Jadwiga Snarska

The outcomes of SILS cholecystectomy in comparison with classic four-trocar laparoscopic cholecystectomy

Introduction General approval of laparoscopy as well as persistent urge to minimize operative trauma with still existing difficulties in putting natural orifice transluminal endoscopic surgery (NOTES) into practice have contributed to the introduction of laparoscopic operations through one incision in the umbilicus named single incision laparoscopic surgery (SILS). Aim The main aim of this study was to assess the benefits to patients of applying SILS cholecystectomy as a method of gallbladder removal based on the comparison with classic four-port laparoscopic cholecystectomy. Material and methods Between 18.03.2009 and 09.12.2009, 100 patients were included in the study and they underwent elective gallbladder removal by applying the laparoscopic technique. All patients were divided into two equal groups: qualified for SILS cholecystectomy (group I) and qualified for classic four-trocar laparoscopic cholecystectomy (group II), whose ASA physical status was I and II. BMI was limited to 35 kg/m2. Outcome measures included operative time, intensity of postoperative pain and consumption of painkillers, hospital stay, need for conversion, complications, and cosmetic effects. Results Mean operating time in group I was 66 min and in group II 47.2 min. Intensity of pain evaluated by using the visual analogue scale (VAS) 6 h after the operation in group I was 3.49 and in group II 4.53, whereas 24 h after the operation in group I it was 1.18 and in group II 1.55. The painkiller requirement in group I was smaller than in group II. Mean hospital stay after the operation in group I was 1.33 days and in group II 1.96 days. There were 4 conversions in group I and one conversion in group II. Among the complications in group I there were noted 2 cases of right pneumothorax, 1 case of choleperitonitis and 4 complications connected with wound healing. There was one injury of the duodenum and one wound infection in group II. Conclusions Single-incision laparoscopic surgery cholecystectomy can be an alternative to classic laparoscopic cholecystectomy, especially with reference to young people with body mass index less than 35 kg/m2, without serious systemic diseases, operated on electively due to benign gallbladder diseases.

Partnership for Transplantation: A New Initiative to Increase Deceased Organ Donation in Poland

Despite the long-standing history of transplantation, the shortage of organs has remained its most restrictive factor. In 2010, the number of actual deceased organ donors in Poland was 13.5/million population (pmp). However, a huge difference in organ recovery rates is evident between various regions, eg, 32 pmp, in western Pomerania compared with 1-3 pmp in southern districts. A substantial number of patients who die while awaiting organ transplantations could be saved were effective programs able to overcome barriers in deceased organ donation. Such programs, eg, the European Donor Hospital Education Program, Donor Action, European Training Program on Organ Donation, United States Collaborative in Donation were introduced several years ago, but after transient improvements there has not been real progress. A new comprehensive program-Regional Partnership for Transplantation-was initiated a year ago in 4 districts of southern Poland by the Polish Union for Transplantation Medicine. The letter of intent to activate the donation program was signed by the local administration, the president of the local medical school, president of the Physicians Chamber, transplant centers, the Polish Union for Transplantation, and the Polish Transplant Coordinating Center. The plan of action included training of in-hospital coordinators, visits to all regional hospitals in company of a representative of the hospital founding body, examination of the real donation pool and the need for participation in a donation program training and education of the hospital staff in legal and organizational aspects of donation, brain death recognition, and various aspects of donor care. In addition, the program included communication skills workshops for intensive care unit physicians (with participation of 2 actors, an experienced anesthesiologist, and a psychologist), lectures for high school and university students and for hospital chaplains as well as alumni of higher seminaries. The preliminary results (after the first year) showed 40%-70% increases in activity of the local hospitals in the organ donation process.

Changes in PDGF concentration in surgically treated colorectal carcinoma.

PURPOSE The aim of the present study was to asses the effect of tumor advancement, differentiation grade and surgery treatment on PDGF- AB level and platelet (PLT) count depending on the site of blood collection. MATERIAL AND METHODS The study included 38 patients submitted to surgical treatment due to diagnosis of colorectal cancer (CRC) without remote metastasis: G2- 20 patients and group G3- 18 patients. The control group consisted of 24 healthy subjects. In CRC patients the blood samples was collected three times: 1) before surgery, 2) intrasurgically and 3) 90 days after surgery. Serum PDGF- AB concentration was determined by ELISA- Kit reagents. RESULTS PDGF concentration in all the patients was several times higher than in the control group, irrespective of tumor differentiation grade and the site of blood collection. However the level of PDGF- AB in intraoperatively collected arterial blood and venous blood in group G3 (arterial blood- 379.9+/-12.1 ng/ml; venous blood- 398.4+/-13.2 ng/ml) was significantly higher than in group G2 (arterial blood- 169.4+/-88.6 ng/ml; venous blood- 194.2+/-84.0 ng/ml). No significant differences were observed between venous and arterial blood. No correlation was found between the PLT count and PDGF- AB concentration. CONCLUSION High blood PDGF- AB concentration in CRC patients but no significant positive correlation observed between the PLT count and PDGF-AB suggest its neoplastic origin beside PLT. Determination of this factor in blood serum may have an important implication in early diagnosis of CRC, which is the second most common malignant neoplasm with high recurrence rates.

Preliminary Outcome of Treatment of Postoperative Primarily Closed Sternotomy Wounds Treated Using Negative Pressure Wound Therapy

UNLABELLED Hospital infections, and in particular infections of the surgical site are a common problem of the procedural departments. Due to continuous progress of surgical techniques and patient population getting older with multiple co-morbidities, multidirectional actions need to be taken to avoid these infections or, if they do occur, achieve optimal treatment outcomes. Vacuum wound therapy is one of the directions that has been developed over the recent years. The aim of the study evaluate wound healing in patients after an off-pump coronary artery bypass grafting procedure, using the internal mammary artery, treated with negative pressure wound therapy system. MATERIAL AND METHODS This prospective, open label study evaluated healing of postoperative sternotomy wounds after their primary closure with negative pressure wound therapy, using continuous negative pressure of -80 mmHg in 40 patients and 40 patients in a control group in whom conventional dressings were applied in the postoperative period. RESULTS The number of patients in whom primary wound healing occurred without complications was significantly higher in the negative pressure wound therapy group versus the control group (x2 test =4.50, p=0.0339) and the number of total superficial infections was significantly smaller versus the control group (x2 test =5; p=0.0254). Antibiotic therapy was also initiated significantly less often as compared to the group treated with conventional dressings (x2 test = 4.11; p=0.0425). CONCLUSIONS Negative pressure wound therapy after primary wound closure reduces the risk of superficial infections in the population with multiple risk factors of complications in the sternotomy wound healing.

Survey on Attitudes and Knowledge on the Organ Recovery From Deceased Donors in Roman Catholic Nuns and Priests

UNLABELLED Deceased donors (DD) organ recovery rate in Poland has never been satisfactory but over the years kidney transplantation from deceased donors has reached the level of 26 transplants/pmp. In 2007 due to a number of reasons, a dramatic fall of organ recovery rate from deceased donors (DD) occurred. The survey on public attitude toward organ transplantation carried out in the same year showed a large reduction of the public trust toward medical profession. Since then, the number of kidney transplantations has never come back to its level from 2006, regardless of a positive attitude toward organ transplantation. The attitude and knowledge survey was recently carried out in 100 physicians and 100 nurses employed in one large district hospital. The results of the attitude survey among the hospital staff showed that the level of knowledge among nurses corresponded to their age and the time since graduation. Younger nurses showed much more appreciation and knowledge toward recovery of organs from the deceased donors. Survey among physicians indicated some hesitation toward recognition of the brain death. In the present paper results of the survey on attitude and knowledge toward organ transplantation among nuns (98 nuns), priests (100 priests) and students (98 students) of the Theological School living in the same area are presented. Despite quite high (>60%) acceptance of the deceased donation, one third of questioned population showed lack of knowledge not only on existing legal regulations, but also of important documents issued by the Catholic Church. CONCLUSIONS Improvement of transplantation program in Poland requires extensive educational program among various parts of the society: most importantly among physicians, nurses and priests. The Partnership for Transplantation program has been directed to achieve these goals.

Air tamponade of the heart

Pneumopericardium is a rare disease defined as the presence of air or gas in the pericardial sac. Among the etiological factors, the following stand out: chest trauma, barotrauma, air-containing fistulas between the pericardium and the surrounding structures, secondary gas production by microorganisms growing in the pericardial sac, and iatrogenic factors. Until now, spontaneous pneumopericardium has been considered a harmless and temporary state, but a review of clinical cases indicates that the presence of air in the pericardium can lead to cardiac tamponade and life-threatening hemodynamic disturbances. We present the case of an 80-year-old patient with a chronic bronchopericardial fistula, who suffered from a cardiac arrest due to air tamponade of the heart.

Single Nucleotide Polymorphisms in the Vitamin D Receptor Gene (VDR) May Have an Impact on Acute Pancreatitis (AP) Development: A Prospective Study in Populations of AP Patients and Alcohol-Abuse Controls

Vitamin D imbalance is suggested to be associated with the development of pancreatitis. Single nucleotide polymorphisms (SNPs), Apa-1, Bsm-1, Fok-1, and Taq-1, in the vitamin D receptor gene (VDR) are known in various diseases, but not yet in pancreatitis. The aim of this study was to explore possible associations of the four SNPs in the VDR receptor gene in a population of acute pancreatitis patients and alcohol-abuse controls, and to investigate the association with acute pancreatitis (AP) susceptibility. The study population (n = 239) included acute pancreatitis patients (n = 129) and an alcohol-abuse control group (n = 110). All patients met the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) criteria for alcohol dependence. DNA was extracted from peripheral leukocytes and analyzed for VDR polymorphisms using a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. Odd ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression analysis. To date, we have found allele T in Taq-1 (OR = 2.61; 95% CI: 1.68–4.03; p < 0.0001) to be almost three times more frequent in the AP group compared to the alcohol-abuse control patients. Polymorphism Taq-1 occurring in the vitamin D receptor may have an impact on the development of acute pancreatitis due to the lack of the protective role of vitamin D.

Septic Shock in the Course of Liver Absces Rescued with Percutaneous Drainage – A Literature Review and Case Report

This study presented a septic shock occurring with striking speed during the percutaneous drainage of a large abscess of the liver in an 18-year-old female patient after an appendectomy performed 3 months earlier using the laparoscopic method because of its phlegmonous and gangraenosus inflammation. The post-operative course was complicated by increased suppuration in places after removal of the trocars. After including the intravenous antibiotic therapy and under the USG control, the percutaneous drainage of the abscess was performed. While withdrawing the guide of the drainage catheter set, the symptoms of septic shock occurred. The pharmacological treatment was applied with continuation of the antibiotic therapy till a negative result of microbiological tests was obtained and the normalization of life parameters. The patient was not qualified for treatment in the ICU. She was discharged in a generally good condition after 24 days of hospitalization. In the case of this patient, the drain covered with the content of the abscess may have contact with the adjacent tiny blood vessels, which may have contributed to the systemic inflammatory response syndrome that was linked with fast-developing sceptic shock.

Exceptionally rare cause of a total stomach resection

The first-ever case of a 54-year-old woman who overdosed on non-steroidal anti-inflammatory drugs in an attempt at suicide. Before that incident, she had not been treated for coexisting diseases such as rheumatoid arthritis or depression. At the time of admission to the General Surgery Department, the patient reported pains in the epigastric region with accompanying nausea and vomiting with mucous content as well as the inability to ingest food orally. Despite parenteral and enteral feeding, the patient exhibited a drop in body mass. The histopathologic examination of a sample taken from the stomach during gastroscopy showed some non-specific necrotic and inflammatory masses with granulation. Intraoperatively, a very small, infiltrated stomach with an initial section of duodenum was identified. A total stomach resection together with the reconstruction of digestive tract continuity was performed using the Roux-Y method. Histopathologic examination of the stomach revealed a deep, chronic and exacerbated inflammatory condition with an extensive ulceration over the entire length of the stomach, reaching up to the pylorus. Additionally, numerous lymphatic glands with inflammatory reaction changes were observed.

RECURRENT RESIDUAL CHOLEDOCHOLITHIASIS AFTER CHOLECYSTECTOMY - ENDOSCOPIC EXPLORATION OF BILE DUCTS PERFORMED 6 TIMES

Abstract Introduction Recurrent residual choledocholithiasis refers to the presence of concretions in the bile ducts found in patients who have undergone cholecystectomy. The incidence of recurrent cholithiasis is estimated to be 2–10%, whereas the incidence of recurrent cholithiasis after endoscopic retrograde cholangiopancreatography (ERCP) amounts to 4–24%. Aim The aim of this paper was to analyze the case of a patient with recurrent choledocholithiasis after laparoscopic cholecystectomy, who underwent endoscopic exploration of the bile ducts performed 6 times, including endoscopic sphincterotomy (ES) and biliary prostheses. Case study A 49-year old patient was admitted to the Teaching Hospital showing symptoms of extrahepatic cholestasis. On admittance, she reported nausea lasting for a few days, meteorism and strong pain typical of biliary colic, located in her right epigastric region and irradiating to her spine. Additionally, she complained of a bitter taste in her mouth and bitter belching. The patient had been operated on 9 years before for acute cholecystitis. Results and discussion This presented case poses a question for a clinician concerning the risk factors for recurrent choledocholithiasis. In the majority of cases, i.e., as many as 80%, recurrent cholithiasis is detected within 3 years following ERCP with sphincterotomy. The risk of choledocholithiasis recurrence after endoscopic evacuation of the stones is within the range of 4–24%. The identification of factors causing this disease will contribute to its prevention, early diagnosis and treatment of any further recurrences and complications from choledocholithiasis. Data from published literature prove that damage to the sphincter causes chronic cholangitis, which then contributes to the formation of concretions. Other risk factors include dilated bile ducts and performed cholecystectomy. All these factors occurred and were observed in the analyzed patient. Conclusions The basic treatment for this recurrent disease is ES performed during an ERCP procedure. This case emphasizes those problems associated with the prevention and treatment of recurrent choledocholithiasis.