Audrius Dulskas

Effect of Coffee on the Length of Postoperative Ileus After Elective Laparoscopic Left-Sided Colectomy: A Randomized, Prospective Single-Center Study.

BACKGROUND: Postoperative ileus is common problem after colorectal surgery. A positive effect of coffee to bowel movement has been described. It is still unclear whether coffee decreases the risk of postoperative ileus. OBJECTIVE: The purpose of this study was to determine whether consuming a 100-mL cup of coffee is effective in preventing or reducing postoperative ileus. DESIGN: This was a prospective, single-center, randomized controlled study. SETTINGS: The study was conducted at a university teaching hospital. PATIENTS: All of the patients who were scheduled for elective laparoscopic left-sided colectomy at our hospital after the detection of malignant disease in a preoperative biopsy between January 2013 and December 2014 entered the study. The patients were assigned randomly before surgery to receive coffee with caffeine (first group), coffee without caffeine (second group), or water (third group) after the procedure (100 mL 3 times daily). MAIN OUTCOME MEASURES: The primary end point was time to first bowel movement; secondary end points were time to first flatus and time to tolerance of solid food. RESULTS: A total of 105 patients were randomly assigned, 35 to each group. Fifteen patients were excluded. Patient demographic characteristics were similar in the groups. The time until the first bowel movement (measured in days) was significantly (p < 0.05) shorter in the decaffeinated coffee group (3.00 ± 1.50) versus the coffee with caffeine (3.75 ± 1.53) and water groups (4.14 ± 1.14). The time until tolerance of solid food was significantly shorter in decaffeinated group versus coffee with caffeine and water groups (1.85 versus 2.60 and 2.80; p < 0.05). Time until the first flatus (1.47 versus 1.57 and 1.77 for decaffeinated coffee versus coffee with caffeine and water; p > 0.05) did not show statistical significance. Postoperative hospital stay was similar in all 3 of the groups. LIMITATIONS: This is a single-center study with a relatively small sample size. CONCLUSIONS: Coffee consumption after colectomy was safe and in the decaffeinated group associated with a reduced time to first bowel action. Caffeine is not a main ingredient affecting the length of postoperative ileus.

A case report of incisional hernia through a 5 mm lateral port site following laparoscopic cholecystectomy

INTRODUCTION: Less than 10 mm port-site herniation is a rare complication after laparoscopic surgery. We report a case of complicated herniation through the 5-mm lateral trocar port site. CASE REPORT: A 63-year old obese female was admitted due to intestinal obstruction. She has undergone the laparoscopic cholecystectomy 1 year ago. On examination, abdomen was bloated and roughly 10 cm size mass was palpable on the right subcostal area. Plane radiogram of the abdomen showed signs of intestinal obstruction. Since conservative treatment was ineffective, the patient was operated on. The laparotomy revealed a protrusion of a part of right large intestine and greater omentum into the subcutaneous space through the abdominal wall defect below right subcostal margin. There was a dilatation of intestines proximally incarcerated colon. It was released and a part of omentum was resected. The peritoneum and fascia-muscular defect was closed by interrupted vicryl sutures. CONCLUSION: Acute herniation through a 5 mm size most lateral trocar port site is a rare complication of laparoscopic surgery requiring prompt differential diagnosis.

Transanal Endoscopic Microsurgery for Patients With Rectal Tumors: A Single Institution's Experience

Purpose The purpose of this study was to look at our complication rates and recurrence rates, as well as the need for further radical surgery, in treating patients with benign and early malignant rectal tumors by using transanal endoscopic microsurgery (TEM). Methods Our study included 130 patients who had undergone TEM for rectal adenomas and early rectal cancer from December 2009 to December 2015 at the Department of Surgical Oncology, National Cancer Institute, Lithuania. Patients underwent digital and endoscopic evaluation with multiple biopsies. For preoperative staging, pelvic magnetic resonance imaging or endorectal ultrasound was performed. We recorded the demographics, operative details, final pathologies, postoperative lengths of hospital stay, postoperative complications, and recurrences. Results The average tumor size was 2.8 ± 1.5 cm (range, 0.5–8.3 cm). 102 benign (78.5%) and 28 malignant tumors (21.5%) were removed. Of the latter, 23 (82.1%) were pT1 cancers and 5 (17.9%) pT2 cancers. Of the 5 patients with pT2 cancer, 2 underwent adjuvant chemoradiotherapy, 1 underwent an abdominoperineal resection, 1 refused further treatment and 1 was lost to follow up. No intraoperative complications occurred. In 7 patients (5.4%), postoperative complications were observed: urinary retention (4 patients, 3.1%), postoperative hemorrhage (2 patients, 1.5%), and wound dehiscence (1 patient, 0.8%). All complications were treated conservatively. The mean postoperative hospital stay was 2.3 days. Conclusion TEM in our experience demonstrated low complication and recurrence rates. This technique is recommended for treating patients with a rectal adenoma and early rectal cancer and has good prognosis.

The functional results of radical rectal cancer surgery: review of the literature.

Abstract Introduction For more than the last 20 years, low anterior resection with total mesorectal excision (TME) is a gold standard for rectal cancer treatment. Oncological outcomes have improved significantly and now more and more reports of functional outcomes appear. Due to the close relationship between the rectum and pelvic nerves, bowel, bladder, and sexual function are frequently affected during TME. Methods A search for published data was performed using the MEDLINE database (from 1 January 2005 to 31 January 2015) to perform a systematic review of the studies that described anorectal, bladder, and sexual dysfunction following rectal cancer surgery. Methodological quality of the included studies was assessed using the MINORS criteria. Results Eighty-nine studies were eligible for analysis. Up to 76% of patients undergoing sphincter preserving surgery will have changes in bowel habits, the so-called “low anterior resection syndrome” (LARS). The duration of LARS varies between a few months and several years. Pre-operative radiotherapy, damage of anal sphincter and pelvic nerves, and height of the anastomosis are the risk factors for LARS. There is no evidence-based treatment available for LARS. Sexual function is more commonly affected after rectal surgery than after urinary function. The main cause of dysfunction is damage to pelvic nerves. Sexual and bladder functional outcomes in females are less well reported. Laparoscopic and robotic surgery allows better visualization of autonomic nerves and, therefore, more precise dissection and preservation. Conclusions It is important that rectal resection is standardized as much as possible, and that new functional outcome research use the same validated outcome questionnaires. This would allow for a high-quality meta-analysis.

Laparoscopic colorectal surgery for colorectal polyps: single institution experience

Introduction Because of their difficult location or size, some polyps are impossible to remove with a flexible colonoscope and must be surgically removed. Laparoscopy is a great alternative. Aim To assess outcomes of a laparoscopic approach for the management of difficult colorectal polyps. Material and methods From 2006 to 2014, patients with polyps that could not be treated by endoscopy were included. Demographic data, histology of the biopsy, type of surgery, length of postoperative stay, complications and final pathology were reviewed prospectively. Results Forty-two patients with a mean age of 64.9 ±8.4 underwent laparoscopic polypectomy. Laparoscopic mobilization of the colonic segment and colotomy with removal of the polyp was performed for 12 (28.6%) polyps. Laparoscopic segmental bowel resection was performed in 30 (71.4%) cases: anterior rectal resection with partial total mesorectal excision in 12 (28.6%), left hemicolectomy in 7 (16.6%), sigmoid resection in 6 (14.3%), ileocecal resection in 2 (4.76%), resection of transverse colon in 2 (4.76%) and sigmoid resection with transanal retrieval of specimen in 1 (2.38%). Mean postoperative hospital stay was 5.9 ±2.6 days. There were 4 complications (9.5%). All patients recovered after conservative treatment. Mean polyp size was 3.6 ±2.2 cm. Final pathology revealed polyps (n = 2), tubular adenoma (n = 6), tubulovillous adenoma (n = 20), carcinoma in situ (n = 10) and invasive cancer (n = 4). Two of these patients underwent laparoscopic left hemicolectomies 14 and 10 days after laparoscopic colotomy and polypectomy. Conclusions For the management of endoscopically unresectable polyps, laparoscopic polypectomy is currently the technique of choice.

Ascariasis of the pancreatic duct

Ascariasis is a common helminthic disease worldwide, although Lithuania and other European countries are not considered endemic areas. The presence of the Ascaris worm in the biliary tree causes choledocholithiasis-like symptoms. We report a case of pancreatic duct ascariasis causing such symptoms. A 73-year-old Lithuanian woman underwent endoscopic retrograde cholangiopancreatography (ERCP) suspecting choledocholithiasis. Contrast injection into the common bile duct demonstrated a slightly dilated biliary tree without any filling defects, and the tail of an Ascaris worm protruding from the opening of the papilla Vater. The worm was captured by a snare but escaped deep into the duct. After a small wirsungotomy the worm was retrieved from the pancreatic duct. The patient received a 150 mg dose of levamisole orally repeated 7 days later and was discharged after complete resolution of symptoms. This first reported sporadic case of pancreatic duct ascariasis in Lithuania was successfully treated with ERCP and Levamisole.

Treatment of hemorrhagic radiation-induced proctopathy with a 4% formalin application under perianal anesthetic infiltration.

AIM To evaluate the results of hemorrhagic radiation proctopathy treatment with a 4% formalin application. METHODS A prospective study was performed. Over a three-year period, 38 patients underwent 4% formalin application under perianal anesthetic infiltration for hemorrhagic radiation proctopathy. All patients included in the study were irradiated for prostate cancer. The patients ranged in age from 56-77 years (average 70 ± 5 years). All of the patients were referred for formalin therapy after noninvasive management had failed. Twenty-four (63.2%) patients underwent a single application, 10 (26.3%) patients underwent 2 applications, and 4 (10.5%) patients underwent 3 applications. RESULTS Two to 36 mo (average 12 ± 3 mo) following treatment, 34 patients were interviewed (four were lost to follow-up). Twenty (58.8%) subjects reported complete cure, 8 (23.5%) subjects reported significant improvement, and 6 (17.7%) subjects reported no change. One patient (who underwent a colostomy at a regional hospital with no specialized services available for previous bleeding episodes from radiation proctopathy) was cured, and the colostomy was closed. One patient (2.6%) developed rectal mucosal damage after the second application. CONCLUSION A 4-min application of 4% formalin for hemorrhagic radiation-induced proctopathy under perianal anesthetic infiltration in patients who have received external radial radiation therapy for prostate cancer is simple, reasonably safe, inexpensive, generally well tolerated, and effective.

Laparoscopic colorectal surgery for colorectal polyps: experience of ten years

Background. Laparoscopy or its combination with endoscopy is the next step for “difficult” polyps. The purpose of the paper was to review the outcomes of the laparoscopic approach to the management of “difficult” colorectal polyps. Materials and methods. From 2006 to 2016, 58 patients who underwent laparoscopic treatment for “difficult” polyps that could not be treated by endoscopy at the National Cancer Institute, Lithuania, were included. The demographic data, the type of surgery, length of post-operative stay, complications, and final pathology were reviewed prospectively. Results. The mean patient was 65.9 ± 8.9 years of age. Laparoscopic mobilization of the colonic segment and colotomy with removal of the polyp was performed in 15 (25.9%) patients, laparoscopic segmental bowel resection in 41 (70.7%) cases: anterior rectal resection with partial total mesorectal excision in 18 (31.0%), sigmoid resection in nine (15.5%), left hemicolectomy in seven (12.1%), right hemicolectomies in two (3.4%), ileocecal resection in two (3.4%), resection of transverse colon in two (3.4%), and sigmoid resection with transanal retrieval of specimen in one (1.7%). Two patients (3.4%) underwent laparoscopic-assisted endoscopic polypectomy. The mean post-operative hospital stay was 5.7 ± 2.4 days. There were four complications (6.9%). All patients recovered after conservative treatment. The mean polyp size was 3.5 ± 1.9 cm. Final histopathology revealed hyperplastic polyps (n = 2), tubular adenoma (n = 9), tubulovillous adenoma (n = 31), carcinoma in situ (n = 12), and invasive cancer (n = 4). Conclusions. For the management of endoscopically unresectable polyps, laparoscopic surgery is currently the technique of choice.

Asymptomatic primary tumour in incurable metastatic colorectal cancer: is there a role for surgical resection prior to systematic therapy or not?

Introduction The role of the resection of asymptomatic primary colorectal cancer in patients with incurable disease is questionable. Aim To evaluate the impact of the resection of asymptomatic primary tumour on overall survival in patients with unresectable distant metastases. Material and methods Patients treated in the National Cancer Institute, Lithuania, in the period 2008–2012, were selected retrospectively. The main inclusion criteria were: metastatic colorectal cancer (mCRC), endoscopically and histologically confirmed adenocarcinoma, without any symptoms for urgent operation, and at least one cycle of palliative chemotherapy administered. Information on patients’ age, gender, tumour histology, localization of the tumour, regional lymph node involvement, number of metastatic sites, surgery and systemic treatment was collected prospectively. Eligible patients for the study were divided into two groups according to the initial treatment – surgery (patients who underwent primary tumour resection) and chemotherapy (patients who received chemotherapy without surgery). The impact of initial treatment strategy, tumour size and site, regional lymph nodes, grade of differentiation of adenocarcinoma and application of biotherapy on overall cumulative survival was estimated using the Kaplan-Meier method. To compare survival between groups the log-rank test was used. Cox regression analysis was employed to assess the effects of variables on patient survival. Results The study group consisted of 183 patients: 103 men and 80 women. The median age was 66 years (range: 37–91). There were no notable imbalances with regard to age, gender, number of metastatic sites, metastases (such as pulmonary, peritoneal, liver, metastases into non-regional lymph nodes and other metastases), the number of received cycles of chemotherapy, first line chemotherapy type or biological therapy. Only 27 (14.8%) patients received biological therapy and the majority of them (n = 25, 92.6%) were treated with bevacizumab. For surgically treated patients 1-year survival was 71.2% (95% CI: 62.1–78.5) and 5-year survival was 4.0% (95% CI: 1.0–10.5). In the chemotherapy group, survival rates were lower – 43.9% (95% CI: 31.4–55.7) and 1.7% (95% CI: 0.1–8.1), respectively. Better survival rates were in the palliative surgery group. Multivariate analysis using the Cox proportional hazards model revealed that the initial palliative surgery and the application of biological therapy were statistically significant independent prognostic factors for survival. Conclusions Our findings suggest that palliative resectional surgery for the primary tumour in patients with incurable mCRC improves survival. Of course, one can argue that patients in the surgery group were “less problematic”. Prospective randomized trials are needed to delineate precisely the role of palliative surgery of the primary tumour in these patients.

The over-the-scope clipping system for treatment of chronic coloenteric fistula: a case report.

Anastomotic leak in colorectal surgery is not very unusual. The over-the-scope clipping (OTSC) system (Ovesco), which was originally developed to treat intestinal perforation and was tested with animals, might be the choice for the patient. We presented the case of a 63-year-old man with chronic coloenteric fistula. Conservative treatment was unsuccessful. The orifice was then closed with two subsequent clips, and the patient recovered well. To our knowledge, this is the first successful case of coloenteric fistula treatment with Ovesco.