Comparison of stump closure techniques during laparoscopic appendectomies for complicated appendicitis - results from Pol-LA (Polish laparoscopic appendectomy) multicenter large cohort study.

Background: In general, the three main options for stump closure in laparoscopic appendectomy are clips, endoscopic staplers and endoloops. However, there is no gold standard, especially regarding complicated acute appendicitis which is generally associated with worse outcomes.Objectives: We aimed to assess the outcomes of different stump closure techniques during laparoscopic appendectomies for complicated appendicitisMethods: Our multicenter observational study of 18 surgical units assessed the outcomes of 1269 laparoscopic appendectomies for complicated appendicitis that used the three main stump closure techniques: clips, staplers and endoloops. Groups were compared in terms of peri- and postoperative outcomes.Results: Staplers were superior in terms of overall morbidity (9.79 vs. 3.29% vs. 7.41%, p = .017) and length of stay (4 vs. 3 vs. 4 days, p < .001) respectively for clips, staplers and endoloops. However, no differences in major complication rates, postoperative intraabdominal abscess formation, reintervention rates and readmission rates were found.Conclusion: Although our results show some clinical benefits of staplers for appendix stump closure, they are based on a non-randomized group of patients and are therefore prone to selection bias. Further well-designed trials taking into consideration not only the clinical benefits, but also, the economic aspects of the surgical treatment of complicated acute appendicitis are needed to confirm our results.

Author Correction: Risk factors for serious morbidity, prolonged length of stay and hospital readmission after laparoscopic appendectomy - results from Pol-LA (Polish Laparoscopic Appendectomy) multicenter large cohort study.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Risk factors for serious morbidity, prolonged length of stay and hospital readmission after laparoscopic appendectomy - results from Pol-LA (Polish Laparoscopic Appendectomy) multicenter large cohort study.

Laparoscopic appendectomy (LA) for treatment of acute appendicitis has gained acceptance with its considerable benefits over open appendectomy. LA, however, can involve some adverse outcomes: morbidity, prolonged length of hospital stay (LOS) and hospital readmission. Identification of predictive factors may help to identify and tailor treatment for patients with higher risk of these adverse events. Our aim was to identify risk factors for serious morbidity, prolonged LOS and hospital readmission after LA. A database compiled information of patients admitted for acute appendicitis from eighteen Polish and German surgical centers. It included factors related to the patient characteristics, peri- and postoperative period. Univariate and multivariate logistic regression models were used to identify risk factors for serious perioperative complications, prolonged LOS, and hospital readmissions in acute appendicitis cases. 4618 laparoscopic appendectomy patients were included. First, although several risk factors for serious perioperative complications (C-D III-V) were found in the univariate analysis, in the multivariate model only the presence of intraoperative adverse events (OR 4.09, 95% CI 1.32-12.65, p = 0.014) and complicated appendicitis (OR 3.63, 95% CI 1.74-7.61, p = 0.001) was statistically significant. Second, prolonged LOS was associated with the presence of complicated appendicitis (OR 2.8, 95% CI: 1.53-5.12, p = 0.001), postoperative morbidity (OR 5.01, 95% CI: 2.33-10.75, p < 0.001), conversions (OR 6.48, 95% CI: 3.48-12.08, p < 0.001) and reinterventions after primary procedure (OR 8.79, 95% CI: 3.2-24.14, p < 0.001) in the multivariate model. Third, although several risk factors for hospital readmissions were found in univariate analysis, in the multivariate model only the presence of postoperative complications (OR 10.33, 95% CI: 4.27-25.00), reintervention after primary procedure (OR 5.62, 95% CI: 2.17-14.54), and LA performed by resident (OR 1.96, 95% CI: 1.03-3.70) remained significant. Laparoscopic appendectomy is a safe procedure associated with low rates of complications, prolonged LOS, and readmissions. Risk factors for these adverse events include complicated appendicitis, postoperative morbidity, conversion, and re-intervention after the primary procedure. Any occurrence of these factors during treatment should alert the healthcare team to identify the patients that require more customized treatment to minimize the risk for adverse outcomes.

Prognostic Factors for Immune Thrombocytopenic Purpura Remission after Laparoscopic Splenectomy: A Cohort Study.

BACKGROUND AND OBJECTIVES: Laparoscopic splenectomy (LS) has become the gold standard for patients with immune thrombocytopenic purpura (ITP). The total remission rate after splenectomy is 70%-90%, of which 66% is long-term. Despite this high response rate, some patients do not benefit from surgery. It is therefore important to try to identify risk factors for an unsatisfactory clinical response. The aim of this study was to assess long-term outcomes of LS for ITP and identify factors associated with increased disease remission rates. MATERIALS AND METHODS: We retrospectively studied consecutive patients with ITP undergoing LS in a tertiary referral surgical center prospectively recorded in a database. Inclusion criteria were: Elective, laparoscopic splenectomy for diagnosed ITP, and complete follow-up. The cohort was divided into two groups-Group 1 (G1) patients with ITP remission after splenectomy and Group 2 (G2) patients without remission. There were 113 G1 patients and 52 G2 patients. Median follow-up was 9.5 (IQR: 5-15) years. RESULTS: In univariate analysis, patient's age, body mass index (BMI), preoperative platelet count, the need for platelet transfusions, and presence of hemorrhagic diathesis were shown to be statistically significant factors. Next, we built a multivariate logistic regression model using factors significant in univariate analysis. Age <41 years (odds ratio (OR) 4.49; 95% CI: 1.66-12.09), BMI <24.3 kg/m2 (OR: 4.67; 95% CI: 1.44-15.16), and preoperative platelet count ≥97 × 103/mm3 (OR: 3.50; 95% CI: 1.30-9.47) were shown to be independent prognostic factors for ITP remission after LS. CONCLUSION: The independent prognostic factors for ITP remission after LS revealed in our study are: age <41 years, BMI <24.3 kg/m2, and preoperative platelet count ≥97 × 103/mm3. Duration of the ITP and the time of treatment are not related to remission after LS.

Complicated appendicitis: Risk factors and outcomes of laparoscopic appendectomy - Polish laparoscopic appendectomy results from a multicenter, large-cohort study.

BACKGROUND: Preoperative classification of complicated and uncomplicated appendicitis (AA) is challenging. However, the differences in surgical outcomes necessitate the establishment of risk factors in developing, complicated AA. This study was an analysis of the clinical outcomes of laparoscopic appendectomies (LA), as well as preoperative risk factors for the development of complicated AA. METHODS: The data of 618 patients who underwent LA in 18 surgical units across Poland and Germany were collected in an online web-based database created by the Polish Videosurgery Society. The surgical outcomes of patients with complicated and uncomplicated appendicitis were compared. Uni- and multivariate logistic regression models were used to establish risk factors for the development of complicated appendicitis. RESULTS: In all, 1269 (27.5%) patients underwent LA for complicated appendicitis (Group 1) and 3349 (72.5%) for uncomplicated appendicitis (Group 2). The conversion rate, number of intra-operative adverse events, re-intervention rate, postoperative complications, and readmission rate was greater in Group 1. The preoperative risk factors associated with complicated appendicitis were: female sex (Odds ratio [OR]: 1.58), obesity (OR: 1.51), age >50 years (OR: 1.51), symptoms >48 hours (OR: 2.18), high Alvarado score (OR: 1.29 with every point), and C-reactive protein level >100 mg/L (OR: 3.92). CONCLUSION: Several demographic and clinical risk factors for complicated AA were identified. LA for complicated appendicitis was associated with poorer outcomes.

Risk factors for intraabdominal abscess formation after laparoscopic appendectomy - results from the Pol-LA (Polish Laparoscopic Appendectomy) multicenter large cohort study.

INTRODUCTION: According to meta-analyses laparoscopic appendectomy is associated with many benefits. However, in comparison to open surgery an increased rate of intraabdominal abscesses (IAA) has been reported. Identification of predictive factors for this complication may help to identify patients with higher risk of IAA. AIM: To identify potential risk factors for intraabdominal abscess after laparoscopic appendectomy (LA). MATERIAL AND METHODS: Eighteen surgical units in Poland and Germany submitted data of patients undergoing LA to the online web-based database created by the Polish Videosurgery Society of the Association of Polish Surgeons. It comprised 31 elements related to the pre-, intra- and postoperative period. Surgical outcomes were compared among the groups according to occurrence of IAA. Univariate and multivariate logistic regression models were used to identify potential risk factors for IAA. RESULTS: 4618 patients were included in the analysis. IAA were found in 51 (1.10%) cases. Although several risk factors were found in univariate analysis, in the multivariate model, only the presence of complicated appendicitis was statistically significant (OR = 2.98, 95% CI: 1.11-8.04). Moreover, IAA has a significant influence on postoperative reintervention rate (OR = 126.95, 95% CI: 67.98-237.06), prolonged length of stay > 8 days (OR = 41.32, 95% CI: 22.86-74.72) and readmission rate (OR = 33.89, 95% CI: 18.60-34.73). CONCLUSIONS: Intraabdominal abscesses occurs relatively rarely after LA. It is strongly associated with complicated appendicitis. Occurrence of this complication has a great influence on the postoperative period and due to the nature of its treatment is associated with the need for reintervention, prolonged length of stay and by extension possible readmission.

Is ITP really a desirable indication for teaching laparoscopic splenectomy? Cohort study.

Background: We aimed to evaluate the outcomes of laparoscopic splenectomy (LS) in patients with immune thrombocytopenic purpura (ITP) compared with operated for other indications. Methods: Retrospective cohort study of patients who underwent LS in 1998-2017. Group 1 consisted of 256 patients operated for ITP, and Group 2 of 231 operated for other indications. Primary outcome was procedure difficulty. Secondary was perioperative course (30 days of surgery). Results: Patients in Group 1 were younger (p < .001) with lower ASA (p < .001). The spleen was larger in Group 2 (p < .001). Operative time was longer in Group 2 [110 (80-150) vs. 90 (65-115) min; p < .001)]. Intraoperative blood loss was greater in Group 2 (p < .001). Conversions were higher in Group 2 (4.76 vs. 6.93%, p = .037), as were intraoperative complications (7.79 vs. 3.91%, p = .048). Morbidity, reoperations and mortality did not differ between groups (respectively, p = .899, .697, and .999). Median length of stay was similar (p = .211). Among the first 10 LSs performed by trainees, 63.66% were done for ITP. Later (after 11+ procedures) this dropped to 48.12% (p = .002). Conclusions: ITP may be a preferred indication for surgeons training for LS. Patients' characteristics and intraoperative factors allow an expectation for a relatively easy and hassle-free operation in those patients.

Quest for the optimal technique of laparoscopic splenectomy - vessels first or hilar transection?

INTRODUCTION: Throughout our 20 years of experience, we have used several different techniques for laparoscopic splenectomy (LS). However, two methods have been used most frequently: "vessels first" and "hilar transection". AIM: To evaluate the outcomes of LS performed with these two different approaches. MATERIAL AND METHODS: It was an observational study based on retrospective analysis of consecutive patients undergoing LS in a tertiary referral surgical center in the period 1998-2017. We excluded patients with splenic trauma, initially submitted to open surgery, stapled transection of splenic hilum, partial resections of the spleen and other spleen-preserving procedures. Patients were divided into two groups: group 1 ("vessels first") with 188 patients, and group 2 ("hilar transection") with 287 patients. RESULTS: Mean operative time was shorter (p < 0.001) and blood loss was lower (p < 0.001) in group 2. The need for blood transfusions and the conversion rate were higher in group 1 (p = 0.044 and p = 0.003 respectively). There was no difference in intraoperative adverse events (p = 0.179). Overall postoperative morbidity did not differ between groups (p = 0.081) and we noted mortality of 0.21% (1 patient of group 2). The morbidity rate associated with accidental injury of the pancreatic parenchyma was significantly higher in group 1 (p = 0.028). Median length of hospital stay was 4 days (range: 1-99) and did not differ between groups (p = 0.175). CONCLUSIONS: The "vessels first" technique is associated with longer operative time, higher blood loss and increased risk of conversion. "Hilar transection" is associated with lower incidence of local complications related most likely to accidental injury of the pancreatic tail. In the case of a large caliber of splenic vessels the "vessels first" approach remains the technique of choice.

The significant impact of age on the clinical outcomes of laparoscopic appendectomy: Results from the Polish Laparoscopic Appendectomy multicenter large cohort study.

Acute appendicitis (AA) is the most common surgical emergency and can occur at any age. Nearly all of the studies comparing outcomes of appendectomy between younger and older patients set cut-off point at 65 years. In this multicenter observational study, we aimed to compare laparoscopic appendectomy for AA in various groups of patients with particular interest in the elderly and very elderly in comparison to younger adults.Our multicenter observational study of 18 surgical units assessed the outcomes of 4618 laparoscopic appendectomies for AA. Patients were divided in 4 groups according to their age: Group 1-<40 years old; Group 2-between 40 and 64 years old; Group 3-between 65 and 74 years old; and Group 4-75 years old or older. Groups were compared in terms of peri- and postoperative outcomes.The ratio of complicated appendicitis grew with age (20.97% vs 37.50% vs 43.97% vs 56.84%, P < .001). Similarly, elderly patients more frequently suffered from perioperative complications (5.06% vs 9.3% vs 10.88% vs 13.68%, P < .001) and had the longest median length of stay (3 [Interquartile Range (IQR) 2-4] vs 3 [IQR 3-5], vs 4 [IQR 3-5], vs 5 [IQR 3-6], P < .001) as well as the rate of patients with prolonged length of hospital stay (LOS) >8 days. Logistic regression models comparing perioperative results of each of the 3 oldest groups compared with the youngest one showed significant differences in odds ratios of symptoms lasting >48 hours, presence of complicated appendicitis, perioperative morbidity, conversion rate, prolonged LOS (>8 days).The findings of this study confirm that the outcomes of laparoscopic approach to AA in different age groups are not the same regarding outcomes and the clinical picture. Older patients are at high risk both in the preoperative, intraoperative, and postoperative period. The differences are visible already at the age of 40 years old. Since delayed diagnosis and postponed surgery result in the development of complicated appendicitis, more effort should be placed in improving treatment patterns for the elderly and their clinical outcome.

The Safety of Selective Use of Splenic Flexure Mobilization in Sigmoid and Rectal Resections-Systematic Review and Meta-Analysis.

BACKGROUND: According to traditional textbooks on surgery, splenic flexure mobilization is suggested as a mandatory part of open rectal resection. However, its use in minimally invasive access seems to be limited. This stage of the procedure is considered difficult in the laparoscopic approach. The aim of this study was to systematically review literature on flexure mobilization and perform meta-analysis. METHODS: A systematic review of the literature was performed using the Medline, Embase and Scopus databases to identify all eligible studies that compared patients undergoing rectal or sigmoid resection with or without splenic flexure mobilization. INCLUSION CRITERIA: (1) comparison of groups of patients with and without mobilization and (2) reports on overall morbidity, anastomotic leakage, operative time, length of specimen, number of harvested lymph nodes, or length of hospital stay. The outcomes of interest were: operative time, conversion rate, number of lymph nodes harvested, overall morbidity, mortality, leakage rate, reoperation rate, and length of stay. RESULTS: Initial search yielded 2282 studies. In the end, we included 10 studies in the meta-analysis. Splenic flexure is associated with longer operative time (95% confidence interval (CI) 23.61⁻41.25; p < 0.001) and higher rate of anastomotic leakage (risk ratios (RR): 1.02; 95% CI 1.10⁻3.35; p = 0.02), however the length of hospital stay is shorter by 0.42 days. There were no differences in remaining outcomes. CONCLUSIONS: Not mobilizing the splenic flexure results in a significantly shorter operative time and a longer length of stay. Further research is required to establish whether flexure mobilization is required in minimally invasive surgery.

Pancreatoduodenectomy for pancreatic head tumors in the elderly - Systematic review and meta-analysis.

The age at which patients are undergoing pancreatoduodenectomy is increasing worldwide. The data on the outcome of this surgical procedure in the elderly is constantly expanding. This meta-analysis aims to assess the safety of pancreatoduodenectomy in elderly population, primarily focusing on morbidity and mortality. We searched the Medline, Embase and Cochrane databases to identify eligible studies. The most recent search was performed on 10th April 2017. Inclusion criteria were: (1) comparison of the characteristics and perioperative outcomes of older patients versus younger patients undergoing pancreatoduodenectomy; (2) objective evaluation of mortality or overall morbidity; and (3), publication in English. Exclusion criteria were: (1) a lack of comparative data; (2) a lack of primary outcomes or insufficient data to analyze; (3) a focus on procedures other than pancreatoduodenectomy; or (4), the impossibility of extraction of data specifically concerning pancreatoduodenectomy. Primary outcomes were overall morbidity and mortality. Secondary outcomes analyzed postoperative complications, R0 rate and length of hospital stay. 45 eligible studies were chosen, with a combined total of 21,295 patients. Older patients compared to younger patients had a higher risk of death (2.26% vs. 4.54%; RR: 2.23; 95% CI 1.74-2.87) and a higher complication rate (47.23% vs. 39.35%; RR: 1.17; 95% CI 1.12-1.24). There were no differences in pancreatic fistula occurrence (p = 0.27), bile leakage (p = 0.81), postoperative hemorrhage (p = 0.08), or R0 rate (p = 0.92). Our review confirms, that in the case of pancreatoduodenectomy, advanced age is a risk factor for increased non-surgical morbidity and, by extension, higher mortality.

Laparoscopic splenectomy for immune thrombocytopenia in patients with a very low platelet count.

INTRODUCTION: Laparoscopic splenectomy (LS) is the gold standard in treating immune thrombocytopenia (ITP). However, there are still some problems in decision-making when considering LS in patients with a very low platelet count (PLT). AIM: To evaluate safety outcomes of LS in patients with severe ITP and very low PLT in comparison to those with higher PLT. MATERIAL AND METHODS: We retrospectively analyzed consecutive patients who underwent LS in a single institution between April 1998 and December 2017. Perioperative care was based on an algorithm developed at our department which takes into consideration the patient's PLT level. Patients were divided into 2 groups depending on the PLT level (cut-off point 50,000/mm3). RESULTS: The mean operative time in the low PLT group and high PLT group was 90 ±42.1 min and 95 ±45 min, respectively (p = 0.59). Intraoperative blood loss was 144 ±226.1 ml in the low PLT group and 83 ±161.24 ml in the high PLT group (p = 0.23). Complications occurred in 5 (9.09%) patients in the low PLT group and 16 (11.51%) in the high PLT group (p = 0.67). There were no conversions in the group with lower PLT, while 2 patients in the group with higher PLT had to be converted to open surgery (p = 0.38). Patients with low PLT preoperatively more often required perioperative platelet transfusions (13 vs. 1, p < 0.001). CONCLUSIONS: Laparoscopic splenectomy is safe and feasible treatment in patients with ITP regardless of the PLT level. Still, patients with critical ITP and marginally low PLT require special awareness.

20 years' experience with laparoscopic splenectomy. Single center outcomes of a cohort study of 500 cases.

BACKGROUND: Laparoscopic splenectomy (LS) has become the gold standard in elective spleen surgery. Although it is considered relatively safe, treatment results vary depending on a hospital's profile and the experience of the surgeon and center. We would like to present experience of a high-volume referral center with minimally invasive operations of the spleen. MATERIAL AND METHODS: The retrospective cohort study included consecutive patients undergoing laparoscopic splenectomy in tertiary referral surgical center in 1998-2017. The entire study population (500 patients) was grouped into 5 cohorts of 100 consecutively operated patients. The primary endpoints were short-term outcomes of LS and secondary - analysis of indications and operative technique. The study group consisted of 316 women and 184 men, 46 (28-59) years old on average. RESULTS: The most common indications for splenectomy were ITP (53%), lymphoma (21%) and spherocytosis (7%). Ratio of ITP versus other indications decreased significantly over time in favor of more difficult cases (<0.001). Average operative time of 100 (75-132.5) min and blood loss of 50 (20-150) ml were changing during study. Forty two patients required a blood transfusion with no difference among groups (p = 0.765). The use of postoperative drainage diminished from 100% to 7% (p < 0.001). The overall conversion rate (3%) and intraoperative complications (5%) did not differ among groups (p = 0.863 and 0.888). Perioperative morbidity was 8.6% and decreased significantly over time (OR: 0.78, 95%CI: 0.62-0.98). We noted mortality of 0.4% (1 patient in 1st and 1 in 5th group). Median LOS was 4 (1-16) days. A significant change in the operative technique from vessels first to hilar transection was noted. CONCLUSION: Laparoscopic splenectomy seems to be a safe method associated with a low risk of perioperative complications and mortality. A careful reproducible operative technique, along with a well-trained team and standardized modern postoperative care is critical to improving outcomes.

Effects of bariatric surgery on cardiovascular risk factors among morbidly obese patients.

AIM OF THE STUDY: The aim of this study was to evaluate the influence of laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric by-pass on risk factors of cardiovascular diseases. MATERIAL AND METHODS: We analyzed prospectively collected data of patients operated for morbid obesity who were qualified for laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric by-pass (LRYGB). Risk factors for wylaczecardiovascular diseases were assessed with the SCORE scale and both full and hard Framingham cardiovascular risk scores (FCRs). The data were collected on admission and one year after the procedures. We enrolled 264 patients (119 females, 116 males, 40.2±9.9 years old), of whom 117 underwent LRYGB and 118 LSG, respectively. RESULTS: Preoperatively, 12% of patients were in the high-risk category of the SCORE scale, 65% were in the moderate risk category, and 24% were in the low-risk category. The median score of the SCORE scale was 1 (1-2). Lipid-based full FCR was 34.5% (24%-68%) and the hard FCR was 17.5% (10%-52%), while the respective BMI-based FCRs were 59% (31%-84%) and 37% (15%-67%). One year after the procedures, the mean %EBMIL (62.88%±20.02%) and %EWL (53.18%±15.87) were comparable between both procedures. Hypertension treatment was not necessary in 33 patients after LSG and in 55 after LRYGB. Diabetes mellitus remitted in 9 and 29 patients, respectively. Both procedures significantly reduced high and moderate risk prevalence in the SCORE scale in favor of the low risk category. Surgical interventions resulted in significant reductions of FCRs 1 year after surgery ( p<0.001). CONCLUSIONS: Both LSG and LRYGB lead to a significant and comparable body mass reduction. Both procedures significantly decrease of the risk of cardiovascular diseases, based on SCORE and Framingham scales.

Laparoscopic approach to splenic aneurysms.

Background Splenic artery aneurysm is a rare disease with possibly mortal complications. For years, the main method of treatment was excision of aneurysm with spleen. In recent years, several methods have been developed in order to salvage the spleen such endovascular techniques and aneurysmectomy. Objective The aim of our study was to determine the feasibility of laparoscopic aneurysmectomy with spleen salvage in cases of splenic artery aneurysm. Materials Analysis of prospectively gathered data containing records of patients operated laparoscopically due to diseases of the spleen in 1998-2016 in our department. Inclusion criteria were attempted laparoscopic aneurysmectomy with intent to salvage spleen. Results Out of 11 patients, seven patients underwent aneurysmectomy with spleen preservation, one patient had partial-splenectomy, two patients had intra-operative splenectomies and one patient had a re-operation on post-op day 1 with splenectomy. Re-operation with splenectomy was the only recorded complication. Conclusions Laparoscopic aneurysmectomy of SAA may be considered as a safe treatment method, with good short- and long-term results; however, a complete evaluation requires further research on a larger study group. It allows permanent treatment of SAA with maintaining spleen function.

Differences in the Clinical Course of Acute Appendicitis in the Elderly in Comparison to Younger Population.

UNLABELLED: Acute appendicitis (AA) still remains the most common acute surgical abdominal emergency. Although 90% of cases occur in children and young adults, the incidence in the elderly amounts up to 10% and is constantly rising. The aim of the study was to assess the differences between clinical presentation in the elderly patients with AA compared to the younger patients. Additional aim was to assess the correlation between in-hospital time delays and patients' outcomes. MATERIAL AND METHODS: We conducted a retrospective analysis of medical data of 274 patients admitted to 3rd Department of General Surgery in Cracow between January 2011 and December 2013 due to AA. The elderly group comprised 23 patients aged 65 and above and the non-elderly group consisted of 251 patients. RESULTS: The groups did not differ in symptoms and their duration, type of surgery and its duration. However, time from admission to ED to the beginning of the procedure was significantly lower in the elderly group (575.56 vs 858.9 min; p=0.03). The elderly had longer hospital stay (6.08 vs 4.69 days; p=0.004). In the elderly group the perforation rate was close to reaching statistical significance (26.1% vs 12.4%; p=0.06). No mortality was noted in both groups and morbidity was slightly higher in elderly group (17.4% vs 10%; p=0.26). CONCLUSIONS: There was no difference in the clinical presentation between elderly and non-elderly patients group. However, elderly patients presented with a more progressed inflammation of the appendix. The hospital stay was longer in the elderly group, without any mortality and with higher rate of morbidity in this group. The length of the preoperative phase was significantly shorter, confirming the awareness of importance of time in the elderly patients with acute abdomen.

Gastrointestinal obstruction in patients previously treated for malignancies.

UNLABELLED: Bowel obstruction is a common condition in acute surgery. Among the patients, those with a history of cancer consist a particular group. Difficulties in preoperative diagnosis - whether obstruction is benign or malignant and limited treatment options in patients with reoccurrence or dissemination of the cancer are typical for this group. The aim of the study was to analyze causes of bowel obstruction in patients with history of radical treatment due to malignancy. MATERIAL AND METHODS: Patients with symptoms of bowel obstruction and history of radical treatment for malignancy who were operated in 2nd and 3rd Department of General Surgery JUCM between 2000 and 2014 were included into the study. The patients were divided into 2 groups based on type of mechanical bowel obstruction (group 1 - adhesions, group 2 - malignant process). RESULTS: 128 patients were included into the study - group 1: 67 (52.3%) and group 2: 61 (47.7%). In the second group bowel obstruction was caused by reoccurrence in 25 patients (40.98%) and dissemination in 36 (59.02%). The mean time between onset of the symptoms of bowel obstruction and the end of treatment for the cancer was 3.7 and 4.4 years, respectively in group 1 and 2 (p>0.05). Median time between onset of the symptoms and admission to Emergency Department was significantly longer in patients with malignant bowel obstruction compared to those with adhesions (11.6 ±17.8 days vs 5.1 ± 6.9 days, p=0.01). Considering type of surgery due to bowel obstruction, in first group in most patients (69.2%) bowel resection was not necessary and in the second group creation of jejuno-, ileo- or colostomy was the most common procedure. Morbidity was significantly higher in second group (45.9% vs 28.26%, p<0.05) but there was no difference in mortality (26% vs 24%, p>0.05). In both groups the most common localization of primary malignancy was colon. CONCLUSIONS: In analyzed group of patients frequency of bowel obstruction caused by adhesions and malignancy was similar. However, in patients with bowel obstruction caused by malignancy morbidity was significantly higher and duration of symptoms was longer. There was no diagnostic procedure which would allow to differentiate the cause of bowel obstruction preoperatively and the diagnosis was made during the operation.

The Use of the Enhanced Recovery After Surgery (ERAS) Protocol in Patients Undergoing Laparoscopic Surgery for Colorectal Cancer--A Comparative Analysis of Patients Aged above 80 and below 55.

UNLABELLED: Age is one of the principal risk factors for colorectal adenocarcinoma. To date, older patients were believed to achieve worse treatment results in comparison with younger patients due to reduced vital capacity. However, papers have emerged in recent years which confirm that the combination of laparoscopy and postoperative care based on the ERAS protocol improves treatment results and may be particularly beneficial also for elderly patients. The aim of the study was to compare the outcomes of laparoscopic surgery for colorectal cancer in combination with the ERAS protocol in patients aged above 80 and below 55. MATERIAL AND METHODS: The analysis included patients aged above 80 and below 55 undergoing elective laparoscopic colorectal resection for cancer at the 2nd Department of General Surgery of the Jagiellonian University. They were divided into two groups according to their age: ≥ 80 years of age (group1) and ≤ 55 years of age (group 2). Both groups were compared with regard to the outcome of surgery: length hospital stay, complications, hospital readmissions, degree of compliance with the ERAS protocol, and recovery parameters (tolerance of oral nutrition, mobilisation, need for opioids, restored gastrointestinal function). RESULTS: Group 1 comprised 34 patients and group 2, 43 patients. No differences were found between both groups in terms of gender, BMI, tumour progression or surgical parameters. Older patients typically had higher ASA scores. No statistically significant differences were found with regard to the length hospital stay following surgery (5.4 vs 7 days, p=0.446481), the occurrence of complications (23.5% vs 37.2%, p=0.14579) or hospital readmissions (2.9% vs 2.4%). The degree of compliance with the ERAS protocol in group 1 and 2 was 85.2% and 83.0%, respectively (p=0.482558). Additionally, recovery parameters such as tolerance of oral nutrition (82.4% vs 72.1%, p=0.28628) and mobilisation (94.1% vs 83.7%, p=0.14510) within 24 hours of surgery did not differ among the groups. However, a smaller proportion of older patients required opioids in comparison with younger patients (26.5% vs 55.8%, p=0.00891). CONCLUSIONS: Similar levels of compliance with the ERAS protocol may be achieved among patients aged ≥ 80 and younger patients. When laparoscopy is combined with the ERAS protocol, age does not seem to be a significant factor that could account for worse outcomes. Therefore, older patients should not be excluded from perioperative care based on ERAS principles.

Autoamputated leiomyoma of the uterus as a rare cause of the mechanical bowel obstruction - report of a case.

Mechanical obstruction of the gastrointestinal tract is one of the most common causes of the emergency surgical intervention. A rare cause of such condition might be the effect of the external pressure on the intestine exerted by i. e. tumor, lymph node package, aneurysm of the abdominal aorta. An extremely rare cause is the pressure of the large loose mass located in the peritoneal cavity called "loose body". We present a case of the mechanical bowel obstruction caused by a giant loose autoamputated leiomyoma of the uterus lying free in the peritoneal cavity. According to our best knowledge it is the largest described loose body in the literature. Moreover, we present a literature review regarding this issue.

The efficacy of risk scores for predicting abdominal wound dehiscence: a case-controlled validation study.

BACKGROUND: The medical literature includes two risk scores predicting the occurrence of abdominal wound dehiscence. These risk indices were validated by the authors on the populations studied. However, whether these scoring systems can accurately predict, abdominal wound dehiscence in other populations remains unclear. METHODS: A retrospective analysis was performed using the medical records of patients treated at a tertiary-care teaching hospital between 2008 and 2011. Patients that underwent laparotomy procedures complicated by the development of postoperative abdominal wound dehiscence were included into the study. For each of the cases, three controls were selected. RESULTS: Among the 1,879 patients undergoing intra-abdominal, 56 patients developed wound dehiscence and 168 patients included in the control group. Calculation of risk scores for all patients, revealed significantly higher scores in the abdominal wound dehiscence group (p < 0.001). The median score was 24 (range: 3-46) and 4.95 (range: 2.2-7.8) vs.10 (range:-3-45) and 3.1 (range:0.4-6.9), for the Veterans Affairs Medical Center (VAMC) and Rotterdam abdominal wound dehiscence risk score in the dehiscence and control groups, respectively. The area under the curve, on the ROC plot, was 0.84 and 0.76; this confirmed a good and moderate predictive value for the risk scores. The fit of the model was good in both cases, as shown by the Hosmer and Lemeshow test. CONCLUSIONS: Both the VAMC and Rotterdam scores can be used for the prediction of abdominal wound dehiscence. However, the VAMC prognostic score had better calibration and discriminative power when applied to the population in this study and taking into consideration our method of control selection.