Introdução: O jejum prolongado pré-operatório aumenta a resistência periférica à insulina. Foi investigado se a abreviação do jejum pré-operatório com uma bebida contendo carboidrato e glutamina melhora a resposta orgânica ao trauma cirúrgico. Métodos: Quarenta e oito pacientes adultas, do sexo feminino (19-62 anos) candidatas a colecistectomia videolaparoscópica eletiva. As pacientes foram aleatoriamente divididas em quatro grupos: grupo jejum convencional (grupo Jejum), ou em três grupos para receber três tipos diferentes bebidas oito horas (400 mL) e duas horas antes da indução anestésica (200ml): água pura (grupo Placebo), água mais dextrinomaltose (grupo carboidrato; 12,5% de dextrinomaltose) e grupo glutamina (grupo glutamina; 12,5% de dextrinomaltose e respectivamente 40 e 10g de glutamina). As amostras de sangue foram coletadas no período pré e pós-operatório. Resultados: não houve nenhum evento de aspiração ou regurgitação do conteúdo gástrico manifesto por sinais e sintomas clínicos, durante a indução anestésica, ou em qualquer outro momento do estudo. Também não houve nenhum óbito ou complicação pós-operatória. A média e o erro padrão médio da resistência à insulina determinada pelo HOMA-IR realizada no pós-operatório foi maior (p<0,05) no grupo que permaneceu em jejum (4,3±1,3) quando comparado com os outros três grupos de pacientes (Placebo, 1,6±0,3); carboidrato, (2,3±0,4) e glutamina, (1,5±0,1). A medida da glutationa peroxidase sérica, medida nos dois períodos foi maior no grupo glutamina (40±3,0) que nos grupos carboidrato (32±2,0) e jejum (32±2,0) (p<0,01). Ao se comparar o comportamento da IL-6 sérica em cada grupo estudado no período pré e pós-operatório, observou-se que o grupo glutamina foi o único sem diferença, enquanto nos demais a IL-6 aumentou no pós-operatório (p<0,01). No período pós-operatório a razão proteína-C-reativa/albumina foi maior no grupo jejum quando comparado com os grupos carboidrato (p=0,04) e glutamina (p=0,01). O balanço nitrogenado acumulativo foi menos negativo no grupo glutamina (-2,5±0,8 gN) que nos grupos placebo (-9,0±2,0 gN; p=0,001) e jejum (-6,6±0,4 gN; p=0,04). Conclusão: A abreviação do jejum pré-operatório com uma bebida contendo carboidrato e glutamina melhora a resistência periférica a insulina, a resposta anti-oxidativa e diminui a resposta inflamatória de pacientes submetidas à colecistectomia videolaparoscópica eletiva / Introduction: Prolonged preoperative fasting increases insulin resistance. We investigated whether an abbreviated preoperative fast with glutamine plus a carbohydrate based beverage would improve the organic response after surgery. Methods: Forty-eight female patients (19-62 years) candidates for video-cholecystectomy were randomized to either standard fasting (fasting group) or to fasting with one of three different beverages. Beverages were consumed 8 hours (400 mL; placebo group: water; glutamine group: water with 50 g maltodextrine plus 40 g glutamine; and carbohydrate group: water with 50 g maltodextrine) and 2 hours (200 mL; placebo group: water; glutamine group: water with 25 g maltodextrine plus 10 g glutamine; and carbohydrate group: water with 25 g maltodextrine) before anesthesia. Blood samples were collected pre- and postoperatively. Results: There were no cases of regurgitation during anesthesia. The mean [SEM] postoperative HOMA-IR was greater (p<0,05) in fasted patients (4,3±1,3) than in the other groups (placebo, 1,6±0,3); carbohydrate, (2.3±0,4); and glutamine, (1,5±0,1). Glutathione peroxidase (U/g hemoglobin) was significantly higher (40±3,0) in glutamine group than both carbohydrate (32±2,0) and fasting (32±2,0) groups (p< 0,01). Interleukin-6 increased in all groups except the glutamine group. The C-reactive protein/albumin ratio was higher in fasting subjects than carbohydrate (p=0,04) and glutamine (p=0,01) groups. The nitrogen balance was less negative in glutamine (-2,5±0,8 gN) than both placebo (-9,0±2,0 gN; p=0,001) and fasting (-6,6±0,4 gN; p=0,04) groups. Conclusions: Preoperative intake of a glutamine-enriched carbohydrate beverage improves insulin resistance and antioxidant defenses, and decreases the inflammatory response after videolaparoscopic cholecystectomy

Author of this dissertation presentation discuss in the begining definition and historical consequences of origin and consecutive evolution of the method of percutaneous electrogastrography. Intimately is described physiology, anatomy, embryology and function of gastrointestinal tract with special interest on construction and function of the stomach. Next to this author analyses current knowledge about location and function of the gastric pace setter. The technique of used perctutaneous electrogastrography equipmentt is described. In the second part results of original studies monitoring restoration of peristalsis in perioperative period at patients after open and laparoscopic cholecystectomy and laparoscopic non-adjustable gastric banding are discussed. Furthermore results of EGG measurement of patients with mechanic, vascular and paralytic intestinal obstruction are presented in correlation with plasma levels of interleukin 1β, interleukin-6, procalcitonin and C-reactive protein. Key words: Percutanous electrogastrography, laparoscopic cholecystectomy, laparoscopic gastric bandage, inflammatory mediators, intestinal obstruction.

Background: Treatment decisions for elderly patients with gallbladder pathology are complex. Little is known about what factors go into treatment decisions in this population. We used Medicare data to examine gender-based differences in the use of cholecystectomy vs. cholecystostomy tube placement in elderly patients with acute cholecystitis. Methods: We queried a 5% random sample of Medicare data (2009-2011) for patients >65 admitted for acute cholecystitis (by ICD-9 code) who subsequently underwent a cholecystectomy and/or cholecystostomy tube placement. Demographic information (age, race), clinical characteristics (Elixhauser index, presence of biliary pathology), and hospital outcomes (case fatality rate, length of stay, need for ICU care) were compared by gender. A multivariable model was used to examine predictors of cholecystectomy vs. cholecystostomy tube placement. Results: Of 4063 patients admitted with cholecystitis undergoing the procedures of interest just over half (58%) were women. The majority of patients (93%) underwent cholecystectomy. Compared to women, men were younger (average age 76 vs. 78, p value < 0.01) and had few comorbidities (average Elixhauser 1.2 vs. 1.4 p value < 0.01). Case fatality rate was similar between men (2.5%) and women (2.4% p value 0.48). A higher percentage of men spent time in the ICU (36%) compared to women (31% p value < 0.01). On multivariable analysis men were 30% less likely to undergo cholecystectomy (OR 0.69, 95% CI 0.53-0.91). Conclusion: Elderly men are less likely than elderly women to undergo cholecystectomy for acute cholecystitis despite being younger with less co morbidity and are more likely to spend time in the ICU. More research is needed to determine whether a difference in treatment is contributing to the higher rate of ICU utilization in elderly men with acute cholecystitis.

Hintergrund: Die Simulation wichtiger Handgriffe und Techniken in der Chirurgie wurde bereits seit der Antike praktiziert. Pflanzen, Menschen- und Tierkadaver, Puppen sowie Phantome haben seit Jahrhunderten diesem Zweck gedient. Das 21. Jahrhundert ist jedoch von virtueller Realität geprägt und es gibt viele technische Neuerungen in der Chirurgie. Erste virtuelle Simulationsmöglichkeiten tauchten auf dem Markt bereits im 20. Jahrhundert auf. Zuerst nur schwarzweiß, rudimentär und nur andeutungsweise einer echten Situation im OP-Saal ähnlich, überzeugen die heutigen Simulatoren durch schnelle Prozessoren, qualitative graphische Darstellung und haptisches Feedback. Der Simulator selbst wird zum Forschungsobjekt, endlich können in Simulationsbedingungen Fragestellungen untersucht werden, die bisher unter Operationsbedingungen weder ethisch vertretbar noch technisch möglich waren. Fragestellung: Zwischen 2016 und 2017 fand am VTG Klinikum des Universitätsklinikums der TU Dresden Carl Gustav Carus eine Studie am chirurgischen Simulator für virtuelle Realität statt. Die untersuchte Fragestellung war die Übertragbarkeit von Fertigkeiten zwischen zwei laparoskopischen Operationen: Appendektomie und Cholezystektomie. Material und Methode: Es wurden 44 Studierende aus dem 3. bis 6. Studienjahr rekrutiert und in zwei Gruppen rand-omisiert. Beide Gruppen übten zunächst die Basisübungen bis bestimmte Leistungskriterien erfüllt wurden. Danach haben Probanden der ersten Gruppe die virtuelle Appendektomie und im Anschluss die virtuelle Cholezystektomie trainiert. Die zweite Gruppe ging sofort zum Cholezystektomie Training über. In beiden Gruppen wurden zum Schluss jeweils drei Wiederholungen der kompletten Cholezystektomie absolviert. Verglichen wurden Geschwindigkeit, Sicherheitsparameter wie z. B. aufgetretene Komplikationen sowie Motorik-Parameter der Instrumente. Des Weiteren wurde der mögliche Einfluss von Schlafverhalten, Koffeinkonsum und Erfahrung mit Videospielen auf die Leistung am Simulator untersucht. Ergebnisse: In der statistischen Analyse zeigte die erste Gruppe eine signifikante Verbesserung der Moto-rik-Parameter wie Instrumentenbewegungen und -strecke. Andere Werte wie Geschwindigkeit und Sicherheitsparameter waren innerhalb der zwei Gruppen ähnlich. Zwischen Schlaf-verhalten, Koffeinkonsum und Erfahrung mit Videospielen und der Leistung am Simulator konnte kein Zusammenhang festgestellt werden. Schlussfolgerungen: Die Studie ergab nur einen partiellen Übertragungseffekt zwischen laparoskopischer Appendektomie und Cholezystektomie. Die Gründe liegen in den jeweils unterschiedlichen Schlüsselmomenten, die die Beherrschung prozedurspezifischer Techniken erfordern. Diese müssen für jede Prozedur separat geübt werden. Die Verbesserung der feinmotorischen Fähigkeiten spricht jedoch dafür, dass eine Übertragung der Fertigkeiten bis zu einem gewissen Grad dennoch stattfand und durch das Trainieren einer zusätzlichen Modalität Vorteile insbesondere in der Bewegungsökonomie gewonnen werden können.:Inhaltsverzeichnis 3 Abkürzungsverzeichnis 7 1. Einleitung 8 1.1 Einblick in die Geschichte der chirurgischen Simulation 8 1.2 Entwicklung chirurgischer Simulatoren 9 1.3 Einsatz der Laparoskopie-Simulatoren in der heutigen chirurgischen Ausbildung 11 1.4 Übertragbarkeit von Fähigkeiten in der minimal invasiven Chirurgie 13 1.5 Laparoskopische Appendektomie und Cholezystektomie 17 1.5.1 Laparoskopische Appendektomie 17 1.5.2 Laparoskopische Cholezystektomie 18 1.6 Sonstige Aspekte des Trainings 19 1.6.1 Kriterien-basiertes Training 19 1.6.2 Betreuerfeedback 19 1.6.3 Leistung unter Beobachtung 20 1.6.4 Leistung unter Simulationsbedingungen 20 1.6.5.1 Schlafdauer 20 1.6.5.2 Kaffeekonsum 21 1.6.5.3 Motivation 21 1.6.5.4 Erfahrung mit Videospielen 22 2. Materialen und Methoden 23 2.1 Fragestellung 23 2.2 Ablauf der MIC Studie 24 2.3. Probandenrekrutierung 25 2.4 Lap Mentor von Simbionix (3D Systems) 27 2.5 Trainingsprotokolle am VRT-Simulator 28 2.5.1 Organisatorische Aspekte 28 2.5.2 Leistungsfeedback am VRT-Simulator 28 2.5.3 Training der Basis-Fertigkeiten (Basic Skills Training) 29 2.5.3.1 Peg Transfer 31 2.5.3.2 Clipping and Grasping 32 2.5.3.3 Electrocautery 33 2.5.3.4 Cutting 34 2.5.3.5 Pattern Cutting: Training Gauze 35 2.5.4 Training der Appendektomie Prozedur 36 2.5.5 Training der Cholezystektomie Prozedur 39 2.5.6 Subjektiver Schwierigkeitsgrad 43 2.6 Statistische Auswertung 44 3. Ergebnisse 45 3.1. Zusammenfassung der Probandencharakteristiken 45 3.2 Alter und Geschlecht der Probanden 45 3.3 Fragebogen 46 3.3.1 Schlaf 46 3.3.2 Kaffeekonsum 48 3.3.3 Motivation 49 3.3.4 Erfahrung mit Videospielen 50 3.3.5 Einflussfaktoren auf das Basistraining 50 3.4 Allgemeine Ergebnisse des Trainings am VRT Simulator 51 3.5 Ergebnisse des Trainings der Basis-Fertigkeiten 52 3.5.1 Peg Transfer 52 3.5.2 Clipping and Grasping 53 3.5.3 Electrocautery 54 3.5.4 Cutting 55 3.5.5 Pattern Cutting (Test Gauze) 56 3.5.6 Subjektiver Schwierigkeitsgrad für die Basis-Übungen 57 3.5.7. Zeitbedarf für das Erreichen der Könner-Kriterien 59 3.6 Ergebnisse des Appendektomie Trainings 60 3.7 Ergebnisse der Cholezystektomie Komplettprozedur 61 3.7.1 Geschwindigkeit 61 3.7.2 Sicherheitskriterien 62 3.7.2.1 Anzahl lebensbedrohlicher Komplikationen 62 3.7.2.2 Sichere Kauterisation 63 3.7.2.3 Anzahl verlorener Clips 63 3.7.2.4 Anzahl der Leberperforationen 64 3.7.2.5 Anzahl nicht kauterisierter Blutungen 64 3.7.3 Effizienz Kriterien 64 3.7.3.1 Anzahl der Instrumentenbewegungen 64 3.7.3.2 Gesamtstrecke der Instrumente 65 3.7.4 Subjektiver Schwierigkeitsgrad für die Cholezystektomie 65 3.7.5 Zeit für Basis Training und Cholezystektomie Parameter 65 4. Diskussion 67 4.1 Der Begriff des Übertragungsphänomens in Sportwissenschaften und seine Anwendbarkeit auf die laparoskopischen Fertigkeiten 67 4.2 Übertragbarkeit von Fertigkeiten zwischen virtueller Appendektomie und Cholezystektomie und Vergleich mit anderen Studien 74 4.3 Exploration zweitrangiger Fragestellungen 78 4.4 Vergleich zentraler Tendenzen der Cholezystektomie-Parameter mit Hersteller-Kriterien und externen Studien 79 4.5 Schlussfolgerungen aus dem Training der Basis-Fertigkeiten 81 4.6 Schlussfolgerungen aus dem Appendektomie Training 82 4.7 Schlussfolgerungen aus dem Cholezystektomie Training 83 4.8 Empfehlungen für das Ausbildungscurriculum an einem VR Simulator 85 4.9 Vorschlag für das Anfängertraining an einem VRT Simulator 91 4.10 Limitierungen der Arbeit 92 4.11 Ausblick 93 5. Zusammenfassung 94 5.1 Summary 96 6. Literatur 98 6.1 Abbildungsverzeichnis 106 6.2 Tabellenverzeichnis 108 7. Anhang 109 7.1 Probandenrandomisierung 109 7.2 Probandeninformationsblatt 110 7.3 Einwilligungserklärung 112 7.4 Beispiel Teilnahmebescheinigung 114 7.5 Zusammenfassung der aufgetretenen Softwarefehler am Lap Mentor II 115 8. Danksagung 116 9. Eigenständigkeitserklärung 117 Anlage 1 118 Anlage 2 120 / Background: Simulation of important surgical procedures and techniques has been practiced since ancient times. Plants, human and animal cadavers, dolls and phantoms have served this purpose for hundreds of years. However, the 21st century is characterized by virtual reality and there are also many technical innovations in the field of surgery. The first virtual simulation possibilities appeared on the market in the 20th century. Initially only black and white, rudimentary and only suggestively similar to a real situation in the operating room, today's simulators convince with fast processors, qualitative graphical representation and haptic feedback. The simulator itself becomes an object of research. At last, questions can be investigated in simulation conditions that were previously neither ethically nor technically possible under operating conditions. Hypothesis: Between 2016 and 2017, at the VTG clinic of the Carl Gustav Carus University Hospital of the TU Dresden a study using a surgical simulator for virtual reality took place. The question investigated was the transferability of skills between two laparoscopic procedures: appendectomy and cholecystectomy. Methods: 44 students from the 3rd to 6th year of study were recruited and randomly divided into two groups. Both groups initially practiced the basic exercises until certain criteria were met. Afterwards, the first group practiced virtual appendectomy and then virtual cholecystectomy. The second group immediately moved on to cholecystectomy training. In both groups, three repetitions of the complete cholecystectomy were completed in the end. Speed, safety parameters such as complications that occurred and efficiency parameters of the instruments were compared. Furthermore, the possible influence of sleep behavior, caffeine consumption and experience with video games on simulator performance was investigated. Results: In the statistical analysis, the first group showed a significant reduction in the efficiency parameters such as instrument movements and distance travelled. Other values like speed and safety parameters were similar within two groups. There was no correlation between sleep behavior, caffeine consumption and experience with video games and simulator performance. Conclusion: The study showed only a partial skill transfer between laparoscopic appendectomy and cholecystectomy. The reasons are the different key moments that require the mastery of procedure-specific techniques. These must be practiced separately for each procedure. However, the improvement of fine motor skills indicates, that by training an additional modality a skill transfer nevertheless took place to a certain degree and that advantages, especially in the economy of movement, were gained.:Inhaltsverzeichnis 3 Abkürzungsverzeichnis 7 1. Einleitung 8 1.1 Einblick in die Geschichte der chirurgischen Simulation 8 1.2 Entwicklung chirurgischer Simulatoren 9 1.3 Einsatz der Laparoskopie-Simulatoren in der heutigen chirurgischen Ausbildung 11 1.4 Übertragbarkeit von Fähigkeiten in der minimal invasiven Chirurgie 13 1.5 Laparoskopische Appendektomie und Cholezystektomie 17 1.5.1 Laparoskopische Appendektomie 17 1.5.2 Laparoskopische Cholezystektomie 18 1.6 Sonstige Aspekte des Trainings 19 1.6.1 Kriterien-basiertes Training 19 1.6.2 Betreuerfeedback 19 1.6.3 Leistung unter Beobachtung 20 1.6.4 Leistung unter Simulationsbedingungen 20 1.6.5.1 Schlafdauer 20 1.6.5.2 Kaffeekonsum 21 1.6.5.3 Motivation 21 1.6.5.4 Erfahrung mit Videospielen 22 2. Materialen und Methoden 23 2.1 Fragestellung 23 2.2 Ablauf der MIC Studie 24 2.3. Probandenrekrutierung 25 2.4 Lap Mentor von Simbionix (3D Systems) 27 2.5 Trainingsprotokolle am VRT-Simulator 28 2.5.1 Organisatorische Aspekte 28 2.5.2 Leistungsfeedback am VRT-Simulator 28 2.5.3 Training der Basis-Fertigkeiten (Basic Skills Training) 29 2.5.3.1 Peg Transfer 31 2.5.3.2 Clipping and Grasping 32 2.5.3.3 Electrocautery 33 2.5.3.4 Cutting 34 2.5.3.5 Pattern Cutting: Training Gauze 35 2.5.4 Training der Appendektomie Prozedur 36 2.5.5 Training der Cholezystektomie Prozedur 39 2.5.6 Subjektiver Schwierigkeitsgrad 43 2.6 Statistische Auswertung 44 3. Ergebnisse 45 3.1. Zusammenfassung der Probandencharakteristiken 45 3.2 Alter und Geschlecht der Probanden 45 3.3 Fragebogen 46 3.3.1 Schlaf 46 3.3.2 Kaffeekonsum 48 3.3.3 Motivation 49 3.3.4 Erfahrung mit Videospielen 50 3.3.5 Einflussfaktoren auf das Basistraining 50 3.4 Allgemeine Ergebnisse des Trainings am VRT Simulator 51 3.5 Ergebnisse des Trainings der Basis-Fertigkeiten 52 3.5.1 Peg Transfer 52 3.5.2 Clipping and Grasping 53 3.5.3 Electrocautery 54 3.5.4 Cutting 55 3.5.5 Pattern Cutting (Test Gauze) 56 3.5.6 Subjektiver Schwierigkeitsgrad für die Basis-Übungen 57 3.5.7. Zeitbedarf für das Erreichen der Könner-Kriterien 59 3.6 Ergebnisse des Appendektomie Trainings 60 3.7 Ergebnisse der Cholezystektomie Komplettprozedur 61 3.7.1 Geschwindigkeit 61 3.7.2 Sicherheitskriterien 62 3.7.2.1 Anzahl lebensbedrohlicher Komplikationen 62 3.7.2.2 Sichere Kauterisation 63 3.7.2.3 Anzahl verlorener Clips 63 3.7.2.4 Anzahl der Leberperforationen 64 3.7.2.5 Anzahl nicht kauterisierter Blutungen 64 3.7.3 Effizienz Kriterien 64 3.7.3.1 Anzahl der Instrumentenbewegungen 64 3.7.3.2 Gesamtstrecke der Instrumente 65 3.7.4 Subjektiver Schwierigkeitsgrad für die Cholezystektomie 65 3.7.5 Zeit für Basis Training und Cholezystektomie Parameter 65 4. Diskussion 67 4.1 Der Begriff des Übertragungsphänomens in Sportwissenschaften und seine Anwendbarkeit auf die laparoskopischen Fertigkeiten 67 4.2 Übertragbarkeit von Fertigkeiten zwischen virtueller Appendektomie und Cholezystektomie und Vergleich mit anderen Studien 74 4.3 Exploration zweitrangiger Fragestellungen 78 4.4 Vergleich zentraler Tendenzen der Cholezystektomie-Parameter mit Hersteller-Kriterien und externen Studien 79 4.5 Schlussfolgerungen aus dem Training der Basis-Fertigkeiten 81 4.6 Schlussfolgerungen aus dem Appendektomie Training 82 4.7 Schlussfolgerungen aus dem Cholezystektomie Training 83 4.8 Empfehlungen für das Ausbildungscurriculum an einem VR Simulator 85 4.9 Vorschlag für das Anfängertraining an einem VRT Simulator 91 4.10 Limitierungen der Arbeit 92 4.11 Ausblick 93 5. Zusammenfassung 94 5.1 Summary 96 6. Literatur 98 6.1 Abbildungsverzeichnis 106 6.2 Tabellenverzeichnis 108 7. Anhang 109 7.1 Probandenrandomisierung 109 7.2 Probandeninformationsblatt 110 7.3 Einwilligungserklärung 112 7.4 Beispiel Teilnahmebescheinigung 114 7.5 Zusammenfassung der aufgetretenen Softwarefehler am Lap Mentor II 115 8. Danksagung 116 9. Eigenständigkeitserklärung 117 Anlage 1 118 Anlage 2 120

<p>UVOD. Bilijarna kalkuloza je najče&scaron;će oboljenje hepatobilijarnog sistema, a holecistektomija predstavlja jedan od najče&scaron;će izvođenih operativnih zahvata. Laparoskopska holecistektomija je danas zlatni standard lečenja holelitijaze. Laparoskopska holecistektomija je pokazala pobolj&scaron;anje u klinički značajnim ishodima kao &scaron;to su skraćenje operativnog vremena, kraća hospitalizacija, smanjenje jačine i trajanja postoperativnog bola i brži povratak dnevnim i radnim aktivnostima. Postoperativna bol i vreme potpunog oporavka ostaju dva glavna problema posle nekomplikovane laparoskopske holecistektomije koje bi trebalo pobolj&scaron;ati. Bol koji je povezan sa laparoskopskom holecistektomijom je kompleksan i multifaktorijalan. On nastaje o&scaron;tećenjem tkiva, disekcijom i uklanjanjem žučne kesice iz svoje lože, stimulacijom periportalnih nerava, iritacijom dijafragme, mehaničkim i hemijskim interakcijama gasa i pneumoperitoneuma, incizijama portova. Istraživanja su označila parijetalni i visceralni bol kao dva glavna mehanizma nastanka bola kod laparoskopske holecistektomije. Bol se ne može meriti nego proceniti jer je subjektivni osećaj. Pokazalo se potrebnim da se na čvr&scaron;ćim naučnim osnovama da odgovor na pitanje da li je moguće blokirati parijetalni i visceralni bol posle laparoskopske holecistektomije u akutnoj fazi. CILJEVI. Cilj studije je da uporedi standardnu analgeziju (ne-opioidnu) (grupa O) sa davanjem parijetalne blokade (grupa P), ili davanjem visceralne blokade (grupa V), ili sa obe date blokade (grupa P+V). Primarni ishodi studije su bolesnikov procenjeni bol pre operacije i posle operacije na 1, 2, 4, 6, 12, 24, 48 sati i 7. dana. Sekundarni ishodi studije su bolesnikova procenjena mučnina na 1,2,4,6,12 sati i bolesnikova procenjena mobilnost 1. 2. i 7. dan. HIPOTEZA. Blokada postoperativnog visceralnog bola i blokada postoperativnog parijetalnog bola posle laparoskopske holecistektomije putem intraperitonealne lokalne infiltracije anestetikom i putem lokalne infiltracije anestetikom pristupnih laparoskopskih portova može značajno smanjiti rani postoperativni bol. MATERIJAL I METODE. Ova prospektivna, randomizirana jednostruko slepa studija je započela septembra 2014. godine i trajala je do januara 2016. godine. Istraživanje je sprovedeno na Klinici za abdominalnu, endokrinu i transplantacionu hirurgiju i Urgentnom centru Kliničkog centra Vojvodine u Novom Sadu kod bolesnika operisanih metodom laparoskopske holecistektomije. Rad je podeljen u nekoliko celina. 1. Procena veličine uzorka; 2. Procena podobnosti za studiju; 3. Anketiranje i uključivanje u studiju; 4. Razvrstavanje u grupe i operativni rad; 5. Period postoperativnog praćenja; 6. Statistička obrada i pisanje rada.<br />1. Procena veličine uzorka. Studija je realizovana podelom bolesnika u 4 grupe. Neophodni broj bolesnika je izračunat uzimajući podatke iz pilot istraživanja slične studije iz 2012. godine. Veličina uzorka je računata za primarni ishod studije&nbsp; (bolesnikov procenjen bol sa NAS) na pretpostavci da treba biti 20% smanjenja bola u prvom postoperativnom satu, uz verovatnoću Tip 1 gre&scaron;ke &alpha;=0.05 i Tipa 2 gre&scaron;ke &beta;=0.10 da postigne adekvatnu statističku snagu oko 80% i da otkrije 20% razlike u srednjoj vrednosti procenjenog bola jedan sat nakon laparoskopske&nbsp; holecistektomije. Procenjeni broj ispitanika po grupama prema zadatim kriterijumima je bio (P+V=65; P=68; V=68; O=65). Studija je započela uključivanjem prvog bolesnika u studiju a zavr&scaron;ena ispunjenim periodom praćenja sve dok poslednji bolesnik nije doneo upitnike o bolu, mučnini i kretanju. 2. Procena podobnosti za studiju. U periodu studije ukupan broj holecistektomiranih bolesnika je bio 1024 (440 klasično i 584 laparoskopski). Samo pogodni bolesnici su anketirani (584) i pročitali su informacioni list o istraživanju. Uključivanje ili procena podobnosti bolesnika za studiju sprovedena je na osnovu uključnih i isključnih kriterijuma. U studiju nije uključeno ukupno 226 bolesnika. Od tog broja 82 bolesnika je odbilo učestvovati u studiji a 144 bolesnika nije ispunilo uključne postavljene kriterijume. Svojim potpisom potvrdilo je uče&scaron;će u studiji 358 bolesnika. 3. Anketiranje i uključivanje u studiju. Nakon prijema bolesnika u bolnicu ispitivači su uzimali anamnezu i bolesnicima je ponuđen informacioni list i informisani pristanak. Nakon čitanja informacije, potpisivanja informisanog pristanka i zadovoljavanja&nbsp; uključnih i isključnih kriterijuma 358 bolesnika je uključeno u studiju. Obavljena je preoperativna priprema i ispitivači su popunili deo podataka u individualnom listu. 4. Razvrstavanje u grupe i operativni rad. Neposredno preoperativno od strane nezavisne osobe neuključene u studiju napravljena je randomizacija izabranih (n=358) u studijske grupe tablicama slučajnog izbora, tako da bolesnici nisu znali kojoj grupi pripadaju, dok su operater i osoblje to znali na početku operacije (jednostruko slepa studija). Nakon randomizacije i operacije bolesnici pripadaju jednoj od sledeće 4 grupe: Kontrolna grupa O=89, u kojoj su bolesnici sa urađenom laparoskopskom&nbsp; holecistektomijom bez visceralne blokade anestetikom i bez parijetalne blokade anestetikom. Eksperimentalna grupa P=88, u kojoj su bolesnici sa urađenom laparoskopskom holecistektomijom bez visceralne blokade anestetikom i sa parijetalnom blokadom anestetikom. Eksperimentalna grupa V=92, u kojoj su bolesnici sa urađenom laparoskopskom holecistektomijom sa visceralnom blokadom anestetikom i bez parijetalne blokade anestetikom. Eksperimentalna grupa P+V=89, u kojoj će biti bolesnici sa urađenom laparoskopskom holecistektomijom sa visceralnom blokadom anestetikom i sa parijetalnom blokadom anestetikom. Primenjivan je uobičajni, standardni protokol anestezije za laparoskopske operacije kod svih ispitanika. Svim bolesnicima plasirana je orogastrična sonda koja se nakon operacije odstranjivala. Kod&nbsp; bolesnika kod kojih je primenjivan lokalni anestetik neposredno pre početka operacije pravio se rastvor lokalnog anestetika (Marcaine&reg; 0,25%). Bolesnici su otpu&scaron;teni sa bolničkog lečenja prvog postoperativnog dana, pod uslovom da nisu imali komplikacija. 5. Postoperativno praćenje i ispunjavanje upitnika. Po dolasku na odeljenje&nbsp; bolesnicima je odmah uključivana ista analgezija. Tokom ispunjavanja informisanog pristanka, bolesnici su dobili upitnik na kojoj će sami procenjivati nivo bola, mučnine i kretanja tokom ležanja u bolnici i vremena praćenja od 7 dana kući. Bolesnici su dolazili na unapred zakazane postoperativne kontrole 7 do 10 dana posle operacije i donosili ispunjene upitnike. Otpu&scaron;teno je i za praćenje ostalo n=302 laparoskopski operisanih bolesnika a isključeno iz studije n=20 bolesnika. 6. Statistička obrada i pisanje rada. Ukupno je analizirano 274 listića operisanih bolesnika: u Grupi P+V =67; u Grupi P =70; u Grupi V =70 i u Grupi O =67. Od osnovnih deskriptivnih statističkih parametara za kvalitativnu i kvantitativnu procenu dobijenih rezultata su kori&scaron;ćeni apsolutni brojevi, relativni brojevi, mediana, mod, aritmetička sredina i standardna devijacija (SD). Obrada podataka se vr&scaron;ila&nbsp; osnovnim i naprednim statističkim metodama i programima. Rezultati su prikazani tabelarno i grafički. REZULTATI. Demografski podaci. Ukupno je bilo 188 žena i 86 mu&scaron;karaca, u odnosu 2,2 : 1. Prosečna starost cele grupe je bila 52,1 &plusmn; 15,72 godine. Ukupno je bilo 179 zaposlenih i 95 nezaposlenih. Ukupno je bilo 45 ispitanika sa osnovnim obrazovanjem, 153 ispitanika sa srednjim obrazovanjem i 76 ispitanika sa visokim obrazovanjem. Ukupno je bilo 186 nepu&scaron;ača i 88 pu&scaron;ača. Prosečna vrednost BMI cele grupe je bila 27,24 &plusmn; 4,21 kg/m2. Prosečna vrednost ASA u celoj grupi je bila 2,03 (mediana=2, mod=2). Ne postoji statistički značajna razlika između posmatranih grupa u odnosu na posmatrane parametre. Laboratorijski podaci. Postoji statistički značajna razlika u vrednosti leukocita između posmatranih grupa (p=0,039), u vrednosti uree između posmatranih grupa (p=0,040). Ne postoji statistički značajna razlika u vrednosti eritrocita, trombocita, hemoglobina, &Scaron;UK-a, kreatinina i bilirubina posmatranih grupa. Operativni i postoperativni podaci. Ne postoji statistički značajna razlika u količini upotrebljenog Fentanila između posmatranih grupa. Postoji statistički značajna razlika u dužini trajanja operacije između posmatranih grupa (p=0,003), u trajanju postavljenog abdominalnog drena između posmatranih grupa (p=0,024), u trajanju hospitalizacije između posmatranih grupa (p=0,027), u broju dana do povratka uobičajenim aktivnostima između posmatranih grupa (p=0,000), u broju uzetih tableta između posmatranih grupa (p=0,000). Prosečna ocena zadovoljstva bolesnika posle operacije u celoj grupi je bila 8,80 (mediana=9; mod=10). Najbolju ocenu zadovoljstva bolesnika posle operacije je imala grupa P+V. Procena bola, mučnine i kretanja. Postoji statistički značajna razlika između posmatranih grupa u proceni jačine bola pre operacije (p=0,003). Postoji statistički značajna razlika između posmatranih grupa u proceni jačine bola 1h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 2h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 4h posle operacije (najbolju procenu bola je imala grupa P); u proceni jačine bola 6h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 12h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 24h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 48h posle operacije (najbolju procenu bola je imala grupa P) i u proceni jačine bola 7 dana posle operacije (najbolju procenu bola je imala grupa P). Procenjena bol se pojačava otprilike 2,5 sata posle operacije sa vrhom 3 sata posle operacije, a smanjuje se na istu vrednost kao 2. sata posle operacije, otprilike 5. sata posle operacije. U vremenskim intervalima 1, 2. i 7. postoperativni dan postoji značajno pobolj&scaron;anje u postoperativnoj mobilnosti bolesnika. U vremenskim intervalima 1, 2, 4, 6 i 12 sati postoji značajno pobolj&scaron;anje u procenjenoj vrednosti mučnine bolesnika. Korelacije. Statistički značajna pozitivna korelacija ocene bola posle 1. sata, posle 2. sata, posle 6. sata, posle 12. sata je utvrđena sa brojem uzetih tableta (p=0,000), kao i procene mučnine (p=0,000). Statistički značajna pozitivna korelacija procene bola posle 4. sata je utvrđena sa brojem uzetih tableta (p=0,006), kao i aktivnosti (p=0,014). Statistički značajna korelacija procene bola posle 24. sata je utvrđena sa brojem uzetih tableta (p=0,000; pozitivna) i trajanjem operacije (p=0,028; negativna). Statistički značajna pozitivna korelacija procene bola posle 48. sata i posle 7 dana je utvrđena sa brojem uzetih tableta (p=0,000). ZAKLJUČCI: Primena lokalnog anestetika datog na bilo koji način značajno smanjuje bol posle laparoskopske holecistektomije. Primena lokalnog anestetika datog i&nbsp; portalno i visceralno (P+V) značajno smanjuje bol u odnosu na samo portalnu (P) ili visceralnu (V) primenu u vremenskim intervalima 2, 6, 12 sat posle laparoskopske holecistektomije. Portalna (P) primena sa ili bez visceralne (V) primene lokalnog anestetika značajno smanjuje bol u vremenskim intervalima 1, 4, 24, 48 sati i 7 dana posle laparoskopske holecistektomije. Najbolje kretanje je bilo u grupi P+V posle laparoskopske holecistektomije. Najbolje smanjenje procenjene mučnine je bilo u grupi P posle laparoskopske holecistektomije. Najraniji povratak uobičajenim aktivnostima zabeležen je u grupi P+V. Najbolja ocena zadovoljstva bolesnika hirur&scaron;kim lečenjem bila je u grupi P+V. Postoperativna bol ima najznačajniju pozitivnu korelaciju sa procenjenom mučninom i brojem tableta uzetih od momenta otpusta do prve kontrole bolesnika.</p> / <p>INTRODUCTION: Biliary calculosis is the most frequent disease of the hepatobiliary system, and cholecystectomy is one of the most frequently performed surgical procedures. Today laparoscopic cholecystectomy represents the golden standard in treating cholelithiasis. Laparoscopic cholecystectomy showed improvement in the clinically significant outcomes, such as: reducing the duration of the surgery, shorter hospital stay, reducing the intensity and duration of postoperative pain and faster return to normal daily and working activities. Postoperative pain and the time of full recovery remain the two major problems after a non-complicated laparoscopic cholecystectomy and they should be improved. The pain related to laparoscopic cholecystectomy is complex and multi-factorial in origin. The pain occurs due to damaged tissues, dissection and removal of gallbladder from its cavity, stimulation of periportal nerves, irritation of the diaphragm, mechanical and chemical interaction of gases and pneumoperitoneum and port incisions. Researches have denoted parietal and visceral pains as two major mechanisms in occurrence of pain in laparoscopic cholecystectomy. Pain cannot be measured, but estimated, as it is a subjective feeling. It was considered necessary to find the answer, based on solid scientific evidence, if it was possible to block parietal and visceral pain after laparoscopic cholecystectomy in its acute phase. OBJECTIVES: The aim of this study is to compare standard, non-opioid, analgesia (group O) with applying parietal blockade (group P), or visceral blockade (group V), or compare with both applied blockades (group P+V). The primary outcomes of the study are the patient&acute;s estimated pain before surgery and 1, 2, 4, 6, 12, 24, 48 hours and 7th day after the surgery. The secondary outcomes of this study are the patient&acute;s estimated nausea level during 1, 2, 4, 6, 12 hours, along with the patient&acute;s estimated mobility 1st, 2nd and 7th day, postoperatively. HYPOTHESIS. Blockade of postoperative visceral pain and blockade of postoperative parietal pain following laparoscopic cholecystectomy, applying intraperitoneal local infiltration with anesthetic and also by local infiltration with anesthetic through accessible laparoscopic ports, can significantly reduce early postoperative pain. MATERIAL AND METHODS: This prospectively randomized single-blinded study started in September 2014 and lasted up to January 2016. The research was carried out at the Clinic for Abdominal, Endocrine and Transplantation Surgery and Emergency Center, Clinical Center of Vojvodina in Novi Sad and it involved patients who underwent laparoscopic cholecystectomy. This study has been divided into several units. 1. Assessment of sample size; 2. Assessment of eligibility for the study; 3. Survey and inclusion in the study; 4. Group formation and operational work; 5. Period of postoperative follow-up; 6. Statistical processing and writing the paper.1. Assessment of sample size. The study was realized by dividing the patients into 4 groups. The number of patients necessary was determined based on the data taken as pilot study from a similar study from 2012. Sample size was calculated for the primary outcome of the study (patient&acute;s estimated pain with NAS) based on the assumption that a pain reduction of 20% should occur during the first postoperative hour, with the probability of Type 1 error &alpha;=0.05 and Type 2 error &beta;=0.10 to reach the adequate statistical power of about 80%, and to reveal 20% difference in the average value of the estimated pain one hour after the laparoscopic cholecystectomy. The assessed number of respondents in groups according to the set criteria was (P+V =65;P =68;V =68; O =65). The study started when the first patient was included and it ended with the complete follow-up period when the last patient handed in the survey about pain, nausea and mobility. 2. Assessment of eligibility for the study. During the study the number of patients undergoing surgery applying the method of cholecystectomy was 1024 (440 classical and 584 laparoscopic). Only the suitable patients were surveyed (584) and given to read the information leaflet about the study. Inclusion and assessment of patients&acute; eligibility was performed on the basis of inclusion and exclusion criteria. A total of 226 patients was not included in the study. Out of that number 82 patients refused to participate in the study and 144 did not fulfill the inclusive criteria set. By signing 358 patients confirmed their participation in the study. 3. Survey and inclusion in the study. After admitting the patients to hospital the surveyors took their anamnesis and the patients were offered an information leaflet and informed consent. Following the reading of the information leaflet, signing the informed consent and satisfying the criteria for inclusion and exclusion, 358 patients were included in the study. Preoperative preparations were performed and the surveyors filled in some of the data on the individual list. 4. Group formation and operational work. Prior to the surgery an independent person not included in the study carried out the randomisation of the patients chosen (n=358) into study groups by random selection tables. The patients did not know which group they belonged to, while it became known to the surgeon and the operation stuff at the beginning of the surgery (singleblinded study). After randomization and surgery the patients belonged to one of the following groups: Control group O=89 of patients with performed laparoscopic cholecystectomy without visceral blockade by anesthetic and without parietal blockade by anesthetic. Experimental group P=88 of patients with performed laparoscopic cholecystectomy without visceral blockade by anesthetic but with parietal blockade by anesthetic. Experimental group V=92 of patients with performed laparoscopic cholecystectomy with visceral blockade by anesthetic but without parietal blockade by anesthetic. Experimental group P+V=89 of patients with performed laparoscopic cholecystectomy with visceral blockade by anesthetic and with parietal blockade by anesthetic. The standard protocol of anesthesia for laparoscopic cholecystectomy was applied to all patients. An orogastric tube used during the surgery, was removed after it. In patients with applied local anesthetic immediately before surgery a solution of local anesthetic was made (Marcaine&reg; 0,25%). The patients were discharged from hospital the first postoperative day, provided that no complications occurred. 5. Postoperative follow-up and completing the questionnaire. When admitted to the ward the patients were given the same kind of analgesia. While completing the informed consent the patients were given a questionnaire for estimating their pain level, nausea and mobility during their stay in hospital and during the 7-day follow-up period at home. The patients were required to come for 7 and 10-day postoperative check-ups by appointment and then they handed in the questionnaires. n=302 patients with performed laparoscopic cholecystectomy were released and designated for follow-up, and n=20 patients were excluded from the study. 6. Statistical processing and writing the paper. In total 274 operated patients&acute; slips were analysed, by groups as follows: in Group P+V =67; in Group P =70; in Group V =70 and in Group O =67. From the basic descriptive statistical parametres for qualitative and quantitative assessment of results obtained, absolute numbers, relative numbers, the median, mode, arithmetic mean and standard deviation (SD) were used. Data processing was carried out using basic and advanced statistical methods and programmes. The results are presented in tabular and graphical manner. RESULTS. Demographic data. In total there were 188 women and 86 men, in proportion 2,2 : 1. The average age of the whole group was 52,1 &plusmn; 15,72 years. In total there were 179 employed and 95 unemployed persons. In total there were 45 surveyed patients with primary education, 153 surveyed patients with secondary education and 76 surveyed patients with higher education. In total there were 186 nonsmokers and 88 smokers. The mean BMI value of the whole group was 27,24 &plusmn; 4,21 kg/m2. The mean value of ASA of the whole group was 2,03 (the median=2, mode=2). There is no significant difference among the groups observed considering the observed parametres. Laboratory data. There is a statistically significant difference in the value of leukocytes among the observed groups (p=0,039), and in the value of urea among the observed groups (p=0,040). There is no statistically significant difference in the value of the erythrocyte, platelets, hemoglobin, blood glucose, creatinine and bilirubin of the&nbsp; observed groups. Operative and postoperative data. There is no statistically significant difference in the amount of Fentanyl&reg; applied among the observed groups. There is statistically significant difference in the length of the surgery among the observed groups (p=0,003), in the duration of the positioning of abdominal drainage among the observed groups (p=0,024), in the duration of hospital stay among the observed groups (p=0,027), in the number of days until getting back to regular activities among the observed groups&nbsp; (p=0,000), in the number of taken pills among the observed groups (p=0,000). The patients&acute; average satisfaction grade after surgery in the whole group was 8,80 (the median=9; mode=10). Group P+V had the best patient&lsquo;s satisfaction grade after the surgery. Assessment of pain, nausea and mobility. There is statistically significant difference in the estimation of pain intensity before surgery among the observed groups (p=0,003). There is statistically significant difference in the estimation of pain intensity 1 hour after surgery among the observed groups (P+V having the best estimated pain); in the estimation of pain intensity 2 hours after&nbsp; surgery (P+V having the best estimated pain); in the estimation of pain intensity 4 hours after surgery (P having the best estimated pain); in the estimation of pain intensity 6 hours after surgery (P+V having the best estimated pain); in the estimation of pain intensity 12 hours after surgery (P+V having the best estimated pain); in the estimation of pain intensity 24 hours after surgery (P+V having the best estimated pain); in the estimation of pain intensity 48 hours after surgery (P having the best estimated pain) also in the estimation of pain intensity 7 days after surgery (P having the best estimated pain). The estimated pain intensifies at about 2,5 hours after surgery and peaks 3 hours after surgery, and decreases to the same level as it was during 2nd hour after surgery approximately during 5th hour after surgery. There is considerable improvement in mobility of patients in the time interval 1st, 2nd and 7th postoperative days. There is considerable improvement in estimated nausea level of patients in the time interval 1, 2, 4, 6 and 12 hours. Correlations. Statistically significant positive correlation in estimated pain after 1st hour, after 2nd hour, after 6th hour and after 12th hour was determined by the number of tablets taken (p=0,000), just like the estimated nausea level (p=0,000). Statistically significant positive correlation in estimated pain after 4th hour was determined by the number of tablets taken (p=0,006), just like the activities (p=0,014). Statistically significant positive correlation in estimated pain after 24th hour was determined by the number of tablets taken (p=0,000; positive), and by the duration of the surgery (p=0,028; negative). Statistically significant positive correlation in estimated pain after 48th hour and after 7 days was determined by the number of tablets taken (p=0,000). CONCLUSIONS: The application of local anesthetic, regardless of how it was applied, considerably reduces pain after laparoscopic cholecystectomy. The application of local anesthetic by port or viscerally (P+V) considerably reduces pain compared to only by port (P) or only visceral (V) application in the time intervals of 2, 6, and 12 hours after laparoscopic cholecystectomy. The application of local anesthetic by port (P), with or without visceral (V), considerably reduces pain in the time intervals of 1, 4, 24, and 48 hours and 7 days after laparoscopic cholecystectomy. The best mobility was shown by group P+V after laparoscopic cholecystectomy. Estimated nausea was most reduced in group P after laparoscopic cholecystectomy. Group P+V presented the earliest return to regular activities. The best patients&acute; satisfaction grade with surgical treatment was shown by group P+V. Postoperative pain is most considerably positively correlated with the estimated nausea and pills taken, from the moment of patient&acute;s release from hospital to the first check-up.<br />&nbsp;</p>

<p>Акутни панкреатитис је ензиматско инфламаторно оболење панкреаса, са инциденцијом око 17/100000 становника. Најчешћи етиолошки чиниоци који се везују за ово стање су билијарна калкулоза (45%) и конзумација алкохолних пића (35%). Ређи узроци су одређени лекови, хипертриглицеридемија, хиперкалијемија, траума, урођени чиниоци, и идиопатски панкреатитис (20%). По међународној Атланској (Atlanta) класификацији, акутни панкреатитис се може манифестовати у умереној, умерено тешкој и тешкој форми. Умерене форме панкреатитиса се јављају у 80%, карактеришу се едемом органа и имају благ и краткотрајан клинички ток, са стопом морталитета од 1%. Основни циљ лечења болесника са акутним панкреатитисом у прва 24 сата хоспитализације јесте олакшавање тегоба, утврђивање узрока панкреатитиса и процена тежине обољења. Акутни панкреатитис билијарне етиологије узрокован је калкулозом жучне кесе и/ или жучних путева. Препоручени третман билијарне калкулозе, у циљу превенције поновног атака умерене форме билијарног панкреатитиса , подразумева уклањање жучне кесе лапароскопском холецистектомијом са интраоперативном холангиографијом. Уколико се дијагностикује калкулоза жучних канала ради се ендоскопска ретроградна холангиопанкреатографија (ЕРЦП) са ендоскопском папилотомијом (ЕПТ) и уклањем__ калкулуса и детритуса уз жучних водова, са циљем обезбеђивања нормалног протока жучи у дванаестопалачно црево. Циљ овог истраживања је оптимализација редоследа примене ЛХ и ЕРЦП са ЕПТ, идентификацијом предикционих показатеља холедохолитијазе, ради скраћења дужине хоспитализације болесника са умереном формом акутног билијарног панкреатитиса. У спроведеној проспективној анамнестичкој студији, учествовало је 100 болесника лечених од умерене форме акутног билијарног панкреатитиса, у Ургентном центру Клиничког центра Војводине, од 2011. до 2015.године, од којих је код 80 урађена само ЛХ, а код 20 ЛХ и ЕРЦП са ЕПТ. Анализом клиничких, ултразвучних и лабораторијских налаза, идентификовано је 5 статистички значајних предиктора холедохолитијазе; директни и укупни билирубин, алкална фосфатаза (АФ), гама глутирил транспепдидаза (гама ГТ) и це реактивни протеин (ЦРП), на основу којих је омогућено креирање математичког модела за предикцију холедохолитијазе, коришћењем теорије потпорних вектора (СВМ). Установљено је да патолошки налази ових параметара значајно указују на холедохолитијазу, те да је ЛХ препоручена као метода првог избора, код болесника код којих налази предиктора холедохолитијазе нису патолошки. Овако лечени болесници су имали значајно краће време хоспитализације. Поред тога, уколико се интраоперативном холангиографијом (ИОХ) при ЛХ установи холедохолитијаза, ЕРЦП са ЕПТ се може урадити без одлагања.</p> / <p>Akutni pankreatitis je enzimatsko inflamatorno obolenje pankreasa, sa incidencijom oko 17/100000 stanovnika. Najčešći etiološki činioci koji se vezuju za ovo stanje su bilijarna kalkuloza (45%) i konzumacija alkoholnih pića (35%). Ređi uzroci su određeni lekovi, hipertrigliceridemija, hiperkalijemija, trauma, urođeni činioci, i idiopatski pankreatitis (20%). Po međunarodnoj Atlanskoj (Atlanta) klasifikaciji, akutni pankreatitis se može manifestovati u umerenoj, umereno teškoj i teškoj formi. Umerene forme pankreatitisa se javljaju u 80%, karakterišu se edemom organa i imaju blag i kratkotrajan klinički tok, sa stopom mortaliteta od 1%. Osnovni cilj lečenja bolesnika sa akutnim pankreatitisom u prva 24 sata hospitalizacije jeste olakšavanje tegoba, utvrđivanje uzroka pankreatitisa i procena težine oboljenja. Akutni pankreatitis bilijarne etiologije uzrokovan je kalkulozom žučne kese i/ ili žučnih puteva. Preporučeni tretman bilijarne kalkuloze, u cilju prevencije ponovnog ataka umerene forme bilijarnog pankreatitisa , podrazumeva uklanjanje žučne kese laparoskopskom holecistektomijom sa intraoperativnom holangiografijom. Ukoliko se dijagnostikuje kalkuloza žučnih kanala radi se endoskopska retrogradna holangiopankreatografija (ERCP) sa endoskopskom papilotomijom (EPT) i uklanjem__ kalkulusa i detritusa uz žučnih vodova, sa ciljem obezbeđivanja normalnog protoka žuči u dvanaestopalačno crevo. Cilj ovog istraživanja je optimalizacija redosleda primene LH i ERCP sa EPT, identifikacijom predikcionih pokazatelja holedoholitijaze, radi skraćenja dužine hospitalizacije bolesnika sa umerenom formom akutnog bilijarnog pankreatitisa. U sprovedenoj prospektivnoj anamnestičkoj studiji, učestvovalo je 100 bolesnika lečenih od umerene forme akutnog bilijarnog pankreatitisa, u Urgentnom centru Kliničkog centra Vojvodine, od 2011. do 2015.godine, od kojih je kod 80 urađena samo LH, a kod 20 LH i ERCP sa EPT. Analizom kliničkih, ultrazvučnih i laboratorijskih nalaza, identifikovano je 5 statistički značajnih prediktora holedoholitijaze; direktni i ukupni bilirubin, alkalna fosfataza (AF), gama glutiril transpepdidaza (gama GT) i ce reaktivni protein (CRP), na osnovu kojih je omogućeno kreiranje matematičkog modela za predikciju holedoholitijaze, korišćenjem teorije potpornih vektora (SVM). Ustanovljeno je da patološki nalazi ovih parametara značajno ukazuju na holedoholitijazu, te da je LH preporučena kao metoda prvog izbora, kod bolesnika kod kojih nalazi prediktora holedoholitijaze nisu patološki. Ovako lečeni bolesnici su imali značajno kraće vreme hospitalizacije. Pored toga, ukoliko se intraoperativnom holangiografijom (IOH) pri LH ustanovi holedoholitijaza, ERCP sa EPT se može uraditi bez odlaganja.</p> / <p>Acute pancreatitis is an enzymatic inflammatory disease of the pancreas, with an incidence of around 17/100000 inhabitants. The most common etiological factors that are associated with this condition are biliary calculi (45%) and consumption of alcoholic beverages (35%). Less common causes include certain medications, hypertriglyceridemia, hyperkalemia, trauma, congenital factors and idiopathic pancreatitis (20%). According to the Atlanta International classification, acute pancreatitis can be manifested in a moderate, moderately severe and severe forms. Moderate forms of pancreatitis occur in 80%, characterized by pancreatic edema and have mild and short clinical course, with a mortality rate of 1%. The main goal of treatment of patients with acute pancreatitis in the first 24 hours of hospitalization is to facilitate complaints, determining the cause of pancreatitis and assessment of severity of the disease. Acute biliary pancreatitis is caused by calculosis of the gallbladder and / or bile ducts. The recommended treatment of biliary calculi, in order to prevent repeated attacks of moderate biliary pancreatitis, involves the removal of the gallbladder thru laparoscopic cholecystectomy with intraoperative cholangiography. If presence of bile duct calculi is established, an endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic papillotomy (EPT) and removes stones and detritus along the bile ducts is indicated, with the aim of ensuring the normal flow of bile into the duodenum. The aim of this study is the optimization of the order of application LH and ERCP with EPT, the identification of predictable indicators of choledocholithiasis, in order to shorten the length of hospitalization of patients with a moderate form of acute biliary pancreatitis. We conducted prospective case control study, with 100 patients involved, treated for moderate forms of acute biliary pancreatitis in the Emergency Center of the Clinical Center of Vojvodina, from 2011 to 2015, of which 80 made only with LH and 20 with LH at and ERCP with EPT . The analysis of clinical, ultrasound and laboratory findings identified 5 significant predictors of choledocholithiasis; direct and total bilirubin, alkaline phosphatase (AF), gamma glutiril transpepdidase (gamma GT) and C reactive protein (CRP), under which enabled the creation of a mathematical model for predicting choledocholithiasis, using the Support vector machines (SVM). It was found that pathological findings of these parameters indicate a significant choledocholithiasis, and LH is recommended as the first choice in patients in whom there are not present pathological predictors of choledocholithiasis. Thus treated patients had a significantly shorter hospital stay. In addition, if the intraoperative cholangiography (IOH) during LH show choledocholithiasis, ERCP with the EPT can be done without delay.</p>

Le bloc opératoire est au coeur des soins délivrés dans l'hôpital. Suite à de nombreux développements techniques et médicaux, il devient équipé de salles opératoires hautement technologiques. Bien que ces changements soient bénéfiques pour le traitement des patients, ils accroissent la complexité du déroulement des opérations. Ils impliquent également la présence de nombreux systèmes électroniques fournissant de l'information sur les processus chirurgicaux. Ce travail s'intéresse au développement de méthodes statistiques permettant de modéliser le déroulement des processus chirurgicaux et d'en reconnaitre les étapes, en utilisant des signaux présents dans le bloc opératoire. Nous introduisons et formalisons le problème consistant à reconnaitre les phases réalisées au sein d'un processus chirurgical, en utilisant une représentation des chirurgies par une suite temporelle et multi-dimensionnelle de signaux synchronisés. Nous proposons ensuite des méthodes pour la modélisation, la segmentation hors-ligne et la reconnaissance en-ligne des phases chirurgicales. La méthode principale, une variante de modèle de Markov caché étendue par des variables de probabilités de phases, est démontrée sur deux applications médicales. La première concerne les interventions endoscopiques, la cholécystectomie étant prise en exemple. Les phases endoscopiques sont reconnues en utilisant des signaux indiquant l'utilisation des instruments et enregistrés lors de chirurgies réelles. La deuxième application concerne la reconnaissance des activités génériques d'une salle opératoire. Dans ce cas, la reconnaissance utilise de l'information 4D provenant d'un système de reconstruction multi-vues / The department of surgery is the core unit of the patient care system within a hospital. Due to continuous technical and medical developments, such departments are equipped with increasingly high-tech surgery rooms. This provides higher benefits for patient treatment, but also increases the complexity of the procedures' workflow. This also induces the presence of multiple electronic systems providing rich and various information about the surgical processes. The focus of this work is the development of statistical methods that permit the modeling and monitoring of surgical processes, based on signals available in the surgery room. We introduce and formalize the problem of recognizing phases within a workflow, using a representation of interventions in terms of multidimensional time-series formed by synchronized signals acquired over time. We then propose methods for the modeling, offline segmentation and on-line recognition of surgical phases. The main method, a variant of hidden Markov models augmented by phase probability variables, is demonstrated on two medical applications. The first one is the monitoring of endoscopic interventions, using cholecystectomy as illustrative surgery. Phases are recognized using signals indicating tool usage and recorded from real procedures. The second application is the monitoring of a generic surgery room workflow. In this case, phase recognition is performed by using 4D information from surgeries performed in a mock-up operating room in presence of a multi-view reconstruction system

Advances in medical technology have altered the need for certain types of surgery to be performed in traditional inpatient hospital settings. Less invasive surgical procedures allow a growing number of medical treatments to take place on an outpatient basis. Hospitals face growing competition from ambulatory surgery centers (ASCs). The competitive threats posed by ASCs are important, given that inpatient surgery has been the cornerstone of hospital services for over a century. Additional research is needed to understand how surgical volume shifts between and within acute care general hospitals (ACGHs) and ASCs. This study investigates how medical technology within the hospital industry is changing medical services delivery. The main purposes of this study are to (1) test Clayton M. Christensen’s theory of disruptive innovation in health care, and (2) examine the effects of disruptive innovation on appendectomy, cholecystectomy, and bariatric surgery (ACBS) utilization. Disruptive innovation theory contends that advanced technology combined with innovative business models—located outside of traditional product markets or delivery systems—will produce simplified, quality products and services at lower costs with broader accessibility. Consequently, new markets will emerge, and conventional industry leaders will experience a loss of market share to “non-traditional” new entrants into the marketplace. The underlying assumption of this work is that ASCs (innovative business models) have adopted laparoscopy (innovative technology) and their unification has initiated disruptive innovation within the hospital industry. The disruptive effects have spawned shifts in surgical volumes from open to laparoscopic procedures, from inpatient to ambulatory settings, and from hospitals to ASCs. The research hypothesizes that: (1) there will be larger increases in the percentage of laparoscopic ACBS performed than open ACBS procedures; (2) ambulatory ACBS will experience larger percent increases than inpatient ACBS procedures; and (3) ASCs will experience larger percent increases than ACGHs. The study tracks the utilization of open, laparoscopic, inpatient and ambulatory ACBS. The research questions that guide the inquiry are: 1. How has ACBS utilization changed over this time? 2. Do ACGHs and ASCs differ in the utilization of ACBS? 3. How do states differ in the utilization of ACBS? 4. Do study findings support disruptive innovation theory in the hospital industry? The quantitative study employs a panel design using hospital discharge data from 2004 and 2009. The unit of analysis is the facility. The sampling frame is comprised of ACGHs and ASCs in Florida and Wisconsin. The study employs exploratory and confirmatory data analysis. This work finds that disruptive innovation theory is an effective model for assessing the hospital industry. The model provides a useful framework for analyzing the interplay between ACGHs and ASCs. While study findings did not support the stated hypotheses, the impact of government interventions into the competitive marketplace supports the claims of disruptive innovation theory. Regulations that intervened in the hospital industry facilitated interactions between ASCs and ACGHs, reducing the number of ASCs performing ACBS and altering the trajectory of ACBS volume by shifting surgeries from ASCs to ACGHs.