Predictive Role of Admission Venous Lactate Level in Patients with Upper Gastrointestinal Bleeding: A Prospective Observational Study.

Upper gastrointestinal bleeding (UGIB) is one of the most common emergencies. Risk stratification is essential in patients with this potentially life-threatening condition. The aim of this prospective study was to evaluate the usefulness of the admission venous lactate level in predicting clinical outcomes in patients with UGIB. All consecutive adult patients hospitalized due to UGIB were included in the study. The clinical data included the demographic characteristics of the observed population, etiology of UGIB, need for surgical intervention and intensive care, bleeding recurrence, and mortality rates. Venous lactate was measured in all patients on admission. Logistic regression analyses were used to calculate the odds ratios (OR) of lactate levels for all outcomes. The receiver operating characteristic (ROC) curve was used to determine the accuracy of lactate levels in measuring clinical outcomes, while Youden index was used to calculate the best cut-off points. A total of 221 patients were included in the study (151M; 70F). There were 24 cases of UGIB recurrence (10.8%), 19 patients (8.6%) required surgery, and 37 individuals (16.7%) required intensive care. Mortality rate was 11.3% (25 cases). The logistic regression analysis showed statistically significant association between admission venous lactate and all clinical outcomes: mortality (OR = 1.39, 95%CI: 1.22-1.58, p < 0.001), recurrence of bleeding (OR = 1.16, 95%CI: 1.06; 1.28, p = 0.002), surgical intervention (OR = 1.17, 95%CI: 1.06-1.3, p = 0.002) and intensive care (OR = 1.33, 95%CI: 1.19-1.5, p < 0.001). The ROC curve analysis showed a high predictive value of lactate levels for all outcomes, especially mortality: cut-off point 4.3 (AUC = 0.82, 95%CI: 0.72-0.92, p < 0.001) and intensive care: cut-off point 4.2 (AUC = 0.76, 95%CI: 0.66-0.85, p < 0.001). Admission venous lactate level may be a useful predictive factor of clinical outcomes in patients with UGIB.

Use of inflammatory markers in the early detection of infectious complications after laparoscopic colorectal cancer surgery with the ERAS protocol.

INTRODUCTION: Thanks to laparoscopy and enhanced recovery protocols (ERAS) it is possible to shorten hospitalization. Therefore, it seems reasonable to search for new early markers of infectious complications in order to select patients who are prone to development of complications. AIM: To assess the usefulness of serum levels of C-reactive protein, interleukin-6 and procalcitonin as early indicators of infectious complications in patients after laparoscopic colorectal surgery with ERAS. MATERIAL AND METHODS: The prospective analysis included consecutive patients who underwent laparoscopic colorectal cancer resection. The following parameters were included in the analysis: C-reactive protein (CRP), interleukin 6 (IL-6) and procalcitonin measured on postoperative days (PODs) 1, 2, 3. Patients were divided into two groups: uncomplicated (group 1) and complicated (group 2). The difference in levels of the markers and the dynamics of changes observed in both groups were analyzed. RESULTS: Group 1 comprised 34 patients, and group 2 consisted of 17 patients. A significant increase of both absolute values and delta increments on all postoperative days was noted. ROC curve analysis showed that the best cut-off values indicating an infectious process were: CRP 129 mg/l on POD3 (92% sensitivity/80% specificity), IL-6 of 78 pg/ml on POD2 (91% sensitivity/97% specificity) and PCT 0.24 ng/ml on POD3 (93% sensitivity/68% specificity). CONCLUSIONS: Our study showed that regular measurement of all analyzed markers in the early postoperative days may be beneficial in the detection of postoperative infectious complications. Further studies are needed to fully assess the role of routine biochemical measurements in the postoperative period after laparoscopic surgery with the ERAS protocol.

Is the laparoscopic approach for rectal cancer superior to open surgery? A systematic review and meta-analysis on short-term surgical outcomes.

INTRODUCTION: Over the past years the incidence of colorectal cancers has increased worldwide. Currently it is the most common gastrointestinal malignancy worldwide. The laparoscopic approach has become the gold standard for surgical treatment. However, a recently published meta-analysis showed no difference in short- and long-term oncological outcomes of laparoscopy for treating rectal cancer. AIM: To assess current literature on short-term outcomes of rectal cancer treatment using laparoscopic surgery in comparison to the open approach. MATERIAL AND METHODS: We performed a systematic review and meta-analysis according to the PRISMA guidelines. The primary outcomes of interest were morbidity and short-term complications. RESULTS: We identified 4,328 potential references. In the end we included 13 randomized controlled trials (RCTs). We did not find any significant differences in terms of morbidity, haemorrhage, ureter injury, anastomotic leakage, mortality, intra-abdominal abscess or postoperative ileus. We found significant differences in the rate of surgical site infections, operative time, blood loss, length of hospital stay and time to first bowel movement. CONCLUSIONS: This systematic review based on available RCTs confirms that laparoscopic rectal cancer surgery is associated with short-term outcomes comparable to the open approach. Moreover, in some aspects it provides better results (e.g. functional postoperative recovery, lower rate of surgical site infections (SSIs)). The quality of evidence is high; therefore in our opinion it is very unlikely that future trials will alter these results, and for this reason the laparoscopic approach can be considered the gold standard for the treatment of the majority of patients.

Laparoscopic splenectomy for immune thrombocytopenia in patients with a very low platelet count.

INTRODUCTION: Laparoscopic splenectomy (LS) is the gold standard in treating immune thrombocytopenia (ITP). However, there are still some problems in decision-making when considering LS in patients with a very low platelet count (PLT). AIM: To evaluate safety outcomes of LS in patients with severe ITP and very low PLT in comparison to those with higher PLT. MATERIAL AND METHODS: We retrospectively analyzed consecutive patients who underwent LS in a single institution between April 1998 and December 2017. Perioperative care was based on an algorithm developed at our department which takes into consideration the patient's PLT level. Patients were divided into 2 groups depending on the PLT level (cut-off point 50,000/mm3). RESULTS: The mean operative time in the low PLT group and high PLT group was 90 ±42.1 min and 95 ±45 min, respectively (p = 0.59). Intraoperative blood loss was 144 ±226.1 ml in the low PLT group and 83 ±161.24 ml in the high PLT group (p = 0.23). Complications occurred in 5 (9.09%) patients in the low PLT group and 16 (11.51%) in the high PLT group (p = 0.67). There were no conversions in the group with lower PLT, while 2 patients in the group with higher PLT had to be converted to open surgery (p = 0.38). Patients with low PLT preoperatively more often required perioperative platelet transfusions (13 vs. 1, p < 0.001). CONCLUSIONS: Laparoscopic splenectomy is safe and feasible treatment in patients with ITP regardless of the PLT level. Still, patients with critical ITP and marginally low PLT require special awareness.

Comparison of the results of laparoscopic appendectomies with application of different techniques for closure of the appendicular stump.

BACKGROUND: Nowadays laparoscopy is used frequently not only in elective surgery but also in abdominal emergencies, including acute appendicitis. There are several techniques used to close the appendicular stump during laparoscopic appendectomy. The aim of the study was to present and compare the results of minimally invasive appendectomies performed with the use of endoscopic staplers (group A), titanium endoclips (group B) and invaginating sutures (group C). METHODS: Three hundred seven patients (mean age = 35.6; SD = 15.9; 178 males,129 females) operated on laparoscopically for acute appendicitis from January 2010 to December 2014 at our department were included in the study. We reviewed retrospectively patients' data including: age, sex, duration of the surgical procedure and hospital stay, mortality, intraoperative and postoperative complication rates in all analyzed groups. RESULTS: There were 102 patients in group A (mean age = 35.8;SD = 15.4; 57 males, 45 females). The average hospital stay in this group was 4.3 days (SD = 1.7), average operation time was 62.0 min (SD = 15), postoperative complication rate was 5.9 %. There were 160 patients in group B (mean age = 35.0; SD = 16.3; 96 males, 64 females). The average hospital stay in this group was 3.6 days (SD = 1.4), average operation time was 62.9 min (SD = 13.5), postoperative complication rate was 5.6 %. There were 45 patients in group C (mean age =37.3; SD = 15.8; 25 males, 20 females). The average hospital stay in this group was 4.6 days (SD = 2.0), average operation time was 73.9 min (SD = 20.8), postoperative complication rate was 6.7 %. There were no intraoperative complications and no mortality in all compared groups of patients operated on laparoscopically for acute appendicitis. CONCLUSIONS: Laparoscopic appendectomies with application of different techniques for closure of the appendicular stump are useful and safe. In our study the shortest hospital stay and lowest complication rate were observed in patients operated with the use of titanium endoclips. The longest hospital stay and operation time and the highest complication rate was associated with the use of invaginating sutures.

Laparosocopic Appendectomy, Cost-Effectiveness of Three Different Techniques Used to Close the Appendix Stump.

UNLABELLED: It is generally agreed that laparoscopic appendectomy is a valuable operative method. The aim of the study was to evaluate cost-effectiveness of three different techniques used to close the appendix stump. MATERIAL AND METHODS: We conducted a retrospective study that compared three groups of patients who were operated on laparoscopically for acute appendicitis in 2013 at our institution. We used an endoscopic clip to close the appendix stump in the first group (n=20), endoscopic stapler was applied in the second group (n=20), and in the third group of patients the appendix base was closed with a laparoscopic suture (n=20). These groups were matched by age, sex and BMI. RESULTS: The average operative cost was the highest in the second group. Cost of the laparoscopic appendectomy with the application of the endoscopic clip was significantly lower (first group) and comparable to the third group. Observed differences in total hospitalization costs were associated only with the chosen appendix stump closure technique. CONCLUSIONS: Clip closure of the appendix base is an easy and cost-effective procedure. The laparoscopic suture technique is the cheapest but technically demanding. According to our experience endoscopic stapler may be useful in some cases, although it is the most expensive method.

Results of laparoscopic appendectomies performed with the use of titanium clips for closure of the appendicular stump.

UNLABELLED: Nowadays laparoscopy is used frequently not only in elective surgery but also in abdominal emergencies, including acute appendicitis. There are several techniques used to close the appendicular stump during laparoscopic appendectomy. The aim of the study was to present the results of minimally invasive appendectomies performed with the use of titanium clips. MATERIAL AND METHODS: Patients operated on laparoscopically for acute appendicitis with the application of titanium clips between October 2012 and December 2013 were included in the study. We reviewed retrospectively patients` data including: age, sex, duration of the surgical procedure and hospital stay, mortality, intraoperative and postoperative complication rates. RESULTS: There were 93 patients (mean age=33.8 years, SD=15.23) in the analyzed group, including 60 men (mean age=33.5 years, SD= 15.07) and 33 women (mean age=33.9 years SD=15.26). The average duration of the surgical procedure was 66 min (SD= 33.15). The average length of hospital stay was 3.38 days (SD=1.62). No intraoperative complications were observed in the analyzed group. Post-operative complication rate was low (6 cases, 6.5%). No mortality was observed. CONCLUSIONS: Laparoscopic appendectomy with the application of titanium clips for closure of the appendicular stump is safe, associated with low complication rates and should be considered as a routine technique in everyday surgical practice.

Short- and long-term outcomes of incarcerated inguinal hernias repaired by Lichtenstein technique.

INTRODUCTION: The use of tension-free inguinal hernia repair techniques using commercially available implants is now rather common. However, it is widely accepted that the use of biomaterials should be limited to non-infected surgical fields. As such, most current studies pertain to the application of various implants during the surgical repair of uncomplicated hernias. AIM: To compare the short- and long-term outcomes of incarcerated inguinal hernia repair using the Lichtenstein or Bassini technique. MATERIAL AND METHODS: Between 1997 and 2012, 107 patients were operated on an emergency basis due to the incarceration of inguinal hernias - 105 subjects were included for further analysis in our study. RESULTS: Postoperative complications were observed in 13 out of the 84 (15.5%) patients subjected to Lichtenstein repair. In 9 of these patients (10.7%), morbidity was associated with the surgical wound. In 2 cases (2.4%), a small inflammatory infiltration was observed and resolved within a few days. Serous fluid accumulation within the wound was observed in 3 patients (3.6%), but the fluid was successfully drained by puncture. Finally, hematoma formed in 4 cases (4.8%). In total, 4 complications (19%) were recorded in the group of 21 patients who were operated on with the Bassini technique. In 3 of these cases (14.3%), the complications were related to suppuration of the surgical wound. CONCLUSIONS: Polypropylene mesh may be safely implanted during the repair of incarcerated hernia and this approach is reflected by satisfactory long-term outcomes.

Single-incision laparoscopic cholecystectomy--can we afford that? Cost comparison of different surgical techniques.

UNLABELLED: One of the most commonly performed surgeries in general surgery wards with laparoscopic technique as a method of choice is gall-bladder excision. In addition to -the commonly used conventional laparoscopic cholecystectomy single incision laparoscopic cholecystectomy is getting more and more attention. Despite many works and studies comparing these methods, there is still a shortage of results assessing efficiency of this new surgical technique. The aim of the study was to evaluate cost-effectiveness of this method in Polish financial reality. We have analyzed costs of three different surgical techniques: conventional (multi- incision) laparoscopic cholecystectomy, SILC and 'no-port' SILC. MATERIAL AND METHODS: We conducted a retrospective study that compared three groups of patients who underwent treatment with conventional laparoscopic cholecystectomy (n=20), SILC (n=20) and no-port SILC (n=20). These groups were matched by age, sex and BMI. Following parameters were analyzed: complication rate, operative time, operative costs, length of hospital stay, hospitalization costs. The SILC cases were performed with one of the three-trocar SILC ports available on the market. The 'no- port' SILC cases were performed by single skin incision in the umbilicus, insertion of one 10 mm trocar for the operating instrument, another instrument and scope were inserted directly thorough small incisions in the aponeurosis without a dedicated port RESULTS: The average operative cost was significantly higher in the SILC group comparing to the conventional laparoscopy group and the no-port SILC group. There was no significant difference in complication rate, operative time, length of hospital stay, or hospitalization costs between the three groups CONCLUSIONS: Currently the cost of the dedicated SILC port does not allow a regular use of this procedure in Polish financial reality. According to our experience improved cosmesis is the only advantage of the single incision laparoscopy, therefore we believe that it is reasonable to consider this technique in a a very selected group of patients.

Application of the single access technique in laparoscopic surgery.

UNLABELLED: Laparoscopic single access technique is a next step in development of minimally invasive surgery. The aim of the study was to present results of different laparoscopic single incision procedures and evaluate application of this technique. MATERIAL AND METHODS: 102 patients (15 males and 87 females) who underwent laparoscopic single incision procedure from 15th October 2009 to 31st December 2012 were included in the study. RESULTS: In the analyzed period we performed 72 cholecystectomies (70.6%), 8 left adrenalectomies (7.8%), 3 right adrenalectomies (2.9%), 7 splenectomies (6.9%), 5 spleen cysts unroofings (4.9%), 2 appendectomies (2%), 1 Nissen fundoplication procedure (1%), 1 removal of the adrenal cyst (1%) and 3 concomitant splenectomies and cholecystectomies (2.9%). There were 3 technical conversions to multiport laparoscopy, but no conversion to open technique. Complications were observed in 5 patients (4.9%). Average operation time was 79 min (SD=40), average hospitalization time 2.4 day (SD=1.4). CONCLUSIONS: Laparoscopic single incision technique is a safe method and can be used as a reasonable alternative to multiport laparoscopy in different minimally invasive procedures especially in young patients to whom an excellent cosmetic effect is particularly important.

[Tension-free technique for the repair of strangulated abdominal hernias]. / Beznapieciowa metoda leczenia uwieznietych przepuklin powlok brzucha.

There are just few studies regarding the use of tension-free techniques during the emergency operations of strangulated hernias among all the articles on the subject of surgical herniorrhaphy. Assessment of safety of the use of mono- or double-filament polypropylene mesh for the repair of strangulated hernia constituted the aim of the study. There were 81 inguinal and 34 other hernias (mostly incisional) in the group of 115 surgically treated patients with strangulated abdominal wall hernias. During the surgical operation in 84 patients strangulated bowel loop was reduced, 22 patients were treated with reduction of larger omentum, 7 patients required bowel resection (including 2 resections of Meckel diverticulum) and 2 resections of the omentum. All patients received prophylactic dose of broad-spectrum antibiotic during the surgical procedure and for 2-4 days after the operation. There were 15 cases of surgical site complications noted. Only two such cases (purulent infection in two patients and necrosis of wound margins in one) constituted potential threat to the implant. The incidence of local surgical complications was somewhat lower in the group of inguinal hernias as compared to the others (11.1% vs. 17.6%). The data from our study confirm the fact that mono- or double-filament polypropylene mesh can be safely used for the repair of strangulated hernia and the risk of local surgical complications is scant.

Is the Lichtenstein operation of strangulated groin hernia a safe procedure?

BACKGROUND: In spite of many published articles describing the hernia repairs, there are only a few original reports concerning the polymer mesh application during emergency procedures for strangulated inguinal hernias. The aim of our study was to evaluate the results of the Lichtenstein and Bassini operations for strangulated groin hernias and to show the changing number of the tension-free repairs. METHODS: From 1997 to 2004, the Bassini procedure was performed in 21 patients, 6 of whom underwent small intestine resection and 2 others required resection of the necrotic omentum. The strangulated intestinal loop or omentum were released in 13 cases. After the repair 1 patient died of shock caused by intestinal necrosis. Of 56 patients who underwent an emergency Lichtenstein procedure, 55 were followed-up. A small intestine resection was performed in 2 cases to correct segmental necrosis. The gangrenous omental appendix of the sigmoid colon was excised in 1 patient, and necrotic omental fragments were resected in 2 cases. The strangulated intestinal loop or omentum was released in 51 patients. All patients were given wide-spectrum antibiotics intravenously. RESULTS: Between 1997 and 2000 tension-free procedures were performed in half of the patients undergoing emergency operation for strangulated hernia; between 2001 and 2004 such procedures were employed in more than 90% of the cases. In 2 patients we observed a small inflammatory infiltration of the wound that resolved within several days after Lichtenstein repair. A serous fluid collection was present in 2 cases. The treatment consisted of puncture and was successful in both cases. CONCLUSIONS: The use of monofilament polypropylene mesh for strangulated inguinal hernia repair is safe, and the risk of the local infectious complications is low.

[Acute appendicitis--open or laparoscopic surgery?]. / Ostre zapalenie wyrostka robaczkowego--operacja technika klasyczna czy laparoskopowa?

UNLABELLED: Laparoscopy is used more and more frequently in the treatment of abdominal emergencies including acute appendicitis. This technique has a lot of advantages especially in the group of the young female patients, where the differential diagnosis between gynecological diseases and appendicitis is difficult. AIM OF THE STUDY: The study is designed to compare the results of open and laparoscopic exploration in patients with suspected appendicitis. MATERIAL AND METHODS: From 1998-2001 we performed 278 operations for suspicion of appendicitis in the 2nd Dept. of Surgery of the Jagiellonian University. There were 127 laparoscopic procedures performed in 46 men and 81 women (mean age 28.6 years) and 151 classical exploration in 99 men and 52 women (mean age 37.9 years). We reviewed retrospectively the patients' data analysing age, sex, duration of the procedure, length of the hospital stay, intraoperative and postoperative complication rate. RESULTS: The patients operated classically were older than patients operated laparoscopically. The proportion of male and female patients was reversed in both types of exploration. The female patients composed a majority (2/3) in the case of laparoscopic procedures and minority (1/3) in the case of open operations. The average duration of open appendectomy was 43 min. as compared with 49 min. of laparoscopic procedure, which was however getting shorter in the analysed period. The mean length of the hospital stay was twice shorter after laparoscopic appendectomy (4.8 days vs 8.4 days). There were only 4 (3.15%) complications connected with laparoscopic technique and 34 (22.52%) complications after open appendectomy. There were 12 (9.45%) conversions, most of them in patients with the retrocoecal position of the appendix. The diagnosis of acute appendicitis was confirmed in similar percentage in both operation types (laparoscopy--78.74%, open technique--79.47%). There were also similar proportions of the patients with no macroscopical changes in the appendix and with other abdominal diseases. CONCLUSIONS: Laparoscopy allows for the precise diagnosis and final treatment in most patients with the suspected acute appendicitis. Some patients also avoid laparotomy. Hospital stay is significantly shorter and complication rate is markedly lower among patients operated laparoscopically.

[Maffucci's syndrome with giant tumor of the thoracic wall]. / Zespól Maffucciego z olbrzymim guzem powlok klatki piersiowej.

Maffucci's syndrome is a rare nonhereditary malformation of mesodremal dysplasia origin which consists of multiple hemangiomas of the soft tissue and multiple enchondromas. Only approximately 170 cases of this disease have been reported in the literature. Maffucci's syndrome is known to be associated with tumors of mesodermal origin. Chondrosarcoma, osteosarcoma and angiosarcoma are the most common malignant neoplasms and the benign tumors consist of pituitary adenoma, adrenal cortical adenoma, parathyroid adenoma, thyroid adenoma and breast fibroadenoma. We present a case report of a 26-year old female patient with Maffucci's syndrome and a giant thorax tumor composed of fibroadenoma and canalicular adenoma.

[The decade of laparoscopic cholecystectomy]. / Dekada cholecystectomii laparoskopowej.

The role of laparoscopy in the treatment of gallbladder stones has been discussed. Operative technique, intraoperative difficulties, complications and its treatment were presented. Indications, postoperative course, advantages and drawbacks of minimally invasive techniques in the treatment of cholelithiasis were discussed.

[Type 1 carcinoids and ECL-cell hyperplasia of the gastric mucosa]. / Rakowiaki typu 1 i rozrosty z komórek ECL blony sluzowej zoladka.

Carcinoids develop from neuroendocrine cells. These cells share the same origin from ancestor stem cells in the regenerative zone of the gut. There are a few types of neuroendocrine cells in the stomach, mainly: G cells (antrum), D cells (corpus and antrum), ECL cells (corpus and fundus), D1 cells, EC cells, P cells and X cells. Each type of the endocrine cell is able to a tumor formation, but the gastric carcinoids are most likely to derive from ECL cells. The dominant type of cells of the corpus and fundus mucosa are the ECL cells. They constitute up to 30-40% of the neuroendocrine cells of the stomach and release histamine which is responsible for parietal cells stimulation. Hypergastrinemia predisposes ECL cells to proliferation. There is a continuity of changes ranging from simple hyperplasia to ECL cells carcinoids (often multiple). Among three types of gastric carcinoids, type three is aggressive and highly malignant, while type one is the most common but of low malignant potential. This publication presents 7 patients with extensive ECL cells hyperplasia and type 1 gastric carcinoids. The endocrine cells and carcinoids were visualized with the immunohistochemical reaction to chromogranin A. Prolonged, lasting several years observations of some of the patients under study confirm the indolent character of the disease. Individual, type-adapted, conservative treatment is sufficient.

[Laparoscopy in abdominal emergencies]. / Laparoskopia ze wskazan doraznych.

Up-to-dated concepts about the use of laparoscopy in the "acute abdomen" have been discussed. Most frequently performed procedures in abdominal emergencies and trauma were presented. Indications, contraindications, advantages and drawbacks with regard to own experience and literature were discussed.

Lichtenstein repair for incarcerated groin hernias.

OBJECTIVE: To evaluate the use of Lichtenstein tension-free repair for incarcerated groin hernias. DESIGN: Prospective consecutive series. SETTING: Tertiary academic surgery department, Poland. SUBJECTS: 27 patients whose incarcerated groin hernias were operated on between November 1997 and June 2001. INTERVENTION: Tension-free hernia repair by the Lichtenstein technique. MAIN OUTCOME MEASURES: Morbidity, recurrence rates and mortality. RESULTS: There were 2 postoperative deaths unrelated to implantation of the mesh (myocardial and cerebral infarction). In 1 patient a subcutaneous fluid collection was noted and was successfully treated by evacuation of the fluid. The remaining 24 patients had no complications during follow-up (mean 18 months, range 2-42 months). CONCLUSION: Monofilament polypropylene mesh can be successfully used not only in elective operations, but also in emergency operations for incarcerated inguinal hernias.