Port site metastases a year after initial laparoscopic cholecystectomy. Should the use of retrieval bags during laparoscopic cholecystectomy be the new gold standard?

As a result of gallbladder cancer being rare, it is often an understudied disease. There is lack of information particularly about long-term outcomes after resection during either laparoscopic or open surgery techniques [4]. There is also little data on the ways in which surgical techniques can be improved to further aid patients diagnosed with gallstones or other indications for cholecystectomy, and resulting positive histopathology. Furthermore, there is a lack of general acknowledgement on the vitality of using plastic retrieval bags during cholecystectomy regardless of the histopathology. The case study at hand shows how critical a plastic bag can be during cholecystectomy in further preventing the risk of local or distant metastasis originating from the gallbladder. This is especially important as it is estimated that almost one third of patients who undergo curative intent surgery for gallbladder cancer develop a tumor recurrence. Specifically, our patient was found to have a distant recurrence occurring a year after the elective surgery, which is in range with the usual median recurrence of 9.5 months or within the first 12 months [5]. </br> </br> Laparoscopic cholecystectomy is a common surgical procedure, and remains the gold standard for the management of benign gallbladder and biliary disease. While this procedure can be technically straightforward, there are some key factors that surgeons must take into consideration with one of them being whether to use a retrieval bag or not. According to the "Guidelines for the Clinical Application of Laparoscopic Biliary Tract Surgery" of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), the use of a retrieval bag for gallbladder extractions is purely at the discretion of the surgeon [6]. Generally, plastic bags should be used when gallbladder cancer is suspected to minimize disseminating tumor cells, or in the case of acute cholecystitis, to avoid spillage of gallbladder contents including possible infected bile, stones or pus. While one study states that when a cholecystectomy is performed due to gallstones, generally, surgeons will only opt for a plastic bag if there are large gallstones, great inflammation or an edematous gallbladder [7, 8]. However, another article claims the adverse, with endoscopic bags being in fact used commonly in elective cholecystectomy, despite the increased cost and apparent benefit [7]. A major drawback, and possible reason why some surgeons may decide not to use retrieval bags could be due to the extra skills needed, or increased difficulty to the surgery. This could be due to the need for enlargement of port site incision, placement of the bag around the gallbladder, as well as the potential risk to abdominal organ damage during the insertion and retrieval of the bag [7]. Sometimes the decision not to use the bag is purely economic, especially in developing countries. Fortunately nowadays commercially available endobags become more inexpensive, and to the very little extent, increase final costs of laparoscopic cholecystectomy. However, in order to reduce these costs several studies have shown that sterile male condoms or surgical non-powdered gloves can be used [9]. </br> </br> Umbilical port site recurrence is traditionally a major concern, however there is still little research around the exact mechanism responsible for port site recurrence. Port site metastasis is the most common form of parietal recurrence with all stages of gallbladder carcinoma being reported at any of the trocar sites. Historically it was proved that the risk of port site metastasis after laparoscopic removal of incidental gallbladder cancer remained at the level of 14-30% of all cases. Recent study conducted to assess the incidence of port site metastasis in incidental gallbladder cancer in the modern era (2000-2014) versus the historic era (1991-1999) proved that this incidence has decreased but is still relatively high to other primary tumors [10]. </br> </br>It generally presents after latency, ranging from a few months to 3-4 years. Many factors can contribute to port site metastasis [9]. One of the most important is intraoperative spillage of bile from gallbladder wall perforation, which has been described in 30% of laparoscopic cholecystectomy cases, and it has been linked to port site metastasis [11]. Interestingly, local recurrence was noted only in a minority of patients, with distant sites such as the liver and peritoneum being the most common sites for disease recurrence [4]. </br> </br> Some hypotheses suggest to elucidate the cause of port site metastasis, including direct "chimney stack effect" in which the cancer cells may spread along trocar wound [12]. However, recent studies indicated that the chimney effect may not be the key reason for port site metastasis after laparoscopy and other factors may play crucial role in the development of this phenomenon, such as biological invasiveness of cancer, local traumatic factors, as well as host immune response [13]. Current evidence suggests that carbon dioxide pneumoperitoneum does not enhance wound metastases following laparoscopic abdominal tumour surgery. Animal studies indicated that overall postoperative wound recurrence of cancer is not significantly different between routine and gasless laparoscopic surgery [14]. null Tissue specimens removed during surgery are examined both macroscopically and microscopically, and despite this, false negatives can still persist. While there is clear data pertaining to false negatives associated with biopsies done with FNA occurring in a staggering 11-41% to detect malignancy before surgery [15], there is little data for false negatives in the postsurgical setting. Although histopathological analysis is usually very reliable to exclude malignancy, it may fail. This is clearly evident with our case, where the result was false negative. The cause for false negativity could be due to, for example, improper sampling despite guidelines indicating that three samples ought to be taken from high-risk areas of the specimen [16]. With false positives being possible both in pre- and postsurgery biopsies, surgeons must be cautious and take this factor into account in their surgical approach [17]. </br></br> At present, the only method that is universally used to reduce the recurrence of gallbladder cancer is cholecystectomy as incision of port sites and the use of endoscopic bags have been variably used among surgeons. Moreover, the use of adjuvant therapy after cholecystectomy has not shown to decrease the rate of recurrence, however, patients who underwent chemotherapy treatment often did slightly better [4]. Port site metastases are independently associated with a worse prognosis. Resection of previous laparoscopy port sites is advised in patients with peritoneal carcinomatosis after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) to ensure complete cytoreduction [18]. </br></br> It is clear from this standpoint that other solutions and ideas are needed. One of these could be permanent implementation of retrieval bags during cholecystectomies, especially due to the fact that it is not always possible to foresee the problems of retraction or to show a positive histopathological result in case of gallbladder rupture [4, 17]. In every cholecystectomy there is a risk of gallbladder perforation and spread of malignant cells. Perforation of the gallbladder is in fact a frequent complication during laparoscopic cholecystectomy, with a much higher risk of perforation in acute conditions like acute cholecystitis or gallbladder empyema. Some other methods that could be used to prevent dissemination of either gallbladder contents or malignant cells include clip application, rubber band ligation or endoscopic loop application. Rubber band ligation is especially good because it is considered as a safe, simple, inexpensive method, not increasing the duration of surgery [19]. Regardless of what method a surgeon decides to use to prevent cell dissemination during cholecystectomy, it is vital that one is used, and that the guidelines are amended. This case study provides the means for this, especially since a negative histopathological biopsy still does not exclude the possibility of traces of cancerous cells being undisclosed, allowing for a potential risk of port site metastases.

Thyroid hormones concentration in portal and peripheral blood in patients with pancreatic cancer: Preliminary study.

BACKGROUND: The prognostic value of D-dimers concentration in portal blood in patients with pancreatic cancer has been established in several studies. Thyroid hormones and their receptors, especially T3 also seems to have a specific role in process of neoplasia and metastatic spread. OBJECTIVE: The aim of the study was to look for changes of thyroid hormones concentration between portal and peripheral blood. METHODS: We included prospectively 8 patients with pancreatic cancer, without liver dysfunction, qualified to surgical treatment. D-dimers, THS, fT3, fT4 concentration was determined in blood samples from portal and peripheral vein taken intraoperatively. RESULTS: The difference and quotient of portal and peripheral concentration of D-dimers, THS, fT3 and fT4 was calculated (D-dimer-; THS-; fT3-; fT4-d and -q). The level of D-dimers measured in portal blood was > 2700 ng/mL in 3 patients. The peripheral fT3 level was significantly higher In high portal D-dimers group. FT3 change coefficients showed strong statistically significant negative correlation with portal D-dimer concentration level. CONCLUSIONS: We suggest that fT3 or its receptors can influence progression of pancreatic malignancies. The results of this study are also a new evidence that both fT3 and portal D-dimers are biologically linked to intensity of local neoplastic process. Nevertheless, deeper knowledge about portal circulation probably constitute missing part in understanding nature of pancreatic neoplasia. Investigations both on larger group and in the field of basic sciences are needed.

Awareness of head and neck cancer - a multicentre survey among young respondents in Poland.

PURPOSE: Head and neck cancer (HNC) is frequently diagnosed at an advanced stage of the disease, which results in suboptimal treatment outcomes, and leads to aesthetic and functional side-effects. Many risky behaviours associated with this type of cancer start at a young age. The aim of the study was to evaluate the level of HNC awareness in the young population in Poland. MATERIALS AND METHODS: An anonymous online survey on HNC was conducted among 1903 people between the ages of 18 and 35 years. Closed-ended questions concerned HNC risk factors, symptoms and prognosis. RESULTS: 85.1% of respondents were familiar with HNC. The main source of information was the Internet (57.3%); 78.2% of participants associated HNC occurrence with smoking, 43.4% with alcohol consumption and 37.2% with the human papillomavirus infection. The main risk factors mentioned by students of non-medical educational institutions included smoking, stress and excessive sunbathing. A quarter of respondents (37.7%, if medical students are excluded) were unaware of any early symptoms of HNC. The symptoms mentioned most frequently included chronic hoarseness (55.3%), a lump in the neck (51.8%) and chronic sore throat (51.4%). Over three-quarters of medical students and half of the remaining respondents connected early diagnosis with a better chance of being cured; 4.6% of medical students and 9.6% of students of other educational institutions would seek medical advice only when symptoms made everyday functioning impossible. CONCLUSIONS: The level of HNC cancer awareness in the young population is alarmingly low. A large number of non-medical students are unaware of risk factors and early symptoms. Educational campaigns aimed at effective prophylaxis, earlier diagnosis and treatment of HNC are needed.

[Skin cancer of the nose - methods and results of surgical treatment].

BACKGROUND: Non-melanoma skin cancer particularly basal cell carcinoma is the most common human malignancy in Caucasians. The majority of these tumours (80-90%) arise on the sun exposed parts of face. Lesions of the nose are the most challenging for the surgeon, because of the aesthetic feature. THE AIM: The aim of the study is to evaluate results of surgical treatment of nose skin cancer. MATERIALS AND METHOD: Authors analysed retrospectively 23 cases of skin cancer of the nose. Demographic data, aesthetic units, surgical methods and complications as well as aesthetic and functional results of treatment were noted. RESULTS: 23 people (9 male and 14 female) with 23 skin lesions were included to the study. The mean age was 72 ± 13 years. Majority of tumours infiltrated more then 1 nose aesthetic subunit. The most common surgical method of reconstruction was bilobed flap. Most of patients presented good aesthetic and functional outcome. CONCLUSIONS: The most important stage of treatment is proper qualification to surgical treatment - selection of reconstruction method, what establish radicalness of resection and good aesthetic and functional results.

PancreApp: An Innovative Approach to Computational Individualization of Nutritional Therapy in Chronic Gastrointestinal Disorders.

Medical nutrition therapy has a pivotal role in the management of chronic gastrointestinal disorders, like chronic pancreatitis, inflammatory bowel diseases (Lesniowski-Crohn's disease and ulcerative colitis) or irritable bowel syndrome. The aim of this study is to develop, deploy and evaluate an interactive application for Windows and Android operating systems, which could serve as a digital diet diary and as an analysis and a prediction tool both for the patient and the doctor. The software is gathering details about patients' diet and associated fettle in order to estimate fettle change after future meals, specifically for an individual patient. In this paper we have described the process of idea development and application design, feasibility assessment using a phone survey, a preliminary evaluation on 6 healthy individuals and early results of a clinical trial, which is still an ongoing study. Results suggest that applied approximative approach (Shepard's method of 6-dimensional metric interpolation) has a potential to predict the fettle accurately; as shown in leave-one-out cross-validation (LOOCV).