Complicated course of biliary inflammatory myofibroblastic tumor mimicking hilar cholangiocarcinoma: A case report and literature review.

BACKGROUND: The inflammatory myofibroblastic tumor (IMT) is a rare, idiopathic, usually benign, mass-forming disease with myofibroblastic proliferation and a varying amount of inflammatory cells. Although it can affect various organs, the biliary tract is a rare localization of primary IMT, clinically, endoscopically and radiologically imitating cholangiocarcinoma. The treatment options are based only on clinical practice experience. CASE SUMMARY: A 70-year-old woman was referred to our center due to progressive fatigue, weight loss, abdominal pain, night sweats, and elevated liver enzymes. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) revealed proximal common hepatic duct and hilar biliary strictures extending bilaterally to lobular bile ducts. Although initial clinical, endoscopic and radiological signs were typical for hilar cholangiocarcinoma, histological examination showed no signs of malignancy. In total, 8 biopsies using different approaches were performed (several biopsies from dominant stricture during ERCP and direct cholangioscopy; ultrasound-guided liver biopsy; diagnostic laparoscopy with liver and lymph node biopsies). Histological examination revealed signs of IMT, and the final diagnosis of biliary IMT was stated. Although IMT is usually a benign disease, in our case, it was complicated. All pharmacological treatment measures were ineffective. The patient still needs permanent stenting, suffers from recurrent infections and mechanical jaundice. Despite that, the patient already survived 24 mo. CONCLUSION: IMT presenting with hilar biliary strictures is a unique diagnostic and clinical challenge as it is indistinguishable from cholangiocarcinoma, and there are no evidence-based treatment options. Our goal is to increase the understanding of this rare disease and its possible course.

Comparison of Endoscopy First and Laparoscopic Cholecystectomy First Strategies for Patients With Gallstone Disease and Intermediate Risk of Choledocholithiasis: Protocol for a Clinical Randomized Controlled Trial.

BACKGROUND: The optimal approach for patients with gallbladder stones and intermediate risk of choledocholithiasis remains undetermined. The use of endoscopic retrograde cholangiopancreatography for diagnosis should be minimized as it carries considerable risk of postprocedural complications, and nowadays, less invasive and safer techniques are available. OBJECTIVE: This study compares the two management strategies of endoscopic ultrasound before laparoscopic cholecystectomy and intraoperative cholangiography for patients with symptomatic cholecystolithiasis and intermediate risk of choledocholithiasis. METHODS: This is a randomized, active-controlled, single-center clinical trial enrolling adult patients undergoing laparoscopic cholecystectomy for symptomatic gallbladder stones with intermediate risk of choledocholithiasis. The risk of choledocholithiasis is calculated using an original prognostic score (the Vilnius University Hospital Index). This index in a retrospective evaluation showed better prognostic performance than the score proposed by the American Society for Gastrointestinal Endoscopy in 2010. A total of 106 participants will be included and randomized into two groups. Evaluation of bile ducts using endoscopic ultrasound and endoscopic retrograde cholangiography on demand will be performed before laparoscopic cholecystectomy for one arm ("endoscopy first"). Intraoperative cholangiography during laparoscopic cholecystectomy and postoperative endoscopic retrograde cholangiopancreatography on demand will be performed in another arm ("cholecystectomy first"). Postoperative follow-up is 6 months. The primary endpoint is the length of hospital stay. The secondary endpoints are accuracy of the different management strategies, adverse events of the interventions, duct clearance and technical success of the interventions (intraoperative cholangiography, endoscopic ultrasound, and endoscopic retrograde cholangiography), and cost of treatment. RESULTS: The trial protocol was approved by the Vilnius Regional Biomedical Research Ethics Committee in December 2017. Enrollment of patients was started in January 2018. As of June 2020, 66 patients have been enrolled. CONCLUSIONS: This trial is planned to determine the superior strategy for patients with intermediate risk of common bile duct stones and to define a simple and safe algorithm for managing choledocholithiasis. TRIAL REGISTRATION: ClinicalTrials.gov NCT03658863; https://clinicaltrials.gov/ct2/show/NCT03658863. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/18837.

Evaluation of Upper Endoscopic and Endoscopic Ultrasound Features in the Differential Diagnosis of Gastrointestinal Stromal Tumors and Leiomyomas in the Upper Gastrointestinal Tract.

BACKGROUND: Differentiation between benign and malignant subepithelial lesions (SELs) in the upper gastrointestinal tract (UGT) leads to far-reaching clinical consequences. An accurate diagnosis can be challenging because of the insufficient diagnostic yield of upper endoscopy, endoscopic ultrasound (EUS), and different types of biopsy. AIM: Our aim was to reveal the efficacy of upper endoscopic and EUS features for the differential diagnosis of hypoechogenic SELs (gastrointestinal stromal tumors [GISTs] and leiomyomas) in the UGT. MATERIALS AND METHODS: The research covers a case series study of 27 hypoechogenic SELs in the UGT between 2012 and 2015 at Vilnius University Hospital Santaros Klinikos. Upper endoscopic and EUS features of SELs were recorded. In order to standardize the diagnostic approach to GISTs and leiomyomas, we assigned scores for seven upper endoscopic and EUS features. RESULTS: The mean total scores in the GIST group were significantly higher than those in the leiomyoma group: 3.25 ± 1.71 and 0.53 ± 0.83 (p < 0.0001), respectively. Increment by one score increased the odds ratio for GIST 5.87 times (95% CI 1.63-21.11; p = 0.007). The total score demonstrated very good discriminatory features of GISTs against leiomyomas (area under the receiver operating characteristic curve 0.94 [0.86-1]). The cutoff value of 1.5 total score indicated 83.3% sensitivity and 93.3% specificity in diagnosing GISTs. CONCLUSIONS: Upper endoscopy and EUS are useful methods in making a definite diagnosis of SELs. Their diagnostic accuracy for the differential diagnosis of GISTs and leiomyomas is sufficient.

Changes in the Velocity of Blood in the Portal Vein in Mild Acute Pancreatitis-A Preliminary Clinical Study.

Background and objective: Portal vein thrombosis is associated with a decrease in the main blood velocity in this vessel. While most studies examine etiological factors of portal vein thrombosis after its occurrence, we aimed to evaluate portal vessels and assess whether mild acute pancreatitis affects blood flow in the portal vein and increases the risk of thrombosis. Materials and methods: This prospective single centered follow-up study enrolled 66 adult participants. Fifty of them were diagnosed with mild acute pancreatitis based on the Revised Atlanta classification, and 16 healthy participants formed the control group. All participants were examined three times. The first examination was carried out at the beginning of the disease and the next two at three-month intervals. Blood samples were taken and color Doppler ultrasound performed the first time, whereas ultrasound alone was performed during the second and third visits. Mean and maximal blood velocities and resistivity index in the main portal vein and its left and right branches were evaluated. Results: Mean velocity of the blood flow in the main portal vein and its right and left branches was not significantly different from healthy individuals during the acute pancreatitis phase: 23.1 ± 8.5 cm/s vs. 24.5 ± 8.2 cm/s (p = 0.827); 16.4 ± 7.9 cm/s vs. 16.4 ± 8.1 cm/s (p = 1.000); and 8 ± 3.4 cm/s vs. 7.4 ± 2.5 cm/s (p = 0.826), respectively. The same was observed when comparing the maximal blood flow velocity: 67.9 ± 29 cm/s vs. 67.5 ± 21 cm/s (p > 0.05); 45.4 ± 27 cm/s vs. 44 ± 23.8 cm/s (p = 0.853); and 22.2 ± 9.8 cm/s vs. 20 ± 7.3 cm/s (p = 0.926), respectively. Changes in venous blood velocities were not significant during the follow-up period in separate study groups. Conclusions: Portal blood flow velocities do not change during mild acute pancreatitis in the inflammatory and postinflammatory periods. This observation suggests that mild acute pancreatitis does not increase the risk of portal vein thrombosis.

Risk assessment of choledocholithiasis prior to laparoscopic cholecystectomy and its management options.

BACKGROUND: Accurate risk evaluation of choledocholithiasis prior to laparoscopic cholecystectomy is essential to determine optimal management strategy. OBJECTIVE: Our study aimed to evaluate the accuracy of separate predictors and Vilnius University Hospital Index (VUHI = A/30 + 0.4 × B; A = total bilirubin concentration (µmol/l), B = common bile duct (CBD) diameter (mm) measured by ultrasound) diagnosing choledocholithiasis and to assess different management strategies (cholecystectomy with intraoperative cholangiography and endoscopic retrograde cholangiopancreatography (ERCP)). METHODS: The retrospective study included 350 patients admitted to a tertiary care centre for laparoscopic cholecystectomy for cholecystolithiasis who were investigated for concomitant choledocholithiasis. RESULTS: Choledocholithiasis was diagnosed in 182 (76.2%) cases in the high-risk group (VUHI value ≥4.7) and 44 (39.6%) in the low, odds ratio is 4.86 (95% CI: 3.00-7.88). Its sensitivity was 80.5%, specificity 54.0%, accuracy 71.1%. Dilated CBD had the highest sensitivity (92.5%) of predictors.ERCP showed better diagnostic performance than intraoperative cholangiography. Complications of ERCP were more frequent for patients without stones. There was no significant difference of outcomes between the two management strategies. CONCLUSION: The prognostic index has good diagnostic accuracy but dividing patients into two risk groups is insufficient. The suggested model allows determining an intermediate-risk group, which requires additional investigation. Both management approaches are appropriate.

Laparoscopically assisted colonoscopic polypectomy - viable option for curative surgery in elderly patients.

INTRODUCTION: Colorectal cancer (CRC) is the third most common cancer worldwide and the fourth most frequent cause of cancer-related death in the world. CRC screening programs have been widely introduced worldwide, allowing for early detection and removal of precancerous lesions and avoiding major surgical intervention. However, not all polyps are suitable for conventional and advanced colonoscopic polypectomy. Thus, laparoscopically assisted colonoscopic polypectomy (LACP) was introduced to clinical practice as a method of choice for these polyps and adenomas. AIM: To overlook our experience in laparoscopically assisted colonoscopic polypectomies and evaluate effectiveness and quality of the procedure. MATERIAL AND METHODS: A retrospective analysis of a prospectively maintained database was performed. using the Vilnius University Hospital Santariskiu Klinikos patient database for the period from 2010 to 2016, resulting in 21 cases in which LACP was performed. All procedures were performed using combined laparoscopy and videocolonoscopy techniques. Morphology of adenomas was classified according to the Paris classification during the procedure. Creation of the database was approved by the Lithuanian Bioethics committee. RESULTS: Twenty-two adenomas were removed from 21 patients, aged 65.33 ±8.9. There was no difference between male and female age, but occurrence of adenomas in females was 2-fold higher. The majority of removed lesions were localized in the cecum and mean size was 27.2 ±11.1 mm. The morphology of adenomas was distributed equally between 0-Is, 0-Ip, and 0-IIa, except one, which belonged to 0-III. Histological analysis revealed that tubulovillous adenoma occurrence was 1.4 times higher than tubulous adenoma. There was only one postoperative complication - bleeding from the adenoma resection site, which was managed by conservative means. One patient developed G2 adenocarcinoma at the polyp resection site and was referred for radical surgery. CONCLUSIONS: The LACP is a safe procedure with minimal risk to the elderly patient. Patient follow-up is essential for detection of recurrence.

Efficacy of deep biopsy for subepithelial lesions in the upper gastrointestinal tract.

INTRODUCTION: Accurate diagnosis of subepithelial lesions (SELs) in the gastrointestinal tract depends on a variety of methods: endoscopy, endoscopic ultrasound and different types of biopsy. Making an error-free diagnosis is vital for the subsequent application of an appropriate treatment. AIM: To evaluate the efficacy of deep biopsy via the endoscopic submucosal dissection (ESD) technique for SELs in the upper gastrointestinal tract. MATERIAL AND METHODS: It was a case series study. Deep biopsy via the ESD technique was completed in 38 patients between November 2012 and October 2014. Thirty-eight SELs in the upper gastrointestinal tract of varying size (very small ≤ 1 cm, small 1-2 cm and large ≥ 2 cm) by means of the ESD technique after an incision with an electrosurgical knife of the overlying layers and revealing a small part of the lesion were biopsied under direct endoscopic view. RESULTS: Deep biopsy via the ESD technique was diagnostic in 28 of 38 patients (73.3%; 95% CI: 59.7-89.7%). The diagnostic yield for SELs with a clear endophytic shape increased to 91.3%. An evident endophytic appearance of a subepithelial lesion, the mean number of biopsied samples (6.65 ±1.36) and the total size in length of all samples per case (19.88 ±8.07 mm) were the main criteria influencing the positiveness of deep biopsy in the diagnostic group compared to the nondiagnostic one (p = 0.001; p = 0.025; p = 0.008). CONCLUSIONS: Deep biopsy via the ESD technique is an effective and safe method for the diagnosis of SELs especially with a clear endophytic appearance in a large number of biopsied samples.

Bowel perforation after endoscopic submucosal dissection due to colon cancer and successful endoscopic treatment using an Ovesco clip.

An 83-year-old woman under intravenous anaesthesia underwent endoscopic submucosal dissection due to early well-differentiated colon cancer with no deep invasion (pT1). Wide perforation in the deep site of excision of the descending colon was identified and an Ovesco clip placed to close the defect. The patient was discharged from the hospital on day 4 after the procedure, with no abdominal pain and no peritoneal signs of inflammation. Follow-up CT and colonoscopy were performed after 6 months, and no recurrence was observed.

Endoscopic ultrasound findings predict the recurrence of esophageal varices after endoscopic band ligation: a prospective cohort study.

OBJECTIVE: Variceal recurrence following endoscopic band ligation (EBL) is common. Esophageal collateral veins (ECV) are observed by endoscopic ultrasound (EUS) in patients with portal hypertension. The aim of the present study was to assess the role of EUS in predicting the recurrence of esophageal varices following EBL. MATERIAL AND METHODS: Forty patients who had undergone EBL for eradication of varices were examined over a 12-month period to detect variceal recurrence. EUS was performed before ligation to detect and describe the type, grade, and the number of ECV. EUS findings obtained prior to EBL were compared in the variceal recurrence and non-recurrence groups. RESULTS: Of the 40 patients, 19 (47.5%) had variceal recurrence within 12 months of EBL. Univariate logistic regression analysis showed that severe peri-ECV (p < 0.001), multiple peri-ECV (p < 0.001), and the presence of perforating veins (p < 0.014) were statistically significantly related to the variceal recurrence after EBL. Multivariate logistic regression model found that only severe peri-ECV (odds ratio [OR] = 24.39; 95% confidence interval [CI]: 2.34-253.78) and multiple peri-ECV (OR = 24.39; 95% CI: 2.34-253.78) remained as independent prognostic factors for variceal recurrence. The sensitivity and specificity of multivariate logistic regression model in predicting variceal recurrence was 89.2% and 90.5%, respectively (prognostic value (AUC) = 0.946). CONCLUSION: Recurrence rate of esophageal varices after EBL is high (47.5%). EUS can clearly depict ECV and has a value in predicting variceal recurrence after EBL; severe peri-ECV and multiple peri-ECV were significant and independent prognostic factors associated with variceal recurrence risk.

Surgical management of gastrointestinal stromal tumors: a single center experience.

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal (GI) tract. Although the therapy targeted at inhibiting tyrosine kinases has shown dramatic results in metastatic and inoperable GISTs, the mainstay of treatment in primary localized forms remains surgical resection. AIM: To provide an overview of our experience of GIST diagnosis and management, with emphasis on comparison of minimally invasive and open surgical resection for primary GISTs. MATERIAL AND METHODS: We retrospectively reviewed the medical records of all patients who underwent surgical removal of GISTs from 2008 to 2012. Patient demographics, clinical data, surgery, complications, histopathological data and clinical course were analyzed. RESULTS: Forty-four patients were identified. Average age at diagnosis was 63 years. Minimally invasive (MIS) and open surgery (OS) were each attempted in 22 (50.0%) patients. Laparoscopic removal was performed in 20, laparoendoscopic in 1, and laparoscopy-assisted endoscopic removal in 1. Conversion to an open procedure was performed in 4 (18.2%). We found significant differences in postoperative length of stay (8.5 days vs. 10.1 days, p < 0.001) and tumor size (2.93 cm vs. 5.78 cm, p = 0.018) between MIS and OS groups, respectively. CONCLUSIONS: Laparoscopic removal is safe and effective for GISTs not exceeding 6 cm. Gastroesophageal junction and cardia GISTs require careful preoperative evaluation and planning to remove safely. We recommend avoiding laparoscopic removal of these tumors due to the high rate of conversion (100.0%) to an open procedure. Laparoendoscopic surgical approach is an appropriate technique for removal of small-sized intraluminal benign GISTs not involving the muscularis propria layer.

The role of collateral veins detected by endosonography in predicting the recurrence of esophageal varices after endoscopic treatment: a systematic review.

Endoscopic therapy is the principal method of treatment for esophageal varices. The recurrence of varices is still common following endoscopic treatment. The aim was to identify predictive factors for variceal recurrence detected by endosonography. We performed a systematic review of studies published prior to June 2013. Studies analyzing gastroesophageal collateral veins as risk factors for variceal recurrence after endoscopic treatment were included. The primary outcome was to identify predictive factors for variceal recurrence investigated by endosonography. After a full-text review, 13 studies were included in our analysis. Analysis of risk factors was not possible for all studies included. Perforating veins and periesophageal collateral veins were related to a higher risk of variceal recurrence (OR = 3.93; 95 % CI 1.06-14.51; I (2) = 96 %; OR = 2.29; 95 % CI 1.58-3.33; I (2) = 55 %). Analysis of cardiac intramural veins and paragastric/cardiac collateral veins showed the same trend, but without reaching statistical significance because of the small group size and wide CI (OR = 3.72; 95 % CI 0.14-101.53; I (2) = 91 %; OR = 1.85; 95 % CI 0.84-4.07; I (2) = 0 %). Analysis of other collateral veins as risk factors for variceal recurrence and analysis of risk factors with regard to the endoscopic treatment method was not possible because of the limited number of cases and different methodologies. A positive association between variceal recurrence and type and grade of collateral veins, investigated by endosonography, was demonstrated. Endosonography is a promising tool for predicting recurrence of esophageal varices following endoscopic treatment. These findings should be interpreted with caution because of the heterogeneity of the studies.

Incidence, risk, management, and outcomes of iatrogenic full-thickness large bowel injury associated with 56,882 colonoscopies in 14 Lithuanian hospitals.

BACKGROUND: The primary goal of this hospital-based retrospective multicenter case series study was to determine the incidence of large bowel full-thickness injury associated with colonoscopy in Lithuania. We assessed characteristics of patients who were treated as a result of this complication; management and outcomes were the secondary goals of this study. METHODS: The medical records of patients with iatrogenic large bowel perforations resulting from colonoscopy within the period January 1, 2007, to December 31, 2011, were retrospectively reviewed. Representatives of 14 Lithuanian public and private hospitals participated in the survey. RESULTS: A total of 56,882 colonoscopies were performed. Forty patients (23 female and 17 male patients) were reported to have iatrogenic full-thickness large bowel injury. Diagnostic and therapeutic colonoscopies resulted in perforation for 28 of 49,795 patients and 12 of 7,087 patients, respectively. A mean age of 70 years and a female preponderance for this complication was revealed. Sigmoid colon and rectosigmoid junction was perforated in 28 patients. All patients underwent surgical management, either primary repair (70.0 %) or bowel resection (30.0 %). Postoperative complications were diagnosed in 15 patients. Immediate treatment resulted in fewer intestinal resections and shorter hospital stays (p < 0.05). Smoking [odds ratio (OR) 14.4, 95 % confidence interval (CI) 1.16-179.8] and a large size perforation site (15 ± 10 vs. 8 ± 5 mm; OR 1.19, 95 % CI 1.03-1.38) were risk factors for developing a postoperative complication after curative surgery. Six patients died. All deaths were related to diagnostic colonoscopy. CONCLUSIONS: Total incidence of large bowel full-thickness injury in Lithuanian hospitals is 0.07 %. Incidence of this complication after diagnostic and therapeutic colonoscopies is 0.056 and 0.169 %, respectively. The most common site of perforation is sigmoid colon and rectosigmoid junction, at 70 %. Risk rises when colonoscopy is performed in low-volume practice centers. Urgent surgical management resulted in overall mortality rate of 15.0 % and morbidity of 37.5 %.

A case report of incisional hernia through a 5 mm lateral port site following laparoscopic cholecystectomy.

INTRODUCTION: Less than 10 mm port-site herniation is a rare complication after laparoscopic surgery. We report a case of complicated herniation through the 5-mm lateral trocar port site. CASE REPORT: A 63-year old obese female was admitted due to intestinal obstruction. She has undergone the laparoscopic cholecystectomy 1 year ago. On examination, abdomen was bloated and roughly 10 cm size mass was palpable on the right subcostal area. Plane radiogram of the abdomen showed signs of intestinal obstruction. Since conservative treatment was ineffective, the patient was operated on. The laparotomy revealed a protrusion of a part of right large intestine and greater omentum into the subcutaneous space through the abdominal wall defect below right subcostal margin. There was a dilatation of intestines proximally incarcerated colon. It was released and a part of omentum was resected. The peritoneum and fascia-muscular defect was closed by interrupted vicryl sutures. CONCLUSION: Acute herniation through a 5 mm size most lateral trocar port site is a rare complication of laparoscopic surgery requiring prompt differential diagnosis.

Delayed gastric emptying and intestinal hormones following pancreatoduodenectomy.

BACKGROUND/AIMS: Delayed gastric emptying (DGE) is frequently reported in patients following pancreatoduodenectomy (PD). The present study tested the hypothesis that gastrointestinal hormones known to effect gastric emptying contribute to DGE in patients after PD. METHODS: Patients with (delayed, n = 9) or without clinical signs of DGE (non-delayed, n = 22) after PD were investigated. Plasma concentrations of motilin, glucagon-like peptide-1 (GLP-1), neurotensin, and peptide YY (PYY) and the gastric emptying rate (GER), assessed by the paracetamol absorption method were measured after a liquid meal on postoperative day 11. RESULTS: Days with a nasogastric tube (p < 0.01), days until solid food was tolerated (p < 0.05), and hospital stay (p < 0.001) were increased in delayed compared to non-delayed patients. The total and incremental integrated peptide responses of motilin and GLP-1 were similar, but the responses of neurotensin and PYY were reduced, in delayed compared to non-delayed patients, whether considered on clinical grounds or by measured GER (p < 0.05-0.005). CONCLUSION: Neurotensin and PYY slow the rate of gastric emptying in humans. Therefore, our findings suggest that reduced hormone responses were the consequence of DGE arising from delayed delivery of nutrients to the distal intestine where the endocrine cells secrete neurotensin and PYY reside.

[Laparoscopic repair of perforated duodenal ulcer: early postoperative results and risk factors]. / Prakiurusiu dvylikapirstes zarnos opu laparoskopines operacijos ir ankstyvieji gydymo rezultatai bei komplikacijas itakojantys veiksniai.

BACKGROUND: Clear patient selection criteria and indications for laparoscopic repair of perforated duodenal ulcers are still of relevance. The purpose of our paper is to describe the early outcome results after this operation and to define the risk factors influencing the genesis of postoperative morbidity. PATIENTS AND METHODS: Fifty-one patients were operated on laparoscopically between October 1996 and October 2003 for perforated peptic ulcers. Out of them, 47 patients with perforated duodenal ulcers entered the final retrospective analysis. Twenty variables were identified, including the duration of acute symptoms before the operation, shock, underlying medical illness, ulcer size, age, Boey score and the predictive value of these variables for morbidity, conversion rates and hospital stay. The univariate data analysis was originally done using the Fisher exact test, t test, Mann Whitney, ANOVA and F tests. The data was reevaluated using multifactorial analysis with logistic and linear regression tests. RESULTS: Patient's age was 32.0+/-12.4 years. Duration of perforation was 8.0+/-10.8 hours. Shock was diagnosed in one patient (2.1%). High surgical risk according to ASA (III-IV) was estimated in 2 patients (4.3%). Laparoscopic duodenography was completed in 36 patients (76.6%). The other 11 patients (23.4%) underwent a conversion to open repair. Seven patients (19.4%) had postoperative complications. Suture leakage was confirmed in 4 patients (11.1%), and other abdominal complications were observed in 3 patients (8.3%). Pneumonia and pneumothorax were diagnosed in 3 patients. Hospital stay was 7.9+/-5.8 (4-45) days. There was no mortality. Ulcer perforation size >4-10 mm is the only significant risk factor influencing the conversion rate. An increase in the suture leakage rate was most significant with delayed presentation of >or=10 hours (p<0.0001). This risk factor influences both the postoperative pneumonia rate (>or=10 hrs., p=0.026) and hospital stay (p<0.05). CONCLUSION: Size of duodenal ulcer perforation and duration of ulcer perforation symptoms were found to be risk factors influencing the rates of conversion to open repair and genesis of postoperative morbidity.

[Laparoscopic colposuspension - effective, minimally invasive method of treatment of female urinary incontinence]. / Laparoskopine kolposuspensija - efektyvus, minimaliai invazinis moteru slapimo nelaikymo gydymo budas.

THE AIM OF WORK: To describe laparoscopic method of treatment of female stress urinary incontinence, indications and contraindications for this operation, to show the first results of this operation in Lithuania, to find out the advantages of this method in comparison with open classical operations. MATERIALS AND METHODS: Ten patients were operated on laparoscopically in the period 1999-2001 due to stress urinary incontinence. The original Burch operation with sutures was performed for two patients, in 8 cases the colposuspension was performed using ligaments (prolene mesh). Transperitoneal colposuspension was performed in 9 cases, extraperitoneal - in one case. Laparoscopic cholecystectomy was performed simultaneously for 3 patients. The average time of hospitalization was 7 days, postoperative stay - 4 days. Catheter in urine bladder was removed after three days, in two cases the remaining urine was observed. RESULTS: Postoperatively in 9 cases the cystocele has disappeared, in one case the recurrence of cystocele was observed. Three months after laparoscopic colposuspension, results as very good were evaluated in 8 cases, good - in one case, satisfactory - in one case (urine continence, imperative urination with minimal urine flow). CONCLUSIONS: Laparoscopic colposuspension - effective method of treatment of stress urinary incontinence, having more advantages in comparison with open operations: shorter time of hospitalization, good postoperative results. The operation is safe, esthetic, with no postoperative hernias. It is an interesting alternative for open operations.