Pobierz program konferencji

th
30 November 2007
Room A
Session A1
Modern approach to gastrointestinal diseases
1.
Meyer H.
Pro and cons of laparoscopic surgery for gastric cancer
(Solingen, Germany)
After the first successful surgical treatment of gastric cancer
performed by Billroth in 1881 R0- resection of the tumor-bearing
organ as well as of the lymph nodes has remained the cornerstone
of surgery for adenocarcinomes of the stomach and esophagogastric
junction. Beside progress of the conventional surgical techniques
and effective perioperative chemotherapy regimens the value of
endoscopic or laparoscopic approaches has been investigated within
the last two decades.
Endoscopic mucosal resection (EMR) or submucosal dissection
(ESD) are indicated and accepted nowadays in special types of early
gastric cancer (uT1a). The spectrum of endoscopic procedures can
be combined with laparoscopic surgery performing wedge resection
of the stomach and intragastric surgery or dissection of the so-called
sentinel lymph nodes.
Furthermore, laparoscopic gastric resection as well as total
gastrectomy was a added as another option compared to
conventional surgery since 1991. The arguments for this procedure
based on general aspects of minimal invasive surgery as less
postoperative pain, faster recovery or shorter hospital stay improving
the early-phase quality of life. Reviewing the actual literature several
single center studies above all in Asia have been carried out
demonstrating that laparoscopic assisted gastric resection for
adenocarcinomas even including D2-lymphadenectomy is feasible
and safe not only in early – but also in advanced tumor stages.
Furthermore, the oncological requirements in regard to the lymph
nodes removed could be fulfilled in some studies but only one
randomized trial with long term results is available.
Although this technique can be preferred by experienced
laparoscopic surgeons the learning curve is long and for shorting
operation time about 30 – 50 cases are necessary above all in
1
patents with a high body mass index. These facts might be the main
problem in the Western countries with decreasing incidence of
tumors localized in the distal stomach, increasing carcinomas of the
esophagogastric junction and patients with high body mass indices
or difficulties to remove the resected specimen with a weight of 3 – 4
kilogram.
Therefore, prospective case registration or randomized controlled
studies are necessary in the future to clarify the short – and long –
term outcomes of laparoscopic surgery for gastric adenocarcinomas.
2.
Kulig J.
Is there a place for Gastric Cancer (GI) treatment improvement in the
next decade?
st
(I Department of Surgery, Jagiellonian University, Krakow, Poland)
Gastric cancer is the one of the most common cancer worldwide,
with a frequency that varies greatly across different geographic
locations. Despite the decreasing worldwide incidence, gastric
cancer accounts for 3% to 10% of all cancer-related deaths.
Although the survival rate for gastric cancer has steadily improved in
countries such as Japan, it has not in Europe and US. Curative
therapy involves surgical resection, most commonly a total or
subtotal gastrectomy, with an accompanying lymphadenectomy. The
overall 5-year survival rate of patients with resectable gastric cancer
ranges from 15% to 40%. Minimal invasive techniques including
endoscopic and laparoscopic resections are used widely in many
centers. In many recent trials chemotherapy vs. best supportive care
consistently demonstrated a significant benefits in terms of overall
survival in favour of the group receiving chemotherapy including
preoperative chemotherapy. This update reviews the methods of
surgical management, multimodal approach and other controversies
over gastric adenocarcinoma.
Predictive models generate important information allowing
a logical evolution in the surgical and pathologic understanding and
therapy for gastric cancer. However, better understanding of the
molecular changes associated with gastric cancer is needed to guide
surgical and medical therapy.
It was concluded that further clinical and basic research studies are
urgently needed to improve results of gastric cancer treatment in the
next decade.
2
3.
Garofalo A.
The role of HIPEC in integrated treatment of peritoneal
carcinomatosis
4.
Philip E. Donahue, M.D.
Foregut Diseases and Endoscopic Tools: Remarkable Development
in Thirty-Five Years.
Endoscopic tools have revolutionized the diagnosis and treatment of
many conditions, including benign and malignant foregut disorders.
During the past 40 years the operative treatments of ulcer disease,
gastroesophageal reflux disease, and achalasia were improved by
endoscopically based modifications. At the same time, improved
medical treatments have led physicians to discourage surgical
interventions; as a result, operations for ulcer disease,
gastroesophageal reflux are infrequently performed. Achalasia of
the esophagus, which is better treated by surgical means, continues
to require surgical treatments, and intraoperative endoscopy is
extremely useful, especially in reoperative surgery.
Combined endoscopic-laparoscopic foregut procedures are
performed for benign conditions such as tumors or cystic lesions
near the gastroesophageal junction or pylorus. In such instance the
endoscopic view confirms that narrowing of the lumen will not occur.
Malignant and premalignant conditions of the esophagus and
stomach can be treated by laparoscopic approaches. Barrett
dysplasia of esophageal mucosa is an ideal indication for
laparoscopic esophageal resection, with gastric interposition.
Gastric cancer, whether localized or advanced, can now treated by
laparoscopic resection with results comparable to open surgery.
Minimally invasive, robotic, and surgical technologies continue to
evolve, presenting administrative staff, hospitals, and surgeons with
difficult choices regarding purchase, maintenance, and use of
equipment. Many challenges remain for the next generation.
5.
Dziki A.
Neoadjuvant therapy in rectal cancer
3
6.
Rosen H.
Modern techniques in the treatment of pelvic floor disorders
(Vienna, Austria)
The “pelvic floor” refers to the pelvic diaphragm, the sphincter
mechanism of the lower urinary tract, the upper and lower vaginal
supports, and the internal and external anal sphincters. Pelvic floor
disorders are problems that affect mostly women’s pelvic organs
When the system of muscles, ligaments and other tissues that hold
up the pelvic organs is damaged or insufficient patients may suffer
from urinary or fecal incontinence or defecation disorders (rectal
outlet obstruction), vaginal prolapse, vaginal pain, sexual
dysfunction, and other problems.
Women who vaginally delivered several children and those who
experienced tears in the perineum and pelvic floor during childbirth,
are at higher risk for pelvic floor disorders.
Additional factors contributing to pelvic floor relaxation include aging,
menopause, connective tissue disorders, history of constipation,,
neurologic conditions, and prior pelvic surgery. Any of these factors
alone or in combination may occur acutely or over time, and result in
some of the very common, above-mentioned problems
While urinary incontinence, vaginal prolapse and other associated
problems are traditionally treated by urologists and gynecologists,
general and colorectal surgeons will be confronted repeatedly with
disorders like faecal incontinence and constipation (with or without
rectal outlet obstruction) due to a raising awareness of patients
affected by these conditions.
While mere mechanical repair of pelvic floor muscles or resectional
surgery of the colon and rectum were the standard of care for most
of these problems in the past, the importance of neurological
pathways for many bowel disorders has become of increasing
interest. Direct stimulation of sacral nerves (sacral nerve stimulation
– SNS) has become an useful and effective tool for the treatment of
many forms of urological as well as faecal incontinence.
Especially, patients with (in the past) so-called idiopathic
incontinence who are regarded to suffer obviously from pudendal
nerve damage, benefit from this method. Furthermore, people
suffering from incontinence based on neurological disorders (e.g.
spinal cord problems ) have shown marked improvement following
SNS.
4
Recently, SNS has also shown first promising effects in the
treatment of patients with constipation based either on slow colon
transit and/or rectal outlet obstruction. However, longer follow up and
a larger number of patients will be necessary to evaluate properly the
effect in this indication.
th
30 November 2007
Room A
Session A2
Evolving surgical techniques
7.
Degiuli M.
Laparoscopic treatment of colorectal cancer
8.
Walz M.
Minimally invasive endocrine surgery
9.
Antoš F., Pilnacek J., Dytrych P.
(Department of Surgery, Institute for Postgraduate Medical
Education, 1st Faculty of Medicine of the Charles University ,
University Hospital Bulovka, Prague, Czech Republic).
Hemicorporectomy as Boundary Problem Solving Procedure
Hemicorporectomy is the most extensive operative procedure at all,
when the body amputation is effected through the lower lumbar area.
The neccessary GI and urinary functions are preserved in the upper
torso.
This extremely rare operation is indicated only as a boundary
problem solving procedure in the cases of :
-crushing trauma to the pelvis
-advance malignant tumors limited to the pelvis
-intractable bedsores with pelvic osteomyelitis
In the literature only 48 cases were described since 1961 when Aust
at the University of Minessota had performed the first successful
5
operation. The best results were achieved in the group of patients
with severe chronic sepsis due to decubitus ulcers with pelvic
osteomyelitis, mostly in traumatic or congenital paraplegics. To this
group our 3 patients can be added ( males of age 34,47 and 35 ).
They underwent the hemicorporectomy 7,6 and 1/2 years ago.
Despite of many specific complications two of them survived and are
living relatively normal life. The third one who had been for several
years in chronic dialysis program died 52 days after the operation
due to pulmonary abscess.
This type of patients need the specific multidisciplinary treatment and
rehabilitation. In order to achieve the successful result the close
cooperation with patient and his active life attitude is mandatory.
10.
Lampe P., Kuśnierz K.
Compression anastomosis clip (CAC) in gastrointestinal surgery –
our experience.
(Katowice, Poland)
Nitinol (Nickel Titanium Naval Ordinance Laboratory),
an alloy containing an almost equal mixture of nickel and titanium,
was invented in the late 1960s.It has generated interest in the
medical device world only in the past decade, when it became a key
component of several revolutionary medical devices including
vascular stents, tools, and grafts.The two physical properties that
make nitinol so remarkable are shape-memory and superelasticity.
These properties enable new types of medical devices to be
designed and produced in diverse fields of medicine.
Gastrointestinal tract anastomosis is a major technical component of
almost all gastrointestinal procedures. The current study was
designed to evaluate the role of a new type of tissue compression
anastomosis performed with a reversible, temperature-dependent
memory-shape device: the compression anastomosis clip (CAC).
The CAC is a double-ring, elliptical device with a diameter of 30 mm.
The elliptical device is immediately introduced into the intestine via
two 5-mm incisions and each ring is slid into one of the two intestinal
loops to be anastomosed. Before the anastomosis is performed, the
CAC is placed in ice water (0°C) to open the rin gs. It then becomes
flexible with an opening angle of 30° to 40°.
The double ring is placed directly on the tissue to exert strong local
pressure and thereby
induce local necrosis.The device has the
ability to recover its original closed shape when it senses a change in
6
ambient temperature (in contact with body temperature). The 5-mm
incision is closed with two 00 or three 000 (PDS,Vicryl) inverting
sutures burying the device.
The continuous compression of the bowel walls entrapped by the
CAC leads to full tissue necrosis after 5 to 7 days. When necrosis
occurs, the ring detaches from the tissue to be expelled with the
stool, and a uniform compression anastomosis is created.
Our experiences-CAC: 8 patients (4 females,4 males), age 48-77.
We performed 8 operations with 9 anastomoses: gastrojejunostomy
– 3, duodenojejunostomy – 1, jejunojejunostomy - 3jejunocolostomy
– 2. We have no complications up today.
11.
Bittner R., Ulrich M.
Laparoscopic sigmoid resection in diverticulitis – how safe is the
double stapling anastomosis? Result of a consecutive series of 350
patients with systematic control of the anastomosis
(Stuttgart, Germany)
According to the literature the rate of clinical relevant anastomotic
insufficiencies after laparoscopic sigmoid resection is mentioned
between 0 – 8 %. Up to now there are no systematically performed
investigations regarding the real leckage rate.
The aim of our study was to investigate with a help of clinical and
laboratory parameters as well as with radiologic anastomotic control
the real rate of insufficiensies after laparoscopic sigmoid resection in
patients with diverticulitis.
Methods
A total of 350 patients who where consecutively operated on
because of sigma diverticulitis where included in this study. In all
patients we measured beside of daily temperature, leukocytes and
CRP preoperatively, at the 2nd, the 4th, and the 6th postoperatively
day. In all patients at the 7th postoperative day we did routinely a
radiologic anastomotic control with an Enema (water-soluble contrast
material).
Results
A clinical relevant anastomotic leakage was found in 5 / 350 (1,4%)
patients.
In
additional
5
/
350
(1,4%)
patients
a radiological detected anastomotic fistula without clinical symptoms
was seen.
7
In the uncomplicated cases CRP and leukocytes were initially
marketly elavated at the 2nd postoperative day, however, already at
the 4th postoperative day a degrease was seen again. Only in the
patients with an insufficiency leukocytes and CRP remain high or
showed a further increase.
Conclusion
The rate of anastomotic leakages after laparoscopic sigmoid
resection because of diverticulitis is low. Temperature, leukocytes
and CRP level are excellent parameters for control of anastomotic
healing. When these parameters do not decrease or even increase
at the 4th postoperative day, there must be suspicion of anastomotic
insufficiency. In these cases a „fast track“ dismission is forbidden.
th
30 November 2007
Room A
Session A3
Inguinal hernia repair
12.
Kingsnorth A.
What is the best mesh for hernia repair
(Great Britain)
Numerous clinical trials indicate that the use of prosthetic material
will reduce recurrence rates for hernia by a factor of 2 or 3. However
mesh requirements for open and laparoscopic repair are different
and mesh requirement for open groin and incisional hernia repair
may be different. A surgeon, before deciding which prosthetic to
apply to the abdominal wall, must be aware of the different
applications, contraindications and incidenceof complications of each
prosthetic material. No ideal material exists and currently at least 80
prosthetic materials are available. There is no long-term clinical or
experimental data supporting the use of most new devices.
The ideal mesh should provide a permanent repair with good
ingrowth characteristics and not alter the compliance of the musculofascial abdominal wall. In addition it should be resistant to infection
with a lack of adhesion formation. Undesirable characteristics such
as seroma formation and risk of intestinal obstruction or fistula
formation with mesh degradation, is another important feature. Pore
8
size and whether a mesh is macro- or micro-filament and whether it
is permanent or absorbable with a competent structure all determine
these characteristics.
Recently there has been a fashion for using lightweight mesh
because of fears of profound foreign body reaction resulting in
reduced abdominal wall compliance leading to stiffness and possibly
pain. However this has not been borne out by experimental studies.
Randomised trials carried out to date indicate that in incisional hernia
there is no advantage for using lightweight meshes. However for
inguinal hernia, although lightweight meshes do not reduce the
incidence of severe groin pain following surgery, there may be some
benefit in terms of feelings of a foreign body and pain on exercise.
Therefore based on these findings a surgeon can determine which
mesh to use in which surgical situation for repair of abdominal wall
hernia.
13.
Kozol R., Novitsky Y.
Inguinal hernia repair, Past Present and Future
(Connecticut, USA)
For about 100 years native tissue repairs were the norm for fixing
inguinal hernias. Late in the 20th century, prospective data revealed
that the recurrence rate for native tissue repairs was 15 to 30%
depending on the size of the hernia and the technique of repair. In
addition, 10 to 20% of patients have chronic pain after surgery. The
relatively high recurrence rates were attributed to tension which is
inherent with native tissue repairs. Surgeons therefore turned to
prosthetic mesh to create “tension free” repairs. This innovation has
significantly lowered recurrence rates.
Laparoscopic repairs were devised in the early 1990s. Early on,
these mesh repairs were plagued by a high recurrence rate due to
insufficient mesh size. This has since been corrected. Prospective
data now suggest a recurrence rate between 5 and 10% for tension
free repairs (open or lapaproscopic). The hernia literature is replete
with individual series claiming recurrence rates of 0-1%.
Most of these papers have poor follow-up or follow-up by phone or
post card rather than physical examination (the gold standard for
hernia follow-up).
Prosthetic mesh materials are foreign bodies and most material is
stiff and unnatural. Whether the chronic pain seen in some patients
is due to mesh or tacks is unclear. The metal tacks are now being
9
replaced by their absorbable counterparts. The development of
reliable biologic glues will further reduce the need ror any tacking of
the mesh in the groin. Furthermore, current evidence suggests that
the old-fashioned “heavy-weight” polypropylene meshes were
associated with an increased local inflammation and dense scar
formation, manifesting clinically by patients’ foreign body sensation
and chronic discomfort. A few newer meshes, so-called “light-weight”
meshes,
have
a
reduced
amount
of
a foreign material, thus minimizing adverse sequella of
a prosthetic mesh. With the advent of tissue engineering, the future
is likely to see repairs with absorbable scaffolding fixed with biologic
glues. The scaffolding would eventually be replaced by fibroblasts
and collagen. Hence, we may be headed to a new era with a return
to a native tissue repair but with a “space age” twist.
14.
Feleshtynsky Ya.P., Mamchich V.I., Chyn’ba O.V., Philip M.S.,
Kuznetsov O.O.
Surgery for difficult recurrent inguinal hernias
(Kyiv, Ukraine)
Recurrent inguinal hernias with pronounced cicatrical/atrophic
changes in the inguinal area and the inguinal ligament destroyed are
of special complexity for technical performance in the repeated
operation. The results of surgery for such hernias remain to be
unsatisfactory as evidenced by the recurrence rate that amounts up
to 25-30% [1, 3, 4].
As a rule, impairments in the inguinal ligament appear following
repeated operative interventions, rugged manipulations, and
herniotomies resulting in cicatrical/atrophic changes in the inguinal
ligament
itself
and
in
the
formation
of
a general inguinal/femoral defect in the abdominal wall, plastic
closure of which not infrequently is an intricate problem [2, 5].
Materials And Methods
During the period of 2000 to 2007, 67 patients, aged 50 to 78, with
recurrent inguinal hernias and the inguinal ligament destroyed were
operated on by a method developed at our Clinic. All the patients
were males.
Sixty recurrences have occurred following inguinal hernioplasties,
7 following femoral hernioplasties. At that, inguinal hernias have
recurred for the second time in 34 patients, and 17 patients have had
10
recurrences 3 to 5 times. Recurrent inguinal hernias were right-sided
in 40, left-sided in 18, and bilateral in 9 patients.
In all of the patients, surgical operations were performed under local
anesthesia combined with neurolepanalgesia. In its essence, the
operation consisted in the following. After approaching the inguinal
canal and removing the cicatrically changed tissues, the spermatic
cord was taken aside on a handle. Then, a hernial sac was
separated, stitched by a purse-string suture and either removed or
invaginated into the abdominal cavity. After that, a polypropylene
mesh with a hole for the spermatic cord was positioned
preperitoneally beneath the transverse fascia and fixed to pubic
tubercle, Cooper’s ligament, inguinal ligament remnants, anterior
superior iliac spine periosteum as well as transverse aponeurosis
and abdominal internal oblique muscle. Then, flaps of the abdominal
external oblique aponeurosis were sutured contactly above the
spermatic cord. The wound was sutured layer-by-layer and drained
by a vacuum method.
The prophylaxis of complications on side of the wound was
accomplished by intravenous amoxyclav 1.2 g 30 minutes prior to
the operation and by adequate drainage.
Results and Discussion
In the immediate postoperative period, serous inflammation in the
area of wound was noted in 4 (6%) patients, infiltrate in 2 (3%),
wound abscess in 2 (3%), orchitis in 1 (1.5%), and local neuralgia in
4 (6%) patients. These complications were treated with conservative
measures,
such
as
non-steroid
anti-inflammatory drugs
(diclophenac, movalis). The remote results of surgery were
examined in 60 of the patients within 1 to 5 years by means of the
follow-up examinations. No recurrence of incisional hernia was
revealed. The absence of recurrences in the remote postoperative
period indicates mechanically reliable hernioplasty by the method
proposed; as far as the polypropylene mesh is fixed to Cooper’s
ligament and anterior superior iliac spine periosteum, the mesh
migration is also precluded.
Conclusion
The results of clinical approbation confirmed that the proposed
method of surgery for recurrent inguinal hernias with the inguinal
ligament destroyed allows a considerable reduction to be reached in
the repeated recurrence rate of inguinal hernias, and can serve as a
method of choice in patients of this category.
11
15.
Pach R., Legutko J.
Short history of groin hernia treatment.
(Krakow, Poland)
Hernia (Greek kele/hernios – bud or offshoot) was present in the
human history from its very beginning. Surgery developed in ancient
times
when
human
had
to
cope
with
traumas.
The role of surgery was restricted to the treatment of huge umbilical
and groin hernias and life – threatening incarcerated hernias.
The treatment of groin hernia can be divided into several eras.
The oldest epoch was ancient era from ancient Egypt to 15th
century. The Egyptian Papirus of Ebers contains description of
a hernia: swelling that comes out during coughing.
Most essential knowledge concerning hernias in ancient times
derives from Galen. He stated that hernia formation is connected
with rupture of the peritoneum. In addition Galen divided hernias into
three groups: bubonocele, enterocele and omphalocele. This
knowledge with minor modifications was valid during Middle Ages
and eventually in the Renaissance the second era of hernia
treatment began. Herniology flourished mainly due to many
anatomical discoveries. In spite of many important discoveries from
18th to 19th century the treatment results were still unsatisfactory.
Astley Coooper stated that no disease treated surgically involves
from surgeon so broad knowledge and skills as hernia and its many
variants.
Introduction of anesthesia and antiseptic procedures constituted the
beginning of modern hernia surgery known as era of hernia repair
under tension (19th to middle 20th century). Three substantial rules
were introduced to hernia repair technique: antiseptic and aseptic
procedures, high ligation of hernia sac and narrowing of the internal
inguinal ring. In spite of the progress the treatment results were poor.
Recurrence rate during four years was ca. 100 per cent and
postoperative mortality gained even 7%.
The treatment results were satisfactory after new surgical technique
described by Bassini was implemented. Bassini introduced the next
rule of hernia repair ie. reconstruction of the posterior wall of inguinal
canal. The next landmark in inguinal hernia surgery was the method
described by Canadian surgeon E. Shouldice. He proposed
imbrication of the transverse fascia and strengthening of the
posterior wall of inguinal canal by four layers of fasciae and
12
aponeuroses of oblique muscles. These modifications decreased
recurrence rate to 3 per cent.
The last epoch in the history of hernia surgery lasting to present days
is referred to as era of tensionless hernia repair. The tension of
sutured layers was reduced by incisions of the rectal abdominal
muscle sheath or using of foreign materials. The turning point in
hernia surgery was discovery of synthetic polymers by Carothers in
1935. The first tensionless technique described by Lichtenstein was
based on strengthening of the posterior wall of inguinal canal with
prosthetic material. Lichtenstein published the data on 1000
operations with Marlex mesh without any recurrence in 5 years after
surgery. Thus fifth rule of groin hernia repair was introduces –
tensionless repair.
Another treatment method was popularized by Rene Stoppa, who
used Dacron mesh situated in preperitoneal space without fixing
sutures. Fist such operation was performed in 1975, and reported
recurrence rates were quite low (1,4%).
The next type of repair procedure was sticking of a synthetic plug
into inguinal canal. Lichtenstein in 1969 used Marlex mesh plug (in
shape of a cigarette) in the treatment of inguinal and femoral hernias.
The mesh was fixated with single sutures. The next step was
introduction of a Prolene Hernia System which enabled repair of the
tissue defect in three spaces: preperitoneal, above transverse fascia
and inside inguinal canal.
Laproscopic treatment of groin hernias began in 20th century.
The first laparoscopic procedure was performed by P. Fletcher in
1979. In 1990 Schultz plugged inguinal canal with polypropylene
mesh. Later such methods like TAPP and TEP were introduced.
The disadvantages of laparoscopic approach were: high cost and
risk connected with general anesthesia.
In conclusion it may be stated that history of groin hernia repair
evolved from life-saving procedures in case of incarcerated hernias
to elective operations. The five milestones of hernia treatment history
are thoroughly described in this presentation.
16.
Solecki R., Matyja A., Szczepanik A., Kulig J.
Emergency inguinal hernia repair
(Krakow, Poland)
Tension-free hernioplasty is a standard method for elective inguinal
hernia repair. Incarcerated hernia is life-threatening condition and
13
should be always managed on emergency. Although many studies
evaluated the role of the mesh for the repair of incarcerated hernias,
the problem is still controversial.
The study evaluates treatment results in a group of patients with
incarcerated inguinal hernias operated on emergency with tensionfree method.
Materials And Methods
Between 2000 and 2006, 66 patients with incarcerated inguinal
hernias were operated on emergency. Lichtenstein tension-free
hernioplasty was performed in 44 patients, PHS method in another
12, and Robbins-Rutkow technique in 10. Fifty patients were
operated under spinal anaesthesia and 16 were subjected to
hernioplasty and laparotomy under general anaesthesia. All patients
received antibiotics. We routinely used Redon’s inguinal drainage
and peritoneal drainage in the patients undergoing laparotomy.
Results were compared with a group of patients treated between
1995 and 1999.
Results
Postoperative complications included 2 wound infections,
4 seromas and 4 neuralgias. Four patients developed transient
retention of urine. The rate of perioperative complications was similar
in the patients operated with tension-free method and in those
undergoing traditional operations between 1995–1999. The
recurrence rate was 1.5% in the study group and 7.3% in the
patients operated with traditional method.
Conclusions
Tension-free hernioplasty is effective for the treatment of
incarcerated inguinal hernia with a low recurrence rate. Incarceration
of inguinal hernia is not a contraindication to the tension-free
procedure.
th
30 November 2007
Room A
Session A4
Techniques of hernia repair
14
17.
Trojanowski P.
Laparoscopic or open hernioplasty - pros and cons
18.
Wróblewski T., Skalski M., Nyckowski P., Krawczyk M.
Laparoscopic approach to abdominal wall hernias
(Warsaw, Poland)
Introduction
Laparoscopic hernia repair with IPOM technique (Intraperitoneal Onlay Mesh) was first reported in 1993. This procedure entails
laparoscopic mesh placement directly on the peritoneum of the
abdominal wall. The mesh covers the hernia defect and is placed
after dissection of the contents of the hernia sac. However the first
results were not satisfactory because of using traditional, no
covered by anti-adhesive layer meshes, earlier applied to inguinal
hernias. They caused the development of adhesions between
jejunum and mesh which eventually led to jejunal fistulas. Recently,
new kind of meshes have been used in IPOM technique. There are
lined on their ventral surface with anti-adhesive material which
protects from described complications.
The aim of the study was to present new possibilities in the treatment
of ventral hernias by IPOM laparoscopic technique. We also report
on the results of applying new anti-adhesive meshes in our patients.
Materials And Methods
Fifteen patients (10 women and 5 men), aged from 26 to 67 years
(mean 42yrs) with 5 umbilical, 4 midline and 6 huge, incisional
hernias were operated on using laparoscopic IPOM technique
between November 2004 and April 2007. We used 3 trocars for
umbilical hernia repair and from 3 to 5 trocars for incisional hernia if
needed. Trocars for umbilical hernia were placed in the anterior
axillar line. First trocar for incisional hernia repair was placed by
“opened” technique to avoid the damage of attached tissues.
To release adhesions between incisional hernias and intestines and
omentum we used harmonic scalpel. New type of meshes: polyestercollagen or polypropylene - PVDF coated were used. All meshes
overlapped minimum 3-4 cm margins of hernias. They were attached
to the abdominal wall using suture-passer for positioning of the mesh
and next stapled each two cm.
15
Umbilicus was placed, under laparoscopic control, in the proper
position using one stitch through all abdominal layers.
Results. The size of meshes ranged from 10cm – for round shaped
umbilical ones to 30x30cm – for huge postoperative hernias.
Uncomplicated postoperative course was observed in 13 patients
and they were discharged on the second (umbilical hernia) or on the
third day for others. Two patients, operated on for midline hernia
experienced symptoms of adynamic ileus that were relieved with
medical treatment after one week period. Both patients had large
30x30cm PVDF meshes implanted. No wound infection, hernia
recurrence or quality of life worsening was noted during the follow up
period.
Conclusion
Laparoscopic IPOM hernia repair technique is an effective method of
ventral hernia repair and can be an interesting alternative to
commonly used techniques. Presented results show benefits of
IPOM technique over the classical approach: no wound infection and
shortening of hospital stay.
19.
Śmietański M.
Standards of groin hernia repair in Europe and USA.
(Gdańsk, Poland)
Standards of care are introduced to identify the minimal level of the
operative technique which is still accepted in the treatment of
described illness. Standards are based on literature reviews of the
scientific publications (indexed in PubMed, Medline or Cohrane
Library) of good quality (metaanalysis, RCT) to create the
recommendation for the clinical practice currently used. In the EU
only few standards of groin hernia repair were published (UK,
Holland, Poland). Similar guidelines were also published in US. In
2007 European Hernia Society will issue the EU guidelines for
inguinal hernia repair.
Author review the existing and proposed issues according to:
1. the need for a mesh in hernia treatment and choice of
the method.
2. method for ideal hernioplasty in young men
3. place of laparoscopy in groin hernia repair in the next
years
4. the choice of anesthesia
16
5. use of mesh in infected field
6. day surgery in the operative treatment of hernia.
7. role of national registers in quality control
Introducing of a standard is also a great challenge for national
surgical societies and health system authorities. Quality of care
should be monitored by national hernia registers, and based on the
standardized protocols. The recommended procedures should be
reimbursed by national health systems according not only to the
costs but also to the results reported by the hospitals. The hernia
centers for education should be create to increase the level of
surgical treatment in the daily hospital practice.
th
30 November 2007
Room B
Session B1a
Breast cancer
20.
Mituś J., Łuczyńska E., Herman K., Anioł J.
Ultrasound guided mammotomy in BI-RADS 4 and 5
(Krakow, Poland)
In addition to mammography, ultrasonography has became
a standard breast- imaging procedure during the last 15 years
because of rapid technological advances such as the use of alldigital high – frequency transducers of up to 13 MHz, color, and
power Doppler imaging, and harmonic imaging. Although breast
sonography has historically been used for differentiating fluid from
solid lesions, there has been growing interest in using sonography to
differentiate benign from malignant solid masses. Ultrasonography
has many advantages as guidance technique for percutaneous
breast biopsy, including lack of ionizing radiation, real- time
visualization of the needle, multidirectional sampling, and low cost.
The main disadvantage of ultrasonographic guidance is that the
lesion must be seen in sonography in order to be biopsied.
Nowadays, sonography plays an important role in guiding
interventional procedures such as needle aspiration, core needle
biopsy, and prebiopsy needle localization.
A lexicon of sonographic descriptions of breast masses with
attendant assessment categories ( breast Imaging Reporting and
17
Data System/ BI-RADS/ has been developed by the American
College of Radiology to enhance the clinical efficacy of breast
sonography and standardize terms for lesion characterization and
reporting. The sonographic BI-RADS lexicon includes sonographic
descriptions for shape, orientation, margins, lesion boundary, echo
pattern, posterior acoustic shadow, and surrounding tissue
alterations.
American College of Radiology BI-RADS Classification. Final
Assessment Categories:
Assessment incomplete Category 0: need additional imaging
evaluation
Assessment complete ( final categories )
Category 1: negative
Category 2: benign finding
Category 3: probably benign finding: short interval follow- up
suggest
Category 4: suggestive abnormality: biopsy should be considered,
Category 5: highly suggestive of malignancy: appropriate action
should be taken
Category 6: known biopsy- proved malignancy
The Mammotome Vacuum biopsy allows the removal of several core
biopsies without replacement of the needle by performing multiple
aspirations following rotation of the mammotome probe through
approximately 90°. The goal of percutaneous biopsy is diagnosis, not
treatment.
The diagnostic accuracy of histological sampling by mammotome
vacuum biopsy in malignant tumors has been found to be as high as
98%. Mammotome Vacuum biopsy is most often used to evaluate
nonpalpable lesion that are suspicious for malignancy ( BI-RADS
category 4). A careful study of the sonographic descriptions
associated with class 4 showed that the lesions that proved to be
malignant were frequently associated with hypoechoic echo pattern,
indistinct margins, antyparallel orientation. Approximately 20- 40 %
of BI- RADS category 4 lesions represent carcinoma. If mammotome
vacum
biopsy
of
a
category
4
lesions
yields
a benign diagnosis concordant with the imaging characteristics (as it
usually does), the woman is usually spared the need for diagnostic
surgical biopsy
Controversy exists regarding the use of Mammotome Vacuum
biopsy in the evaluation of lesions that are highly suggestive of
18
malignancy ( BI-RADS category 5) approximately 75- 90 % of which
represent carcinoma. These lesions generally show more than
3 suggestive characteristics of malignancy: irregular shape, indistinct
or angular margins, parallel orientation, echogenic halo, and
posterior acoustic shadowing. In the beginning, the doctors weren’t
confident in biopsying the BI-RADS 5 lesions with the Mammotome.
The usefulness of vacuum-assisted biopsy for category 5 lesions
depends on the surgical treatment protocol. If the vacuum-assisted
biopsy is performed and confirms the presence of carcinoma, it
would spare a surgical procedure. If the size of the lesion is small
and carcinoma is not confirmed, the patient stays under observation.
In case of non-surgical, large lesions obtaining the samples and
histopathological recognition allows for establishing the treatment
plan.
If vacuum-assisted biopsy of small lesions category BI-RADS 4 and
5 is performed, it is required to place a localizing clip at the place of
biopsy.
21.
Popiela T.J.
Mammotome biopsy of preclinical breats pathologies guided by
visualizing methods
(Krakow, Poland)
The study evaluates the effectiveness of the mammotome biopsy
(MB) in detecting preclinical breats lesions.
Materials And Methods
The study was conducted in 853 women qualified to mammotome
biopsy based on the results of clinical examination, mammography,
ultrasonography and additionally magnetic resonance findings in a
group of women at high risk. Out of these 28 women underwent
open surgical biopsy due to the localization of pathology or lack of
informed consent to the mamotome biopsy. Ultrasound-guided
mammotome biopsy was performed in a total of 496 women, digital
mammography guided mammotome biopsy in 323, and MR-guided
MB in 6.
MR-guided mammotome biopsy was performed in a group of
patients at high risk, where other visualizing examinations failed to
detect suspected focal lesions. All women with histopathologically
confirmed cancer foci or atypical ductal hyperplasia (ADH) were
qualified to surgery. The remaining
686 patients
with
19
histopathologically confirmed benign lesions were included in the
long-term follow-up with the use of visualizing examinations. The
period of follow-up for 411 (60%) women, who reported to control
examinations was 4 years.
Results
Mammotome biopsy detected 99 (12%) breast cancers and 726
(88%) benign lesions with the sensitivity of 97.2% and specificity of
100%. Four (0.4%) patients developed haematoma over 2cm in
diameter requiring aspiration.
Conclusion
Mammotome biopsy is an alternative method to open surgical biopsy
connected with low risk of complications and may be used on
ambulatory basis. It should be used as a procedure of choice in the
patients undergoing MR-guided biosy.
22.
Herman K., Wysocki W.M., Mituś J., Tabor J.
Wire-guided breast tumorectomy and sentinel node biopsy - one step
procedure in BI-RADS 5 lesions
(Krakow, Poland)
There is ongoing debate on the optimal diagnostic and curative
procedure for non-palpable breast lesions combined with sentinel
node biopsy in patients with very strong suspicion of breast cancer
(BI-RADS 5). In these patients it is tempting to perform in one-step
both diagnostic procedure (i.e. tumorectomy) and ultimate staging
(i.e. minimally invasive evaluation of axillary sentinel node). Currently
two competitive breast localization techniques are available: wireguided open breast biopsy and radio-guided occult lesion localization
(ROLL). Both techniques seems to be equally effective in terms of
diagnostic accuracy and curative potential. ROLL technique warrants
usage of radio-tracer, which is also necessary to perform sentinel
node biopsy. Therefore proponents of this approach argue that
ROLL should be first-choice procedure if sentinel node biopsy is also
planned, because it is resource efficient and time advantageous.
Wire-guided localization on the other hand is less technically
demanding and less expensive (however health cost estimation
varies greatly between European countries). Proponents of this
technique underline, that reported deterioration in the quality
visualization of sentinel node was not due to the wire itself, but due
to generally low sentinel node detection rate. Additional argument for
20
simultaneous breast tumorectomy (wire-guided or radio-guided) and
sentinel node biopsy is that both procedures could be performed
using the same skin incision (with exception of lesions located in the
medial breast quadrants). Therefore in the patients with very high
probability of breast malignancy (i.e. BI-RADS 5) invasiveness of the
diagnostic tumorectomy is only slightly increased by simultaneous
sentinel node biopsy. Additional morbidity is minimal and advantage
of one-step procedure for diagnosis and treatment is very promising.
In the Department of Surgical Oncology, MSC Memorial Institute of
Oncology wire-guided breast biopsy combined with sentinel node
biopsy was performed in 30 BI-RADS-5 patients from 2005 to 2007.
The probability of malignancy in BI-RADS 5 patients averages 98%,
therefore invasive diagnostic and curative approach in these cases is
justified. Wire-guided tumorectomy combined with simultaneous
sentinel node biopsy is simple and effective method for both
diagnosis in BI-RADS 5 patients and subsequent treatment tailored
at breast conservation.
23.
Polkowski W.P., Romanek J., Kurylcio A., Stanisławek A.,
Jankiewicz M., Winkler B.,
Mielko J., Lewicka M., Gołębiewska R., Chrapko B., Kurylcio L.
Targeted Intraoperative Radiotherapy and Sentinel Node Biopsy for
Breast Conserving Treatment in Patients with Early Breast Cancer
(Lublin, Poland)
Introduction
Intraoperative radiotherpy (IORT) facilitates delivery of a single dose
of radiation directly to the tumour bed following wide local excision of
the tumour by surgeon in a standard operation theatre. Sentinel node
biopsy (SNB) is a minimally invasive method of regional lymph node
evaluation, that enables selective axillary lymphadenectomy only in
breast cancer patients with proven lymph node involvement. The aim
of the study is analysis of early results of the breast conserving
treatment (BCT) in patients with breast carcinoma using both
techniques (IORT+SNB) simultaneously.
Patients and Methods
Between January 2006 and September 2007, BCT was performed in
186 patients (59% of all patients treated surgically for breast
carcinoma). The treatment protocol was approved by our local
Ethical Committee and only patients who signed the written informed
21
consent were entered. Diagnosis was based on clinical examination,
mammography, ultrasound and core biopsy. Patients with primary
tumour ≤ 2 cm and clinically negative axillary lymph nodes
(ultrasound ±fine needle aspiration cytology) were eligible for BCT
using IORT+SNB. SNB was done using isotope-dye technique with
the preoperative lymphoscintigraphy. The INTRABEAM PRS 500
system (Carl Zeiss, Oberkochen, G) was used for irradiation of the
tumour bed with the dose of 20 Gy at the applicator surface (energy
18 keV). After completion of the adjuvant treatment (chemo/hormonotherapy), whole breast external beam irradiation was
performed with a total dose of 50 Gy, omitting the tumour bed.
Results
Out of the 186 BCT procedures, the IORT+SNB was done in 61
patients. Two patients had moderate reddening of the skin wound
which was noted postoperatively and disappeared spontaneously
within two weeks. One patient has wound infection and delayed
wound healing. Another three patients had minor seroma formation
which resolved after several punctures of fluid collection.
In 8 patients (13%), surgical specimen pathology report revealed
microscopically positive margin. Re-excision of the margins was
performed in 7 of these patients, resulting in breast conservation and
good cosmetic effect. In one patient mastectomy was necessary
because neoplastic cells found in re-excison specimen. In 8 patients
(selective) axillary lymphadenectomy was necessary following
positive SNB(+IORT), while the sentinel lymph node was found to be
the only positive axillary node in 3 patients. In another patient both
positive SNB and positive margins necessitated subsequent
mastectomy. In all patients after breast conservation we observed
a very good immediate (mean observation time 40 weeks) cosmetic
effect. All patients scored the cosmetic effect as very good. There
was no delay in the start of the adjuvant treatment; all patients
received the treatment within 3 weeks postoperatively.
Conclusions
In our experience, the combined SNB, wide local excision of the
tumour
and
IORT
is
a
safe
surgical
procedure.
The combination of the BCT components leads to improved patients’
satisfaction by excellent cosmetic effect and shortening the time of
treatment. Preliminary results of the treatment justify to continue
participation in the international randomised clinical trial evaluating
targeted IORT (TARGIT).
22
th
30 November 2007
Room B
Session B1b
Infectious complication in surgery
24.
Kulig J., Grabowska I., Pach R., Gara K.
Infections in surgery – still the diagnostic and therapeutic dilemma.
Introduction:
Even though microbes are small and their life is so short they take
a heavy toll of human lives and involve a lot of expenses from the
hospital budget. The pivotal role in their biological success play
unique properites of the procaryotic cell. Thanks to them bacteria
can for example avoid beeing killed by immunity system of the host
or survive despite of the antimicrobials precence in environment.
The patiens undergoing surgical procedures are paricularly sensitive
to consequences of the microbes activity because of the injury, the
presence of foreign devices and immunity system failure.
Aim
This presentation will be focused on the diagnostic and therapeutic
difficulties The most important thing is to obtain reliable diagnostic
data as soon as possible to optimize initial, empirical treatment. The
progress of
the microbiology, molecular biology
and
the
introduction of the automatic systems contribute to shortening
waiting time for results. Unfortunately treatment team have to make
decision on the basis of the tentative diagnostic data and incomplete
information because therapy cannot be deferred in many cases.
Knowledge of the patients clinical condition, the source of the
infection and the local, epidemiological data are very supportive in
planning the treatment strategy and the reasonable use of
antibiotics. This decision influence not only one patients because of
adverse events or ineffectiveness. There is shown that the empiric
therapy is the most important cause of the drug resistant strains
selection which causes mortality and morbidity in the hospital.
Surveillance study performed in the I Dept. of General and GI
Surgery in Krakow between Jan. 2005 and Sep. 2007 showed
positive results of therapy with cephoperazone+sulbactam. The
treatment outcomes of 139 patients, indications to antimicrobial
23
therapy, pathogens’ isolated and their susceptibility to antimicrobial
agents are reported in this presentation.
Conclusion
In the making decisions process we still move on the very wide field
of uncertainty. Microbiology data are irreplaceable and the laboratory
“feedback” is really helpful to decrease consequences of the
antimicrobial therapy limitations.
25.
Bulanda M.
Current approach to Gram positive nosocomial infections.
th
30 November 2007
Room B
Session B2
Adjuvant treatment in cancer
26.
Ruka W.
Treatment of advanced gastrointestinal stromal tumours (GISTs) with
imatinib. Combined imatinib therapy and surgery.
The introduction of imatinib mesylate (Glivec®; Novartis),
a small-molecule selective inhibitor of the receptor tyrosine kinases
stem-cell factor receptor (KIT, CD117), BCR-ABL and PDGFRs-α
and -β, revolutionized the treatment of advanced CD117+ GISTs the most common mesenchymal neoplasms of digestive tract. The
clinical activity of imatinib was confirmed in several clinical trials
conducted in GIST patients. The results of clinical trials indicate on
significant rate of therapeutic responses with imatinib leading to 3year overall and disease-free survival rate approximately 70% and
50%, respectively. These results were confirmed by analysis of
imatinib treatment outcomes in the group of 232 patients with
advanced inoperable/metastatic GIST in a prospectively collected
Polish Clinical GIST Registry. Consecutive computed tomography
imaging is regarded as a method of choice for evaluating efficacy of
imatinib in GIST, but there are controversies about the adequate
assessment using RECIST criteria. With longer follow-up time the
resistance to imatinib therapy and increase of disease progression
24
rate is observed. Surgical removal of residual disease during imatinib
treatment may allow for complete remission in selected GIST
patients after response to therapy, theoretically prolonging durable
remission. In a selected group of patients with advanced GIST who
had responded to targeted therapy surgical excision seems to be an
independent factor for better treatment outcomes.
27.
Szawłowski A.
Postoperative radio-chemotherapy for advanced gastric cancer
28.
Schlag P.
Diagnosis and therapeutic strategy of peritoneal carcinoamtosis in
gastric cancer
29.
Gruenberger T.
Visions of tumour resection and Avastin therapy
30.
Ruka W.
SUTENT – the second-line drug in the therapy of GIST
Sunitinib malate (SUTENT®; Pfizer), an oral multitargeted tyrosine
kinase inhibitor of KIT and PDGFRs-α and -β, as well as VEGFRs-1,
-2, -3, FLT3, CSF-1R, and RET, combining antiproliferative and
antiangiogenic activity, is the first compound to receive multinational
approval for treatment of imatinib-resistant or -intolerant advanced
gastrointestinal stromal tumors (GIST). Sunitinib has demonstrated
significant antitumor activity in the clinical setting: the results of
phase I/II and randomized phase III trials showed objective clinical
benefit in more than 50% GIST patients who received sunitinib after
failure of prior imatinib treatment, especially in exon 9 KIT mutations
or wild-type carriers. In a randomized, double-blind, placebocontrolled phase III trial sunitinib demonstrated reduction the risk of
death by 51% as compared with placebo. Similar results were
observed during treatment of more than 40 patients in Poland
(partially in clinical trial and partially with reimbursement of cost o
therapy by National Health Fund). In five cases of 40 sunitinib
therapy caused partial remission of advanced GIST leading to
possibility of resection of residual lesions. These patients continued
25
sunitinib therapy after resection and demonstrated long-term disease
remission. Sunitinib therapy should be started from the dose of 50
mg once daily in the regimen 4 weeks on/2 weeks off. The dose of
SUTENT may be modified in case of toxicity by decrease to 37.5 or
even 25 mg. Currently under investigation is continuous schedule of
dosing (37.5 mg every day), which shows promising results. The
most serious treatment-related adverse events reported by GIST
patients receiving SUTENT include hand-foot syndrome, fatigue,
neutropenia, thrombocytopenia, anaemia, diarrhea, arterial
hypertension and hypothyroidism.
31.
Preto J., Pimenta A., Gouveia A., Almeida T., Soares C.,
Magalhães A., Ferreira A., Oliveira Alves J., Sousa R., Cardoso
de Oliveira M.
“Early” carcinoma of stomach and cardia
(Porto, Portugal)
Objective
Study retrospectively a series of patients with the diagnosis of “early”
carcinoma (T1) of stomach and cardia. The aim is to analyse the
clinical-pathological characteristics and to select the factors that
influence the survival of the patients treated for these “early
cancers”.
Materials And Methods
The authors have selected the patients with “early” carcinoma of
stomach and cardia (Siewert type II and III) treated between January
1977 and February 2006 in the Esophago-Gastric Unity of our
Service. In the 115 cases found (10,4% of all treated cases), the
following clinical-pathological parameters were analyzed: age and
gender, size and location of tumours, depth of wall penetration
(mucosa vs submucosa), lymph node metastases and stage (pTNM);
classifications of Lauren and WHO, lymphatic permeation and
venous invasion. Survival was calculated by the Kaplan-Meier
method.
Results
The average of ages in this subgroup of patients was 59,75 and the
median 63; there were 65 men and 50 women. The tumors were
located in the gastric antrum in 81 patients (71,7%) and 47,2% of the
cases had tumor size ≤ 2 cm; the carcinoma were confined to
26
mucosa in 52 cases (45,2%) and had submucosal invasion in 63
(54,8). Twenty six patients (22,8%) had lymph node metastases and
10 (9,1%) presented venous invasion.
In univariate analysis, significant differences were observed in the
survival of the patients according to classification of Lauren
(p=0.004), venous invasion (p=0.007), lymphatic permeation
(p<0.02), and lymph node metastases (p<0.02).The 5 year
cumulative survival rate of this group of patients was 77,4%.
Conclusion
These results emphasize the prognostic value of the parameters
venous invasion, lymphatic permeation and lymph node
metastization, in “early” carcinomas of stomach and cardia.
Otherwise, they show a statistically significant association between
lymph node metastization, in one side, and size and depth of wall
penetration (mucosa vs submucosa) of tumors, by other side.
32.
Gouveia A., Pimenta A., Preto J., Soares C., Magalhães A.,
Almeida T., Ferreira A., Oliveira Alves J., Rodrigues S.,
Amendoeira I., Cardoso de Oliveira M.
The value of peritoneal lavage cytology in gastric carcinoma
(Porto, Portugal)
Objectives
Study a group of patients with gastric carcinoma, treated in an
Esophageal-Gastric Pathology Unit of a General Surgery Service,
and evaluate the value of cytology of intra-operative peritoneal
lavage (IOPL) on the prognosis and therapeutic decision of these
tumours.
Materials And Methods
Patients with gastric carcinoma in which a cytological exam was
performed on the IOPL, were studied in the period between January,
1996 and February, 2006. In the 295 selected cases, the results of
the cytologies performed at the beginning and the end of the surgical
intervention were analyzed, besides the various other clinicalpathological parameters. The survival was calculated by the KaplanMeier method, and the multivariate analysis performed according to
a logistic regression model.
RESULTS: The average of ages of the patients studied was 64,4
years and the median was 66 years. The tumours presented sizes >
27
2 cm in 199 cases (86,1 %) and were located in the antrum in 148
(63,5 %). The resection rate was 83,3 % and the peritoneal lavage
was positive in 38 patients (12,9 %).
The univariate analysis of the different parameters revealed
statistical significance for the type of surgery (resection vs. non
resection), size, depth wall penetration, the existence or not of
exteriorization to the serosa and/or invasion to near organs, lympth
node metastases, stage, venous invasion, classification of WHO,
invasion of surgical margins, presence of peritoneal implants (micro
and/or macroscopic) and the result of the cytology of the peritoneal
lavage. In multivariate analysis, the positive result of the cytology of
the IOPL revealed to be, in these patients, an independent prognosis
factor (p<0.001).
Conclusions
The results obtained underline the prognostic value of
a positive peritoneal lavage cytology in patients with gastric
carcinoma. The influence that this method may have on deciding
upon adjuvant therapy for these patients, needs to be confirmed by
other randomized clinical and pathological studies.
th
30 November 2007
Room B
Session B3
Colorectal diseases
33.
Herman R.
Contemporary minimally invasive treatment of anorectal diseases
34.
Bujko K., Richter P., Nowacki M.P., Popiela T., Gach T., Olędzki
J., Sopyło R., Meissner W., Wierzbicki R., Kowalska T.,
Stryczyńska G., Paprota K.
Preoperative radiotherapy and local excision for rectal cancer:
Preliminary results of randomised trial.
(Warszawa, Krakow, Poland)
Background
Preoperative radiotherapy and local excision for radiosensitive
28
tumours is an attractive treatment due to organ sparing.
The rationale of this management is based on association between
radiosensitivity of primary tumour and nodal metastases.
Furthermore, the correlation between tumour radiosensitivity and
favourable outcomes has been found. Optimal schedule of
preoperative radiotherapy is unknown.
Materials And Methods
Between October 2003 and May 2007, 40 patients with
extraperitoneal tumour (less than 4 cm; G1-2; cT1-3N0) were treated
either with 5 x 5 Gy + 4 Gy boost or with chemoradiation 55.8 Gy
(50.4 Gy + 5.4 Gy boost, 1.8 per fraction) plus 5-fluorouracyl and
Leucovorin. Before treatment, mucosa at tumour edges was
tattooed. Interval to local excision was 5-6 weeks. Conversion to
open surgery should be offered to patients with poor response (T2-3,
positive margin).
Results
In 19 patients radiotherapy schedule was randomly allocated. The
remaining 21 patient were treated during the phase I of the study,
refused randomization or were unfit for chemotherapy. Short-course
radiotherapy received 28 patients and 12 received chemoradiation.
Of 35 patients with available pathological and surgical data,
transrectal endoscope microsurgery was carried out in 15 patients,
technique with the use of retractors in 19 and Kraske procedure in
one. The postoperative complications requiring intervention were
recorded in 3 patients. The acute radiation toxicity was 26% (6/23) in
the short-course radiotherapy group vs. 58% (7/12) in the
chemoradiation group. The corresponding values for complete
pathological response were 40% (10/25) vs. 60% (6/10). There was
poor correlation between complete clinical response (cCR) and
pathological response (pCR); of 12 patients with cCR, cancer was
found in four (33%) and of 22 patients with palpable tumour, there
was no cancer in 8 (36%). Conversion to open surgery underwent
five patients; five refused or were unfit. At 14 months of median
follow-up (range 0-41) local recurrence was detected in two patients
(including one intramucosal cancer) and late complications in three.
Conclusion
Acceptable local control, early and late toxicity and high rate of pCR
indicate study continuation.
29
35.
Richter P.
Minimally invasive surgery in rectal cancer
36.
Szmeja J., Banasiewicz T., Drews M.
Diagnostic, surgical treatment and control investigations at the
familial polyposis coli syndromes (Poznań, Poland)
During last 25 years in Chair and Department of General,
Gastroenterological
and
Endocrynological
Surgery,
K Marcinkowski University of the Medical Sciences 158 patients with
polyposis syndromes were treated surgically: 101 restorative
proctocolectomy, 51 colectomy and 6 other operations were done.
The patients with polyposis syndromes needs a special, complex
and sometimes multi-disciplinar treatment due to early age of the
malignant transformation, hereditary reason of the disease, extended
surgical procedure and the possibility of the extracolonic
manifestations.
The main diagnostic problems are: still undefined age of the
beginning of the control clinical examinations (reffered age: 18 years
old, the youngest patient with colon cancer in our group – 16 years
old), possibility of the extracolonic manifestations and collaboration
with asymptomatic patients (15%-20% of the asymptomatic family
members don’t accept control investigations).
The most important part of treatment is surgery. The open question
is a time of operation and
type of surgery (restorative
proctocolectomy vs colectomy).
In postoperative follow-up the quality of life decreased in most cases
(we mostly operate the asymptomatic patients ). The patient need to
understand the necessity of control examination after surgery – the
operation is only part of treatment. The control endoscopical
examination must be done regular due to the risk of polyps
recurrence in the rectum (colectomy) or polyps formation de novo in
the intestinal pouch(proctocolectomy). In our material 2 cases of
malignat transformation of the intestinal pouch mucosa were
observed.
The treatment of the patients with polyposis syndromes is serious
and complicated, the patients should be treated in the reference
centers by expired surgeons.
30
th
30 November 2007
Room B
Session B4
Endoscopy and laparoscopy
37.
Rydzewska G.
Double balloon enteroscopy – a new option for diagnosis and
treatment of small bowel diseases
38.
Hoskovec D., Varga J., Dytrych P., Antoš F., Kašpar M.,
Hledík E.
Laparoscopic vs. open repair of perforated gastroduodenal ulcers
(Prague, Czech Republic)
Aim
Aim of the study is retrospective comparison of the short-term
outcomes after laparoscopic (LR) and open (OR) repair of the
perforated peptic ulcer.
Patients and Methods
We compared 24 patients operated on laparoscopicaly to 28 patients
operated on by open laparotomy. We compared age, history of the
ulcer disease, history of the NSAID intake, delay of surgery, time of
surgery, Mannheim peritonitis index (MPI), ulcer site and type of
repair, length of antibiotics treatment, post surgical complications,
reoperation and mortality.
Results
Both groups are comparable for age (LR : OR 59 : 57 years),
duration of the surgery (LR : OR 66 : 70 minutes), antibiotics
treatment (LR : OR 5,5 : 5,7 days) and MPI (LR :OR 16,4 : 17,6).
Delay of surgery was shorter in the LR group (LR : OR 12 : 18,7
hours).
Preferable repair in the OR was excision, suture and omentoplasty.
Most patients in the LR group were treated by suture and
omentoplasty but Graham’s patch was used too.
There was difference in the postoperative outcome. In-hospital state
was shorter in the LR group (10,2 : 13,5 days). There was 1
31
reoparation in the LR group against 5 in OR group (4,2% : 17:9%).
Complications were more often in the OR group (20,8% : 46,4%).
Mortality was higher in the OR group too (4,2% :17:9%).
Conclusion
Our results are not statistically significant. But they show the
potential of the laparoscopic repair of the ulcer perforation especially
in morbidity and possibly mortality. Other benefit (not shown in this
study) is long term outcome – especially less incisional hernias in LR
group.
39.
Santarelli G., Iarussi T., Camplese P., Cipollone G., Di Nuzzo D.,
Massari M., Mucilli F., Marolla A., Sacco R.
Bronchopleural fistula after tracheal sleeve pneumonectomy:
endoscopic stenting
(Chieti, Italy)
Objectives
Anastomotic dehiscence is one of the more frequent complications
after tracheal sleeve pneumonectomy. Induction therapy and in
particular preoperative radiotherapy seems to be one of the main
causes of bronchopleural fistula in correspondence of the
anastomosis that represents with ARDS the most important letal
complications with an incidence ranging from 5% to 10% in most
series. This complication can lead the patient to death because of a
consequent respiratory failure and pleural and mediastinal infections
so it is very important to treat this complication quickly. We report
two cases of bronchopleural fistula after right tracheal sleeve
pneumonectomy after induction therapy treated with nitinol silicone
coated stenting (Ultraflex®).
Materials and Methods
Two patients, a 51-year-old and a 53-year-old smoking men had
undergone chemotherapy and high-doses radiotherapy in other
medical centers (60 Gy). Surgery was consequent to a good clinical
and radiological response and to young age, although complications
might outcome by their induction therapy. To protect the
anastomosis, we used the anterior serratus muscle to wrap it around
the anastomosis and to isolate it from mediastinum and pleural
space.
A subcutaneous and mediastinal emphysema in the first patient and
32
a
dyspnea
with
fever
in
the
second
made
a fibrobronchoscopy necessary to have a diagnosis of anastomotic
dehiscence. In a few hours and after a thorax CT scan that excluded
a mediastinal and pleural effusion, an Ultraflex® covered stent was
inserted during a rigid bronchoscopy under general anesthesia.
Results
No postoperative complications occurred. All symptoms disappeared
quickly in both of patient and endoscopic control showed a well
placed and clean stent.
Conclusions
In the presence of a dehiscence after tracheal sleeve
pneumonectomy endoscopic silicone stenting represents one of the
therapeutic
choices
before
sepsis
begins.
Using
a minimal invasive device we can avoid madiastinal and pleural
infections and a complete wrong alignment of trachea and bronchus
which are responsible of a heavy respiratory failure.
40.
Hurayevskyy A., Palfiy I., Yurchenko V., Stasyshyn A.
Laparoscopy in emergency abdominal surgery
(Lviv, Ukraine)
The laparoscopic technique has changed most of the concepts of
traditional surgery and today is the standard approach in elective
surgery for many diseases. Emergency laparoscopic surgery allows
both the evaluation of acute abdominal pain cause and the treatment
of many common acute abdominal disorders.
The aim of our work was to evaluate the outcome following
laparoscopic approach in emergency abdominal surgery.
Materials and Methods
We studied 224 cases treated laparoscopically in Endoscopic
Department of Lviv Emergency Care Hospital during 2006 year. We
gathered the group of 69 (31 %) males and 155 (69 %) females with
an average age of 45,9 years. Among acute abdorminal diseases
were: acute cholecystitis 138 cases (61,6 %), acute appendicitis
&#8211; 23 (10,3 %), small bowel obstruction &#8211; 4 (1,8 %),
perforated peptic ulcer &#8211; 8 (3,6 %), incarcerated hernia
&#8211; 10 (4,4 %), gynecologic disorders &#8211; 18 (8,0 %),
33
obstructive colorectal cancer &#8211; 8 (3,6 %). Diagnostic
laparoscopy only was carried out in 15 (6,7 %) patients.
Results
Urgent laparoscopic surgical procedures were performed in all
patients up to 6 hours after hospitalization. There were no serious
intra-, postoperative complications in our group. The mean hospital
stay was 5 days. The laparoscopic technique conversion rate was in
4 cases (1,8 %). In 11 cases acute abdorminal diseases were
accompanied by peritonitis which diagnosed and treated
laparoscopically. All patients had received medical antibioticotherapy
pre- and postoperatively. In 2 cases during diagnostic laparoscopy
were ascertained total mesenteric ischemia (arterial occlusion)
which patients have died up to 24 hours after surgery.
Conclusions
The laparoscopic approach to abdominal emergencies is safe and
effective as conventional surgery, with a higher diagnostic yield and
allows for lesser trauma and a more rapid postoperative recovery.
Such features make laparoscopy a challenging alternative to open
surgery in the treatment of abdominal emergencies. Laparoscopy
have a major impact on the management of abdominal emergencies
and must become an indispensable technique in urgent surgery.
41.
Pisello F., Geraci G., Sciumè C., Li Volsi F., Modica G.
What to do when endoscopic retrograde cholangio-pancreatography
fails?
(Palermo, Italy)
Background
ERCP (endoscopic retrograde cholangiopancreatography) failure is a
rare but dramatic reality for the management of bilio-pancreatic tract
disorders and in these cases it needs to utilize others technique to
solve the bilio-pancreatic disease.
Methods
Over a 6-year period, a total of 757 ERCPs were performed.
Seventeen of these ERCPs failed with the standard endoscopic
technique (selective biliary cannulation, sphincterotomy). We
employed others techniques such as interventional radiology or
34
surgical management or double endoscopic approach in selected
cases to solve or palliate the pathology.
Results
In all 17 failed ERCPs the alternative procedures (rendez-vous,
ERCP with gastroscope, double guide-wire, pre-cut) allow successful
to solve the biliopancreatic disease.
Conclusion
ERCP is an operator-dependent procedure. Even in expert hands
failure occurs in 3% to 10% of cases. ERCP failure doesn't must be a
dramatic situation in the management of the biliopancreatic disease
because of the existence of cooperating group (e.g.: endoscopist,
surgeon and radiologic interventetion) who allows to success.
th
30 November 2007
Room C
Session C1
New technologies
42.
Prof. C.L. Cutajar
(Medical School, Malta).
Robotics in surgery – the future is now!
During the early 1990’s the development and application of minimally
invasive technology, particularly laparoscopy, revolutionalised
surgery. However laparoscopy has certain limitations, such as fixed
axis points at the trocar insertion sites, 2 D imaging, limited dexterity
at the instrument tips and lack of haptic sensation, which make
advanced minimally invasive surgery difficult to perform and teach.
The creation of surgical robot systems with 3 D visual capacity and
with advanced degree of freedom movements, seems to have been
the answer to these limitations and holds the key to future progress
in the art and science of surgery.
Robotics are now being used in many surgical fields including
general surgery. Three major advances aided by surgical robots
35
have been: the extended application of minimally invasive surgery,
the feasibility of remote surgery and even of unmanned surgery.
Although these robotic techniques are still the subject of debate and
even scepticism among some surgeons in the surgical community
who question their feasibility and cost effectiveness, others are
already postulating how to improve the next generation of telemanipulations and in so doing are looking beyond today’s horizons to
find simpler solutions. The surgeon of the future will be able to
routinely tele-monitor, tele-consult and even tele-manipulate at a
distance, even in space. The operating room of the future will be an
integrated environment with global reach. Surgeons will operate with
three dimensional vision, use real time three dimensional
reconstructions of patient anatomy as well as miniaturised, minimally
invasive, robotic technology. Robot-assisted technology will allow
more complex surgical procedures to be performed through small
incisions with enhanced patient care and safety.
What, until a few years ago, appeared to be science fiction has
become the reality of the present.
43.
Marvik R.
Navigation in surgery.
44.
Felice A.
The barber’s supercomputer
(Malta)
The commonly held belief that supercomputers are by far superior to
the human brain in terms of ability, processing power and
adaptability is, at present, inaccurate. The human brain is superior as
regards speed, computational power and adaptability, while it
compares well as regards memory. The human mind works as a
general purpose processor and is therefore inferior when performing
specific functions. Developing supercomputers that would emulate
and surpass the human brain is possible but will need time and a lot
of investment.
The human mind, on the other hand, is available and cheap.
Analysing and improving its functions and processes in surgical
practice should be worth the effort.
Optimal decisions result from the application of a statistical decisionrule to data, as occurs in mathematics. Clinical decision-making, on
36
the other hand, is inherently uncertain and most processes involve
close-call decisions, trade-offs and probabilities. They could
therefore be classified as sub-optimal decisions.
Expertise in clinical reasoning thus depends on both mastery of
logical rules, and accumulation of experience.
This paper analyses these factors in the conviction that at present
and for some time to come, the surgeon’s mind is his best
supercomputer.
45.
Sobocki J., Herman R.M.
Capability of ens-neuromodulation to improve gastrointestinal motility
after gi surgery.
(Krakow, Poland)
Objectives
The aim of the study was to evaluate effect of enteric nervous
system (ENS) neuromodulation on gut motility.
Materials and methods: Six patients (2 Male, 4 Female, age 62.5+/17.8, weight 63.6+/-12.5) scheduled for elective laparoscopic
cholecystectomy were included in the study. Under general
anesthesia (N2O 4l/min, Thiopental 400mg, Chlorsuccillin 70mg,
Pancuronium 6mg, Fentanyl 0.5mg) one bipolar electrode pair was
laparoscopically implanted in the distal antrum close to the large and
small curvature close to the pylorus. Contractile activity of the
stomach and small bowel was observed and recorded on DVD.
Results
No side effects or adverse events were noted. All patients recovered
nicely and exhibited no postoperative nausea, in contrast to 46% of a
historical postoperative group that underwent the same operation.
The applied stimulation resulted in invoked amplitude-dependent
local gastric contractions, which were clearly noted at stimulation
amplitudes 16.0+/-2.19mA and higher, and became lumen-occluding
at 17,6+/-2.34mA. The average NGES amplitude that invoked
secondary antral motility was 14.0+/-2.19mA. This secondary motility
occurred approximately 20s after the primary stimulation. About 10
minutes after the administration of stimulation, powerful jejunal
contractions occurred lasting several minutes until the end of the
operation.
Conclusions: ENS stimulation is capable to produce both primary
and
secondary
contractions
in
the
stomach
with
37
a subsequent antiemetic effect during post-operative recovery, and
induces secondary but powerful small bowel motility.
46.
Barbarisi A., Rosso F., Marino G., Giordano A., Avenia N.,
Calzolai F., Sacco R.
Trim prob radiation interaction with prostate cells: effect on cellular
activity and implication for carcinoma diagnosis
(Napoli, Perugia, Catanzano, Italy)
Objectives
Malignant and normal tissues are known to have different
electromagnetic properties, and various attempts have been made to
use
these
information
for
diagnostic
purposes.
A nonlinear tuneable oscillator (Trimprob) generating extremely low
energy multiple electromagnetic fields has been developed for noninvasive analysis of electromagnetic anisotropy in humans.
Low energy electromagnetic waves generated by Trimprob interact
with biological tissues generating different signals. The nature and
intensity of these signals depend on the organization of target tissue
at macroscopic and microscopic levels.
It has been proposed that cancer exposed to a low level of
electromagnetic incident waves may behave differently than healthy
tissue; the specific resonances of involved charges in pathological
states can be used to investigate the tissue’s biophysical properties
by means of a weak electromagnetic interaction.
Today, encouraging results have been obtained in the diagnosis of
prostate cancer using a device based on electromagnetic emission
(TRIMprob).
The aim of this work was to study the effect of these waves on
cellular systems derived from human prostate (normal and
carcinoma).
Materials and Methods
As cellular models we choose PWR-1E cells derived from normal
prostate and 22Rv1 cells derived from prostate cancer. The effect of
Trimprob waves interaction with cell cultures were investigated at
different exposition times, culture density and irradiation length.
The biological parameters considered were:
1. Cell viability/proliferation by MTT method,
2. Cell morphology by optic and Environmental Scanning Electron
Microscopy (ESEM);
38
3. Citoskeletal organization by confocal laser microscopy;
4. Focal adhesion kinase (FAK) activation by immunoblotting.
Moreover, the signal emitted from cell cultures after interaction with
Trimprob waves were analysed in terms of intensity and wavelength
composition.
Results
First of all, we assessed that interaction of Trimprob waves with
PWR-1E cells derived from normal prostate and 22Rv1 cells derived
from prostate cancer didn’t caused marked variation in the viability
and proliferation rate.
More interestingly, we concluded that a good correlation exist
between intensity and wavelength composition of signals detected by
Trimprob apparatus and cell culture nature (normal and tumoral)
and/or density.
47.
Eitenmueller J.
Experience with a combined two functional instrument bipolar
coagulation and scissors in laparoscopic surgery
(Castrop-Rauxel)
Purpose
The scissors are the most important surgical instrument which has a
lot of other functions than only cutting. We created
a combined scissors which has additionally the function of
a clamp to grip the tissue and to perform bipolar coagulation
without instrument changing.
Materials and Methods
First of all the surgeon can use the scissors with all the possibilities
that scissors have in surgery, further he can use the bipolar
coagulation equipment in different methods of application. We use
this scissors since 5 years. Until now we have carried out with this
instrument 80 colonical resections of different types, 45 Nissen
fundoplications, 42 gastric banding
operations and 30 divisions of adhesions.
Results
The use of this scissors reduces operating times and saves money.
There was no occurrence of afterbleeding. The main operating time
39
for a colonic resection took about 180 minutes, whereas the Nissen
procedures lasted about 110 minutes.
Conclusion
The results demonstrate a very good feasibility of these operations
with this instrument within a short operating time. The multifunctionality
of
this
instrument
allows
not
only
a time-saving operative procedure in laparoscopic surgery, but also
the avoidance of very costly equipment.
48.
Cherenko S.M., Larin O.S., Randolph G.W.
Nerve integrity monitoring as a way to minimize laryngeal nerves injury
in cases of thyroidectomy for recurrent nodular goiter
(Kyiv, Ukraine; Boston, USA)
Background
Recurrent goiter is of high risk of laryngeal paresis after
thyroidectomy (up to 10-15 % comparing with 1% in initial thyroid
surgery). Material and methods. During 2004-2006 years 1620
patients were operated on thyroid nodules. 97 of these patients (6%)
were previously operated on thyroid and they were of our particular
interest. During the last two years 65 patients were operated with
Recurrent Laryngeal Nerve (RLN) electrophysiological monitoring
(NIM 2, Medtronic, Xomed) as described by Randolph (Harvard
Medical School, MEEI).
Results
Conventional RLN visualization was associated with the acceptable
rate of laryngeal paresis after primary operation on goiter (1.4%
temporary and 0.6% permanent). The first group of repeated
operations (32 patients) was managed with visual identification of
RLN. We observed 3 (9.4%) cases of transient and 2 (6.3%) cases
of permanent unilateral laryngeal paresis on the side of previous
thyroid resection. 65 recent operations were performed using
intraoperative NIM with only one case (1.5%) of transient RLN
paresis. In 3 patients distal segment of previously cut nerve was
found using NIM and end-to-end anastomosis with proximal segment
of RLN was performed. Improvement of voice function without
restoration of normal vocal motility was observed in 2 of 3 patients
during follow up.
40
49.
Gambino G., Di Bona A., Maione C., Scio A., Concetta G.M.,
Buscemi G., Lo Monte A.I.
Thyroidectomy using the Harmonic scalpel. Retrospective analysis of
188 consecutive cases.
(Palermo, Italy)
Objectives
The technique of thyroidectomy has undergone little change in
several years. The harmonic scalpel has been widely used in
laparoscopic surgery and is documented to be safe. In this paper we
analysed the advantages of harmonic scalpel in thyroid surgery in
terms of operative time , length of hospitalization and complications.
Patients: 77 consecutive patients underwent thyroidectomy with the
use of the harmonic scalpel. They were retrospectively compared
with a group of 112 patients who underwent thyroidectomy using
conventional techniques.
Results
The two groups were similar in age and sex. Mean ± SD operative
time was shorter in the harmonic scalpel group compared with the
conventional techniques. Length of hospitalization and number of
complications were similar in both group and no statistical
differences were observed. There were no death, no intraoperative
complications and no definitive sequelae.
Conclusion
The use of the harmonic scalpel in thyroid surgery is safe, doesn’t
increase morbidity and resulted in a reduction of the operative time.
50.
Fanello G., Caronna R., Cardi M., Benedetti M., Schiratti M.,
Prezioso G., Romeo B.G., Mangioni S., Ferramondo F., Spera G.,
Fusco G., Rogano A., Papini F, Meniconi R.L., Chirletti P.
Role of new bio-material in hepatobiliopancreatic surgery
(Rome, Italy)
Introduction
Hemorrhagic complications, biliary and pancreatic fistulas still
represent a dangerous event in hepatobiliary pancreatic surgery with
an incidence up to the 30% of the cases. Most of them develop
41
postoperative sepsis with an significant increase of the times of
hospitalization and mortality.
Recently a new bio-material has been proposed (TachoSil®) that
conjugates together fibrinogen and human thrombin with equine
collagen and human albumin in a patch which doesn’t need any
preparation. The Authors show their experience in the treatment of
liver surface section and in the treatment of the pancreaticojejunostomy and hepatico-jejunostomy after duodenopancreatic
resection.
Materials And Methods
In 11 patients (3 left epatectomies, 8 resections for liver metastases)
submitted to liver resection we have applied TachoSil® on the
hepatic section surface, so that to get a complete coverage to reach
the whole liver surface.
In 23 patients submitted to pancreaticoduodenectomy we applied
a patch of TachoSil® on the pancreatico-jejunostomy. Equally a strip
of TachoSil® has been applied on the hepatico-jejunostomy made
by a continuous suture in prolene 5/0. In 2 patients submitted to
enucleation of pancreatic neuroendocrine neoplasms, a patch of
TachoSil® has been applied on the bed of resection so that to stick
on the surrounding pancreatic capsule.
We have been therefore evaluate the results of such treatment in
terms of development of bleeding and biliary or pancreatic fistulas in
the patients treated with TachoSil® in comparison to a group of
control patients with similar characteristics, previously operated.
Results
In the study group patients, those submitted to liver resection had no
postoperative bleeding while one developed a biliary fistula with
spontaneous recovery in 30 days without development of sepsis.
In patients who underwent pancreatic resections, no bleeding or
pancreatic
fistulas
were
observed
both
after
pancreaticoduodenectomy or enucleations.
In the control study group, one out 11 hepatic resections developed
an intraperitoneal bleeding and two had biliary fistulas while in
patients after pancreatic surgery we observed one biliary and three
pancreatic fistulas one of which complicated by hemoperitoneo.
Conclusions
Decrease of incidence of bleeding and fistulas after liver and
pancreatic surgery represents one of the main topics. The new bio-
42
material (TachoSil®) with its combined properties of fibrine glue,
thrombin and collagen, that is ready for use and with contained
costs, represents an effective solution to reach such objectives.
51.
Jaraczewska I., Madej K., Szmidt J.
Experience in application of silver impregnated polyester grafts in
vascular emergencies
(Warsaw, Poland)
Introduction
Prosthetic graft infection remains the most formidable challenge in
vascular surgery. The market is now targeting at infection resistant
prosthetic vascular graft, especially in high-risk emergency cases.
Aim of the study: To assess the results of vascular emergency repair
with silver acetate impregnated dacron graft.
Materials And Methods
Of 62cases treated for vascular emergencies in 2004-2007, 16 met
the inclusion criteria (mean follow-up of 16mts). InterGard™ Silver
Grafts were inserted in aorto-iliac segment in 8 cases (3 cases as
a scheduled sequential graft replacement), 5 of these due to IIB graft
infection, 3 due to ruptured AAA (1 case of infected AAA, 2 cases of
inflammatory AAA). There were 2 cases of MRSA, 1 case of E. coli
and 2 cases of fungal infection. Another 4 cases included ruptured
pseudoaneurysm
(rPA)
with
retroperitoneal
hematoma
(3 anastomotic, 1 iatrogenic). 4 cases of iliac graft limb replacement
due to thrombosis and infection , in 2 cases complicated with jejunalgraft erosion. All patients had cavitary vascular emergencies, 9 were
ASA III/IV, 6 presented with shock or sepsis. 12 were operated via
transabdominal approach, 6 via retroperitoneal. Mean operative time
was 3hr 15min, blood loss 1200ml, hospital stay 21days.
Results
There were no intraoperative deaths, 4 patients died in the 30 day
postoperative period (3 due to SIRS, 1 due to coagulopathy), 3 in the
infected graft group. There were 2 cases of late graft infection
(1 reinfection in patient with secondary duodenal fistula).
2 graft occluded, 1 complicated with infection and acute limb
ischemia necessitating above knee amputation.
Overall survival was73%, graft patency 80%.
43
Conclusion
Postoperative mortality, morbidity, patency and reinfection rates
using silver impregnated aorto-iliac grafts, compare favorably with
most series of different treatment modalities in similar clinical cases.
52.
Jaraczewska I., Rowiński O., Gałązka Z., Szmidt J.
Utilisation of stentgraft accomodating to thoracic aortic curve in aortic
wall pathological weakness (trauma, Marfan syndrome, dissections)
(Warsaw, Poland)
Introduction
Thoracic devices tend to be too rigid and poorly comply with arch
tortuosity, protruding into the lumen at the lesser curvature. Shorter
necks needs more oversizing, thus endangering the aortic wall,
especially in TEVAR for pathologically weakened isthmus: traumatic
aortic rupture (TAR), acute type B dissections (ABD) or secondary
endoleaks (SE) with aortic enlargement over 50mm.
Aim of the study: To present the first experience with the Relay®
Thoracic Stent Graft, specifically designed for complex thoracic aorta
anatomy in demanding group of patients with acquired or genetic
isthmic wall weakness.
Materials And Methods
Prospective, nonrandomized, consecutive, observational singlecentre study with descriptive components. From 10/05 to 06/07 11
patients with isthmus pathology were enrolled for TEVAR. Mean age
of 55 (IQR 42-79), M/F 8:3. Relay thoracic graft was used in 3 TAR
(2 with pseudoaneurysm), 3 ABD (1 Marfan syndrome), 4 TAA (2
with SE after previous thoracic grafting, 1 hemothorax with
impending aortic rupture) and 1 descending thoracic aorta tortuosity
and intramural posttraumatic hematoma. All grafts were introduced
transfemoraly under spinal anesthesia. Average procedure time was
80minutes, contrast dose 150ml (IQR 100-300), mean hospital stay
10days. All patients were followed by CT before discharge, at 3, 6
and 12 months therafter.
Results
95% procedural success, 1 early IIb endoleak, treated with extension
graft (Zenith). 2 cases of left subclavian coverage- one total, one
partial, complicated in 1 case with arm claudication (treated
conservatively). No perioperative death or postprocedural
paraplegia/ paralysis. Either graft migration, nor aortic enlargement
44
in follow-up CT at 6 months minimum were observed. In 2 cases of
SE after previous TEVAR for TAA (one in MS), the additional
stentgrafts for IIa and IIb late endoleaks were required. One patient
with posttraumatic paraplegia died of PE in 30 days follow-up period.
Conclusion
Highly favorable preliminary outcome in heterogenous thoracic aortic
wall pathology. Procedural success was high, while no operative
mortality, stroke and paraplegia. Long term follow-up will be required
to demonstrate durability, especially in younger patients with TAR or
ABD.
th
30 November 2007
Room C
Session C2
Laparoscopy
53.
Kotsifas Th., Sikalias N., Vasilopoulos J., Kourakos Ath.,
Dedegikas D., Mountzalia L., Chaniotakis E.
When is the best time for laparoscopic cholecystectomy?
(Pireaus, Greece)
Laparoscopic cholecystectomy is no more an elective procedure.
Aim
The question is when to perform laparoscopic cholecystectomy in the
face of acute cholecystitis.
Patients-Methods
The last decade (1995-2004) 297 patients had a laparoscopic
cholecystectomy for acute cholecystitis.146 of them were operated in
the first 24-48h after the onset of symptoms (group I), 68 were
operated in less than 4 weeks time after the attack of the acute
cholecystitis (group II), while the rest 83 patients had a history of
acute cholecystitis at least four weeks before their elective
laparoscopic cholecystectomy (group III).
Results
Analysis of the operative time, complications and hospital stay
45
showed that laparoscopic cholecystectomy in acute cholecystitis is
the recommended surgical procedure. The success of the operation
depends on the degree of the inflammatory changes in the
gallbladder and the expertise of the operator both in emergency and
laparoscopic surgery.
Conclusions: Timing of the operation is crucial to executing
a successful procedure. The operation is easier, faster and safer
when performed in first 4-5 days of the onset of symptoms.
54.
Jovanovic M., Kitanovic A., Zdravkovic R., Zajic S., Filipovic G.,
Kulic V., Smiljkovic M., Gajic M.
Laparoscopic cholecystectomy in regional surgical center development and our experiences
(Krusevac, Serbia)
With this work we want to show our experiences as small regional
center in introduction and development of laparoscopic surgery in
routine practice. During the period between January 1st 1999 and
December 31st 2006 on Surgical ward of Health Center Krusevac we
have done 12062 operations, due to 1432 (11,87%) was
cholecystectomies because of gallstones, and 300 (20,95%) of that
number had been done laparoscopicly. Regarding the sex of the
patients 244 cases (81,33%) were women and 56 cases (18,67%)
were men. The youngest patient was only 15, and the oldest was 75
(The average age of the operated patients was 46,88 year). We had
17 (5,67%) conversion mostly because of bleeding which we couldn't
stopped laparoscopicaly or because of serious acute cholecystitis
when we didn't be able to identify and carried elements safely. Due
to postoperative complications we had 1 (0,33%) case of serious
acute pancreatitis with biliary peritonitis because of fall down clypse
from cystic duct because of increasing intraductal preasure as
a result of impaction gallstone in papila Vateri. The average time of
hospitalisation in group of laparoscopicaly done cholecystectomies
were 2 days, and in group of opened cholecystectomies were
5 days. Laparoscopic cholecystectomy is surgical procedure wich
now is "gold standard" in the world and over 70% of all
cholecystectomies is laparoscopic. In our Center this few last years
after we introduced, developed and routine applied of laparoscopic
cholecystectomy, percentage of laparoscopic cholecystectomies was
hardly 30%. The reason for this is very simple and we find it in fact
that open cholecystectomy is free of cost, while price of laparoscopic
46
cholcystectomy is 300 euros. However, our surgeons are accepted
this procedure with enthusiasm and we now practice laparoscopic
cholecystectomy routinely. We still hope that economicaly situation
and standard in Serbia will be improve and consecutively the number
and variety of laparoscopic procedures will become more frequent.
55.
Sobocki J., Herman R.M., Wałęga P.
Short term results of laparoscopic vs. open colostomy
(Krakow, Poland)
Objectives
The aim of the study was evaluation of clinical outcomes of open vs.
laparoscopic colostomy in terms of quality of perioperative care.
Materials And Methods
Five patients (1 men, 4 woman, age 48-72) underwent laparoscopic
colostomy for unhealed perianal fistula (3) and unresectable rectal
cancer. A historical group of 5 patients who underwent open
colostomy was assumed as controls. The following parameters was
estimated: time to spontaneous ambulation, time to evacuation of
stool, requirement for analgesics, oral intake of calories, morbidity
and economic outcome.
Results
Two or 3 trockars were used for laparoscopic technique. In
laparoscopic group all patients were mobilized and ambulated freely
a few hours after surgery. At the same day all patients tolerated oral
diet. The passage of gases and stool was observed form the stoma
within first 24 hour. Oral caloric intake covered 100% of requirement
in the 1st postoperative day. Any patient required opiates, and
adequate analgesia was obtained by the use of I group analgesics.
Laparotomy group ambulation was delayed 2.1 day, only clear fluids
were tolerated in the first day, use of opiates was inevitable. No
complications was observed. The procedure was less expensive vs.
laparotomy in all of the following categories: direct cost of surgery,
perioperative pharmacotherapy and time of hospital stay.
Conclusions
Laparoscopic colostomy is easy and safe alternative for open
surgery. The main advantages of this procedure include: improved
QoL, lower costs, easy location and postoperative stomy care.
47
Previous abdominal implants are not contraindications for this
method.
56.
Testini M., Piccinni G., Lissidini G., Di Venere B., Gurrado A.,
Lardo D., Poli E., Valentini M.P., Greco L.
Management of descending duodenum injuries secondary to
laparoscopic cholecystectomy
(Bari, Italy)
Introduction
The rapid development of laparoscopic cholecystectomy (LC) has
been based on the observation that it was a safe low-risk technique.
Nevertheless, LC has been associated with the occurrence of
serious complications, some of these are typical of laparoscopic
access and unexpected when the same procedure is carried out by
open surgery. Descending duodenum perforation is an extremely
rare but severe complication secondary to LC and sometimes it may
be fatal.
Materials And Methods
Between June 1992 and September 2006, 5 cases (1 female and 4
males; median age: 59 years, range: 49-67 years) of descending
duodenum injury as a consequence of a laparoscopic
cholecystectomy were managed at our Academic Department of
General Surgery.
Results
In all cases an emergency laparotomy showed an injury to the
descending duodenum. The following procedures were performed: in
two patients direct suture of the duodenum and a biliary T-tube
drainage, in 1 a duodenojejunostomy and in another a
duodenopancreatectomy. In the last patient drainage of the
duodenum using a Petzer-tube was performed. It was followed five
days later by gastric resection, closure of the duodenal stump and
repair of the duodenal hole by suture. The mean post-operative stay
was 44 days (range: 11-87) and the mortality rate was 20.0%
Conclusion
An overall incidence of 0.04% of duodenal injuries secondary to LC
is reported in literature. The overall mortality rate of duodenal
perforation secondary to LC ranges from 8.3% to 16%, but mortality
48
varies from 30% to 75% when the sepsis results in a MOFS. When
the lesion is immediately recognized or re-surgery occurs shortly
after LC, a direct suture of the duodenum and drainage is safe, and
successful primary repair by laparoscopic approach could be
performed too. Otherwise, when diagnosis is delayed and peritonitis
is inveterate, direct suture of the duodenum is not recommended for
the risk of suture line dehiscence. The site of the duodenum injury is
crucial in the surgical approach. Laceration of the duodenal bulb or
superior flexure can be safely treated by gastric resection closing the
duodenal stump. However, when the injury is in front of or below the
Vater papilla or even if it affects the descending portion of the
duodenum adhering to the head of the pancreas preventing the
execution of a duodenal transection, the management is more
complex. Gastric resection with direct duodenal suture or with
external duodenal drainage by Foley or Petzer tubes, mucosal or
serosal patches and a pedicled graft with a free vascular pedicle
manufactured from stomach, jejunum, or ileum tissue, tube
decompression by duodenal drainage, pyloric temporary exclusion,
gastrojejunostomy,
feeding
jejunostomy,
Roux-en-Y
duodenojejunostomy and duodenopancreatectomy procedures have
been proposed. In our experience 2 patients, in whom diagnosis was
immediate or shortly delayed, were successfully treated by a direct
suture of the duodenum hole and external drainage of bile with a Ttube. The patients in whom the diagnosis was delayed and who
underwent more complex surgical procedure had a long hospital-stay
with a higher morbidity and mortality rate. The surgical management
of this complication remains controversial and must be immediate,
safe and effective; not-recognizing it during the laparotomy will surely
be fatal. The time of diagnosis and the site of the injury are the most
important prognostic factors. Primary repair of the duodenum must
be reserved to injuries detected intra-operatively or shortly delayed.
Afterwards, direct suture could result in the failure of the procedure
and more complex surgical management is needed. The absence of
codification leaves the final choice to the individual surgeon’s
experience with contrasting and non homogeneous results.When this
complication occurs in rural or small hospitals, it is mandatory to
refer the patient to hepato-bilio-pancreatic surgery experienced
centres.
49
57.
Urbanek T.
Venous thromboembolism pharmacological thromboprophylaxis in
laparoscopic surgery – is it justified?
(Katowice, Poland)
Minimal invasive character of the procedure, rapid postoperative
mobilisation, shorter hospital stay and relatively low incidence of
venous thromboembolism in patients undergoing laparoscopic
surgery do not totaly eliminate the risk of postoperative DVT or PE in
this population. According to the literature, the laparoscopic
cholecystectomy can result in the modest activation of the
coagulation system. Additinally, the use of pneumoperitoneum and
the reverse Trendelenburg position reduce venous return from the
leg leading to the lower extremity vein system stasis. It seems to be
extremly important in the cases of the prolonged or complicated
surgery, especially in patients with additional VTE risk factors.
Despite usually minimal invasive character of this kind of surgery
there is still the discussion which patient undergoing laparoscopic
procedures should receive venous thrombombolim prophylaxis and
what kind of pophylaxis should be preferred. The European
Association for Endoscopic Surgery has recommended that
intraoperative IPC be used for all prolonged laparoscopic
procedures. According to the Society of American Gastrointestinal
Endoscopic Surgeons in patients undergoing laparoscopic surgery
the use of the same thromboprophylaxis options with laparoscopic
procedures as for the equivalent open surgical procedures should be
advised. The statement of the Seventh ACCP Conference on
Antithrombotic and Thrombolytic Therapy recommend against
routine thromboprophylaxis in these patients, other than aggressive
mobilization. In patients who have additional thromboembolic risk
factors the thromboprophylaxis with one or more of the following:
LDUH, LMWH, IPC, or GCS should be used. In the lecture, venous
thromboembolism risk factors, epidemiology and evidence based
results of the VTE prophylaxis in patients undergoing laparoscopic
surgery are presented. Currently available recomendations, as well
as the problems of the proper prophylaxis selection in patients
undergoing various kind of laparoscopic surgery are discussed.
50
th
30 November 2007
Room C
Session C3
Adjuvant treatment and nutrition
58.
Tomkowski W.
Management and treatment of venous thromboembolism in
malignant diseases
59.
Nová K, Marvan J., Dytrych P., Antoš F.,.Šerclová Z.,
Marvan J., Dytrych P.
Accelerated postoperative rehabilitation after bowel surgery
(Prague, Czech Republic)
Introduction
It is presumed that application of complex system of peri-operative
steps called Accelerated recovery or Fast Track reduces the
postoperative stress and frequency of postoperative complications.
This process consists of dietetic precautions including pre-operation
intake of carbohydrates and early postoperative oral feeding . It is
also conditioned by a modern way of anesthesia, considerate
surgical methods, perfect postoperative analgesia preserving
cognitive and reducing alteration of GI functions and intensive
postoperative rehabilitation with pro-kinetic effect.
The aim of our prospective randomized study is to prove the positive
effect of accelerated rehabilitation in patients after open bowel
resections on postoperative healing by means of ours own protocol.
Patients And Methods
First 25 patients were included and compared with 20 patients from a
classical
group.
Patients
from
monitored
group
drink
a solution containing carbohydrates until 2-4 hours prior the surgery.
Postoperative analgesia is ensured by combined method of
intravenous and epidural analgesia using PCA (patient controlled
analgesia). The epidural catheter is inserted in section L2/L3 of the
spine to the depth of 10 – 15 cm in this group. Naropin 0,2% and
Sufentanyl are continuously applied after surgery with the possibility
of bolus dose increase. The analgesia is amended by intravenous
51
administration of non-steroid analgesic. The efficacy of analgesia is
monitored on an analgesia scale. Patients do not have a nasogastric
tube and in the day of surgery they receive liquid (eventually semiliquid) diet without proteins according to their taste. This day apart
from respiratory rehabilitation they rehabilitate out side of bed as
well. On the next days the receive semi-liquid or solid diet according
to their tolerance, 2 to 3 day we continue with epidural and
intravenous analgesia, rehabilitation outside the bed 3 – 4 times per
day. The rehabilitation is performed on the tread mill. All catheters
and drains are removed on the 1st or 2nd postoperative day.
Patients are randomized before a surgery into classical (analgesia
without PCA, NGS, jejunal tube for early enteral nutrition,
rehabilitation according to the patient) and study group. We compare
the effect of analgesia, days of paralytic ileus, oral intake,
postoperative complications and total protein, albumin, pre-albumin,
cholinesterase and weight in both groups.
Results
Monitored group had lower pain points by 2,8 points (on scale 0 –
10), all of those patients were capable of unlimited rehabilitation on
their bed on the day of surgery, including sitting and intensive
respiratory rehabilitation (measured by spirometry), they could walk
on the l. postoperative day (by 1,5 day sooner than in the
retrospective group), their oral intake was accelerated. They could
walk since the lst postoperative day (by 1,5 day sooner than in the
retrospective group), their oral intake was accelerated. Difference in
postoperative complications and overall hospital stay was not
significant as well as the difference in detected biochemical
parameters. In both groups the peri-operative weight lost was 2,5 kg
and after one month there was no difference between those two
groups. The study group patients experienced general higher level
of comfort during their hospital stay.
Conclusion
The accelerated rehabilitation protocol is favorably perceived by
patients after intestinal surgeries. It ensures faster restitution of GI
functions and enables superior analgesia. Positive influence on
postoperative healing could not have been proved as well as the
difference in biochemical nutritional markers.
Introduction of multimodal process into praxis is difficult, because
this process requires excitement and close cooperation of number of
52
medical fields participating in peri-operative preparation. But it is
possible.
The study is supported by IGA MZCR No NR 8420- 3.
60.
Kulig J., Kłęk S., SierŜęga M., Szczepanek K., Szybiński P., Gach
T., Pach R., Szczepanik A.
The clinical value of standard and immunostimulating enteral and
parenteral nutrition in patients after surgery of the stomach and
pancreas – a prospective randomized trial
(Krakow, Poland)
Background&Aim
Immunomodulating nutrition is supposed to reduce the number of
complications and hospital stay during postoperative period in
patients after major gastrointestinal surgery. The aim of the study
was to assess the clinical effect of immunostimulating enteral and
parenteral nutrition in patients undergoing resection for gastric and
pancreatic cancer.
Materials And Methods
209 patients operated on for gastric and pancreatic carcinoma
between June 2001 and December 2005 were initially enrolled and
randomly allocated into one of four groups: standard enteral (SEN),
immunostimulating enteral (IMEN), standard parenteral (SPN) and
immunostimulating parenteral (IMPN) nutrition during postoperative
period. Immunostimulating enteral and parenteral formulas included
arginine, glutamine and omega-3- fatty acids. Enteral nutrition was
started 6 hours while parenteral 16 hours after surgery and
continued for 8 days. Number and type of complications, length of
hospital stay, mortality, treatment tolerance, visceral proteins
concentration, liver and kidney function were analyzed as
primary and secondary endpoints.
Results
20 of 211 patients were excluded, so 191 patients (137 M, 54 F,
mean age 61.1) underwent final assessment. Median postoperative
hospital stay was 12.8 days (8-41; SD 6.2) in SEN group and 12.9
days (8-39, SD 7.6) in IMEN group (p=0.454). There were no
differences in liver and kidney function and treatment tolerance,
changes in visceral proteins (albumin, prealbumin) concentration
were alike (p>0.05). Surgical complications occurred in 8 (15.6%)
53
patients of SEN group and in 8 (18.1%), 7 (14.5%) and 6 (12.5%) of
IMEN, PN, and PNIM groups, respectively (p>0.05). Generally,
complications were observed in 18 patients (35.5%) in SEN, 17
(38.6%) in IMEN, 15 (31.2%) PN and 17 (35.4%) patients in IMPN
groups (p>0.05). 8 (8.8%) patients in SEN group and 10 (10.8%) in
IMEN had surgical complications (p>0.05). Four fatal outcomes were
observed in all groups (2.1%, one each)
Conclusion
Clinical and laboratory parameters showed no benefit of
immunomodulating postoperative nutrition when compared to
standard enteral and parenteral nutrition in patients after major
gastrointestinal surgery.
61.
Sobocki J., Herman R.M., Gwóźdź P., Wałęga P.
Enhanced recovery after colorectal surgery improves early
postoperative results
(Krakow, Poland)
Objectives
The aim of the study was to compare early outcomes (30 days) of
Enhanced Recovery Protocol (ERP) vs. classic care after elective
colorectal surgery for cancer.
Materials And Methods
31 patients were divided into two groups and subjected to classical
treatment (16pts, av. age 66.8, 10 males, 6 females) or ERP (15pts,
av. age 70.3, 7 males, 8 females). In all cases intraabdominal
anastomosis was performed. The ERP protocol was developed
according to EBM. The following criteria were evaluated: time to first
bowel evacuation, postoperative caloric requirement covered by oral
intake, requirement for analgesics, morbidity, mortality, hospital stay
and readmission rate.
Results
The following average results were observed in classical vs. ERP
group: time to first bowel evacuation 3.5 vs. 1.1 day, postop. day of
100% caloric requirement oral intake 7.2 vs. 4.2 and hospital stay
10.5 vs. 5.8, respectively. No morbidity were observed. Requirement
for analgesics was 30% lower in ERP group. Any patient of both
54
groups required readmission in this series.
Conclusions
Early results shows that ERP is feasible and improves early
outcomes. Further studies are necessary for and optimization of the
protocol.
62.
Gorobeiko M.B., Larin O.S., Nastenko D.V.
The first report of evidence-based analysis of topical treatment of
wounds in cases of syndrome of diabetic foot (SDF) by wound
dressing with combination of oxidized regenerated cellulose (ORC)
and collagen (Kiyev, Ukraine).
Background
It was estimated results of treatment of wounds on 2nd and 3rd
stage of healing process of SDF using wound dressing with
combination of oxidized regenerated cellulose (ORC) and collagen
Promogran.
Materials And Methods
For objectification results we used PEDIS classification.
A criterion for effectiveness of it was selected speed of wound
healing which was measured by digital method in sq cm ± 0.05 sq
cm (with digital camera and especially created software). 246
patients were selected on 3 groups according to level of TcPO2.
Group 1 TcPO2 <25 mm Hg (58 patients), Group 2 26< TcPO2 but
<59 (112 patients), and Group 2 TcPO2> 60 mm Hg (76 patients). All
patents had been treated before and hyperglycaemia was
compensated. Active infection process in wound was treated.
According to PEDIS the grades of patients were D1-2, I0, S1. A half
of each groups had a dressing with Promogran, a half &#8211;
traditional topical treatment with debridement, dressing etc. In both
subgroups we had similar middle wound size 6,17±3,02 sq cm. We
estimated as absolute speed of healing (sq cm per week) as relative
speed (changing of percentage of area of wound a week).
Results
After 1 week of beginning of topical treatment weekly speed in
promogran and without promogran subgroups; was +0,37±0.13 sq
cm vs. in +0,29±0.11 sq cm Group 1, +2.73±0.43 sq cm
vs.+1.89±0.25 sq cm in Group 2 and +3.89±0.15 sq cm vs.
55
+3.64±0.05 sq cm in Group 3. After 2 weeks speed of healing
decreased and was in promogran; subgroups 2.01±1.96% a week,
21±3.17% and 29±4.22% per week. Final healing (3 months) in
subgroups (promogran vs without) in Group1 3% vs 0%, Group286% vs 70%, Group3
95% vs 92%.
Conclusion
Healing process at TcPO2 less then 20 mm Hg in general is
impossible, independently from type of topical treatment. , and 12
patients wound were healed up to 60 days.
Wound dressing with combination of oxidized regenerated cellulose
(ORC) and collagen validity improves healing process, especially in
cases of non-critical limb ischemia. It could be used in in-patient and
out-patient departments and in diabetic foot clinic.
63.
Butyrsky O.
Effectiveness of topical using semi-permeable biogenic membranes
for treatment of venous leg ulcers
(Crimen, Ukraine)
The work develops using xenogenous biogenic active covers based.
2 groups of patients who got the same conservative treatment were
compared. But they got different topical treatment: patients of I
(control) group (33 persons) got treatment of ulcers like non-healing
wounds, II group (experimental, 33 persons) - with local using
mollusk coat as a cover with properties of biogenic semi-permeable
membrane (BSPM). Testing includes clinical, microbiological,
cytological & histological methods.
Usage of xenografts with properties of BSPM demonstrated
considerable acceleration of regenerative processes, rapid
& complete epithelization of ulcers’ surface, maturing of granulation
tissue followed with formation of fibrous connective tissue that is
associated with intensive synthetic function of fibroblasts. Xenografts
with properties of BSPM don’t cause inflammation or allergy in
tissues; moreover, they reduce the level of disproteinosis, provide
local immunity-stimulation, and prevent rough instable scarring. By
morphohistochemical results we confirm opinion about development
of leg ulcers as auto-immune process of ІІ type. One of mechanisms
of this method is a property of xenografts to change the course of
regeneration. It provides optimal conditions for ulcers healing that is
56
confirmed by clinical supervivion. For example, term of granulations
appearance & start of epithelization in experimental group
considerably anticipates indexes of control group (7±1,5 & 5±0,8
days in experimental group against 19±1,7 & 13±1,6 days in control
group, р<0,001 for both). The result of perfected treatment of leg
ulcers is 23% shortening patients’ stay at the hospital.
Besides morpho-functional shifts in tissues of ulcers treatment is
accompanied with depletion of microbial association with sharp
reduction of microbes & change of pathogenic strains by saprophytic
ones. The final result of xenografts influence on the ulcers in patients
of experimental group is a decrease of number of microorganisms in
tissues of ulcers & exhaustion of microbial association up to
complete sterility (in 35% of cases) by the 40th day of observation. In
the control group the number of colonies is significantly more (up to
1000 per a gram of tissue), microbial content is changed by
saprophytic flora in 30% of cases, conditional-pathogenic – in 40%,
sterile smears were got in 8% only, high-pathogenic flora is smeared
by the 30th day of observation in 3% of patients. Such action is
provided both by properties of xenografts & method of their
preservation in solution of DMSO.
Cytological research reveals local immunity-stimulation action of
xenografts with properties of SPBM that is manifested with decrease
of number of WBC, intensification of their macrophagal function,
reduction of their destructive forms. Phagocytosis is characterized
with prevalence of completed one. These phenomena are revealed
in patients of experimental group in earlier terms & in more shown
degree & confirmed clinically.
Thus, xenograft with property of SPBM stimulates healing of venous
leg ulcers. It makes its usage particularly important for elderly
patients weakened by chronic diseases.
th
30 November 2007
Room C
Session C4
Surgical training
57
64.
P.L.O. Broos
What means: educating a surgical trainee into a fully responsible
surgeon?
(Dpt. of Surgery, University Hospitals Leuven, Belgium)
A successful education of a surgical trainee should feel like
accomplishing
a
‘mission
impossible’.
While
ensuring
a dignified life, a suitable person has to be selected, coached and
needs to acquire all necessary skills of a responsible and capable
surgeon in a limited timeframe. Indeed, too often this seems
impossible. Before starting a proper education, selection of the finest
candidates should be done in an objective and centralized manner
while keeping an eye on the medical and psychological profile of the
candidate.
As giving an education means continuous evaluation and guidance,
a well organised and correct procedure of decision-making and
implementation is an absolute must for candidate and society. The
training co-ordinator plays a key-role and has to be selected but also
judged with prudence. Besides easy-to-test theoretical knowledge,
simulators and the co-ordinator’s opinion should also take part in the
evaluation of a surgical trainee. Due to the fact that skills are
a dynamic entity and even gold standards fade away, permanent
studying is required and should maybe merit compensation. The
society has the right to highly specialized and educated surgeons,
where highly specialized surgeons are entitled to respect from
society and politics.
By informing others and learning from others we search for
a balanced and clearly structured education-program. Although there
are still many hurdles to take, we believe that our strategy will help
us to accomplish this ‘mission impossible’.
65.
L. Cutajar
The European Board of Surgery and the harmonisation of surgery
in Europe
(Malta)
66.
Srinivasaiah N., Joseph B., Gunn J., Hartley J., Monson J.R.T.
A qualitative analysis of a focus group discussion on patient decision
making in cancer care (Hull, UK)
58
Background
Cancer psychology is an important aspect of cancer care. Qualitative
research is a gateway to explore this. We aim to explore thoughts
among surgical colleagues about “patient decision making in cancer
care”.
Methods
A pilot focus group discussion among members of the academic
surgical unit involving 4 consultants, 3 registrars and 3 research
fellows. Qualitative methodology was adopted for analysis. Thematic
analysis using framework approach was done thereby identifying
Themes & Outcomes. Results: Themes that emerged are Evidence
based clinical practice, Knowledge, Decision making, Patient
Information, Risk, Communication, Consent, Socioeconomic factors
and Patient empowerment. Outcomes derived are to increase the
evidence base, Increase the clinician and patient knowledge, provide
adequate information, Decisions to be based on patients best
interest, Communicate risk in a understandable manner, Take
patients views, knowledge and demands into consideration,
Conclusion
Patient decision making in cancer care is slowly evolving, where
decisions are not only made taking into account patients views,
knowledge and demand but are also driven by patients in a minority.
Time is a factor and in years to come the patients will play an
increased role in their treatments taking into account tradeoffs and
risks between survival and quality of life.
67.
Szczepanik A.M., Spieszny M., Szczepanik M., Klocek T.,
Kubisz A.
The level of coordination skills in surgical staff – preliminary results
of computer-assisted test
(Krakow, Poland)
Coordination skills belong to the most important elements of human
motoric ability.
These skills influence the quality and results of performance in sport
and in some professions. In numerous situations coordination skills
limit the effectiveness of motoric processes.
Surgery is the area, where the final result of procedures depends on
the combination of human knowledge, concentration, and motoric
59
ability. The use of new techniques such as surgical endoscopy,
laparoscopy, imaging-guided surgery requires new type of
coordination skills in comparison to open surgery. Therefore, proper
training of surgical residents is the key to safe and effective surgery.
The new branch of training is based on sophisticated computerized
simulators, however the final training must take place on the patient
site. The aim of this study was to assess several coordination skill in
surgical staff and to compare the results between the group of
residents and fully trained surgeons.
The group of 16 surgical staff members ( 9 residents and 7 fully
trained surgeons) were tested using the standard computerized
protocol. The test was divided into 5 parts: - simple eye-hand
reaction, combined eye-hand reaction, Piorkowski aptitude test,
concentration – diversity test and orientation-perception test. The
mean ratios of the results (+/- SD) were calculated for each test.
Results
The level of coordination measured by each of the tests was in the
upper 1/2 of the general population results. The simpler the test was,
the results of residents tend to be higher than for fully trained
surgeons. The latter group achieved significantly better results in
most complicated orientation- perception test.
The results showed that simple coordination tests probably correlate
with the age, but more complicated skills are higher in more
advanced group. The overall coordination skills may be the marker of
predisposition for surgical profession.
th
30 November 2007
Room D
Time for thrombosis prophylaxis - session sponsored by Sanofi
Aventis
st
1 December 2007
Room A
Session A5
Pancreatic diseases
60
68.
Stipa S., Stipa F.
Duodenocephalopancreasectomy for adenocarcinoma of head of
pancreas and papilla of Vater an experience
(Rome, Italy)
Objective
The AA report consecutive experience of adenocarcinoma /ADC) of
head of pancreas and Papilla of Vater with revision of the literature to
achieve the best study and treatment of patients.
Materials And Methods
170 (131 in head of pancreas and 39 in Papilla of Vater) operated
upon for ADC with duodenocephalopancreasectomy with radical
programme. In 81 patients the stomach has been resected and in 89
pylorus has been preserved.
The majority of patients after operation, has been treated with
somatostatine or octreotide.
Follow-up was made in all patients. No patient had neoadjuvant or
adjuvant radio and chemotherapy.
Results
Postoperative morbidity was observed in 66 patients (38,8%) and
reinterventions were performed in 23 patients (13,5%). Pancreatic
fistulae were observed in 39 patients (22,9%). Total postoperative
mortality was observed in 16 patients (9,4%), but in the last 10 years
in 4/97 patients (4,1%).
Five-year survival was, in ADC of pancreas in 75% in stage IA, 3,9%
in stage IB, in 43,9% in stage IIA and in 3,2% in stage IIB. In stage III
no one survived.
In ADC of papilla of Vater, for the same stages, survival has been
54,4%, 51,4%, 0 and 37,5%.
Conclusion
In the study of patients and the treatment we recommend:
CT + PET
Laparoscopy with cytologic examination
Preoperative biliary drainage is rarely indicated
Duct of Wirsung has to be sutured to jejunum and the section
of pancreas has to be checked for the vascularisation and for the
control of the neoplastic invasion
61
The enlarged lymphadenectomy, beside the standard
peripancreatic excision is not useful
Maintenance of pylorus has no contraindication.
This surgery has to be performed in Centres with great experience.
69.
Kulig J, SierŜęga M.
Pancreatic cancer – have we reached the boundaries yet?
Therapy for pancreatic cancer has greatly evolved over the last 30
years in terms of surgical achievements and combined modality
therapy. A marked reduction in postoperative mortality rates is one of
the greatest accomplishments, evidently correlated with hospital
volume and improved perioperative care. Nevertheless, long-term
outcomes are still very poor, and determined mainly by the extent of
the disease. Numerous aggressive surgical procedures were
implemented to change this situation, including extended
lymphadenectomy and vascular resections, but they all provided
relatively small improvements with only a minority of patients
surviving
5 years. Similarly, even modern regimens of chemo- and
radiotherapy do not offer much hope for the patients with advanced
tumours. Considering high costs of care and utilisation of health
resources, there is an urgent need for evidence-based approach to
patients with pancreatic cancer. Results of numerous clinical trials
are contradictory and no general agreement exists about the optimal
patient care. This review summarises the current state of knowledge
on pancreatic cancer with a special emphasis on the newly emerging
possibilities.
70.
Aranha G.
Central (middle segment) pancreatectomy: A suitable operation for
lesions of the neck of the pancreas.
Traditional resections for pancreatic malignancies include distal
pancreatectomy
with
or
without
splenectomy
and
pancreaticoduodenectomy. Alternative resections for pancreatic
disease are used to minimize the resection of normal pancreatic
tissue and splenic parenchyma.
Central (middle segment)
pancreatectomy is one of these alternative resections. When
choosing a non-traditional pancreatic resection such as central
62
pancreatectomy, two questions must be answered:
1) Is the
non-standard resection as safe as the traditional operation, both in
terms of eradicating the disease process and in morbidity and
mortality rates? 2) Does performing the non-standard resection offer
a benefit and outcome over the traditional resections? Recently, the
mortality for pancreaticoduodenectomy in major centers has been
reported at less than 5% and for distal pancreatectomy at less than
2%. From the available literature of the published 217 cases, the
mortality associated with central pancreatectomy is less than 1%.
The morbidity of pancreaticoduodenectomy is mainly pancreatic
fistula and occurs in about 16% of the patients.
In distal
pancreatectomy, this morbidity occurs in 20% of the patients.
However, in central pancreatectomy, the fistula rate is greater than
20% and approaches in some series at 40%. Therefore, in answer
to the first question, the mortality of central pancreatectomy is less
than in either distal pancreatectomy or pancreaticoduodenectomy.
However, the morbidity, namely fistula formation, is higher. In
relation to the second question, endocrine insufficiency, namely
diabetes, is related to the amount of pancreas resected and has
been reported to be between 10 and 20% for Whipple
pancreaticoduodenectomy and up to 60% for distal pancreatectomy.
In central pancreatectomy, only 6% incidence of diabetes has been
reported. At the same time, exocrine insufficiency has been reported
in 60% of patients for having pancreaticoduodenectomy. Whereas,
in central pancreatectomy, postoperative exocrine insufficiency has
been reported to range from 0 to 8%. Therefore, the answer to the
second question is that central pancreatectomy is less morbid as far
as diabetes and exocrine insufficiency goes.
Conclusion: It is concluded that central pancreatectomy should be
reserved for patients with benign tumors and low-grade malignancies
of the neck of the pancreas. Its morbidity and its mortality are less
than the traditional pancreatic resections. However, pancreatic
fistula formation is greater, but the incidence of diabetes and
exocrine insufficiency in central pancreatectomy is far less than in
pancreaticoduodenectomy and distal pancreatectomy.
71.
Kingsnorth A.
Multi-disciplinary approach to necrotizing pancreatitis
(Great Britain)
63
The decision to intervene depends on the clinical picture (evidence
of sepsis) and demonstration by CT scan of pancreatic or peripancreatic necrosis. There is consensus that all patients with
infected necrosis require intervention by radiological or surgical
drainage. The infection may be diagnosed either by the presence of
gas within the pancreatic collection or by fine needle aspiration.
Patients with persistent symptoms for more than 7 days and greater
than 30% pancreatic necrosis and those with smaller areas of
necrosis and clinical suspicion of sepsis should undergo imageguided fine needle aspiration (FNA) to obtain material for culture.
FNA is safe and there are very few complications as well as highsensitivity and specificity for the detection of infection.
Patients with apparently sterile necrosis may occasionally require
operation but this is relatively uncommon.
There is controversy over the rules for radiological drainage and
surgical necrosectomy in the management of infected pancreatic and
peri-pancreatic necrosis. Standard surgical practice is that all
patients with infected necrosis should undergo necrosectomy. This
has been challenged by retrospective studies from referral centres
describing good outcome in patients managed by percutaneous
drains. Percutaneous wide-bore drainage may be sufficient for the
treatment of infected necrosis.
However many surgeons are
sceptical that solid necrotic tissue can be evacuated along
a drain of any size unless the necrotic tissue has already softened
and liquefied as in pancreatic abscess.
Thorough debridement of necrotic tissue is essential during any
surgical intervention. The abdomen may be closed over drains,
packed and left open or closed over drains and the pancreatic cavity
irrigated. There is no clear evidence to support one or other of these
techniques. The choice of surgical technique should be based on
clinically derived experience and local expertise. A new approach for
surgical debridement with minimal systemic disturbance can be
achieved by approaching the cavity along the track of
a percutaneously placed drain.
The cavity is then debrided
piecemeal with an operating nephroscope. Further evidence is
required to evaluate the place of this technique in the management
of pancreatic necrosis.
72.
Durlik M.
The role of minimally invasive techniques in surgical management of
severe acute pancreatitis
64
73.
Plaudis H., Purmalis G., Zeiza K., Pupelis G.
Early oral administration of synbiotics in the management of patients
with severe acute pancreatitis
(Riga, Latvia)
Introduction
Recent experience with early enteral administration of
prebiotics/probiotics (Synbotics) in the conservative management
protocol of SAP has demonstrated immunomodulatory effect of this
novel treatment modality. The aim of our pilot study was to evaluate
the clinical effectiveness and perspective of the early oral
administration of Synbiotics in
the treatment of SAP.
Materials And Methods
Patients suffering SAP (n = 115) with extensive signs of SIRS and/or
MODS were prospectively enrolled. Early Synbiotic supplements in
addition to routine protocol treatment were administrated in 35
patients (ESS group). Comparator groups consisted of 40 patients
who were treated according to routine protocol (Routine group) and
of 40 patients who were treated with continuous veno-venouse
haemofiltration (CVVH group) in addition to routine protocol.
Synbiotics consisted of a mixture of four bioactive lactic acid
bacteria, one from each of the four main genera of lactobacillus, and
four bioactive plant fibres. Synbiotics were administered orally with
standard enteral nutrition formulas when patients were able to sip
water and tolerate enteral nutrition. Overall infection rate, success of
the conservative treatment, dynamics of SIRS, MODS, complication
rate and outcomes were evaluated.
Results
Patients in all groups were comparable regarding the severity of the
disease, gender and age. Early oral administration of Synbiotics
resulted in lower operation rate, ICU and Hospital
stay and mortality (see table 1).
65
Table 1.
ESS /
CVVH
ESS /
Routine
Operations
3 vs. 13
p=0,006
3 vs. 15
p=0,001
ICU stay
5.6 vs. 12,6
p=0,003
5,6 vs.
9,1NS
Hospital stay
16,8
vs.28,1NS
16,8 vs.
23,9NS
Mortality
0 vs. 12p
<0.005
0 vs.
7p=0.006
Conclusion
Early oral supplements with Synbiotics seem to be rational
constituent of the routine treatment protocol of SAP. Prospective
randomised trials are justified.
74.
Pio V.T., Fersini A., Santacroce C., Neri V.
Validity of the magnetic resonance cholangio-pancreatography
(MRCP) before the videolaparocholecystectomy (VLC) in the
patients with mild acute biliary pancreatitis
(Foggia, Italy)
Objective
The therapeutic ERCP before the VLC in the patients with moderatesevere acute biliary pancreatitis (ABP) is a well recognized practice;
the necessity of ERCP in the patients with mild acute biliary
pancreatitis is not well defined. Aim of the study: to evaluate the
usefulness of the MRCP before the VLC in patients with mild ABP.
Materials And Methods
In the period 2003-2006, twenty-five patients were submitted to a
MRCP (15 females, 10 males, mean age 62 years, range 32-75) with
mild ABP (Glasgow’s criteria) without increase of the cholestasis
tests (direct bilirubin, alkaline phosphatase, gamma-GT) and
absence of choledocholithiasis at ultrasonography. During a followup period of 15-60 days after the VLC, the presence of jaundice or
relapse of ABP were evaluated in all patients by means of
clinical/laboratory/instrumental examinations.
Results
Six patients had choledocholithiasis (stones/sand/sludge) at the
MRCP and they were submitted to an ERCP, stones removal and
after to the VLC; 19 patients with a negative MRCP were submitted
to the VLC. All the 25 patients did not have jaundice or relapse of the
66
ABP during the follow-up period.
Conclusions
The MRCP was an accurate investigation for the preoperatory
diagnosis of choledocholithiasis; so, it is an important procedure for
patients with mild ABP, avoiding the ERCP.
75.
Kędra B., Kamocki Z., Roszkowski A.
Local radical excision of neoplasm of extrahepatic biliary ducts and
of ampulla of Vater – own experience
Neoplasma of biliary ducts occurrence after six decare of life. Only
25% of cancer are situated in middle of extrahepatic biliary ducts.
Because of anatomical structure and natural biology radical surgical
excision is almost impossible There is non of good and successful
non surgical treatment witch will be lengthening a life.
Authors report ten cases of local radical excision of neoplasma of
extrahepatic biliary ducts (5 patients) and ampulla Vater (5 patients) .
In all of the patients before operating was recognition local stricture
of extrahepatic biliary ducts witch was situated in orifice of cisticus
duct. Endoscopy treatment was non effective and in all of the cases
jaundice was accrue. In other 5 patients tumor of ampullae of Vater
was observed. In all of the patients was qualifited to surgical
treatment.
In 5 cases was confirmed a neoplasma tumor witch was situated in
middle of extrahepatic biliary ducts and enlarged lymph nodes of
ligament heatico-duodenalis intraoperativly. In other 5 patients tumor
was situated in ampulla of Vater. In all of patients scheme of
surgical
procedures
was
the
same.
First
step
was
a cholecystectomy, second was limphadenectomy of ligament
hepatico-duodenalis and identifications of structure of this ligament.
After made a manoeuvre of Koher and regional limphadenectomy,
excision a middle segment of extrahepatic biliary ducts was
performed. In cases of ampulla of Vater duodenotomy and local
excision was performed. In inraoperative histopathological
examination confirmed a cancer in excise segment, both marginal
ends of cut and lymph nodes was free of carcinoma cells. Proximal
end of biliary ducts was sewing to relases duodenum. In all of the
cases postoperative period was non complicated.
67
Authors believe than in cancer of extrahepatic biliary duct and
ampulla of Vater can be radical excision but it have to be nailed in
very early phase.
st
1 December 2007
Room B
Session B5
Liver diseases
76.
Krawczyk M., Cieślak B., Najnigier B., Mackiewicz A.
Focal Nodular Hiperplasia (FNH) as an indication for liver resection
(Warsaw, Poland)
Introduction
Focal Nodular Hyperplasia is a mass lesion composed of benign
hepatocytes. This lesion belongs to the most frequent solid benign
liver lesion but in many clinical situations we have no knowledge
whether
and
when
we
should
operate
on
a patient with Focal Nodular Hyperplasia.
The aim of our study was to find out when Focal Nodular Hyperplasia
is an indication for liver resection.
Material consisted of 87 patients treated between 1995 and 2007
due to suspicion of FNH. We treated 61 women and 26 men. The
age of our patients ranged from 19 to 62, average – 31. Mean
observation time was 18 months. The majority of lesions was
discovered incidentally on ultrasonography examination.
Symptoms of our patients were differentiated. Most of our patients
were without any signs – 65%. About 37% patients suffered from non
specific abdominal pain. 7% of patients had abdominal distension.
We controlled hepatic tests and found that 100% patients had normal
liver tests (AST, ALT, GGTP, Bilirubin). Also hepatic neoplastic
markers (AFP, CEA. Ca-19-9) were normal.
80,5 % (of our group) were treated surgically.
Indications for the surgery were as follow: in about 60% psychological aspect, in 31 % - increased diameter of the tumor and
in 5,5% the diagnosis was unclear and it was impossible to prove if
the tumor is benign. Only 3,7% of patients suffered from pain.
The type of resection was depended on size and localization of the
tumor. In about 60% nonanatomical liver resection was done, in 18%
68
- left hemihepatectomy, in 12% - right hemihepatectomy, in 6% extended left hepatectomy. In the remaining 6% we did extended
right hemihepatectomy. Only a few complications were observed:
wound infection in 2%, pneumonia in 2% and postoperative hernia in
2%. There were no mortality after liver resection due to FNH.
Conclusion
1. The most common indication for liver resection due to FNH
was a psychological aspect
2. Another indication for liver resection was tumor growth and
indistinct preoperative diagnosis
3. Suspicion of malignancy is not a frequent indication for liver
resection
4. Liver resection due to FNH is a safe procedure developing
none of the complications
77.
Schilling M.
Dissection devices in liver surgery
78.
Milkiewicz P.
Liver transplantation in acute liver failure
79.
Wójcicki M.
Diagnostics and treatment of liver tumors
80.
Costanini R., Liddo G., Cellini C., Iacovetta D., Cieri M.,
Napolitano L., Francomano F., Innocenti P.
Hepatic resections for primary and secondary tumoral lesions
(Chieti, Italy)
Objectives
Hepatic lesions, especially of malignant tumoral origin, both primary
and metastatic, are very frequent. The aim of the study was to
assess effectiveness and safety of surgical resections in the 7-year
casuistry of our Surgery Center.
69
Methods
Patients with hepatic lesions were considered;
preoperative
instrumental procedures employed were: hematochemical analyses
(markers of hepatic function, tumor markers [e.g., alpha-Fetoprotein,
carcinoembryonic antigen (CEA), carcinoma antigen 19 (CA-19)],
abdominal ultrasounds, CT scans, magnetic resonance imaging
(MRI), hepatic biopsy. Surgical procedures included major (3 or
more segments) and minor resections. Intraoperative ultrasound
evaluation was also applied.
Results
From January 2000 to February 2007, n. 101 resections were
performed (in 73 men and 28 women, mean age: 64.7 years, 35-87
years). Over 90% of the lesions were tumors (38 primary, and 53
secondary), in particular: 31 hepatocellular carcinomas (HCC), 6
cholangiocarcinomas (CC), 1 hepatic adenoma, 6 gallbladder
carcinomas, 41 metastatic lesions from colorectal carcinomas
(CLML), 6 metastatic lesions from non colorectal carcinomas (non
CRML).
Ten
cases
were
non-tumoral
lesions
from
traumas/abscesses. The interventions performed included: 28 major
resections (27.7%) and 73 minor resections, of which: 29
segmentectomies (28.7%), 11 bisegmentectomies (10.9%), and 33
atypical resections or enucleation of one or more nodules (32.7%).
The mean surgical operative time was 252 min. No intraoperative
deaths
or
complications
occurred.
Postoperative
mean
hospitalization time was 10 days. Postoperative mortality was 4.95%
(2 diffuse peritonitis, 2 hemoperitoneum, 1 acute hepatic
insufficiency). Postoperative morbidity was 30.6% [surgical
complications: 1 peritonitis, 1 hemoperitoneum, 1 hepatic fistula, 1
intestinal occlusion, 3 abscesses; medical complications: 13 pleural
effusion, 4 anemia, 4 hyperpyrexia, 2 cardiac/renal failure, 1 genital
edema]. Adjuvant therapy was performed in 54 patients (48
chemotherapy,
4
radiotherapy,
1
radiofrequency,
1
chemoembolization). The follow-up showed that 35% of all patients
operated on for malignancies, showed tumoral recurrence (22.5% for
HCC at 23,3 months, 39% for CRLM at 13,3 months, 83.3% for
cholangiocarcinoma at 16 months, 66.6% for gallbladder carcinoma
at 10 months, 50% for metastases from non CRLM tumors at12,3
months).
Conclusion
The results of our casuistry in terms of mortality and morbidity of
70
hepatic resections are in line with those of the literature. They
confirm that hepatic resection represents the most important
therapeutic option for tumoral lesions, both primary and secondary.
Alone or in association with other medical treatments, it provides the
best results in terms of survival time.
81.
Śledziński Z., ZadroŜny D.
Minimally invasive treatment of the liver matastasis – thermoablation
(Gdańsk, Poland)
Introduction
Radiofreqency ablation (RFA) is one of the palliative treatment
techniques for primary and secondary liver tumors. It can be
performed during open surgical procedure or by minimally invasive
percutaneous approach. We present our results of management of
patients with liver metastasis by use of
percutaneous RFA.
Materials And Methods
A retrospective analysis was conducted on patients who underwent
percutaneous RFA from February 2001 to July 2007. Data were
collected on patient and tumor characteristics. Survival data of 95
patients with liver metastases from colorectal cancer treated with
RFA and chemotherapy 5FU-leucovorin were analyzed.
Results
Two hundred and sixty two patients (145 men, 117 women) with
metastatic liver disease were treated with use of percutaneous RFA.
Three hundred and fifteen ablations were performed. Our overall
complication and mortality rate was 0,031% and 0.006%,
respectively. Kaplan-Meier survival analysis of 95 patients with liver
metastases from colorectal cancer revealed a 5-year survival of 18%
and median survival of 24 months.
Conclusions
Percutaneous radiofrequency ablation of liver metastasis is
a safe procedure with low mortality and morbidity rates. Our results
suggest that nearly 20% of patients after RFA with chemotherapy
(5FU-LV) will survive about 5 years post thermoablation.
71
82.
Rossi P, De Majo A, Venza M, Benavoli D, Cenci L, Tognoni V,
Sica GS, Gaspari AL.
Blood-less Hepatic Resection with multielectrode bipolar
radiofrequency device: preliminary experience
(Division of General Surgery, Department of Surgery,
Tor Vergata University of Rome).
Introduction
Hepatic resection is still the gold standard in the treatment of primary
and secondary liver tumours. Despite the progress in imaging,
anesthesia, surgical technique and availability of several tools, liver
resection remains a complex procedure. Intra-operative blood loss,
biliary leakage and hepatic failure remains major concerns during
liver resection. In particular blood-loss is associated with higher
postoperative complications and shorter long-term survival. The
authors report their preliminary experience using an innovative
instrument made by a RF generator and multielectrode device
(Surtron SB).
Material And Method
Surtron SB is composed by an RF bipolar generator connected with
a multielectrode probe consisting of 6 needles electrodes of 1,5 mm
diameter, outdistanced of 4,5 mm each, mounted in-line on a 4-cm
base. Each application of the probe cause 1 cm width and 3,5 length
parenchymal coagulative necrosis. In order to obtain an optimal
coagulation of liver parenchyma we performed a double parallel line
of application of the probe. Coagulated parenchyma can be cutted by
a cold knife.
After an experimental clinical study on 6 patients focused on the
feasibility and safety we performed this thecnique in
18 more patients.
11 patients entered the study from June 2005 to Feb 2007. (M=10;
F=1, range 37-75 years).
8 patients had liver metastasis from colo-rectal cancer,
2 patients had suspected gallbladder tumor (one colecyctitis and one
gallbladder cancer at postoperative histological analysis) and 1
patient a suspected intra-hepatic cholangiocarcinoma (post infarctual
necrosis at histological analysis). In the group of patients with liver
metastasis,
2 patients had a single lesion, 4 patients had two metastases and 2
patients had three mets. Three standard left lobectomy (II-III), 1 left
72
hepatectomy, 3 right hepatectomy, 1 lateral right sectorectomy (VIVII), 4 wedge resections for metastases and two gallbladder bed
resections were performed. From March 2007 to September 2007, 7
more patients received the treatment for colorectal metasteases.
Combined to resections we performed three RF ablation with
monopolar cool tip needle of three mets in 3 patients. In three
patients we performed an ileo-colo anastomosis, a total colectomy
and splenectomy, and an ileostomy closure respectively.
Preliminary portal pedicle vascular control was performed in
regulated resections except in two patiens: one left lobectomy and
one right lateral sectorectomy (VI+VII seg.). An endoscopic GIA
endovascular stapler was used for the division of the correspondent
hepatic vein. Pringle manouvre was performed in any patient.
The transection was performed with a common scalpel after
coagulation of liver parenchyma by multiple (double line coagulation)
application of the device. Each application produced a zone of
coagulative desiccation of the all thickness of the parenchyma with
a mean of 3,5 cm of length and a mean 1 cm of width.
Results
Intraoperative blood loss during the transection phase was between
30 and 50 cc in all patients. There was no biliary leakage nor
abscess. Mean hospital postoperative stay was 9,8 days (range 8-18
days). One patient (9%) died for acute myocardial infarction in early
postoperative period. Despite full eparine treatment there was no
bleeding from liver edge. Only one patient (9%), who was affected by
piastrinopenia, recived 1 unit of blood transfusion for anemia caused
by abdominal wall ematoma. Two patients (18,8%) had
postoperative serum collection. One of them required percoutaneous
drainage, and the other had spontaneous resolution. One patient,
who underwent an ileostomy closure, had postoperative ileous (9%)
with spontaneous resolution. Mean follow up in neoplastic patiens
was 9,3 months (range 1-21 months). There was no recurrence in
liver edge at CT control, one recurrence occurred in a metastasis
treated by monopolar RFA.
Conclusions:
The coagulation with multielectrode bipolar radiofrequency device
allows a blood-less liver resection. Liver resection assisted by
“SURTRON SB” is feasible and safe. This method for liver resection
is absolutely tolerable by the patient with no systemic complication or
adverse reaction. This new technique offers a method for a blood
73
less hepatic transesection without the need for sutures, ties, staples
or tissue glue. After coagulation the transection line could remain
neoplastic cells free.
st
1 December 2007
Award session
83.
Hartmann J., Braumann Chr., Menenakos Ch., Nocon M., Jacobi
Ch.A., Müller J.M.
Long term results after traditional laparoscopic procedure versus Da
Vinci robotic surgery in treatment of gastroesophageal reflux disease
()
Introduction
Gastroesophageal Reflux Disease (GERD) has a significant
increasing incidence in Germany affecting 10-20% of the population.
It is a serious medical problem with economical implications. 1997
the first robotic assisted surgical procedure was performed by
Cardiere. The exactly surgical treatment of GERD needs a lot of
surgical experience in dissection and reconstruction of the
gastroesophageal junction. We report long term results after
traditional laparoscopic procedure versus Da Vinci robotic surgery.
Materials And Methods
In 2003 surgical procedures of GERD were documented
prospectively. Patients were either operated with the Da Vinci
surgical system or by traditional laparoscopy. All patients had have
preoperative reflux symptoms and regulary diagnostics like
gastroscopy, pH-metrie and manometry indicating treatment. The
standard procedure in our department is the Dor-type fundoplication.
In 2007 the patients answered to a standard written questionery.
The aim of the study was to analyse long term differences in quality
of life and Visick-Reflux Score.
Results
In 2003, 79 patients underwent a laparoscopic treatment of GERD.
The results of 60 patients were analysed, because of response from
76% (n = 60). 18 Da Vinci procedures and 48 traditional laparoscopic
procedures were compared. The groups were not different in age
and gender (Figure 1). The median operating time in the Da Vinci
74
group was 206 min versus 116 min in traditional laparoscopic group.
There was no significant difference in long term qualitiy of life (GQLI
36) 107 ± 23 Da Vinci procedure versus 106 ± 23 in traditional
laparoscopic group.
Conclusion
There are no significant differences in long term follow up between
traditional laparoscopy and Da Vinci surgical procedure in treatment
of GERD. Fundoplication can be save and fast performed by
traditional laparoscopy. Because of the high costs and longer
operating
time
we
can´t
recommend
a robotic procedure for treatment of GERD at the moment. However,
major advantages of the Da Vinci robotic system are a better degree
of freedom of the instruments combined with few limitation of the
endowrist movement especially in difficult anatomical sites (narrow
esophageal hiatus in upside down stomach
or oesophagus
resection).
Da Vinci Procedure
N
Sex male/ female N
(%)
Age (Mean ± SD)
Operating time
(Mean ± SD)
Hospital stay (Mean
± SD)
Quality of Life (Mean
± SD)
Visick Score (Mean ±
SD)
18
9 (50%) / 9 (50%)
Traditional
Laparoscopy
42
18 (43%) / 24 (67%)
57 ± 13
207 ± 45
55 ± 13
116 ± 63
7.2 ± 5.8
6.3 ± 2.3
107 ± 23
106 ± 23
25 ± 11
25 ± 13
84.
SierŜęga M., Kulig J., Nowak K., Popiela T.
Number of metastatic but not their ratio or location is an independent
prognostic factor in ampullary cancer
(Krakow, Poland)
Objective
The purpose of this study was to verify if the number and location of
75
metastatic lymph nodes was a prognostic factor for survival following
curative pancreaticoduodenectomy for
ampullary cancers.
Materials And Methods
Between 1980 and 2004, 111 patients underwent potentially-curative
pancreaticoduodenectomy for ampullary cancers. Location of lymph
nodes was described according to the Japanese Society of Biliary
Surgery rules. The best cut-off value for the number of metastatic
nodes (NMN; 0, 1-3, >3) and lymph node ratio (LNR; 0, 0-20%,
>20%) was estimated with reverse Helmert contrasts method.
Results
The median number of resected nodes was 15 (95% CI, 13 to 17;
range, 4-62). Metastatic lymph nodes were found in 52 (47%)
patients and the median number of involved nodes was 3 (95% CI, 3
to 4; range 1-17). The overall median survival was 64 months (95%
CI, 31 to 96) with 3-year and 5-year survival rates of 63% and 56%,
respectively. The median survival was significantly shorter if a
metastatic node was found in any of the evaluated LN stations.
However, limiting the analysis to node-positive patients, no lymph
node group was associated with a significantly poorer outcome
compared to metastatic pancreaticoduodenal nodes. In a univariate
analysis, the presence of metastatic nodes, their number (0, 1-3, >3),
ratio of metastatic nodes (0, 0-20%, >20%), and depth of tumor
invasion, significantly correlated with patients’ survival. However,
only the number of metastatic nodes and depth of tumor invasion
were the independent prognostic factors in the multivariate analysis.
Conclusion
Number of metastatic nodes seems to be a new promising
prognostic factor in patients with resectable ampullary cancer.
85.
Bruns C. J., Christians S., Kleespies A., Eichhorn M., Angele M.
K., Jauch K.W.
Progostic value of the lymph node staging in pancreatic
adenocarcinoma
(Munich, Germany)
76
Introduction
The prognosis of ductal adenocarcinoma of the pancreas remains
poor. Surgical resection is the only chance for cure or for long-term
survival. Some recent studies reported the ratio of metastatic /
examined lymph nodes (LNR) as an important prognostic factor in
patients undergoing resection of pancreatic adenocarcinoma. The
prognostic relevance of histopathological factors and the effect
especially of extended lymph node dissection on survival continues
to be debated. In this study we want to re-evaluate the LNR and the
prognostic factors according to histopathological data.
Patients And Data Collection
This file describes patients with ductal adenocarcinoma of the
pancreas who underwent surgery with curative intention between
January 2000 and December 2006 at the University of Munich
Medical Center Grosshadern. Demographic and operative data as
well as pathological data were evaluated. Special attention was paid
to the histopathological factors of microinvasion and the LNR, tumor
size and resection margins. Surgically resected specimens were
histopathologically classified according to the UICC 2002
classification. Follow-up data were obtained from the records of the
Tumor-Register Munich. The study endpoint was the overall survival.
Results And Methods
149 patients underwent surgical resection, 71 were female, 78 male.
The median age was 64 years (32 – 84 years). Type of surgery was
partial pancreatectomy (51%), pylorus- preserving pancreatoduodenectomy (24,2%), total pancreatectomy (9,4 %) and distal
pancreatectomy (15,4 %). Portal vein resection was performed in 22
cases (14,7%). The median survival following resection was 16
months (CI: 12,09 – 19,91).
Patients were staged to UICC IA in 2%, to UICC IB In 0%, to UICC
IIA in 32,9%, to UICC IIB in 40,3 %, to UICC III in 7,4 % and to
stage IV in 16,8 %. Histological findings of lymph vessel invasion
were found in 19,5%, blood vessel invasion in 8,1% and perineural
invasion in 50,3 %.
Lymph node metastasis occurred in 59,06 %, distant metastasis in
16,78 %. Median number of harvested lymph nodes was 11 (1 - 40),
median number of metastasized lymph nodes was 2 (1-19). Median
tumor size was 3,5 cm (0,9 – 8,0 cm), 59,7% of the tumors were
poorly differentiated. Overall-survival curves were calculated and
plotted by the Kaplan-Meier method. The Log-rank test was used for
77
comparison of the survival curves of patient groups. The relative
prognostic importance of parameters was investigated using the Cox
proportional hazards model. The Chi-Quadrat test and Fisher´s exact
test
were
used
to
assess
the
association
between
pathomorphological and histopathological features. P-values less
than 0,05 were considered statistically significant.
There was no difference in survival in patients undergoing extended
lymphadenectomy from those whose lymph nodes were resected by
the standard procedure. Survival of patients with histopathologically
infiltrated lymph nodes in the compartment D3 equalled those with
peritoneal carcinosis or distant metastases. There seemed to be an
association of lymph vessel invasion and perineural invasion (p =
0,012).
Discussion
In contrast to recent studies, LNR had no prognostic value in our
patients undergoing pancreatic surgery for ductal adenocarcinoma of
the pancreas. Our data show prognostic strength of microscopical
blood vessel invasion, significant in univariate and borderline
significant in multivariate analysis, for patients’ overall survival.
In the univariate analysis, the survival of patients with microinvasion
of lymph vessels and perineurium did not differ from patients without
these factors (L1/L0 p = 0,923, NS1/NS0 p = 0,339). For accurate
staging it seems to be necessary to harvest more than 12 lymph
nodes including lymph nodes of the compartment D3. Patients with
infiltration of paraortic lymph nodes show survival rates as poor as
those with distant metastasis or peritoneal carcinosis.
Conclusion
Our results demonstrate that patients undergoing surgery for
pancreatic adenocarcinoma with a resection of less than 12 lymph
nodes may be understaged. A minimum of 12 lymph nodes should
be examined to achieve correct staging. Further studies are needed
to evaluate the prognostic value of microscopical blood vessel
invasion and of paraortic lymph node metastasis.
86.
Geraci G., Pisello F., Sciumè C., Modica G.
Trocar related abdominal wall bleeding in 200 laparoscopic
cholecystectomy . Personal experience.
(Palermo, Italy)
78
Aim
To determine the amount of complication and the incidence of first
and second access-related vascular injuries in
videolaparoscopic cholecistectomy.
Methods
We retrospectively reviewed vascular injuries of 200 consecutive
patients who underwent videolaparoscopic cholecistectomy from
2003 to 2005. The patients were separated into GROUP A (conical
radially expanding trocars, 101 patients) and GROUP B (pyramidal
tipped trocars, 99 patients). All the patients were submitted to open
access according to Hasson for the first trocar.
Results
There were no episodes of intraoperative cannula-site bleeding in
group A compared with 7 episodes in 99 patients (7.1%) in group B,
with a statistically significant difference (P < 0.01). No mortality was
registered.
Significantly more vascular lesions were found (P < 0.01) in group 2.
Conclusions
The advantage of Hasson technique is that peritoneal cavity access
is gained under direct vision, potentially preventing most severe
injuries.The open technique with radially expanding trocars is
recommended for secure access to the abdominal cavity in
videolaparoscopy.Great care has been taken, to avoid major
complications and understanding the abdominal wall anatomy is
important for reducing bleeding during or after trocars placement.
87.
Serclova Z., Antoš F. , Dytrych P., Marvan J.
Vacuum assisted closure. New possibility in the treatment of infected
abdominal wounds at septic Surgical ICU
(Prague, Czech Republic)
Introduction
Abdominal sepsis, tertiary peritonitis and re-operative abdominal
surgery lasting for many hours are inflicted with number of
postoperative complications including operative wound one.
Necrotizing fascitis, dehiscence of laparotomy or small leakage of
anastomosis
with
entero-cutaneous
fistulas
prolong
the
hospitalization of patients at the ICU. Deep purulent complications in
79
the operative wound demand expensive, painful and many weeks
lasting dressing changes.
Patients And Methods
We have been using Vacuum assisted closure (V.A.C.) system in the
treatment of such complications since June 2004. . It is a sandwich
method where we insert semi-permeable folia or mesh nonpermeable folia into open laparotomy. Polyurethane foam and
adhesive non-permeable folia is placed on top into which centre
target with vacuum catheter is placed. In case of fascitis the foam is
placed directly onto the wound and its edges are sealed up with nonpermeable folia with a target. The wound is then continuously or
intermittently evacuated and dressing is changed once every 4-5
days.
Results
The system was used in 18 patients in the period between 06/2004 12/2006. The dressing had have to be changed 6 times in average,
then the subcutaneous layer and skin was sawn up or a stomy
device was possible to apply. The wound healed within 32 days in
average. In one pt the system enabled the healing of dermoepidermal plasty around the enterocutaneus fistula.
Conclusion
VAC system is a modern and promising possibility in the
management of complicated infected abdominal wounds. Active
vacuum prevents pus retention, effectively lowers pus secretion,
decreases edematous inflammatory reaction and supports
granulation. Main advantages are seen in faster healing and lower
number of painful dressing changes. This system is almost
irreplaceable treatment of large dehiscent abdominal wounds and
enterocutaneous fistulas. The other important advantage, especially
for ICU, is closeness of the system and therefore lower risk of
spreading the hospital related infection.
88.
Demidov V.M, Demidov S. M., Novikov D. V.
The method of postoperative adhesions preventing in patients with
acute pancreatitis
(Odessa, Ukraine)
80
Acute pancreatitis (AP) is one of the important problem of the urgent
surgery, often registered in surgical patients. The number of the
cases of AP manifestations is increasing. AP patients are 5-10% of
the whole number of surgical patients, and the disease has a
destructive character approximately in 15-20%. Despite certain
progress in curing patients with AP at the earliest stages of the
disease they die throughout the latest stages because of the
polyorganic insufficiency and sepsis that are the main causes of the
deaths in 80% of the patients with AP. Late or wrong diagnostics
alone with nonadequate treatment are the main causes for the
above-mentioned situation in the surgical pancreatology.
Roentgenendovascular surgery (REVS) represents the effective new
method in diagnostical and curing procedures in patients with AP.
This miniinvazive method constitutes new approach in AP patients
management due to intravascular diagnostical and curative
manipulations through catheters under the X-ray control. So, the
main issue of the present work is to summarize both REVS
diagnostical and treating efficacy in patients with AP.
Clinical observations were performed throughout 2002-2007 in 102
patients with AP in surgical departments of the Odessa Municipal
Hospitals N2 and N10. 81 of them had the slight expression of the
pathological process or only its initial stage – oedematic AP. The rest
of the patients were cures traditionally. REVS diagnostic was
provided to 21 patients by contrast compound injection selectively
into the abdominal trunk. Pancreatic gland branch destruction was
evaluated in case of AT one or two arteries contrasting failure as well
as in case of portal vena earliest contrasting. To 28 patients we used
also intra-arterial infusion therapy during which sandostatin was
intravascularly administered directly to the destructed part of the
pancreatic gland under the X-ray control.
Performed method of REVS diagnostical procedure allowed us to
diagnose the acute pancreatic gland inflammation on its beginning
stage. All the patients undergone by these diagnostical
manipulations were treated conservatively, none of them had
complications and/or side-effects afterwards. The efficacy of the
sequentially performed REVS diagnostics and treatment was proved
by pain syndrome disappearance in 26 of 28 patients with AP; pain
intensity decreasing was observed in other 2 patients. Toxic tests
indices and C-reactive protein data diminished as a result of the
performed miniinvazive treatment of AP patients. The pancreatic
gland ultrasound investigation after REVS treatment is characterized
81
by echo-signal lower intensity together with pancreatic parenchyma
nonmassive structure in imaging.
Therefore, the data obtained showed a possibility of the quickest
(during 3 days), qualified and effective treatment of the patients with
acute inflammatory destruction of the pancreatic gland parenchyma.
The efficacy of treatment was proved by the pancreatic enzymes
plasma content dynamic as well as by clinical conditions and data of
the pancreatic gland ultrasound investigation of patients with AP
normalization.
Thus, our data are in favour of the great efficacy of the REVS
method of patients with AP diagnostics and treatment. The following
features are very important in the method that we used: a) we
succeeded in earliest diagnostics of the pancreatic gland
parenchyma inflammatory destruction; b) we achieved the possibility
of the nontraumatized way of treatment of patients with AP that is
perspective from the prognostic point of view for patients; c) REVS
method of curing resulted in the pain syndrome reduction, plasma
biochemical and pancreatic parenchyma morphological changes
were quickly and effectively normalized; d) we use sandostatin twofold lower dose compared with its dose in case of compound
intrabursal administration; e) it seems to be very important to use the
direct compound injection into the destructed part of the pancreatic
gland that allows to reach the effective and quickest results of
treatment.
89.
Lechner P., Brustbauer R., Zeh B.
Radio-Immuno-Guided Surgery for neuro-endocrine tumors – A new
approach to adequate surgery
(Tulln, St. Poelten, Austria)
Introduction
Radical surgery comprising the removal of the primary lesion and of
all affected lymph-nodes is the treatment of choice for neuroendocrine cancer ( NET ). In NET-tumours of the small intestine the
lymphatic involvement determines the extent of intestinal resection,
and with it the clinical outcome. It is therefore mandatory to remove
as many nodes as necessary, but as few as possible.
Materials And Methods
Mrs. A.O. ( 52 yrs.) presented with small intestine obstruction
resulting from previous abdominal procedures. She had small bowel
82
resection for –histological proven- chronic adhesive peritonitis.
Pathology incidentally found a so far unsuspected T-2- NET and 2
involved nodes in the mesentery. We performed 18FDG-Pet that
revealed one residual lesion in the mesentery, and so we decided to
re-operate on the patient.
10 days before surgery, she had an 111In- Octreotide-Scan that
confirmed the mesenteric hot spot.
Immediately after laparotomy we performed a thorough exploration
of the mesentery with a hand-held gamma-detector ( C-Trak® ). The
probe identified four additional nodes, the cancerous involvement of
which was confirmed by frozen-section histology. The margins after
resection turned out clear.
Results
A re-staging procedure including 18FDG-Pet, CT-scan, and
Chromogranin A three months after surgery was negative, and the
patient is perfectly well.
Discussion
Octreotide, a somatostatin analogue, can easily be labelled with 111
In. The tracer accumulates in tumours that bear somatostatin
receptors and turns these tumours into gamma-emitters. The probe,
the physical resolution properties of which are significantly higher
than that of a scintigraphy, thus can identify all receptor-positive
cancer tissue which than is removed.
Conclusion
The intra-operative use of a gamma-probe seems to allow for stageadjusted surgery for NET of the small intestine.
th
30 November 2007
Poster session 1
90.
Gladky A.V., Valetsky V.L.
High frequency inductive termoablation: Combined therapy of liver
neoplasms.
(Kyiv, Ukraine)
The aim of the research is to determine the efficiency of the
application of high frequency inductive termoablation and its paths of
83
combined use at treatment of liver neoplasms.
Materials And Methods
There was viewed the basics of the application of high frequency
inductive termoablation, its way of action, methods and indications.
In the clinic of interventional radiology department and hospital
surgery department the ELEKTROTOM 106 HiTT mobile system
(manufactured by “Berchtold” company), a device for high frequency
inductive devitalization of tumors in parenchymatous organs was
used. We applied the system for treatment of metastatic liver lesions
in 37 patients and for treatment of primary liver cancer in 4 patients.
Results
In 4 of 10 patients the so-called post-ablative syndrome consisted of
sub-febrile temperature for 3-5 days, weakness, drowse,
hyperhidrosis, feeling of weight in right subcostal area was observed.
Adequate hydration before and after procedure, indication of nonsteroid analgesics and preventive doses of antibiotics allow to
reduce quantity and expression of these symptoms noticeably.
Termoablation in combination with infusion of cytostatics allows
receiving better results confirmed by thick-needle biopsy and
histomorphological data in 1-2-3 months.
Conclusions
High frequency termoablation has following advantages in
comparison with surgical method: rare complications, low cost,
simplicity of carrying-out for interventional radiology specialist, short
period of rehabilitation. The procedure is highly effective and safe,
almost always carries out without general anaesthetic, in case of
need it can be conducted repeatedly and easy combined with other
methods of treatment.%
91.
Bilianskiy L., Lavryk A., Todurov J., Manoylo M.
Preoperative progressive pneumoperitoneum in the repaire of giant
hernias with loss of domain.
(Ukraine)
Induction of preoperative progressive pneumoperitoneum is an
elective procedure in patients with hernias with loss of domain. The
purpous of study is to impruve the results of treatment of the patients
with giant hernias. Materials and methods. A prospective study was
84
carried out during 2004 to 2006. Preoperative progressive
pneumoperitoneum
was
induced
using
a
double-lumen
intraabdominal catheter inserted through a Veress needle or opencontrol technique and daily insufflation of ambient air. Variables
analyzed were age, sex, body mass index, type, location and size of
defective hernia, number of previous repairs, number of days
pneumoperitoneum was maintained, type of hernioplasty, and
incidence of complications. Of 28 patients there were 22 females and
6 males. The patients\' average age was 58.7 years, average body
mass index was 41.3, and evolution time of their hernias ranged from
1.5 to 14 years. Twenty six patients had ventral hernias and two had
an inguinal hernia. Pneumoperitoneum was maintained for an
average of 17.4 days and there were no serious complications relating to the puncture or the maintenance of the pneumoperitoneum.
After this procedure a tension-free hernioplasty was successful in all
patients, twenty one with the Rives-Stoppa technique, five with
combination of Rives-Stoppa and Ramirez technique, and two using
the preperinoneal method for inguinal hernia repair. Six patients
were undergone gastric-bending as a first stage of treatment.
Conclusion. The progressive pneumoperitoneum is a usefull adjunct
in the hernia repair in patients with hernia with loss of domain.
Complications are infrequent, patient tolerability is adequate, and the
proposed modification to the puncture technique makes the
procedure even safer.
92.
Breuer J.P., Seifert S., Prochnow L., Bosse G., Martin J.,
Schleppers A., Geldner G., Spies C.
Preoperative Fasting – A national survey.
(Berlin, Göppingen, Germany)
The dogma of nothing by mouth (NPO) after midnight has been
critically discussed within the last years (1). Reduced preoperative
fasting improves clinical outcome without higher risk for the patient
(2). As a consequence, since October 2004 the German Society of
Anaesthesiology and Intensive Care (DGAI) has officially
recommended a shorter fast of 6h for food and 2h for clear fluids
before elective surgery (3). As a first step to implementation of these
evidence based guidelines (4) the presented data show the
acceptance of, and possible barriers to, this liberalized practice in
German anaesthesiology departments.
85
Methods
Anonymous written standardized questionnaire was mailed to 3751
DGAI members either in leading positions or self-employed (07/2006
to 03/2007).
Results. The overall response rate was 61.7% (N=2315). Of those
responding, 2102 (91.6%) claimed to know the new guidelines. 821
anaesthesiologists (35.8%) said they had adopted the new
recommendations. Further, 334 (11.2%) allow a 2h fast for clear
fluids, and a fast of more than 6h for solid food. The traditional NPO
after midnight is still practiced by 136 of the respondents (5.9%).
With reference to clear liquids alone 1266 (55.2%) allow an intake up
to 2h preoperatively. Reasons for adopting the new guidelines
were:‚improved preoperative well-being‘ (n=1253, 76.3%), ‚increased
patient comfort‘ (n=1754, 75.4%) and ‚reduction of perioperative
complications‘ (n=956, 41.3%); reasons against them were: ‚low
flexibility in OR management‘ (n=387, 16.7%). ‚increased risk of
aspiration‘ (n=281, 12.1%) and‚ ‚confusion in everyday routine‘
(n=231, 10%).
Conclusions
The new guidelines are well known under German leading
Anaesthesiologists (>90%). They are mainly adopted to aim for an
increased patient comfort. They seemed to be followed entirely in
a third of the German anaesthesiology departments and, referring to
clear fluids, in half of them.
References. (1) Spies, Breuer, Gust et al. Anästhesist 2003; (2)
Ljungqvist et al. Br J Surg 2003; (3) Stellungnahme der DGAI und
des BDA Anästh Intensivmed 2004; (4) Bosse, Breuer, Spies Best
Prac Res Clin Anaesth 2006.
93.
Ausch Ch., Buxhofer-Ausch V., Hofmann M.,Rosen H.R., Egger
T., Kitzweger E., Hinterberger W., Ogris E., Schiessel R.
Measurement of apoptotic and necrotic cell death modes in the sera
of colorectal cancer patients.
(Vienna, Austria)
Apoptosis is implemented in colorectal cancer (CRC) development
and has emerged as a potential target for cancer treatment at
various stages of tumor progression. Measurement of the apoptosis
(M30)/necrosis (M65) ratio may have a role in therapy monitoring. To
define the value of preoperative assessment of apoptosis and
86
necrosis we measured these parameters in the sera of CRC patients
and correlated these values with conventional clinical parameters.
Patients And Methods
We used an enzyme linked immunosorbent assay (ELISA) to detect
an apoptosis specific product and necrosis (M30- and M65-antigens
respectively) in the sera of 84 patients total. Fifty one patients had
CRC; UICC I: n: 17; UICC II: n: 7, UICC III: n: 12; UICC IV: n: 10;
Relapse: n: 5 and 27 patients served as non cancer (NC) controls. In
addition M30- and M65-antigens were measured in an independent
group of 6 patients receiving paliative chemotherapy therapy for
colorectal cancer.
Results
Patients with colorectal cancer showed significant higher M30
antigen levels (p=0.001). When stratified to tumor stages the
different preoperative M30 antigen expressions between normal
controls and tumor patients remained throughout all stages.
Preoperative M65 antigen serum levels were also significantly
(p<0.001) higher than in normal controls. No correlation was found
between M30 and A65 serum antigen levels and tumor grading and
preoperative CEA levels. The M30/M56 ratio was 0.117 (25%
Percentile: 0.094, 75 Percentile 0.170) in the Patient group versus
0.279 (25% Percentile: 0208, 75 Percentile 0.279) in the normal
control group.
Conclusion
Differences in M30 and M65 antigen expression between normal
and CRC patients occur already in early stages of the disease.
Therefore measurement of M30 and M65 antigen serum levels might
have the potential to be used as a biomarker in determining
prognosis. Larger studies are needed to verify this hypothesis and to
determine, if the M30/M65 ratio might be useful in predicting
adjuvant treatment response in colorectal cancer patients.
94.
Eitenmueller J.P., Volckmann E.
Experience with a combined two functional instrument: bipolar
coagulation and scissors in laparoscopic surgery.
(Castrop-Rauxel)
87
Purpose
The scissors are the most important surgical instrument which has a
lot of other functions than only cutting. We created
a combined scissors which has additionally the function of
a clamp to grip the tissue and to perform bipolar coagulation without
instrument changing.
Materials And Methods
First of all the surgeon can use the scissors with all the possibilities
that scissors have in surgery, further he can use the bipolar
coagulation equipment in different methods of application. We use
this scissors since 5 years. Until now we have carried out with this
instrument 80 colonical resections of different types, 45 Nissen
fundoplications, 42 gastric banding operations and 30 divisions of
adhesions.
Results
The use of this scissors reduces operating times and saves money.
There was no occurrence of afterbleeding. The main operating time
for a colonic resection took about 180 minutes, whereas the Nissen
procedures lasted about 110 minutes.
Conclusion
The results demonstrate a very good feasibility of these operations
with this instrument within a short operating time. The multifunctionality of this instrument allows not only a time-saving
operative procedure in laparoscopic surgery, but also the avoidance
of very costly equipment.
95.
Torelli F., Izzo G., Cosenza A., Renzi A., Monaco L., Izzo D.,
Basciotti A., Brillantino A., Schettino M. and Di Martino N.
Surgical treatment of gastric gist: our experience.
(Napoli, Italy)
Introduction And Aim Of The Work
Gastrointestinal Stromal Tumors (GIST) are an extremely
eterogeneous group of gastrointestinal tumors and they represent
only 1% of tumors of the gastrointestinal tract. These tumors
originates more frequently from the stomach (75%) and, in a shorter
percentage, from the small bowel (12%), the esophagus (6%), colonrectum (3%) and duodenum (2%). The most frequent symptoms at
88
the diagnosis are bleeding and abdominal pain. The surgical
treatment still represent the most important step in terapeutical
approach.
Materials And Methods
The aim of this work is to report our experience regarding four
patients with gastric Gist came to our attention in the year 2006: one
59 y.o. Male (pt. N. 1) and three Females (Pt. N. 2, 3, 4) (50, 53 and
60 y.o. respectively). The n.1 pt. had a tumor (2 cm of maximum
diameter) located at the sovrapiloric region (lesser curve side); the
n.2 pt. had an easily bloody tumor of the gastric fundus; In the n.3 pt.
the tumor was located in the sub-cardial region, while in pt. n. 4 the
tumor (3cm of maximum diameter) was located in the gastric body at
the lesser curve side.
Results
The two pts who had a tumor located at the lesser curve side
underwent a video-laparoscopic resection (Wedge resection). A wide
border of disease-free tissue was left. The other two patients (n.2
and n.3) underwent an “open” total gastrectomy.
Conclusions
Thanks to a more precise classification and evaluation of the
biological behaviour of these tumors, Surgery has been able to
develop mini-invasive techniques and nowadays it represents the
gold standard. The tumors located on the anterior wall and on the
greater curve are more suitable for a video-laparoscopic ablation.
The laparotomic approach is preferable, instead, for those lesions
located at the cardial or pyloric side where the risk stenosis exsist. In
conclusion laparoscopic surgery can be a valid choice to treat gastric
GISTs.
96.
Fiocca F. , Donatelli G., Ceci V., Cereatti F., Fanello G., Bruni A.,
Corona M., Salvatori F.M., Minervini S., Caronna R., Chirletti P.
Treatment of colo-rectal anastomotic stricture with self expandable
metal stent (sems).
(Rome, Italy)
Introduction
New SEMS Niti-S Stent Tae-Woong Medical Co-Ltd full covered and
that can be removed, are now available: a nylon stitch at the distal
89
end of the prosthesis is placed. Endoscopically the stich can be
pulled with a foreign body forcep: the prosthesis closes itself and it
can slip along the bowel.
Up to now SEMS were only used for palliative treatment of malignant
intestinal strictures as they cannot be removed.
The most frequent complications after digestive surgery are leaks
and
stenosis
of
the
sutured
bowel,
occurring
with
a frequency of 11-13 %. Strictures are commonly treated with
conservative treatments such as repeated ballon dilatations or
endoscopic incision but sometimes a new surgical treatment is
needed.
To maintain the patency of the stricture the use of this removable
SEMS should be proposed.
Patients with ileostomy and complete anastomotic closure were
succesfully treated with a rendez-vous recanalization and SEMS
positioning, avoiding surgery, achieving the complete recovery of the
patient.
Aims and Methods
31 patients with benign colo-rectal anastomotic strictures were
treated with balloon dilatation along a guide-wire placed with
endoscopic and fluoroscopic control and a removable esophageal
SEMS, 22 mm in diameter with distal and proximal enlargement up
to 28 mm to avoid dislocation, was positioned. The procedures were
carried out with a conscious sedation. After 1-3 months the prothesis
were removed and the patients considered for follow-up at 3-6-12
months to evaluate bowel patency.
Results
3 patients lost their prosthesis through the anus after 20 days. At
clinical and endoscopic follow-up 28 patients showed good patency
of the colo-rectal anastomosis, and those with an ileostomy had that
closed at the end of treatment. 3 patients had a stricture recurrence
that required two sessions of ballon dilatation combined with argonplasma coagulation of the scar.
Conclusion
The placement of removable SEMS in order to maintain an adequate
lumen and to avoid any possible leak of an anastomotic stricture in
colo-rectal surgery has demonstrated to be the gold standard. The
use of removable SEMS seems valid also in term of cost-benefit as it
90
is cheaper than repeated endoscopic treatments or a new surgical
approach.
97.
Megrelishvili G., Megrelishvili Z., Burjaliani B.
Comparative assessment of strangulated groin inguinal hernia repair
results, using tension - free and Bassini technique.
(Tbilisi, Georgia)
Introduction
Use of prosthetic repairs in the management of strangulated hernias
has so far been very limited due to the fear of an associated higher
incidence of complications, especially those related to the presence
of the mesh. The aim of this study was to prospectively determine
whether the use of the Lichtenstein repair in the management of
strangulated groin hernias was associated with a higher rate of
wound infection and/or mesh-related complications than in the
elective setting.
Methods
In the period 1998-2006, 65 patients were submitted to emergency
operation because of strangulated inguinal hernia. 33 patients
underwent
tension-free
repair
utilizing
a polypropylene mesh (group A), whereas the remaining 32 patients
underwent
a
modified
Bassini
technique
(group
B).
In Both groups were underwent the same antibacterial treatment.
Results
In group A, one patient (3%) developed a scrotal hematoma. No
other postoperative complications were encountered, whether
related or unrelated to the presence of the mesh. No complications
were encountered in group B patients. Throughout the 6-month
duration of the present study, no mesh had to be removed and no
recurrences were encountered in either group.
Conclusions: The good short-term results of the present study in
terms of absence of wound infection, mesh-related complications
and recurrence suggest that use of the Lichtenstein repair in the
management of strangulated groin hernias is safe and is not
associated with a higher rate of complications compared to its use in
the elective setting.
The presence of a strangulated inguinal hernia cannot be considered
a contraindication for the use of a prosthetic mesh.
91
98.
Gambino G., Di Bona A., Maione C., Scio A., Concetta G.M.,
Buscemi G., Lo Monte A.I.
Mesh fixation in hernia repair: suture versus human glue fibrin.
(Palermo, Italy)
Objectives
Prosthetic repair techniques are currently the most valid solution for
surgical treatment of inguinal hernia. The crucial point of this
technique is securing the mesh in the position of the posterior wall of
the inguinal canal. Suturing the mesh with polypropylene remains,
still today, the standard but many innovation techniques have been
described. In this paper we compare two methods of mesh fixation
herniorrhaphy with HFG, versus sutures and we, further, report our
preliminary results. Materials and methods: This prospective
observational study was carried out between January 2005 and
February 2006 at the Operative Unit of General Surgery, University
of Palermo. 42 consecutive patients with primary unilateral inguinal
hernia were enrolled. These were randomized either to the control
group (Group A, mesh fixed with 3/0 polypropylene suture) or the
study group (Group B, mesh secured with HFG, Tissucol, Baxter
Healthcare, Deerfield, IL, USA). Results: There were 23 patients in
the control group (Group A) and 19 in the study group (Group B).
Regarding to operative time and short and long term complications
no statistical significant difference were observed between the two
groups.
Conclusions
The modified hernia repair is feasible, has a low intra and post
operative morbidity and, as showed by literature, there is
a tendency to better postoperative course.
99.
Gvenetadze T., Chkhaidze Z., Chikobava G., Kiladze M.,
Mamamtavrishvili G., Chkhetia N.,Tatishvili O., Giorgobiani G.,
Soselia N.
Treatment of the giant ventral hernia.
(Tbilisi)
Introduction
Surgical treatment of large post operative hypogastric hernia is a
substantial surgical reconstructive problem, especially in case of
92
obesity and hanging abdomen. This kind of operations represent
“major abdominoplastic surgery”.
Objectives
To determine the effectiveness of simultaneous hernioplastic and
abdominoplastic by using mesh.
Materials And Methods
Following are the component parts of the mentioned operations :
a) Correct surgical approach towards aponeurosis defect by taking
into consideration
hypogastric architectonics and individual
changes of venrtroptosis;
b) Skin and subcutaneous fat tissue proper cut;
c) Intraoperative ascertainment of autoplastic possibilities of
parahernial muscular-aponeurosis layer;
d) Selection of the method of closing the defect of abdomen side
and selection of sewing material;
e) Similar surgical plastic - constructive correction of the lower part
of bulged abdomen side,
f) Prevention of the possible postoperative complications.
In the period of 2003-2006 77 patients were operated with
lipodermoctomy by hernioplasty, their weight was above 100 kg.
They all had so called hanging abdomen and
level 4 obesity.
Female were 69 (89,7 %) and male - 8 (10,3%); their age ranged
between 35-65. In pre-surgical period concomitant diseases were
treated in all patients , respiratory- hemodynamic disfunction was
corrected, thromboembolistic difficulties were prevented. All
operations were performed by endotracheal anesthetization.
Hernoplastic was performed in 27 (35%) cases by “Sublay”
technique and in 50 (65 %) cases “Onlay” technique was used. We
consider that for completing the operation
drainage of hypodermic
subcutaneous tissue is necessary. Patient’s early return to physical
activity is also important.
Results
In the post operation period hematoma was observed in 9 (11,6 %)
cases, in 11 (14,2 %) cases wound infiltration was observed. The
mentioned complications were resolved by conservative treatment.
Long time results were studied in 57 (74 %) cases. Hernia
recurrence was not observed in any of the cases.
93
Conclusion
Combined operations and the post treatment results make obvious
the effectiveness of surgical interference that gives possibility to
solve medical, social and esthetic problems.
100.
Kulig J., Kołodziejczyk P., SierŜęga M., Bobrzyński Ł., Jędrys J.,
Szczepanik AM., Popiela T.
Final results of randomized, multicenter, clinical trial on adjuvant
chemotherapy with etoposide, adriamycin and cisplatin (EAP) for
gastric cancer patients.
(Krakow, Poland)
Background
Gastric cancer (GC) is associated with poor prognosis, mainly due to
the high prevalence of advanced tumors. Although surgery remains
the best available therapeutic option, long-term outcome in non-early
GC is still unsatisfactory. No standard regimen of adjuvant
chemotherapy is available at the moment and many clinical trials
produced contradictory results. Initial results in advanced GC treated
with a combination of etoposide, doxorubicin, and cisplatin (EAP)
produced promising results.
Methods
Patients undergoing potentially curative resection for GC were
recruited and randomly allocated to the EAP or control arm. Patients
in the chemotherapy group received three courses of the EAP
regimen, administered every 28 days as initially proposed by
Preusser et al. The overall survival was selected as the primary
outcome measure. Secondary outcome measures included diseasefree survival and chemotherapy-related toxicity.
Results
Of 309 eligible patients, 141 were randomly allocated to
chemotherapy and 154 to the supportive care group. The median
time between surgery and the first dose of chemotherapy was 27
days (95%CI, 23 to 31). One hundred and forty-one patients given at
least one dose of chemotherapy were assessable for toxicity. Four
(2.8%) treatment related deaths were recorded, including 3 due to
septic complications of myelosuppression and 1 due to
cardiocirculatory failure. Grade 3 or 4 toxicities were found in 17
(22%) patients. Of 141 patients in the chemotherapy group, 101
94
(72%) completed all three cycles of adjuvant chemotherapy.
According to the ITT analysis, the median survival was 41.3 months
(95%CI, 24.5 to 58.2) and 35.9 months (95%CI, 25.5 to 46.3) in the
chemotherapy and control group, respectively (P=0.398). Median
and 5-year disease-free survival in the chemotherapy group was 37
months and 51%. The corresponding values in the supportive care
group were 35 months and 45%, respectively, and no statistically
significant differences could be demonstrated between both study
arms. Subgroup analysis revealed survival benefit from
chemotherapy in patients with tumors infiltrating serosa and those
with 7 to 15 metastatic lymph nodes.
Conclusions
This randomized study demonstrated a limited benefit of the EAP
regimen used in patients with radically resected gastric cancer. For
further trials adequate selection of patients who have the greatest
benefits from adjuvant therapy should be considered.
101.
Kavallieratos N., Sikalias N., Vasilopoulos J., Kourakos Ath.,
Dedegikas D., Mountzalia L., Chaniotakis E.
Endoscopic ligation of hemorrhoids.
(Pireaus, Greece)
Hemorrhoids is a common disease which makes patients seek
health services’ aid due to bleeding. In 3rd and 4th degree Longo
hemorrhoidectomy tends to be classic treatment. In 2nd and 3rd
degree endoscopic ligation is an effective method of treatment
applicable in primary care services. Aim of the study is presentation
of relevant experience in outpatient department of a large regional
hospital.
Material
Data from 93 patients treated for hemorrhoids by appointment were
revised. Main complaint has been hemorrhage. One ligation has
been applied in 33% of cases, 2 in 40% and 3 in 27% in one or two
appointments. Methods: No anesthesia has been performed. In most
cases a multiple use metallic ligator has been used the hemorrhoid
snag being ligated while prolapsing through the ring of the tool, or
grasped with a laparoscopic grasper. In some cases a single use
plastic ligator with suction has been used.
95
Results
In 6 cases a chronic anal crack was excised concomitantly, while in 2
a polypectomy was performed. No complication has been recorded
during the procedure or after it. One patient under steroid therapy for
a systematic disease presented with relapse of hemorrhage and
a Longo procedure was performed. Another patient has undergone
a Milligan-Morgan procedure in another hospital.
Conclusion
Endoscopic ligation is an effective and practically complication-free
method applicable in 2nd and 3rd degree hemorrhoids on an
outpatient basis.
102.
Kiladze M., Lursmanashvili G., Chkhetia N.
Esophageal injury: diagnosis and treatment.
(Tbilisi, Georgia)
Background
Esophageal perforating injury still remains one of the most complex
and serious problem in surgical practice. Mortality rate is high and
rises to more than 50% in the presence of extensive injuries and
delay of treatment. Some aspects of diagnostics and treatment of
this severe group of patients are still controversial among the
surgeons.
Materials And Methods
We present our experience and the data of 5 patients with
esophageal injury,who were treated in our institution since 2003 (4
males and 1 female, age – from 18 to 56 yrs).The causes of injuries
were: iatrogenic – 3 and trauma – 2; the perforation sites:cervical
segment – 4 and thoracic – 1case. Admission time after injury: the
first 12-24 hours – 4 and after 5 days delay – 1 case with combine
tracheoesophageal injury.
The clinical signs of esophageal injury were the similar and as
follows: dysphagia, dyspnea, pain, edema, emphysema(crepitance),
fever,mediastinal widening.4 patients were operated during 6 hours
after admission and 1 – after 72 hours of delay because of advanced
mediastinitis and vital conditions.
96
Operative Procedure
Exposure of esophagus (cervical segment – left sided cervicotomy,
thoracic – right sided thoracotomy) and mediastinotomy; Repair of
injury (2 layer suture over n/g tube); Suction drainage of suture line
site, mediastinum and pleural cavity. Postoperative period: broadspectrum high dose antibiotics,atropin,parenteral nutrition,suction of
drains and nasogastric ( or gastrostomy) tube.Control X-ray
examination with gastrographin swallow – on 7-th p/o day.
Results
1 patient died because of tracheal suture line disruption (combine
tracheoesophageal injury case),septic shock and poliorganic failure,
in 4 cases p/o course was uneventful (so in all 5 cases suture line of
esophageal wall was intact) and patients were discharged on 10-12
p/o days and at the present time they are doing well.
Conclusions
In analogical cases the diagnostic algorhytm should be as
follows:chest X-ray, contrast study of esophagus, endoscopy
(esophago- and bronchoscopy), US and CT.
Treatment should be individualized,which depends on many factors:
cause,site,extent and duration of perforation; advanced mediastinitis;
patient,s general codition.
Within 24 hours – the aggressive radical surgical management
(direct closure of injury plus drainage procedures) offers the most
reliable results.
Early diagnosis and immediate surgery are essential to achieve
optimal results and save the patients life.
103.
Kotsifas Th., Sikalias N., Vasilopoulos J., Dedegikas D.,
Mountzalia L., Chaniotakis E., Moschopoulos N.,
Giannopoulos D.
Management of low draining enterocutaneous fistulas on an out
patient basis.
(Piraeus, Greece)
Fistulas are abnormal communications linking two epithelialized
surfaces. External digestive fistulas occur between a hollow organ
and the outside body surface permit the passage of fluids and
secretions. These fistulas are catastrophic situations, occurring after
an abdominal inflammatory disease, cancer, surgery and trauma.
97
Methods
At the last decade (1996-2006), we treated 31 consecutive patients
with external postoperative digestive fistulas (males:19, females:12,
mean age:62,1years). The data on these patients were collected
prospectively and analyzed. The patients had fistulas of at least 7-10
days duration Penrose or tubular drains were preferred, and the
fistulous tracts were at least 10 cm long. Enteric and colonic fistulas
were included. Abdominal imaging with computer tomography,
ultrasound and fistulography were used to exclude clinically
suspected intra-abdominal peri-fistulous abscess and to measure the
length of the fistulous tract. Fistula output was measured daily from 3
days before starting treatment. Fistulas were considered as high
output when there was >500 ml fluid loss/24 h, moderate output if
fluid loss was 200-500 ml/24 h, and low output if fluid loss was <200
ml/day. In this study we present our experience with a simple method
for treating patients with established ECFs using a high pressure
vacuum with a balloon-tipped catheter to obdurate the tract, and
a portable vacuum flask to keep it dry. Statistical analysis was
performed using Student's t test for paired data and the Fisher's
exact test for comparison between proportions with respect to
closure of fistulas. Differences were considered significant when
p<0.05.
Results
Between 1996 and 2006, patients with ECFs were prospectively
treated and analyzed. No patient died. Serum albumin was
predominantly 3.5 g/dl or greater and in no patient was it lower than
2.5 g/dl. There was a significant difference between the mean serum
albumin (p < 0.05) and transferrin (p < 0.05) when compared to the
beginning of treatment and after closure of the fistulas. 27 (87,09%)
fistulas were classified as moderate to low output, and they showed
the best results with the treatment. The patients in whom high
pressure vacuum treatment failed required surgical closure and were
supplemented with enteral nutrition. In all 31 cases there was
a lateral fistula with the bowel in continuity. 3 (11,1%) fistulas closed
after 5 days, 7 (25,9%) after 10 days, 11 (40,7%) after 15 days and
6 (22,2%) after 20 days. The difference among these proportions
was significant (p < 0.0001). The treatment failed in 4 (12,9%)
patients.
98
Conclusions
The vacuum system had good results and proved to be useful in the
treatment of recent and well-defined fistulas. It included simplicity,
low cost, short hospital stay, possibility of home care use, absence of
skin breakdown, immediate cessation of bad odor in colon fistulas,
and the opportunity of maintaining normal eating, good nutrition and
activity patterns.
104.
Kraemer B., Wallwiener M., Wallwiener C., Wallwiener D.,
Rajab T.K.
Adhesion prophylaxis after laparoscopic myomectomy using
a novel resorbable membrane consisting of D,L-Polylactid
(Supraseal®). (Tuebingen, Germany)
Introduction / Purpose
Post-operative adhesions constitute an important clinical problem. As
a result, a number of liquid and solid barrier agents are being
developed. However, there is no consensus on which strategy (liquid
or solid) is more suitable.
Here we report data from a clinical trial using Supraseal®,
a novel resorbable membrane designed to prevent adhesions and
compare it to the liquid barrier Adept ®.
Materials And Methods
Supraseal®
is
a
copolymer
based
on
D,L-lactide,
trimethylenecarbonate and caprolactone. Adept® is a 4% icodextrin
solution with validated efficacy that is routinely used for adhaesion
prophylaxis.
30 patients admitted for laparoscopic myomectomy were randomised
to receive adhesion prophylaxis with either Supraseal ® (n=15), a
solid adhesion barrier consisting of D,L-polylactid or Adept® (n=15),
a liquid barrier consisting of icodextrin 4% solution. Efficacy of the
respective barrier was analysed according to the following
parameters: Visual Analogue Scale for pain, requirement for further
operations, fever, constipation, nausea, dyspareunia and
dysmenorrhoea after 1, 2, 3, 7 and 14 days as well as 3 months after
surgery. Moreover, intra-operative handling of the respective barrier
was analysed using a questionnaire for the surgeons.
99
Results
There was no evidence for a significant difference in the postoperative outcome between patients receiving Adept® or
Supraseal®. However, intra-operatively Supraseal was considerably
more difficult to use (p<0.05) because of its texture.
Conclusions
We conclude that the clinical efficacy of Supraseal® is equal to
Adept®, the efficacy of which has been verified in the literature. Yet
the handling of Supraseal® is more time-consuming and therefore
we plan to improve the material characteristics of Supraseal ®.
105.
Kraemer B., Wallwiener M., Wallwiener C., Wallwiener D.,
Rajab T.K.
Experimental models to induce standardised adhaesions in the rat.
(Tuebingen, Germany)
Introduction
Easily reproducable animal models are pivotal for research into the
pathogenesis and prophylaxis of post-operative adhaesions. Here
we compare and contrast four different models to induce
standardised peritoneal adhesions in the rat.
Methods
Model 1: Bipolar electrocautery (40-60W) of a standardised area of
the parietal peritoneum and/or visceral peritoneum
Model 2: Monopolar electrocautery (50W) as for model 1.
The peritoneal defects in models 1 and 2 were either closed with 5
interrupted 3-0 vicryl sutures or left open.
Model 3: Peritoneal traumatisation using a cyto-brush
Model 4: Peritoneal traumatisation by punch-biopsy (8mm)
Results
Only adhesion induction according to model 1 with closure of the
peritoneal defect lead to objectively and quantitatively scorable
adhesions in all animals. We observed weaker adhesions in models
3 and 4. These could be scored semi-quantitatively. Exact
standardisation between different surgeons was relatively difficult.
Trauma to the visceral peritoneum leads to significantly increased
adhesion formation. There were no significant differences between
animals treated with different electrocautery Watt powers (p>0.05)
100
Conclusions
Model 1 is best suited to induce standardised adhesions and is
therefore employed by our group for further analysis of postoperative adhesions.
106.
Lo Monte A.I.,Moscato F., Romano G., Gioviale M.C., Maione C.,
Buscemi G., Romano M.
Giant incisional hernia in the elderly patient. A rapid and simple
surgical technique.
(Palermo, Italy)
Objectives
The aim is to obtain a) a safe procedure to repair the large
abdominal defect and reinforce the
fragile zones around;
b) a simple and rapid technique to reduce the operation time.
Materials And Methods
Retrospective review of medical records of 72 elderly patients in
whom intraperitoneal mesh placement was used between January
1988 and June 2005.
Results
No intraoperative complication occurred. In the postoperative stage
7 seromas, 4 haematomas, 2 infections occurred, all solved with
conservative treatment.
Conclusion
The incidence of incisional hernia (IH) vary between 1% and 15 %,
with increasing risk of recurrence in relation to the age of patients,
wound infection, obesity and to the closure technique. Primary
closure is preferred even if it is impossible to apply it in all patients
because of an important relapse rate, from 30% to 50% as reported
by several studies, for IH repaired without prothesis.
Various
techniques have been proposed to repair IH, using a prosthetic
material. Here we describe a rapid and simple method of
intraperitoneal mesh placement in elderly with large IH. This surgical
procedure allows to obtain several advantages over other technique,
including minimal dissection of subcutaneous tissues from fascial
and muscular structures.
101
Moreover it improve the mechanical adhesion of the prothesis to
posterior side of the abdominal wall, reinforces the incisional areas
near the abdominal defect, reduces the operative time
107.
Kiudelis M., Venclauskas L., Mickevicius A., Maleckas A.
Short term results of incision hernia repair.
(Kaunas, Lithuania)
Incision hernias are the common problem in general surgery
practice. This hernia’s is found in 10 – 30% after abdominal surgery.
The Aim of Study: To compare two different methods of incision
hernia repair.
Materials And Methods
This is randomized clinical study, where patients with incision hernia
were operated. All the patients were divided in to two groups. The
first group patients were operated using Onlay technique. The
second group – Sublay technique. The mesh in this group was
placed under the rectal muscle. Postoperative evaluation included
complications, pain and discomfort in the abdomen, physical activity
and recurrence rate after surgery. The patient’s observation time was
2 weeks, 1, 3 and 6 months after surgery. Statistical evaluation was
conduced using descriptive analysis: the unpaired Student t test to
compare parametric criterions between two study groups, MannWhitney U test to compare the unpaired nonparametric criterions
between two study groups, X2 test – to investigate nonparametric
criterions between these groups.
Results
We analyzed 55 patients. 31 patients were in the first group, 24 – in
the second group. The patient’s age, BMI and hospitalization time
were similar in both groups (56 ± 11,7 vs. 55,8 ± 18,1 years; 28,5 vs.
27,8; 8,5 ± 2,1 vs. 9,8 ± 1,4 days). The operation time was
significantly longer in the second group – 152 vs. 186 minutes (p <
0,05). The intraabdominal pressure changes were less in the Sublay
group – 2,13 vs. 2,03 (p > 0,05). Postoperative complications: wound
seroma was significantly higher in Onlay group – 38,7% vs. 20,8% (p
< 0,05); pain in the abdomen 2 weeks after surgery was significantly
less in the second group; pain was similar in both groups1 month
and later after hernia repair. Patient’s recurrence to normal physical
activity 2 weeks after surgery was significantly faster in Sublay group
102
- 62,5% vs. 76,6% (p < 0,05). Time, when patients return to normal
physical activity after surgery (1 - 6 months) was similar in both
groups. There was one incision hernia recurrence case (3,2%)
6 months after surgery in the Onlay technique group.
Conclusions
Our study results demonstrate, that Sublay technique of incision
hernia repair is better than Onlay technique especially in the early
postoperative period.
108.
Kanavos E., Amicucci G., Ruscitti C.
The right laparoscopic transperitoneal adrenalectomy.
(Aquila, Italy)
Laparoscopic adrenalectomy has become the preferred surgical
approach to manage adrenal disorders. Bilateral adrenalectomy is
performed for diseases that are unresponsive to medical
management and, frequently,for neoplastic disease. Laparoscopic
adrenalectomy is considered a gold standard procedure in benign
adrenal disease but its value in malignancy, in terms of oncological
effectiveness, is not known.
Laparoscopic bilateral adrenalectomy is safe and effective. Patients
are discharged postoperatively in a relatively short time with few
complications. The advantages of the laparoscopic approach include
shorter
length
of
stay
(LOS),
a decrease in postoperative pain, faster return to preoperative
activity level, improved cosmesis, and reduced complications. For
these reasons is considered, at the moment, the “Gold Standard” for
One Day Surgery. We report our experience with laparoscopic
adrenalectomy via lateral transperitoneal approach.
Between May 1996 and April 2007, we performed 40 lateral
laparoscopic transperitoneal adrenalectomies in 40 patients. In 25
cases, the adrenalectomy was right-side lesions and in the other was
left-side lesions.
Laparoscopic adrenalectomy is technically feasible and reproducible.
The lateral transperitoneal technique offers distinct advantages to
the laparoscopist, including better visibility of familiar anatomic
landmarkers, easy access to other organ systems, the use of gravity
to retract the spleen and liver, and a wide exposure, which allows
removal of large adrenal lesions.
103
109.
Madani R., Gupta A., Oshowo A., Ingham Clark C., Mukhtar H.
Does involvement of the circumferential margin correlate with the
clinical prediction?
(London, Great Britain)
A circumferential resection margin involved (CRMI) is <1mm after
curative resection of rectal cancer and is considered
a positive resection margin. The association between CRMI and
local recurrence varies in different studies although generally it is
thought that a CRMI will lead to high local recurrence. Post surgical
resection surgeons will record whether the procedure was curative or
palliative depending on tumour resection. We aimed to see whether
clinical prediction correlates with histopathological outcomes.
Methods
We looked at a specialist colorectal unit’s rectal cancer patient’s
database between May 2001 and May 2006. Data were collected
from the patients’ records and the histology as reported by
accredited colorectal histopathologist.
Results
A total of 137 patients (56F/ 81M) were diagnosed with rectal cancer,
of which 98 had surgical resection. CRMI was seen in 13 patients
however 4.1% (4/98) were positive in procedures with curative
intend.
Conclusion
We found 4.1% rate of CMRI in patients after curative rectal cancer
resection. Colorectal surgeons, with specialist training, performing
total mesorectal excision can predict involvement of CRM at the time
of operation in majority of cases.
110.
Cambal M., Labas P., Krumpalova Z., Kozanek M., Takac P.,
Satko I.
Maggot debridement therapy – a modality for chronic wounds
treatment.
(Bratislava, Slovak Republic)
Maggot debridement therapy has become a new modern modality to
treat chronic non-healing soft tissue wounds, such as pressure
104
ulcers, venous ulcers, neuropatic wounds etc. This method is based
on application of sterile maggots of blowfly Lucilia sericata to soft
tissue wounds in two possible ways: 1. direct application or 2.
application in „biobag“, which is a product of authors of this paper.
The effect of Maggot debridement therapy is a complex activity of
maggots excrements and works in three levels: 1.debridement,
2. sterilisation and 3. improving healing due to many cytokines
produced by larvae.
In the last 3 years authors have established this technique as a new
possibility for patients with chronic non-healing wounds. They have
established a production of sterile maggots, founded a teaching
center in University Hospital Bratislava, and have began to spread
this method all around in Slovak republic to give a possibility to
improve healing of chronic wounds.
Authors have treated 34 patient with chronic wounds with remarkable
results.
Despite the fact, that the Maggot debridement therapy is often used
as a last resort for patients with poor prognoses, in our experiences
MDT was more offective and efficient in debriding non-healing
wounds than conservative treatment.
111.
Maslakova N.D., Vasilevskij V.P., Gadzhieva F.G.
Microinvasive ultrasound-controlled procedures in abdominal
pathology.
(Grodno)
Ultrasound controlled procedures give possibility not only to
diagnose but to cure abdominal pathology even irrespective of the
patient's state. These operations are often alterative to odinary
operative manipulations (as laparothomy or laparoscopy). According
to present ecological and radiactive situation we see the tendency
towards dicreasing of the immune activity, non-steril immunity,
tolerance to modern antbiotics, increase in allergological
background. These all lead to augmentation in suppurative diseases.
One of the most dangerous localizations of suppurative processes is
abdominal cavity (liver abscesses of different localizations and
ethiology; splenic abscesses, parapancreatic cysts and etc.). Risk of
the operative investigation in such patients is high, may lead to
generalized infection of the abdomen, that can cause relaparothomy.
A prolonged period of recovery needs bigger amount of
pharmaceutical preparations.
105
Matherials And Methods
We analysed the results of 72 transcutaneous therapeutical
abdominal interventions, perfomed undet the ultrasound control
(ALOKA SSP-63D Japan) with sectoral and line probes, acting at the
frequency of 2-5 MHz. Transcutaneous manipulations were
perfomed with the help of stilet catheters (diametr 0,3-7 mm) under
local anesthesia. The least traumatic traectory had been chosen in
every case. According to the localization of the affective area the
percutaneous dreinage was perfomed through: lig.gastrolienale,
lig.gastrocolicae, stomach, liver, lesser omentum, translumbar.
Among 72 procsdures there were: Abdominal abscess - 13.
Abdominal cysts - 7. Subdiagrahmatic and subhepatic abscesses - 8.
Purulent cysts of pancreas and parapancreatic area - 24. Acute false
cysts of pancreas - 17. Policystosis - 2.
Results
The average treatment-day course was from 7 to 16 days (to
compare: after traditional manipulatins – 30-45 days). There were no
deadly outcomes. Traditional operation was perfomed onle in one
case of parapancreatic abscess.
Conclusions
These types of microinvasive manipulations have limited
contraindications, can be perfomed irrespective to patient's state; are
more effective and economically advantageous. Today this
tecnological manipulation is becoming popular in different clinics, but
still its application has limited indications.
112.
Otto M., Dzwonkowski J.
Laparoscopic adrenalectomy : method or standard of surgical
treatment (Warsaw, Poland)
113.
Fomin P., Nikishaev V., Golovin S., Lemko I., Boyko V.,
Ivanchov P.
Endoscopical diagnosis and correction of early postoperative
complications in gastric surgery.
(Kiev, Ukraine)
106
Introduction
Modern miniinvasive endoscopical methods (MEM) allow to
diagnose and treat some postoperative complications after surgery
of complicated gastroduodenal peptic ulcer (CPU) and gastric cancer
(GC).
Materials And Methods
From 1984 to 2006 years in 1758 + 721 (2479) patients (pts) after 9
different kinds of operations and using different types of internal
sutures and materials (absorbable or nonabsorbable) on CPU
(various vagotomies -1128, gastric resections -630) and GC (total –
271, subtotal – 500 gastrectomies) we carried out endoscopical
monitoring (EM) on 3, 5-7, 8-12 days after operation for the studying
of the healing
internal suture-line. Endoscopical findings we
compared with clinical signs.
Results
The data of EM allowed establishing 2 types of the healing (primary
or secondary tension) of internal suture-line, which depended upon
the methods of operation, types of suture and materials. In 247
(9,9%) pts (CPU -168 (9,6% ), GC -79 (13,9%)) we found
endoscopical signs of functional motility disorders (FMD) without 198 (8,0%) pts (CPU -143 (8,1%), GC -55 (7,6%)) and with -40
(1,6%) pts (CPU -25 (1, 4%), GC – 15 (2,1%)) clinical symptoms of
disorders of evacuation from stomach. These findings allowed to
correct postoperative treatment without MEM. Different degrees of
motility disorders caused by mechanical lesions were in 196 (7,9%)
pts: anastomositis – 178 (7,2%) pts (CPU -118 (6,7%), GC – 60
(8,3%)) erroneously sutured anterior and posterior gastric or
duodenal walls in zone of Finney pyloroplasty – 8 (0,5%),
compression of duodenum by external inflammatory infiltrate – 10
(0,6%). For correction we used MEM: endoscopical dilation of
anastomosis and compressed duodenum by endoscope (53) or
improvised intra-gastric balloon (125), endoscopical cutting of the
sutured anterior and posterior walls in the zone of Finney
pyloroplasty (8), inserting narrow probe through anastomosis into
jejunum for nutrition during 3-9 days. Internal gastric bleeding (IGB)
was found in-70 (2,8%) pts (CPU - 55 (3,1%), GC - 15 (2,1%)): from
internal suture line – 40 (1,6%) pts ( CPU -32 (1,8%), GC - 8 (1,1%)),
acute gastric ulcers – 17+7 (1,0%) pts (CPU - 17 (1,0%), GC - 7
(1,0%)), sutured peptic ulcer -6 (0,3%) and in 50 (2,0%) pts ( CPU 33 (1,9%), GC - 17 (2,4%)) IGB was recognized before development
107
of clinical signs of bleeding. In 70 (2,8%) pts (CPU - 49 (2, 8%), GC 21 (2,9%)) were clinical signs of esophageal dysphagia caused by
motility disorders in 56 pts (CPU - 39 (2,2%), GC - 17 (2,4%) and
mechanical extraluminal compression in 10 + 4(0,6%) after
correction esophagogastric junction during gastric surgery. One or
two sessions of endoscopical and pneumatic dilation of
esophagogastric junction gave good results.
Conclusion
We proved EM to be useful in the cases of complex gastric surgery
due to early revealing some postoperative complications before its
clinical manifestations and correct them in time by MEM.
114.
Piotrovych S.M, Tutchenko M.I., Lysenko V.M., Kolomiyets P.V.
Evaluation of the allohernioplasty results depending on mesh implant
types.
(Kyiv, Ukraine)
Purpose
To examine effects of the mesh implant type used for alloplasty on
quality of life in patients with inguinal hernias. Used were mesh
implants from the only manufacturer, Ethicon (prolene, ultrapro,
wipro).
Materials And Methods
The surgery results were analyzed in 140 male patients with inguinal
hernias operated on during the period 2005 to 2006. Median age of
the patients was 46.4±0.8 years. According to an inguinal hernia
classification by A. Gilbert, II type hernia was in 51, III type in 50, and
V type in 39 patients.
Depending upon mesh implant types used for alloplasty, the patients
were randomized into three groups. In the first group (n=63), a
prolene mesh was used; in the second group (n=62) – an ultrapro
mesh; and in the third group a wipro mesh. In each of the groups,
allohernioplasties were performed using Lichtenstein technique
under local anesthesia. In each of the groups, the prophylaxis of
complications on the side of postoperative wound was standard and
generally accepted.
108
Results And Discussion
Pain syndrome in the postoperative wound areas was comparable
between all the groups at Day 1 following the operation. In the first
group patients, pain syndrome persisted for 3 to 4 days.
Complications on the side of postoperative wound in the form of
serous inflammation were noted in 10 (15.9%) patients. Among
them, prolonged serous exudation from the wound (7 to 12 days)
took place in 3 (4.8%) patients. In 6 (9.5%) patients of this group,
infiltrate of the postoperative wound area was noted without sepsis
signs, and in 3 (4.8%) moderate testis edema. Painful sensations
and discomfort in the postoperative scar area, especially with
physical activity and repositioning the body, persisted for 3 to 8
weeks in 30 (47.6%) patients. Depending on kind of work, recovery
of working capacity required 2 to 4 weeks following the operation.
In the second group, pain syndrome was so insignificant at Day 2
following the operation, as to justify the use of non-steroid antiinflammatory drugs. Complications of inflammatory nature on the
side of wound without any signs of sepsis were noted in 3 (4.8%)
patients. Sensations of discomfort in the postoperative scar area
were noted 2 to 4 weeks in 6 (9.7%) patients. Recovery of working
capacity occurred 1 to 2 weeks following the operation.
In the third group, pain syndrome severity was comparable with that
in the second group. However, tissue edema in the postoperative
scar area and significant serous exudation from the wound were
observed 10 to 14 days in 10 (66.7%) patients. This fact
necessitated us to abandon the further use of wipro mesh for
inguinal alloplasty.
Recurrent hernias were not observed in either of the groups.
Conclusion
Quality of life in patients with inguinal hernia was better following
alloplasty by Lichtenstein technique with the use of ultrapro mesh as
compared to that with the use of wipro mesh. The use of wipro mesh
in inguinal allohernioplasty seems to be unreasonable.
115.
Popiela T., Richter P., Kowalska T., Kulig J., Pach R.
Value of preoperative radiotherapy 25 Gy in the treatment of
resectable middle and low rectal cancer in stage II and III acc. to
UICC.
(Krakow, Poland)
109
Background And Patients
Between the year 1999 and 2006 two hundred and fourteen patients
with rectal cancer were operated on in the 1st Department of
General and Gastrointestinal Surgery in Cracow after neoadjuvant
radiotherapy dose of 25 Gy applied during 5 days. Patients qualified
to this treatment regimen had rectal cancer in clinical stage II or III
acc. to UICC. The aim of the study was to assess the long-term
treatment results after preoperative radiotherapy and to compare
them with those achieved after surgery alone.
Methods
Endorectal ultrasound (ERUS), CT scan of the abdomen and pelvis,
rectoscopy and chest X-ray picture were performed to establish the
clinical stage of rectal cancer. The neoplasm was always confirmed
in histological examination of the biopsy specimen. 214 patients with
rectal cancer localized in middle or low rectum, with clinical stage
uT2-3, N0/+, M0 were qualified to preoperative radiotherapy 25 Gy
applied during 5 days followed by radical surgery. Then they were
randomized into groups with either early (7-10 days) or prolonged (45 weeks) time-interval between irradiation and surgical treatment.
Treatment results (systemic and local recurrence free time,
prognosed 5-year survival, rate of negative margin operations) were
compared with those achieved in historical group of 160 patient
operated on by the same surgical team and according to the same
surgical standards (TME) between 1992 and 2000 without previous
radiotherapy. The control group was homogenous to the group with
preoperative irradiation with regard to age, sex, tumour localization
and clinical staging (paired analysis).
Results
Statistically significant increase in negative margin operation rate
and decrease in local recurrence rate (12% vs 2,4%) were observed
in patients with rectal cancer operated on after neoadjuvant
radiotherapy 25 Gy. No increase in overall survival was observed in
group with neoadjuvant treatment.
Conclusion
Preoperative radiotherapy 25 Gy applied during 5 days (5x5 Gy)
improves treatment results in patient with locally advanced rectal
cancer localized in middle and low rectum. It increases the rate of
radical operations and decreases local recurrence rate.
110
116.
Tutchenko M., Susak Ya., Vasilchuk A., Yaroshuk D.
Laparoscopic technologies in treatment of perforated duodenal ulcer
complicated by peritonitis.
(Kyiv, Ukraine)
Introduction
Laparoscopic surgeries have opened a new stage in treatment of
peritonitis during perforated duodenal ulcer. Real question is scope
of laparoscopic interventions at presence of various forms of
peritonitis.
Materials And Methods
Work is based on experience of treatment of 150 patients with
perforated duodenal ulcer, complicated by peritonitis, who underwent
laparoscopic interventions. The age of patients was within 17-75
years old.
Results And Discussions
Depending on perforation diameter, ulcer sizes, prevalence and a
stage of a peritonitis was performed laparoscopic suturing at 82
(54.6 %) by patients, dissection ulcers with the subsequent
duodenoplasty at 42 (28 %) patients, mending or dissection was
added highly selective vagotomy at 18 (12 %) patients. 8 patient
(5,3 %), underwent laparoscopy assisted duodenoplasty.
Localized peritonitis was diagnosed at 14 (9.3 %) patients, poured at
110 (73.4 %) patients, general at 26 (17.3 %) patients. During first 6
hours of our supervision in 55.3 % of cases we found sterile liquid.
From 6 till 12 hours liquid was sterile only in 32 % of cases. After 12
hours all patients had bacterial contamination.
For sanation of abdomen cavity from 1 up to 10 liters of solutions of
antiseptics was used. Simple irrigational sanation is used in 65.3 %
of cases, reusable isobaric sanation - in 34.7 %. 7 (4.7 %) the
patients who have been accepted after 12 hours from the moment of
punching, after laparoscopic surgeries, within 12-24 hour was
executed scheduled video laparoscopic sanation of abdomen cavity.
Duration laparoscopic surgeries makes from 35 till 210 minutes, on
the average 100-120 minutes. Complications in the early
postoperative period are noted at 4 (2.8 %) patients.
A suppuration about wounds - 2 (1.4 %) patients, an inconsistency of
suturing in 2 (1.4 %) cases. Conservative treatment was effective.
111
Are written out from a hospital in a satisfactory condition for
7-14 day.
Conclusions
1. Usage of laparoscopic technologies is reliable enough and safe
method of adequate sanation of abdomen cavity at
a
peritonitis
caused
by
perforated
duodenal
ulcer.
2. Laparoscopic surgeries are effective method of performance of
palliative and radical operations at duodenal ulcer perforation.
117.
Kryshen V., Kudryavtsev A., Muschynin V., Sheptun Y.
Comparative description of traditional and laparoscopic plastic
methods at inguinal hernia.
(Dnepropetrovsk, Ukraine)
The 1198 scheduled operations are performed at inguinal hernia
during 2003 – 2006 years. Two methods were used: traditional
operations according to Lichtenstein and laparoscopic hernioplastic.
Age of patients was from 22 to 91 years, average 49 years, 79% of
patients were men, 21% - women. In all it was performed 565 plastic
according to Lichtenstein, the size of implanted mesh was mainly
10x15 cm in typical cases, time of surgical operation - 20-30
minutes. Taking into account the features of method, 1500 mg of
zynacef was obligatory administered before the operation
Fraxiparine 0,3 ml used in cases of high risk tromboembolia as well.
It was performed 633 laparoscopic operations, 94 of them was
performed simultaneously at two-sided hernia. The typical size of
implant was 15x15 cm, so that it closed all inguinal fossae, at 20-30
minutes average time of typical operation.
In a post-operation period after a laparoscopic method, patients
livened up already in a few hours after the operation, pain was
moderate or mild. Patients which were operated by the opened
method livened up later, on the average in a next morning after the
operation, sometimes required more powerful anesthesia. Time for
which patient stays in surgical department is: at laparoscopic
hernioplastic - 1 -10 days, on the average - 3,2 days, at a traditional
method - 4-14 days, on the average 7,1 days, that is more than 2
times higher than at laparoscopic hernioplastic. There were following
complications: at the opened operations – funiculits - 2,48%, orchitis,
epididimitis - 0,38%, transitory disuriae - 0,76%, infiltrate - 0,19%,
haematoma - 1,12 %, seroma - 0,38%, neuralgia of superficial
112
nerves - 0,76%. One the whole percent of complications was 6,07%.
At laparoscopic hernioplastic - funiculitis 1,1%, traumas of epigastric
vessels - 0,31%, orchitis, epididimitis -0,15%, transitory disuria 0,75%. Common rate of complications at this method was 2,76%.
There were not relapses for indicated period in both groups.
Conclusions
This laparoscopic methods of alloplastic of inguinal hernia is
reducing the frequency of funiculitis, epididimitis more than twice,
and such complications as wound infiltrates or haematomas. At
application of laparoscopic hernioplastic, we accomplished better
results in comparison with the opened operation by Liechtenstein.
Evidently the laparoscopic method has certain advantages.
118.
Kryshen V., Trofimov N.
The specificity of the adjuvant therapy of Mallory-Weiss syndrome.
(Dnepropetrovsk, Ukraine)
Purpose
The complex clinical and laboratorial investigation observation and
treatment for 602 Mallory-Weiss syndrome diseased (MWS) were
carried out with the purpose of improvement of their treatment
results.
Methods
Clinical, endoscopic, morphological, and immune-histological
features were analyzed, as well as the special immune-histological
examination of G-cells of the stomach mucosa antral zone with the
different variants of clinical course was carried out.
Results
It was proved that in 86,7 % of cases there were diffuse inflammatory
atrophic changes in the esophagus and the stomach mucosa, which
were the most apparent in the stomach antral zone. With the view of
its morphological characteristics the histopathologic feature of the
mucosa rupture zone had signs of an acute ulcer. The hyperplasia of
G-cells in the mucosa of the antral stomach zone was manifested in
33,3 % of cases, and under the condition of recurrent haemorrhage
such changes were found in 80,0 % of the diseased. More than 90,0
% of the patients had the stomach mucosa insemination by
microorganisms of Helicobacter pylori type. Changes like this are
113
characteristic of acid-dependent diseases, such as chronic gastritis
and duodenal ulcer.
Microbiological examination of the stomach mucosa rupture zone
revealed its insemination by mostly microorganisms of E. сoli,
Streptococcus
a-haemoliticus,
Streptococcus
b-haemoliticus,
Klebsiella pneumoniae, Staphylococcus aureus and fungi Candida
albicans, which are the most sensitive to cephalosporin compositions
of the second and third generation and fluoroquinolones.
The examination of the main immunological rates pointed to
immunodeficiency
together
with
the
phenomenon
of
autoimmunization which are characterized by inhibition of T-cell
population as a result of T-helper subpopulation decrease and Tsuppressors activation as well as B-cell population increase and
native killer population abrupt decrease. This phenomenon wos most
evident with ruptures of big sizes, intensive blood last and presence
of recurrent haemorrhage.
Conclusions
Taking into consideration the results of the study, we recommend to
include modern proton pump inhibitor, standard anti-helicobacter
(due to the last recommendations of the Maastricht group ), antibacterial (in example zynacef, ofloxacin) and effective
immunomodulating (during 5-7 days) therapy into the treatment
complex.
Putting into practice the variants of the therapy we used, let reduce
the percentage of recurrent haemorrhage from 24,92% to 13,58%
and the average period of hospitalization terms more than twice.
119.
Valetsky V.
Neoadjuvant and adjuvant chemotherapy in combined treatment of
gastric cancer.
(Kyiv, Ukraine)
Aim
The analysis of efficacy of combined treatment of gastric cancer
included preoperative intraarterial chemotherapy, radical operation
and intraoperative intraperitoneal chemotherapy with immobilized
cytostatics.
Patients and methods: Preoperative intraarterial chemotherapy was
performed by cathetherization of arteria gastrica sinistra or arteria
gastroepiploica dextra by Seldinger technique. Fluorouracyl (1000
114
mg/m2) and doxorubicin (30 mg/m2) perfused during 3-5 days.
Intraoperative intraperitoneal chemotherapy was performed with
immobilized on polymethylsilloxan fluorouracyl and doxorubicin in the
same doses. We analyzed survival of 38 patients after preoperative
intraarterial chemotherapy, radical operation and intraoperative
intraperitoneal
chemotherapy
with
immobilized
cytostatics
(IACh+RO+IPCh), 38 patients after preoperative intraarterial
chemotherapy and radical operation (IACh+RO) and 204 patients
after radical operation.
Results
Immidiate results showed no increase of postoperative complication
rate and mortality. 3- and 5-years survival of gastric cancer patients
was analyzed by KaplanMayer method.
Conclusion
It was elaborated the new scheme of gastric cancer combined
treatment included preoperative intraartherial polychemotherapy,
operation and intraopera
120.
Valetsky V.
The effect of intraoperative intraperitoneal chemotherapy on healing
of operative wound and anastomosis in gastric cancer patients.
(Kyiv, Ukraine)
Objective
The advantages of
regional chemotherapy in gastric cancer
combine treatment have been showed earlier. Immobilization of
cytostatics on polymethylsilloxan makes possibility to use it locally
during operation. However healing of operative wound and
anastomosis after intraperitoneal chemotherapy with immobilized
cytostatics remains unknown.
Patients and methods: Immobilized fluorouracyl (1000 mg/m2) and
doxorubicin (30 mg/m2) have been used intraperitoneally in 61
patients with unresectable gastric cancer during explorative or
symptomatic operation and 177 patients with advanced gastric
cancer during radical operation. 40 patients with unresectable tumor
and 214 with resectable gastric cancer after respective operations
have been taken as control groups.
115
Results
The rate of postoperative complications was 5% vr control 15% in
unresectable gastric cancer and 10% vr control 13% in resectable
tumor. The postoperative mortality was correspondently 3,2% vr
2,5% and 3,9% vr 4,6%. In groups with unresectable gastric cancer
an
anastomosis failure was not detected after intraoperative
chemotherapy with immobilized cytostatics but it was 5% after
operation only (control). In groups with resectable gastric cancer an
anastomosis failure developed in 0,6% (1 from 177 cases) after
intraoperative chemotherapy with immobilized cytostatics vr 2,3% (5
from 214 cases) in control. The duration of operation wound healing
was assessed in both patients with unresectable gastric cancer and
resectable tumor after operation as well as after operation and
intraperitoneal chemotherapy with immobilized cytostatics. No
severe toxic events were observed in all groups.
121.
Vasilevsky V.P., Tsilindz A.T., Maslakova N.D., Kardis A.I.,
Mozheiko M.A.
Minimally invasive surgery in patients with chronic venous disease of
lower limbs.
(Grodno, Belarus)
Matherials And Methods
309 patients were operated on and 82 injection sclerotherapy
procedures were performed because chronic venous disease with
different clinical presentation. Most patients were performed 199
standart operations (flash saphenofemoral ligation (crossectomy) +
stripping of the magistral saphenous veins (magna and parva) and
multiple phlebectomies. Nowadays we had aesthetic approaches in
treatment of varicose disease of the lower limbs: minimization of the
operative trauma and efficiency at the same time, phlebectomy of
veins with incompetent valves only, using the partial stripping
changing some stages of operations on phlebosclerotherapy. The
indication to surgery in most such cases was not complicated
varicose disease (CEAP C П-Ш stage) – 110 patients. Among the
patients of these clinical stages according to CEAP classification
there were 76 partial strippings (short – 20, middle – 50 and distal 6 ). Surgical treatment consisted only of miniphlebectomies (without
stripping of the magistral saphenous veins) in 22 patients with
absence of pathological venous reflux according to ultrasound
doppler and duplex scanning . «Thread veins» and varicose veins of
116
1-П СEAP stages were the causes for 82 injection sclerotherapy
procedures. 12 patients had combination of surgical treatment +
injection sclerotherapy. We had good clinical and cosmetic results in
all cases.
Conclusion
Clinical manifestation as well as the course of chronic venous
pathology and the results of investigations were important factors for
the choice of the surgery or the combination of treatment.
122.
Zarkov K., Nickolov N., Petkov Chr., Assenov A.
Results of radical anterior rectal resections (Sofia, Bulgaria).
Aims
We analyze the performed radical anterior rectal resection with
stapler and hand suture technique - postoperative morbidity and
mortality, relapses, 3- and 5-years survival.
Methods
We report 299 rectal cancer patients operated through 2001-2006.
Anterior rectal resection - done in 196 cases – 148 stapled and 48
hand suture. Age from 32 to 87.
In all cases we performed total mesorectal exision. In 45 - biilial and
paraortal lymphadenectomy. In low rectal cancer cases distal margin
is 3cm from tumor. Anastomosis layed under pelvic peritoneum.
Miles operation- in 57cases (tumors located within 5cm above anal
verge). Hartmann operation – 46.
Results
Anterior rectal resection patients staging: TNM I - 35, II - 53, III – 45;
IV - 15. Removed lymph nodes - 9 to 42 per patient; found metastatic
- 1 to 10 nodes in 16 patients.
Postoperative complication – anastomotic leakage leading to
perianal fistula formation in 27 (13.7%). In 8 of these ( 29.6% or 4%
of all 196 patients) – proximal stoma made later. The rest were
treated conservatively within 20 - 40 days. Detailed information
regarding leakage and anastomosis level is presented. Mortality is
2.5% (5/196).
Detailed information on 3- and 5-years survivals and survival related
to TNM staging are presented.
117
Conclusions
We prefer using staplers in low rectal cancer cases because:
decreased operating time - 40-50min less; decreased postoperative
complications. No proximal stoma together with anastomosis.
Postoperative perianal fistulas are treated conservatively with
success. Proximal stomas made later after anastomotic leakage - not
significantly high in number.
123.
Zhandarov K.N., Garelik P.V., Savitskij S.E., Bezmian I.A.,
Oslavskij A.I., Beljuk K.S., Tokov V.A.
Endoscopy sanitation in treatment of the acute destructive
pancreatitis / clinic and tomographic criterias in definition of tactics
and forecasting of the acute destructive pancreatitis treatment.
(Grodno, Belarus)
The Purpose Of Research
To develop precise clinics and tomographic estimation criteria of the
area and severity of the pancreatic and peritoneal fat damage with
prognosis of the treatment, on the basis of the results of treatment of
the patients with an acute destructive pancreatitis (ADP).
Materials And Methods
111 patients with ADP were treated in the clinic. The area of the
damage was estimated by MRT. Peritoneal area was divided into
four areas.
Results
Intensive conservative therapy was used in group I (28 patients),
damage of the peritoneal fat was seen in no more than I and II areas
without any signs of the infectious process. In the II group of patients
(37), damage of the peritoneal fat was no more than I, II and III
areas, treatment began with intensive conservative therapy if the
signs of the infection were absent. The damage of the peritoneal fat
extend to I, II, III and IV areas, clinical signs of the fat’s necrotic
infection and positive results of the punctures of the liquid formations
in the absence of restriction of process were present in case of
progressing process in the III group of patients (26), operative
treatment was perfomed with open or semiopen methods.
118
Conclusion
Conservative therapy is indicated for sterile ADP. If the damage of
the peritoneal fat extend to more than 3 areas and if the signs of
peritonitis are present, performaning of the laparoscopic and
puncture-drainage interventions are strongly recommended.
124.
Kulig J., Kawiorski W., Richter P., Kibil W., Popiela T.
Nissen fundoplication – 10 year experience (Krakow, Poland).
Background
Gastroesophageal reflux disease (GERD) is a common nonmalignant gastrointestinal disease. The introduction of minimally
invasive surgical techniques and the high costs of pharmacotherapy
increased the number of patients subjected to surgical antireflux
treatment. Also, the use of advanced technique of manometry including intraoperative video-assisted continuous pressure
monitoring - made possible complicated but objective analysis of the
pressure profile in the newly created area of gastroesophageal
junction.
Materials And Methods
The analysis was conducted in 159 patients. A group consisted of 93
men and 66 women at the mean age of 38 years, range 18-72,
subjected to antireflux surgery with continuous intraoperative videoassisted manometry of pressure in the newly created
gastroesophageal junction (fundoplication wrap). Surgical procedure
was individually tailored in each case depending on the motility
parameters and GERD etiology. Eighty seven patients (55%)
underwent 3600 Nissen fundoplication, 17 “floppy” Nissen procedure
(11%), 22 Dor hemifundoplication (14%), and 33 Toupet
hemifundoplication (21%).
Results
Of 159 patients subjected to antireflux procedures only 8 (5.0%)
developed dysphagia, and 12 (7.5%) recurrent reflux disease.
Recurrent reflux symptoms were most frequently caused by the
dislocation of the fundoplication wrap. Dysphagia occurred in the
patients with too tight fundoplication wrap or its dislocation with
subsequent rotation and angulation that impaired food passage. In
some patients objective causes of dysphagia have not been found.
In these patients no abnormalities were detected by the
119
postoperative visualising examinations, and mean pressures in the
fundoplication wrap did not exceed critical values. In these cases
dysphagia was caused probably by the impaired gastric motility.
Conclusions
1. GERD with multifactor etiology requires individually tailored
surgery based on the results of motility studies.
2. Final result depends on appriopriate calculations of the
intraoperative pressure in the newly created fundoplication
wrap.
3. Appropriate fixing of the fundoplication wrap to the
diaphragm is very important for lowering the rate of GERD
recurrences due to the dislocation of the wrap.
125.
Kulig J., Popiela T., Kawiorski W., Richter P., Kibil W.
Hiatal hernia – hernioplasty and fundoplication in GERD patients.
(Krakow, Poland)
Background
Gastroesophageal reflux disease (GERD) is a common nonmalignant gastrointestinal disease. The introduction of minimally
invasive surgical techniques as well as high costs of
pharmacotherapy increased the number of patients subjected to
surgical antireflux treatment. Also, the use of advanced technique of
manometry - including intraoperative video-assisted continuous
pressure monitoring - made possible complicated but objective
analysis of pressure profile in the newly created area of
gastroesophageal junction. The purpose of the study was to assess
the value of continuous intraoperative LES pressure monitoring,
based on the final clinical results following Nissen antireflux
procedures.
Materials And Methods
The analysis was conducted in 105 patients. A group consisted of 67
and 38 women at the mean age of 36 years, range 18-69, subjected
to antireflux surgery with continuous intraoperative video-assisted
manometry of pressure in the newly created gastroesophageal
junction (fundoplication wrap). Surgical procedure was individually
tailored in each case depending on the motility parameters and
GERD etiology. sixty seven patients underwent 3600 Nissen
120
fundoplication, 22
hemifundoplication.
Dor
hemifundoplication
and
26
Toupet
Results
Of 105 patients subjected to antireflux procedures only 5 (5.%)
developed dysphagia, and 8 (7.5%) recurrent reflux disease.
Recurrent reflux symptoms were most frequently caused by the
dislocation of the fundoplication wrap. Dysphagia occurred in the
patients with too tight fundoplication wrap or its dislocation with
subsequent rotation and angulation that impaired food passage. In
some patients objective causes of dysphagia have not been found.
In these patients no abnormalities were detected by the
postoperative visualising examinations, and mean pressures in the
fundoplication wrap did not exceed critical values. In these cases
dysphagia was caused probably by the impaired gastric motility.
Conclusions
1. GERD with multifactor etiology requires individually tailored
surgery based on the results of motility studies.
2. Finnal result depends on appriopriate calculations of
intraoperative pressure in newly created fundoplication wrap.
3. Appropriate fixing of the fundoplication wrap to the
diaphragm is very important for lowering the rate of
GERD recurrences due to the dislocation of wrap.
126.
Kawiorski W., Legutko J.
Duodenogastric reflux – the usefulness of continuous 24-h
spectrometric bilirubin monitoring test (BILITEC 2000).
(Krakow, Poland)
Several clinical studies showed that Duodenogastric Biliary Reflux
(DGR) increased significantly following cholecystectomy (CHC). The
role of this "alkaline reflux" has been controversial because of the
problems with its detection. Now the new 24-hr fiberoptic
spectrophotometry monitoring system (BILITEC 2000) has become
available to assess bile concentration.
The aim of present study was to evaluate the incidence of gastric
biliary reflux following cholecystectomy.
Patients and method. 46 patients with cholelithiasis were studied
before and 1-2 years following CHC. Gastroduodenoscopy
121
(histology) and 24-hour spectrophotometric bile monitoring using
Bilitec 2000 system were performed in each patient. Additionally,
each patient filled in the self-examination questionnaire (modified
Visick scale). Clinical assessment of reflux based upon the criteria
applied by Cooperman. The results were computer analyzed using
Oesophogram, Synectics Medical software.
Results
Biliary reflux were gastroscopically suspected just before surgery in
21 patients (45%). Histological lesions typical for bile gastritis
postoperatively we observed in 29 patients (vs. preoperatively in 12
patients). In postoperative Bilitec examination the incidence of
medium bilirubin absorption time (above 0,14) increased significantly
from 86 minutes to 617 min. These pathology were observed in 76%
of patients. In this group, clinical symptoms occurred in 27 cases.
Total bilirubin absorbance increased from 13,8% before CHC to
49,7% following surgery.
Conclusion
The incidence of DGR and total exposure of gastric mucosa to biliary
contents (bilirubin) significantly increased following cholecystectomy.
The ambulatory 24-hour bilirubin absorption measurement system
(BILITEC 2000) seems to be an easy and recommended method of
DGR analysis.
127.
Kawiorski W., Kibil W., Richter P., Kulig J.
Pneumatic dilatation for the treatment of oesophageal achalasia.
(Krakow, Poland)
Oesophageal achalasia is frequently occurring oesophageal motility
disorder that makes considerable diagnostic and
therapeutic problem.
The aim of the study is evaluation of the effectiveness of pneumatic
dilatation for the treatment of oesophageal achalasia.
Materials And Methods
A study group consisted of 104 patients ( 71 women and 33 men,
mean age 43.5 years, age range 19 - 75 years) treated at the
Department of Surgery between 1997 - 2005. Duration of disease 6
months - 22 years. All patients underwent manometric evaluation,
radiological, and endoscopic examinations with histopathological
122
verification of specimens. The patients received two-phase
treatment. If two or three repetitions of dilatation did not improve the
results,
Heller's
cardiomyotomy
was
performed.
Results
Clinically good or excellent outcome of pneumatic dilatation was
observed in 73 (70.2%) of all 104 patients undergoing treatment. The
procedure was repeated in only 8 (11%) cases for recurrent
dysphagia. In the remaining 31 (29.8%), who did not respond to
pneumatic dilatation, Heller's cardiomyotomy was performed.
Conclusions
Pneumatic dilatation is effective treatment of oesophageal achalasia.
In the patients in whom clinically good result of pneumatic achalasia
was not obtained, oesophagogastric passage frequently improved
giving rise to nutritional parameters of the patients before surgery.
128.
Kibil W., Kawiorski W., Richter P., Kulig J.
Manometric evaluation of anorectal functions after local resections
and anterior rectal resections
(Krakow, Poland)
Anorectal operations may cause fecal incontinence of various degree
and deteriorate patient's life comfort. The method that objectively
evaluates incontinence degree is anorectal manometry.
Aim
The study evaluates anorectal manometry performed 6 months - 1
year after surgery in the patients after local tumor resections with
TEM technique and using Parks' retractor, after anterior rectal
resections (anastomosis 5-10 cm from anal verge), and after low
anterior rectal resections (anastomosis below 5cm from anal verge).
Materials And Methods
The authors analyzed a total of 592 patients operated between 1996
- 2006 divided in two groups. The first group consisted of 304
patients after local tumor resection using TEM (196 patients :107
men, 80 women, mean age 60.1 years) and 108 operated using
Parks' retractor (47 men, 61 women, mean age 61.7 years). The
second group consisted of 288 patients, who underwent anterior
123
rectal resection: 196 (104 men, 92 women, mean age 61.2 years)
and low anterior rectal resection: 92 (47 men, 45 women, mean age
65.6 years). Grading of anal incontinence was classified according to
the score of Holschneider that covers subjective and objective
evaluation as well as anorectal manometry findings. Pull-through
anorectal manometry was performed using Synectics equipment.
Preand
postoperative
findings
were
compared.
Results
Complete control of stool continence or episodes of sporadic
incontinence (grade I and II acc. to the Holschneider score) occurred
in 82% of patients after anterior resections and in 74% after low
anterior rectal resections. The remaining 8% vs. 26% had
symptomatic stool incontinence, grade III and IV acc. to
Holschneider score). Grade I stool incontinence was found in 2.5%
of
patients
after
resections
with
TEM
and
in
2.7% after procedures performed using Parks' retractor.
Conclusion: Anorectal manometry confirmed anorectal dysfunction in
some patients after anterior and low anterior rectal resection and in a
small group of patients after local tumor resections. Anorectal
manometry allows evaluation of anorectal dysfunction before elective
surgical procedures, before patient's qualification to surgery and
postoperatively.
129.
Kulig J., Richter P., Gurda-Duda A., Gach T., Kłęk S.
The role and value of endorectal ultrasonography in diagnosing
rectal tumors.
(Krakow, Poland)
Colorectal cancer in 50-60% of cases is localized in the rectum and if
early diagnosed can be locally excised.
The authors evaluated the diagnostic accuracy of the preoperative
ERUS in the staging of rectal tumors and the usefulness of the
method for the qualification of patients to the local excision.
In the retrospective analysis we analyzed 29 patients with rectal
cancer.
The depth of invasion into the rectum wall was assessed by ERUS
and all patients were qualified for tumor excision with TEM. We
analyzed overall accuracy of ERUS and the effectiveness of
treatment.
124
In the analyzed group diagnostic accuracy of ERUS was 89.2%,
sensitivity 92.3% and specificity 50%. Local excision with TEM was
curative in 86.2% patients with rectal tumors detected by ERUS.
ERUS is an accurate method of preoperative discriminating between
T1 and T2 carcinomas and diagnostic accuracy is adequate to
qualify patients for anal saving operations.
130.
Pimenta A., Gouveia A., Preto J., Baptista M., Madureira A.J.,
Pimenta M., Magalhães A., Cardoso de Oliveira M.
The surgeon and the oncological patient…or the story of
a long road of care and dedication
(Porto, Portugal)
A male patient was operated for the first time by our surgical team at
the age of 53, due to cardia carcinoma. A proximal gastrectomy was
performed through a left thoracophrenolaparotomy. The tumor
invaded the muscularis externa of the gastric wall and there were no
metastasized lymph nodes.
Seven years after this surgery, he was reoperated, due to
a metacronous carcinoma of the distal portion of the stomach.
A degastrogastrectomy was performed. In the post operative period,
the patient developed necrosis of the plasty. The esophago-jejunal
anastomosis
was
taken
down
and
a jejunostomy and a cervical esophagostomy performed. Four
months after surgery, digestive continuity between the esophagus
and the jejunum was estabilished with the use of
a colon plasty. The esophagus remained excluded, given the general
clinical status of the patient.
Eleven years after the last surgery, the patient was reoperated due
to an esophagocel.
The poster reveals the diagnostic images, the findings during the
different surgeries and the surgical options in each case.
131.
Gouveia A., Pimenta A., Preto J., Lopes J.M., Sousa Rodrigues
J., Ferreira A., Oliveira Alves J., Cardoso de Oliveira M.
Gastric gist with invasion of the transverse colon
(Porto, Portugal)
A 53 year old male patient was admitted to the Emergency
Department
due
to
melenas.
A
hemogram
revealed
125
a hemoglobin of 8,5 g/dl. Besides this upper GI bleeding, the patient
referred, for the past 15 days, astenia and dyspneia for medium
efforts.
The abdominal exam revealed a mass that occupied part of the
epigastrum and mesogastrum, apparently not adherent to the
anterior abdominal wall and with some mobility in the vertical and
transversal planes.
An upper GI endoscopy revealed, in the posterior wall of the antrum,
a
volumous
submucosa
lesion,
partially
ulcerated.
A contrasted digestive x-ray confirmed the existence of an ulcerated
tumoral lesion and revealed a distal deviation of the transverse
colon. A CT scan demostrated that the mass had
a heterogenous content and that there were no signs of nearby
organ invasion, ascitis or distance metastasis.
The poster shows images of the diagnostic exams performed, the
findings during laparotomy and the therapeutic option for removal of
the mass.
132.
Preto J., Pimenta A., Gouveia A., Sousa Rodrigues J., Oliveira
Alves J., Ferreira A., Cardoso de Oliveira M.
The surgeon and the dificulty of therapeutic options in a patient with
a non palpable tumor – gastric carcinoid
(Porto, Portugal)
A 41 year old male patient complained of heartburn and regurgitation
during two and a half years. His last upper GI endoscopy, performed
one month prior to this admission, revealed a grade I peptic
esophagitis, a small sliding hiatal hérnia and, at the level of the
gastric body, signs of cronic and redness gastropathy. A biopsy of
these last lesions was performed. The pathological report revealed
the existence of a neuroendocrine tumor.
A CT scan performed for staging purposes did not reveal images of
hepatic metastasis. An octreoscan demonstrated various images
compatible with secundary lesions of the liver.
The poster shows images of the diagnostic studies performed, the
findings during laparotomy, the therapeutic option and the
pathological report of the surgical specimen.
126
133.
Preto J., Pimenta A., Gouveia A., Magalhães A., Costa S.,
Ferreira A., Oliveira Alves J., Sousa Rodrigues J., Amendoeira
I., Cardoso de Oliveira M.
The value of cytology of the n-g tube lavage in carcinomas of the
cardia and the stomach
(Porto, Portugal)
Introduction
The recurrence of stomach/cardia carcinomas, namely in the area of
the anastomosis, might be explained by seeding of the tumor cells
from the naso-gastric tube (NGT). The objectives of this study was to
evaluate this possibility and compare the clinical-pathological and
recurrence profile according to the presence of malignancy in the
cytology of the NGT lavage.
Materials And Methods
A cytology exam was performed in 42 patients submitted to surgical
resection for cardia/stomach carcinoma (7/35), between Jan/03 and
Mar/06. There were 22 females and 20 males with an average age of
66 years. The NGT was removed immediately before the creation of
the anastomosis; the distal segment (15 cm) was submerged in 20
ml of saline solution and sent for cytological study. The following
parameters were compared: age, gender, type of gastrectomy,
location and size of tumour, gross appearance, histological
classification (WHO, Lauren/Carneiro, and Ming), depth wall
invasion, lymph node and distance metastases, venous, perineural
and lymphatic invasion. The patients were followed in outpatient
clinic.
Results
Respectively, 62,0 %, 28,6 % and 9,4 % of the patients had a
negative, positive and inconclusive (were excluded) cytological
result. Of the patients with a positive cytology 83,3 % were male
(p<0.05) and none had T1 tumours (p<0.05). 57,1 %, 33,3 % and
12,5 % of the lesions of the cardia, fundus/body and antrum,
respectively, presented positive cytologies (p=0.12). Six recurrences
were detected – negative cytology: peritoneal (1), hepatic (2),
supraclavicular lympth node (1); positive cytology – hepatic (1) and
anastomotic area (1).
127
Conclusions
These results confirm the possibility of the NGT contributing to the
dissemination of neoplastic cells, principally in patients with proximal
tumours, ulcero-vegetating or ulcero-infiltrative and > T1. This study
allows us to reconsider the introduction of the NGT only after the
tumour has been ressected and also reformulate the method of
follow-up of the patients with a positive NGT cytology.
134.
Gouveia A., Pimenta A., Preto J., Magalhães A., Lopes J.M.,
Ferreira A., Oliveira Alves J., Sousa Rodrigues J., Cardoso de
Oliveira M.
A gist of the gastric fundus – a rare cause of upper GI bleeding
(Porto, Portugal)
A 69 year old patient was admitted, through the Emergency
Department, due to hematemesis and melenas of an unknown
cause, that began two days before. An upper GI endoscopy revealed
a wide based, ulcerated polypoid formation in the submucosa of the
gastric fundus.
A contrasted esophago-gastric x-ray confirmed the location and
tumor ulceration.
A CT scan did not reveal signs of invasion to near by organs, ascitis
or distance metastasis.
An EUS revealed a 56x45 mm nodular formation that was situated
on the anterior wall of the stomach, in the muscularis externa. The
poster reveals images of the various diagnostic exams, the surgical
findings and the therapeutic option that was taken in order to remove
the mass.
135.
Gouveia A., Pimenta A., Preto J., Faria G., Oliveira Alves J.,
Carneiro J.C., Ferreira A., Sousa Rodrigues J., Cardoso de
Oliveira M.
Correlation between blood groups abo and the clinical-pathological
characteristics of patients with cardia adenocarcinoma
(Porto, Portugal)
Objective
The correlation of blood groups ABO, clinical and pathological
characteristics and prognosis has been studied in several cancers.
It is postulated the hypothesis that malignant cells produce an A-like
128
antigen, so that in individuals negative for this antigen (blood group B
and O), the antibody might protect against tumoral growth and
dissemination. The authors propose to study this correlation in cardia
adenocarcinoma (CA) patients.
Materials And Methods
Retrospective analysis of the clinical data of 122 patients with CA,
submitted to surgical treatment between 1989 and 2005. We
analyzed the following parameters: ABO blood group, gender, age,
tumour location, size and histological type, depth of penetration,
lymph node invasion, metastasis, TNM stage, lymphatic and venous
invasion.
Results
Of the 122 patients, 91 were male and 31 female. Median age was
63 years. In the studied parameters we only established
a statistically significant association between blood group and
lymphatic invasion. In the individuals with group B antigens, the
lymphatic invasion rate was 76,5% (13/17) while it was 95.2%
(80/84) (p=0.0009) in individuals with anti-B antibody. The presence
of lymphatic invasion is a determinant of worse prognosis (mean
survival time with/without lymphatic invasion: 64/164 months –
p=0.01). There seems to be a trend towards a lesser rate of lymph
node metastasis in individuals with antigen B (65% vs 85% p=0.053). We found no differences between blood groups in the
other items studied.
Conclusion
Individuals expressing antigen B (groups B and AB) present
protection against tumour lymphatic spreading. The presented
hypothesis of tumour production of antigen A-like is not consistent
with the lack of protection for lymphatic spreading in individuals with
anti A antibody (blood group O). Global survival is similar in every
blood group. Prospective studies will be necessary in order to
determine the validity of this association and also molecular studies
to try to understand its origin.
136.
Preto J., Pimenta A., Gouveia A., Cunha A.L., Lopes J., Gonzaga
R., Castanheira A., Cardoso de Oliveira M.
Mixed gastric carcinoma (endocrine/exocrine)
(Porto, Portugal)
129
Introduction
Mixed gastric carcinoma (endocrine / exocrine) is a rare entity
characterized by the presence of approximately the same propotion
of neuroendocrine and glandular neoplastic cells.
Case Report
Male patient, 70 years old, with complaints of progressive dysphagia
for
solid
foods,
with
a
duration
of
2
months.
An upper GI endoscopy revealed an ulcero-vegetant neoplasia
involving the cardia and the upper part of the gastric body (Siewert
type III). A biopsy confirmed the existence of an adenocarcinoma.
Pre-operative staging did not reveal distance metastasis. The patient
was submitted to a total gastrectomy, distal esophagectomy and
splenectomy associated with a D2 lymphadenectomy (via left
thoracophrenolaparotomy). During surgery, a suspicious hepatic
nodule (1,7 cm) was resected. Post operative period ran without
compliocations. In the surgical specimen 39 lymph nodes were
isolated.
The pathological report revealed a mixed gastric carcinoma Na peça
cirúrgica foram isolados 39 gânglios. O exame anatomo-patológico
revelou um carcinoma gástrico misto T2N0M1, with vascular and
perineural invasion. Adjacent to this neoplasia, another neoplasia
was observed (tubular adenocarcinoma; pT1), also with
neuroendocrine differentiation. Immunohistochemistry confirmed
neuroendocrine fenotype in the larger tumor (synaptofisin positive),
and also in the smaller tumor (synaptofisin and chromogranin
positive). Cronic atrophic gastritis with intestinal metaplasia was
observed in the remaining gastric mucosa.
Comments
The existence of mixed malignant neoplasias of the stomach
(endocrine and exocrine) reinforces the hypothesis that
neuroendocrine and epithelial cells of the gastrointestinal tract may
derive from multidirectional differentiation of the same primitive cell.
Given its rarity, the prognosis of these tumors is not well known.
Some authors affirm that the prognosis is similar to advanced staged
gastric adenocarcinoma.
130
137.
Pimenta A., Gouveia A., Preto J., Sousa Rodrigues J., Oliveira
Alves J., Ferreira A., Cardoso de Oliveira M.
Carcinoma of the cardia – results of surgical treatment
(Porto, Portugal)
Objectives
Evaluate the clinical-pathological characteristics and the factors that
influence the survival of the patients treated for adenocarcinoma of
the cardia in a General Surgery Service.
Materials And Methods
Retrospective
study of
295
consecutive
patients
with
adenocarcinoma of the cardia, treated in our Service between
January 1976 and December 2005. In the group of patients
submitted to resectable surgery (n=189), several clinical-pathological
parameters were analyzed. Survival was calculated by the KaplanMeier method and multivariate analysis was performed by a logistic
regression model (Cox).
Results
The average of ages in this group of patients was 62,1 and the
median 65 (min: 20; max: 87). According to location (Siewert
Classification), 24,7 % of the cases presented tumours type I, 11,7 %
were type II, and 63,6 % were type III. The global resection rate was
70,8 % and the type of surgery most frequent was a left
thoracophrenolaparotomy (64,2 %); 8,6 % of the patients were not
submitted to surgery. In univariate analysis, significant differences
were observed in the survival of the patients according to age
groups, location, gross appearance, positive surgical margins,
Classification of Ming, venous invasion, lymphatic permeation, depth
wall penetration, lymph node metastases and stage. In multivariate
analysis, only Siewert’s Classification of the tumours presented a
prognostic value with a statistical significance (p<0.04). The 5 year
cumulative survival rate of all of the patients with cardia carcinoma
was 21,4 % and in the group of patients submitted to resection
surgery was 30,8%.
Conclusions
The authors encountered a rising number of patients with the
diagnosis of cardia carcinoma. Adjusting the surgical strategy
according to the location and extension of the tumours, high
131
resections rates (70,8 %) and R0 resections (87,3 %) were achieved.
The tumours located in the esophago-gastric junction (Siewert type
II) presented a better survival in our group of patients. The
application of Siewert’s Classification to cardia carcinomas
emphasizes the differences between its three types, corroborating
the notion that these tumors do not belong to a homogeneous
clinical-pathological entity.
138.
Pimenta A., Carneiro F., Moreira H., Preto J., Gouveia A.,
Portugal R., Guimarães S., Cardoso de Oliveira M.
New challenges in surgical decision: prophylactic total gastrectomy
(Porto, Portugal)
A 33 year old male patient is a carrier of a germinative missense
type mutation of the E Cadherin gene, located at position 1901 of the
codon 634 (exon 12), responsible for the substitution of the
aminoacid alanin for valin. This mutation was already identified in the
DNA isolated from the gastric mucosa of a deceased brother that
was diagnosed at age 23 with diffuse type invasive gastric
carcinoma. In the family history, there was also another older brother
that died 4 years before, at age 26, with diffuse type gastric
carcinoma. It was not possible, in this patient, to obtain good quality
biological material that would enable diagnosis of the referred
mutation.
The patient of this case report, was submitted to two upper GI
endoscopies, with multiple biopsies of the fundus, body and gastric
antrum, that did not reveal malignant cells. Given the fact that he
was a carrier of a germinative mutation of the E cadherin gene
characterized of being highly agressive (previously demonstrated in
sporadic forms of gastric carcinoma and some forms of colo-rectal
carcinoma) and with a high penetration rate (70-80 %), the patient
was submitted, on his request, to a prophylactic total gastrectomy.
The poster shows the findings during laparotomy, the therapeutic
options and the patological report after numerous samples taken
from the surgical specimen.
st
1 December 2007
Poster session 2
132
139.
Antonopoulos P., Tavernaraki K., Alexiou K., Haralabopoulos
G., Konstantinidis F., Fotopoulos A., Economou N., Karanikas I.,
Konstantinidou E., Antsaklis G.
Rapture of liver hydatid cyst towards the biliary tract. The role of
computer tomography (ct) in the preoperative evaluation.
(Sismanoglion)
Aim
We present a retrograde study in order to evaluate the role of
Computer Tomography (CT) in the preoperative diagnosis of
echinococcal cyst rupture into the biliary tract.
Materials And Methods
Eight patients, 62 to 84 years old were studied. They were admitted
to the outpatient department with clinical symptoms followed by
laboratory confirmation of cholangitis. Abdominal CT was diagnostic
in all cases, representing rupture of the echinococcal cyst into the
intrahepatic bile ducts and in one case into the gallbladder. All
patients were operated on and the intraoperative findings confirmed
the preoperative CT diagnosis.
Results
Seven patients presented with rupture of the echinococcal cyst into
the
intrahepatic
bile
ducts.
One
of
them
had
a simultaneous rupture in the subcapsular hepatic region. The
diagnosis was confirmed by: a) disruption of the echinococcal cyst
architecture and b) intrahepatic bile duct dilatation and
air-bubbles in 5 out of 7 patients. One patient presented with rupture
of the echinococcal cyst into the gallbladder as diagnosed
preoperatively by CT. The diagnosis, in this case too, was confirmed
by: a) disruption of the echinococcal cyst architecture and b)
dilatation of gallbladder and intrahepatic bile ducts containing airbubbles.
Conclusion
CT represents a valuable imaging method for quick and accurate
diagnosis of intrahepatic biliary tract and gallbladder hydatid cyst
rupture. It highly contributes to the preoperative evaluation and timed
operative treatment of these patients.
133
140.
Chkhaidze Z, Kazarian G.
The results of the transplantation of beta-cells of gastric gland in
abdominal pathology accompanied by diabetes type 2.
(Tbilisi, Georgia)
Last time there is a strong tendency of increase in number of
patients with insulin dependent diabetes mellitus (IDDM). The
treatment of postoperativeinfectious complications is IDDM patients
presents a difficulty. It is caused by the increase in number of
patients who have other surgical pathologies together with IDDM.
According to several authors, in this group of patients, the lethal
outcome caused by infectious complications is up to 22%.
The transplantation of the cells of the gastric gland is an effective
surgical method in the complex cure of different forms and types of
diabetes. Allotransplantation of endocrine tissue of gastric gland
helps the patients with abdominal surgical pathology with the
compensation of hydrogen exchange in post-surgical period and in
this way avoids the discompensation of diabetes.
The intraportal allotransplantation cells gastric gland at the patients
with chronicle calcular cholecystit and stomach-ulcer disease and
12th intestine accompanied by diabetes influence positively on the
post-surgical period, promoting the normal limit of glicemy and this
way warning the origin of discompenstation of disease.
The intraportal and intramuscular allotransplantation, cells and
gastric gland help be patients with chronicle calcular cholecysthit
stomachuler disease and 12th intestine in promoting the close of the
wound in the post-operation period.
The maximum effect of allotransplantation, cells and gastric gland in
most cases last from 1 to 2 months. Allotransplantation, cells and
gastric gland mahe a curative influence also the exchange at the
patients with diabetes.
141.
Ciechański A., Wallner G., Jaworski T., , Ćwik G., Ciechańska
M., Skoczylas T., Bury P., Dąbrowski A.
The angiogenetic factors VEGF and bFGF evaluations in patients
with resectable rectal cancer – preliminary report.
(Lublin, Poland)
134
The Vascular Endothelial Growth Factor (VEGF) and basic
Fibroblast Growth Factor (bFGF) are considered to be the most
important stimulators of angiogenesis.
Aim of the study was the prospective evaluation of the relationship
between angiogenetic factors:VEGF and bFGF serum levels, of and
cancer stage according to pTNM (UICC) classification in patients
with resectable (R0) rectal cancer.
Materials And Methods
The study group: 61 patients (34M and 27F mean age 60.8) with
confirmed rectal adenocarcinoma in stage: I - 6 patients (9.8%), II 22 (36.1%), III - 33 (54.1% ). In 41 patients the lymph nodes
metastases were present. The control group was composed of 30
healthy subjects. Levels of VEGF and bFGF were measured by
means of ELISA immunoenzymatic method (Quantikine R&D
Systems).
Results
VEGF and bFGF median levels were statistically significantly
different in the studied group, in comparison to control group: VEGF
(stage I - 43.81 pg/ml, p=0.0279; st. II - 67.29 pg/ml, p=0.000625;
st.III - 100,46 pg/ml, p=0.000552) and bFGF (stage I - 5.77 pg/ml,
p=0.000346; st. II - 6.42 pg/ml, p=0.000058; st. III – 3.12 pg/ml,
p=0.000801). In the patients with lymph nodes metastases
statistically significant higher VEGF levels (p<0,001) and lower bFGF
levels (p<0.003) were observed.
Conclusion
Monitoring of VEGF and bFGF serum levels may be useful in
diagnosis and prognosis in patients with resectable rectal cancer.
142.
Dias Santos D., Ribeiro J., Barradas J., Oliveira H.
Recurrent cholangitis after Whipple’s procedure, can it be secondary
to radiotherapy? A clinical report.
(Lisbon, Portugal)
A 63 years-old male with history of cholangiocarcinoma underwent
Whipple’s procedure in July’2002 followed by chemotherapy and
radiotherapy, presented to the clinic consultation in November’2005
with symptoms of obstructive jaundice and recurrent cholangitis. The
lab evaluation revealed elevation of alkaline phosphatase and
135
&#61540;-glutamyl transferase. Abdominal ultrasonografy, CT and
ERCP showed no evidence of recurrent neoplasia or any reason for
repeated cholangitis. Percutaneous cholangiography was performed
with drainage of the common bile duct. A colangio-CT with 3D
reconstruction showed a stenosis of the small arm of the Roux-en-Y
anastomosis. The patient was submitted to an exploratory
laparotomy in June’2006. We performed resection of the stenotic
segment and direct re-anastomosis. There was no evidence of
recurrent disease locally. The histology of the stenotic segment
confirmed chronic inflammation and fibrosis related to the secondary
effects of radiotherapy.
The patient was discharged and remains asymptomatic.
Radiation therapy is a mainstay of therapy for cholangiocarcinoma.
Patients receiving radiation therapy will experience some symptoms
from acute radiation injury to the gastrointestinal tract. Late injury
results of obliterative endarteritis and ischemia. the epithelium shows
atrophy and the intestinal wall develops fibrosis, manifesting by
strictures, fistulae and obliteration of tissue planes. The presence of
obstructive jaundice is not always a sign of recurret neoplasic
disease.
143.
Demidov V.M., Demidov S.M.
Management of acute pancreatitis: miniinvasive
roentgenendovascular method of diagnostics and treatment.
(Odessa, Ukraine)
Acute pancreatitis (AP) is one of the important problem of the urgent
surgery, often registered in surgical patients. The number of the
cases of AP manifestations is increasing. AP patients are 5-10% of
the whole number of surgical patients, and the disease has
a destructive character approximately in 15-20%. Despite certain
progress in curing patients with AP at the earliest stages of the
disease they die throughout the latest stages because of the
polyorganic insufficiency and sepsis that are the main causes of the
deaths in 80% of the patients with AP. Late or wrong diagnostics
alone with nonadequate treatment are the main causes for the
above-mentioned situation in the surgical pancreatology.
Roentgenendovascular surgery (REVS) represents the effective new
method in diagnostical and curing procedures in patients with AP.
This miniinvazive method constitutes new approach in AP patients
management due to intravascular diagnostical and curative
136
manipulations through catheters under the X-ray control. So, the
main issue of the present work is to summarize both REVS
diagnostical and treating efficacy in patients with AP.
Clinical observations were performed throughout 2002-2007 in 102
patients with AP in surgical departments of the Odessa Municipal
Hospitals N2 and N10. 81 of them had the slight expression of the
pathological process or only its initial stage – oedematic AP. The rest
of the patients were cures traditionally. REVS diagnostic was
provided to 21 patients by contrast compound injection selectively
into the abdominal trunk. Pancreatic gland branch destruction was
evaluated in case of AT one or two arteries contrasting failure as well
as in case of portal vena earliest contrasting. To 28 patients we used
also intra-arterial infusion therapy during which sandostatin was
intravascularly administered directly to the destructed part of the
pancreatic gland under the X-ray control.
Performed method of REVS diagnostical procedure allowed us to
diagnose the acute pancreatic gland inflammation on its beginning
stage. All the patients undergone by these diagnostical
manipulations were treated conservatively, none of them had
complications and/or side-effects afterwards. The efficacy of the
sequentially performed REVS diagnostics and treatment was proved
by pain syndrome disappearance in 26 of 28 patients with AP; pain
intensity decreasing was observed in other 2 patients. Toxic tests
indices and C-reactive protein data diminished as a result of the
performed miniinvazive treatment of AP patients. The pancreatic
gland ultrasound investigation after REVS treatment is characterized
by echo-signal lower intensity together with pancreatic parenchyma
nonmassive structure in imaging.
Therefore, the data obtained showed a possibility of the quickest
(during 3 days), qualified and effective treatment of the patients with
acute inflammatory destruction of the pancreatic gland parenchyma.
The efficacy of treatment was proved by the pancreatic enzymes
plasma content dynamic as well as by clinical conditions and data of
the pancreatic gland ultrasound investigation of patients with AP
normalization.
Thus, our data are in favour of the great efficacy of the REVS
method of patients with AP diagnostics and treatment. The following
features are very important in the method that we used: a) we
succeeded in earliest diagnostics of the pancreatic gland
parenchyma inflammatory destruction; b) we achieved the possibility
of the nontraumatized way of treatment of patients with AP that is
perspective from the prognostic point of view for patients; c) REVS
137
method of curing resulted in the pain syndrome reduction, plasma
biochemical and pancreatic parenchyma morphological changes
were quickly and effectively normalized; d) we use sandostatin twofold lower dose compared with its dose in case of compound
intrabursal administration; e) it seems to be very important to use the
direct compound injection into the destructed part of the pancreatic
gland that allows to reach the effective and quickest results of
treatment.
144.
Gambino G., Di Bona A., Maione C., Scio A., Buscemi G., Lo
Monte A.I.
LigasureTM haemorrhoidectomy: our experience on fifty patients.
(Palermo, Italy)
Objectives
Haemorrhoidectomy is the treatment of choice for patients with grade
III and IV haemorrhoids but it is frequently associated with
postoperative pain and prolonged hospital stay. A new technique
using bipolar diathermy seems to have advantages over
conventional open haemorrhoidectomy in terms of operating time
and postoperative pain.
Materials And Methods
From June 2005 to July 2006, 50 consecutive patients affected by
grade III and IV haemorroids, underwent surgical treatment by
LigasureTM
The operative time, the postoperative pain, the
median total 7-days analgesic requirement, the hospital stay and the
complications were documented.
Results
All patients were admitted to hospital the same day of the surgical
operation; The median operative time was 8.2 minutes (range 4-21);
the pain score was 4.2 (range 2-8) of the VAS scale and the median
total 7-days analgesic requirement was 140mg (range 90-240) .
Conclusion
In our experience haemorrhoidectomy performed with Ligasure
device seems to be a quick bloodless technique and it is associated
with a less analgesic requirement.
138
145.
Gambino G., Di Bona A., Maione C., Scio A., Concetta G.M.,
Buscemi G., Lo Monte A.I.
The use of marginal donors in kidney transplantation: our
experience.
(Palermo, Italy)
Objectives
The use of elderly donors has been advocated to expand the organ
donor pool because of increased needs and organ shortage. The
aim of the study was to analyse whether old age of donors and the
use of marginal kidney affect the outcome of renal transplantation.
Materials And Methods
We present data of 126 kidney transplantation performed during the
period between January 1996 and September 2003 where in 32 from
marginal donors (group A) and 94 from ideal donors (group B). We
analyzed the medical and surgical complications, the graft survival
at a median follow-up of 18 months, comparing the results obtained
with grafts from marginal donors with those retrieved from ideal
donors.
Results
Medical and surgical complications occurred in 22% and 5% and 7%
and 4% in group A and B respectively. The mean cold ischemia time
and the mean age were higher for patients undergone kidney
transplantation from marginal donors. No differences were in graft
survivor in group A and B.
Conclusions
Our data suggests that, with appropriate strategy and a correct
selection of the patients, marginal kidneys can be used safely, and
can decrease the gap between demand and supply.
146.
Gladky A., Gladka L., Krechkovsky O., Dryzunina N.
Adequate analgesia in internventional radiology.
(Kiev, Ukraine)
Introduction
Modern methods of anesthesia are not reliable enough during X-Ray
operations and mini-invasive interventions.
139
The Aim
Development of adequate analgesic scheme during X-Ray
operations and mini-invasive interventions and in post-operation
period.
Materials And Methods
Narcotic analgesic and non-steroid anti-inflammatory drugs were
used during mini-invasive interventions according traditional
schemes as well as according Patient-Controlled Analgesia (PCA).
PCA was carried-out with using SP-14S PCA Aitecs pump-syringe
and ‘Micropump’ MP-100.
Results And Discussion
Effectiveness of Standart-scheme analgesia during X-Ray operations
is 25-30%. Application of PCA increases quantity of cases of
adequate analgesia up to 82-95% depending on anesthetics
combination.
Conclusion
The article represents the results of applications PCA (Patient
Controlled Analgesia) during mini-invasive interventions carrying out
with using narcotic analgesic and non-steroid anti-inflammatory
drugs. Best results in combination of basis analgesia with ketorolak
and PCA with tramadol were reclived. Good results of analgesia in
92% of patients were achieved.
147.
Merante Boschin I., Toniato A., Bernante P., Piotto A., Pagetta
C., De Piccoli N., Pelizzo M.R.
Spontaneous rupture of a parathyroid adenoma.
(Padua, Italy)
Introduction
Spontaneous haemorrhage of the neck occurs rarely and may be
fatal (1). This report describes a case of cervical and mediastinal
haematoma caused by the spontaneous rupture of a cervical
parathyroid adenoma.
Case Report
A 56-year-old woman presented to our hospital 3 days after the
sudden development of neck swelling and pain with no associated
external injury.
140
A 10-MHz ultrasound study revealed a voluminous right thyroid lobe
(83.5 mm) with a isoechoic nodular lesion of 51.3 mm. A computed
tomography (CT) scan of the neck revealed a right cervical
haematoma, extended from the angle of the mandible to the thoracic
inlet into the superior mediastinum. Laboratory tests revealed a high
serum calcium level (3.18 mmol/L). The operation consisted in the
evacuation of the haematoma, right upper parathyroidectomy and
right thyroid lobectomy.
Discussion
Spontaneous haemorrhaging of a parathyroid gland occurs when the
gland is enlarged by an adenoma or by primary or secondary
hyperplasia, or by a cyst (2). The haemorrhage may remain
intracapsular or expand outside the thin capsule, dissecting into
cervical and mediastinal tissue (2,3). An elevated serum calcium
level is a diagnostic feature. In our case report the patient presented
preoperatively
acute
neck
swelling
and
hypercalcemia;
postoperatively the serum calcium levels gradually decreased.
Serum calcium and parathyroid hormone levels should be measured
in patients who present with a spontaneous cervical haematoma of
unknown origin .
References
1.
Chin KW, Sercarz JA, Wang MB, Andrews R. Spontaneous
cervical haemorrhage with near complete airway obstruction. Head
and Neck 1998;350-353
2.
Hotes LS, Barzilay J, Cloud LP, et al. Spontaneous
haematoma of a parathyroid adenoma. Am J Med Sci 1989; 297:
331-33
3.
Tonerini M, Orsitto E, Fratini L, Tozzini A, Chelli A, Santi S,
Rossi M. Cervical and mediastinal haematoma: presentation of an
asymptomatic cervical parathyroid adenoma: case report and
literature review. Emerg Radiol 2004;10:213-15
148.
Kulig J., SierŜęga M., Kołodziejczyk P., Szczepanik A.M.,
Popiela T.
Inadequately staged gastric cancer in term to lymph nodes
metastases.
(Krakow, Poland)
141
Background
Up to 70 % of patients with gastric cancer cannot be adequately
staged in Western countries due to a small number of lymph nodes
dissected during surgery. Although the ratio of metastatic to resected
lymph nodes (LNR) could possibly be adopted to improve accuracy
of staging, data for this population of patients are lacking.
Methods
Using a multicenter data set, we performed a retrospective analysis
of 738 patients with gastric cancer who underwent gastrectomy from
1986 to 1998 with 15 or less lymph nodes dissected. LNR was
analysed and evaluated with other prognostic factors.
Results
The median number of resected nodes was 8 (95 % confidence
interval [CI] 8.0 to 8.1, range 1-15) and the median LNR was 42.8 %
(95 % CI 38.5 to 50.0). The number of metastatic nodes significantly
affected survival only in univariate analysis. Patients’ age, depth of
tumour infiltration, and LNR were identified as independent
prognostic factors using the Cox proportional hazards model. With
reference to node-negative patients, hazard ratio with LNR ≤40 %
was 1.852 (95 % CI 1.415 to 2.423; p<0.001) and increased to 2.934
(95 % CI 2.271 to 3.792; p<0.001) when the ratio exceeded 40 %.
Conclusions
Although LNR cannot be used as a substitute for staging with
adequate lymphadenectomy, it may help in stratifying patients in
terms of their prognosis when only a limited number of lymph nodes
has been resected.
149.
Kotsifas Th., Sikalias N., Vasilopoulos J., Mountzalia L.,
Chaniotakis E.
Emergency surgical treatment of colon and rectum obstruction.
(Pireaus, Greece)
Background
The management of colon and rectum obstruction under emergency
conditions represents a common problem between surgeons in
treatment of these patients. AIM: this study presents our experience
and highlights our principles in managing patients with colorectal
obstruction in emergency base. METHODS-PATIENTS: in the last
142
eight years (1999-06) 279 patients (males:157, females:122, mean
age: 65,8 years) presenting with primary colorectal disease and 91
patients from them underwent to emergency operation, in the first 48
hours of admission in hospital, for acute intestinal obstruction (61
patients), perforation and peritonitis (23 patients) or severe
haemorrhage (7 patients). RESULTS: 27 patients (29,67%) with
complicated cancer of the right colon underwent to one-stage
primary resection and anastomosis (right hemicolectomy and
ileocolonic anastomosis),
9 patients (9,89%) with obstructed
carcinomas of the left colon, one patient (1,1%)with sigmoid volvulus
(ischemic rupture) and 13 patients (14,3%) with complicated sigmoid
diverticulitis were subjected to primary resection, 32 patients (35%)
with complicated cancer of the left colon were subjected to
Hartmann's operation and 9 patients (9,89%) with complicated
cancer of the rectum (5 patients – 5,5%) and left colon (4 patients –
4,4%) were managed with diverting colostomy. The overall
postoperative morbidity rate was 25,27% and mortality rate was
9,89% and increased with advanced tumour disease, perforation,
peritonitis, advanced cardiopulmonary disease and septic or
hypovolemic shock. The average length of hospitalisation was 14
(12-26) days. CONCLUSIONS: One-stage primary resection and
anastomosis of the right colon carcinomas, Hartmann's operation
and diverting colostomy for left colon carcinomas and diverticulitis or
ruptured sigmoid volvulus and diverting colostomy for rectum
carcinomas are the most used options in cases of emergency.
Primary resection and anastomosis for left colon may be performed
safely in selected patients. Preoperative severe cardiopulmonary or
metabolic disease, ileus, perforation with peritonitis and advanced
carcinoma (Dukes' C or D) were statistically related to an increased
rate of morbidity and mortality. The long-term survival rate following
emergency surgery was worse than after elective surgery.
150.
Kotsifas Th., Sikalias N., Vasilopoulos J., Mountzalia L.,
Chaniotakis E.
Non-operative treatment of splenic rupture after blunt abdominal
trauma.
(Pireaus, Greece)
Objectives
The last decade non operative treatment of splenic trauma has been
proposed when the patient’s haemodynamic condition is stable.
143
Following modern trends we adopted the non-operative management
of splenic ruptures after blunt trauma.
Patients And Methods
In this study we present our experiences and discuss the strategy
we followed treating isolated injuries of the spleen. During the last
decade (1995-2004) we have treated 509 patients (males: 398,
females: 111, range of age: 16-93 years) with splenic rupture after
abdominal trauma. Following US, CT and clinical criteria we selected
for non-operative treatment 104 (males: 76, females:28, range of
age: 17-78 years) patients with isolated splenic injuries grade I-IV.
Results: the overall mortality rate was 1,9%, the mean hospital stay
was 16,4 days and 47 patients required blood transfusion (average
blood volume: 3,5 units) during the non-operative treatment. Failure
of non-operative treatment led to laparotomy and splenectomy for 19
patients (18,26%). Conclusions: non-operative treatment of splenic
trauma is feasible and safe in most of selected patients. This has
become possible as a consequence of increasing experience in
pursuing a non-operative approach based on accurate diagnostic
methods. Skilled surgeons and experienced radiologists with US &
CT scanner are the corner stones of the non-operative treatment.
151.
Lozhanidze G., Magalashvili R., Grigolia N, Tokhadze L,
Demetrashvili Z., Giorgobiani G., Labauri L.,
Gvenetadze T.
The incidence rate of the complicated forms of peptic ulcer disease.
Introduction
Despite the advanced achievements in the treatment of the Peptic
Ulcer Disease (PUD), the rate of the complicated forms of the PUD is
still enough high in Georgia, due to the various subjective and
objective reasons.
Goals
The goal of our study was to evaluate and analyze the frequency and
character of the complicated forms of PUD, according to the
localization of the ulcer.
Materials And Methods
Have been evaluated 548 case studies of the patients with
complicated forms of PUD. 443 of them (80,8%) were male; 105
144
(19,2%) female. The age of the patients varied from 19 to 78 years.
The length of the disease varied from 3 months to 34 years.
According to the H.D. Johnson’s classification, the type I ulcer was
observed in 278 cases (50,8%); type II – 227 (41,4%); type III – 43
(7,8%).
Results
The severe complications were observed in 365 cases (66,6%).
Among them: the upper GI hemorrhage – 127 (23,2); stenosis – 94
(17,2%); ulcer penetration – 77 (14%); ulcer perforation – 38 (6,9%);
and malignization in 29 cases (5,3%).
Conclusions
As from our results, the upper GI bleeding is the most common type
from the list of complications. Among these, in 23 (18%) cases the
emergency surgery was indicated. Complication with stenosis is
typical mainly to the type II gastric ulcers – 79 cases (84%). The
penetration of the ulcer in 47 cases (61%) was in pancreas. In 23
cases of the perforated ulcers, patients had already undergone the
surgery before (as from anamneses); only 15 patients were operated
first time. Among the 29 cases of the malignant gastric ulcers, 19
patients (65,5%) had the type I ulcer, while the ret 10 patients
(34,5%) had type II ulcer.
152.
Luchkov A.I.
Management of the uterine fibroids using the miniinvasive treatment
through uterine artery embolization.
(Odessa, Ukraine)
Uterine leiomyomas are the most frequent tumors of the female
genital tract that involve approximately 17 to 32% of all women in
childbearing age. One could consider two apparent clinical
approaches to the treatment of symptomatic uterine fibroids –
conservative and surgical. Each of them has its own indications,
contraindications and clinical reasonability. Moreover, apart from
abdominal or vaginal hysterectomy as well as abdominal fibroid
enucleation, that have been used successfully to treat such women
for more than a century, the more recently established surgical
miniinvasive technology provides an additional option to treat
fibroids. Uterine artery embolization became a common miniinvasive
surgical procedure for the symptomatic fibroids treatment after it was
145
successfully used for bleeding limitation in cases of pelvis advanced
tumors hemorrhage as well as in cases of postpartum bleeding.
Being it widely accepted in the Europeans’ and Worlds’
gynecological clinics as the miniinvasive surgical alternative to the
traditional massive surgical interventions in women with uterine
fibroids for more than 25 years, this clinical methodology has
received limited recognition among both gynecologists and patients
in Ukraine. We have had more than 5 years experience in
symptomatic fibroids treatment by miniinvasive intraarterial catheterprovided embolization of uterine artery (s) that gave us the
opportunity to improve our clinical approach, on one side, and
postoperative efficacy of such treatment, on the other.
During the last 5 years, clinical observations were performed with 86
women aged from 26 to 59 years, who suffered from diverse
symptoms caused by uterine fibroids involvement. After complex
clinical and laboratory observations, these patients were divided in
two groups: the first group of women refused the proposed
miniinvasive treatment and was treated separately on a conservative
procedure or using traditional abdominal/vaginal interventions. The
second group, on the other hand, was composed of 17 women that
agreed to undergo the uterine artery embolization procedure and
who presented fibroids size equal to pregnancy of 8-10 weeks.
Endovascular embolization of the uterine artery was made under
roentgenological control under local anesthesia. The gynecologist
who performed this procedure had 20 years of general gynecological
and surgical experience. The symptoms taken for the operation
efficacy determination were the following: uterus size as well as
fibroids size decreasing and menorrhagia cessation.
From a technical perspective, all the miniinvasive intraarterial
interventions were successful: uterine arteries were embolized. This
was a positive result also from a medical point of view. All women
were allowed to go home 2-3 days after the intervention. There were
neither complications nor side-effects during the 1, 3, 6 and 12months follow-up observation periods. Uterus size decreased of 1.52 times in 14 cases out of 16, with fibroids size decreasing and the
forthcoming disappearing in 100% of cases. Anemia symptoms
followed the same pattern of recovery. In all the childbearing agepatients, previously observed menorrhagia changed into
olygomenorrhea and amenorrhea in a 2-6 months period after the
procedure. Two women became pregnant 1.5 and 3 years after the
miniinvasive uterine fibroids treatment.
146
Therefore, our results are in line with the analogous clinical data from
Europeans’ gynecological clinics. Certainly, uterine artery
embolization for symptomatic uterine fibroids treatment becomes
only an additional/reserve option for doctors or patients that take into
consideration the possibility to preserve uterus as the main organ for
a prospective pregnancy as well as to reduce the risk of possible
complications or side-effects commonly observed within the
traditional surgical treatment of this pathology.
153.
Mozheiko M.A., Sushko A.A., Vasilevsky V.P.
Treatment of acute suppurative mediastinitis.
(Grodno, Belarus)
Matherials And Methods
For six years period 53 patients with acute suppurative mediastinitis
were operated on. 16 patients had posttraumatic acute supparative
mediastinitis (14- after esophageal trauma, 2 – spontaneous damage
of esophagus (Boerhaave syndrome)). Secondary acute suppurative
mediastinitis was marked in 37 patients (odontogenic- 16, tonsillar –
14 and infected haemathoma of mediastinum – 7 cases). For
suppurative focus sanation the method of continuous irrigation of the
mediastinum by sodium hupochloride with active aspiration was
used. In injuries of the esophagus mediastinal drainage as well as
rupture site suturation were performed. In injurres of the lower third
of the esophagus esophagofundoplication by Nissen was applied
considering the reflux of aggressive gastric contents. Empyema of
pleura was caused by spreading inflammatory process in 12
patients. Videothoracoscopic sanitation with pleural drainage and
active aspiration were done in these patients.
Results
However, 11 patients with total acute suppurative mediastinitis died.
The oftered complex of operative and therapeutic measures in
suppurative mediastinitis has lowered the mortality rate to 20,7 %.
Conclusion
The treatment of suppurative mediastinites included suppurative
focus sanation, antibacterial and immune treatment and therapy
aimed at catabolic losses correction.
147
154.
Myasoyedov S. D., Myasoyedov D.V., Oliynichenko G. P., Koshel
K.V., Leshchenko Yu. N., Yatsenko S. N.
The effect of application of low-molecular heparin in adjuvant therapy
for cancer recti in combined and complex treatment.
(Kiev, Ukraine)
Background
In the Ukraine the cancer recti incidence had raised permanently in
1995-2005 yrs period from 7463 to 8645 individuals, while the
schemes of the patients management and the results of treatment
did not change essentially. Application of anticoagulant therapy after
performance of oncological treatment permits to improve its
immediate results due successful prophylaxis of thromboembolic and
purulent complications achieved. The investigation deals with
analysis of late antitumoral effects of routine postoperative
anticoagulant course usage.
Materials
Of 495 cancer recti patients (T1-4N0M0 and T1-4N1M0) 190 (38,4 ;
3,3%) were surgically treated in 1996-2001 years. Combined and
complex treatment, accomplished in 305 (61,6%) patients, had
included 20 Gy of preoperative and 42 Gy of postoperative
radiotherapy. These radically treated patients were divided on
groups, according to additional treatment with 7-day course of
fraxiparine (daily dosage 0,3-0,6 ml) subcutaneously,
nonfractionized heparin (daily dosage 20000 Units) and non taking
anticoagulant therapy. The patients were followed during 5 yrs
postoperatively, analyzing the patients' survival using Kaplan-Meier
method.
Results
Of the Group I patients, who obtained additionally fraxiparine, 79,5
4,0% had survived 3 yrs and 59,7 4,4% - 5 years, of the Group II
patients, who obtained additionally nonfractionized heparin, - 78,0
4,6% and 51,8 4,1% accordingly, and of the Group III patients, in
whom anticoagulants were not applied, - 67,7 6,4% and 45,5 5,6%
accordingly. These follow-up results in the Group I patients differs
such of the Group II and Group III statistically significantly (P < 0.05)
and trusts that administration of fraxiparine in postoperative period
after radical surgical treatment increases the cancer recti patients
survival essentially.
148
Conclusion
Application of modern low-molecular heparins permits to increase
essentially the nonrecurrency survival period for cancer recti patients
after performance of radical surgical, combined and complex
oncological treatment.
155.
Nazarewski S., Gałązka Z., Grochowiecki T., Szmidt J.
Videoscopic nephrectomy technique as a promotion method of living
kidney donation in Poland.
(Warsaw, Poland)
As in most countries across the world, the shortage of cadaver
kidneys in combination with the increased demands is
a permanent problem in Poland. The shortage of donor organs has
led to an increased reliance on live donor transplantation.
Unfortunately, live donor renal transplantation only accounts for 2%
to 4% of all renal transplants performed in Poland. During the past
decade, most intra-abdominal surgical procedures have been shown
to be technically feasible using a laparoscopic approach. The main
advantages of this method were minimal donor morbidity, decreased
pain, significant improvements in donor recovery and cosmesis.
Videoscopic live donor nephrectomy in the clinical setting, as an
alternative approach to open surgery has gained worldwide
acceptance with a consequent donor pool expansion. As a rational
consequence of satisfactory results reported in the world, handassisted retroperitoneoscopic donor nephrectomy was introduced for
living donors in our Department.
Patient #1. A 59-year-old male left kidney donor to a 54-year-old
diabetic donor’s brother.
Patient #2. A 26-year-old male left kidney donor to a 29-year-old
unrelated male recipient.
Donor Operation
The patient was positioned in a 45° modified latera l decubitus
position, right side down. A 7-cm infraumbilical midline incision was
made, the peritoneum was left intact, and a preperitoneal space was
created
through
manual
dissection.
Afterwards
a hand port was introduced into the wound through which the
surgeon’s left hand was inserted into the preperitoneal space. A total
of
three
12-mm
laparoscopic
ports
were
utilized.
149
Pneumoretroperitoneum was then established at a pressure of 12
mm Hg. The left ureter and left kidney were identified and freed. The
vascular pedicle was prepared starting with the renal vein. The artery
and vein were divided with an ENDO-GIA stapler. The kidney was
then manually removed through the hand-assist port and the ureter
divided under direct vision. On a back table, the extracted kidney
was then perfused with cold Ringer’s solution in preparation for
standard transplantation into the recipient.
There were no postoperative surgical complications in both donors.
Warm ischemia times were 300 and 230 seconds respectively.
Donor serum creatinine levels at the day of discharge were 1.78
mg/dL and 1.63 mg/dL respectively.
We started to combine the benefits of hand-assistance to increase
safety and control of the laparoscopic technique and the
retroperitoneal approach to minimize the risk of complications
associated with the transabdominal approach. These advantages
have a great impact on the motivation of healthy individuals who
intend to donate. Due to advantages of this method, an expansion of
the donor pool is expected.
156.
Rajab T.K.,Wallwiener M., Wallwiener C., Wallwiener D.,
Kraemer B.
Adhaesion prophylaxis using a novel resorbable biomaterial based
on D,L-polylactide (Supraseal®) - experimental and clinical results.
(Tuebingen, Germany)
Introduction / Purpose
Adhaesions are an important complication of abdominal and pelvic
surgery. Supraseal® is a newly developed membrane designed to
prevent post-operative adhaesions. Here we report both
experimental data from an objective rat model as well as clinical
results from a randomised trial with 30 patients admitted for
laparoscopic myomectomy.
Materials And Methods
Supraseal®
is
a
copolymer
based
on
D,L-lactide,
trimethylenecarbonate and caprolactone. Adept® is a 4% icodextrin
solution with validated efficacy that is routinely used for adhaesion
prophylaxis.
In the experimental part of our study, standardised peritoneal trauma
was induced in 45 female Wistar rats. During these operations the
150
animals received either Supraseal® (n=15), Adept® (n=15), or no
adhaesion prophylaxis (n=15) according to a randomisation plan. On
the 14th post-operative day the resulting adhaesions were evaluated
in a blinded fashion using an objective scoring system.
In the clinical part of our study, 30 patients admitted for laparoscopic
myomectomy were randomised to receive adhaesion prophylaxis
with either Supraseal ® (n=15) or Adept® (n=15). The post-operative
outcome was evaluated according to the following parameters: visual
analogue scale for pain, requirement for further operations, fever,
constipation, nausea and dyspareunia after 1, 2, 3, 7 and 14 days as
well as 3 months after surgery. Moreover, intra-operative handling of
the respective barrier was analysed using a questionnaire for the
surgeon.
Results
The experimental part of our study showed that the adhaesion
scores of animals receiving either Supraseal® or Adept® were
improved compared to no treatment (p<0.05). Moreover, adhesions
in animals treated with Supraseal® were significantly less severe in
extent (p<0.05) and severity (p<0.01) than in animals treated with
Adept®.
The clinical part of our study demonstrated no evidence for
a significant difference in the post-operative outcome between
patients receiving Adept® or Supraseal®. However, intra-operatively
Supraseal® was considerably more difficult to use than Adept®
(p<0.05).
Conclusions
We conclude that Supraseal ® is an efficacious, new barrier to
prevent post-operative adhaesions and that further clinical trials
involving second look laparoscopy are warranted to help translate
this new agent into a further option for our patients.
157.
Madani R., Gupta A., Nwoko O., Opel S., Mukhtar H.
Does a newly qualified colorectal consultant meet the ACPGBI
guidelines in surgically treated colorectal cancer patients?
(London, Great Britain)
Objectives
There are clear guidelines on the outcome of colorectal cancer
patients in the United Kingdom. Specialist training in the UK is highly
151
valued however competency of surgical skills is not formally
assessed.
Methods
We look at one colorectal consultant’s 5 year patient database from
when appointed as a consultant after completion of his Specialist
Registrar training. Data from all patients diagnosed with colorectal
cancer, between May 2001 and May 2006, were collected from the
patients’ records.
Results
209 patients were diagnosed with colorectal cancer. 23 had no
surgical interventions. Of the 186 with surgical interventions, 158
were elective & 28 were emergency cases. Resection was with
curative intention in 129 and palliative in 41 patients (16 unknown).
The operative mortality was 6.96% (11/158) in elective and 17.86%
(5/28) in emergency cases. A total of 3.2% (6/186) of the cases
developed anastomotic dehiscence, equally distributed between
elective and emergency patients. Anastomotic dehiscence was the
obvious cause of death in 25% (4/16) of the mortalities. The
remaining mortalities were not secondary to known surgical
complications.
Conclusion
Our data shows that a the UK colorectal specialist training
programme enables recently appointed consultants to achieve the
qualities and standards required for the treatment of colorectal
cancer patients.
158.
Costi R., Mazzeo A., Di Mauro D., Veronesi L., Sansebastiano G.,
Violi V., Roncoroni L., Sarli L.
Palliative resection of colorectal cancer: Does it prolong survival?
(Parma, Italy; St.-Germain-en-Laye, France)
Background
It is still a matter of debate as to whether resective surgery of the
primary tumor may prolong the survival of patients affected by
incurable colorectal cancer (CRC). The main goal of this
retrospective study, carried out on patients not undergoing any
therapy other than surgery, was to quantify the benefit of primary
tumor removal in patients with differently presenting incurable CRC.
152
Methods
One hundred and thirty consecutive patients were operated on for
incurable CRC (83 undergoing resective and 47 non-resective
procedures). With the purpose of comparing homogenous
populations and of identifying patients who may benefit from primary
tumor resection, the patients were classified according to classes of
disease, based on the “metastatic pattern” and the “resectability of
primary tumor”.
Results
In patients with “resectable” primary tumors, resective procedures
are associated with longer median survival than after non-resective
ones (9 months vs. 3). Only patients with distant spread without
neoplastic ascites/carcinosis benefit from primary tumor removal
(median survival: 9 months vs. 3). Morbidity and mortality of
resective procedures is not significantly different from that of nonresective surgery, either in the population studied or in any of the
groups considered.
Conclusions
Palliative resection of primary CRC should be pursued in patients
with unresectable distant metastasis (without carcinomatosis), and,
intraoperatively, whenever the primary tumor is technically
resectable.
159.
Siaperas P., Alexiou K., Fotopoulos A., Karanikas I., Hinopoulos
G., Lazaridis S., Mauroides B., Neofytou N., Antsaklis G.
Hydatid disease in the cervical region. A case report.
(Athens, Greece)
Aim Of The Study
An 81 year old male patient was admitted to our clinic, with
a history of a slowly growing mass on the right cervical region over
the last 5 years.
Materials And Methods
During physical examination a painless semi-solid mass with size
5x7cm was palpated on the right cervical region in proximity with the
right sternocleidomastoid muscle, extending in the supraclavicular
region. CT scan revealed an encapsulated cystic mass with a double
layer membrane on its wall, highly suggestive of a hydatid cyst.
153
Abdominal ultrasonography, CT scan (cranial, thoracic, abdominal),
as well as plain chest X-ray, were negative for hydatid cyst in any
other region of the patient’s body. Under general anaesthesia, the
overlying skin was incised and the neck was explored.
A mass was found in the right cervical region, in proximity with the
right supraclavicular fossa. Careful dissection of the adhesions of the
mass with the adjacent structures was performed, in order to avoid
spillage of the contents, followed by total excision of the mass. The
operation field was irrigated with hypertonic saline solution (40%).
Histopathologic evaluation confirmed the diagnosis of hydatid cyst.
The patient remains free of disease after one year of treatment.
Comments
Primary hydatid cysts located in the neck are extremely rare.
Diagnosis can be made with clinical presentation, imaging
techniques, like U/S and CT, and serological tests. Surgical removal
of the cyst is the only treatment of choice.
160.
Sikalias N., Alexiou K., Fotopoulos A., Economou N.,
Frangiadakis I., Zagourianos V., Seretis K., Karanikas I.,
Antsaklis G.
Torsion of the greater omentum presented as acute appendicitis:
Three case reports and review of the literature.
(Athens, Greece)
Torsion of the greater omentum is a rare cause of acute abdominal
pain. We report three cases with omental torsion presented at the
A&E department with right lower quadrant pain and tenderness
suggesting acute appendicitis. In all of them surgical exploration of
the
abdominal
cavity
revealed
a twisted and heavily congested segment of the right part of the
greater omentum accompanied by intrabdominal serosanguinous
fluid. Omental torsion is a bening self-limiting disorder, though a
diagnostic chance for the physicians because it mimics other more
serious abdominal diseases in presentation. Most of the published
cases bad been diagnosed at operating theater. Correct diagnosis is
based on the clinical, but mainly on ultrasound and CT findings, with
the CT scan superior.
According to the current literature, although a correct diagnosis is
difficult, it is important to be made because omental torsion can be
154
treated in most of the cases conservatively without any
complications, avoiding thus
a surgical interversion. However, patients under conservative
treatment should be under continuous clinical and laboratory
observation because upon worsening of the symptoms there must be
surgical interversion for total cure.
Laparoscopy either for diagnosis or for treatment is the proposed
method of choice.
161.
Sikalias N., Mountzalia L., Alexiou K., Triantafyllis V., Mitsos S.,
Bobotis E., Antsaklis G.
Familial echinococcal infection.
(Athens, Greece)
We are presenting our experience of a nine-member family, infected
with echinococcus. The mother was investigated for right upper
quadrant abdominal pain. The investigation revealed a cystic
formation on the upper, medial surface of the spleen. This was
followed by anti-echinococcal antibody tests of the mother and the
rest of the family. All tests were positive for all the members of the
family. The family underwent anti-echinococcal treatment. The
hydatid cyst of the mother remained stable and she underwent
surgical excision of the cyst six months after the first diagnosis. Two
members of the family retained the raised titre of antibodies, without
any evidence of any organ involvement during the seventeen months
of the follow-up. Six family members had negative antibody tests
after treatment for three months and had no evidence of any organ
involvement.
We are presenting our ideas concerning the treatment of patients
with serological evidence of infection, but without the diagnosis of
any cystic formations.
162.
Sivananthan S., Shah N., Lavery K.
Neck dissections and shoulder syndrome: are they related?
(London, Great Britain)
Neck dissection remains the mainstay of surgical treatment to stop
the spread of head and neck cancer. Surgeons have modified their
strategy since the introduction of dissection by Crile in 1906. Postoperatively patients present with ‘shoulder syndrome’ with reduced
155
shoulder
movement
and
pain.
We investigated the symptoms of this syndrome and assessed
function of the shoulder and activities of daily living in patients who
had undergone selective neck dissections at our hospitals for
malignancy. Patients were assessed post-operatively in the ward
and at clinic appointments. They were set certain manoveurs to do
that required complex movements of the shoulder. In addition they
were questioned on the activities of daily living such as washing,
dressing, feeding and combing hair. We report that there is no
correlation between selective neck dissection and shoulder
syndrome. However there is minor reduction in external rotation of
the shoulder in 50% of patients. We also investigated the literature to
discuss if there are new ways to modify the surgical approach to
neck dissection with electromyography and electrophysiology to
locate major muscle and nerve groups. In addition we looked into
controversial arguments that surround the use of sentinel node
sampling to investigate micro-lymphatic spread of tumour.
163.
Sivananthan S., Josan G.
Co-existing gastrointestinal stromal tumours and caecal tumours are
they a common encounter?
(London, Great Britain)
Gastrointestinal
stromal
tumour
(leiomyoma)
generally
a benign growth of the stroma of the gastrointestinal tract. These are
rare and not much is known about their cause. However it is widely
known to turn malignant if not excised. We report the case of a 64
year old diabetic man admitted for collapse on the medical ward.
Clinical history revealed severe breathlessness and black stools.
Blood test revealed low haemoglobin and was transfused with 3
units of blood. The patient was sent for urgent endoscopy with
negative result.
A CT scan of the abdomen found tumour protruding from the
duodenum in keeping with Gastrointestinal Stromal tumour (GIST) ,
wide spread masses on the lung and liver. Urgent colonoscopy
revealed a 5cm sigmoid polyp and and 3cm caceal tumour.
Histology revealed adenocarcinoma of the caecum. The patient
underwent laporascopic right hemicolectomy and was given
GleevecR to shrink the Gastrointestinal Stromal tumour. We discuss
the management of the two types of tumours and investigate the
concept of whether the GIST and adenocarcinoma of the caecum
156
are linked. We look into new interventions in tumour biology such as
KIT proto-oncogene and tyrosine kinase inhibitor drug (imatinib
mesylate) and the role of surgical resection.
164.
Smolarz B, Romanowicz-Makowska H Wojnarowska R.,
Wałecka-Panas E., Kulig A
The significance of polymorphism of interleukin 1β (il-1β) and
interleukin 6 (il-6) gene in colorectal cancer
(Lodz, Poland)
Colorectal cancer is one of the most common forms of cancer in the
Western world. IL-6 and IL-1β plays a pivotal role in immune
responses and certain oncologic conditions.
In the present work the distribution of genotypes and frequency of
alleles of the 174G/C polymorphism of IL-6 gene and 1/2
polymorphism of IL-1β in 92 subjects with colorectal cancer in
samples of cancer tissue and distant mucosa samples as well as in
blood was investigated. The IL-6 and IL-1β gene polymorphism were
determined by PCR-RFLP methods.
No differences in the genotype distributions and allele frequencies
between blood, distant mucosa samples and cancer tissue were
detected. However, the distribution of the genotypes of the 174G/C
and 1/2 polymorphism in patients differed significantly (p < 0.05) from
those predicted by the Hardy-Weinberg equilibrium. There were
significant differences in the frequencies of alleles between the
colorectal cancer subjects and controls (p < 0.05). The results
support the hypothesis that the IL-6 and IL-1β gene polymorphism
may be associated with the incidence of colorectal cancer.
165.
Srinivasaiah N., Alabi A., Joseph B., Suppaiah A., Mackey P.,
Gunn J., Hartley J., Monson J. R.T.
A qualitative analysis of the survey of members of ACPGBI on
preliminary CRO7 results.
(East Yorkshire)
Background
The role of Neoadjuvant therapy (NAT) in management of rectal
cancers has not reached a consensus. We aimed to assess the
correlation b/n preliminary results of CRO7 trial and current UK
157
practice. This abstract is a subset of qualitative findings from the
comments section of the questionnaire.
Methods
A 14 item questionnaire inquired into the current management
strategy of operable rectal cancers and the possible role of
Neoadjuvant radiotherapy. Postal questionnaires were sent to 400
ACPGBI members. Data for this subset of results is derived from the
comments section on the questionnaire. Analysis was done by
qualitative methodology.
Results
Of 400 questionnaires, 200 (50%) were returned fully completed. Of
these only 52 (26%) of surgeons completed the comments section.
Themes that emerged from thematic analysis are Patient groups,
Treatment, Evidence based practice, Professional consensus and
Service provisions.
Conclusions
Despite preliminary evidence supporting the use of Neo adjuvant
short course radiotherapy for operable rectal cancer and CR07 data
yet to be published in full paper format, there are a few issues which
need a thought. The above themes identified needs addressing in
terms of individualizing treatment because of the difficult elderly
treatment group, provide safer and less harmful treatment, increase
role of multi disciplinary teams, increase awareness of the current
evidence based literature, develop protocols and guidelines along
with shortening the delay in implementing evidence based practice.
Service provisions should also be improved. Some of the above
findings will aid the policy makers & opinion leaders in the NHS
166.
Srinivasaiah N., Marshall J., Gardiner A., Duthie G.S.
Rectal irrigation (RI) is a boon for chronic constipation –
a prospective review.
(Hull, Grat Britain)
Purpose
Rectal-Irrigation is used in constipation to relieve symptoms
& improve QOL. We aim to evaluate efficacy & acceptability using
health outcome measures.Methods: Review of prospective database
of RI between 2002 - 2005. Results: 175 patients with a median
158
follow-up of 20 months. 111(63%) found RI useful & 64(37%)
unhelpful. 79 of 175 were referred for constipation. 39 (49%) had
success with RI. The success/failure rate is significantly different for
patients with constipation vs. other diagnosis (Chi Sq=12.28,
p=0.000). Up to one third had RI once a day. GSQ: Improvement in
straining, incomplete emptying, wind & urinary leak on stress (95%CI).SF36: 71 of 111 completed SF36 pre RI & 43 of these also
completed it post RI. Median MCS increased from 43 to 55 and PCS
increased from 47 to 66 (p = 0.03). In the constipation group the
percentage increase in MCS & PCS is 20% and 33%
respectively.FIQL: Clinical Improvement seen
in QOL
but
statistically insignificant. Conclusions: Constipation accounted for
nearly half of referrals. RI was successful in nearly half of the
referred population. RI offers symptomatic improvement & most
patients find it acceptable.Note : MCS – Mental Component Score,
PCS- Physical Component Score
167.
Srinivasaiah N., Marshall J., Gardiner A., Duthie G.S.
Rectal irrigation in the treatment of disorders of faecal continence A prospective review.
(Hull, Grat Britain)
Introduction
Rectal Irrigation (RI) has been used in faecal continence disorders to
relieve symptoms and improve quality of life (QOL). We aimed to
evaluate the efficacy and acceptability of RI using health outcome
measures.Patients and methods: Review of prospective database of
patients who had RI between 2002 and 2005. Symptom
quantification determined efficacy of RI using general standardized
questionnaires (GSQ). The acceptability of RI was determined using
SF-36 and FIQL.Results: 175 patients’ data is used. 111 cases were
successful and 64 failed. Analysis is done only for the successful
ones. Pre RI, the number of patients who completed GSQ, SF-36
and FIQL were 72, 71 and 32 respectively. Of these only 43, 43 and
22 completed the GSQ, SF-36 and FIQL post RI respectively. GSQ
analysis showed significant improvement in symptoms of straining,
incomplete emptying, wind leakage and urinary leak (95% CI) pre
and post RI. SF-36 demonstrated significant difference in Physical
Functioning (PF), Social Functioning (SF) and General Health (GH),
pre and post RI (95% CI). FIQL analysis showed no statistically
significant difference in the QOL post RI.Conclusion: In patients with
159
faecal continence disorders, RI can offer symptomatic improvement.
Most patients find the treatment acceptable.
168.
Tutchenko M., Susak Ya.
UKRAIN in the treatment of advanced pancreatic cancer.
(Kiev, Ukraine)
Introduction
Pancreatic cancer accounts for 2 – 3% of malignant tumors and the
fifth most common cause of cancer death. with an incidence of
approx. 9 per. 100.000. Recent studies of chemotherapy for
advanced pancreatic cancer have used gemcitabine, a novel
nucleoside analogue. The effect of chemotherapy on survival in
pancreatic cancer is negligible. Surgical palliations are using in more
then 70% of patients. Because, of the unsatisfactory results of
standard therapy and encouraging results of Ukrain ( NSC-631570,
Nowicky Pharma, Vienna, Austria ).
Materials And Methods
This study included 42 patients with pathologically diagnosed
advanced pancreatic cancer with biliary obstruction. Only patients
who refused chemotherapy were proposed to enter the study. All the
patients received biliary (hepatico-jeunostomy) and with or without
gastric bypasses. The Ukrain therapy cycle was defined as 10 mg
intravenously, X10, every other day.
Results
One year survival of the patients was 76% . Median durations of
response was 10 month. Four patients were completely free from
pain and did not need analgesics. Blood and urine examinations
revealed no negative or toxic effect of Ukrain and moreover showed
an improvement in the immune profile.
There was no allergic reaction in any Ukrain-treated patients.
Conclusion
The prognosis in patients wits advanced pancreatic cancer is
extremely poor and improving their prognosis requires effective
therapy. Patients 12-month survival were 76 % and we observed a
decrease in pain intensity in most of them, usually from 10 – 15 days
after the start of the treatment. Our results wits Ukrain in the
treatment of advanced pancreatic cancer are promising with regard
160
to improving quality of life and lengthening patient’s survival. Further
investigations are needing.
169.
Versaci A., Macrì A., Sfuncia G., Leonello G., Terranova M.,
Spagnolo I., Famulari C.
Gallstone ileus, a current pathology: our experience.
(Messina, Italy)
Background
Gallstone ileus is a rare cause of mechanical intestinal obstruction
(0,5-3%), caused by the migration of
a large stone from the biliary tract in the intestinal lumen through a
biliary-digestive fistula; diagnosis and treatment are still under
discussion.
The most common site of obstruction is the terminal ileum and the
ileocecal valve, less common sites are the proximal ileum, the
jejunum, the stomach (Bouveret’s syndrome) and the sigmoid colon.
The clinical course, quite aspecific, is characterised by intermittent
sub-occlusive episodes, related to the progressive migration of the
stone in the intestinal lumen; it is usually divided into three clinical
phases, sometimes quite distant, onset of an acute cholecystitis,
formation of a biliary-digestive fistula, start of a tumbling obstruction.
Indicant but infrequent is Rigler’s triad: pneumobilia, bowel dilatation
with levels and presence of ectopic gallstone in anomalous sites.
Patients
From January 1995 to December 2006, we observed 8 patients,
3 men and 5 women, average age 72 - range 62-84, with a gallstone
ileus; the site of impaction was in six cases (75%) the terminal ileum,
the pylorus in one (12.5%), and
a scar stenosis in the sigmoid colon in one (12.5%).
Patients referred with symptoms of obstruction, characterized, in 7
cases, by no bowel movement and gas and colic-type pain and in
one case by vomit and fever.
The diagnosis of gallstone ileus was correctly formulated in all cases
with the use of plain and barium contrast radiographs, and in 2 cases
with a CT scan. In all patients there was a cholecystoenteric fistula:
in 6 cases (75%) cholecystoduodenal, cholecystogastric (12,5%) and
cholecystocolic (12,5%) in one case respectively. In the 6 cases of
ileum obstruction, an enterotomy was carried out and stone
removed; in the case of Bouveret’s syndrome, after an unsuccessful
161
attempt of endoscopic extraction, was manipulated the stone back
into the stomach and removed via a gastrotomy. The case of sigmoid
obstruction was treated with a Hartman resection.
Only in three patients (37,5%), classificated as ASA II we performed
at the same time the closure of the cholecystoenteric fistula by
a cholecistectomy with enterorrhaphy.
There were no deaths, while morbidity was characterised by one
case of evisceration (12.5%) which was reoperated without any
further consequences.
Conclusion
The treatment of gallstone ileus is always considered an urgency
that need the removal of obstructing gallstone, there is still debate on
treating at the same time the biliary-enteric fistula. This can be a
long and complex operation, which carries a higher mortality rate
(16.7% vs 11.7%), also on account that, more often the bilioenteric
sinus resolves spontaneously.
In our experience we carried out with entero-lithotomy the
cholecystectomy and the treatment of the fistula only in patients with
low surgical risk, with no increase in morbidity and mortality; with no
case of cholangitis or biliary ileus relapse in the group of patients
treated only for intestinal obstruction.
In our experience we correctly identified the cause of the obstruction
in the preoperative period, in all patients, with the radiology
examination and this is comparable to cases found in literature,
where correct identification is reported in 100% of cases.
In conclusion, it should be underlined that diagnostic-therapeutic
problems are still to be found in a pathology identified back by
Bartolin in 1654, due to the rarity of the pathology which does not
allow controlled clinical studies.
Bibliography
1) Rigler LG, Borman CN, Noble JF. Gallstone obstruction.
Pathogenesis and roentgen manifestations. JAMA 1941; 117:1753-9.
2) Versaci A, Famulari C, Pirrone G, Perri S, Notti P. Su di un caso di
ostruzione piloro-bulbare da calcolo biliare (Sindrome di Bouveret).
Argomenti di Chirurgia 1982, vol 3, (2): 371-77.
3) Tan YM, Wong WK, Ooi LLP. A comparison of two surgical
strategies for the emergency treatment of gallstone ileus. Singapore
Med J. 2004, vol 45 (2): 69-72.
4) Ishiku H, Sakata A, Kimura S, Okitsu H, Ishikawa M, et al.
Gallstone ileus of the colon. Images in Surgery. 2005: 138: 540-42.
162
170.
Zarkov K., Nickolov N., Petkov Chr., Assenov A.
Pelvic exenterations for advanced primary or relapse rectal,
urological and genital carcinomas.
(Sofia, Bulgaria)
Aims
We discuss surgical technique problems in pelvic exenterations
regarding the management of bowel and urine passage. We assess
postoperative complications and compare survival for exenteration
and palliation patients.
Methods: We studied 48 patients operated through 1992-2006 in our
hospital - performed were 15 total, 15 posterior and 18 anterior pelvic
exenterations for advanced primary or relapse rectal, urological and
genital carcinomas. Both internal iliac arteries are ligated. Colostomy
is formed at left abdominal wall side. Left ureter is implanted into the
right and urostomy is formed at right abdominal wall side. The
formed pelvic cavity is separated from the rest abdominal cavity by
implanting a mesh.
Results
Patients are aged from 33 to 75. Operation duration – 3 to 5 hours.
Intraoperative mortality – 0%. Postoperative mortality to 30th day – 2
patients. Pelvic cavity discharge ended in 25 to 45 days.
Complications
Hydronephrosis - in 4 patients - percutaneous nephrostomy was
formed in one of them. Necrosis of the distal ureter formed like
urostomy - resulting in reoperation - 4 patients. Radiation colitis after
radiotherapy in one led to bowel passage correction.
All patients survived the 1st postoperative year. 5-years survival for
21 patients operated before 2002 is 3 patients (14%).
Discussion And Conclusions
Despite the high level of invalidism, pelvic exenteration is the only
more radical method for treatment of advanced primary and relapse
tumors in the pelvis. Indications for exenteration are precise – to
cases when radical operation is pursued. Postoperative results are
poor when the tumor is too widely spread.
163
171.
Zhandaraw C .N., Savitskij S.E., Bezmian I.A., Oslavskij A.I.,
Beljuk K.S., Tokunov V.A.
Economic aspects in treatment of the acute destructive pancreatitis.
(Grodno, Belarus)
The purpose of research. To define the ways of saving financial
resources and treatment results improvement on the basis of the
detailed clinical and economic analysis of the resources expended
on the patients with acute destructive pancreatitis (ADP) treatment.
Materials And Methods
The treatment results of the patients with ADP during the period from
2002 - 2006 was analazed. 111 patients were treated during this
period. All patients were divided into 3 groups: the group 1 (37
patients) –were given only conservative therapy; the group 2 (48) –
early open operations was used within 1 week from the moment of
the disease; the group 3 (19) – underwent conservative therapy and
were operated with endoscopic methods (laparoscopic drainage of
the abdomen cavity and necrotic centers with their programmed
sanitation – tactics applied since 2006
Results
The general cost on the treatment of 102 patients during 5 years
made up to 324000 $. The main financial resources was expended
on the patients treated in the reanimation department (128838 $ 1078 days), medicines cost (128835 $), cleaning (17125$– 846
days) and purulent (9193 $ – 69 days) departments of surgery,
examination cost (30751 $), operations and bandagings (14046 $).
Maximal treatment cost was in group 2 – 5184 $. The minimal
treatment cost were received if only conservative therapy of the ADP
applicated (1301 $).
Conclusion
It is possible to reduce average treatment cost of the patient with
ADP by 2747$ due to application of conservative therapy at the initial
stages of treatment, with maximum possiblility on terms, subsequent
operative treatment with the application of endoscopic methods.
164
172.
Zhandarov K.N., Bezmian I.A., Oslavskij A.I., Beljuk K.S.,
Tokunov V.A.
Pancreatocystowirsungojejunostomy in treatment of the chronic
pancreatic hypertensia
(Grodno, Belarus)
The purpose of research to develop the method of operative
treatment, including possibility of adequate internal drainage of the
pancreatic cyst located on a back surface of the pancreas and the
main pancreatic channel in case of chronic pancreatic hypertension.
Materials And Methods
Approach to pancreas is carried out through the gastrocolic ligament.
After the visualization and punctures of the main pancreatic duct, its
longitudinal opening is probably made on maximal extention. The
puncture of the cyst is performed on the back or lateral walls of the
opened main pancreatic duct through the tissue of the pancreas.
Then, the opening of cyst is perfomed with the dithermocoagulator or
ultrasonic scalpel in a needle-direction along the all extention of
adjacent cyst to pancreas. Bleeding vessels are stitched with a
resolving material. The second stage of the operation begins after
the control of
hemostasis. Then isoperistaltic longitudinal
pancreatojejunoanastomosis was made from the digestion loop of
the jejunum in length not less than 30 cm by technique RU.
Result
11 patients were successfully operated using such technique. There
were no complications during the operation, in the nearest and
remote periods. There was long-term follow-up for more than 1 year,
former patients returned to work in their respective fields.
Conclusion
So, the use of the such technique that is simultaneous adequate cyst
drainage and the dilatation of the main pancreatic duct to jejunum
and duodenal lumen at restores of a natural way of outflow, that
considerably improves the results of the surgical treatment of chronic
pancreatitis.
165
173.
Jędrys J., Rudnicka-Sosin L., Hodorowicz-Zaniewska D., Nowak
W., Stachura J.
Differentiation between cancerous and normal hyperplastic cells in
breast lesions using an antibody against the apoptotic purinergic
receptors P2X7 – preliminary results.
(Krakow, Poland)
Potential molecular agents in development of breast cancer are
heterogenous. Determining the risk of cancerous transformation in
hyperplastic cell is essential in the breast lesion treatment. Standard
haemotoxylin and eosin staining in many cases is inefficient. In our
study new immunohistochemic methods are being explored for
improving breast cancer detection. Preliminary results of using
anibodies against the purinergic recepors present in the cancerous
and in some atypical hyperplastic cells in immunohistochemistry
examination will help to determine early stages of breast neoplasia
and though improve the treatment results. One hundred of patients
diagnosed with invasive and noninvasive ductal carcinoma, atypical
ductal hyperplasia, hyperplasia without atypia in haemotoxylin and
eosin staining were examined using antibodies produced in rabbits
against the apoptotic purinergic receptor P2X7. Expression of
purynergic receptors, their localization and clinical significance in
cancerous
and
atypical
cells
were
analyzed.
Studying new diagnostic methods in breast tissue examination
determined by cytolytic P2X7 receptor labeling in atypical
hyperplastic breast lesions will improve differentiation between
cancerous and normal hyperplastic cells.
174.
Kulig J., Popiela T., Richter P., Milanowski W., Bucki K.
The use of transrectal surgical techniques in the treatment of
anastomotic leakage after rectal resections with sphincter
preservation
(Krakow, Poland)
Background
The most common complication after anterior and lower anterior
resection of the rectum, which influences the outcome, increases the
perioperative mortality and results in stoma formation is anastomotic
leak.
166
Aim of the study: the assessment of transrectal surgical techniques
in the treatment of anastomotic leakage after rectal resections with
sphincter preservation.
Materials And Methods
Between 1984-2004 2067 patients with colorectal cancer (out which
1062 with rectal carcinoma). Resections with sphincter preservation
and hand suture were done in case of 58.7% patients (1984-1991),
while in case of 65.8% stapler technique was used (1992-2004).
Results
On the group of 496 patients after rectal resections with sphincter
preservation 28 anastomotic leaks were diagnosed. In 19 patients
relaparotomy and colostomy was perfomed, while in 9 patients, in
whom the break of anastomosis was smaller than 1/3 of
circumference, transrectal surgical techniques were applied and no
colostomy was needed.
Conclusions
Transrectal surgical techniques applied in case of anastomotic leak
after rectal resections with sphincter preservation provide the chance
of complete healing and save patients from colostomy.
175.
Zając A., Kłęk S., Milanowski W., Kulig J.
Endoscopic drainage of pancreatic cyst – preliminary results.
(Krakow, Poland)
Aim Of The Study
The assessment of clinical efficiency of internal, endoscopic
drainage.
Materials And Methods
The group of 9 patients (6 M, 3 F, mean age 51.0) was assessed. All
patients underwent internal, endoscopic drainage of pancreatic
cysts. The procedure was performed only in case of recurrent cyst or
ineffective previous therapy and in case of general contraindications
to surgery.
Results
In 8 patients the drainage was effective; the results were confirmed
in computed tomography and ultrasonography. In one case the
167
drainage was ineffective because the qualifications were errant. The
were no complications observed. In one case the relocation of the
stent three weeks after procedure was noted.
Conclusions
The endoscopic drainage of pancreatic cyst is
a safe and effective procedure, enabling the successful treatment of
pancreatic fluid collections even in patients who cannot be qualified
to surgery because of contraindications.
176.
Kulig J., Kołodziejczyk P., Szybiński P., Hubalewska A.,
Popiela T.
Sentinel node detection as a new approach for minimal invasive
gastric surgery.
(Krakow, Poland)
The aim of the study was to test feasibility and accuracy of
intraoperative lymphatic mapping (ILM) and the sentinel nodes (SNs)
biopsy among patients with gastric cancer. Identification of the SNs
may alter the extent of resection and improve cancer staging without
increasing
significantly
time
or
morbidity.
Materials And Methods
83 consecutive patients with not advance gastric cancer (T1-3, N0,
M0) were included in the study. The human albumin labeled with
technetium 99m was endoscopically injected in the base of the tumor
one day before surgery. In all included cases ILM was performed
with the use of blue dye injected intraoparitively in the tumor area
under the gastric serous. Standard radical gastrectomy with
adequate lymphadenectomy was performed in all patients. After
localization of SNs with the gamma probe (Navigator) or by the
visual inspection of the epigastric area the nodules were removed
and histologically examined.
Results
In 17 cases the cancer was located in cardiac area, in 35 within the
body and in 31 within prepyloric area. The tumors size were in the
range of 5 mm to 110 mm ( mean size 58 mm). In 81 patients
(97,6%) the SN identification was positive. In two patients with more
advanced tumors (T4, N3) lymphatic mapping as well as staining did
not reveal SNs. The phenomenon of skip metastases was observed
168
in case of 9 patients (10,8%). The number of stained sentinel
nodules was between 1 – 4 (average 2,3). In the group of patients
with the tumor in the upper 1/3 part of the stomach SN most
frequently were situated in the left gastric artery region (38,2%) and
close to the cardiae (26,4%). When tumor was situated in the gastric
body, SNs were found close to gastric curvatures (greater - 25,8%
minor- 22,3%) and left gastric artery (18,8%). In the group of
patients with prepyloric tumors most common SN site were gastric
wall (32,3%) and duodenum (23,5%).
Conclusion
The results of the study show, that sentinel node navigator surgery
for gastric cancer is a promising technique although the lymphatic
streams from the stomach is very complex, resulting in few sentinel
lymph nodes. The question if this method can determine the extent
of lymphadenectomy necessary in the patients with gastric cancer is
still open. To final evaluation of its clinical value and influence on the
extent of lymph node dissection in gastric cancer the prospective
study including more patients as well as longer follow up period are
needed.
177.
Richter P., Nowak W., Hodorowicz – Zaniewska D., Jędrys J.,
Kowalska T., Pszon J.
Intraoperative radiotherapy (IORT) in the patients with breast cancer
– preliminary report.
(Krakow, Poland)
Aim
The authors are presenting preliminary results obtained from the
patients with early breast cancer undergoing breast conserving
surgery.
Materials And Methods
Between 2004 – 2006, ten patients, aged 49 – 69 years (mean age
57.9 years) were treated with intraoperative radiotherapy (IORT) for
breast cancer, stage I and IIA. In 3 patients breast quadrantectomy
with sentinel node biopsy was performed and in 7 complete axillary
lymph nodes resection. All patients received intraoperative
radiotherapy of tumor site using mobile linear accelerator (Mobetron
1000) with a dose of 10Gy. Histopathological examination confirmed
7 intraductal carcinomas, 2 tubular , and 1 papillary. In 1 case,
multifocal breast lesions were detected and this patient underwent
169
mastectomy. 4 patients received adjuvant chemotherapy, in 9 cases
treatment was continued with adjuvant radiotherapy in reduced
doses, and in 6 hormone therapy was continued.
Results
None of the patients developed toxic effects related to intraoperative
radiotherapy. In 1 patient recurrence in the same breast was found
in the follow-up observation.
Conclusion
Intraoperative radiotherapy is becoming an interesting alternative for
the high dose postoperative radiotherapy in the patients with breast
cancer treated with breast conserving therapy.
178.
Richter P, Gach T., Szura M., Kulig J.
Transanal endoscopic microsurgery in selected group of patients
with rectal tumours. (Krakow, Poland)
Purpose
Transanal Endoscopic Microsurgery (TEM) is a standard method
used to treat rectal adenomas, although its use for the treatment of
rectal cancer is still debated. The study analyzes the results of
treatment of patients with rectal tumours treated with TEM at the 1st
Department of General and GI Surgery Jagiellonian University in
Cracow.
Patients And Methods
From April 1996 to December 2006, 195 TEM procedures were
performed. Eighty-three cases of rectal cancer and seventy-nine
cases of adenomas and thirty-three cases of carcinoids, GIST, and
inflammatory polyps were treated with TEM. In case of rectal cancer
the criteria of inclusion for TEM were: low risk rectal cancer, diameter
of tumour less than 4 cm, distance from anal verge less than 3 to
15cm. In case of rectal adenomas the criteria of inclusion were:
plane adenomas up to 50 percent of circumference of the rectum,
distance from anal verge 2 to 20 cm. Preoperative diagnostics
included chest X-ray, colonoscopy, rectoscopy, abdominal
ultrasonography, transrectal ultrasonography or spiral CT of pelvis,
histopathological examination of tumour and anorectal motility
studies. The group o patients with stage I rectal cancer treated with
TEM was included to the clinical protocol of preoperative
170
radiotherapy: 25 (5x5) Gy vs. 50.4 – 55 Gy. Recurrence and survival
rates, and complications were analyzed.
Results
In group of patients with rectal cancer we observed 2 cases of local
recurrence and 2 cases of local recurrence and distal metastases.
Overall recurrence rate in this group was 5.3%. Four patients with
rectal cancer died due to progression of disease. Eight patients with
rectal cancer (9.6%) subjected to TEM procedures underwent radical
reoperation due to margin involvement. We observed eleven cases
of recurrence (13.9%) in group of patients with rectal adenomas.
Overall complication rate after TEM was 15.8 %. There were no
cases of perioperative mortality.
Conclusions.
TEM is a useful technique for treatment of large or sessile adenomas
of the rectum and in selected group of rectal cancers. The authors
recommend transanal endoscopic microsurgery due to the small
number of complications and recurrences.
179.
Kawiorski W., Richter P., Kulig J., Legutko J., Kibil W.
Oesophageal manometry-based decision about the treatment
(pharmacoterapy/surgery) in GERD patients.
(Krakow, Poland)
Gastroesophageal Reflux Disease (GERD) is the most common
disease of upper GI tract with the morbidity of 80 cases in 100 000
population in Western Europe. GERD as well as its complications
make a serious diagnostic and therapeutic problem, the treatment of
which demands the use of new computer methods, such as
manometry and pH-metry. The aim of the study is presentation of the
applied tactics in the management of patient with GERD depending
on oesophageal manometric and pH-metric examinations.
Material
162 patients involved were subjected to diagnostic radiological,
endoscopic examinations, pH-metry, and oesophageal manometry.
The following parameters were analysed: LES resting pressure, LES
pre-contraction relaxation, peristaltic propulsivity of oesophageal
body, and peristaltic waves amplitude. These parameters have been
found to have effect on the functional insufficiency of antireflux
mechanism.
171
All patients received pharmacoptherapy (acid antrum – PPI,
prokinetics, protective and antacids drugs; alkaline reflux –
prokinetics, alginic acid medicines) for 3-months, and subsequently
treatment results were analyzed.
Results
Of 162 patients treated, most had acid antrum. In only 32 (19%)
alkaline or mixed reflux was confirmed. Mean LES resting pressure
was 14 mmHg (6-24 mmHg).
No expected effect of
pharmacotherapy has been achieved in 49 (30%) patients: 11
developed LES functional insufficiency (pressure range 6 – 10
mmHg), in 32 LES pressure ranged from 11 – 14 mmHg, and in
another 6 from 15-20 mmHg. In 42 (86%) patients low amplitude of
peristaltic waves was found or no waves were detected. Alkaline
reflux was confirmed by spectrophotometry in 26 patients, i.e. 81%
of all examined with alkaline reflux.
Conclusion
Pharmacotherapy does not bring about expected outcomes in the
patients with the mean LES pressure below 14 mmHg and
accompanying disorders of oesophageal body peristalsis.
Additionally, the patients with alkaine reflux benefit less from the
pharmacotherapy,and in these cases antireflux surgery should be
considered.
180.
Szybiński P., Kłęk S., Kulig J.
The value of contrast enhanced ultrasonography in detection of liver
metastases from colorectal cancer
(Krakow, Poland)
Objective
The aim of the study was to compare contrast enhanced
ultrasonography (CEUS) with conventional ultrasonography (US) in
detection of liver metastases in patients with colorectal
adenocarcinoma (CRC)
Materials And Methods
A study of 57 patients referred to the I Department of and GI Surgery
with primary or local recurrence of CRC with suspicion of
dissemination. In order to detect possible liver metastases all
patients underwent liver US, followed by CEUS. Each patient was
172
referred to intraoperative ultrasonography (IOUS). All lesions were
histologically confirmed in preoperative fine-needle biopsy or by the
biopsy during surgery. The presence of focal liver lesions along with
the number, size, pre- and post-contrast sonographic features were
recorded digitally.
Results
In the study group 35 patiens had distance metastases to the liver
confirm in ologic examination. Patients suspected of having liver
metastases were examined with B-mode imaging, followed by
contrast-enhanced ultrasound (2.4 ml SonoVue).. CEUS improved
the sensitivity for detecting liver lesions from 26 (74.2%) to 30
patients (85.7%) (p<0.01). In particular, the contrast agent led to an
improvement in ultrasonographic detection in the following cases:
nodular metastases smaller than one centimeter; after adjuvant
chemotherapy; for tumors near the surface of the liver; and for
lesions situated around the ligamentum teres.
Conclusion
CEUS increased diagnostic confidence in the detection and
characterization of hepatic metastases compared with standard
sonography. Real-time contrast-enhanced sonography is particularly
advantageous in detecting small tumour.
181.
Popiela T., Kulig J., Richter P, Bucki K.
Long-term survival after extended lymhadenectomy in negative
margin resectable rectal cancer.
(Krakow, Poland).
Radical extended surgery is accepted standard in today surgical
oncology. The developments of treatment modalities in rectal cancer,
including local excisions, preoperative radio- or chemo-radiotherapy
and adjuvant chemotherapy determine the role of surgery from
minimally invasive (LE) to radical multivisceral resections. The role of
lymphadenectomy (both selective and elective) is still controversial.
Aim Of Study
The authors are presenting the results obtained by one surgical team
and analyze the effects of extended lymphadenectomy (D3) in rectal
cancer with radical resections.
173
Material
1062 patients with rectal cancer (mean age 61.52 yrs) were treated
between 1984 - 2004. From these group study inclusion criteria were
accepted in 672 pts. : WHO general status I-II; potentially radical
operation; age < 75; no concomitant diseases; no previous oncology
diseases; surgery colorectal team .
After surgical resections of T3-4,NO-2,MO-1 cancers ( stage II, III,
IV), the patients were treated with adjuvant chemotherapy. The
results were analyzed for two groups of patients: group A - resection
with standard lymphadenectomy D1/D2 /n=326/ and group Bresection with extended retroperitoneal lymphadenectomy D3
/n=346/.
In group B in node positive patients (164/346) we found 12,8%
(21/164) D3 positive macrometastases in standard histopathological
examination.
Results
Five-year survival after radical curative resections RO in both groups
was about 64%. In II stage acc. to UICC there was significant
difference
in
5-year
Survival
Rate
between
standard
lymphadenectomy - 59% vs. 75% with extended lymphadenectomy.
Also in stage III- T3 tumors the results of 5-year Survival Rate were
better in extended lymphadenectomy group (48% vs. 35%). It was
observed that extended lymphadenectomy prolonged diseases free
5 year survival with lower systemic recurrence rate.
Conclusions
Improved long - term results observed for 21 years correlate with
surgical radicality in organ resection. Extended lymphadenectomy is
an important prognostic factor in rectal cancer surgery. This result
indicates problem of micrometastases that cannot be evaluated by
standard histological examination.
182.
Popiela T., Kulig J., Kawiorski W., Richter P., Legutko J.,
Kibil W.
Late complications in patients after antireflux procedures with using
intraoperative continuous LES computer-video manometry
monitoring.
(Krakow, Poland)
174
Background
Gastroesophageal reflux disease (GERD) is a common nonmalignant gastrointestinal disease. The introduction of minimally
invasive surgical techniques as well as high costs of
pharmacotherapy increased the number of patients subjected to
surgical antireflux treatment. Also, the use of advanced technique of
manometry - including intraoperative video-assisted continuous
pressure monitoring - made possible complicated but objective
analysis of pressure profile in the newly created area of
gastroesophageal junction.
Materials And Methods
The analysis was conducted in 159 patients. A group consisted of 93
men and 66 women at the mean age of 38 years, range 18-72,
subjected to antireflux surgery with continuous intraoperative videoassisted manometry of pressure in the newly created
gastroesophageal junction (fundoplication wrap). Surgical procedure
was individually tailored in each case depending on the motility
parameters and GERD etiology. Eighty seven patients (55%)
underwent 3600 Nissen fundoplication, 17 “floppy” Nissen procedure
(11%), 22 Dor hemifundoplication (14%), and 33 Toupet
hemifundoplication (21%).
Results
Of 159 patients subjected to antireflux procedures only 8 (5.0%)
developed dysphagia, and 12 (7.5%) recurrent reflux disease.
Recurrent reflux symptoms were most frequently caused by the
dislocation of the fundoplication wrap. Dysphagia occurred in the
patients with too tight fundoplication wrap or its dislocation with
subsequent rotation and angulation that impaired food passage. In
some patients objective causes of dysphagia have not been found.
In these patients no abnormalities were detected by the
postoperative visualising examinations, and mean pressures in the
fundoplication wrap did not exceed critical values. In these cases
dysphagia was caused probably by the impaired gastric motility.
Conclusions
1. GERD with multifactor etiology requires individually tailored
surgery based on the results of motility studies.
2. Finnal result depends on appriopriate calculations of
intraoperative pressure in newly created fundoplication wrap.
175
3. Appropriate fixing of the fundoplication wrap to the
diaphragm is very important for lowering the rate of GERD
recurrences due to the dislocation of wrap.
183.
Szura M., Zając A., Kulig A.
Narrow band imaging (NBI) complement endoscopic follow-up after
polypectomy
(Krakow, Poland)
Narrow-band imaging is one of the latest technological achievements
of the digital endoscopy. The technique is using interference filter to
light surfaces in narrow bands of red, green, and blue colour that
visualizes the differences in mucosa colouring and enhances
contrast between the mucosa surface and submucosa vascular
network. The NBI makes easier differentiating between pathologic
lesions from normal mucosa.
The study evaluates the possibility of using NBI for monitoring
of the patients after endoscopic polypectomy of the colon.
Materials And Methods
The study was conducted in 50 patients after endoscopic
polypectomies for colonic adenomas with high-grade dysplasia.
Control NBI endoscopy was performed 3 months after polypectomy
using HDTV Olympus equipment series 180. During the study the
attempts were made to localize polypectomy site, and the
polypectomy scar was evaluated in the traditional light and using
narrow band light. The material was taken for histopathological
examination. The quality of obtained images was evaluated using a
score system.
Results
NBI failed to localize endoscopic polypectomy site in 19 patients, in
24 localized polypectomy scar and in the remaining 7 remaining or
reccurent polyp. NBI illumination detected remaining adenoma in 6
patients with the localized polypectomy scar. Histopathological
examination revealed low-grade adenoma in 6 patients with the
remaining polyp and in 5 with polypectomy scar, as well as
inflamatory reaction in the remaining cases.
176
Conclusions
A new technique of NBI enhances the visibility of lesions in mucosa,
and the preliminary results are encouraging for the assessment of
the endoscopic treatment accuracy.
184.
Szura M., Osuch Cz., Richter P., Kulig J.
Fast-track rehabilitation after colorectal surgery for cancer
(Krakow, Poland)
The patients after colorectal surgery undergo complex rehabilitation
postoperatively. A standard model of the postoperative rehabilitation
covered complete mobilization of the patient on the second
postoperative day and oral feeding 4 – 5 days after surgery. With this
model mean time of postoperative hospitalization ranged between
6 – 10 days and the risk of postoperative complications was about
20%.
The study is evaluating a new fast-track model of the postoperative
rehabilitation in the patients after colon resections for cancer.
Materials And Methods
One hundred consecutive patients undergoing colorectal surgery for
cancer underwent fast-track rehabilitation (group A). These patients
were mobilized on the first postoperative day. They received liquids
6 hours after surgery, and complete oral feeding was introduced 2-3
days after surgery. The results obtained from this group were
compared with computer-matched patients operated earlier, who
underwent standard rehabilitation (group B). Both groups were
comparable for age, sex, coexisting diseases, stage of cancer, and
type of surgery performed.
Results
Mean age of the patients was 68 years (+/- 4.7 years) in both groups.
The time of postoperative hospitalization for group A was 4.8 days
(+/- 1.9), and for group B 8.6 days (+/- 2.3) (p<0.05). Defecation
occurred on the second day (+/- 1.1) in group A and 4.2 days (+/2.0) after surgery in group B (p<0.05). The rate of postoperative
complications of 13% was lower in group A compared with 18% in
group B (NS). Anastomotic leak occurred in 2 patients from group A
and in 3 from group B (NS).
177
Conclusions
The time of postoperative hospitalization, the
complications and the time of first defecation after
shorter in the patients undergoing fast-tract
programme. Such management had no effect on the
intestinal anastomosis leaks.
185.
Kruszyna T., Zając A., Kubisz A.
Sphincter of Odi manometry in acute biliary pancreatitis.
(Krakow, Poland)
178
number of
surgery was
rehabilitation
frequency of
Alabi A. 165
Alexiou K. 139, 159, 160, 161
Almeida T. 31, 32
Amendoeira I. 32, 133
Amicucci G. 108
Angele M. K. 85
Anioł J. 20
Antonopoulos P. 139
Antoš F. 9, 38, 59, 87
Antsaklis G. 139, 159, 160, 161
Aranha G. 70
Assenov A. 122, 170
Ausch Ch. 93
Avenia N. 46
Banasiewicz T. 36
Baptista M. 130
Barbarisi A. 46
Barradas J. 142
Basciotti A. 95
Beljuk K.S. 123, 171, 172
Benavoli D. 82
Benedetti M. 50
Bernante P. 147
Bezmian I.A. 123, 171, 172
Bilianskiy L. 91
Bittner R. 11
Bobotis E. 161
Bobrzyński Ł. 100
Bosse G. 92
Boyko V. 113
Braumann Chr. 83
Breuer J.P. 92
Brillantino A. 95
Broos P. 64
Cutajar L. 65
Bruni A. 96
Bruns C. J. 85
Brustbauer R. 89
Bucki K. 174, 181
Bujko K. 34
Bulanda M. 25
Burjaliani B. 97
Bury P. 141
Buscemi G. 49, 98, 106, 144, 145
Butyrsky O. 63
Buxhofer-Ausch V. 93
Calzolai F. 46
179
Cambal M. 110
Camplese P. 39
Cardi M. 50
Cardoso de Oliveira M. 31, 32, 130, 131, 132, 133, 134, 135, 136, 137, 138
Carneiro F. 138
Carneiro J.C. 135
Caronna R. 50, 96
Castanheira A. 136
Ceci V. 96
Cellini C. 80
Cenci L. 82
Cereatti F. 96
Chaniotakis E. 53, 101, 103, 149, 150
Cherenko S.M. 48
Chikobava G. 99
Chirletti P. 50, 96
Chkhaidze Z 99, 140
Chkhetia N. 99, 102
Chrapko B. 23
Christians S. 85
Chyn’ba O.V. 14
Ciechańska M. 141
Ciechański A. 141
Cieri M. 80
Cieślak B. 76
Cipollone G. 39
Concetta G.M. 49, 98, 145
Corona M. 96
Cosenza A. 95
Costa S. 133
Costanini R. 80
Costi R. 158
Cunha A.L. 136
Cutajar L. 42, 65
Ćwik G. 141
Dąbrowski A. 141
De Piccoli N. 147
Dedegikas D. 53, 101, 103
Degiuli M. 7
Demetrashvili Z. 151
Demidov S. M. 88, 143
Demidov V.M. 88, 143
De Mayo A. 82
Di Bona A. 49, 98, 144, 145
Di Martino N. 95
Di Mauro D. 158
Di Nuzzo D. 39
180
Di Venere B. 56
Dias Santos D. 142
Donahue P. 4
Donatelli G. 96
Drews M. 36
Dryzunina N. 146
Durlik M. 72
Duthie G.S. 166, 167
Dytrych P. 38, 59, 87
Dziki A. 5
Dzwonkowski J. 112
Economou N. 139, 160
Egger T. 93
Eichhorn M. 85
Eitenmueller J. 47, 94
Famulari C. 169
Fanello G. 50, 96
Faria G. 135
Feleshtynsky Ya.P. 14
Felice A. 44
Ferramondo F. 50
Ferreira A. 31, 32, 131, 132, 133, 134, 135, 137
Fersini A. 74
Filipovic G. 54
Fiocca F. 96
Fomin P. 113
Fotopoulos A. 139, 159, 160
Francomano F. 80
Frangiadakis I. 160
Fusco G. 50
Gach T. 34, 60, 129, 178
Gadzhieva F.G. 111
Gajic M. 54
Gałązka Z. 52, 155
Gambino G. 49, 98, 144, 145
Gara K. 24
Gardiner A. 166, 167
Garelik P.V. 123
Garofalo A. 3
Gaspari A. 82
Geldner G. 92
Geraci G. 41, 86
Giannopoulos D. 103
Giordano A. 46
Giorgobiani G. 99, 151
181
Gioviale M.C. 106
Gladka L. 146
Gladky A. 146
Gladky A.V. 90
Gołębiewska R. 23
Golovin S. 113
Gonzaga R. 136
Gorobeiko M.B. 62
Gouveia A. 31, 32, 130, 131, 132, 133, 134, 135, 136, 137, 138
Grabowska I. 24
Greco L. 56
Grigolia N 151
Grochowiecki T. 155
Gruenberger T. 29
Guimarães S. 138
Gunn J. 66, 165
Gupta A. 109, 157
Gurda-Duda A. 129
Gurrado A. 56
Gvenetadze T. 99, 151
Gwóźdź P. 61
Haralabopoulos G. 139
Hartley J. 165
Hartley J. 66
Hartmann J. 83
Herman K. 20, 22
Herman R. 33
Herman R.M. 45, 55, 61
Hinopoulos G. 159
Hinterberger W. 93
Hledík E. 38
Hodorowicz – Zaniewska D. 173, 177
Hofmann M. 93
Hoskovec D. 38
Hubalewska A. 176
Hurayevskyy A. 40
Iacovetta D. 80
Iarussi T. 39
Ingham Clark C. 109
Innocenti P. 80
Ivanchov P. 113
Izzo D. 95
Izzo G. 95
Jacobi Ch.A. 83
Jankiewicz M. 23
Jaraczewska I. 51, 52
Jauch K.W. 85
182
Jaworski T. 141
Jędrys J. 100, 173, 177
Josan G. 163
Joseph B. 66, 165
Jovanovic M. 54
Kamocki Z. 75
Kanavos E. 108
Karanikas I. 139, 159, 160
Kardis A.I. 121
Kašpar M. 38
Kavallieratos N. 101
Kawiorski W. 124, 125, 126, 127, 128, 179, 182
Kazarian G. 140
Kędra B. 75
Kibil W. 124, 125, 127, 128, 179, 182
Kiladze M. 99, 102
Kiladze M. 99
Kingsnorth A. 12, 71
Kitanovic A. 54
Kitzweger E. 93
Kiudelis M. 107
Kleespies A. 85
Kłęk S. 60, 129, 175, 180
Klocek T. 67
Kołodziejczyk P. 100, 148, 176
Kolomiyets P.V. 114
Konstantinidis F. 139
Konstantinidou E. 139
Koshel K.V. 154
Kotsifas Th. 53, 103, 149, 150
Kourakos Ath. 53, 101
Kowalska T. 34, 115, 177
Kozanek M. 110
Kozol R. 13
Kraemer B. 104, 105, 156
Krawczyk M. 18, 76
Krechkovsky O. 146
Krumpalova Z. 110
Kruszyna T. 185
Kryshen V. 117, 118
Kubisz A. 67, 185
Kudryavtsev A. 117
Kulic V. 54
Kulig A 164
Kulig J. 2, 16, 24, 60, 69, 84, 100, 115, 124, 125, 127, 128, 129, 148, 174,
175, 176, 178, 179, 180, 181, 182, 183, 184
Kurylcio A. 23
183
Kurylcio L. 23
Kuśnierz K. 10
Kuznetsov O.O.14
Labas P. 110
Labauri L. 151
Lampe P. 10
Lardo D. 56
Larin O.S. 48, 62
Lavery K. 162
Lavryk A. 91
Lazaridis S. 159
Lechner P. 89
Legutko J. 15, 126, 179, 182
Lemko I. 113
Leonello G. 169
Leshchenko Yu. N. 154
Lewicka M. 23
Li Volsi F. 41
Liddo G. 80
Lissidini G. 56
Lo Monte A.I. 49, 98, 106, 144, 145
Lopes J. 136
Lopes J.M. 131, 134
Lozhanidze G. 151
Luchkov A.I. 152
Łuczyńska E. 20
Lursmanashvili G. 102
Lysenko V.M. 114
Mackey P. 165
Mackiewicz A. 76
Macrì A. 169
Madani R. 109, 157
Madej K. 51
Madureira A.J. 130
Magalashvili R. 151
Magalhães A. 31, 32, 130, 133, 134
Maione C. 49, 98, 106, 144, 145
Maleckas A. 107
Mamamtavrishvili G. 99
Mamchich V.I. 14
Mangioni S. 50
Manoylo M. 91
Marino G. 46
Marolla A. 39
Marshall J. 166, 167
Martin J. 92
Marvan J. 59, 87
184
Marvick R. 43
Maslakova N.D. 111, 121
Massari M. 39
Matyja A. 16
Mauroides B. 159
Mazzeo A. 158
Megrelishvili G. 97
Megrelishvili Z. 97
Meissner W. 34
Menenakos Ch. 83
Meniconi R.L. 50
Merante Boschin I. 147
Meyer H. 1
Mickevicius A. 107
Mielko J. 23
Milanowski W. 174, 175
Milkiewicz P. 78
Minervini S. 96
Mitsos S. 161
Mituś J. 20, 22
Modica G. 41, 86
Monaco L. 95
Monson J. R.T. 66, 165
Moreira H. 138
Moscato F. 106
Moschopoulos N. 103
Mountzalia L. 53, 101, 103, 149, 150, 161
Mozheiko M.A. 121, 153
Mucilli F. 39
Mukhtar H. 109, 157
Müller J.M. 83
Muschynin V. 117
Myasoyedov D.V. 154
Myasoyedov S. D. 154
Najnigier B. 76
Napolitano L. 80
Nastenko D.V. 62
Nazarewski S. 155
Neofytou N. 159
Neri V. 74
Nickolov N. 122, 170
Nikishaev V. 113
Nocon M. 83
Nová K. 59
Novikov D. V. 88
Novitsky Y. 13
Nowacki M.P. 34
185
Nowak K. 84
Nowak W. 173, 177
Nwoko O. 157
Nyckowski P. 18
Ogris E. 93
Olędzki J. 34
Oliveira Alves J. 31, 32, 131, 132, 133, 134, 135, 137
Oliveira H. 142
Oliynichenko G. P. 154
Opel S. 157
Oshowo A. 109
Oslavskij A.I. 123, 171, 172
Osuch Cz. 184
Otto M. 112
Pach R. 15, 24, 60, 115
Pagetta C. 147
Palfiy I. 40
Papini F. 50
Paprota K. 34
Pelizzo M.R.147
Petkov Chr. 122, 170
Philip M.S. 14
Piccinni G. 56
Pimenta A. 31, 32, 130, 131, 132, 133, 134, 135, 136, 137, 138
Pimenta M. 130
Pio V.T. 74
Piotrovych S.M 114
Piotto A. 147
Pisello F. 41, 86
Plaudis H. 73
Poli E. 56
Polkowski W.P. 23
Popiela T. 34, 84, 100, 115, 124, 125, 148, 174, 176, 181, 182
Popiela T.J. 21
Portugal R. 138
Preto J. 31, 32, 130, 131, 132, 133, 134, 135, 136, 137, 138
Prezioso G. 50
Prochnow L. 92
Pszon J. 177
Pupelis G. 73
Purmalis G. 73
Rajab T.K. 104, 105, 156
Randolph G.W. 48
Renzi A. 95
Ribeiro J. 142
Richter P. 34, 35, 115, 124, 125, 127, 128, 129, 174, 177, 178, 179, 181,
182, 184
186
Rodrigues S. 32
Rogano A. 50
Romanek J. 23
Romano G. 106
Romano M. 106
Romanowicz-Makowska H 164
Romeo B.G. 50
Roncoroni L. 158
Rosen H. 6
Rosen H.R. 93
Rossi P. 82
Rosso F. 46
Roszkowski A. 75
Rowiński O. 52
Rudnicka-Sosin L. 173
Ruka W. 26, 30
Ruscitti C. 108
Rydzewska G. 37.
Sacco R. 39
Sacco R. 46
Salvatori F.M. 96
Sansebastiano G. 158
Santacroce C. 74
Santarelli G. 39
Sarli L. 158
Satko I. 110.
Savitskij S.E. 123, 171
Schettino M. 95
Schiessel R. 93
Schilling M. 77
Schiratti M. 50
Schlag P. 28
Schleppers A. 92
Scio A. 49, 98, 144, 145
Sciumè C. 41, 86
Seifert S. 92
Šerclová Z. 59, 87
Seretis K. 160
Sfuncia G. 169
Shah N. 162
Sheptun Y. 117
Siaperas P. 159
Sica G.S. 82
SierŜęga M. 60, 69, 84, 100, 148
Sikalias N. 53, 101, 103, 149, 150, 160, 161
Sivananthan S. 162, 163
Skalski M. 18
187
Skoczylas T. 141
Śledziński Z. 81
Śmietański M. 19
Smiljkovic M. 54
Smolarz B 164
Soares C. 31, 32
Sobocki J. 45, 55, 61
Solecki R. 16
Sopyło R. 34
Soselia N. 99
Sousa R. 31
Sousa Rodrigues J. 131, 132, 133, 134, 135, 137
Spagnolo I. 169
Spera G. 50
Spies C. 92
Spieszny M. 67
Srinivasaiah N. 66, 165, 166, 167
Stachura J. 173
Stanisławek A. 23
Stasyshyn A. 40
Stipa F. 68
Stipa S. 68
Stryczyńska G. 34
Suppaiah A. 165
Susak Ya. 116, 168
Sushko A.A. 153
Szawłowski A. 27
Szczepanek K. 60
Szczepanik A.M. 16, 60, 67, 100, 148
Szmeja J. 36
Szmidt J. 51, 52, 155
Szura M. 178, 183, 184
Szybiński P. 60, 176, 180
Tabor J. 22
Takac P. 110
Tatishvili O. 99
Tavernaraki K. 139
Terranova M. 169
Testini M. 56
Todurov J. 91
Tognoni V. 82
Tokhadze L 151
Tokov V.A. 123
Tokunov V.A. 171, 172
Tomkowski W. 58
Toniato A. 147
Torelli F. 95
188
Triantafyllis V. 161
Trofimov N. 118
Trojanowski P. 17
Tsilindz A.T. 121
Tutchenko M. 116, 168
Tutchenko M.I. 114
Ulrich M. 11
Urbanek T. 57
Valentini M.P. 56
Valetsky V. 119, 120
Valetsky V.L. 90
Varga J. 38
Vasilchuk A. 116
Vasilevskij V.P. 111, 121, 153
Vasilopoulos J. 53, 101, 103, 149, 150
Venclauskas L. 107
Venza M. 82
Veronesi L. 158
Versaci A. 169
Violi V. 158
Volckmann E. 94
Wałecka-Panas E. 164
Wałęga P. 55, 61
Wallner G. 141
Wallwiener C. 104, 105, 156
Wallwiener D. 104, 105, 156
Wallwiener M. 104, 105, 156
Walz M. 8
Wierzbicki R. 34
Winkler B. 23
Wójcicki M. 79
Wojnarowska R. 164
Wróblewski T. 18
Wysocki W.M. 22
Yaroshuk D. 116
Yatsenko S. N. 154
Yurchenko V. 40
ZadroŜny D. 81
Zagourianos V. 160
Zając A. 175, 183, 185
Zajic S. 54
Zarkov K. 122, 170
Zdravkovic R. 54
Zeh B. 89
Zeiza K. 73
Zhandaraw C .N. 171
Zhandarov K.N. 123, 172
189