Stanisław Hać and Zbigniew Śledziński
Jarosław Kobiela, Stanisław Hać and Zbigniew Śledziński
In this article we introduce a novel technique of repeated single-port transgastric debritment of walledoff pancreatic necrosis using TriPort ™ Access System. The presented technique seems an appealing and innovative approach to the treatment of walled-off pancreatic necrosis in acute pancreatitis patients. Studies proving feasibility, safety and efficiency are necessary to elucidate real value of the technique
Stanisław Hać, Sebastian Dobrowolski and Zbigniew Śledziñski
Pancreatogastrostomy After Pancreatoduodenectomy
Pancreatoduodenectomy has almost a hundred years of history. After resection, the pancreatic stump requires an anastomosis with the digestive tract. There is ongoing discussion about the optimal standard of digestive tract reconstruction. Two major groups of pancreatic anastomosis are used: pancreatogastrostomy and pancreatojejunostomy, but after some randomized and several other documented series there is no agreement on the superiority one over another method.
The important feature related to pancreatic anastomosis' complication rate is the number of procedures performed each year in a facility.
This manuscript summarizes the experience of the Gdansk Surgical Department with pancreatogastrostomy.
Bartosz Goyke, Elżbieta Goyke, Tomasz Śledziński, Krystian Adrych, Sylwia Raczyńska, Zbigniew Śledziński and Julian Świerczyński
Human Serum Paraoxonase Activity Decreases After Vertical Banded Gastroplasty*
The aim of the study. Investigation of the effect of vertical banded gastroplasty (VBG), which is an effective method of treating patients with morbid obesity on serum paraoxonase (PON) activity.
Material and methods. Serum PON activity was measured in twenty eight morbidly obese patients 6 and 12 months after surgery. PON activity was also measured in the serum and liver of rats maintained on a restricted diet for one month.
Results. We found that VBG-induced significant reduction in body weight and serum PON activity at 6 and 12 months after surgery. Similar patterns of decreases in serum paraoxonase activity in obese patients after VBG were observed in A, AB and B paraoxonase/esterase phenotypes. After VBG, several clinically relevant events occurred: a) a decrease of serum triacylglycerol concentration was observed; b) no significant changes in total serum cholesterol and LDL-cholesterol concentrations were found; c) serum HDL-cholesterol concentration increased slightly.
Paraoxonase activity in the serum of rats maintained on a restricted diet, which induced approximately 30% and 50% of rat body weight and fat mass loss, respectively, was lower than in control animals.
Conclusions. This study indicates that after VBG significant decreases in serum paraoxonase activity occur in obese subjects. It is likely that less food ingestion and possibly a different type of food consumed by the obese subjects after VBG (compared to type of food consumed before surgery) may contribute to decreases in serum PON activity.
Monika Proczko-Markuszewska, Tomasz Stefaniak, Łukasz Kaska and Zbigniew Śledziński
Early Results of Roux-en-Y Gastric By-Pass on Regulation of Diabetes Type 2 in Patients with BMI Above and Below 35 Kg/m2
The idea of surgical treatment of type 2 diabetes was established in the U.S. and was based on observation of patients after bariatric operations. Performed in cases of morbid obesity exclusion of the duodenum and anastomose the stomach with the central part of the intestines cause shortened absorbtion of nutrients, what showed a beneficial effect on weight loss, resolution of comorbidities and reduce the risk of developing cardiovascular diseases and cancer. Analysis of the results of surgical treatment of obese patients with type 2 diabetes confirmed the usefulness of surgical methods.
The aim of the study was to evaluate the impact of Roux-en-Y gastric by-pass (RYGB) on diabetes in patients with BMI below and above 35 kg/m2.
Material and methods. The study comprised 66 patients with DM2, who underwent Roux-en-Y gastric bypass due to morbid obesity (BMI above 35 kg/m2) and three patients with DM2 and BMI below 35 kg/m2. In patients with DM2 and BMI < 35 kg/m2 criteria for inclusion in the operational treatment were: DM2 difficult to be regulated pharmacologically lasting less than 10 years and BMI at the qualification about 35 kg/m2. Indications have been determined on the basis of three consecutive measurements of HbA1c values above 7%, and measurements of blood glucose (frequent fluctuations in blood glucose levels on the value of hypoglycemia to hyperglycemia).
Results. The criteria for diagnosing resolution of DM2 included the level of HbA1c < 6% and glucose fasting level below 100 mg/ dl. In a group of 66 patients with DM2 and obesity, regression of DM2 was observed in 48 patients (73%) as early as during the hospitalization. In 11 patients (16.7%) glycaemia and HBA1c were stabilized within 8 weeks after surgery. In 7 (10.6%) cases of patients with difficult to control DM2, there was still need for antidiabetic medication, but glycemic control was much more effective. After one year remission was observed in 89% of patients. In all three patients with DM2 and BMI < 35 kg/m2 total glycemic resolution of DM2 was observed during hospitalization. In this group there has been no postoperative complications. In the group of 66 obese patients with DM2 postoperative complications were found in 7 cases, they were related to infection and prolonged healing of surgical wound. One patient had an intraabdominal abscess located in the left subphrenic region, it was punctured under ultrasound guidance.
Conclusions. The ultimate evaluation of this method demands several years of meticulous clinical studies. Despite of that, considering high cost of life-long conservative therapy of DM2 and its complications, severe impact on quality of life and serious consequences of the disease, the surgical metabolic intervention may become the most resonable solution in many cases.
Sebastian Dobrowolski, Zbigniew Śledziński, Krzysztof Sworczak, Małgorzata Hellmann and Anna Babińska
Surgical Treatment of Neuroendocrine Tumors of the Pancreas
Management of patients with neuroendocrine tumors (NETs) of the pancreas causes considerable controversy because rarity of this neoplasm.
The aim of the study was to present our results of treatment of patients with NETs and to sum up our experience in surgical management.
Material and methods. Thirty four patients with neuroendocrine tumors of the pancreas were treated in Department of General, Endocrine and Transplant Surgery of Medical University in Gdańsk (24 inulinomas and 10 nonfunctioning neuroendocrine tumors). Insulinoma was present in the head of the pancreas in 3 cases, in the body in 8 cases, and 10 patients had lesion situated within the tail.
Results. Localization of the tumor in patients with organic hyperinsulinism was possible in 21 out of 24 operated patients (17 patients with use of preoperative imaging studies, 4 patients with Intraoperative ultrasonography). In 3 remaining patients the localization of the pathologic mass was impossible with use of pre- and intraoperative techniques.
Conclusions. Treatment of choice of patients with neuroendocrine tumors of the pancreas is surgery. Management of patients with islet cells adenomatosis is still difficult clinical problem.
Dariusz Łaski, Stanisław Hać and Zbigniew Śledziński
Maksymilian Czerepko, Stanislaw Hać, Wioletta Sawicka and Zbigniew Śledziński
Enteral Nutrition Without the Use of An Endoscope in Patients with Severe Acute Pancreatitis
One of the main elements of acute pancreatitis therapy is nutritional treatment, which should ensure the implementation of the patients' energetic needs, limit the exocrine activity of the pancreas, and maintain the gastrointestinal passage. The most important argument in favor of the above-mentioned is the fact that enteral nutrition in case of severe acute pancreatitis prevents infectious complications. The most effective method is enteral nutrition. The unavailability of bedside endoscopy, and thus the need to transport the patient in order to obtain access, considerably complicates the procedure. Literature data described various bedside techniques consisting in the blind introduction of the feeding tube, which are rarely used, despite the fact that they are cheaper and as effective as endoscopy.
Jarosław Kobiela, Łukasz Naumiuk, Dariusz Łaski and Zbigniew Śledziński
Bartosz Skonieczny, Maciej Pytka, Tomasz Stefaniak, Wojciech Skonieczny, Zbigniew Grzybowski and Zbigniew Śledziński
Factors Influencing Frequency of Conversion During Laparoscopic Cholecystectomy
The aim of the study was to evaluate factors influencing the frequency of conversion during laparoscopic cholecystectomy; to observe dynamic trends concerning frequency of classic versus laparoscopic cholecystectomies; and to evaluate correlations between the experience of a surgeon and conversion incidence.
Material and methods. A retrospective study was performed, reviewing the records of 3337 patients operated on for gallbladder stones from January 2000 to December 2005 in three hospitals in the Pomeranian Region of Poland: Department of General, Endocrine and Transplant Surgery, Medical University of Gdańsk; Department of Surgery, 110th Military Hospital in Elbląg and Department of Surgery, Hospital in Słupsk.
The main issues evaluated were: dynamic changes in frequency of laparoscopic versus classic cholecystectomies; frequency of conversions, reasons for conversion; correlation between experience of a surgeon and conversion incidence; and demographic data.
Results. Out of 3337 patients, there were 2390 (71.62%) females and 947 (28.3%) males. For these patients, 1493 procedures (45.2%) were performed as classical, 1804 (54.06%) as laparoscopic, and 176 (9.7%) as converted from laparoscopy to open procedure. Sex distribution in the laparoscopic group was 1352:452 (F:M 74.9%:25.05%) and in the converted group was 107:69 (60.8%:39.2%).
The main problems relating to conversion during laparoscopic cholecystectomy were: adhesions - 108 (61.36%), gall-bladder perforations - 8 (4.5%), tumors - 10 (5.6%), technical problems - 28 (15.9%), hemostasis problems - 11 (6.25%), unrecognizable anatomical structures - 24 (13.6%), complications of ‘e fundo’ cholecystectomy - 24 (13.6%) and equipment problems - 4 (2.27%).
It was also observed that SHO's and surgeons with greater experience are performing more conversions during laparoscopic procedures.
Conclusions. Laparoscopic cholecystectomy is a safe procedure recommended as a gold standard for gallbladder stone treatment. Frequency of this procedure is rising in centers in the Pomeranian region.
The highest incidence of conversions is associated with adhesions after previous open operations.
Consultants perform earlier conversion due to greater experience and better estimation of risk factors.