Jacek Hermann

Hamartomatous polyposis syndromes.

Hamartomas are tumour-like malformations, consisting of disorganized normal tissues, typical of the site of tumour manifestation. Familial manifestation of hamartomatous polyps can be noted in juvenile polyposis syndrome (JPS), Peutz-Jeghers’ syndrome (PJS), hereditary mixed polyposis syndrome (HMPS) and PTEN hamartoma tumour syndrome (PHTS). All the aforementioned syndromes are inherited in an autosomal dominant manner and form a rather heterogenous group both in respect to the number and localization of polyps and the risk of cancer development in the alimentary tract and other organs. Individual syndromes of hamartomatous polyposis frequently manifest similar symptoms, particularly during the early stage of the diseases when in several cases their clinical pictures do not allow for differential diagnosis. The correct diagnosis of the disease using molecular methods allows treatment to be implemented earlier and therefore more effectively since it is followed by a strict monitoring of organs that manifest a predisposition for neoplastic transformation.

Endoscopic vacuum-assisted closure system (E-VAC): case report and review of the literature

Negative pressure wound therapy (NPWT) has become a standard in the treatment of chronic and difficult healing wounds. Negative pressure wound therapy is applied to the wound via a special vacuum-sealed sponge. Nowadays, the endoscopic vacuum-assisted wound closure system (E-VAC) has been proven to be an important alternative in patients with upper and lower intestinal leakage not responding to standard endoscopic and/or surgical treatment procedures. Endoscopic vacuum-assisted wound closure system provides perfect wound drainage and closure of various kinds of defect and promotes tissue granulation. Our experience has shown that E-VAC may significantly improve the morbidity and mortality rate. Moreover, E-VAC may be useful in a multidisciplinary approach – from upper gastrointestinal to rectal surgery complications. On the other hand, major limitations of the E-VAC system are the necessity of repeated endoscopic interventions and constant presence of well-trained staff. Further, large-cohort studies need to be performed to establish the applicability and effectiveness of E-VAC before routine widespread use can be recommended.

Migration of biomaterials used in gastroenterological surgery

UNLABELLED Mesh biomaterials have become the standard in the treatment of hernias, regardless the location. In addition to the obvious advantages of the methods based on implantable biomaterials, one should be aware of the possible complications, such as their migration to the abdominal organs. MATERIAL AND METHODS The study group comprised patients operated at the Department of General, Gastroenterological Oncology, and Plastic Surgery during the period between 2008 and 2011, due to hernia surgery with mesh implantation. We also analysed the number of patients operated, due to complications of mesh migration during the same period. RESULTS 368 patients were subject to mesh implantation, due to hernias during the period between 2008 and 2011. Three patients underwent surgery because of symptomatic migration of the mesh (ileus, fistula). CONCLUSIONS The frequency of mesh migration is difficult to determine because of the different criteria of migration, observation period, and other factors. In patients after mesh implantation the potential migration of the biomaterial should be considered in case of unclear or acute abdominal symptoms.

Strangulation of the stomach and the transverse colon following laparoscopic esophageal hiatal hernia repair

The authors present a 32-year-old male patient with incarceration of a recurrent esophageal hiatal hernia after laparoscopic repair. A life-threatening strangulation of the stomach and the transverse colon occurred within a few days after the operation. Relapse of hiatal hernias amounts to almost half of early complications characteristic for the laparoscopic approach. General recommendations regarding surgical technique as well as perioperative care have been proposed in order to decrease the risk of relapse. Also, routine contrast radiology on the first or second day following the laparoscopic operation facilitates early diagnosis of relapse of hiatal hernia with emergent reoperation. This may result in decreased morbidity and improved overall outcome of the treatment.

''Sandwich technique'' with bridging, a modification of negative pressure wound therapy for anal fistulas

The surgical treatment of anal fistulas is a complex problem, associated with high relapse rates. Wounds frequently heal by the secondary intention. The process is time-consuming and frequently causes discomfort to the patient. Negative pressure wound therapy seems to be one of the methods which might accelerate the healing process in patients who have undergone surgery for anal fistula. Nevertheless, this approach is seldom used. The principal challenge in applying negative pressure wound therapy (NPWT) in the anal and perineal regions remains appropriate application of particular elements forming the negative pressure dressing and above all tight pasting of the foil.

Current management of anal fistulas in Crohn’s disease

Anal fistulas occurring in Crohns disease (CD) comprise a risk factor of severe course of inflammation. They are frequently intractable due to various factors such as penetration of the anal canal or rectal wall, impaired wound healing, and immunosuppression, among others. Anal fistulas typical to CD develop from fissures or ulcers of the anal canal or rectum. Accurate identification of the type of fistula, such as low and simple or high and complex, is crucial for prognosis as well as for the choice of treatment. If fistulotomy remains the gold standard in the surgical treatment of the former, it is contraindicated in high and complex fistulas due to possible risk of damage to the anal sphincter with subsequent faecal incontinence. Therefore, the latter require a conservative and palliative approach, such as an incision and drainage of abscesses accompanying fistulas or prolonged non-cutting seton placement. Currently, conservative, sphincter-preserving, and definitive procedures such as mucosal advancement or dermal island flaps, the use of plugs or glue, video assisted anal fistula treatment, ligation of the intersphincteric track, and vacuum assisted closure are gaining a great deal of interest. Attempting to close the internal opening without injuring the sphincter is a major advantage of those methods. However, both the palliative and the definitive procedures require adjuvant therapy with medical measures.

Perineal wound healing after abdominoperineal resection for rectal cancer: a systematic review and meta-analysis.

To the Editor—recently, Musters et al published a very interesting review on perineal wound healing after abdominoperineal resection (APr) for rectal cancer. the authors discussed various methods of perineal wound closure, as well as treatment options for potential complications of primary closure. We did not find any information in the article about the implementation of negative pressure wound therapy (NPWt). NPWt has been demonstrated to be an effective method for the management of complicated and chronic wounds. Perianal wounds, both postoperative and posttraumatic, remain a challenging problem. Because of an impaired healing process (radiation therapy), as well as difficulty in dressing and nursing, we strongly recommend implementing NPWt after an APr procedure. Based on our experience, we found NPWt to be a helpful method for management of this type of wound. the crucial aspect of NPWt is to apply the dressing in the appropriate manner, particularly in the anal and genital regions. Keeping the entire system sealed is challenging and usually requires the use of a stoma paste or silicone plate. our results are consistent with other publications that have reported good results when using NPWt after an APr procedure. NPWt has been used to support the healing process from complicated perineal wounds after APr procedures, as well as for gracilis muscle flap transposition and an omentoplasty technique after an APr procedure. Promising results were also demonstrated concerning incisional NPWt used postoperatively. Although the application of NPWt for a perineal wound is not considered a goldstandard procedure, in our opinion NPWt is an effective method for primary wound closure and a method of choice during impaired healing of perineal wounds after an APr procedure.

Primary ileo-anal pouch anastomosis in patients with acute ulcerative colitis

Introduction Proctocolectomy with ileal pouch-anal anastomosis (IPAA) was performed in ulcerative colitis (UC) for emergent or urgent indications in three stages. Since the three-step procedure imposes enormous demands on a patient, there was an attempt to introduce primary IPAA for urgent indications. The aim of this study was to compare early complications after Hartmanns colectomy (HC) and IPAA in a selected group of patients. Material and methods Medical records of 274 patients who underwent surgery for UC between 1996 and 2010 were retrospectively evaluated. Finally, a group of 77 patients with acute form of UC entered this study. Results All patients were divided into two groups. Group 1 consisted of 32 (42%) patients who underwent HC, whereas group 2 comprised 45 (58%) patients after IPAA. There was no postoperative mortality. Respiratory failure occurred in 8 (24%) patients after HC and in 6 (14%) patients who underwent IPAA. Intra-abdominal sepsis developed in 4 (12%) patients after HC and in 8 (17%) undergoing IPAA. Fascia dehiscence was present in 3 (8%) patients after HC and in 4 (9%) with IPAA. Bowel obstruction occurred in 1 (4%) patient after the former operation and in 3 (6%) patients after the latter one. Wound infection was diagnosed in 6 (20%) patients after HC and in 9 (20%) after IPAA. The differences between the investigated groups of patients were not statistically significant. Conclusions The IPAA could be performed for urgent indications only in the patients with no critical dilatation of the colon or with active UC but without signs of severe malnutrition.

Palliative treatment of anal fistulas in Crohn's disease.

Anal fistula in Crohns disease is frequently an intractable condition. Methods of treatment are still debated because the results of various procedures are unsatisfactory. Available studies show that results can be improved using a combination of surgical and medical methods. Most patients undergo rather palliative than radical, curative procedures such as incision and drainage of abscesses and prolonged non‐cutting seton placement. Surgery is combined today with biological therapy using infliximab, a murine‐human chimeric monoclonal antibody against TNF‐α or adalimumab a human monoclonal anti‐TNF antibody to increase the healing process and in an attempt to prevent fistula recurrence.

Fever of unknown origin: a clinical mask of malignant peritoneal mesothelioma

The authors present a patient suffering from malignant peritoneal mesothelioma. Differential diagnosis has become the major concern in the fatally ill patient. Pain, increasing abdominal girth, anorexia and weight loss, and recurrent ascites are the most frequent presenting symptoms. In this patient, fever of unknown origin was a clinical mask of mesothelioma. The diagnostic process was focused on infections and collagen-vascular diseases since they are the most common causes of the systemic inflammatory response syndrome. However, persistent pyrexia can also occur, less frequently, in the course of any malignant disease.