Quality Improvement in an Anaesthesiology and Intensive Care Unit Through Pain Assessment and Control.

The aim of the study is to determine whether the assessment of postoperative pain and timely measures to control it improve the quality of medical care in intensive care units (ICUs). To develop an improvement model with a focus on pain assessment and control. 151 patients were included in the study, divided into two groups: a retrospective group (RG)-60 patients and a prospective group (PG)-91 patients. A multimodal approach to pain control was applied to all patients. We administered the Critical Care Pain Observational Tool (CPOT) to PG upon admission to the ICU. Visual analog scale (VAS) for pain assessment was used in all non intubated patients in 6 hours intervals. In the PG, а model for improvement was applied using a PDSA (Plan, Do, Study/ Check, Act) cycle. The following indicators have been used: process, outcome, and balancing indicators. A survey of the PG was also conducted. The developed Model of improvement increased the VAS score reporting success rate from 40 to 95%, which allowed significantly better pain control. In PG the registered CPOT score was 1.71 ± 0.73. 90% of patients in PG have an average VAS score below 5 after the improvement model, while in RG-50% of patients, which is statistically significant (P < 0.001). There was no statistically significant difference in balancing indicators between the two groups. Conclusion: The conducted survey confirmed the positive effect of the model. Quality improvement in the ICU depends on accurate assessment of postoperative pain and timely and adequate treatment.

Contrast-enhanced Chest Ultrasound in the Control of Transthoracic Tru-cut Needle Biopsies: A Case Report.

INTRODUCTION: The current article presents a clinical case of ultrasound controlled transthoracic tru-cut needle biopsy of a small metastatic lesion in the left lung, performed with contrast-enhanced ultrasonography (CEUS). The following case demonstrates a real-time interventional manipulation of a very small lesion, which was done under local anesthesia, with a minimal invasion to the patient. CASE PRESENTATION: A 72-year-old woman is presented, hospitalized for a left-sided pleural effusion with bilateral, multiple nodulеs of different sizes in the lungs. Thoracentesis revealed data for atypical cells in the pleural fluid. The CT scan suspected a probable neoplastic process, but the subsequently performed fiberbronchoscopy couldn't prove the existence of the same. The final diagnosis was established after ultrasound controlled transthoracic tru-cut needle biopsy of a pulmonary lesion with the application of a contrast medium. CONCLUSION: The CEUS allows precise detection of the metastatic area because of its unique perfusion characteristics and ability to remain hypocontrasted after the application of the contrast medium sulfur hexafluoride. The persistence of a concomitant left-sided pleural effusion is used as an ultrasound window during the performance of the manipulation, with the successful verification of the pathology as primary pulmonary adenocarcinoma. By the application of this minimally invasive manipulation, an accurate final histological result was obtained.

Germ cell tumor located in the midline of the anterior neck.

Primary germ cell tumors involving midline of the anterior neck are extremely rare. Here we report a 68-year-old male who was operated due to a mass lesion in the anterior neck with infiltration of the isthmus of the thyroid gland. Histopathological examination revealed a germ cell tumor with extragonadal localization in the anterior neck infiltrating the isthmus of the thyroid gland.

[Lymph nodes metastases in differentiated thyroid cancer--prognostic value and syrgical results with 430 patients for 30 years period (1980-2010)].

In this we review 430 differentiated thyroid cancer patients underwent surgery for 30 years period since 1980 to December 2009. The stage of disease was T1-3.Na-b.Mo(TNM). Papillary thyroid cancer patients were 77.2% and folicular thyroid cancer--22.8%. The regional lymph nodes metastases distribution were analyzed according to the age, sex, of the patients and tumor histology. Preoperatively,clinically involved were neck nodes in 35 patients 8.3%--26 patients with PTC and in 9 patients with FTC. Surgical procedures for low-risk group of patients were variable from lobectomy and istmusectomy to near total thyroidectomy and modified radical lymph node dissections of the neck and patients in high risk group underwent total thyroidectomy and radiojodine therapy. The level of regional recurrences was 1.7 folds higher in patients treated by total thyroidectomy and radiotherapy J131.

Lymph nodes metastases in differentiated thyroid cancer--prognostic value and surgical results with 430 patients for 30 years period (1980-2010).

The papillary cancer and the follicular cancer are the most common forms of thyroid malignitet. Based on 30-year follow up of 430 patients, who underwent differentiated thyroid cancer surgery, the incidence of the lymph nodes metastases and the rate of postoperative recurrence of the disease was studied and the performance criteria of modified radical lymph node dissection of the neck were specified. Papillary cancer patients were 77.2% (332 people) and follicular cancer patients were 22.8% (98%). At the time of the diagnosis 8.2% (35 people) of the patients had palpable lymph nodes metastases. All patients with lymph nodes metastases, which developed after the surgery, underwent successful treatment with a modified lymph node dissection of the neck. In none of the cases the lymph node metastases led to a fatal outcome.

[Retrosternal thyroid goiter: 20 years experience].

Retrosternal localization of thyroid pathology is not rare. We present a retrospective 20-years' research on 4225 patients with different thyroid diseases. 803 of them were with a different level/stage) of retrosternal localization of the gland. Our analysis reveals that the possibility of malignancy and difficult diagnosis make surgical treatment obligatory. It should be performed only by experienced in thyroid surgery specialists.

[Surgical diseases of thyroid gland].

Medical reports of 8,768 patients with various diseases of thyroid gland were analyzed. There were 1,563 (17.8) male and 7,201 (82.2%) female patients aged 6 to 86 years. One-nodular goiter was diagnosed at 13.85% patients, multinodular goiter - at 67.2%, diffuse toxic goiter - at 5.85%, thyreotoxic adenoma - at 4.91%, Hashimoto's thyroiditis - at 8.16% patients. Thyroid cancer was revealed at 1.56 patients with nodular goiter, at 8.45% - with multinodular goiter, at 2.72% - with diffuse toxic goiter, at 3.71% - with thyreotoxic adenoma, and at 27.09% patients with Hashimoto's thyroiditis. Totally thyroid cancer was diagnosed at 741 (8.45%) patients including 71.12% papillary cancer, 26.47% follicular cancer and 2.42% medullar (anablastic) cancer. Some patients had metastases. It is concluded that all the patients with goiter should be operated. At diffuse toxic goiter the surgical treatment is indicated at the patients with recurrences or after 6 - 12 months of conservative treatment without clinical improvement.

[Subtotal resection of thyroid gland - optimal method for threatment of Bazedow disease. Prognosis].

Subtotal thyroidectomy is a widely accepted surgical procedure for Basedow disease. The purpose of this work is to evaluate functional long-term results and determine predictive prognostic factors of postoperative thyroid function. This is a retrospective study conducted on 207 patients with Basedow disease undergoing subtotal thyroidectomy during the period 1983-2004. Predictive prognostic factors of final thyroid status were investigated and probability of hypothyroidism during the years of follow-up was obtained by the Kaplan-Meier method. Surgery controlled hyperthyroidism in 199 out of 207 patients (97%). The probability of hypo-, eu-, and hyperthyroidism at 5 years was 63%, 36%, and 2%, respectively. No statistical change in thyroid function occurred in the follow-up after 5 years. Multivariate analysis by a logistic ordinal regression analysis showed that weight of the remnant, age, and gender seemed to influence long-term thyroid function. The higher rates of euthyroidism were obtained when the remnant weight was between 6 and 8 g. No recurrence or persistence of hyperthyroidism occurred with remnant weights under 5 g. Subtotal thyroidectomy controlled hyperfunction symptoms in 97% of our patients. Cure (euthyroidism) of Basedow disease patients should be attempted by leaving a thyroid tissue remnant between 6 and 8 g. Even more significant, our results suggest that euthyroidism rates could be improved by leaving a smaller remnant in elderly women and greater remnants in young men. No need for long term medical therapy is emphasised.

[Surgical diseases of the thyroid gland].

7264 patients with different thyreopathies have been analysed, as follows: Basedov's disease (446 = 6.13%), thyreotoxic adenoma (Plummer's disease - 974 = 14.4%), nodular struma (1077 - 14.82%), polynodular struma (3291 = 45.3%), Hashimoto's thyreoiditis (1476 = 20.31%). 2879 of them have been having indications of thyreotoxicosis 39.63%). Carcinoma has been found in 908 patients = 12.5%. In the different forms, carcinoma has been found in 5.15% of the cases of Basedov's disease, 5.03% of the cases of thyreotoxic adenoma, in 8.91% of the cases of nodular struma, in 12.57% of the patients with polynodular struma, and in 32.21% of the cases of Hashimoto's thyreoiditis. The relatively high percentage of carcinoma in Hashomoto's thyreoiditis turns the disease into precancerocis. The positions of the authors are ... concerning the operative treatment of each thyreopathy.

[Current aspects in surgical treatment of benign adrenal cystic lesions].

PURPOSE: To determine the safety and efficacy of retroperitoneal endoscopic adrenalectomy for benign cystic adrenal lesions. PATIENTS AND METHODS: 4 patients underwent retroperitoneal endoscopic adrenalectomy of benign cystic adrenal lesions at our center between March-September 2006. RESULTS: Retroperitoneal endoscopic adrenalectomy was successfully performed in all patents, no conversion was needed. The mean operative time was 60 minutes (range 45-90 min) and no complications were observed. The average hospital stay was 2 days. Neither clinical, no US-scan recurrence was observed on the first month postoperativelly. CONCLUSIONS: Retroperitoneal endoscopic adrenalectomy is a safe and efficacious procedure that offers a favorable minimally invasive alternative for the treatment of benign cystic adrenal lesions.

[Primary ectopic intraosseous meningioma associated with multiple meningioma in a patient with central neurofibromatosis].

We present a case of multiple meningiomas (MM) as initial manifestation of central neurofibromatosis (NF2). A 19 y. o. woman was admitted with increasing signs of spinal cord compression at Th5-7 level. At CT assisted myelography, an entirely extradurally situated meningioma was detected and totally removed. Two years later increasing right-sided exophthalmos, without visual impairment was observed. The CT scan revealed thickening and abnormal shape of the sphenoid and the bony structures of the orbit. The retrobulbar space was narrowed and the optic nerve was shifted. At operation, ala parva of the sphenoid bone, the roof and the lateral orbital wall appeared thickened, laminated, fragile and exceedingly vascularized. The subdural space was found intact. The histopathological study revealed primary intraosseous meningioma of the sphenoid. There was no family history for neurofibromatosis (NF). The clinical findings at this time could not fulfil the criteria for NF2 and the case was considered as "true" multiple meningiomas occurring in different compartments of the neuraxis. The cytogenetical examination demonstrated a deletion of the long arm of the chromosome 22: 46 XX, del 22 (q 11.2). She was followed up and five years after the initial symptoms asymptotic bilateral vestibular schwannomas were found at CT and MRI. These findings finally led to the diagnosis NF2. There are no specific features distinguishing true MM from those associated with NF2, but we recall the importance of such manifestations for this diagnosis. We have not found any comparable case with these features in the medical literature.

[Medullary thyroid carcinoma--current surgical aspects. Overview and retrospective analysis of 22 cases].

BACKGROUND: Medullary thyroid carcinoma (MTC) accounts for 5% to 10% of all thyroid malignancies. Approximately 75% of cases are sporadic. Familial forms of medullary thyroid carcinoma account for the remaining 25% of cases--MEN IIa, MEN IIb and FMTC. METHODS: Retrospectively 22 cases of medullary carcinoma of thyroid gland were analysed. Total thyroidectomy with selective lymph dissection was performed in all patients. RESULTS: 18 patients were with sporadic form of medullary thyroid carcinoma, 4--with FMTC; 21 were with primary carcinoma, 1--with recurrent carcinoma Mean age--32 years (22-59). At the follow-up control (max 10 years) there is no evidence of disease recurrence. CONCLUSION: Recent advances in genetic testing allow early diagnosis and treatment of familial MTC syndromes. Despite some advances in treatment, optimal management is still controversial. Total thyroidectomy with selective lymph dissection remains the choice of surgical treatment. In the familial forms medullary carcinoma is associated with well-characterized, germline mutations in the RET protooncogene. Both genetic and biochemical screening are of essential significance for early diagnosis and adequate and optimal surgical treatment.

[Retroperitoneal endoscopic adrenalectomy vs. conventional adrenalectomy in treatment of benign adrenal lesions--comparative analysis].

BACKGROUND: Miniinvasive adrenalectomy is considered to be the standard of care for the surgical treatment of the adrenal gland's pathology. Since the initial report of laparoscopic adrenalectomy in 1992 and of retroperitoneal endoscopic adrenalectomy in 1994, it has evolved into a feasible and safe minimally invasive procedure for benign adrenal tumors. METHODS: Clinical characteristics and outcomes of 63 retroperitoneal endoscopic adrenalectomies (REAs) and 45 conventional adrenalectomies (CAs) from 1996 to 2004 were evaluated. RESULTS: 61 patients underwent 63 REAs. Tumor size varied from 2 to 8 cm. Median age was 48.6 years. Mean operative time was 135 min (45-240), mean intraoperative blood loss - 85 ml (30-550). The complication rate was 17.77%. Median postoperative hospital stay was 5 days (2-10). 44 patients underwent 45 conventional adenalectomies. Median age was 44.5 years (16-71). Intraoperative complication rate was 17.77%, postoperative - 22.22%, Mean operative time was 120 min (75-240). Median postoperative hospital stay was 10 days (6-21). CONCLUSION: No statistically significant difference was established between mean operative times of REA- and CA-groups (p=0.91). Conventional adrenalectomy was associated with a significantly increased complication rate (p=0.009). Hospitalization was also longer after the open technique (p < 0.0001). Introduced in 1994 and displaying all advantages of minimal access surgery REA has become the standard of care for benign adrenal tumors.

[Thymectomy for myastenia gravis: 25-year experience]. / Timektomiia za miasteniia gravis: 25-godishen opit.

OBJECTIVE: Thymectomy is considered an effective therapeutic option for patients with myasthenia gravis (MG). We reviewed our 25-years experience with surgical treatment of MG with respect to long-term results and factors affecting outcome. METHODS: Between 1978 and 2002, we performed 232 thymectomies for MG. Fifteen patients were lost to follow-up; the remaining 217 form the object of our study. 32 patients (28.4%) had thymoma. Myasthenia was graded according to a modified Osserman classification: 51 patients (23.5%) were in class I, 81 (37.3%) in class IIA, 52 (24%) in class IIB, 26 (12%) in class III and seven (3.2%) in class IV. Mean duration of symptoms before the operation was 14 +/- 10 months. Fifty-eight thymectomies for thymoma were performed through a median sternotomy and four through a clamshell incision. Forty-six thymectomies for non-thymomatous MG were performed through a standard cervicotomy, 155 procedures through a partial upper sternal-splitting incision and eight through a complete median sternotomy. RESULTS: Operative mortality was 0.92% (two patients). After a mean follow-up of 119 months, 77% of all patients improved their clinical status (26% without medications and asymptomatic; 45% with a reduction of medications and/or clinically improved); 39 (18%) have a stable disease with no clinical modifications; 12 (5%) presented a deterioration of their clinical status with worse symptoms, required more medications, or both. Thirteen patients (6%) died because of MG (mean survival 34.3 +/- 3.6 months). The presence of a thymoma negatively influenced the prognosis. Younger patients showed a more favorable outcome as well as patients with a shorter duration of symptoms before the operation; patients with lower classes of myasthenia showed a higher rate of remission. CONCLUSIONS: Thymectomy is effective in the management of patients with MG at all stages with low morbidity. Patients with thymoma present a less favorable outcome.

[Possibilities of retroperitoneal endoscopic surgery in treatment of adrenal diseases]. / Vuzmozhnosti na ednoskopskata khirurgiia v lechenieto na zaboliavaniiata na nadbubrechnite zhlezi.

UNLABELLED: After introduction of the transperitoneal endoscopic adrenalectomy in 1992 and retroperitoneal adrenalectomy (RA) in 1994, the both techniques were widely accepted in the routine surgery practices. Now some authors described them as a "golden standard" in the surgical treatment of adrenal disorders. MATERIAL AND METHOD: 34 retroperitoneal endoscopic adrenalectomy were performed in our clinic for the period of May 1996-December 2002. RESULTS: The mean operating time was 125 minutes (45-220 min.) The average itraoperative blood loss was 70 ml. Only in one case the blood loss was 300 ml, causing conversion to open adrenalectomy. In 6 cases we converted to open adrenalectomy for other reasons--17.6%. In the last 15 cases we had no need of conversion to open adrenalectomy. Intraoperative complications were minor--2 cases (5.88%). Consumption of analgesics was low. Hospitalization period was 3 days. CONCLUSIONS: In summary, EA is associated with fewer complications than have been reported with OA. Despite the limitations of retrospective analysis, the results of this technique are very impressing in relation to diminishing the operative trauma, postoperative pain syndrome and faster recovery. EA is to become a method of choice in surgical treatment of the benign adrenal disorders.

[Video-assisted thoracoscopic surgery (VATS) for treatment of pleural empyema]. / Video-asistirana torakoskopska khirurgiia (VATS) za lechenie na plevralniia empiem.

During 1996-2003 a total of 359 patients were treated for empyema. Forty eight of them (with parapneumonic empyema) were prospectively randomized into 2 groups of 24 patients who underwent early decortication either by thoracotomy or VATS. Comparing to thoracotomy group, VATS group had a significantly shorter chest tube duration (5.8+/-1.1 vs 9+/-1.3 days; p=0.03) and postoperative in-hospital stay with parapneumonic empyema (8.7+/-0.9 vs 12.8+/-1.1 days; p=0.009). VATS has been found to be particularly useful for treating the fibrinopurulent phase of empyema, in which multiple loculations could be easily disrupted to allow adequate drainage of a "cleaned" pleural space. On the other hand, although VATS is highly effective, it is not indicated in every patient and it's indiscriminate use may lead to none required operative interventions.

[Retrospective analysis of the results of surgical treatment of 407 patients with differential thyroid gland cancer over a period of 23 years]. / Retrospektiven analiz na rezultatite ot khirurgicheskoto lechenie na 407 bolni s diferentsiran rak na shtitovidnata zhleza za 23-godishen period.

Over a period of 23 years (1980-2002) 407 cases of differential thyroid gland cancer were operated, monitored and analyzed at the Endocrine Surgery Clinic of Alexandrovska University Hospital. Of them 71.7% were monitored over a period of more than 10 years (up to 23 years), and 39.3% were monitored between 15 and 23 years. The youngest patient was 12 years old, and the oldest--78 years old. All patients were at a T(1-3) N(a-b) M0 stage. 308 (75.7%) patients had papillary carcinoma, and multi-centric localization was established in 3.9%, while capsular invasion and unilateral lymph-nodular metastases--in 6.2% of those patients. Follicular cancer was found in 24%, and vascular invasion--in 15.1%. 72.4% of the patients fall within the low-risk age groups (women under 50 years of age and men under 40). The treatment of 22.1% (90) of the patients comprised thyroidectomy with a follow-on 131J therapy. 77.9% (317) of the patients underwent radical thyroid gland resections of various size. Bilateral subtotal resections were applied most often--in 64.5% of all cases, and the rest of the patients underwent lobectomy with contra-lateral subtotal resection. The recurrence rate among the patients treated with radical resections is 6.1%, mainly within the high-risk age group. No correlation was established between the recurrence rate and the type of organ-saving surgery. In the group of patients treated with thyroidectomy and 131J, recurrences of the disease were established in 16.2%, again mainly within the high-risk age group. Remote metastases and mortality were established in 3% and 2.5% respectively. In conclusion, preference is given to organ-saving surgical treatment of differential thyroid gland cancer, and it is recommended that in the high-risk age groups the operations be of a broader scope.

[Surgical treatment of the diabetic septic foot]. / Khirurgichno lechenie na diabetnoto septichno khodilo.

An opening and a major stage of the diabetic septic foot surgical treatment is the primary surgical processing that is usually combined with amputation of separate fingers or with various types of transmetatarsal amputations. Out of the total of 379 operated patients 35.7% underwent amputation of separate fingers, combined with resection of the metatarsal bone head. 18.3% of the patients underwent transmetatarsal amputations by Sharp with plantar lambo shaping, and 14.9% had oblique resections with dermatological plastic surgeries. As a result of this treatment the foot amputations were reduced to 5.7%. The extended use of conservative treatment combined with primary surgical processing is a major precondition for restricting the suppurative gangrenous process. Staged surgical treatment ensures a drastic decrease in the number of foot amputations. The reconstruction plastic foot operations enable the shaping of an adequate foot area with good biomechanics.

[Surgical treatment of creeping infections of the flexor foot tendons in diabetic patients]. / Khirurgichno lechenie na pulziashtite infektsii po fleksornite sukhozhiliia na khodiloto pri diabetnobolni.

UNLABELLED: The creeping infections of the flexor foot tendons are a common reason for amputation of limbs in diabetic patients. Usually the process starts from the fingers and spreads through their long flexors. METHODS: Of the total of 149 operated patients, 49 underwent selective removal of the m. flexor hallucis longus tendon, and amputation of the 1st finger. The long flexors of the foot fingers were totally removed through a transmethatarsal amputation in 78 patients, and in 22 the long flexor tendons of the 4 lateral fingers were selectively removed through an oblique foot resection. After this type of surgical operations, limb amputation as a result of losing control over the suppurative-gangrenous process, became necessary in 7 patients. CONCLUSIONS: The infection spreading through the long flexors of the foot fingers in diabetic patients is a serious surgical complication that can only be treated surgically. The method of selective resection and removal of the infected long flexors of the foot fingers allows to avoid the limb amputation in most patients. Following this type of surgical interventions the foot biomechanics and the steadiness of the patient is inconsiderably disrupted.