Eligijus Poškus

Improved perioperative care is associated with improved long-term survival in colorectal cancer

PurposeTo compare perioperative colorectal cancer care and survival in patient cohorts operated in 2005 and in 2010 in Lithuania.MethodsComparative observational cohort study was performed. The study was conducted in the three Lithuanian cancer hospitals. Patients, who underwent curative surgery for colorectal cancer in 2005 and 2010, were included. Demographic characteristics, distribution of the tumors, preoperative diagnostics and staging, surgical treatment, the quality of pathological examination, morbidity, and mortality were analyzed. One- and 5-year overall survival data were compared between the groups.ResultsColorectal cancer diagnostics and treatment improved from 2005 to 2010 significantly. The disease was identified as stage III–IV for 45 vs. 48% of the patients; however, computed tomography staging scan was performed only for 5.9 vs. 17.8% in 2005 and 2010, respectively. Laparoscopic operations were performed 1.5 vs. 10.5% and abdominoperineal resections—42.7 vs. 31.7% in 2005 and 2010, respectively. The number of harvested lymph nodes was mentioned in 55.8 vs. 97.7% of the cases, whereas more than 12 lymph nodes were examined in 18 vs. 66.6% of cases after histological examination. The overall 5-year survival was 52.1 vs. 63.1% (p < 0.0001), while the 5-year survival of the patients with stage IV of disease was 4.2 vs. 17.8% in 2005 and 2010, respectively.ConclusionPreoperative investigation, surgical treatment, pathological examination, and postoperative course are associated with improved overall survival in colorectal cancer patients, undergoing curative surgery in the resource-limited settings.

Is acute appendicitis still misdiagnosed

Abstract Objective The optimal diagnostics and treatment of acute appendicitis continues to be a challenge. A false positive diagnosis of appendicitis may lead to an unnecessary operation, which has been appropriately termed negative appendectomy. The aim of our study was to identify the effectiveness of preoperative investigations in preventing negative appendectomy. Methods A retrospective study was performed on adult patients who underwent operation for suspected acute appendicitis from 2008 to 2013 at Vilnius University Hospital Santariskiu Klinikos. Patients were divided into two groups: group A underwent an operation, where appendix was found to be normal (non-inflamed); group B underwent an appendectomy for inflamed appendix. Groups were compared for preoperative data, investigations, treatment results and pathology findings. Results 554 patients were included in the study. Preoperative laboratory tests results of hemoglobin, hematocrit concentrations and white blood cell count were significantly higher in group B (p<0.001). Ultrasonography was performed for 78 % of patients in group A and 74 % in group B and did not provide any statistically significant results. Comparing Alvarado score results, there were more patients with Alvarado score less than 7 in group A than in group B. In our large series we could find only four independent risk factors, and they could only account for 24 % of cases. Conclusions In summary, acute appendicitis is still often misdiagnosed and the ratio of negative appendectomies remains rather high. Additional investigations such as observation and computed tomography should be used to prevent this.

C-reactive protein is a predictor of complications after elective laparoscopic colorectal surgery: five-year experience

Introduction With the development and improvement of laparoscopic surgery, procedures have become common. However, post-operative complications occur when patients are released from hospital. These complications increase patients’ morbidity and mortality. They also lead to re-hospitalization, an extended recovery period, and an increase in the cost of treatment. Aim To evaluate and determine the prognostic properties of C-reactive protein in the early diagnosis of postoperative complications after a laparoscopic colon resection. Material and methods The prospective study included patients who underwent laparoscopic colorectal surgery in 2010–2014. The patients were divided into two groups – uncomplicated ones and those with complications. C-reactive protein concentrations in their blood serum were measured on the 2nd, 4th and 6th day after surgery. Logistic regression analysis was used to evaluate the relation between C-reactive protein values measured on the 2nd, 4th and 6th postoperative day and related complications. Receiver operating characteristic curves were used to determine the sensitivity and specificity of each C-reactive protein value measured on the 2nd, 4th and 6th postoperative day. Results One hundred and six patients were included in the trial; 14 of them had complications. On the second day, a C-reactive protein cut-off value of 88.6 mmol/l provided the highest sensitivity and specificity for predicting evolving complications, being 71.4% and 84.8% respectively (p = 0.003). The significant predictive cut-off value decreases and becomes more sensitive and specific each post-operative day. Conclusions It is possible to detect developing post-operative complications early on by monitoring C-reactive protein concentration levels in the blood serum on the 2nd, 4th, and 6th post-operative days.

Cytoreductive Surgery and HIPEC in the Baltic States: An International Scientific Workshop with Live Surgery

Background: Around the globe a new interest in the multidisciplinary management of peritoneal metastases using neoadjuvant chemotherapy, cytoreductive surgery (CRS), hyperthermic intraperitoneal chemotherapy (HIPEC), and adjuvant systemic chemotherapy has occurred. The combined use of these treatment modalities has required the creation of centers of excellence to manage patients with peritoneal metastases with a high level of success as well as a low incidence of adverse events. Methods: A 2-day workshop hosted by the Center of Abdominal Surgery, Vilnius University Hospital, with 230 participants was organized to explore the current practice in the Baltic states. Live surgery with video transmission initiated the efforts. Then, presentations by five experts from high-volume peritoneal surface malignancy centers were made and discussed. A summary of the efforts to date in Lithuania and Estonia was presented and collected for publication. Results: The live surgery served as a focal point for all subsequent presentations. The five invited speakers reviewed the rationale, current literature, indications and contraindications, implementation, and current European guidelines for management. The results of CRS and HIPEC from five centers in Lithuania and Estonia currently active revealed 127 patients treated to date, half of whom carried a diagnosis of ovarian cancer. There was an incidence of major complications of 11.8% and a mortality of 1.6%. Data regarding long-term survival benefits will require further follow-up. Conclusions: Progress in peritoneal surface oncology in the Baltic states was confirmed. With a low morbidity and mortality, these clinical programs promise to provide continued benefit for patients with peritoneal metastases - a condition judged to be terminal in the past.

Surgical management of gastrointestinal stromal tumors: a single center experience.

Introduction Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal (GI) tract. Although the therapy targeted at inhibiting tyrosine kinases has shown dramatic results in metastatic and inoperable GISTs, the mainstay of treatment in primary localized forms remains surgical resection. Aim To provide an overview of our experience of GIST diagnosis and management, with emphasis on comparison of minimally invasive and open surgical resection for primary GISTs. Material and methods We retrospectively reviewed the medical records of all patients who underwent surgical removal of GISTs from 2008 to 2012. Patient demographics, clinical data, surgery, complications, histopathological data and clinical course were analyzed. Results Forty-four patients were identified. Average age at diagnosis was 63 years. Minimally invasive (MIS) and open surgery (OS) were each attempted in 22 (50.0%) patients. Laparoscopic removal was performed in 20, laparoendoscopic in 1, and laparoscopy-assisted endoscopic removal in 1. Conversion to an open procedure was performed in 4 (18.2%). We found significant differences in postoperative length of stay (8.5 days vs. 10.1 days, p < 0.001) and tumor size (2.93 cm vs. 5.78 cm, p = 0.018) between MIS and OS groups, respectively. Conclusions Laparoscopic removal is safe and effective for GISTs not exceeding 6 cm. Gastroesophageal junction and cardia GISTs require careful preoperative evaluation and planning to remove safely. We recommend avoiding laparoscopic removal of these tumors due to the high rate of conversion (100.0%) to an open procedure. Laparoendoscopic surgical approach is an appropriate technique for removal of small-sized intraluminal benign GISTs not involving the muscularis propria layer.

Fecal incontinence after transanal endoscopic microsurgery

PurposeTransanal endoscopic microsurgery (TEM) procedure could potentially influence the development of fecal incontinence later in life. The aim of our study was to assess long-term functional outcomes after TEM and to determine possible variables related to incontinence.MethodsPatients, enrolled in a prospectively collected TEM operation database, were interviewed using a postal questionnaire. The questionnaire consisted of EuroQol (EQ)-5D-5L quality of life questionnaire, Wexner fecal incontinence grading scale, and additional questions about other perianal operations and obstetric history for women. We divided patients into two groups: no or minor fecal incontinence (Wexner score of 2 and less) and non-minor incontinence (Wexner score of 3 or more).ResultsOne hundred thirty-two patients were included in the study. Patients’ median follow-up time was 96 (12–168) months from their operation. Thirty-eight patients (28.8%) reported Wexner score of 3 or more, and they reported significantly worse quality of life in all tested life spheres. They were older at the time of the operation (63 (18–82) vs. 68 (50–89) years; p = 0.004), underwent longer operations (50 (10–140) vs. 60 (15–210) min; p = 0.017), and more often were operated for malignant lesions (17 (18.3%) vs. 14 (36.8%); p = 0.040). Older age at the time of operation was an independent risk factor in multivariate model (OR 1.057, 95% CI 1.010–1.106; p = 0.016).ConclusionsFecal incontinence after TEM is more common than thought previously, resulting in significantly impaired quality of life. Older age at the time of operation was an independent risk factor for developing significant fecal incontinence.

Case report: Laparoscopic approach in the treatment of presacral lipoma

Retrorectal lipoma, as well as other retrorectal tumours, is a relatively rare disorder. Retrorectal tumours accounted for 1 in 40,000 hospital admissions. We present a case of retrorectal lipoma, 15 cm × 10 cm × 8 cm in size, treated by the laparoscopic approach. The preoperative magnetic resonance imaging visualised a mass, 12 cm × 6.7 cm × 8.6 cm in diameter, in the retrorectal space, spreading toward the left obturator foramen. Surgery was indicated due to exclude malignant process certainly, because it is difficult to differentiate lipoma from low-grade liposarcoma on non invasive imaging. Laparoscopic extirpation of the tumour was performed. The overall operative time was 80 min. The diagnosis of lipoma was established on histological examination. The patient was discharged from hospital on the 2nd day after the surgery. We have found this minimally invasive operation to be an effective and well-tolerated treatment option, determined by the experience of the surgeon.

Does a retrorectal tumour remain a challenge for surgeons

Abstract Background: Retrorectal tumours are lesions with a wide range of histological differentiation that are often diagnostic and clinical challenges due to their rare occurrence. Many cases of this pathology are treated in regional hospitals, which results in serious complications because physicians fail to recognize this pathology. We present our experience in treating these tumours. Methods: A retrospective analysis of a prospectively maintained database was performed using the Vilnius University Hospital Santaros Clinics patient database. Thirty-five cases were identified. Results: Occurrence of retrorectal tumours was higher in women than in men and accounted for 82.86% and 17.14%, respectively. Computer tomography and magnetic resonance imaging were the main methods used to confirm diagnosis and plan surgical treatment. We have used a laparotomy, perineal or combined approach for tumour extirpation. The laparotomy approach was the most used, followed by perineal extirpation. The most common histological type was cystic hamartoma, accounting for 20% of cases. In 80% of cases, the histological findings greatly varied. Hospital stays varied from 3 to 21 days with a mean of 11.6 ± 5.83 days. The postoperative complication rate was 17.14% and was present in six cases. Overall survival was 85.17%, with an average follow-up period of 71.83 months. There were no recurrent tumours diagnosed during follow-up. Conclusion: Retrorectal tumours are a very rare pathology with high histological heterogeneity and problematic diagnostics. Patients should be referred to a tertiary centre that has experience and diagnostic capabilities for the best diagnostic and treatment options.

Laparoscopically assisted colonoscopic polypectomy – viable option for curative surgery in elderly patients

Introduction Colorectal cancer (CRC) is the third most common cancer worldwide and the fourth most frequent cause of cancer-related death in the world. CRC screening programs have been widely introduced worldwide, allowing for early detection and removal of precancerous lesions and avoiding major surgical intervention. However, not all polyps are suitable for conventional and advanced colonoscopic polypectomy. Thus, laparoscopically assisted colonoscopic polypectomy (LACP) was introduced to clinical practice as a method of choice for these polyps and adenomas. Aim To overlook our experience in laparoscopically assisted colonoscopic polypectomies and evaluate effectiveness and quality of the procedure. Material and methods A retrospective analysis of a prospectively maintained database was performed. using the Vilnius University Hospital Santariskiu Klinikos patient database for the period from 2010 to 2016, resulting in 21 cases in which LACP was performed. All procedures were performed using combined laparoscopy and videocolonoscopy techniques. Morphology of adenomas was classified according to the Paris classification during the procedure. Creation of the database was approved by the Lithuanian Bioethics committee. Results Twenty-two adenomas were removed from 21 patients, aged 65.33 ±8.9. There was no difference between male and female age, but occurrence of adenomas in females was 2-fold higher. The majority of removed lesions were localized in the cecum and mean size was 27.2 ±11.1 mm. The morphology of adenomas was distributed equally between 0–Is, 0–Ip, and 0–IIa, except one, which belonged to 0–III. Histological analysis revealed that tubulovillous adenoma occurrence was 1.4 times higher than tubulous adenoma. There was only one postoperative complication – bleeding from the adenoma resection site, which was managed by conservative means. One patient developed G2 adenocarcinoma at the polyp resection site and was referred for radical surgery. Conclusions The LACP is a safe procedure with minimal risk to the elderly patient. Patient follow-up is essential for detection of recurrence.

Enterogenous cyst of the small bowel mesentery: a case report and review of the literature

Abstract Introduction: Enterogenous cysts are a very rare congenital abnormality that can be found anywhere within the gastrointestinal tract, most commonly in the small intestine. The incidence is approximately one in 4500–10,000 live births. Diagnosis can be suggested by ultrasound (US), computed tomography (CT) scans or magnetic resonance imaging (MRI) findings, although histological examination confirms the definitive diagnosis. Patients: We present a case of enterogenous cyst in an adult female who underwent a resection of the tumour. Results: After two years of observation, there is no evidence of tumour recurrence.