Tomas Poškus

Initial results of the National Colorectal Cancer Screening Program in Lithuania.

The aim of the present study was to review the National Colorectal Cancer Screening Program (the Program) in Lithuania according to the criteria set by the European Union. In Lithuania, screening services are provided free of charge to the population. The National Health Insurance Fund (NHIF) reimburses the institutions for performing each service; each procedure within the Program has its own administrative code. All the information about the performance of the Program is collected in one institution – the NHIF. The results of the Program were retrieved from the database of NHIF from the start of the Program from 1 July 2009 to 1 July 2012. Descriptive analysis of epidemiological indicators was carried out. Results were compared with the references in the guidelines of the European Union for quality assurance in colorectal cancer (CRC) screening and diagnosis. Information service [which involves fecal immunochemical test (FIT)] was provided to 271 396 of 890 309 50–74-year-old residents. The screening uptake was 46.0% over 3 years. During this period, 19 455 (7.2%) FITs were positive and 251 941 (92.8%) FITs were negative. Referral for colonoscopy was performed in 10 190 (52.4%) patients. Colonoscopy was performed in 12 864 (66.1%) patients. Colonoscopy did not indicate any pathological findings in 8613 (67.0%) patients. Biopsies were performed in 4251 (33.0%) patients. The rate of high-grade neoplasia reported by pathologists was 3.9%; the rate of cancer was 3.1% of all colonoscopies. The rate of CRC detected by the Program was 0.2%. The CRC screening program in Lithuania meets most of the requirements for standardized CRC screening programs. The invitation coverage and rate of referral for colonoscopy after positive FIT should be improved.

Improved perioperative care is associated with improved long-term survival in colorectal cancer

PurposeTo compare perioperative colorectal cancer care and survival in patient cohorts operated in 2005 and in 2010 in Lithuania.MethodsComparative observational cohort study was performed. The study was conducted in the three Lithuanian cancer hospitals. Patients, who underwent curative surgery for colorectal cancer in 2005 and 2010, were included. Demographic characteristics, distribution of the tumors, preoperative diagnostics and staging, surgical treatment, the quality of pathological examination, morbidity, and mortality were analyzed. One- and 5-year overall survival data were compared between the groups.ResultsColorectal cancer diagnostics and treatment improved from 2005 to 2010 significantly. The disease was identified as stage III–IV for 45 vs. 48% of the patients; however, computed tomography staging scan was performed only for 5.9 vs. 17.8% in 2005 and 2010, respectively. Laparoscopic operations were performed 1.5 vs. 10.5% and abdominoperineal resections—42.7 vs. 31.7% in 2005 and 2010, respectively. The number of harvested lymph nodes was mentioned in 55.8 vs. 97.7% of the cases, whereas more than 12 lymph nodes were examined in 18 vs. 66.6% of cases after histological examination. The overall 5-year survival was 52.1 vs. 63.1% (p < 0.0001), while the 5-year survival of the patients with stage IV of disease was 4.2 vs. 17.8% in 2005 and 2010, respectively.ConclusionPreoperative investigation, surgical treatment, pathological examination, and postoperative course are associated with improved overall survival in colorectal cancer patients, undergoing curative surgery in the resource-limited settings.

Is acute appendicitis still misdiagnosed

Abstract Objective The optimal diagnostics and treatment of acute appendicitis continues to be a challenge. A false positive diagnosis of appendicitis may lead to an unnecessary operation, which has been appropriately termed negative appendectomy. The aim of our study was to identify the effectiveness of preoperative investigations in preventing negative appendectomy. Methods A retrospective study was performed on adult patients who underwent operation for suspected acute appendicitis from 2008 to 2013 at Vilnius University Hospital Santariskiu Klinikos. Patients were divided into two groups: group A underwent an operation, where appendix was found to be normal (non-inflamed); group B underwent an appendectomy for inflamed appendix. Groups were compared for preoperative data, investigations, treatment results and pathology findings. Results 554 patients were included in the study. Preoperative laboratory tests results of hemoglobin, hematocrit concentrations and white blood cell count were significantly higher in group B (p<0.001). Ultrasonography was performed for 78 % of patients in group A and 74 % in group B and did not provide any statistically significant results. Comparing Alvarado score results, there were more patients with Alvarado score less than 7 in group A than in group B. In our large series we could find only four independent risk factors, and they could only account for 24 % of cases. Conclusions In summary, acute appendicitis is still often misdiagnosed and the ratio of negative appendectomies remains rather high. Additional investigations such as observation and computed tomography should be used to prevent this.

C-reactive protein is a predictor of complications after elective laparoscopic colorectal surgery: five-year experience

Introduction With the development and improvement of laparoscopic surgery, procedures have become common. However, post-operative complications occur when patients are released from hospital. These complications increase patients’ morbidity and mortality. They also lead to re-hospitalization, an extended recovery period, and an increase in the cost of treatment. Aim To evaluate and determine the prognostic properties of C-reactive protein in the early diagnosis of postoperative complications after a laparoscopic colon resection. Material and methods The prospective study included patients who underwent laparoscopic colorectal surgery in 2010–2014. The patients were divided into two groups – uncomplicated ones and those with complications. C-reactive protein concentrations in their blood serum were measured on the 2nd, 4th and 6th day after surgery. Logistic regression analysis was used to evaluate the relation between C-reactive protein values measured on the 2nd, 4th and 6th postoperative day and related complications. Receiver operating characteristic curves were used to determine the sensitivity and specificity of each C-reactive protein value measured on the 2nd, 4th and 6th postoperative day. Results One hundred and six patients were included in the trial; 14 of them had complications. On the second day, a C-reactive protein cut-off value of 88.6 mmol/l provided the highest sensitivity and specificity for predicting evolving complications, being 71.4% and 84.8% respectively (p = 0.003). The significant predictive cut-off value decreases and becomes more sensitive and specific each post-operative day. Conclusions It is possible to detect developing post-operative complications early on by monitoring C-reactive protein concentration levels in the blood serum on the 2nd, 4th, and 6th post-operative days.

Echinococcus multilocularis infection of the liver presenting as abdominal wall fistula

Echinococcus multilocularis causes infection where the most commonly affected organ is the liver, followed by the lung, kidney, bone and the brain. Other sites such as the heart, spleen, pancreas and soft tissues are very rarely affected. Surgical treatment combined with chemotherapy using various technical approaches remains the main therapeutic modality for echinococcal liver disease. To the best of our knowledge there are less than five clinical cases of cutaneous presentation of liver alveolar echinococcosis described. We present a unique case of liver echinococcosis presenting as recurrent abdominal wall fistula and abscess in a 29-year-old man. Diagnosis was based on CT imaging, serological analysis and histological findings from the fistula. Medical treatment with albendazole was initiated and liver resection was performed. The patient has no symptoms and signs of recurrence 1 year after operation, while still on albendazole therapy. This case description highlights the importance of early suspicion and treatment of unusual echinococcosis clinical presentations.

Gracilis muscle interposition with primary rectal without urethral repair for moderate sized rectourethral fistula caused by brachytherapy for prostate cancer: a case report

IntroductionThere is a 0.16% chance of a rectourethral fistula after prostate brachytherapy monotherapy using Palladium-103 or Iodine-125 implants. We present an unusual case report of a rectourethral fistula following brachyradiotherapy monotherapy for prostate adenocarcinoma. It was also associated with unusual management of the fistula.Case presentationA 58-year-old Caucasian man underwent brachyradiotherapy monotherapy as definitive treatment for verified intracapsular prostate adenocarcinoma receiving 56 Iodine-125 implants using a transrectal ultrasound-guided technique. The patient started to complain of severe perineal pain and mild rectal bleeding 15Â months after brachyradiotherapy. A biopsy of mucosa of his anterior rectal wall was performed. A moderate sized rectourethral fistula was confirmed 23Â months after implantation of Iodine-125 seeds. Laparoscopic sigmoidostomy and suprapubic cystostomy were then performed. Long-term cortisone applications in combination with 30 sessions of hyperbaric oxygen therapy, and antibacterial therapies were initiated due to necrotic infection. A gracilis muscle interposition to create a partition between the patients rectum and urethra in conjunction with primary rectal repair but without urethral repair were performed 6 months later. The 3cm rectal defect was repaired via a 3cm-long horizontal perineal incision. The 1.5cm urethral defect just below the prostate was not repaired. The patient underwent an optic internal urethrotomy 3Â months later for a 1.5cm-long urethral stricture. Several planned preventive urethral buginages were performed to avoid urethral stricture recurrence. At 12Â months postoperatively, there were no signs of a fistula and cancer recurrence. He now has a normal voiding and anal continence.ConclusionSevere rectal pain, bleeding, and local anterior necrotic proctitis are predictors of a rectourethral fistula. Urinary and fecal diversion is the first-step operation. Gracilis muscle interposition in conjunction with primary rectal repair but without urethral reconstruction is one of the reconstructive surgery options for moderate 2cm to 3cm rectourethral fistulas. Internal urethrotomy is a procedure for postoperative urethral strictures of 1.5cm in length.

Management of colorectal anastomotic stricture with transanal endoscopic microsurgery (TEM)

Two percent of patients with handsewn and 8% of patients with stapled colorectal anastomosis develop anastomotic stricture [1]. Endoscopic balloon dilatation helps to overcome this complication for most of these patients. Those who do not benefit from balloon dilatation require surgical treatment. Although transabdominal resection is considered to be the most effective, it is a major operation. Other, less invasive surgical procedures, such as transanal endoscopic microsurgery (TEM), have been described [2–5] as treatment options for these patients. The aim of our study was to evaluate treatment of colorectal anastomotic strictures with TEM.

Fecal incontinence after transanal endoscopic microsurgery

PurposeTransanal endoscopic microsurgery (TEM) procedure could potentially influence the development of fecal incontinence later in life. The aim of our study was to assess long-term functional outcomes after TEM and to determine possible variables related to incontinence.MethodsPatients, enrolled in a prospectively collected TEM operation database, were interviewed using a postal questionnaire. The questionnaire consisted of EuroQol (EQ)-5D-5L quality of life questionnaire, Wexner fecal incontinence grading scale, and additional questions about other perianal operations and obstetric history for women. We divided patients into two groups: no or minor fecal incontinence (Wexner score of 2 and less) and non-minor incontinence (Wexner score of 3 or more).ResultsOne hundred thirty-two patients were included in the study. Patients’ median follow-up time was 96 (12–168) months from their operation. Thirty-eight patients (28.8%) reported Wexner score of 3 or more, and they reported significantly worse quality of life in all tested life spheres. They were older at the time of the operation (63 (18–82) vs. 68 (50–89) years; p = 0.004), underwent longer operations (50 (10–140) vs. 60 (15–210) min; p = 0.017), and more often were operated for malignant lesions (17 (18.3%) vs. 14 (36.8%); p = 0.040). Older age at the time of operation was an independent risk factor in multivariate model (OR 1.057, 95% CI 1.010–1.106; p = 0.016).ConclusionsFecal incontinence after TEM is more common than thought previously, resulting in significantly impaired quality of life. Older age at the time of operation was an independent risk factor for developing significant fecal incontinence.

Lynch syndrome and sextuple primary malignancies

Abstract Lynch syndrome or hereditary nonpolyposis colorectal cancer is the most common of hereditary colorectal cancer and accounts for 1–3%. Lynch and Chapelle estimated that it accounts 5–8% for all colorectal cancers. It is an autosomal dominant syndrome characterized by predisposition of various cancers (colorectal, stomach, endometrial, ovarian, renal, small bowel, and hepatobiliary tract) at earlier age than in general population and occurs as a result of mutation in DNA mismatch repair genes. This article presents a rare clinical of a 61-year-old female diagnosed with extracolonic Lynch syndrome with six metachronous tumours acquiring in digestive tract during the period from 1993 to 2014 (over 21 years). No other cases of six primary malignancies in patient with Lynch syndrome have been reported in literature. Upon diagnosis of Lynch syndrome, it is important to screen patient for malignancies of different localization as this syndrome predisposes appearance of various cancers at earlier age than in general population.

Does a retrorectal tumour remain a challenge for surgeons

Abstract Background: Retrorectal tumours are lesions with a wide range of histological differentiation that are often diagnostic and clinical challenges due to their rare occurrence. Many cases of this pathology are treated in regional hospitals, which results in serious complications because physicians fail to recognize this pathology. We present our experience in treating these tumours. Methods: A retrospective analysis of a prospectively maintained database was performed using the Vilnius University Hospital Santaros Clinics patient database. Thirty-five cases were identified. Results: Occurrence of retrorectal tumours was higher in women than in men and accounted for 82.86% and 17.14%, respectively. Computer tomography and magnetic resonance imaging were the main methods used to confirm diagnosis and plan surgical treatment. We have used a laparotomy, perineal or combined approach for tumour extirpation. The laparotomy approach was the most used, followed by perineal extirpation. The most common histological type was cystic hamartoma, accounting for 20% of cases. In 80% of cases, the histological findings greatly varied. Hospital stays varied from 3 to 21 days with a mean of 11.6 ± 5.83 days. The postoperative complication rate was 17.14% and was present in six cases. Overall survival was 85.17%, with an average follow-up period of 71.83 months. There were no recurrent tumours diagnosed during follow-up. Conclusion: Retrorectal tumours are a very rare pathology with high histological heterogeneity and problematic diagnostics. Patients should be referred to a tertiary centre that has experience and diagnostic capabilities for the best diagnostic and treatment options.