Results Following Stent-Graft Coverage of the Hypogastric Artery in the Management of Aortoiliac Aneurysms in Endovascular Aneurysm Repair.

<b><br>Aim:</b> The aim of our study was to assess the outcomes of stent-graft coverage of the hypogastric artery in the management of aortoiliac aneurysms with endovascular aneurysm repair (EVAR).</br> <b><br>Material and methods:</b> From January 2013 to March 2017, a total of 93 patients with aortoiliac aneurysms were treated with EVAR, which required occlusion of one or both of the hypogastric arteries. The patients of the Department of General, Vascular, Endocrine and Transplant Surgery were included in the study continuously and all procedures were elective.</br> <b><br>Results:</b> A total of 93 patients with aortoiliac aneurysms required a unilateral or bilateral procedure. Six patients were excluded from our study because they did not appear at their follow-up appointments. The study included 87 patients (80 men; mean age 71.9 (7.9) years, range 54-88), of which 30 had a unilateral procedure and 57 had a bilateral procedure. In 8 procedures (5.55%, n = 7) there was a type II endoleak that resolved during follow-up and required no surgical intervention. In 10 procedures (6.94%, n = 10) there was a type IB endoleak, with 8 procedures requiring surgical re-intervention in the form of an extension. In 12 procedures (8.33%, n = 9), the hypogastric artery thrombosed.</br> <b><br>Conclusion:</b> Coverage of the hypogastric artery by stent-graft has been proven to be a safe procedure, but there is still a risk of type II endoleak. Although 5.55% (n = 7) of the procedures in our study had a type II endoleak, none required surgical intervention.</br>.

Rapid Formation and Hybrid Treatment of a Large Superior Mesenteric Artery Aneurysm.

BACKGROUND Superior mesenteric artery (SMA) aneurysms account for about 5.5% of all visceral aneurysms, and are most commonly secondary to infectious causes or dissection. They tend to expand and rupture. Here, we present our successful diagnosis and treatment of a 41-year-old man with asymptomatic coeliac trunk stenosis, in whom the large aneurysm of the branch of the SMA developed in a very short time after conservative treatment of plastron appendicitis. CASE REPORT A 41-year-old man was diagnosed with plastron appendicitis during abdomen ultrasound (US) examination. Following 2 weeks of conservative treatment with intravenous antibiotic therapy, complete resolution of symptoms was obtained and confirmed in the computed tomography (CT) scan, and no other pathologies were diagnosed. Three weeks later, during the US examination, a 33-mm aneurysm of the branch of the SMA was diagnosed. The patient was admitted to the Vascular Surgery Department, where a critical stenosis of the coeliac trunk secondary to the compression by median arcuate ligament and a 33-mm true visceral aneurysm of one of the branches of the SMA were diagnosed. Successful treatment of the aneurysm was performed. Surgical decompression of the coeliac trunk and subsequent elective endovascular embolization of the SMA aneurysm with angioplasty of the coeliac trunk were performed. The postoperative period was uneventful and the patient was released from the hospital and remains asymptomatic. CONCLUSIONS Visceral artery aneurysm can form very quickly. In some of the aneurysms, a combination of open surgical and endovascular methods should be performed.

Towards More Efficient Rényi Entropy Estimation.

Estimation of Rényi entropy is of fundamental importance to many applications in cryptography, statistical inference, and machine learning. This paper aims to improve the existing estimators with regard to: (a) the sample size, (b) the estimator adaptiveness, and (c) the simplicity of the analyses. The contribution is a novel analysis of the generalized "birthday paradox" collision estimator. The analysis is simpler than in prior works, gives clear formulas, and strengthens existing bounds. The improved bounds are used to develop an adaptive estimation technique that outperforms previous methods, particularly in regimes of low or moderate entropy. Last but not least, to demonstrate that the developed techniques are of broader interest, a number of applications concerning theoretical and practical properties of "birthday estimators" are discussed.

Influence of Selective Biochemical and Morphological Agents on Natural History of Aneurysm of Abdominal Aorta Development.

BACKGROUND The development of abdominal aortic aneurysm (AAA) is probably influenced by many factors. The role of some of these factors, such as intraluminal thrombus (ILT) or cystatin C serum levels, remains controversial. Proving their influence could have therapeutic implications for some patients with AAA. Associations between the rate of increase in diameter of an aneurysm and ILT, as well as other factors, including biochemical factors (C-Reactive Protein - CRP, cystatin C), age, sex, and comorbidities, could predict disease progression in individual patients. MATERIAL AND METHODS Seventy patients with small AAA were included into the study. The patients were followed using ultrasound and CT imaging. We evaluated aneurysm dimensions and aneurysm wall thickness, as well as ILT and its dimensions, aneurysm wall morphology, CRP, and cystatin C. RESULTS We observed significant growth of AAA and thinning of aneurysmal wall. Aneurysms over 4 cm grew significantly faster in the second year of observation. ILT grew together with AAA size. Age, sex, smoking, dyslipidemias, or controlled arterial hypertension had no influence on aneurysm progression rate. Changes in serum of CRP concentration did not reach statistical significance, but cystatin C levels did. CONCLUSIONS Presence and size of ILT, wall thickness, and cystatin C levels may be considered in prediction of AAA progression. ILT might exert a protective influence on the risk of aneurysm rupture. However, larger aneurysms containing larger thrombi grow faster and their walls undergo more rapid degradation, which in turn increases the risk of rupture. This matter requires further studies.

Endovascular treatment of traumatic rupture of thoracic aorta: long term results.

BACKGROUND: The aim of this study was to evaluate the endovascular treatment of acute post-traumatic thoracic aorta rupture. Rupture of the thoracic aorta is caused in a majority of cases by blunt trauma of the chest as a result of motor vehicle accident. Hypovolemic shock due to massive hemorrhage leads to death in almost 90% of victims. Nowadays the treatment of choice is endovascular procedure with stent-graft, which quickly seals the rupture site. METHODS: Forty patients with post-traumatic rupture were treated in our department. In 92.5% of them, the aneurysm appeared after a road traffic accident. In all cases but one it was located below the left subclavian artery. RESULTS: All patients underwent surgery. One-hundred per cent technical success was observed with no device failure. Six patients (15%) died in the postoperative period. All fatalities were attributable to severe generalized trauma, not to the endovascular procedure. In early postoperative follow-up we saw no serious stent-graft related complications, such as spinal cord ischemia. Nine patients (22.5%) were operated later on, due to other organs trauma. In one case (2.5%), in which the endograft was deployed below the left subclavian artery, the patient suffered from stroke, requiring conservative treatment. One early type IA endoleak was diagnosed and sealed by proximal extension. Among the patients still being followed for up to 14 years, 82% remain asymptomatic, without evidence of endoleak or stent-graft migration on angio-CT. Two type IA endoleak were found due to stent-graft infolding: one was solved with balloon-plasty, the other with a proximal extension. CONCLUSIONS: Endovascular procedure in traumatic rupture of descending aorta is the method of choice. Endovascular procedures have a lower mortality and morbidity than open surgery.

Laparoscopic treatment of adrenal cysts--own research and literature review.

MATERIAL AND METHODS: Over the last 18 months we operated on six patients with large adrenal gland cysts in our centre. This consisted of 8.2% of all patients treated in said period due to adrenal gland pathologies. On ruling out malignancy or parasitic nature of the lesions, all patients were surgically treated in order to excise the cysts while leaving the gland untouched. In five patients the cysts were resected but the adrenal gland was spared. However, in one patient the adrenal gland coated the entire cystic mass, which imposed performance of adrenalectomy in addition to cystectomy. During surgeries we tried not to clip the suprarenal vein, which we managed to do in four out of six cases. RESULTS: A one-year remote follow-up period revealed no cyst recurrence in ultrasound or CT, and it was possible to visualise the remaining part of the adrenal gland in all cases. CONCLUSION: Thus, in our opinion resection of benign cysts is well justified and recommendable.

Unilateral laparoscopic adrenalectomy following partial transsphenoidal adenomectomy of pituitary macroadenoma - life-saving procedure in a patient with ACTH-dependent Cushing's syndrome.

INTRODUCTION: Cushing's disease is the most common cause of endogenous hypercortisolemia, in 90% of cases due to microadenoma. Macroadenoma can lead to atypical hormonal test results and complete removal of the tumour is unlikely. CASE REPORT: A 77-year-old woman with diabetes and hypertension was admitted because of fatigue, proximal muscles weakness, lower extremities oedema, and worsening of glycaemic and hypertension control. Physical examination revealed central obesity, 'moon'-like face, supraclavicular pads, proximal muscle atrophy, and skin hyperpigmentation. Biochemical and hormonal results were as follows: K 2.3 mmol/L (3.6-5), cortisol 8.00 86 µg/dL (6.2-19.4) 23.00 76 µg/dL, ACTH 8.00 194 pg/mL (7.2-63.3) 23.00 200 pg/mL, DHEAS 330 µg/dL (12-154). CRH stimulation test showed lack of ACTH stimulation > 35%, overnight high dose DST revealed no suppression of cortisol. Chest and abdominal CT as well as somatostatin receptor scan didn't show ectopic tumour responsible for ACTH oversecretion. MRI revealed a pituitary macroadenoma (28 × 20 × 17 mm) extending towards the left cavernous sinus. After partial transsphenoidal adenomectomy, serum cortisol of 40 µg/dL was obtained. The patient's condition was still very poor, so unilateral adrenalectomy was performed. After surgery, serum morning cortisol level dropped to 20 µg/dL and the patient's condition improved significantly. 26 months after the operations, the patient remains in remission. Because her life expectancy exceeds the prognosed duration of remission with the presence of pituitary tumour remnants and intact left adrenal gland, the patient was qualified to radiosurgery with a Gamma Knife. CONCLUSION: In selected cases, unilateral, laparascopic adrenalectomy may serve as a life-saving procedure in a patient with ACTHdependent Cushing's syndrome.

The local spread of pheochromocytoma after adrenalectomy with a rupture of the tumor capsule at the time of the surgery.

INTRODUCTION: We present a case of a 29-year-old patient treated due to fully symptomatic pheochromocytoma of the right adrenal gland. CASE PRESENTATION: Patient was operated on and an open right-sided adrenalectomy was performed. At the time of the surgery, a rupture of the tumor capsule occurred. Five years post-operatively, a recurrence of the symptoms of chromaffin-cell tumor was noted. After the exact localization of the multiple recurrences, the patient was reoperated on. CONCLUSION: The case of pheochromocytoma is presented due to the possibility of chromaffin-cell seeding into the peritoneum, with no signs of distal metastases so far.

Location and incidence rate of anastomotic aneurysms--own clinical material and literature review.

UNLABELLED: Anastomotic aneurysms occurs at various levels of arterial system. Determining their location and incidence rate required investigation of large patient clinical material. MATERIAL AND METHODS: In the years 1989-2010 in local centre 230 anastomotic aneurysms were operated in 180 patients. RESULTS: For 187 (81.3%) patients anastomotic aneurysms were localised in the groin, while for remaining 43 (18.7%) they occurred in other localisations. In aortic arch branch they occurred four times (1.7), in descending aorta--three times (1.3%), in abdominal aorta--14 (6.1%) and in iliac arteries--6 (2.6%). While for anastomosis with popliteal artery they were diagnosed in 16 (7%) patients. Own clinical material was compared with literature data. CONCLUSIONS: Anastomotic aneurysms in over 80% of cases occur in the groin, remaining percentage corresponds to other localisations.

A spontaneous paraganglioma-pheochromocytoma syndrome.

We present a case of a 40-year old woman diagnosed with a four-place spontaneous paraganglioma-pheochromocytoma syndrome, which was treated surgically. The presence of the succinate dehydrogenase complex subunit D (SDHD) mutation that causes the pheochromocytoma was confirmed but no mutations in the family members were found. After the excision of the paragangliomas located in the areas of the division of carotid arteries, and mediastinum, as well as a tumor on the left site of the celiac trunk, the patient remains asymptomatic and is regularly followed-up.

The effect of surgical treatment of phaeochromocytoma on concomitant arterial hypertension and diabetes mellitus in a single-centre retrospective study.

INTRODUCTION: Phaeochromocytoma is one of the numerous causes of secondary hypertension. Furthermore, phaeochromocytoma may first present with type 2 diabetes mellitus. The objective of our study was to evaluate the effects of adrenalectomy on patient recovery with regards to normotension and well-controlled glycaemia. MATERIAL AND METHODS: The retrospective analysis involved 67 patients with phaeochromocytoma operated between 2006 and mid-2012. The pre-operative diagnoses were made in the departments of internal medicine and endocrinology. Based on laboratory tests and diagnostic imaging, we were able to confirm the diagnosis of phaeochromocytoma in 42 (62.7%) patients. We verified the influence of adrenalectomy on the level of patient recovery, with regards to normotension and glycaemic control: arterial pressure and fasting glycaemia levels were obtained on the day of hospital discharge, at follow-up 3 months post-operatively and 1 year after surgical intervention. RESULTS: Of the 67 patients operated for phaeochromocytoma, 48 (71.6%) were treated laparoscopically, whereas 19 (28.4%) underwent open adrenalectomy. Arterial hypertension was recorded in 53 (79.1%) cases. Furthermore, among this group, diabetes mellitus coexisted in 21 (31.3%) cases. Postoperatively, 70% of cases of arterial hypertension and 90% of type 2 diabetes mellitus were cured. Additionally, a high rate of patients reported a quantitative reduced use of antihypertensive medicines. CONCLUSIONS: In the majority of patients, surgical treatment of symptomatic phaeochromocytoma leads to a regression of arterial hypertension, or a reduction of the number or doses of medicines taken in one's treatment, and glucose-intolerance symptoms.

Anastomotic aneurysms--20-years of experience from one center.

UNLABELLED: Anastomotic aneurysms may develop after any type of vascular surgery, in different areas of the arterial system, and require reoperation. The frequency of occurrence of the above-mentioned is estimated at 1-5%. MATERIAL AND METHODS: During the period between 1989 and 2010, 180 patients with 230 anastomotic aneurysms were subject to surgical intervention at the Department of General and Thoracic Surgery, Warsaw Medical University. The study group comprised 21 (11.7%) female and 159 (88.3%) male patients, aged between 30 and 87 years (mean age - 62.8 years). In relation to the number of anastomoses aneurysms were diagnosed in 2.1% of cases. Twenty-four (10.4%) patients were diagnosed with recurrent aneurysms. RESULTS: Surgical procedures performed were as follows: artificial prosthesis implantation (119), reanastomosis (40), patch plasty (25), graftectomy (19), prosthesis replacement (9), and stent-graft (7) implantation. 195 (84.8%) aneurysms were subject to planned surgery, while 35 (15.2%) required emergency intervention. 77.8% of patients were diagnosed with aseptic aneurysms, while the remaining 22.2% with infected perioperative aneurysms. Good treatment results were obtained in 149 (82.8%) patients. Limb amputations were performed in 19 (10.5%) cases. Twelve (6.7%) patients died as a consequence of infection and general complications. CONCLUSIONS: Vascular reoperations are a difficult clinical problem and are burdened with a high rate of complications. The above-mentioned often require complex treatment, in order to improve therapeutic results.

Is tumour size a contraindication to laparoscopic adrenalectomy? Case report.

The authors present a case report of a patient with a large, hormonally silent tumour of the right adrenal gland. Due to the patient's numerous strains, the necessity of two gynaecological operations, and treatment of broken bones, adrenalectomy was contraindicated for 2 years. After that time, the size of the tumour reached 18 cm × 12 cm. The patient was selected for laparoscopic adrenalectomy, which was successful. The size of the tumour and performed abdominal surgery did not constitute substantial obstacles, and the less invasive procedure was additionally justified by computed tomography and magnetic resonance imaging results, which demonstrated a benign lesion.

Laparoscopic adrenalectomy in a patient with situs inversus levocardia.

The article presents a case of an adrenal adenoma (Conn's syndrome) in a 50-year-old man with situs inversus with levocardia. Laparoscopic adrenalectomy was performed and the patient made a full recovery. It has been concluded that diagnostic assessment by means of imaging techniques providing details of the organ anatomy and the experience of the medical team are the key factors determining the outcome of such surgery.

Laparoscopic adrenalectomy--assessing the learning curve.

UNLABELLED: Laparoscopic adrenalectomy (LA) has become the "gold standard" for treatment of most of adrenal tumors in last few years. It has many benefits comparing to open surgery, but still is considered as complicated procedure requiring experienced surgical team. THE AIM OF THE STUDY: was to assess the learning curve of laparoscopic adrenalectomy and the outcome of the first consecutive 154 LA. MATERIAL AND METHODS: 154 consecutive patients undergoing LA between 2007 and 2010 were reviewed. Collected data included: patients demographics, clinical and histological diagnosis, side and length of operation, conversions to open surgery, complications and hospitalization time. Learning curve was evaluated by dividing all patients into three groups (group I - first 50 patients, group II - second 50 patients and group III last 54 patients). Differences between the groups were analyzed. RESULTS: There were 154 LAs performed. Indications for LA were hormonally inactive adrenal adenoma(n=57), Conn's syndrome (n=30), Cushing's syndrome (n=28), pheochromocytoma (n=27), adrenal cyst (n=8), and others (n=4). Mean tumor size was 45.28 mm. There were 79 left-sided and 75 right-sided procedures and the average time of hospitalization was 4.64 days. Mean operative time was statistically different between the groups (216.2 min. - 164.6 min. - 131.9 min.; p<0.01) as well as the number of conversions to open surgery (18% - 4% - 3.7%; p=0.013). There was not any significant difference in the number of complications between analyzed groups (2% - 2% -3.7%). CONCLUSION: To improve the outcome of LA it is necessary to perform approximately 40 to 50 procedures.

Results of general surgical treatment of patients over 80 years of age in single-site experience.

UNLABELLED: The aim of the study was to evaluate the results of general surgical treatment of patients over 80 years of age. MATERIAL AND METHODS: Three hundred and four patients aged 80 to 105 years with general surgical disorders, treated in 2005-2009, were retrospectively included in the study. The collected information included demographic data, coexisting diseases, the mode of admission, the diagnosis, the method and result of treatment, and also potential complications and 30-day mortality. The data were subjected to statistical analysis. RESULTS: The study group included 186 women and 118 men. Two hundred patients (65.8%) were admitted in an emergency setting. The most common causes of immediate hospitalisation were: mechanical ileus (26.5%), gastrointestinal bleeding (22%), trauma (16%), and gall-bladder disorders (8.5%). The remaining 104 (34.2%) patients were operated upon on an elective basis. An emergency operation was required by 121 (60%) of the patients admitted in an emergency setting; the remaining ones were treated conservatively. Hernia plasties (27.5%), cholecystectomies (15.3%), colorectal resections (13.2%), strumectomies (11.2%) and endoscopies (6.1%) predominated among elective surgeries.The total number of complications and mortality were 19.4% and 14.5%, respectively. The number of complications and mortality were significantly higher in the group of patients admitted in an emergency setting (25.5% and 20.5%, respectively) than in patients admitted on an elective basis (8.7% and 2.9%, respectively), p<0.01.The mean duration of hospitalisation was 9.7 days (1 to 60 days), with a small difference between the groups of patients treated on an elective and emergency basis (8.5 and 10.4 days), p=0.181. CONCLUSIONS: The results of surgical treatment of elderly patients do not significantly differ from the results of treatment of the general population. Much worse results, coupled with a significant increase in mortality, are observed in patients admitted and treated on an emergency basis.

Adrenal tumors - diagnostics and the factual situation.

The study presented three cases of patients diagnosed with adrenal tumors subject to surgical intervention during the past 6 months in our Department. The patients presented with radiological diagnostic difficulties, as to the character and location of the primary tumor. The aim of the study was to demonstrate differences between radiological examination results and the factual situation observed during the adrenalectomy. In all the presented cases patients' were subject to laparoscopic intervention. In two cases conversion to open surgery was necessary. The histopathological results of the surgically removed samples were as follows: leiomyoma, myoperycytoma and pheochromocytoma. In selected cases imaging examinations might be of limited value, especially when determining the character and location of the primary lesion of the adrenal gland.