Sporadic pancreatic neuroendocrine neoplasms: A retrospective clinicopathological and outcome analysis from a Latvian study group.

Background: Although pancreatic neuroendocrine neoplasms (PNEN) are rare, there has been a constant increase in incidence. Furthermore, PNEN present unique clinical behaviors and long-term survival can be expected even in the presence of metastases as compared with ductal adenocarcinoma of the pancreas. Determining the best therapeutic approach and proper timing of therapy requires knowledge of reliable prognostic factors. Therefore, the aim of this study was to explore clinicopathological features, treatment, and survival outcomes of patients with PNEN based on Latvian gastroenteropancreatic neuroendocrine neoplasm (GEP-NEN) registry data. Method: Patients with confirmed PNEN at Riga East Clinical University Hospital and Pauls Stradins Clinical University Hospital, between 2008 and 2020, were retrospectively analyzed. Data were collected and included in EUROCRINE, an open-label international endocrine surgical registry. Results: In total, 105 patients were included. The median age at diagnosis was 64 years (IQR 53.0-70.0) for males and 61 years (IQR 52.5-69.0) for females. In 77.1% of patients, tumors were hormonally nonfunctional. Among those with functioning PNEN, 10.5% of patients presented with hypoglycemia and were diagnosed with insulinoma, 6.7% of patients presented with symptoms related to carcinoid syndrome; 30.5% of patients showed distant metastases at the time of diagnosis, and surgery was performed in 67.6% of patients. Notably, for five patients with nonfunctional PNEN <2 cm, a "watch and wait" approach was used; none of the patients developed metastatic disease. The median length of hospital stay was 8 days (IQR 5-13). Major postoperative complications were found in 7.0% of patients, and reoperation was conducted for 4.2% of patients, due to postpancreatectomy bleeding (2/71) and abdominal collection (1/71). The median follow-up period was 34 months (IQR 15.0-68.8). The OS at the last follow-up was 75.2% (79/105). The observed 1-, 5- and 10-year survival rates were 87.0, 71.2 and 58.0, respectively. Seven of the surgically treated patients had tumor recurrence. The median time of recurrence was 39 months (IQR 19.0-95.0). A univariable Cox proportional hazard analysis provided evidence that a nonfunctional tumor, a larger tumor size, the presence of distant metastases, a higher tumor grade, and the tumor stage were strong, negative predictors of OS. Conclusion: Our study represents the general trends of clinicopathological features and treatment of PNEN in Latvia. For PNEN patients, tumor functionality, size, distant metastases, grade, and stage may be useful to predict OS and must be confirmed in further studies. Furthermore, a "surveillance" strategy might be safe for selected patients with small asymptomatic PNEN.

The Course and Surgical Treatment of Acute Appendicitis during the First and Second Wave of the COVID-19 Pandemic: A Retrospective Analysis in University Affiliated Hospital in Latvia.

Background and Objectives: Acute appendicitis is the most common abdominal emergency requiring surgery and it has an estimated lifetime risk of 6.7 to 8.6%. The COVID-19 pandemic has transformed medical care worldwide, influencing diagnostic tactics, treatment modalities and outcomes. Our study aims to compare and analyze management of acute appendicitis before and during the first and second waves of the pandemic. Materials and Methods: Patients suffering acute appendicitis were enrolled retrospectively in a single-center study for a 10-month period before the pandemic (pre-COVID-19 period: 1 March to 31 December 2019) and during the pandemic (COVID-19 period: 1 March to 31 December 2020). The total number of patients, disease severity, diagnostic methods, complications, length of hospitalization and outcomes were analyzed. Results: A total number of 863 patients were included, 454 patients in the pre-COVID-19 period and 409 patients in the COVID-19 period. Compared to the pre-COVID-19 period, the number of complicated appendicitis increased in the COVID-19 period (24.4% to 37.2%; p < 0.001). The proportion of laparoscopic appendectomies increased during the COVID-19 period but did not show statistically significant differences between periods. In both time periods, we found that open technique was the chosen surgical approach more frequently in elderly patients (p < 0.001). Generalized peritonitis was significantly more common during the COVID-19 period (3.5% vs. 6.1%, p < 0.001). The postoperative course of patients was similar in the pre-COVID-19 period and during the COVID-19 period, with no significant differences in ICU admissions, overall hospital stay or morbidity. Conclusions: The COVID-19 pandemic has led to a significant increase in complicated forms of acute appendicitis; however, no significant impact was observed in terms of diagnostic or treatment approach.

Artificial Deformity Creation as a Method for Limb Salvage for Patients with Massive Tibial and Soft Tissue Defects: A Report of 26 Cases.

Soft tissue and bone defects that occur consequence of high-energy trauma are serious and challenging problems. The aim of this retrospective cohort study is to show that the artificial deformity creation (ADCr) method allows the closure of soft-tissue defects, avoids amputation, and can facilitate the reconstruction of bone defects and restore limb length. Patients and methods: Twenty-six adult patients (age range 20-81 years) with soft tissue defects of the lower limb were treated at the Riga East University Hospital from 2018 to 2021. All patients were treated using the ADCr method which is the technique of establishing an interim deformity for resolving tissue loss. The lower extremity functional scale (LEFS) and application of methods of ilizarov (ASAMI) criteria were used for the evaluation of bone healing and lower extremity function. Results: Complete union was achieved in all cases. The functional evaluation showed that most patients could achieve excellent and good results and return to activities of daily living. The functional result was poor in one case of a multi-fragmentary distal tibial articular fracture for which an ankle fusion was performed. Final union in this case was achieved with some residual deformity. Conclusion: The method of ADCr is an effective surgical technique in cases of severe tibial injuries with concomitant loss of bone and soft tissues. This method could be used in cases when either a plastic or microsurgeon is not available or for instances when closing the defect with a flap is either impossible or contraindicated. Excellent and good functional results are possible without severe complications. How to cite this article: Plotnikovs K, Kamenska J, Movcans J, et al. Artificial Deformity Creation as a Method for Limb Salvage for Patients with Massive Tibial and Soft Tissue Defects: A Report of 26 Cases. Strategies Trauma Limb Reconstr 2023;18(3):133-139.

Sphincter muscle activity before and after delivery: Does it depend on the type of birth?

AIM: There are ongoing discussions whether cesarean section is the safest mode of childbirth to prevent pelvic floor disorders. Pelvic floor electromyography (EMG) allows the analysis of external anal sphincter (EAS) function during voluntary contractions. The primary objective of this study was the evaluation of EMG amplitude of external anal sphincter in women who had vaginal delivery, compared to women who had cesarean section. The secondary objective was to evaluate the anal incontinence score changes before and after delivery between the groups, and to look for any relationship between the clinical and EMG findings. METHODS: Multichannel surface EMG was detected during maximal contractions in three sessions: (i) during pregnancy, (ii) 6 weeks after delivery and (iii) 1 year after delivery. Women were divided into two groups: cesarean section and vaginal delivery. RESULTS: External anal sphincter EMG amplitude decreases 6 weeks after vaginal deliveries from 10.1 to 8.6 µV with effect size of 0.4, but returns to baseline after 1 year. No differences were observed between groups in all other variables. CONCLUSION: No differences were observed after 1 year in EMG activity between the two groups; however, a slight decrease of sphincter muscle amplitude was noted 6 weeks after vaginal delivery. The delivery mode does not have effect on the EAS amplitude 1 year after delivery. Incontinence score slightly increased in both groups after delivery, with no significant differences between the two groups. No association was observed between the increase of incontinence score and the decrease of EMG signal amplitude.

The Role of Laparoscopic Ultrasonography in the Evaluation of Suspected Choledocholithiasis. A Single-Center Experience.

Background and objectives: Opinions differ regarding the optimal diagnostic methods for patients with suspected choledocholithiasis. The aim of this study was to assess the diagnostic accuracy of laparoscopic ultrasonography (LUS) and compare it to pre-operative magnetic resonance cholangio-pancreatography (MRCP); Materials and Methods: In all patients with suspected choledocholithiasis LUS was performed during laparoscopic cholecystectomy to evaluate biliary stones. According to availability, part of the patients had pre-operative MRCP. Data for diagnostic accuracy and main outcomes were collected prospectively and analyzed retrospectively; Results: Choledocholithiasis was detected in 178 of 297 patients by LUS (59.93%) and in 39 of 87 patients by MRCP (44.8%), p = 0.041. LUS yielded a sensitivity of 99.4%, a specificity of 94.3%, a positive predictive value of 96.1% and a negative predictive value of 99.1%. However, pre-operative MRCP had a sensitivity of 61.7%, a specificity of 92.3%, a positive predictive value of 94.9% and a negative predictive value of 51.1%. Moreover, of the 47 patients with no choledocholithiasis by MRCP, in 23 cases it was later detected by LUS (a false negative MRCP finding-38.3%), p < 0.001. Median duration of hospitalization was significantly shorter in patients evaluated without pre-operative MRCP-8 days (interquartile range - IQR 11-6) vs. 11 days (IQR 14-9), p = 0.001; Conclusions: LUS may reduce the role of pre-operative MRCP and can become a rational alternative to MRCP as a primary imaging technique for the detection of choledocholithiasis.

Fluorescence-based cholangiography: preliminary results from the IHU-IRCAD-EAES EURO-FIGS registry.

INTRODUCTION: Near-infrared fluorescence cholangiography (NIRF-C) is a popular application of fluorescence image-guided surgery (FIGS). NIRF-C requires near-infrared optimized laparoscopes and the injection of a fluorophore, most frequently Indocyanine Green (ICG), to highlight the biliary anatomy. It is investigated as a tool to increase safety during cholecystectomy. The European registry on FIGS (EURO-FIGS: www.euro-figs.eu ) aims to obtain a snapshot of the current practices of FIGS across Europe. Data on NIRF-C are presented. METHODS: EURO-FIGS is a secured online database which collects anonymized data on surgical procedures performed using FIGS. Data collected for NIRF-C include gender, age, Body Mass Index (BMI), pathology, NIR device, ICG dose, ICG timing of administration before intraoperative visualization, visualization (Y/N) of biliary structures such as the cystic duct (CD), the common bile duct (CBD), the CD-CBD junction, the common hepatic duct (CHD), Visualization scores, adverse reactions to ICG, operative time, and surgical complications. RESULTS: Fifteen surgeons (12 European surgical centers) uploaded 314 cases of NIRF-C during cholecystectomy (cholelithiasis n = 249, cholecystitis n = 58, polyps n = 7), using 4 different NIR devices. ICG doses (mg/kg) varied largely (mean 0.28 ± 0.17, median 0.3, range: 0.02-0.62). Similarly, injection-to-visualization timing (minutes) varied largely (mean 217 ± 357; median 57), ranging from 1 min (direct intragallbladder injection in 2 cases) to 3120 min (n = 2 cases). Visualization scores before dissection were significantly correlated, at univariate analysis, with ICG timing (all structures), ICG dose (CD-CBD), device (CD and CD-CBD), surgeon (CD and CD-CBD), and pathology (CD and CD-CBD). BMI was not correlated. At multivariate analysis, pathology and timing remained significant factors affecting the visualization scores of all three structures, whereas ICG dose remained correlated with HD visualization only. CONCLUSIONS: The EURO-FIGS registry has confirmed a wide disparity in ICG dose and timing in NIRF-C. EURO-FIGS can represent a valuable tool to promote and monitor FIGS-related educational and consensus activities in Europe.

Epidemiological Data and Treatment of Gastroenteropancreatic Neuroendocrine Neoplasms: Insights From Tertiary Referral Hospitals in Latvia.

BACKGROUND: Gastroenteropancreatic neuroendocrine neoplasms (GEP-NEN) are rare, heterogeneous group which tend to rise in incidence. Epidemiological profile and outcomes of GEP-NEN may vary among countries. The aim of study was to provide baseline clinical and histopathological features of patients with GEP-NEN from tertiary referral hospitals in Latvia. METHODS: A retrospective study of patients with histologically confirmed diagnosis of GEP-NEN treated between 2006 and 2018. Joinpoint regression modeling was used to estimate annual percentage change (APC) for incidence trends. Overall survival (OS) rate was obtained by Kaplan-Meier method. RESULTS: In total, 205 patients were included. The median age at diagnosis was 61.0 (IQR 52.0-70.5) years, 69.3% were females. The age-adjusted incidence per 100 000 inhabitants increased from 0.03 in 2006 to 0.67 in 2018 with APC of 24.1%, p < 0.005. The most common primary tumor site was pancreas (30.7%), followed by stomach (24.9%) and small intestine (20.5%). Non-functional tumors are present in 83.4%, while carcinoid syndrome in 7.8%. Stage IV metastatic disease was present in 27.8% tumors. The majority of patients (82%) received an operation with radical or palliative intent. The 1- and 3-year OS rate were 88.0% (95% CI 83.3-92.7) and 77.1% (95% CI 70.4-83.8), respectively. Increasing tumor grade, stage and the presence of distant metastases were associated with significantly worse OS. CONCLUSION: Our study highlights increasing incidence of GEP-NEN in Latvia. The most common primary site was pancreas and surgery considered as main modality of treatment. Registry and long-term data collection are necessary to develop GEP-NEN management concept in Latvia.

Could the correct side of mediolateral episiotomy be determined according to anal sphincter EMG?

INTRODUCTION AND HYPOTHESIS: Mediolateral episiotomy is one of the most frequent surgical interventions performed in obstetrics. There is conflicting evidence as to whether mediolateral episiotomy reduces the risk of obstetric anal sphincter injuries (OASI). Recent studies suggest that functional asymmetry of pelvic floor innervation exists in healthy women and is strongly associated with postpartum incontinence when the trauma occurs on the dominant side of innervation. Mediolateral episiotomy is the most common cause of perineal trauma during delivery, and the surgical incision is usually performed on the mediolateral right side. Surface electromyography (EMG) has been recently applied in obstetrics for detecting electrical activity of the external anal sphincter (EAS). METHODS: Two hundred and forty-five pregnant nulliparous women at their second and third trimester of pregnancy were recruited, and EMG signals were detected using a multichannel cylindric anal probe. Measurements were repeated and compared 6-8 weeks after delivery on a subgroup of 167 women who were divided in two groups according to EMG amplitude asymmetry before delivery and two subgroups according to type of delivery: (1A) asymmetric left, episiotomy right; (1B) asymmetric left, other types of deliveries; (2A) asymmetric right, episiotomy right; (2B) asymmetric right, other type of deliveries. RESULTS: The reduction of EMG amplitude after right episiotomy was larger in women with right asymmetric sphincter compared with women with left asymmetry and women with other types of delivery. CONCLUSIONS: Prenatal EMG may be used to predict the impact of right-sided mediolateral episiotomy on EAS and perhaps also function following delivery.

Safe laparoscopic clearance of the common bile duct in emergently admitted patients with choledocholithiasis and cholangitis.

BACKGROUNDS/AIMS: Laparoscopic treatment of patients with choledocholithiasis and cholangitis is challenging due to mandatory recovery of the biliary drainage and clearance of the common bile duct (CBD). The aim of our study was to assess postoperative course of cholangitis and biliary sepsis after laparoscopic clearance of the CBD in emergently admitted patients with choledocholithiasis and cholangitis. METHODS: Emergently admitted patients who underwent laparoscopic clearance of the CBD were included prospectively and stratified in 2 groups i.e., cholangitis positive (CH+) or negative (CH-) group. Patient demographics, comorbidities, preoperative imaging data, inflammatory response, surgical intervention, complication rate and outcomes were compared between groups. RESULTS: Ninety-nine of a total 320 patients underwent laparoscopic clearance of the CBD, of which, 60 belonged to the acute cholangitis group (CH+) and 39 to the cholangitis negative group (CH-). Interventions were done on average 4 days after admission, operation duration was 95-105 min, and the conversion rate was 3-7% without differences in the groups. Preoperative inflammatory response was markedly higher in the CH+ group. Inflammation signs on intraoperative choledochoscopy were more evident in patients with cholangitis. Postoperative inflammatory response did not differ between the groups. The overall complication rate was 8.3% and 5.1%, respectively. Laparoscopic clearance of the CBD resulted in 1 lethal case (CH+ group), resulting in 1% mortality rate and a similar 12-month readmission rate. CONCLUSIONS: Single-stage laparoscopic intraoperative US and choledochoscopy-assisted clearance of the CBD is feasible in emergently admitted patients with choledocholithiasis and cholangitis.

The role of the open abdomen procedure in managing severe abdominal sepsis: WSES position paper.

The open abdomen (OA) procedure is a significant surgical advance, as part of damage control techniques in severe abdominal trauma. Its application can be adapted to the advantage of patients with severe abdominal sepsis, however its precise role in these patients is still not clear. In severe abdominal sepsis the OA may allow early identification and draining of any residual infection, control any persistent source of infection, and remove more effectively infected or cytokine-loaded peritoneal fluid, preventing abdominal compartment syndrome and deferring definitive intervention and anastomosis until the patient is appropriately resuscitated and hemodynamically stable and thus better able to heal. However, the OA may require multiple returns to the operating room and may be associated with significant complications, including enteroatmospheric fistulas, loss of abdominal wall domain and large hernias. Surgeons should be aware of the pathophysiology of severe intra-abdominal sepsis and always keep in mind the option of using open abdomen to be able to use it in the right patient at the right time.

Focused open necrosectomy in necrotizing pancreatitis.

BACKGROUND: The control of sepsis is the primary goal of surgical intervention in patients with infected necrosis. Simple surgical approaches that are easy to reproduce may improve outcomes when specialists in endoscopy are not available. The aim of the present study was to describe the experience with a focused open necrosectomy (FON) in patients with infected necrosis. METHOD: A prospective pilot study conducted to compare a semi-open/closed drainage laparotomy and FON with the assistance of peri-operative ultrasound. The incidence of sepsis, dynamics of C-reactive protein (CRP), intensive care unit (ICU)/hospital stay, complication rate and mortality were compared and analysed. RESULTS: From a total of 58 patients, 36 patients underwent a conventional open necrosectomy and 22 patients underwent FON. The latter method resulted in a faster resolution of sepsis and a significant decrease in mean CRP on Day 3 after FON, P = 0.001. Post-operative bleeding was in 1 versus 7 patients and the incidence of intestinal and pancreatic fistula was 2 versus 8 patients when comparing FON to the conventional approach. The median ICU stay was 11.6 versus 23 days and the hospital stay was significantly shorter, 57 versus 72 days, P = 0.024 when comparing FON versus the conventional group. One patient died in the FON group and seven patients died in the laparotomy group, P = 0.139. DISCUSSION: FON can be an alternative method to conventional open necrosectomy in patients with infected necrosis and unresolved sepsis.

Early continuous veno-venous haemofiltration in the management of severe acute pancreatitis complicated with intra-abdominal hypertension: retrospective review of 10 years' experience.

BACKGROUND: Conservative treatment of patients with severe acute pancreatitis (SAP) may be associated with development of intra-abdominal hypertension (IAH), deterioration of visceral perfusion and increased risk of multiple organ dysfunction. Fluid balance is essential for maintenance of adequate organ perfusion and control of the third space. Timely application of continuous veno-venous haemofiltration (CVVH) may help in balancing fluid replacement and removal of cytokines from the blood and tissue compartments. The aim of the present study was to determine whether CVVH can be recommended as a constituent of conservative treatment in patients with SAP who suffer IAH. METHODS: A retrospective analysis of 10 years' experience with low-flow CVVH application in patients with SAP who develop IAH was. In all patients, measurement of the intra-abdominal pressure (IAP) was done indirectly through the urinary bladder. Sequential organ failure assessment (SOFA) score was calculated for severity assessment, and necrotizing forms were verified by contrast-enhanced computed tomography. Dynamics of IAP were analysed in parallel with signs of systemic inflammation, dynamics of C-reactive protein and cumulative fluid balance. All variables, complication rate and outcomes were analysed in the whole group and in patients with IAH (CVVH and no-CVVH groups). RESULTS: From the total of 130 patients, 75 were treated with application of CVVH and 55 without CVVH. Late hospitalization was associated with application of CVVH. Infection was observed in 28.5% of cases regardless of the type of treatment received, with a similar necessity for surgical intervention. IAH was observed in 68.5% of patients, and they had significantly higher SOFA scores compared to patients with normal IAP. CVVH treatment resulted in negative cumulative fluid balance starting from day 5 in patients with IAH, whereas without this treatment, fluid balance remained increasingly positive after a week. Finally, application of CVVH resulted in a lower infection rate and shorter hospital stay, 26.7% vs. 37.9%, and a median of 32 (interquartile range (IQR) = 60 to 12) days vs. 24 (IQR = 34 to 4) days, p = 0.05, comparing CVVH vs. no-CVVH group. Mortality rate reached 11.7% in the CVVH group and 13.8% in the no-CVVH group. CONCLUSIONS: Early application of CVVH facilitates negative fluid balance and reduction of IAH in patients with SAP; it is not associated with increased infection or mortality rate and may reduce hospital stay.

Abdominal negative-pressure therapy: a new method in countering abdominal compartment and peritonitis - prospective study and critical review of literature.

BACKGROUND: Application of abdominal negative-pressure therapy (NPT) is lifesaving when conservative measures fail to reduce sustained increase of the intra-abdominal pressure and it is impossible to achieve source control in a single operation due to severe peritonitis. The aim of this study is to share the initial experience with abdominal NPT in Latvia and provide a review of the relevant literature. METHODS: In total, 22 patients were included. All patients were treated with KCI® ABThera™ NPT systems. Acute Physiology and Chronic Health Evaluation II (APACHE II) score on admission, daily sequential organ failure assessment score and Mannheim peritonitis index (MPI) were calculated for severity definition. The frequency of NPT system changes, daily amount of aspirated fluid effluent and the time of abdominal closure were assessed. The overall hospital and ICU stay, as well as the outcomes and the complication rate, were analysed. RESULTS: A complicated intra-abdominal infection was treated in 18 patients. Abdominal compartment syndrome due to severe acute pancreatitis (SAP), secondary ileus and damage control in polytrauma were indications for NPT in four patients. The median age of the patients was 59 years (range, 28 to 81), median APACHE II score was 15 points (range, 9 to 32) and median MPI was 28 points (range, 21 to 40), indicating a prognostic mortality risk of 60%. Sepsis developed in all patients, and in 20 of them, it was severe. NPT systems were changed on a median of every 4 days, and abdominal closure was feasible on the seventh postoperative day without needing a repeated laparotomy. Two NPT systems were removed due to bleeding from the retroperitoneal space in patients with SAP. Intestinal fistulae developed in three patients that were successfully treated conservatively. Incisional hernia occurred in three patients. The overall ICU and hospital stay were 14 (range, 5 to 56) and 25 days (range, 10 to 87), respectively. Only one patient died, contributing to the overall mortality of 4.5%. CONCLUSIONS: Application of abdominal NPT could be a very promising technique for the control of sustained intra-abdominal hypertension and management of severe sepsis due to purulent peritonitis. Further trials are justified for a detailed evaluation of abdominal NPT indications.