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Open access

Andrzej Żyluk and Tomasz Budzyński

Conservative vs Operative (Fixation with K-wires) Treatment of Isolated Fractures of Metacarpal Bones — Results of the Prospective, Randomized Study

Hand fractures (phalanges and metacarpals) are very common and they constitute a cause of considerable ambulatory and surgical departments workload. Isolated, undisplaced and displaced but stable fractures are usually treated non-operatively, and classical indication to surgery are unstable, oblique, spiral, intra-articular, open and complex fractures. Results of some studies suggest that oblique, spiral and apparently unstable fractures can be successfully treated conservatively, questioning afore-mentioned indications to surgery

The aim of this prospective and randomized study was to compare the results of conservative versus operative (by fixation with K-wires) treatment of isolated, displaced and extra-articular metacarpal fractures.

Material and methods. Forty-seven patients, 36 male (77%) and 11 female (23%) with a mean age of 34 years (range 16-75), with isolated metacarpal fractures, were randomly allocated to operative, by intramedullary fixation with K-wires (24 patients), or conservative, by reduction and immobilization (23 patients) treatment. Patients were followed-up at 2 and 6 months, and the assessments included measurements of active range of motion of fingers, total grip and pinch strengths, angular deformity on X-rays and subjective hand function with DASH questionnaire.

Results. In one patient (4%) treated conservatively, an unacceptable secondary displacement occurred, and he was withdrawn from the study. and given surgical treatment. All fractures consolidated. At 2 months assessment, no statistically significant differences between the variables in the operative and conservative treatment groups were noted, except of the angular deformity on X-rays, which was significantly greater after conservative than operative treatment (median 31° vs 9°). At 6 months assessment, an active range of motion of involved fingers was statistically significantly greater in operative, than in conservative treatment group (median 269° vs 250°) and the angular deformity was significantly lesser after operative than conservative treatment (median 24° vs 12°). There were no statistically significant differences between the groups with regard other analysed parameters. None healing disturbances and malrotations were noted.

Conclusions. The results of this study indicate the equal effectiveness of both the operative by K-wiring, and conservative treatment of fractures of the metacarpals. The better anatomical outcomes in terms of the degree of angular deformity did not translate directly into the better function of the hand.

Open access

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.

Open access

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.

Open access

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.

Open access

Andrzej Budzyński, Anna Gwóźdź, Jan Kulawik, Marcin Strzałka and Maciej Matłok

Laparoscopic Spleen Preserving Procedures

Laparoscopic splenectomy evolved into one of the principal operations of the spleen. High short- and long-term morbidity associated with asplenia has prompted surgeons to implement spleen preserving procedures.

The aim of the study was to evaluate laparoscopic spleen preserving procedures with regard to their feasibility and treatment results.

Material and methods. Prospective evaluation of treatment results in patients submitted to laparoscopic operations of the spleen in 2nd Department of General Surgery CM UJ in Cracow.

From August 1998 until May 2009 we performed 278 laparoscopic operations of the spleen. The group consisted of 164 females and 114 males, of which 256 (92.09%) patients were operated on electively and 22 (7.91%) in emergency settings. 235 patients (84.53%) were assigned to total splenectomy (most for ITP - 142 patients). In 43 patients (15.47%) the laparoscopic spleen preserving procedure was attempted. The indications included rupture of the spleen, cysts, tumors and abscess.

Results. Laparoscopic spleen preserving procedure was successfully performed in 23 out of 43 patients (53.49%). There were 9 excisions of the splenic cysts, 8 hemostases from ruptured spleen, 5 resections of the tumors and one drainage of the abscess. Postoperative complications were observed in 16 (7.66%) patients after total splenectomy, including 8 (3.4%) infectious. 3 patients (6.98%) after spleen preserving procedure were re-operated due to bleeding. There were no infectious complications in this group.

Conclusions. There is a limited number of indications for laparoscopic procedures preserving splenic parenchyma. Despite high failure rate attempts to perform laparoscopic spleen sparing operation are usually beneficial due to low risk of complications, particularly infections.

Open access

Piotr Budzyński, Michał Pędziwiatr, Jakub Kenig, Anna Lasek, Marek Winiarski, Piotr Major, Piotr Wałęga, Michał Natkaniec, Mateusz Rubinkiewicz, Joanna Rogala and Andrzej Budzyński

Abstract

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.

Open access

Maciej Stanek, Michał Pędziwiatr, Dorota Radkowiak, Anna Zychowicz, Piotr Budzyński, Piotr Major and Andrzej Budzyński

Abstract

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.

Open access

Maciej Matłok, Piotr Major, Michał Pędziwiatr, Marek Winiarski, Piotr Budzyński, Piotr Małczak, Leif Hynnekleiv and Andrzej Budzyński

Abstract

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.

Open access

Piotr Major, Michał Pędziwiatr, Maciej Matłok, Mateusz Ostachowski, Marek Winiarski, Kazimierz Rembiasz and Andrzej Budzyński

Cystic Adrenal Lesions - Analysis of Indications and Results of Treatment

Cysts are a rare pathology of adrenal glands. As the development of new diagnostic techniques takes place, the occurrence of adrenal cystic lesions has been rapidly increasing. The majority of them are solid adrenal lesions, but localized fluid collections are also more frequently diagnosed. In case of solid adrenal lesions, there are straight indications for surgery, but on the other hand there are no clear guidelines and recommendations in case of adrenal cysts.

The aim of the study was to analyze surgical methods and evaluate treatment effects in patients who were qualified for laparoscopic adrenalectomy due to adrenal cystic lesions.

Metarial and methods. Identical criteria were used to qualify patients with solid and cystic lesions of the adrenal gland for surgery. Out of the whole number of 345 patients who underwent laparoscopic surgery for adrenal tumors, 28 had adrenal cysts. 16 of them (57%) were women and 12 (43%) men. The average age of the studied group was 46.4 years (25-62 years). The average cyst diameter in CT was 5.32 cm (1.1-10 cm). Most of the lesions were hormonally inactive (22 patients), but in 6 cases increased level of adrenal hormones was observed.

Results. Pathological analysis revealed 4 (14%) pheochromocytomas and 2 (7%) dermoid cysts. In case of 22 (79%) patients, the postoperative material was profiled by pathologists as insignificant according to potential neoplasmatic transformation risk: 5 (17.5%) - endothelial vascular cysts, 3 (11%) endothelial lymphatic cysts, 7 (25.5%) pseudocysts, 3 (11%) simple cysts, 2 (7%) bronchogenic cysts, 1 (3.5%) - cortical adenoma and 1 (3.5%) cyst was of myelolipoma type.

Conclusions. Based on the performed research and previous experience in treating patients with adrenal lesions we can conclude that application of the same evaluating algorithm for both cystic and solid lesions is valid.

Open access

Kazimierz Rembiasz, Andrzej Budzyński, Jan Kulawik, Maciej Matłok, Marcin Migaczewski, Alicja Hubalewska-Dydejczyk and Filip Gołkowski

Laparoscopic Transperitoneal Approach to Adrenal Gland Malignancies

Even though there is not enough good data, the use of laparoscopic approach in malignant disease is regarded by some controversial issue. On the other hand it seems that transperitoneal access to the adrenal gland allows for effective and safe oncological removal of adrenal gland neoplasms.

The aim of the study was to present our experience with the use of transperitoneal approach in patients with adrenal gland malignancies.

Material and methods. From March 2003 till May 2009 we performed 200 laparoscopic transperitoneal adrenalectomies. There were 82 hormonally silent tumors (1.5-14 cm in diameter) and 118 hormonally active (63 pheochromocytomas, 26 Conn's syndrome, 25 Cushing's syndrome and 4 virylizing tumors).

Results. 197 procedures were completed laparoscopically and 3 were converted (including one for inability to assess resectablility of the tumor). 14 tumors (7%) were overtly malignant; 7 arising form the adrenal (adrenal cortex - 3, pheochromocytoma - 3, lymphoma - 1) and 7 metastatic (squamous cell cancer of the lungs - 2, clear cell carcinoma of the kidney - 2, collecting duct carcinoma of the kindey - 1, hepatocellular cancer - 1, NET lung tumor - 1). Further 19 tumors (9.5%) were assessed histologically as potentially malignant (pheochromocytomas - 16, tumors of neural origin - 2, oncocytomas - 1). One malignant tumor was unresectable other were operated radically. Progression of the cancer was observed in 3 patients with metastatic tumors.

Conclusions. Laparoscopic transperitoneal adrenalectomy allows for safe and radical removal of adrenal gland malignancies. Longer follow-up and larger patients volume are needed for better evaluation of long-term results.