Radosław Pach

The impact of immunostimulating nutrition on infectious complications after upper gastrointestinal surgery: a prospective, randomized, clinical trial.

Background and Aim:Immunomodulating nutrition is supposed to reduce the number of complications and lengthen of hospital stay during the postoperative period in patients after major gastrointestinal surgery. The aim of the study was to assess the clinical effect of immunostimulatory enteral and parenteral nutrition in patients undergoing resection for gastrointestinal cancer in the group of well-nourished patients. Material and Methods:Between June 1, 2001, and December 31, 2005, a group of 214 well-nourished patients was initially assessed (150 men, 64 women, mean age 61.2 years) to participate in the study. Nine patients were subsequently excluded and the remaining 205 subjects were randomly assigned in a 2 × 2 factorial design into 4 study groups, ie, standard enteral nutrition (n = 53), immunomodulating enteral nutrition (n = 52), standard parenteral nutrition (n = 49), and immunomodulating enteral nutrition (n = 51). The study was designed to test the hypothesis that immunonutrition and enteral nutrition would reduce the incidence of infectious complications after upper gastrointestinal surgery; the secondary objective of the study was to evaluate the effect of nutritional intervention on overall morbidity and mortality rates, and hospital stay. The study was registered in the Clinical Trials Database–number NCT 00558155. Results:The overall morbidity rate was 33% and the incidence of individual complications was comparable between all groups. Infectious complications occurred in 26 of 102 patients given standard diets and in 22 of 103 patients receiving immunomodulatory formulas (odds ratio 0.81; 95% CI, 0.43–1.50). There were no significant differences between infectious complications in patients using parenteral nutrition (22 of 100 patients) and parenteral formulas (26 of 105, odds ratio 1.14; 95% CI, 0.61–2.14). Neither immunostimulating formulas nor enteral feeding significantly affected secondary outcome measures, including overall morbidity and mortality rates, and hospital stay. Conclusions:Our study failed to demonstrate any clear advantage of routine postoperative immunonutrition in patients undergoing elective upper gastrointestinal surgery. Both enteral and parenteral treatment options showed similar efficacy, tolerance, and effects on protein synthesis. Parenteral nutrition composed according to contemporary rules showed similar efficiency to enteral nutrition. However, because of its cost-efficiency, enteral therapy should be considered as the treatment of choice in all patients requiring nutritional therapy.

Ludwik Rydygier — contributor to modern surgery

Modern surgery is usually considered to have begun in nineteenth century Europe. One of the most famous contributors to gastric cancer surgery was the Polish surgeon Ludwik Rydygier, born in 1850. He initiated new methods in several fields, such as gastrointestinal surgery, orthopedics, gynecology, and urology. He was the second surgeon in the world to perform an antral resection, which he carried out on November 16, 1880. The patient, a 64-year-old man, suffered from pyloric cancer and died 12 hours after the procedure as a result of postoperative shock. The next pyloric resection was performed by Billroth in Vienna in 1881. In the nineteenth century few gastric resections were performed for peptic ulcer. The first successful antral resection for gastric ulcer penetrating to the pancreas was also performed by Ludwik Rydygier, in 1881. For many years Rydygier advocated resection in the treatment of gastric ulcers, although it was considered too dangerous for benign disease. He eventually proposed four indications for gastric resection: antral cancer, gastric ulcer, perforated gastric ulcer, and bleeding ulcers. Another operation performed for the first time by Ludwik Rydygier was gastroenterostomy, in a patient with a duodenal ulcer. In the following years other types of partial gastric resection and total gastrectomy were introduced. In 1992 the Ludwik Rydygier Association was founded in Krakow to commemorate the achievements of and pay tribute to this great surgeon. The Eighth International Gastric Cancer Congress will take place in 2009 in Krakow, where Ludwik Rydygier built a new surgical clinic in 1889.

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.

Abdominal Ultrasonography in Detecting and Surgical Treatment of Pancreatic Carcinoma

THE AIM OF THE STUDY was to asses the clinical value of percutaneous abdominal ultrasonography in diagnosis, staging and surgical treatment of patients with pancreatic carcinoma. MATERIAL AND METHODS Prospective clinical trial on diagnostic accuracy of percutaneous abdominal ultrasonography was conducted in 409 consecutive patients with pancreatic cancer which were operated on at the I Dept. of General Surgery in Cracow between 2000 and 2010. RESULTS Diagnostic accuracy of percutaneous abdominal ultrasonography in pancreatic cancer was 91,1%. The accuracy in detecting different stages of local advancement according to TNM classification was assessed respectively 92.3%-T1, 91.3%-T2, 89.4%-T3, 92.1%-T4, a whole T1-T4 on 91.3%. Diagnostic accuracy of percutaneous abdominal ultrasonography in diagnosis of metastasis to lymph nodes, vascular infiltration, and resectability was respectively 80.7%, 86%, 91.4%. CONCLUSIONS Percutaneous abdominal ultrasonography has high diagnostic accuracy in diagnosis, staging and predicting surgical treatment of patients with pancreatic carcinoma.

Prognostic Implications of Expression Profiling for Gemcitabine-Related Genes (hENT1, dCK, RRM1, RRM2) in Patients With Resectable Pancreatic Adenocarcinoma Receiving Adjuvant Chemotherapy

Objectives The aim of this study was to examine the relevance of expression profiling of 4 genes involved in the action of gemcitabine among patients with pancreatic ductal-cell adenocarcinoma (PDAC). Methods A group of 100 patients who underwent pancreatic resections for PDAC and received adjuvant chemotherapy with gemcitabine between 2007 and 2010 was identified. Expression of mRNAs for human equilibrative nucleoside transporter 1 (hENT1), ribonucleotide reductase subunits (RRM1, RRM2), and deoxycytidine kinase (dCK) was examined by quantitative real-time polymerase chain reaction, normalized to glyceraldehyde-3-phosphate dehydrogenase (GAPDH), and dichotomized into groups of low and moderate/high expression levels grouped by tertiles. Results Significantly better median survival times were found for high/moderate expression levels of hENT1 (27.9 vs 12.4 months, P = 0.001) and dCK (19.7 vs 10.5 months, P = 0.003), as well as low expression of RRM1 (23.4 vs 11.4 months, P = 0.027). A Cox proportional hazards model identified low expression of hENT1 (hazard ratio [HR], 3.38; 95% confidence intervals [CI], 2.28–10.50) and dCK (HR, 2.24; 95% CI, 1.63–3.39), and high/moderate levels of RRM1 (HR, 1.65; 95% CI, 1.23–2.45) as negative prognostic factors. Conclusions Expression of hENT, RRM1, and dCK genes provides important prognostic information for PDAC patients treated with adjuvant gemcitabine.

Ultrasonography in the Diagnosis of Acute Abdominal Disorders

The possibility of the rapid implementation of real-time imaging and small requirements concerning the positioning and preparation of the patient render the ultrasound examination an increasingly performed method in case of patients diagnosed during emergency service. The surgeon performing the examination obtains immediate information supplementing the physical examination and medical history, enabling differential diagnosis and the implementation of proper treatment.It has been shown that an ultrasound examination performed during emergency service in case of a patient with abdominal pain of unknown cause increases the diagnostic accuracy and reliability of the diagnosis (1, 2). The ultrasound examination increases the diagnostic accuracy in case of patients with acute abdominal right upper quadrant pain (3). Still no significance was established concerning the ultrasound diagnosis of appendicitis-the value of the ultrasound examination depends on the experience of the examining physician (4), although several publications reported the efficiency of the method (5, 6). The ultrasound examination performed in the ER facilitates the decision concerning the need for surgical intervention (7). Indications for abdominal ultrasound in the ER are as follows (8): – blunt abdominal trauma, – suspicion of peritoneal bleeding, – suspicion of abdominal aortic aneurysm complications, – suspicion of acute pancreatitis,

History and future Directions in Ultrasonography

The development of ultrasonography would not be possible without the earlier findings concerning ultrasounds. As early as the thirteenth century Lazzarro Spalanzani observed that bats use hearing rather than sight, considering location in space. In 1938, Donald Griffin described the phenomenon of echolocation in these mammals. In 1880, Pierre and Jaques Curie showed the piezoelectric phenomenon consisting in the creation of an electrical charge inside the crystal quartz or Seignette’s salt (sodium and potassium tartrate), under pressure (1). The name of the phenomenon is derived from the Greek language meaning ‘to push’. The Curie brothers also observed the inverse piezoelectric crystal vibration phenomenon involving the effect of an external electrical field. Piezoelectricity is only present in the crystals, being elementary cells, which do not have a center of symmetry, such as quartz crystals. In the first half of the 20-th century the sonar was constructed-a device using sound waves to track and classify mobile and immobile submerged objects. The first idea for such a device was patented by an English meteorologist, Lewis Richardson in 1912, and one year thereafter, by Alexander Behm in Germany. In 1941, Sproule and Firestone working independently, constructed a device that used ultrasounds to detect defects in the hull of vessels (1). The designed ‘supersonic reflectoscope” by Firestone was soon adapted for the use in shipbuilding. Christian Andreas Doppler (fig. 1), an Austrian physicist and mathematician was the first in 1842 who described the color change under the influence of movement in the system of submerged stars. This effect consists in the development of frequency differences sent by the source and recorded by the observer, who moves in relation to the source, being applied in ultrasonography. Shigeo Satomura was the pioneer of Doppler ultrasonography, a physicist from the Univer-

Rationale and feasibility of mucin expression profiling by qRT-PCR as diagnostic biomarkers in cytology specimens of pancreatic cancer

BACKGROUND Aberrantly expressed mucin glycoproteins (MUC) play important roles in pancreatic ductal adenocarcinoma (PDAC), yet their use as a diagnostic aid in fine-needle aspiration biopsy (FNAB) is poorly documented. The aim of this study was to investigate the rationale and feasibility of mucin (MUC1, MUC2, MUC3, MUC4, MUC5AC, and MUC6) expression profiling by RT-PCR for diagnostic applications in cytology. METHODS Mucin expression was examined by RT-PCR and immunohistochemistry in specimens resected from patients with pancreatic (n = 101), ampullary (n = 23), and common bile duct (n = 10) cancers and 33 with chronic pancreatitis. Furthermore, mucin profiling by RT-PCR was prospectively compared in surgical and biopsy specimens of 40 patients with pancreatic solid tumours qualified for FNAB prior to surgery. RESULTS A logistic regression model to distinguish PDAC from chronic pancreatitis using RT-PCR profiling included MUC3, MUC5AC, and MUC6. The same set of mucins differentiated ampullary and bile duct cancers from chronic pancreatitis. AUCs for the ROC curves derived from the two models were 0.95 (95%CI 0.87-0.99) and 0.92 (95%CI 0.81-0.98), respectively. The corresponding positive likelihood ratios were 6.02 and 5.97, while the negative likelihood ratios were 0.10 and 0.12. AUCs of ROC curves obtained by RT-PCR and immunohistochemistry demonstrated that both analytical methods were comparable. Surgical and cytological samples showed significantly correlated values of ΔCt for individual mucins with the overall Pearsons correlation coefficient r = 0.841 (P = 0.001). CONCLUSIONS Mucin expression profiling of pancreatic cancer with RT-PCR is feasible and may be a valuable help in discriminating malignant lesions from chronic pancreatitis in FNAB cytology.

The Impact of Postoperative Enteral Immunonutrition on Postoperative Complications and Survival in Gastric Cancer Patients – Randomized Clinical Trial

ABSTRACT Background: Immunomodulating enteral nutrition in the perioperative period may reduce postoperative complications in cancer patients. Little is known if this effect translates to the better survival. The aim of study was to assess the impact of postoperative immunomodulating enteral nutrition on postoperative complications and survival of gastric cancer patients. Methods: A group of 98 gastric cancer patients was randomly assigned for postoperative immunomodulating enteral nutrition n = 44 (Reconvan, Fresenius Kabi, Bad Homburg, Germany), or standard enteral nutrition n = 54 (Peptisorb, Nutricia, Schipol, The Netherlands). Postoperative complications, mortality, 6-mo and 1-yr survival were analyzed. Results: The overall postoperative morbidity did not differ between the groups. The rate of pulmonary complications (excluding pneumonia) was significantly lower in immunomodulation group (0% vs 9.3%, p = 0.044), as well as 60-day mortality (0% vs. 11.1%, p = 0.037). There was no difference in 6-mo and 1-yr survival between the groups. Conclusions: Postoperative immunomodulating enteral nutrition may reduce respiratory complications and postoperative mortality in comparison to standard enteral nutrition. Despite this effect, it did not improve 6-mo and 1-yr survival in immunomodulation group. Probably the beneficial effect of immunomodulating enteral nutrition is too weak to be significant in such a number of patients.

Effectiveness of mesh hernioplasty in incarcerated inguinal hernias

Introduction The use of mesh is still controversial in patients undergoing emergency incarcerated hernia repair, mostly because of potential infectious complications. Aim The main aim of this study was to assess the efficacy of tension-free methods in treating incarcerated inguinal hernias (IIH), with and without intestine resection. The secondary aim was to establish an algorithm on how to proceed with incarcerated hernias. Material and methods A retrospective analysis of patients who underwent surgery due to an inguinal hernia at the First Department of General Surgery Jagiellonian University Medical College in Krakow, in the period 1999–2009. Operative methods included Lichtenstein, Robbins-Rutkow and Prolene Hernia System. The rate of postoperative complications was compared in patients who underwent elective and emergency surgery. Results The study group consisted of 567 patients (546 male) age 19–91 years. In this group 624 hernias were treated using the three tension-free techniques – 295 using the Lichtenstein method, 236 using PHS and 93 using the RR technique. Out of the 561 operations 89.9% were elective. No correlation (p > 0.05) was found between the type of surgery and such complications as postoperative pain duration and intensity, fever, micturation disorders, wound healing disorders, testicle hydrocoele, testicle atrophy, spermatic cord cyst, sexual dysfunction, wound dehiscence, wound suppuration, seroma, haematoma and hernia recurrence. Conclusions Mesh repairs can be safely performed while operating due to an IIH. The use of a synthetic implant, in emergency IIH repairs, does not increase the rate of local complications. Synchronous, partial resection of the small intestine, due to intestinal necrosis, is not a contraindication to use mesh.