Dariusz Szymański

Randomized clinical trial of postoperative hernia prophylaxis in open bariatric surgery.

Postoperative hernia following bariatric procedures is more common than in other groups of surgical patients, and remains a serious problem. Gastric bypass is the most often performed bariatric procedure and, despite the increasing popularity of a laparoscopic approach, many morbidly obese patients are still offered open procedures. The aim of this study was to assess the effects of prophylactic polypropylene mesh in morbidly obese patients undergoing gastric by‐pass surgery.

Primary perivascular epithelioid cell tumor (PEComa) of the liver: Report of a case

PEComa is very rare mesenchymal neoplasm which is formed by perivascular epithelioid cells and is characterized by dual melanocytic and myoid differentiation. Up to now only a very few cases of PEComa of the liver have been described worldwide. We herein present a patient who underwent a right hemihepatectomy for a huge tumor which could not be identified by imaging investigations. A final histopathologic examination revealed a benign epithelioid tumor with a solid growth pattern, abundant vascularity, and frequently dilated vascular channels. Immunohistochemically, the tumor cells were strongly positive for HMB-45, moderately positive for actin, and faintly positive for S-100, respectively. Based on the above findings, a diagnosis of a primary clear cell “sugar” tumor was established. Because the natural history of PEComas is mostly unpredictable, the patient has been closely followed up; however, no recurrence has so far been observed. Immunohistochemical findings play a crucial role in avoiding a misdiagnosis, and a surgical resection with an adequate margin of healthy tissue remains the gold standard of treatment. A long-term periodic follow-up is reasonable in all cases presenting with PEComa.

Preoperative high level of D-dimers predicts unresectability of pancreatic head cancer.

AIM To assess the value of D-dimer level in determining resectability of pancreatic cancer. METHODS Preoperative prediction of pancreatic head cancer resectability remains inaccurate. The use of hemostatic factors may be of potential help, since D-dimers correlate with tumor stage. Single center clinical trial study comprised patients with potentially resectable pancreatic head tumor and without detectable venous thrombosis (n = 64). Resectability was defined as no evidence of nodal involvement, distant spread and no invasion of mesenteric vessels. Final decision of resectability was confirmed intraoperatively. Experienced pancreatic surgeon performed all surgeries. Following the dissection of hepatoduodenal ligament, samples of portal blood and bile were taken. Peripheral blood via central line and urine via Foley catheter were sampled. D-dimer levels were further measured. RESULTS At laparotomy only 29 (45.3%) tumors were found to be resectable. Our analysis showed higher by 57.5% (P < 0.001) mean D-dimer values in peripheral and 43.7% (P = 0.035) in portal blood of patients with unresectable pancreatic cancer. Significant differences were not observed when analyzing D-dimer levels in bile and urine. Peripheral D-dimer level correlated with pancreatic cancer resectability. When cut-off D-dimer value of 570.6 μg/L was used, the sensitivity for assessment of tumor unresectability was 82.8%. Furthermore, D-dimer level in peripheral blood of metastatic disease (n = 15) was significantly higher when compared to locally advanced (n = 20) pancreatic cancer (2470 vs 1168, P = 0.029). The area under ROC curve for this subgroup of patients was 0.87; for determination of unresectable disease when threshold of 769.8 μg/L was used, sensitivity and specificity was 86.6% and 80%, respectively. CONCLUSION Patients with resectable pancreatic head cancer based on preoperative imaging studies and high D-dimer level may be considered unresectable due to occult hepatic metastases. These patients may benefit from diagnostic laparoscopy to avoid exploratory laparotomy.

Gastrojejunostomy in patients with unresectable pancreatic head cancer - the use of Roux loop significantly shortens the hospital length of stay.

AIM To evaluate the use of the Roux loop on the postoperative course in patients submitted for gastroenteroanastomosis (GE). METHODS Non-jaundiced patients (n = 41) operated on in the Department of General and Transplant Surgery in Lodz, between January 2010 and December 2011 were enrolled. The tumor was considered unresectable when liver metastases or major vascular involvement were confirmed. Patients were randomized to receive Roux (n = 21) or conventional GE (n = 20) on a prophylactic basis. RESULTS The mean time to nasogastric tube withdrawal in Roux GE group was shorter (1.4 ± 0.75 vs 2.8 ± 1.1, P < 0.001). Time to starting oral liquids, soft diet and regular diet were decreased (2.3 ± 0.86 vs 3.45 ± 1.19; P < 0.001; 3.3 ± 0.73 vs 4.4 ± 1.23, P < 0.001 and 4.5 ± 0.76 vs 5.6 ± 1.42, P = 0.002; respectively). The Roux GE group had a lower use of prokinetics (10 mg thrice daily for 2.2 ± 1.8 d vs 3.7 ± 2.6 d, P = 0.044; total 62 ± 49 mg vs 111 ± 79 mg, P = 0.025). The mean hospitalization time following Roux GE was shorter (7.7 d vs 9.6 d, P = 0.006). Delayed gastric emptying (DGE) was confirmed in 20% after conventional GE but in none of the patients following Roux GE. CONCLUSION Roux gastrojejunostomy during open abdomen exploration in patients with unresectable pancreatic cancer is easy to perform, decreases the incidence of DGE and lowers hospitalization time.

Very high concentration of D-dimers in portal blood in patients with pancreatic cancer.

UNLABELLED Nowadays, increasing attention has been focused on relation between increased D-dimer levels and cancer among patients without detectable thrombosis. The aim of the study was to measure plasma D-dimer levels in portal and peripheral blood in pancreatic cancer patients with absence of venous thromboembolism. MATERIAL AND METHODS Fifteen consecutive patients hospitalized in the Department of General and Transplant Surgery of Medical University in Łódź, from January to March 2012 who underwent surgery due to a pancreatic cancer were enrolled. At laparotomy, portal and peripheral blood were sampled concurrently. D-dimer and fibrinogen levels were measured. Moreover, to investigate overall coagulation function prothrombin time (PT), prothrombin index (PI), international normalized ratio (INR), thrombin time (TT), activated partial thromboplastin time (APTT), TT and APTT index were evaluated. RESULTS Peripheral plasma D-dimmer levels above normal range were found in 10/15 patients (66,67%), whereas D-dimer above normal values were confirmed in all portal blood samples. Mean D-dimer values were higher in portal than in peripheral blood (3279.37 vs 824.64, by 297%, p=0,025). These discrepancies were accompanied by normal limits of portal and peripheral levels of fibrinogen and comparable coagulation function indexes. CONCLUSION Our preliminary study showed the close relation between activation of hemostasis, reflected by elevated D-dimers in portal blood and presence of pancreatic cancer. These data suggest that measurement of portal blood D-dimer levels may be a potentially useful technique for screening the pancreatic cancer.

D-dimers revisited: a new marker of pancreatic cancer.

To the Editor: The excellent article of Sun et al elucidated the clinical and prognostic significance of coagulation assays in pancreatic cancer (PC) patients with absence of venous thromboembolism. The manuscript, with a review of the literature, comes to the conclusion that the pretreatment level of plasma D-dimers (DD) was a potential predictor of prognosis in PC patients without venous thromboembolism. Various solid tumors including lung, prostate, cervical, and colorectal cancer are found to have elevated DD levels in the peripheral plasma. However, we found a very high concentration in portal blood, but only a moderately elevated value of DD in peripheral blood of patients with PC and without detectable DVT (n = 89, 3738.4 ± 3999.8 vs. 1217.7 ± 1718.9, respectively, P < 0.001). On this basis, we hypothesized that the site of blood sampling for DD assessment influences the laboratory results and may be of great clinical importance. Portal, but not peripheral blood DD level may help to better differentiate malignant from benign pancreatic tumors. We confirmed this hypothesis in another analysis comparing the DD level in portal and peripheral blood of patients with PC (n = 89) and chronic pancreatitis (ChP, n = 28) (in peripheral blood, the DD levels were 1100.4 ± 1856.9 for the PC group and 1217.7 ± 1718.9 for the ChP group, P = 0.504; in portal blood the DD levels were 3738.4 ± 3999.8 vs. 1141.2 ± 1847.5, for the PC and ChP groups, respectively, P < 0.001). High DD are associated with a poor prognosis in cancer patients; therefore, we have carried out another study on DD portal and peripheral blood levels in patients with metastatic pancreatic cancer (mPC, n = 19) and nonmetastatic pancreatic cancer (nmPC, n = 70). The results of the study showed that the mean DD value in peripheral blood was higher in mPC when compared with nmPC patients (2139.3 ± 2752.5 vs. 963.9 ± 1213.2, P < 0.001). Portal blood DD concentration in both the groups studied (mPC and nmPC) remained at a very high level (3128.2 ± 3565.1 vs. 3908.9 ± 4121.4, respectively, P = 0.573). Therefore, we hypothesized that the liver might contribute toward elimination of DD from portal blood. To determine whether the liver acts as a “levee” for this marker, we attempted a study to elucidate DD in bile of patients with PC. Our analysis found a higher DD level in bile of patients with PC (n = 52) when compared with the control group of ChP (n = 29) (2583.3 ± 3455.2 vs. 654.5 ± 1054.5, respectively, P = 0.006). From the above study, we concluded that the hepatic barrier for DD may be responsible for only moderately elevated values of this marker in patients with nonmetastatic pancreatic adenocarcinoma. In contrast, in metastatic disease DD by-pass hepatic sieve and its concentration becomes very high in the general circulation of blood. Therefore, peripheral blood DD might be a novel marker in the diagnostic algorithm for the exclusion of occult hepatic metastases before surgery of patients with PC. All our studies were approved by the local Ethics Committee and written informed consents were obtained from all patients. After the dissection of the hepatoduodenal ligament, samples of portal blood and bile were taken, as described earlier. Peripheral blood from the central line was sampled. Portal, peripheral plasma, and bile DD levels were measured using commercial kits (VIDAS D-Dimer Exclusion II, bioMérieux, France). All statistical calculations were carried out using the SigmaPlot version 12.0 (Systat Software Inc., San Jose, CA) with the level of statistical significance at P < 0.05. As described by Sun et al plasma coagulation parameters including DD may be associated with tumor progression, metastasis, and prognosis. However, measurement of plasma DDs has limited specificity in cancer diagnosis as many conditions are associated with fibrin formation. Nonetheless, to date, only peripheral blood has been investigated in cancer patients. Our analyses on various novel sites of assessing DD levels indicate that it may help overcome the limitations of this assay. Further multicenter studies to assess clinical applicability of portal blood, bile, and urine DD levels for the diagnosis of PC are definitely needed. Adam Durczynski, MD, PhD* Anna Kumor, MD, PhDw Piotr Hogendorf, MD, PhD* Dariusz Szymanski, MD, PhD* Grazyna Poznanska, MDz Piotr Grzelak, MD, PhDy Janusz Strzelczyk, MD, PhD* Departments of *General and Transplant Surgery wAllergology and Pulmonary Diseases yRadiology and Diagnostic Imaging, Medical University of Lodz zDepartment of Anesthesiology and Intensive Care, Barlicki Teaching Hospital, Lodz, Poland

Synchronous occurrence of multiple focal nodular hyperplasia and huge hepatic Perivascular epithelioid cells tumor (PEComa) in young woman after oral contraceptive use – is there a common pathogenesis?

The association of focal nodular hyperplasia (FNH) and various neoplasms was described, but coincidence of multiple FNH and hepatic perivascular epithelioid cells tumor (PEComa) has not been reported. The clinical debate of oral contraceptive (OC) influence on FNH growth is ongoing, but no evidence exists about association of hepatic PEComa with OC use. Herein, we report a case of two FNH lesions and huge (150x100x80 mm) left hepatic lobe PEComa that occurred simultaneously in 18-year-old female with previous two year history of OC use, who underwent left hemihepatectomy and right hepatic FNH enucleation. Up to date, the patient has been followed-up for 65 months and remained disease-free. FNH and PEComa have a common vascular cytogenetic denominator. Our case raising a question of a causal relationship of FNH and PEComa with OC use that might be attributed to vascular changes. Future researches of larger sample sizes should further address this issue.

Sentinel lymph node mapping in tumors of the pancreatic body: preliminary report

Aim of the study Actual lymphatic drainage of pancreatic body neoplasms and the proper extent of lymphadenectomy remain unknown. The aim of the study was to define the exact lymphatic draining pattern using the dye mapping method. Material and methods The study enrolled patients who were operated on for tumor of the pancreatic body in the Department of General and Transplant Surgery of the Medical University of Lodz during 2010, with injection of 1 ml of blue dye (Patent Blue, Guerbet) in the centre of the neoplasm and sentinel node identification. Radical surgical management included distal pancreatectomy, whereas gastrojejunal or triple bypass anastomoses were performed in irresectable cases. Results The study group consisted of 13 patients with locally advanced tumors of the pancreatic body (T3 and T4, mean tumor size 4.9 cm). Lymphatic mapping was able to identify sentinel nodes in 5 of 13 cases (38.46%). A sentinel node was found in station 11p (3 cases) and 9 (1 case). Skip metastasis to the left gastric artery node (group 7) was noted. All identified sentinel nodes were metastatic; tumor deposits were confirmed in non-sentinel nodes as well. Conclusions In advanced pancreatic body tumors feasibility of sentinel node navigation is considerably restricted. Further studies in smaller tumors using optimized newer markers may define the exact lymphatic draining pattern.

CA 125 concentration in portal blood as a predictor of resectability in pancreatic tumor.

Aim of the study Pancreatic cancer is one of the most frequent cancers in the world. Only 20% of patients seem to have disease confined to the pancreas, but in only every second case the tumor turns out to be resectable during surgery. Tumor markers may be a useful tool in differentiating benign from malignant pancreatic tumors and in clinical staging. The purpose of the study is to assess CA 125 utility as a predictor of resectability in pancreatic tumor. Material and methods 66 patients were operated on for pancreatic tumor between October 2010 and July 2012. CA 125 concentration was measured in peripheral and portal blood. 57 patients were diagnosed with malignant and 9 with inflammatory tumor. Seven patients had metastases to the liver. Radical surgery was performed in 34 patients. Results Significantly higher CA 125 concentration in portal blood was found in the pancreatic cancer than in the inflammatory tumor group (36.5 ±99.6 vs. 16.4 ±26.5; p < 0.05). CA 125 concentration in peripheral blood and in portal blood as well of patients with malignant pancreatic tumors and with metastases to the liver was significantly higher than in the group without metastases (146.15 ±256.1 vs. 18.5 ±17.5; p < 0.01 and 147.5 ±261.2 vs. 19.7 ±24.3; p < 0.05, respectively). CA 125 values in the group without metastases to the liver and in the case of radical surgery were significantly higher in portal than in peripheral blood (19.7 ±24.3 vs. 18.5 ±17.5; p < 0.001 and 13.2 ±15.0 vs. 13.0 ±15.2; p < 0.001, respectively). Conclusions Determination of CA 125 concentration in peripheral blood and in portal blood as well might be a useful tool in differentiating between malignant and inflammatory pancreatic tumors and when decisions on surgery extensiveness are being made.

Neutrophil-lymphocyte ratio and creatinine reduction ratio predict good early graft function among adult cadaveric donor renal transplant recipients. Single institution series

Background Delayed graft function (DGF) is a common complication following kidney transplantation and is associated with ischemia-reperfusion injury (IRI). Lymphocytes contribute to the pathogenesis of IRI and ischemia-reperfusion related delayed graft function Materials and Methods 135 Caucasian patients received a kidney graft from deceased heart-beating organ donors. We divided patients into 2 groups- patients with the eGFR>=30 on the 21st day post-transplantation (n=36) and patients with the eGFR<30 on the 21st day post-transplantation (n=99) to assess kidney graft function. We measured the serum creatinine levels on 1st and 2nd post-transplant day and preoperative levels of monocytes, lymphocytes, platelets and neutrophils and their ratios. Results We have found statistically significant differences between the eGFR<30 and the eGFR>=30 groups in the average lnLymphocytes (0,36 +/-0,6 vs -0,016 +/-0,74 respectively p=0,004) lnNLR ( 1,27 +/-0,92 vs. 1,73+/-1,08 p=0,016) lnLMR (1,01 +/-0,57 vs. 0,73 +/-0,64 p=0,02), lnPLR (4,97 +/-0,55 vs. 5,26 +/- 0,67 p=0,023) and CCR2% (-20,20 +/- 21,55 vs. -4,29 +/- 29,62 p=0,004 . On univariate analysis, factors of lnLymphocytes >=0,22 (OR=0,331 95%CI 0,151-0,728 p=0,006), lnLMR>=1,4 (OR=0,255 95%CI 0,072-0,903 p=0,034) were associated with worse graft function while lnNLR>=1,05 (OR=2,653 95%CI 1,158-6,078 p=0,021), lnPLR>=5,15 (OR=2,536 95%CI 1,155-5,566 p=0,02) and CRR2 (OR=3,286 95% CI 1,359-7,944 p=0,008) indicated better graft function Conclusion Higher absolute lymphocyte count (lnLymphocytes) and lnLMR as well as lower lnNLR and lnPLR were associated with lower eGFR on the 21st day after kidney transplantation. On multivariate analysis CRR2 in combination with either lnLymphocytes, lnNLR or lnPLR improved the accuracy of detecting patients with poor graft function.