Laparoscopic radical antegrade modular pancreatosplenectomy (RAMPS) for adenocarcinoma of the body and tail of the pancreas - technical considerations with analysis of surgical outcomes.

PURPOSE: The aim of this study was to establish whether laparoscopic RAMPS (L-RAMPS) is a safe procedure with better oncological outcomes compared to laparoscopic distal pancreatectomy (LDP) with splenectomy among patients with distal pancreatic ductal adenocarcinoma (PDAC). METHODS: This is a retrospective study performed on consecutive patients who underwent L-RAMPS and LDP with splenectomy for resectable or borderline resectable PDAC of the body and tail. In this paper, we presented our technique of laparoscopic RAMPS and analyzed intraoperative and perioperative complications, oncological efficacy, and long-term survival. RESULTS: The study included 12 patients in the L-RAMPS group and 13 patients in the LDP with splenectomy. L-RAMPS was associated with significantly higher rates of R0 resection (91.7% vs. 69.2%, p = 0.027). There were no differences between the L-RAMPS and LDP with splenectomy groups in intraoperative blood loss (400 mL vs 400 mL, p = 0.783) and median operative time (250 min vs 220 min, p = 0.785). No differences were found in terms of perioperative complications, including the incidence of pancreatic fistula. CONCLUSION: Laparoscopic RAMPS is a feasible and safe procedure. It provides higher radicality as compared with LDP with splenectomy, without increasing the risk of complications. Further studies are necessary to evaluate long-term outcomes.

Metagenomic Analysis of Duodenal Microbiota Reveals a Potential Biomarker of Dysbiosis in the Course of Obesity and Type 2 Diabetes: A Pilot Study.

Numerous scientific studies confirm that, apart from environmental and genetic factors, a significant role is played by gastrointestinal microbiota in the aetiology of type 2 diabetes and obesity. Currently, scientists mainly focus on the distal intestinal microbiota, while the equally important proximal parts of the intestine are overlooked. The aim of the study was a qualitative analysis of the structure of the duodenal mucosa microbiota in groups of patients with obesity and with type 2 diabetes and where obesity qualified for bariatric surgery: sleeve gastrectomy. The microbiological results obtained were compared with some clinical parameters. As a result, it was possible to determine the microbiological core that the treatment and control groups had in common, including phyla: Firmicutes, Proteobacteria, and Actinobacteria. The patients with obesity and with type 2 diabetes and obesity presented a significantly lower number of genus Bifidobacterium compared to healthy subjects. Furthermore, the numbers of Bifidobacterium were positively correlated with the high density lipoprotein (HDL) concentration in the groups under study. The obtained results indicate that bacteria of the genus Bifidobacterium should be considered in the future in the context of a potential biomarker in the progress of type 2 diabetes and obesity.

Laparoscopic treatment of large gastrointestinal stromal tumors (> 5 cm).

INTRODUCTION: Although laparoscopic techniques are currently a recognized type of treatment of small stromal tumors (GISTs) of the stomach, their application in the case of larger tumors has been the subject of debate. AIM: To evaluate the technical feasibility, safety and early results of the laparoscopic treatment of large GISTs with a diameter of more than 5 cm. MATERIAL AND METHODS: A retrospective analysis was performed using data on patients who underwent laparoscopic surgery for gastric GIST in the period from 2009 to 2016. The patients selected for the study were divided into two groups based on the diameter of the tumor: patients who developed a tumor with a diameter smaller than or equal to 5 cm (group 1), and those whose tumors exceeded 5 cm in diameter (group 2). The following factors were established and compared for the two groups: duration of surgery, amount of intra-operative blood loss, length of hospital stay, and the number and nature of post-operative complications. RESULTS: No deaths occurred in the 30-day post-operative period, and no statistically significant differences regarding complications in the post-operative period were observed. In group 2, statistically significantly more pronounced blood loss and longer hospital length of stay were observed. No difference in the duration of surgery between the investigated groups was observed. CONCLUSIONS: It appears that the surgical treatment of GISTs with a diameter of more than 5 cm by means of minimally invasive procedures is a viable and safe alternative.

Gastric gastrointestinal stromal tumors: clinical features and short- and long-term outcomes of laparoscopic resection.

INTRODUCTION: Although minimally invasive techniques are currently recognized as effective and validated treatment for small gastric gastrointestinal stromal tumors (GISTs), the role of laparoscopy is not yet established, especially in the institutions that have less experience in minimally invasive surgery. AIM: To evaluate the outcomes of laparoscopic treatment of gastric gastrointestinal stromal tumors compared to the results obtained in a group of patients treated with conventional surgery. MATERIAL AND METHODS: A retrospective analysis of data collected for a group of 68 patients treated for gastric GIST in the period from 2002 to 2017 was performed. Forty-six patients were treated laparoscopically (group 1) and 22 patients underwent conventional surgery (group 2). The analyzed medical data included clinical and pathomorphological features of removed tumors, perioperative parameters as well as short and long-term results of surgical treatment. RESULTS: Histopathological examination confirmed radical resection for all patients. No deaths were reported in the 30-day post-operative period. Patients in group 1 had significantly shorter length of hospital stay (3 vs. 9 days), less intra-operative blood loss (25 vs. 175 ml) and fewer perioperative complications (13% vs. 41%) compared to group 2. The mean post-operative follow-up was 57 months. During this period, four patients died for reasons unrelated to the primary disease. None of the patients who underwent a laparoscopic procedure had a recurrence of the tumor in the follow-up period. CONCLUSIONS: Laparoscopy in the treatment of gastric GISTs has unquestionable advantages, including decreased blood loss, reduced risk of complications, and shorter hospital stay.

Laparoscopic gastric resections with per oral specimen extraction in treatment of intramural gastric tumors.

AIM: The goal of this work was to present our experiences and results of treatment of gastric tumors using the per oral specimen extraction (POSE) technique. MATERIAL AND METHODS: A retrospective analysis a group of patients treated with laparoscopic stomach wedge resection of gastrointestinal stromal tumor (GIST). During that time 50 patients underwent laparoscopy due to the suspicion of GIST. In 12 patients resected material was removed endoscopically per os (POSE). In the remaining 38 subjects it was evacuated through minilaparotomy. Mean age of patients treated using POSE technique was 65.6 years (48-81 years). There were 9 women and 3 men in this group Results: Mean time of the POSE procedure was 92.5 min (40-160 min). Size of removed tumors ranged from 14 mm to 40 mm (mean: 25 mm). The mean length of hospital stay was 3.2 days (2 to 8 days) for patients treated with POSE. One patient (8.3%) required longer hospitalization (8 days) due to the presence of a fluid collection at the site of gastric suture. This patient was treated conservatively. One patient (8.3%) was diagnosed with surgical site infection (navel wound after an optical trocar). Histopathological examination confirmed radical excision in all of our patients (R0). CONCLUSIONS: It seems that the POSE technique is the next stage of development of minimally invasive surgery and may constitute a link in evolution of natural orifice translumenal surgery techniques. Removal of excised material through oral cavity is an attractive, effective, and safe method despite its many limitations.

Impact of bariatric surgery on non-alcoholic fatty liver disease.

Introduction; p to 300 million people have the body mass index (BMI) greater than 30 kg/m2. Obesity is the cause of many serious diseases, such as type 2 diabetes, hypertension, and non-alcoholic fatty liver disease (NAFLD). Bariatric surgery is the only effective method of achieving weight loss in patients with morbid obesity. OBJECTIVES: The aim of the study was to assess the impact of bariatric surgery on non-alcoholic fatty liver disease in patients operated on due to morbid obesity. MATERIAL AND METHODS: We included 20 patients who were qualified for bariatric procedures based on BMI > 40 kg/ m2 or BMI > 35kg/m2 with the presence of comorbidities. The average body weight in the group was 143.85kg, with an average BMI of 49.16kg/m2. Before the procedure, we evaluated the severity of non-alcoholic fatty liver disease in each patient using the Sheriff-Saadeh ultrasound scale. We also evaluated the levels of liver enzymes. Follow-up evaluation was performed twelve months after surgery. RESULTS: Twelve months after surgery, the average weight was 102.34 kg. The mean %WL was 33.01%, %EWL was 58.8%, and %EBMIL was 61.37%. All patients showed remission of fatty liver disease. Liver damage, evaluated with ultrasound imaging, decreased from an average of 1.85 on the Sheriff-Saadeh scale, before surgery, to 0.15 twelve months after surgery (p < 0.001). As regards liver enzymes, the level of alanine aminotransferase decreased from 64.5 (U/l) to 27.95 (U/l) (p < 0.001), and the level of aspartate aminotransferase decreased from 54.4 (U/l) to 27.2 (U/l). CONCLUSIONS: Bariatric procedures not only lead to a significant and lasting weight loss, but they also contribute to the reduction of fatty liver disease and improve liver function.

Early results of liver resection using laparoscopic technique.

UNLABELLED: The aim of the study was to present early outcomes of liver resection using laparoscopic technique. MATERIAL AND METHODS: Retrospective analysis of patients who underwent liver resection using laparoscopic method was conducted. The analyzed group included 23 patients (11 women and 12 men). An average patient age was 61.3 years (37 - 83 years). Metastases of the colorectal cancer to the liver were the cause for qualification to the procedure of 15 patients, metastasis of breast cancer in 1 patient and primary liver malignancy in 5 patients. The other 2 patients were qualified to the liver resection to widen the surgical margins due to gall-bladder cancer diagnosed in the pathological assessment of the specimen resected during laparoscopic cholecystectomy, initially performed for other than oncology indications. RESULTS: Hemihepatectomy was performed in 11 patients (9 right and 2 left), while the other 12 patients underwent minor resection procedures (5 metastasectomies, 4 nonanatomical liver resections, 1 bisegmentectomy, 2 resections of the gall-bladder fossa). An average duration of the surgical procedure was 275 minutes 65 - 600). An average size of the resected tumors was 28 mm (7 - 55 mm). In three cases conversion to laparotomy occurred, caused by excessive bleeding from the liver parenchyma. Postoperative complications were found in 4 patients (17.4%). Median hospitalization duration was 6 days (2 - 130 days). One patient (4.3%) was rehospitalized due to subhepatic abscess and required reoperation. Histopathology assessment confirmed radical resection (R0) in all patients in our group. CONCLUSION: Laparoscopic liver resections seem to be an interesting alternative in the treatment of focal lesions in the liver.

Cost minimization analysis of laparoscopic surgery for colorectal cancer within the enhanced recovery after surgery (ERAS) protocol: a single-centre, case-matched study.

INTRODUCTION: The goal of modern medical treatment is to provide high quality medical care in a cost-effective environment. AIM: To assess the cost-effectiveness of laparoscopic colorectal surgery combined with the enhanced recovery after surgery protocol (ERP) in Poland. MATERIAL AND METHODS: We designed a single-centre, case-matched study. Economic and clinical data were collected in 3 groups of patients (33 patients in each group): group 1 - patients undergoing laparoscopy with ERP; group 2 - laparoscopy without ERP; group 3 - open resection without ERP. An independent administrative officer, not involved in the treatment process, matched patients for age, sex and type of resection. Primary outcome was cost analysis. It was carried out incorporating institutional costs: hospital bed stay, anaesthesia, surgical procedure and equipment, drugs and complications. Secondary outcomes were length of stay (LOS), readmission and complication rate. RESULTS: Cost of laparoscopic procedure alone was significantly more expensive than open resection. However, implementation of the ERAS protocol reduced additional costs. Total cost per patient in group 1 was significantly lower than in groups 2 and 3 (EUR 1826 vs. EUR 2355.3 vs. EUR 2459.5, p < 0.0001). Median LOS was 3, 6 and 9 days in groups 1, 2 and 3 respectively (p < 0.001). Postoperative complications were noted in 5 (15.2%), 6 (18.2%) and 13 (39.4%) patients in groups 1, 2, 3 respectively (p = 0.0435). CONCLUSIONS: In a low medical care expenditure country, minimally invasive surgery combined with ERP can be a safe and a cost-effective alternative to open surgery with traditional perioperative care.

A Periampullary Duodenal Diverticula in Patient with Choledocholithiasis - Single Endoscopic Center Experience.

The reported prevalence of periampullary duodenal diverticula varies between 9 and 32.8%. The aim of the study was to evaluate the prevalence of periampullary diverticula in the studied population and establish whether their presence influence the risk of choledocholithiasis and the risk of Endoscopic Retrograde Cholangio Pancreatography (ERCP) related complications. MATERIAL AND METHODS: The study group of 3788 patients who underwent ERCP between 1996 and 2016 at the 2nd Department of General Surgery Jagiellonian University Medical College in Kraków were analyzed. The group comprised of 2464 women (mean age 61.7 years) and 1324 men (mean age 61.8 years). The patients were divided into two groups. Group A included patients in whom there were no periampullary diverticula detected. Group B included patients in whom the opening of the bile duct was in the vicinity of a duodenal diverticulum. RESULTS: There were 3332 patients included in group A (2154 women and 1178 men) and 456 patients in group B (310 women and 146 men). The prevalence of periampullary duodenal diverticula in the analyzed group was 12.8%. The presence of stones or biliary sludge was diagnosed in 1542 patients (47.6%) in group A and 290 patients (68.1%) in group B. Recurrence of choledocholithiasis occurred in 4.5% of patients (70/1542) in group A and 10.3% of patients (30/290) in group B. Complications occurred in a total of 76 patients in group A (2.3%) and 22 patients in group B (4.8%). CONCLUSIONS: The presence of choledocholithiasis and the risk of ERCP related complications are significantly higher in the group with duodenal diverticula.

Changing patterns in the surgical treatment of perforated duodenal ulcer - single centre experience.

INTRODUCTION: Although the surgical treatment of patients with perforated duodenal ulcer is the method of choice, the introduction of effective pharmacotherapy has changed the surgical strategy. Nowadays less extensive procedures are chosen more frequently. The introduction of laparoscopic procedures had a significant impact on treatment results. AIM: To present our experience in the treatment of perforated duodenal ulcer in two periods, by comparing open radical anti-ulcer procedures with laparoscopic ulcer repair. MATERIAL AND METHODS: The analysis covered patients operated on for perforated duodenal ulcer. Two groups of patients were compared. Group 1 included 245 patients operated on in the period 1980-1994 with a traditional method (pyloroplasty + vagotomy) before introduction of proton pump inhibitors (PPI). Group 2 included 106 patients treated in the period 2000-2014 with the laparoscopic technique supplemented with PPI therapy. Groups were compared in terms of patients' demographic structure, operative time, complication rate and mortality. RESULTS: The mean operative time in group 1 was shorter than in group 2 (p < 0.0001). Complications were noted in 57 (23.3%) patients in group 1 and 14 (13.5%) patients in group 2 (p = 0.0312). Reoperation was necessary in 13 (5.3%) cases in group 1 and in 5 cases in group 2 (p = 0.8179). The mortality rate in group 1 was significantly higher than in group 2 (10.2% vs. 2.8%, p = 0.0192). In group 1, median length of hospital stay was 9 days and differed significantly from group 2 (6 days, p < 0.0001). CONCLUSIONS: Within the last 30 years, significant changes in treatment of perforated peptic ulcer (PPU) have occurred, mainly related to abandoning routine radical anti-ulcer procedures and replacing the open technique with minimally invasive surgery. Thus it was possible to improve treatment results by reducing complication and mortality rates, and shortening the length of hospital stay. Although the laparoscopic operation is longer, it improves outcomes. In the authors' opinion, in each patient with suspected peptic ulcer perforation, laparoscopy should be the method of choice.

Laparoscopic removal of gastrointestinal stromal tumors of uncinate process of pancreas.

The pancreas is an extremely rare location for gastrointestinal stromal tumors (GIST). We present a case of a patient with a GIST located in the uncinate process of the pancreas that was treated successfully with a laparoscopic technique. Computed tomography, magnetic resonance imaging and scintigraphy suggested a neuroendocrine tumor. Due to the fact that the image suggested a neuroendocrine tumor with a diameter below 2 cm, the patient was qualified for a laparoscopic procedure of tumor enucleation. Postoperative care proceeded in accordance with the principles of the ERAS concept. The postoperative course was uncomplicated. He was discharged home on the second postoperative day. In the obtained histopathology result a GIST was found. During a 6-month observation, including control computed tomography examination, no signs of tumor progression were found. Despite the fact that stromal tumors of the gastrointestinal tract localized in the pancreas are very rare, they should be considered in the differential diagnosis of tumors of this organ.

Early implementation of Enhanced Recovery After Surgery (ERAS®) protocol - Compliance improves outcomes: A prospective cohort study.

Enhanced Recovery After Surgery protocol in colorectal surgery allows shortening length of hospital stay and reducing complication rate. Despite the clear guidelines and conclusive evidence their full implementation and putting them into daily practice meets certain difficulties, especially in the early stage. The aim of the study was to analyse the course of implementation of the ERAS protocol into daily practice on the basis of adherence to the protocol. Group included 92 patients (43F/49M) with colorectal cancer submitted to laparoscopic resection during the years 2013-2014. Perioperative care in all of them based on ERAS protocol consisting of 16 items. Its principles and discharge criteria were based on the guidelines of the ERAS Society guidelines. The entire analysed group of patients was divided into 3 subgroups (30 patients) depending on the time from ERAS protocol implementation. We analysed the compliance with the protocol and its influence on length of hospital stay, postoperative complications and readmission rate in different subgroups. The average compliance with the protocol differed significantly between groups and was 65% in group 1, 83.9% in group 2 and 89.6% in group 3. The compliance with subsequent protocol elements was different. The length of stay and complication rate was statistically different in analysed subgroups. The whole group demonstrated an inverse correlation between compliance and length of stay. This analysis leads to the conclusion that the introduction of the ERAS protocol is a gradual process, and its compliance at the level of 80% or more requires at least 30 patients and the period of about 6 months. The initial derogation from the assumed proceedings is inevitable and should not discourage further action. Particular emphasis in the initial stage should be put on continuous training of personnel of all specialties and continuous evaluation of the results.

Quality of Life After Bariatric Surgery.

INTRODUCTION AND PURPOSE: Morbid obesity together with obesity-related diseases has a negative impact on the quality of life. The aim of the study was to assess the quality of life amongst patients with morbid obesity as well as the impact of bariatric treatment on body weight and obesity-related diseases in addition to conducting an analysis of changes in the quality of life after surgical treatments, in the context of the surgical procedure type and degree of body weight loss. MATERIAL AND METHODS: Sixty-five patients were treated for morbid obesity. The sample group consisted of 34 patients treated with laparoscopic sleeve gastrectomy (LSG) and 31 persons qualified for laparoscopic Roux-en-Y gastric bypass (LRYGB). The average body weight before the procedure was 146.2 kg. In the sample group, 89 % of persons qualified for the surgical treatments were diagnosed with hypertension and 52 % persons that were operated on were diagnosed with diabetes type 2 before the surgical procedure. Before commencement of the surgical treatment, the quality of life was assessed, which in both groups qualified for given types of bariatric procedures was considerably low. RESULTS AND CONCLUSIONS: Percentage excessive weight loss (%EWL) was 58.8 %. No significant differences in body weight loss were noted between the two types of procedures. Improvement was observed in the treatment of obesity-related diseases. Also, the quality of life was enhanced significantly. No differences were noted in terms of the quality of life improvement between particular types of surgical procedures. No significant differences were observed during the analysis of body weight loss impact on the quality of life improvement.