Grzegorz Ćwik

Morphological changes of the pancreas in course of acute pancreatitis during treatment with Ulinastatin

UNLABELLED Acute pancreatitis is a severe clinical conditio that causes significant mortality in patients. Since we do not have at the moment effective causal treatment research on the use of pro tease inhibitors can produce tangible benefits. In view of the growing number of cases and high mortality in severe AP with one hand, and the lack of a usal treatment research efforts undertaken to search for effective drugs for this disease seem to have deep reasons. AIM OF THE STUDY was to determine the histopathological changes in the pancreas in the treatment of acute pancreatitis with Ulinastatin. MATERIAL AND METHODS The study was conducted in male Wistar rats weighing 250-300 grams. 150 individuals were used for the experiment, 60 of them were treated with Ulinastatin. Experimental acute pancreatitis was induced by the model proposed by Aho and Henckel using sodium taurocholate. Ulinastatin dose numer depended on the duration of the experiment. For histopathological examination pancreatic fragments weighing approximately 1 g each were taken. Assessment and documentation of histopathological preparations were made by light microscopy. RESULTS Evaluation of the histological preparations of various time groups showed significantly improved results after application of Ulinastatin, depending on the duration of the inflammation and the number of doses of the drug. CONCLUSIONS Application for the treatment of UTI leads to inhibition of the inflammatory process at the stage of pancreatic edema and in cases of severe necrotizing course limits the progression of the disease which gives grounds for its clinical use in humans.

Errors and mistakes in the ultrasound diagnosis of the pancreas

The differential diagnosis of the focal lesions in the region of the pancreas is difficult due to the similarity of clinical and radiological pictures of neoplastic and non-neoplastic lesions. This paper presents the most common causes of errors in ultrasound diagnosis of pancreatic pathologies. Attention was paid to the errors resulting from the structural variants of the pancreas and those caused by the neighborhood of intestine, stomach and other organs or vessels. Moreover, the article presents mistakes in the interpretation of ultrasound images of normal pancreas as well as its inflammatory and neoplastic lesions. The errors and mistakes in question were divided into three categories: 1) mistakes related to the anatomical structure of the pancreas (anatomical variants, echostructure and echogenicity, course of the splenic artery); 2) mistakes related to anatomical structures localized in the vicinity of the pancreas (caudate lobe of the liver, other organs and intestinal loops surrounding the head of the pancreas, vessels and bile ducts, lymph nodes in the region of the pancreas or duodenal diverticula and tumors); 3) mistakes related to the pathologies of the pancreas (inflammatory and neoplastic lesions including differentiation between inflammatory tumors and malignant masses). In spite of the progress of imaging techniques, the differential diagnosis of focal solid lesions remains the prime problem of imaging examinations of the pancreas. The major aim of the ultrasound examination is early detection of pancreatic neoplasm. Improper performance of the examination or a failure to perform a repeated scan when the conditions for the assessment of the pancreas are not favorable or, what is worse, description of normal pancreas when it is not clearly and entirely visible, constitute errors.

Standards of the Polish Ultrasound Society - update. Pancreas examination.

Ultrasound examination of the pancreas constitutes an integral part of the abdominal ultrasound. It is mostly indicated to diagnose pain in the epigastrium, discomfort and jaundice as well as to monitor the patients with acute pancreatitis. The assessment of this organ in an ultrasound examination may be problematic due to its anatomical location and the fact that it might be covered by gastric and duodenal contents as well as due to a number of possible pathological changes, including inflammation and benign or malignant neoplasms, which require differentiation. The basis for establishing a correct diagnosis is the knowledge of the examination technique, correct pancreas structure and images of individual pathologies. This paper presents the standards of ultrasound examination published in 2011 and updated with the current knowledge. The following are discussed: preparation of the patient for the examination, abnormal lesions in the pancreas, acute pancreatitis, chronic pancreatitis, cystic lesions (benign and malignant cysts) and solid focal lesions. Ultrasound is also used to guide the drainage of fluid cisterns, abscesses and cysts. The prime role in the diagnosis and treatment of selected diseases of the upper gastrointestinal tract and parenchymal organs of the abdomen belongs to endosonography of the upper gastrointestinal tract, with the possibility to conduct a fine needle aspiration biopsy, and intraoperative or laparoscopic ultrasound.

The value of ultrasound in the assessment of cervical and abdominal lymph node metastases and selecting surgical strategy in patients with squamous cell carcinoma of the thoracic esophagus treated with neoadjuvant therapy

PURPOSE To establish the role of ultrasound (US) in the assessment of cervical and abdominal lymph node metastases and its impact on making decision about surgical strategy in patients with squamous cell carcinoma of the thoracic esophagus. MATERIAL/METHODS The results of US lymph node assessment before and after a neoadjuvant treatment in 83 patients were compared with the results of histopathological evaluation of lymph nodes harvested during surgery (transthoracic esophagectomy and 2-field extended or 3-field lymph node dissection). A diagnostic value of cervical and abdominal US in terms of sensitivity, specificity, positive and negative predictive value after a neoadjuvant treatment were determined. RESULTS The sensitivity, specificity, positive and negative predictive value of the US assessment of cervical lymph node metastases were 100%, 96%, 81% and 100%, respectively. The sensitivity, specificity, positive and negative predictive value of the US assessment of abdominal lymph node metastases were 82%, 94%, 91.5% and 87%, respectively. CONCLUSIONS The high sensitivity and specificity of cervical US make this investigational method sufficient in the assessment of cervical nodal involvement. In esophageal cancer patients with negative cervical lymph nodes on US, three-field lymph node dissection could be avoided. In patients with positive cervical lymph nodes on US one should consider to extend lymph node dissection about lymph nodes of the neck to achieve a curative resection. In patients with negative abdominal US this investigation should be supplemented by more detailed diagnostic methods.

Intraoperative ultrasound in the treatment of pancreatic diseases.

UNLABELLED Intraoperative ultrasound (IOUS) allows confirming and verifying the preoperative diagnosis. In many cases it allows correct determination of the severity of the disease, safe surgery performance and shortening its duration. Proper assessment of anatomic structures during the surgery and evaluation of the operating field after the treatment termination, in combination with their ultrasound evaluation that permits more complete assessment of radical treatment. The aim of the study was to define current indications for the use of intraoperative ultrasound in the treatment of pancreatic lesions, based on our own experience and the cited literature. MATERIAL AND METHODS The Clinic, where the authors work, uses intraoperative ultrasound in everyday practice. In this paper we try to share our experience in this imaging technique. Studies were compared before the procedure both in the ultrasound and CT examination rooms with the images obtained intraoperatively. Intraoperative examination was performed by the surgeon who performed assessment before the procedure, what enabled verification of diagnoses. Presented material refers to 102 IOUS procedures performed during laparotomy due to pancreatic lesions. RESULTS AND CONCLUSIONS IOUS is a reliable test for the evaluation of both inflammatory and acute lesions in the pancreas during the surgery of chronic, symptomatic pancreatitis. It correctly determines the extent of the planned surgery. In the case of pancreatic cancer it verifies local severity of the tumour lesions, assessing involving of the peripancreatic vessels, lymph nodes and the presence of local and distant metastases, including those in the liver. IOUS proved highly effective in the evaluation of endocrine and cystic pancreatic tumours. The study significantly improves the effectiveness of intraoperative BAC and aspiration or drainage of fluid reservoirs.

Evaluation of the utility value of percutaneous drainage of symptomatic hepatic cysts combined with an obliteration attempt

Aim The goal of the paper was to evaluate the procedure of percutaneous drainage of symptomatic hepatic cysts under the transabdominal ultrasound control combined with obliteration. Material and method Within the period from 2005 to 2015, 70 patients diagnosed with a simple hepatic cyst of symptomatic nature were subject to hospitalization and treated at the 2nd General, Gastroenterological and Cancer Surgery of the Alimentary System Center and Clinics of the Medical University of Lublin. All the patients subject to evaluation were qualified to percutaneous drainage under an ultrasound control. The drainage utilized typical sets of drains with the diameter of at least 9 F, most often of pigtail type. The fluid aspirated form the cyst was dispatched for complex laboratory testing. Further, a 10% sodium chloride solution was administered to the cyst through the drain, in the volume depending on the previous size of the cyst and the patients reaction. Results Patients reported for a re-visit within the period from 3 to 9 months following the procedure. Complete obliteration of the cyst was confirmed only in 8 patients (11%). Cyst recurrence was reported in cases when during the ultrasound evaluation, the diameter of the cyst following aspiration and obliteration enlarged to over 75% of the initial dimension. In this group, in 10 out of 12 examined (83%) there was a relapse of the previously observed ailments. Among patients, who has a cyst imaged within the period of observation, which had the diameter from 50% to 75% of the previous size, only in 6 cases (37.5%) the initial symptoms relapsed. Conclusions The utilization of a drainage and obliteration enables one to achieve the acceptable result of the therapy as well as significant decrease in the number of previously reported ailments and symptoms described.

What’s new about symptomatic reflux disease

Abstract During the last 4 decades reflux disease (GERD) has evolved from being a rare clinical problem to a disease with high incidence. This automatically rises its social costs. First descriptions came from western countries only but nowadays there are many published papers from Asia and Middle East that can be found on the Internet. There is no clear explanation for this fact. Our understanding of GERD has changed over the time. At first GERD, hiatal hernia and oesophagitis were synonyms. Since the 1940s when the first manometrical studies were done it was concerned as lower oesophageal sphincter or peristaltic disfunction. The following years gave a definition of acid-peptic disorder. Nowadays all this concepts are mixed together and we are considering GERD as a heterogeneous clinical problem. In this paper we would like to present up-to-date knowledge about GERD.

Applications of intraoperative ultrasound in the treatment of complicated cases of acute and chronic pancreatitis and pancreatic cancer - own experience.

Both acute and chronic inflammation of the pancreas often lead to complications that nowadays can be resolved using endoscopic and surgical procedures. In many cases, intraoperative ultrasound examination (IOUS) enables correct assessment of the extent of the lesion, and allows for safe surgery, while also shortening its length. Aim of the research At the authors’ clinic, intraoperative ultrasound is performed in daily practice. In this paper, we try to share our experiences in the application of this particular imaging technique. Research sample and methodology Intraoperative examination conducted by a surgeon who has assessed the patient prior to surgery, which enabled the surgeon to verify the initial diagnosis. The material presented in this paper includes 145 IOUS procedures performed during laparotomy due to lesions of the pancreas, 57 of which were carried out in cases of inflammatory process. Results and conclusions IOUS is a reliable examination tool in the evaluation of acute inflammatory lesions in the pancreas, especially during the surgery of chronic, symptomatic inflammation of the organ. The procedure allows for a correct determination of the necessary scope of the planned surgery. The examination allows for the differentiation between cystic lesions and tumors of cystic nature, dictates the correct strategy for draining, as well as validates the indications for the lesions surgical removal. IOUS also allows the estimation of place and scope of drainage procedures in cases of overpressure in the pancreatic ducts caused by calcification of the parenchyma or choledocholitiasis in chronic pancreatitis. In pancreatic cancer, IOUS provides a verification of the local extent of tumor-like lesions, allowing for the assessment of pancreatic and lymph nodes metastasis, and indicating the presence of distant and local metastases, including the liver. IOUS significantly improves the effectiveness of intraoperative BAC aspiration or drainage of fluid reservoirs.

Haemorrhage in the course of subcardial gastrointestinal stromal tumor - a case description.

This paper is a discussion of the case of a 51-year-old female patient admitted urgently for haemorrhage from the upper gastrointestinal tract and increased dysphagia. After preliminary treatment, the patient was qualified for surgery, during which a large lesion was discovered in the shape of a stromal tumor closely connected with the oesophago-gastric junction. A resection of the tumor and part of the oesophagus was carried out, and a cervical fistula was formed. After a 4-month period, the continuity of the gastrointestinal tract was restored by forming a substitute organ out of the ascending colon and the end of the small intestine, anastomosed on the cervix. The patient was discharged in good overall condition.

Significance of ultrasonography in selecting methods for the treatment of acute cholecystitis.

Surgical removal of the gallbladder is indicated in nearly all cases of complicated acute cholecystitis. In the 1990s, laparoscopic cholecystectomy became the method of choice in the treatment of cholecystolithiasis. Due to a large inflammatory reaction in the course of acute inflammation, a laparoscopic procedure is conducted in technically difficult conditions and entails the risk of complications. The aim of this paper The aim of this paper was: 1) to analyze ultrasound images in acute cholecystitis; 2) to specify the most common causes of conversion from the laparoscopic method to open laparotomy; 3) to determine the degree to which the necessity for such a conversion may be predicted with the help of ultrasound examinations. Material and methods In 1993–2011, in the Second Department and Clinic of General, Gastroenterological and Oncological Surgery of the Medical University in Lublin, 5,596 cholecystectomies were performed including 4,105 laparoscopic procedures that constituted 73.4% of all cholecystectomies. Five hundred and forty-two patients (13.2%) were qualified for laparoscopic procedure despite manifesting typical symptoms of acute cholecystitis in ultrasound examination, which comprise: thickening of the gallbladder wall of > 3 mm, inflammatory infiltration in the Calots triangle region, gallbladder filled with stagnated or purulent contents and mural or intramural effusion. Results In the group of operated patients, the conversion was necessary in 130 patients, i.e. in 24% of cases in comparison with 3.8% of patients with uncomplicated cholecystolithiasis (without the signs of inflammation). The conversion most frequently occurred when the assessment of the anatomical structures of the Calots triangle was rendered more difficult due to local inflammatory process, mural effusion and thickening of the gallbladder wall of >5 mm. The remaining changes occurred more rarely. Conclusions Based on imaging scans, the most common causes of conversion included inflammatory infiltration in the Calots triangle region, mural effusion and wall thickening to > 5 mm. The classical cholecystectomy in acute cholecystitis should be performed in patients with three major local complications detected on ultrasound examination and in those, who manifest acute clinical symptoms.