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).

The effect of salivary gland extract of Lucilia sericata maggots on human dermal fibroblast proliferation within collagen/hyaluronan membrane in vitro: transmission electron microscopy study.

BACKGROUND: Lucilia sericata maggots are applied to chronic wounds to aid healing when conventional treatments have failed. After their application into a necrotic wound, they potentially influence wound healing with a combination of specific proteinases that are involved in the remodeling of extracellular matrix. These proteases cause changes in fibroblast adhesion and spread upon extracellular matrix protein surfaces, affecting integrity of the protein surfaces-especially fibronectin-while maintaining cell viability. OBJECTIVE: This study focused on in vitro monitoring of the effect of homogenate substances prepared from maggot salivary gland of L sericata on the ultrastructure of human neonatal fibroblasts. METHODS: Collagen/hyaluronan membrane was used as the synthetic substitute of extracellular matrix. The cultured human neonatal fibroblasts B-HNF-1 were seeded on the surface of the collagen/hyaluronan membrane and cultured with maggot salivary gland extract (SGE) at a concentration of 2.4 glands/1 mL. RESULTS: The authors observed increased cell metabolism and protein production (euchromatic nucleus, voluminous nuclear membrane, large reticular nuclei, distended and filled cisterns of rough endoplasmic reticulum, Golgi apparatus with saccules, and vesicles packed with fine fibrillar material) after incubating the cells in culture medium with SGE. CONCLUSION: The authors believe that increased cell metabolism and protein production corresponded with formation of microfibrillar net used for migration of fibroblasts in culture, but mainly for proper production of extracellular matrix. The authors suggest that their results may help explain the effect of SGE on wound healing and support implementation of maggot therapy into human medicine.

Growth and Survival of Bagged Lucilia sericata Maggots in Wounds of Patients Undergoing Maggot Debridement Therapy.

Maggot debridement therapy (MDT) is an established method of debridement of nonhealing wounds. Despite intense clinical research about its efficacy and effects of substances produced by the larvae, growth and development of maggots in the wounds remain largely unexplored. In the present study, the bags with larvae (n = 52), which had been used to debride traumatic, ischemic, diabetic and venous ulcers, were collected and examined. Survival, length, width and larval instar of the maggots within each bag were recorded and analyzed with respect to the wound type and duration of the treatment. Survival of maggots after a 48-h cycle of MDT ranged between 63.6 and 82.7%. Maggots in venous ulcers had on average 9-19% higher mortality than maggots within traumatic, ischemic, and diabetic ulcers. Length of larvae after 48 h cycle of MDT reached on average 7.09-9.68 mm, and average width varied between 1.77 and 2.26 mm. Larvae in venous ulcers were significantly smaller after 48 h, but not after 72 h treatment compared to the other wound types. Further studies should be aimed to identify other patient-associated factors which might influence growth and survival of the larvae during maggot debridement therapy.

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.