Is there a difference between acute appendicitis in pregnant and non-pregnant women?

OBJECTIVE: Acute appendicitis is the most common indication for surgical intervention during pregnancy for non-gynaecological or non-obstetric causes. The aim of this study was to compare perioperative and postoperative outcomes of acute appendectomies in pregnant and non-pregnant patients of childbearing age. METHODS: A retrospective clinical study focused on the comparison of perioperative and postoperative outcomes of acute appendectomy in pregnant and non-pregnant patients of reproductive age between January 2012 and December 2021 at the University Hospital in Ostrava. RESULTS: A number of 308 patients underwent acute appendectomy, 25 pregnant and 283 non-pregnant. There were no statistically significant differences in age, ASA (American Society of Anesthesiologists) classification, duration of complaints, baseline C-reactive protein values, sensitivity or specificity of sonography. A statistically significant difference was found in the leukocyte count between subgroups (P = 0.014) and in the number of laparoscopic procedures performed between the two subgroups (P < 0.001; 98.9% non-pregnant vs. 80.0% pregnant). There was also a statistically significant difference in the length of hospital stay, with the pregnant subgroup having a longer hospital stay (P = 0.014) and a statistically significant difference in the rate of postoperative complications between the defined subgroups (P = 0.039). Serious complications were described predominantly in the subgroup of pregnant patients, where they reached 12% compared to non-pregnant patients, where they were 2.8%. The mortality rate of the cohort was zero. CONCLUSION: The results of the study support the fact that pregnancy may be associated with complicated forms of acute appendicitis. Accurate and early diagnosis not only prevents the development of complicated forms of appendicitis but also reduces the number of negative appendectomies in pregnancy.

Diverting ileostomy in laparoscopic rectal cancer surgery: high price of protection.

BACKGROUND: Anastomotic leakage presents the most feared complication after low anterior resection (LAR). A proximal diversion of the gastrointestinal tract is recommended to avoid septic complications of anastomotic leakage. The aim of the present study was to evaluate the benefits and risks of diverting ileostomy (DI) created during laparoscopic LAR because of low rectal cancer. METHODS: This was a retrospective clinical cohort study conducted to assess outcomes of laparoscopic LAR with/without DI in a single institution within a 6-year period. RESULTS: In total, 151 patients were enrolled in the study (73 patients without DI, 78 patients with DI). There were no significant differences between both groups regarding demographic and clinical features. Overall 30-day morbidity rates were significantly lower in patients without DI (23.3 vs. 42.3 %, P = 0.013). Symptomatic anastomotic leakage occurred more frequently in patients without DI (9.6 vs. 2.5 %, P = 0.090); surgical intervention was needed in 6.8 % of patients without DI. Post-operative hospital stay was significantly longer in the group of patients with DI (11.3 ± 8.5 vs. 8.1 ± 6.9 days, P = 0.013). Stoma-related complications occurred in 42 of 78 (53.8 %) patients with DI; some patients had more than one complication. Acute surgery was needed in 9 patients (11.5 %) because of DI-related complications. Small bowel obstruction due to DI semi-rotation around its longitudinal axis was seen in 3 patients (3.8 %) and presents a distinct complication of DI laparoscopic construction. The mean interval between LAR and DI reversal was more than 8 months; only 19.2 % of patients were reversed without delay (≤4 months). Morbidity after DI reversal was 16.6 %; re-laparotomy was necessary in 2.5 % of patients. CONCLUSIONS: The present study indicates that DI protects low rectal anastomosis from septic complications at a cost of many stoma-related complications, substantial risk of acute surgery necessity and long stoma periods coupled with decreased quality of life.

Acute appendicitis in pregnancy - do we treat correctly, or do we delay unnecessarily?

OBJECTIVES: Acute appendicitis is the most common non-gynaecological indication for surgical intervention during pregnancy. The aim of this study was to compare perioperative and postoperative results of surgical treatment of acute appendicitis in the early and late stage of pregnancy. MATERIAL AND METHODS: This is a retrospective study focused on the evaluation of perioperative and postoperative results of appendectomy in pregnancy. The study included all pregnant patients who underwent laparoscopic or open appendectomy at the University Hospital Ostrava during the observed 10-year period (January 2012-December 2021). The patients were divided into two subgroups according to the stage of pregnancy in relation to the expected viability of the foetus (the viability limit was defined as the 23rd week of pregnancy). RESULTS: In the monitored 10-year period, a total of 25 pregnant patients underwent appendectomy. Comparing the two subgroups of patients, there were no statistically significant differences in any of the admission parameters. Laparoscopy was performed in 100% of the patients in the lower stage of pregnancy (< 23 g.w.) and in 61% of the subgroup of patients with more advanced pregnancy (> 23 g.w.); this difference was statistically significant (p = 0.039). Differences in subgroups regarding duration of surgery, risk of revision and 30-day postoperative morbidity were not statistically significant. In the subgroup of patients < 23 g.w., uncomplicated forms of appendicitis predominated (66%), whereas in the subgroup > 23 g.w., complicated forms predominated (69%); this difference was statistically significant (p = 0.026). When comparing the two subgroups of patients, there was a statistically significant difference in the length of hospitalization (p = 0.006). The mortality rate of the group was zero. CONCLUSIONS: The results of the study confirm the fact that advanced pregnancy may be related to complicated forms of appendicitis. Therefore, early appendectomy is still the method of choice. In accordance with the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) recommendations, laparoscopic approach is preferred in pregnant patients, even in advanced pregnancy.

A novel labeling modality of intra-abdominal lesions with Magseed magnetic marker and extirpation by Sentimag probe navigation.

OBJECTIVE: This study aimed to evaluate our experience with the use of Magseed, the magnetic metallic marker, as a localization technique followed by Sentimag probe detection in patients with solitary intra-abdominal local metastases with subsequent resection of the lesions. METHODS: Five patients underwent resection after the lesion was marked with the Magseed magnetic marker. Prior to the surgery, a computed tomography scan of the chest and abdomen and/or positron emission tomography was performed to rule out the dissemination of the disease. The indication for surgery was evaluated in a meeting of a multidisciplinary team, and the placement of the magnetic marker under computed tomography control had been performed the day before the planned procedure. RESULTS: The present preliminary outcomes have revealed that Magseed might be a promising technique that is feasible and safe, particularly when the postsurgical anatomic conditions in the abdominal cavity are altered and the lesions are not visible or palpable. Surgical extirpation of lesions occurred without complications in each case. In all the cases, the resection was complete and curative, and one wound infection in all (20%), without any major complications, had occurred. The mean hospital stay was 6.6 days. CONCLUSION: Magseed utilization, as a localization technique, followed by Sentimag probe detection in intra-abdominal tumors has not been reported before. Improving the visualization and, consequently, the precise marking of the lesion with subsequent radical removal can prevent insufficient or excessive removal of healthy tissue, leading to a faster diagnosis and better overall clinical outcomes.

Obesity in cases undergoing the surgical procedure of lung lobectomy: risk or benefit?

OBJECTIVE: The aim of the study was to evaluate the effect of body mass index on patients' short-term results following lung lobectomy. METHODS: In this retrospective study, we compared the perioperative and short-term postoperative results of obese (BMI≥30 kg/m2) versus non-obese patients (BMI<30 kg/m2) who underwent anatomical lung resection for cancer. The two groups had the same distribution of input risk factors and the same ratio of surgical approaches (thoracoscopy vs. thoracotomy). RESULTS: The study included a total of 144 patients: 48 obese and 96 non-obese patients. Both groups had the same ratio of thoracoscopic vs. thoracotomy approach (50/50%), and were comparable in terms of demographics and clinical data. The g roups did not significantly differ in the frequency of perioperative or postoperative complications. Postoperative morbidity was higher among non-obese patients (34.4 vs. 27.1%), but this difference was not statistically significant (p=0.053). Hospital stay was similar in both study groups (p=0.100). Surgery time was significantly longer among obese patients (p=0.133). Postoperative mortality was comparable between the study groups (p=0.167). CONCLUSIONS: Obesity does not increase the frequency of perioperative and postoperative complications in patients after lung lobectomy. The slightly better results in obese patients suggest that obesity may have some protective role.

Laparoscopic approach to retrorectal cyst.

Retrorectal cysts are rare benign lesions in the presacral space which are frequently diagnosed in middle-aged females. We report here our experience with two symptomatic female patients who were diagnosed as having a retrorectal cyst and managed using a laparoscopic approach. The two patients were misdiagnosed as having an ovarian cystic lesion after abdominal ultrasonography. Computer tomograghy (CT) scan was mandatory to establish the diagnosis. The trocar port site was the same in both patients. An additional left oophorectomy was done for a coexisting ovarian cystic lesion in one patient in the same setting. There was no postoperative morbidity or mortality and the two patients were discharged on the 5th and 6th post operative days, respectively. Our cases show that laparoscopic management of retrorectal cysts is a safe approach. It reduces surgical trauma and offers an excellent tool for perfect visualization of the deep structures in the presacral space.

Intrathoracic splenosis - lesson learned: a case report.

BACKGROUND: Intrathoracic splenosis presents an extremely rare thoracic lesion occurring after a simultaneous rupture of the spleen and diaphragm as a consequence of heterotopic autotransplantation and implantation of splenic tissue. Intrathoracic splenosis is usually an asymptomatic, incidental finding, which should be ideally managed without surgical intervention. CASE PRESENTATION: We present a case of 68-year old woman with intrathoracic splenosis. Patient presented with a 2-month history of a dry cough unresponsive to administered antibiotics and antimycotics. Computed tomography (CT) of the chest revealed two homogeneous pleural nodules (diameters of 2 and 4 cm) in the left upper lung field. Two consequent CT-assisted transthoracic core-cut biopsies were performed. Histopathology examination of both biopsy specimens was inconclusive (haemorrhagic and non-specific tissue). After that, patient was referred to the department of thoracic surgery with a suspicion of malignant mesothelioma or metastatic lesions. Thoracoscopic revision of the left pleural cavity was performed and the presence of pleural nodules was confirmed. Bloody looking nodules were resected (standard thoracoscopic resection). Postoperative recovery was uneventful. The histopathology examination of the specimen showed normal splenic tissue. Only with the histopathology report in hand, a detailed medical history was taken. It revealed a gunshot injury requiring splenectomy (without known diaphragm or lung injury) 44 years ago (one of the longest time periods in the literature). CONCLUSIONS: We would like to point out that following the recommendations regarding splenosis may be very difficult in daily routine practice. The simple question regarding abdominal trauma in a patient's history can lead the clinician to the diagnosis of splenosis, which can be unequivocally established via scintigraphy. The importance of thorough medical history taking, therefore, cannot be underestimated.

Laparoscopic colorectal surgery in obese patients.

BACKGROUND: The aim of the study was to the evaluate results of laparoscopic colorectal surgery in obese patients. METHODS: All patients who underwent elective laparoscopic colorectal surgery from January 1993 to December 2003 were included in the study. BMI>30 was used as an objective obesity criterion. The evaluated parameters included BMI, age, sex, diagnosis and associated diseases, American Society of Anesthesiologists classification score (ASA), type and duration of procedure, peroperative and postoperative complications, postoperative course, reoperation, length of hospitalization, morbidity and early mortality. RESULTS: 435 patients were evaluated. There were 80 patients (18%) in the obese group, and 355 patients (82%) were non-obese. The samples were comparable in terms of age, gender, ASA, diagnosis and procedure. Peroperative complications occurred more frequently in the obese group of patients (4% vs 2.5%, P>0.05) and the operating time was longer as well (151 min vs 141 min, P>0.05), both statistically not significant. There was no difference in postoperative course in both groups with regard to intravenous administration of analgesics (2 days), start of solid diet (day 3) and first bowel movement (day 4). Morbidity was higher in the obese group of patients (33% vs 24%, P>0.05), and reoperations were also more frequent here (13% vs 7%, P>0.05), which was reflected in prolonged hospital stay (14 days vs 12 days, P>0.05). On the other hand, early mortality was surprisingly lower in the obese group of patients (2.5% vs 6%, P>0.05). However, none of these differences achieved statistical significance on the set significance level of P=0.05. CONCLUSION: With sufficient experience, laparoscopic colorectal surgery in obese patients is feasible and safe. It is associated with no increased risk of complications and preserves all benefits of the mini-invasive approach.

Laparoscopic gastric resection with natural orifice specimen extraction for postulcer pyloric stenosis.

Although natural orifice specimen extraction is now relatively widely performed, there have been no reports on gastric resection with specimen extraction through the transgastric route for peptic ulcer disease. A hybrid technique of the laparoscopic and endoscopic approach is presented in the case of a 58-year old male patient. Preoperative gastric fibroscopy showed postulcer pyloric and antral stenosis. Laparoscopic exploration confirmed gastric enlargement. Laparoscopic two-thirds gastrectomy was performed. The staple line suture of the residual stomach was excised and the specimen was extracted through the esophagus and mouth with a gastroscope. Finally, the residual stomach was closed again using linear endostaplers. Reconstruction was performed according to the Roux-en-Y method. Gastric resection using natural orifice specimen extraction (NOSE) may be a feasible operative procedure. The NOSE with the combination of standard laparoscopy and specimen extraction through a natural orifice can be considered as a bridge to natural orifice translumenal endoscopic surgery.

Impact of blood transfusions on survival and recurrence in colorectal cancer surgery.

The aim of our study was to evaluate the prognostic significance of blood transfusion on recurrence and survival in patients undergoing curative resections for colorectal cancer. Retrospective analysis of prospectively collected data of patients after elective resections for colorectal cancer between January 2001 and December 2009 was undertaken. The main endpoint was overall survival, disease-free survival, and recurrence rate. These data were evaluated in relation to blood transfusion (group A, no blood transfusion; group B, one to two blood transfusions; group C, three and more blood transfusions). A total of 583 patients met the criteria for inclusion in the study. Of these, 132 (22.6 %) patients received blood transfusion in the perioperative period. There were 83 (14.2 %) patients who received one or two blood transfusions and 49 (8.4 %) patients who required three or more transfusions. Patients with three or more transfusions had a significantly worse 5-year overall survival, disease-free survival, and increased incidence of distant recurrences in comparison with the group without transfusion or the group with one or two transfusions. Multivariate analysis showed that the application of three or more blood transfusions is an independent risk factor for overall survival (P = 0.001; HR 2.158; 95 % CI 1.370-3.398), disease-free survival (P < 0.001; HR 2.514; 95 % CI 1.648-3.836), and the incidence of distant recurrence (P < 0.001; HR 2.902; 95 % CI 1.616-5.212). Application of three or more blood transfusions in patients operated for colorectal carcinoma is an adverse prognostic factor. Indications for blood transfusion should be carefully considered not only with regard to the risk of early complications, but also because of the possibility of compromising long-term results.

Laparoscopic approach for duodenal carcinoid.

Carcinoids are a heterogeneous group of neuroendocrine tumours. Duodenal localization is associated with relatively benign behaviour of the tumour, slow progression, low metastatic potential, and absence of endocrine activity. Type and extent of surgery depend on size and staging of the tumour. In this article, we present a case study of a 27-year-old female patient with well-differentiated carcinoid in the second part of the duodenum. The tumour of a size 5 mm × 3 mm × 2 mm manifested with abdominal symptomatology and did not invade the muscularis propria. Scintigraphy did not demonstrate other pathological deposits of somatostatin receptors. The wedge resection of the duodenal wall was performed laparoscopically with perioperative endoscopic localization and marking of the tumour. Uneventful operation and postoperative course presents a contribution of miniinvasive surgery of specific duodenal lesions.

Impact of conversion on outcome in laparoscopic colorectal cancer surgery.

INTRODUCTION: Long-term results after laparoscopic surgery with conversion to open surgery for colorectal cancer are seldom published. AIM: The study analysed the impact of conversion of laparoscopic surgery to open resection for colorectal cancer on short- and long-term results. MATERIAL AND METHODS: The prospectively collected data of 469 patients with colorectal cancer in the period from 1 January 2001 to 31 December 2006 were analysed. Short- and long-term results were compared. RESULTS: The relative frequency of conversion was 7%. The subgroups were statistically similar regarding age, gender, body mass index (BMI), localization of tumour, T stage, and TNM stage. We observed a lower frequency of previous surgery (p = 0.018) in the group of patients with conversions to open surgery as well as statistically significantly higher frequency of patients with American Society of Anesthesiologists (ASA) score II (p = 0.039). There was no statistical difference in morbidity, mortality, or the length of hospital stay between both the groups of patients. The operating time was significantly higher in the group of patients with conversion (p = 0.00001). There was a significantly higher blood loss in the patient groups with conversion to open surgery and in the group with primarily open surgery (p = 0.00023). There was no difference in the overall survival (p = 0.712), disease-free survival (p = 0.072) or in the local (p = 0.432) or distant (p = 0.957) recurrence. CONCLUSIONS: No negative impact on short- or long-term results of conversion to open surgery was verified in patients with colorectal surgery.