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Open access

Michał Pędziwiatr, Magdalena Pisarska, Maciej Matłok, Piotr Major, Michał Kisielewski, Mateusz Wierdak, Michał Natkaniec, Piotr Budzyński, Mateusz Rubinkiewicz and Rzej Budzyński

Abstract

Postoperative insulin resistance, used as a marker of stress response, is clearly an adverse event. It may induce postoperative hyperglycemia, which according to some authors can increase the risk of postoperative complications. One of the elements of modern perioperative care is preoperative administration of oral carbohydrate loading (CHO-loading), which shortens preoperative fasting and reduces insulin resistance.

The aim of the study is to establish the influence of CHO-loading on the level of insulin resistance and cortisol in patients undergoing elective laparoscopic cholecystectomy.

Material and methods. Patients were randomly allocated to one of 2 groups. The intervention group included 20 patients who received CHO-loading (400 ml Nutricia pre-op®) 2 hours prior surgery. The control group received a placebo (clear water). In every patient blood samples were taken 2 hours prior to surgery, immediately after surgery, and on the 1st postoperative day. Levels and changes in glucose, cortisol and insulin resistance were analyzed in both groups.

Results. Although there were differences in the levels of cortisol, insulin, and insulin resistance, no statistically significant differences were observed between groups in every measurement. The length of stay and postoperative complications were comparable in both groups.

Conclusions. We believe that CHO-loading is not clinically justified in case of laparoscopic cholecystectomy. No effect on the levels of glucose, insulin resistance and cortisol was observed. Even though such procedure is safe, in our opinion there is no clinical benefit from CHO-loading prior to laparoscopic cholecystectomy.

Open access

Michał Pędziwiatr, Magdalena Pisarska, Mateusz Wierdak, Piotr Major, Mateusz Rubinkiewicz, Michał Kisielewski, Maciej Matyja, Anna Lasek and Andrzej Budzyński

Abstract

Age is one of the principal risk factors for colorectal adenocarcinoma. To date, older patients were believed to achieve worse treatment results in comparison with younger patients due to reduced vital capacity. However, papers have emerged in recent years which confirm that the combination of lap-aroscopy and postoperative care based on the ERAS protocol improves treatment results and may be particularly beneficial also for elderly patients.

The aim of the study was to compare the outcomes of laparoscopic surgery for colorectal cancer in combination with the ERAS protocol in patients aged above 80 and below 55.

Material and methods. The analysis included patients aged above 80 and below 55 undergoing elective laparoscopic colorectal resection for cancer at the 2nd Department of General Surgery of the Jagiellonian University. They were divided into two groups according to their age: ≥80 years of age (group1) and ≤55 years of age (group 2). Both groups were compared with regard to the outcome of surgery: length hospital stay, complications, hospital readmissions, degree of compliance with the ERAS protocol, and recovery parameters (tolerance of oral nutrition, mobilisation, need for opioids, restored gastrointestinal function).

Results. Group 1 comprised 34 patients and group 2, 43 patients. No differences were found between both groups in terms of gender, BMI, tumour progression or surgical parameters. Older patients typically had higher ASA scores. No statistically significant differences were found with regard to the length hospital stay following surgery (5.4 vs 7 days, p=0.446481), the occurrence of complications (23.5% vs 37.2%, p=0.14579) or hospital readmissions (2.9% vs 2.4%). The degree of compliance with the ERAS protocol in group 1 and 2 was 85.2% and 83.0%, respectively (p=0.482558). Additionally, recovery parameters such as tolerance of oral nutrition (82.4% vs 72.1%, p=0.28628) and mobilisation (94.1% vs 83.7%, p=0.14510) within 24 hours of surgery did not differ among the groups. However, a smaller proportion of older patients required opioids in comparison with younger patients (26.5% vs 55.8%, p=0.00891).

Conclusions. Similar levels of compliance with the ERAS protocol may be achieved among patients aged ≥80 and younger patients. When laparoscopy is combined with the ERAS protocol, age does not seem to be a significant factor that could account for worse utcomes. Therefore, older patients should not be excluded from perioperative care based on ERAS principles.

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.

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

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

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

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

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

Piotr Budzyński, Jadwiga Dworak, Michał Natkaniec, Michał Pędziwiatr, Piotr Major, Marcin Migaczewski, Maciej Matłok and Andrzej Budzyński

Abstract

The aim of the study was to verify the Mannheim Peritonitis Index (MPI) suitability to determine the probability of death among patients in Polish population operated due to peritonitis and to assess the possibility of using the Index to determine the risk of postoperative complications, relaparotomy and need for postoperative hospitalization in intensive care unit.

Material and methods. Retrospective analysis covered 168 patients (M: F = 83: 85, mean age = 48.45 years, SD ± 22.2) treated for peritonitis. The MPI score was calculated for each patient. According to MPI results, patients were divided to the appropriate groups (<21, 21‑29, > 29) and within analyzed. The statistical analysis used Chi-square, Mann Withney U and Kolmogorov-Smirnov test. The best cut-off point for MPI was calculated on the basis of ROC analisys.

Results. Mortality in the study group was 13.1%. In groups <21, 21‑29 and > 29 points according to MPI mortality was 1.75%, 28.13% and 50% respectively, the difference was statistically significant (p = 0.0124). Significant differences were observed in mortality depending on the diagnosis. Based on the ROC curve the cut-off point was identified as 32 with an accuracy of 85.9% and AUC = 81%. There has been a significant correlation between the MPI count and and the occurrence of: cardio-respiratory failure, acidosis, electrolyte imbalance, surgical wound complications, the need for treatment in the intensive care unit after surgery.

Conclusions. The MPI is a simple and effective predictor of death among patients operated due to peritonitis. It can also provide assistance in assessing the risk of postoperative complications and the need for treatment in the intensive care unit.

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.