Atypical Locations of Renal Cell Carcinoma Metastases to the Pancreas and Duodenum.

INTRODUCTION: Pancreatic tumors account for a small percentage of all malignancies. Most of them are primary and originate from cells of the exocrine pancreas. The remaining primary changes are neuroendocrine tumors. The pancreas may also be a target of metastatic lesions. The most common cancer that metastasizes to the pancreas is renal cell carcinoma. CASE STUDIES: The paper presents two cases of rare metastases to organs of the abdominal cavity: the first patient treated surgically due to two metastatic lesions of renal cell carcinoma in the pancreas, diagnosed many years after radical nephrectomy. The second case of high gastrointestinal obstruction in the course of metastasis of renal cell carcinoma to the duodenum. The first patient underwent distal laparotomic resection of the pancreas. The second patient underwent resection of the duodenum and the first jejunal loop with side-to-side duodeno-jejunal anastomosis. Both patients remain under oncological supervision. CONCLUSION: Patients after radical nephrectomy due to renal cell carcinoma require long-term systematic monitoring. Due to the anatomical position of the pancreas and duodenum as well as the number, location and size of metastatic lesions, the course of the disease may be initially asymptomatic or oligosymptomatic. Aggressive surgical treatment of pancreatic metastases creates opportunities for long-term survival.

The correlation of crystalline and elemental composition of urinary stones with a history of bacterial infections: TXRF, XRPD and PCR-DGGE studies.

The aim of this study was to analyze the correlation between past bacterial infections and the type and chemical composition of urinary stones experienced by human patients. Bacteria have been recognized to contribute to urinary stones; however, the role of uropathogens in the development of specific stones has not been extensively investigated. The detection of past bacterial infection (eleven different bacterial species) in urinary stones from 83 patients was made on a DNA level using polymerase chain reaction (PCR) and denaturing gradient gel electrophoresis (DGGE) and correlated with the chemical composition of urinary stones measured using X-ray powder diffraction (XPRD) technique and their elemental composition by total reflection X-ray fluorescence (TXRF). In this study, two scenarios of urinary stones formation mediated by Proteus sp. or Escherichia coli are presented. The first one is associated with Proteus spp. which dominated in 84% of infectious urinary stones and is strongly correlated with struvite and calcium phosphate, in whose matrix additionally strontium, phosphorus, potassium, nickel and zinc are detected. The formation of these stones is closely correlated with urease activity. The second scenario for urinary stone mineralization is associated with E. coli identified in weddellite stones, in which matrix iron was detected. In conclusion, the statistical correlations of bacterial infections with crystalline and elemental composition showed that in mixed bacterial infections, one scenario dominated and excluded the second one.

Oesophageal perforation - therapeutic and diagnostics challenge. Retrospective, single-center case report analysis (2009-2015).

BACKGROUND: Esophageal perforation is a life-threatening condition of a complex etiology. No clear guidelines are available regarding the management of this condition. In this study, we review publications related to esophageal perforation, and analyze patients treated for this condition at our Department of Thoracic, General and Oncological Surgery. OBJECTIVE: The objective of the study was to retrospectively assess and analyze management methods for esophageal perforations of different etiologies. All patients were treated in the Department of Thoracic, General and Oncological Surgery in years 2009-2015. Patients with perforations resulting from post-operational leaks within surgical anastomoses were excluded from the study. Material, methods, results: The analysis involved a total of 16 cases of esophageal ruptures. All cases were treated in years 2009-2015. Patients with perforations resulting from postoperative leaks within surgical anastomoses following elective surgeries for either oncological or non-oncological causes were excluded. The most common reason for esophageal rupture was iatrogenic injury (7 cases, 44%). Other causes included Boerhaave syndrome (5 cases, 31.2%), blunt trauma (2 cases, 12.5%), abscess perforation (1 case, 6.2%), and ulcer perforation (1 case, 6.2%). Ten patients underwent surgery, and the rest underwent esophageal prosthesis placement, of whom 2 cases required drainage of the mediastinum and pleural cavity. The mortality rate in the study group was 9/16 cases (56.2%). CONCLUSIONS: Esophageal perforation poses a significant interdisciplinary challenge regarding diagnostic workup, selection of treatment methods, and management of potential postoperative complications. This retrospective study was conducted in a single center. Although the analyzed period was long, we found only 16 cases. In spite of a variety of etiologies present, we found several statistically significant results of potential clinical value. 1. Most perforations that are not diagnosed within 48 hours affected the lower part of the esophagus and presented with unclear symptoms and imaging findings 2. Delaying diagnosis and treatment beyond 24 hours was associated with a higher mortality rate.

Comparison of treatment costs of laparoscopic and open surgery.

INTRODUCTION: Laparoscopy has been a standard procedure in most medical centres providing surgical services for many years. Both the range and number of laparoscopic procedures performed are constantly increasing. Over the last decade, laparoscopic procedures have been successfully applied both in emergency and oncological surgery. However, treatment costs have become a more important factor in choosing between open or laparoscopic procedures. AIM: To present the total real costs of open and laparoscopic cholecystectomy, appendectomy and sigmoidectomy. MATERIAL AND METHODS: Between 1 May 2010 and 30 March 2015 in the Department of Thoracic Surgery, General and Oncological Surgery, Medical University of Lodz, and in the Department of General Surgery of the Saint John of God Hospital, Lodz, doctors performed 1404 cholecystectomies, 392 appendectomies and 88 sigmoidectomies. A total of 97% of the cholecystectomy procedures were laparoscopic and 3% were open. Similarly, 22% of total appendectomies were laparoscopic and 78% were open, while 9% of sigmoidectomies were laparoscopic and 91% open. RESULTS: The requirement for single-use equipment in laparoscopic procedures increases the expense. However, after adding up all other costs, surprisingly, differences between the costs of laparoscopic and open procedures ranged from 451 PLN/€ 114 for laparoscopic operations to 611 PLN/€ 153 for open operations. CONCLUSIONS: Laparoscopic cholecystectomy, considered the standard surgery for treating gallbladder diseases, is cheaper than open cholecystectomy. Laparoscopic appendectomy and sigmoidectomy are safe methods of minimally invasive surgery, slightly more expensive than open operations. Of all the analyzed procedures, one-day laparoscopic cholecystectomy is the most profitable. The costs of both laparoscopic and open sigmoidectomy are greatly underestimated in Poland.

Strangulation of a Meckel's diverticulum in a femoral hernia (Littre's hernia).

Femoral hernia is usually presented as a flexible, round, domed shape lying on the medial side of the thigh about 2-3 cm below the inguinal ligament. Among the external hernias, femoral hernia is the second most common inguinal hernia. Its prevalence reaches 20%. Among all inguinal hernias, femoral hernias are characterised by a high level of incarceration and strangulation. This can be as high as 60%. We would like to present a case of 71-year-old patient who was admitted to the Clinic urgently due to strangulation of Meckel's diverticulum in a right-sided femoral hernia. Strangulation of Meckel's diverticulum in femoral hernia is an extremely rare entity. It was described for the very first time in 1700 by Littre.

Application of biochemical markers CA 19-9, CEA and C-reactive protein in diagnosis of malicious and benign pancreatic tumors.

INTRODUCTION: We would save many lives and spare a lot of suffering if we could only detect and accurately determine the character and TMN staging of pancreatic tumors (PTs). With improved diagnosis, we could offer specific treatment that would result in better treatment outcome. The aim of study was to determine the significance of neoplastic markers CA 19-9 and CEA for prognosis in inflammatory and carcinomatous PTs. MATERIAL AND METHODS: We based our research upon a group of 170 patients. The patients were treated in our Oncologic Surgery Department from January 2007 to December 2010 for PTs. The patients were divided into four groups depending on the character of the tumor and underwent the following treatments: group 1 - 34 patients with carcinoma of the ampulla of Vater, group 2 - 64 patients with PTs at different stages (1, 2, 3) according to TMN classification, group 3 - 62 patients with PTs at stage 4 on the TMN scale (unresectable tumors), group 4 - 28 patients with inflammatory PTs. RESULTS: The results of Ca 19-9 in group 2 were 736.00 (25-75% 220.40-4285.00) ng/ml before surgery, 53.00 (25-75% 12.60-84.00) ng/ml in the 7 days after surgery, 29.4 (25-75% 7.90-113.00) ng/ml at day 30, and 119.00 (25-75% 96.30-621.00) ng/ml 3 months after the operation. These results were significantly higher than the control group but were significantly lower than the results for group 3 (unresectable tumors). The highest average concentration and median for CA 19-9 and CEA were noted in patients with unresectable PTs (the 3(rd) group). The average concentration for CEA was lowest in group 4, but much higher than the lab limits. CONCLUSIONS: The sensitivity of the CA 19-9 marker may be as high as 88%. Values of CA 19-9 above 852 U/ml may indicate TNM stage 4, consistent with an unresectable PT. In the cases where CA 19-9 is within normal limits but C-reactive protein is above normal limits (often thirty times the upper limit), in comparison to the control group and to patients with pancreatic neoplasms, strong consideration should be given towards the inflammatory characteristics of the pancreatic changes and conservative treatment should be applied.

Assessment of adhesion formation after laparoscopic intraperitoneal implantation of Dynamesh IPOM mesh.

INTRODUCTION: Formation of adhesions after laparoscopic hernia repair using the intra-peritoneal onlay mesh (IPOM) procedure can lead to intestinal obstruction or mesh erosion into intestinal lumen. The aims of this study included: measurement of adhesion formation with Dynamesh IPOM after laparoscopic intraperitoneal implantation, and assessment of the occurrence of isolated adhesions at the fastening sites of slowly absorbable sutures. MATERIAL AND METHODS: Twelve healthy pigs underwent laparoscopic implantation of 2 Dynamesh IPOM mesh fragments each, one was fastened with PDSII, and the other with Maxon sutures. An assessment of adhesion formation was carried out after 6 weeks and included an evaluation of surface area, hardness according to the Zhulke scale, and index values. The occurrence of isolated adhesions at slowly absorbable suture fixation points was also analyzed. RESULTS: Adhesions were noted in 83.3% of Dynamesh IPOM meshes. Adhesions covered on average 37.7% of the mesh surface with mean hardness 1.46 and index value 78.8. In groups fixed with PDS in comparison to Maxon sutures adhesions covered mean 31.6% vs. 42.5% (p = 0.62) of the mesh surface, mean hardness was 1.67 vs.1.25 (p = 0.34) and index 85.42 vs. 72.02 (p = 0.95). CONCLUSIONS: The Dynamesh IPOM mesh, in spite of its anti-adhesive layer of PVDF, does not prevent the formation of adhesions. Adhesion hardness, surface area, and index values of the Dynamesh IPOM mesh are close to the mean values of these parameters for other commercially available 2-layer meshes. Slowly absorbable sutures used for fastening did not increase the risk of adhesion formation.

The estimation of metaloproteinases and their inhibitors blood levels in patients with pancreatic tumors.

BACKGROUND: The aim of the study was to evaluate the concentration of proteolytic enzymes, MMP-2 and MMP-9, and their tissue inhibitors, TIMP-1 and TIMP-2, in the blood of patients with benign and malignant pancreatic tumors. METHODS: MMP-2, MMP-9, TIMP-1, and TIMP-2 were evaluated in the patients with benign and malignant pancreatic tumors before surgery and in the 30-day follow-up. The study covered 134 patients aged 54 to 76 years, who were divided into groups by TNM staging. RESULTS: Before the operation, the highest mean concentration of MMP-2 was found in patients with unresectable cancer, whereas the highest level of MMP-9 was in patients with resectable cancer. The highest level of TIMP-1 was noted in patients with inflammatory tumors. In 1 month following the operation, the highest level of MMP-2 was also in patients with unresectable cancer and the highest level of TIMP-2 in patients with inflammatory tumors. CONCLUSIONS: The evaluation of the level of the studied cytokines in the pancreatic tumor patients can be diagnostically significant in the differentiation of benign and malignant changes. The changes in the levels of the studied enzymes and their inhibitors can have a prognostic value in the clinical severity of pancreatic cancer.

Isolated retroperitoneal mixed germ cell tumor presenting as acute abdomen - case report.

Extragonadal germ cell tumors are an uncommon clinical entity. Their prevalence varies between 1 and 5% of all germ cell tumors. Approximately 85-90% of cases have metastatic changes at the time of diagnosis. In our article we would like to present a case of an 18-year-old patient who was admitted to the hospital due to acute abdominal symptoms. A day earlier, the patient suffered blunt abdominal trauma during workout. Post-traumatic changes, which were described after admission in computed tomography, intraoperatively proved to be masses of extraperitoneal tumor.

Giant mesentery fibromatosis presenting as acute abdomen - case report.

Mesentery fibromatosis, also called abdominal desmoid, is a rare clinical entity. It is part of the clinical-pathologic spectrum of so-called deep fibromatoses. The deep fibromatoses encompass a group of benign fibroproliferative processes that are locally aggressive; they may infiltrate the adjacent organs or recur, but do not create distant metastatic lesions. The small bowel mesentery is the most common site of intraabdominal fibromatosis. However, the omentum, ileocolic mesentery, transverse or sigmoid mesocolon, or ligamentum teres may be the site of origin for intraabdominal fibromatosis. Mesenteric fibromatosis occurs in a wide age range of patients, and has no gender or race predilection. Most cases of abdominal fibromatosis occur sporadically. In this article we would like to present a case report of a patient who was admitted to the clinic due to severe abdominal pain with clinically advanced peritoneal signs. The intraoperative findings were astonishing; we found a giant desmoid which originated in the mesentery. The tumor oppressed the ileum, leading to its obstruction.

A case of upper gastrointestinal acute bleeding as a complication of renal carcinoma metastases to the papilla Vateri.

Acute bleeding from metastatic tumour of the papilla Vateri is an extremely rare case. In this report the case of a woman who suffered from complications after a metastatic tumour of the papilla is described. Seventeen years following resection of the kidney due to clear cell carcinoma the patient was admitted to the clinic because of massive bleeding (Forrest IB) to the upper digestive tract in the form of sanguineous vomiting. The conducted diagnostics revealed a bleeding tumour of the papilla Vateri. Endoscopic treatment could not effectively stop the bleeding. A surgical procedure was performed by Whipple's method. A histopathological examination showed a metastatic clear cell tumour of the kidney. The patient was discharged from hospital on the 8(th) day following her admission and was also referred for further oncological treatment. The discussion is based on other cases of rare bleeding from the digestive tract within tumours of the bile duct and papilla Vateri.

Evaluation of the effectiveness of thoracic sympathectomy in the treatment of primary hyperhidrosis of hands and armpits using the measurement of skin resistance.

INTRODUCTION: Hyperhidrosis is excessive sweating beyond the needs of thermoregulation. It is disease which mostly affects young people, often carrying a considerable amount of socio-economic implications. Thoracic sympathectomy is now considered to be the "gold standard" in the treatment of idiopathic hyperhidrosis of hands and armpits. AIM: Assessment of early effectiveness of thoracic sympathectomy using skin resistance measurements performed before surgery and in the postoperative period. MATERIAL AND METHODS: A group of 20 patients with idiopathic excessive sweating of hands and the armpit was enrolled in the study. Patients underwent two-stage thoracic sympathectomy with resection of Th2-Th4 ganglions. The skin resistance measurements were made at six previously designated points on the day of surgery and the first day after the operation. RESULTS: In all operated patients we obtained complete remission of symptoms on the first day after the surgery. Inhibition of sweating was confirmed using the standard starch iodine (Minor) test. At all measurement points we obtained a statistically significant increase of skin resistance, assuming p < 0.05. To check whether there is a statistically significant difference in the results before and after surgery we used sequence pairs Wilcoxon test. CONCLUSIONS: Thoracic sympathectomy is an effective curative treatment for primary hyperhidrosis of hands and armpits. Statistically significant increase of skin resistance in all cases is a good method of assessing the effectiveness of the above surgery in the early postoperative period.

Gastric tube resection due to metachronic cancer and a recurrence in anastomosis after Ivor-Lewis esophagectomy--case report.

Gastric tube after esophagectomy can be the site of local recurrence or the development of second primary tumor which implies poor prognosis. The study presents an extremely rare case of a patient after Ivor-Lewis esophagectomy for squamous cell carcinoma, in whom there was detected local recurrence in the anastomosis associated with metachronous primary tumor in gastric tube. Esophageal reresection with the upper part of the stomach was performed. Left colonic segment supplied by middle colic vessels transposed through retrosternal route was used as new esophageal substitute.

Comparison of early results of surgical treatment in patients with pancreatic cancer.

UNLABELLED: Pancreatic tumours are a serious medical and social issue. Patients come to the doctor too late, when the disease is well advanced. The most frequently applied method of surgical treatment is pancreatoduodenectomy (Whipple procedure). The most frequently used technique of pancreatoduodenectomy is the Child-Waugh method. The procedure can be performed in a classic way or as modified by Traverso (with preservation of the pylorus). MATERIAL AND METHODS: Between August 2008 and June 2011, in the Department of Thoracic, General and Oncologic Surgery of Medical University in Lódz, a total of 79 patients with pancreatic tumours were hospitalized. In 61, pancreatoduodenectomy was performed. The patients were divided into two groups, depending on the diagnosis and the procedures performed: group 1 comprised patients in whom the pylorus was resected (n = 43); group 2 comprised patients in whom the pylorus was preserved (Traverso-Longmire procedure; n = 18). RESULTS: Mean duration of surgery was about 3 hours and 50 minutes in both groups. Mean duration of hospitalization after the procedure was 15.6 days in group 1 and 12.2 days in group 2 (p < 0.05). Early complications (within 30 days of the procedure) were observed in 33.2% of patients in both groups. Blood transfusion was necessary in 21% of patients in group 1 and 28% of patients in group 2 (p>0.05). CONCLUSIONS: There are specific indications for each method of surgical treatment, however, it seems that both techniques of pancreatic resection can be recommended as standard surgical treatment, and the number of complications after both procedures is similar.

Assessment of quality of life in patients with non-operated pancreatic cancer after videothoracoscopic splanchnicectomy.

INTRODUCTION: Pancreatic tumours are a crucial medical issue. The majority of patients report sick in the late stage of carcinoma clinical advancement, which considerably limits the possibility of surgical treatment. Pancreatic cancer patients with no other alternative but palliative treatment constitute a large group. AIM: To assess pain intensity levels and quality of life of pancreatic cancer patients after videothoracoscopic splanchnicectomy. MATERIAL AND METHODS: Between 2001 January and 2010 November in the Department of Thorax, General Surgery and Oncology of the Medical University of Lodz 262 patients with pancreatic tumours were hospitalized. In 121 cases grade 3 and grade 4 tumours were observed. Hundred and twenty-one videothoracoscopic procedures of sympathetic trunk and ganglion excision were performed in 89 patients. RESULTS: Before the procedure the pain intensity level according to VAS was 5.66 (3.9-7.2; SD 1.24) in the trial group and 5.46 (4.1-7.1; SD 1.15) in the control group. The quality of life average assessment in both groups did not differ statistically (p = 1.07) and was 46.3 (32-66; SD 0.92) in patients before the operation and in the control group 50.3 (41-63; SD 0.75). On the 7(th) postoperative day the pain intensity on average was 2.33 (1.2-3.9; SD 0.78) and 4.57 (3.6-5.5; SD 0.69) respectively. One week after the procedure the quality of patients' life was estimated at 64.1 (39-83; SD 1.38) and in the control group at 52.2 (42-65; SD 0.71); the differences are significant (p < 0.05). Thirty days after the procedure 12 patients did not take any painkillers (13.5%), and in the others a considerable decrease of the taken drugs was observed. On average, the pain intensity was estimated at 1.78 (0.6-3.6; SD 0.68). The quality of life, on the other hand, improved considerably in relation to the state prior to the procedure, but increased insignificantly in relation to the state on the 7(th) postoperative day to 70.9 (52-88; SD 1.14). CONCLUSIONS: Splanchnicectomy is a safe method of cancer pain treatment in patients with advanced pancreatic tumours. Videothoracoscopic excision of visceral nerve thoracic section contributes to the statistically significant decrease of cancer pain intensity and considerably improves the quality of patients' lives.

[Methods of treatment on different clinical stages in pancreatic cancer]. / Sposoby postepowania na róznych stopniach zaawansowansowania klinicznego raka trzustki.

UNLABELLED: Pancreatic cancer is a great surgical problem. Clinical observations confirm 10-15% level of R0 resection ability. Dissatisfying treatment effects results from: lach of simple screening tests, low specificity of methods used to diagnose less than 2 cm lesions, low availability of advanced diagnostic methods (endoscopic ultrasonography), anatomy of pancreatoduodenic area, ability of infiltration adhering structures and causing metastatic tumors. AIM: Retrospective evaluation of treatment methods administered to patients with pancreatic cancer according to different clinical stages. MATERIAL AND METHODS: Medical documentation of 97 patients treated during 2001-2006 period for pancreatic cancer was analyzed. The age of patients was 42-90 years (medium 66.04, SD 10.27). There were 47 women (48.45% of group) aged 43-90 (medium 67.89, SD 9.93) and 50 men (51.55%) aged 42-86 (medium 64.31, SD 10.64). RESULTS: In analyzed group 87 tumors were located in the head of pancreas, 5 in the corpus and 5 in the cauda. In 13 cases (13.40%) partial resection of pancreas was performed. By passing anastomoses were applied in 45 cases: 26 (26.80% of total group) biliar and gastrointestinal, 19 (19.59%) only biliar anastomoses. Thoracovideoscopic splanchnicectomy was performed 26 times (26.80%) as a method of decreasing pain. 6 patients were treated with bile ducts drainage: endoscopic (4) or percutaneous (2). In 7 cases operations were limited to explorative laparotomy. Complication occurred in 5 (38.46%) cases following resection of the pancreas and 13 cases (15.38%) following paliative operations. Perioperative mortality accomplished 15.38% following pancreatic resection and 4.44% in remaining cases. CONCLUSIONS: Pancreatic cancer is a neoplasm connected with unsuccessfull course. In most of cases diagnose is confirmed in clinical stage that disables resection with the aim of curation. Although huge progress in diagnostic methods, operational technique and perioperative care postoperative mortality is high. Videothoracoscopic splanchnicectomy is a worth reccomending method of decreasing pain.

[Thoracoscopic splanchnicectomy--a good therapy of chronic pain related with advanced stage pancreatic cancer]. / Torakoskopowa splanchnicektomia jako metoda leczenia bólu przewleklego u pacjentów z zaawansowanym rakiem trzustki.

At the beginning 1990s, rapid development of videooptic techniques made possible the introduction to the practice, modern method--thoracoscopic splanchnicectomy. This is a little invasive method use in chronic epigastric visceral pain therapy. The aim of the study is presentation of our own experiences in use thoracoscopic splanchnicectomy in therapy of chronic pain related with advanced stage pancreatic cancer. MATERIAL AND THE METHODS: From 2001 to 2006 in the Department of Chest Surgery, Oncologic and General Surgery, University Hospital No. 2, Medical University of Lodz was made 26 thoracoscopic splanchnicectomy at patients with pancreas cancer. Patients were qualified to the operation on the basis of the Prince Henry Hospital Pain Scale (PHHPS)--medially 2.8 the point. In examined group were 16 men (61%) and 10 women (39%). The average age was 58 years. RESULTS: After the operation obtained the significant decrease of the pain intensity, in the third day after surgery patients ranked their epigastric pain at the average of 1.3 the point in PHHPS. All patients could to decrease significantly the doses of their analgesic medications and three from them completely put it away. CONCLUSIONS: Thoracoscopic splanchnicectomy is effective little invasive method therapy of chronic pain related with advanced stage pancreatic cancer.