Analysis of risk factors for conversion in laparoscopic adrenalectomy: a single-institution series of 256 patients

Introduction

Although introduction of the laparoscopic approach for adrenal gland surgery revolutionized the strategy in management of adrenal gland tumors, open surgery is still a method of choice in some clinical scenarios. Moreover, laparoscopy may have limitations resulting in conversion.

Aim

To assess risk factors predisposing for conversion based on our own material, including 256 laparoscopic adrenalectomies performed in 2009-2016.

Material and methods

A retrospective analysis of patients who underwent adrenalectomies between 2009 and 2016 was conducted. Patients were analyzed for sex, body mass index (BMI), size of the adrenal gland lesion, final histopathological diagnosis and operated side of the adrenal gland, its impact on conversion rate.

Results

A total of 256 patients underwent laparoscopic adrenalectomy. The reported study comprised of 94 (36.7%) men and 162 (63.3%) women. The most common indication for adrenalectomy were adrenal cortex adenoma (n = 149; 58.2%) and pheochromocytoma (n = 48; 18.75%). The conversion rate was 3.91% (n = 10 patients). Mean BMI of patients without conversion was 27.6 kg/m2, whereas in the group of patients with conversion, BMI was 29.7 kg/m2 (p > 0.05). The conversion rate was precisely the same when comparing the right (5/126; 3.9%) and left (5/126; 3.9%) adrenal gland. There was no correlation between the size of the adrenal lesion and the risk of conversion.

Conclusions

The laparoscopic approach remains an efficient and safe procedure for adrenal gland tumors. Based on our study, obese patients and those with pheochromocytoma are associated with a higher risk of conversion but without any statistical significance. There was no difference in the conversion rate when analyzing the size of the adrenal gland tumor. No difference was also revealed in the conversion rate when comparing both sides of laparoscopic adrenalectomy.

Stoma close to the abdominal wound: a real technical problem. A description of a novel care strategy

IntroductionIn some clinical scenarios, stoma site may be located close to the abdominal wound edge impeding optimal wound management and stoma care. We present a novel strategy of utility NPWT for management of simultaneous abdominal wound healing with stoma presence. Material and methodsRetrospective analysis of seventeen patients treated with a novel wound care strategy was conducted. Application of NPWT within wound bed, around stoma site and skin between allows for: 1) separating wound from stoma site, 2) maintaining the optimal environment for wound healing, 3) protecting peristomal skin and 4) facilitating application of ostomy appliances.ResultsThe study group comprised of twelve female (70,6 %) and five male (29,4%) with the mean age of 49.1 18.4 years The most common underlying pathology was Crohn s disease (n-5; 29,4%). Since NPWT was implemented, patients had undergone from 1 to 13 surgeries. Thirteen patients (76,5%) required intensive care unit admission. The mean time of hospital stay was 65,3 28,6 days (range: 36 134). The mean session of NPWT was 10.8 5.2 (range: 5 - 24) per patient. The range of the level of negative pressure was from -80 to 125 mmHg. In all patients, progress in wound healing was achieved resulting in granulation tissue formation, minimizing wound retraction and thus reduction of the wound area. As a result of NPWT, wound was granulated entirely, tertiary intension closure were achieved or patients were qualified for reconstructive surgery.DiscussionNPWT is safe and useful therapy for complicated abdominal wounds with the presence of stoma close to wounds edges. A novel care strategy allows for simultaneous technical opportunity to separate stoma from wound bed and facilitate wound healing.

Challenges in restoring bowel continuity: An analysis of 91 patients undergoing a reversal procedure

Introduction: The restoration of bowel continuity is associated with significant postoperative morbidity. Aim: The aim of the study was to report the outcomes of restoring intestinal continuity in a large patient cohort. Material and methods: A retrospective analysis was conducted on 91 patients with terminal stoma who were qualified for restoration of GI tract continuity between January 2015 and March 2020. The following demographic and clinical characteristics were analyzed: age, gender, BMI, comorbidities, indication for stoma creation, operative time, the need for blood replacement, the site and type of the anastomosis, and complication and mortality rates. Results: The study group was comprised of 40 women (44%) and 51 men (56%). The mean BMI was 26.8 ±4.9 kg/m2. Only 29.7% of the patients (n = 27) were at normal weight (BMI: 18.5–24.9) and only 11% (n = 10) did not suffer from any comorbidities. The most common indications for index surgery were complicated diverticulitis (37.4%) and colorectal cancer (21.9%). The stapled technique was used in the majority of patients (n = 79, 87%). The mean operative time was 191.7 ±71.4 min. Nine patients (9.9%) required blood replacement peri- or postoperatively, whereas 3 patients (3.3%) required intensive care unit admission. The overall surgical complication rate was 36.2% (n = 33) and the mortality rate was 1.1% (n = 1). Discussion: Restoration of bowel continuity is quite a demanding and complex procedure and thus should be performed by an experienced surgical team. In the majority of patients, the complication rate represents only minor complications. The morbidity and mortality rates are acceptable and comparable to other publications.

Severe deep neck infections successfully treated with negative pressure wound therapy with instillation - a case report

Background: Deep neck infection (DNI) is a life-threatening complication associated with significant mortality and morbidity rates. The most common causes of DNI are the tonsilitis, dentitis, salivary glands inflammation, malignancies, and foreign bodies. As a result of neck infection, patients are at high risk of potential secondary complications which include: descending mediastinitis, pleural empyema, septicemia, jugular vein thrombosis, pericarditis. We presented a case of successful management of DNI with the utility of negative pressure wound therapy with instillation (iNPWT). Method: A 37-year-old male with deep neck infection due to dentitis was qualified for iNPWT. Due to previous incisions and drainage of the neck abscesses, some undermined wounds drained towards each other’s were revealed with an excessive amount of purulent content. Standard NPWT dressing was placed and polyurethane foam was covered with contact layer dressing. Additionally, an inflow drain was placed within one of the wounds in regard to instill an antimicrobial solution. The wound was instilled four times daily. Results: The patient underwent a total of eight iNWPT sessions. Locally, a reduction in purulent content was achieved with a decrease of wounds’ dimensions and improvement of wound bed granulation. Moreover, improvement of the patient’s general condition and decrease of inflammatory markers was achieved. Conclusions: iNPWT may play an important role in the management of combined, complicated wounds due to DNI. The instilled antimicrobial solution facilitates dissolving and removing of the purulent content that impairs the wound healing.

Prevention and therapy of acute and chronic wounds using NPWT devices during the COVID-19 pandemic, recommendation from The NPWT Working Group

Recent SARS-CoV-2 pandemic leading to a rapidly increasing number of hospitalizations enforced reevaluation of wound management strategies. The optimal treatment strategy for patients with chronic wounds and those recovering from emergency and urgent oncological surgery should aim to minimize the number of hospital admissions, as well as the number of surgical procedures and decrease the length of stay to disburden the hospital staff and to minimize viral infection risk. One of the potential solutions that could help to achieve these goals may be the extensive and early use of NPWT devices in the prevention of wound healing complications. Single-use NPWT devices are helpful in outpatient wound treatment and SSI prevention (ciNPWT) allowing to minimize in-person visits to the health care center while still providing the best possible wound-care. Stationary NPWT should be used in deep SSI and perioperative wound healing disorders as soon as possible. Patient’s education and telemedical support with visual wound healing monitoring and video conversations have the potential to minimize the number of unnecessary in-person visits in patients with wounds and therefore substantially increase the level of care.

Ileal pouch anal anastomosis leak after restorative proctocolectomy without protective stoma successfully treated with endoscopic vacuum therapy

Aim An ileal pouch anal anastomosis (IPAA) leak is one of the most severe complication after restorative proctocoletomy (RPC). We present a rare case of a successful management of IPAA leak after RPC without defunctionig stoma with the utility of endoscopic vacuum therapy. Methods A 57-year-old male with a ileal pouch anal anastomosis leak after RPC due to ulcerative colitis with presacral abscess was qualified for endoscopic vacuum therapy (EVT). The abscess of the left buttock was drained and secured with suction drain (redon drain). Due to the lack of defunctioning stoma, a system for contain and divert fecal matter was placed within afferent limb of the J-pouch and EVT was placed directly within IPAA dehiscence. EVT was changed every third day. Results The patient underwent a total of five EVT sessions. Improvement of patient's general condition characterized with lack of pelvic pain, fever and reduction of inflammatory markers was achieved. Locally, anastomosis dehiscence was healed with prominent reduction in the defect's dimension, contraction and revascularization. Based on imaging studies no chronic presacral sinus or any other perianal disturbances were revealed at the time of five months follow up. Conclusions EVT is a promising method for management of IPAA leak. Although, it remains extremely difficult, EVT may serve as a method of choice in early pouch-related septic complications after RPC performed without defunctioning stoma.

Instillation-TIME (iTIME) as a rationale amendment for TIME conception. Is there enough evidence for the efficiency of negative pressure wound therapy with instillation (iNPWT) to announce a breakthrough idea for wound treatment?

An increased number of patients developing difficult-to-heal wounds results in billions spending for chronic wound care management. Introduction of TIME conception has been a breakthrough idea for wound healing based on phase-adapted wound therapy that interacts and influence each other and included: T – tissue management, I - infection control, M - moisture balance, E - edge of the wound. Negative pressure wound therapy (NPWT) revolutionized the management of wound healing. Moreover, recently NPWT with instillation (iNPWT) has gained the popularity of optimizing wound healing. In the context of acceleration of wound healing, iNPWT meets the criteria of the TIME conception. All individual components of TIME strategy are found in iNPWT providing “all in one” conception. Such management is easy to apply, monitor and it is well- tolerated by patients. Based on the current studies, iNPWT is found to be an important alternative for other methods of wound healing. It is believed that iNPWT will evolve and gain popularity as an innovative treatment for TIME conception.

A novel model of acellular dermal matrix plug for anal fistula treatment. Report of a case and surgical consideration based on first utility in Poland

Anal fistula (AF) is a pathological connection between anus and skin in its surroundings. The main reason for the formation of anal fistula is a bacterial infection of the glands within the anal crypts. One of the modern techniques for the treatment of fistulas that do not interfere with the sphincters consists in implantation of a plug made from collagen material. We are presenting the first Polish experience with a new model of biomaterial plug for the treatment of anal fistula. We also point out key elements of the procedure (both preoperative and intraoperative) associated with this method. In the authors' opinion, the method is simple, safe and reproducible. Innovative shape of the plug minimizes the risk of its migration and rotation. It also perfectly blends with and adapts to the course and shape of the fistula canal, allowing it to become incorporated and overgrown with tissue in the fistula canal. The relatively short operation time, minor postoperative pain and faster convalescence are with no doubt additional advantages of the method. Long-term observation involving more patients is essential for evaluation of the efficacy of the treatment of fistulas with the new type of plug.

The influence of rifaximin on diverticulitis rate and quality of life in patients with diverticulosis

Diverticulosis, its associated symptoms and complications are one of the most common pathologies of the gastrointestinal tract in more economically developed countries. Presence of diverticuli and their clinical consequences can be divided into four categories: 1) diverticulosis, i.e. an asymptomatic presence of diverticuli that are usually found by accident 2) symptomatic uncomplicated diverticulosis 3) diverticulitis (acute uncomplicated diverticulitis) 4) complications of diverticulitis (conditions requiring hospital stay). The aim of this study was to retrospectively analyze the efficacy of rifaximin in preventing diverticulitis in patients visiting proctology clinics. The diagnostic criterium for diverticulosis was confirmation by colonoscopy, barium enema or CT colography (virtual colonoscopy) as well as history of at least one documented episode of diverticulosis. History of diverticulosis was evaluated based on medical records, clinical symptoms, elevated level of CRP (>5.0) and/or diagnostic imaging (ultrasound, CT). After setting strict exclusion criteria, 248 patients were qualified for the study out of 686, and they were later divided into two groups: control group (group I - 145 patients) and studied group (group II - 103 patients receiving rifaximin prophylaxis). Diverticulitis rate was comparable in both groups over a period of 6 months before study (p = 0.1306) and 6 months of treatment (p=0.3044). Between the 6th and 12th month of treatment, a significantly lower rate of diverticulitis was noted in the group receiving rifaximin compared to control group (p<0.0001). Patients receiving rifaximin reported higher quality of life (which was assessed using the VAS scale) compared to control group after 12 months. The results confirmed the efficacy of riaximin in prevention of diverticulitis, even in the scheme of repeated courses every 3 months. Not only did application of rifaximin lower the rate of diverticulitis and its complications in patients after an episode of diverticulitis, but also it improved the patients' quality of life. It seems that diverticulitis prophylaxis based on rifaximin can be economically efficient, however, it requires further research.

Late Band Migration After SAGB. Case Report

Obesity, a major public health issue of the 21st century, is increasingly common in adults and children. No good results of pharmacological treatment of obesity results in rapid development of bariatric surgery, which treats obesity and comorbidities associated. There are many surgical options for treating obesity. Options for surgical management of morbid obesity include restrictive (adjustable gastric banding, vertical band gastroplasty), restrictive/resective (sleeve gastrectomy), restrictive/malabsorptive (Rouxen-Y gastric by-pass, biliopancreatic diversion with duodenal switch) and purely malabsorptive procedures (duodenal switch). Among them, swedish adjustable gastric banding (SAGB) or laparoscopic adjustable gastric banding (LAGB) have been more frequently performed. SAGB is considered to be safe and effective method of weight loss and elimination of diseases associated with obesity. Laparoscopic gastric banding offers the advantages of minimally invasive surgery, adjustability, and reversibility. Despite fewer number of complications than other bariatric operations, patients after SAGB may have unique complications that are characteristic of the SAGB and require special management and treatment. This paper presents a rare case of complete migration of the band into the gastric lumen.

Gastrointestinal tract anastomoses with the biofragmentable anastomosis ring: is it still a valid technique for bowel anastomosis? Analysis of 203 cases and review of the literature

PURPOSE

Biofragmentable anastomosis ring (BAR) is an alternative to manual and stapled anastomoses performed within the upper and lower gastrointestinal (GI) tract. The aim of this study was to evaluate the effectiveness of BAR utility for bowel anastomoses based on our own material.

METHODS

A retrospective analysis was performed to a total of 203 patients who underwent bowel surgery with the use of BAR anastomosis within upper and lower gastrointestinal tract between 2004 and 2014. Data for the analysis was collected based on medical records, treatment protocols, and the results of histological examinations.

RESULTS

The study group consisted of 86 women and 117 men. The most common underlying pathology was a malignant disease (n = 165). Biofragmentable anastomosis ring (BAR) size 31 was the most commonly used (n = 87). A total of 169 colocolic or colorectal anastomoses and 28 ileocolic and 8 enteroenteric anastomoses were performed. The mortality rate was 0.5 % (n = 1) whereas re-surgery rate within 30 days was 8.4 % (n = 17). Twenty-eight patients developed perioperative complications with surgical site infection as the most common one (n = 11). Eight patients developed specific complications associated with BAR including an anastomotic leak (n = 6) and intestinal obstruction (n = 2). The mean time of hospital stay after surgery was 12.7 days.

CONCLUSIONS

The use of BAR for the GI tract anastomoses is simple and rapid method and it is characterized with an acceptable number of perioperative mortality and complication rates. Based on our experience, we recommend the use of BAR anastomosis in different types of intestinal anastomosis in varying clinical scenarios.

Botulinum Toxin Injection for Treatment of Chronic Anal Fissure: Is There Any Dose-Dependent Efficiency? A Meta-Analysis

BACKGROUND

Chronic anal fissure (CAF) is a linear split of the anoderm. The minimally invasive management of CAF such as botulinum toxin (BT) injection is recommended. However, the exact efficient dose of BT, number of injections per session and the injection sites are still debatable. The aim of this analysis was to assess the dose-dependent efficiency of botulinum toxin injection for CAF.

METHODS

PubMed and Web of Science databases were searched for terms: "anal fissure" AND "botulinum toxin." Studies published between October 1993 and May 2015 were included and had to meet the following criteria: (1) chronic anal fissure, (2) prospective character of the study, (3) used simple BT injection without any other interventions and (4) no previous treatment with BT.

RESULTS

A total of 1577 patients from 34 prospective studies used either Botox or Dysport formulations were qualified for this meta-analysis. A total number of BT units per session ranged from 5 to 150 IU, whereas the efficiency across analyzed studies ranged from 33 to 96 %. Surprisingly, we did not observe a dose-dependent efficiency (Spearman's rank correlation coefficient, ρ = 0.060; p = 0.0708). Moreover, there were no BT dose-dependent postoperative complications or fecal incontinence and significant difference in healing rates compared BT injection into the anal sphincter muscles.

CONCLUSIONS

BT injection has been an accepted method for the management of CAF. Surprisingly, there is no dose-dependent efficiency, and the postoperative incontinence rate is not related to the BT dosage regardless the type of formulation of botulinum neurotoxin used. Moreover, no difference in healing rate has been observed in regard to the site and number of injections per session.

Surgical Management of Complications with Peritoneal Dialysis

This report reviews the most common surgical interventions and complications of chronic peritoneal dialysis (PD) patients. Based on the current knowledge as well as our experience we detail the role of these surgical procedures. We supplement the reported knowledge in the field with our own experience in this area. The areas discussed include early complications such as surgical wound hemorrhage, bleeding from the catheter, intestinal perforation and urinary bladder perforation, dialysate leakage through the wound, as well as late complications including catheter kinking or occlusion, retention of fluid in the peritoneal recess, hernias and hydrothorax, and encapsulating peritoneal sclerosis. We also briefly cover the surgical aspects of exit-site infection and peritonitis. An understanding by nephrologists of the role for surgical intervention in PD patients will improve their care and outcomes.

Anatomic variations of brachial and lumbosacral plexus models in different rat strains

PURPOSE

Selection of an appropriate model for preclinical assessment of new methods of peripheral nerve injury management is crucial. This report presents anatomic variations within brachial and lumbosacral plexuses in three selected rat strains Sprague Dawley (Hsd:Sprague Dawley SD), Lewis (LEW/SsNHsd), and Athymic Nude (Hsd:RH-Foxn1^rnu ) rats.

METHODS

Based on their strain eighteen rats were divided into three groups. A total of 90 brachial plexus nerves (axillary, musculocutaneous, median, ulnar, and radial nerves) and 72 lumbosacral plexus nerves (sciatic, tibial, common peroneal, and sural nerves) were analyzed for the length, diameter and correlation with the body weight. A detailed anatomic course of each nerve within the brachial and lumbosacral plexuses was outlined.

RESULTS

The sural nerve was the longest nerve in all studied rat strains, whereas the sciatic nerve had the largest diameter. Comparison of all the nerves' length demonstrated that the Lewis rat sciatic and sural nerves were significantly shorter (P < 0.05). No significant differences in nerve diameters were found among the analyzed rat strain groups. Significant correlation was revealed between the length of sciatic nerve and the rats' weight, which is irrelevant to the rats' genetic background.

CONCLUSIONS

This study confirmed that nerves' length within rat's brachial and lumbosacral plexus depends on the inter-individual variations within the rat strains rather than on the differences in the peripheral nerve development, which is inherent to the specific rat strain. Correlation between the nerve length and body weight, suggests that bigger rats should be considered for studies requiring access to the long nerves. © 2016 Wiley Periodicals, Inc. Microsurgery 37:327-333, 2017.

Negative pressure wound therapy with instillation (NPWTi): Current status, recommendations and perspectives in the context of modern wound therapy

Introduction of negative pressure wound therapy (NPWT) revolutionized the conception of wound healing. Currently, there are an increased number of studies confirmed the high efficiency of this therapy in many clinical scenarios. Moreover, some innovations have been introduced in recent years to improve the management of complex and chronic wound.NPWT with instillation (NPWTi) combines traditional NPWT with application of topical irrigation solutions within bed of the wound. Bioburden reduction, decrease time to wound closure, promotion in granulation tissue formation, fewer operative visits have been revealed using NPWTi compared to standard NPWT.However, there are still some questioned aspect of the NPWTi and thus its superiority over standard NPWT has not been fully indicated. Moreover, based on current studies no firm conclusions have been taken concerning the type of instilled solution preferably used, range of dwell- time phase, range of negative pressure and others.The main goal of the publication is to overview and summarize the current state of art concerning NPWTi. Moreover, mechanisms of action, review of the most common used instilled solution are discussed and clinical evidence of NPWTi are described.

Management of enteroatmospheric fistula with negative pressure wound therapy in open abdomen treatment: a multicentre observational study

The management of enteroatmospheric fistula (EAF) in open abdomen (OA) therapy is challenging and associated with a high mortality rate. The introduction of negative pressure wound therapy (NPWT) in open abdomen management significantly improved the healing process and increased spontaneous fistula closure. Retrospectively, we analysed 16 patients with a total of 31 enteroatmospheric fistulas in open abdomen management who were treated using NPWT in four referral centres between 2004 and 2014. EAFs were diagnosed based on clinical examination and confirmed with imaging studies and classified into low (<200 ml/day), moderate (200-500 ml/day) and high (>500 ml/day) output fistulas. The study group consisted of five women and 11 men with the mean age of 52·6 years [standard deviation (SD) 11·9]. Since open abdomen management was implemented, the mean number of re-surgeries was 3·7 (SD 2·2). There were 24 EAFs located in the small bowel, while four were located in the colon. In three patients, EAF occurred at the anastomotic site. Thirteen fistulas were classified as low output (41·9%), two as moderate (6·5%) and 16 as high output fistulas (51·6%). The overall closure rate was 61·3%, with a mean time of 46·7 days (SD 43·4). In the remaining patients in whom fistula closure was not achieved (n = 12), a protruding mucosa was present. Analysing the cycle of negative pressure therapy, we surprisingly found that the spontaneous closure rate was 70% (7 of 10 EAFs) using intermittent setting of negative pressure, whereas in the group of patients treated with continuous pressure, 57% of EAFs closed spontaneously (12 of 21 EAFs). The mean number of NPWT dressing was 9 (SD 3·3; range 4-16). In two patients, we observed new fistulas that appeared during NPWT. Three patients died during therapy as a result of multi-organ failure. NPWT is a safe and efficient method characterised by a high spontaneous closure rate. However, in patients with mucosal protrusion of the EAFs, spontaneous closure appears to be impossible to achieve.

A Prospective, Descriptive Study to Assess the Effect of Dietary and Pharmacological Strategies to Manage Constipation in Patients with a Stoma

The term constipation with regard to patients with a stoma is defined as impaired bowel movements associated with increased stool consistency or long periods without bowel movements that lead to discomfort, flatulence, and abdominal pain. Information about constipation in patients with a stoma is limited. A prospective, descriptive study was conducted among patients attending ostomy and proctology outpatient clinics in Poznan, Poland between January 2011 and December 2014 to assess the role of dietary and pharmacological strategies in the management of constipation in patients with a stoma. Patients were included if they experienced a 3-day period without bowel movements leading to abdominal discomfort and bloating. Patients who were terminally ill from neoplastic disease or could not provide informed consent for study participation were not eligible to participate. Patients underwent 3 evaluations 3 months apart: the first assessed problems with passing stool through the stoma, at which time patients were told to increase fiber and fluid intake. During the next 2 visits, patients were asked if their symptoms had improved. If dietary changes were not successful, first-line pharmacological interventions were suggested (laxatives, osmotic agents, and probiotics). If no improvement was reported during the third assessment, second line pharmacologic therapy (eg, stimulant laxatives) were prescribed. Of the 405 patients initially assessed for participation, 331 met the initial screening criteria and were scheduled for followup. Of those, 93 (28%) had constipation; 50 (15%) required a surgical referral for morphological stoma changes and 43 (12.9%) met the study inclusion criteria for dietary recommendations. Almost all (42) had a colostomy and most (28) had a history of stoma creation due to diverticular disease. Twenty-five (25) men and 18 women (average age 55.9 ± 9.3 years) received dietary recommendations during the first visit. Diet modifications were effective and sufficient to resolve the problem with constipation in more than half (24) of the patients. Among the remaining 19 patients, only 2 did not improve after using first-line or second-line pharmacological management strategies. One patient required emergency surgery due to complicated colonic diverticulosis (perforation). The results of this study suggest constipation among patients with a stoma can be associated with morphological stoma changes and in the absence of morphologic changes the majority of patients respond well to a change in diet. Additional studies are needed to increase understanding about the incidence and optimal management strategies of constipation in persons with a stoma.

Surgical methods of treatment of intestinal passage disturbances with the characteristics of constipation in patients with intestinal stoma based on own experience

Stoma is an intestinal fistula created in emergency or by elective indications, and it is done to drain out the digestive tract content. In some patients there is a disturbance passage of gastric contents through the stoma, which may take the form of chronic constipation or even periodic subileus that will sooner or later require surgical treatment. The aim of the study was the assessment of the causes and method of treatment of constipation in patients with intestinal stoma.

MATERIAL AND METHODS

A total of 331 patients with stoma followed by Ostomy and Proctology Outpatient Clinic were included in the study in the years 2011-2014. The study included 146 women and 185 men and the average age was 61.3 ± 12.7 years. Within the entire froup, 273 patients had the end stoma performed whereas in 58 patients the loop stoma was created. The highest percentage of patients were the ones with diverticulosis and colorectal cancer, i.e. 132 and 114 patients respectively. A stoma was created in 35 patients due to inflammatory bowel disease (IBD), in 23 patients because of cancer, in 14 as a result of injuries and in 13 due to rectovaginal fistula.

RESULTS

Out of the entire group subject to study (331 patients) 93 patients (28.1%) suffered from constipation. 50 patients with constipation required surgical intervention. The most common indication for surgical treatment was the parastomal hernia (36 patients, 72%), other indications were the narrowing of the stoma (5 patients, 10%), its collapse (6 patients, 12%) or prolapse (3 patients, 6%). Parastomal hernia was responsible for 84% of constipation within the stoma and 86.1% were treated with laparotomy (31 out of 36 patients). Other causes of constipation were the stomal stenoses (5 patients), collapse of the stoma (6 patients) and stomal prolapse (3 patients). All patients were treated surgically with a good final result.

CONCLUSIONS

Constipation associated with dysfunction of the stoma in most cases should be treated surgically. Parastomal hernia is the most common cause of constipation in the stoma. Treatment should be performed in due time because of the possibility of developing complications, especially dangerous one is a strangulated parastomal hernia and ischemia of stoma.

Assessment of the Results of Surgical Treatment of Zenker'S Diverticulum in Own Material

Zenker diverticulum (ZD) is the most common type of diverticula of the esophagus. Most often refers to men with a peak incidence in the seventh and eighth decade of life. In the majority diverticula remains asymptomatic and in patients with symptomatic course of the disease symptoms are often nonspecific. Aim of the study was to present the authors' own experience in surgical treatment of Zenker diverticulum.

MATERIAL AND METHODS

In this paper we present an analysis of 31 patients with confirmed ZD treated surgically at the Clinic in 2004-2014. Patients were analyzed in terms of age, gender, clinical symptoms, diverticulum size, type of surgery, the time to return to the oral intake, hospital stay and perioperative complications.

RESULTS

22 men and 9 women were enrolled it this study. The mean age of the patients was 64.8 (SD, 10.7; in the range of 28 to 82 years). 29 patients (93.5%) underwent resection of the diverticulum, while diverticulopexy was performed in two patients. In 25 (80.6%) cases stapler device was used, while in 4 (12.9%) resection was performed manually. The average size of resected diverticulum was 4.9 cm (SD, 1.5). Following the surgery in four patients (12.9%) complications were present. The average operating time was 118.7 minutes (SD, 42.2, in the range of 50 to 240 minutes). The mean length of hospital stay was 9.3 (SD, 3.3).

CONCLUSIONS

Surgical treatment of ZD is associated with high effectiveness and low recurrence rate. Despite the advantages of endoscopic techniques, surgical treatment is characterized by one- stage procedure. The use of mechanical suture (stapler) significantly improves the operation, although on the basis of our own analysis there was no superiority revealed over hand sewn. Unquestionable adventage of classical technique is the opportunity to histopathological evaluation of resected diverticulum what is impossible to achieve in endoscopic techniques.

Postoperative pancreatic fistula successfully treated with "PEG-Like" endoscopic vacuum therapy

INTRODUCTION

One of the latest methods for management of pancreaticogastrostomy (PG) leakage after pancreaticoduodenectomy (PD) is endoscopic vacuum therapy.

SUBJECTS AND METHODS

PD was performed on a 72-year-old man suffering from a nonfunctioning pancreatic neuroendocrine tumor of the head of the pancreas. On postoperative Day 6 after the primary surgery, postoperative pancreatic fistula (POPF) of the PG was revealed. Based on the International Study Group of Pancreatic Fistula recommendations, total parenteral nutrition, a regimen of somatostatin analogs, and intravenous antibiotics were implemented. The patient was qualified for a re-exploration because of the doubtful safety of percutaneous drainage of fluid collection detected in the ultrasonography scan. However, this management was not efficient. Endoscopic vacuum treatment (E-VAC) was initiated. The E-VAC was placed directly into the POPF site using a modified "percutaneous endoscopic gastrostomy (PEG)-like" technique.

RESULTS

Over the next few days, the E-VAC was started. The volume of fluid collection from percutaneous drainage rapidly decreased, whereas the volume of E-VAC the following day after vacuum therapy was approximately 1000 mL. There were no signs of leakage of PG confirmed with endoscopy, and there was no fluid collection from peripancreatic drainage. The E-VAC therapy was stopped after 6 days. The patient's general condition improved significantly. There were no abnormalities observable in both clinical and imaging examinations.

CONCLUSIONS

In selected patients, the "PEG-like" modification can be used successfully in the management of POPF. This technique allows the E-VAC to be placed directly in the POPF site under the endoscopic camera, which is what makes this method safe and efficient.

Iatrogenic bile duct injury. A significant surgical problem. Assessment of treatment outcomes in the department's own material

Iatrogenic bile duct injuries (BDI) are still a challenging diagnostic and therapeutic problem. With the introduction of the laparoscopic technique for the treatment of cholecystolithiasis, the incidence of iatrogenic BDI increased. The aim of the study was a retrospective analysis of 69 patients treated at the department due to iatrogenic BDI in the years 2004-2014.

MATERIAL AND METHODS

In this paper, we presented the results of a retrospective analysis of 69 patients treated at the Department due to iatrogenic BDI in the years 2004-2014. The data were analysed in terms of age, sex, type of biliary injury, clinical symptoms, the type of repair surgery, the time between the primary surgery and the BDI management, postoperative complications and duration of hospital stay.

RESULTS

82.6% of BDI occurred during laparoscopic cholecystectomy, 8.7% occurred during open cholecystectomy, whereas 6 cases of BDI resulted from surgeries conducted for other indications. In order to assess the degree of BDI, Bismuth and Neuhaus classifications were used (for open and laparoscopic cholecystectomy respectively). 84.1% of patients with confirmed BDI, were transferred to the Department from other hospitals. The average time between the primary surgery and reoperation was 6.2 days (SD 4). The most common clinical symptom was biliary fistula observed in 78.3% of patients. In 28 patients, unsuccessful attempts to manage BDI were made prior to the admission to the Department in other centres. The repair procedure was mainly conducted by laparotomy (82.6%) and by the endoscopic approach (15.9%). Hepaticojejunostomy was the most common type of reconstruction following BDI (34.7%).

CONCLUSIONS

The increase in the rate of iatrogenic bile duct injury remains a challenging surgical problem. The management of BDI should be multidisciplinary treatment. Referring patients with both suspected and confirmed iatrogenic BDI to tertiary centres allows more effective treatment to be implemented.

Comparison of the Effectiveness of the Treatment Using Standard Methods and Negative Pressure Wound Therapy (NPWT) in Patients Treated with Open Abdomen Technique

Open abdomen technique is a surgical treatment in which the fascia and skin are left open in order to reduce the value of the intra-abdominal pressure. According to the World Society of the Abdominal Compartment Syndrome (WSACS) normal values of the intra-abdominal pressure are between 5 and 7 mm Hg. Intra-abdominal hypertension occurs when the pressure value is equal to or exceeds 12 mm Hg.

was to compare the results of the open abdomen treatment using standard methods and negative pressure wound therapy.

. The study was in the form of a retrospective analysis of the documentation of the patients treated with open abdomen technique. The study included 37 patients treated in the Department of General and Endocrine Surgery and Gastroenterological Oncology and in the Department of Anesthesiology and Intensive Care of the Medical Sciences since 2009-2012. Patients were divided into two groups: group 1 (n = 20) was treated with standard surgical procedures (laparostomy, repeated peritoneal cavity lavage) and group 2 (n =17) was treated using negative pressure wound therapy (NPWT). The analysed clinical data included the period of hospitalization and clinical outcome (survival vs death), the occurrence of enteroatmospheric fistulae, cyclical determination of the quantitative C-reactive protein levels.

. The number of deaths during hospitalization in the group treated with NPWT was lower than in the group treated with standard methods (3 vs 9). The number of fistulae during hospitalization in the group treated with NPWT dropped as compared to the group treated using standard procedures (18% vs 70%). The decrease in the CRP levels was recorded in the group treated with NPWT and its increase - in the group treated with standard methods. Conclusions. The use of NPWT in patients requiring open abdomen treatment is reasonable due to the positive results with respect to survival rates and the decrease in the number of gastrointestinal fistulae. It is necessary to train the physicians in using this type of therapy in the form of workshops and in the clinical setting.

Large bowel mucosal neoplasia in the original specimen may increase the risk of ileal pouch neoplasia in patients following restorative proctocolectomy for ulcerative colitis

PURPOSE

Restorative proctocolectomy is a current gold standard procedure for patients who require a colectomy for ulcerative colitis. The incidence of ileal pouch neoplasia is low. The aims of this study were to assess the prevalence of neoplasia in ileal pouch and investigate the risk factors for ileal pouch neoplasia.

METHODS

A total of 276 patients who underwent restorative proctocolectomy for ulcerative colitis between 1984 and 2009 were analyzed. Results of histological examinations of both original specimen and biopsies from the J-pouch taken during routine pouch endoscopy were evaluated. Patients' records were analyzed for ulcerative colitis duration, the time from pouch creation to pouch neoplasia, presence of pouchitis, as well as the concurrent primary sclerosing cholangitis.

RESULTS

Analyzing the original specimen of large bowel, fifty-six lesions of low-grade dysplasia, twenty-five high-grade dysplasia, and five adenocarcinoma were revealed. All patients with dysplasia (n = 8) or adenocarcinoma (n = 1) of the J-pouch were positive for dysplasia in the original specimen. Duration of ulcerative colitis before surgery and duration time following restorative proctocolectomy were found as risk factors for J-pouch neoplasia with a significant difference (p = 0.01 and p = 0.0003, respectively). Patients with pouch neoplasia developed significantly more severe pouchitis (p = 0.00001).

CONCLUSIONS

Neoplasia of the J-pouch is rare. Patients with neoplasia in the original specimen are more susceptible to develop neoplasia in the J-pouch. Precise follow-up in patients with neoplasia lesions in the original specimen should be recommended. Moreover, in patients with risk factors, the exact surveillance pouch endoscopy should be recommended.

In Vitro Studies of Antibacterial and Antifungal Wound Dressings Comprising H2TiO3 and SiO2 Nanoparticles

The incidence rate of the infected and complex wound is established at approximately 40,000/1 million of the world's adult population. The aim of this study was to assess the efficiency of three novel types of wound dressings comprising sodium chloride, metatitanic acid and silicon dioxide nanoparticles. The study design was to prove their antimicrobial properties against the microorganisms most commonly causing wound infections. The study evaluated the antimicrobial effect of tested dressings on referenced strains of bacteria (ATCC collection, Argenta, Poland) and strains of fungi species (our own collection of fungi cultured from patients). The dressings were tested with both bacterial and fungal strains on solid media (Mueller-Hinton, Sobouraud, bioMerieux, France) in the standard method. The results confirmed the inhibition of growth of bacteria and revealed zones of inhibition for Escherichia coli, Staphylococcus aureus and Enterococcus faecalis. Significant zones of inhibition were established for Staphylococcus aureus and for fungi species of the Candida sp. These results would be crucial due to the fact of the low availability of antifungal therapeutics for both systemic and topical usage. Moreover, the current standard of antifungal treatment is associated with high costs and high toxicity in general. The preliminary results are very promising but further studies are necessary. Based on the obtained results, the tested dressings may contribute to the development of the surgical armamentarium of complex wound management in the near future.

Development of a new, simple and cost-effective diagnostic tool for genetic screening of hereditary colorectal cancer--the DNA microarray assay

Detection of mutations in families with a hereditary predisposition to colon cancer gives an opportunity to precisely define the high-risk group. 36 patients operated on for colon cancer, with familiar prevalence of this malignancy, were investigated using the DNA microarrays method with the potential detection of 170 mutations in MLH1, MSH2, MSH6, CHEK2, and NOD2 genes. In microarrays analysis of DNA in 9 patients (25% of the investigated group), 6 different mutations were found. The effectiveness of genetic screening using the microarray method is comparable to the effectiveness of other, much more expensive and time-consuming methods.

Development of a new, simple and cost-effective diagnostic tool for genetic screening of hereditary colorectal cancer--the DNA microarray assay

Detection of mutations in families with a hereditary predisposition to colon cancer gives an opportunity to precisely define the high-risk group. 36 patients operated on for colon cancer, with familiar prevalence of this malignancy, were investigated using the DNA microarrays method with the potential detection of 170 mutations in MLH1, MSH2, MSH6, CHEK2, and NOD2 genes. In microarrays analysis of DNA in 9 patients (25% of the investigated group), 6 different mutations were found. The effectiveness of genetic screening using the microarray method is comparable to the effectiveness of other, much more expensive and time-consuming methods.