Background: The embryological connection between the dorsal and ventral pancreatic regions divides the pancreas into two segments. This anatomical dependence allows segmental pancreatic resection through the embryological fusion plane (EFP). The advantages of limited pancreatic resection are the preservation of the natural continuity and function of the gastrointestinal tract and the avoidance of the metabolic and endocrine consequences of total resection of the pancreas and the duodenum. Materials and methods: Two patients are described who underwent anatomical segmentectomy of the pancreatic head along the EFP for the treatment of pancreatic cystic tumour and main duct intraductal papillary-mucinous neoplasm. The authors suggested diagnostic and intraoperative management leading to qualification for pancreatic resection along the EFP. Results: Pancreas and duodenum sparing surgery is an opportunity for patients in terms of the post-operative quality of life. Indications for this kind of surgery are limited and case selection is very difficult. The procedure for embryological bud resection is highly complicated includes a high rate of possible complications. On the other hand high volume centres may offer this procedure at an acceptable rate of complications in selected cases. Conclusions: Accurate diagnosis with a vascular anatomy and biliary and pancreatic duct configuration give grounds to analyse pancreas-sparing surgery. The operation plan requires careful three-dimensional planning and an experienced team. Bipolar electrocautery, micro-surgical tools and intraoperative cholangiography and pancreatography are helpful.

Introduction/BackgroundThe laparoscopy has been found to be attractive and safe technique in gynaecological oncology. However, some recent retrospective and prospective reports on early-stage cervical cancer have shown unexpected contrary results in terms of overall and disease-free survival. In our opinion, published discussions to date do not fully address the subject and that it is worth considering important issues that were not given enough attention before.MethodologyWe conducted a systematic analysis of current knowledge about laparoscopy in early-stage cervical cancer by reviewing the relevant literature from the fields of basic and clinical research, starting with the results of the Laparoscopic Approach to Cervical Cancer (LACC) study, and including analysis of its appendix and protocol.ResultsThe preferred surgical access in cervical cancer cases was the subject of a single prospective randomized clinical trial. Other, similarly designed studies on other pelvic tumours are sparse. The biology of cancer, cancer epidemiology, as well as surgical skills and details of laparoscopic techniques underlie the observed differences in survival rates.ConclusionThere are some possibilities (such as limiting the manipulation of the uterus, closure of tubes and ligation of the parametria before using the manipulator, closure of the vaginal cuff, applying warmed and humidified CO2, and limiting intra-abdominal gas pressure) that, if considered and applied, may affect oncological results in selecting laparoscopy as the operative method for early-stage cervical cancer.DisclosureNothing to disclose.

Pancreatic duct and parenchyma has different benchmarks in nomenclature. The author discusses the proposition to unify the description system of procedures and surgeries within pancreas according to the direction of pancreatic juice natural flow.

BACKGROUND:The role of ureteric stenting in kidney transplant recipients is still debatable. Stenting can reduce the incidence of urine leaks and ureter stenosis, but can be also associated with specific complications, particularly urinary tract infections (UTIs). MATERIAL AND METHODS:To estimate the influence of ureteric stenting on urological complications in kidney transplantation (KTx), we retrospectively analyzed all KTx performed between January 2011 and December 2016 in Gdansk Transplantation Centre, a total of 628 patients. Ureteric stenting was used in 502 patients (80%)-double-J (DJ) group. Catheters were implanted during the surgical procedure and left in situ for a mean time of 30 days. RESULT:The frequency of urinary leaks was 10 times higher in patients without stenting (10%). Ureter stenosis was also more frequent in the non-DJ group (8.7% vs 1.6%, P < .05). Multiple-regression modeling showed that the urinary not stenting was a risk factor for urinary leak (adjusted odds ratio [AOR] = 0,1; 95% confidence interval [CI]: 0.03-0.26; P < .01), ureter stenosis (AOR = 0,16; 95% CI: 0.06-0.41; P < .01), and generally reoperation after KTx (AOR = 0,46; 95% CI: 0.28-0.77; P < .01). Acute rejection and delayed graft function were equal in both groups. Mean serum creatinine concentration 1 month after transplantation was similar in both groups (1.5 mg/dL in the DJ group and 1.44 mg/dL in the non-DJ group, P > .05). UTIs were more frequent in the DJ group (22.1% vs 16.7%), but the difference was not significant. Time of hospitalization was longer in patients with UTI (34 vs 22 days, P < .05). CONCLUSIONS:Ureteric stenting can protect patients from most frequent urological complications like urine leaks and ureter stenosis. The influence of ureteric stenting on UTI development is not strong in our material.

There is eternal discussion on the best surgical method of pancreatoduodenectomy and reconstruction method. Several different methods of pancreatic stump anastomosis exist. The most popular argument taken into account in the discussion is the frequency of early postoperative complications. Relatively fewer papers analyse the late functional outcome of pancreatic surgery and the method of anastomosis employed. Authors presented short series of 12 patients after pancreatic surgery with analysis of pancreatic remnant morphology and function. Pancreatic remnant volume, pancreatic duct distension and stool elastase-1 test were analysed. There was no correlation of pancreatic exo- or endocrine insufficiency with the volume of pancreatic remnant or the kind of surgery or anastomosis performed.

Aim  The goal of this registry study was to compare open surgery with planned laparoscopy and then with laparoscopic to open conversion for rectal cancer surgery.

INTRODUCTION:Malignant tumours are the second largest cause of death in Europe. Colorectal cancer takes second place within this group and is responsible for every eighth tumour-related death. CURRENT SITUATION:Surgical quality assurance requires a prospective observational study, any different type of study is not possible. A complete recording of all treated patients is a prerequisite for quality assurance. Currently, there are quality assurance programmes in Sweden, Norway, Denmark, Great Britain, Spain, Belgium, the Netherlands as well as the multinational study for patients from Germany, Poland and Italy. These projects deliver comprehensive information regarding the treatment of colorectal cancer. However, this information is deeply rooted in the organisation of the health-care system in the given country and is not easily transferable into international settings. Also, an interpretation of the collected data is often possible only within the given health-care system. FUTURE PERSPECTIVES:First, unified initial diagnostics is a prerequisite for quality assurance -  for the local extent and exclusion / confirmation of distant metastases. Until these criteria are unified, any comparison is limited, including a comparison of survival. Second, quality-of-life is not recorded in any of the current projects. Third, the main focus of a quality assurance project must be on therapy-dependent factors. The most sensible method of quality control remains within the connection of preoperative diagnostics (estimate of a best-case scenario), the surgical technique (the actual result) and a standardised pathological examination (evaluation of the actual result). These parameters can be recorded and compared within a quality assurance project regardless of the limitations of the national health-care systems. There is no alternative to a unified diagnostics model and unified histopathological evaluation, a complete picture of treatment quality is also not possible without systematic analysis of the quality of life.

Aim The study aimed to determine whether hospitals within a quality assurance programme have outcomes of colon cancer surgery related to volume.Method Data were used from an observational study to determine whether outcomes of colon cancer surgery are related to hospital volume. Hospitals were divided into three groups (low, medium and high) based on annual caseload. Cancer staging, resected lymph nodes, perioperative complications and follow up were monitored. Between 2000 and 2004, 345 hospitals entered 31 261 patients into the study: 202 hospitals (group I) were classified as low volume (< 30 operations; 7760 patients; 24.8%), 111 (group II) as medium volume (30-60; 14 008 patients; 44.8%) and 32 (groups III) as high volume (> 60; 9493 patients; 30.4%).Results High-volume centres treated more patients in UICC stages 0, I and IV, whereas low-volume centres treated more in stages II and III (P < 0.001). There was no significant difference for intra-operative complications and anastomotic leakage. The difference in 30-day mortality between the low and high-volume groups was 0.8% (P = 0.023). Local recurrence at 5 years was highest in the medium group. Overall survival was highest in the high-volume group; however, the difference was only significant between the medium and high-volume groups. For the low and high-volume groups, there was no significant difference in the 5-year overall survival rates.Conclusion A definitive statement on outcome differences between low-volume and high-volume centres participating in a quality assurance programme cannot be made because of the heterogeneity of results and levels of significance. Studies on volume-outcome effects should be regarded critically.

We present a novel technique developed in our institution: repeated single-port transgastric debridement of walled-off pancreatic necrotic tissue using TriPort Access System (Olympus, Warsaw, Poland).

P>Ligation of the inferior mesenteric artery (IMA) during sigmoid colectomy may cause sympathetic denervation of the rectal stump. The purpose of our study was to investigate the functional results after sigmoid resection following ligation or preservation of the IMA. We prospectively analysed 44 patients (21 female and 23 male, mean age 60.6 +/- 11.79 years) with sigmoid tumour. Sigmoid colectomy with preservation of the IMA was performed in 21 patients, and ligation of the IMA with sigmoidectomy was carried out in 23 patients. Bowel function follow-up was performed by use of questionnaires: standardized functional questionnaire, constipation-specific, and incontinence scales before, 6 and 12 months after surgery. The quality of life was measured by means of the Fecal Incontinence Quality of Life (FIQL) scale. After sigmoid colectomy with division of the IMA, patients presented with a higher rate of fecal incontinence and increased stool frequency compared with patients after sigmoid resection with preservation of the IMA. Deterioration of FIQL was also observed in patients with ligated IMA. Preservation of the IMA during sigmoid colectomy in selected patients lowers the frequency of postoperative impaired anorectal function.

An 87-year-old woman presented at the emergency room with breathlessness and acute chest pain following an outpatient colonoscopy that was carried out 2 hours earlier. She suffered from chronic coronary disease and hypertension, and was taking medication for both conditions. The endoscopy was very painful. Abdominal discomfort was accompanied by a dull, heavy pain in the center and right side of the chest, radiating to the right shoulder. Retrosternal ailments were worsening (hypoxia, hypotension, tachycardia). Physical examination revealed moderately, dull respiratory murmur, and tympanic percussion note on the right side. Lower abdomen discomfort was also worsening. Radiographs revealed perforation, intestinal pneumatosis, and right-sided pneumothorax (Figure [1]). Concomitant myocardial infarction and other pathologies were excluded.

INTRODUCTION:Acute pancreatitis is a disease involving pro-inflammatory mediators. Two complex and multifactorial pathogenetic ways lead to edematous or necrotizing pancreatitis. The course of the disease is thought to be the consequence of an acute inflammatory response.AIM:The authors examined the impact of Escherichia coli LPS on the acute cerulein pancreatitis in rats.METHODS:The study was performed on rats using the ceruleine pancreatitis model. The activation status of polymorphonuclear cells, blood IL-6 concentration, oxidative stress parameters, pancreatic enzymes concentration and microscopic alterations were determined at 5th and 9th h observations.RESULTS:In acute pancreatitis and acute pancreatitis with LPS groups, the peripheral polymorphonuclear cells activity was lower than in control one. Authors noticed the same neutrophil activation in acute pancreatitis after lipopolysaccharide administration although the peripheral blood polymorphonuclear cells count was significantly higher at the 9th h observation. LPS neither changed the oxidative stress within pancreatic gland, nor amylase or serum lipase activity. LPS given to acute pancreatitis animals resulted in significant increase of serum IL-6 concentration at 5th observation turning normal after 9th h.CONCLUSIONS:Collected data supports thesis of early polymorphonuclear cells involvement in acute pancreatitis and oxidative stress evidence in pancreatic parenchyma. However, results did not reveal that administration of LPS amplified inflammatory response during the course of acute pancreatitis.

Microcirculatory disturbances are important early pathophysiological events in various organs during acute pancreatitis (AP). The aim of the study was to investigate an influence of L-arginine (nitric oxide substrate) and N-G-nitro-L-arginine (L-NNA, nitric oxide synthase inhibitor) on organ microcirculation in experimental acute pancreatitis induced by four consecutive intraperitoneal cerulein injections (15 mu g/kg/h). The microcirculation of pancreas, liver, kidney, stomach, colon and skeletal muscle was measured by laser Doppler flowmeter. Serum interleukin 6 and hematocrit levels were analyzed. AP resulted in a significant drop of microperfusion in all examined organ. L-arginine administration (2x100 mg/kg) improved the microcirculation in the pancreas, liver, kidney, colon and skeletal muscle, and lowered hematocrit levels. L-NNA treatment (2x25 mg/kg) caused aggravation of edematous AP to the necrotizing situation, and increased IL-6 and hematocrit levels. A further reduction of blood perfusion was noted in the stomach only. It is concluded that L-arginine administration has a positive influence on organ microcirculatory disturbances accompanying experimental cerulein-induced AP. NO inhibition aggravates the course of pancreatitis.

Polymorphonuclear cells (PMN) activation is an essential step in acute pancreatitis (AP). We investigated the activation status of PMN, oxidative stress and pancreatic damage in early stage of experimental ceruleine pancreatitis in rats. The PMN action was modulated by monoclonal antibody CD 11b administration. The circulating WBC and polymorphonuclear cells count was reduced after AP induction. Chemiluminescence of whole blood PMN was remarkably reduced in AP group and increased after MoAb CD 11b administration. The CD 11b blockade significantly reduced the WBC infiltration and malondialdehyde (MDA) concentration within pancreatic gland. These data suggest that activated PMN are an important factor in early AP pathogenesis. Neutrophil aggregation within pancreatic gland modulated by monoclonal antibody CD11b contribute to the extent of injury during the early stage of ceruleine experimental pancreatitis in rats.

Endoscopic polypectomy is a standard method of treatment of gastrointestinal polyps, but is associated with substantial risk of complications. The most common is hemorrhage, the rate of which varied between 0.3%, and 6%. Various prophylactic techniques have been used to reduce this incidence. The aim of this study was to establish whether the prophylactic injection of adrenaline–saline solution reduces the risk of postpolypectomy bleeding in colonoscopic polypectomy.

Pancreatic fistula is a rare postoperative complication, usually occurring after pancreatic surgery. Majority of them heal spontaneously, some patients require somatostatin/octreotide treatment. The authors have presented 11 patients with postoperative pancreatic fistula, in whom octreotide therapy in dose of 0.1 mg t.i.d./10 days has been ineffective. The causes of pancreatic fistula have been as follows: necrosectomy of the infected pancreatic necrosis--5 patients, distal pancreatic resection--2 patients, insulinoma enucleation--2 patients, gastrectomy with partial pancreatectomy--2 patients. In 9 patients endoscopic stenting of the main pancreatic duct has been performed. In remained 2 patients after Roux-en-Y gastrectomy the endoscopic access to Vater papilla has been impossible and the patients have received one intramuscular injection of long acting somatostatin analogue. In 8 of 9 patients with pancreatic stenting and in two patients after gastrectomy the fistula has been closed within the period of 6-17 days. In one patient after the necrosectomy the prosthesis implacement has been ineffective. This patient has been successfully treated with two additional injections of long acting somatostatin analogue (one injection/14 days). Authors have concluded that endoscopic pancreatic stenting has been an effective method of treatment of the postoperative pancreatic fistula, resistant to octreotide therapy. In some cases, additional administration of long acting somatostatin analogue has been necessary.

The aim of this study was to investigate the impact of L-arginine (nitric oxide synthase substrate), L-NG-nitro-L-arginine (nitric oxide synthase inhibitor), and heparin on the pancreas microcirculation, serum IL-6 level and microscopic alterations of the pancreas in acute pancreatitis in rats. Acute pancreatitis was induced by 4 i.p. injections of cerulein (15mg/kg). Microcirculatory values were measured by means of laser Doppler flowmetry 5 h after the first cerulein injection. Remarkable histopathological changes in the pancreas, including parenchymal necrosis, an elevation of serum IL-6 level, and a significant drop of pancreatic capillary perfusion was observed in rats with nitric oxide synthase inhibition. L-arginine improved the pancreatic microcirculation but worsened the microscopic alterations within the pancreas. Heparin had a beneficial effect on the microcirculatory values, serum IL-6 concentration, and morphologic changes. Authors conclude that inhibition of nitric oxide synthase aggravates acute pancreatitis. L-arginine treatment improves pancreatic perfusion but potentiates morphological alterations. Heparin, improving the microcirculation and inflammatory changes within the pancreatic gland, may be considered as a promising therapeutic agent in acute pancreatitis.

Local microcirculatory dysfunction within the pancreatic gland might be an important factor in the conversion of oedematous to necrotizing pancreatitis. Therapeutic agents, improving the pancreatic blood flow, might be valuable in acute pancreatitis treatment. An influence of nitric oxide, heparin and procaine treatment on microcirculatory values in acute pancreatitis (AP) in rats was investigated. Acute pancreatitis was induced by i.p. injection of cerulein in four doses of 15 μg kg−1each at 1-h intervals. The rats with pancreatitis were divided into five groups, 12 animals each. One group remained without treatment, four groups were treated i.p. either with NO synthase inhibitorl-NNA (2×25 mg kg−1or heparin 2×2.5 mg kg−1orl-arginine 2×100 mg kg−1or procaine 2×25 mg kg−1. Five control groups, ten animals each, received saline,l-NNA, heparin,l-arginine or procaine only. Five hours after the first ceruleine injection microcirculatory values within the pancreas were measured by means of laser Doppler flowmetry. Acute pancreatitis caused a significant drop of microcirculatory value to 37% of the basal value. Thel-NNA administration resulted in a further insignificant reduction of the pancreatic blood flow to 34%. An improvement of microcirculation was observed in rats with pancreatitis receiving heparin (76%) andl-arginine (72%). Procaine had no effect on microcirculatory disturbances within the pancreas in rats with pancreatitis. Cn-induced acute pancreatitis (AP) causes microcirculatory deterioration within the pancreas. Heparin and nitric oxide donor,l-arginine, might be considered as therapeutic agents, improving the diminished pancreatic tissue perfusion observed in acute pancreatitis. Procaine does not improve the pancreatic blood flow in acute pancreatitis.