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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

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 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

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

Małgorzata Musztyfaga-Staszuk, Łukasz Major, Grzegorz Putynkowski, Anna Sypień, Katarzyna Gawlińska, Piotr Panek and Paweł Zięba

Abstract

Potential impact of copper replacing silver in the paste used for the front electrode fabrication in crystalline silicon solar cells was investigated. The copper was applied as a new CuXX component with about 2 wt.% to 6 wt.% share of XX modifier. The generated CuXX molecules were analyzed using transmission microscopy. Based on the commercial Du Pont PV19B paste, CuXX and XX materials, the new PV19B/CuXX paste with 51 wt.% share of Cu and the PV19B/XX paste with 51 wt.% share of XX only were developed. Comparative studies of the effect of the commercial PV19B paste made by DuPont Company, and the pastes with the CuXX component and with the modifier XX alone on the electrical parameters of solar cells produced on crystalline silicon were carried out. The solar cells were characterized by the current-voltage technique. As a final result, the Cz-Si solar cell with the 51 wt.% share of Cu in the front electrode having a series resistance of 0.551 Ω·cm2, an efficiency of 14.08 % and, what is more important, the fill factor of 0.716, was obtained. It is the best result ever obtained concerning direct Cu application for solar cells fabricated in thick-film technology.

Open access

Michał Kisielewski, Michał Pędziwiatr, Magdalena Pisarska, Piotr Major, Mateusz Rubinkiewicz, Maciej Matłok, Marcin Migaczewski, Piotr Budzyński and Andrzej Budzyński

Abstract

The aim of the study was to assess safety of elective laparoscopic cholecystectomy (LC) performed by residents that are undergoing training in general surgery.

Material and methods. A retrospective analysis was conducted on 330 patients operated electively due to cholelithiasis. Patients with acute cholecystitis, choledocholithiasis, undergoing cholecystec-tomy as a part of more extensive operation and patients with gall-bladder cancer were excluded. Group 1 included patients operated by resident, group 2 – by specialist. Duration of operation, mean blood loss, number of major complications, number of conversions to the open technique and conversions of the operator, reoperations and length of hospital stay were analyzed.

Results. Mean operative time overall was 81 min (25 – 170, SD±28.6) and 71 min (30-210, SD±29.1) in groups 1 and 2 respectively (p=0.00009). Mean blood loss in group 1 was 45±68.2 ml and in group 2 – 41±73.4 ml (p=0.23). Six major complications has occurred (1.81%) – 2 (2%) in group 1 and 4 (1.7%) in group 2. 18 cases (15.5%) of conversion of the operator occurred in group 1, and 6 cases (2.6%) of conversion of the operator happened in group 2. Average LOS was 1.9 days in group 1 and 2.3 days in group 2 (p=0.03979).

Conlcusions. Elective LC performed by a supervised resident is a safe procedure. Tactics of “conversion of operator” allowed to prevent major complications. Longer LC by residents is natural during the learning curve. Modifications of residency program in the field of laparoscopy may increase its accessibility.

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

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

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.