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Vacuum-assisted closure (VAC) therapy is a widely acknowledged method for chronic and traumatic wound healing. The feasibility of VAC therapy used for the treatment of intestinal fistulas is still a subject of debate. Complex postoperative wounds pose significant therapeutic problems, especially when there are several fistula openings in the wound area and other sites, usually at the site of previous drains. This paper describes the treatment of three patients in a critical condition, with complex postoperative wounds complicated by multiple fistulas. Vacuum-assisted closure therapy was based on effective drainage of the biggest fistula opening and ensuring conditions promoting the healing process of other fistulas and the wound. A considerable improvement in general condition and wound healing was noted within 2-4 weeks and both the number of fistulas and the volume of excreted contents decreased. After 5-7 weeks a significant improvement in wound healing was observed in all patients. Once the general condition of all patients was considered satisfactory (2-6 months), they underwent surgery aimed at restoration of the digestive tract continuity.In our opinion, VAC therapy used for the treatment of postoperative wounds with multiple fistulas in the wound area and other sites should aim mainly at the improvement of patients’ general condition, limitation of the number of fistulas as well as accelerated wound healing. This may lead to formation of one stoma-type fistula, which can be dressed and cared for by patients until the continuity of the digestive tract has been surgically restored.

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The local anesthesia in thyroid surgery is rarely used, only in selected patients. Majority of centers performing thyroid surgery with local anesthesia have possibility to convert to the general anesthesia. the aim of the study was to present our experiences with partial thyroidectomy under local anesthesia performed in 49 consecutive subjects in the Central African Republic (bilateral subtotal strumectomy, total resection of the one lobe, subtotal resection of the one lobe). Material and methods. All admitted patients with clinically significant goiter were accepted for surgical treatment. For infiltration anesthesia 1% lignocaine was used. Because of the shortage of medical resources, potential conversion to the general anesthesia was impossible. Before the operation patients had received an oral sedation and antibiotic. In 16 patients general anesthesia was used, in other 33 it was impossible. Results. Subtotal bilateral thyroidectomy was performed in 37 patients, 12 patients underwent lobectomy or partial lobectomy of the affected portion of the gland. There were no intraoperative and postoperative complications noticed in the reported group, including complications related to laryngeal nerve injury. The mean duration of the procedure was 127 minutes and mean medical follow-up was 3 days. General condition of all patients on the day of discharge from hospital was good. conclusions. Surgery for goiter under local anesthesia may be a safe alternative where general anesthesia is not available or contraindicated for medical reasons. The infiltration anesthesia is simple to perform and reduces the number of complications potentially occurred at the C2-C4 neck plexus block.

The results of this study show that postoperative patient-controlled pain therapy in children with piritramide is - in a similar way as with adults - a safe method involving a low incidence of side effects. A special pump parameter setting is required with larger bolus dose sizes and longer lockout intervals, not very different from the experience gained with adults, and which is based on other values than those recommended up to now with morphine for paediatric PCA. Side effects were rarely observed. The fear of respiratory depression constitutes no rational reason to deny the younger patients this form of analgesia provided that monitoring is guaranteed.

Surgery for goitre under local anaesthesia may be a safe alternative where general anaesthesia is not available or contraindicated for medical reasons.

IntroductionProctocolectomy with ileal pouch-anal anastomosis (IPAA) was performed in ulcerative colitis (UC) for emergent or urgent indications in three stages. Since the three-step procedure imposes enormous demands on a patient, there was an attempt to introduce primary IPAA for urgent indications. The aim of this study was to compare early complications after Hartmann's colectomy (HC) and IPAA in a selected group of patients.Material and methodsMedical records of 274 patients who underwent surgery for UC between 1996 and 2010 were retrospectively evaluated. Finally, a group of 77 patients with acute form of UC entered this study.ResultsAll patients were divided into two groups. Group 1 consisted of 32 (42%) patients who underwent HC, whereas group 2 comprised 45 (58%) patients after IPAA. There was no postoperative mortality. Respiratory failure occurred in 8 (24%) patients after HC and in 6 (14%) patients who underwent IPAA. Intra-abdominal sepsis developed in 4 (12%) patients after HC and in 8 (17%) undergoing IPAA. Fascia dehiscence was present in 3 (8%) patients after HC and in 4 (9%) with IPAA. Bowel obstruction occurred in 1 (4%) patient after the former operation and in 3 (6%) patients after the latter one. Wound infection was diagnosed in 6 (20%) patients after HC and in 9 (20%) after IPAA. The differences between the investigated groups of patients were not statistically significant.ConclusionsThe IPAA could be performed for urgent indications only in the patients with no critical dilatation of the colon or with active UC but without signs of severe malnutrition.

The placement of an infraclavicular plexus catheter is a suitable method for pain management in the upper limb. This approach may have advantages in patients with severe injuries who cannot abduct the arm. Our results are encouraging in terms of catheterisation time, patient comfort and incidence of complications.