Diffusion-Weighted Magnetic Resonance Imaging of 103 Patients with Rectal Adenocarcinoma Identifies the Apparent Diffusion Coefficient as an Imaging Marker for Tumor Invasion and Regional Lymph Node Involvement.

BACKGROUND This retrospective study included 103 patients diagnosed with rectal adenocarcinoma at a single center in Poland who underwent preoperative diffusion-weighted magnetic resonance imaging (DWI) and aimed to determine whether the apparent diffusion coefficient (ADC) was an imaging marker for tumor invasion and regional lymph node involvement. MATERIAL AND METHODS We analyzed primary staging magnetic resonance examinations of the rectum of 103 consecutive patients with histologically proven non-mucinous adenocarcinoma who underwent surgical treatment. In 85 patients, surgery was preceded by long-course chemoradiotherapy (n=18) or short-course radiotherapy (n=67). The following DWI parameters were measured: ADC mean, minimum, maximum, and standard deviation in the region of interest (ADC SD-in-ROI). Values were compared between subgroups based on histological parameters from the report: tumor stage, lymph node stage, differentiation grade, the presence of extranodal tumor deposits, angioinvasion, and perineural invasion. Statistical analysis was performed using the Mann-Whitney U test and the unilateral t test. RESULTS ADC mean values were lower for cases in which postoperative histopathological examination lymph node invasion (P=0.04) and tumor deposits were found (P=0.04). Minimal ADC value was higher in cases in which tumor deposits were not found (P=0.009). ADC SD-in-ROI values were lower in cases in which lymph nodes invasion was confirmed (P=0.014). There were no statistically significant differences for other parameters. CONCLUSIONS The ADC values in pre-treatment DWI in patients with rectal adenocarcinoma were correlated with tumor invasion and regional lymph node metastases. Therefore, ADC values from the pre-treatment MRI may help plan adjuvant therapy in patients with rectal adenocarcinoma.

The significance of comorbidity burden among older patients undergoing abdominal emergency or elective surgery.

BACKGROUND: Comorbidities may cause complications in perioperative care and affect treatment outcomes of older patients. The study aim was to analyse comorbidity burdens with respect to their predictive power in outcome prediction in elderly qualified for abdominal elective or emergency surgery. METHODS: Consecutive patients undergoing major abdominal surgery between 2010 and 2017 at a secondary referral hospital were included in the retrospective study, for a total of 1586 patients. To explain the relationship between the comorbidity types and 30-day mortality and morbidity logistic regression analysis was performed. Morbidity was assessed using the Clavien-Dindo Score. Major complications were defined as a C-D score ≥ 3. We also presented the data concerning need for reoperation and ICU admission. RESULTS: 85.9% of patients had at least one comorbidity. In the group of emergency patients age and number of comorbidities were independent risk factors of 30-day mortality and major morbidity. In elective patients age, dementia (OR:3.52; 95%CI:1.35-9.20) and kidney disease (OR:1.64; 95%CI:1.04-2.57) were found to be independent risk factors of 30-day postoperative mortality. Age (1.04; 95%CI:1.00-1.08) and heart disease (OR:1.30, 95%CI:1.04-1.63) were found to be independent risk factors of 30-day major morbidity. CONCLUSIONS: In patients undergoing elective surgery 30-day mortality and morbidity was associated with age. 30-day mortality, but not morbidity was associated with kidney disease and dementia. 30-day morbidity, but not mortality, was associated with heart disease.

Usefulness of scoring systems in outcome prediction for older cancer patients undergoing abdominal surgery.

BACKGROUND: Several postoperative outcome scoring systems have been developed and validated, combining both pre- and intraoperative factors. Among others are the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM), the Estimation of Physiologic Ability and Stress (E-PASS) and the Surgical Apgar Score combined with the American Society of Anesthesiologists physical status classification (SASA). The aim of this study was to compare the above scoring systems in the prediction of 30-day postoperative outcome in older patients with cancer undergoing abdominal surgery. METHODS: Consecutive patients ≥70 years were prospectively enrolled. Pre- and intraoperative variables were used to calculate the scores, the ROC and perform logistic regression analysis. RESULTS: The study sample comprised 201 patients with a median age of 77 (range 70-93) years. The most common surgical procedure was for colorectal (75%), followed by gastric (10.4%) pancreas (7.0%), gall bladder (3.5%), small bowel (2.5%), and other (1.5%) types of cancer. All scores were independent predictors of 30-day postoperative mortality. In case of 30-day morbidity only SASA turned to be significant. The ROC curves were highly valid and area under the curve showed fair to good discriminatory ability (0.60-0.77) for 30-day postoperative mortality and fair (AUC 0.6) in case of SASA for the 30-day postoperative. CONCLUSION: The SASA, E-PASS, and P-POSSUM were confirmed to be predictive of 30-day postoperative mortality in older patients undergoing abdominal elective cancer surgery. Only SASA demonstrated as independent factor predicting postoperative 30-day major morbidity.

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.

Treatment outcomes of pancreatic cancer in the elderly - literature review.

BACKGROUND: The older population is very heterogeneous with regard to the co-morbidityand the physical reserve. This can result in unacceptably high postoperative complications rates. Therefore, the aim of the study was to review the literature regarding the outcomes of older patients treated for pancreatic cancer, including the usage of minimal invasive techniques. METHODOLOGY: A review of the literature was carried out including studies on pancreatic cancer in older patients published between 2011 and 2016. RESULTS: Seventeen retrospective studies were included. The total number of patients was 9981 with the age range of 65 years and more. Studies on surgical treatment alone (1.4%), neoadjuvant/adjuvant treatment with or without surgery (89.4%) and palliative therapy (9.2%) were assessed separately. Appropriate comparison was diffcult due to the retrospective character and heterogeneity of the study population. Mortality was low, yet there was a great difference in morbidity ranging from some percent to even 100% of the study population. Long-term results were poor. CONCLUSIONS: The functional status, not the chronological age alone, is the factor limiting therapeutic options in older patients with pancreatic cancer.

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.

Idiopathic rectal necrosis in 72-year-old women: report of a case and a literature review.

Rectal necrosis is a rare pathology, with little reports published in the literature. There are nonspecific symptoms, but clinical course may be dramatic, with necessity of urgent surgery and intensive care. A 72-year-old female was admitted to hospital with complaints of bloody stool and dull abdominal pain. Symptoms started one week before and aggravated progressively. Physical examination revealed abdominal tenderness and flatulence, with no signs characteristic for peritonitis. Digital rectal examination demonstrated ulceration on the anterior rectal wall. Laboratory tests showed anemia, hypokalemia and elevated inflammatory parameters, whereas stool cultures revealed presence of Salmonella. During endoscopy, large rectal narrowing has been demonstrated. Because of this lesion and deteriorated clinical state, patient was qualified to urgent surgery. Necrotizing changed rectum has been observed intraoperatively. Additionally, extensive ischemia of the colon was present. Surgeons decided to perform proctocolectomy with end ileostomy. Although rectal necrosis occurs greatly seldom, it can be associated with life-threatening clinical course. Symptoms of this entity are untypical and it is easy to misdiagnose patient with necrosis of the rectum. Treatment of necrotic rectal injury is predominantly surgical and consists in segmental bowel resection.

[Bilateral neck exploration with intraoperative iPTH assay in patients not eligible for minimally invasive parathyroidectomy]. / Obustronna eksploracja szyi ze sródoperacyjnym monitoringiem stezenia parathormonu u chorych niekwalifikujacych sie do maloinwazyjnej paratyreoidektomii.

BACKGROUND AND AIMS: Bilateral neck exploration (BNE) is the preferred surgical technique in patients with primary hyperparathyroidism (pHPT) not eligible for minimally invasive parathyroidectomy (MIP). The aim of this study was to assess indications for BNE in the era of MIP, including short-term outcomes of surgery with intraoperative intact parathyroid hormone (iPTH) monitoring added-value. METHODS: Data of 155 patients with pHPT qualified for BNE with intraoperative iPTH monitoring and treated in 2003-2012 were retrospectively analysed. All patients underwent biochemical and imaging testing in the preoperative work-up. The following endpoints were analysed in this study: indications for BNE, short-term outcomes of surgery, and intraoperative iPTH monitoring added-value. RESULTS: Indications for BNE were: negative preoperative imaging in 65 (41.9%) patients, concomitant goitre necessitating surgical removal in 51 (32.9%) patients, MEN 1 syndrome in 17 (11.0%) patients, lithium treatment in 12 (7.7%) patients, lacking consent for MIP in 5 (3.2%) patients, and MEN 2A syndrome in 5 (3.2%) patients. The extent of parathyroidectomy was a solitary parathyroid adenoma removal in 97 (62,6%) patients, subtotal parathyroidectomy in 41 (26.4%) patients, and double-parathyroid adenoma removal in 17 (11,0%) patients. Use of intraoperative iPTH monitoring influenced on the extent of parathyroid tissue resection in 16(10.3%) patients. Normalised total serum calcium values were observed in 154 (99.4%) patients during a 6-month follow-up. CONCLUSIONS: BNE in patients with pHPT is the preferred surgical technique in the following circumstances: a suspicion of multiglandular parathyroid disease (MEN 1 or 2A syndrome, familial hyperparathyroidism, lithium therapy), a negative preoperative imaging, in patients not consenting for MIP, and in cases with concomitant goitre necessitating surgical treatment. Use of intraoperative iPTH monitoring influences on the extent of parathyroid tissue resection in one often patients, hence assuring the highest quality of surgical treatment.

[Evaluation of different intraoperative iPTH assay criteria in monitoring of minimally invasive parathyroidectomy for primary hyperparathyroidism]. / Ocena trafnosci róznych kryteriów prognostycznych sródoperacyjnego monitoringu stezenia parathormonu w maloinwazyjnej chirurgii pierwotnej nadczynnosci przytarczyc.

INTRODUCTION: Intraoperative iPTH assay (IOPTH) is often used during minimally invasive parathyroidectomy (MIP) to predict operative success. The aim of this study was to evaluate diagnostic accuracy of IOPTH during MIP with respect to few prognostic criteria most commonly used. METHODS: A retrospective study of 455 patients with sporadic primary hyperparathyroidism undergoing MIP with IOPTH at our institution between 2003 and 2012 was undertaken. Diagnostic accuracy of few prognostic criteria most commonly used was done including Halle, Miami, Rome and Vienna criteria. Results of IOPTH were compared to outcomes of MIP in 6-months follow-up after surgery (serum calcium and iPTH levels). Both ROC (Receiver Operating Characteristics) curve and error matrix analysis were used for accuracy assessment of IOPTH prognostic criteria. Based on this method the following accuracy parameters were calculated for each IOPTH criterion separately: sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and overall accuracy. RESULTS: The following diagnostic accuracy parameters of IOPTH were found for each of the tested criteria (sensitivity, specificity, PPV, NPV, accuracy), respectively: for Halle criterion 63.2%, 100.0%, 100.0%, 12.6%, 65.1%; for Miami criterion 97.7%, 96.4%, 99.8%, 73.0%, 97.6%; for Rome criterion 84.4%, 100.0%, 100.0%, 27.2%, 85.3%; for Vienna criterion 93.7%, 92.3%, 99.5%, 47.1%, 93.6%. CONCLUSIONS: Miami criterion of IOPTH is the most accurate in prognostication of postoperative serum calcium levels after MIP. Use of other criteria may involve a higher risk of false negative results and unnecessary conversion to more extensive neck dissection in search for non-existent hyperfunctioning parathyroid tissue.

Comorbidity assessment methods and their significance in predicting the results of treatment of older patients undergoing elective abdominal surgeries for cancer - A scoping review.

INTRODUCTION: The scoping review was performed to identify methods of comorbidity assessment and to evaluate their significance in predicting the results of treatment of older patients undergoing elective abdominal surgeries for cancer. MATERIALS AND METHODS: Ovid MEDLINE, Embase, CENTRAL, Web of Science, ClinicalTrials.gov and European Trials Register were searched for eligible studies investigating the impact of comorbidity on various postoperative outcomes of patients aged ≥65. Findings were narratively reported. RESULTS: The review identified 40 studies with a total population of 59,612 patients, using eight different methods of comorbidity assessment. The most used was Charlson Comorbidity Index (60 % of studies) and presence of specific comorbid conditions (38 %). No study provided rationale for the choice of specific comorbidity measure. Most of the included studies reported short-term results (75 %), such as postoperative complications (43 %) and mortality (18 %) as main clinical endpoint. The results were inconsistent across the studies. DISCUSSION: There is still no consensus regarding the choice of comorbidity measures and their role in postoperative outcome prediction. Further efforts are needed to develop new, well-designed, more effective comorbidity assessments tools.

[Staging of thyroid cancer--comparison of cases diagnosed preoperatively versus incidentally after surgery for benign goiter]. / Porównanie stopnia zaawansowania raka tarczycy rozpoznanego przedoperacyjnie i przypadkowo po operacji wola nienowotworowego.

INTRODUCTION: The aim of this study was to compare staging of incidentally diagnosed thyroid cancer (TC) to staging of preoperatively suspected TC. METHODS: This was a retrospective study of 224 patients who underwent surgery for primary TC between 2009 and 2011. Clinical and pathological data included in the TNM and AJCC staging system (7th edition, 2010) were analysed. Staging of incidentally diagnosed TC was compared to staging of preoperatively suspected TC. RESULTS: Suspicion of TC was made before surgery in 57.6% patients, and in 42.4% patients TC was diagnosed postoperatively. Papillary TC was predominant and followed by follicular TC, which were suspected in 88.4% and 4.7% of patients before surgery, and were diagnosed in 77.9% and 16.8% of patients postoperatively (p=0.035 and p<0.001, respectively). Preoperatively diagnosed TC was predominant in patients below 45 years of age (64.3% vs. 25.3%; p<0.001), was at lower stage at the diagnosis (according to AJCC in stage I : 42.6% vs. 67.4%; p<0.001; in stage II: 6.2% vs. 12.6%; p=0.095; in stage III: 38.0% vs. 16.8%; p<0.001; in stage IV: 13.2% vs. 3.2%; p=0.009, respectively), and it was more common multicentric (29.5% vs. 9.5%; p<0.001) than incidental TC. CONCLUSIONS: Approximately 40% of cases of TC is diagnosed incidentally based on postoperative pathology report. Incidental TC is predominant below age 45 years, is revealed with early-stage more common than TC diagnosed preoperatively, and occurs multicentric less frequently.

Predicting Functional Recovery and Quality of Life in Older Patients Undergoing Colorectal Cancer Surgery: Real-World Data From the International GOSAFE Study.

PURPOSE: The GOSAFE study evaluates risk factors for failing to achieve good quality of life (QoL) and functional recovery (FR) in older patients undergoing surgery for colon and rectal cancer. METHODS: Patients age 70 years and older undergoing major elective colorectal surgery were prospectively enrolled. Frailty assessment was performed and outcomes, including QoL (EQ-5D-3L) recorded (3/6 months postoperatively). Postoperative FR was defined as a combination of Activity of Daily Living ≥5 + Timed Up & Go test <20 seconds + MiniCog >2. RESULTS: Prospective complete data were available for 625/646 consecutive patients (96.9%; 435 colon and 190 rectal cancer), 52.6% men, and median age was 79.0 years (IQR, 74.6-82.9 years). Surgery was minimally invasive in 73% of patients (321/435 colon; 135/190 rectum). At 3-6 months, 68.9%-70.3% patients experienced equal/better QoL (72.8%-72.9% colon, 60.1%-63.9% rectal cancer). At logistic regression analysis, preoperative Flemish Triage Risk Screening Tool ≥2 (3-month odds ratio [OR], 1.68; 95% CI, 1.04 to 2.73; P = .034, 6-month OR, 1.71; 95% CI, 1.06 to 2.75; P = .027) and postoperative complications (3-month OR, 2.03; 95% CI, 1.20 to 3.42; P = .008, 6-month OR, 2.56; 95% CI, 1.15 to 5.68; P = .02) are associated with decreased QoL after colectomy. Eastern Collaborative Oncology Group performance status (ECOG PS) ≥2 is a strong predictor of postoperative QoL decline in the rectal cancer subgroup (OR, 3.81; 95% CI, 1.45 to 9.92; P = .006). FR was reported by 254/323 (78.6%) patients with colon and 94/133 (70.6%) with rectal cancer. Charlson Age Comorbidity Index ≥7 (OR, 2.59; 95% CI, 1.26 to 5.32; P = .009), ECOG ≥2 (OR, 3.12; 95% CI, 1.36 to 7.20; P = .007 colon; OR, 4.61; 95% CI, 1.45 to 14.63; P = .009 rectal surgery), severe complications (OR, 17.33; 95% CI, 7.30 to 40.8; P < .001), fTRST ≥2 (OR, 2.71; 95% CI, 1.40 to 5.25; P = .003), and palliative surgery (OR, 4.11; 95% CI, 1.29 to 13.07; P = .017) are risk factors for not achieving FR. CONCLUSION: The majority of older patients experience good QoL and stay independent after colorectal cancer surgery. Predictors for failing to achieve these essential outcomes are now defined to guide patients' and families' preoperative counseling.

Doppler-guided hemorrhoid artery ligation with Recto-Anal-Repair modification: functional evaluation and safety assessment of a new minimally invasive method of treatment of advanced hemorrhoidal disease.

PURPOSE: We present 12-month followup results of functional evaluation and safety assessment of a modification of hemorrhoidal artery ligation (DGHAL) called Recto-Anal-Repair (RAR) in treatment of advanced hemorrhoidal disease (HD). METHODS: Patients with grade III and IV HD underwent the RAR procedure (DGHAL combined with restoration of prolapsed hemorrhoids to their anatomical position with longitudinal sutures). Each patient had rectal examination, anorectal manometry, and QoL questionnaire performed before 3 months, and 12 months after RAR procedure. RESULTS: 20 patients completed 12-month followup. There were no major complications. 3 months after RAR, 5 cases of residual mucosal prolapse were detected (25%), while only 3 patients (15%) reported persistence of symptoms. 12 months after RAR, another 3 HD recurrences were detected, to a total of 8 patients (40%) with HD recurrence. Anal pressures after RAR were significantly lower than before (P < 0.05), and the effect was persistent 12 months after RAR. One patient (5%) reported occasional soiling 3 months after RAR. CONCLUSIONS: RAR seems to be a safe method of treatment of advanced HD with no major complications. The procedure has a significant influence on anal pressures, with no evidence of risk of fecal incontinence after the operation.

Prevalence of frailty syndrome in urological patients undergoing major elective surgical procedure due to malignancy.

Introduction: The group of elderly urological patients is growing. A majority of urological operations is performed in this group. The current model of preoperative assessment is developed to be effective in younger groups of patients but not in the elderly. Frailty syndrome has been confirmed to be an effective risk stratification tool in many surgical settings. It can be diagnosed using a variety of screening tools, but the only objective tool is comprehensive geriatric assessment (CGA). However it is time consuming, difficult and to our best knowledge, has not been attempted in Polish urological patients. Material and methods: We assessed the prevalence of frailty in elderly urological patients undergoing surgery due to malignancy using CGA and screening tests. A total of 68 patients over 65 years of age qualified to elective major urological surgery underwent the preoperative assessment including use of traditional tools (medical history, physical examination, ASA score), CGA and frailty-screening tests. The 30-day postoperative complications rate using the Clavien-Dindo scale was also evaluated. Results: The mean age of patients was 71 years. The most common procedures were radical prostatectomy (47.1%), radical nephrectomy (36.6%) and radical cystectomy (11.8%). The prevalence of frailty was 39.7% using CGA and 4.4-10.3% using screening tests. The complication rate was significantly higher in frail individuals when using CGA. Conclusions: Frailty is common in urological elderly patients. The CGA is a time-consuming but reliable tool to diagnose frailty syndrome and predict complications. Screening tests can be useful for selecting patients who should undergo CGA but their predictive value is low.

Short- and long-term predictive power of the preoperative Geriatric Assessment components in older cancer patients undergoing high-risk abdominal surgery.

INTRODUCTION: The pathological stage of the cancer and presence of postoperative complications are the most important predictors of survival in older oncologic patients. Therefore, determining biological age, and risks connected with it, should be the key factor in the preoperative assessment. It may be accomplished by using a Geriatric Assessment (GA). However, it is not established which components are most useful for predicting short- and long-term postoperative outcomes in cancer patients undergoing high-risk abdominal surgery. MATERIALS AND METHODS: A total of 334 consecutive cancer patients aged ≥70 years underwent elective abdominal surgery and were followed-up prospectively for 12 months. The preoperative GA consisted of eight domains: functional, physical activity, comorbidity, polypharmacotherapy, nutritional, cognition, mood, and social support. Logistic regression analyses were used to analyse the predictive ability. RESULTS: All components of GA were independent risk factors of 30-day major morbidity apart from ADL, BOMC, Polypharmacy (OR 0.6-1.3; p < 0.001). However, ADL, TUG, the polypharmacy and the MOS-SSS turned out to be significant predictors of 30-day mortality (OR 0.72-1.46; p < 0.001). In turn, only ADL, CDT and MOS-SSS were valid predictors of 12-months mortality (OR 0.46-0.85; p < 0.001). Frailty (surrogate of the biological age), not the chronological age, were also independent predictors of all outcomes (OR 4.71-8.56 p < 0.001). CONCLUSION: Not the chronological age but components of GA and frailty are significant predictors of both 30-day postoperative outcome and 12-months mortality in older cancer patients undergoing high-risk abdominal surgery.

Functional and clinical results of transanal endoscopic microsurgery combined with endoscopic posterior mesorectum resection for the treatment of patients with t1 rectal cancer.

BACKGROUND: Rectum-sparing transanal endoscopic microsurgery (TEM) is a well-established treatment for T1 carcinomas of the rectum. However, it is associated with an increased rate of local recurrence compared with extended resection. In most cases, this failure is linked to the presence of clinically nondetectable metastases in the regional lymph nodes. Endoscopic posterior mesorectal resection (EPMR) makes it possible to remove the relevant lymphatic drainage of the lower third of the rectum in the minimally invasive way, which can help with adequate tumor staging. The study evaluated the influence of combined TEM and EPMR treatment on the anorectal functions of this group of patients. METHODS: Six consecutive patients (3 women and 3 men; mean age, 71.3 years) with T1 cancer of the rectum were operated on using TEM in combination with EPMR as a two-stage procedure between 2007 and 2009. RESULTS: After a median follow-up of 19 (range, 8-30) months, none of our patients complained of symptoms of incontinence during the postoperative period apart from one woman with gas incontinence, who was diagnosed preoperatively. There was no statistically significant difference in BAP, SAP, HPZL, or in fecal continence control assessed using the Fecal Incontinence Severity Index before and 1, 3, and 6 months after the procedure. We observed one case of intraoperative complication (perforation) and one case of minor postoperative complication (hematoma formation). There was no evidence of locoregional recurrence. CONCLUSIONS: EPMR in combination with TEM seems to be safe, feasible, and with no impact on the basic anorectal functions.

Congenital dysfibrinogenemia as a rare cause of recurrent gastrointestinal bleeding.

<b>Introduction: </b>Gastrointestinal bleeding is a common disease that surgeons encounter in everyday clinical practice. It is most often easy to diagnose and treat. However, rare causes of bleeding can lead to delayed diagnosis and ineffective treatment. Dysfibrinogenemia is a qualitative fibrinogen disorder in which functional fibrinogen level is reduced with normal antigenic level. <br><b> Case report:</b> Herein we present the case of a 59-year-old female with recurrent gastrointestinal bleeds, that turned out to be an unusual manifestation of congenital dysfibrinogenemia. Detailed imaging and endoscopic diagnostics revealed portal hypertension with a non-bleeding 1-cm gastrointestinal stromal tumor and multiple angiodysplastic lesions in close proximity.

Frailty, geriatric assessment and prehabilitation in elderly patients undergoing urological surgery - is there a need for change of the daily clinical practice? Synthesis of the available literature.

INTRODUCTION: The population of older people is heterogeneous and constantly growing. Over 50% of urological operations are performed in elderly patients. Some elderly patients present with frailty syndrome - a state of increased vulnerability to external stressors resulting in increased risk of hospitalizations, adverse treatment outcomes and death. Currently, there is no widely accepted system of qualification and preparation for surgical treatment developed specifically for elderly patients. MATERIAL AND METHODS: We searched Medline/Pubmed, Embase and Cochrane Libraries databases from 2000-2020 (week 5). The following medical subject headings (MeSH) terms were used to ensure the sensitivity of the searches: geriatric assessment, frailty, urology, and prehabilitation. Relevant articles were also identified through a manual search of the reference lists of potentially relevant articles. RESULTS: A total of 23 papers met the criteria and were included in the current study. Screening for frailty seems to be promising in predicting adverse outcomes, but frail patients should undergo detailed geriatric assessment (GA) which may indicate a need for preoperative intervention which can be unavailable during the hospitalization. The concept of prehabilitation is becoming increasingly discussed in thoracic and abdominal surgery, but only a few studies are available in the field of urology. CONCLUSIONS: Geriatric assessment seems to be a valuable tool for urologists in daily clinical practice. A proper form of prehabilitation may provide enhanced recovery after surgery.

Geriatric assessment among elderly patients undergoing urological surgery: A systematic literature review.

The elderly constitute the group of patients who most often undergo elective urological procedures, and they are at the highest risk of poor surgical outcomes because of comorbidity and frailty. The current model of qualification for surgery is often subjective and based on tools which do not address the characteristics of the elderly. The Comprehensive Geriatric Assessment (CGA) and screening tools can help in the evaluation of older, particularly frail patients. The aim of the study was to review the literature on the usefulness of preoperative geriatric evaluation in patients undergoing urological treatment. The review was based on MEDLINE/PubMed, Embase and Cochrane Library bibliographic databases from 2000-2017 for full-text, English-language publications meeting pre-defined criteria. Six prospective and 3 retrospective studies were selected for further analysis. The patient populations, methods of geriatric assessment, interventions, and outcome measures varied between the studies. None of the studies were randomized controlled trials. In 2 studies, the CGA was used; in other studies, rather basic screening tests were used. In only 2 studies, an intervention was performed after the CGA. In general, the variables of the CGA were both prospectively and retrospectively significant predictors of complications of urological surgery. Although the use of CGA is not a standard practice in everyday urological clinical practice, components of the CGA appear to be predictive of postoperative complications. Therefore, inclusion of geriatric assessment as part of routine preoperative care in geriatric urology patients should be considered. Because of the lack of randomized controlled trials on preoperative CGAs in urology patients, further studies are needed.

Usefulness of eight screening tools for predicting frailty and postoperative short- and long-term outcomes among older patients with cancer who qualify for abdominal surgery.

INTRODUCTION: The aim of this study was to compare the ability of eight frailty screening scores to predict short- (30-day major morbidity and mortality), long-term outcomes (12-month mortality) and to compare their accuracy for predicting frailty among older patients with cancer undergoing elective abdominal surgery with curative intent. MATERIALS AND METHODS: Consecutive patients aged ≥70 years were enrolled prospectively. The diagnostic performance of eight screening tests were evaluated: The Vulnerable Elderly Survey (VES-13), Triage Risk Screening Tool (TRST), Geriatric 8 (G8), Groningen Frailty Index (GFI), abbreviated Comprehensive Geriatric Assessment (aCGA), Rockwood, Balducci and Fried score. Frailty was defined based on the Geriatric Assessment (GA) with two (2ID) or three impaired domains (3ID). RESULTS: The study included 269 consecutive patients; median age 78 (range 70-94) years. The prevalence of frailty based on the reference GA was: 40.9% (2ID), 34.2% (3ID) and using screening tools 40-75.5%. The area under the curve (AUC) for predicting the postoperative outcome was: 0.58-0.75 (30-day morbidity), 0.54-0.71 (30-day mortality) and 0.59-0.74 (12-month mortality), respectively, being the highest for the G8. The AUC for the frailty screening tests was: 0.67-0.85 (at the 2ID) and 0.63-0.83 (at the 3ID), being the highest for the aCGA. CONCLUSION: The G8 was the best predictor of 30-day major morbidity, 30-day and 12-month mortality. It also had the highest sensitivity and negative predictive value in frailty screening, in case of both frailty definitions. In turn, the aCGA had the highest discriminatory ability in terms of frailty screening.