Jacek Szeliga and Marek Jackowski
Arkadiusz Fabiszewski and Marek Jackowski
Bleding From the Splenic Artery into a Pancreatic Pseudocyst with a Coexisting Microfistula to the Transverse Colon as Atypical Recurent Masive Gastrointestinal Bleding
Here we present a case of a 49-year old male patient who was hospitalized at our Clinic from 2 to 16 December 2008 due to recurrent massive gastrointestinal bleeding. It was a patient with a history of recurrent pancreatitis. He had a history of surgical treatment for postinflamamtory pancreatic cyst (Jurasz cystogastrostomy). From 28.01.2007 to 16.12.2008 he was hospitalized five times. During the last hospitalization he received a total of 12 units of packed red blood cells. Neither gastroscopy nor colonoscopy did demonstrate the site of bleeding. AngioCT of the abdominal cavity demonstrated clearly enlarged spleen and a well delineated region, 30×35 mm, reaching spleen hilum, filled with dense fluid suggesting a vascular fistula, in the projection of the body and tail of the pancreas. The patient was qualified for laparotomy. Intraoperatively, bleeding from the splenic artery into the pancreatic pseudocyst with coexisting microperforation to the transverse colon was detected. The pancreatic cyst was opened and drained, the bleeding blood vessel as well as the splenic artery were underpinned. Splenectomy was performed and wall of the transverse colon was repaired. The patient underwent reoperation due to adhesion related small bowel obstruction on day 30 after the procedure. Currently the patient is in good general condition, without complaints, undergoes periodic follow up in the outpatient setting.
Arkadiusz Fabiszewski, Łukasz Brycht and Marek Jackowski
Primary Small Intestine Tumour as the Cause of Gastrointestinal Tract Occlusion
The following paper presents the case of a 40-year-old patient staying in our Clinic between 2 March 2010 and 12 March 2010 due to the symptoms of permeable occlusion of gastrointestinal tract. This is a patient with a several weeks' history of non-specific abdominal pain, vomiting and significant weight loss (ca 20 kg). Until recently he has not suffered from any serious illnesses. In the performed abdominal ultrasound, gastroscopy and colonoscopy no pathology was affirmed. CT scan with intravenous and oral contrast showed significantly widened intestinal loops with residual liquid matter in the stomach, duodenum and a part of the jejunum without any distinguishing pathological mass, and also single mesenteric lymph nodes and para-aortic nodes enlarged to the size of 12 mm. The patient was qualified for laparatomy. During the surgery, a 4-cm tumour of the jejunum, concentrically narrowing intestinal lumen was found. Segmental resection of the small intestine was performed with side to side anastomosis with the use of a linear stapler. Currently the general condition of the patient is good, without any ailments, and the patient is undergoing systemic treatment.
Ewa Sztuczka, Marek Jackowski and Wioletta Żukowska
Wound healing is a complex and time-phased process. The occurrence of numerous negative conditions as well as external factors have a significant influence on the risk of potential complications. Preparing the patient for surgery, attention should be paid to a number of factors determining the proper healing process.
The aim of the study was to compare the results of the early period of surgical wound healing process with access via laparotomy using techniques, which are self-adaptive sutures and mechanical staplers used for skin closure.
Material and methods. The study included 120 patients divided into three groups, according to the degree of wound continence, in accordance with the CDC (Center for Disease Control and Prevention). Exclusion criteria based on objective analysis were applied for patients with a higher risk of complications. In all cases the skin layer was closed with monofilament suture or single-patient use stapler. A ten-day observation of the wound healing process was implemented. The study was randomized.
Results. In the case of patients groups identified as a “Clean Wound” and “ Clean / Infected Wound” no significant differences were discovered. In the group “Contaminated/Infected Wound” significantly higher percentage of wound-healing complications were reported (p < 0.05) for which monofilament sutures was used.
Conclusions. The study showed, that mechanical stapler is recommended for contaminated/infected surgical wounds due to significantly lower risk of complications. In the case of wounds divided as a “Clean” and “Clean/Infected” type of suturing material has no significant effect on wound healing.
Grzegorz Jarczyk, Marek Jackowski, Krzysztof Szpila, Grażyna Boszek, Sławomir Kapelaty, Elżbieta Skwarek and Mariusz Michalak
Biosurgical Treatment Results in Patients with Chronic Crural and Foot Ulcerations
Blowfly maggots have been used in the treatment of wounds since antiquity. For more than ten years, advances in modern technology have enabled us to safely and widely apply larval therapy as one of the methods used to treat poorly healing ulcerations.
The aim of the study was to determine the degree of non-healing wound debridement after the application of sterile Lucilia sericata blowfly maggots.
Material and methods. The study group comprised 19 patients including 15 with crural ulcerations due to chronic venous insufficiency and four with diabetic feet. Each was subjected to larval therapy. Five patients were additionally diagnosed with advanced lower leg atherosclerosis. The study group comprised 12 female and 7 male patients between 48 and 86 years of age. The ulcerations were present for a period ranging between 1 and 420 months before the study. Twenty-one wounds were analyzed. The type and degree of vascular insufficiency of the lower legs was evaluated on the basis of Doppler ultrasound examinations utilizing the ankle/brachial index. Lucilia sericata blowfly maggots were placed in the wound, ten for every 1 cm2, and left for a period of 2-3 days. The external part of the dressing was changed 2-3 times per day. In addition to photographic documentation of the wound, swabs were collected for bacteriological examination before and after treatment.
Results. The surface area of the wounds subjected to larval therapy ranged between 2 and 139 cm2. The mean surface area for venous ulcerations was 60 cm2, whereas, the mean for diabetic ulcerations was 47 cm2. The maggots were applied once to 9 wounds, twice to 4 wounds, three times to 4 wounds, four times to 3 wounds, and five times to one wound. Nine of the ulcerations were debrided from necrotic tissue by 90-100%, six by 70-90%, two by 55-60%, and three by 20-40%. In the case of one patient, the wound was not cleansed and the limb was amputated. Good biosurgical treatment results prevented three patients with diabetic feet from possible amputation at the level of the thigh (two patients), and lower leg (one patient). Debridement results were worse in patients where therapy was stopped due to acute pain (two patients) or significant bleeding (two patients), as well as in those with concomitant atherosclerosis.
Conclusions. Biosurgical treatment of chronic lower leg ulcerations with the use of sterile Lucilia sericata blowfly maggots is a safe and effective method on the basis of debridement of wounds from necrotic tissue and purulent exudate.
Andrzej Lehmann, Jacek Piątkowski, Mariusz Nowak, Marek Jackowski, Maciej Pawlak, Mieczysław Witzling and Maciej Śmietański
Inguinal hernia repair and cholecystectomy are amongst the most common surgical procedures performed worldwide. In the recent decades, early disease detection has notably increased due to easily accessible ultrasound.
The aim of the study was to assess the safety and the possibility of performing a simultaneous hernia repair and cholecystectomy using the laparoscopic approach.
Material and methods. Eight patients (M=100%) with inguinal hernia (3 with bilateral hernia) and cholelithiasis were included in the study. The presence of gallstones was confirmed by imaging. Mean age of the patients was 61.75 years (ranging from 47-72). Simultaneous laparoscopic cholecystectomy and transabdominal pre-peritoneal hernia repair was performed in all patients. Postoperative complications were analyzed to assess the safety and feasibility of the procedure.
Results. Mean operating time was 55 minutes (ranging from 30-60) and average length of stay was 3.625 days (ranging from 2-7). In order to perform a cholecystectomy, 1-2 additional trocars were used. No intra-operative complications were observed. At a follow-up visit on postoperative day 7, a small hematoma (10 ml of blood was punctured) in the right groin was noted in one patient. Another patient developed fever postoperatively, treated conservatively with antibiotics.
Conclusions. Simultaneous TAPP and cholecystectomy proved to be a safe and feasible procedure. Acceptable operating time and hospital stay, as well as lack of influence on the length of convalescence, may present an interesting alternative to two separate procedures