Marek Dobosz

Lichtenstein inguinal hernioplasty using butyl-2-cyanoacrylate versus sutures. Preliminary experience of a prospective randomized trial.

The Lichtenstein hernioplasty has become a popular method in inguinal hernia repair. This study compared two methods of mesh fixation and wound closure. Forty-six men with unilateral inguinal hernia were randomized into two groups. In the control group polypropylene mesh was anchored with 3/0 Dexon sutures, fascia and skin were closed with sutures 3/0 Dexon and 3/0 Monosof. In the study group, the mesh was secured with butyl-2-cyanoacrylate adhesive and the fascia and skin were also glued with the adhesive. The costs of materials, duration of the operation, amount of postoperative analgesic doses, pain score after the first and the 7th postoperative day and return to daily activity were recorded. No recurrences during the mean follow-up of 4.7 months were observed and the cosmetic effect was very good. In the study group with tissue adhesive the patients had significantly lower pain score after the first postoperative day and had a tendency to require less analgetic doses and to return earlier to their daily activity. Duration of the operation was similar in both groups. The cost of sutures and tissue adhesive used in both procedures was comparable. The use of tissue adhesive in mesh fixation and wound closure seems to be a promising technique in Lichtenstein hernia repair.

Does Nitric Oxide Protect from Microcirculatory Disturbances in Experimental Acute Pancreatitis in Rats

The aim of the study was to investigate the potential role of nitric oxide (NO) on the microcirculation in experimental acute pancreatitis in rats. Twenty-five rats were divided into the following groups: group A (5 rats) = control; group B (5 rats) = acute pancreatitis induced by retrograde taurocholate infusion into the pancreatobiliary duct without treatment; group C (5 rats) = acute pancreatitis treated with the NO donor L-arginine; group D (5 rats) = acute pancreatitis treated with the NO synthase inhibitor N-nitro-L-arginine (L-NNA); group E (5 rats) = without pancreatitis receiving L-NNA. The animals were observed throughout 4 h. The microcirculatory values of the pancreas, liver, colon, stomach and kidney were measured by means of laser Doppler flowmetry. Three animals of group D died after the third hour of the experiment. In rats with pancreatitis, a rapid decrease in microcirculatory values was observed. The most pronounced drop in capillary blood flow within all the organs was observed in rats treated with the NO synthase inhibitor L-NNA, L-arginine administration in rats with acute pancreatitis slightly improved the microcirculatory values, although the improvement was significant in colon perfusion only. We conclude that NO may have a beneficial influence on the capillary organ perfusion in acute pancreatitis. The administration of an NO synthase inhibitor seems to have a detrimental effect on acute pancreatitis.

Management of acute pancreatitis (AP) – Polish Pancreatic Club recommendations

The presented recommendations concern the current management of acute pancreatitis. The recommendations relate to the diagnostics and treatment of early and late phases of acute pancreatitis and complications of the disease taking into consideration surgical and endoscopic methods. All the recommendations were subjected to voting by the members of the Working Group of the Polish Pancreatic Club, who evaluated them every single time on a five-point scale, where A means full acceptance, B means acceptance with a certain reservation, C means acceptance with a serious reservation, D means rejection with a certain reservation and E means full rejection. The results of the vote, together with commentary, are provided for each recommendation.

Pancreatic duct diversity.

Objectives: The formation of the pancreatic duct system is the result of the fusion of 2 embryonic buds, the ventral and dorsal primordia. Frequently, this fusion process is localized in the pancreatic head; variations, however, may account for the structural diversity of the duct system. Pancreatic duct anomalies and diversity of body and tail are thought to be casuistic. Methods: Ninety-nine consecutive adult autopsies with reference to macroscopic anomalies in the distal part of the gland were evaluated. Pancreatograms were performed after large duodenal papilla cannulation. Ducts parallel to gland axis with a diameter of at least one third of the main pancreatic duct at the junction point and aberrant duct with different shapes and/or abnormal third-degree ductuli architecture were noted. Results: Our study revealed a 9.9% frequency of main pancreatic duct diversity in the pancreatic corpus and tail. Eleven atypical ducts were visible, 9 cranially and 2 caudally from the main pancreatic duct. Conclusions: The pancreatic duct system in the body and the tail presents abnormal configuration not described in the past.

Prospective Evaluation of the Defecatory Functional Results in Patients Following Aorto-Aortic Reconstruction Surgery for an Abdominal Aortic Aneurysm

PurposeAnterior rectal resections have been associated with postoperative bowel function abnormalities, a condition defined as anterior resection syndrome. Autonomic denervation could be one of the possible mechanisms underlying this complication. Damage to the preaortic tissue containing autonomic nervous plexus during abdominal aortic reconstruction surgery may affect the anorectal defecation function.MethodsThe anorectal function was prospectively studied in 22 patients undergoing abdominal aortic reconstruction surgery. The patients were examined preoperatively and 6 months postoperatively by symptom-specific questionnaires.ResultsPostoperatively, the patients showed no significant impairment of the anorectal functions in both constipation- and fecal incontinence-specific questionnaires. Self-estimation of the defecatory function was slightly lower compared with preoperative scores.ConclusionAn injury to the intermesenteric, inferior mesenteric, and superior hypogastric plexuses does not significantly influence the defecatory functions in patients following abdominal reconstruction surgery for an abdominal aortic aneurysm.

A case of traumatic rupture of the pancreas. Combined surgical and endoscopic management.

Traumatic rupture of the pancreas is a rare and difficult diagnostic and therapeutic problem. The authors present a case of traumatic rupture of the pancreas (grade IV on AAST scale) where concurrent endoscopic and surgical management was used.

Multifocal Extra-Adrenal Paraganglioma – Case Report

Paraganglioma is a rare neoplasm originating from extra-adrenal pheochromocytes of the sympathetic and parasympathetic nervous system. It is usually benign and the treatment method of choice is a complete resection of the tumour. The authors present a case of 66-year-old female patient with a multifocal benign retroperitoneal paraganglioma, which was completely removed during surgery.

Preoperative fasting - is it really necessary?

For over several decades of the twentieth century preoperative fasting was one of the inviolable canons of medicine. The recom-mended time to refrain from eating and fluids was at least 6-8 hours, however, in clinical practice it lasted 12 hours and more. Thanks to the use of medicine based on reliable clinical studies (evidence-based medicine), we observed the ease of restrictive guidelines and changes in the recommendations of leading scientific societies. However, their introduction into clinical practice is still not widespread and encounters numerous problems. The aim of the study was to answer the question whether preoperative fasting is re-ally necessary, based on available literature data and our own experience. Fasting and surgical stressSurgery, similarly to trauma or acute stress induces a multidirectional neuroendocrine response, which significantly influences the body metabolism (1). As a result, there is a burst of hormones of the hypothalamus-pitu-itary system, and ensuing increase of anti-insulin hormones (catecholamines, cortisol, growth hormone, glucagon), which results in hyperglicemia. This leads to the mobilization of substrates (through gluconeogenesis, gly-cogenolysis and proteolysis) and reduction of peripheral tissues response to insulin (2). This is a crucial mechanism of adaptation, where in spite of normal or elevated insulin levels, its effect on muscle tissue (to a lesser extent adipose tissue) is reduced. This natural mech-anism known as insulin-resistance occurs in response to trauma, stress, and starvation. It enables to provide and maintain the supply of the most important energy substrate for the brain-glucose, unfortunately, at the expense of shifting homeostasis towards catabolism and increased proteolysis. In situations when substrates supply is limited, insulin-resistance might ensure survival. However, in case of a patient after uncomplicated surgery this phe-nomenon seems less beneficial, and in light of existing data must be regarded as downright harmful (3, 4).Physiologically, the human body is sub-jected to a daily hormonal cycle, where the catabolic activity of cortisol predominates, both at night and in the morning, while during the day the anabolic effect of insulin is more pro-nounced. Physiologically, the morning meal enables to switch the metabolism from night fasting to morning satiety and increased insu-linemia (60-70 µU/ml), with additional sensi-tization of peripheral tissues to its activity (3). Historical recommendationsIn contrast to the above-mentioned consid-erations, one may observe the traditional method of preparing for surgery-fasting, which was already recommended in 1848, that is two years after the introduction of general anes-thesia. This was in response to the first report concerning a young female patient, sated be-

Calcifiying fibrous pseudotumor of the small bowel mesentery - case report.

Calcifiyng fibrous pseudotumor (CFPT) is a benign mesenchymal tumor diagnosed in children and young adults, located in the subcutaneous tissue of the trunk and limbs. Its intraabdominal localization is a unique rarity. The Authors of the study presented a case of a 48-year old female patient with an accidentally diagnosed small bowel mesentery tumor during surgery.

Surgical Morphology of the Pancreatic Isthmus

Background: Pancreatic isthmus method anastomosis following pancreatic resection is an important factor of postoperative fistula formation. While the anatomy and vascular supply of the pancreatic head have been studied in detail, little is known about the morphology of the pancreatic isthmus. The authors determine the anatomy and morphology of the pancreatic isthmus. Methods: 99 consecutive cadaveric pancreatic specimens were taken during standard autopsy. Organs were transected at the isthmus and pancreatograms and microscopic specimens of the transection plane were analyzed. Results: The mean size of the Wirsung duct at the isthmus was 2.89 mm (±0.87 mm, from 1.4 to 6 mm). The main pancreatic duct was located approximately in the middle of the pancreatic cross-section plane in almost all specimens. The total number of second-degree pancreatic ducts visible on pancreatograms within the isthmus was 1.77 (±1.00, from 0 to 4) and 1.83 (±1.4, from 0 to 5) on microscopic analysis. Conclusions: The presence of second-degree pancreatic ducts at the transection site might favor the use of a pancreaticoenteric anastomosis with stump invagination to reduce the risk of anastomotic leakage.