Analysis of Factors Determining Spleen Preservation during Laparoscopic Distal Pancreatectomy - A Cohort Study.

BACKGROUND: Spleen preservation during laparoscopic distal pancreatectomy (LSPDP) should be pursued if safe and oncologically justified. The aim of the presented study was to compare surgical outcomes and identify risk factors for unplanned splenectomy during laparoscopic distal pancreatectomy and evaluate short and long-terms outcomes. METHODS: The following study is a retrospective cohort study of consecutive patients who underwent laparoscopic distal pancreatectomy, with the intention of preserving the spleen, for benign tumors of the body and tail of the pancreas between August 2012 and December 2022. Follow-up for patients' survival was completed in January 2023. In all, 106 patients were in total included in this study. Median age was 58 (41 to 67) years. The study population included 29 males (27.4%) and 77 females (72.6%). RESULTS: Spleen preservation was possible in 67 (63.2%) patients. The tumor size was larger in the splenectomy group (respectively, 30 (16.5 to 49) vs. 15 (11 to 25); P<0.001). Overall, serious postoperative morbidity was 13.4% in the LSPDP group and 20.5% in the second group (P=0.494). There were no perioperative deaths. The postoperative pancreatic fistula rate was 18% in the splenectomy group and 14.9% in the LSPDP group, while B and C fistulas were diagnosed in 15.4% and 10.5% of patients, respectively. In the multivariate logistic regression model, tumor size >3 cm was found to independently increase odds for unplanned splenectomy (OR 8.41, 95%CI 2.89-24.46; standardized for BMI). CONCLUSION: Unplanned splenectomy during the attempt of LSPDP does not increase the risk for postoperative morbidity and postoperative pancreatic fistula. The independent risk factor for unplanned splenectomy during LSPDP is tumor size above 3 cm.

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.

MCPIP1 Inhibits Hepatic Stellate Cell Activation in Autocrine and Paracrine Manners, Preventing Liver Fibrosis.

BACKGROUND & AIMS: Hepatic fibrosis is characterized by enhanced deposition of extracellular matrix (ECM), which results from the wound healing response to chronic, repeated injury of any etiology. Upon injury, hepatic stellate cells (HSCs) activate and secrete ECM proteins, forming scar tissue, which leads to liver dysfunction. Monocyte-chemoattractant protein-induced protein 1 (MCPIP1) possesses anti-inflammatory activity, and its overexpression reduces liver injury in septic mice. In addition, mice with liver-specific deletion of Zc3h12a develop features of primary biliary cholangitis. In this study, we investigated the role of MCPIP1 in liver fibrosis and HSC activation. METHODS: We analyzed MCPIP1 levels in patients' fibrotic livers and hepatic cells isolated from fibrotic murine livers. In vitro experiments were conducted on primary HSCs, cholangiocytes, hepatocytes, and LX-2 cells with MCPIP1 overexpression or silencing. RESULTS: MCPIP1 levels are induced in patients' fibrotic livers compared with their nonfibrotic counterparts. Murine models of fibrosis revealed that its level is increased in HSCs and hepatocytes. Moreover, hepatocytes with Mcpip1 deletion trigger HSC activation via the release of connective tissue growth factor. Overexpression of MCPIP1 in LX-2 cells inhibits their activation through the regulation of TGFB1 expression, and this phenotype is reversed upon MCPIP1 silencing. CONCLUSIONS: We demonstrated that MCPIP1 is induced in human fibrotic livers and regulates the activation of HSCs in both autocrine and paracrine manners. Our results indicate that MCPIP1 could have a potential role in the development of liver fibrosis.

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

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

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.

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.

Initial experience with laparoscopic revisional single anastomosis duodeno-ileal bypass (SADI-S) after failed sleeve gastrectomy.

Introduction: Laparoscopic sleeve gastrectomy (SG) is currently the most commonly performed bariatric operation, but re-do surgery may be necessary in up to half of the patients. Single anastomosis duodeno-ileal bypass (SADI-S) is quickly gaining recognition as a revisional procedure after failed SG. Aim: To discuss the surgical technique and analyze initial outcomes after introduction of SADI-S after SG with 1-year follow-up. Material and methods: This is a retrospective cohort study of consecutive patients who underwent re-do bariatric surgery - revisional SADI-S - in 2021 at a secondary referral public hospital. All patients' follow-up was completed 1 year after. Results: 14 consecutive patients, 6 (43%) males and 8 females, were included. Median maximal body mass index (BMI) was 52.29 (47.96-77.16) kg/m2, BMI before SADI-S was 43.09 (41.64-48.99) kg/m2. No perioperative morbidity was recorded. Four (28%) patients reported recurrent abdominal crampy pain and diarrhea that required dietary advisement and pharmacological therapy in the postoperative period. No reoperations, mortality or readmissions were recorded during 1-year follow-up. SADI-S was associated with further weight loss, resulting in median BMI of 37.55 (36.29-39.43) kg/m2 1 year after SADI-S. Observed additional percentage total weight loss (%TWL) 1 year after SADI-S was 18.65% (17.25-21.89%), while additional percentage excess body mass index loss (%EBMIL) was 35.88% (29.18-41.92%). There was 1 case of diabetes mellitus type 2 remission and improvement in glycemic control in 1 patient. 4/6 patients (66.67%) had improvement in control of hypertension. Conclusions: SADI-S is promising re-do surgery after SG with low postoperative morbidity. Additional %TWL 1 year after SADI-S is ~19%, while additional %EBMIL is ~36%, with significant improvement of obesity-related comorbidities.

Hepatic MCPIP1 protein levels are reduced in NAFLD patients and are predominantly expressed in cholangiocytes and liver endothelium.

BACKGROUND AND AIMS: NAFLD is characterized by the excessive accumulation of fat in hepatocytes. NAFLD can range from simple steatosis to the aggressive form called NASH, which is characterized by both fatty liver and liver inflammation. Without proper treatment, NAFLD may further progress to life-threatening complications, such as fibrosis, cirrhosis, or liver failure. Monocyte chemoattractant protein-induced protein 1 (MCPIP1, alias Regnase 1) is a negative regulator of inflammation, acting through the cleavage of transcripts coding for proinflammatory cytokines and the inhibition of NF-κB activity. METHODS: In this study, we investigated MCPIP1 expression in the liver and peripheral blood mononuclear cells (PBMCs) collected from a cohort of 36 control and NAFLD patients hospitalized due to bariatric surgery or primary inguinal hernia laparoscopic repair. Based on liver histology data (hematoxylin and eosin and Oil Red-O staining), 12 patients were classified into the NAFL group, 19 into the NASH group, and 5 into the control (non-NAFLD) group. Biochemical characterization of patient plasma was followed by expression analysis of genes regulating inflammation and lipid metabolism. The MCPIP1 protein level was reduced in the livers of NAFL and NASH patients in comparison to non-NAFLD control individuals. In addition, in all groups of patients, immunohistochemical staining showed that the expression of MCPIP1 was higher in the portal fields and bile ducts in comparison to the liver parenchyma and central vein. The liver MCPIP1 protein level negatively correlated with hepatic steatosis but not with patient body mass index or any other analyte. The MCPIP1 level in PBMCs did not differ between NAFLD patients and control patients. Similarly, in patients' PBMCs there were no differences in the expression of genes regulating ß-oxidation (ACOX1, CPT1A, and ACC1) and inflammation (TNF, IL1B, IL6, IL8, IL10, and CCL2), or transcription factors controlling metabolism (FAS, LCN2, CEBPB, SREBP1, PPARA, and PPARG). CONCLUSION: We have demonstrated that MCPIP1 protein levels are reduced in NAFLD patients, but further research is needed to investigate the specific role of MCPIP1 in NAFL initiation and the transition to NASH.

Splenectomy and tumor size are risk factors for serious perioperative morbidity of laparoscopic distal pancreatectomies.

<b><br>Introduction:</b> The determinants influencing the risk for complications of laparoscopic distal pancreatectomies (LDP) are not yet fully defined, thus we aimed to determine risk factors for serious perioperative morbidity after LDP with spleen preservation, LDP and radical antegrade modular pancreatosplenectomy for adenocarcinoma of the body and tail of the pancreas (RAMPS).</br> <b><br>Material and methods:</b> Retrospective cohort study of consecutive patients that underwent LDP between January 2019 and December 2022. The study group included cases of serious perioperative morbidity (III-V grades in Clavien-Dindo classification) during a 30-day period after operation. The control group consisted of patients without serious perioperative morbidity. As many as 142 patients were included in the study.</br> <b><br>Results:</b> Serious perioperative morbidity was found in 33 (23.24%) operated patients, while mortality in 3 cases (2.11%). Serious perioperative morbidity after LDP with spleen preservation was found in 9/68 (13.2%) patients (27.3% of the perioperative morbidity group). Thirteen out of 51 patients, i.e. 25.5%, after LDP with splenectomy were included in the perioperative morbidity group (39.4%). Serious perioperative morbidity after RAMPS was found in 11/23 (47.8%) patients (33.3% of the perioperative morbidity group). In multivariate logistic regression, the need for splenectomy during pancreatectomy (OR 3.66, 95%CI 1.20-11.18) and tumor above 28 millimeters in size (OR 3.01, 95%CI 1.19-9.59) were independent risk factors for serious perioperative morbidity.</br> <b><br>Conclusions:</b> The need for splenectomy during laparoscopic distal pancreatectomy and tumor size above 28 millimeters were independent risk factors for serious perioperative morbidity after laparoscopic distal pancreatectomies.</br>.

Laparoscopic pancreatectomies for borderline tumors with major venous resections.

Introduction: Resection of the portal vein or superior mesenteric vein infiltrated by the pancreatic cancer is currently a standard during open pancreatic surgery for cancer. When found intraoperatively it often leads to conversion. Nowadays, research data for laparoscopic pancreatectomies with major venous resections and reconstructions are scarce. Aim: To present our own results of laparoscopic total pancreatectomies, pancreaticoduodenectomy and distal pancreatectomies (RAMPS) performed for cancer with major venous resection and reconstructions of the portal system. Material and methods: This is a retrospective study of our own clinical material of consecutive patients treated for adenocarcinoma of pancreas who underwent laparoscopic pancreatectomies with major venous resection and reconstruction in 2020 and 2021. Results: The study included 6 females and 2 males in median age of 68 years (56-77). 6 tumors were located in the pancreatic head, 1 in the pancreatic neck and 1 in the pancreatic body. Surgical procedures included 5 total pancreatectomies, 2 RAMPS and 1 Whipple pancreaticoduodenectomy. There were no conversions. Median time of vascular closure was 55.5 (41-70) min. Median blood loss was 500 (250-900) ml. Median length of hospital stay (LOS) was 18.5 (11-34) days. We observed no complications related directly to vascular resection. Conclusions: Laparoscopic approach for pancreatectomies with portal or superior mesenteric vein resections could be a safe and feasible approach in the hands of an experienced surgeon.

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.

Learning curve for laparoscopic Roux-en-Y gastric bypass based on the experience of a newly created bariatric center.

<b> Introduction:</b> Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most common treatments for morbid obesity. The learning curve for this procedure is 50-75 cases for an independent surgeon, and it is considered the most important factor in decreasing complications and mortality. We present our experience and learning curve with LRYGB for a newly established bariatric center in Poland. <br><b>Material and methods:</b> A prospectively collected database containing 285 LRYGB procedures performed in the II Department of General Surgery of the Jagiellonian University MC in Krakow between 06.2010 and 03.2019 was retrospectively reviewed. Patients were divided into groups of 30 (G1-G10) in the order of the procedures performed by each surgeon. The study analyzed the course of the operation and patient hospitalization, comparing those groups. Learning curve for the newly created bariatric center was established. <br><b>Results:</b> Operative time in G1-G3 differed significantly from G4-G10 (P < 0.0001). The stabilization point was the 90th procedure. Perioperative complications were observed in 36 (12.63%) patients. Perioperative complications, intraoperative difficulties and adverse events did not differ importantly among groups. Liberal use of "conversions of the operator" from a surgeon to a senior surgeon provides reasonable safety and prevents complications. <br><b>Conclusions:</b> The institutional learning process stabilization point for LRYGB in a newly established bariatric center is around the 90th operation. LRYGB can be a safe procedure from the very beginning in newly established bariatric centers. Specific bariatric training with active proctoring by an experienced surgeon in a bariatric centre can improve the laparoscopic gastric bypass outcome during the learning curve.

The hundred most frequently cited studies on sleeve gastrectomy.

INTRODUCTION: Sleeve gastrectomy (SG) is one of the most popular bariatric operations and one of the most frequently studied areas in bariatric surgery. AIM: To summarise the characteristics of the most frequently cited studies focusing on SG. MATERIAL AND METHODS: We used the Web of Science database to identify all studies focused on SG published from 2000 to 2018. The term "sleeve gastrectomy" and synonyms were used to reveal the 100 most cited records. RESULTS: The most frequently cited publication had 493 citations. The highest mean number of citations per year was 73.00. Studies were most frequently published in the years 2010 and 2012. Articles were most commonly published in bariatric surgery-oriented journals. CONCLUSIONS: Our study indicates an increase in medical researchers' interest in the subject of SG and underlines the need to perform studies with a higher level of evidence to further analyse the outcomes and basic science behind SG.

Evaluation of the learning curve of transanal total mesorectal excision: single-centre experience.

INTRODUCTION: Transanal total mesorectal excision (TaTME) has been recently proposed to overcome the difficulties of the standard TME approach, allowing better visualization and dissection of the mesorectal fascia. Although TaTME seems very promising, the evidence and body of knowledge on achieving proficiency in performing it are still sparse. AIM: To evaluate the learning curve of TaTME based on a single centre's experience. MATERIAL AND METHODS: Consecutive patients undergoing TaTME since 2014 in a tertiary referral department were included in the study. All procedures were performed by one experienced surgeon. CUSUM curve analyses were performed to evaluate learning curves. RESULTS: Sixty-six patients underwent TaTME. After analysis of postoperative morbidity rate, intraoperative adverse effects and operative time, we estimated that 40 cases are needed to achieve TaTME proficiency. Subsequently, patients were divided into two groups: before (40 patients) and after overcoming the learning curve (26 patients). Group 1 had higher readmission (p = 0.041) and complication rates (p = 0.019). There were no statistically significant differences in terms of intraoperative adverse effects, length of stay or pathological quality of the specimen. CONCLUSIONS: Transanal total mesorectal excision is a promising yet technically demanding procedure and requires at least 40 cases to complete the learning curve. More data are needed to introduce it as a standard procedure for low rectal cancer treatment.

Integrative genomics reveal a role for MCPIP1 in adipogenesis and adipocyte metabolism.

Obesity is considered a serious chronic disease, associated with an increased risk of developing cardiovascular diseases, non-alcoholic fatty liver disease and type 2 diabetes. Monocyte chemoattractant protein-1-induced protein-1 (MCPIP1) is an RNase decreasing stability of transcripts coding for inflammation-related proteins. In addition, MCPIP1 plays an important role in the regulation of adipogenesis in vitro by reducing the expression of key transcription factors, including C/EBPß. To elucidate the role of MCPIP1 in adipocyte biology, we performed RNA-Seq and proteome analysis in 3T3-L1 adipocytes overexpressing wild-type (WTMCPIP1) and the mutant form of MCPIP1 protein (D141NMCPIP1). Our RNA-Seq analysis followed by confirmatory Q-RT-PCR revealed that elevated MCPIP1 levels in 3T3-L1 adipocytes upregulated transcripts encoding proteins involved in signal transmission and cellular remodeling and downregulated transcripts of factors involved in metabolism. These data are consistent with our proteomic analysis, which showed that MCPIP1 expressing adipocytes exhibit upregulation of proteins involved in cellular organization and movement and decreased levels of proteins involved in lipid and carbohydrate metabolism. Moreover, MCPIP1 adipocytes are characterized by decreased level of insulin receptor, reduced insulin-induced Akt phosphorylation, as well as depleted Glut4 level and impaired glucose uptake. Overexpression of Glut4 in 3T3-L1 cells expressed WTMCPIP1 rescued adipogenesis. Interestingly, we found decreased level of MCPIP1 along with an increase in body mass index in subcutaneous adipose tissue. The presented data show a novel role of MCPIP1 in modulating insulin sensitivity in adipocytes. Overall, our findings demonstrate that MCPIP1 is an important regulator of adipogenesis and adipocyte metabolism.

Post-occlusive reactive hyperemic response of skin microcirculation among extremely obese patients in the short and long term after bariatric surgery.

OBJECTIVE: To assess changes of post-occlusive reactive hyperemic response in skin microcirculation among extremely obese patients 10 days and 6 months after bariatric surgery for patients with and without hypertension. METHODS: Skin blood flow was measured using PeriFlux laser Doppler fluxmetry. Data were analyzed in the entire group and two subgroups: with and without hypertension. RESULTS: Data from 88 patients (mean age 42.1 ± 11.2 years, 40.5% men) were analyzed. Six months after bariatric surgery, the time to reach peak flows had been shortened (2.4 ± 1.7 vs 2.1 ± 1.0 seconds, P < .05) and the area of hyperemia had increased (1027 ± 791 vs 1386 ± 699 AU*s, P < .05). The total power of post-occlusive reactive hyperemic after occlusion had been augmented mainly with power intensification of endothelial and myogenic origin. Post-occlusive reactive hyperemic parameters had changed mainly in the subgroup with hypertension. Variations of anthropometric parameters, metabolic characteristic, and adipokines mainly influenced on studied hyperemic flow parameters variations after the intervention in multiple regression analysis. CONCLUSION: Cutaneous post-occlusive reactive hyperemic reactivity in time and frequency domains improved 6 months after bariatric surgery, and improvements in microvascular function were observed mainly in patients with hypertension. Variations of anthropometric parameters, metabolic characteristics, and adipokines had influence on hyperemic flow reactivity.

Decision-making based on 3D printed models in laparoscopic liver resections with intraoperative ultrasound: a prospective observational study.

OBJECTIVES: The aim of this study was to evaluate impact of 3D printed models on decision-making in context of laparoscopic liver resections (LLR) performed with intraoperative ultrasound (IOUS) guidance. METHODS: Nineteen patients with liver malignances (74% were colorectal cancer metastases) were prospectively qualified for LLR or radiofrequency ablation in a single center from April 2017 to December 2018. Models were 3DP in all cases based on CT and facilitated optical visualization of tumors' relationships with portal and hepatic veins. Planned surgical extent and its changes were tracked after CT analysis and 3D model inspection, as well as intraoperatively using IOUS. RESULTS: Nineteen patients were included in the analysis. Information from either 3DP or IOUS led to changes in the planned surgical approach in 13/19 (68%) patients. In 5/19 (26%) patients, the 3DP model altered the plan of the surgery preoperatively. In 4/19 (21%) patients, 3DP independently changed the approach. In one patient, IOUS modified the plan post-3DP. In 8/19 (42%) patients, 3DP model did not change the approach, whereas IOUS did. In total, IOUS altered surgical plans in 9 (47%) cases. Most of those changes (6/9; 67%) were caused by detection of additional lesions not visible on CT and 3DP. CONCLUSIONS: 3DP can be helpful in planning complex and major LLRs and led to changes in surgical approach in 26.3% (5/19 patients) in our series. 3DP may serve as a useful adjunct to IOUS. KEY POINTS: • 3D printing can help in decision-making before major and complex resections in patients with liver cancer. • In 5/19 patients, 3D printed model altered surgical plan preoperatively. • Most surgical plan changes based on intraoperative ultrasonography were caused by detection of additional lesions not visible on CT and 3D model.

Perioperative changes in lymphocyte subpopulations in patients undergoing surgery for colorectal cancer.

Surgical procedure has immense impact on the immune balance. However, little is known about perioperative changes in T regulatory and Th17 lymphocyte subpopulations in patients undergoing colorectal resection. Patients with resectable colon cancer were enrolled in the study. Blood samples were obtained on two occasions, i.e. before the procedure and two days after the surgery. We also recruited a control group of young, healthy individuals. Lymphocyte subpopulations were analyzed with the use of flow cytometry. Investigated subpopulations consisted of total lymphocyte count, CD4+, CD8+, T regulatory Foxp3+ (Tregs), Th17 lymphocytes and white blood cell (WBC) count. There were significant differences in immune cell levels before and after the surgery. Reduction was recorded in the CD4+, CD8+, Tregs and total lymphocyte counts (p=0.002, p=0.01, p=0.008 and p=0.001, respectively). Increase was observed in total WBC and Th17 cells, however, Th17 lymphocytes did not reach statistical significance (p=0.01 and p=0.5, respectively). In conclusion, surgical intervention caused changes in all lymphocyte subpopulations investigated in patients undergoing surgery for colorectal cancer. However, it seemed to be an effect of perioperative trauma. Further studies are needed to investigate the impact of surgical intervention on lymphocyte subpopulations.

Laparoscopic adrenalectomy - is it safe in hands of residents in training?

BACKGROUND: Laparoscopic adrenalectomy (LA) has become the "gold standard" for treating most adrenal tumors in the past decade. However, it is still considered a relatively complicated procedure requiring experience from surgeon. The aim of the study was to evaluate the safety of laparoscopic adrenalectomy performed by residents who are undergoing training in general surgery. METHODS: A prospectively collected database containing all 300 transperitoneal laparoscopic adrenalectomies performed in II Department of General Surgery JU MC, Krakow between January 2013 and March 2018 was retrospectively reviewed. Patients were divided into two groups; patients operated on by residents (group 1, 54 operations) and by attending general surgeons (group 2, 246 operations). We compared the course of the operation and patient hospitalization in these two groups. If the operation was completed by a different person than the one who started the procedure, we refer to this as "operator conversion". RESULTS: We found no differences in demographic factors or comorbidities between the two groups. The mean operative time was similar in the residents' and the specialists' groups (p = 0.5761). Median blood loss did not differ between the groups (p = 0.4325). The overall ratio of intraoperative adverse events was similar in both groups (p = 0.8643). The difference in the ratio of perioperative complications between the groups was not statistically significant (p = 0.6442). The average mean hospital stay after surgery was 2 days for both groups. We identified 25 cases (8.33%) of operator conversion; the difference in operator conversions between two groups was not statistically significant (p = 0.1741). CONCLUSIONS: Laparoscopic transperitoneal adrenalectomy performed by a supervised resident is a safe procedure. The course of the operation and patient hospitalization did not differ importantly when comparing procedures performed by residents and attending surgeons. Liberal use of operator conversions from resident to attending surgeon and from a surgeon to a senior surgeon provides reasonable safety and prevents complications. In high-volume centers performing minimally invasive techniques, closed supervision allows residents to safely perform LA.