The effect of a small dose of ketamine on postoperative analgesia and cytokine changes after laparoscopic cholecystectomy.

BACKGROUND AND OBJECTIVES: In this study we assesed the effect of a small dose of ketamine on the production of TNFα, IL-1ß and IL-6 and the postoperative pain in patients undergoing laparoscopic cholecystectomy. METHODS: Fifty patients undergoing laparoscopic cholecystectomy were randomized in two equal groups. Patients in the ketamine group after induction in anesthesia received ketamine--025 mg/kg(-1). At the same time patients from the control group received sodium chloride. Postoperatively, the pain was assessed with VAS at periods of 30 min at 1, 2, 4, 8, 18, 24 and 48 hours. TNFα, IL-1ß and IL-6 were evaluated before surgery at 4, 18 and 24h after the operation. RESULTS: Differences of mean values of TNFα and IL-1ß between the two groups in the postoperative period were not significant. Mean values of IL-6 in the investigated group A were significantly lower than the mean values of IL-6 in the investigated group B after the 4th hour (p=0.00990), after the 18th hour (p=0.00133) and as after the 24th hour following surgery (p=000860). the difference in pain intensity according to the VAS scale was also statistically significantly smaller in group A after 30 min, 1,2,8 and 12 hours after surgery. CONCLUSIONS: The addition of a small-dose of ketamine in patiens undergoing laparoscopic cholecystectomy resulted in attenuation of secretion of TNFα, IL-1ß, IL-6 and reduction of postoperative pain.

Functional outcome and quality of life after restorative proctocolectomy and ileal pouch-anal anastomosis.

Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice for patients with medically refractory ulcerative colitis, ulcerative colitis with dysplasia or cancer, or familial adenomatous polyposis (FAP). The aim of this study is to report our 6-year experience of restorative proctocolectomy and IPAA at a tertiary referral centre. Chart review was performed for 7 patients undergoing IPAA from 2006 to 2010. Preoperative histopathological diagnoses were ulcerative colitis (n=5), FAP (n=1) and other (n=1). We collected data regarding patient demographics, type and du-ration of the disease, previous operations and indications for surgery. We analysed the operative protocols and postoperative pathological diagnoses. Early (within 30 days after surgery) and late complications were noted. Follow-up was conducted upon annual function and a quality of life questionnaire, physical examination and endoscopic evaluation of the pouch. Postoperative histopathological diagnoses were: ulcerative colitis (n=3), indeterminate colitis (n=2), FAP (n=1) and colonic necrosis and gangrene (n=1). The average age of the operated patients was 48, with a female predomination of 71%. The mean duration of the follow-up was 4 years. We report 2 cases of steroid use prior to operation as well as 2 cases of extraintestinal manifestations. We report no septic complications and 3 cases of pouchitis. Functional results and quality of life were good to excellent in all 7 cases of IPAA. Restorative proctocolectomy with IPAA is a safe procedure with a low morbidity rate. Functional results are generally good and patient satisfaction is high.

Preservation of the vegetative pelvic nerves and local reccurence in the operative treatment of rectal cancer.

Life quality of the patients operated from rectal cancer is a serious problem. Despite the curing as a primary objective in the treatment of the rectal cancer, special attention is paid to the life quality upon the performed operation on the subjected patients. The analyzed series consists of 29 patients with rectal cancer, operated on at the Digestive Surgery Clinic within the framework of the Clinical Centre in Skopje, in the period between 2001-2006. Our series involves patients from the T2 and T3 stage of the illness, where it possible to preserve the vegetative pelvic nerves, that are characterized by a relatively long-lasting symptomatology and relatively high percentage of lymphatic metastases. The standardization of the operative intervention resulted in an increase in the number of patients with continuous operations and preservation of the neuro-vegetative plexus without influencing the radicalism of the intervention. The application of the Stapler and Double Stapler technique brought about an increase in the number of continuous operations characterized by a termino-terminal colorectal anastomosis. On the other hand the preventive creation of LOOP ileostomies in the case of the ultra low resections resulted in a decrease in the level of dehiscence of this type as one of the most common and most difficult complications. The preservation of the pelvic neuro-vegetative plexus prolongs the operation time by 30 to 60 minutes, depending on the case and the patient. We assume that the procedure does not have a particular influence on the frequency of the complications, and at the same time it positively affects the revival of the urinal and sexual function. Taking into consideration the fact that the lymphatic dissection increases the possibility of removal of the malignant tissue and enables an adequate "staging" and on the other hand the preservation of the pelvic plexus improves the quality of life, both in terms of the sexual function and the function of the urinary bladder, it is recommended that this way of treatment becomes an integral part in the surgical treatment of the rectal cancer.