Biological welding – novel technique in the treatment of esophageal metaplasia

Introduction: Biological welding – controlled action of high frequency current on living tissues, which leads to their structural changes and weld formation – connection with unique biological properties (strength, high elasticity, insensitivity to microbial infection, stimulating effect on the regeneration process, speed and quality which surpasses the normal uncomplicated healing) [22]. This method is used in various fields of surgery, but at the moment there is no data on its use in case of esophageal cylindrocellular (intestinal) metaplasia (further esophageal metaplasia or Barrett’s esophagus). Objective: The goal of this study is to evaluate biologic welding as a treatment option for patients with Barrett’s esophagus. Materials and methods: Single-center retrospective review of patients with short-segment Barrett’s esophagus and metaplasia were treated by argon plasma coagulation (APC) or Paton’s welding. This was followed by Nissen fundoplication. Primary outcome of this study was mucosal healing with morphological confirmation of the absence of metaplasia. The groups included patients with a short segment of the esophagus Barrett’s C2-3M3-4 (Prague Classification 2004) and high dysplasia without nodule formation in combination with hiatal hernia (VI World Congress of the International Society for Esophageal Diseases; ISED) [23–25]). Results: A total of 49 patients were included in the study with 25 patients treated by APC laser and 24 by biowelding. Four patients (16.0%) in the APC group developed stenosis and 5 patients (20.0%) developed recurrence compared to none in the biowelding group. Patients in the biowelding group had a significantly faster rate of mucosal healing leading to faster progression to Nissen fundoplication (at average 53 days) compared to APC laser group (surgery at 115 days). Conclusions: Biological welding of Paton’s is a safe and effective treatment option for patients with esophageal metaplasia

Antireflux surgery is required after endoscopic treatment for Barrett’s esophagus

Introduction: Barrett’s esophagus is an acquired condition that develops as a result of transformation of normal stratified squamous epithelium in the lower part of the esophagus into columnar epithelium. Barrett’s esophagus is considered to be a complication of gastroesophageal reflux disease (GERD). Various endoscopic techniques have been shown to be successful in the treatment of this condition. However, long-term success in preventing further esophageal dysplasia is not clear. Biological welding consists in the application of controlled high-frequency current on living tissues and has been used to stop gastrointestinal bleeding, similarly to the APC technique which involves ablation of small intestinal metaplasia of the esophageal mucosa. Aim: The goal of this study was to evaluate the effectiveness of endoscopic techniques in the treatment of Barrett’s esophagus and verify the need for a subsequent surgical intervention in patients with GERD complicated by Barrett’s esophagus. Material and methods: Patients with Barrett’s esophagus C1-3M2-4 (Prague classification from 2004) and high dysplasia without nodules, as well as patients with confirmed GERD without hiatal hernia, were included in this study. Endoscopic treatment was performed with the use of argonoplasmic coagulation (APC) and high-frequency welding of living tissues (HFW). After the examination the patients were re-examined. Patients with recurrence of metaplasia and high DeMeester score (˃ 100) underwent antireflux surgery – crurography and Nissen fundoplication with creation of a soft and short cuff.Results: A total of 89 patients were included in the study, 81 of whom were reexamined after ablation of Barrett’s esophagus.In 12 patients, a recurrence of intestinal metaplasia resembling the small intestine was identified. Implementation of two-stage treatment was required for 9 patients – it involved a second procedure of ablation of the esophagus, followed by antireflux surgery. Surgical treatment was refused by 3 patients, who underwent only the second ablation procedure. All patients received drug therapy, consisting of prokinetics and proton pump inhibitors. Esophageal pH monitoring was repeated 3 months after surgery, showing normalization of the DeMeester score. As a result, the patients experienced no complaints such as heartburn, chest pain or dysphagia, which significantly improved their quality of life. Esophagogastroduodenoscopy and biopsy of the mucous membrane of the lower third of the esophagus were performed in accordance with the Seattle Protocol. After examining histological specimens, no regions of metaplasia were identified. Conclusion: Antireflux surgery is required as a part of the treatment for Barrett’s esophagus, which prevents further dysplasia and development of esophageal cancer

Rozszerzona profilaktyka w leczeniu długotrwałej żylnej choroby zakrzepowo-zatorowej rywaroksabanem u pacjentów po poważnym zabiegu w obrębie miednicy i jamy brzusznej – omówienie bezpieczeństwa i wczesnych wyników

Wstęp: Żylna choroba zakrzepowo-zatorowa (ŻChZZ), będąca następstwem operacji jelita grubego, jest dobrze udokumentowanym powikłaniem, w związku z czym zaleca się rozszerzoną profilaktykę po wypisie ze szpitala. Rywaroksaban, będący inhibitorem aktywnego czynnika X, to podawana raz dziennie tabletka zatwierdzona w leczeniu ŻChZZ oraz profilaktyce po operacjach ortopedycznych. Cel: Celem badania jest ocena bezpieczeństwa rywaroksabanu w rozszerzonej profilaktyce u pacjentów po poważnym zabiegu w obrębie miednicy i jamy brzusznej. Metody: Dokonano retrospektywnej analizy pacjentów po poważnej operacji jelita grubego wykonanej w szpitalu regionalnym w Kijowie na Ukrainie. Chorzy otrzymali okołooperacyjną profilaktykę ŻChZZ w formie podskórnych iniekcji heparyny, a następnie rywaroksaban przez 30 dni. Odnotowano występowanie poważnego oraz niewielkiego krwawienia, przy czym konieczna była transfuzja krwi oraz ponowna interwencja. W 30. dniu po operacji pacjenci wzięli udział w wywiadzie telefonicznym w celu oceny przestrzegania zaleceń dotyczących przyjmowania leku oraz satysfakcji ze schematu leczenia. Wyniki: W badaniu udział wzięła grupa 51 pacjentów, których średni wiek wynosił 62,4 lat. W 71% przypadków zabieg dotyczył jamy brzusznej, w 29% miednicy, zaś w 59% operację wykonano laparoskopowo. Wystąpił jeden epizod poważnego krwawienia w obrębie jamy brzusznej, w którym konieczny był powrót do sali operacyjnej. Ponadto pojawiły się dwa epizody niewielkiego stopnia krwawienia, niewymagające interwencji. W badanej grupie nie stwierdzono zdarzeń ŻChZZ. Wskaźnik odpowiedzi na wywiad telefoniczny wyniósł 100%. Spośród wszystkich osób, jedna zgłosiła ukończenie pełnego cyklu leczenia rywaroksabanem. Pacjenci zgłaszali, że łatwo im było przestrzegać zaleceń profilaktyki doustnej i preferowali tę metodę w porównaniu do zastrzyków. Wniosek: Wdrożenie rozszerzonej profilaktyki rywaroksabanem jest łatwe, bezpieczne i nie prowadzi do zwiększenia częstości krwawienia pooperacyjnego

Chirurgiczne leczenie ostrego zapalenia pęcherzyka żółciowego u pacjentów otyłych

Wprowadzenie: Współczesna nauka i medycyna wchodzą w nową epokę. Na obecnym poziomie rozwoju technologicznego istnieją tysiące „nowych” problemów i schorzeń. O ile uprzednio znane schorzenia posiadały cechy pewnej odrębności, w trzecim tysiącleciu stajemy przed problemem złożoności i synergicznego oddziaływania znanych chorób. Problemem trzeciego tysiąclecia jest otyłość, która – jak wiadomo – stanowi główny czynnik rozwoju szeregu schorzeń przewlekłych [1–3]. Przy nadwadze i otyłości dochodzi do przesycenia żółci cholesterolem, co skutkuje wzrostem wskaźnika litogenności, a co za tym idzie – wzrostem częstości kamicy żółciowej; ten ostatni sięga w tym przypadku 50–60% [4]. U 20% pacjentów kamica żółciowa współistnieje z otyłością [5]. Otyłość jest więc jednym z czynników odpowiedzialnych za rozwój kamicy żółciowej i zapalenia pęcherzyka żółciowego [6]. Wystąpienie ostrego zapalenia pęcherzyka żółciowego stwarza największy problem u pacjentów z kamicą żółciową, zaś otyłość zwiększa ryzyko powikłań śródoperacyjnych w związku ze zmienną homeostazą i obniżoną objętością zapasową [7]. Retrospektywne zbadanie tego problemu [8] doprowadziło do sformułowania pytań odnośnie do możliwości wpływania na: przebieg choroby w okresie przedoperacyjnym, poprawę i aspekty techniczne zabiegu chirurgicznego wykonywanego u pacjentów z ostrym zapaleniem pęcherzyka żółciowego i otyłością. Znalezienie odpowiedzi m.in. na pytania z tej listy stało się głównym zamierzeniem niniejszego badania. Cel: Celem pracy było zbadanie i wybranie optymalnej metody chirurgicznej stosowanej u pacjentów z ostrym zapaleniem pęcherzyka żółciowego i otyłością. Materiał i metody: W badaniu wykorzystano analizę prospektywną, której poddano 67 przypadków pacjentów z rozpoznaniem ostrego zapalenia pęcherzyka żółciowego leczonych w Regionalnym Szpitalu Klinicznym w Kijowie w okresie od września 2018 r. do 1 marca 2020 r. U osób z ostrym zapaleniem pęcherzyka żółciowego wykonywano „tradycyjną” lub zmodyfikowaną cholecystektomię laparoskopową. Wyniki: Jak wykazała retrospektywna analiza, u pacjentów z ostrym zapaleniem pęcherzyka żółciowego i otyłością wykonywanie tradycyjnej cholecystektomii laparoskopowej jest technicznie trudne i kosztowne. Zaproponowano zmodyfikowaną procedurę cholecystektomii laparoskopowej, ułatwiającą i usprawniającą zabieg u pacjentów z ostrym zapaleniem pęcherzyka żółciowego i otyłością. Wykonywanie zmodyfikowanej cholecystektomii laparoskopowej zmniejszało czas trwania operacji o 9,01 ± 0,41 minut (p = 0,001; α = 0,05). Wnioski: Wykonywanie zmodyfikowanej cholecystektomii laparoskopowej zmniejszało czas trwania operacji o 9,01 ± 0,41 minut (p = 0,001; α = 0,05) i zapobiegało rozwojowi kwasicy metabolicznej (pH 7,39 ± 0,03 vs 7,30 ± 0,005, p = 0,001; α = 0,05, pCO2 5,05 ± 0,36 vs 6,03 ± 0,38, p = 0,02; α = 0.05), zmniejszając ryzyko nadkrzepliwości. Zmodyfikowana LHE jest skuteczna w przypadkach otyłości II i III stopnia (p = 0,001; α = 0,05)

Surgical treatment of acute cholecystitis in obese patients

Introduction: In today’s technological climate, science and medicine have entered a new era. At the level of technological progress, we have identified millennia of “new” problems and diseases. If earlier diseases had a certain individuality then, in the third millennium, we face compliance and synergistic influence of diseases. Obesity is a problem of the third millennium. It is known that obesity is the main factor in the development of various chronic diseases [1–3]. With excess weight and obesity, bile is oversaturated with cholesterol, resulting in an increase of its lipogenicity index. As a result, frequency of gallstone disease increases; findings from this study document an increase of disease frequency as high as 50% to 60% [4]. In 20% of patients, housing concerns are combined with obesity [5]. Thus, obesity is one of the factors in the development of cholelithiasis and cholecystitis [6]. The presence of acute cholecystitis represents the most difficult situation for patients with gallstones. When obesity is also present, the patient’s risk of surgical complications increases due to altered homeostasis and reduced reserve capacity [7]. A retrospective study of this issue [8] posed a number of questions about the possibility of influencing the course of disease in the preoperative period as well as the improvement and impact of surgical technicalities in patients with acute cholecystitis and obesity. Addressing these and additional questions is the main goal of this study. Aim: The aim of the study was to study and select the optimal method of surgery in patients with acute cholecystitis and obesity. Materials and methods: In our study, a prospective analysis was used. We analyzed 67 cases with diagnosis of acute cholecystitis and obesity; all were treated at Kyiv Regional Clinical Hospital in the period from September 2018 to March 2020. Patients with acute cholecystitis and obesity received either traditional or modified laparoscopic cholecystectomy. Results: Retrospective analysis indicates traditional laparoscopic cholecystectomy is technically difficult and costly in patients with acute cholecystitis and obesity. A modified laparoscopic cholecystectomy has been proposed to improve and enhance surgery in patients with acute cholecystitis and obesity. Surgical duration was shortened by 9.01 ± 0.41 minutes (p = 0.001; αα= 0.05) when a modified laparoscopic cholecystectomy was performed. Conclusions: Performing a modified laparoscopic cholecystectomy reduced the duration of surgery by 9.01 ± 0.41 minutes (p = 0.001; α = 0.05), prevents development of metabolic acidosis pH 7.39 ± 0.03 vs 7.30 ± 0.005 = 0.001; αα= 0.05, pCO2 5.05 ± 0.36 vs 6.03 ± 0.38 (p = 0.02; αα= 0.05), reducing the risk of hypercoagulation. Modified laparoscopic cholecystectomy (LHE) is effective in II and III degrees of obesity (p = 0.001; α = 0.05)

Implementation of extended prolonged venous thromboembolism prophylaxis with rivaroxaban after major abdominal and pelvic surgery – overview of safety and early outcomes

Purpose: Venous thromboembolism (VTE) after colorectal surgery is a well-documented complication, resulting in a general recommendation of extended post-discharge prophylaxis. Rivaroxaban, a factor Xa inhibitor, is a daily tablet approved for treatment of VTE and prophylaxis after orthopedic surgery. Aim: The purpose of this study is to evaluate the safety of rivaroxaban for extended prophylaxis after major abdominal and pelvic surgery. Methods: This is a retrospective review of patients undergoing major colorectal surgery at a regional hospital in Kiev, Ukraine. Patients received peri-operative VTE prophylaxis with subcutaneous heparin and then transitioned to rivaroxaban for a total of 30 days. Occurrences of major or minor bleeding, blood transfusion, and a need for re-intervention were noted. Phone surveys were administered on post-operative day 30 to assess compliance and satisfaction with the regimen. Results: A total of 51 patients were included in the study with an average age of 62.4 years. Seventy-one percent of the cases were abdominal, 29% were pelvic cases and 59% were done laparoscopically. There was one episode of major intra-abdominal bleeding requiring return to the operating room. There were 2 minor bleeding episodes which did not require intervention. There were no VTE events in the group. The phone survey response rate was 100%. All but one patient reported having completed the full course of rivaroxaban. Patients reported that oral prophylaxis was easy to adhere to and preferable compared to injections. Conclusion: Implementation of extended prophylaxis with rivaroxaban is easy, safe and does not increase rates of postoperative bleeding

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research