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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

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

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.

Open access

Maciej Matłok, Andrzej Budzyński, Michał Pędziwiatr, Jan Bahyrycz, Jan Kulawik, Monika Zazula and Paweł Kuczia

Occurrence of New Adenomas in Patients After Performed Radical Endoscopic Polypectomy

The aim of the study was to analyze recurence of large intestine adenomas after polypectomy and its co-incidence with DNA microsatellite instability (MSI).

Material and methods. Among 2880 patients who underwent polypectomy during colonoscopy in our department from June 2004 to February 2007 we revealed adenomas in 259 cases (8.99%). Then we chose 97 patients who agreed to participate in further study. Mean age of the group was 65.1 yrs. In these patiens we removed 207 adenomas of the large intestine. Within 90-360 days all of the patients underwent control colonoscopy in our department. All removed lesions were verified histologically and genetically to determine presence of microsatellite instability.

Results. In 15 (17.4%) patients we revealed recurence of adenomas. Microsatellite instability was detected in 16 (18.6%) patients. The recurence of polyps was more frequent in patients with MSI (4 cases - 25%) than in patients without MSI (11 cases - 15.7%).

Conclusions. In our opinion further study may help to determine the group of patients with faster adenoma recurence. In those cases more frequent colonoscopy may be justified.

Open access

Mateusz Rubinkiewicz, Marcin Migaczewski, Michał Pędziwiatr, Maciej Matłok, Marcin Dembiński and Andrzej Budzyński

Abstract

Laparoscopic surgery is becoming an approved technique in pancreatic surgery. It offers some advantages over an open approach due to shorter hospital stay and decreased complication rate. Regardless the technique the most significant problem of pancreatic surgery is postoperative pancreatic fistula. There are numerous methods attempted at reduction of its incidence. One of the possibilities is preoperative pancreatic duct stenting. It aims at decreasing the pressure in the pancreatic duct, which is supposed to facilitate pancreatic juice flow to the duodenum.

The aim of the study was to determine the role of preoperative pancreatic duct stenting in pancreatic surgery.

Material and methods. Nineteen patients undergoing laparoscopic pancreatic resection were enrolled into the study. Prior to the surgery, all of the patients were submitted for the Endoscopic Retrograde Choleangiopancreatography (ERCP) with pancreatic duct stenting. Following the subsequent laparoscopic pancreatic resection, all patients were monitored to detect the pancreatic fistula appearance. The pancreatic stent was removed 6‑8 weeks after the surgery.

Results. With an exception of two patients, all other patients underwent successful ERCP with pancreatic duct stenting before the surgery. In one case the placement of the prosthesis failed due to a tortuous pancreatic duct. Five patients had an episode of acute pancreatitis including two severe courses as a complication of preoperative ERCP. One of the patient died due to severe GI bleeding 2 weeks after stenting. Among the procedures there were 15 distal pancreatectomies, two enucleations of the tumor localized in the uncinate process and in the body of the pancreas and one central pancreatectomy. The median time of surgery duration was 186 minutes (90‑300; ±56). No conversions to an open approach were necessary. Likewise, there was neither any major complications reported in a postoperative course nor incidence of pancreatic fistula in any of the patients undergoing surgery.

Conclusions. Preoperative pancreatic duct stenting can decrease the incidence of pancreatic fistula. However, a number of serious complications exceed the potential benefit of this method.

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

Marek Winiarski, Maciej Matłok, Zbigniew Biesiada, Leszek Bolt, Magdalena Woźniak and Anna Merak

Gastrointestinal Bleeding in Patients with Acute Surgical Diseases

The aim of the study was to analyse patients in whom upper gastroinentestinal bleeding appeared during hospitalization in the surgical clinic.

Material and methods. The study group consisted on 61 patients. 35 were women and 26 were men. The mean age of women was 76 and men 64.8 years. The mean age of the whole group was 72.3 years. 30 patients (49%) were hospitalized in general surgery ward, 16 (26%) in trauma unit and 15 patients (25%) in intensive care unit.

Results. The reasons of hospitalisation in general surgery ward were: acute cholecystitis, acute pancrtatitis, peritonitis, lower extremity ischemia with foot necrosis, large bowel cancer and cancer of the gall-bladder. Patients were admitted to trauma unit because of hip and pelvic fractures. Patients were hospitalized in intensive care unit because of polytrauma, diffuse peritonitis, isolated head trauma and necrotising pancreatitis. The main source of bleeding were duodenal and gastric ulcers. It appeared in 28 (45.9%) and 18 (29.5%) patients respectively. The other reasons of bleeding were: erosive gastritis (9 patients) and Mallory-Weiss syndrome (6 patients). Bleeding recurrence was found in 21 patients (34.4%). This group of patients was characterised by high mortality rate 43%. The highest was among patients in intensive care unit. It reached 60%.

Conclusions. Based on the performed analysis we come to the following conclusions: 1. Upper gastrointestinal bleeding is serious complication during hospitalisation in surgical clinic; 2. Usually it affects older patients; 3. This complication is associated with high rate of rebleeding and high mortality rate.

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 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.