Two-stage bilateral laparoscopic adrenalectomy for large pheochromocytomas

A 66-year-old Lithuanian female patient with a history of hypertension was diagnosed with bilateral adrenal tumors during a routine sonoscopy. Scintigraphy with metaiodobenzylguanidine and computed tomography scan revealed right 130/116/93 mm and left 85/61/53 mm pheochromocytomas. The patient suffered from hypertension with blood pressure over 240/100 mm Hg and heartbeat disturbances. Blood adrenaline levels exceeded the norm 10-fold. After possible spread of tumors was rejected, laparoscopic transperitoneal adrenalectomy was planned in 2 stages, starting on the right then followed by the left side. After preoperative treatment with adrenoblockers, 2-stage bilateral laparoscopic adrenalectomy was performed. 13 cm × 12 cm × 9.5 cm right adrenal and, 3 months later, 8.5 cm × 8 cm × 6 cm left adrenal pheochromocytomas were removed. Histologically – radical extirpation, pheochromocytomas with possible malignant potential. Stable remission of hypertension was achieved postoperatively. Laparoscopic transperitoneal adrenalectomy is a safe and feasible method of treatment of large benign and possible malignant, but noninvasive pheochromocytomas

Kavos poveikis žarnyno veiklai po žarnyno laparoskopinės rezekcinės operacijos: perspektyvusis atsitiktinių imčių tyrimas

TikslasPooperacinis žarnų nepraeinamumas – dažnai pasitaikantis žarnyno rezekcinių operacijų padarinys. Nustatytas teigiamas kavos poveikis žarnyno motorikai sveikiems tiriamiesiems. Lieka neaišku, ar kava galėtų sumažinti pooperacinio žarnyno nepraeinamumo riziką. Tyrimo tikslas – nustatyti kavos ir kofeino poveikį žarnyno veiklai po žarnyno rezekcinių operacijų.Ligoniai ir metodaiVilniaus universiteto Onkologijos institute 2013 01 01–2014 12 31 atliekamas atsitiktinės atrankos kontroliuojamas perspektyvusis tyrimas. Įtraukti pacientai, kuriems atlikta laparoskopinė storosios žarnos operacija. Prieš operaciją ligoniai paskirstytiį tris grupes: pooperaciniu laikotarpiu gaunančių vandens (100 ml 3 kartus per dieną), dekofeinizuotos kavos ir kavos su kofeinu. Pirminės svarbos tikslas – laikas iki pirmojo pasituštinimo. Antrinės svarbos tikslai – laikas, iki išėjo dujos, ir laikas ikimaisto toleravimo.RezultataiLigoniai buvo suskirstyti į tris grupes po 16 kiekvienoje. Šeši buvo atšaukti: keturi – dėl operacijos pasikeitimo, du atsisakė dalyvauti. Demografiniai pacientų rodikliai buvo panašūs visose grupėse. Ligoniai, kurie gėrė dekofeinizuotą kavą bei kavą sukofeinu, pasituštino anksčiau negu vandenį gėrusios grupės ligoniai: 3,23±1,36 ir 3,64±1,29 paros vs 3,9±0,99, p<0,05. Laikas iki maisto toleravimo – 1,63 ir 2,42 paros vs 2,82, p<0,05, laikas, iki išėjo dujos, – 1,44 ir 1,62 vs 1,92, p<0,05.IšvadosKavos vartojimas po kolektomijos yra saugus ir sumažina laikotarpį iki pasituštinimo. Kofeinas žarnų funkcijos neskatina.Does coffee affect the duration of postoperative ileus following elective laparoscopic colectomy? A randomized prospective single-center studyAudrius Dulskas, Michail Klimovskij, Marija Vitkauskienė, Narimantas Evaldas Samalavičius Background / objectivePostoperative ileus is a common problem after colorectal surgery. A positive effect of coffee on the bowel motor activity has been described. It is still unclear whether coffee consumption decreases the risk of postoperative ileus. The aim of the study was to determine whether consuming an 8-ounce cup of coffee is effective in preventing or reducing postoperative ileus.Patients and methodsFrom January 1st, 2013 to December 31st 2014, a prospective study is being performed at the Institute of Oncology of Vilnius University. Patients with a malignant or benign disease, undergoing elective laparoscopic colectomy, are assigned randomly before surgery to receive either coffee with caffeine (group 1), coffee without caffeine (group 2), or water (group 3) (100 ml three times daily) after the procedure. The primary endpoint is the time to first bowel movement, and the secondary endpoints are the time to the first flatus and the time to solid food tolerance.ResultsA total of 48 patients have been randomized, 16 to each group. Six patients were excluded: four due to a change in the surgical procedure, and two refused to participate. Patients’ demographic characteristics were similar in all groups. The time till the first bowel movement was significantly (p < 0.05) shorter in the decaffeinated coffee (3.23; SD 1.36) and coffee with caffeine (3.64; SD 1.29) groups versus the water group (3.90; SD 0.99). The time till the tolerance of solid food (1.63 and 2.42 versus 2.85; p < 0.05) and the time till the first flatus (1.44 and 1.66 versus 1.92; p < 0.05) showed a similar trend.ConclusionsCoffee consumption after colectomy has been safe and associated with a reduced time to the first bowel action. Caffeine consumption does not decrease the length of postoperative ileus. Note: these are the preliminary data which should be evaluated as a trend of the future final results

Is transanal irrigation the best treatment possibility for low anterior resection syndrome? A multicenter, randomized clinical trial: study protocol

BackgroundUp to 50% of patients who undergo rectal resection suffer from various and partly severe functional problems, despite the preservation of the anal sphincter. These complaints are defined as low anterior resection syndrome (LARS). So far, there are no randomized clinical trials regarding the most effective treatment for LARS. Our aim is to evaluate whether transanal irrigation improves bowel function and quality of life in patients following low anterior resection compared to best supportive care.MethodsPatients who have undergone low anterior resection will be approached for this study. On patient's visit, complaints regarding the defecation as well as any deterioration in their overall quality of life will be assessed using questionnaires such as the Low Anterior Resection Syndromes score, Wexner score, European Organization for Research and Treatment of Cancer (EORTC) Quality of Life (QOL) CR-29, and Measure Yourself Medical Outcome Profile tool. Few additional target questions will be also asked, such as “Would you recommend the treatment to anybody; did you expect the improvement following the treatment; etc.” Questionnaires and scales will be filled on follow-up visits every 3 months for 1 year.DiscussionThis multicenter, randomized controlled trial will lead to a better understanding of LARS treatment. Moreover, it will be a hypothesis-generating study and will inform areas needing future prospective studies. Clinical Trial RegistrationClinicalTrials.gov, identifier (NCT05920681)

Infundibulinės laparoskopinės cholecistektomijos metodika turi kokybiškai atsinaujinti: 18 metų 13 274 cholecistektomijų analizė, 45 jatrogeninių tulžies latakų sužalojimų aptarimas ir įvertinimas

BackgroundThis is an audit of the incidence of bile duct injury (BDI) in emergency and elective laparoscopic as well as open cholecystectomies in Vilnius Republican University Hospital from 1996 till 2013. We used these results to estimate the risk of the iatrogenic bile duct injury related to laparoscopic cholecystectomy (LC).MethodsInformation was retrieved from hospital databases, annual reports, and personal records. The standard infundibular technique and the use of metalic clips for a laparoscopic cholecystectomy was employed routinely. The Bismuth–Strasberg classification was used to describe the bile duct injuries as follows: A (a leaking cystic, segmental or Luschka duct), B (lobar orsectorial bile duct injury without bile leak), C (lobar or sectorial bile duct injury with bile leak), D (perforation of common hepatic duct (CHD) or common bile duct (CBD), and E (transsection, full compression or stricture of CHD or CBD). Standard statistical univariate and multivariate logistic regression analysis methods were employed.ResultsDuring the study period, a total of 13,274 cholecystectomies were performed. Of these 11,189 (84%) were performed laparoscopicallywhile the remainder 2085 (16% ) were open. Of the total number of 13,274 cholecystectomies, 5241 (39.5%) were performed in the emergency setting, the remainder being elective cases. Overall, there were 45 BDIs identified, of which 42 were related to a LC. Forty two of them were related to a LC. The incidence of BDI was 2.7 times higher in the laparoscopic surgery group compared to the open surgery group (0.38% vs 0.14%, OR 2.6149, 95% CI 0.8097–8.4442, z = 1.607, p = 0.1080). Furthermore, the incidence of BDI in patients undergoing emergency cholecystectomy was twice that of those having elective surgery (0.5% vs 0.24%, OR 2.1029, 95% CI 1.1627–3.8034, z = 2.459, p = 0.0140). Of the 45 BDIs which occured during the study period, 19 (42.2%) were identified during the index surgery, the remaining 26 (57.8%) were diagnosed in the postoperative period. An urgent postoperative ERCP was the definitive diagnostic tool for 24 (92.3%) of those 26 patients. The Bismuth–Strasberg D class bile duct injury was most the frequent – 18 cases (40.0%), followed by A (13 cases, 28.9%), E (11 cases,24.4%), and C (3 cases, 6.7%). Bile duct stenting was a definitive curative procedure for 20 patients of those who underwent an ERCP. Open reconstructive bile duct surgery was performed for the remaining 25 patients. The overall hospital mortality rate for patients who sustained a BDI was 11.1% (5/45). No independent risk factors for mortality were identifed. The overall estimated risk of BDI related to a LC was 1:261. The estimated risk for a class-specific BDI related to a LC was as follows: 1:323 for A, 1:247 for D, 1:1243 for E, and 1:1400 for C. The estimated risk for any injury of CHD or CBD (D and E classes) was 1:430.ConclusionsBile duct injury in LC is an uncommon but serious complication of cholecystectomy. In our series, the incidence of BDI was higher in patients undergoing LC compared to open cholecystectomy, and in those having emergency surgery. The development of safe surgical practise in LC is a requirement in all institutions admitting patients with biliary disease. We propose a step-wise approach of 25 principles to minimize risk to patients.ĮžangaAtliktas Respublikinės Vilniaus universitetinės ligoninės 1996–2013 metų tulžies pūslės chirurgijos retrospektyvusis auditas, apibendrinantis 18 metų operacijų patirtį. Svarbiausias tyrimo tikslas – apibūdinti su laparoskopine cholecistektomija (LC) siejamą tulžies latakų sužalojimo riziką.MetodaiLC metu, siekdami identifikuoti tulžies pūslės lataką ir jos arteriją, laikėmės infundibulinės metodikos principų. Jatrogeniniai tulžies latakų sužalojimai susisteminti į penkias klases pagal Bismutho ir Strasbergo klasifikaciją. Siekdami nustatyti Lietuvos gydytojų publikacijas, kuriose analizuojamos laparoskopinės cholecistektomijos komplikacijos, naudojomės http://scholar.google.co.uk paieškos sistema. Taikyti standartiniai vienfaktoriai ir daugiafaktoriai statistinės analizės būdai.RezultataiAtliktos 13 274 cholecistektomijos, iš jų LC – 11 189 kartus (84,29 %). 5241 (39,48 %) pacientas laparoskopiškai operuotas dėl ūminio, 8033 (60,52 %) – dėl lėtinio cholecistito. Tulžies latakai sužaloti 45 ligoniams, iš jų 42 sužalojimai siejami su LC. Laparoskopinės operacijos metu tulžies latakai buvo sužaloti 2,7 karto dažniau nei per atvirąją (0,38 % vs 0,14 %, ŠS = 2,6149, 95 % PI 0,8097–8,4442, z = 1,607, p = 0,1080). Operuojant pacientus dėl ūminio cholecistito, jatrogeninių tulžies latakų sužalojimų pasitaikė du kartus dažniau (0,5 % vs 0,24 %, ŠS = 2,1029, 95 % PI 1,1627–3,8034, z = 2,459, p = 0,0140). Su LC siejamų jatrogeninių tulžies latakų sužalojimų rizika yra 1:261. 2010–2013 metais jų padaugėjo. Tulžies pūslės latako nesandarumo rizika po LC yra 1:323 (tai didele dalimi atspindi specifinę technologijos problemą). Pagrindinių šoninių tulžies latakų sužalojimų rizika yra 1:247 (tai chirurginės technikos problema). E klasės sužalojimo rizika 1:1243. 2000–2013 metais su LC siejama 40 % (17/42) jatrogeninių tulžies latakų sužalojimų. Hospitalinis mirštamumas nuo tulžies latakų sužalojimo buvo 11 % (5/45).IšvadosJatrogeniniai tulžies latakų sužalojimai yra nedažni, bet pavojingi. Tyrimas išryškino koncepcinius, sisteminius ir techninius LC trūkumus. Kadangi laparoskopinės cholecistektomijos kultūra prasideda nuo operacijai tinkamų pacientų atrankos, išsamiai infomuoto paciento sutikimo, šiuolaikinių pripažintų technologinių ir techninių priklausinių bei racionalių, pacientų saugumą užtikrinančių sprendimų, ji turi keistis. Ir ne tik įstaigoje, kurioje buvo atliktas šis klinikinis tyrimas, bet ir visose kitose geografinio regiono gydymo įstaigose, jeigu jose praktikuojama tokia pati arba metodologiškai panaši tulžies pūslės chirurgija

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries