Leszek Brongel and Piotr Budzyński
Marcin Strzałka, Andrzej Budzyński, Andrzej Bobrzyński, Piotr Budzyński and Anna Gwóźdź
Analysis of Conversion Rates and Reasons in Minimally Invasive Surgery
Nowadays the number and range of laparoscopic procedures is quickly increasing and contraindications are limited. But laparoscopic operations cannot be performed in every case, what leads to conversion.
The aim of the study was to present the conversion rates and reasons in different types of laparoscopic procedures, both emergency and elective.
Material and methods. 7685 patients operated laparoscopically in the 2nd Department of General Surgery of the Jagiellonian University between 1993 and 2008 were included in the study. Minimally invasive approach was used at the beginning in 608 patients with acute appendicitis (average age = 28,4 years), in 101 patients with perforated peptic ulcer (average age = 46.4 years), in 236 patients who underwent splenectomy (average age = 41 years), in 166 patients who had adrenalectomy (average age = 53 years), in 117 patients who underwent Nissen fundoplication (average age = 44,4 years), in 834 individuals who had inguinal hernia repair (average age = 49.4 years), in 5311 who had cholecystectomy (average age = 52.1 years and in 212 patients who underwent other procedures.
Results. The conversion rates in the analyzed period were 2.88% in whole material, in case of appendectomy 3,95%, perforated ulcer operation 19,80%, splenectomy 2.12%, adrenalectomy 1.81%, Nissen fundoplication 1.71%, inguinal hernia repair 0.96% and cholecystectomy 2.92%. Emergency surgery was related to higher (4.98%) conversion rate than elective procedures (1.88%). Most frequently convestions were related to technical reasons (2,48%), than enforced by complications (0.41%).
Conclusion. Most conversions were caused by technical reasons, not complications. The change of the approach from laparoscopic to open one was more frequent in case of emergency procedures.
Kazimierz Rembiasz, Marcin Bednarek, Piotr Budzyński, Marek Poźniczek and Andrzej Budzyński
Endoscopic-Ultrasound Guided Drainage of the Pancreatic Pseudocyst
The aim the study was the evaluation of the treatment results of the internal ultrasound and gastroscopy-guided pancreatic pseudocysts.
Material and methods. From 1994-2008 at the 2nd Department of General Surgery UJ CM there were 126 patients (incl. 45 female and 81 male) treated for pancreatic pseudocyst. Mean age of the women was 41.05 years (25-81) while men 48 years (19-79). Ultrasound and gastroscopy-guided drainage by the means of insertion of double pig tail drain was attempted in 46 patients (17 female and 29 male). Mean diameter of the cyst was 11.02 cm (from 2.5-20 cm).
Results. Out of 46 patients assigned to the internal ultrasound, gastroscopy guided drainage, the procedure was technically feasible in 39. Internal marsupialization was successful in 24 patients (52.17%). We did not observe serious complications mentioned in the literature incl. iatrogenic injuries of the intraabdominal organs or fistulas. Drain was removed after 5 month (1-9 month).
Conclusions. Endoscopic drainage consists an interesting minimally invasive approach in the management of pancreatic pseudocyst. More precise inclusion criteria could increase its efficacy.
Piotr Budzyński, Michał Pędziwiatr, Jakub Kenig, Anna Lasek, Marek Winiarski, Piotr Major, Piotr Wałęga, Michał Natkaniec, Mateusz Rubinkiewicz, Joanna Rogala and Andrzej Budzyński
Bowel obstruction is a common condition in acute surgery. Among the patients, those with a history of cancer consist a particular group. Difficulties in preoperative diagnosis – whether obstruction is benign or malignant and limited treatment options in patients with reoccurrence or dissemination of the cancer are typical for this group.
The aim of the study was to analyze causes of bowel obstruction in patients with history of radical treatment due to malignancy.
Material and methods. Patients with symptoms of bowel obstruction and history of radical treatment for malignancy who were operated in 2nd and 3rd Department of General Surgery JUCM between 2000 and 2014 were included into the study. The patients were divided into 2 groups based on type of mechanical bowel obstruction (group 1 – adhesions, group 2 – malignant process).
Results. 128 patients were included into the study – group 1: 67 (52.3%) and group 2: 61 (47.7%). In the second group bowel obstruction was caused by reoccurrence in 25 patients (40.98%) and dissemination in 36 (59.02%). The mean time between onset of the symptoms of bowel obstruction and the end of treatment for the cancer was 3.7 and 4.4 years, respectively in group 1 and 2 (p>0.05). Median time between onset of the symptoms and admission to Emergency Department was significantly longer in patients with malignant bowel obstruction compared to those with adhesions (11.6 ±17.8 days vs 5.1 ± 6.9 days, p=0.01). Considering type of surgery due to bowel obstruction, in first group in most patients (69.2%) bowel resection was not necessary and in the second group creation of jejuno-, ileo- or colostomy was the most common procedure. Morbidity was significantly higher in second group (45.9% vs 28.26%, p<0.05) but there was no difference in mortality (26% vs 24%, p>0.05). In both groups the most common localization of primary malignancy was colon.
Conclusions. In analyzed group of patients frequency of bowel obstruction caused by adhesions and malignancy was similar. However, in patients with bowel obstruction caused by malignancy morbidity was significantly higher and duration of symptoms was longer. There was no diagnostic procedure which would allow to differentiate the cause of bowel obstruction preoperatively and the diagnosis was made during the operation.
Maciej Matłok, Piotr Major, Michał Pędziwiatr, Marek Winiarski, Piotr Budzyński, Piotr Małczak, Leif Hynnekleiv and Andrzej Budzyński
Currently, laparoscopic sleeve gastrectomy is one of bariatric surgeries most commonly performed in the world. The most frequent complications of surgeries of this type, with the highest mortality rate, include bleeding into the GI tract and peritoneal cavity, and sleeve staple line leaks. These severe complications prolong the hospital stay, and often are a cause of patient’s death. While in a case of bleeding the procedure appears to be obvious, so far no uniform and standard guidelines have been established for the group of patients with staple line leaks.
The aim of the study was to report results of treatment for staple line leaks following laparoscopic sleeve gastrectomy with a laparoscopic procedure and simultaneous endoscopic insertion of a self-expandable stent.
Material and methods. 152 laparoscopic sleeve gastrectomies were performed from April 2009 to December 2014. The BMI median was 46.9, and the age median was 42 years. Staple line leaks developed in 3 out of 152 people (1.97%). All patients who developed this complication were included in the study. The treatment involved laparoscopic revision surgery with simultaneous endoscopic insertion of a self-expandable stent (Boston Scientific, Wallflex Easophageal Stent, 150×23 mm) into the gastric stump during gastroscopy.
Results. Leaks following laparoscopic sleeve gastrectomy were diagnosed on day 5 after the procedure, on average. Intervention consisting of laparoscopy and endoscopic insertion of a self-expandable stent was initiated within 14 hours of diagnosing the leak, on average. The mean time for which the stent was kept was 5 weeks (4–6 weeks). Stenting proved to be fully effective in all patients, where after discharging home, a cutaneous fistula, periodically (every 2-3 weeks) discharging several millilitres of matter, persisted in one patient. The mean time for the leak healing in 2 patients, in whom the described method was successful in treatment of this complication, was 37 days. No patient died in the perioperative or follow-up period.
Conclusions. The proposed method for treatment of staple line leaks following laparoscopic sleeve gastrectomy by combined laparoscopic rinsing and draining of the peritoneal cavity and endoscopic insertion of a self-expandable stent is an interesting and worth recommending method for treatment of this complication.
Marcin Strzałka, Maciej Matyja, Maciej Matłok, Marcin Migaczewski, Piotr Budzyński and Andrzej Budzyński
Laparoscopic single access technique is a next step in development of minimally invasive surgery.
The aim of the study was to present results of different laparoscopic single incision procedures and evaluate application of this technique.
Material and methods. 102 patients (15 males and 87 females) who underwent laparoscopic single incision procedure from 15th October 2009 to 31st December 2012 were included in the study.
Results. In the analyzed period we performed 72 cholecystectomies (70.6%), 8 left adrenalectomies (7.8%), 3 right adrenalectomies (2.9%), 7 splenectomies (6.9%), 5 spleen cysts unroofings (4.9%), 2 appendectomies (2%), 1 Nissen fundoplication procedure (1%), 1 removal of the adrenal cyst (1%) and 3 concomitant splenectomies and cholecystectomies (2.9%). There were 3 technical conversions to multiport laparoscopy, but no conversion to open technique. Complications were observed in 5 patients (4.9%). Average operation time was 79 min (SD=40), average hospitalization time 2.4 day (SD=1.4).
Conclusions. Laparoscopic single incision technique is a safe method and can be used as a reasonable alternative to multiport laparoscopy in different minimally invasive procedures especially in young patients to whom an excellent cosmetic effect is particularly important.
Piotr Budzyński, Marek Kuliś, Leszek Brongel, Marek Trybus and Waldemar Hładki
Ultrasound in Diagnosing Torso Injuries
In patients with torso injuries, especially the ones with suspicion of injuries of intraabdominal organs, prompt making of diagnosis and decision about further management plays crucial role. Nowadays ultrasound is the first imaging technique used in Emergency Room in such cases.
The aim of the study. Assessment of the value of ultrasound in diagnostics of patients with torso injuries, especially in qualification for operative or conservative treatment.
Material and methods. 808 patients with an average age of 44.92 with torso injuries treated in the Department of Emergency Medicine and Multiple Injuries of 2nd Chair of General Surgery, Medical College of Jagiellonian University from 2004 to 2008, in whom ultrasound according to FAST protocol was used were included in the study. Results of sonographic examinations were verified during surgical operation (in patients treated surgically), or with the use of computed tomography (in patients treated conservatively), or on the basis of post-mortem examination (in patients who died due to sustained injuries), or on the basis of clinical course of hospitalization.
Results. Sensitivity of ultrasound in the study material amounted to 90.43%, while specificity as much as 99.44%. Positive predictive value (so percentage of patients with truly positive result amongst the patients with positive result of diagnostic test) for whole study material was 95.5 while negative predictive value was 98.75.
Conclusion. Results of the study confirm that ultrasound constitutes imaging technique of unique value in diagnostics of patients suffering from torso injuries, especially the circulatory unstable ones, allowing for precise qualification for prompt surgery.
Maciej Stanek, Michał Pędziwiatr, Dorota Radkowiak, Anna Zychowicz, Piotr Budzyński, Piotr Major and Andrzej Budzyński
The aim of the study was to present early outcomes of liver resection using laparoscopic technique.
Material and methods. Retrospective analysis of patients who underwent liver resection using laparoscopic method was conducted. The analyzed group included 23 patients (11 women and 12 men). An average patient age was 61.3 years (37 – 83 years). Metastases of the colorectal cancer to the liver were the cause for qualification to the procedure of 15 patients, metastasis of breast cancer in 1 patient and primary liver malignancy in 5 patients. The other 2 patients were qualified to the liver resection to widen the surgical margins due to gall-bladder cancer diagnosed in the pathological assessment of the specimen resected during laparoscopic cholecystectomy, initially performed for other than oncology indications.
Results. Hemihepatectomy was performed in 11 patients (9 right and 2 left), while the other 12 patients underwent minor resection procedures (5 metastasectomies, 4 nonanatomical liver resections, 1 bisegmentectomy, 2 resections of the gall-bladder fossa). An average duration of the surgical procedure was 275 minutes 65 – 600). An average size of the resected tumors was 28 mm (7 – 55 mm). In three cases conversion to laparotomy occurred, caused by excessive bleeding from the liver parenchyma. Postoperative complications were found in 4 patients (17.4%). Median hospitalization duration was 6 days (2 – 130 days). One patient (4.3%) was rehospitalized due to subhepatic abscess and required reoperation. Histopathology assessment confirmed radical resection (R0) in all patients in our group.
Conclusion. Laparoscopic liver resections seem to be an interesting alternative in the treatment of focal lesions in the liver.
Jacek Lorkowski, Leszek Brongel, Waldemar Hładki, Piotr Budzyński, Magdalena Żeglin, Marek Kuliś, Rafał Nazimek and Piotr Guzik
Evaluation of Long Term Therapy Outcomes for Achilles Tendon Ruptures
The aim of the study was to assess the results of treatment for partial and complete Achilles tendon ruptures.
Material and methods. We evaluated 94 patients suffering from the injury (61 males and 33 females) with an average age of 43.8.
Results. The most common mechanism of injury was sport-related (57 participants) or walking-related overstraining (32 participants). 81 patients underwent surgical procedures. In 77 patients, Kessler's suture was used and in 12 patients, transplantation of iliotibial tract was performed. A group of 13 patients underwent a conservative therapy. Plantar flexion immobilization was used for 3 months (constant immobilization for 6 weeks) in all groups. Every patient underwent rehabilitation following surgery. The follow up period was 2.5 years. 85 patients fully recovered lower limb function. In 9 patients, complications were noted: 4 had flexor contractions in the ankle joint requiring further treatment, 2 patients suffered from reoccurrence of tears, and 2 had thrombophlebitis. One patient developed diffuse necrosis of the posterior region of the distal leg, which required amputation.
Conclusions. An appropriate approach to the treatment of Achilles tendon injuries is surgery followed by intensive physiotherapy. During the surgical procedure, it is essential to properly realign the anatomic structures including the fibers rotating within the tendon.
Michał Kisielewski, Michał Pędziwiatr, Magdalena Pisarska, Piotr Major, Mateusz Rubinkiewicz, Maciej Matłok, Marcin Migaczewski, Piotr Budzyński and Andrzej Budzyński
The aim of the study was to assess safety of elective laparoscopic cholecystectomy (LC) performed by residents that are undergoing training in general surgery.
Material and methods. A retrospective analysis was conducted on 330 patients operated electively due to cholelithiasis. Patients with acute cholecystitis, choledocholithiasis, undergoing cholecystec-tomy as a part of more extensive operation and patients with gall-bladder cancer were excluded. Group 1 included patients operated by resident, group 2 – by specialist. Duration of operation, mean blood loss, number of major complications, number of conversions to the open technique and conversions of the operator, reoperations and length of hospital stay were analyzed.
Results. Mean operative time overall was 81 min (25 – 170, SD±28.6) and 71 min (30-210, SD±29.1) in groups 1 and 2 respectively (p=0.00009). Mean blood loss in group 1 was 45±68.2 ml and in group 2 – 41±73.4 ml (p=0.23). Six major complications has occurred (1.81%) – 2 (2%) in group 1 and 4 (1.7%) in group 2. 18 cases (15.5%) of conversion of the operator occurred in group 1, and 6 cases (2.6%) of conversion of the operator happened in group 2. Average LOS was 1.9 days in group 1 and 2.3 days in group 2 (p=0.03979).
Conlcusions. Elective LC performed by a supervised resident is a safe procedure. Tactics of “conversion of operator” allowed to prevent major complications. Longer LC by residents is natural during the learning curve. Modifications of residency program in the field of laparoscopy may increase its accessibility.