Uterine fibroids (leiomyomas and myomas) are the most common benign gynecological condition in patients presenting with abnormal uterine bleeding, pelvic masses causing pressure or pain, infertility and obstetric complications. Almost a third of women with fibroids need treatment due to symptoms. Objectives: In this review we present all currently available treatment modalities for uterine fibroids. Methods: An extensive search for the available data regarding surgical, medical and other treatment options for uterine fibroids was conducted. Review: Nowadays, treatment for fibroids is intended to control symptoms while preserving future fertility. The choice of treatment depends on the patient’s age and fertility and the number, size and location of the fibroids. Current management strategies mainly involve surgical interventions (hysterectomy and myomectomy hysteroscopy, laparoscopy or laparotomy). Other surgical and non-surgical minimally invasive techniques include interventions performed under radiologic or ultrasound guidance (uterine artery embolization and occlusion, myolysis, magnetic resonance-guided focused ultrasound surgery, radiofrequency ablation of fibroids and endometrial ablation). Medical treatment options for fibroids are still restricted and available medications (progestogens, combined oral contraceptives andgonadotropin-releasing hormone agonists and antagonists) are generally used for short-term treatment of fibroid-induced bleeding. Recently, it was shown that SPRMs could be administered intermittently long-term with good results on bleeding and fibroid size reduction. Novel medical treatments are still under investigation but with promising results. Conclusions: Treatment of fibroids must be individualized based on the presence and severity of symptoms and the patient’s desire for definitive treatment or fertility preservation.

Background: The aim of this study was to investigate the influence of IL-6, TNF-α and hs-CRP on insulin sensitivity during postoperative follow-up in patients with laparoscopic cholecystectomy (LC) or open hernia repair (OHR). Methods: 65 patients were studied: after laparoscopic cholecystectomy (LC; n=40) or open hernia repair (OHR; n=25). Glucose, insulin, hs-CRP, IL-6 and TNF-α were determined at day 0 (before the operation) and at days 1, 3 and 7 (after the operation). Results: There were no difference between LC and OHR groups concerning age, BMI, glucose, insulin, hs-CRP, IL-6 and TNF-α at day 0. hs-CRP increased at day 1, 3 and 7 vs. day 0 (p<0.0005), without difference between groups (p=0.561). IL-6 increased at day 1 and day 3 vs. day 0 (p<0.005). IL-6 was higher at day 1 in OHR group in comparison with LC group (p=0.044). There were no differences in TNF-α levels between LC and OHR groups (p=0.056). There was increase of HOMA-IR at day 1, 3 and 7 vs. day 0 (p<0.0005) in both groups. Significantly higher increase of HOMA-IR was in OHR group compared with LC group at day 1 (p=0.045). There was a positive correlation between hs-CRP and HOMA-IR (r=0.46; p=0.025) and between IL-6 and HOMA-IR at day 1 in OHR group (r=0.44; p=0.030). Conclusions: Significantly higher HOMA-IR was found in OHR group compared with LC. Positive correlation between hs-CRP and IL-6 with HOMA-IR in OHR group at day 1, indicate possible influence of this mediators on impairment of insulin sensitivity.

Surgical procedures are associated with stress reaction, that leads to inflammation and insulin resistance. Insulin resistance is protective mechanism developed in postoperative period, in order to protect sources of carbohydrate for glucose-dependent organs, such as brain. Surgery, and other types of tissue traumatization, increase metabolism, oxidative processes and catabolic reactions as degradation of glycogen, fats and proteins. Insulin resistance occurs in extra hepatic tissue, especially in skeletal muscles. The degree of insulin resistance and its duration, depends of tissue damage. Less invasive surgical interventions induce weaker inflammatory response, shorter decrease in insulin sensitivity, less number of postoperative complications (infections and cardiovascular complications), followed by shorter postoperative hospitalization. Interleukin 6 (IL-6) and Tumor necrosis factor alpha (TNF-alpha) are increased in postoperative period, as well as C-reactive protein (CRP), marker of inflammation. Preoperative glucose infusion with insulin leads to less catabolic effect, and has positive effect on insulin sensitivity. The level of insulin resistance, irrespective of type of surgery, has direct influence on duration of hospital stay and postoperative complications. Postoperative surgical stress and postoperative insulin resistance could be lowered by minimal invasive surgery.

Cirrhotic cardiomyopathy (CCM) is a diagnostic entity defined as cardiac dysfunction (diastolic and/or systolic) in patients with liver cirrhosis, in the absence of overt cardiac disorder. Pathogenically, CCM stems from a combination of systemic and local hepatic factors that, through hemodynamic and neurohormonal changes, affect the balance of cardiac function and lead to its remodeling. Vascular changes in cirrhosis, mostly driven by portal hypertension, splanchnic vasodilatation, and increased cardiac output alongside maladaptively upregulated feedback systems, lead to fluid accumulation, venostasis, and cardiac dysfunction. Autocrine and endocrine proinflammatory cytokines (TNF-alpha, IL-6), as well as systemic endotoxemia stemming from impaired intestinal permeability, contribute to myocardial remodeling and fibrosis, which further compromise the contractility and relaxation of the heart. Additionally, relative adrenal insufficiency is often present in cirrhosis, further potentiating cardiac dysfunction, ultimately leading to the development of CCM. Considering its subclinical course, CCM diagnosis remains challenging. It relies mostly on stress echocardiography or advanced imaging techniques such as speckle-tracking echocardiography. Currently, there is no specific treatment for CCM, as it vastly overlaps with the treatment of heart failure. Diuretics play a central role. The role of non-selective beta-blockers in treating portal hypertension is established; however, their role in CCM remains somewhat controversial as their effect on prognosis is unclear. However, our group still advocates them as essential tools in optimizing the neurohumoral pathologic axis that perpetuates CCM. Other targeted therapies with direct anti-inflammatory and antioxidative effects still lack sufficient evidence for wide approval. This is not only a review but also a comprehensive distillation of the insights from practicing clinical hepatologists and other specialties engaged in advanced approaches to treating liver disease and its sequelae.

Introduction: Obesity is associated with high risk for coronary artery disease, high blood pressure, elevated serum cholesterol level, malignancy and Type 2 diabetes mellitus. After weight loss, especially after bariatric surgery there is improvement in blood pressure, metabolic parameters and ventilatory anaerobic threshold. Material and methods: Ergospirometry (Shiller CS-200, Bruce protocol) was performed in 50 obese patients before and six months after R en Y gastric bypass. Baseline characteristics were: BMI 43.8 kg/m2, 43±12.7 years of age (female n=37, male n=13). Changes in pulse rate, systolic blood pressure (SBP) in rest and maximal SBP, diastolic blood pressure in rest (DBP) and maximal DBP, ventilatory anaerobic threshold (VAT/VO2) and peak in oxygen consumption (VO2) were analyzed. Baseline VO2 less than 14 ml/kg per min was exclusion criteria for bariatric surgery. Results: Change in pulse rate (98.7±12.2 vs 88.01±13.46/min) was significant (P<0.0001). SBP in rest decreased (135±14 vs 131±13 mmHg) with significance P=0.017. Max SBP decreased with high significance (181±26 vs 162±22 mmHg; P<0.0001). DBP in rest also decreased (85±8 vs 80±9 mmHg; P<0.0001) and max DBP decreased from 98±12 to 92±10 mmHg (P=0.002). There was improvement in VAT/VO2 (17.8±3.44 vs 20.86±4.70 ml/kg per min; P<0.0001) and in peak of oxygen consumption, VO2 (20.79±3.63 vs4.97±4.37 ml/kg per min; P<0.0001). Conclusion: Our results suggest that bariatric surgery could improve cardiorespiratory fitness. Ventilatory anaerobic threshold, oxygen consumption, pulse rate, maximal systolic and diastolic blood pressure as well as systolic and diastolic blood pressure in rest were improved six months after RYGB.

Introduction: Gastric bypass surgery in obese patients results in weight loss, changes in gastrointestinal and pancreatic hormones and improvement of insulin sensitivity. Methods: GLP-1, insulin and glucose levels were measured after test meal (Fresubin drink a 200 ml; 200 kcal, 15% protein, 30% fat and 55% carbohydrate) before (day 0) and 5, 90 and 180 days after gastric bypass surgery. Glycaemia (mmol/l; glucose oxidase);GLP-1 (Active 7–36) (pM/l; ELISA, ALPCO diagnostics) and insulin (ECLIA, Roche Diagnostics, pmol/l) were determined in 49 obese patients (age: 37.8±1.6; BMI: 43.45±0.77 kg/m²) in 4 separate days in 0, 15, 30, 45, 60, 90 and 120 min. Results: There were significant difference between area under the glucose curve (X±S.D.): 679.12±31.25 mmol/l × min⁻¹ (day 0) vs 638.77±29.27 (day 5) vs 658.53±38.64 (day 90) and no difference in day 180 (623.37±28.56). There was significant increase in area under the GLP-1 curve in days 5 (980.12±114.09 pmol/l × min^-1), days 90 (682.92±141.39) and days 180 (778.71±210.78) in comparison with day 0 (287.74±118.72) (P<0.05). There was significant difference betwen the area under the insulin curve for days 0 and 5 (33 832.21±3643.67 vs 22 111.59±2399.34) (P=0.002) while there were no differences for day 90 (29 757.06±4135.41) and day 180 (28 378.14±5242.49). There were no significant differences between basal glucose and GLP-1 levels, while there was significant increase in peak GLP-1 levels in day 5 (16.920±2.371), day 90 (14.566±2.914) and day 180 (17.258±3.172) in comparison with day 0 (3.719±1.023) (P<0.05). Conclusion: GLP-1 response after mixed test meal is significantly increased up to 6 months after gastric bypass surgery. Changes in insulin and glucose levels indicate improvement in insulin sensitivity The improvement in GLP-1 response after test meal after gastric bypass may be responsible for the beneficial metabolic effects of bariatric surgery.