Dawid Janczak

Incidental gallbladder cancer after cholecystectomy: 1990 to 2014

Introduction Cancer of the gallbladder is a serious diagnostic and therapeutic problem. According to the literature, 30% of cases are not confirmed before surgery. Other cases are detected incidentally by histopathology. Clinical trials and meta-analyses show that incidental gallbladder cancer (iGBC) occurs in 0.19%–2.8% of patients after cholecystectomy. The aim of this study was to analyze the incidence and severity of iGBC in cholecystectomy procedures performed in the surgical department at the 4th Military Teaching Hospital in Wroclaw during the years 1990–2014. Patients and methods In the years 1990–2014, a total of 7,314 cholecystectomies were performed in the surgical department because of cholecystolithiasis: 6,145 were performed using the laparoscopic approach (84.02%), 867 were performed as open surgery (11.8%), and 302 cases required conversion (5.1%). In this group, 5,214 of the patients were females (71.3%) and 2,100 were males (28.7%), with an average age of 54.7 years. Results We found 64 iGBC cases which were confirmed by histopathology. This represented 0.87% of all cases. In this group, 50 patients were females (78.1%) and 14 were males (21.8%), with an average age of 67.1 years. Of this group, 40 patients underwent a classic cholecystectomy, while 24 underwent laparoscopic procedures, out of which 13 cases ultimately required traditional surgery. The histopathology showed 15 carcinomas that were classified as G1 (23.4%), 28 were G2 (43.75%), and 21 were G3 (32.8%). Conclusion iGBC detected after a cholecystectomy due to cholecystolithiasis is a rare disease. We found iGBC in 0.87% of cases, which is on a comparable scale to the world literature. In the case of cancer, we frequently found it necessary to convert to an open surgical procedure. This cancer is more common in females and in people over 60 years of age.

Rivaroxaban and Apixaban for Initial Treatment of Acute Venous Thromboembolism of Atypical Location

Objectives: To assess the outcome of direct oral anticoagulants (DOACs), specifically Xa inhibitors: rivaroxaban and apixaban, for the treatment of venous thromboembolism (VTE) of atypical location (VTE‐AL), portal, mesenteric, hepatic, splenic, gonadal, renal, and cerebral veins, prospectively collected data of Mayo Thrombophilia Clinic Registry were used. Methods: Patients with acute VTE‐AL treated with DOACs, enrolled between March 1, 2013, and February 1, 2017, were compared with patients with VTE of typical location (VTE‐TL: deep vein thrombosis of extremities and/or pulmonary embolism) receiving DOACs and with patients with VTE‐AL treated with enoxaparin. Results: Out of 623 patients with acute VTE receiving the study drug within 14 days of diagnosis, there were 63 with VTE‐AL: 36 on DOAC, 23 on enoxaparin, and 4 on warfarin; 352 received DOAC for VTE‐TL. The VTE‐AL treated with DOAC/enoxaparin included the following: splanchnic (26/22), ovarian (8/2), renal (3/5), and cerebral veins (1/1), respectively. Recurrence rate (per 100 person‐years) for the VTE‐AL group receiving DOAC was 7.3, which was not different when compared with those for VTE‐TL (2.4; P=.13) and VTE‐AL groups receiving enoxaparin (23.7; P=.37). Major bleeding rate in the VTE‐AL group receiving DOAC was not different compared with those for VTE‐TL (7.2 vs 3.0; P=.26) and VTE‐AL groups on enoxaparin (22.4; P=.31). Mortality was higher in the VTE‐AL group on DOAC compared with the VTE‐TL group (21.45 [95% CI, 7.87‐46.69] vs 8.26 [95% CI, 5.35, 12.20]; P=.03). All patients with VTE‐AL with events had cancer. Conclusion: The VTE recurrence and bleeding rates for rivaroxaban and apixaban used in VTE‐AL are not different from those in patients with VTE‐TL and similar to that for enoxaparin.

An evaluation of the diagnostic efficacy of fine needle aspiration biopsy in patients operated for a thyroid nodular goiter

Background Thyroid cancer (TC) comprises 1% of all carcinomas and is the most common malignancy of the endocrine system. The disease is more common in women, with its peak morbidity observed in 40–50-year-old patients. The main risk factors include radiation, iodine deficiency, hereditary background, and genetic mutations. Among all diagnosed thyroid nodules, 5%–30% will evolve into cancer. The gold-standard procedure in the preoperative evaluation of a nodular goiter, apart from ultrasonography, is fine needle aspiration (FNA) biopsy. The FNA biopsy is favored for its simplicity, safety, and high specificity and sensitivity rates. Aim The aim of our study was to evaluate the clinical efficacy of FNA based on the patients’ register. Materials and methods In the Department of Surgery at the 4th Military Teaching Hospital in Wroclaw, 2,133 patients underwent thyroid surgery for thyroid goiter between 1996 and 2015. One hundred and eight cases of TC were diagnosed and of these, 66 patients had a preoperative FNA. Results Fourteen FNA biopsies (21%) revealed cancer, all of which were confirmed in the postoperative histopathology, although six cases of FNA-diagnosed cancer revealed a different histological type postoperatively. Eighteen FNA biopsies (27%) were suspected of being malignant. A disturbingly high rate of “benign” FNA biopsies (32 cases; 48%) revealed TC after surgery. Conclusion It is of great importance that the quality and quantity of FNA biopsies that are performed have been improved, especially due to the wide adoption of the Bethesda cytological evaluation system. FNA biopsy remains an obligatory and valuable diagnostic tool in thyroid nodules, but it is still insufficient as a standard procedure. A preoperative biopsy should always be related to all the available clinical data in order to provide the best treatment option for each patient individually.

Ex vivo pyelotomy, nephroscopy and holmium laser lithotripsy of a staghorn stone in a donor kidney prior to renal transplant

This case report presents the diagnostic and treatment procedures of stone removal from the kidney of a 67-year-old donor, the transplantation of the kidney to a 65-year-old recipient, and the postoperative course until the end of hospitalization. Computed tomography performed before collecting the organ showed a staghorn stone in the renal pelvis and lower calyces in the right donor kidney. The stones were removed ex-vivo using a rigid ureteroscope and a holmium laser prior to transplantation. Then the organ was transplanted to the left iliac fossa of a 65-year-old man with end-stage renal failure. The authors think there is a possibility of increasing the kidney pool, by using organs containing large calculi. In such cases stones should be removed before the operation and the patient should be monitored regularly, especially in the first months after the transplant.

The Role of Mediastinoscopy in the Diagnosis of Thoracic Disease: One-Year Single Center Experience

Our experience of using mediastinoscopy for the diagnosis of enlarged mediastinal lymph nodes or mediastinal mass is presented in this study. We reviewed 54 consecutive patients (34 men and 20 women) with mediastinal pathology of varied etiologies who underwent a standard cervical mediastinoscopy from January to December 2012. The histological results were positive in 32 cases (59.2%), and negative in 22 cases (40.8%). Transient laryngeal recurrent nerve palsy manifested as prolonged hoarseness of voice was the only minor complication in 3 cases (5.5%). The sensitivity of the procedure was 72%, and the specificity was 100%. We recommend the use of a mediastinoscopy in the staging of lung cancer and the diagnosis of mediastinal mass when other non-invasive procedures are ineffective.

Glomus Tumor of the Stomach - A Case Report and A Literature Review.

The study presented a case of a patient with a glomus tumor of the stomach, a mesenchymal neoplasm manifesting with upper gastrointestinal bleeding (Forrest IB). The patient was operated twice. First, he underwent elective laparotomy, during which Billroth I (Rydygiers method) gastric resection was performed. This his was followed by Billroth II resection with Brauns anastomosis. Histopathological examination revealed glomus tumor tissue. Literature data on the glomus tumor of the stomach are presented.

Giant saccular superior vena cava aneurysm-a rare and difficult clinical case.

A superior vena cava (SVC) aneurysm is an extremely rare case of vascular malformation in the chest cavity. This is a report of a case of a 57-year-old woman with a saccular SVC aneurysm which was 8 cm wide. The chest computed tomography (CT) scan confirmed a giant 75 mm × 79 mm × 81 mm mass containing the contrast medium from SVC, constricting the right lung parenchyma, narrowing the right innominate vein, in contact with the anterolateral chest cavity wall, and adjoining the superior mediastinum. Under general anesthesia and employing the median sternotomy approach, using a cardiopulmonary bypass (CPB), the venous aneurysm was successfully resected. The postoperative period was uneventful. Radical surgical resection using a sternotomy and a CPB is recommended.

The cytokines within the carotid plaque in symptomatic patients with internal carotid artery stenosis

The aim of the study was the evaluation of the inflammatory cytokines within atheromatic carotid plaque.Materials and methodsThe experiment was carried out on 100 symptomatic patients with internal carotid artery stenosis that underwent carotid endarterectomy. Every patient had the wall of the carotid artery resected during organ harvesting surgery in order to evaluate some cytokines (TGF-β, VEGF, FGF, TNF-α) and to perform the immunohistochemistry (IHC). An immunoreactive score (IRS) was calculated based on the staining intensity and the number of cells stained. Over a 3-year period, 7 patients died, and 2 patients were lost to follow-up. The study group consisted of 91 patients. The control group comprised 20 young organ donors with confirmed death brain, who had their normal carotid artery sampled.ResultsIn all healthy donors (control group) with normal carotid arteries the three cytokines (TGF-β, VEGF, TNF-α) were not discovered. The presence of FGF was confirmed in 25% of healthy donors, probably due to an intima fibroblasts activity, responsible for the synthesis of elastin and collagen to the extracellular matrix (ECM). Only three cytokines (TGF-β, FGF, TNF-α) were found within atheromatous plaques (study group).ConclusionsOur research confirmed that these factors may accelerate the development of atheromatic plaque and its destabilisation.

W-type suture in Anderson-Hynes laparoscopic pyeloplasty: a novel approach to an old technique

Introduction Anderson-Hynes (A-H) dismembered pyeloplasty has remained nearly unchanged since its introduction in 1949. The authors present a modification of the uretero-pelvic anastomosis as described by Anderson and Hynes. The new approach, called the W-type suture, is thought to be more watertight and associated with fewer complications than the original. Aim To assess the effectiveness of the modification of Anderson-Hynes dismembered pyeloplasty named the W-type suture. Material and methods The research is a retrospective study of 99 patients who underwent laparoscopic A-H pyeloplasty. In 49 patients unmodified laparoscopic A-H pyeloplasty was carried out. Fifty patients underwent laparoscopic A-H pyeloplasty with the anastomosis made using the aforementioned W-type suture. To assess the effectiveness of the W-type suture, we compared urine leakage duration – a direct indicator of anastomosis tightness – and frequency of postoperative complications. Results The mean duration of urinary leakage was 3 ±1.16 days for the W-type suture anastomosis group and 3.57 ±1.14 days for the unmodified A-H pyeloplasty group (p < 0.05). The frequency of post-operative complications did not statistically significantly differ between the groups except for fever (18.4% vs. 4%; p < 0.05). Conclusions The analysis of the collected data showed that the W-type suture might be a promising alternative to a traditional approach of performing the ureteropelvic anastomosis. Further research should be done to minimize biases present in this study, which might have influenced our results.

Thrombosis of atypical location: how to treat patients in the era of direct oral anticoagulants?

In 4% of cases, venous thromboembolism (VTE) involves organ‑related venous territories such as splanchnic, renal, gonadal, and cerebral venous segments, and is often called venous thromboembolism of atypical location (VTE‑AL). Recommendations regarding the method, intensity, and duration of anticoagulant therapy for VTE‑AL are not well established. Direct oral anticoagulants (DOACs) have been a promising alternative to vitamin K antagonists in the treatment of acute VTE. However, all major clinical trials on DOACs excluded patients with VTE‑AL. Therefore, data on the use of DOACs in patients with VTE‑AL are still limited to case reports and small clinical series, with a relative predominance of publications on splanchnic vein thrombosis including mesenteric, splenic, portal, and hepatic vein thrombosis. The only randomized clinical trial comparing a clinical outcome of patients with acute portal vein thrombosis randomized to either rivaroxaban or warfarin treatment yielded significantly impaired results due to the use of an atypical rivaroxaban dose. A prospective registration of clinical outcome for DOACs used in patients with VTE‑AL, in those with VTE of typical location, and in those with VTE‑AL treated with enoxaparin showed similar VTE recurrence and major bleeding rates in all 3 groups. High cancer prevalence, typical for VTE‑AL, significantly impacted survival as well as VTE recurrence rates and major bleeding outcomes in this study. In general, although still limited, the results for DOAC use in VTE‑AL are encouraging and we do not hesitate to use DOACs, particularly rivaroxaban or apixaban, in selected patients with VTE‑AL.