Direct MRI fistulography with hydrogen peroxide in patients with recurrent perianal fistulas: a new proposal of extended diagnostics.

BACKGROUND: Perianal fistulas are malformations of the anorectal area. Accurate preoperative assessment of perianal fistula tract is a main assumption in diagnosis of the disease, affecting the operation efficiency. The aim of the study was to present our experience in application of a new diagnostic protocol based on the magnetic resonance imaging (MRI) examination using a mixture of hydrogen peroxide (HP) and gadolinium as a direct contrast medium in evaluation of recurrent fistulas tract. The method is referred to as HPMRI. MATERIAL AND METHODS: The study group consisted of 12 subjects operated on from 2011. Direct HPMRI fistulography was performed in all subjects before the operation. All types of fistulas were precisely evaluated by HPMRI examination. RESULTS: Intraoperative state confirmed complete course of fistulas in 11 cases. In 1 case, an internal opening was not found. CONCLUSIONS: We suggest that this new method of direct HPMRI fistulography may improve visualization of the tracts of recurrent fistulas and improve efficacy of surgical procedures.

Effective treatment of solitary rectal ulcer syndrome using argon plasma coagulation.

Solitary rectal ulcer syndrome (SRUS) is a chronic, multiform, non-cancerous disorder of the rectum, the final diagnosis of which is based upon histopathological criteria. This disorder is often accompanied by latent proctoptosis. We present a patient who (in 1996) was the first case in which argon plasma coagulation (APC) was used for SRUS treatment. In the years 2004-2005 the same patient underwent 15 APC sessions (at monthly intervals) obtaining full recovery from SRUS, although she had been treated unsuccessfully for 17 years prior to that. Six-year observation did not show any relapse. Local therapy with APC seems to be an important alternative in SRUS treatment without prolapse of the rectum and could become a basic method for bleeding treatment in SRUS.

[Total pelvic exenteration in vaginal cancer--case report]. / Calkowite wytrzewienie narzadów miednicy mniejszej z powodu raka pochwy--opis przypadku.

Vaginal cancer is a rare neoplasm and in about 65% to 90% of cases it is a metastatic one. It is diagnosed in women aged from 60 to 70 years, but it can also appear in younger patients. Squamous cell carcinoma is the most frequently found histopathological type. Risk factors for the development of vaginal cancer are thought to be similar to those of cervical cancer. We present a case of a 52-year old woman with vaginal cancer treated with brachytherapy. Due to neoplasm recurrence, additional examinations were performed in the course of one year. The patient was qualified for total pelvic exenteration. A leakage from the abdominal wound was observed post operatively. It was successfully noninvasively treated. In 3 months time she was hospitalized because of the superficial abdominal abscess which was located next to the left ureterostomy. The patient undergoes regular gynecological, surgical and urological control examinations. So far the results do not show any recurrence of the neoplastic process. Total pelvic exenteration should be considered in selected groups of patients.

PTEN expression profiles in colorectal adenocarcinoma and its precancerous lesions.

The aim of the study was to determine expression of the PTEN suppressor gene in colorectal adenocarcinoma and its precancerous lesions (adenomatous polyps) in correlation with common clinical and histopathological features. Forty-four patients with adenomatous polyps and 32 with primary adenocarcinoma of the colon or rectum were enrolled in the study. They underwent endoscopic removal of polyps or major surgery and postoperative adjuvant chemo- and radiotherapy depending on staging of the disease. No patient had received chemotherapy and/or radiotherapy before the surgery. PTEN expression was evaluated using immunohistochemical staining on paraffin-embedded specimens and compared to clinicopathological features of tumors. In colorectal cancers, PTEN expression was found to be significantly lower than in normal intestinal mucosa and adenomatous polyps. That was associated with complete loss of PTEN expression observed more frequently in colorectal cancer, contrary to reduction of PTEN expression occurring mostly in polyps. A correlation between polyp diameter and loss of PTEN was demonstrated as well as between tumor size and TNM advanced stage and PTEN expression. The obtained results suggest that the PTEN/PI3K/Akt pathway may play an important role in early stages of sporadic colorectal carcinogenesis and reduced PTEN expression in late oncogenesis is associated with some adverse clinical and pathological features.

[Infectious complications of stress urinary incontinence treatment with TVT procedure]. / Powiklania infekcyjne leczenia wysilkowego nietrzymania moczu metoda tasmy TVT.

We present case report of 51-year-old female patient admitted to surgery ward because of presence of pyogenic discharge in perianal region since 7 months. Eighteen months earlierthe patient underwent stress urinary incontinence procedure with use of TVT synthetic implant. Diagnosis of wast, bilateral, composite vagino-perianal fistule was made. After carrying out four operations with two stage sling removal final postfistule wound healing was obtained.

Mikulicz's procedure with levator muscle and external anal sphincter plasty in the treatment of rectal prolapse.

UNLABELLED: Rectal prolapse is the partial or complete protrusion of the rectal wall into the anal canal. The most common etiology consists in the insufficiency of the diaphragm of the lesser pelvis and anal sphincter apparatus. Methods of surgical treatment involve perineal or abdominal approach surgical procedures. The aim of the study was to present the method of surgical rectal prolapse treatment, according to Mikulicz's procedure by means of the perineal approach, based on our own experience and literature review. MATERIAL AND METHODS: The study group comprised 16 patients, including 14 women and 2 men, aged between 38 and 82 years admitted to the department, due to rectal prolapse, during the period between 2000 and 2012. Nine female patients, aged between 68 and 82 years (mean age-76.3 years) with fullthickness rectal prolapse underwent surgery by means of Mikulicz's method with levator muscle and external anal sphincter plasty. The most common comorbidities amongst patients operated by means of Mikulicz's method included cardiovascular and metabolic diseases. RESULTS: Mean hospitalization was 14.4 days (ranging between 12 and 17 days). Despite advanced age and poor general condition of the patients, complications during the perioperative period were not observed. Good early and late functional results were achieved. The degree of anal sphincter continence was determined 6-8 weeks after surgery showing significant improvement, as compared to results obtained prior to surgery. One case of recurrence consisting in mucosal prolapse was noted, being treated surgically by means of Whitehead's method. Good treatment results were observed. CONCLUSION: Transperineal rectosigmoidectomy using Mikulicz's method with levator muscle and external anal sphincter plasty seems to be an effective, minimally invasive and relatively safe procedure that does not require general anesthesia. It is recommended in case of patients with significant comorbidities and high surgical risk.

Analysis of PTEN expression in large intestine polyps and its relation to the recognized histopathological and clinical risk factors for cancer development in this location.

AIM OF THE STUDY: PTEN is an important gene whose protein product is double specific phosphatase holding key regulatory functions in sending signals from membrane receptors for growth factors into the cell downstreams. Its participation, mainly by PI3K/AKT signaling pathway in the pathomechanism of many malignant cancers was unambiguously confirmed. The PTEN function gets disturbed on many levels and for various reasons. Disorders of PTEN protein expression seem to be even more common in many carcinomas. The aim of the study is to enquire the meaning of PTEN expression in the cancer transformation process in large intestine glandular polyps. MATERIAL AND METHODS: The group includes 40 patients, 21 men and 19 women, age median 64 years (51-83) qualified to endoscopic removal of large intestine polyp. Tissue material obtained during polyp removal endoscopy was immediately fixed in 4% buffered formalin solution with the mixture of phosphatase activity inhibitors (PhosStop Roche). Time of fixation 24-48 h. After fixation, the material was embedded in paraffin. PTEN visualization was based on specific rabbit monoclonal antibodies (Cell Signaling). The expression of PTEN protein in large intestine and rectum polyps was marked by a semi-quantitative method and an attempt to correlate the results with the acknowledged clinical and histopathological malignancy risk factors was undertaken. RESULTS: Loss or weakening of protein expression was found in 45% cases. Moreover, the relationship between polyp diameter and a loss of PTEN expression was proved. The received results can indicate a significant participation of PTEN gene in early oncogenesis stages of large intestine cancer.

[Solitary rectal ulcer syndrome]. / Zespól samotnego wrzodu odbytnicy.

Solitary rectal ulcer syndrome (SRUS) is a chronic, benign, polymorphic disease of the rectum, the final diagnosis of which is based on histopathologic criteria. Microscopic examination shows glandular changes, oedema and obliteration of the normal architecture in the region of the lamina propria, with muslce fibre penetrating into lamina. Although SRUS pathogenesis is bound up with defecation disorder, it still remains unclear. Disease symptoms are nonspecific--in most cases defecation disorders appear (incomplete defecation, blood and mucus in stool). In some patients emotional disorders can be observed. SRUS treatment is a complex and long-lasting process. Usually it is ineffective or gives only passing effects. SRUS can often be accompanied by rectal prolapse, sometimes a hidden one. In these cases there are more therapeutic possibilities and the prognosis is slightly better. There is no method of choice for SRUS treatment and the prognosis is hard to predict. The treatment should be selected individually, depending on the symptoms intensity and the occurrence of rectal prolapse.

Usefulness assessment of preoperative MRI fistulography in patients with perianal fistulas.

BACKGROUND: Accurate preoperative assessment of the perianal fistulous tract is the main purpose of the diagnostics and to a large extend determines surgery effectiveness. One of the useful diagnostic methods in perianal fistulas is magnetic resonance imaging. The authors presented experiences in the application of MRI fistulography for evaluation of cases of perianal fistulas difficult to diagnose and treat. MATERIAL/METHODS: Own examination method was described; MRI fistulography findings were analyzed and compared with intraoperative conditions in 14 patients (11 men and 3 women) diagnosed in the years 2005- 2009. Eight patients had recurrent fistulas and 6 had primary fistulas. Imaging was performed with a GE SIGNA LX HS scanner with a 1.5-Tesla field strength and a dedicated surface coil placed at the level of hip joints. Contrast agent was a gadolinium-based solution. RESULTS: Intraoperative findings were consistent with radiological descriptions of 13 MRI fistulographies. Only in one case, according to surgery findings, it was a transsphincteric fistula with an abscess in the ischioanal fossa, with an orifice in the posterior crypt; the radiologist described it as a transsphincteric, internal blind fistula. CONCLUSIONS: Due to its accuracy in the assessment of the perianal fistulous tracts in soft tissues, MRI fistulography becomes a useful and recommended diagnostic method in this pathology. It shows the location of the fistula regarding the system of anal sphincters, and identifies the internal orifice and branching of the fistula. It enables precise planning of surgical treatment. Authors suggest that this diagnostic method should be improved and applied more commonly.

[Searching for new wound healing strategies--problems and pitfalls]. / Problemy i pulapki w poszukiwaniach nowych strategii gojenia ran.

Authors present the most recent and prospective trends in wound healing procedures, which are expected to solve problems with acute and chronic wounds management. While searching for new strategies to optimize the would healing process, reduce the complication probability, and support or replace the classical treatment procedures, researchers are faced with many diagnostic and therapeutic problems and pitfalls. That leads to creating highly complicated and expensive treatment procedures which, however, have not yet been proven to exceed the effectiveness of the moist wound therapy.

Perioperative high dose rate (HDR) brachytherapy in unresectable locally advanced pancreatic tumors.

PURPOSE: The aim of the study was to present an original technique of catheter implantation for perioperative HDR-Ir192 brachytherapy in patients after palliative operations of unresectable locally advanced pancreatic tumors and to estimate the influence of perioperative HDR-Ir192 brachytherapy on pain relief in terminal pancreatic cancer patients. MATERIAL AND METHODS: Eight patients with pancreatic tumors located in the head of pancreas underwent palliative operations with the use of HDR-Ir192 brachytherapy. All patients qualified for surgery reported pain of high intensity and had received narcotic painkillers prior to operation. During the last phase of the surgery, the Nucletron® catheters were implanted in patients to prepare them for later perioperative brachytherapy. Since the 6th day after surgery HDR brachytherapy was performed. Before each brachytherapy fraction the location of implants were checked using fluoroscopy. A fractional dose was 5 Gy and a total dose was 20 Gy in the area of radiation. A comparative study of two groups of patients (with and without brachytherapy) with stage III pancreatic cancer according to the TNM scale was taken in consideration. RESULTS AND CONCLUSIONS: The authors claim that the modification of catheter implantation using specially designed cannula, facilitates the process of inserting the catheter into the tumor, shortens the time needed for the procedure, and reduces the risk of complications. Mean survival time was 5.7 months. In the group of performed brachytherapy, the mean survival time was 6.7 months, while in the group of no brachytherapy performed - 4.4 months. In the group of brachytherapy, only one patient increased the dose of painkillers in the last month of his life. Remaining patients took constant doses of medicines. Perioperative HDR-Ir192 brachytherapy could be considered as a practical application of adjuvant therapy for pain relief in patients with an advanced pancreatic cancer.

Autologous platelets and leukocytes can improve healing of infected high-energy soft tissue injury.

Despite advances in surgical techniques and pharmacology, healing of injury-associated soft tissue defects is frequently complicated by infections, which often requires a secondary intervention. Cytokines are important mediators of healing. Application of autologous platelet-rich plasma enriched in growth factors and antimicrobial proteins, known also as platelet-leukocyte rich plasma (PLRP), represents a novel approach to the treatment of soft tissue and bone healing disturbances. This case is the first report on the application of PLRP in an infected high-energy soft tissue injury and shows that the volume and concentration of platelets and leukocytes is adequate to induce healing processes despite concurrent infection.

[Madelung's disease]. / Choroba Madelunga.

Madelung's disease (Md) is a rare metabolic disorder which presents with multiple symmetrical nonencapsulated fatty masses situated mainly around the head, neck and nape. The main indications for Md treatment are: shortness of breath, head's movement restrictions, swallowing disorders (dysphagia), aesthetic considerations, and the fear of cancer. The standard treatment of Md is the surgical excision of pathological tissues. The disease is progressive, relapses after removal of tissue are often observed. The discussion is based on a three-year observation of Md patient operated by the authors. A good cosmetic result and symptoms subsidence were observed. There were no sings of disease recurrence.

[Obstruction of jejunum due to adenocarcinoma]. / Niedroznosc spowodowana gruczolakorakiem jelita czczego.

The paper presents a rare case of jejunum adenocarcinoma at a 66-year old female. The patient was admitted to the hospital due to not characteristic abdominal pain and periodical nausea and vomitting lasting few months. After realized laboratory investigation, especially on the basis of contrast, radiological procedure of the gastrointestinal tract, the high obstruction was detected. Then the patient has been operated on. Postoperative period proceeded without complications. Eleven monthly observation after the operation showed no recurrence of cancer. The presented case confirms vole of contrast radiological procedure of the gastrointestinal tract, which is simple and generaly available examination, in the diagnosis of bowel obstruction. The correct interpretation of the result was an indication of surgical intervention. However the final diagnose is established on the base of postoperative histopatological examination.

Methylation of the MGMT and p16 genes in sporadic colorectal carcinoma and corresponding normal colonic mucosa.

BACKGROUND: Colorectal cancer, one of the most aggressive cancers, occurs with a high incidence in most countries. The usual treatment is surgery and subsequent chemotherapy and radiotherapy. Cancer development and progression is dictated by series of alterations in genes such as tumor suppressor genes, DNA repair genes, oncogenes and others. In colorectal carcinogenesis disturbances different from mutations called an epigenetic regulation are also taken into consideration. Epigenetics is defined as a modifications of the genome, heritable during cell division, which do not involve a change in the DNA sequence. In our study we analyzed methylation of CpG islands in the MGMT and p16 genes in sporadic colorectal cancers and normal corresponding colonic mucosa. MATERIAL/METHODS: Fresh tissue samples were obtained from 68 patients (age of 23 to 81 years) with primary colorectal adenocarcinoma and corresponding normal tissues. We used methylation-specific polymerase chain reaction (MSP) for analysis of the methylation status of MGMT and p16. RESULTS: Methylation of MGMT and p16 was detected in 59% and 53% of tumors, respectively. In corresponding normal colonic mucosa methylation of MGMT was detected in 20% and p16 in 18%. The normal colon mucosa obtained from younger patients (age of <65 years) showed less methylation frequency as compared with the normal mucosa from the older ones (age of >65 years). CONCLUSIONS: The older age and female gender are generally associated with higher methylation levels for most CpG islands in normal colonic mucosa. These results indicate that MGMT and/or p16 aberrant methylation may play an important role in colorectal cancer.

Neopterin--a potential factor for differentiation between pancreatic cancer and chronic pancreatitis.

BACKGROUND/AIMS: Pancreatic cancer constitutes a difficult diagnostic and therapeutic problem. It remains the fourth cause of death among gastrointestinal malignancies. The present study aimed to investigate whether neopterin can be used as a significant marker in pancreatic cancer and to establish any possible relationships between serum neopterin levels and the differentiation between chronic pancreatitis, pancreatic cancer, and acute pancreatitis. METHODOLOGY: The research was done on a group of 65 patients with a diagnosed pancreatic tumor and on a group of 21 patients with a diagnosed acute pancreatitis. Serum neopterin concentration was determined in all patients on the first day of hospitalization. RESULTS: Based on intraoperative and postoperative histopathological findings, pancreatic cancer was diagnosed in 42 patients and chronic pancreatitis in 23 patients. Neopterin concentrations in pancreatic cancer patients, chronic pancreatitis patients, and acute pancreatitis patients were 13.01-29.64 nmol/L (mean 18.16), 0.95-11.81 nmol/L (mean 6.52), and 9.64-25.0 nmol/L (mean 13.61), respectively. Mean neopterin levels in pancreatic cancer and acute pancreatitis patients were higher than the accepted norm (norm<10 nmol/L). Serum neopterin concentrations in patients with chronic pancreatitis remained within the norm. CONCLUSIONS: In our opinion, neopterin might be a promising factor of differentiation between pancreatic tumors. However, the use of neopterin as a nonspecific tumor marker requires further studies.

[Madelung disease--case report]. / Lagodna lipomatoza szyi nasladujqca wole--opis przypadku.

Madelung disease-benign symetric lipomatosis--is uncommon condition affecting adults in age 30-60 years, characterized by symmetric accumulation of fatty tissue in the neck (type I), and upper back, shoulder girdle (type II). Type III is described as disproportionate accomodation of subcutaneous tissue in pelvic gridle. Pathogenesis of this disorder is not recognized well, but one of the most common risk factor is an alcohol consumption. In this paper a case of 60 years old man is described. Lipomatosis of neck started as single nodulus 6 years ago, and led to severe decrese of neck movements. As diagnosis has been established, the patient was surgicaly treated with good results.

[Diagnostic difficulties in rare causes of gastrointestinal bleeding]. / Trudnosci diagnostyczne w rzadkich przyczynach krwawienia z przewodu pokarmowego.

Peptic and duodenal ulcer and haemorrhagic gastritis are the most common causes of gastrointestinal bleeding. Pathologic changes of the small intestine are rare and difficult to diagnose. The aim of the study is to evaluate the diagnostic strategy regarding patients with gastrointestinal bleeding of obscure origin. From 1996 to 1999, 626 patients were treated for gastrointestinal bleeding. There were difficulties in finding the source of bleeding in three out of 626 patients. Endoscopy of the upper and the lower gastrointestinal tract, hydrosonography of the large intestine and gastrointestinal passage were performed in these three patients. The site of bleeding was not determined after the above mentioned medical examinations. Three patients underwent exploratory laparotomy, and two of them also intraoperative endoscopy of the small intestine. One patient had tumor of the small intestine, and pathologic examination revealed leiomyoma. One patient had Meckel's diverticulum with presence of ectopic gastric mucosa diagnosed. One patient had inflammatory infiltration in the distal ileum. The presence of chronic, non-specific inflammation was proved by histologic examination. In case of patients for whom it was difficult to determine the source of gastrointestinal bleeding the very reason for such a bleeding is often found in the small intestine. It frequently happens that laparotomy and intraoperative endoscopy of the small intestine allows making the diagnosis.

[Primary suture following the bile duct exploration in cholelithiasis]. / Pierwotne zszycie przewodu zólciowego po rewizji dróg zólciowych w przebiegu kamicy zólciowej.

Classical performance of bile duct exploration is always strictly connected with the problem of an incised bile duct closure. In majority of surgical centers an external T-tube drainage was carried out in last century. But is an external drainage the best method to be used? The aim of the paper was to establish criteria for including (or excluding) patients to groups undergoing primary suture of bile duct. The comparison of the patients in whom bile duct exploration was followed by primary suture with the group in which T-tube was left in bile duct lumen was performed. Recently in our Department a classical method has been used to operate on 65 patients with cholelithiasis. In 42 patients a preoperatively planned bile duct exploration has been performed. In 14 patients a T-tube was left after the exploration, in 24 patients bile duct was closed with a primary suture. In other 18 patients with residual and recurrent bile duct stones T-tube was left in bile duct only in two patients. Based on literature analysis, our observations, and surgical experience criteria for including and excluding patients for primary suture of bile duct have been established. Groups of patients with and without T-tube were compared, considering complications and economic aspects of hospitalization. Our opinion is that whenever in specialized surgical centers detailed criteria are established and followed precisely, primary bile duct closure is a simple and safe procedure, responsible for few complications. The cost of hospitalization in the case of primary suture is half as much as the price of the hospitalization in the case of T-tube.

[Abdominal Spigelian hernia]. / Przepuklina boczna brzucha Spigela.

Hernia in Spigel's semilunar line is a rare, diagnostic difficult type of abdominal external hernia at all. Case report of female patient aged 50-years treated surgically because of untypical situated (upon the navel) Spigelian hernia was described. The woman complained of painful left epigastrium with periodically revealed orange-like-tumor. Spigelian hernia was operated in general anaesthesia. Postoperative period was uncomplemented.