Visual Impairment in Hemodialyzed Patients-An IVIS Study.

Background and Objectives: The growing and aging population of hemodialysis patients has become increasingly disabled, with more complex comorbidities, and are older upon initiating dialysis. Visual impairment can adversely affect their quality of life and life satisfaction. Treatment evaluation should not only consider remission of the disease, but also the improvement of quality of life and life satisfaction. This is a single-center cross-sectional study. It was designed to evaluate visual impairment in hemodialyzed patients, its correlation with quality of life and life satisfaction, and its relationship to clinical outcomes in hemodialyzed patients. Materials and Methods: Seventy patients with chronic kidney disease undergoing hemodialysis and aged 18 years or older were recruited from a single Dialysis Unit. The Impact of Visual Impairment Scale (IVIS), WHOQOL-BREF, and Cantril Ladder questionnaires were utilized to assess both sociodemographic and clinical variables. Results: It was found that, among all assessed variables (i.e., sex, marital status, level of education, months on hemodialysis, history of kidney transplantation, Kt/V, URR, and UF), only age and central venous catheter placement were positively correlated with IVIS scores, while arteriovenous fistula and willingness to become a kidney transplant recipient were negatively correlated. Furthermore, a comparison between patients with moderate and severe visual impairment yielded supplemental data indicating that individuals whose dialysis access was through a dialysis catheter and those ineligible or unwilling to undergo transplantation suffered more often from severe visual impairment. This finding may be attributed to age. Conclusions: Older patients were predominantly observed to experience visual impairment. Patients intending to receive a kidney transplant and whose dialysis access was through an arteriovenous fistula were less prone to visual impairment, compared to those who may be ineligible or unwilling to receive transplantation and those with hemodialysis catheters. This phenomenon can be attributed to age-related distinctions in patients' suitability for specific dialysis access and transplantation. Those reporting visual impairment gave lower ratings in all four domains of their quality of life (comprising physical health, psychological health, social relationships, and environment) and in both present and anticipated five-year life satisfaction. More severe visual impairment was related to an additional reduction in physical health, social relationship, and environment domains, and in life satisfaction.

Gender as a predictive factor in cholecystectomy - is it true or false?

INTRODUCTION: Cholecystolithiasis is one of the most frequent disorders of the human digestive system in a present population. It is common to point out that male gender is one of strong risk factors for complications during cholecystectomy, however the debate about that seems to be still open. AIM OF THE STUDY: The aim of this study was to compare the values related to the course and treatment effects between gender in patients undergoing cholecystectomy, based on own material. MATERIALS AND METHODS: The study encompassed 504 patients who were admitted to General Surgery And Polytraumatic Injury Department of University Hospital in Kraków, Poland between 2013 and 2018, with the initial diagnosis of cholecystolithiasis (scheduled cases) and acute cholecystitis (emergency cases). The patients underwent surgical gallbladder removal. In this group there were 326 (64.7%) female and 178 (35.3%) male patients. RESULTS: Statistically significant differences between both genders were found containing age, type of admission, numeric rating scale of pain during admission, results in American Society of Anesthesiologists physical status classification system, outcomes in Acute Physiology And Chronic Health Evaluation II severity-of-disease classification system, percentage of conversions, mortality, period of time from admission to surgical procedure, mean duration of the procedure, blood tests and histopathological results. CONCLUSIONS: Subgroups of the cases where determining factor is gender are strongly heterogeneous. Although treatment results were different for both subgroups and these differences were partly statistically significant, it cannot be clearly determined on the basis of a study with such selection of patients, that gender is an independent risk factor for surgical gallbladder removal.

Preoperative Neutrophil-Lymphocyte and Lymphocyte-Monocyte Ratios Reflect Immune Cell Population Rearrangement in Resectable Pancreatic Cancer.

BACKGROUND: Neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and lymphocyte-monocyte ratio (LMR) may serve as a simple index of the immune function. The aim of this study was to investigate the prognostic significance of NLR, PLR, and LMR in patients with resectable pancreatic ductal adenocarcinoma (PDAC) and to verify whether such biomarkers are associated with changes in populations of lymphoid cells. METHODS: The prognostic implications of blood count parameters were evaluated in a retrospective cohort of 442 subjects undergoing pancreatic resections for PDAC. Subpopulations of lymphocytes and monocytes in peripheral blood were identified by FACS in a prospective cohort of 54 patients. RESULTS: In the univariate analysis, NLR < 5 and LMR ≥ 3 were associated with significantly longer median survival of 25.7 vs 12.6 months and 29.2 vs 13.1 months, respectively. PLR did not influence survival. The Cox proportional hazards model showed that high NLR (HR 1.66, 95 % CI 1.12 to 2.46, P = 0.012) and low LMR (HR 1.65, 95 % CI 1.06 to 2.58, P = 0.026) were independent predictors of poor prognosis. NLR ≥ 5 and LMR < 3 correlated with an approximately twofold decrease in counts of helper and cytotoxic T cells, B cells, and NK cells. High NLR was also accompanied with increased neutrophil counts, while low LMR showed increased numbers of monocytes, mostly classical. CONCLUSIONS: NLR and LMR may carry important prognostic information for patients with resected PDAC. The unfavorable prognosis likely correlates with reduced numbers of immune cells effective against the tumor and increased populations of cells involved in immune suppression.

Accuracy of preoperative tumor localization in large bowel using 3D magnetic endoscopic imaging: randomized clinical trial.

BACKGROUND: Laparoscopic surgery has become the standard treatment for colorectal cancer. A tumor that does not involve serosa is invisible intraoperatively, and manual palpation of the tumor during laparoscopy is not possible. Therefore, accurate localization of the neoplastic infiltrate remains one of the most important tasks prior to elective laparoscopic surgery. The aim of this study was to evaluate the utility of a magnetic endoscopic imaging (MEI) for precise preoperative endoscopic localization of neoplastic infiltrate within the large bowel. MATERIALS AND METHODS: The study enrolled 246 patients who underwent elective surgery for colorectal cancer in 2012-2015 with accurate preoperative colonoscopic localization of the tumor. The analysis concerned patients with neoplastic infiltrate localized more than 30 cm from the anal verge. For evaluative purposes and accuracy of localization, the intestine was divided anatomically into 13 parts. Colonoscopic examinations were conducted with two types of endoscopes: group I-with MEI and group II-without MEI. Patients were assigned to the groups by random allocation. Ultimate confirmation of the tumor localization was accomplished by intraoperative evaluation. RESULTS: Group I involved 127 patients and group II 129. The two groups were compared in terms of age, sex, BMI and frequency of previous abdominal procedures. Proper localization of the lesion was confirmed in 95.23 % of group I patients and in 83.19 % of group II patients (p < 0.05). The greatest discrepancy in localization occurred in 8.9 % of patients from group I and 20 % of patients from group II in which the lesion was assessed primarily in the distal sigmoid. CONCLUSIONS: A magnetic endoscopic imaging allows more accurate localization of neoplastic infiltrate within the large intestine compared to standard colonoscopy alone, especially within the sigmoid colon. This method can be particularly useful in planning and performing laparoscopic procedures to diminish the likelihood of improper bowel segment resection. CLINICALTRIALS. GOV NUMBER: NCT01688557.

Impact of responsive insertion technology (RIT) on reducing discomfort during colonoscopy: randomized clinical trial.

BACKGROUND: In many countries, colonoscopies for colorectal cancer screening are performed without sedation due to the cost. Changes in the structure of the endoscopes are designed to facilitate the colonoscopic examination, reduce the duration of the procedure, and improve the imaging of the intestinal lumen. The variable stiffness of the endoscope and the recently introduced responsive insertion technology (RIT) are features aimed at easing colonoscope insertion and reducing the discomfort and pain during the examination. The aim of the study is to analyze whether the new RIT system can improve the practice of colonoscopy under no anesthesia with respect to the widely available variable stiffness colonoscopes. MATERIALS AND METHODS: This analysis included 647 patients who underwent complete colonoscopy in the screening program. All colonoscopies were performed without sedation. Olympus series 180 and 190 endoscopes equipped with a magnetic positioning system were used. Group I included patients who were examined using endoscopes equipped with responsive insertion technology (RIT), and group II included patients who were examined using conventional variable stiffness colonoscopies. The main objective was to evaluate the cecal intubation time, the number of loops, the requirement to apply manual pressure to different areas of the abdomen and the degree of discomfort and pain expressed on a visual analogue scale (VAS). ClinicalTrials.gov number, NCT01688557. RESULTS: Group I consisted of 329 patients, and group II included 318 patients. The mean age of the patients was 58.4 years (SD ± 4.21). Both groups were compared in terms of age, sex, and BMI. The mean cecal intubation time was 209 s in group I and 224 s in group II (p < 0.05). Increased loop formation was observed upon endoscope insertion in group II (1.7 vs. 1.35) (p < 0.05) and required more manual pressure to the abdomen (2.2 vs. 1.7) (p = 0.001). In group I, less discomfort and pain, as graded on a VAS (2.3 vs. 2.6), were noted. CONCLUSIONS: The implementation of RIT reduced of the cecal intubation time. The modified structure of the endoscope rendered the colonoscopic examination easier by reducing loop formation upon insertion with a subsequently reduced rate of auxiliary maneuvers.

Two-stage optical system for colorectal polyp assessments.

BACKGROUND AND AIMS: Macroscopic real-time evaluations of the histopathology and degree of invasion of colorectal polyps help to select the most suitable endoscopic treatment method. Dual-focus (DF) narrow-band imaging (NBI) is a new imaging enhancement system that uses digital and optical methods to enhance the view of blood vessels on mucosal surfaces. However, the superiority of this technique over standard imaging techniques has not been previously reported. The aim of this study was to determine whether the two-stage optical systems in a new generation of endoscopes will increase the diagnostic accuracy of colorectal polyp recognition. METHODS: The study included 270 patients, and 386 colorectal polyps were diagnosed and removed. The polyps were assessed with white light and NBI using one- and two-stage optical systems, respectively. After being classified according to the Kudo pit pattern schemes, the polyps were removed and histopathologically verified. RESULTS: Regarding non-neoplastic lesions (Kudo I and II), no difference was observed in the recognition of polyps when using the NBI-DF function. We observed improved accuracy in the preliminary diagnoses of Kudo IIIL lesions (from 87.16 to 90.09%, p < 0.05) and Kudo IIIS lesions (from 87.29 to 92.79%, p < 0.01). NBI-DF also increased the accuracy of preliminary diagnoses of Kudo IV lesions (from 88.24 to 94.12%, p < 0.01). The Kudo V pit patterns were also more distinct with NBI-DF imaging, increasing the diagnostic accuracy from 91.67 to 100%. CONCLUSIONS: Using a two-stage optical system with electronic colorization of the mucosa increased diagnostic accuracy for differentiating colorectal polyps with neoplastic potential.

Telocytes: New Players in Gallstone Disease.

Cholesterol gallstone disease is highly prevalent in Western countries, particularly in women and some specific ethnic groups. The mechanisms behind the formation of gallstones are not clearly understood, but gallbladder dysmotility seems to be a key factor that triggers the precipitation of cholesterol microcrystals from supersaturated lithogenic bile.Given that newly described interstitial cells, telocytes, are present in the gallbladder and they are located in close vicinity of smooth muscle cell and neural fibers possibly interfering with gallbladder motility or contractility, authors are trying to summarize the current knowledge on the role of telocytes with respect to disturbed gallbladder function in gallstone disease.

Factors predicting adequate lymph node yield in patients undergoing pancreatoduodenectomy for malignancy.

BACKGROUND: Most pancreatoduodenectomy resections do not meet the minimum of 12 lymph nodes recommended by the American Joint Committee on Cancer for accurate staging of periampullary malignancies. The purpose of this study was to investigate factors affecting the likelihood of adequate nodal yield in pancreatoduodenectomy specimens subject to routine pathological assessment. METHODS: Six hundred sixty-two patients subject to pancreatoduodenectomy between 1990 and 2013 for pancreatic, ampullary, and common bile duct cancers were reviewed. Predictors of yielding at least 12 lymph nodes were evaluated with a logistic regression model, and a survival analysis was carried out to verify the prognostic implications of nodal counts. RESULTS: The median number of evaluated nodes was 17 (interquartile range 11 to 25), and less than 12 lymph nodes were reported in surgical specimens of 179 (27 %) patients. Tumor diameter ≥20 mm (odds ratio [OR] 2.547, 95 % confidence interval [CI] 1.225 to 5.329, P = 0.013), lymph node metastases (OR 2.642, 95 % CI 1.378 to 5.061, P = 0.004), and radical lymphadenectomy (OR 5.566, 95 % CI 2.041 to 15.148, P = 0.01) were significant predictors of retrieving 12 or more lymph nodes. Lymph node counts did not influence the overall prognosis of the patients. However, a subgroup analysis carried out for individual cancer sites demonstrated that removing at least 12 lymph nodes is associated with better prognosis for pancreatic cancer. CONCLUSIONS: Few variables affect adequate nodal yield in pancreatoduodenectomy specimens subject to routine pathological assessment. Considering the ambiguities related to the only modifiable factor identified, appropriate pathology training should be considered to increase nodal yield rather than more aggressive lymphatic dissection.

Number and distribution of interstitial cells of Cajal in human gallbladder.

Based on the review of current literature and on their own studies authors postulate that decreased number of interstitial cells in the wall of gallbladder may be pathognomonic for gallstone disease (cholelithiasis).

Metabolism of bile with respect to etiology of gallstone disease - systematic review.

Based on current literature authors reviewed information on bile metabolism, i.e. production and chemical compounds, synthesis of bile acids, their hepato-intestinal circulation with respect to etiology of cholelithiasis - its epidemiology and clinical aspects.

Telocytes: new insight into the pathogenesis of gallstone disease.

The major mechanisms of gallstone formation include biliary cholesterol hypersecretion, supersaturation and crystallization, mucus hypersecretion, gel formation and bile stasis. Gallbladder hypomotility seems to be a key event that triggers the precipitation of cholesterol microcrystals from supersaturated lithogenic bile. Telocytes, a new type of interstitial cells, have been recently identified in many organs, including gallbladder. Considering telocyte functions, it is presumed that these cells might be involved in the signalling processes. The purpose of this study was to correlate the quantity of telocytes in the gallbladder with the lithogenicity of bile. Gallbladder specimens were collected from 24 patients who underwent elective laparoscopic cholecystectomy for symptomatic gallstone disease. The control group consisted of 25 consecutive patients who received elective treatment for pancreatic head tumours. Telocytes were visualized in paraffin sections of gallbladders with double immunofluorescence using primary antibodies against c-Kit (anti-CD117) and anti-mast cell tryptase. Cholesterol, phospholipid and bile acid levels were measured in gallbladder bile. The number of telocytes in the gallbladder wall was significantly lower in the study group than that in the control group (3.03 ± 1.43 versus 6.34 ± 1.66 cell/field of view in the muscularis propria, P < 0.001) and correlated with a significant increase in the cholesterol saturation index. The glycocholic and taurocholic acid levels were significantly elevated in the control subjects compared with the study group. The results suggest that bile composition may play an important role in the reduction in telocytes density in the gallbladder.

Glucagon-like peptide-1 receptor imaging with [Lys40(Ahx-HYNIC- 99mTc/EDDA)NH2]-exendin-4 for the detection of insulinoma.

PURPOSE: The objective of this article is to present a new method for the diagnosis of insulinoma with the use of [Lys(40)(Ahx-HYNIC-(99m)Tc/EDDA)NH2]-exendin-4. METHODS: Studies were performed in 11 patients with negative results of all available non-isotopic diagnostic methods (8 with symptoms of insulinoma, 2 with malignant insulinoma and 1 with nesidioblastosis). In all patients glucagon-like peptide-1 (GLP-1) receptor imaging (whole-body and single photon emission computed tomography/CT examinations) after the injection of 740 MBq of the tracer was performed. RESULTS: Both sensitivity and specificity of GLP-1 receptor imaging were assessed to be 100 % in patients with benign insulinoma. In all eight cases with suspicion of insulinoma a focal uptake in the pancreas was found. In six patients surgical excision of the tumour was performed (type G1 tumours were confirmed histopathologically). In one patient surgical treatment is planned. One patient was disqualified from surgery. In one case with malignant insulinoma pathological accumulation of the tracer was found only in the region of local recurrence. The GLP-1 study was negative in the other malignant insulinoma patient. In one case with suspicion of nesidioblastosis, a focal accumulation of the tracer was observed and histopathology revealed coexistence of insulinoma and nesidioblastosis. CONCLUSION: [Lys(40)(Ahx-HYNIC-(99m)Tc/EDDA)NH2]-exendin-4 seems to be a promising diagnostic tool in the localization of small insulinoma tumours, but requires verification in a larger series of patients.

Does bile protect or damage interstitial Cajal-like cells in the human gallbladder?

the etiology of gallstone disease is considered to be multifactorial, including biliary cholesterol hypersecretion, supersaturation and crystallization, stone formation, bile stasis and mucus hypersecretion and gel formation. Gallbladder hypomotility seems to be a key process that triggers the precipitation of cholesterol microcrystals from supersaturated lithogenic bile. the purpose of the current study was to determine whether ICLCs in the gallbladder were influenced by lithogenic bile. Gallbladder specimens were collected from 30 patients (8 males and 22 females) who underwent elective laparoscopic cholecystectomy for symptomatic gallstone disease. The control group consisted of 25 consecutive patients (11 males and 14 females) who received elective treatment for pancreatic head tumors. ICLCs were visualized in paraffin sections of gallbladders using double immunofluorescence protocol with monoclonal c-kit antibodies and mast cell tryptase. Cholesterol, phospholipid and bile acid concentrations were measured in bile samples obtained by needle aspiration from the gallbladder at the time of surgery. The number of ICLCs in the gallbladder wall was significantly lower in the study group than in the control group (3.35 ± 1.23 vs. 7.06 ± 1.82 cell/FOV in the muscularis propria, P < 0.001) and correlated with a significant increase in the cholesterol saturation index. The glycocholic and taurocholic acid levels were significantly elevated in the control subjects compared with the study group. The results suggest that bile composition may play an important role in the reduction of ICLC density in the gallbladder.

Serial echocardiographic evaluation of COVID-19 patients without prior history of structural heart disease: a 1-year follow-up CRACoV-HHS study.

Background: It is a well-known fact that COVID-19 affects the cardiovascular system by exacerbating heart failure in patients with preexisting conditions. However, there is a poor insight into the cardiovascular involvement and sequelae in patients without preexisting conditions. The aim of the study is to analyse the influence of COVID-19 on cardiac performance in patients without prior history of structural heart disease. The study is part of the CRACoV project, which includes a prospective design and a 12-month follow-up period. Material and methods: The study included 229 patients hospitalised with a diagnosis of COVID-19 (median age of 59 years, 81 were women). A standard clinical assessment and laboratory tests were performed in all participants. An extended echocardiographic image acquisition was performed at baseline and at a 3-, 6-, and 12-month follow-up. All analyses were performed off-line. A series of echocardiographic parameters was compared using repeated measures or Friedman analysis of variance. Results: In all subjects, the left ventricular (LV) ejection fraction at baseline was preserved [63.0%; Q1:Q3 (60.0-66.0)]. Elevated levels of high-sensitivity cardiac troponin T were detected in 21.3% of the patients, and elevated NT-proBNP levels were detected in 55.8%. At the 1-year follow-up, no significant changes were observed in the LV diameter and volume (LV 48.0 ± 5.2 vs. 47.8 ± 4.8 mm, p = 0.08), while a significant improvement of the parameters in the biventricular strain was observed (LV -19.1 ± 3.3% vs. -19.7 ± 2.5%, p = 0.01, and right ventricular -19.9 ± 4.5% vs. -23.2 ± 4.9%, p = 0.002). In addition, a decrease in the LV wall thickness was also observed (interventricular septum 10.4 ± 1.6 vs. 9.7 ± 2.0 mm, p < 0.001; LV posterior wall 9.8 ± 1.4 vs. 9.1 ± 1.5 mm, p < 0.001). Conclusions: In an acute phase of COVID-19, the elevation of cardiac biomarkers in patients with normal left ventricular ejection fraction is a frequent occurrence; however, it does not translate into clinically significant cardiac dysfunction after 1 year. The serial echocardiographic evaluations conducted in patients without preexisting structural heart disease demonstrate an overall trend towards an improved cardiac function and a reduced myocardial thickening at 1-year follow-up. This suggests that the acute cardiac consequences of COVID-19 are associated with systemic inflammation and haemodynamic stress in patients without preexisting conditions.

The Association of Polish Surgeons (APS) clinical guidelines for the use of laparoscopy in the management of abdominal emergencies. Part I.

Introduction: Over the past three decades, almost every type of abdominal surgery has been performed and refined using the laparoscopic technique. Surgeons are applying it for more procedures, which not so long ago were performed only in the classical way. The position of laparoscopic surgery is therefore well established, and in many operations it is currently the recommended and dominant method. Aim: The aim of the preparation of these guidelines was to concisely summarize the current knowledge on laparoscopy in acute abdominal diseases for the purposes of the continuous training of surgeons and to create a reference for opinions. Material and methods: The development of these recommendations is based on a review of the available literature from the PubMed, Medline, EMBASE and Cochrane Library databases from 1985 to 2022, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. Recommendations were formulated in a directive form and evaluated by a group of experts using the Delphi method. Results and conclusions: There are 63 recommendations divided into 12 sections: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia, acute cholecystitis, acute appendicitis, acute mesenteric ischemia, abdominal trauma, bowel obstruction, diverticulitis, laparoscopy in pregnancy, and postoperative complications requiring emergency surgery. Each recommendation was supported by scientific evidence and supplemented with expert comments. The guidelines were created on the initiative of the Videosurgery Chapter of the Association of Polish Surgeons and are recommended by the national consultant in the field of general surgery. The first part of the guidelines covers 5 sections and the following challenges for surgical practice: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia and acute cholecystitis. Contraindications for laparoscopy and the ERAS program are discussed.

Evaluation of magnetic scope navigation in screening endoscopic examination of colorectal cancer.

BACKGROUND: Colorectal cancer is the most common cancer in Europe. Early diagnosis and treatment gives the patient a chance for complete recovery. Screening colonoscopies in the symptom-free patients are currently performed on a wide scale. The examinations are performed under local anesthesia which does not eliminate all discomfort and pain related to the examination. The aim of this study was to evaluate magnetic scope navigation in screening endoscopic examinations performed to detect early-stage colorectal cancer. METHODS: The study group consisted of 200 patients, aged 40-65 years, who were free from colon cancer symptoms. All patients underwent complete colonoscopy under local anesthesia. The equipment could be fitted with the scope that allows three-dimensional observation of instrument localization in the bowel. The examination was performed by three experienced endoscopists, each of whom performed over 5,000 colonoscopies. The patients were randomized to two groups: those whose equipment did not have 3D navigation (group I) and those whose equipment did have 3D navigation (group II). Each group consisted of 100 cases matched by gender, age, and BMI. The authors compared the duration of introducing instrument to cecum, the pulse rate before the examination and at the time the instrument reached the cecum, and subjective pain evaluation by the patient on the visual analog scale. RESULTS: Group I consisted of 54 women and 46 men with a mean age of 54.6 years and mean BMI of 27.8 kg/m(2), and group II had 58 women and 42 men, mean age of 55.1 years and mean BMI of 26.4 kg/m(2). The average time it took for the instrument to reach the cecum was 216s in group I and 181s in group II (P < 0.05). Pain measured on the 10-point VAS scale was 2.44 in group I and 1.85 in group II (P < 0.05). The results showed a significantly shorter time for the instrument to reach the cecum in group II and significantly lower pain intensity during the examination was reported by the group II patients. No significant differences were found in the pulse measurements between the groups (P = 0.5). CONCLUSIONS: 3D navigation during colonoscopy decreases the time for the instrument to reach the cecum and lowers pain intensity subjectively reported by the patients. The use of 3D and the possibility to observe instrument localization and maneuvers brings more comfort to the patients.

Adherent umbilical hernia containing Meckel's diverticulum resected due to intraoperative injury.

PURPOSE: The aim of this report was to describe a rare case of a male patient with dry umbilical hernia with Meckel's diverticulum adherent to the neck of hernia sac. The patient's history, results of physical examination, laboratory testing, intraoperative findings, treatment method and postoperative course are summarized in details in this report. Follow-up visits were performed 14 days, one month and one year after the operation. CASE REPORT: A 35-year-old overweight Caucasian male patient (initials: D-B, body weight 90 kg, height 172 cm) was admitted to the hospital on 2nd April 2009 with reducible umbilical hernia for elective surgical treatment. The patient was operated on in the Specialist Diagnostic and Therapeutic Centre Medicina in Cracow and discharged from the hospital on fourth postoperative day. This case is compared with a few similar cases which have been described in the literature till now--all of these reports dealt with strangulated umbilical hernias but not reducible one. The patient underwent elective operation performed on the day of admission. Antibiotic prophylaxis included single dose of pefloxacine (400 mg intravenously) administered just before start of the operation. Subarachnoid anaesthesia was applied 15 minutes before start of the operation. The procedure lasted 75 minutes. Hernia sac was dissected and opened. In the hernia neck adherent Meckel's diverticulum was found. It was localised 80 cm from ileocecal valve and its length was 45 millimetres. During dissection process the diverticulum was injured in the apical region so cuneiform resection of the ileum with Meckel's diverticulum was performed. Ileum was sutured with two layers of absorbable sutures. The tissue defect in umbilical region was repaired primarily with onlay synthetic mesh prosthesis (polypropylene mesh, size 7 x 12 cm). CONCLUSIONS: 1) Adherent incidental Meckel's diverticulum in a sac of reducible umbilical hernia is a very rare finding. 2) During umbilical herniorrhaphy (elective or urgent) the presence of Meckel diverticulum in hernia sac should be taken into consideration. 3) If Meckel diverticulum is adherent to the hernia sac it requires careful dissection and resection of the diverticulum in selected patients. 4) When there is a tumour palpable in the wall or basis of Meckel diverticulum segmental resection of the small intestine with appropriate margins should be performed.

[Symptoms and early diagnostic possibilities of pancreatic endocrine cells hyperplasia (nesidioblastosis)]. / Symptomatologia i mozliwosci wczesnej diagnostyki hiperplazji kom6rek dokrewnych trzustki (nesidioblastosis).

Nesidioplastosis in adults is one of a rare causes of hyperinsulinemic hypoglycemia. Symptoms include chronic or recurrent hypoglycemias, often with neurological signs. Due to the looses of consciousness with coexisting seizures, in many cases patients are treated on epilepsy. Right diagnosis is usually late established, when the damages in the central nervous system (CNS) are irreversible. Early diagnosis of the disease and appropriate treatment might help to avoid serious disability in these patients. The aim of the study was to asses modern diagnostics of the nesidioblastosis with an emphasis on the biochemical and hormonal tests and imaging modalities. Patients enrolled to the study were aged between 18 and 72 years of age, and had chronic or recurrent hypoglycemia caused by hyperinsulinemia. In all patients fasting glucose and fasting insulinemia tests were performed, as well as the fasting blood test or in the 24-hour profile tests. Several techniques were used including ultrasound (US), abdominal computer tomography (CT), in two patients magnetic resonance imaging, scintigraphy of somatostatin receptors in seven patients, and in two patients scintigraphy with glucagone-like peptide-1 (GLP-1) analogue-labeled marker was done. In the performed tests low values of the blood glucose were found, whereas insulin levels, however not adequate to the blood glucose, were nearly always within the normal range. In the standard imaging only in one patient tumor lesion in the pancreatic tail was revealed, though not confirmed in the intraoperative histology. In the scintigraphy examination with the somatostatin analogue in one patient slightly increased collection of the marker in whole pancreas was reported and in the other patient focal collection in the pancreatic tail was observed. Scintigraphy with GLP-1 analogue revealed focal collection of the marker in one case. Five patients were underwent surgical treatment. In the histopathology in all operated patients hyperplasia of the endocrine pancreatic cells with positive immuno. histochemic reaction on the insulin was found. In the three cases despite hyperplasia of pancreatic islets, small sizes insulinomas were detected as well. 1. The diagnosis of nesidioblastosis should be taken into consideration in all patients with unclear-cause hypoglycemias, in whom simultaneously insulin blood level is inadequate to the level of glucose. 2. Widely available imaging examinations: US, CT, MRI are useless in the diagnosis of nesidioblastosis. 3. Among the imaging methods in preoperative diagnostics of hypoglycemia with concomitant hyperinsulinemia somatostatin receptor scintigraphy seems to have specific, though limited role - it is valuable only in the severe, diffused lesions. 4. Recurrent hypoglycemias after 70% excision of the pancreas may indicate the possibility of coexistence of pancreatic islets hyperplasia and insulin secreting insulinoma.

Comparison of two minimally invasive biopsy techniques - Breast Lesion Excision System and vacuum-assisted biopsy - for diagnosing and treating breast lesions.

Introduction: The vacuum-assisted biopsy (VAB) and the Breast Lesion Excision System (BLES) are minimally invasive biopsy techniques, both used as diagnostic and therapeutic tools. The aim of the study is to compare these two methods and assess them in the context of discomfort, early and late complications and their diagnostic and therapeutic potential. Material and methods: The study involved 173 patients who underwent a VAB or a BLES breast biopsy in the period between 2009 and 2016. Approximately 3 months after the biopsy, the patients completed a questionnaire in which they assessed the procedure for discomfort associated with the procedure and the final cosmetic outcome. The cosmetic effect of the biopsy was also assessed by a surgeon. Results: The BLES and the VAB breast biopsies did not differ in terms of pain, duration, and discomfort of the procedure, breast bruising, breast tenderness about 24 h after the procedure or pain lasting over 3 months after the biopsy. Subsequently, the biopsies were evaluated in terms of the cosmetic effect assessed by the patient and by a surgeon and no differences were observed. There were no significant differences between the VAB and the BLES breast biopsies in the course of the procedure, early and late complications and cosmetic effect. Conclusions: Since the BLES breast biopsy makes it possible to evaluate the margins, it is a good alternative to the open breast biopsy.

Predictive Role of Admission Venous Lactate Level in Patients with Upper Gastrointestinal Bleeding: A Prospective Observational Study.

Upper gastrointestinal bleeding (UGIB) is one of the most common emergencies. Risk stratification is essential in patients with this potentially life-threatening condition. The aim of this prospective study was to evaluate the usefulness of the admission venous lactate level in predicting clinical outcomes in patients with UGIB. All consecutive adult patients hospitalized due to UGIB were included in the study. The clinical data included the demographic characteristics of the observed population, etiology of UGIB, need for surgical intervention and intensive care, bleeding recurrence, and mortality rates. Venous lactate was measured in all patients on admission. Logistic regression analyses were used to calculate the odds ratios (OR) of lactate levels for all outcomes. The receiver operating characteristic (ROC) curve was used to determine the accuracy of lactate levels in measuring clinical outcomes, while Youden index was used to calculate the best cut-off points. A total of 221 patients were included in the study (151M; 70F). There were 24 cases of UGIB recurrence (10.8%), 19 patients (8.6%) required surgery, and 37 individuals (16.7%) required intensive care. Mortality rate was 11.3% (25 cases). The logistic regression analysis showed statistically significant association between admission venous lactate and all clinical outcomes: mortality (OR = 1.39, 95%CI: 1.22-1.58, p < 0.001), recurrence of bleeding (OR = 1.16, 95%CI: 1.06; 1.28, p = 0.002), surgical intervention (OR = 1.17, 95%CI: 1.06-1.3, p = 0.002) and intensive care (OR = 1.33, 95%CI: 1.19-1.5, p < 0.001). The ROC curve analysis showed a high predictive value of lactate levels for all outcomes, especially mortality: cut-off point 4.3 (AUC = 0.82, 95%CI: 0.72-0.92, p < 0.001) and intensive care: cut-off point 4.2 (AUC = 0.76, 95%CI: 0.66-0.85, p < 0.001). Admission venous lactate level may be a useful predictive factor of clinical outcomes in patients with UGIB.