Maciej Matyja

Telocytes: new insight into the pathogenesis of gallstone disease

The major mechanisms of gallstone formation include biliary cholesterol hypersecretion, supersaturation and crystallization, mucus hypersecretion, gel formation and bile stasis. Gallbladder hypomotility seems to be a key event that triggers the precipitation of cholesterol microcrystals from supersaturated lithogenic bile. Telocytes, a new type of interstitial cells, have been recently identified in many organs, including gallbladder. Considering telocyte functions, it is presumed that these cells might be involved in the signalling processes. The purpose of this study was to correlate the quantity of telocytes in the gallbladder with the lithogenicity of bile. Gallbladder specimens were collected from 24 patients who underwent elective laparoscopic cholecystectomy for symptomatic gallstone disease. The control group consisted of 25 consecutive patients who received elective treatment for pancreatic head tumours. Telocytes were visualized in paraffin sections of gallbladders with double immunofluorescence using primary antibodies against c‐Kit (anti‐CD117) and anti‐mast cell tryptase. Cholesterol, phospholipid and bile acid levels were measured in gallbladder bile. The number of telocytes in the gallbladder wall was significantly lower in the study group than that in the control group (3.03 ± 1.43 versus 6.34 ± 1.66 cell/field of view in the muscularis propria, P < 0.001) and correlated with a significant increase in the cholesterol saturation index. The glycocholic and taurocholic acid levels were significantly elevated in the control subjects compared with the study group. The results suggest that bile composition may play an important role in the reduction in telocytes density in the gallbladder.

Laparosocopic Appendectomy, Cost-Effectiveness of Three Different Techniques Used to Close the Appendix Stump.

UNLABELLED It is generally agreed that laparoscopic appendectomy is a valuable operative method. The aim of the study was to evaluate cost-effectiveness of three different techniques used to close the appendix stump. MATERIAL AND METHODS We conducted a retrospective study that compared three groups of patients who were operated on laparoscopically for acute appendicitis in 2013 at our institution. We used an endoscopic clip to close the appendix stump in the first group (n=20), endoscopic stapler was applied in the second group (n=20), and in the third group of patients the appendix base was closed with a laparoscopic suture (n=20). These groups were matched by age, sex and BMI. RESULTS The average operative cost was the highest in the second group. Cost of the laparoscopic appendectomy with the application of the endoscopic clip was significantly lower (first group) and comparable to the third group. Observed differences in total hospitalization costs were associated only with the chosen appendix stump closure technique. CONCLUSIONS Clip closure of the appendix base is an easy and cost-effective procedure. The laparoscopic suture technique is the cheapest but technically demanding. According to our experience endoscopic stapler may be useful in some cases, although it is the most expensive method.

Interstitial Cajal-Like Cells and Bile Lithogenicity in the Pathogenesis of Gall-Stone Disease

UNLABELLED Gall-stone disease constitutes a serious clinical problem and is the most frequent cause of elective cholecystectomies. There are many etiopatogenic factors however; lithogenic bile and its stasis due to gall-bladder hypomotility seem to be the most important. In recent years discovery of pacemaker function of Interstitial Cells of Cajal changed our understanding of smooth muscle physiology and helped to disclose many gastrointestinal motility disorders. THE AIM OF THE STUDY was identification and quantification of interstitial Cajal-like cells (ICLCs) in gall-bladder muscle wall from patients with cholelithiasis and in gall-stone-free controls, as well as determination of the relationship between the number of ICLCs and Cholesterol Saturation Index (CSI) of bile in both analyzed groups. MATERIAL AND METHODS 20 patients operated for symptomatic cholelithiasis were enrolled into the study group. The control group consisted of 20 patients operated for pancreatic head tumors, with no pre- and intraoperative signs of gall-stones. Identification of ICLCs in the gall-bladder was performed by means of double immunofluorescence technique with anti c-Kit and anti-mast cell tryptase antibodies. Quantitative analysis was carried out under fluorescence microscopy conjoined with image analysis software. Bile samples were used for calculation of CSI. RESULTS ICLCs were detected within gall-bladder muscle wall. Number of ICLCs was statistically significantly lower in patients from the study group as compared to control. The study also revealed statistically significantly higher CSI in the study group. CONCLUSIONS The quantity of ICLCs is diminished in the gall-bladder from patients with cholelithiasis and there is negative correlation between the number of ICLCs and CSI of bile. Regarding the role of ICCs in regulation of GI tract motility, it appears that reduction in their number may be important etiopatogenic factor of cholelithiasis.

The Use of the Enhanced Recovery After Surgery (ERAS) Protocol in Patients Undergoing Laparoscopic Surgery for Colorectal Cancer – A Comparative Analysis of Patients Aged above 80 and below 55

UNLABELLED Age is one of the principal risk factors for colorectal adenocarcinoma. To date, older patients were believed to achieve worse treatment results in comparison with younger patients due to reduced vital capacity. However, papers have emerged in recent years which confirm that the combination of laparoscopy and postoperative care based on the ERAS protocol improves treatment results and may be particularly beneficial also for elderly patients. The aim of the study was to compare the outcomes of laparoscopic surgery for colorectal cancer in combination with the ERAS protocol in patients aged above 80 and below 55. MATERIAL AND METHODS The analysis included patients aged above 80 and below 55 undergoing elective laparoscopic colorectal resection for cancer at the 2nd Department of General Surgery of the Jagiellonian University. They were divided into two groups according to their age: ≥ 80 years of age (group1) and ≤ 55 years of age (group 2). Both groups were compared with regard to the outcome of surgery: length hospital stay, complications, hospital readmissions, degree of compliance with the ERAS protocol, and recovery parameters (tolerance of oral nutrition, mobilisation, need for opioids, restored gastrointestinal function). RESULTS Group 1 comprised 34 patients and group 2, 43 patients. No differences were found between both groups in terms of gender, BMI, tumour progression or surgical parameters. Older patients typically had higher ASA scores. No statistically significant differences were found with regard to the length hospital stay following surgery (5.4 vs 7 days, p=0.446481), the occurrence of complications (23.5% vs 37.2%, p=0.14579) or hospital readmissions (2.9% vs 2.4%). The degree of compliance with the ERAS protocol in group 1 and 2 was 85.2% and 83.0%, respectively (p=0.482558). Additionally, recovery parameters such as tolerance of oral nutrition (82.4% vs 72.1%, p=0.28628) and mobilisation (94.1% vs 83.7%, p=0.14510) within 24 hours of surgery did not differ among the groups. However, a smaller proportion of older patients required opioids in comparison with younger patients (26.5% vs 55.8%, p=0.00891). CONCLUSIONS Similar levels of compliance with the ERAS protocol may be achieved among patients aged ≥ 80 and younger patients. When laparoscopy is combined with the ERAS protocol, age does not seem to be a significant factor that could account for worse outcomes. Therefore, older patients should not be excluded from perioperative care based on ERAS principles.

Application of the Single Access Technique in Laparoscopic Surgery

UNLABELLED Laparoscopic single access technique is a next step in development of minimally invasive surgery. The aim of the study was to present results of different laparoscopic single incision procedures and evaluate application of this technique. MATERIAL AND METHODS 102 patients (15 males and 87 females) who underwent laparoscopic single incision procedure from 15th October 2009 to 31st December 2012 were included in the study. RESULTS In the analyzed period we performed 72 cholecystectomies (70.6%), 8 left adrenalectomies (7.8%), 3 right adrenalectomies (2.9%), 7 splenectomies (6.9%), 5 spleen cysts unroofings (4.9%), 2 appendectomies (2%), 1 Nissen fundoplication procedure (1%), 1 removal of the adrenal cyst (1%) and 3 concomitant splenectomies and cholecystectomies (2.9%). There were 3 technical conversions to multiport laparoscopy, but no conversion to open technique. Complications were observed in 5 patients (4.9%). Average operation time was 79 min (SD=40), average hospitalization time 2.4 day (SD=1.4). CONCLUSIONS Laparoscopic single incision technique is a safe method and can be used as a reasonable alternative to multiport laparoscopy in different minimally invasive procedures especially in young patients to whom an excellent cosmetic effect is particularly important.

Results of laparoscopic appendectomies performed with the use of titanium clips for closure of the appendicular stump.

UNLABELLED Nowadays laparoscopy is used frequently not only in elective surgery but also in abdominal emergencies, including acute appendicitis. There are several techniques used to close the appendicular stump during laparoscopic appendectomy. The aim of the study was to present the results of minimally invasive appendectomies performed with the use of titanium clips. MATERIAL AND METHODS Patients operated on laparoscopically for acute appendicitis with the application of titanium clips between October 2012 and December 2013 were included in the study. We reviewed retrospectively patients` data including: age, sex, duration of the surgical procedure and hospital stay, mortality, intraoperative and postoperative complication rates. RESULTS There were 93 patients (mean age=33.8 years, SD=15.23) in the analyzed group, including 60 men (mean age=33.5 years, SD= 15.07) and 33 women (mean age=33.9 years SD=15.26). The average duration of the surgical procedure was 66 min (SD= 33.15). The average length of hospital stay was 3.38 days (SD=1.62). No intraoperative complications were observed in the analyzed group. Post-operative complication rate was low (6 cases, 6.5%). No mortality was observed. CONCLUSIONS Laparoscopic appendectomy with the application of titanium clips for closure of the appendicular stump is safe, associated with low complication rates and should be considered as a routine technique in everyday surgical practice.

Cecal intubation rates in different eras of endoscopic technological development

Introduction Colonoscopy plays a critical role in colorectal cancer (CRC) screening and has been widely regarded as the gold standard. Cecal intubation rate (CIR) is one of the well-defined quality indicators used to assess colonoscopy. Aim To assess the impact of new technologies on the quality of colonoscopy by assessing completion rates. Material and methods This was a dual-center study at the 2nd Department of Surgery at Jagiellonian University Medical College and at the Specialist Center “Medicina” in Krakow, Poland. The CIR and cecal intubation time (CIT) in three different eras of technological advancement were determined. The study enrolled 27 463 patients who underwent colonoscopy as part of a national CRC screening program. The patients were divided into three groups: group I – 3408 patients examined between 2000 and 2003 (optical endoscopes); group II – 10 405 patients examined between 2004 and 2008 (standard electronic endoscopes); and group III – 13 650 patients examined between 2009 and 2014 (modern endoscopes). Results There were statistically significant differences in the CIR between successive eras. The CIR in group I (2000–2003) was 69.75%, in group II (2004–2008) was 92.32%, and in group III (2009–2014) was 95.17%. The mean CIT was significantly reduced in group III. Conclusions Our study shows that the technological innovation of novel endoscopy devices has a great influence on the effectiveness of the CRC screening program. The new era of endoscopic technological development has the potential to reduce examination-related patient discomfort, obviate the need for sedation and increase diagnostic yields.

Colonoscopy for colorectal cancer screening - is it effective in the hands of a general surgery resident?

INTRODUCTION Colonoscopy is considered to be a gold standard for colorectal cancer (CRC) screening. Endoscopy training is an essential component of general surgery training program. Patients should receive care at the highest level possible, nevertheless residents need to gain experience. The aim of our study was to evaluate the effectiveness of colonoscopy performed by general surgery residents by comparing quality indicators between surgical trainees and consultants MATERIALS AND METHODS: The analysis included 6384 patients aged 40-65 who underwent screening colonoscopy between October 2014 and February 2018. The patients were divided into two groups: group I - patients examined by residents, group II - patients examined by board certified general surgeons. Quality indicators such as cecal intubation rate, adenoma detection rate and patient tolerance scale were compared between the two groups. RESULTS Group I comprised 2268 (35.53%) and group II 4116 (64.47%) patients. The overall cecal intubation rate (CIR) was 95.99%, equal for the both groups (p=0.994). There was no statistically significant difference in adenoma detection rate: 29.30% in residents group and 27.66% among consultants (p=0.203). Patient tolerance for exam was very good (4-point scale) in consultants group in 78.98% of cases and in 75.18% cases among residents (p<0.001). CONCLUSION . Within a proper learning environment general surgery residents are able to perform high quality and effective screening colonoscopy. However, residents need to continue the progress in their technique to improve patient tolerance in order to reach the proficiency of the consultant.

Operative Management of Liver Injury in Polytrauma Patients: Experience of One Trauma Center

Introduction: The liver is one of two most frequent abdominal parenchymal organs involved in trauma. Liver injury (LI) remains an important cause of trauma-related mortality. It is often accompanied by trauma to the other organs. Materials, methods and results: During 9 years in the Provincial Trauma Center, out of 10,191 hospitalized patients, there were 1,702 trauma-related hospitalizations and 393 multiorgan traumas; 217 patients underwent surgery due to multiorgan trauma and coexisting LI. The most frequent coinvolved organs were spleen (83.9%), colon (33.6%), kidney (18.9%), small intestine (18.9%), pancreas (17.5%), gallbladder (16.6%), diaphragm (15.7%), and ileocecal valve (12.9%), with 33.2% of rib fractures and 31.3% of pneumothorax and pneumohemothorax. Grade of liver trauma was assessed according to American Association for the Surgery of Trauma—Organ Injury Scale (AAST-OIS). Fifty-two liver injuries (24,9%) were classified as AAST-OIS grade I, 54 (24.9%) as grade II, 46 (21.2%) as grade III, 41 (18.4%) as grade IV, and 25 (11.5%) as grade V. Patients received laparotomy (n = 205, 94.5%) or thoracolaparotomy (n = 12, 5.5%). Liver injuries were managed with electrocoagulation (n = 64, 29.5%), parenchymal sutures (n = 87, 40.1%), resectional debridement (n = 12, 5.5%), and perihepatic packing (n = 54, 24.9%). Predominance of males and young patients with a mean age of 36 corresponds to accident statistics. Among patients receiving surgery, 88.9% had blunt trauma, with a high predominance of motor vehicle accidents. Conclusion: Liver injuries predominantly follow a blunt abdominal injury. Despite good results of nonoperative management in hemodynamically stable patients with blunt trauma, surgery is still required due to complexity and seriousness of multiorgan injuries. Complex liver injuries require surgery in a well-equipped ORIGINAL ARTICLE 1Consultant, 2General Surgeon, 3,4Professor 1Department of General and Vascular Surgery, Regional Specialist Hospital, Czestochowa, Poland 2Department of General Surgery and Endoscopic, Metabolic and Soft Tissue Tumor Surgery, Jagiellonian University Medical College, Krakow, Poland 3Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland 4Department of General, Oncological and Gastrointestinal Surgery, Jagiellonian University Medical College, Krakow Poland Corresponding Author: Leszek Sulkowski, Consultant Department of General and Vascular Surgery, Regional Specialist Hospital, Czestochowa, Poland, Phone: +48792244177, e-mail: leszeksulkowski@icloud.com 10.5005/jp-journals-10036-1176 and active trauma center, since the mortality rate of surgical management of major liver injuries remains high.

Satisfaction with Life among Dialyzed Patients: A Cantril Ladder Survey

Introduction: End-stage renal disease (ESRD) patients consider hemodialysis (HD) to be an invasive and time-consuming procedure. The total success of HD depends not only on the medical parameters, but also on the patients’ satisfaction with life (SwL). The purpose of this study was to evaluate ESRD patients’ self-reported SwL and compare it with patient-related and dialysis-related factors. Materials and methods: Fifty-nine patients [average age = 63.3 (standard deviation, SD = 12.3), 19 women (32.2%)] were evaluated in the survey. Both the present and expected 5-year SwL scores were evaluated according to the Cantril ladder (CL). Findings: The relations between the present and expected 5-year CL-SwL scores and gender, education, fulfillment of medical recommendations, months on dialysis, type of vascular access, urea reduction ratio (URR), and ultrafiltration (UF) were excluded. The results indicated highly positive relationships between high expected 5-year CL-SwL scores and being in a relationship, having a kidney graft performed in the past, and willingness to have a kidney graft performed in the future. The group of ESRD patients who were not in a relationship, did not undergo kidney grafts in the past, did not want to undergo a kidney graft in the future, and the eldest patients expected their SwL in 5 years to be significantly lower. Practical implications: Cantril ladder is a useful tool for SwL measurements among ESRD patients. The ESRD patients who expected their SwL in 5 years to be significantly lower (who were not in a relationship, did not undergo a kidney graft, did not desire a kidney graft, and the eldest patients) must be provided with psychological support. Originality: This article fills the gap in the ESRD patients’ quality of life assessment. The self-reported present SwL was evaluated along with expected 5-year SwL.