Laparoscopic Transperitoneal Lateral Adrenalectomy for Large Adrenal Tumors.

BACKGROUND: Laparoscopic adrenalectomy is the gold standard for treatment of benign adrenal lesions. Tumor size is a factor that might influence decision-making concerning the use of laparoscopic approach. The aim of this study was to analyze the results of adrenalectomy for tumors ≥6 cm in diameter. METHODS: Two groups of patients were analyzed: first group comprised 441 patients with tumors <6 cm in diameter and second group consisted of 89 patients with tumors ≥6 cm. Both groups were compared with regard to the duration of surgery, intraoperative blood loss, conversion and complications rate. RESULTS: Median duration of surgery in groups 1 and 2 amounted to 86.6 and 111.9 min (p < 0.0001), respectively. Median intraoperative blood loss in groups 1 and 2 was 56.5 and 172.8 ml (p < 0.0001), respectively. There was a linear relationship between tumor size and the duration of surgery, and between tumor size and intraoperative blood loss (p < 0.0001). There were 2 (0.5%) and 6 (6.7%) conversions in groups 1 and 2, respectively. There were 41 (9.3%) and 14 (15.7%) complications in groups 1 and 2 (p = 0.0692), respectively. CONCLUSIONS: Laparoscopic adrenalectomy of tumors ≥6 cm is more difficult, but it can be regarded safe and beneficial for patients.

Monocyte chemoattractant protein-induced protein 1 impairs adipogenesis in 3T3-L1 cells.

Monocyte chemoattractant protein-induced protein 1 (MCPIP1) encoded by the ZC3H12a gene (also known as Regnase-1) is involved in the regulation of degradation of mRNA of inflammatory modulators and for processing of pre-miRNA. These functions depend on the presence of the PIN domain. Moreover, MCPIP1 was described as a negative regulator of NF-κB and AP-1 signaling pathways although mechanisms underlying such activity remain unknown. We aimed at determining the role of MCPIP1 in adipogenesis. Here, we present evidence that Mcpip1 transcription is transiently activated during 3T3-L1 transition from pre- to adipocytes. However Mcpip1 protein expression is also strongly decreased at day one after induction of adipogenesis. Knockdown of Mcpip1 results in an upregulation of C/EBPß and PPARγ mRNAs, whereas overexpression of MCPIP1 reduces the level of both transcription factors and impairs adipogenesis. MCPIP1-dependend modulation of C/EBPß and PPARγ levels results in a modulation of the expression of downstream controlled genes. In addition, decreased C/EBPß, but not PPARγ, depends on the activity of the MCPIP1 PIN domain, which is responsible for RNase properties of this protein. Together, these data confirm that MCPIP1 is a key regulator of adipogenesis.

One hundred seventy-nine consecutive bariatric operations after introduction of protocol inspired by the principles of enhanced recovery after surgery (ERAS®) in bariatric surgery.

BACKGROUND: Obese patients are a very large high-risk group for complications after surgical procedures. In this group, optimized perioperative care and a faster recovery to full activity can contribute to a decreased rate of postoperative complications. The introduction of ERAS®-based protocol is now even more important in bariatric surgery centers. The results of our study support the idea of implementation of ERAS®-based protocol in this special group of patients. MATERIAL AND METHODS: This analysis included 170 patients (62 male/108 female, mean BMI 46.7 kg/m2) who had undergone laparoscopic bariatric surgery, and whose perioperative care was conducted according to a protocol inspired by ERAS® principles. Examined factors included oral nutrition tolerance, time until mobilization after surgery, requirements for opioids, duration of hospitalization, and readmission rate. RESULTS: During the first 24 postoperative hours, oral administration of liquid nutrition was tolerated by 162 (95.3%) patients and 163 (95.8%) were fully mobile. In 44 (25.8%) patients it was necessary to administer opioids to relieve pain. Intravenous liquid supply was discontinued within 24 hours in 145 (85.3%) patients. The complication rate was 10.5% (mainly rhabdomyolysis and impaired passage of gastric contents). The average time of hospitalization was 2.9 days and the readmission rate was 1.7%. CONCLUSIONS: The introduction of an ERAS® principles-inspired protocol in our center proved technically possible and safe for our patients, and allowed for reduced hospitalization times without increased rate of complications or readmissions.

Enhanced Recovery After Surgery (ERAS®) protocol in patients undergoing laparoscopic resection for stage IV colorectal cancer.

BACKGROUND: There is strong evidence for the use of Enhanced Recovery After Surgery (ERAS) protocol with colorectal surgery. However, in most studies on ERAS, patients with stage IV colorectal cancer (CRC) are commonly excluded. It is not certain if the ERAS protocol combined with laparoscopy improves outcomes in this group of patients as well. The aim of the study is to assess the feasibility of the ERAS protocol implementation in patients operated laparoscopically due to stage IV CRC. METHODS: A prospective analysis of patients undergoing laparoscopic colorectal surgery was performed. Group 1 included patients with stages I-III, and group 2 included patients with stage IV CRC. Demographic, surgical factors, length of stay (LOS), complications, readmissions, ERAS implementation and early postoperative recovery were compared between the groups. RESULTS: Group 1 included 168 patients, and group 2 included 20 patients. There was no difference in the age, sex, BMI, ASA, cancer localisation or surgical parameters. No statistically significant difference was noted in complications (26.8 vs 20 %, p = 0.51344), LOS (4.7 vs 5.7 days, p = 0.28228) or readmissions (6 vs 10 %, p = 0.48392). The ERAS protocol compliance was 86.3 and 83.0 %, respectively (p = 0.17158). CONCLUSIONS: Implementation of the ERAS protocol and laparoscopic surgery among patients with stage IV CRC is feasible and provides similar short-term clinical outcomes and recovery as with patients with stages I-III.

Laparoscopic transperitoneal lateral adrenalectomy for malignant and potentially malignant adrenal tumours.

BACKGROUND: Laparoscopic adrenalectomy is still controversial in cases where malignancy is suspected. However, many proponents of this technique argue that in the hands of an experienced surgeon, laparoscopy can be safely performed. The aim of this study is to present our own experience with the application of laparoscopic surgery for the treatment of malignant and potentially malignant adrenal tumours. METHODS: Our analysis included 52 patients who underwent laparoscopic adrenalectomy in 2003-2014 due to a malignant or potentially malignant adrenal tumour. Inclusion criteria were primary adrenal malignancy, adrenal metastasis or pheochromocytoma with a PASS score greater than 6. We analyzed the conversion rate, intra- and postoperative complications, intraoperative blood loss and R0 resection rate. Survival was estimated using the Kaplan-Meier method. RESULTS: Conversion was necessary in 5 (9.7%) cases. Complications occurred in a total of 6 patients (11.5%). R0 resection was achieved in 41 (78.8%) patients and R1 resection in 9 (17.3%) patients. In 2 (3.9%) cases R2 resection was performed. The mean follow-up time was 32.9 months. Survival depended on the type of tumour and was comparable with survival after open adrenalectomy presented in other studies. CONCLUSIONS: We consider that laparoscopic surgery for adrenal malignancy can be an equal alternative to open surgery and in the hand of an experienced surgeon it guarantees the possibility of noninferiority. Additionally, starting a procedure with laparoscopy allows for minimally invasive evaluation of peritoneal cavity. The key element in surgery for any malignancy is not the surgical access itself but the proper technique.

[Coagulation profile in patients undergoing elective laparoscopic surgery]. / Aktywacja ukladu krzepniecia u chorych operowanych z dostepu laparoskopowego w trybie planowym.

INTRODUCTION: Insuflation abdominal cavity with carbon dioxide during laparoscopic surgery increases abdominal pressure, which may cause stasis of the blood flow in inferior vena cava and common iliac veins. Moreover, reverse Trendelenburg position, in which laparoscopic cholecystectomy is performed, decreases venous return. All of this factors makes episode of venous thromboembilism (VTE), an asymptomatic state that could cause serious complications, more probable. AIM: The aim of the study was to asses influence of pneumoperitoneum during laparoscopic procedures on coagulation state and to asses relation between body mass index (BMI), age of patients undergoing laparoscopic procedures and coagulation profile in the postoperative period. MATERIAL AND METHODS: The study enrolled 35 patients (F:M = 28:7, mean age 48.3 ± 14.6, mean BMI 26 ± 4.5 kg/m2), without VTE risk factors, not undergoing anticoagulant therapy and without abnormal platelet count. Subjects underwent laparoscopic cholecystectomy. Alteration in coagulation profile was assesed on the basis of aPTT, PT and TT results. Blood samples were taken twice: in the day of admission (samle A) and 5 hours after surgery (sample B). Statistical analysys was performed using Wilcoxon signed rank test and Spearman correlation. RESULTS: Mean aPTT, PT and TT value of the A sample was 34.54 ± 6.32s, 1.11± 0.14 INR; 16.35 ± 1.93s respectively. Mean aPPT, PT and TT value of the B sample was 34.4 ± 7.13s; 1.17 ± 0.11 INR; 16.41 ± 1.88s, respectively. Change of PT value pre- and postoperatively was statistical significant (p = 0.0009). There was statistical significant correlation between duration of the surgery and sample B PT and TT values (p = 0.0115 and 0.0218 respectively). No other correlation between BMI, age and sample B values was observed. CONCLUSIONS: Creation of pneumoperitoneum has no influence on shortening of clotting times. Because of early mobilisation, fast discharge and recovery that makes natural anticoaculant prevention available short after surgery, clinical risk of DVT is not high.

Prognostic value of the Rockall score in patients with acute nonvariceal bleeding from the upper gastrointestinal tract.

UNLABELLED: Non-variceal upper gastrointestinal bleeding (UGIB) is a common problem in everyday clinical practice. While treating patients affected by UGIB, the estimation of the risk of complications is very important. The Rockall Score is one of the methods used in clinical practice that allows doing that. The aim of this paper is to assess the usefulness of the aforementioned scoring system while treating patients with UGIB. MATERIAL AND METHODS: The analysis included, 651 patients with nonvariceal UGIB. The average age of the group was 62.86+16.96 years. Each patient was subjected to the retrospective analysis according to the Rockall Scale's criteria. Then the entire group was divided into the complication risk groups according to the obtained amount of points (low<3, moderate 3 to 8, high>8). After dividing into groups the effort has been taken to find a relationship between Rockall Score points and the occurrences of individual complications. RESULTS: Mortality among the respondents amounted to 11.36%. The hospitalization of 97.70% patients with <3 points on the scale progressed without complications (p<0.001; X2=22.90). In the moderate risk group the highest frequency of re-bleeding and need for surgery were observed. Whereas among patients with >8 points the mortality of 78.95% was noted. CONCLUSIONS: Rockall Score is a simple and useful method for assessing prognosis for patients with the non-variceal UGIB. The highest scores are obtained by the patients with a great risk of demise. Rockall Score may be used for classifying patients to appropriate risk groups.

Neuroendocrine tumours of rare location.

Neuroendocrine tumours (NETs) arising from dispersed endocrine system may originate from almost every location, although they are most commonly found in the gastrointestinal tract and respiratory system. NETs are considered as particularly rare if they constitute less than 1% of all neuroendocrine tumours. The aim of the paper is to present ten rare NETs from the database of the Endocrinology Department of the Jagiellonian University, Medical College: 4 NETs of the ampulla of Vater, 2 of the gallbladder, and 1 of the ovary, sphenoid sinus, Meckel's diverticulum, and epiglottis. The clinical presentation of such tumours and their management are discussed.

Metabolic and Bariatric Surgery Chapter of the Association of Polish Surgeons. Bariatric and metabolic surgery care standards.

The Metabolic and Bariatric Surgery Chapter of the Association of Polish Surgeons (Polish acronym: SCMiB TCHP) is a Polish specialist scientific society representing bariatric surgeons as well as specialists from other disciplines and professions cooperating with them during the provision of services in the field of bariatric and metabolic surgery, as well as the entire care process before and after surgery. The following standards constitute the minimum requirements set by the SCMiB TCHP for good practice of the basic process of bariatric care throughout its entire period, which ensure satisfactory safety and effectiveness of the obesity treatment and its metabolic complications.

[Endoscopic piecemeal removal of large adenomatous duodenal polyp]. / Endoskopowa, kesowa polipektomia duzego polipa gruczolakowatego dwunastnicy.

Duodenal polyps are rare pathologies. They can be single or multiple, like in familial adenomatous polyposis or Gardner syndrome. Histologically they are usually bening: adenomas, myomas, lipomas, carcinoids, Brunner adenomas or hamartomas. Malignant lesions are mainly adenocarcinomas localized in the ampulla of the Vater area. Small polyps localized in the superior or descending segment of duodenum can be usually removed endoscopically. Larger or more distally localized polyps must be excised surgically. The largest polyps, up to several centimeters, are adenomas. Ileus or anemia are the main symptoms. Here we report the case of a 52 year old woman with a large polyp (7 cm diameter) localized in the duodenal bulb presenting with anemia. The polyp was removed endoscopically with a piecemeal method using diathermic loop. Histopthologic examination revealed that it was a ademona with grade II dysplasia.

Present trends in bariatric surgery in Poland.

INTRODUCTION: As obesity has become a major health problem in Poland and bariatric procedures are the best way of treatment, an increasing trend has been observed in Polish bariatric surgery for the last decade. AIM: Our purpose was to provide an updated overview of the bariatric surgical procedures performed in Polish institutions in comparison to the situation in Europe as well as to analyze the trends in Polish bariatric surgery over the last decades. MATERIAL AND METHODS: A questionnaire about the number and type of bariatric procedures performed in 2016 was sent to all Polish surgical departments. Two hundred and sixty surgical departments returned the questionnaires. RESULTS: Twenty-seven departments reported having performed bariatric operative or endoscopic procedures in 2016. The total number of procedures reported was 1958, the most popular being the laparoscopic sleeve gastrectomy (LSG). More than 99% of procedures were performed using laparoscopic techniques. The most common operations were: LSG (64.6%, n = 1032) and laparoscopic Roux-en-Y gastric bypass (LRYGB) (18.2%; n = 291), followed by one anastomosis gastric bypass (OAGB) (8.3%; n = 132) and laparoscopic adjustable gastric banding (LAGB) (7.3%; n = 117). CONCLUSIONS: Registers of bariatric procedures provide information that helps in planning treatment and predicting possible complications. Adequate reporting of bariatric procedures is necessary to present the importance of the high incidence of obesity and the importance of its treatment. To collect reliable data, a national Polish bariatric surgery registry should be created.

Challenges associated with bariatric surgery - a multi-center report.

INTRODUCTION: Due to the constantly growing demand for surgical treatment of obesity, it is necessary to create new bariatric centers and further improve presently active ones. AIM: To identify which stages of conducting peri-operative care and organizing a modern bariatric center currently pose the greatest challenge. MATERIAL AND METHODS: An anonymous survey was designed and distributed to bariatric surgeons. Our questionnaire was divided into three parts: demographic characteristics, difficulties associated with peri-operative care for bariatric patients (assessed on a scale of 1-5) and difficulties associated with organization or running of bariatric centers in which participants are currently working (assessed on a scale of 1-5). RESULTS: Overall, 70 surgeons and surgical residents from 17 surgical centers participated in our survey. The most difficult element of the pre-operative care was compliance with the recommendation to cease smoking (3.47 ±1.28). The most difficult obstacle during the postoperative care period was implementation of the enhanced recovery after surgery (ERAS) protocol (2.27 ±1.31). Funding for the bariatric treatment was obtained exclusively from the National Health Fund by 60 (85.7%) respondents working in 15 different bariatric centers (88.2%). Among elements of bariatric infrastructure access to operating theater equipment sized for morbidly obese patients was reported to be the most difficult (3.8 ±1.68). CONCLUSIONS: Pre-operative recommendations including smoking, physical activity or weight loss, as well as introducing ERAS protocol based peri-operative care, are difficult to execute in bariatric departments. Future specialized bariatric centers should be included in the centralized register and equipped with specialized infrastructure for morbidly obese patients.

Gastric solid glomus tumor and multiple glomangiomyomas of the large bowel with intravascular spread, multifocal perivascular proliferations and liver involvement.

The authors present a case of multiple glomus tumors (GTs) of the gastrointestinal tract, representing the type of a gastric glomus tumor proper and large bowel glomangiomyomas with myopericytoma-like features, observed in a 46-year old female, with multifocal perivascular proliferations of primitive cells and hepatic involvement. Histologically, the multilobular gastric tumor and hepatic lesions corresponded to a typical glomus tumor, while the tumor situated in the transverse colon, up to 7 cm in diameter, presented as a glomangiomyoma infiltrative (with myopericytoma-like foci), and satellite tumors in the large bowel mucosa, 0.5-0.7 cm in diameter, represented small glomangiomyomas. In addition, the patient demonstrated two types of concomitant vascular lesions: 1/ intravascular spread in the form of neoplastic plugs that obliterated the lumen of medium-size veins, and 2/ microscopic perivascular proliferation of primitive, small cells seen in the vicinity of the main tumor and in the adjacent adipose tissue. The patient has been ill for 2.5 years; she has been subjected to a partial colectomy with a resection of the small intestinal loop, greater omentum and the right ovary, followed by chemotherapy. At present, she is stable, and the infiltration--especially in the epigastric region--has decreased. The picture may confirm the theory that multiple GTs develop in association with multifocal proliferation of perivascular stem cells, as well as that their ability to penetrate into the lumen of large vessels gives origin to satellite tumors, which are not necessarily metastatic. It seems that at present, the group of perivascular SMA+ tumors may include infantile-type myofibromatosis in adults, myopericytoma, glomangio(myo)pericytoma, glomangiomyoma, glomus tumor proper, and glomangioma. Most likely, also some tumors previously classified as hemangiopericytomas belong to this group. The distinctive feature present in at least some of the above listed perivascular tumors is their synchronous or metachronous growth in a particular region and their ability to occupy intravascular space as nodules or solid bands, which in turn may give origin to satellite tumors. Multifocal lesions associated with a short survival in a given patient will obviously support the presence of metastatic disease. In the remaining cases, determination whether the patient has metastatic disease requires deep consideration and caution, also while deciding on treatment to be employed.

Case-Control Study of Postoperative Blood Pressure in Patients with Hemorrhagic Complications after Laparoscopic Sleeve Gastrectomy and Matched Controls.

INTRODUCTION: Laparoscopic sleeve gastrectomy is associated with a moderate risk of hemorrhagic complications (HC). There is a debate regarding the relationship between HC and high blood pressure in postoperative period. AIM: The aim is to clarify whether the postoperative blood pressure is an independent risk factor for hemorrhagic complications after laparoscopic sleeve gastrectomy. METHODS: Medical records of 522 patients were reviewed. A case-control study of postoperative blood pressure was undertaken in patients with bleeding after LSG and matched controls. Patients who required surgical revision, due to the hemorrhagic complications within 72 hours, were identified as the cases. Controls were matched (1:1) with cases by age (±1 year), gender (female versus male), staple line reinforcement (running suture versus haemostatic clips) and surgeon's experience (>50 or <50 LSG procedures per year). 12-hour postoperative blood pressure was recorded. RESULTS: 17 patients after LSG with HC in postoperative period were matched with 17 controls. Patients who experienced hemorrhagic complications after LSG had non statistically significant decreased mean systolic blood pressure (mmHg) in 12 hours observation (130.7 ± 12.9 versus 139.1 ± 10.8); p = 0.15; mean difference - 11.6 (95% CI -29.5 - 6.1). Mean 12 hour diastolic pressure was also comparable. The detailed analysis of controls revealed a significantly higher systolic blood pressure measurements in 5th and 11th hour postoperatively, as well as higher diastolic blood pressure in 12th hour postoperatively. However, the differences were not clinically significant. CONCLUSION: Compared with closely matched control subjects, patients with HC after LSG have decreased systolic blood pressure without clinical significance.

Is ERAS in laparoscopic surgery for colorectal cancer changing risk factors for delayed recovery?

There is evidence that implementation of enhanced recovery after surgery (ERAS) protocols into colorectal surgery reduces complication rate and improves postoperative recovery. However, most published papers on ERAS outcomes and length of stay in hospital (LOS) include patients undergoing open resections. The aim of this pilot study was to determine the factors affecting recovery and LOS in patients after laparoscopic colorectal surgery for cancer combined with ERAS protocol. One hundred and forty-three consecutive patients undergoing elective laparoscopic resection were prospectively evaluated. They were divided into two subgroups depending on their reaching the targeted length of stay-LOS (75 patients in group 1-≤4 days, 68 patients in group 2->4 days). A univariate and multivariate logistic regression analysis was performed to assess for factors (demographics, perioperative parameters, complications and compliance with the ERAS protocol) independently associated with LOS of 4 days or longer. The median LOS in the entire group was 4 days. The postoperative complication rate was higher (18.7 vs. 36.7 %), and the compliance with ERAS protocol was lower (91.2 vs. 76.7 %) in group 2. There was an association between the pre- and postoperative compliance and the subsequent complications. In uni- and multivariate analysis, the lack of balanced fluid therapy (OR 3.87), lack of early mobilization (OR 20.74), prolonged urinary catheterization (OR 4.58) and use of drainage (OR 2.86) were significantly associated with prolonged LOS. Neither traditional patient risk factors nor the stage of the cancer was predictive of the duration of hospital stay. Instead, compliance with the ERAS protocol seems to influence recovery and LOS when applied to laparoscopic colorectal cancer surgery.

Reduction of the risk of rhabdomyolysis after bariatric surgery with lower fluid administration in the perioperative period: a cohort study.

INTRODUCTION    Obesity is a growing worldwide problem. One of the most effective treatments is a bariatric procedure; however, surgery is associated with the risk of complications, such as staple line leakage, suture line bleeding, and rhabdomyolysis (RML). OBJECTIVES    The objective of our study was to assess the risk of RML after bariatric surgery related to intravenous fluid administration in the perioperative period. PATIENTS AND METHODS    The study involved 194 patients who underwent a bariatric surgery (laparoscopic sleeve gastrectomy or laparoscopic gastric bypass). We studied an association between the development of RML and sex, age, weight, duration of surgery, type of surgery, and the volume of intravenously administered fluids during the perioperative period. RESULTS    The median duration of surgery was 132.5 minutes. The median volume of administered fluids was 3150 ml from the introduction of anesthesia to 24 hours after surgery. Biochemical RML (creatine phosphokinase >1000 U/l) was observed in 30 patients (15.46%). RML with clinical manifestations developed in 6 patients. Multivariate logistic regression revealed an increase in the odds ratio of biochemical RML with an increase of weight on the day of surgery, operative time, and volume of intravenous fluids. A multiple regression model showed that every 500 ml of transfused fluid over the median volume increases creatine phosphokinase concentrations in the first postoperative day by 241.77 U/l over the median level, with the operative time and patient's weight remaining at median values. CONCLUSIONS    We observed an association between the administration of lower fluid volumes and a lower risk of RML. We postulate that decreasing intravenous fluid administration may reduce the risk of RML after bariatric surgery.

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.

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.

Endoscopic Insertion Of A Self-Expandable Stent Combined With Laparoscopic Rinsing Of Peritoneal Cavity As A Method For Staple Line Leaks Treatment In Patients Post Laparoscopic Sleeve Gastrectomy.

UNLABELLED: Currently, laparoscopic sleeve gastrectomy is one of bariatric surgeries most commonly performed in the world. The most frequent complications of surgeries of this type, with the highest mortality rate, include bleeding into the GI tract and peritoneal cavity, and sleeve staple line leaks. These severe complications prolong the hospital stay, and often are a cause of patient's death. While in a case of bleeding the procedure appears to be obvious, so far no uniform and standard guidelines have been established for the group of patients with staple line leaks. The aim of the study was to report results of treatment for staple line leaks following laparoscopic sleeve gastrectomy with a laparoscopic procedure and simultaneous endoscopic insertion of a self-expandable stent. MATERIAL AND METHODS: 152 laparoscopic sleeve gastrectomies were performed from April 2009 to December 2014. The BMI median was 46.9, and the age median was 42 years. Staple line leaks developed in 3 out of 152 people (1.97%). All patients who developed this complication were included in the study. The treatment involved laparoscopic revision surgery with simultaneous endoscopic insertion of a self-expandable stent (Boston Scientific, Wallflex Easophageal Stent, 150×23 mm) into the gastric stump during gastroscopy. RESULTS: Leaks following laparoscopic sleeve gastrectomy were diagnosed on day 5 after the procedure, on average. Intervention consisting of laparoscopy and endoscopic insertion of a self-expandable stent was initiated within 14 hours of diagnosing the leak, on average. The mean time for which the stent was kept was 5 weeks (4-6 weeks). Stenting proved to be fully effective in all patients, where after discharging home, a cutaneous fistula, periodically (every 2-3 weeks) discharging several millilitres of matter, persisted in one patient. The mean time for the leak healing in 2 patients, in whom the described method was successful in treatment of this complication, was 37 days. No patient died in the perioperative or follow-up period. CONCLUSIONS: The proposed method for treatment of staple line leaks following laparoscopic sleeve gastrectomy by combined laparoscopic rinsing and draining of the peritoneal cavity and endoscopic insertion of a self-expandable stent is an interesting and worth recommending method for treatment of this complication.

The usefulness of the Mannheim Peritonitis Index score in assessing the condition of patients treated for peritonitis.

UNLABELLED: The aim of the study was to verify the Mannheim Peritonitis Index (MPI) suitability to determine the probability of death among patients in Polish population operated due to peritonitis and to assess the possibility of using the Index to determine the risk of postoperative complications, relaparotomy and need for postoperative hospitalization in intensive care unit. MATERIAL AND METHODS: Retrospective analysis covered 168 patients (M: F = 83: 85, mean age = 48.45 years, SD ± 22.2) treated for peritonitis. The MPI score was calculated for each patient. According to MPI results, patients were divided to the appropriate groups (<21, 21-29, > 29) and within analyzed. The statistical analysis used Chi-square, Mann Withney U and Kolmogorov-Smirnov test. The best cut-off point for MPI was calculated on the basis of ROC analisys. RESULTS: Mortality in the study group was 13.1%. In groups <21, 21-29 and > 29 points according to MPI mortality was 1.75%, 28.13% and 50% respectively, the difference was statistically significant (p = 0.0124). Significant differences were observed in mortality depending on the diagnosis. Based on the ROC curve the cut-off point was identified as 32 with an accuracy of 85.9% and AUC = 81%. There has been a significant correlation between the MPI count and and the occurrence of: cardio-respiratory failure, acidosis, electrolyte imbalance, surgical wound complications, the need for treatment in the intensive care unit after surgery. CONCLUSIONS: The MPI is a simple and effective predictor of death among patients operated due to peritonitis. It can also provide assistance in assessing the risk of postoperative complications and the need for treatment in the intensive care unit.