Impact of Intragastric Balloon Placement on the Stomach Wall: A Prospective Cohort Study.

PURPOSE: Endoscopic intragastric balloon (IGB) placement is a minimally invasive treatment for morbid obesity that is sometimes used as a preparatory step before surgical intervention. This study was performed to analyze the changes in the stomach wall induced by IGB placement, with particular emphasis on pathomorphology, inflammatory markers, and tissue growth factors. MATERIAL AND METHODS: In total, 30 patients with morbid obesity were prospectively analyzed. A total of 16 patients with body mass index (BMI) ≥ 53 kg/m2 underwent two-stage treatment comprising IGB placement followed by laparoscopic sleeve gastrectomy (LSG) (IGB group), while 14 patients underwent one-stage LSG (non-IGB group). The gastric specimens removed during LSG were examined. The two groups were compared regarding the surgical results, microscopic structure and inflammatory process exponents of the stomach wall, and receptors for selected tissue growth factors. RESULTS: The IGB group had a longer median hospital stay than that of the non-IGB group. Compared with the non-IGB group, the IGB group had a thicker stomach wall, more submucosal fibrosis, and increased amounts of growth factors and inflammatory markers. CONCLUSION: Patients with IGB placement before LSG showed greater changes in the stomach wall than those of patients who received LSG alone. IGB placement was associated with stomach muscle layer thickening, submucosal fibrosis, and increased levels of inflammatory markers and tissue growth factors.

Learning curve for laparoscopic Roux-en-Y gastric bypass based on the experience of a newly created bariatric center.

<b> Introduction:</b> Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most common treatments for morbid obesity. The learning curve for this procedure is 50-75 cases for an independent surgeon, and it is considered the most important factor in decreasing complications and mortality. We present our experience and learning curve with LRYGB for a newly established bariatric center in Poland. <br><b>Material and methods:</b> A prospectively collected database containing 285 LRYGB procedures performed in the II Department of General Surgery of the Jagiellonian University MC in Krakow between 06.2010 and 03.2019 was retrospectively reviewed. Patients were divided into groups of 30 (G1-G10) in the order of the procedures performed by each surgeon. The study analyzed the course of the operation and patient hospitalization, comparing those groups. Learning curve for the newly created bariatric center was established. <br><b>Results:</b> Operative time in G1-G3 differed significantly from G4-G10 (P < 0.0001). The stabilization point was the 90th procedure. Perioperative complications were observed in 36 (12.63%) patients. Perioperative complications, intraoperative difficulties and adverse events did not differ importantly among groups. Liberal use of "conversions of the operator" from a surgeon to a senior surgeon provides reasonable safety and prevents complications. <br><b>Conclusions:</b> The institutional learning process stabilization point for LRYGB in a newly established bariatric center is around the 90th operation. LRYGB can be a safe procedure from the very beginning in newly established bariatric centers. Specific bariatric training with active proctoring by an experienced surgeon in a bariatric centre can improve the laparoscopic gastric bypass outcome during the learning curve.

Laparoscopic adrenalectomy - is it safe in hands of residents in training?

BACKGROUND: Laparoscopic adrenalectomy (LA) has become the "gold standard" for treating most adrenal tumors in the past decade. However, it is still considered a relatively complicated procedure requiring experience from surgeon. The aim of the study was to evaluate the safety of laparoscopic adrenalectomy performed by residents who are undergoing training in general surgery. METHODS: A prospectively collected database containing all 300 transperitoneal laparoscopic adrenalectomies performed in II Department of General Surgery JU MC, Krakow between January 2013 and March 2018 was retrospectively reviewed. Patients were divided into two groups; patients operated on by residents (group 1, 54 operations) and by attending general surgeons (group 2, 246 operations). We compared the course of the operation and patient hospitalization in these two groups. If the operation was completed by a different person than the one who started the procedure, we refer to this as "operator conversion". RESULTS: We found no differences in demographic factors or comorbidities between the two groups. The mean operative time was similar in the residents' and the specialists' groups (p = 0.5761). Median blood loss did not differ between the groups (p = 0.4325). The overall ratio of intraoperative adverse events was similar in both groups (p = 0.8643). The difference in the ratio of perioperative complications between the groups was not statistically significant (p = 0.6442). The average mean hospital stay after surgery was 2 days for both groups. We identified 25 cases (8.33%) of operator conversion; the difference in operator conversions between two groups was not statistically significant (p = 0.1741). CONCLUSIONS: Laparoscopic transperitoneal adrenalectomy performed by a supervised resident is a safe procedure. The course of the operation and patient hospitalization did not differ importantly when comparing procedures performed by residents and attending surgeons. Liberal use of operator conversions from resident to attending surgeon and from a surgeon to a senior surgeon provides reasonable safety and prevents complications. In high-volume centers performing minimally invasive techniques, closed supervision allows residents to safely perform LA.

Quest for the optimal technique of laparoscopic splenectomy - vessels first or hilar transection?

INTRODUCTION: Throughout our 20 years of experience, we have used several different techniques for laparoscopic splenectomy (LS). However, two methods have been used most frequently: "vessels first" and "hilar transection". AIM: To evaluate the outcomes of LS performed with these two different approaches. MATERIAL AND METHODS: It was an observational study based on retrospective analysis of consecutive patients undergoing LS in a tertiary referral surgical center in the period 1998-2017. We excluded patients with splenic trauma, initially submitted to open surgery, stapled transection of splenic hilum, partial resections of the spleen and other spleen-preserving procedures. Patients were divided into two groups: group 1 ("vessels first") with 188 patients, and group 2 ("hilar transection") with 287 patients. RESULTS: Mean operative time was shorter (p < 0.001) and blood loss was lower (p < 0.001) in group 2. The need for blood transfusions and the conversion rate were higher in group 1 (p = 0.044 and p = 0.003 respectively). There was no difference in intraoperative adverse events (p = 0.179). Overall postoperative morbidity did not differ between groups (p = 0.081) and we noted mortality of 0.21% (1 patient of group 2). The morbidity rate associated with accidental injury of the pancreatic parenchyma was significantly higher in group 1 (p = 0.028). Median length of hospital stay was 4 days (range: 1-99) and did not differ between groups (p = 0.175). CONCLUSIONS: The "vessels first" technique is associated with longer operative time, higher blood loss and increased risk of conversion. "Hilar transection" is associated with lower incidence of local complications related most likely to accidental injury of the pancreatic tail. In the case of a large caliber of splenic vessels the "vessels first" approach remains the technique of choice.

Influence of TNF-α promoter variability on stage and grade in individuals with colorectal cancer.

Carcinogenesis is a multistep process in which inflammation plays an important role. Tumour necrosis factor a (TNF-α) is a cytokine that plays a major role in inflammation. Activity of the TNF cytokine family could influence progression of colorectal cancer (CRC). The aim of the study was to establish an association between TNF-α promoter variability and stage/grade in individuals with sporadic CRC. The study included 152 CRC patients and 107 healthy volunteers. Four single nucleotide polymorphisms (rs361525, rs1800629, rs1799724, and rs1799964) located at the promoter of TNFA gene were genotyped using commercially available TaqMan allelic discrimination assays by real-time PCR. CRC stage was described on the basis of preoperative imaging studies and postoperative histopathological report. The grade was described on the basis postoperative pathological examination of the specimen. In the case of rs361525, there was a statistically significant association with M-score (p = 0.0209). Rs361525 has significant association with tumour grade (p = 0.0260). We failed to demonstrate significant association between the other 3 SNPs and cancer grade. Rs361525 potentially could be under consideration when the survival rate and prognosis is assessed.

Risk factors for prolonged hospitalization in patients undergoing laparoscopic adrenalectomy.

INTRODUCTION: Even though laparoscopic adrenalectomy is currently a standard, there are important variations between different centres in short-term treatment results such as length of hospital stay (LOS) or morbidity. AIM: To determine the factors affecting LOS in patients after laparoscopic transperitoneal lateral adrenalectomy (LTA). MATERIAL AND METHODS: The study enrolled 453 patients (173 men and 280 women, mean age 57 years) who underwent LTA between 2009 and 2017. Discharge from hospital after more than median hospital stay was considered as prolonged LOS. We evaluated factors that potentially may influence LOS (primary length of stay after surgery, excluding readmissions). Logistic regression models were used in univariate and corrected multivariate analyses, in order to identify the factors related to prolonged LOS. RESULTS: The median LOS after LTA in the studied group was 2 days. One hundred seventy-five (38.5%) patients required prolonged hospitalization. Univariate logistic regression showed that the following factors were related to prolonged LOS: presence of any comorbidity, cardiovascular disease, intraoperative complications, postoperative complications, day of the week of operation (surgery on Thursday or Friday), intraoperative blood loss, need for transfusion, hormonal activity, postoperative drainage, ASA (III-IV) and histological type - pheochromocytoma. Multivariate logistic regression showed that only complications (OR = 3.86; 95% CI: 1.84-8.04), day of the week of operation (Thursday or Friday) (OR = 4.85; 95% CI: 3.04-7.73), need for drainage (OR = 3.63; 95% CI: 1.55-8.52), and histological type - pheochromocytoma (OR = 2.48; 95% CI: 1.35-4.54) prolonged LOS. CONCLUSIONS: Prolonged length of hospital stay following laparoscopic transperitoneal lateral adrenalectomy is strongly associated with the presence of postoperative complications, day of the week of operation (Thursday or Friday), need for drainage, and histological type - pheochromocytoma.

Changes in plasma albumin levels in early detection of infectious complications after laparoscopic colorectal cancer surgery with ERAS protocol.

BACKGROUND: Combination of laparoscopic approach with ERAS protocol in colorectal surgery allows for an early discharge. However there is a risk that some of the discharged patients are developing, asymptomatic at the time, infectious complications. This may lead to a delay in diagnostics and proper treatment introduction. We aimed to assess the usefulness of preoperative plasma albumin concentration and their changes as indicators of infectious complications in patients undergoing colorectal cancer surgery. METHODS: Prospective analysis included 105 consecutive patients who underwent laparoscopic colorectal cancer resection between August 2014 and September 2016. In all cases standardised 16-item perioperative care ERAS protocol was used (mean compliance > 85%). Patients with IBD, distant metastases, undergoing emergency or multivisceral resection were excluded. Blood samples were collected preoperatively and on POD 1, 2, 3. Plasma albumin concentration was measured. Patients were divided into two groups depending on the presence of infectious complications. We analysed the differences in the levels of albumin and the dynamics of changes. RESULTS: Group 1-82 not complicated patients, Group 2-23 patients with at least one infectious complication. Preoperatively, there were no significant differences in the levels of serum albumin between those groups (Group 1-38.7 ± 4.9 g/l; Group 2-37.7 ± 5.0 g/l). In postoperative period, decrease was observed in both (POD 1: Group 1-36.5 ± 4.2 g/l, Group 2-34.7 ± 4.2 g/l, p = 0.07; POD 2: Group 1-36.2 ± 4.1 g/l, Group 2-32.6 ± 5.6 g/l, p = 0.01; POD 3: Group 1-36.0 ± 4.4 g/l, Group 2-30.9 ± 3.5 g/l, p = 0.01). The decrease was significantly greater in Group 2 on POD 2 and 3. CONCLUSIONS: We showed that a regular measurement of albumin in the early postoperative days may be beneficial in the detection of postoperative infectious complications. Although changes in albumins are observed early after surgery, this parameter is relatively unspecific.

Analysis of Laparoscopic Sleeve Gastrectomy Learning Curve and Its Influence on Procedure Safety and Perioperative Complications.

PURPOSE: Laparoscopic sleeve gastrectomy (LSG) has become an attractive bariatric procedure with promising treatment effects yet amount of data regarding institutional learning process is limited. MATERIALS AND METHODS: Retrospective study included patients submitted to LSG at academic teaching hospital. Patients were divided into groups every 100 consecutive patients. LSG introduction was structured along with Enhanced Recovery after Surgery (ERAS) treatment protocol. Primary endpoint was determining the LSG learning curve's stabilization point, using operative time, intraoperative difficulties, intraoperative adverse events (IAE), and number of stapler firings. Secondary endpoints: influence on perioperative complications and reoperations. Five hundred patients were included (330 females, median age of 40 (33-49) years). RESULTS: Operative time in G1-G2 differed significantly from G3-G5. Stabilization point was the 200th procedure using operative time. Intraoperative difficulties of G1 differed significantly from G2-G5, with stabilization after the 100th procedure. IAE and number of stapler firings could not be used as predictor. Based on perioperative morbidity, the learning curve was stabilized at the 100th procedure. The morbidity rates in the groups were G1, 13%; G2, 4%; G3, 5%; G4, 5%; and G5, 2%. The reoperation rate in G1 was 3%; G2, 2%; G3, 2%; G4, 1%; and G5, 0%. CONCLUSION: The institutional learning process stabilization point for LSG in a newly established bariatric center is between the 100th and 200th operation. Initially, the morbidity rate is high, which should concern surgeons who are willing to perform bariatric surgery.

Patients criteria determining difficulty of the laparoscopic lateral transperitoneal adrenalectomy. A retrospective cohort study.

BACKGROUND: Identification of patients in whom adrenalectomy may be more difficult, can help in decision making in borderline and doubtful cases. The aim of the study was to determine patients criteria influencing difficulty of laparoscopic lateral transperitoneal adrenalectomy (LTA). MATERIAL AND METHODS: The study enrolled 275 patients who underwent LTA. We analyzed the impact of gender, age, history of previous abdominal surgery, body mass index, risk of anesthesia measured as ASA scale, size, localization (left/right), and histological type of the tumor on parameters reflecting the level of difficulty of the procedure: operative time, intraoperative blood loss, conversion rate and intraoperative complications rate. RESULTS: Multivariate logistic regression showed that following factors were associated with longer operative time: gender, tumor size and malignant lesions. In another model it was shown that age, size of the tumor and malignancy were associated with more excessive blood loss. Moreover, it was shown, that tumor size predictive factor for conversion. Univariate analysis showed a relation with malignancy, but multivariate analysis revealed no significance. CONCLUSIONS: Patient age, gender, size and histological type of the tumor are criteria influencing parameters reflecting the level of difficulty. This criteria could be considered as predictors of the difficulty of LTA. Surgery in case of patients with combination of this risk factors should be handled by surgeon with sufficient experience to minimalize the risk of adverse events.

Are bariatric operations performed by residents safe and efficient?

BACKGROUND: The growing need for surgeons who are educated and trained in bariatric surgery has raised many issues related to training in this field. OBJECTIVES: This study was performed to evaluate the safety and efficacy of laparoscopic sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) performed by doctors-in-training during their residency in general surgery. SETTING: Tertiary referral university teaching hospital, Poland. METHODS: We retrospectively analyzed the data of patients who underwent bariatric surgery. One group underwent surgery performed by at least third-year residents learning particular types of surgeries (trainee group), and the second group underwent surgeries performed by experienced bariatric surgeons (mentor group). The primary endpoint was the safety of the procedures. We analyzed factors related to the intraoperative and postoperative course. The secondary endpoint was long-term weight reduction. A lower body mass index (BMI), fewer co-morbidities, and preferably female sex were the selection criteria for patients in the trainee group. RESULTS: We enrolled 408 patients who met all inclusion criteria. Among them, 233 underwent SG and 175 underwent LRYGB. For both SG and LRYGB, the median maximum preoperative weight was significantly lower in the trainee than mentor group. We found no statistically significant differences in the demographic factors or co-morbidities between the 2 groups. The median duration of SG and LRYGB surgery was significantly longer in the trainee than mentor group. The median number of stapler firings during SG was significantly lower in the trainee than mentor group. The number of stapler firings during LRYGB did not differ between the 2 groups. The incidence of intraoperative difficulties, which were based on the operator's subjective opinion, was higher in the trainee than mentor group for both SG and LRYGB. However, intraoperative difficulties had no significant impact on the intraoperative complication rate or risk of perioperative complications. The average percentage weight loss (%WL), percentage excess weight loss (%EWL), and percentage excess BMI loss (%EBMIL) in the all study group were 31.14%±9.11%, 56.17%±17.27%, and 65.42%±19.28%, respectively. For patients who underwent SG, we found no significant difference in %WL, %EWL, or %EBMIL between the trainee and mentor groups. CONCLUSIONS: The performance of bariatric surgeries by residents does not affect the risk of reoperation, intraoperative adverse events, or surgical complications. Performance of SG and LRYGB by trainees takes significantly longer but has no untoward consequences for the patient. Both SG and LRYGB performed by a doctor-in-training and experienced operator lead to comparable outcomes in terms of weight reduction.

Laparoscopic transperitoneal adrenalectomy in morbidly obese patients is not associated with worse short-term outcomes.

OBJECTIVES: To evaluate the impact of obesity and morbid obesity on short-term outcomes after laparoscopic adrenalectomy. METHODS: The study included 520 consecutive patients undergoing laparoscopic adrenalectomy for adrenal tumor. The entire study group was divided depending on the body mass index: group 1 (normal weight), <25 kg/m2 ; group 2 (overweight), 25-30 kg/m2 ; and group 3 (obese) 30-40 kg/m2 . Additionally, group 4 (morbidly obese) was distinguished. Study end-points were: operative time, intraoperative blood loss, total length of hospital stay, morbidity rate and 30-day readmission rate. RESULTS: The mean operative times were 88.8, 94.7, 93.5, and 99.9 min in groups 1, 2, 3 and 4, respectively (P = 0.1444). Complications were comparable between groups (12.8% vs 8.8% vs 8.2% vs 11.5%, P = 0.5295). The mean intraoperative blood loss was 66.8 versus 78.3 versus 60.7 versus 92.4, P = 0.1399. There were no differences in conversion rate between groups. CONCLUSIONS: Obesity has no influence on short-term outcomes of laparoscopic transperitoneal adrenalectomy. This procedure is feasible regardless of the body mass index. Therefore, it can be offered to all patient groups including those morbidly obese individuals in whose case preoperative weight loss seems unnecessary.

Risk factors for complications of laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Although bariatric procedures are considered safe, yet still they involve a risk of possible perioperative complications. Identification of risk factors for complications would allow for appropriate preoperative optimization of the patient, as well as reasonable postoperative care and early diagnosis and treatment of possible complications. The aim of this study was to determine the risk factors for perioperative complications after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). MATERIAL AND METHODS: A retrospective analysis of prospectively collected data of patients operated for morbid obesity. Regarding postoperative complications defined as adverse events occurring within 30 days of the procedure. Factors associated with patient characteristics and those related to the surgical procedure were determined. 408 patients met inclusion criteria and were submitted to surgical treatment. LSG and LRYGB were performed in 233 and 175 patients, respectively. RESULTS: Complications were observed in 30 (7.3%) patients. The maximum preoperative body weight and BMI, as well as body weight and BMI on the day of surgery were associated with increased complication rate. The type of the procedure did not influence perioperative complications (LRYGB vs. LSG; OR: 1.14; CI: 0.53-2.44; p = 0.74). Although operative time statistically significantly increased the risk of complications, it did not seem clinically relevant (OR: 1.01; CI: 1.00-1.02; p = 0.003). An increase in the number of stapler firings used significantly increased complication rate only in LSG group. CONCLUSION: Longer duration of LSG and the increase in the number of stapler firings used during LSG should alert a surgeon to an increased risk of postoperative complications. In patients submitted to LRYGB the risk of possible complications increases with BMI.

A Periampullary Duodenal Diverticula in Patient with Choledocholithiasis - Single Endoscopic Center Experience.

The reported prevalence of periampullary duodenal diverticula varies between 9 and 32.8%. The aim of the study was to evaluate the prevalence of periampullary diverticula in the studied population and establish whether their presence influence the risk of choledocholithiasis and the risk of Endoscopic Retrograde Cholangio Pancreatography (ERCP) related complications. MATERIAL AND METHODS: The study group of 3788 patients who underwent ERCP between 1996 and 2016 at the 2nd Department of General Surgery Jagiellonian University Medical College in Kraków were analyzed. The group comprised of 2464 women (mean age 61.7 years) and 1324 men (mean age 61.8 years). The patients were divided into two groups. Group A included patients in whom there were no periampullary diverticula detected. Group B included patients in whom the opening of the bile duct was in the vicinity of a duodenal diverticulum. RESULTS: There were 3332 patients included in group A (2154 women and 1178 men) and 456 patients in group B (310 women and 146 men). The prevalence of periampullary duodenal diverticula in the analyzed group was 12.8%. The presence of stones or biliary sludge was diagnosed in 1542 patients (47.6%) in group A and 290 patients (68.1%) in group B. Recurrence of choledocholithiasis occurred in 4.5% of patients (70/1542) in group A and 10.3% of patients (30/290) in group B. Complications occurred in a total of 76 patients in group A (2.3%) and 22 patients in group B (4.8%). CONCLUSIONS: The presence of choledocholithiasis and the risk of ERCP related complications are significantly higher in the group with duodenal diverticula.

Laparoscopic adrenalectomy for pheochromocytoma is more difficult compared to other adrenal tumors.

INTRODUCTION: Laparoscopic adrenalectomy is the gold standard for the treatment of benign adrenal tumors. However, some authors raise the problem of differences in surgery for pheochromocytoma in comparison to other lesions. AIM: To compare laparoscopic adrenalectomy for pheochromocytoma and for other tumors. MATERIAL AND METHODS: Four hundred and thirty-seven patients with adrenal tumors were included in the retrospective analysis. Patients were divided into two groups: 1 (124 patients treated for pheochromocytoma) and 2 (313 patients with other types of tumor). The two groups were compared with respect to mean operative time, intraoperative blood loss, conversion rate, complication rate and the relationship of tumor size with operative time. RESULTS: The mean operative time in group 1 was 91 min, and in group 2 it was 82 min (p = 0.016). In both groups 1 and 2, tumor size correlated with operative time (p < 0.0001 and p = 0.0003, respectively). The mean blood loss in groups 1 and 2 was 117 ml and 54 ml, respectively (p = 0.0011). The complication rate in groups 1 and 2 was 4% and 4.2%, respectively (p = 0.9542). In groups 1 and 2, conversion was necessary in 2 (1.6%) and 5 (1.6%) cases, respectively (p = 0.9925). CONCLUSIONS: Longer operative time and higher blood loss after laparoscopic adrenalectomy for pheochromocytoma indicate its greater difficulty. However, despite these drawbacks, minimally invasive surgery still seems to be an effective and safe method.

The usefulness of the Mannheim Peritonitis Index score in assessing the condition of patients treated for peritonitis.

UNLABELLED: The aim of the study was to verify the Mannheim Peritonitis Index (MPI) suitability to determine the probability of death among patients in Polish population operated due to peritonitis and to assess the possibility of using the Index to determine the risk of postoperative complications, relaparotomy and need for postoperative hospitalization in intensive care unit. MATERIAL AND METHODS: Retrospective analysis covered 168 patients (M: F = 83: 85, mean age = 48.45 years, SD ± 22.2) treated for peritonitis. The MPI score was calculated for each patient. According to MPI results, patients were divided to the appropriate groups (<21, 21-29, > 29) and within analyzed. The statistical analysis used Chi-square, Mann Withney U and Kolmogorov-Smirnov test. The best cut-off point for MPI was calculated on the basis of ROC analisys. RESULTS: Mortality in the study group was 13.1%. In groups <21, 21-29 and > 29 points according to MPI mortality was 1.75%, 28.13% and 50% respectively, the difference was statistically significant (p = 0.0124). Significant differences were observed in mortality depending on the diagnosis. Based on the ROC curve the cut-off point was identified as 32 with an accuracy of 85.9% and AUC = 81%. There has been a significant correlation between the MPI count and and the occurrence of: cardio-respiratory failure, acidosis, electrolyte imbalance, surgical wound complications, the need for treatment in the intensive care unit after surgery. CONCLUSIONS: The MPI is a simple and effective predictor of death among patients operated due to peritonitis. It can also provide assistance in assessing the risk of postoperative complications and the need for treatment in the intensive care unit.