Immunomodulating versus high-protein oral preoperative supplement in surgical patients - A two-center, prospective, randomized clinical trial.

OBJECTIVES: For many years, immunonutrition was believed to reduce postoperative complications in patients undergoing major abdominal surgery. However, recent studies questioned that belief. Moreover, the perioperative intake of proteins has gained more and more attention and has shown clinical value. Therefore, the aim of this study was to compare the clinical effect of immunomodulating (IM) plus high-protein (HP) and pure HP supplements during the preoperative period. METHODS: Between January 2011 and December 2020, 299 well-nourished patients (130 female and 169 male; mean age: 60.8 y) undergoing major abdominal surgery at two surgical centers were randomized to receive either preoperative IM or HP oral supplements for 7 d after surgery. In all patients, an enhanced recovery after surgery protocol was applied. Outcome measures of the intend-to-treat analysis were number and type of complications, length of hospitalization, and mortality. RESULTS: Both groups were comparable in terms of age, sex, and type of surgery. The median length of postoperative hospital stay was 8 d (range, 6-12 d) in the IM group and 7 d (range, 6-10 d) in the HP group (P = 0.153). Postoperative complications were observed in 29 patients (21.3%) in the IM group and 28 (17.8%) in the HP group (P = 0.442) The risk of readmission was comparable (5.1% vs 4.9%; P = 0.924) for IM and HP supplements, respectively. Postoperative nausea and vomiting occurred in 21 patients in the IM group (15.4%) and 17 patients in the HP group (10.4%; P = 0.195). No difference in gastrointestinal function evaluated with time to first flatus was observed (P = 0.272) CONCLUSIONS: The study demonstrated no difference between preoperative IM + HP and HP supplements in surgical patients. Therefore, the routine preoperative use of IM supplements in all surgical patients cannot be recommended.

Enhanced Recovery after Surgery (ERAS) Protocol Is a Safe and Effective Approach in Patients with Gastrointestinal Fistulas Undergoing Reconstruction: Results from a Prospective Study.

BACKGROUND AND AIMS: An enterocutaneous fistula (ECF) poses a major surgical problem. The definitive surgical repair of persistent fistulas remains a surgical challenge with a high rate of re-fistulation and mortality, and the reasons for that is not the surgical technique alone. Enhanced Recovery after Surgery (ERAS®) is an evidence-based multimodal perioperative protocol proven to reduce postoperative complications. The aim of the study was to assess the clinical value of the ERAS protocol in surgical patients with ECF. METHODS: ERAS protocol was used in all patients scheduled for surgery for ECF at the Stanley Dudrick's Memorial Hospital in Skawina between 2011 and 2020. A multidisciplinary team (MDT) was in charge of the program and performed annual audits. A consecutive series of 100 ECF patients (44 females, 56 males, mean age 54.1 years) were evaluated. Postoperative complications rate, readmission rate, length of hospital stay, prevalence of postoperative nausea and vomiting were assessed. Registered under ClinicalTrials.gov Identifier no. NCT04771832. RESULTS: ERAS protocol was successfully introduced for ECF surgeries; however, eight modifications to the ERAS program was performed in 2015. They led to improvement of surgical outcomes: reduction of postoperative nausea and vomiting (15 vs. 17% patients, p = 0.025), overall complication rate (11 vs. 10, p = 0.021), median length of hospital stay (overall and after surgery, p = 0.022 and 0.002, respectively). CONCLUSIONS: ERAS protocol can be successfully used for ECF patients. Prescheduled audits can contribute to the improvement of care.

Early closure of the protective ileostomy after rectal resection should become part of the Enhanced Recovery After Surgery (ERAS) protocol: a randomized, prospective, two-center clinical trial.

INTRODUCTION: Protective loop ileostomy (PLI) is used to reduce the anastomotic leak rate after resection of the rectum. It is an effective, yet burdensome procedure contradicting the aims of enhanced recovery after surgery (ERAS) by slowing down recovery. Early closure (EC) of the PLI has the potential to change the situation, and it should become part of ERAS. AIM: To analyze the effectiveness of EC in ERAS patients. MATERIAL AND METHODS: A randomized clinical trial was performed between October the 1st, 2016 and December the 31st, 2017. Fifty-eight adult patients (24 females, 34 males, mean age: 55.7 and 56.2) operated on for rectal carcinoma according to the ERAS protocol with PLI were randomly assigned to the late (L) or early (E) closure group (14 days after discharge). Time to start adjuvant chemotherapy, complication rate, and health care costs were analyzed. RESULTS: There were no significant differences between groups regarding the length of surgery (83.2 ±15.9 vs. 87.1 ±21.7 min, in E and L, respectively), intraoperative blood loss (15.2 ±7.5 vs. 17.3 ±11.1 ml, respectively), median hospital stay, or the time to pass flatus and stool. The difference in the time needed to start the adjuvant treatment (38.7 ±5.7 vs. 33.2 ±5.8 days, p < 0.01), was compensated by the reduction of time living with a stoma (17.2 vs. 299.0 days) and health care costs: (43.68 vs. 698.42 USD). CONCLUSIONS: Early closure is a safe and effective therapeutic approach, improving the recovery. Therefore it should be implemented as part of the ERAS protocol for rectal cancer patients.

Upper extremity surface electromyography signal changes after laparoscopic training.

INTRODUCTION: Objective measures of laparoscopic skill in training are lacking. AIM: To evaluate the changes in the surface electromyography (sEMG) signal during laparoscopic training, and to link them to intracorporeal knot tying. MATERIAL AND METHODS: Ten right-handed medical students (6 female), aged 25 ±0.98, without training in laparoscopy, were enrolled in the study. With no additional training, they tied intracorporeal single knots for 15 min. Then underwent laparoscopic training and redid the knot tying exercise. During both events, sEMG was recorded from 8 measurement points on the upper extremities and neck bilaterally. We analyzed changes in sEMG resulting from training and tried to find sEMG predictive parameters for higher technical competence defined by the number of knots tied after the training. RESULTS: The average number of knots increased after the training. Significant decreases in activity after the training were visible for the non-dominant hand deltoid and trapezius muscles. Dominant and non-dominant hands had different activation patterns. Differences largely disappeared after the training. All muscles, except for the dominant forearm and non-dominant thenar, produced a negative correlation between their activities and the number of tied knots. The strongest anticorrelation occurred for the non-dominant deltoid (r = -0.863, p < 0.05). Relatively strong relationships were identified in the case of the non-dominant trapezius and forearm muscles (r = -0.587, r = -0.504). CONCLUSIONS: At least for some muscle groups there is a change in activation patterns after laparoscopic training. Proximal muscle groups tend to become more relaxed and the distal ones become more active. Changes in the non-dominant hand are more pronounced than in the dominant hand.

Current treatment options for advanced choriocarcinoma on the basis of own case and review of the literature.

Choriocarcinoma is one of rare neoplasms of female reproductive organs. In the last decade only a few cases of this disease have been registered in Poland. The paper presents the current principles of diagnosis and treatment options for this rare disease based on the authors' clinical experience (description of the case) and literature review. This paper provides basic information on epidemiology, FIGO classification, and also discusses the chemotherapy regimens used in the medical treatment of choriocarcinoma. Surgical options were also considered. A thematic review of the most important papers published in international journals in recent years has also been made.

How does preclinical laboratory training impact physical examination skills during the first clinical year? A retrospective analysis of routinely collected objective structured clinical examination scores among the first two matriculating classes of a reformed curriculum in one Polish medical school.

OBJECTIVE: As a result of a curriculum reform launched in 2012 at our institution, preclinical training was shortened to 2 years instead of the traditional 3 years, creating additional incentives to optimise teaching methods. In accordance with the new curriculum, a semester-long preclinical module of clinical skills (CS) laboratory training takes place in the second year of study, while an introductory clinical course (ie, brief introductory clerkships) is scheduled for the Fall semester of the third year. Objective structured clinical examinations (OSCEs) are carried out at the conclusion of both the preclinical module and the introductory clinical course. Our aim was to compare the scores at physical examination stations between the first and second matriculating classes of a newly reformed curriculum on preclinical second-year OSCEs and early clinical third-year OSCEs. DESIGN: Analysis of routinely collected data. SETTING: One Polish medical school. PARTICIPANTS: Complete OSCE records for 462 second-year students and 445 third-year students. OUTCOME MEASURES: OSCE scores by matriculation year. RESULTS: In comparison to the first class of the newly reformed curriculum, significantly higher (ie, better) OSCE scores were observed for those students who matriculated in 2013, a year after implementing the reformed curriculum. This finding was consistent for both second-year and third-year cohorts. Additionally, the magnitude of the improvement in median third-year OSCE scores was proportional to the corresponding advancement in preceding second-year preclinical OSCE scores for each of two different sets of physical examination tasks. In contrast, no significant difference was noted between the academic years in the ability to interpret laboratory data or ECG - tasks which had not been included in the second-year preclinical training. CONCLUSION: Our results suggest the importance of preclinical training in a CS laboratory to improve students' competence in physical examination at the completion of introductory clinical clerkships during the first clinical year.

Ultrasound-guided percutaneous 'push-introducer' gastrostomy is a valuable method for accessing the gastrointestinal tract.

Percutaneous endoscopic gastrostomy (PEG) is the most effective and least invasive method for enteral nutrition (EN). The most common system for PEG is the 'pull' technique, which . It is not available in case endoscopy cannot be performed. The 'push' technique may be an option if effective identification of the abdominal structures can be achieved. X-ray or ultrasonography can be used for that purpose. The aim was to assess the clinical value of ultrasound-guided 'push' gastrostomy. A retrospective analysis of eleven patients (6 F, 5 M, mean age 65.1) including the procedure itself, complication rate, and cost was conducted. In all eleven patients the surgery was successful, and EN was introduced 4-6 hours afterwards. Complications included pain requiring removal of a supporting stitch (n = 1) and balloon deflation (n = 1). All patients were successfully fed enterally. Ultrasound-guided 'push' technique gastrostomy should become a method of choice if the 'pull' method is unavailable.

La gastrostomía endoscópica percutánea (GEP) es el método más eficaz y menos invasivo para la nutrición enteral (NE). El sistema más frecuente para la GEP es la técnica 'pull', que no está disponible en el caso de que la endoscopia no se pueda realizar. La técnica 'push' puede ser una opción si se consigue una identificación efectiva de las estructuras abdominales. Para este propósito, se pueden usar los rayos X o la ecografía. El objetivo fue evaluar la validez clínica de la gastrostomía 'push' guiada por ecografía. Se realizó un análisis retrospectivo en 11 pacientes (6 M, 5 H, edad media 65,1) que incluía el propio procedimiento, la tasa de complicaciones y el coste. En los 11 pacientes la cirugía fue exitosa y la NE se introdujo a las 4-6 horas. Las complicaciones incluían dolor, que requirió la retirada del punto de soporte (n = 1), y el deshinchado del globo (n = 1). A todos los pacientes se les alimentó con éxito entéricamente. La técnica de gastrostomía 'push' guiada por ecografía debería convertirse en el método de elección cuando la técnica 'pull' no esté disponible.

Ultrasound-guided percutaneous «push - introducer» gastrostomyis a valuable method for accessing the gastrointestinal tract / La gastrostomía percutánea por ultrasonido «push-introducer» es un método válido para acceder al tracto gastrointestinal

Percutaneous endoscopic gastrostomy (PEG) is the most effective and least invasive method for enteral nutrition (EN).The most common system for PEG is the ‘pull’ technique, which. It is not available in case endoscopy cannot be performed. The ‘push’ technique may be an option if effective identification of the abdominal structures can be achieved. X-ray or ultrasonographycan be used for that purpose. The aim was to assess theclinical value of ultrasound-guided ‘push’ gastrostomy. Aretrospective analysis of eleven patients (6 F, 5 M, mean age65.1) including the procedure itself, complication rate, and cost was conducted. In all eleven patients the surgery was successful, and EN was introduced 4-6 hours afterwards. Complications included pain requiring removal of a supporting stitch (n = 1)and balloon deflation (n = 1). All patients were successfully fedenterally. Ultrasound-guided ‘push’ technique gastrostomy should become a method of choice if the ‘pull’ method is unavailable (AU)

La gastrostomía endoscópica percutánea (GEP) es el método más eficaz y menos invasivo para la nutrición enteral (NE). El sistema más frecuente para la GEP es la técnica ‘pull’, que no está disponible en el caso de que la endoscopia no se pueda realizar. La técnica ‘push’ puede ser una opción si se consigue una identificación efectiva de las estructuras abdominales. Para este propósito, se pueden usar los rayos X o la ecografía. El objetivo fue evaluar la validez clínica de la gastrostomía ‘push’ guiada por ecografía. Se realizó un análisis retrospectivo en 11 pacientes (6 M, 5 H,edad media 65,1) que incluía el propio procedimiento, la tasa de complicaciones y el coste. En los 11 pacientes la cirugía fue exitosa y la NE se introdujo a las 4-6 horas. Las complicaciones incluían dolor, que requirió la retirada del punto de soporte (n = 1), y el deshinchado del globo (n = 1). A todos los pacientes se les alimentó con éxito entéricamente. La técnica de gastrostomía ‘push’ guiada por ecografía debería convertirse en el método de elección cuando la técnica ‘pull’ no esté disponible (AU)

Two-center experience in the treatment of hemorrhoidal disease using Doppler-guided hemorrhoidal artery ligation: functional results after 1-year follow-up.

INTRODUCTION: Doppler-guided hemorrhoidal artery ligation (DGHAL), as a method of treating hemorrhoidal disease, is currently used in many centers across Europe, Asia, and Australia. The aim of our study was to evaluate the clinical effectiveness and functional results of DGHAL as estimated by means of anorectal manometry. MATERIALS AND METHODS: Between 2000 and 2006 the DGHAL procedure was performed on 507 patients with II-IV degree hemorrhoids in two centers (Poland and Austria). Three hundred eight patients were included in the initial phase of the study, designed to estimate the method's effectiveness. During the second phase (199 patients) selected functional results were also assessed. Patients were classified as having grade II (144), III (319), and IV (44) hemorrhoids. RESULTS: There were no intra- and immediate postoperative complications. Good results were reported by 351 patients (69.2%), and were acceptable in a further 75 cases (4.8%). When the patients were grouped according to the stage of hemorrhoidal disease, 133 out of 144 patients (92.4%) with grade II and 272 out of 324 (84%) with grade III had very good or good results. Only 18 out of 44 patients (41%) with grade IV were satisfied with the operation. Fifty-nine patients after anorectal folds, fissure or anal canal polyp excision required analgesics for 1-2 days. Apart from lower contraction amplitude and contraction speed after 1 month there were no differences in anorectal functional tests. CONCLUSION: Based on our results we may conclude that DGHAL is a safe and effective method and may offer an important alternative to operative hemorrhoidectomy with no risk of postoperative stool incontinence, minimal postoperative pain, and early return of patients to their normal activities. Nevertheless, this is a fairly new procedure with a short-term follow-up. Until 5-year observations of large, multicenter, randomized trials are published we cannot recommend this method as a gold-standard procedure, although it still can offer significant benefits to patients.