Mirosław Szura

Upper non-variceal gastrointestinal bleeding - review the effectiveness of endoscopic hemostasis methods

Upper non-variceal gastrointestinal bleeding is a condition that requires immediate medical intervention and has a high associated mortality rate (exceeding 10%). The vast majority of upper gastrointestinal bleeding cases are due to peptic ulcers. Helicobacter pylori infection, non-steroidal anti-inflammatory drugs and aspirin are the main risk factors for peptic ulcer disease. Endoscopic therapy has generally been recommended as the first-line treatment for upper gastrointestinal bleeding as it has been shown to reduce recurrent bleeding, the need for surgery and mortality. Early endoscopy (within 24 h of hospital admission) has a greater impact than delayed endoscopy on the length of hospital stay and requirement for blood transfusion. This paper aims to review and compare the efficacy of the types of endoscopic hemostasis most commonly used to control non-variceal gastrointestinal bleeding by pooling data from the literature.

Carbon dioxide insufflation during screening unsedated colonoscopy: a randomised clinical trial.

One of the methods used to reduce pain and discomfort during colonoscopy is insufflation of carbon dioxide instead of air. However, the actual benefit of carbon dioxide insufflation is not unequivocally proven. The aim of the study was to evaluate the advantages of carbon dioxide insufflation during screening colonoscopy. A total of 200 patients undergoing screening colonoscopy between 2010 and 2011 were included in the prospective, randomized study carried out in a surgical referral center. Screening unsedated colonoscopy with either air or carbon dioxide insufflation was performed; patients were randomly assigned to air or carbon dioxide group by means of computer-generated randomization lists. All examinations were performed in an ambulatory setting with standard videocolonoscopes. The main outcomes analyzed were (a) duration of the entire procedure, (b) cecal intubation time, and (c) pain severity immediately, 15, and 60 min after the procedure. Group I included 59 women and 41 men and group II included 51 women and 49 men. The duration of the procedure was circa 10 min in both groups. Pain score values immediately and 15 min after the procedure were similar in both groups (P=0.624 and 0.305, respectively). A lower pain score was observed only after 60 min in patients insufflated with carbon dioxide (1.28 vs. 1.54, P=0.008). No pain reduction was observed in women and in obese patients (BMI>30). Carbon dioxide insufflation during unsedated screening colonoscopy does not decrease the duration of the procedure and appears to reduce pain intensity at 60 min after examination to an extent without clinical significance. The study was registered at ClinicalTrials.gov, number NCT01461564.

Bifocal esophageal and rectal cancer palliatively treated with argon plasma coagulation.

Primary multiple neoplasms make a serious diagnostic and therapeutic problem. They occur infrequently; however, they must be considered in the diagnosis as the detection of simultaneous neoplastic foci requires change of therapeutic approach. We present a case of a patient with synchronous esophageal and rectal cancer treated at the Department of Surgery. Because of the advanced neoplastic process and concomitant diseases, the patient was qualified for minimally invasive procedures with recanalization using argon plasma coagulation to avoid injuring palliative procedures and to improve quality of life. The patient died of the primary disease without symptoms of gastrointestinal tract obstruction.

Biliary Polyunsaturated Fatty Acids and Telocytes in Gallstone Disease.

It has been reported that intake of ω-3 polyunsaturated fatty acids (PUFAs) reduces the risk of coronary heart disease. It also influences bile composition, decreasing biliary cholesterol saturation in the bile of patients with gallstones. In addition to bile composition disturbances, gallbladder hypomotility must be a cofactor in the pathogenesis of cholelithiasis, as it leads to the prolonged nucleation phase. Our current knowledge about gallbladder motility has been enhanced by the study of a population of newly described interstitial (stromal) cells—telocytes (TCs). The purpose of this study was to determine whether TC loss, reported by our team recently, might be related to bile lithogenicity, expressed as cholesterol saturation index or the difference in biliary PUFA profiles in patients who suffer from cholecystolithiasis and those not affected by this disease. We determined biliary lipid composition including the fatty acid composition of the phospholipid species in bile. Thus, we investigated whether differences in biliary fatty acid profiles (ω-3 PUFA and ω-6 PUFA) in gallbladder bile may influence its lithogenicity and the quantity of TCs within the gallbladder wall. We conclude that the altered PUFA concentrations in the gallbladder bile, with elevation of ω-6 PUFA, constitute important factors influencing TC density in the gallbladder wall, being one of the possible pathophysiological components for the gallstone disease development. This study established that altered bile composition in patients with cholelithiasis may influence TC quantity within the gallbladder muscle, and we concluded that reduction in TC number may be a consequence of the supersaturated bile toxicity, while some other bile components (ω-3 PUFA, glycocholic, and taurocholic acids) may exert protective effects on TC and thus possibly influence the mechanisms regulating gallbladder and extrahepatic bile duct motility. Thus, ω-3 PUFA may represent a possible option to prevent formation of cholesterol gallstones.

Alternative staging of regional lymph nodes in gastric cancer

The TNM pN stage based on the number of metastatic lymph nodes is an independent prognostic factor in gastric cancer. Many studies have highlighted the phenomenon of stage migration and problems in comparing groups of patients with different numbers of total lymph nodes harvested within TNM staging. The current version of UICC/AJCC and JGCA TNM classifications postulates a minimal number of 16 lymph nodes as the base for N stage determination. Alternative systems such as lymph node ratio (LNR), positive to negative lymph node ratio (PNLNR), and LOGODDS (or LODDS), were implemented to increase the quality of LN assessment. These methods have reached the background in the literature, but to date no standard approach according to the cut-offs for the stages has been implemented. LOGODDS is the method that most reflects the number of harvested lymph nodes. The rationale for alternative staging methods, their correlations, and limitations are presented.

Elevated level of some chemokines in plasma of gastric cancer patients

Introduction Gastric cancer is one of the most common cancer-related causes of death. This is mainly due to the lack of good noninvasive method/biomarkers suitable for early-tumour diagnosis and planning of further therapy modalities. Chemokines play an important role in cancer progression and metastasis formation. In gastric cancer patients, clinical relevance of CXCL12 and CCL5 level has been postulated. Aim of the study Efforts were undertaken to examine whether expanded chemokine range may be relevant for evaluation of preoperative staging of gastric cancer patients. Material and methods Plasma from 66 gastric cancer patients and 11 healthy controls was obtained, and CCL2, CCL3, CCL4, CCL5, CXCL8, CXCL9, and CXCL10 levels were determined by flow cytometry FlexSet system. Results In gastric cancer patients’ plasma an increased level of CCL2, CCL4, CCL5, CXCL8, CXCL9, and CXCL10 was observed. In the case of CCL2, CXCL9, and CXCL10, the chemokine levels correlated with advanced (III and IV in TNM classification) disease stage. In the case of CCL4, CCL5, and CXCL8, elevated levels were observed in all cancer patients in comparison to healthy donors. Conclusions The accuracy of preoperative diagnosis in gastric cancer may include the monitoring of a wide range of chemokines in patients’ plasma. Increased levels of chemokines may warn that the disease is more advanced than conventional diagnostic procedures suggest.

Practical Approach to Inguinal Hernia Treatment -Guidelines of the Association of Polish Surgeons

Department of General, Oncological and Gastroenterological Surgery, University Hospital, Collegium Medicum Jagiellonian University in Cracow1 Kierownik: prof. dr hab. J. kulig Department of Anatomy, Collegium Medicum Jagiellonian University in Cracow2 Kierownik: prof. dr hab. J. Walocha 2nd Department of General Surgery, University Hospital, Collegium Medicum Jagiellonian University in Cracow3 Kierownik: prof. dr hab. A. budzyński Department of General and Vascular Surgery, Ceynowa Hospital in Wejherowo4 Kierownik: dr n. med m. Witzling 2nd Department of General, Gastroenterological and Digestive Tract Surgery, Medical University in Lublin5 Kierownik: prof. dr hab. g. Wallner

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.

How to improve the adenoma detection rate in colorectal cancer screening? Clinical factors and technological advancements

Introduction Colonoscopy has been widely regarded as the gold standard in colorectal cancer (CRC) screening. Within recent years different endoscopic imaging techniques have been introduced to improve the quality of colonoscopy. The adenoma detection rate (ADR) is the single most important quality indicator for colonoscopy. The aim of this study was to evaluate the quality of CRC screening expressed by ADR in two different eras of endoscopic technology advancement. Material and methods We conducted a dual-center study that enrolled 24 055 patients, who underwent colonoscopy as part of a national screening program. Patients were sorted into two groups according to the advancement of endoscopic equipment used for colonoscopic examination: group I – 10 405 patients examined between 2004 and 2008 (standard electronic endoscopes); group II – 13 650 patients examined between 2009 and 2014 (modern endoscopes). The ADR in two different eras and the impact of endoscopic novelties were determined. Results The ADR in group I was 29.14%, in group II 31.73% (p < 0.001). The overall ADR was 30.88% – 38.80% and 25.95% (p < 0.001) for the male and female patients, respectively. The mean adenoma number per colonoscopy was 0.366 (95% CI: 0.357–0.375; p < 0.001), 0.337 (0.321–0.352) and 0.380 (0.369–0.392) for patients in group I and group II, respectively. Conclusions Our study shows that technological innovation, novel endoscopy devices and diagnostic techniques improve the quality in CRC screening by increasing the ADR. However, we need to determine which of the technologies are supreme to achieve excellence in colorectal cancer screening.