Michał Nowakowski

Doppler guided haemorrhoidal arterial ligation with recto‐anal‐repair (RAR) for the treatment of advanced haemorrhoidal disease

Objective  A modification of Doppler guided haemorrhoidal artery ligation (DGHAL) to include the addition of recto‐anal repair is reported. Preliminary results of function and safety of third and fourth degree haemorrhoidals are given.

Geometry assessment of anal sphincter muscle based on monopolar multichannel surface EMG signals

Anatomical studies on the external anal sphincter (EAS) indicate that superficial muscle fibres are circular at low depth within the anal canal. A more complex geometry of the fibres is documented for increasing depth within the muscle and along the anal canal. Monopolar intra-anal EMG signals recorded using an array of electrodes placed in circular direction have no common mode components if the muscle fibres are circular, with constant depth within the muscle and parallel to the detection array. Thus, the presence of common mode signals may provide indications about the geometry of muscle fibres of EAS. Intra-anal EMG signals were recorded from EAS of 12 subjects using an anal probe carrying three circumferential arrays of 16 electrodes at three depths within the anal canal. Contribution of common mode components in single MUAPs was lower for MUs located superficially in the muscle (Pearson correlation coefficient: R=-0.75, p≪0.001) and at a lower depth within the anal canal (non-parametric one way Kruskal-Wallis ANOVA, Χ=17.3, p<0.001), in line with EAS anatomy. A large contribution of common mode components was found in the interference signal, suggesting that the signal receives contributions from far, large muscles (e.g. puborectalis, glutei).

Defining the histopathological changes induced by nonablative radiofrequency treatment of faecal incontinence - a blinded assessment in an animal model

Nonablative radiofrequency (RF) sphincter remodelling has been used to treat gastro‐oesophageal reflux disease (GERD) and faecal incontinence (FI). Its mechanism of action is unclear. We aimed to investigate the histomorphological and pathophysiological changes to the internal and external anal sphincter (IAS and EAS) following RF remodelling.

Anatomical landmarks for the localization of the greater palatine foramen – a study of 1200 head CTs, 150 dry skulls, systematic review of literature and meta-analysis

Accurate knowledge of greater palatine foramen (GPF) anatomy is necessary when performing a variety of anaesthesiological, dental or surgical procedures. The first aim of this study was to localize the GPF in relation to multiple anatomical landmarks. The second aim was to perform a systematic review of literature, and to conduct a meta‐analysis on the subject of GPF position to aid clinicians in their practice. One‐hundred and fifty dry, adult, human skulls and 1200 archived head computed tomography scans were assessed and measured in terms of GPF relation to other anatomical reference points. A systematic literature search was performed using the PubMed, Embase and Web of Science databases, and a meta‐analysis on the subject of GPF relation to the maxillary molars was conducted. On average, in the Polish population, the GPF was positioned 15.9 ± 1.5 mm from the midline maxillary suture (MMS), 3.0 ± 1.2 mm from the alveolar ridge (AR) and 17.0 ± 1.5 mm from the posterior nasal spine (PNS); 74.7% of GPF were positioned opposite the third maxillary molar (M3). Twenty‐seven studies were included in the systematic review and 23 in the meta‐analysis (n = 6927 GPF). The pooled prevalence of the GPF being positioned opposite the M3 was 63.9% (95% confidence interval = 56.6–70.9%). Concluding, the GPF is most often located opposite the M3 in the majority of the worlds populations. The maxillary molars are the best landmarks for locating the GPF. In edentulous patients the most useful points for approximating the position of the GPF are the AR, MMS and PNS. This study introduces an easy and repeatable classification to reference the GPF to the maxillary molars.

Cost minimization analysis of laparoscopic surgery for colorectal cancer within the enhanced recovery after surgery (ERAS) protocol: a single-centre, case-matched study

Introduction The goal of modern medical treatment is to provide high quality medical care in a cost-effective environment. Aim To assess the cost-effectiveness of laparoscopic colorectal surgery combined with the enhanced recovery after surgery protocol (ERP) in Poland. Material and methods We designed a single-centre, case-matched study. Economic and clinical data were collected in 3 groups of patients (33 patients in each group): group 1 – patients undergoing laparoscopy with ERP; group 2 – laparoscopy without ERP; group 3 – open resection without ERP. An independent administrative officer, not involved in the treatment process, matched patients for age, sex and type of resection. Primary outcome was cost analysis. It was carried out incorporating institutional costs: hospital bed stay, anaesthesia, surgical procedure and equipment, drugs and complications. Secondary outcomes were length of stay (LOS), readmission and complication rate. Results Cost of laparoscopic procedure alone was significantly more expensive than open resection. However, implementation of the ERAS protocol reduced additional costs. Total cost per patient in group 1 was significantly lower than in groups 2 and 3 (EUR 1826 vs. EUR 2355.3 vs. EUR 2459.5, p < 0.0001). Median LOS was 3, 6 and 9 days in groups 1, 2 and 3 respectively (p < 0.001). Postoperative complications were noted in 5 (15.2%), 6 (18.2%) and 13 (39.4%) patients in groups 1, 2, 3 respectively (p = 0.0435). Conclusions In a low medical care expenditure country, minimally invasive surgery combined with ERP can be a safe and a cost-effective alternative to open surgery with traditional perioperative care.

Analysis of Laparoscopic Sleeve Gastrectomy Learning Curve and Its Influence on Procedure Safety and Perioperative Complications

PurposeLaparoscopic sleeve gastrectomy (LSG) has become an attractive bariatric procedure with promising treatment effects yet amount of data regarding institutional learning process is limited.Materials and MethodsRetrospective study included patients submitted to LSG at academic teaching hospital. Patients were divided into groups every 100 consecutive patients. LSG introduction was structured along with Enhanced Recovery after Surgery (ERAS) treatment protocol. Primary endpoint was determining the LSG learning curve’s stabilization point, using operative time, intraoperative difficulties, intraoperative adverse events (IAE), and number of stapler firings. Secondary endpoints: influence on perioperative complications and reoperations. Five hundred patients were included (330 females, median age of 40 (33–49) years).ResultsOperative time in G1–G2 differed significantly from G3–G5. Stabilization point was the 200th procedure using operative time. Intraoperative difficulties of G1 differed significantly from G2–G5, with stabilization after the 100th procedure. IAE and number of stapler firings could not be used as predictor. Based on perioperative morbidity, the learning curve was stabilized at the 100th procedure. The morbidity rates in the groups were G1, 13%; G2, 4%; G3, 5%; G4, 5%; and G5, 2%. The reoperation rate in G1 was 3%; G2, 2%; G3, 2%; G4, 1%; and G5, 0%.ConclusionThe institutional learning process stabilization point for LSG in a newly established bariatric center is between the 100th and 200th operation. Initially, the morbidity rate is high, which should concern surgeons who are willing to perform bariatric surgery.

Comparison of the early effects of out-of-hospital resuscitation in selected urban and rural areas in Poland. A preliminary report from the Polish Cardiac Arrest Registry by the Polish Resuscitation Council

BACKGROUND The chain of survival is a set of most important factors affecting survival after an out-of-hospital cardiac arrest (OHCA). Recognising the difficulties in applying the chain is the key to improving outcomes. Early return of spontaneous circulation (ROSC) after a cardiac arrest is a fundamental factor for patient survival. AIM To assess the degree to which the location of OHCA affects ROSC during resuscitation efforts. METHODS Emergency medical service (EMS) teams filled cardiac arrest forms based on standard (Utstein) guidelines. The registry covered data from January 2013 to May 2014 collected over the area of 23,706 km2 with the population density of 90 persons/km2. This constitutes 7.6% of the area of Poland. The average population density in Poland is 123 persons/km2. RESULTS Over the time period covered by the study, 5185 cases of OHCA were reported. Resuscitation was attempted in 2415 (46.6%) cases. ROSC was achieved in 736 (30.48%) cases, including 374 (32.13%) cases in urban areas and 362 (28.94%) cases in rural areas. This difference was not statistically significant. Compared to urban areas, event witnesses in rural areas were more likely to perform bystander resuscitation and receive instructions from the EMS dispatchers. In the whole study group, cardiac disorders were the most common underlying cause of cardiac arrest (70.35%). The median time of ambulance arrival to the scene was significantly shorter in urban areas compared to rural areas (median time 6 min and 12 min, respectively). CONCLUSIONS No significant relation was found between the location of OHCA and ROSC despite the fact that the time to ambulance arrival was significantly shorter in urban areas. In rural areas, resuscitation was more frequently initiated by the event witnesses. Both in urban and rural areas, OHCA was most commonly due to cardiac causes, and the initial recorded cardiac rhythm was a non-shockable one.

Can surface electromyography improve surgery planning? Electromyographic assessment and intraoperative verification of the nerve bundle entry point location of the gracilis muscle

PURPOSE To verify the precision of surface electromyography (sEMG) in locating the innervation zone of the gracilis muscle, by comparing the location of the IZ estimated by means of sEMG with in vivo location of the nerve bundle entry point in patients before graciloplasty procedure due to fecal incontinence. METHODS Nine patients who qualified for the graciloplasty procedure underwent sEMG on both gracilis muscle before their operations. During surgery the nerve bundle was identified by means of electrical stimulation. The distance between the proximal attachment and the nerve entry point into the muscles body was measured. Both measurements (sEMG and in vivo identification) were compared for each subject. RESULTS On average, the IZ was located 65.5mm from the proximal attachment. The mean difference in location of the innervation zones in each individual was 10±9.7mm, maximal - 30mm, the difference being statistically significant (p=0.017). It was intraoperatively confirmed, that the nerve entered the muscle an average of 62mm from the proximal attachment. The largest difference between the EMG IZ estimation and nerve bundle entry point was 5mm (mean difference 2.8mm, p=0.767). CONCLUSION Preoperative surface electromyography of both gracilis muscles is a safe, precise and reliable method of assessing the location of the innervation zones of the gracilis muscles. The asymmetry of the IZ location in left and right muscles may be important in context of technical aspects of the graciloplasty procedure.

The knowledge of Polish medical students about surgical treatment of obesity

SummaryBackgroundSurgical treatment of morbid obesity is becoming an increasingly important approach for the treatment of this condition. However, knowledge about the possibility of surgical procedures among general practitioners is far from satisfactory. The source of the problem might be due to a lack of information about bariatric surgery in university curriculum.MethodsWe assessed the knowledge of students from four Polish medical universities. The survey was conducted among 468 students, in their sixth (final) year of study. The survey included two parts—the first nine questions assessed of the level of the students’ knowledge about the methods of surgical treatment of obesity, and the following three questions allowed for an evaluation of the amount of information on metabolic surgery provided to students during surgery courses.ResultsThe results demonstrate a low level of knowledge on the possibility of applying metabolic surgery to treat morbid obesity. The students themselves expressed a need to improve their knowledge and favorably assessed the proposition of expanding the curriculum to include more information on the subject of metabolic surgery.ConclusionThe awareness of surgical treatment for morbid obesity among medical students should be improved. The development of an interesting curriculum that is based on current guidelines should be undertaken.

Postoperative complications are associated with worse survival after laparoscopic surgery for non-metastatic colorectal cancer – interim analysis of 3-year overall survival

Introduction Postoperative morbidity after colorectal resections for cancer remains a significant problem. Data on the influence of complications on survival after laparoscopic colorectal resection are still limited. Aim To analyze the impact of postoperative complications on long-term survival after radical laparoscopic resection for colorectal cancer. Material and methods Two hundred and sixty-five consecutive non-metastatic colorectal cancer patients undergoing laparoscopic colorectal resection for cancer were included in the analysis. The entire study group was divided into two subgroups based on the occurrence of postoperative complications. Group 1 included patients without postoperative morbidity and group 2 included patients with complications. The primary outcome was overall survival. Results Median follow-up was 45 (IQR: 34–55) months. Group 1 consisted of 187 (70.5%) patients and group 2 comprised 78 (29.5%) patients. Studied groups were comparable in terms of sex, age, body mass index, ASA class, cancer staging, localization of the tumor and operative time. Patients in group 1 had significantly better overall 3-year survival compared to those with complications (84.9% vs. 69.8%, p = 0.022). Kaplan-Meier curves showed significantly improved survival rates in patients without complications compared with complicated cases. The Cox proportional multivariate model showed that postoperative complications (HR = 2.83; 95% CI: 1.35–5.92; p = 0.0058) and AJCC III (HR = 3.17; 95% CI: 1.52–6.6; p = 0.0021) were independent predictors of worse survival after laparoscopic colorectal cancer surgery. Conclusions Our analysis of interim results after 3 years confirms that complications after laparoscopic colorectal cancer surgery have an impact on survival. For this reason, these patients should be carefully monitored after surgery aiming at early detection of recurrence.