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Solitary rectal ulcer syndrome (SRUS) is an uncommon chronic disorder with a wide range of endoscopic findings, clinical presentations and characteristic histopathological features. There is no clear consensus regarding SRUS management, because of its poorly understood pathogenesis and frequent association with various pelvic floor disorders. Laparoscopic resection rectopexy and transanal endoscopic microsurgery (TEM) were used for the treatment of non-healing SRUS. The present paper reports a case of non-healing SRUS due to obstructive defecation syndrome based on combined pelvic floor disorders (rectocele, enterocele, internal rectal prolapse and dolichosigma) successfully managed by a novel combined mini-invasive approach which has never been previously reported in the literature (laparoscopic resection rectopexy and TEM). The new minimally invasive concept seems to be safe and feasible – laparoscopic resection rectopexy results in effective correction of the obstructive defecation syndrome, while TEM allows comfortable access for radical resection of a rectal ulcer.

The successful management of a rectovesical fistula after radical prostatectomy is difficult. Minimally invasive treatment by over-the-scope clip (OTSC) is a novel method. The authors present results with the use of OTSC. This method was used in 2 patients. The first patient had a rectovesical fistula detected on the fifth day after a prostatectomy. The second patient experienced rectal perforation during prostatectomy and a recurrent fistula after fistulorrhaphy. Both patients had a small fistula located in the vesicourethral anastomosis. Both patients underwent endoscopic OTSC placement. The median follow-up was 26 months. The success rate was 50%. The first patient healed successfully and the second patient had a relapse. The York-Mason procedure was eventually successful. According to our initial experience, the OTSC is suitable for small fistulas detected shortly after a prostatectomy. A more complex fistula, though small, carries a higher recurrence risk.

Introduction: Laparoscopic repair is becoming an increasingly popular alternative in the treatment of abdominal wall hernias. In spite of numerous studies evaluating this technique, indications for laparoscopic surgery have not been established. Similarly, implant selection and fixation techniques have not been unified and are the subject of scientific discussion. Aim: To assess whether there is a consensus on the management of the most common ventral abdominal wall hernias among recognised experts. Material and methods: Fourteen specialists representing the boards of European surgical societies were surveyed to determine their choice of surgical technique for nine typical primary ventral and incisional hernias. The access method, type of operation, mesh prosthesis and fixation method were evaluated. In addition to the laparoscopic procedures, the number of tackers and their arrangement were assessed. Results: In none of the cases presented was a consensus of experts obtained. Laparoscopic and open techniques were used equally often. Especially in the group of large hernias, decisions on repair methods were characterised by high variability. The technique of laparoscopic mesh fixation was a subject of great variability in terms of both method selection and the numbers of tackers and sutures used. Conclusions: Recognised experts have not reached a consensus on the management of abdominal wall hernias. Our survey results indicate the need for further research and the inclusion of large cohorts of patients in the dedicated registries to evaluate the results of different surgical methods, which would help in the development of treatment algorithms for surgical education in the future.

Negative pressure wound therapy (NPWT) has become a standard in the treatment of chronic and difficult healing wounds. Negative pressure wound therapy is applied to the wound via a special vacuum-sealed sponge. Nowadays, the endoscopic vacuum-assisted wound closure system (E-VAC) has been proven to be an important alternative in patients with upper and lower intestinal leakage not responding to standard endoscopic and/or surgical treatment procedures. Endoscopic vacuum-assisted wound closure system provides perfect wound drainage and closure of various kinds of defect and promotes tissue granulation. Our experience has shown that E-VAC may significantly improve the morbidity and mortality rate. Moreover, E-VAC may be useful in a multidisciplinary approach – from upper gastrointestinal to rectal surgery complications. On the other hand, major limitations of the E-VAC system are the necessity of repeated endoscopic interventions and constant presence of well-trained staff. Further, large-cohort studies need to be performed to establish the applicability and effectiveness of E-VAC before routine widespread use can be recommended.

Introduction Sentinel lymph node biopsy (SLNB) is a standard procedure in the therapeutic management of patients with non-advanced breast cancer. Aim To analyse the utility of ultrasound scan (USS) examination in the process of patient qualification for SLNB and to estimate the optimal time to perform USS in the clinical preoperational assessment of axillary lymph nodes. Material and methods A prospective analysis of 702 patients with invasive breast cancer treated with SLNB between 7.03.2012 and 27.05.2013 was performed. The patients were divided into three groups: I (USS < 8 weeks before SLNB), II (USS > 8 weeks before SLNB and another one on the day before SLNB) and III (USS > 8 weeks before SLNB without perioperative USS). In these patients the percentage of metastases in the sentinel lymph node and the clinical factors influencing the diagnostic value of preoperative ultrasound scan were assessed. Results Metastatic lesions in sentinel lymph nodes were found in 154 (21.9%) patients. The highest percentage of metastases was noted in patients operated on in the second and third month from the beginning of preoperative diagnostics. None of the factors tested (size of the original tumour, histological malignancy grading, kind of preoperative diagnostics, Ki-67 value, biological type of the tumour, age) had a statistically significant influence on the diagnostic value of perioperative USS examination in the analysed time span. Conclusions The lowest percentage of metastases in the sentinel lymph node was noted in the patients qualified for SLNB who had the ultrasound performed directly before the surgical procedure (not more than 4 weeks before the surgery).

Faecal incontinence is a very debilitating problem. Many techniques have been proposed to treat this condition, with controversial results. Autologous transplant of fat tissue is an established procedure used for the repair of tissue damage, and recent studies revealed the potentiality of tissue regeneration by human adipose-derived stem cells. We treated this condition with the injection, in the intersphincteric anal groove, of lipoaspirate processed by an innovative technology (Lipogems). The aim of the study was to evaluate the efficacy of Lipogems injection for the treatment of faecal incontinence. In February 2014 we treated 3 patients with faecal incontinence. The surgical procedure required three phases: lipoaspiration, processing of lipoaspirate with the Lipogems system, and injection of the obtained product in the intersphincteric anal groove. An accurate proctological examination followed at 1 week, 1 month and 6 months after treatment. Each patient reported an improved Wexner incontinence score at 1 month after the procedure. We observed an increase of resting pressure (by at least 10 mm Hg) and thickness of the internal anal sphincter respectively at ano-rectal manometry and by ultrasound (US) evaluation at the sixth month of follow-up. Our preliminary results are encouraging, but multicentric studies with longer follow-up are needed to validate this novel technique for treatment of faecal incontinence.

Introduction Haemorrhages from the genital tract remain a major threat to the life of patients with advanced cervical cancer. It is possible to achieve haemostasis by both surgical techniques and the procedure of endovascular uterine artery embolization. However, in some women with loco-regionally advanced cervical cancer the obliteration of the uterine arteries is not effective. Aim Evaluation of morphological changes in uterine arteries in patients with advanced cervical cancer and comparison of their changes with the achieved haemostatic effect of obliteration. Material and methods The prospective study included a group of 8 women with cervical cancer at a clinical stage of IIB to IIIC according to the FIGO classification. 3D quantitative coronary angiography (QCA) was performed before uterine embolization. The haemostatic effect of uterine artery embolization was compared with observed vascular changes. Results Mean uterine artery length in patients who achieved complete hemostasis: 39.5 mm - right uterine artery; 38.7 mm - left uterine artery. Mean uterine artery length in patients who achieved partial satisfactory haemostasis: 32 mm - right uterine artery; 30.5 mm - left uterine artery. Mean uterine artery length in patients who achieved unsatisfactory haemostasis: 10.5 mm - right uterine artery; 19 mm - left uterine artery. Conclusions Shortening of uterine arteries worsens prognosis of the haemostatic effect of their obliteration in patients with advanced cervical cancer.

Introduction Afferent loop syndrome (ALS) is a rare and dreaded complication after pancreaticoduodenectomy (PD). Malignant ALS after PD is usually difficult to manage due to patients’ poor condition. Effective and safe therapeutic strategies for these patients are reported scarcely at present. Aim To analyze and evaluate the clinical characteristics and treatment of these patients. Material and methods We analyzed 3 patients with malignant ALS after PD. They were treated by endoscopic enteral metal stent placement in our hospital. Meanwhile we retrospectively reviewed 49 cases with ALS after PD through available English literature. All these patients’ clinical features, laboratory study, treatment and outcome were evaluated. Results A total of 52 cases were analyzed in the study. The most common presenting symptoms of ALS after PD were jaundice (56.5%), upper abdominal pain (45.7%), fever (26.1%), and vomiting (23.9%). Sixty percent of ALS cases were caused by tumor recurrence. The mean time from prior surgery to diagnosis of ALS was 13.3 months. The rates of treatment with the endoscopic approach, percutaneous stenting or drainage, surgery, and the conservative method were 40.4%, 32.7%, 11.5%, and 15.4%, respectively. Endoscopic enteral metal stent placement proved more effective and less invasive in the treatment of malignant ALS after PD. Conclusions Cholangitis and cholangiectasis are the major manifestations of malignant ALS after PD. Invasive interventions are enjoying more and more acceptance for treatment. Endoscopic enteral metal stent placement appears to be a promising technique with effective palliation in these patients.

Introduction: New surgical treatment methods are being investigated in sacrococcygeal pilonidal sinus disease. Minimal invasive methods such as endoscopic pilonidal sinus treatment (EPSIT) and sinus laser therapy (SiLaT) have promising results and advantages of laparoscopic surgery. Aim: To compare the efficiency and safety of EPSIT with SiLaT. Material and methods: Seventy-three patients with pilonidal sinus who had undergone EPSIT or SiLaT within 2 years were evaluated retrospectively. Data of patients’ demographics, complications and postoperative course were collected and compared between the two groups. Results: We analyzed seventy-three patients who underwent EPSIT or SiLaT, with a mean age of 23.4 ±8.4 (12–46) years and body mass index (BMI) of 25.5 ±4.5 (18–38) kg/m2. Among them, 36 patients (26 males, ten females) underwent EPSIT and 37 patients (27 males, ten females) underwent SiLaT. Mean operative time was similar for both groups (32.3 ±14.8 vs. 31.0 ±14.8; p = 0.757). Early complications (minimal bleeding) were recorded in 2 patients in the SiLaT group. The duration of analgesic use was significantly lower in the EPSIT group compared to the SiLaT group (1.3 ±0.5 (1–3) vs. 1.9 ±1.1 (1–5); p = 0.005). The mean postoperative time of total wound healing was similar for both groups: 23.6 ±14.7 (12–90) vs. 25.2 ±14.5 (14–90) days (p = 0.385). There was no significant difference in the average time of return to total daily activity (3.4 ±0.9 (2–5) vs. 3.6 ±1.2 (2–7) days, p = 0.679). There were no significant differences between the groups regarding late postoperative complications (recurrence: 7). Conclusions: Both methods have similar early and late complications. The duration of need for analgesic usage was shorter in EPSIT patients. © 2023 Termedia Publishing House Ltd.. All rights reserved.

Intragastric balloon placement is a common method of treatment of obesity and is often used by non-surgical teams in endoscopy departments. The likelihood of spontaneous intragastric balloon damage is a well-known phenomenon. We describe a patient who was disqualified from surgical obesity treatment and in whom intragastric fluid-filled balloons had already been inserted twice and removed due to their intolerance. Therefore we qualified this patient for placement of the air-filled balloon Heliosphere BAG. Two months after the planned check-up, he arrived at the surgery department complaining of nausea and vomiting and due to symptoms of ileus diagnosed with an X-ray and ultrasound examination we qualified him for emergency surgery. We would like to emphasise the following issues: the necessity of air-filled balloon removal according to the producer's instructions and multidisciplinary specialist team care along with appropriate diagnostic tools in every case of intragastric balloon insertion.

We present a case of a 55-year-old female patient with pancreatic head cancer who was treated with total laparoscopic pylorus-preserving pancreatoduodenectomy (TLPD) on 13.12.2013. The procedure as well as the postoperative course was uncomplicated. The patient was mobilized on the day of surgery; a liquid diet was introduced on day 1 and a full hospital diet on day 2 postoperatively. Drains were removed on the 3rd day after the procedure. Length of hospital stay was 6 days. The final pathology report confirmed the diagnosis of cancer. According to our knowledge this is the first report on total laparoscopic pancreatoduodenectomy in Poland performed by an entirely Polish team of surgeons. In our opinion, TLPD is feasible and similarly to other laparoscopic operations may improve postoperative recovery.

Introduction: Esophageal hiatal hernias are the most frequent types of internal hernias. This condition involves distur- bance of normal functioning of the stomach cardiac mechanism and reflux of the gastric contents to the esophagus. Aim: To evaluate postoperative results in our Clinic and the comparison of these results to data from the literature. Material and methods: One hundred and seventy-eight patients underwent surgery due to esophageal hiatal her- nia at the Clinic of General, Gastroenterological and Oncological Surgery, Collegium Medicum, Bydgoszcz, Nico- laus Copernicus University, Torun, Poland, from 2006 to 2011. All operations were performed using laparoscopy. Fundoplication by means of the Nissen-Rossetti method was carried out in 172 patients while Toupet's and Dor's methods were applied in 4 and 2 patients, respectively. Results: Average time of the surgery was 82 min (55-140 min). Conversion was performed in 4 cases. No serious in- traoperative complications were noted. In the postoperative period, dysphagia was reported in 20 patients (11.2%). Postoperative wound infection was observed in 1 patient (0.56%). Hernias in the trocar insertion area were reported in 3 patients (1.68%). Ailments recurred in 6 patients. The recurrence of esophageal hiatal hernia was confirmed in 2 patients. Patients with recurrent hernia were re-operated using a laparoscopic approach. Conclusions: Laparoscopic surgery is a simple and effective approach for patients with gastroesophageal reflux symptoms due to diaphragmatic esophageal hiatus hernia. The number of complications is lower after laparoscopic procedures than after "open" operations.

Type IV endoleak is a very rare complication observed after implantation of aortobiiliac stent grafts. The difficult diagnosis of type IV endoleak leads to the application of many imaging methods in the diagnostic process. We present a case report of a patient who underwent implantation of an aortobiiliac stent graft in 2004. After surgery, the size of the aneurysm sac was monitored continually in the subsequent imaging studies. Progression of the aneurysm sac volume was detected in 2009. In a short period of time, the diameter of the aneurysm increased from 100 to 140 mm. Angio-computed tomography and angiography did not reveal the location of the endoleak. The attempt at localization and endovascular closure of the source of the endoleak failed. It was decided to treat the patient surgically. Intraoperatively, the source of the endoleak was visualized, and the endoleak was closed with surgical sutures.

Introduction: Barrett's esophagus is the most significant precancer of the esophagus. Its malignization gives rise to most adenocarcinomas of the esophagus. Therefore selection of adequate therapy for this precancerous condition is of the utmost importance. Aim: The authors of the work addressed the question of whether effective therapy of reflux disease alone may halt the process of malignization of Barrett's mucosa or even cause its regression. Material and methods: The analyzed set comprised 50 patients with Barrett's esophagus, who in 48 cases under- went laparoscopic fundoplication and in two cases underwent an indirect antireflux procedure in the form of gastric resection with a Roux-en-Y gastrojejunal anastomosis. The effect of the procedure was evaluated by comparing pre- operative and postoperative endoscopic examinations, as well as histological analysis by biopsy taken from Barrett's mucosa. Results: In 19 patients (38%), Barrett's mucosa was not detected postoperatively. An improved finding in terms of disappearance of mucosal dysplasia was found in 8 (16%) patients. Findings remained unchanged in 18 (36%) pa- tients. In 5 (10%) patients progression of the disease was discovered. Conclusions: A surgical antireflux procedure, primarily in the form of laparoscopic fundoplication, is considered an effective method for treating Barrett's esophagus up to the stage of mild dysplasia. If this therapy is unsuccessful, the method of choice is local therapy, either an endoscopic mucosectomy or radiofrequency ablation.

Gastrointestinal bleeding is a common medical emergency. Although endoscopic treatment is effective in controlling non-variceal upper gastrointestinal bleeding, in cases of persistent bleeding radiological or surgical interventions are required. Application of cyanoacrylate for treatment of difficult-to-arrest non-variceal upper gastrointestinal bleeding is poorly investigated. We describe patients in whom cyanoacrylate for acute non-variceal gastrointestinal bleeding was used to stop the bleeding after failure of conventional endoscopic treatment. Five patients were treated with cyanoacrylate application (injection and/or spraying) for persistent bleeding (duodenal ulcer in 3, gastric ulcer in 1 and gastric Dieulafoy's lesion in 1) despite conventional endoscopic therapies. Hemostasis was achieved in all patients (100%). One patient (20%) developed recurrent bleeding 4 days after initial treatment. No complications or adverse events attributed to the cyanoacrylate application during the follow-up period of 57 days were observed. Application of cyanoacrylate is a safe and effective method to achieve immediate hemostasis when conventional endoscopic treatment is unsuccessful. This technique is easy to perform and should be considered in cases of patients with difficult-to-arrest acute non-variceal upper gastrointestinal bleeding.

Introduction: Malignant tumors of the paranasal sinuses are traditionally managed through external approaches. Advances in endoscopic transnasal surgery have allowed for the endoscopic treatment of some of these tumors. Aim: To present the results of treatment of a series of patients with paranasal sinus malignancies treated with an endoscopic approach at a single institution. Material and methods: The data on tumor type, operative technique, perioperative complications and postoperative course were analyzed. Results: Eleven patients meeting the inclusion criteria were identified. The histopathology was as follows: malignant melanoma in 3 patients, squamous cell carcinoma in 2, adenocarcinoma in 2, poorly differentiated carcinoma in 1, hemangiopericytoma in 1, adenoid cystic carcinoma in 1 and fibrosarcoma in 1. There were no severe perioperative complications with the exception of 1 case of cerebrospinal fluid leak, which was successfully closed. The mean ob- servation period was 13.5 months. One of the patients died of disease, another was lost to follow-up, and one was reoperated on due to recurrence. The remaining 8 patients are alive with no signs of recurrence. Conclusions: Our initial experience seems to confirm results obtained by other authors indicating that in selected cases endoscopic surgery of sinonasal malignancies is similarly effective as external approach surgery.

Introduction: Tissue perfusion disorders can be present in various diseases and progress in the form of arterial isch- emia or venous stasis with accompanying local changes in temperature. Aim: To use of thermography in the diagnostics of early periods of tissue perfusion disorders before the clinical symptoms occur. Material and methods: Thirty-two male rats were used. After anesthesia the skin on lower limbs was shaved and femoral vessels of both sides were exposed. In 10 rats the left femoral artery was ligated, in 12 rats the left femoral vein was ligated and in the 10 remaining rats both left femoral vessels were ligated. Thermography of the limbs was performed before the vessels were ligated and after a period of 24 h. The pictures were taken every 5 s during 3 min. Before the measurement, the tissues were cooled down for 20 s with a 5°C water compress. The rate of temperature return to the limbs was evaluated. Results: Statistically significant differences were observed after the 24-hour period on the thigh after the ligation of the vein, and on the shank and the foot after ligation of the artery. After the ligature of both vessels, statistically sig- nificant differences occurred immediately after their ligature within the thigh and shank and after 24 h on the foot. Conclusions: The results show that cameras with an accuracy of 0.05°C can be used to detect tissue perfusion disor- ders. The special diagnostic value is the ability to detect perfusion disorders before clinical symptoms occur.

Most patients with early esophageal cancer restricted to the mucosa may be offered endoscopic therapy, which is similarly effective, less invasive and less expensive than esophagectomy. Selection of appropriate relevant treatment and therapy methods should be performed at a specialized center with adequate facilities. The selection of an endoscopic treatment method for high-grade dysplasia and early-stage esophageal adenocarcinoma requires that tumor infiltration is restricted to the mucosa and that there is no neighboring lymph node metastasis. In squamous cell carcinoma, this treatment method is accepted in cases of tumors invading only up to the lamina propria of mucosa (m2). Tumors treated with the endoscopic method should be well or moderately differentiated and should not invade lymphatic or blood vessels. When selecting endoscopic treatments for these lesions, a combination of endoscopic resection and endoscopic ablation methods should be considered.

Introduction: Haemorrhagic complications are commonly reported in the course of acute pancreatitis (AP). The most dangerous are pseudoaneurysms secondary to wall erosion of the vessels crossing the inflammation area. Aim: To evaluate the efficacy of different embolisation techniques of pseudoaneurysms secondary to AP. Material and methods: The treatment outcomes in 10 AP patients were analysed in a follow-up period of 1 to 10 months (most frequently: splenic or gastroduodenal artery aneurysms). A total of 12 endovascular procedures were performed (thrombin embolisation, coil embolisation or combined). The efficacy of aneurysm sac exclusion and the patency of the treated vessel were compared. Results: The follow-up examination on postprocedural day 7 revealed aneurysm refilling in 3 out of 11 cases. Three patients showed an occlusion of the aneurysm-parent vessel. One month after the procedures, involving 10 patients, a vessel occlusion was confirmed in 3 and aneurysm sac refilling in another 2 patients. Taking into consideration the type of the procedure performed, treatment failure in the form of sac refilling was observed in half of thrombin-based procedures, 25% of coil embolisations and 33% of sandwich technique procedures. Similar failure distribution was noted for vessel occlusion. Conclusions: It seems that thrombin injection was least successful, whereas thrombin injection into the sac and implantation of coils into the aneurysm neck seems to be the optimal procedure, in respect to both the cost-effec- tiveness of the procedure and late outcomes.

Introduction: Occurrence of anastomotic leaks following Roux-en-Y gastric bypass (RYGB), arising principally from the gastro-jejunal anastomosis, is associated with significant morbidity and mortality. Their early detection and treatment is essential. However, a significant number of postoperative oral contrast studies fail to identify leaks, and a negative study providing false reassurance can lead to a delay in diagnosis and treatment. Physiological features including tachycardia, increased respiratory rate and pyrexia or elevations in C-reactive protein and white cell count are seen in patients with leaks. In this study we examine physiological and laboratory parameters in patients with and without anastomotic leaks following RYGB to try and improve the detection of leaks. Aim: To evaluate clinical signs and laboratory tests in determination of the development of gastrojejunal leaks after gastric bypass surgery. Material and methods: The study examined 116 consecutive patients undergoing laparoscopic RYGB. Clinical signs and laboratory results were reviewed retrospectively. Results: Four gastrojejunostomy leaks in our series were identified after RYGB surgery. All these patients were treat- ed successfully. Leak patients' in-hospital stay was longer. Tachycardia among leak patients occurs from day 1 with 100% sensitivity and 87% specificity at a cut-off point of 90 bpm. A temperature difference appears on day 2 in leak patients. The CRP was higher on day 2 and 3 in leak patients. Higher intravenous fluid requirements were observed in patients with leaks. Conclusions: Gastrojejunal anastomosis leak is associated with longer in-hospital treatment. The earliest significant indicators of a leak are tachycardia and positive fluid balance. A temperature spike and CRP rise occur on day 2. Leak patients matched SIRS WBC count criteria on day 3.

Introduction Minimally invasive techniques in thyroid surgery including video-assisted technique originally described by Miccoli have been accepted in several continents for more than 10 years. Aim To analyze our preliminary results from minimally invasive video-assisted thyroidectomy (MIVAT) and to evaluate the feasibility and effects of this method in a general department over a 4-year period. Material and methods Initial experience was presented based on a series of 200 patients selected for MIVAT at the General Surgery Department of Yantai Yuhuangding Hospital affiliated with Qingdao University during the period from May 2008 to June 2012. The enrolling criteria were rigorously observed. An above sternal incision with average length of 2.5 cm (1.5–3.0 cm) was made. Clinicopathologic characteristics, postoperative pain, length of hospital stay, cosmetic results and complications were retrospectively analyzed. Results All patients received general anesthesia. Thyroid unilateral lobectomy was successfully accomplished in 108 cases, total thyroidectomy in 84, and partial lobectomy in 8. Conversion to standard conventional thyroidectomy was required in 6 patients (3%) because of thyroiditis and bleeding. The mean lymph node yield of the cancer specimens was 3.6 per patient. Permanent unilateral recurrent laryngeal nerve (RLN) palsy occurred in 1 case (0.5%), transient unilateral RLN palsy in 6 patients (3.0%, complete recovery after 1–6 months), and transient hypocalcemia in 7 patients (3.5%). No definitive hypocalcemia was observed. No postoperative hematomas occurred. Postoperative pain was endurable. The cosmetic result was excellent in most cases. Conclusions The MIVAT is feasible and safe in selected patients, with better results comparable to conventional thyroidectomy. The MIVAT can also be performed in a general surgery department.

Introduction: Lymphorrhea due to classical and mini-invasive surgical interventions on femoral and popliteal arteries is a serious hindrance to patient treatment. Depending on the experience of a particular center, the incidence and frequency of this type of complication may constitute a serious clinical problem. While the level of lymphorrhea intensity and its duration result in certain foreseeable consequences, their treatment can be a time-consuming and multistep procedure. Aim: To compare different types of vascular interventions with lymphorrhea occurrence. Material and methods: The authors conducted a retrospective analysis of lymphatic complications based on the material collected between 2005 and 2012 at the Department of Vascular and Endovascular Surgery of the Military Institute of Medicine in Warsaw and in the Department of Interventional Cardiology and Angiology of the Institute of Cardiology in Anin, Warsaw, in 2009-2012. Results: Maintaining due thoroughness when dissecting tissues and treating the cutting line in this area with liga- tures and tissue puncture are the most reliable methods of minimizing the risk of lymphatic leakage after surgical procedures performed in a classical way. The lymphatic complication under analysis is far less likely to occur when procedures are performed as planned and an endovascular technique is used - statistical significance p < 0.05. Min- imally invasive and fully percutaneous procedures performed via needle puncture, including the use of the fascial closure technique to close the femoral artery, eliminate the likelihood of the occurrence of this vascular complication - statistical significance was found with p value less than 0.05. Conclusions: We concluded that in every case by minimizing the vascular approach we protected the patient against lymphatic complications.

Aim: To evaluate the usefulness, diagnostic accuracy, and cost-effectiveness of transvaginal hydrolaparoscopy (THL) in infertile women with abnormal hysterosalpingogram (HSG) results without obvious pelvic pathology. Material and methods: Thirty infertile women (age: 20–40 years) who had tubal pathology in HSG were enrolled in the study. All patients underwent THL instead of standard laparoscopy. A cost analysis was performed comparing HSG and THL methods. Results: In comparison of the HSG of cases by considering the chromopertubation results by THL, the sensitivity and specificity of HSG were 85.1% and 56%, respectively. The reasons for preferring standard laparoscopy rather than THL were: failure in accessing of Douglas (n = 3), insufficient monitoring of pelvis (n = 1), hydrosalpinx (n = 1), and intense peritubal adhesion (n = 1), which were 10%, 3%, 3%, and 3%, respectively. The complication rate was 3.8%. Cost analysis of the procedures showed that the total cost of the THL group was 34.8% lower than the HSG group. Conclusions: In the elective patients group, THL is more feasible than HSG. Transvaginal hydrolaparoscopy is effective, simple and safe, avoiding the cost, possible complications, time and postoperative patient discomfort compared to conventional laparoscopy.

Introduction: Type 1 autoimmune pancreatitis (AIP) is the pancreatic manifestation of a systemic fibroinflammatory IgG4-related disease. Accurate diagnosis of AIP can avoid major hepatobiliary and pancreatic surgery as it respond dramatically to corticosteroid therapy. Aim: This research investigated the feasibility of using peripheral blood cell immunohistochemistry, serum IgG4, T-cell receptor (TCR) and serum isoelectric focusing electrophoresis in the screening of type 1 autoimmune pancreatitis (AIP). Material and methods: The peripheral blood from 3 type 1 AIP patients, 10 pancreatic cancer patients and 40 nor- mal controls was collected. Sediment smears were jointly incubated with anti-IgG4 and anti-IgG. The percentage of IgG4/IgG positive cells was counted and serum TCR and IgG4 were detected through the whole process. After serum isoelectric focusing electrophoresis, anti-IgG4 and anti-IgG were used to confirm the components of serum. Results: In the serum isoelectric focusing electrophoresis, IgG4 and IgG strips showed mirrored distribution in type 1 AIP patients, while there were no strips in the normal controls and pancreatic cancer. Compared with pancreatic tumor patients and healthy controls, serum TCR was significant increased in AIP. The percentage of IgG4/IgG positive cells of peripheral blood cell immunohistochemistry was related to serum IgG4 and hormone therapy reactions. Conclusions: Peripheral blood cell immunohistochemistry, serum IgG4, TCR and serum isoelectric focusing electro- phoresis is suitable for the screening of type 1 AIP and monitoring its response assessment.

Introduction: Several preoperative scoring systems have been proposed to predict the difficulty of laparoscopic cho- lecystectomy in order to optimize the results of surgical treatment by either selection of patients for the procedure or providing an adequately experienced surgical team for a given patient. Nevertheless, none of them has achieved significant penetration into everyday practice. Aim: To propose and validate a novel risk score based on the patient's history, physical examination and abdominal ultrasonography parameters. Material and methods: The risk score was defined by the presence of the following risk factors: male sex, biliary colic within the last 3 weeks prior to surgery, history of acute cholecystitis treated conservatively, previous upper abdom- inal surgery, right upper quadrant pain, rigidity in right upper abdomen and ultrasonographic parameters - thicken- ing of the gallbladder wall ≥ 4 mm, hydropic gallbladder (diameter exceeding 4.5 cm) and shrunken gallbladder. One point was allocated for each risk factor, except for previous upper abdominal surgery, which scored two. Difficulty of the surgery was assessed by operating time (OT) and the postoperative subjective evaluation score (PSES). Results: Five hundred and eighty-six consecutive patients were enrolled in the prospective observational study. A sig- nificant linear correlation was observed between the risk score and measures of difficulty employed. Five levels of difficulty were defined (score 0, 1, 2, 3, ≥ 4) with significant differences in OT, PSES and conversion rates (p < 0.001). Conclusions: The suggested risk score is designed as a simple and reliable predictive model, possibly effective to over - come the negative effect of the individual proficiency gain curve and/or to select 'easy' cases for day surgery, single incision laparoscopic surgery or natural orifice translumenal endoscopic surgery procedures.

INTRODUCTION The main treatment of burns is early excision of injured tissues. AIM TO COMPARE TWO DIFFERENT METHODS OF EXAMINATION OF BURNED PATIENTS: clinical burn depth examination (CDE) and laser Doppler imaging (LDI). MATERIAL AND METHODS A prospective randomized study of 57 burn patients treated in 2009-2011 was carried out. The burned patients were randomized into a CDE group and an LDI group. The CDE and LDI scan were performed 72 h after injury, with the second and third CDE and LDI scan on the 7(th) and 14(th) day after the burn. Age, sex, length of inpatient stay, cost of burn treatment, burn depth, cause and localization of the burns were analyzed between the two groups. RESULTS Fifty-seven patients were treated during 2 years. Thirty-two patients were in the CDE group and 25 patients were in the LDI group. Most of the patients were male (45 male vs. 12 female, p < 0.001). The age was similar between the males and the females (female: 46.4 ±16.9 years vs. male: 46.3 ±12.5 years; p = 0.11). The mean length of stay in hospital was significantly higher in the CDE group (47 ±34.4 day vs. 25 ±10.8 day; p = 0.005). The mean cost of treatment of burned patients was significantly higher in the CDE group. CONCLUSIONS The length of stay and cost of treatment of burn patients depends upon early diagnosis of the deep burns and well-timed surgical treatment of burn wounds.

The number of breast reconstruction procedures has been increasing in recent years. One of the suggested treatment methods is breast reconstruction with a pedicled skin and muscle TRAM flap (transverse rectus abdominis muscle – TRAM). Surgical incisions performed during a cholecystectomy procedure may be located in the areas significant for flap survival. The aim of this paper is to present anatomical changes in abdominal walls secondary to pedicled skin and muscle (TRAM) flap breast reconstruction, which influence the planned access in cholecystectomy procedures. The authors present 2 cases of cholecystectomy performed due to cholelithiasis in female patients with a history of TRAM flap breast reconstruction procedures. The first patient underwent a traditional method of surgery 14 days after the reconstruction due to acute cholecystitis. The second patient underwent a laparoscopy due to cholelithiasis 7 years after the TRAM procedure. In both cases an abdominal ultrasound scan was performed prior to the operation, and surgical access was determined following consultation with a plastic surgeon. The patient who had undergone traditional cholecystectomy developed an infection of the postoperative wound. The wound was treated with antibiotics, vacuum therapy and skin grafting. After 7 weeks complete postoperative wound healing and correct healing of the TRAM flap were achieved. The patient who had undergone laparoscopy was discharged home on the second postoperative day without any complications. In order to plan a safe surgical access, it is necessary to know the changes in the anatomy of abdominal walls following a pedicled TRAM flap breast reconstruction procedure.

Introduction: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastro- intestinal (GI) tract. Although the therapy targeted at inhibiting tyrosine kinases has shown dramatic results in metastatic and inoperable GISTs, the mainstay of treatment in primary localized forms remains surgical resection. Aim: To provide an overview of our experience of GIST diagnosis and management, with emphasis on comparison of minimally invasive and open surgical resection for primary GISTs. Material and methods: We retrospectively reviewed the medical records of all patients who underwent surgical removal of GISTs from 2008 to 2012. Patient demographics, clinical data, surgery, complications, histopathological data and clinical course were analyzed. Results: Forty-four patients were identified. Average age at diagnosis was 63 years. Minimally invasive (MIS) and open surgery (OS) were each attempted in 22 (50.0%) patients. Laparoscopic removal was performed in 20, laparo- endoscopic in 1, and laparoscopy-assisted endoscopic removal in 1. Conversion to an open procedure was performed in 4 (18.2%). We found significant differences in postoperative length of stay (8.5 days vs. 10.1 days, p < 0.001) and tumor size (2.93 cm vs. 5.78 cm, p = 0.018) between MIS and OS groups, respectively. Conclusions: Laparoscopic removal is safe and effective for GISTs not exceeding 6 cm. Gastroesophageal junction and cardia GISTs require careful preoperative evaluation and planning to remove safely. We recommend avoiding laparoscopic removal of these tumors due to the high rate of conversion (100.0%) to an open procedure. Laparo- endoscopic surgical approach is an appropriate technique for removal of small-sized intraluminal benign GISTs not involving the muscularis propria layer.

Introduction: Videoscopic adrenalectomy is the gold standard for the surgical treatment of benign adrenal tumours. The two most common approaches are the lateral transperitoneal approach (LTA) and the posterior retroperitoneal approach (PRA). So far it has not been established which is the preferable one. The choice depends primarily on the surgeon's preference and contraindications for a particular approach in individual cases. Aim: To compare the two most common approaches for videoscopic adrenalectomy, LTA and PRA, based on a liter- ature review and our own experience. Material and methods: We reviewed the literature (PubMed and Cochrane 1990 - current) and analysed retrospec- tively our own patients who underwent videoscopic adrenalectomy between 2009 and 2013. The analysis covered patient features, tumour characteristics, reasons for qualification for each approach, operative time and postopera- tive complications. Results: Out of 71 videoscopic adrenalectomies, 50 were performed using PRA and 21 using LTA. Patients in the PRA group on average were older, but had smaller tumours. There was no significant difference in perioperative morbidity between PRA and LTA. Mean blood loss and total operative time were smaller/shorter for the PRA group in comparison to the LTA group. Time to first oral intake and the average postoperative hospital stay were shorter for PRA than LTA. Conclusions: Videoscopic adrenalectomy is a safe and efficient technique performed using both LTA and PRA ap- proaches. The choice of technique should be guided, most of all, by surgeon experience, patient characteristics, tu- mour size and location. Our preferable approach is PRA, especially for small (< 6 cm) benign tumours. We find LTA ad- vantageous for tumours of larger size, with suspected malignant character (either primary or secondary), in ectopic position, as well as in patients lacking an ipsilateral kidney or when a simultaneous abdominal operation is planned.

Introduction: The indications for videothoracoscopy are very broad and include the treatment of mediastinal tu- mours. Aim: To present our experience of using the minimally invasive technique in treating benign neurogenic tumours. Material and methods: Twenty-two patients were treated due to tumours of the posterior mediastinum from 2003 to 2012. The size of the tumours ranged from 2 cm to 25 cm. Tumours up to the size of 6 cm were treated using videothoracoscopy (VT), bigger ones through thoracotomy. Results: The videothoracoscopy technique was used in 17 patients, thoracotomy in 5. In 2 cases conversion was required due to adhesions in the pleural cavity preventing VT treatment. Complications related to the procedure were not observed. The average time of hospital stay after VT treatment was 4 days, while after thoracotomy it was 6 days. Histologically, tumours of benign nature were found in all cases. Schwannoma was diagnosed in 15 patients, ganglioneuroma in 3 patients, neurofibroma in 3 patients, and chemodectoma in 1 patient. None of the 3 cases of neurofibroma was associated with Recklinghausen's disease. At a mean follow-up of 60 months no recurrence of the tumour was found. Conclusions: In the case of tumours up to 6 cm the best surgical technique is videothoracoscopy. In the case of large tumours the best access is the open technique. The minimally invasive technique allows one to shorten the patient's treatment time, reduce postoperative pain and obtain a good cosmetic effect of the treatment.

Introduction: Laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB) are accept- able options for primary bariatric procedures in patients with body mass index (BMI) 35-55 kg/m 2 . Aim: The aim of this study is to compare the effects of these two bariatric procedures 6, 12 and 24 months after surgery. Material and methods: Two hundred and two patients were included 72 LSG and 130 LAGB patients. The average age was 38.8 ±11.9 and 39.4 ±10.4 years in LSG and LAGB groups, with initial BMI of 44.1 kg/m 2 and 45.2 kg/m 2 , p = NS. Results: The mean percentage of excess weight loss (%EWL) at 6 months for LSG vs. LAGB was 36.3% vs. 30.1% (p = 0.01) and at 12 months was 43.8% vs. 34.6% (p = 0.005). The greatest difference in the mean %EWL at 12 months was observed in patients with initial BMI of 40-49.9 kg/m 2 in favor of LSG (47.5% vs. 35.6%; p = 0.01). Two years af- ter surgery there was no advantage of LSG and in the subgroup of patients with BMI 50-55 kg/m 2 there was a trend in favor of LAGB (57.2% vs. 30%; p = 0.07). The multiple regression model of independent variables (age, gender, initial BMI and the presence of comorbidities) proved insignificant in prediction of the best outcome in means of %EWL for either operative modality. None of these factors in the logistic regression model could determine the type of surgery that should be used in particular patients. Conclusions: During the first 2 years after surgery, the best results were obtained in women with lower BMI undergoing LSG surgery. The LSG provides greater %EWL after a shorter period of time though the difference decreases in time.

Although a variety of techniques have been used to manage the distal ureter during laparoscopic radical nephroureterectomy (LNU), a consensus has not yet been established. Recently, some authors have used a single-port transvesical approach to excise the distal ureter and bladder cuff following LNU. The aim of the study was to present our initial experience in "en bloc" dissection of the distal ureter and bladder cuff during LNU, using a transvesical single-port approach (T-LESS) and standard laparoscopic instruments. From April to October 2012, 5 patients aged 45 to 73 years with upper urinary tract urothelial tumors were subjected to LNU/T-LESS. After a standard LNU was performed, a TriPort+(®) device was introduced into the bladder and the pneumovesicum was established. A bladder cuff with a distal ureter was dissected and put in the paravesical tissue. The bladder wall defect was closed with the V-loc(®) 3/0 suture. The LNU was then completed in the flank position. All procedures were completed successfully. No significant blood loss or complications were observed. The mean operative time was 250 min (range: 200-370) for a total procedure and 59 min (range: 42-80) for the T-LESS stage. The postoperative hospital stay was 5.2 days (range: 4-9). Pathologic examination revealed no positive margin in any of the cases. The LNU/T-LESS approach is an efficient and safe procedure. A well-visualized dissection of the distal ureter, closing the defect of the bladder, the use of standard laparoscopic instruments and a good cosmesis are advantages of the method.

Introduction: Progress in the development of surgical techniques has led to the growing use of video-assisted thora- coscopic surgery (VATS) techniques in mediastinal cyst treatment. Aim: To present our experience of treating mediastinal cysts with the minimally invasive technique. Material and methods: Fifty patients with mediastinal cysts were treated from 2001 to 2011. There were 32 women and 18 men. The age of the patients ranged from 17 to 72, the mean age being 42 years. All patients underwent basic preoperative diagnostic tests of the chest: X-ray, computed tomography (CT), bronchoscopy and spirometry; 4 patients underwent endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and 3 fine needle aspiration biopsy (FNAB) of the described lesions. Results: The VATS was performed in each case. Conversion was carried out due to superior mediastinal location in 10 cases and pleural adhesions in 3 cases. The partial resection of a cyst was performed in 3 patients. One patient was treated conservatively due to heart failure. In that patient the transthoracic needle aspiration of a cyst under ultrasound guidance using alcoholisation with 76% ethanol with a good effect was performed twice. Cyst recurrence was observed in 1 case. Conclusions: The surgical access depends on the location of a cyst. The VATS resection of a superior mediastinal cyst is not always feasible. Surgery of mediastinal cysts is both diagnostic and curative.