The complication rate, but not the mortality rate, lower after percutaneous endoscopic gastrostomy than after open surgical gastrostomy: comparison of two methods in a high volume group of patients.

Introduction: Percutaneous endoscopic gastrostomy (PEG) has become the primary procedure for long-term enteral nutrition of most, but not all patients with dysphagia. Still in some patients gastrostomy may only be performed with open surgical technique (SG). Finally, in some patients due to relative contraindications to both methods, surgeons have to choose one of them. Aim: To compare PEG with SG in terms of effectiveness and safety. Material and methods: A retrospective study of 612 patients with dysphagia, who underwent PEG (573) or SG (39) was conducted. Authors analysed effectiveness of PEG and SG procedures as well as the type, frequency and treatment methods of complications classified according to Clavien-Dindo Classification. Results: The rate of all complications was significantly lower for PEG than for SG and a significant effect of the treatment type on the probability of serious complications was observed - notably lower after PEG (OR = 0.21, 95% CI: 0.05-0.8, p = 0.02). The 30-day mortality rate was 1.74% for PEG and 0% for SG. PEG patients who required laparotomy were over 30 times more likely to die than others. No significant effect of the nutrition status on the probability of serious complications was observed (OR = 0.83, 95% CI: 0.51-1.34, p = 0.46). Conclusions: A significant effect of the treatment type on the probability of serious complications was confirmed. This result was robust to the preoperative patients' nutrition status which was found to be insignificant. A lower risk of postoperative complications, a relatively easy procedure make PEG a procedure of choice in patients with dysphagia.

The Role of Serotonin Neurotransmission in Gastrointestinal Tract and Pharmacotherapy.

5-Hydroxytryptamine (5-HT, serotonin) is a neurotransmitter in both the central nervous system and peripheral structures, acting also as a hormone in platelets. Although its concentration in the gut covers >90% of all organism resources, serotonin is mainly known as a neurotransmitter that takes part in the pathology of mental diseases. Serotonin modulates not only CNS neurons, but also pain transmission and platelet aggregation. In the periphery, 5-HT influences muscle motility in the gut, bronchi, uterus, and vessels directly and through neurons. Serotonin synthesis starts from hydroxylation of orally delivered tryptophan, followed by decarboxylation. Serotonin acts via numerous types of receptors and clinically plays a role in several neural, mental, and other chronic disorders, such as migraine, carcinoid syndrome, and some dysfunctions of the alimentary system. 5-HT acts as a paracrine hormone and growth factor. 5-HT receptors in both the brain and gut are targets for drugs modifying serotonin neurotransmission. The aim of the present article is to review the 5-HT receptors in the gastrointestinal (GI) tract to determine the role of serotonin in GI physiology and pathology, including known GI diseases and the role of serotonin in GI pharmacotherapy.

Simultaneous surgical treatment of hepatocellular carcinoma with tumor thrombus in the inferior vena cava and ischemic heart disease own research and literature review.

<b> Introduction:</b> Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death worldwide. Tumor penetration into the inferior vena cava/right atrium is rare, as it occurs only in 34% of HCC patients. There are no clear guidelines for the management of this stage of disease. </br></br> <b>Aim:</b> This is a case report of a patient with HCC and tumor thrombus in the inferior vena cava and with advanced coronary artery disease. </br></br> <b> Materials and methods:</b> The patient was qualified for a simultaneous cardiac surgery and liver resection with removal of the tumor thrombus from the inferior vena cava due to a high risk of sudden cardiac death. The first stage involved aortocoronary bypass followed by a right-sided hemihepatectomy with removal of the tumor thrombus from the inferior vena cava (this part of the operation was performed by extracorporeal circulation). The postoperative period was uneventful. Surgical treatment is one of the therapeutic options that offers a chance to radically remove the tumor and extend the patient's life. From a standpoint, these operations are extremely difficult and carry a high risk of perioperative complications (up to 40%). At the same time, the patient is at risk of complications due to cancer, such as pulmonary embolism, tricuspid stenosis, and congestive heart failure, which should be considered when choosing a treatment method. A significant number of patients also suffer from chronic conditions that worsen the prognosis. Cardiac diseases combined with tumor thrombus in the inferior vena cava may cause sudden cardiac death. </br></br> <b>Conclusions:</b> Surgical treatment should be considered in patients with HCC and tumor thrombus in the inferior vena cava, especially in patients with cardiovascular disease burden, as it is not only a chance to prolong life, but also to protect them against life-threatening cardiac complications.

Brain-derived neurotrophic factor in gastroenterology oncology - short review of current literature.

Brain-derived neurotrophic factor (BDNF) is a member of the neurotrophins group which plays a crucial role in brain development and neurogenesis. In the hypothalamus it is described as playing a role in energy metabolism and feeding behaviour. The hippocampal concentration of BDNF is believed to play an important role in learning and memory, it has a protective role in neurodegeneration and stress responses. BDNF is also known to take part in many other processes, e.g. angiogenesis, proliferation, cell migration and apoptosis. With its receptor TrkB, neurotrophins are important agents that playa role in neural diseases, as well as in cardiovascular and metabolic disorders, such as diabetes mellitus or acute coronary syndrome. Over the last few years, BDNF interaction with TrkB has also been found to be involved in cancer development, including brain, breast, urinary and gastrointestinal cancer. TrkB expression itself has been described as an aggressive neural tumour. BDNF/TrkB signalling takes part in promoting tumour growth and metastasis. The presented review focuses on gastrointestinal cancer and presents the current literature concerning influence of BDNF and TrkB receptor in cancer progression. Special attention is also paid to data confirming the possible role of BDNF/TrkB interaction in chemotherapy resistance. This might present the opportunity to assess the BDNF and TrkB pathway as a possible novel target for anticancer therapies.

Brain derived neurotrophic factor declines after complete curative resection in gastrointestinal cancer.

BACKGROUND: Brain derived neurotrophic factor (BDNF) is a neurotrophin involved in neural and metabolic diseases, but it is also one of the crucial factors in cancer development and metastases. In the current study, we investigated serum BDNF concentrations in patients that underwent surgical treatment for colorectal cancer or pancreatic cancer. METHODS: Serum BDNF concentrations were measured with standard enzyme-linked immunosorbent assays, before and on the third day after the operation, in 50 consecutive patients with colorectal cancer and 25 patients with pancreatic cancer (tumours in the head of pancreas). We compared pre- and postoperative BDNF levels, according to the subsequent TNM stage, histologic stage, lymph node involvement, neuro- or angio-invasion, and resection range. RESULTS: In the pancreatic cancer group, BDNF concentrations fell significantly postoperatively (p = 0.011). In patients that underwent resections, BDNF concentrations fell (p = 0.0098), but not in patients that did not undergo resections (i.e., laparotomy alone). There were significant pre- and postoperative differences in BDNF levels among patients with (p = 0.021) and without (p = 0.034) distant metastases. Significant reductions in BDNF were observed postoperatively in patients with small tumours (i.e., below the median size; p = 0.023), in patients with negative angio- or lymphatic invasion (p = 0.028, p = 0.011, respectively), and in patients with lymph node ratios above 0.17 (p = 0.043). In the colon cancer group, the serum BDNF concentrations significantly fell postoperatively in the entire group (p = 0.0076) and in subgroups of patients with or without resections (p = 0.034, p = 0.0179, respectively). Significant before-after differences were found in subgroups with angioinvasions (p = 0.050) and in those without neuroinvasions (p = 0.049). Considering the TNM stages, the postoperative BDNF concentration fell in groups with (p = 0.0218) and without (p = 0.034) distant metastases and in patients with tumours below the median size (p = 0.018). CONCLUSION: Our results suggested that BDNF might play an important role in gastrointestinal cancer development. BDNF levels were correlated with tumour volume, and with neuro-, angio- and lymphatic invasions. In pancreatic cancer, BDNF concentrations varied according to the surgical procedure and they fell significantly after tumour resections. Thus, BDNF may serve as a potential marker of complete resections in underdiagnosed patients. However, this hypothesis requires further investigation. In contrast, no differences according to the procedure was made in patients with colon cancer.

Surgical Repair of Small Bowel Fistulas: Risk Factors of Complications or Fistula Recurrence.

BACKGROUND Definitive surgical repair of persistent fistulas of the small intestine remains a surgical challenge with a high rate of re-fistulation and mortality. The aim of this study was to evaluate the type and incidence of complications after definitive surgical repair, and to identify factors predictive of severe postoperative complications or fistula recurrence. MATERIAL AND METHODS This was a retrospective study of 42 patients who underwent elective surgical repair of a persistent fistula of the small intestine. The analysis included preoperative and intraoperative parameters. RESULTS The healing rate after definitive surgery was 71.4%. Postoperative complications developed in 88.1% of patients. The mortality rate was 7.2%. Fistula recurrence was recognized in 21.4% of cases. Overall, 93 complications occurred in 37 patients. The most common complications were septic (48.0%). Hemorrhagic and digestive tract-related complications accounted for 19.0% and 15.0% of all complications, respectively. Severe complications (Clavien-Dindo grade III-V) made up 28.0% of all complications. In univariate analysis, multiple fistulas (p=0.03), higher C-reactive protein level (p=0.01), and longer time interval from admission to definitive surgery (p=0.01) were associated with an increased risk of severe complications or fistula recurrence. In multivariate analysis, only multiple fistulas were an independent risk factor for severe complications or fistula recurrence (OR=8.2, p=0.04). CONCLUSIONS Fistula complexity determines the risk of severe postoperative complications or fistula recurrence after definitive surgical repair of the persistent small intestine fistulas. Inflammatory parameters should be normalized before definitive surgery.

Surgical management of the grade C pancreatic fistula after pancreatoduodenectomy.

BACKGROUND: Surgical management of severe pancreatic fistula after pancreatoduodenectomy remains challenging, and carries high mortality. The aim of this retrospective study was to compare different surgical techniques used at relaparotomy for pancreatic fistula after pancreatoduodenectomy, and to identify factors predictive of failure to rescue. METHODS: A total of 43 patients after pancreatoduodenectomy developed a pancreatic fistula requiring relaparotomy. The perioperative data and outcomes were reviewed retrospectively. RESULTS: Completion pancreatectomy, simple drainage of the pancreatic anastomosis and external wirsungostomy were performed in 17, 16, and 10 cases, respectively. The mortality rate for completion pancreatectomy was 47.1%, compared with 56.3% for simple drainage (p = 0.598) and 50.0% for external wirsungostomy (p = 0.883). Simple drainage was associated with a higher rate of further relaparotomies (56.3%) in comparison with completion pancreatectomy (23.5%, p = 0.055) and external wirsungostomy (0%, p = 0.003). A rescue resection of the pancreatic remnant after failed simple drainage resulted invariably in death. On multivariate analysis, the factors predictive of mortality after relaparotomy for pancreatic fistula were organ failure on the day of reoperation (p = 0.001) and need of further surgical reintervention (p = 0.007). CONCLUSION: Timely reintervention and appropriate surgical technique are essential for reducing mortality after reoperation for pancreatic fistula after pancreatoduodenectomy.

Carcinoembryonic antigen and matrix metalloproteinase 2 serum and peritoneal washes concentration in staging and prognosis in colorectal cancer patients.

PURPOSE: The aim of the study was to determine of carcinoembryonal antigen and matrix metalloproteinase 2 peritoneal washes and serum concentration in patients suffering from colorectal cancer concerning tumor staging and 5-year survival rate in these patients. METHODS: 80 patients who underwent curative surgery for colorectal cancer were included into the study. Preoperative serum and intraoperative peritoneal washes CEA and MMP-2 concentrations were measured. RESULTS: Concerning tumor penetration CEA-s and CEA-p concentration was higher in subsequent stages from T2 to T4. Both CEA-s and CEA-p concentration was lower in T2 comparing to T3 and T4. Significant difference of CEA-s and CEA-p was noted between T2 and T4 stages. MMP2-s concentration was higher in T3 comparing to T2, the highest MMP2-p concentration was in T4, with no statistical significance. Concerning nodular status significant difference of CEA-s was noted between N0 and N1. For CEA-p significance was found between N0 and N2 as between N1 and N2. MMP2-s concentration was the highest in N1, MMP2-p concentration was the highest in T4, with no statistical significance. 5-year survival rate for all patients was 63,53%. There were significant differences in CEA-s and CEA-p concentration between patients with negative and positive 5-year survival. CONCLUSION: Intraoperative peritoneal washes concentration of CEA may potentially serve as an important factor for more precise colorectal cancer staging. CEA-p and CEA-s concentration correlates with survival rate in patients suffering from colorectal cancer and can be useful as an additional prognostic factor. Usefulness of MMP2 measurement still requires further studies.

A review of methods for preventing pancreatic fistula after distal pancreatectomy.

Pancreatic fistula is one of the most severe complications after pancreatic surgeries. The risk of pancreatic fistula after distal pancreatectomy is up to 60%. Effective methods to prevent pancreatic fistula are still sought. A unified definition of pancreatic fistula, which was introduced in 2005 by the International Study Group of Pancreatic Surgery (ISGPS), has allowed for an easier diagnosis and determination of fistula severity, as well as for a reliable inter-center comparison of data. Furthermore, a number of publications point out the risk factors of pancreatic fistula, which may be classified into patient-related risk factors, such as MBI, gender, smoking tobacco or pancreatic structure; and surgery-related risk factors, such as blood loss, prolonged surgery and non-underpinning of the major pancreatic duct. The analysis of risk factors and the use of different methods for the prevention of pancreatic fistula, including novel surgical techniques, may reduce both, the formation and severity of fistula. This will, in turn, lead to reduced secondary complications and mortality, as well as a shorter hospital stay. We present a literature review on different strategies used to prevent pancreatic fistula. It seems, however, that multicenter, prospective, randomized studies in two large groups of patients after pancreatectomy are necessary to establish clear recommendations for the preventive management.

Can round ligament of the liver patch decrease the rate and the grade of postoperative pancreatic fistula?

UNLABELLED: The most serious complication after pancreatic surgical procedures is still a postoperative pancreatic fistula. In clinical practice there are various methods to prevent the formation of pancreatic fistula, but none of them is fully efficient. Recently, the role of grafting the round ligament of the liver on the pancreas is emphasized as a promising procedure which reduces the severity and shortens the healing time of postoperative pancreatic fistula. The aim of the study was to assess the impact of grafting a round ligament patch on the pancreatic stump or the area of the pancreatic anastomosis on the severity and healing of pancreatic fistula after surgical treatment of the pancreas (alternatively on prevention of pancreatic fistula formation). MATERIAL AND METHODS: The retrospective study covered patients operated due to pancreatic tumors in the Department of General, Gastrointestinal and Oncologic Surgery of the WUM. Pancreatic fistula was diagnosed according to the definition developed by the ISGPS (International Study Group of Pancreatic Surgery). RESULTS: 10 patients with pancreatic tumors of different location were operated. The round ligament was grafted on the pancreatic stump, the area of the pancreatic anastomosis or on the site of the local tumor removal. Pancreatic fistula developed in 9 patients, including grade A pancreatic fistula in 5 patients, grade B fistula in 3 patients, and grade C fistula in 1 patient. Distant complications occurred in one patient. None of the patients required a reoperation and no deaths were reported. The average hospital stay was 22.4 days. The hospital stay of patients with grade A fistula was shorter than in case of patients with grade B and C fistula. CONCLUSIONS: Grafting of the round ligament of the liver on the pancreatic stump did not prevent the development pancreatic fistula. Grade A pancreatic fistula developed most often. Grade C fistula developed in 1 patient and was complicated by intraabdominal abscesses and sepsis. Although the patient did not require a repeated surgery, but only a continuation of conservative treatment on an outpatient basis. Patients with grade B fistula required prolonged drainage and in the end were supervised by the surgical polyclinic.

A very rare case of a small bowel leiomyosarcoma leading to ileocaecal intussusception treated with a laparoscopic resection: a case report and a literature review.

BACKGROUND: Small bowel tumours are rare and comprise less than 2% of all primary gastrointestinal neoplasms. Among these tumours, a leiomyosarcoma belonging to soft tissue sarcomas is extremely rare and accounts for about 1 % of malignant mesenchymal lesions in the gastrointestinal tract. Due to its aggressive nature and slow growth, it is often diagnosed at the late stage when curative treatment is impossible. Authors report a first case of leiomyosarcoma with chronic recurrent ileocaecal intussusception and literature review to analyse diagnosis and treatment features of the ileum mesenchymal tumours. CASE PRESENTATION: We present a case of an 87-year-old Caucasian man suffering from cramp-like abdominal pain for months. Due to lack of clinical signs and unspecific complaints, a diagnosis was delayed. Despite a detailed in-hospital examination, a proper diagnosis was established as late as during an operation. The patient was treated by surgery with good results. An uncommon laparoscopic resection of the small bowel with a tumour was performed. A histopathological investigation confirmed a very rare mesenchymal lesion of the distal ileum. The patient is under control with no recurrence for 1 year of the follow-up period. CONCLUSIONS: Reported case indicates that a usually asymptomatic tumour can cause uncommon chronic recurrent ileus signs. CT and MRI scans are investigation of choice in such cases, but they are sometimes inconclusive. It might be worth highlighting the good results of laparoscopic leiomyosarcoma lesion resection with a very good outcome.

Giant gastrointestinal stromal tumour of rare sarcomatoid epithelioid subtype: case study and literature review.

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the gastrointestinal tract, but they represent less than 3% of all gastrointestinal tract malignancies. This is a detailed case study of a 52-year-old male patient treated for very uncommon histological subtype of gastric GIST with atypical clinical presentation, asymptomatic progress and late diagnosis. The resected tumour, giant in diameters, was confirmed to represent the most rare histopathologic subtype of GISTs - sarcomatoid epithelioid GIST. We report this case and review the literature with a special focus on pathomorphological evaluation, biological aggressiveness and prognostic factors. To our knowledge this is the first report of giant GIST of very uncommon sarcomatoid epithelioid subtype. It is concluded that clinicians should pay attention to the fact that initial diagnosis may be delayed due to mildly asymptomatic and non-specific clinical presentation. Asymptomatic tumours diagnosed at a late stage, which is often the case, can be large on presentation. Prognosis for patients diagnosed with GIST depend on tumour size, mitotic rate, histopathologic subtype and tumour location. That is why early diagnosis and R0 resection, which is usually feasible and safe even in giant gastric sarcomatoid epithelioid subtype of GISTs, are the key factors for further treatment and good prognosis.

Gigantic solitary fibrous tumour of extra-peritoneal space. A case report and review of the literature.

Solitary fibrous tumour (SFT) is a rare soft tissue tumour which belongs to fibroblastic/myofibroblastic group of tumours. The most often it appears in pleura, also in pericardium, internal organs, peritoneum and extraperitoenal space. SFT was first described as a new type of pleura's tumour by Klemperer and Rabin in 1931. The histogenesis of SFT's has been discussed for years suggesting its mesothelial origin. Recently, SFT has been classified as a mesenchymal fibroblastic tumour. We report a very rare case of 71-year old man suffering from gigantic solitary fibrous tumour of extraperitoneal space who underwent curative surgery in the Department of General, Gastroenterological and Oncologic Surgery in 2011.

Small bowel transplantation--harvesting technique and graft preparation in pigs.

BACKGROUND: In more and more frequently occurring short bowel syndrome, requiring total parenteral nutrition therapy, the complications of the latter not seldom prevent its use. The idea of treating these patients with small bowel transplantation pushed the authors to start the program aiming at development of small bowel harvesting, preservation and transplantation technique in experimental settings. Additionally, an attempt to find which, if any, and to what extent, histological changes of the preserved bowel may be of prognostic value for the early transplant failure. MATERIAL/METHODS: The experiment was carried out on 20 pigs. Two distinct techniques, corresponding to two clinical circumstances in humans, were tested. In the first group of animals, the small bowel was harvested during a model of multivisceral operation, corresponding to the organ harvesting from a brain-dead donor. In the remaining pigs, an isolated segment of the small bowel was explanted, constituting a model of a living related donor surgery. All small bowels were preserved in hypothermia, in Celsior preserving solution for a different, predefined period. During 16 procedures, the harvested small bowel segment was replanted in the same donor, using different vascular anastomotic techniques. RESULTS: Vascular thrombosis was significantly more frequent in grafts anastomosed by end-to-side technique, as well as in more proximal bowel segments, regardless the anastomotic technique. Following two hours of reimplantation, excised bowel segments did not demonstrate significant differences on histological examination, as compared to the hypothermia-preserved segments (from the same donor) of the same age from primary excision. In most cases, the increase of mucosal damage with preservation time was observed, although statistical significance was reached only for the presence of erosions and necrotic lesions. CONCLUSIONS: On the basis of this experiment one may state, that an ileal graft, assuring the long vascular pedicle (derived from ileocolic vessels) and vascular end-to-end anastomoses are at lesser risk of early vascular thrombosis. While applying the presented technique of purging the graft and its preservation, the act of transplantation itself practically does not influence the histological structure of the bowel, thus is not related to the early graft failure which seems to depend, to the greatest extent, upon the technical aspects of the procedure.