The usefulness and effectiveness of interactive telemedicine in surgery classes - a survey of Polish medical students.

<b>Introduction:</b> Computer-based interactive techniques are becoming an important tool in medical education. One of the important benefits of the use of telemedicine in surgical training is the reduction of the number of people in the operating room. As shown in the studies, this can lead i.a. to the reduction in the risk of surgical site infections.<b>Aim:</b> The aim of this survey as held among fifth-year medical students at three academic centers was to assess the usefulness and effectiveness of telemedicine as a surgery-teaching tool.<b>Material and methods:</b> A transmission of a surgical procedure was carried out by each of the three participating centers according to a previously prepared schedule. Each transmission was preceded by the diagnostics, indications, and the course of the surgical procedure being discussed by the facilitator physician who also coordinated the transmission throughout the procedure. After the class, students received anonymous surveys consisting of fourteen questions as per the attached protocol so as to evaluate the class using the rating scale of 1 (the lowest rating) through 5 (the highest rating). The survey assessed the educational value (the knowledge acquired from the class), the form (interactivity, facilitator complicity), and the usefulness of the class for overall surgical education.<b>Results:</b> The survey was completed by 232 students, with 95% of respondents rating the usefulness of telemedicine classes in surgical education as very good or good. As many as 97% of students declared that the transmission had been a good or a very good tool in terms of delivery or adding to their knowledge of topographical anatomy and basic aspects of surgical technique. Higher ratings were given to the usefulness of comments and remarks by the facilitating physician (96% of very good or good ratings) who had been watching the procedure along with the students as compared to those provided by the operating physician (81%).<b>Discussion:</b> The use of telemedicine-based teaching models in surgical education facilitates a better view of the operating field for the students, greater accessibility of educational content delivered simultaneously to multiple groups of students, increased safety of the surgical procedure by reducing the number of people in the operating room as well as reduced burden on the operating physician (thanks to the introduction of class facilitator).<b>Conclusions:</b> In our opinion, the advantages of the presented teaching model are: better view (particularly in case of open procedures), ability to pinpoint surgical field structures (on the participants' and operator's monitors), absence of additional people (students) in the operating room (increasing the safety of the procedure and reducing the risk of surgical site infections) and the ability to go back to recorded operations and perform various types of educational analyses.

Analysis of risk factors for surgical site infection and other postoperative complications in patients following loop ileostomy reversal.

<b>Introduction:</b> Loop ileostomy reversal (LIR) procedure is still associated with a relatively high risk of complications. Surgical site infection (SSI) is the most common complication in this group of patients. SSI leads to prolonged hospital stays, delays the adjuvant therapy, and increases hospital costs.<b>Aim:</b> The aim of the study was to analyze the risk factors for SSI in patients following loop ileostomy reversal procedure.<b>Material and methods:</b> A single-center retrospective analysis was conducted in a tertiary reference center. Finally, 65 patients following loop ileostomy reversal procedure performed between 2018 and 2022 were enrolled in the study. Data were collected retrospectively based on the available medical charts. The study group comprised 23 women (35%) and 42 men (65%) with a mean age of 48.9 14.5 years and a mean body mass index of 24.3 4.9 kg/m² . The most common indication for index surgery was ulcerative colitis (33%) and colorectal cancer (29%). Preferably, handsewn anastomosis was performed (n = 42; 64.6%).<b>Results:</b> The most important parameter evaluated in the above study was the diagnosis of surgical site infection, which influenced e.g. hospitalization after surgery, the need for antibiotic therapy, or C-reactive protein (CRP) values. Nine patients (13.8%) were diagnosed with SSI during their hospital stay (more than 86% without SSI). In the group with SSI, hospital stay exceeded 13 days compared to almost 6 days in the group without SSI (P = 0.00009). The time of the procedure had a statistically significant correlation with antibiotic therapy introduction (P = 0.01). The type of intestinal anastomosis had a significant impact on the operative time (P = 0.0011) and the time of hospital stay after surgery (P = 0.04).<b>Conclusions:</b> Most of the analyzed clinical factors were directly related to the impact on the duration of postoperative hospitalization. The duration of hospitalization is an independent and undeniable factor increasing the risk of other postoperative complications and significantly increasing the cost of hospitalization. Another factor that has a large clinical impact on postoperative treatment is the presence of comorbidities which make patients more likely to develop SSI, CRP increase, or the need for antibiotic therapy. An important factor was the level of CRP, the elevated value of which may be a predictor of many negative aspects in postoperative treatment.

Negative Pressure Level and Effects on Bacterial Growth Kinetics in an in vitro Wound Model.

Negative Pressure Wound Therapy (NPWT) has been widely adopted in wound healing strategies due to its multimodal mechanism of action. While NPWT's positive impression on wound healing is well-established, its effect on bacterial load reduction remains equivocal. This study investigates NPWT's efficacy in reducing bioburden using an in vitro porcine skin model, focusing on the impact of Staphylococcus aureus and Staphylococcus epidermidis. Custom-made negative pressure chambers were employed to apply varying negative pressures. Porcine skin was cut into 5 × 5 cm squares and three standardized wounds of 6 mm each were created using a biopsy punch. Then, wounds were infected with S. aureus and S. epidermidis bacterial suspensions diluted 1:10,000 to obtain a final concentration of 1.5 × 104 CFU/ml and were placed in negative pressure chambers. After incubation, bacterial counts were expressed as colony-forming units (CFU) per ml. For S. aureus at 120 hours, the median CFU, mean area per colony, and total growth area were notably lower at -80 mmHg when compared to -250 mmHg and -50 mmHg, suggesting an optimal negative pressure for the pressure-dependent inhibition of the bacterial proliferation. While analyzing S. epidermidis at 120 hours, the response to the negative pressure was similar but less clear, with the minor CFU at -100 mmHg. The influence of intermittent negative pressure on the S. epidermidis growth showed notably lower median CFU with the interval therapy every hour compared to the S. aureus control group. This study contributes valuable insights into NPWT's influence on the bacterial load, emphasizing the need for further research to reformulate its role in managing contaminated wounds.

The influence of supportive therapy with a six-component myophlebotropic preparation on the reduction of symptoms in patients with symptoms of hemorrhoidal disease.

<b>Introduction:</b> Hemorrhoidal disease is the most common disease treated in proctology ambulatories. Conservative treatment is the basic form of treatment for this disease. One of the elements of treatment may be preparations with myoand phlebotropic effects.<b>Aim:</b> To assess the effect of a multi-ingredient myophlebotropic dietary supplement used as an adjunct on the rate and effectiveness of symptom relief in patients with stage II and III hemorrhoidal disease.<b>Material and method:</b> Patients with stage II and III hemorrhoidal disease with clinical symptoms such as pain, burning, itching and bleeding were qualified for the study. The patients were divided into two groups. The control group (Group I) of 29 patients receiving standard local treatment plus placebo and the study group (Group II) of 32 patients receiving the same local treatment and a six-component myophlebotropic product. Symptoms were analyzed at the time of inclusion in the study (day 0), after 4 and 10 days of therapy. The severity of hemorrhoidal disease and the feeling of relief were assessed on the day of inclusion (W0) and after 30 days of therapy.<b>Results:</b> There were no statistical differences between the groups in terms of disease advancement, age, gender, and duration of symptoms. Compared to the moment of inclusion in the study (W0), after 4 days (W1), after 10 days (W2) of taking the multi- -component product, there was a statistically significant improvement in the VAS scale: spontaneous pain and pain during defecation. In the qualitative assessment (yes/no), there were statistically significantly fewer cases of burning in the anus and itching. The treatment did not affect the rate of spontaneous bleeding, which was low at the beginning of the study, but significantly reduced the rate of bleeding during defecation. After 30 days of observation, it was found that the improvement in the severity of hemorrhoidal disease symptoms was significantly higher in the group using the tested preparation. Relief after a month of the study (one-question method) was noted in the group of patients receiving the tested product.<b>Conclusions:</b> The tested six-component myophlebotropic product proved to be effective in reducing the severity of symptoms such as spontaneous pain, pain during defecation, burning/burning in the anus and bleeding during defecation. Statistical significance was demonstrated in the symptom's relief and reduction in the severity of hemorrhoidal disease.

Principles of minimize bleeding and the transfusion of blood and its components in operated patients - surgical aspects.

One of the target of perioperative tratment in surgery is decreasing intraoperative bleeding, which increases the number of perioperative procedures, mortality and treatment costs, and also causes the risk of transfusion of blood and its components. Trying to minimize the blood loss(mainly during the operation) as well as the need to transfuse blood and its components (broadly understood perioperative period) should be standard treatment for a patient undergoing a procedure. In the case of this method, the following steps should be taken: 1) in the preoperative period: identyfication of risk groups as quickly as possible, detecting and treating anemia, applying prehabilitation, modyfying anticoagulant treatment, considering donating one's own blood in some patients and in selected cases erythropoietin preparations; 2) in the perioperative period: aim for normothermia, normovolemia and normoglycemia, use of surgical methods that reduce bleeding, such as minimally invasive surgery, high-energy coagulation, local hemostatics, prevention of surgical site infection, proper transfusion of blood and its components if it occurs; 3) in the postoperative period: monitor the condition of patients, primarily for the detection of bleeding, rapid reoperation if required, suplementation (oral administration preferred) nutrition with microelements (iron) and vitamins, updating its general condition. All these activities, comprehensively and in surgical cooperation with the anesthesiologist, should reduce the blood loss and transfusion of blood and its components.

Analysis of risk factors for conversion in laparoscopic adrenalectomy: a single-institution series of 256 patients.

Introduction: Although introduction of the laparoscopic approach for adrenal gland surgery revolutionized the strategy in management of adrenal gland tumors, open surgery is still a method of choice in some clinical scenarios. Moreover, laparoscopy may have limitations resulting in conversion. Aim: To assess risk factors predisposing for conversion based on our own material, including 256 laparoscopic adrenalectomies performed in 2009-2016. Material and methods: A retrospective analysis of patients who underwent adrenalectomies between 2009 and 2016 was conducted. Patients were analyzed for sex, body mass index (BMI), size of the adrenal gland lesion, final histopathological diagnosis and operated side of the adrenal gland, its impact on conversion rate. Results: A total of 256 patients underwent laparoscopic adrenalectomy. The reported study comprised of 94 (36.7%) men and 162 (63.3%) women. The most common indication for adrenalectomy were adrenal cortex adenoma (n = 149; 58.2%) and pheochromocytoma (n = 48; 18.75%). The conversion rate was 3.91% (n = 10 patients). Mean BMI of patients without conversion was 27.6 kg/m2, whereas in the group of patients with conversion, BMI was 29.7 kg/m2 (p > 0.05). The conversion rate was precisely the same when comparing the right (5/126; 3.9%) and left (5/126; 3.9%) adrenal gland. There was no correlation between the size of the adrenal lesion and the risk of conversion. Conclusions: The laparoscopic approach remains an efficient and safe procedure for adrenal gland tumors. Based on our study, obese patients and those with pheochromocytoma are associated with a higher risk of conversion but without any statistical significance. There was no difference in the conversion rate when analyzing the size of the adrenal gland tumor. No difference was also revealed in the conversion rate when comparing both sides of laparoscopic adrenalectomy.

Stoma close to the abdominal wound: a real technical problem. A description of a novel care strategy.

IntroductionIn some clinical scenarios, stoma site may be located close to the abdominal wound edge impeding optimal wound management and stoma care. We present a novel strategy of utility NPWT for management of simultaneous abdominal wound healing with stoma presence. Material and methodsRetrospective analysis of seventeen patients treated with a novel wound care strategy was conducted. Application of NPWT within wound bed, around stoma site and skin between allows for: 1) separating wound from stoma site, 2) maintaining the optimal environment for wound healing, 3) protecting peristomal skin and 4) facilitating application of ostomy appliances.ResultsThe study group comprised of twelve female (70,6 %) and five male (29,4%) with the mean age of 49.1 18.4 years The most common underlying pathology was Crohn s disease (n-5; 29,4%). Since NPWT was implemented, patients had undergone from 1 to 13 surgeries. Thirteen patients (76,5%) required intensive care unit admission. The mean time of hospital stay was 65,3 28,6 days (range: 36 134). The mean session of NPWT was 10.8 5.2 (range: 5 - 24) per patient. The range of the level of negative pressure was from -80 to 125 mmHg. In all patients, progress in wound healing was achieved resulting in granulation tissue formation, minimizing wound retraction and thus reduction of the wound area. As a result of NPWT, wound was granulated entirely, tertiary intension closure were achieved or patients were qualified for reconstructive surgery.DiscussionNPWT is safe and useful therapy for complicated abdominal wounds with the presence of stoma close to wounds edges. A novel care strategy allows for simultaneous technical opportunity to separate stoma from wound bed and facilitate wound healing.

Challenges in restoring bowel continuity: An analysis of 91 patients undergoing a reversal procedure

Introduction: The restoration of bowel continuity is associated with significant postoperative morbidity. Aim: The aim of the study was to report the outcomes of restoring intestinal continuity in a large patient cohort. Material and methods: A retrospective analysis was conducted on 91 patients with terminal stoma who were qualified for restoration of GI tract continuity between January 2015 and March 2020. The following demographic and clinical characteristics were analyzed: age, gender, BMI, comorbidities, indication for stoma creation, operative time, the need for blood replacement, the site and type of the anastomosis, and complication and mortality rates. Results: The study group was comprised of 40 women (44%) and 51 men (56%). The mean BMI was 26.8 ±4.9 kg/m2. Only 29.7% of the patients (n = 27) were at normal weight (BMI: 18.5­24.9) and only 11% (n = 10) did not suffer from any comorbidities. The most common indications for index surgery were complicated diverticulitis (37.4%) and colorectal cancer (21.9%). The stapled technique was used in the majority of patients (n = 79, 87%). The mean operative time was 191.7 ±71.4 min. Nine patients (9.9%) required blood replacement peri- or postoperatively, whereas 3 patients (3.3%) required intensive care unit admission. The overall surgical complication rate was 36.2% (n = 33) and the mortality rate was 1.1% (n = 1). Discussion: Restoration of bowel continuity is quite a demanding and complex procedure and thus should be performed by an experienced surgical team. In the majority of patients, the complication rate represents only minor complications. The morbidity and mortality rates are acceptable and comparable to other publications.

Recommendations on the use of prehabilitation, i.e. comprehensive preparation of the patient for surgery.

Prehabilitation is a comprehensive preparation of a patient for primarily surgical treatments. Its aim is to improve the patient'sgeneral condition so as to reduce the risk of complications and ensure the fastest possible recovery to full health. Thebasic components of prehabilitation include: improvement of nutritional status, appropriate exercises to improve functioning,psychological support, and help in eliminating addictions. Other important aspects of prehabilitation are: increasinghemoglobin levels in patients with anemia, achieving good glycemic control in patients with diabetes, treatment or stabilizationof any concurrent disorders, or specialist treatment associated with a specific procedure (endoprostheses, ostomyprocedure). This article organizes and outlines the indications for prehabilitation, its scope, duration, and the method to conductit. Experts of various specialties related to prehabilitation agree that it should be an element of surgery preparationwhenever possible, especially in patients with co-existing medical conditions who have been qualified for major procedures.Prehabilitation should be carried out by interdisciplinary teams, including family physicians and various specialists in thetreatment of comorbidities. Prehabilitation requires urgent systemic and reimbursement solutions.

Effect of closed incision negative pressure wound therapy on incidence rate of surgical site infection after stoma reversal: a pilot study.

INTRODUCTION: The stoma reversal (SR) procedure is associated with a relatively high risk of perioperative complications with surgical site infection (SSI) as the most common. Recently closed incision negative pressure wound therapy (ciNPWT) was applied widely to prevent SSI. AIM: To investigate the efficiency of ciNPWT in terms of the incidence rate of SSI after SR surgery. MATERIAL AND METHODS: As an exploratory observational cohort study patients were treated either with ciNPWT (n = 15) or standard sterile dressing (SSD) (n = 15). CiNPWT was applied every 3 days whereas SSD was changed every day. Clinical evaluation for SSI signs, C-reactive protein level and pain assessment using the visual analogue scale (VAS) were analyzed. RESULTS: The incidence rate of SSI was in 13% (2/15) in the ciNPWT group and 26% (4/15) in the SSD group (p = 0.651, OR = 0.44, 95% CI: 0.03-3.73). All patients in the SSD group who developed SSI presented both local and generalized signs of infection. Pain-VAS levels assessed on the 1st (MdnciNPWT = 4, MdnSSD = 5, p = 0.027, W = 51.5) and 3rd postoperative day (MdnciNPWT = 2, MdnSSD = 4, p = 0.014, W = 45.5) were significantly lower in the ciNPWT group than in the SSD group. CONCLUSIONS: CiNPWT seems not to have a benefit to reduce SSI after the SR procedure. Further investigation is needed to establish firmly the benefit of using ciNPWT in this group of patients.

Crohn's Disease Susceptibility and Onset Are Strongly Related to Three NOD2 Gene Haplotypes.

The genetic background and the determinants influencing the disease form, course, and onset of inflammatory bowel disease (IBD) remain unresolved. We aimed to determine the NOD2 gene haplotypes and their relationship with IBD occurrence, clinical presentation, and onset, analyzing a cohort of 578 patients with IBD, including children, and 888 controls. Imaging or endoscopy with a histopathological confirmation was used to diagnose IBD. Genotyping was performed to assess the differences in genotypic and allelic frequencies. Linkage disequilibrium was analyzed, and associations between haplotypes and clinical data were evaluated. We emphasized the prevalence of risk alleles in all analyzed loci in patients with Crohn disease (CD). Interestingly, c.2722G>C and c.3019_3020insC alleles were also overrepresented in ulcerative colitis (UC). T-C-G-C-insC, T-C-G-T-insC, and T-T-G-T-wt haplotypes were correlated with the late-onset form of CD (OR = 23.01, 5.09, and 17.71, respectively), while T-T-G-T-wt and C-C-G-T-wt were prevalent only in CD children (OR = 29.36, and 12.93, respectively; p-value = 0.001). In conclusion, the presence of c.3019_3020insC along with c.802C>T occurred as the most fundamental contributing diplotype in late-onset CD form, while in CD children, the mutual allele in all predisposing haplotypes was the c.2798 + 158T. Identifying the unique, high-impact haplotypes supports further studies of the NOD2 gene, including haplotypic backgrounds.

Endoscopic vacuum therapy with instillation (iEVT) - a novel endoscopic concept for colorectal anastomotic leak and perianal complications.

INTRODUCTION: Anastomotic leaks remain the most fearful complications. AIM: We present a novel endoscopic salvage therapy known as endoscopic vacuum therapy with instillation (iEVT) as a combination of standard endoscopic vacuum therapy (EVT) and negative pressure wound therapy with instillation (iNPWT). MATERIAL AND METHODS: A case series of 6 consecutive patients treated with iEVT is presented. A Redon drain and a central venous catheter were introduced within polyurethane foam used as a self- made device for iEVT and antimicrobial solution was instilled. RESULTS: A total of 6 patients with the mean age of 29.5 ±8.9 were treated with iEVT. The mean number of iEVT sessions was 5.8 ±2.3. The mean time of iEVT management was 20.7 ±8.8 days. Locally, a reduction in purulent discharge and defect's dimension with contraction were revealed confirmed with imaging studies. CONCLUSIONS: iEVT is a very encouraging, novel method for complicated perianal diseases and anastomotic leak.

LapVac - a laparoscopic approach for negative pressure wound therapy application in open abdomen management: a porcine animal model.

INTRODUCTION: Negative pressure wound therapy (NPWT) in the open abdomen (OA) is recognized as a gold standard management method. Currently minimally invasive procedures are implemented in many clinical scenarios. AIM: To demonstrate the feasibility of using negative pressure wound therapy in a laparoscopic approach for OA management in a porcine model termed as a laparoscopic vacuum (LapVac). MATERIAL AND METHODS: An adult female swine underwent a laparoscopic procedure. Briefly, a small incision was made and secured with a wound protector, pneumoperitoneum was created and two additional ports were placed. Then, a non-adhesive layer was precisely placed within the abdominal cavity. RESULTS: Finally, polyurethane foam and adhesive drape were applied. A volume of 200 ml of saline solution was instilled and drained completely within 30 min. We did not observe any technical problems with NPWT application. CONCLUSIONS: This study confirmed the technical feasibility of NPWT application in the laparoscopic approach. LapVac seems to be a promising technique which may minimize the trauma and lead to better outcomes.

Efficacy of combined prophylactic therapy (rifaximine alpha + prebiotic arabinogalactan with lactofferin) on GUT function in patients with diagnosed symptomatic uncomplicated diverticular disease.

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Lactose intolerance, lactose malabsorption and genetic predisposition to adult-type hypolactasia in patients after restorative proctocolectomy.

This study provides up-to-date findings on lactose malabsorption, lactose intolerance and genetic predisposition to adult-type hypolactasia in 72 patients after restorative proctocolectomy (RPC). The lactose malabsorption was assessed by hydrogen-methane breath test. Genetic predisposition to adult-type hypolactasia was assessed by detecting -13910T/C polymorphism in the lactase gene. Lactose intolerance was more frequent in UC (ulcerative colitis) patients than FAP (familial adenomatous polyposis) patients (77.5% vs. 55.2%; p=0.01). The C/C genotype of the lactase gene was observed in 39.1% subjects with no significant difference between UC and FAP patients. Lactose malabsorption occurred in 10.1% of subjects and almost only in patients with genetic predisposition, with the same frequency in UC and FAP patients.

Ileal pouch anal anastomosis leak after restorative proctocolectomy without protective stoma successfully treated with endoscopic vacuum therapy.

Aim An ileal pouch anal anastomosis (IPAA) leak is one of the most severe complication after restorative proctocoletomy (RPC). We present a rare case of a successful management of IPAA leak after RPC without defunctionig stoma with the utility of endoscopic vacuum therapy. Methods A 57-year-old male with a ileal pouch anal anastomosis leak after RPC due to ulcerative colitis with presacral abscess was qualified for endoscopic vacuum therapy (EVT). The abscess of the left buttock was drained and secured with suction drain (redon drain). Due to the lack of defunctioning stoma, a system for contain and divert fecal matter was placed within afferent limb of the J-pouch and EVT was placed directly within IPAA dehiscence. EVT was changed every third day. Results The patient underwent a total of five EVT sessions. Improvement of patient's general condition characterized with lack of pelvic pain, fever and reduction of inflammatory markers was achieved. Locally, anastomosis dehiscence was healed with prominent reduction in the defect's dimension, contraction and revascularization. Based on imaging studies no chronic presacral sinus or any other perianal disturbances were revealed at the time of five months follow up. Conclusions EVT is a promising method for management of IPAA leak. Although, it remains extremely difficult, EVT may serve as a method of choice in early pouch-related septic complications after RPC performed without defunctioning stoma.

A novel model of acellular dermal matrix plug for anal fistula treatment. Report of a case and surgical consideration based on first utility in Poland.

Anal fistula (AF) is a pathological connection between anus and skin in its surroundings. The main reason for the formation of anal fistula is a bacterial infection of the glands within the anal crypts. One of the modern techniques for the treatment of fistulas that do not interfere with the sphincters consists in implantation of a plug made from collagen material. We are presenting the first Polish experience with a new model of biomaterial plug for the treatment of anal fistula. We also point out key elements of the procedure (both preoperative and intraoperative) associated with this method. In the authors' opinion, the method is simple, safe and reproducible. Innovative shape of the plug minimizes the risk of its migration and rotation. It also perfectly blends with and adapts to the course and shape of the fistula canal, allowing it to become incorporated and overgrown with tissue in the fistula canal. The relatively short operation time, minor postoperative pain and faster convalescence are with no doubt additional advantages of the method. Long-term observation involving more patients is essential for evaluation of the efficacy of the treatment of fistulas with the new type of plug.