP, bleeding, or duodenal perforation. A group especially exposed to the risk of complications in the form of AP are young patients aged under 40 with a narrow CBD.