Percutaneous management of acute necrotizing pancreatitis

OBJECTIVES: The study aims to evaluate the efficacy of percutaneous necrosectomy (PN) performed under ultrasound control and of endoscopic necrosectomy through secondary sinus track (ENTSST) using nephroscope and cystoscope.MATERIAL AND METHOD: Puncture of fluid collections in the pancreas was performed under ultrasonographic control to 23 patients with acute necrotizing pancreatitis (ANP). ENTSST using nephroscope and cystoscope was performed to 47 patients after open or percutaneous necrosectomy and persistent sepsis (without satellite collection of CT).RESULTS: Seventeen patients (74%) treated with percutaneous necrosectomy recovered without open surgery. Two of this group died. The average hospital stay was 42 days. Twenty-three patients required an average of two (range 1-4) ENTSST.CONCLUSIONS: Based on our initial results we believe that the percutaneous necrosectomy and ENTSST in well selected patients might be the better choice than open necrosectomy and postoperative lavage. Common solution for these methods has not been reached yet

Association of mechanical bowel preparation with oral antibiotics and anastomotic leak following left sided colorectal resection:an international, multi-centre, prospective audit

Introduction: The optimal bowel preparation strategy to minimise the risk of anastomotic leak is yet to be determined. This study aimed to determine whether oral antibiotics combined with mechanical bowel preparation (MBP+Abx) was associated with a reduced risk of anastomotic leak when compared to mechanical bowel preparation alone (MBP) or no bowel preparation (NBP). Methods: A pre-planned analysis of the European Society of Coloproctology (ESCP) 2017 Left Sided Colorectal Resection audit was performed. Patients undergoing elective left sided colonic or rectal resection with primary anastomosis between 1 January 2017 and 15 March 2017 by any operative approach were included. The primary outcome measure was anastomotic leak. Results: Of 3676 patients across 343 centres in 47 countries, 618 (16.8%) received MBP+ABx, 1945 MBP (52.9%) and 1099 patients NBP (29.9%). Patients undergoing MBP+ABx had the lowest overall rate of anastomotic leak (6.1%, 9.2%, 8.7% respectively) in unadjusted analysis. After case-mix adjustment using a mixed-effects multivariable regression model, MBP+Abx was associated with a lower risk of anastomotic leak (OR 0.52, 0.30–0.92, P = 0.02) but MBP was not (OR 0.92, 0.63–1.36, P = 0.69) compared to NBP. Conclusion: This non-randomised study adds ‘real-world’, contemporaneous, and prospective evidence of the beneficial effects of combined mechanical bowel preparation and oral antibiotics in the prevention of anastomotic leak following left sided colorectal resection across diverse settings. We have also demonstrated limited uptake of this strategy in current international colorectal practice

Evaluating the incidence of pathological complete response in current international rectal cancer practice

The mainstay of management for locally advanced rectal cancer is chemoradiotherapy followed by surgical resection. Following chemoradiotherapy, a complete response may be detected clinically and radiologically (cCR) prior to surgery or pathologically after surgery (pCR). We aim to report the overall complete pathological response (pCR) rate and the reliability of detecting a cCR by conventional pre-operative imaging.A pre-planned analysis of the European Society of Coloproctology (ESCP) 2017 audit was performed. Patients treated by elective rectal resection were included. A pCR was defined as a ypT0 N0 EMVI negative primary tumour; a partial response represented any regression from baseline staging following chemoradiotherapy. The primary endpoint was the pCR rate. The secondary endpoint was agreement between post-treatment MRI restaging (yMRI) and final pathological staging.Of 2572 patients undergoing rectal cancer surgery in 277 participating centres across 44 countries, 673 (26.2%) underwent chemoradiotherapy and surgery. The pCR rate was 10.3% (67/649), with a partial response in 35.9% (233/649) patients. Comparison of AJCC stage determined by post-treatment yMRI with final pathology showed understaging in 13% (55/429) and overstaging in 34% (148/429). Agreement between yMRI and final pathology for T-stage, N-stage, or AJCC status were each graded as 'fair' only (n = 429, Kappa 0.25, 0.26 and 0.35 respectively).The reported pCR rate of 10% highlights the potential for non-operative management in selected cases. The limited strength of agreement between basic conventional post-chemoradiotherapy imaging assessment techniques and pathology suggest alternative markers of response should be considered, in the context of controlled clinical trials

Manual Colonic Decompression - Faster Than On-Table Lavage in Obstructed Left Colon Cancer

We are presenting the advantage of manual decompression over the on-table lavage as a way of saving time during an emergency surgery in obstructed left colon cancer (OLCC). Introduction: Left colon cancer can present as an emergency due to obstruction in about 20% of the cases. Therefore, we are often forced to operate on these patients in conditions of an unprepared colon. Aim: We are presenting the advantage of manual decompression over the on-table lavage as a way of saving time during an emergency surgery in obstructed left colon cancer (OLCC).Materials and Methods: We analyzed 54 cases of acute left colon obstruction caused by colon cancer. All were operated as emergency cases in a condition of an unprepared colon. Both, manual decompression and on-table lavage were used for intraoperative colon cleansing (28/26, respectively).Results: The time used for on-table lavage was significantly longer than that for the manual decompression group (>0.05). In all patients, a segmental colon resection and primary anastomosis were done. Conclusion: On-table lavage was technically more challenging. In the future, in large series, we can expect complications with this method because of the weak place on the site of the appendectomy. Both manual decompression and on-table lavage can be used in cases of OLCC for colon cleansing as safe methods, with the only significant difference being time-saving with the manual decompression

The Chevrel Technique in the Treatment of Midline Giant Incisional Hernia

Introduction: Giant incisional hernia (GIH) is a serious pathological entity which is characterized with a massive loss of muscle and fascial tissue and a total impairment of the anatomical and physiological function of the anterior abdominal wall, which also leads to severe respiratory and visceral malfunction. Reconstruction is accompanied with a high rate of relapses, complications and even mortality.Materials and Methods: During a 15-year period (2000-2015), 319 patients in total have been operated on for midline GIH. Using the Chevrel classification, it is classified as an M4-W4R type of incissional hernia. The patients have been electively operated on under general endotracheal anesthesia. Standard reconstruction by Chevrel`s techniqe was used with the creation of a new linea alba. The defect on the anterior rectus sheath was covered with polypropylene mesh. Female to male ratio was 209/110 with a median age of 48 (31-72). The median BMI was 32.1. Concomitant cholecystectomies were done in 11 patients and dermolypectomies were performed on 31 at the same time.Results: There were no cases of intraoperative complications and mortality. Postoperative mortality, as a result of a perforated peptic ulcer was seen in one patient. The operative time after the improvement of the technique varied between 60-70 min. The average time of hospitalization was 8.8 days (range 7-21). SSI were noted in 56 (17%) patients. Seroma was a leading complication in our series. Partial necrosis of the skin was seen in 12 patients (4%). Hernia recurrence was observed in 7 patients (2.1%) during the follow-up period (6-48 months) in the controlled 284 patients.Conclusion: The original Chevrel technique consists of tissue reconstruction on the linea alba and approximation of rectus muscle, strengthened with a mesh lining. It represents an acceptable method with very good results. The low recurrence and complication rate, as well as the functional results, influence the acceptance of this method by highly specialized institutions that deal with the treatment of GIH

(OSMS)- One Step Melanoma Surgery for Nevoid melanoma?

We describe a 48-year-old patient with a present cutaneous pigment lesion located in the left scapular area. About 15 years duration of the finding, as the lesion being suspected clinically and dermatoscopically for cutaneous melanoma. The patient was initially treated with a surgical margin of 0.5 cm in all directions, with a tumor thickness of 3 mm immediately established afterwards. The subsequent surgical session 9 days later (as recommended by the AJCC) included: 1) removal of 4 sentinel lymph nodes: 3 of them located infrascapularly and one axillary apically to the left and 2) reexcision of the primary surgical wound with a safety margin of 1.5 cm in all directions. Lymph node involvement data are lacking and the patient is staged as IIA (T3a N0M0).</jats:p

Head and neck malignant melanomas - clinical cases and treatment guidelines

Malignant melanomas are among the deadliest and fastest growing malignant tumors in human body. Although several decades ago they were considered rare, their frequency has increased dramatically in recent years.Our aim is to present several of our own cases of malignant melanoma in head and neck area and outline treatment guidelines.The extent of surgery is determined by the stage, location and size of the tumor: local excision; excision with sentinel lymph node biopsy; excision with selective modified or radical neck dissection. The advanced cases are treated by chemotherapy but the prognosis is poor. Promising seem to be the immuno-medications based on specific receptor antibodies.Good collaboration with dermatologists is important for early diagnosis - a fundamental prerequisite for therapeutic success.Der Erstautor gibt keinen Interessenkonflikt an