Short hospital stays after laparoscopic gastric surgery under an Enhanced Recovery After Surgery (ERAS) pathway: experience at a single center.

INTRODUCTION: Recently, first reports on benefits from Enhanced Recovery After Surgery (ERAS) pathway in patients undergoing gastric surgery have appeared. It seems that maximal reduction of unfavorable surgery-induced trauma in patients with gastric malignancy via ERAS protocol combined with minimally invasive techniques can improve outcomes. OBJECTIVE: The aim of this study was to determine the influence of laparoscopic surgery and ERAS protocol in oncological gastric surgery on early outcomes. MATERIALS AND METHODS: Prospective analysis involved 28 patients (18 female and 10 male) with gastric malignancy who underwent laparoscopic gastric resection between 2009 and 2013. Gastric tumors (gastrointestinal stromal tumors or adenocarcinoma) were the indication for the surgery. A total of 17 patients underwent laparoscopic local excision, and 11 patients with adenocarcinoma or multiple neuroendocrine tumors underwent laparoscopic D2 total gastrectomy. Perioperative care was based on ERAS principles. Length of hospital stay, postoperative course, perioperative complications, and readmission rates were analyzed. RESULTS: There was one conversion in the gastrectomy group. All patients were mobilized on the day of surgery. Oral fluids were introduced on day 0 and were well tolerated. Full hospital diet was started on day 2 in all patients, but was well tolerated in only 18 of them. One postoperative complication requiring reoperation was noted. The length of stay after gastrectomy and gastric wedge resection was 4.6 (2-6) and 3.3 (2-6) days, respectively. No readmissions were noted in the entire group. CONCLUSIONS: The implementation of ERAS protocol to clinical practice in combination with laparoscopy in patients with gastric tumors can result in improved postoperative care quality, shortening of hospital stay, and quicker return to normal activity.

SILS (single incision laparoscopic surgery) - new surgical approach to peritoneal cavity.

PURPOSE: The objective of the modern surgery is not only to perform surgical procedures aiming to improve the health condition of the patient, but whenever possible to use minimally invasive approach and to ensure the satisfying cosmetic result. During the last years we can observe an intense development of surgical technique minimizing the access to peritoneal cavity to just one small incision, most frequently localized in the umbilicus. MATERIAL/METHODS: Between October 2009 and May 2010 an overall number of 34 laparoscopic procedures through a single abdominal wall incision were performed at the 2nd Department of Surgery, Jagiellonian University, Medical College in Krakow. There were 28 women and 6 men in the study group ranging in age from 19 - 76 years. Among indications for surgery there were: symptomatic gallbladder stones (21 patients), adrenal gland tumours (8 patients), ITP - Immune Thromocytopenic Purpura (2 patients), appendicitis (2 patients) and splenic cyst (one patient). RESULTS: There were 31 out of 34 procedures completed with pure Single Incision Laparoscopic Surgery (SILS) technique as intended preoperatively without any intraoperative complications. In 3 patients additional trocars were needed for safe continuation of the procedure. There were no intraoperative complications. The mean operating time was 82 minutes ranging from 25 minutes (appendectomy) to 180 minutes (right adrenalectomy). Mean intraoperative blood loss was 0 - 30 ccm. CONCLUSIONS: SILS surgical procedures constitute the next step in the development of minimally invasive surgery. In the hands of experienced surgeon this particular technique may constitute a safe alternative for classical laparoscopy.

Cyclooxygenase-2 (COX-2) is the key event in pathophysiology of Barrett's esophagus. Lesson from experimental animal model and human subjects.

Mixed reflux of the gastroduodenal contents induces the esophageal mucosal damage and inflammation progressing chronic esophagitis and premalignant Barrett's esophagus (BE). The role of cyclooxygenase-2 (COX-2) and chronic inflammation in the progression of BE toward adenocarcinoma of the esophagus has not been extensively studied in experimental models of BE in animals and in human subjects. We evaluated the expression of COX-2 in rat model of BE and examined the usefulness of COX-2 expression in determining the risk of malignant transformation in patients with BE treated with argon plasma coagulation (APC) that allows for effective ablation of metaplastic mucosa (group A) without or with proton pump inhibitors (PPI). In addition, the group B of patients was subjected to laparoscopic Nissen's fundoplication and group K that served as control, received PPI treatment only. Expression of COX-2 was evaluated in fresh-frozen biopsy specimens obtained from the distal esophagus in all 60 patients before and 12 months after treatment. In experimental studies, eighty rats were surgically prepared with esophagogastroduodenal anastomosis (EGDA) resulting in chronic esophagitis. At 4 months, the esophageal damage in EGDA rats was evaluated by macroscopic and histological index score, the plasma IL-1beta and TNF-alpha levels was determined by ELISA and the mucosal expression of COX-2 mRNA and COX-2 protein were assessed by RT-PCR and Western Blot, respectively. Chronic esophagitis was developed in all EGDA animals followed by the rise in the plasma TNF-alpha and IL-1beta levels. Histology revealed extensive esophageal ulcerations with development of columnar epithelium, formation of mucus glands in squamous epithelium, intestinal metaplasia distant to anastomosis consisting of goblet cells, infiltration of inflammatory cells including plasma cells and lymphocytes. COX-2 mRNA was absent in the esophageal mucosa of sham-control animals but strongly upregulated in metaplastic Barrett's epithelium. In BE patients, the overexpression of COX-2 was documented in patients with dysplasia. After APC (group A) or Nissen's fundoplication (group B), the expression of COX-2 mRNA was markedly reduced and these effects were positively correlated with histopathological findings. Controls failed to show significant alterations in COX-2 expression. We conclude that 1) EGDA rats serve as the suitable model of the chronic esophagitis by the gastrointestinal refluxate resembling many features of those observed in human Barrett's esophagus, as confirmed by severe morphology changes, excessive release of proinflammatory cytokines TNF-alpha and IL-1beta and overexpression of COX-2, and 2) the significant correlation of the degree of COX-2 overexpression with histopathological findings indicates the usefulness of this inducible biomarker as a valuable indicator of the risk of malignant transformation in patients with BE.