Transarterial (chemo)embolisation versus systemic chemotherapy for colorectal cancer liver metastases.

BACKGROUND: The liver is affected by two groups of malignant tumours: primary liver cancers and liver metastases. Liver metastases are significantly more common than primary liver cancer, and five-year survival after radical surgical treatment of liver metastases ranges from 28% to 50%, depending on primary cancer site. However, R0 resection (resection for cure) is not feasible in most people; therefore, other treatments have to be considered in the case of non-resectability. One possible option is based on the concept that the blood supply to hepatic tumours originates predominantly from the hepatic artery. Transarterial chemoembolisation (TACE) of the peripheral branches of the hepatic artery can be achieved by administering a chemotherapeutic drug followed by vascular occlusive agents and can lead to selective necrosis of the cancer tissue while leaving normal liver parenchyma virtually unaffected. The entire procedure can be performed without infusion of chemotherapy and is then called bland transarterial embolisation (TAE). These procedures are usually applied over a few sessions. Another possible treatment option is systemic chemotherapy which, in the case of colorectal cancer metastases, is most commonly performed using FOLFOX (folinic acid, 5-fluorouracil, and oxaliplatin) and FOLFIRI (folinic acid, 5-fluorouracil, and irinotecan) regimens applied in multiple sessions over a long period of time. These therapies disrupt the cell cycle, leading to death of rapidly dividing malignant cells. Current guidelines determine the role of TAE and TACE as non-curative treatment options applicable in people with liver-only or liver-dominant metastatic disease that is unresectable or non-ablatable, and in people who have failed systemic chemotherapy. Regarding the treatment modalities in people with colorectal cancer liver metastases, we found no systematic reviews comparing the efficacy of TAE or TACE versus systemic chemotherapy. OBJECTIVES: To evaluate the beneficial and harmful effects of transarterial embolisation (TAE) or transarterial chemoembolisation (TACE) compared with systemic chemotherapy in people with liver-dominant unresectable colorectal cancer liver metastases. SEARCH METHODS: We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, and three additional databases up to 4 April 2024. We also searched two trials registers and the European Medicines Agency database and checked reference lists of retrieved publications. SELECTION CRITERIA: We included randomised clinical trials assessing beneficial and harmful effects of TAE or TACE versus systemic chemotherapy in adults (aged 18 years or older) with colorectal cancer liver metastases. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were all-cause mortality; overall survival (time to mortality); and any adverse events or complications. Our secondary outcomes were cancer mortality; health-related quality of life; progression-free survival; proportion of participants dying or surviving with progression of the disease; time to progression of liver metastases; recurrence of liver metastases; and tumour response measures (complete response, partial response, stable disease, and progressive disease). For the purpose of the review and to perform necessary analyses, whenever possible, we converted survival rates to mortality rates, as this was our primary outcome. For the analysis of dichotomous outcomes, we used the risk ratio (RR); for continuous outcomes, we used the mean difference; and for time to event outcomes, we calculated hazard ratios (HRs), all with 95% confidence intervals (CI). We used the standardised mean difference with 95% CIs when the trials used different instruments. We used GRADE to assess the certainty of evidence for each outcome. We based our conclusions on outcomes analysed at the longest follow-up. MAIN RESULTS: We included three trials with 118 participants randomised to TACE versus 120 participants to systemic chemotherapy. Four participants were excluded; one due to disease progression prior to treatment and three due to decline in health. The trials reported data on one or more outcomes. Two trials were performed in China and one in Italy. The trials differed in terms of embolisation techniques and chemotherapeutic agents. Follow-up ranged from 12 months to 50 months. TACE may reduce mortality at longest follow-up (RR 0.86, 95% CI 0.79 to 0.94; 3 trials, 234 participants; very low-certainty evidence), but the evidence is very uncertain. TACE may have little to no effect on overall survival (time to mortality) (HR 0.61, 95% CI 0.37 to 1.01; 1 trial, 70 participants; very low-certainty evidence), any adverse events or complications (3 trials, 234 participants; very low-certainty evidence), health-related quality of life (2 trials, 154 participants; very low-certainty evidence), progression-free survival (1 trial, 70 participants; very low-certainty evidence), and tumour response measures (presented as the overall response rate) (RR 1.81, 95% CI 1.11 to 2.96; 3 trials, 234 participants; very low-certainty evidence), but the evidence is very uncertain. No trials reported cancer mortality, proportion of participants dying or surviving with progression of the disease, and recurrence of liver metastases. We found no trials comparing the effects of TAE versus systemic chemotherapy in people with colorectal cancer liver metastases. AUTHORS' CONCLUSIONS: The evidence regarding effectiveness of TACE versus systemic chemotherapy in people with colorectal cancer liver metastases is of very low certainty and is based on three trials. Our confidence in the results is limited due to the risk of bias, inconsistency, indirectness, and imprecision. It is very uncertain whether TACE confers benefits with regard to reduction in mortality, overall survival (time to mortality), reduction in adverse events or complications, improvement in health-related quality of life, improvement in progression-free survival, and tumour response measures (presented as the overall response rate). Data on cancer mortality, proportion of participants dying or surviving with progression of the disease, and recurrence of liver metastases are lacking. We found no trials assessing TAE versus systemic chemotherapy. More randomised clinical trials are needed to strengthen the body of evidence and provide insight into the benefits and harms of TACE or TAE in comparison with systemic chemotherapy in people with liver metastases from colorectal cancer.

Is operation time over the benchmark value a risk factor for worse short-term outcomes after laparoscopic liver resection?

Introduction: Laparoscopic liver resection is a challenging surgical procedure that may require prolonged operation time, particularly during the learning curve. Operation time significantly decreases with increasing experience; however, prolonged operation time may significantly increase the risk of postoperative complications. Aim: To assess whether prolonged operation time over the benchmark value influences short-term postoperative outcomes after laparoscopic liver resection. Material and methods: A retrospective cohort study based on data from the National Polish Registry of Minimally Invasive Liver Surgery was performed. A total of 197 cases consisting of left lateral sectionectomy (LLS), left hemihepatectomy (LH), and right hemihepatectomy (RH) with established benchmark values for operation time were included. Data about potential confounders for prolonged operation time and worse short-term outcomes were exported. Results: Most cases (129; 65.5%) were performed during the learning curve, while the largest rate was observed in LLS (57; 78.1%). Median operation time exceeded the benchmark value in LLS (Me = 210 min) and LH (Me = 350 min), while in RH the benchmark value was exceeded in 39 (44.3%) cases. Textbook outcomes were achieved in 138 (70.1%) cases. Univariate analysis (OR = 1.11; 95% CI: 0.61-2.06; p = 0.720) and multivariate analysis (OR = 1.16; 95% CI: 0.50-2.68; p = 0.734) did not reveal a significant impact of prolonged surgery on failing to achieve a textbook outcome. Conclusions: Prolonging the time of laparoscopic liver resection does not significantly impair postoperative results. There is no reason related to the patients' safety to avoid prolonging the time of laparoscopic liver resection over the benchmark value.

Comparison of revisional surgeries after OAGB versus RYGB: Results from the multicenter Polish Revision Obesity Surgery Study (PROSS).

<br><b>Introduction:</b> Roux-en-Y gastric bypass (RYGB) is a leading bariatric surgery globally. One-anastomosis gastric bypass (OAGB), a modification of RYGB, ranks as the third most common bariatric procedure in Poland. While clinical trials show that OAGB outcomes are comparable to those of RYGB regarding weight loss, remission of comorbidities, and hormonal impact, there is limited data on long-term outcomes and complications.</br><br><b>Aim:</b> The aim of the study was to compare the outcomes of revisional surgeries conducted after OAGB <i>versus</i> RYGB.</br> <br><b>Material and methods:</b> This retrospective study analyzed patients undergoing revisional bariatric surgeries from January 2010 to January 2020 across 12 Polish centers. The inclusion criteria were an age of at least 18 years and prior OAGB or RYGB surgery. Those with incomplete primary surgery data and follow-up post-revision were excluded. Data were collected regarding parameters for anthropometrics, comorbidities, and perioperative details. The patients were categorized based on their initial surgery: OAGB or RYGB. The primary endpoints were the reasons for and types of revisional surgery and weight changes; the secondary endpoints were postoperative complications and length of hospital stay (LOS).</br> <br><b>Results:</b> In total, 27 patients participated, with a mean age of 38.18 7 years. Differences between the OAGB (13 patients) and RYGB (14 patients) groups included median initial body weight (100 kg <i>vs.</i> 126 kg, p<0.016), number of postoperative complications (9 <i>vs.</i> 3, p = 0.021), and median LOS (3 <i>vs.</i> 4.5 days, p = 0.03). GERD was the primary reason for OAGB revisions (69.2%), whereas insufficient weight loss led to the most RYGB revisions (42.9%).</br><br><b>Conclusions:</b> The RYGB patients commonly needed revisions due to weight issues, whereas reoperations in the OAGB patients were conducted due to postoperative complications. The postoperative complications and LOS were similar between the groups.</br> <br><b>The importance of research for the development of the field:</b> The results may influence clinical surgeons' choice of surgical technique.</br>.

Effect of preoperative intragastric balloon treatment on perioperative and postoperative outcomes after laparoscopic sleeve gastrectomy: A retrospective cohort study.

<b><br>Introduction:</b> Intragastric balloon (IGB) insertion is used as a bridging therapy in patients with body mass index (BMI) ≥ 50 kg/m2 . We arranged a retrospective study to evaluate whether pre-operative IGB treatment influences perioperative and postoperative weight loss outcomes after laparoscopic sleeve gastrectomy (SG), and especially to evaluate the impact of post - IGB percentage of excessive weight loss (%EWL) on postoperative %EWL.</br> <b><br>Materials and methods:</b> Patients who underwent IGB placement followed by laparoscopic SG were divided into the following groups considering %EWL after IGB: Group 1 <=10.38%; Group 2 >10.38% and <=17.27%; Group 3 >17.27% and <=24.86%; Group 4 >24.86%. 1 year after SG data were collected. The following parameters were compared between groups: operative time, total blood loss, length of stay and weight, BMI, percentage of total weight loss (%TWL), %EWL.</br> <b><br>Results:</b> There were no statistically significant differences between groups in perioperative results. Post-SG %EWL was the highest in intermediate groups: 2 and 3. Post-treatment results were observed: body weight and BMI were the lowest in Group 4 and the highest in Group 1. Post-treatment %EWL was the highest in Group 4, the lowest in Group 1 and grew gradually in subsequent groups.</br> <b><br>Discussion:</b> The study confirmed the impact of weight loss on IGB on postoperative results. The study showed that %EWL after the IGB treatment influences %EWL after SG and most of all affects definitive %EWL after two-stage treatment and it could be a foreshadowing factor of these outcomes.</br> <b><br>Importance:</b> The importance of research for the development of the field %EWL after IGB influences the final BMI and final weight, which means that patients with the greatest %EWL after IGB are more likely to have the greatest postoperative weight loss and overall weight loss.</br>.

Robotic versus Laparoscopic Liver Resections for Colorectal Metastases: A Systematic Review and Meta-Analysis.

Colorectal cancer is the third most common cancer worldwide, and the liver is the most common localization of metastatic disease. The incidence of minimally invasive liver surgery is increasing, and robotic surgery (RLR) is believed to overcome some limitations of a laparoscopic approach (LRL). We performed a systematic review and meta-analysis of operative and short-term oncologic outcomes of the laparoscopic versus robotic-assisted liver resection for colorectal liver metastases. An online search of PubMed, Embase, Scopus, and the Cochrane databases was performed. Eight studies involving 3210 patients were considered eligible for the meta-analysis. In the LRL group, a higher conversion to open rate (12.4%) was observed compared to the RLR (6.7%; p = <0.001). 30-day mortality was 0.7% for the LRL group compared to 0.5% for the RLR group (p = 0.76). Mortality in longer periods among LLR and RLR amounted to 18.2% vs. 8.0% for 1-year mortality (p = 0.07), 34.1% vs. 26.7% for 2-year mortality (p = 0.13), and 52.3% vs. 48.3% for 3-year mortality (p = 0.46). The length of hospital stay was 5.6 ± 2.5 vs. 5.8 ± 2.1 days, respectively (p = 0.47). There were no significant differences between the incidence of individual complications in the LRL and RLR groups (p = 0.78). Laparoscopic or robotic approaches for colorectal liver metastases are comparable in terms of safety and effectiveness. There are significant advantages to robotic surgery, although there is still no long-term evidence concerning overall survival, and the number of patients operated on using RLR remains small.

Microwave coagulation for liver metastases.

BACKGROUND: Liver metastases (i.e. secondary hepatic malignancies) are significantly more common than primary liver cancer. Long-term survival after radical surgical treatment is approximately 50%. For people in whom resection for cure is not feasible, other treatments must be considered. One treatment option is microwave coagulation utilising electromagnetic waves. It involves placing an electrode into a lesion under ultrasound or computed tomography guidance. OBJECTIVES: To evaluate the beneficial and harmful effects of microwave coagulation versus no intervention, other ablation methods, or systemic treatments in people with liver metastases regardless of the location of the primary tumour. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest date of search was 14 April 2023. SELECTION CRITERIA: Randomised clinical trials assessing beneficial or harmful effects of microwave coagulation and its comparators in people with liver metastases, irrespective of the location of the primary tumour. We included trials no matter the outcomes reported. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methodological procedures. Our primary outcomes were: all-cause mortality at the last follow-up and time to mortality; health-related quality of life (HRQoL); and any adverse events or complications. Our secondary outcomes were: cancer mortality; disease-free survival; failure to clear liver metastases; recurrence of liver metastases; time to progression of liver metastases; and tumour response measures. We used risk ratios (RR) and hazard ratios (HR) with 95% confidence intervals (CI) to present the results. Two review authors independently extracted data and assessed the risk of bias using the Cochrane RoB 1 tool. We used GRADE methodology to assess the certainty of the evidence. MAIN RESULTS: Three randomised clinical trials fulfilled the inclusion criteria. The control interventions differed in the three trials; therefore, meta-analyses were not possible. The trials were at high risk of bias. The certainty of evidence of the assessed outcomes in the three comparisons was very low. Data on our prespecified outcomes were either missing or not reported. Microwave coagulation plus conventional transarterial chemoembolisation (TACE) versus conventional TACE alone One trial, conducted in China, randomised 50 participants (mean age 60 years, 76% males) with liver metastases from various primary sites. Authors reported that the follow-up period was at least one month. The trial reported adverse events or complications in the experimental group only and for tumour response measures. There were no dropouts in the trial. The trial did not report on any other outcomes. Microwave ablation versus conventional surgery One trial, conducted in Japan, randomised 40 participants (mean age 61 years, 53% males) with multiple liver metastases of colorectal cancer. Ten participants were excluded after randomisation (six from the experimental and four from the control group); thus, the trial analyses included 30 participants. Follow-up was three years. The reported number of deaths from all causes was 9/14 included participants in the microwave group versus 12/16 included participants in the conventional surgery group. The mean overall survival was 27 months in the microwave ablation and 25 months in the conventional surgery group. The three-year overall survival was 14% with microwave ablation and 23% with conventional surgery, resulting in an HR of 0.91 (95% CI 0.39 to 2.15). The reported frequency of adverse events or complications was comparable between the two groups, except for the required blood transfusion, which was more common in the conventional surgery group. There was no intervention-related mortality. Disease-free survival was 11.3 months in the microwave ablationgroup and 13.3 months in the conventional surgery group. The trial did not report on HRQoL. Microwave ablation versus radiofrequency ablation One trial, conducted in Germany, randomised 50 participants (mean age 62.8 years, 46% males) who were followed for 24 months. Two-year mortality showed an RR of 0.62 (95% CI 0.26 to 1.47). The trial reported that, by two years, 76.9% of participants in the microwave ablationgroup and 62.5% of participants in the radiofrequency ablation group survived (HR 0.63, 95% CI 0.23 to 1.73). The trial reported no deaths or major complications during the procedures in either group. There were two minor complications only in the radiofrequency ablation group (RR 0.19, 95% CI 0.01 to 3.67). The trial reported technical efficacy in 100% of procedures in both groups. Distant recurrence was reported for 10 participants in the microwave ablation group and nine participants in the radiofrequency ablation group (RR 1.03, 95% CI 0.50 to 2.08). No participant in the microwave ablation group demonstrated local progression at 12 months, while that occurred in two participants in the radiofrequency ablation group (RR 0.19, 95% CI 0.01 to 3.67). The trial did not report on HRQoL. One trial reported partial support by Medicor (MMS Medicor Medical Supplies GmbH, Kerpen, Germany) for statistical analysis. The remaining two trials did not provide information on funding. We identified four ongoing trials. AUTHORS' CONCLUSIONS: The evidence is very uncertain about the effect of microwave ablation in addition to conventional TACE compared with conventional TACE alone on adverse events or complications. We do not know if microwave ablation compared with conventional surgery may have little to no effect on all-cause mortality. We do not know the effect of microwave ablation compared with radiofrequency ablation on all-cause mortality and adverse events or complications either. Data on all-cause mortality and time to mortality, HRQoL, adverse events or complications, cancer mortality, disease-free survival, failure to clear liver metastases, recurrence of liver metastases, time to progression of liver metastases, and tumour response measures were either insufficient or were lacking. In light of the current inconclusive evidence and the substantial gaps in data, the pursuit of additional good-quality, large randomised clinical trials is not only justified but also essential to elucidate the efficacy and comparative benefits of microwave ablation in relation to various interventions for liver metastases. The current version of the review, in comparison to the previous one, incorporates two new trials in two additional microwave ablation comparisons: 1. in addition to conventional TACE versus conventional TACE alone and 2. versus radiofrequency ablation.

MalnutritiOn assessment with biOelectrical impedaNce analysis in gastRic cancer patIentS undergoing multimodaltrEatment (MOONRISE)-Study protocol for a single-arm multicenter cross-sectional longitudinal study.

European data suggests that over 30% of gastric cancer (GC) patients are diagnosed with sarcopenia before surgery, while unintentional weight loss occurs in approximately 30% of patients following gastrectomy. Preoperative sarcopenia significantly increases the risk of major postoperative complications, and preoperative body weight loss remains a superior predictor of outcome and an independent prognostic factor for overall survival (OS) in patients with GC. A standardized approach of nutritional risk screening of GC patients is yet to be established. Therefore, the MOONRISE study aims to prospectively analyze the changes in nutritional status and body composition at each stage of multimodal treatment among GC patients from five Western expert centers. Specifically, we seek to assess the association between nutritional status and body composition on tumor response following neoadjuvant chemotherapy (NAC). Secondary outcomes of the study are treatment toxicity, postoperative complications, quality of life (QoL), and OS. Patients with locally advanced gastric adenocarcinoma scheduled for multimodal treatment will be included in the study. Four consecutive nutritional status assessments will be performed throughout the treatment. The following study was registered in ClinicalTrials.gov (Identifier: NCT05723718) and will be conducted in accordance with the STROBE statement. The anticipated duration of the study is 12-24 months, depending on the recruitment status. Results of this study will reveal whether nutritional status and body composition assessment based on BIA will become a validated and objective tool to support clinical decisions in GC patients undergoing multimodal treatment.

Early adoption of laparoscopic liver surgery in Poland: a national retrospective cohort study.

BACKGROUND: The need for safe and efficient dissemination of minimally invasive approach in liver surgery is among the current challenges for hepatobiliary surgeons. After the stage of innovators and pioneers, the following countries should adopt a laparoscopic approach. The aim of this study was to assess the national experience and trend in implementing laparoscopic liver resection (LLR) in Poland. MATERIALS AND METHODS: A national registry of LLR performed in Poland was established in June 2020. All LLR cases performed before were included retrospectively, followed by prospectively collected new cases. Baseline characteristics, preoperative and intraoperative data, short-term results and long-term follow-up were recorded. RESULTS: Since 2010 up to the end of 2022 there were 718 LLRs performed in Poland. The national rate of laparoscopic approach has gradually increased since 2017 ( P <0.001), reaching the rate of 11.7% in 2022. There were 443 (61.7%), 107 (14.9%), and 168 (23.4%) LLRs performed in accordance to increasing grades of difficulty. The move towards more demanding cases had an increasing trend over the years ( P <0.001). Total intraoperative adverse event and postoperative severe complications rates were estimated for 13.5% ( n =97) and 6.7% ( n =48), respectively. 30-day reoperation, readmission and postoperative mortality rates were 3.6% ( n =26), 2.8% ( n =20), and 0.8% ( n =6), respectively. While the R0 resection margin was assessed in 643 (89.6%) cases, the total textbook outcomes (TO) were achieved in 525 (74.5%) cases. Overcoming the learning curve of 60 LLRs, resulted in an increasing TO rate from 72.3 to 80.6% ( P =0.024). CONCLUSIONS: It is the first national analysis of a laparoscopic approach in liver surgery in Poland. An increasing trend of minimizing invasiveness in liver resection has been observed. Responsible selection of cases in accordance with difficulty may provide results within global benchmark values and textbook outcomes already during the learning curve.

Principles of minimize bleeding and the transfusion of blood and its components in operated patients - surgical aspects.

One of the target of perioperative tratment in surgery is decreasing intraoperative bleeding, which increases the number of perioperative procedures, mortality and treatment costs, and also causes the risk of transfusion of blood and its components. Trying to minimize the blood loss(mainly during the operation) as well as the need to transfuse blood and its components (broadly understood perioperative period) should be standard treatment for a patient undergoing a procedure. In the case of this method, the following steps should be taken: 1) in the preoperative period: identyfication of risk groups as quickly as possible, detecting and treating anemia, applying prehabilitation, modyfying anticoagulant treatment, considering donating one's own blood in some patients and in selected cases erythropoietin preparations; 2) in the perioperative period: aim for normothermia, normovolemia and normoglycemia, use of surgical methods that reduce bleeding, such as minimally invasive surgery, high-energy coagulation, local hemostatics, prevention of surgical site infection, proper transfusion of blood and its components if it occurs; 3) in the postoperative period: monitor the condition of patients, primarily for the detection of bleeding, rapid reoperation if required, suplementation (oral administration preferred) nutrition with microelements (iron) and vitamins, updating its general condition. All these activities, comprehensively and in surgical cooperation with the anesthesiologist, should reduce the blood loss and transfusion of blood and its components.

The impact of perioperative fluid therapy on the short-term outcomes after laparoscopic colorectal cancer surgery with ERAS protocol: a prospective observational study.

The main goals of the Enhanced recovery after surgery (ERAS) protocol are focused on shortening the length of hospital stay (LOS), expediting convalescence, and reducing morbidity. A balanced perioperative fluid therapy is among the significant interventions incorporated by the ERAS protocol. The article contains extensive discussion surrounding the impact of this individual intervention on short-term outcomes. The aim of this study was to assess the impact of perioperative fluid therapy on short-term outcomes in patients after laparoscopic colorectal cancer surgery. The analysis included consecutive patients, who had undergone laparoscopic colorectal cancer operations between 2013 and 2020. Patients were divided into two groups: restricted (≤ 2500 ml) or excessive (> 2500 ml) perioperative fluid therapy. A standardized ERAS protocol was implemented in all patients. The study outcomes included recovery parameters and the morbidity rate, LOS and 30 days readmission rate. There were 361 and 80 patients in groups 1 and 2, respectively. There were no statistically significant differences between the groups in terms of demographic parameters and factors related to the surgical procedure. Logistic regression showed that restricted fluid therapy as a single intervention was associated with improvement in tolerance of diet on 1st postoperative day (OR 2.18, 95% CI 1.31-3.62, p = 0.003), accelerated mobilization on 1st postoperative day (OR 2.43, 95% CI 1.29-4.61, p = 0.006), lower risk of postoperative morbidity (OR 0.58, 95%CI 0.36-0.98, p = 0.046), shorter LOS (OR 0.49, 95% CI 0.29-0.81, p = 0.005) and reduced readmission rate (OR 0.48, 95% CI 0.23-0.98, p = 0.045). A balanced perioperative fluid therapy on the day of surgery may be associated with faster convalescence, lower morbidity rate, shorter LOS and lower 30 days readmission rate.

The Association of Polish Surgeons (APS) clinical guidelines for the use of laparoscopy in the management of abdominal emergencies. Part II.

Introduction: Over the past three decades, almost every type of abdominal surgery has been performed and refined using the laparoscopic technique. Surgeons are applying it for more procedures, which not so long ago were performed only in the classical way. The position of laparoscopic surgery is therefore well established, and in many operations it is currently the recommended and dominant method. Aim: The aim of the preparation of these guidelines was to concisely summarize the current knowledge on laparoscopy in acute abdominal diseases for the purposes of the continuous training of surgeons and to create a reference for opinions. Material and methods: The development of these recommendations is based on a review of the available literature from the PubMed, Medline, EMBASE and Cochrane Library databases from 1985 to 2022, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. The recommendations were formulated in a directive form and evaluated by a group of experts using the Delphi method. Results and conclusions: There are 63 recommendations divided into 12 sections: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia, acute cholecystitis, acute appendicitis, acute mesenteric ischemia, abdominal trauma, bowel obstruction, diverticulitis, laparoscopy in pregnancy, and postoperative complications requiring emergency surgery. Each recommendation was supported by scientific evidence and supplemented with expert comments. The guidelines were created on the initiative of the Videosurgery Chapter of the Association of Polish Surgeons and are recommended by the national consultant in the field of general surgery. The second part of the guidelines covers sections 6 to12 and the following challenges for surgical practice: acute appendicitis, acute mesenteric ischemia, abdominal injuries, bowel obstruction, diverticulitis, laparoscopy in pregnancy and postoperative complications requiring a reoperation.

A longer pelvis is associated with longer operative time in transanal total mesorectal excision (TME) but not in laparoscopic TME. Results from a retrospective cohort study.

Introduction: A narrow pelvis, obesity, and bulky low rectal tumor are perceived as risk factors for intraoperative difficulties during total mesorectal excision (TME), particularly in the laparoscopic approach. A transanal approach has been developed to overcome the difficulties encountered during laparoscopic TME. There is no clear definition of a narrow pelvis that would guide preoperative surgical planning. Aim: To evaluate different MRI-based pelvic measurements in patients undergoing TME to identify factors predictive of intraoperative difficulties in transabdominal compared to the transanal approach. Material and methods: A retrospective analysis of 48 patients treated with laparoscopic TME and 62 with transanal TME for rectal tumors was performed. Multiple logistic regressions analyzed demographic, tumor, and pelvimetry factors that correlate with intraoperative difficulties measured as intraoperative blood loss, operation time, and perioperative complications in both surgical approaches. Results: Multivariate analysis showed that age was associated with higher blood loss (OR = 1.09, 95% CI: 1.00-1.18, p = 0.038), male gender (OR = 0.13, 95% CI: 0.02-0.86, p = 0.029) and body mass index with longer operating time (OR = 1.32, 95% CI: 1.06-1.64, p = 0.010) in the LAR group. Multivariate analysis showed that age increased the odds of intraoperative blood loss > 100 ml (OR = 1.08, 95% CI: 1.02-1.15, p = 0.013), and pelvic length > 119 mm increased operating time (OR = 5.76, 95% CI: 1.33-25.01, p = 0.016) in the TaTME group. Conclusions: Pelvic measurements are not associated with intraoperative difficulties in LAR. Longer pelvis was associated with longer operative time in TaTME.

The Association of Polish Surgeons (APS) clinical guidelines for the use of laparoscopy in the management of abdominal emergencies. Part I.

Introduction: Over the past three decades, almost every type of abdominal surgery has been performed and refined using the laparoscopic technique. Surgeons are applying it for more procedures, which not so long ago were performed only in the classical way. The position of laparoscopic surgery is therefore well established, and in many operations it is currently the recommended and dominant method. Aim: The aim of the preparation of these guidelines was to concisely summarize the current knowledge on laparoscopy in acute abdominal diseases for the purposes of the continuous training of surgeons and to create a reference for opinions. Material and methods: The development of these recommendations is based on a review of the available literature from the PubMed, Medline, EMBASE and Cochrane Library databases from 1985 to 2022, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. Recommendations were formulated in a directive form and evaluated by a group of experts using the Delphi method. Results and conclusions: There are 63 recommendations divided into 12 sections: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia, acute cholecystitis, acute appendicitis, acute mesenteric ischemia, abdominal trauma, bowel obstruction, diverticulitis, laparoscopy in pregnancy, and postoperative complications requiring emergency surgery. Each recommendation was supported by scientific evidence and supplemented with expert comments. The guidelines were created on the initiative of the Videosurgery Chapter of the Association of Polish Surgeons and are recommended by the national consultant in the field of general surgery. The first part of the guidelines covers 5 sections and the following challenges for surgical practice: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia and acute cholecystitis. Contraindications for laparoscopy and the ERAS program are discussed.

Minimizing blood loss and transfusion rate in laparoscopic liver surgery: a review.

Laparoscopic liver resection has become a standard practice in many surgical wards in elective liver surgery, due to its positive impact on reducing hospital stay and postoperative complications, including lower blood loss and transfusion rate. However, achieving proper hemostasis in liver surgery, due to its vast blood supply, still remains a main concern to surgeons. Therefore, numerous techniques were and are still being developed to further reduce blood loss and transfusion rate. The aim of this literature review was to summarize the best available methods for achieving the minimal blood loss and transfusion rate in laparoscopic liver surgery, according to the newest data.

The analysis of factors increasing the odds for type 2 diabetes mellitus remission following re-do bariatric surgery after laparoscopic sleeve gastrectomy- cohort study.

INTRODUCTION: Metabolic/bariatric surgery is the only proven treatment for type 2 diabetes mellitus (T2D) with curative intent. However, in a number of patients, the surgery is not effective or they may experience a relapse. Those patients can be offered re-do bariatric surgery (RBS). PURPOSE: The study aimed to determine factors increasing the odds for T2D remission one year after RBS following primary laparoscopic sleeve gastrectomy. METHODS: A multicenter retrospective cohort study was conducted between January 2010 and January 2020, which included 12 bariatric centers in Poland. The study population was divided into groups: Group 1- patients with T2D remission after RBS (n = 28) and Group 2- patients without T2D remission after RBS (n = 49). T2D remission was defined as HBA1c < 6.0% without glucose-lowering pharmacotherapy and glycemia within normal range at time of follow-up that was completed 12 months after RBS. RESULTS: Fifty seven females and 20 males were included in the study. Patients who achieved BMI < 33 kg/m2 after RBS and those with %EBMIL > 60.7% had an increased chance of T2D remission (OR = 3.39, 95%CI = 1.28-8.95, p = 0.014 and OR = 12.48, 95%CI 2.67-58.42, p = 0.001, respectively). Time interval between primary LSG and RBS was significantly shorter in Group 1 than in Group 2 [1 (1-4) vs. 3 (2-4) years, p = 0.023]. CONCLUSIONS: Shorter time interval between LSG and RBS may ease remission of T2D in case of lack of remission after primary procedure. Significant excess weight loss seems to be the most crucial factor for T2D remission.

Is triggering receptor expressed on myeloid cell 1 (TREM-1) protein a new marker of serious infectious complications in colorectal surgery?: case-matched pilot study.

PURPOSE: The purpose of the study was to evaluate the usefulness of the triggering receptor expressed on myeloid cell 1 (TREM-1) protein as a marker for serious infectious complications during laparoscopic colorectal surgery. METHODS: Sixty-four patients with colon or rectal cancer, who underwent an elective laparoscopic colorectal cancer surgery from November 2018 to February 2020, were included in the analysis. Blood samples of the TREM-1 protein testing were collected four times from each patient: before and on three following postoperative days (PODs). Patients were divided into two groups according to the presence of infectious complications. Subsequently, patients with infectious complications (group 1) were matched 1:1 with patients without complications (group 2). The case-matched analysis was done by selecting patients from the control group by age, ASA scale, cancer stage, and type of surgery. RESULTS: There was no significant difference in demographic and operative characteristics between the two groups. The median length of hospital stay was longer in group 1 than in group 2 (11 days vs. 5 days, p < 0.001). Preoperative measurements of TREM-1 protein did not differ between the two groups. There were no significant differences in the measurements on the first and third postoperative days. However, the median TREM-1 measurement was higher in group 1 on the second postoperative day (542 pg/ml vs. 399 pg/ml; p = 0.040). The difference was more apparent when only severe postoperative complications were considered. When compared to the group without any complications, the median TREM-1 level was significantly higher in the group with severe infection complications in POD 1, POD 2, and POD 3 (p < 0.05). The receiver operating characteristic (ROC) curve demonstrated that TREM-1 readings in POD 2 had a sensitivity of 83% and a specificity of 84% for the presence of severe infection complications at a value of 579.3 pg/ml (AUC 0.8, 95%CI 0.65-0.96). CONCLUSION: TREM-1 measurements might become a helpful predictive marker in the early diagnosis of serious infectious complications in patients following laparoscopic colorectal surgery.

Duodenal microbiota and weight-loss following sleeve gastrectomy and Roux-en-Y gastric bypass - a pilot study.

BACKGROUND: Bariatric surgery is the most effective method of morbid obesity treatment. Microbiota has many functions in human body and many of them remain to be unknown. The aim of this study was to establish if the composition of duodenal microbiota influences success rate of bariatric surgery. METHODS: It was a prospective cohort study. The data concerning demographics and comorbidities was collected perioperatively. The duodenal biopsies were collected prior to surgery with the gastroscope. Then DNA analysis was conducted. The data connected to the operation outcomes was gathered after 6 and 12 months after surgery. RESULTS: Overall, 32 patients were included and divided into two groups (successful - group 1 and unsuccessful - group 0) based on percentage excess weight loss after 6 months were created. The Total Actual Abundance was higher in group 0. In group 0 there was a significantly higher amount of Roseburia and Arthrobacter (p = 0.024, p = 0.027, respectively). Genus LDA effect size analysis showed Prevotella, Megasphaera and Pseudorhodobacter in group 1 to be significant. Whereas abundance of Roseburia and Arthrobacter were significant in group 0. CONCLUSIONS: Duodenal microbiota composition may be a prognostic factor for the success of the bariatric surgery but further research on the larger group is needed.

Influence of Bariatric Surgery on Erectile Dysfunction-a Systematic Review and Meta-Analysis.

INTRODUCTION: Obesity is associated with a higher prevalence of various comorbidities including erectile dysfunction (ED). Bariatric surgery leads to weight loss and remission of weight-related diseases. The exact influence of bariatric treatment on ED is yet to be established; however, the number of papers on the subject is growing. METHODOLOGY: A systematic review with meta-analysis comparing erectile dysfunction before and after surgery was conducted according to PRISMA guidelines with a literature search performed in June 2022. Inclusion criteria involved (1) ED assessment using the International International Index of Erectile Function (IIEF) and (2) longitudinal study design. Secondary endpoints involved hormonal changes and specific fields of IIEF. RESULTS: An initial search yielded 878 records. Fourteen studies were included in the meta-analysis involving 508 patients. The quality of analyzed studies was moderate. Analysis showed significant differences in IIEF before and after surgery (Std. MD = 1.19, 95% CI 0.72 to 1.66, p<0.0001). Testosterone after surgery is higher by 156.32 pg/ml (95% CI 84.78 to 227.86, p<0.0001). There were differences in erectile function (MD:4.86, p < 0.0001), desire (MD: 1.21, p < 0.0001), intercourse satisfaction (MD: 2.16, p < 0.0001), and overall satisfaction (MD: 1.21, p = 0.003). There were no differences in terms of orgasms (MD: 0.65, p = 0.06). CONCLUSION: There are differences in ED before and after bariatric surgery. Patients achieve 19% more in the IIEF questionnaire showing improvement. Further studies, including multivariate regression models on large cohorts, are required to determine whether the surgery is an independent factor in alleviating ED.

Total versus partial adrenalectomy in bilateral pheochromocytoma - a systematic review and meta-analysis.

Background: In patients with bilateral pheochromocytoma, partial adrenalectomy offers the chance to preserve adrenal function and avoid the need for lifelong steroid supplementation. However, the risk of tumour recurrence raises questions about this procedure. The aim of our study was to compare partial and total adrenalectomy in bilateral pheochromocytoma through a systematic review with meta-analysis. Methods: A systematic search was carried out using databases (MEDLINE, EMBASE, Scopus, Web of Science, CENTRAL) and registers of clinical trials (ClinicalTrials.gov, European Trials Register, WHO International Trials Registry Platform). This meta-analysis included studies up to July 2022 without language restrictions. A random effects model meta-analysis was performed to assess the risk of tumor recurrence, steroid dependence and morbidity in these patients. Results: Twenty-five studies were included in the analysis involving 1444 patients. The relative risk (RR) of loss of adrenal hormone function during follow-up and the need for steroid therapy was 0.32 in patients after partial adrenalectomy: RR 0.32, 95% Confidence Interval (CI): 0.26-0.38, P < 0.00001, I2 = 21%. Patients undergoing partial adrenalectomy had a lower odds ratio (OR) for developing acute adrenal crisis: OR 0.3, 95% CI: 0.1-0.91, P=0.03, I2 = 0%. Partial adrenalectomy was associated with a higher risk of recurrence than total adrenalectomy: OR 3.72, 95% CI: 1.54-8.96, P=0.003, I2 = 28%. Conclusion: Partial adrenalectomy for bilateral pheochromocytoma is a treatment that offers a chance of preserving adrenal hormonal function, but is associated with a higher risk of local tumor recurrence. There was no difference for the risk of metastasis and in overall mortality among the group with bilateral pheochromocytomas undergoing total or partial adrenalectomy. This study is in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (A Measurement Tool to Assess Systematic Reviews) Guidelines (10, 11). Systematic review registration: https://osf.io/zx3se.

Recommendations for modern perioperative care for elective surgery: consensus of panel of exerts.

INTRODUCTION: Correct surgical technique and perioperative care are two factors that can reduce the number of complications, improve treatment outcomes and shorten the length of hospital stay. The introduction of enhanced recovery protocols has changed the approach to patient care in some centers. However, there are significant differences among centers, and in some the standard of care has remained unchanged. AIM: the goal of the panel was to develop recommendations for modern perioperative care in accordance with current medical knowledge in order to reduce the number of complications associated with surgical treatment. An additional goal was to optimize and standardize perioperative care among Polish centers. MATERIALS AND METHODS: the development of these recommendations was based on a review of the available literature from the PubMed, Medline and Cochrane Library databases from January 1, 1985 to March 31, 2022, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. Recommendations were formulated in a directive form and were assessed using the Delphi method. RESULTS AND CONCLUSIONS: 34 recommendations for perioperative care were presented. They cover aspects of pre-, intra- and post-operative care. Implementation of the presented rules allows to improve the results of surgical treatment.