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Open access

Maciej Matyja, Marcin Strzałka and Kazimierz Rembiasz

Abstract

It is generally agreed that laparoscopic appendectomy is a valuable operative method.

The aim of the study was to evaluate cost-effectiveness of three different techniques used to close the appendix stump.

Material and methods. We conducted a retrospective study that compared three groups of patients who were operated on laparoscopically for acute appendicitis in 2013 at our institution. We used an endoscopic clip to close the appendix stump in the first group (n=20), endoscopic stapler was applied in the second group (n=20), and in the third group of patients the appendix base was closed with a laparoscopic suture (n=20). These groups were matched by age, sex and BMI.

Results. The average operative cost was the highest in the second group. Cost of the laparoscopic appendectomy with the application of the endoscopic clip was significantly lower (first group) and comparable to the third group. Observed differences in total hospitalization costs were associated only with the chosen appendix stump closure technique.

Conclusions. Clip closure of the appendix base is an easy and cost-effective procedure. The laparoscopic suture technique is the cheapest but technically demanding. According to our experience endoscopic stapler may be useful in some cases, although it is the most expensive method.

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

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, Wojciech Kostarczyk, Maciej Matłok, Andrzej Budzyński, Michał Pędziwiatr and Jan Bahyrycz

Intraoperative Colonoscopy in Obstructing Colon Cancer

The aim of the study was to present our experience with the use of intraoperative colonoscopy in patients with obstructing colon cancer in whom complete preoperative colonoscopy was not possible.

Material and methods. We treated 480 patients with colon cancer from 2002 to 2008 in our department. In 80 patients (28 female and 52 male) we performed intraoperative colonoscopy due to obstructing colon cancer. Mean age of female patients was 67.8 yrs. (35-84 yrs.) and mean age of male patients was 66.5 yrs. (38-81 yrs.). In all of the patients preoperative complete colonoscopy was not possible.

Results. Thanks to intraoperative colonoscopy we revealed new synchronous cancer lesions in 7 patients (8.75%) and therefore we extended the operation. In 28 patients (35%) we revealed polyps which, in 24 (85.7%) cases, were removed endoscopically and in 4 cases we decided to extend the operation.

Conclusions. Intraoperative colonoscopy is efficient method in diagnosis of colon cancer especially in patients with obstructing colon cancer. Thanks to intraoperative colonoscopy patients with synchronous lesions may benefit from detection of lesions and avoid further operation.

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.

Open access

Marcin Strzałka, Maciej Matyja and Kazimierz Rembiasz

Abstract

Nowadays laparoscopy is used frequently not only in elective surgery but also in abdominal emergencies, including acute appendicitis. There are several techniques used to close the appendicular stump during laparoscopic appendectomy.

The aim of the study was to present the results of minimally invasive appendectomies performed with the use of titanium clips.

material and methods. Patients operated on laparoscopically for acute appendicitis with the application of titanium clips between October 2012 and December 2013 were included in the study. We reviewed retrospectively patients` data including: age, sex, duration of the surgical procedure and hospital stay, mortality, intraoperative and postoperative complication rates.

Results. There were 93 patients (mean age=33.8 years, SD=15.23) in the analyzed group, including 60 men (mean age=33.5 years, SD= 15.07) and 33 women (mean age=33.9 years SD=15.26). The aver-age duration of the surgical procedure was 66 min (SD= 33.15). The average length of hospital stay was 3.38 days (SD=1.62). No intraoperative complications were observed in the analyzed group. Post-operative complication rate was low (6 cases, 6.5%). No mortality was observed.

Conclusions. Laparoscopic appendectomy with the application of titanium clips for closure of the appendicular stump is safe, associated with low complication rates and should be considered as a routine technique in everyday surgical practice.

Open access

Maciej Matłok, Monika Zazula, Kazimierz Rembiasz, Andrzej Budzyński, Michał Pędziwiatr and Piotr Major

Dysplasia and Microsatellite DNA Instability in Colorectal Adenomas

Microsatellite DNA instability (MSI) is a consequence of disorder within mismatch repair genes coding DNA repair proteins, protecting the cell against replication errors. Their dysfunction leads to gathering of adverse mutations within a cell, which may result in its neoplastic transformation.

The aim of the study was to analyse the occurrence of microsatellite DNA instability in polypoid adenomas of large intestine removed during endoscopic polypectomy.

Material and methods. The study covered 97 patients (30 women and 67 men), who underwent colonoscopic polypectomy in Endoscopy Ward, 2nd Department of Surgery, Jagiellonian University, Medical College in Cracow, between 2004 and 2007. Sampled materials was verified histopathologically and genetic tests were performed with the use of ABI PRISM 310 sequenator, which enabled to diagnose microsatellite DNA instability. Between 90 and 360 days from the first colonoscopy, 86 (78.2%) patients underwent following endoscopic colonoscopy in order to search for new polyps of large intestine.

Results. 130 polypoid adenomas were removed in 97 patients. Sigmoid colon was the most common location of lesions. Microsatellite DNA instability was diagnosed in 21 (16.6%) polyps, loss of heterozygosity was observed in 25 (19%) polyps. During control colonoscopy performed a year after the initial colonoscopy recurrence of polyps was stated in 15% of patients (7% of women and 15% of men). Microsatellite DNA instability was most commonly diagnosed for loci p53 di and DCC. Microsatellite DNA instability was more common in group of younger people and was related with larger polyps.

Conclusions. Analysis of microsatellite DNA instability in polypoid adenomas of large intestine provides further essential information within the scope of studies on transformation of adenomas in malignant adenoma of large intestine.

Open access

Maciej Matyja, Marcin Strzałka, Anna Zychowicz, Damian Kołodziej, Kazimierz Rembiasz and Andrzej Budzyń

Abstract

One of the most commonly performed surgeries in general surgery wards with laparoscopic technique as a method of choice is gall-bladder excision. In addition to -the commonly used conventional laparoscopic cholecystectomy single incision laparoscopic cholecystectomy is getting more and more attention. Despite many works and studies comparing these methods, there is still a shortage of results assessing efficiency of this new surgical technique. The aim of the study was to evaluate cost-effectiveness of this method in Polish financial reality. We have analyzed costs of three different surgical techniques: conventional (multi- incision) laparoscopic cholecystectomy, SILC and ‘no -port’ SILC. Material and methods. We conducted a retrospective study that compared three groups of patients who underwent treatment with conventional laparoscopic cholecystectomy (n=20), SILC (n=20) and no-port SILC (n=20). These groups were matched by age, sex and BMI. Following parameters were analyzed: complication rate, operative time, operative costs, length of hospital stay, hospitalization costs. The SILC cases were performed with one of the three-trocar SILC ports available on the market. The ‘no- port’ SILC cases were performed by single skin incision in the umbilicus, insertion of one 10 mm trocar for the operating instrument, another instrument and scope were inserted directly thorough small incisions in the aponeurosis without a dedicated port Results. The average operative cost was significantly higher in the SILC group comparing to the conventional laparoscopy group and the no-port SILC group. There was no significant difference in complication rate, operative time, length of hospital stay, or hospitalization costs between the three groups Conclusions. Currently the cost of the dedicated SILC port does not allow a regular use of this procedure in Polish financial reality. According to our experience improved cosmesis is the only advantage of the single incision laparoscopy, therefore we believe that it is reasonable to consider this technique in a a very selected group of patients.

Open access

Piotr Major, Marcin Dembiński, Marek Winiarski, Michał Pędziwiatr, Mateusz Rubinkiewicz, Maciej Stanek, Jadwiga Dworak, Magdalena Pisarska, Kazimierz Rembiasz and Andrzej Budzyński

Abstract

The reported prevalence of periampullary duodenal diverticula varies between 9 and 32.8%.

The aim of the study was to evaluate the prevalence of periampullary diverticula in the studied population and establish whether their presence influence the risk of choledocholithiasis and the risk of Endoscopic Retrograde Cholangio Pancreatography (ERCP) related complications.

Material and methods. The study group of 3788 patients who underwent ERCP between 1996 and 2016 at the 2nd Department of General Surgery Jagiellonian University Medical College in Kraków were analyzed. The group comprised of 2464 women (mean age 61.7 years) and 1324 men (mean age 61.8 years). The patients were divided into two groups. Group A included patients in whom there were no periampullary diverticula detected. Group B included patients in whom the opening of the bile duct was in the vicinity of a duodenal diverticulum.

Results. There were 3332 patients included in group A (2154 women and 1178 men) and 456 patients in group B (310 women and 146 men). The prevalence of periampullary duodenal diverticula in the analyzed group was 12.8%. The presence of stones or biliary sludge was diagnosed in 1542 patients (47.6%) in group A and 290 patients (68.1%) in group B. Recurrence of choledocholithiasis occurred in 4.5% of patients (70/1542) in group A and 10.3% of patients (30/290) in group B. Complications occurred in a total of 76 patients in group A (2.3%) and 22 patients in group B (4.8%).

Conclusions. The presence of choledocholithiasis and the risk of ERCP related complications are significantly higher in the group with duodenal diverticula.