Metabolic and Bariatric Surgery Chapter of the Association of Polish Surgeons. Bariatric and metabolic surgery care standards.

The Metabolic and Bariatric Surgery Chapter of the Association of Polish Surgeons (Polish acronym: SCMiB TCHP) is a Polish specialist scientific society representing bariatric surgeons as well as specialists from other disciplines and professions cooperating with them during the provision of services in the field of bariatric and metabolic surgery, as well as the entire care process before and after surgery. The following standards constitute the minimum requirements set by the SCMiB TCHP for good practice of the basic process of bariatric care throughout its entire period, which ensure satisfactory safety and effectiveness of the obesity treatment and its metabolic complications.

Present trends in bariatric surgery in Poland.

INTRODUCTION: As obesity has become a major health problem in Poland and bariatric procedures are the best way of treatment, an increasing trend has been observed in Polish bariatric surgery for the last decade. AIM: Our purpose was to provide an updated overview of the bariatric surgical procedures performed in Polish institutions in comparison to the situation in Europe as well as to analyze the trends in Polish bariatric surgery over the last decades. MATERIAL AND METHODS: A questionnaire about the number and type of bariatric procedures performed in 2016 was sent to all Polish surgical departments. Two hundred and sixty surgical departments returned the questionnaires. RESULTS: Twenty-seven departments reported having performed bariatric operative or endoscopic procedures in 2016. The total number of procedures reported was 1958, the most popular being the laparoscopic sleeve gastrectomy (LSG). More than 99% of procedures were performed using laparoscopic techniques. The most common operations were: LSG (64.6%, n = 1032) and laparoscopic Roux-en-Y gastric bypass (LRYGB) (18.2%; n = 291), followed by one anastomosis gastric bypass (OAGB) (8.3%; n = 132) and laparoscopic adjustable gastric banding (LAGB) (7.3%; n = 117). CONCLUSIONS: Registers of bariatric procedures provide information that helps in planning treatment and predicting possible complications. Adequate reporting of bariatric procedures is necessary to present the importance of the high incidence of obesity and the importance of its treatment. To collect reliable data, a national Polish bariatric surgery registry should be created.

Challenges associated with bariatric surgery - a multi-center report.

INTRODUCTION: Due to the constantly growing demand for surgical treatment of obesity, it is necessary to create new bariatric centers and further improve presently active ones. AIM: To identify which stages of conducting peri-operative care and organizing a modern bariatric center currently pose the greatest challenge. MATERIAL AND METHODS: An anonymous survey was designed and distributed to bariatric surgeons. Our questionnaire was divided into three parts: demographic characteristics, difficulties associated with peri-operative care for bariatric patients (assessed on a scale of 1-5) and difficulties associated with organization or running of bariatric centers in which participants are currently working (assessed on a scale of 1-5). RESULTS: Overall, 70 surgeons and surgical residents from 17 surgical centers participated in our survey. The most difficult element of the pre-operative care was compliance with the recommendation to cease smoking (3.47 ±1.28). The most difficult obstacle during the postoperative care period was implementation of the enhanced recovery after surgery (ERAS) protocol (2.27 ±1.31). Funding for the bariatric treatment was obtained exclusively from the National Health Fund by 60 (85.7%) respondents working in 15 different bariatric centers (88.2%). Among elements of bariatric infrastructure access to operating theater equipment sized for morbidly obese patients was reported to be the most difficult (3.8 ±1.68). CONCLUSIONS: Pre-operative recommendations including smoking, physical activity or weight loss, as well as introducing ERAS protocol based peri-operative care, are difficult to execute in bariatric departments. Future specialized bariatric centers should be included in the centralized register and equipped with specialized infrastructure for morbidly obese patients.

Case-Control Study of Postoperative Blood Pressure in Patients with Hemorrhagic Complications after Laparoscopic Sleeve Gastrectomy and Matched Controls.

INTRODUCTION: Laparoscopic sleeve gastrectomy is associated with a moderate risk of hemorrhagic complications (HC). There is a debate regarding the relationship between HC and high blood pressure in postoperative period. AIM: The aim is to clarify whether the postoperative blood pressure is an independent risk factor for hemorrhagic complications after laparoscopic sleeve gastrectomy. METHODS: Medical records of 522 patients were reviewed. A case-control study of postoperative blood pressure was undertaken in patients with bleeding after LSG and matched controls. Patients who required surgical revision, due to the hemorrhagic complications within 72 hours, were identified as the cases. Controls were matched (1:1) with cases by age (±1 year), gender (female versus male), staple line reinforcement (running suture versus haemostatic clips) and surgeon's experience (>50 or <50 LSG procedures per year). 12-hour postoperative blood pressure was recorded. RESULTS: 17 patients after LSG with HC in postoperative period were matched with 17 controls. Patients who experienced hemorrhagic complications after LSG had non statistically significant decreased mean systolic blood pressure (mmHg) in 12 hours observation (130.7 ± 12.9 versus 139.1 ± 10.8); p = 0.15; mean difference - 11.6 (95% CI -29.5 - 6.1). Mean 12 hour diastolic pressure was also comparable. The detailed analysis of controls revealed a significantly higher systolic blood pressure measurements in 5th and 11th hour postoperatively, as well as higher diastolic blood pressure in 12th hour postoperatively. However, the differences were not clinically significant. CONCLUSION: Compared with closely matched control subjects, patients with HC after LSG have decreased systolic blood pressure without clinical significance.

Reduction of the risk of rhabdomyolysis after bariatric surgery with lower fluid administration in the perioperative period: a cohort study.

INTRODUCTION    Obesity is a growing worldwide problem. One of the most effective treatments is a bariatric procedure; however, surgery is associated with the risk of complications, such as staple line leakage, suture line bleeding, and rhabdomyolysis (RML). OBJECTIVES    The objective of our study was to assess the risk of RML after bariatric surgery related to intravenous fluid administration in the perioperative period. PATIENTS AND METHODS    The study involved 194 patients who underwent a bariatric surgery (laparoscopic sleeve gastrectomy or laparoscopic gastric bypass). We studied an association between the development of RML and sex, age, weight, duration of surgery, type of surgery, and the volume of intravenously administered fluids during the perioperative period. RESULTS    The median duration of surgery was 132.5 minutes. The median volume of administered fluids was 3150 ml from the introduction of anesthesia to 24 hours after surgery. Biochemical RML (creatine phosphokinase >1000 U/l) was observed in 30 patients (15.46%). RML with clinical manifestations developed in 6 patients. Multivariate logistic regression revealed an increase in the odds ratio of biochemical RML with an increase of weight on the day of surgery, operative time, and volume of intravenous fluids. A multiple regression model showed that every 500 ml of transfused fluid over the median volume increases creatine phosphokinase concentrations in the first postoperative day by 241.77 U/l over the median level, with the operative time and patient's weight remaining at median values. CONCLUSIONS    We observed an association between the administration of lower fluid volumes and a lower risk of RML. We postulate that decreasing intravenous fluid administration may reduce the risk of RML after bariatric surgery.

Laparoscopic Transperitoneal Lateral Adrenalectomy for Large Adrenal Tumors.

BACKGROUND: Laparoscopic adrenalectomy is the gold standard for treatment of benign adrenal lesions. Tumor size is a factor that might influence decision-making concerning the use of laparoscopic approach. The aim of this study was to analyze the results of adrenalectomy for tumors ≥6 cm in diameter. METHODS: Two groups of patients were analyzed: first group comprised 441 patients with tumors <6 cm in diameter and second group consisted of 89 patients with tumors ≥6 cm. Both groups were compared with regard to the duration of surgery, intraoperative blood loss, conversion and complications rate. RESULTS: Median duration of surgery in groups 1 and 2 amounted to 86.6 and 111.9 min (p < 0.0001), respectively. Median intraoperative blood loss in groups 1 and 2 was 56.5 and 172.8 ml (p < 0.0001), respectively. There was a linear relationship between tumor size and the duration of surgery, and between tumor size and intraoperative blood loss (p < 0.0001). There were 2 (0.5%) and 6 (6.7%) conversions in groups 1 and 2, respectively. There were 41 (9.3%) and 14 (15.7%) complications in groups 1 and 2 (p = 0.0692), respectively. CONCLUSIONS: Laparoscopic adrenalectomy of tumors ≥6 cm is more difficult, but it can be regarded safe and beneficial for patients.

Is ERAS in laparoscopic surgery for colorectal cancer changing risk factors for delayed recovery?

There is evidence that implementation of enhanced recovery after surgery (ERAS) protocols into colorectal surgery reduces complication rate and improves postoperative recovery. However, most published papers on ERAS outcomes and length of stay in hospital (LOS) include patients undergoing open resections. The aim of this pilot study was to determine the factors affecting recovery and LOS in patients after laparoscopic colorectal surgery for cancer combined with ERAS protocol. One hundred and forty-three consecutive patients undergoing elective laparoscopic resection were prospectively evaluated. They were divided into two subgroups depending on their reaching the targeted length of stay-LOS (75 patients in group 1-≤4 days, 68 patients in group 2->4 days). A univariate and multivariate logistic regression analysis was performed to assess for factors (demographics, perioperative parameters, complications and compliance with the ERAS protocol) independently associated with LOS of 4 days or longer. The median LOS in the entire group was 4 days. The postoperative complication rate was higher (18.7 vs. 36.7 %), and the compliance with ERAS protocol was lower (91.2 vs. 76.7 %) in group 2. There was an association between the pre- and postoperative compliance and the subsequent complications. In uni- and multivariate analysis, the lack of balanced fluid therapy (OR 3.87), lack of early mobilization (OR 20.74), prolonged urinary catheterization (OR 4.58) and use of drainage (OR 2.86) were significantly associated with prolonged LOS. Neither traditional patient risk factors nor the stage of the cancer was predictive of the duration of hospital stay. Instead, compliance with the ERAS protocol seems to influence recovery and LOS when applied to laparoscopic colorectal cancer surgery.

Cost minimization analysis of laparoscopic surgery for colorectal cancer within the enhanced recovery after surgery (ERAS) protocol: a single-centre, case-matched study.

INTRODUCTION: The goal of modern medical treatment is to provide high quality medical care in a cost-effective environment. AIM: To assess the cost-effectiveness of laparoscopic colorectal surgery combined with the enhanced recovery after surgery protocol (ERP) in Poland. MATERIAL AND METHODS: We designed a single-centre, case-matched study. Economic and clinical data were collected in 3 groups of patients (33 patients in each group): group 1 - patients undergoing laparoscopy with ERP; group 2 - laparoscopy without ERP; group 3 - open resection without ERP. An independent administrative officer, not involved in the treatment process, matched patients for age, sex and type of resection. Primary outcome was cost analysis. It was carried out incorporating institutional costs: hospital bed stay, anaesthesia, surgical procedure and equipment, drugs and complications. Secondary outcomes were length of stay (LOS), readmission and complication rate. RESULTS: Cost of laparoscopic procedure alone was significantly more expensive than open resection. However, implementation of the ERAS protocol reduced additional costs. Total cost per patient in group 1 was significantly lower than in groups 2 and 3 (EUR 1826 vs. EUR 2355.3 vs. EUR 2459.5, p < 0.0001). Median LOS was 3, 6 and 9 days in groups 1, 2 and 3 respectively (p < 0.001). Postoperative complications were noted in 5 (15.2%), 6 (18.2%) and 13 (39.4%) patients in groups 1, 2, 3 respectively (p = 0.0435). CONCLUSIONS: In a low medical care expenditure country, minimally invasive surgery combined with ERP can be a safe and a cost-effective alternative to open surgery with traditional perioperative care.

Changing patterns in the surgical treatment of perforated duodenal ulcer - single centre experience.

INTRODUCTION: Although the surgical treatment of patients with perforated duodenal ulcer is the method of choice, the introduction of effective pharmacotherapy has changed the surgical strategy. Nowadays less extensive procedures are chosen more frequently. The introduction of laparoscopic procedures had a significant impact on treatment results. AIM: To present our experience in the treatment of perforated duodenal ulcer in two periods, by comparing open radical anti-ulcer procedures with laparoscopic ulcer repair. MATERIAL AND METHODS: The analysis covered patients operated on for perforated duodenal ulcer. Two groups of patients were compared. Group 1 included 245 patients operated on in the period 1980-1994 with a traditional method (pyloroplasty + vagotomy) before introduction of proton pump inhibitors (PPI). Group 2 included 106 patients treated in the period 2000-2014 with the laparoscopic technique supplemented with PPI therapy. Groups were compared in terms of patients' demographic structure, operative time, complication rate and mortality. RESULTS: The mean operative time in group 1 was shorter than in group 2 (p < 0.0001). Complications were noted in 57 (23.3%) patients in group 1 and 14 (13.5%) patients in group 2 (p = 0.0312). Reoperation was necessary in 13 (5.3%) cases in group 1 and in 5 cases in group 2 (p = 0.8179). The mortality rate in group 1 was significantly higher than in group 2 (10.2% vs. 2.8%, p = 0.0192). In group 1, median length of hospital stay was 9 days and differed significantly from group 2 (6 days, p < 0.0001). CONCLUSIONS: Within the last 30 years, significant changes in treatment of perforated peptic ulcer (PPU) have occurred, mainly related to abandoning routine radical anti-ulcer procedures and replacing the open technique with minimally invasive surgery. Thus it was possible to improve treatment results by reducing complication and mortality rates, and shortening the length of hospital stay. Although the laparoscopic operation is longer, it improves outcomes. In the authors' opinion, in each patient with suspected peptic ulcer perforation, laparoscopy should be the method of choice.

Changes in levels of selected incretins and appetite-controlling hormones following surgical treatment for morbid obesity.

INTRODUCTION: The hormonal brain-gut axis is a crucial element in appetite control and the response to surgical treatment for super obesity. However, mechanisms underlying the metabolic response to surgical treatment for morbid obesity are still not clearly specified. AIM: To evaluate and compare the effects of surgical treatment for super obesity by laparoscopic sleeve gastrectomy (LSG) and by laparoscopic Roux-en-Y gastric bypass (LRYGB) on selected incretins and appetite-controlling hormones. MATERIAL AND METHODS: Thirty-five patients were enrolled in a prospective study. Laparoscopic sleeve gastrectomy was performed in 45.8% of patients, and LRYGB in the remaining 54.2% of patients. Before the procedure fasting blood serum was collected from patients and preserved, to determine levels of selected incretins and brain-gut hormones: glucagon-like peptide 1 (GLP-1), peptide YY (PYY), leptin, and ghrelin. RESULTS: Twenty-eight patients came to a follow-up visit 12 months after the surgery. In these patients selected parameters were determined again. The percentage weight loss was 58.8%. The ghrelin levels had decreased, and no statistically significant difference was observed between the two procedures. After both surgical procedures a statistically significant reduction in the leptin level was also observed. Peptide YY levels statistically significantly increased in the whole studied group. The GLP-1 level increased after the surgical procedure. However, the observed change was not statistically significant. CONCLUSIONS: Both treatment methods result in modification of secretion patterns for selected gastrointestinal hormones, and this was considered to be a beneficial effect of bariatric treatment. The laparoscopic sleeve gastrectomy, being a procedure resulting in a metabolic response, seems to be an equally effective method for treatment of super obesity and comorbidities as the laparoscopic gastric bypass.

Laparoscopic adrenalectomy for pheochromocytoma is more difficult compared to other adrenal tumors.

INTRODUCTION: Laparoscopic adrenalectomy is the gold standard for the treatment of benign adrenal tumors. However, some authors raise the problem of differences in surgery for pheochromocytoma in comparison to other lesions. AIM: To compare laparoscopic adrenalectomy for pheochromocytoma and for other tumors. MATERIAL AND METHODS: Four hundred and thirty-seven patients with adrenal tumors were included in the retrospective analysis. Patients were divided into two groups: 1 (124 patients treated for pheochromocytoma) and 2 (313 patients with other types of tumor). The two groups were compared with respect to mean operative time, intraoperative blood loss, conversion rate, complication rate and the relationship of tumor size with operative time. RESULTS: The mean operative time in group 1 was 91 min, and in group 2 it was 82 min (p = 0.016). In both groups 1 and 2, tumor size correlated with operative time (p < 0.0001 and p = 0.0003, respectively). The mean blood loss in groups 1 and 2 was 117 ml and 54 ml, respectively (p = 0.0011). The complication rate in groups 1 and 2 was 4% and 4.2%, respectively (p = 0.9542). In groups 1 and 2, conversion was necessary in 2 (1.6%) and 5 (1.6%) cases, respectively (p = 0.9925). CONCLUSIONS: Longer operative time and higher blood loss after laparoscopic adrenalectomy for pheochromocytoma indicate its greater difficulty. However, despite these drawbacks, minimally invasive surgery still seems to be an effective and safe method.

Bipolar spectrum features in obese individuals.

UNLABELLED: AIM : The relationships between obesity and bipolar spectrum disorders (BSD) are unclear. Thus, the aim of our study were to approximate the prevalence of soft bipolar features in patients seeking treatment for obesity. METHODS: We performed a nested case-control study (cases: 90 patients with the mean BMI=38.1±7.0 [range: 30.1-62.5]; controls: 70 healthy volunteers with the mean BMI=21.6±2.1 [range: 18.5-24.9]). The participants were screened for the BSD symptoms with the Mood Disorder Questionnaire. RESULTS: Patients with obesity were significantly more likely to score ≥7 pts. on the MDQ 25.6% vs. 8.6%; p=0.01). In comparison to non-obese individuals, the obese patients scored significantly higher in MDQ section I and on the MDQ items referring to the 'irritability-racing thoughts' dimension of hypomania. The multiple logistic regression analysis revealed that obesity had been significantly related to the odds of obtaining ≥7 pts. on the MDQ section 1 (odds ratio [OR] = 2.07; 95% confidence interval [CI]: 1.17-3.63), and marginally significantly related to experiencing periods of 'ups' and 'downs'(OR = 1.67; 95% CI: 1.00-2.81). CONCLUSIONS: Our study adds to previous suggestions that obesity may be significantly related to the BSD. However, the clinical implications of this finding need to be determined in further studies, performed in accordance with the paradigm of evidence based medicine (EBM).

Enhanced Recovery After Surgery (ERAS®) protocol in patients undergoing laparoscopic resection for stage IV colorectal cancer.

BACKGROUND: There is strong evidence for the use of Enhanced Recovery After Surgery (ERAS) protocol with colorectal surgery. However, in most studies on ERAS, patients with stage IV colorectal cancer (CRC) are commonly excluded. It is not certain if the ERAS protocol combined with laparoscopy improves outcomes in this group of patients as well. The aim of the study is to assess the feasibility of the ERAS protocol implementation in patients operated laparoscopically due to stage IV CRC. METHODS: A prospective analysis of patients undergoing laparoscopic colorectal surgery was performed. Group 1 included patients with stages I-III, and group 2 included patients with stage IV CRC. Demographic, surgical factors, length of stay (LOS), complications, readmissions, ERAS implementation and early postoperative recovery were compared between the groups. RESULTS: Group 1 included 168 patients, and group 2 included 20 patients. There was no difference in the age, sex, BMI, ASA, cancer localisation or surgical parameters. No statistically significant difference was noted in complications (26.8 vs 20 %, p = 0.51344), LOS (4.7 vs 5.7 days, p = 0.28228) or readmissions (6 vs 10 %, p = 0.48392). The ERAS protocol compliance was 86.3 and 83.0 %, respectively (p = 0.17158). CONCLUSIONS: Implementation of the ERAS protocol and laparoscopic surgery among patients with stage IV CRC is feasible and provides similar short-term clinical outcomes and recovery as with patients with stages I-III.

Randomized Clinical Trial To Compare The Effects Of Preoperative Oral Carbohydrate Loading Versus Placebo On Insulin Resistance And Cortisol Level After Laparoscopic Cholecystectomy.

UNLABELLED: Postoperative insulin resistance, used as a marker of stress response, is clearly an adverse event. It may induce postoperative hyperglycemia, which according to some authors can increase the risk of postoperative complications. One of the elements of modern perioperative care is preoperative administration of oral carbohydrate loading (CHO-loading), which shortens preoperative fasting and reduces insulin resistance. The aim of the study is to establish the influence of CHO-loading on the level of insulin resistance and cortisol in patients undergoing elective laparoscopic cholecystectomy. MATERIAL AND METHODS: Patients were randomly allocated to one of 2 groups. The intervention group included 20 patients who received CHO-loading (400 ml Nutricia pre-op®) 2 hours prior surgery. The control group received a placebo (clear water). In every patient blood samples were taken 2 hours prior to surgery, immediately after surgery, and on the 1st postoperative day. Levels and changes in glucose, cortisol and insulin resistance were analyzed in both groups. RESULTS: Although there were differences in the levels of cortisol, insulin, and insulin resistance, no statistically significant differences were observed between groups in every measurement. The length of stay and postoperative complications were comparable in both groups. CONCLUSIONS: We believe that CHO-loading is not clinically justified in case of laparoscopic cholecystectomy. No effect on the levels of glucose, insulin resistance and cortisol was observed. Even though such procedure is safe, in our opinion there is no clinical benefit from CHO-loading prior to laparoscopic cholecystectomy.

Comparison of efficacy and safety of first-line palliative chemotherapy with EOX and mDCF regimens in patients with locally advanced inoperable or metastatic HER2-negative gastric or gastroesophageal junction adenocarcinoma: a randomized phase 3 trial.

The aim of the study was to compare efficacy and safety of first-line palliative chemotherapy with (EOX) epirubicin/oxaliplatin/capecitabine and (mDCF) docetaxel/cisplatin/5FU/leucovorin regimens for untreated advanced HER2-negative gastric or gastroesophageal junction adenocarcinoma. Fifty-six patients were randomly assigned to mDCF (docetaxel 40 mg/m(2) day 1, leucovorin 400 mg/m(2) day 1, 5FU 400 mg/m(2) bolus day 1, 5FU 1000 mg/m(2)/d days 1 and 2, cisplatin 40 mg/m(2) day 3) or EOX (epirubicin 50 mg/m(2) day 1, oxaliplatin 130 mg/m(2) day 1, capecitabine 1250 mg/m(2)/d days 1-21). The primary endpoint was overall survival. The median overall survival was 9.5 months with EOX and 11.9 months with mDCF (p = 0.135), while median progression-free survival was 6.4 and 6.8 months, respectively (p = 0.440). Two-year survival rate was 22.2 % with mDCF compared to 5.2 % with EOX. Patients in the EOX arm had more frequent reductions in chemotherapy doses (34.5 vs. 3.7 %; p = 0.010) and delays in subsequent chemotherapy cycles (82.8 vs. 63.0 %; p = 0.171). There was no statistically significant difference in the rates of grade 3-4 adverse events (EOX 79.3 vs. mDCF 61.5 %; p = 0.234). As compared with the mDCF, the EOX regimen was associated with more frequent nausea (34.5 vs. 15.4 %), thromboembolic events (13.8 vs. 7.7 %), abdominal pain (13.8 vs. 7.7 %) and grades 3-4 neutropenia (72.4 vs. 50.0 %), but lower incidences of anemia (44.8 vs. 61.5 %), mucositis (6.9 vs. 15.4 %) and peripheral neuropathy (6.9 vs. 15.4 %). In conclusion, the mDCF regimen was associated with a statistically nonsignificant 2.4-month longer median overall survival without an increase in toxicity. This trial is registered at ClinicalTrials.gov, number NCT02445209.

Laparoscopic transperitoneal lateral adrenalectomy for malignant and potentially malignant adrenal tumours.

BACKGROUND: Laparoscopic adrenalectomy is still controversial in cases where malignancy is suspected. However, many proponents of this technique argue that in the hands of an experienced surgeon, laparoscopy can be safely performed. The aim of this study is to present our own experience with the application of laparoscopic surgery for the treatment of malignant and potentially malignant adrenal tumours. METHODS: Our analysis included 52 patients who underwent laparoscopic adrenalectomy in 2003-2014 due to a malignant or potentially malignant adrenal tumour. Inclusion criteria were primary adrenal malignancy, adrenal metastasis or pheochromocytoma with a PASS score greater than 6. We analyzed the conversion rate, intra- and postoperative complications, intraoperative blood loss and R0 resection rate. Survival was estimated using the Kaplan-Meier method. RESULTS: Conversion was necessary in 5 (9.7%) cases. Complications occurred in a total of 6 patients (11.5%). R0 resection was achieved in 41 (78.8%) patients and R1 resection in 9 (17.3%) patients. In 2 (3.9%) cases R2 resection was performed. The mean follow-up time was 32.9 months. Survival depended on the type of tumour and was comparable with survival after open adrenalectomy presented in other studies. CONCLUSIONS: We consider that laparoscopic surgery for adrenal malignancy can be an equal alternative to open surgery and in the hand of an experienced surgeon it guarantees the possibility of noninferiority. Additionally, starting a procedure with laparoscopy allows for minimally invasive evaluation of peritoneal cavity. The key element in surgery for any malignancy is not the surgical access itself but the proper technique.

The usefulness of the Mannheim Peritonitis Index score in assessing the condition of patients treated for peritonitis.

UNLABELLED: The aim of the study was to verify the Mannheim Peritonitis Index (MPI) suitability to determine the probability of death among patients in Polish population operated due to peritonitis and to assess the possibility of using the Index to determine the risk of postoperative complications, relaparotomy and need for postoperative hospitalization in intensive care unit. MATERIAL AND METHODS: Retrospective analysis covered 168 patients (M: F = 83: 85, mean age = 48.45 years, SD ± 22.2) treated for peritonitis. The MPI score was calculated for each patient. According to MPI results, patients were divided to the appropriate groups (<21, 21-29, > 29) and within analyzed. The statistical analysis used Chi-square, Mann Withney U and Kolmogorov-Smirnov test. The best cut-off point for MPI was calculated on the basis of ROC analisys. RESULTS: Mortality in the study group was 13.1%. In groups <21, 21-29 and > 29 points according to MPI mortality was 1.75%, 28.13% and 50% respectively, the difference was statistically significant (p = 0.0124). Significant differences were observed in mortality depending on the diagnosis. Based on the ROC curve the cut-off point was identified as 32 with an accuracy of 85.9% and AUC = 81%. There has been a significant correlation between the MPI count and and the occurrence of: cardio-respiratory failure, acidosis, electrolyte imbalance, surgical wound complications, the need for treatment in the intensive care unit after surgery. CONCLUSIONS: The MPI is a simple and effective predictor of death among patients operated due to peritonitis. It can also provide assistance in assessing the risk of postoperative complications and the need for treatment in the intensive care unit.

Preoperative pancreatic duct stenting in patients undergoing laparoscopic pancreatic surgery ­ a preliminary report.

UNLABELLED: Laparoscopic surgery is becoming an approved technique in pancreatic surgery. It offers some advantages over an open approach due to shorter hospital stay and decreased complication rate. Regardless the technique the most significant problem of pancreatic surgery is postoperative pancreatic fistula. There are numerous methods attempted at reduction of its incidence. One of the possibilities is preoperative pancreatic duct stenting. It aims at decreasing the pressure in the pancreatic duct, which is supposed to facilitate pancreatic juice flow to the duodenum. The aim of the study was to determine the role of preoperative pancreatic duct stenting in pancreatic surgery. MATERIAL AND METHODS: Nineteen patients undergoing laparoscopic pancreatic resection were enrolled into the study. Prior to the surgery, all of the patients were submitted for the Endoscopic Retrograde Choleangiopancreatography (ERCP) with pancreatic duct stenting. Following the subsequent laparoscopic pancreatic resection, all patients were monitored to detect the pancreatic fistula appearance. The pancreatic stent was removed 6-8 weeks after the surgery. RESULTS: With an exception of two patients, all other patients underwent successful ERCP with pancreatic duct stenting before the surgery. In one case the placement of the prosthesis failed due to a tortuous pancreatic duct. Five patients had an episode of acute pancreatitis including two severe courses as a complication of preoperative ERCP. One of the patient died due to severe GI bleeding 2 weeks after stenting. Among the procedures there were 15 distal pancreatectomies, two enucleations of the tumor localized in the uncinate process and in the body of the pancreas and one central pancreatectomy. The median time of surgery duration was 186 minutes (90-300; ±56). No conversions to an open approach were necessary. Likewise, there was neither any major complications reported in a postoperative course nor incidence of pancreatic fistula in any of the patients undergoing surgery. CONCLUSIONS: Preoperative pancreatic duct stenting can decrease the incidence of pancreatic fistula. However, a number of serious complications exceed the potential benefit of this method.

Modification of internal hernia classification system after laparoscopic Roux-en-Y bariatric surgery.

INTRODUCTION: The occurrence of internal hernia is not an uncommon late complication following the laparoscopic bariatric Roux-en-Y gastric bypass procedure. In some instances, it can be life threatening if not treated in a timely manner. Although there are numerous publications in the literature addressing internal hernia, they are mostly retrospective, and focus mainly on describing the different reconstructive orientation as far as the bowel is concerned. AIM: Our study aim is to address the relationship between the three basic elements of internal hernia, namely: intestinal mesentery defect, the involved intestine and herniated loop direction. Although a developed and widely accepted classification system of internal hernia has not been established yet, we hope this study can help the system to be established. MATERIAL AND METHODS: We studied all patients who underwent revision bariatric operations in the Freiburg and Lübeck University Hospitals (2007-2013). A single surgeon performed and documented all revision procedures for internal hernia. The post-operative follow-up period is up to 6 years. All patients with internal hernias were included whether their primary surgery was performed in our center or performed in other institutions, being referred to our center for further management. The presence of hernia defect, the type of herniated intestinal loop and the direction by which the herniated intestinal loop migrated were analyzed. RESULTS: Twenty-five patients with internal hernia were identified; in 2 patients more than one hernia type coexisted. The most frequent constellation of internal hernias was BP limb herniation into the Brolin space and migrating from left to right direction (28%). The highest incidence of internal hernia was found to be following Roux-en-Y gastric bypass (68%); the biliopancreatic limb (BP) limb was the most commonly involved intestine (51.9%). The incidence of Petersen hernia was the highest (59.3%), and left-right direction was more common. The most common hernia direction of the biliopancreatic limb was from left to right (92.6%), but alimentary limb (AL; 57.1%) and common channel (CC; 66.7%) often favor the other course. CONCLUSIONS: There are existing different types of internal hernias after bariatric operations including separate mesenterial spaces, various intestine parts and herniation direction. Our SDL classification system may offer a useful pathway that facilitates the understanding, and systematic approach to internal hernia, which can be used by bariatric quality registers.

Laparoscopic removal of gastrointestinal stromal tumors of uncinate process of pancreas.

The pancreas is an extremely rare location for gastrointestinal stromal tumors (GIST). We present a case of a patient with a GIST located in the uncinate process of the pancreas that was treated successfully with a laparoscopic technique. Computed tomography, magnetic resonance imaging and scintigraphy suggested a neuroendocrine tumor. Due to the fact that the image suggested a neuroendocrine tumor with a diameter below 2 cm, the patient was qualified for a laparoscopic procedure of tumor enucleation. Postoperative care proceeded in accordance with the principles of the ERAS concept. The postoperative course was uncomplicated. He was discharged home on the second postoperative day. In the obtained histopathology result a GIST was found. During a 6-month observation, including control computed tomography examination, no signs of tumor progression were found. Despite the fact that stromal tumors of the gastrointestinal tract localized in the pancreas are very rare, they should be considered in the differential diagnosis of tumors of this organ.