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Tomasz Stefaniak

Erythrophobia - Problems of Diagnostics and Treatment

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Tomasz J. Stefaniak and Marta Ćwigoń

The side effects following thoracic sympathectomy for primary hyperhidrosis include pain and compensatory/ reflex sweating.

The aim of the study was the evaluation of the results of the endoscopic sympathicotomy with clips with emphasis on the frequency of side effects following the operation.

Material and methods. Two-hundred-eighty-three patients were qualified to thoracic T3-T4 sympathicotomy with clips. In all cases bilateral procedure in prone position with CO2 insufflation was performed. The subjective intensity of disease was evaluated by VAS scale (0 - no sweating; 10 - maximal possible sweating) while the recurrence of the sweating in primary localization, intensity and dynamics of compensatory and plantar sweating were evaluated post-operatively. Follow-up data were obtained during office visits 3, 12 and 36 months after surgery. The overall follow-up response was 74.6%.

Results. There was no mortality. Perioperative morbidity included 6 cases of pneumothorax. The mean duration of surgery was 57 minutes bilaterally. The postoperative intercostal pain was present in all patients (100%) with mean duration of 21.88 days but in 72.6% of cases it did not demand any medication as early as 48 hours after surgery. Strong or very strong compensatory sweating was observed in 17.5% of cases 3 months after ETS, in 14.1% after 12 months and in 23.6% after 36 months.

Conclusions. Thoracic sympathicotomy with clips is a safe treatment that provides satisfactory longterm results. The incidence of side-effects (intercostal pain, compensatory sweating) is high and does not change with time in most of the cases.

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Tomasz J. Stefaniak, Łukasz Dobosz, Maciej Kaczor and Marta Ćwigoń

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Monika Proczko-Markuszewska, Tomasz Stefaniak, Łukasz Kaska and Zbigniew Śledziński

Early Results of Roux-en-Y Gastric By-Pass on Regulation of Diabetes Type 2 in Patients with BMI Above and Below 35 Kg/m2

The idea of surgical treatment of type 2 diabetes was established in the U.S. and was based on observation of patients after bariatric operations. Performed in cases of morbid obesity exclusion of the duodenum and anastomose the stomach with the central part of the intestines cause shortened absorbtion of nutrients, what showed a beneficial effect on weight loss, resolution of comorbidities and reduce the risk of developing cardiovascular diseases and cancer. Analysis of the results of surgical treatment of obese patients with type 2 diabetes confirmed the usefulness of surgical methods.

The aim of the study was to evaluate the impact of Roux-en-Y gastric by-pass (RYGB) on diabetes in patients with BMI below and above 35 kg/m2.

Material and methods. The study comprised 66 patients with DM2, who underwent Roux-en-Y gastric bypass due to morbid obesity (BMI above 35 kg/m2) and three patients with DM2 and BMI below 35 kg/m2. In patients with DM2 and BMI < 35 kg/m2 criteria for inclusion in the operational treatment were: DM2 difficult to be regulated pharmacologically lasting less than 10 years and BMI at the qualification about 35 kg/m2. Indications have been determined on the basis of three consecutive measurements of HbA1c values above 7%, and measurements of blood glucose (frequent fluctuations in blood glucose levels on the value of hypoglycemia to hyperglycemia).

Results. The criteria for diagnosing resolution of DM2 included the level of HbA1c < 6% and glucose fasting level below 100 mg/ dl. In a group of 66 patients with DM2 and obesity, regression of DM2 was observed in 48 patients (73%) as early as during the hospitalization. In 11 patients (16.7%) glycaemia and HBA1c were stabilized within 8 weeks after surgery. In 7 (10.6%) cases of patients with difficult to control DM2, there was still need for antidiabetic medication, but glycemic control was much more effective. After one year remission was observed in 89% of patients. In all three patients with DM2 and BMI < 35 kg/m2 total glycemic resolution of DM2 was observed during hospitalization. In this group there has been no postoperative complications. In the group of 66 obese patients with DM2 postoperative complications were found in 7 cases, they were related to infection and prolonged healing of surgical wound. One patient had an intraabdominal abscess located in the left subphrenic region, it was punctured under ultrasound guidance.

Conclusions. The ultimate evaluation of this method demands several years of meticulous clinical studies. Despite of that, considering high cost of life-long conservative therapy of DM2 and its complications, severe impact on quality of life and serious consequences of the disease, the surgical metabolic intervention may become the most resonable solution in many cases.

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Jarek Kobiela, Monika Proczko-Markuszewska, Tomasz Stefaniak and Birjit Dijkstrak

Cervical Chyloma After Thyroidectomy - Two Case Reports and Review of the Literature

Thoracic duct injuries are a rare complication of thyroid surgery. This report documents two cases of thoracic duct injury complicated by formation of chyloma following thyroid surgery. The injury was identified post-operatively and treated successfully. We review the diagnostic and therapeutic options and discuss their applicability to our patients.

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Tomasz Śledziński, Monika Proczko-Markuszewska, Łukasz Kaska, Tomasz Stefaniak and Julian Świerczyński

Serum Cystatin C in Relation to Fat Mass Loss After Bariatric Surgery"

Serum cystatin C concentration, generally accepted as renal function marker, is associated with cardiovascular risk and metabolic syndrome. Recent studies indicate that cystatin C increases in human obesity and that adipose tissue contributes to enhanced serum cystatin C concentration in obese subjects.

The aim of the study was to assess whether a reduction in body and fat mass after bariatric surgery has any impact on serum cystatin C concentrations.

Material and methods. Serum from 27 obese patients were tested before and 6 months after bariatric surgery. Twenty healthy subjects with normal body weight served as controls. Serum cystatin C concentrations were assayed by ELISA.

Results. Serum cystatin C concentrations were significantly higher in obese patients compared with non-obese subjects. Decrease of body and fat mass after bariatric surgery resulted in improvement of several parameters associated with cardiovascular risk and metabolic syndrome, like serum lipids, blood pressure and insulin sensitivity. Surprisingly the mean postoperative serum cystatin C concentration was not significantly different from that before surgery. Serum creatinine and GFR also remained unchanged.

Conclusion. The results presented here suggest that serum cystatin C concentration is not tightly associated with body and fat mass loss in obese patients after bariatric surgery.

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Tomasz J. Stefaniak, Dariusz Łaski, Maciej Patrzyk, Justyna Bigda and Zbigniew Śledziński

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Monika Proczko-Markuszewska, Jarosław Kobiela, Tomasz Stefaniak, Andrzej Łachiński and Zbigniew Śledziński

Postoperative PTH Measurement as a Predictor of Hypocalcaemia After Thyroidectomy

Hypocalcemia after thyroidectomy is the most common postoperative complication with reported incidence from 0.5% to even half of the operated patients. Hypoparathyroidism could be a result of careless or inadequate preparation during the surgical procedure. There is a variety of proposed options for prediction of the incidence of hypocalcemia. The most effective of them are the perioperative and intraoperative measurements of PTH level.

The aim of the study was to assess the potential correlation between the iPTH levels after the operation and development of hypocalcaemia. The possible prediction value of postoperative iPTH levels was to be evaluated assessed.

Material and methods. A prospective study was performed on 100 patients who underwent total thyroidectomy from January 2007 to June 2009. The total calcium level and intact human PTH (iPTH) levels were measured 24 hours before, 1 and 24 hours after the surgery.

Results. We have presented a significant correlation between early iPTH measurement and risk of hypocalcaemia. Moreover a significant correlation between the iPTH level 1 hour after operation with the calcium level 24 hours after the operation was demonstrated.

Conclusions. Early postoperative assessment of iPTH levels can be used to identify the group of patients at risk of hypocalcaemia after thyroidectomy. Pre-emptive calcium supplementation can lead to avoidance of complications causing prolonged hospital stay and most importantly to prevent severe hypocalcemia.

Open access

Bartosz Skonieczny, Maciej Pytka, Tomasz Stefaniak, Wojciech Skonieczny, Zbigniew Grzybowski and Zbigniew Śledziński

Factors Influencing Frequency of Conversion During Laparoscopic Cholecystectomy

The aim of the study was to evaluate factors influencing the frequency of conversion during laparoscopic cholecystectomy; to observe dynamic trends concerning frequency of classic versus laparoscopic cholecystectomies; and to evaluate correlations between the experience of a surgeon and conversion incidence.

Material and methods. A retrospective study was performed, reviewing the records of 3337 patients operated on for gallbladder stones from January 2000 to December 2005 in three hospitals in the Pomeranian Region of Poland: Department of General, Endocrine and Transplant Surgery, Medical University of Gdańsk; Department of Surgery, 110th Military Hospital in Elbląg and Department of Surgery, Hospital in Słupsk.

The main issues evaluated were: dynamic changes in frequency of laparoscopic versus classic cholecystectomies; frequency of conversions, reasons for conversion; correlation between experience of a surgeon and conversion incidence; and demographic data.

Results. Out of 3337 patients, there were 2390 (71.62%) females and 947 (28.3%) males. For these patients, 1493 procedures (45.2%) were performed as classical, 1804 (54.06%) as laparoscopic, and 176 (9.7%) as converted from laparoscopy to open procedure. Sex distribution in the laparoscopic group was 1352:452 (F:M 74.9%:25.05%) and in the converted group was 107:69 (60.8%:39.2%).

The main problems relating to conversion during laparoscopic cholecystectomy were: adhesions - 108 (61.36%), gall-bladder perforations - 8 (4.5%), tumors - 10 (5.6%), technical problems - 28 (15.9%), hemostasis problems - 11 (6.25%), unrecognizable anatomical structures - 24 (13.6%), complications of ‘e fundo’ cholecystectomy - 24 (13.6%) and equipment problems - 4 (2.27%).

It was also observed that SHO's and surgeons with greater experience are performing more conversions during laparoscopic procedures.

Conclusions. Laparoscopic cholecystectomy is a safe procedure recommended as a gold standard for gallbladder stone treatment. Frequency of this procedure is rising in centers in the Pomeranian region.

The highest incidence of conversions is associated with adhesions after previous open operations.

Consultants perform earlier conversion due to greater experience and better estimation of risk factors.

Open access

Monika Proczko, Łukasz Kaska, Jarek Kobiela, Tomasz Stefaniak, Dariusz Zadrożny and Zbigniew Śledziński

Recent years, obesity is a growing health problem also in patients with chronic renal failure and end it’s end stage. This situation has a negative impact both on the extension of the waiting period for transplantation, and the survival rate of the transplanted organ and the recipient. Weight loss through lifestyle modification before transplantation is ambiguous. Its well known fact of rapid body mass gain after transplantation, and finnaly the results of transplantation are not better than those of patients who have not reduced body weight.

The paper presents preliminary experience associated with bariatric operations of three chronic dialysed patients with morbid obesity BMI> 35 kg/m2, all patients had been treated by Roux-en-Y gastric by-pass (RYGB). All operated patients were classified as potential recipients were listed by Poltransplant. One of them three months after RYGB surgery underwent without complications a renal transplantation. Preliminary experiences based on operating these three caese confirmed the complete safety of this type of approach in patients with end-stage chronic kidney disease (CKD).