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

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

What determines complications and prognosis among patients subject to multivisceral resections for locally advanced gastric cancer?

BACKGROUND: Locally advanced gastric cancer (GC) extending to the surrounding tissues may require a multivisceral resection (MVR) to provide the best chance of cure. However, little is known about how the extent of organ resection affects the risks and benefits of surgery. METHODS: An electronic database of patients treated between 1996 and 2020 in an academic surgical centre was reviewed. MVRs were defined as partial or total gastrectomy combined with splenectomy, distal pancreatectomy, or partial colectomy. RESULTS: Suspected intraoperative tumour invasion of perigastric organs (cT4b) was found in 298 of 1476 patients with non-metastatic GC, and 218 were subject to MVRs, including the spleen (n = 126), pancreas (n = 51), and colon (n = 41). MVRs were associated with higher proportions of surgical and general complications, but not mortality. A nomogram was developed to predict the risk of major postoperative morbidity (Clavien-Dindo's grade ≥ 3a), and the highest odds ratio for major morbidity identified by logistic regression modelling was found for distal pancreatectomy (2.53, 95% CI 1.23-5.19, P = 0.012) and colectomy (2.29, 95% CI 1.04-5.09, P = 0.035). Margin-positive resections were identified by the Cox proportional hazards model as the most important risk factor for patients' survival (hazard ratio 1.47, 95% CI 1.10-1.97). The extent of organ resection did not affect prognosis, but a MVR was the only factor reducing the risk of margin positivity (OR 0.44, 95% CI 0.21-0.87). CONCLUSIONS: The risk of multivisceral resections is associated with the organ being removed, but only MVRs increase the odds of complete tumour clearance for locally advanced gastric cancer.

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.

Textbook Oncological Outcome in European GASTRODATA.

OBJECTIVE: To assess the rate of textbook outcome (TO) and textbook oncological outcome (TOO) in the European population based on the GASTRODATA registry. BACKGROUND: TO is a composite parameter assessing surgical quality and strongly correlates with improved overall survival. Following the standard of treatment for locally advanced gastric cancer, TOO was proposed as a quality and optimal multimodal treatment parameter. METHODS: TO was achieved when all the following criteria were met: no intraoperative complications, radical resection according to the surgeon, pR0 resection, retrieval of at least 15 lymph nodes, no severe postoperative complications, no reintervention, no admission to the intensive care unit, no prolonged length of stay, no postoperative mortality and no hospital readmission. TOO was defined as TO with the addition of perioperative chemotherapy compliance. RESULTS: Of the 2558 patients, 1700 were included in the analysis. TO was achieved in 1164 (68.5%) patients. The use of neoadjuvant chemotherapy [odds ratio (OR) = 1.33, 95% CI: 1.04-1.70] and D2 or D2+ lymphadenectomy (OR = 1.55, 95% CI: 1.15-2.10) had a positive impact on TO achievement. Older age (OR = 0.73, 95% CI: 0.54-0.94), pT3/4 (OR = 0.79, 95% CI: 0.63-0.99), ASA 3/4 (OR = 0.68, 95% CI: 0.54-0.86) and total gastrectomy (OR = 0.56, 95% CI: 0.45-0.70), had a negative impact on TO achievement. TOO was achieved in 388 (22.8%) patients. Older age (OR = 0.37, 95% CI: 0.27-0.53), pT3 or pT4 (OR = 0.52, 95% CI: 0.39-0.69), and ASA 3 or 4 (OR = 0.58, 95% CI: 0.43-0.79) had a negative impact on TOO achievement. CONCLUSIONS: Despite successively improved surgical outcomes, stage-appropriate chemotherapy in adherence to the current guidelines for multimodal treatment of gastric cancer remains poor. Further implementation of oncologic quality metrics should include greater emphasis on perioperative chemotherapy and adequate lymphadenectomy.

Difficulties in the diagnosis and treatment of ruptured pheochromocytoma.

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

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

Selected Body Composition Parameters Analysis Based on Bioelectrical Impedance in Patients Operated for Gastrointestinal Cancer.

BACKGROUND/AIM: Bioelectrical Impedance Analysis is a method that evaluates body composition, useful in assessing the nutritional status of cancer patients. The analysis of its indicators may be helpful in predicting clinical course. The aim of the study was to evaluate the following body composition parameters: fat mass (FM), fat-free mass (FFM), skeletal muscle mass (SMM), muscle mass index (MMI), visceral fat (VF) and body mass index (BMI) measured before and after surgery in patients with gastrointestinal cancer and to determine the relationship between body composition and the course of treatment. PATIENTS AND METHODS: The study included 125 patients, aged 65-68, operated on due to gastric, pancreatic or colorectal cancer. Body composition was assessed with electrical bioimpedance before and on the fifth postoperative day. The severity of complications was assessed with the Clavien-Dindo classification. RESULTS: In the whole group of patients, the percentage of FM, VF, and BMI levels measured before surgery were significantly higher in curative surgery patients in comparison to palliative surgery patients, p<0.001. The MMI value was also significantly higher, p=0.045. In patients after curative surgery, the values of BMI and FM significantly decreased (BMI - p<0.001; FM - p=0.003) after the surgery. There was no relation between body composition parameters and severity of postoperative complications. CONCLUSION: In the investigated group, body composition differed between radical and palliative surgery groups. Surgery with curative intent produced more changes in body composition parameters in the early postoperative period than palliative surgery. These observations may be helpful in prehabilitation planning for such patients.

Polish Consensus on Gastric Cancer Diagnosis and Treatment - Update 2022.

This document - "Polish Consensus on Gastric Cancer Diagnosis and Treatment - Update 2022" - represents an expert consensus following a year's worth of dedicated effort by a team of specialists throughout 2021, put forward in a conference in December 2021 in Krakow, and finalized below for publication in 2022. The effective date of this document is June 14th 2022. The work that went into updating this consensus was made under auspices of the Polish Society of Surgical Oncology and the Association of Polish Surgeons.

Prognostic value of lymph node ratio in resectable rectal cancer after preoperative short-course radiotherapy-results from randomized clinical trial.

PURPOSE: The value of the lymph node ratio (LNR) in patients with rectal cancer has not yet been unequivocally established. This study aims to assess the effect of the lymph node ratio on the prognosis of rectal cancer in patients operated after short-course preoperative 25 Gy radiotherapy, at 10-year follow-up. METHODS: This is a substudy based on data from a prospective randomized clinical trial. A total of 141 patients with resectable rectal cancer were included. Lymph node yield was compared in patients with short and long time intervals between radiotherapy and surgery. Survival curves were compared between patients with different ypN and LNR categories. Univariate and multivariate analyses were performed to identify independent prognostic factors for overall survival and disease-free survival. RESULTS: Survival and recurrence data were available for a median follow-up of 11.6 years. The lymph node yield did not differ significantly between the patients in the short- and long-interval groups. A greater difference in 10-year survival was observed in patients with LNR ≤ 0.41 and > 0.41 when compared to the ypN categories. Separate prognostic factor analyses were performed for the entire population and for subgroups that had < 12 and 12 lymph nodes resected. LNR was identified as an independent prognostic factor for overall survival, in multivariate analyses, for all patients and those with less than 12 retrieved lymph nodes. CONCLUSION: The lymph node yield is comparable in patients with different time intervals between radiation therapy and surgery. LNR better discriminates patients in terms of overall survival than ypN categories. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT01444495, date of registration: September 30, 2011.

A Retrospective, Single-Centre Study on the Learning Curve for Liver Tumor Open Resection in Patients with Hepatocellular Cancers and Intrahepatic Cholagangiocarcinomas.

BACKGROUND: Liver resections have become the first-line treatment for primary malignant tumors and, therefore, are considered a core aspect of surgical training. This study aims to evaluate the learning curve for the safety of open hemihepatectomy procedures for patients suffering from hepatocellular carcinoma (HCC) or intrahepatic cholangiocarcinoma (ICC). METHODS: This single tertiary center retrospective analysis includes 81 consecutive cases of right or left hemihepatectmy. A cumulative sum (CUSUM) control chart was used to investigate the learning curve. RESULTS: The CUSUM curve for operative time and blood loss level peaked at the 29th and 30th case, respectively. The CUSUM curve for minor adverse effects (mAEs) and severe adverse effects (sAEs) showed a downward slope after the 27th and 36th procedures; the curve, however, remained within the acceptable range throughout the entire study. CONCLUSION: When performing open hemihepatectomies in patients with HCC and ICC, the stabilization of the operative time and intraoperative blood loss level are gained earlier than sAEs risk reduction.

Learning Curve for Metastatic Liver Tumor Open Resection in Patients with Primary Colorectal Cancer: Use of the Cumulative Sum Method.

BACKGROUND: Liver resections have become the first-line treatment for primary and metastatic tumors and, therefore, are considered a core aspect of surgical training. This study aims to evaluate the learning curve of the extent and safety of liver resection procedures for patients with metastatic colorectal cancer. METHODS: This single tertiary center retrospective analysis includes 158 consecutive cases of small liver resection (SLR) (n = 107) and major liver resection (MLR) (n = 58) procedures. A cumulative sum control chart (CUSUM) method was used to investigate the learning curve. RESULTS: The operative time, total blood loss level, and incidence of adverse effects showed a learning curve. For SLRs, the CUSUM curve for operative time and blood loss level peaked at the 19th and 17th case, respectively, while for MLRs, these curves peaked at the 28th and 24th case, respectively. The CUSUM curve for minor adverse effects (MAEs) and severe adverse effects (SAEs) showed a downward slope after the 16th and 68th procedures in the SLRs group and after the 29th and 39th procedures in the MLRs cohort; however, it remained within the acceptable range throughout the entire study. CONCLUSION: SLR procedures were performed faster with less intraoperative blood loss and shorter postoperative stays than MLRs, and a higher number of completed procedures was required to gain stabilization and repeatability in the operating time and intraoperative blood loss level. In MLR procedures, the reduction of SAEs was accomplished significantly later than the stabilization of the operative time and intraoperative blood loss level.

Preoperative radiotherapy 5 × 5 Gy and short versus long interval between surgery for resectable rectal cancer: 10-Year follow-up of the randomised controlled trial.

BACKGROUND: Studies on short-course preoperative radiotherapy in combination with total mesorectal excision for rectal cancer reported improved local control without clear survival benefits. The optimal fractionation and interval between radiotherapy and surgery are still under debate. We, therefore, aimed to report 10-year results of a randomized clinical trial (RCT, NCT01444495) comparing different time intervals between irradiation and surgery for rectal cancer. MATERIAL AND METHODS: Data from the RCT conducted at a single academic centre were reviewed based on regular control visits with the median follow-up of 12 years. Patients with rectal cancer were randomly assigned to short-course preoperative radiotherapy (5 × 5 Gy) followed by surgery 7-10 days (short interval) or 4-5 weeks (long interval) after the end of irradiation. The primary endpoint was the local recurrence rate at 5 years. The secondary endpoints included overall survival, disease-free survival, systemic recurrence rate, and downstaging. RESULTS: A total of 154 patients were randomly assigned to short (n = 77) or long interval (n = 77) surgery. The cumulative incidence of local recurrence at 10 years was 1.3% and 11.7% in the short and long-interval groups, respectively (p = 0.031). Accordingly, the incidence of systemic relapse was 14.3% versus 9.1% (p = 0.0319). There were no differences in the overall 10-year survival between patients subject to short and long-interval surgery (58% vs 61%, p = 0.754). However, patients with downstaging after radiotherapy had significantly better 10-year survival rates than non-responders. CONCLUSIONS: Short-course preoperative radiotherapy with delayed surgery demonstrated an increased risk of local relapse over a 10-year follow-up.

Changes in γδT Cells in Peripheral Blood of Patients with Ulcerative Colitis Exacerbations.

The role of γδT cells in ulcerative colitis (UC) is well confirmed in experimental animals and demonstrated in many clinical observations. Recent investigations have indicated that UC is associated with several forms of immune imbalance, such as an imbalance between effector T cells and regulatory T cells. However, little is known about the cellular aspect of clinical colitis exacerbations. We observed 140 patients with histologically confirmed UC over the course of 8 years. We investigated the percentage of γδT and αßT cells in peripheral blood of patients and also the expression of various surface markers (CD25, CD54, CD62L). Patients were assembled into stable colitis and exacerbated colitis groups. The percentage of γδT and αßT cells was evaluated by Ortho Cytorone Absolute flow cytometer. In patients with exacerbated colitis we observed a decrease of γδT cells in peripheral blood and an increased ratio of αßT/γδT. Additionally, we found that exacerbation results in a significant increase of percentage of γδTCD25, γδTCD54 and γδTCD62L lymphocytes in peripheral blood when compared to patients with stable colitis. Exacerbation of ulcerative colitis results in a decreased percentage of γδT cells in peripheral blood with increase of CD25, CD54 and CD62L expressing γδT cells. This may represent the effect of cell activation and migration, similar to that observed after the surgical trauma. We hope that this observation may help to predict exacerbations in colitis patients.

Preoperative Short-Course Radiotherapy and Surgery versus Surgery Alone for Patients with Rectal Cancer: A Propensity Score-Matched Analysis at 18-Year Follow-Up.

A significant problem for long-term rectal cancer survivors may be the late toxicity of radiotherapy. It creates the possible risk of developing second primary malignancy and a theoretical decrease in overall survival. This study aimed to assess the influence of short-course preoperative radiotherapy in patients with locally advanced rectal cancer on overall survival, local recurrence rate, and second malignancy at 18-year follow-up. The rectal cancer trial was conducted in a single tertiary center between February 1992 and June 2006. A total of 389 patients with locally advanced rectal cancer (cT2-cT4, cN0/+, cM0) were included in the study. Preoperative radiotherapy was conducted in 148 patients and 241 patients underwent surgery alone. The propensity-matched group consisted of 105 patients operated on after radiotherapy and 105 controls. The number of local recurrences was 7 (6.7%) in the preoperative radiotherapy group and 22 (21%) in the surgery alone group (p = 0.016). The 18-year survival analysis showed no survival benefit in the preoperative radiotherapy group (38% versus 48%, p = 0.107) but improved recurrence-free survival (81% versus 58%, p = 0.001). The preoperative short-course radiotherapy significantly decreases the risk of local recurrence in locally advanced rectal cancer and may improve recurrence-free survival without an increased risk of second primary malignancy.

Analysis of Prognostic Factors Affecting Short-term and Long-term Outcomes of Gastric Cancer Resection.

BACKGROUND: The aim of this study was the analysis of the influence of prognostic factors on short- and long-term outcomes of gastric cancer resection. PATIENTS AND METHODS: A database of 709 patients who had gastric cancer resection between 2007 and 2015 was compiled. RESULTS: Total gastrectomy (TG) and subtotal proximal gastrectomy (SPG) significantly increased the risk of overall complications (p=0.0015 and 0.0173, respectively) and surgical complications (p=0.0141 and 0.0035, respectively). Moreover the resection of an additional organ was an independent prognostic factor of overall complications (p<0.0001), systemic complications (p=0.0503), surgical complications (p<0.0001) and relaparotomy (p=0.0259). T stage (p<0.0001), N stage (p<0.0001), M stage (p<0.0001) and radical resection (p<0.0001) significantly affected 5-year survival rates. CONCLUSION: Early diagnosis and radical resection was crucial in 5-year survival rates. However, the type of gastrectomy and the resection of an additional organ were the most important factors in short-term outcomes of treatment for such patients.

Watch-and-wait strategy in rectal cancer: Is there a tumour size limit? Results from two pooled prospective studies.

BACKGROUND: Frequency and predictive factors for a clinical complete response (cCR) in unselected patients are unclear. MATERIAL AND METHODS: Two prospective observational studies were designed and pooled to explore predictive factors for cCR. Both studies evaluated the watch-and-wait strategy in consecutive patients; the first single-institutional study in elderly with a small tumour, the second multi-institutional study in all the patients receiving standard of care preoperative radiotherapy. RESULTS: Four hundred and ninety patients were analysed. Short-course radiotherapy alone, or with consolidation chemotherapy or chemoradiation was given to 40.6%, 40.2% and 19.2% of the patients, respectively. The median interval from the radiation start to the first tumour response assessment was 10.2 weeks for short-course radiation and 13.2 weeks for chemoradiation. Seventy-three patients had cCR and 71 underwent w&w with the median follow-up of 24 months. The regrowth rate was 26.8%. cCR rate was 39.0% for low-risk cancer (cT1-2N0), 16.8% for intermediate-risk (cT3 with unthreatened mesorectal fascia [MRF-] or cT2N+) and 5.4% for high-risk (cT4 or MRF+). In the multivariable analysis, tumour volume (or tumour length and circumferential extent) and cN status were significant predictors for cCR. In circular cancers or with a length ≥7 cm (n = 184), cCR rate was only 2.7%, sustained cCR 1.6% and the sensitivity of cCR diagnosis 23.1%. None of 27 patients with a tumour larger than 120 cm3 achieved cCR. CONCLUSIONS: Considering watch-and-wait strategy is questionable in patients with circular tumours or with tumour length ≥7 cm.

Hypothermic Machine Perfusion of Kidneys Compensates for Extended Storage Time: A Single Intervention With a Significant Impact.

INTRODUCTION: Delayed graft function (DGF) adversely affects graft survival and function. Machine perfusion (MP) improves DGF rate and may compensate for extended storage time. MATERIAL AND METHODS: In this single-center cohort study, we included 193 consecutive kidney transplantations. MP was used in 78 kidneys (36%) and static cold storage (CS) in 115 kidneys (64%). CS kidneys were transplanted first followed by MP kidneys if stored differently. Pairs of kidneys from the same donor were subjected for subgroup analysis and included 58 pairs. The primary endpoints were the rate of DGF and 1- and 5-year graft survival. The secondary endpoints were the rate of the primary nonfunction, mortality, acute rejection, duration of DGF, and 5-year estimated glomerular filtration rate. RESULTS: Median cold ischemia time (CIT) was significantly different between the MP and CS groups (24 vs 20 hours, P < .05). MP significantly reduced the rate of DGF (MP vs CS: 21.8% vs 42.6%, P < .05, odds ratio 0.34, 95% confidence interval 0.17-0.67) with no impact on overall 1- and 5-year survival rates. Storage method did not affect the duration of DGF, mortality rate, acute rejection, or the 5-year estimated glomerular filtration rate. CONCLUSIONS: Hypothermic pulsatile MP significantly reduced the rate of DGF in kidneys transplanted with CIT equal to or longer than 12 hours. It is safe and may compensate for longer storage time.

Medical student experience with robot-assisted surgery after limited laparoscopy exposure.

The purpose of the study was to evaluate the objective and subjective experience of medical students completing robotic surgery tasks after limited laparoscopy exposure. Twenty-three medical students without previous laparoscopy and robotic surgery experience self-enrolled into 0 min (n = 11), 20 min (n = 6), and 40 min (n = 6) laparoscopy training groups. Subjects completed rope passing and ball placement tasks on a laparoscopy trainer before repeating similar tasks on the Senhance Surgical System, a robot-assisted digital laparoscopy device. Videos were recorded to evaluate objective measures including time, completion rate, clutch use, out of view instruments, ball drops, and manual adjustments. The NASA-TLX survey was administered to assess subjective experience using workload and task demand measures. There were no statistically significant differences in objective performance between the groups (p > 0.05). Subjects who completed laparoscopy training reported higher workloads, but these differences were not statistically significant (p > 0.05). NASA-TLX workload was correlated with time performance on Pearson and Spearman tests (r = 0.623, rho = 0.681, p < 0.01). Initial experience of medical students with robot-assisted surgery did not differ significantly after limited laparoscopy exposure.

Pre-operative ultrasound diagnosis and successful surgery of a stomach incarcerated in epigastric hernia: a rare case report.

An incarcerated epigastric hernia (localized in linea alba) is a very rare observation. Here, we present a case of a 66-year-old white male who was admitted to the emergency department due to vomiting and epigastric pain. On physical examination, the only observed abnormality was a painless soft epigastric tumor located in the upper midline, measuring about 12 cm in diameter. The patient claimed that he had the tumor for more than 30 years and it never changed in diameter nor caused him any discomfort. A lipoma was initially suspected. However, an ultrasound of the abdomen revealed an incarcerated stomach, trapped due to the defect in the epigastric abdominal wall. The patient was sent for surgery and the presence of an incarcerated epigastric hernia of the linea alba, which contained the anterior wall of the stomach was confirmed. The presented case confirms that the use of ultrasonography may be an effective method to recognize unusual types of hernias, and that ultrasonography should be routinely used in emergency departments.