Necrosis of the duodenal wall with retroperitoneal perforation as a complication of perirenal abcess. Case report and management.

Duodenal perforation is a rare and severe acute surgical condition which commonly follows the complications of endoscopic and laparoscopic procedures. Small degree of damage in this mechanism and an early diagnosis allow for an effective primary management. The most difficult surgical challenge is an effective management of retroperitoneal duodenal perforation together with coexisting pathological changes of its wall. In this work we present a case of duodenal necrosis with excessive necrosis of a fragment of its wall due to perinephric abscess, with an effective method of management of a defect in an isolated free small intestinal loop in association with gastroduodenal passage exclusion.

Chest reconstruction using a custom-designed polyethylene 3D implant after resection of the sternal manubrium.

INTRODUCTION: Resection of manubrium or body of the sternum is associated with a necessity of chest wall reconstruction. Large sternal defects require the use of different types of implants to ensure acceptable esthetic effect for the patient and chest stabilization. AIM: The purpose of this case report is to present a novel method of reconstruction of manubrium removed due to renal cancer metastasis to the sternum. CASE: We present the case of a patient, who had underwent right nephrectomy for clear cell kidney cancer, diagnosed with a metastatic tumor in the sternum resulting in destruction of manubrium. The patient undergone tumor resection with primary reconstruction with an individual prosthesis. Sternal defect was filled with a personalized, computed tomography scan-based 3D-milled implant made of polyethylene. RESULTS: Sternal reconstruction was uneventful. The patient endured surgery well, and has been under surveillance in outpatient clinic, without any respiration disorders, implant movement or local recurrence. CONCLUSION: Custom-designed sternal implants created by 3D technique constitute an interesting alternative for previous methods of filling defects after resection of a tumor in this location.

Repair of postpneumonectomy bronchopleural fistula using pedicled pericardial flap supported by fibrin glue.

Effective closure of the postpneumonectomy bronchopleural fistula (PBF) with the use of different techniques still remains a challenge for thoracic surgeons. The aim of this study was to evaluate the efficacy of modified method of PBF closure using pedicled pericardial flap (PPF) supported by fibrin glue (FG). The efficacy of the late PBF closure with the use of two surgical methods was compared. In 10 patients, the edges of the PBF were covered with FG and PPF. In the second group of nine patients, myoplasty was used to close the bronchial fistula. Postsurgical follow-up was for 1 year. In the first group, the healing of the fistula was achieved in 100% of the cases, whereas in the second, myoplasty group, healing was achieved in only 66·67% of the cases. The number of complications was similar in both groups. Pericardial flap supported by fibrin glue can be an effective method adjunctive to the treatment of PBF in selected patients.

Strangulation of a Meckel's diverticulum in a femoral hernia (Littre's hernia).

Femoral hernia is usually presented as a flexible, round, domed shape lying on the medial side of the thigh about 2-3 cm below the inguinal ligament. Among the external hernias, femoral hernia is the second most common inguinal hernia. Its prevalence reaches 20%. Among all inguinal hernias, femoral hernias are characterised by a high level of incarceration and strangulation. This can be as high as 60%. We would like to present a case of 71-year-old patient who was admitted to the Clinic urgently due to strangulation of Meckel's diverticulum in a right-sided femoral hernia. Strangulation of Meckel's diverticulum in femoral hernia is an extremely rare entity. It was described for the very first time in 1700 by Littre.

Pericardial flap: an effective method of surgical repair of late post-pneumonectomy fistula.

BACKGROUND: We report our experience with the surgical closure of late post-pneumonectomy bronchopleural fistula (PBF) using our own method of coverage of the bronchial stump: Pedicled pericardial flap in combination with fibrin glue. METHODS: We reviewed the surgical results of 33 patients who underwent surgical closure of PBF by thoracotomy access using three methods: Myoplasty (MYO)-12, omentoplasty (OMT)-10, and pedicled pericardial flap (PPF) with fibrin glue-11. Post-operative follow up was six months. RESULTS: The patients' demography was comparable among the groups. The diameter of the fistulas ranged from 5 mm to total dehiscence. The mean time of the fistula manifestation (in weeks) was 21.5 in the MYO group, 19.50 in the OMT, and 20.1 in the PPF group. The shortest period of hospital drainage of the pleural space was noted in the PPF group. Healing of the fistula was obtained in 66.67% in the MYO group, 80% in the OMT, and 100% in the PPF group. The number of complications was similar in all groups. The hospitalization time was significantly shorter in the PPF group (13.00 d) versus the MYO group (19.58 d) and the OMT (20.01 d). Overall mortality rate was 18.18%; 33.33% of the patients in the MYO group and 20% in the OMT group died. There were no hospital deaths in the PPF group. CONCLUSION: Pericardial flap supported by fibrin glue can be an effective method adjunctive to the treatment of postpneumonectomy PBF in selected patients. Compared with other methods of bronchial stump coverage (omentopasty and myoplasty), this one showed a higher percentage of healing of the fistulas and shorter duration of hospital drainage and hospitalization.

Comparison of early results of surgical treatment in patients with pancreatic cancer.

UNLABELLED: Pancreatic tumours are a serious medical and social issue. Patients come to the doctor too late, when the disease is well advanced. The most frequently applied method of surgical treatment is pancreatoduodenectomy (Whipple procedure). The most frequently used technique of pancreatoduodenectomy is the Child-Waugh method. The procedure can be performed in a classic way or as modified by Traverso (with preservation of the pylorus). MATERIAL AND METHODS: Between August 2008 and June 2011, in the Department of Thoracic, General and Oncologic Surgery of Medical University in Lódz, a total of 79 patients with pancreatic tumours were hospitalized. In 61, pancreatoduodenectomy was performed. The patients were divided into two groups, depending on the diagnosis and the procedures performed: group 1 comprised patients in whom the pylorus was resected (n = 43); group 2 comprised patients in whom the pylorus was preserved (Traverso-Longmire procedure; n = 18). RESULTS: Mean duration of surgery was about 3 hours and 50 minutes in both groups. Mean duration of hospitalization after the procedure was 15.6 days in group 1 and 12.2 days in group 2 (p < 0.05). Early complications (within 30 days of the procedure) were observed in 33.2% of patients in both groups. Blood transfusion was necessary in 21% of patients in group 1 and 28% of patients in group 2 (p>0.05). CONCLUSIONS: There are specific indications for each method of surgical treatment, however, it seems that both techniques of pancreatic resection can be recommended as standard surgical treatment, and the number of complications after both procedures is similar.

Assessment of quality of life in patients with non-operated pancreatic cancer after videothoracoscopic splanchnicectomy.

INTRODUCTION: Pancreatic tumours are a crucial medical issue. The majority of patients report sick in the late stage of carcinoma clinical advancement, which considerably limits the possibility of surgical treatment. Pancreatic cancer patients with no other alternative but palliative treatment constitute a large group. AIM: To assess pain intensity levels and quality of life of pancreatic cancer patients after videothoracoscopic splanchnicectomy. MATERIAL AND METHODS: Between 2001 January and 2010 November in the Department of Thorax, General Surgery and Oncology of the Medical University of Lodz 262 patients with pancreatic tumours were hospitalized. In 121 cases grade 3 and grade 4 tumours were observed. Hundred and twenty-one videothoracoscopic procedures of sympathetic trunk and ganglion excision were performed in 89 patients. RESULTS: Before the procedure the pain intensity level according to VAS was 5.66 (3.9-7.2; SD 1.24) in the trial group and 5.46 (4.1-7.1; SD 1.15) in the control group. The quality of life average assessment in both groups did not differ statistically (p = 1.07) and was 46.3 (32-66; SD 0.92) in patients before the operation and in the control group 50.3 (41-63; SD 0.75). On the 7(th) postoperative day the pain intensity on average was 2.33 (1.2-3.9; SD 0.78) and 4.57 (3.6-5.5; SD 0.69) respectively. One week after the procedure the quality of patients' life was estimated at 64.1 (39-83; SD 1.38) and in the control group at 52.2 (42-65; SD 0.71); the differences are significant (p < 0.05). Thirty days after the procedure 12 patients did not take any painkillers (13.5%), and in the others a considerable decrease of the taken drugs was observed. On average, the pain intensity was estimated at 1.78 (0.6-3.6; SD 0.68). The quality of life, on the other hand, improved considerably in relation to the state prior to the procedure, but increased insignificantly in relation to the state on the 7(th) postoperative day to 70.9 (52-88; SD 1.14). CONCLUSIONS: Splanchnicectomy is a safe method of cancer pain treatment in patients with advanced pancreatic tumours. Videothoracoscopic excision of visceral nerve thoracic section contributes to the statistically significant decrease of cancer pain intensity and considerably improves the quality of patients' lives.

[Methods of treatment on different clinical stages in pancreatic cancer]. / Sposoby postepowania na róznych stopniach zaawansowansowania klinicznego raka trzustki.

UNLABELLED: Pancreatic cancer is a great surgical problem. Clinical observations confirm 10-15% level of R0 resection ability. Dissatisfying treatment effects results from: lach of simple screening tests, low specificity of methods used to diagnose less than 2 cm lesions, low availability of advanced diagnostic methods (endoscopic ultrasonography), anatomy of pancreatoduodenic area, ability of infiltration adhering structures and causing metastatic tumors. AIM: Retrospective evaluation of treatment methods administered to patients with pancreatic cancer according to different clinical stages. MATERIAL AND METHODS: Medical documentation of 97 patients treated during 2001-2006 period for pancreatic cancer was analyzed. The age of patients was 42-90 years (medium 66.04, SD 10.27). There were 47 women (48.45% of group) aged 43-90 (medium 67.89, SD 9.93) and 50 men (51.55%) aged 42-86 (medium 64.31, SD 10.64). RESULTS: In analyzed group 87 tumors were located in the head of pancreas, 5 in the corpus and 5 in the cauda. In 13 cases (13.40%) partial resection of pancreas was performed. By passing anastomoses were applied in 45 cases: 26 (26.80% of total group) biliar and gastrointestinal, 19 (19.59%) only biliar anastomoses. Thoracovideoscopic splanchnicectomy was performed 26 times (26.80%) as a method of decreasing pain. 6 patients were treated with bile ducts drainage: endoscopic (4) or percutaneous (2). In 7 cases operations were limited to explorative laparotomy. Complication occurred in 5 (38.46%) cases following resection of the pancreas and 13 cases (15.38%) following paliative operations. Perioperative mortality accomplished 15.38% following pancreatic resection and 4.44% in remaining cases. CONCLUSIONS: Pancreatic cancer is a neoplasm connected with unsuccessfull course. In most of cases diagnose is confirmed in clinical stage that disables resection with the aim of curation. Although huge progress in diagnostic methods, operational technique and perioperative care postoperative mortality is high. Videothoracoscopic splanchnicectomy is a worth reccomending method of decreasing pain.

[The case of numerous foreign bodies in bronchial tree of both lungs and digestive tract]. / Przypadek wystepowania mnogich cial obcych w drzewie oskrzelowym obu pluc i w przewodzie pokarmowym.

The article shows the description of the seldom met case of simultaneous appearing of numerous foreign bodies situated both in air passages and in the alimentary canal at patient of mentally handicapped with the tendency to swallowing of small objects. After observing by guardians of the patients fact of swallowing metallic foreign bodies by him the specified research were made (X-ray pictures, computer tomography) and the presence in the bronchial tree of both lungs and in the upper and lower section of the alimentary canal were confirmed. Swallowed and aspirated objects did not cause no complaints at the patient. Revealed foreign bodies were removed from air passages by using of the bronchofiberoscopy method and the surgical treatment. Foreign bodies of the alimentary canal were voided by patient through natural tract.

[Thoracic sympathectomy performed by videothoracoscopic technique]. / Zabiegi sympatektomii piersiowej wykonywane metoda wideotorakoskopowa.

UNLABELLED: Thoracic sympathectomy is a method for a segmental elimination of functions of the sympathetic system by the excision of its Th2-Th3 ganglia. The procedure can be performed both using open and videoscopic technique. OBJECTIVE: The purpose of the study was the evaluation of efficacy of videoscopic thoracic sympathectomy. MATERIAL AND METHOD: From 1993 to 2003 we performed 53 videoscopic thoracic sympathectomies in patients with Raynaud's syndrome and upper limb hyperhidrosis. RESULTS: In all patients that underwent thoracic sympathectomy we obtained a positive reaction to a segmental excision of the sympathetic trunk. Patients with Raynaud's showed a significant improvement in symptoms in 76% of cases after a 4-year observation while patients with hyperhidrosis in 100%. The time of hospitalisation was 3.5 days in average. Postoperative complications were observed in two patients (3.7%). Videoscopic thoracic sympathectomy provides good therapeutic and cosmetic results and deserves more common use compared with open technique.

[Thoracoscopic splanchnicectomy for control of epigastric pain of neoplastic origin]. / Zastosowanie torakoskopowej splanchnicektomii w zwalczaniu dolegliwosci bólowych pochodzenia nowotworowego w nadbrzuszu.

UNLABELLED: One of the methods for control of epigastric splanchnic pain is thoracoscopic transsection of splanchnic nerves. The purpose of the study is to evaluate the effect of thoracoscopic splanchnicectomy on pain intensity in patients with unresectable epigastric malignancies. MATERIAL AND METHODS: From 2001 to March 2004 we performed thoracoscopic splanchnicectomy in 26 patients (17 males and 9 females) aged from 42 to 76 years. Indications for the procedure were as follows: unresectable pancreatic cancer (17 cases), gastric cancer (7 cases), gallbladder cancer (2 cases). In all patients the intensity of pain was evaluated before the operation, two days and one month postoperatively by Prince Henry Hospital Pain Scale (PHHPS). RESULTS: 26 patients were evaluated during their hospitalisation and 24 of them one month postoperatively. The intensity of pain measured by PHHS before the procedure was 2.77 points in average and 1.26 point and 1.5 point in average two days and one month postoperatively respectively. All patients demanded lower doses of analgesics after an operation. CONCLUSION: Thoracoscopic splanchnicectomy is a safe and efficient method for control of pain caused by unresectable epigastric malignancies.

[Analysis of complications after laparoscopic cholecystectomy on the basis of our thirteen-years experience]. / Analiza powiklan cholecystektomii laparoskopowej na podstawie trzynastoletnich doswiadczen wlasnych.

UNLABELLED: The objective of study is to present and discuss complications observed in our patients after laparoscopic cholecystectomy throughout nine years of using this technique. MATERIAL AND METHODS: Between 1992 and 2003, 3146 laparoscopic cholecystectomies were performed in our clinic for symptomatic or complicated cholecystolithiasis. The number of laparoscopic cholecystectomies (LC) increases constantly compared to open cholecystectomies (OC). At the beginning the ratio of LC to OC was 1:20, then 1:1, for a short time, and it is 10:1 presently. Approximately 280 LC and merely 30 OC are carried out in our clinic annually. RESULTS: The most common complications of LC in our material were suppuration of a infraumbilical wound (23) and umbilica hernia (14). A common bile duct injury was observed in nine cases and intraoperative haemorrhage in 11 patients. Infrahepatic abscess (2), bile peritonitis (2), digestive tract injury (1) and abdominal wall haemorrhage (1) appeared rarely. Conversion into an open technique had to be done in 91 cases (2.89%) but only in 34 cases due to intraoperative complications. No deaths connected with LC were observed. CONCLUSIONS: The number of complications after laparoscopic cholecystectomy is not higher than after open cholecystectomy. Laparoscopic cholecystectomy is a save operative technique in the hands of an experienced surgeon.

[CD11b and CD62L receptors expression on neutrophils after laparoscopic versus open cholecystectomy]. / Ekspresja receptorów CD11b i CD62L na powierzchni neutrofilów obojetnochlonnych po cholecystektomii laparoskopowej w porównaniu z cholecystektomia klasyczna.

UNLABELLED: The development of immunology correlated with surgery enables close recognition of multiple mechanisms responsible for more frequent complications observed after open surgical procedures than after minimally invasive operations. OBJECTIVE: Evaluation of selected elements of non-specific immunity in patients undergoing open cholecystectomy (OC) versus laparoscopic cholecystectomy (LC). MATERIAL AND METHODS: 30 postmenopausal females with non-complicated cholecystolithiasis were analysed. Both OC and LC was performed in 15 cases. Blood samples for an analysis were collected 24 hours before surgery and 24 and 72 hours postoperatively. Qualitative changes of neutrophils measured by the expression of CD11b and CD62L receptors on their surface without or with formyl-methionyl-leucyl-phenylalanine (fMLP) stimulation were evaluated. RESULTS: The expression of CD11b and CD62L receptors show no significant changes in patients that underwent LC while patients that underwent OC had significant changes 24 hours postoperatively compared both with their preoperative values and values observed in patients after LC. CONCLUSION: The activation of neutrophils measured by changes of the expression of CD11b and CD62L receptors on their surface is connected with the magnitude of trauma and is only observed in patients after OC.

[The assessment of hepatic portal flow using Doppler's technique in patients after laparoscopic cholecystectomy]. / Ocena watrobowego przeplywu wrotnego metoda Dopplera u chorych po cholecystektomii laparoskopowej.

UNLABELLED: A decrease in hepatic portal flow was observed within two days after open cholecystectomy but such an analysis was not done for laparoscopic cholecystectomy. OBJECTIVE: To answer the following problems: 1. Is there any difference between the volume of hepatic portal flow in patients with cholecystolithiasis and without it. 2. Does hepatic portal flow change within two days after laparoscopic cholecystectomy compared with its preoperative value. MATERIAL AND METHODS: 30 patients without hepatic parenchyma diseases were qualified for the study (21 cases of cholecystolithiasis and 9 cases without cholecystolithiasis). In the group of patients with cholecystolithiasis a maximal portal velocity (Vmax) was measured by Doppler's technique and the diameter of the portal vein (D) before laparoscopic cholecystectomy and 1 and 2 days postoperatively. In the group without cholecystolithiasis these values were measured once. On the basis of Vmax a mean velocity (Vmean = 0.57 x Vmax) of portal flow was calculated. Using Vmean and D values a volume of portal flow was calculated. RESULTS: A mean hepatic portal flow volume in patients with cholecystolithiasis was 725+/-187 ml/min and without it 792+/-229 ml/min. The difference between these values was not statistically significant. No statistically significant differences were also found between values of preoperative and postoperative hepatic portal flow volume. CONCLUSIONS: No statistically significant difference was found between hepatic portal flow volume in patients with and without cholecystolithiasis. Hepatic portal flow does not change significantly within 2 days after laparoscopic cholecystectomy.

[The results of treatment of acute haemorrhagic necrotizing pancreatitis in the own material]. / Wyniki leczenia martwiczo-krwotocznej postaci ostrego zapalenia trzustki w materiale wlasnym.

AIM OF WORK: The retrospective estimation of surgical procedure and the results of treatment of haemorrhagic necrotizing pancreatitis in the own material. MATERIAL AND METHODS: The estimated group consist of 161 patients from the clinic treated for heavy grade of acute pancreatitis. Characteristics which qualified patients to the chosen group were: aggravating general condition, biochemical parameters of disease's progression, results of radiological investigations (USG, CT of abdomen) and bacteriological culture from peritoneal cavity. RESULTS: 142 patients (88.2%) were surgically treated in different duration periods of illness (from 0 to 53 day of illness). Firstly, they were intensively treated with conservative treatment. After about 9.6 days they were operated on (from 0 to 51 day of treatment). Clinical symptoms such as: rapid aggravating general condition of patients, septic shock, as well as infected necrosis in radiological and bacteriological investigations, were indication to surgical intervention. The methods of surgical treatments were: laparotomy and flow drainage 73 patients, closed drainage 31 patients, repeated relaparotomy 25, Bradley's method 13. Mortality in the group of operated patients was 5.9%. The most common causes of death were: respiratory insufficiency 29.4%, multiorgan insufficiency 21.6%, circulatory insufficiency 13.8%, insufficiency of kidneys 9.8% CONCLUSIONS: The authors suggest that the most important in deciding about necessity and time of surgical intervention of haemorrhagic necrotizing acute pancreatitis are individual clinical characteristics of patients. The lowest mortality was in the group of operated patients in later period of illness and who did not required reoperation.