Fluorescent ICG angiography in laparoscopic rectal resection - a randomized controlled trial. Preliminary report.

Introduction: Anastomotic leakage is one of the most dangerous complications after rectal surgery. It can cause systemic complications, reduce the quality of life and worsen the results of oncological treatment. One of the causes of anastomotic leak is insufficient blood supply to the anastomosis. Intraoperative infrared angiography with indocyanine green (ICG) is expected to improve the assessment of intestinal perfusion and thus prevent anastomotic leakage. Aim: To present the results of the use of ICG intraoperative angiography during rectal surgery in the prevention of anastomotic leakage. Material and methods: The study included 76 patients undergoing rectal cancer surgery. Patients were randomized to 2 groups: Group I - 41 patients with ICG intraoperative angiography; and Group II - 35 patients without ICG imaging. Anastomotic leak, length of hospitalization, and complication rate were compared. Results: Group I patients received intravenous ICG before the anastomosis. Average time of intestinal wall contrasting was 42 s (22-65 s). Average ICG procedure time was 4 min (3.2% of total time of surgery). Three (7.3%) patients after angiography revealed intestinal ischemia requiring widened resection. No anastomotic leak was found post-operatively, and no side effects were observed after administration of ICG. In group II, 3 (8.6%) anastomotic leakages were diagnosed, 2 of which required reoperation. Conclusions: Intraoperative angiography with ICG in near-infrared light is a safe and effective method of assessing intestinal perfusion. ICG angiography may change the surgical plan and reduce the risk of anastomotic leakage. It is necessary to continue the study until the assumed number of patients is reached.

The impact of full-spectrum endoscopy on pathological lesion detection in different regions of the colon: a randomised, controlled trial.

INTRODUCTION: Colonoscopy is crucial for detecting and localising pathological lesions within the colon. Colonoscopy quality is defined by the caecal intubation rate, withdrawal time, adenoma detection rate, and polyp detection rate. The newly introduced full-spectrum endoscope (FUSE®) provides a 330° field of view, allowing endoscopists to observe more colonic anatomy. It is intended to increase detection of pathological lesions, especially those situated behind the haustral folds of the bowel. This diagnostic modality should increase the adenoma detection rate (ADR), especially in the right hemicolon. The aim of this study was to explore the efficacy of FUSE for detecting pathologic lesions in different colonic regions. MATERIAL AND METHODS: The study enrolled 408 patients who were randomised to either a standard frontal view (SFV) or the novel full-spectrum colonoscopy. Analysis was performed among three broad regions of the colon: right, transverse, and left colon, according to the Boston Bowel Preparation Scale. RESULTS: FUSE yielded a higher diverticula detection rate (DDR) in the right and middle colon (DDR-R (p < 0.05), DDR-T (p < 0.05), DDR-L (p = 0.862)). ADR (p = 0.761), advanced ADR (aADR) (p = 0.950), and DDR (p = 0.967) in respective regions of the colon were similar between the groups; however, the total number of adenomas detected with FUSE was higher in the right and middle regions of the colon compared with those detected by SFV (p < 0.05). CONCLUSIONS: Full-spectrum colonoscopy allows for effective recognition of pathological lesions in the right and middle regions of the colon. Although full-spectrum colonoscopy did not statistically affect ADR, the absolute number of adenomas detected was higher compared with classical endoscopy.

Accuracy of preoperative tumor localization in large bowel using 3D magnetic endoscopic imaging: randomized clinical trial.

BACKGROUND: Laparoscopic surgery has become the standard treatment for colorectal cancer. A tumor that does not involve serosa is invisible intraoperatively, and manual palpation of the tumor during laparoscopy is not possible. Therefore, accurate localization of the neoplastic infiltrate remains one of the most important tasks prior to elective laparoscopic surgery. The aim of this study was to evaluate the utility of a magnetic endoscopic imaging (MEI) for precise preoperative endoscopic localization of neoplastic infiltrate within the large bowel. MATERIALS AND METHODS: The study enrolled 246 patients who underwent elective surgery for colorectal cancer in 2012-2015 with accurate preoperative colonoscopic localization of the tumor. The analysis concerned patients with neoplastic infiltrate localized more than 30 cm from the anal verge. For evaluative purposes and accuracy of localization, the intestine was divided anatomically into 13 parts. Colonoscopic examinations were conducted with two types of endoscopes: group I-with MEI and group II-without MEI. Patients were assigned to the groups by random allocation. Ultimate confirmation of the tumor localization was accomplished by intraoperative evaluation. RESULTS: Group I involved 127 patients and group II 129. The two groups were compared in terms of age, sex, BMI and frequency of previous abdominal procedures. Proper localization of the lesion was confirmed in 95.23 % of group I patients and in 83.19 % of group II patients (p < 0.05). The greatest discrepancy in localization occurred in 8.9 % of patients from group I and 20 % of patients from group II in which the lesion was assessed primarily in the distal sigmoid. CONCLUSIONS: A magnetic endoscopic imaging allows more accurate localization of neoplastic infiltrate within the large intestine compared to standard colonoscopy alone, especially within the sigmoid colon. This method can be particularly useful in planning and performing laparoscopic procedures to diminish the likelihood of improper bowel segment resection. CLINICALTRIALS. GOV NUMBER: NCT01688557.

Impact of responsive insertion technology (RIT) on reducing discomfort during colonoscopy: randomized clinical trial.

BACKGROUND: In many countries, colonoscopies for colorectal cancer screening are performed without sedation due to the cost. Changes in the structure of the endoscopes are designed to facilitate the colonoscopic examination, reduce the duration of the procedure, and improve the imaging of the intestinal lumen. The variable stiffness of the endoscope and the recently introduced responsive insertion technology (RIT) are features aimed at easing colonoscope insertion and reducing the discomfort and pain during the examination. The aim of the study is to analyze whether the new RIT system can improve the practice of colonoscopy under no anesthesia with respect to the widely available variable stiffness colonoscopes. MATERIALS AND METHODS: This analysis included 647 patients who underwent complete colonoscopy in the screening program. All colonoscopies were performed without sedation. Olympus series 180 and 190 endoscopes equipped with a magnetic positioning system were used. Group I included patients who were examined using endoscopes equipped with responsive insertion technology (RIT), and group II included patients who were examined using conventional variable stiffness colonoscopies. The main objective was to evaluate the cecal intubation time, the number of loops, the requirement to apply manual pressure to different areas of the abdomen and the degree of discomfort and pain expressed on a visual analogue scale (VAS). ClinicalTrials.gov number, NCT01688557. RESULTS: Group I consisted of 329 patients, and group II included 318 patients. The mean age of the patients was 58.4 years (SD ± 4.21). Both groups were compared in terms of age, sex, and BMI. The mean cecal intubation time was 209 s in group I and 224 s in group II (p < 0.05). Increased loop formation was observed upon endoscope insertion in group II (1.7 vs. 1.35) (p < 0.05) and required more manual pressure to the abdomen (2.2 vs. 1.7) (p = 0.001). In group I, less discomfort and pain, as graded on a VAS (2.3 vs. 2.6), were noted. CONCLUSIONS: The implementation of RIT reduced of the cecal intubation time. The modified structure of the endoscope rendered the colonoscopic examination easier by reducing loop formation upon insertion with a subsequently reduced rate of auxiliary maneuvers.

Effectiveness of mesh hernioplasty in incarcerated inguinal hernias.

INTRODUCTION: The use of mesh is still controversial in patients undergoing emergency incarcerated hernia repair, mostly because of potential infectious complications. AIM: The main aim of this study was to assess the efficacy of tension-free methods in treating incarcerated inguinal hernias (IIH), with and without intestine resection. The secondary aim was to establish an algorithm on how to proceed with incarcerated hernias. MATERIAL AND METHODS: A retrospective analysis of patients who underwent surgery due to an inguinal hernia at the First Department of General Surgery Jagiellonian University Medical College in Krakow, in the period 1999-2009. Operative methods included Lichtenstein, Robbins-Rutkow and Prolene Hernia System. The rate of postoperative complications was compared in patients who underwent elective and emergency surgery. RESULTS: The study group consisted of 567 patients (546 male) age 19-91 years. In this group 624 hernias were treated using the three tension-free techniques - 295 using the Lichtenstein method, 236 using PHS and 93 using the RR technique. Out of the 561 operations 89.9% were elective. No correlation (p > 0.05) was found between the type of surgery and such complications as postoperative pain duration and intensity, fever, micturation disorders, wound healing disorders, testicle hydrocoele, testicle atrophy, spermatic cord cyst, sexual dysfunction, wound dehiscence, wound suppuration, seroma, haematoma and hernia recurrence. CONCLUSIONS: Mesh repairs can be safely performed while operating due to an IIH. The use of a synthetic implant, in emergency IIH repairs, does not increase the rate of local complications. Synchronous, partial resection of the small intestine, due to intestinal necrosis, is not a contraindication to use mesh.

Primary adenocarcinoma of the appendix - a case report.

Abstract Primary adenocarcinoma of the vermiform appendix is a rare clinical condition. It usually presents as an acute abdominal process or as a mass in the right lower quadrant. The gross pathologic and microscopic characteristics of this disease are the same as for colon carcinoma and carry a serious prognosis. We report a case of a 64-year old male patient presenting symptoms of acute appendicitis. The patient underwent laparoscopic appendectomy that revealed a severely inflamed appendix. Histopathological examination has shown that it was a poorly differentiated, high grade adenocarcinoma invading the periappendicular fat. According to the histopathological findings, a right hemicolectomy was further advised and performed. Right hemicolectomy is the generally recommended method of treatment for invasive adenocarcinoma of the appendix.

[Elevated blood glucose level as a risk factor of hospital-acquired pneumonia among patients treated in the intensiv care unit (ICU)]. / Podwyiszone stezenie glukozy jako czynnik ryzyka szpitalnego zapalenia pluc u chorych w oddziale intensywnej terapii.

Hospital acquired-pneumonia is the most frequently occurring hospital-acquired infection in intensive care units (ICU). The study group consisted of 233 patients treated over 12 months in the ICU of the 1st Department of General Surgery and Gastroenterological Surgery Clinics, University Hospital in Krakow. Patients were divided in two groups: experimental--consisting of 92 patients with hospital-acquired pneumonia, and control--consisting of 141 patients without the disease. The following risk factors of hospital-acquired pneumonia risk were analysed for both groups: length of stay in the ICU, duration of mechanical ventilation, kind of treatment applied, presence of a gastrointestinal tube, blood glucose levels. Significantly more patients with hospital-acquired pneumonia than controls had blood glucose level above 6 mmol/l (OR = 2.23). Monitoring and maintainment of glucose level within the normal ranges is an important element of successful treatment. In fact, glucose level is the only risk factor that can be easily modified compared with other analyzed factors.

[Treatment of the inguinal haernias with the use of synthetic mesh with prolen hernia system (PHS) and Robbins-Rutkow methods--review of outcomes]. / Ocena wyników leczenia przepuklin pachwinowych przy uzyciu wszczepów syntetycznych--metodami prolen hernia system (PHS) i Robbins-Rutkow.

OBJECT OF RESEARCH: Evaluation of methods and outcomes of inguinal region haernias' treatment with the use of synthetic implants. MATERIAL: An analysis of 867 patients operated with the use of synthetic implants between 1999 and 2005 has been made (PHS, Robbins-Rutkow). The group consisted of 695 men, and 172 women and the average age was 44.5 years. In 860 (99%) patients a subarachnoid anaesthesia and in (1%) patients a local anaesthesia were performed. All patients received antibiotic prophylaxis. RESULTS: Between 1999-2005 867 surgical treatments of the inguinal region haernias were performed using synthetic implants--PHS 363 (41.9%), Robbins-Rutkow 504 (58.1%). Most patients received subarachnoid anaesthesia (99%). Only 1% of the patients were given local anaesthesia due to the load pertaining to internal medicine and the presence of spondylosis. Complications which occured after surgery were: suppuration of the wound in 17 patients (2%), hematoma in the wound in 8 patients (1%), relapse of haernia in 4 patients (0.5%). All patients were activated in the first twenty-four hours after the operation. Return to full physical activity was observed 14 days after the surgery. CONCLUSIONS: 1. Analysing both methods of treatment, no statistically significant differences were found in the frequency of posoperative complications and haernia relapse. 2. The choice of method is dependent on the type of haernia found intraoperatively. 3. The proper method choice guarantees the efficacy of treatment as well as little amount of complications and relapses.

[16-year experience with one-day surgery inguinal hernia repair]. / Leczenie przepuklin pachwinowych w systemie chirurgii jednego dnia na podstawie 16 lat wlasnych doswiadczen.

AIM OF THE STUDY: Evaluation of inguinal hernia repair techniques and results. MATERIAL: Study group consist of patients undergoing inguinal hernia repair between 1990-1998 326 patients (305 men, 21 women, mean age 45.5 yrs), and between 1999-2006 693 patients (662 men, 31 women, mean age 48.5 yrs). METHOD: Inguinal hernia repair techniques and anesthesia: 1990-1998: Bassini--234 (47.7%), Girard--52 (15.9%), Shouldice--36 (11.8%), PHS--2 (0.6%); general anesthesia--140 (430%), spinal anesthesia--186 (57%), 1999-2006: Lichtestein--207 (30.0%). Robbins-Rutkow--299 (43.1%), PHS--148 (21.3%), Shouldice--39 (5.6%); general anesthesia--28 (4%), spinal anesthesia--665 (96%). RESULTS AND CONCLUSION: 1. The use of synthetic mesh significant reduces inguinal hernia recurrences. 2. Returning to normal daily activities within short time after surgery. 3. The use of lowered doses of analgesics after surgery. 3. The use of lowered doses of analgesics after surgery. 4. After the use of synthetic hernia mesh the number of wound infections, hametaomas or seromas did not increase. 5. There were no differences in the intensity of postoperative pain related to synthetic mesh used. Inguinal hernia repair-management diagram. 1. Patients operated on through one-day surgery. 2. Hospital stay--12 hours. 3. Spinal anaesthesia. 4. The administration of antibiotic prophylaxis for elective inguinal hernia repair cannot be universally recommended. 5. We prefer Lichtenstein repair ("gold standard"). 6. Patient fully ambulated 4-6 hours after surgery. 7. Returning to normal daily activities after 2 weeks.

[The history of treatment of groin hernia]. / Rys historyczny leczenia chirurgicznego przepuklin.

Hernia (Greek kele/hernios--bud or offshoot) was present in the human history from its very beginning. The role of surgery was restricted to the treatment of huge umbilical and groin hernias and life-threatening incarcerated hernias. The treatment of groin hernia can be divided into five eras. The oldest epoch was ancient era from ancient Egypt to 15th century. The Egyptian Papirus of Ebers contains description of a hernia: swelling that comes out during coughing. Most essential knowledge concerning hernias in ancient times derives from Galen. This knowledge with minor modifications was valid during Middle Ages and eventually in the Renaissance the second era of hernia treatment began. Herniology flourished mainly due to many anatomical discoveries. In spite of many important discoveries from 18th to 19th century the treatment results were still unsatisfactory. Astley Cooper stated that no disease treated surgically involves from surgeon so broad knowledge and skills as hernia and its many variants. Introduction of anesthesia and antiseptic procedures constituted the beginning of modern hernia surgery known as era of hernia repair under tension (19th to middle 20th century). Three substantial rules were introduced to hernia repair technique: antiseptic and aseptic procedures. high ligation of hernia sac and narrowing of the internal inguinal ring. In spite of the progress the treatment results were poor. Recurrence rate during four years was ca. 100% and postoperative mortality gained even 7%. The treatment results were satisfactory after new surgical technique described by Bassini was implemented. Bassini introduced the next rule of hernia repair ie. reconstruction of the posterior wall of inguinal canal. The next landmark in inguinal hernia surgery was the method described by Canadian surgeon E. Shouldice. He proposed imbrication of the transverse fascia and strengthening of the posterior wall of inguinal canal by four layers of fasciae and aponeuroses of oblique muscles. These modifications decreased recurrence rate to 3%. The next epoch in the history of hernia surgery lasting to present days is referred to as era of tensionless hernia repair. The tension of sutured layers was reduced by incisions of the rectal abdominal muscle sheath or using of foreign materials. The turning point in hernia surgery was discovery of synthetic polymers by Carothers in 1935. The first tensionless technique described by Lichtenstein was based on strengthening of the posterior wall of inguinal canal with prosthetic material. Lichtenstein published the data on 1,000 operations with Marlex mesh without any recurrence in 5 years after surgery. Thus fifth rule of groin hernia repair was introduced--tensionless repair. Another treatment method was popularized by Rene Stoppa, who used Dacron mesh situated in preperitoneal space without fixing sutures. First such operation was performed in 1975, and reported recurrence rates were quite low (1.4%). The next type of repair procedure was sticking of a synthetic plug into inguinal canal. Lichtenstein in 1968 used Marlex mesh plug (in shape of a cigarette) in the treatment of inguinal and femoral hernias. The mesh was fixated with single sutures. The next step was introduction of a Prolene Hernia System which enabled repair of the tissue defect in three spaces: preperitoneal, above transverse fascia and inside inguinal canal. Laproscopic treatment of groin hernias began in 20th century. The first laparoscopic procedure was performed by P. Fletcher in 1979. In 1990 Schultz plugged inguinal canal with polypropylene mesh. Later such methods like TAPP and TEP were introduced. The disadvantages of laparoscopic approach were: high cost and risk connected with general anesthesia. In conclusion it may be stated that history of groin hernia repair evolved from life-saving procedures in case of incarcerated hernias to elective operations performed within the limits of 1 day surgery.

[Duodenal diverticula and choledocholithiasis in own material]. / Uchylki dwunastnicy a kamica przewodowa w materiale wlasnym.

The detectability of duodenal diverticula (DD), a common duodenal pathology, has been growing with the increasing availability of endoscopic examinations, and especially of endoscopic retrograde cholangio-pancreatography (ERCP). The study is a retrospective analysis of incidence rates of DD and accompanying diseases of bile ducts, liver and pancreas detected by ERCP. We performed 8642 ERCP examinations between 1974 and 2001, which detected DD in 622 (7.2%) patients. Of these, 409 (65.8%) had choledocholithiasis, and 97 (15.6%) liver, gallbladder, bile ducts or pancreatic cancer. In the remaining 106 (17.0%) patients no pathologies requiring surgical intervention were found by radiological examination of bile ducts and pancreatic duct. In 10 (1.6%) patients with DD, caniulation of Vater papilla was not performed due to its anatomical location. Obtained results confirm relationship between DD and choledocholithiasis. It has not been established whether DD predispose to choledocholithiasis by interfering with bile duct emptying and causing bile lithogenicity, or rather that duodenal diverticula are caused by a concrement moved to duodenum by contractions of the gallbladder or sphincter of Oddi.

[Solid and papillary epithelial neoplasm of the pancreas--a rare malignant tumor of pancreas]. / Solid and papillary epithelial neoplasm of the pancreas--rzadki guz nowotworowy trzustki.

The paper presents two cases of solid and papillary epithelial neoplasm of the pancreas (SPENP)--a rare pancreatic neoplasm in a 45-year-old woman admitted to the hospital with the diagnosis of pancreatic tail tumor and 22-year-old woman with the diagnosis of pancreatic head tumor. First patient was subjected to peripheral pancreatic resection; the second patient was subjected to Whipple pancreatoduodenectomy. Histopathological examination confirmed SPENP. The authors present cases and review of the literature on SPENP.