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Introduction: Frailty increases the risk of poor surgical outcomes in the older population. Some intraoperative factors may also influence the final result and can be evaluated. The Surgical Apgar Score (SAS) is a simple system predicting postoperative mortality and morbidity. However, the utility of the SAS remains unknown in fit and frail older patients undergoing elective laparoscopic cholecystectomy due to benign gallbladder diseases., Aim: To evaluate the usefulness of the SAS in predicting 30-day morbidity and 1-year mortality in older fit and frail patients undergoing elective laparoscopic cholecystectomy., Material and Methods: Consecutive patients (≥ 70 years) were enrolled in the prospective study. The Comprehensive Geriatric Assessment (CGA) was used to diagnose frailty. Logistic regression was conducted to investigate the association between the scores and the outcomes., Results: The study included 144 consecutive older patients with a median age of 76 (range: 70-91) years. The prevalence of frailty was 44.4%. The 30-day mortality and morbidity were 0% and 11.8%, respectively. The 1-year mortality was 6.3% and 7 out of 9 occurred in the frail group. SAS < 7 points was identified as an independent predictor of 30-day postoperative morbidity (OR = 5.1; 95% CI: 1.5-18.1). Age > 85 years (OR = 1.9; 95% CI: 1.2-16.4) and frailty (OR = 3.4; 95% CI: 1.1-19.3) were predictors of 1-year mortality., Conclusions: Laparoscopic cholecystectomy can be safely performed in older fit and frail patients. The SAS, not age, turned out to be the most important predictor of 30-day morbidity. Frailty and age > 85 years were predictors of 1-year mortality. Older patients with SAS < 7 points should be followed meticulously in order to diagnose and treat potential complications early on.

Introduction: As the population ages, the number of elderly patients with esophageal cancer increases. Esophageal cancer has a poor prognosis and is associated with decreased life quality., Aim: To review the literature about the outcome of esophageal cancer in patients over 65., Material and Methods: Articles published between January 2006 and November 2016 in the PubMed/Medline and ResearchGate databases were reviewed. Nineteen retrospective studies were included., Results: Six thousand seven hundred and twenty-nine patients over 65 were analyzed. Thirty-day mortality ranges from 3.2% to 8.1%. Overall 5-year survival rates range from 0% to 49.2%, and the median survival rate ranges from 9.6 to 108.2 months. The incidence of complications in the surgery group ranges from 27% to 69%. Chemoradiotherapy grade ≥ 3 toxicity was observed in 22-36% of patients., Conclusions: Chronological age seems to have little influence on outcome of esophageal cancer. Open esophagectomy seems to be the mainstay of treatment for patients with esophageal cancer, regardless of age. There is still high mortality and morbidity involved in this procedure. To reduce them, some less invasive methods are being trialed.

Introduction: Minimally invasive parathyroidectomy (MIP) with intraoperative parathyroid hormone assay (IOPTH) has successfully replaced conventional neck exploration in most patients with primary hyperparathyroidism (pHPT) and preoperatively localized parathyroid adenoma., Aim: To compare outcomes of video-assisted MIP (MIVAP) to open MIP (OMIP)., Material and Methods: A retrospective case-controlled study of 455 patients with sporadic pHPT undergoing MIP with IOPTH at our institution in 2003-2012 was undertaken. The primary outcome measure was postoperative pain. Secondary outcome measures were: duration of surgery, recurrent laryngeal nerve (RLN) identification rate, conversion rate, length of hospital stay, cure rate, patients' satisfaction with cosmetic outcome, morbidity, costs, and diagnostic accuracy of IOPTH., Results: Of 455 patients with pHPT and a solitary parathyroid adenoma on preoperative imaging, 151 underwent MIVAP and 304 had OMIP. The following outcomes were favourable for MIVAP vs. OMIP: lower pain intensity during 24 h postoperatively (p < 0.001), lower analgesia request rate (p < 0.001), lower analgesics consumption (p < 0.001), higher recurrent laryngeal nerve identification rate (p < 0.001), shorter scar length (p < 0.001), and better cosmetic satisfaction at 1 month (p = 0.013) and at 6 months (p = 0.024) after surgery. However, MIVAP vs. OMIP had longer duration of surgery (p < 0.001), and was more expensive (p < 0.001). No differences were noted in the conversion rate, length of hospital stay, and morbidity., Conclusions: Both MIVAP and OMIP approaches were equally safe and effective. However, the outcomes of MIVAP operations were superior to OMIP in terms of lesser postoperative pain, lower analgesics consumption, and better cosmetic satisfaction resulting from a smaller scar.

Introduction: Rectum-sparing transanal endoscopic microsurgery (TEM) is a well-established treatment for T1 rectal cancer (RC). However, it is associated with an increased rate of local recurrence in comparison with extended resection. In most cases this failure is linked to inappropriate case selection and the presence of clinically non-detectable metastases in the regional lymph nodes. Endoscopic posterior mesorectal resection (EPMR) makes it possible to remove the relevant lymphatic drainage of the lower third of the rectum in a minimally invasive way, which in turn can help in adequate tumor staging., Aim: To evaluate the long-term clinical results and influence of combined TEM and EPMR treatment on the anorectal functions., Material and Methods: Ten consecutive patients with T1 RC were operated on using TEM and EPMR as a two-stage procedure between 2007 and 2009., Results: After a median follow-up of 42.6 (range: 36-80) months, none of our patients complained of symptoms of incontinence apart from one female patient with gas incontinence diagnosed preoperatively. There was no statistically significant difference in basal anal pressure, squeeze anal pressure, high pressure zone length or fecal continence assessed using the Fecal Incontinence Severity Index before and in follow-up months after the procedure. Postoperative morbidity consisted of one hematoma formation and one male patient complaining about sexual dysfunction until 6 months postoperatively. There was no evidence of locoregional recurrence., Conclusions: Endoscopic posterior mesorectal resection in combination with TEM appears to be safe, feasible and with no impact on the basic anorectal functions in the 3-year follow-up.

Introduction: Appendicitis remains the most common cause of an acute abdomen. Obtaining intra-abdominal cultures is routine surgical practice. There are studies showing no efficacy of such procedures in cases where open appendectomies are performed., Aim: The goal of this study was to assess the need for obtaining intra-abdominal cultures during laparoscopic appendectomies., Material and Methods: Between 2007 and 2012, 369 patients were operated on with the diagnosis of histopathologically proven acute appendicitis. Sixty-two percent of them were operated on using laparoscopic techniques. The microbiological assessment was routinely done for the open procedures and in 42% of cases that underwent a laparoscopic operation., Results: In 57% (134) the swabbing results were negative. Among 43% (102) of the patients with a positive result, Escherichia coli was isolated in 76.5% (78), Proteus mirabilis in 13.7% (14), Pseudomonas aeruginosa in 4.9% (5) and Citrobacter freundii in 4.9% (5). Five cases had bacteria resistant to the antibiotic given preoperatively (that is 4.9% of all positive cultures and 1.4% of all operated patients). However, these cases did not affect the incidence of postoperative complications. Consideration of the postoperative morbidity showed that there was no statistically significant difference between the laparoscopic group with and without intra-operative swabbing (p > 0.05)., Conclusions: The postoperative patient outcome was more dependent on the pathology of the appendix than on the results of the microbiological assessment at the time of surgery. Hence, routine intra-operative cultures during laparoscopic appendectomies appear to have little value in patient management. Swabbing during laparoscopic procedures should be limited to only selected high-risk groups.

Introduction: Pathological lesions of the rectum are common and their management requires detailed knowledge of pelvic anatomy. There has been considerable debate as to the definition of the rectum and the variability of the level of the peritoneal reflection. The lack of a clear consensus was proven in the research by McCullen et al. regarding the current pattern of practice for the investigation of primary rectal cancer by general surgeons., Aim: To carry out bibliographic research on the definition of the rectum and level of the peritoneal reflection., Material and Methods: A web-based published literature search of PubMed, Ovid Medline, Science Direct and Springer was made., Results: The paper presents the current definitions of proximal and distal margin of the rectum and level of peritoneal reflection based not only on the results of tests on cadavers but also on living humans., Conclusions: The results of tests on living humans allow more accurate qualification of patients for local excision, which is particularly important for patients with colorectal cancer.