Flying endoscopists in the Arctic: initiatives for quality assurance of endoscopies in Greenland.

BACKGROUND: Surgical coastal expeditions (SCEs) have been organized in Greenland for many years. They aim to provide small coastal hospitals with specialist services, such as endoscopies (SCEEs), by deploying specialist personnel, surgeons, and the necessary equipment to the hospital temporarily. The purpose of this program is to increase accessibility for patients, while simultaneously reducing the costs associated with patient transport to the central hospital. METHODS: This retrospective pilot review of medical records identified quality indicators, such as bowel cleansing (BP), cecal intubation rate (CIR), and adenoma and advanced adenoma detection rates (ADR, AADR), to investigate the status and establish a system for quality monitoring of SCEsE in Greenland. RESULTS: During two SCEs (8 working days), 89 SCEE were performed at Qaqortoq and Sisimiut Hospitals. The 60 patients who underwent colonoscopy included 32 men and 28 women with a mean age of 61 years (range 24-80 years). The unadjusted CIR was 91.7%. In eight (13.3%) examinations, bowel preparation was rated as unsatisfactory, resulting in two incomplete procedures. The ADR and AADR were 35% and 11.7%, respectively, and one cancer was detected (1.7%). CONCLUSION: The results showed satisfactory ADR, AADR, and CIR levels. However, the review also highlighted the need for increased attention to BP by developing a new procedure that considers differences due to specific eating habits in Greenland and provides much better information for patients. The review provided a snapshot of the quality of colonoscopies in Greenland, highlighting the necessity to continue this process to ensure that the quality is up to standard. Furthermore, SCE helps reduce the environmental footprint of gastrointestinal endoscopy by avoiding the need for patient air transport; instead of 77 round trips (61,830 km), only 8 (6440 km) were required.

Current treatment of the inguinal hernia - the role of the totally extraperitoneal (TEP) hernia repair.

Inguinal hernia repairs are one of the most common procedures performed in general surgical departments. Approximately 20 million hernia repairs are performed annually all over the world. According to the EHS guidelines, the recommended treatment methods of the inguinal hernia are tension-free techniques: the Lichtenstein open hernia repair and the laparoscopic transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) methods. The TEP hernia repair, first performed by Duluq in 1992, is one of the three current leading techniques in the inguinal hernia repair. The most important advantage of this technique is minimal invasive access without the need to open the peritoneum, which carries a lower risk of abdominal organs injury. Additionally, the TEP method facilitates shorter recovery time, less postoperative pain and an earlier discharge form hospital. The aim of the article is to present the TEP method by comparing it with the other inguinal hernia repair techniques, on the basis of the available literature.

Accuracy of preoperative tumor localization in large bowel using 3D magnetic endoscopic imaging: randomized clinical trial.

BACKGROUND: Laparoscopic surgery has become the standard treatment for colorectal cancer. A tumor that does not involve serosa is invisible intraoperatively, and manual palpation of the tumor during laparoscopy is not possible. Therefore, accurate localization of the neoplastic infiltrate remains one of the most important tasks prior to elective laparoscopic surgery. The aim of this study was to evaluate the utility of a magnetic endoscopic imaging (MEI) for precise preoperative endoscopic localization of neoplastic infiltrate within the large bowel. MATERIALS AND METHODS: The study enrolled 246 patients who underwent elective surgery for colorectal cancer in 2012-2015 with accurate preoperative colonoscopic localization of the tumor. The analysis concerned patients with neoplastic infiltrate localized more than 30 cm from the anal verge. For evaluative purposes and accuracy of localization, the intestine was divided anatomically into 13 parts. Colonoscopic examinations were conducted with two types of endoscopes: group I-with MEI and group II-without MEI. Patients were assigned to the groups by random allocation. Ultimate confirmation of the tumor localization was accomplished by intraoperative evaluation. RESULTS: Group I involved 127 patients and group II 129. The two groups were compared in terms of age, sex, BMI and frequency of previous abdominal procedures. Proper localization of the lesion was confirmed in 95.23 % of group I patients and in 83.19 % of group II patients (p < 0.05). The greatest discrepancy in localization occurred in 8.9 % of patients from group I and 20 % of patients from group II in which the lesion was assessed primarily in the distal sigmoid. CONCLUSIONS: A magnetic endoscopic imaging allows more accurate localization of neoplastic infiltrate within the large intestine compared to standard colonoscopy alone, especially within the sigmoid colon. This method can be particularly useful in planning and performing laparoscopic procedures to diminish the likelihood of improper bowel segment resection. CLINICALTRIALS. GOV NUMBER: NCT01688557.

Impact of responsive insertion technology (RIT) on reducing discomfort during colonoscopy: randomized clinical trial.

BACKGROUND: In many countries, colonoscopies for colorectal cancer screening are performed without sedation due to the cost. Changes in the structure of the endoscopes are designed to facilitate the colonoscopic examination, reduce the duration of the procedure, and improve the imaging of the intestinal lumen. The variable stiffness of the endoscope and the recently introduced responsive insertion technology (RIT) are features aimed at easing colonoscope insertion and reducing the discomfort and pain during the examination. The aim of the study is to analyze whether the new RIT system can improve the practice of colonoscopy under no anesthesia with respect to the widely available variable stiffness colonoscopes. MATERIALS AND METHODS: This analysis included 647 patients who underwent complete colonoscopy in the screening program. All colonoscopies were performed without sedation. Olympus series 180 and 190 endoscopes equipped with a magnetic positioning system were used. Group I included patients who were examined using endoscopes equipped with responsive insertion technology (RIT), and group II included patients who were examined using conventional variable stiffness colonoscopies. The main objective was to evaluate the cecal intubation time, the number of loops, the requirement to apply manual pressure to different areas of the abdomen and the degree of discomfort and pain expressed on a visual analogue scale (VAS). ClinicalTrials.gov number, NCT01688557. RESULTS: Group I consisted of 329 patients, and group II included 318 patients. The mean age of the patients was 58.4 years (SD ± 4.21). Both groups were compared in terms of age, sex, and BMI. The mean cecal intubation time was 209 s in group I and 224 s in group II (p < 0.05). Increased loop formation was observed upon endoscope insertion in group II (1.7 vs. 1.35) (p < 0.05) and required more manual pressure to the abdomen (2.2 vs. 1.7) (p = 0.001). In group I, less discomfort and pain, as graded on a VAS (2.3 vs. 2.6), were noted. CONCLUSIONS: The implementation of RIT reduced of the cecal intubation time. The modified structure of the endoscope rendered the colonoscopic examination easier by reducing loop formation upon insertion with a subsequently reduced rate of auxiliary maneuvers.

Does combination of "cold" and "hot" somatostatin analogs prolong survival of patients with neuroendocrine neoplasms?

A number of detected neuroendocrine neoplasms (NENs) has been on the increase due to our awareness of the NENs risk and the development of different imaging techniques. Therapy of NENs involves surgery, chemotherapy, "cold" somatostatin analogs (SSA), peptide receptor radionuclide therapy (PRRT) and kinase inhibitors in pancreatic NENs. The aim of this study is to assess the efficacy of SSA in combination with "hot" somatostatin analogs, and the survival rate of our patients with advanced NENs. Seventy nine patients with metastatic NEN and positive somatostatin receptor scintigraphy (SRS) were enrolled in the study. Every patient was supposed to receive a dose of 7.4 GBq/m2 PRRT in 4-5 cycles every 4-9 weeks. Response to the therapy was assessed according to Response Evaluation Criteria In Solid Tumors (RECIST). SSA were administered one month after the last cycle of PRRT and have been continued during the whole follow up period. Median observation time was 33 months (IQR 13.6-55.6), median time to progression was 28 months (IQR 12.1-39.2) and median time to event was 28 months (IQR 12.1-39.2). Overall survival for this group of patients was 60 months. PFS was 39 months and EFS was equal to 33 months. In our group of patients not many serious adverse events were observed. PRRT using radiolabelled somatostatin analogs followed by therapy with "cold" somatostatin analogs is a promising treatment option for patients with metastatic or inoperable somatostatin receptor-positive NENs with the possibility of survival prolongation.

Two-stage optical system for colorectal polyp assessments.

BACKGROUND AND AIMS: Macroscopic real-time evaluations of the histopathology and degree of invasion of colorectal polyps help to select the most suitable endoscopic treatment method. Dual-focus (DF) narrow-band imaging (NBI) is a new imaging enhancement system that uses digital and optical methods to enhance the view of blood vessels on mucosal surfaces. However, the superiority of this technique over standard imaging techniques has not been previously reported. The aim of this study was to determine whether the two-stage optical systems in a new generation of endoscopes will increase the diagnostic accuracy of colorectal polyp recognition. METHODS: The study included 270 patients, and 386 colorectal polyps were diagnosed and removed. The polyps were assessed with white light and NBI using one- and two-stage optical systems, respectively. After being classified according to the Kudo pit pattern schemes, the polyps were removed and histopathologically verified. RESULTS: Regarding non-neoplastic lesions (Kudo I and II), no difference was observed in the recognition of polyps when using the NBI-DF function. We observed improved accuracy in the preliminary diagnoses of Kudo IIIL lesions (from 87.16 to 90.09%, p < 0.05) and Kudo IIIS lesions (from 87.29 to 92.79%, p < 0.01). NBI-DF also increased the accuracy of preliminary diagnoses of Kudo IV lesions (from 88.24 to 94.12%, p < 0.01). The Kudo V pit patterns were also more distinct with NBI-DF imaging, increasing the diagnostic accuracy from 91.67 to 100%. CONCLUSIONS: Using a two-stage optical system with electronic colorization of the mucosa increased diagnostic accuracy for differentiating colorectal polyps with neoplastic potential.

Elevated level of some chemokines in plasma of gastric cancer patients.

INTRODUCTION: Gastric cancer is one of the most common cancer-related causes of death. This is mainly due to the lack of good noninvasive method/biomarkers suitable for early-tumour diagnosis and planning of further therapy modalities. Chemokines play an important role in cancer progression and metastasis formation. In gastric cancer patients, clinical relevance of CXCL12 and CCL5 level has been postulated. AIM OF THE STUDY: Efforts were undertaken to examine whether expanded chemokine range may be relevant for evaluation of preoperative staging of gastric cancer patients. MATERIAL AND METHODS: Plasma from 66 gastric cancer patients and 11 healthy controls was obtained, and CCL2, CCL3, CCL4, CCL5, CXCL8, CXCL9, and CXCL10 levels were determined by flow cytometry FlexSet system. RESULTS: In gastric cancer patients' plasma an increased level of CCL2, CCL4, CCL5, CXCL8, CXCL9, and CXCL10 was observed. In the case of CCL2, CXCL9, and CXCL10, the chemokine levels correlated with advanced (III and IV in TNM classification) disease stage. In the case of CCL4, CCL5, and CXCL8, elevated levels were observed in all cancer patients in comparison to healthy donors. CONCLUSIONS: The accuracy of preoperative diagnosis in gastric cancer may include the monitoring of a wide range of chemokines in patients' plasma. Increased levels of chemokines may warn that the disease is more advanced than conventional diagnostic procedures suggest.

Peritoneal "melanosis".

A case of a23 year old female with peritoneal melanosis associated with adenocarcinoma of the rectum is reported. During laparoscopic anterior resection of the rectum, diffuse black pigmentations on the parietal peritoneum, greater omentum, mesenteric lymph nodes and ovaries were discovered. The histopathological findings revealed the presence of macrophages packed with black pigment. These results together with clinical data excluded metastatic melanoma and confirmed the diagnosis of the race condition called peritoneal melanosis. Due to the begin character of the lesions the laparoscopic treatment was continued. There were no remissions or progression of the reported in English literature and this is the second case of peritoneal melanosis that has been associated with adenocarcinoma of the large intestine.

Upper gastrointestinal bleeding - state of the art.

Upper gastrointestinal (GI) bleeding is a condition requiring immediate medical intervention, with high associated mortality exceeding 10%. The most common cause of upper GI bleeding is peptic ulcer disease, which largely corresponds to the intake of NSAIDs and Helicobacter pylori infection. Endoscopy is the essential tool for the diagnosis and treatment of active upper GI hemorrhage. Endoscopic therapy together with proton pump inhibitors and eradication of Helicobacter pylori significantly reduces rebleeding rates, mortality and number of emergency surgical interventions. This paper presents contemporary data on the diagnosis and treatment of upper gastrointestinal bleeding.

Number and distribution of interstitial cells of Cajal in human gallbladder.

Based on the review of current literature and on their own studies authors postulate that decreased number of interstitial cells in the wall of gallbladder may be pathognomonic for gallstone disease (cholelithiasis).

Metabolism of bile with respect to etiology of gallstone disease - systematic review.

Based on current literature authors reviewed information on bile metabolism, i.e. production and chemical compounds, synthesis of bile acids, their hepato-intestinal circulation with respect to etiology of cholelithiasis - its epidemiology and clinical aspects.

[Perioperative risk assessment tailored to elderly patients]. / Ocena ryzyka okolooperacyjnego u chorych w podeszlym wieku.

Proper preparation of the patient for surgery has a crucial impact on the outcome. Due to the continuous increase in life expectancy more and more often the problem of proper perioperative preparation of the patients over 65 years of age burdened with a higher risk of perioperative complications is undertaken. Proper assessment of the health condition and physical capacity allows to optimize treatment and thus minimize the risk of complications. In many countries, the recommended procedure is to perform the Comprehensive Geriatric Assessment (CGA), which, however, due to the need to carry out a number of additional diagnostic tests and consultations is too expensive for the vast majority of hospitals. Therefore the search for more convenient methods of abbreviated assessment is undertaken, the methods that will identify patients at greatest risk of complications. The Comprehensive Geriatric Assessment includes a series of tests and scales assessing, interalia, cognitive functions, motor efficiency, dependency, nutrition and mood. Applied abbreviated methods of perioperative assessment also have limitations in predicting the course of hospitalization. So far, there is no general practice guidelines for patients over 65 years of age. But it seems reasonable to perform the CGA in case of an unfavorable outcome of abbreviated assessment or when the threat of frailty syndrome is suspected. This procedure enables to select the best method of treatment, the implementation of appropriate prevention, thus improving the outcome of treatment and quality of life.

Repair of type II paraesophageal hernia with Nissen fundoplication in a patient with von Willebrand disease and spondylolisthesis - a clinical case report.

Hiatal hernias continue to be fairly common in clinical practice. However, the variety of different symptoms presented by patients may hinder establishing the ultimate diagnosis. Nevertheless, currently, the diagnosis of hiatal hernia can be easily established, based on barium swallow radiography. We would like to present a clinical case report of a patient with complex medical history, including von Willebrand disease, degenerative spinal disease, and chronic sinusitis, who was finally diagnosed with hiatal hernia and treated with a standard laparoscopic Nissen fundoplication. Our case focuses on the significance of comorbidities on patients' symptoms, which sometimes may mislead the therapeutic process.

Did safety-engineered device implementation contribute to reducing the risk of needlestick and sharps injuries? Retrospective investigation of 20 years of observation in a specialist tertiary referral hospital.

OBJECTIVES: In Poland, there are numerous cases of injuries caused by sharp instruments annually, still significantly more than in other European Union countries. The aim of this study was to analyze work-related injuries among healthcare workers in a selected hospital before and after the implementation of safety-engineered devices (SED). MATERIAL AND METHODS: Retrospective analysis of medical documentation regarding occupational needlestick and sharps injuries (NSSI) in a tertiary referral surgical hospital in 1998-2018. The study group consisted of nurses and doctors who had been injured and reported the incident. The frequency of injury reports, injury rate, and characterization of circumstances surrounding NSSI are presented. RESULTS: Over the period of 20 years, a total of 257 NSSI incidents were reported. The average injury rate was statistically significant for nurses (p = 0.004) and was higher before the introduction of SED. Moreover, the number of injuries among nurses showed a downward trend during the study period. However, for doctors, there was no statistically significant difference in the median puncture rate (p = 0.099), and the number of injuries showed an increasing trend. CONCLUSIONS: In this study, the authors' have demonstrated not only the occurrence of injuries and punctures in the daily work of medical personnel but also the potential for their reduction through the use of safety equipment at every workstation where healthcare services are provided using sharp medical instruments. Int J Occup Med Environ Health. 2024;37(2):234-43.

Does bile protect or damage interstitial Cajal-like cells in the human gallbladder?

the etiology of gallstone disease is considered to be multifactorial, including biliary cholesterol hypersecretion, supersaturation and crystallization, stone formation, bile stasis and mucus hypersecretion and gel formation. Gallbladder hypomotility seems to be a key process that triggers the precipitation of cholesterol microcrystals from supersaturated lithogenic bile. the purpose of the current study was to determine whether ICLCs in the gallbladder were influenced by lithogenic bile. Gallbladder specimens were collected from 30 patients (8 males and 22 females) who underwent elective laparoscopic cholecystectomy for symptomatic gallstone disease. The control group consisted of 25 consecutive patients (11 males and 14 females) who received elective treatment for pancreatic head tumors. ICLCs were visualized in paraffin sections of gallbladders using double immunofluorescence protocol with monoclonal c-kit antibodies and mast cell tryptase. Cholesterol, phospholipid and bile acid concentrations were measured in bile samples obtained by needle aspiration from the gallbladder at the time of surgery. The number of ICLCs in the gallbladder wall was significantly lower in the study group than in the control group (3.35 ± 1.23 vs. 7.06 ± 1.82 cell/FOV in the muscularis propria, P < 0.001) and correlated with a significant increase in the cholesterol saturation index. The glycocholic and taurocholic acid levels were significantly elevated in the control subjects compared with the study group. The results suggest that bile composition may play an important role in the reduction of ICLC density in the gallbladder.

Can the POLARS tool accurately predict low anterior resection syndrome in rectal cancer patients undergoing laparoscopic resection?

Introduction: Radical rectal cancer resection can lead to a long-term bowel function impairment known as low anterior resection syndrome (LARS). It remains unclear how to determine which patients are at a higher risk of developing LARS post-surgery. The POLARS tool was designed to predict the onset and severity of LARS in rectal cancer patients after surgery. The study aimed to assess the accuracy of POLARS in predicting the onset of LARS. Material and methods: A total of 66 rectal cancer patients treated laparoscopically between January 2016 and December 2017 were included in this retrospective study. Using POLARS, the predictive value for the occurrence of LARS was documented. During an average 17-month follow-up period, the bowel function of the patients was assessed using the dedicated LARS questionnaire. The predicted and actual scores were then compared. Results: Study participants included 36 women (54.5%) and 30 men (45.5%), with a mean age of 62.55 years (standard deviation: 10.2; range: 37-81). The mean predicted score according to POLARS was 24.5 (i.e. category "minor LARS"), and the mean actual score in the follow-up period was 16.42 ("no LARS" category). In only 39% of patients, the predicted LARS category was the same as the actual LARS category assessed by the questionnaire. Worse bowel function than reported at follow-up was predicted in 75% of all mispredictions. Conclusions: POLARS did not prove to be accurate in predicting the risk and severity of LARS in these patients, although the average numbers appear promising. Further evaluation of the POLARS tool using a larger cohort is needed.

Fluorescent ICG angiography in laparoscopic rectal resection - a randomized controlled trial. Preliminary report.

Introduction: Anastomotic leakage is one of the most dangerous complications after rectal surgery. It can cause systemic complications, reduce the quality of life and worsen the results of oncological treatment. One of the causes of anastomotic leak is insufficient blood supply to the anastomosis. Intraoperative infrared angiography with indocyanine green (ICG) is expected to improve the assessment of intestinal perfusion and thus prevent anastomotic leakage. Aim: To present the results of the use of ICG intraoperative angiography during rectal surgery in the prevention of anastomotic leakage. Material and methods: The study included 76 patients undergoing rectal cancer surgery. Patients were randomized to 2 groups: Group I - 41 patients with ICG intraoperative angiography; and Group II - 35 patients without ICG imaging. Anastomotic leak, length of hospitalization, and complication rate were compared. Results: Group I patients received intravenous ICG before the anastomosis. Average time of intestinal wall contrasting was 42 s (22-65 s). Average ICG procedure time was 4 min (3.2% of total time of surgery). Three (7.3%) patients after angiography revealed intestinal ischemia requiring widened resection. No anastomotic leak was found post-operatively, and no side effects were observed after administration of ICG. In group II, 3 (8.6%) anastomotic leakages were diagnosed, 2 of which required reoperation. Conclusions: Intraoperative angiography with ICG in near-infrared light is a safe and effective method of assessing intestinal perfusion. ICG angiography may change the surgical plan and reduce the risk of anastomotic leakage. It is necessary to continue the study until the assumed number of patients is reached.

Creating an Innovative Artificial Intelligence-Based Technology (TCRact) for Designing and Optimizing T Cell Receptors for Use in Cancer Immunotherapies: Protocol for an Observational Trial.

BACKGROUND: Cancer continues to be the leading cause of mortality in high-income countries, necessitating the development of more precise and effective treatment modalities. Immunotherapy, specifically adoptive cell transfer of T cell receptor (TCR)-engineered T cells (TCR-T therapy), has shown promise in engaging the immune system for cancer treatment. One of the biggest challenges in the development of TCR-T therapies is the proper prediction of the pairing between TCRs and peptide-human leukocyte antigen (pHLAs). Modern computational immunology, using artificial intelligence (AI)-based platforms, provides the means to optimize the speed and accuracy of TCR screening and discovery. OBJECTIVE: This study proposes an observational clinical trial protocol to collect patient samples and generate a database of pHLA:TCR sequences to aid the development of an AI-based platform for efficient selection of specific TCRs. METHODS: The multicenter observational study, involving 8 participating hospitals, aims to enroll patients diagnosed with stage II, III, or IV colorectal cancer adenocarcinoma. RESULTS: Patient recruitment has recently been completed, with 100 participants enrolled. Primary tumor tissue and peripheral blood samples have been obtained, and peripheral blood mononuclear cells have been isolated and cryopreserved. Nucleic acid extraction (DNA and RNA) has been performed in 86 cases. Additionally, 57 samples underwent whole exome sequencing to determine the presence of somatic mutations and RNA sequencing for gene expression profiling. CONCLUSIONS: The results of this study may have a significant impact on the treatment of patients with colorectal cancer. The comprehensive database of pHLA:TCR sequences generated through this observational clinical trial will facilitate the development of the AI-based platform for TCR selection. The results obtained thus far demonstrate successful patient recruitment and sample collection, laying the foundation for further analysis and the development of an innovative tool to expedite and enhance TCR selection for precision cancer treatments. TRIAL REGISTRATION: ClinicalTrials.gov NCT04994093; https://clinicaltrials.gov/ct2/show/NCT04994093. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/45872.

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.