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Introduction : Pneumoperitoneum (PP) is known to cause ischemia in kidneys and other intra-abdominal organs because of decreased splanchnic blood flow. Aim : We aimed to determine the degree of renal injury that occurs due to a PP and prolonged PP. We measured renal injury biomarkers and made a histopathological evaluation to estimate the degree of injury and assessed the correlation of biomarkers with histopathological findings. Material and methods : Twenty-one female Sprague Dawley rats were separated randomly into three groups. Group 1 was the control group and was given anesthesia for 3 h. In group 2, a PP was administered under anesthesia for 1 h. A pneumoperitoneum was administered under anesthesia to animals in group 3 for 3 h. Results : Pathological analysis showed a significant statistical difference between the 3 groups. In particular, neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C (Cys C) levels at the 24th h and preoperative mean urea levels showed a significant difference between the groups. The 24th-hour NGAL level in group 3 was significantly higher than that of group 1. The preoperative Cys C level was higher in group 1 than in either group 2 or 3. Cys C was decreased significantly in group 1 and increased significantly in both groups 2 and 3. Conclusions : The increase in NGAL and Cys C levels directly correlated with the duration of PP and intra-abdominal pressure, and they are therefore good biomarkers in diagnosing acute renal injury in the early phase. Serum creatinine level is not a good biomarker in the early phase of renal injury.

Introduction: Esophagogastroduodenoscopy (EGD) is a diagnostic method used in the investigation of upper gastrointestinal system diseases. A high level of anxiety of patients who undergo EGD increases the duration of the procedure and the sedation and analgesic requirements. Sedation is used to increase patient comfort and tolerance by reducing the anxiety and pain associated with endoscopic procedures. Aim: In this study, the effect of anxiety scores on medication doses was investigated in patients who underwent EGD under sedation. Material and methods: A psychiatrist, an endoscopist and an anesthesiologist conducted a prospective observational study blindly to investigate the effect of pre-procedural (before EGD) anxiety level on medication doses for sedation. Patients were divided into two groups, with and without additional medication doses. Results: The study included 210 consecutive patients who underwent EGD under sedation. The average STAI-S score was 40.28 and the average STAI-T score was 40.18. There was no relationship between anxiety scores and gender (p = 0.058, p = 0.869). Statistically significant results were obtained for anxiety scores with additional sedation dosing (p < 0.05). It was observed that an additional dose of medication was affected by age, body mass index and anxiety scores (p < 0.005). Patients who were young, had a low body mass index and had high anxiety scores had significantly higher additional dose requirements. Conclusions: The medications used for sedation during EGD may be inadequate or an additional dose of medication may be needed for patients who have higher anxiety scores, younger age, and lower body mass index.

Introduction Caesarean scar pregnancy (CSP) is a relatively rare yet life-threatening condition in which the embryo is implanted in the scar after caesarean section. Recent studies have reported that uterine artery chemoembolisation (UAC) can be safe and effective method in treating CSP. Aim To present the clinical outcome of UAC with a mixture of methotrexate and gelatine sponge for the treatment of CSP and analysis of procedural failure. Material and methods Forty-one patients diagnosed with CSP were treated with selective endovascular chemoembolisation of uterine arteries. Short- and long-term results, reasons for procedural failure, and clinical outcome were analysed. Results Primary procedure failed in 7 out of 41 (17%) cases. In 4 cases additional blood supply to the CSP was disclosed; 3 out of 4 from an ovarian artery and one from a superior vesical artery. In other 3 patients, reperfusion of uterine arteries was observed. All these 7 patients underwent successful secondary embolisation. The majority of the followed-up patients reported regular menses after the intervention. Four women suffered from amenorrhoea and 2 from hypomenorrhoea that continued after 90 days. Twelve patients expressed the desire for subsequent pregnancy. From this group, 5 conceived within a year of the procedure. The rest did not achieve a pregnancy. Conclusions UAC proved to be a safe and effective method and should be considered as an option for CSP treatment, especially for women hoping to preserve their fertility. However, the presence of collateral blood supply should always be considered.

Introduction: Although filters are still preferred during carotid stenting, proximal protection systems (PPS) are increasingly used during these procedures. PPS seem to be safer than distal systems, especially in symptomatic patients, but evidence supporting their use is limited. Aim: This was a post hoc survey with 30-day mid-term and long-term follow up, which was aimed at assessment of the safety and efficacy of stenting of the internal carotid artery under PPS in symptomatic patients. Material and methods: We analysed the results of stenting in 120 symptomatic patients presenting with at least 60% stenosis. Patients were aged 67.9 ±9.8 years, and 12 patients were older than 80 years. An occlusion of contralateral artery was found in 5 patients and bilateral stenosis in 26 patients. The primary endpoint of this study was the proportion of patients who had new neurological events, including transient ischemic attack and minor or major stroke in 30-day follow-up. The secondary endpoint was a composite of technical and clinical success. During longterm follow-up we assessed new neurological events and stenoses of implanted stents. Results: The incidence of new neurological events during 30-day follow-up was 0.8%. The rate of technical success defined by secondary endpoint was 100%. Mean internal carotid artery stenosis before and after stent implantation was 93.8 ±9% and 8.4 ±6.3%, respectively (p < 0.001). Procedural success was achieved in all cases. During longterm follow-up there were two (1.7%) asymptomatic in-stent stenoses and no (0%) new neurological events. Conclusions: Endovascular management of symptomatic carotid stenosis under PPS is safe, feasible, and appears to be a good alternative to surgical endarterectomy.

Introduction Pleural empyema is the condition of the pleural cavity when initially sterile pleural effusion has become infected. In the majority of cases, it is of parapneumonic origin. Parapneumonic effusions and pleural empyemata usually continuously progress in severity. The American Thoracic Society divides them into three stages: exudative, fibrinopurulent and organizing. The therapy depends on the stage. Aim To assess whether thoracoscopy should be considered better than conservative treatment and to assess the feasibility of the thoracoscopic approach to the 3rd phase of pleural empyema. Material and methods The clinical course of 115 patients treated from 1996 to 2017 was analyzed. 45 patients operated on thoracoscopically after the failure of conventional treatment were compared with 70 patients treated by primary thoracoscopic drainage and decortication. Results The results of the study demonstrated that patients treated primarily by thoracoscopy had a shortened length of hospital stay (16.6 vs. 19.3 days), reduced drainage time (7.9 vs. 9.8 days), and shorter time of general therapy (31.8 vs. 38.0 days). They required fibrinolysis less frequently (12.8 vs. 26.7% of patients) and had reduced risk of reoperation (10 vs. 15.6% of cases). Operation time in the 3rd stage was only 15 min longer. The difference in length of hospital stay was only 0.8 days in favor of less severe cases. Conclusions The thoracoscopic approach is safely feasible in the 3rd stage of pleural empyema and should be considered as the preferred approach. Furthermore, the post-operative stay and general course of the disease are milder whenever surgery would not be delayed by prolonged conservative treatment attempts.

Introduction Malignant hilar biliary obstruction (MHBO) can arise in patients with malignant hilar hepatobiliary tumors or lymph nodules. Most MHBO patients are not suitable for surgical resection due to the advanced tumor stage. The only palliative treatment available is provided by endoscopic or percutaneous stenting. Aim To compare the efficacy of endoscopic unilateral versus bilateral metal stent insertion for treating MHBO. Material and methods A search of the PubMed, Embase, and Cochrane Library databases identified all relevant studies published until June 2020. The meta-analysis was undertaken using RevMan v5.3. Results We identified 154 studies initially, eight of which were used in our meta-analysis. The eight studies included 818 MHBO patients treated using either endoscopic unilateral (n = 396) or bilateral (n = 422) metal stenting. No significant differences were observed between the two groups in clinical success rate (OR = 2.64; p = 0.18), complication rate (OR = 0.63; p = 0.46), or OS (HR = 1.03; p = 0.53). The bilateral group had a lower stent dysfunction rate without significance (OR = 1.43; p = 0.09). Significantly longer stent patency was observed in the bilateral group (HR = 1.28; p = 0.01). Technical success rate was significantly higher in the unilateral group (OR = 0.26; p = 0.04). Funnel plot analysis indicated an absence of publication bias related to the selected study endpoints. Conclusions Our meta-analysis indicated that endoscopic unilateral stenting had a greater technical success rate for MHBO patients than bilateral stenting. However, the bilateral stenting could achieve longer stent patency.

Introduction The benefit of three-dimensional (3D) visualization for liver disease is uncertain. Aim To evaluate the effectiveness and safety of 3D versus two-dimensional (2D) video-assisted hepatectomy for LD. Material and methods We searched PubMed, Embase, Cochrane Library, Medline, and Web of Science for studies addressing 3D versus 2D for 2D until 30 February 2020. Study-specific effect sizes and their 95% confidence intervals (CIs) were combined to calculate the pooled value using a fixed-effects or random-effects model. Results Nine studies with 808 patients were included. The 3D group had shorter operative time (mean difference (MD) = 34.39; 95% CI = 59.50, 9.28), experienced less intraoperative blood loss (MD = 106.55; 95% CI = 183.76, 29.34), and a smaller blood transfusion volume (MD = 88.25; 95% CI = 141.26, 35.24). The 3D group had a smaller difference between the predicted volume and the actual resected volume (MD = 103.25; 95% CI = 173.24, 33.26) and a lower rate of postoperative complications (odds ratio (OR) = 0.57; 95% CI: 0.35, 0.91). Conclusions During surgery, 3D video-assisted hepatectomy could effectively reduce operative time, intraoperative bleeding, and blood transfusion volume, and had a smaller difference between the predicted volume and the actual resected volume and a lower rate of postoperative complications. More high-quality randomized controlled trials are required to verify the reliability and validity of our conclusion.

Introduction Although laparoscopic Roux-en-Y gastric bypass (RYGB) is still widely accepted as a valid procedure in the treatment of obesity and type 2 diabetes mellitus (T2DM), there continues to be a significant controversy about how long the Roux and biliopancreatic limb should be bypassed for optimum results. Aim To assess the effect of a longer biliopancreatic limb (BPL) length on glycemic control after RYGB in T2DM patients. Material and methods Eighty-four patients with uncontrolled T2DM who underwent RYGB between May 2010 and April 2017 were collected from the prospectively designed database. Forty patients (S-BPL group) received BPL lengths ≤ 50 cm, including 30 cm (n = 1), 40 cm (n = 1), and 50 cm (n = 38). Forty-four patients (L-BPL group) received 100 cm BPL. Anthropometry, serum glucose and lipid metabolic parameters were measured at baseline and 1, 3, 6, 12, 24 and 36 months after surgery. Results Comparing the two groups, there were no significant differences in anthropometric and biochemical measures, except the weight and body mass index, which were higher in the S-BPL group (85.91 ±20.32 vs. 76.25 ±16.99, p = 0.038; 31.87 ±6.61 vs. 28.7 ±4.29, p = 0.005) compared to the L-BPL group. The body weight, glucose and lipid metabolic parameters decreased over time and then remained essentially stable from the first year in both groups. Two years after surgery, the remission (HbA1c% ≤ 6%) of T2DM was 31.2% in the S-BPL group and 37.5% in the L-BPL group (p = 0.685). Conclusions With consistent total small bowel bypass (AL + BPL) lengths, lengthening of the BPL from 30 to 100 cm did not affect the post-RYGB glycemic control and weight loss.

Introduction There are several options for vessel-sparing anastomotic procedures that allow one to avoid disturbances in the normal blood supply to the spongy body and successfully perform plastic surgery of distal urethral strictures. Aim To perform a comparative analysis of the effectiveness of reconstructive surgical treatment of strictures of the bulbo-membranous urethra with anastomotic surgery with and without vessel-sparing. Material and methods A prospective study was carried out on 28 patients with a diagnosis of stricture of the bulbo-membranous urethra who underwent treatment in the period 2012–2018 in the conditions of a urological hospital of Irkutsk City Clinical Hospital No. 1. Anastomotic urethroplasty was performed using one of two methods: with full mobilization of the spongy body bulb and a vessel-sparing method when the spongy body does not intersect. Results The effectiveness of the classical method of anastomosing EPA-TWW ((excision and primary anastomosis urethroplasty (Turner-Warwick) and excision and Jordan’s technique of vessel sparing excision and primary anastomosis)) was comparable with the method of anastomosing without crossing the (spongy body of EPA-J). Postoperative changes in the parameters of the functional status of patients based on the International Prostate Symptom Score (IPSS), International Index of Erectile Function, and Quality of Life were comparable in patients undergoing EPA-TWW and EPA-J. The final data indicate a statistically equivalent risk of developing complications such as urinary incontinence, shortening of the penis, and decreased erectile function. Conclusions The study did not demonstrate a statistically significant difference in the effectiveness of the treatment and the risks of complications during anastomotic surgery with or without vessel-sparing. However, an unformalized assessment demonstrates the best state of erectile function in patients after vascular-preserving surgery.

Introduction Laparoscopic surgery is not easily performed by junior surgeons who have limited experience. Aim To investigate the safety and feasibility of the first experience of junior surgeons with laparoscopic distal gastrectomy (LDG) who were trained in super high-volume centers. Material and methods Clinicopathological data from the first 85 LDG cases performed by three gastric cancer surgeons were collected. All three surgeons were trained for > 1 year in super high-volume centers. The surgical and postoperative outcomes of the first experiences of junior surgeons were compared with the short-term outcomes reported in a multicenter randomized controlled trial (Korean Laparoendoscopic Gastrointestinal Surgery Study, KLASS-01 trial), conducted by the KLASS group, which is composed of experienced surgeons who practice in a high-volume center. Results A significantly greater number of older patients with longer operation times and lower estimated blood loss was observed for the junior surgeons than in the KLASS data. Although junior surgeons performed significantly more Billroth II anastomoses with D1+ lymph node dissection, there was no difference between the two groups in terms of hospital stay, number of retrieved lymph nodes, or postoperative morbidity. Conclusions The surgical outcomes of early gastric cancer managed by laparoscopic surgery performed by well-trained beginners were similar to the outcomes reported in the large-scale trial. Therefore, with regard to the surgical training system, training at super high-volume centers may be considered to provide some assurance in terms of surgical technique-related safety.

Introduction Chronic vertebral basilar artery occlusion is one of the most common causes of ischemic stroke, which accounts for roughly 20% of all cases. However, the evidence for the precise clinical effect in treatment of the initial segment of chronic vertebral basilar artery occlusion is not sufficient. Aim To evaluate the feasibility and efficacy of endovascular therapy in the initial segment of chronic vertebral basilar artery occlusion. Material and methods This is a retrospective study based on data obtained from Lishui Hospital of Zhejiang University. We identified patients who underwent treatment for initial segment occlusion of the vertebral basilar artery from September 2014 to September 2018. Results Among a total of twenty-two subjects, 77.27% of them were men and the median age was 61 years old. The primary medical history of these patients included hypertension (15, 68.18%), hyperlipidemia (13, 59.09%), diabetes mellitus (11, 50.00%), and coronary artery disease (6, 27.27%). About 54.54% of the patients were current smokers. Successful recanalization was achieved in 86.36% of patients. Five cases of balloon dilatation were recanalized and fourteen cases were treated by balloon dilation combined with stent implantation. During the follow-up period, there were no recurrent cerebral ischemic events, including transient ischemic attack or stroke. Six (27.27%) arteries were found to exhibit angiographic re-stenosis. Conclusions The clinical effect of balloon dilatation or balloon dilatation combined with stenting in the treatment of chronic vertebral basilar artery occlusion in the beginning segment was feasible and safe.

Introduction Gastric cancer (GC) is a common malignant tumor with a high mortality rate. Aim To determine the accuracy of preoperative imaging information obtained from the combined use of general gastroscopy (GS), endoscopic ultrasonography (EUS), and multi-detector computed tomography (MDCT) regarding absolute indication of endoscopic submucosal dissection (ESD) in early gastric cancer (EGC). Material and methods The relationship between clinical features of 794 EGC patients and lymph node metastasis (LNM) was analyzed. Multivariate logistic regression analysis was used to investigate the risk factors for LNM. Additionally, the accuracy of diagnosis of imaging techniques for ESD indications was determined by receiver operating characteristic (ROC) analysis. Results Data showed that tumor size > 2 cm (p = 0.0071), T1b stage (p < 0.0001), undifferentiated histology (p < 0.0001), and vascular invasion (p = 0.0007) were independent risk factors for LNM in patients with EGC. Indications for ESD have a specificity of 100% for the diagnosis of patients with LNM. Additionally, the diagnostic efficacy of the use of GS, EUS, and MDCT in identifying node positive status, T1a disease, tumor size ≤ 2 cm, and ulceration was found to be moderate with area under the curve (AUC) of receiver operating characteristic curve (ROC) of 0.71, 0.64, 0.72, and 0.68, respectively. Furthermore, the use of imaging techniques for overall indication criteria for ESD had a moderate utility value with an AUC of 0.71. Conclusions Our data suggested that, based on the combined use of GS, EUS, and MDCT, a high specificity of patient selection for ESD treatment can be achieved.

Introduction There is a strong need to make laparoscopic cholecystectomy as safe as possible, but sometimes complications in the form of bile duct and/or vascular injury occur. The safe plane of dissection can be precisely identified with intraoperative ultrasound, ensuring reduction of the complication rate to a minimum. Aim To evaluate the advantages of the cholecystectomy protocol based on the use of intraoperative ultrasound during laparoscopic and open cholecystectomy. Material and methods The study group consisted of 700 patients with symptomatic cholecystolithiasis, which was divided into two subgroups: with the critical view of safety only (312 patients) and with the critical view of safety + laparoscopic/open cholecystectomy ultrasound (388 patients). Laparoscopic cholecystectomy and conversion in patients from the second subgroup were performed under the control of intraoperative ultrasound. Results We did not observe any biliary complications, and the visualization of the common bile duct, the proper hepatic artery and the portal vein was obtained in every patient from the critical view of safety + laparoscopic/open cholecystectomy ultrasound group. The mean time of the operation was significantly shorter and the conversion, biliary injury and intraoperative bleeding rates were significantly lower in this group of patients. Conclusions Intraoperative ultrasound is a very efficient and safe method of guidance, and its use should be standard along with the critical view of safety during cholecystectomy.

Introduction The gold standard of vascular access for chronic hemodialysis patients is the arteriovenous fistula (AVF). If an AVF cannot be created, the hemodialysis catheter can be inserted into the internal jugular, femoral or subclavian vein. After exhausting the abovementioned standard accesses, translumbar access to the inferior vena cava (IVC) is considered a quick, last-chance and rescue method. Aim Retrospective analysis of early complications (EC) of translumbar IVC catheterization using one type of catheter by one medical team. Material and methods From January 2010 to October 2019, a total of 34 translumbar IVC catheters were implanted in 27 patients. Results A major EC was found in 1 (2.9%) procedure. Minor EC occurred in 23.5 attempts. None of these complications required an intervention. Conclusions In patients with exhausted possibilities of obtaining standard vascular access for HD, translumbar IVC cannulation proved to be a safe and effective method.

Introduction Hemorrhagic complications after laparoscopic sleeve gastrectomy (LSG) are among the most common adverse events. The last 10 min of LSG are essential in terms of hemostasis. Aim To assess the blood pressure profile in the last 10 min of LSG in patients who experienced hemorrhagic complications after laparoscopic sleeve gastrectomy. Material and methods We performed a retrospective case-control study. The medical records of 867 patients who underwent primary LSG were analyzed. Cases were defined as patients who required surgical revision due to hemorrhagic complications within 72 h. Controls were matched (1 : 1) with cases by age, body mass index, gender, staple line reinforcement, comorbidities and surgeon's experience. Comparison of the last three intraoperative blood pressure measurements at the end of surgery was made. Results The bleeding rate was 3.0%. A total of 24 subjects (12 matched pairs) were included in the study. Cases had statistically significant increased mean arterial blood pressure (mm Hg) 5 min before the end of surgery (87.8 ±11.9 vs. 79.4 ±8.8 mm Hg, p = 0.049) and at the end of surgery (89.2 ±11.7 vs. 77.5 ±11.8 mm Hg, p = 0.011). Higher diastolic blood pressure measurements were observed 5 min before the end (72.1 ±10.7 vs. 62.8 ±8.1 mm Hg, p = 0.023) and at the end of surgery (74.2 ±10.0 vs. 60.8 ±11.2 mm Hg, p = 0.004). Conclusions Compared with closely matched control subjects, patients with HC after LSG have increased mean arterial pressure in the last 5 min of surgery. This phenomenon has not been reported in the literature before.

Introduction Radiofrequency ablation (RFA) is one of the best curative treatments for hepatocellular carcinoma in selected patients, and this procedure can be applied either percutaneously or laparoscopically. Laparoscopic RFA has the benefit of direct visual control of the RFA procedure. Cluster electrodes (Octopus RF electrodes) can create a common ablation zone. Aim Using these two methods (laparoscopic approach and no touch technique), this present study evaluated the technical and clinical outcomes of early experience with laparoscopic RFA and a no-touch technique. Material and methods Between November 2015 and November 2018, 21 patients underwent laparoscopic RFA for hepatocellular carcinoma with a no-touch technique using cluster electrodes. Laparoscopic RFA is recommended for patients with a contraindication for surgical resection, patients wants and a relative contraindication for conventional percutaneous RFA, such as lesions adjacent to the gastrointestinal tract, gallbladder, bile duct, or heart. Results In the 21 tumors, 2 were treated with a single electrode, 12 with 2 electrodes, and 7 tumors with 3 electrodes. The mean time of ablation per lesion was 20.43 ±8.77 min. There was no mortality, local tumor progression, delayed destructive biliary damage, or liver abscess at the follow-up computed tomography. No technical failures occurred. Conclusions Laparoscopic RFA can access lesions for which percutaneous RFA is contraindicated or risky. Cluster electrodes can create sufficient ablation zones without contact and can achieve a sufficient margin with a low complication rate and no tumor dissemination. Therefore, laparoscopic RFA with a no-touch technique might be a safe and feasible treatment for HCC tumor in selected patients.

Introduction Upper urinary tract calculus is a common disease of the urinary system. Aim To compare the therapeutic effects of flexible ureteroscopy alone and in combination with external physical vibration on upper urinary tract calculi. Material and methods A total of 146 patients were randomly divided into control and experimental groups (n = 73). The control group received flexible ureteroscopy lithotripsy, and the experimental group underwent the same but combined with external physical vibration. The rate of finding stones in the urine on the day after treatment, clearance rate, components of stones, levels of renal function indices blood urea nitrogen (BUN) and serum creatinine (Scr), and incidence of complications were compared. The stone-free rate during 1-year follow-up was analysed by Kaplan-Meier method. Results The rate of finding stones in the urine on the day after treatment was higher in the experimental group (100%) than that in the control group (29.73%) (p < 0.05). The clearance rates on the day, at 1 week, and at 2 weeks after treatment in the experimental group were 71.23%, 87.67%, and 95.89%, respectively, which surpassed those of the control group at corresponding time points (p < 0.05). BUN and Scr levels decreased after treatment in both groups, especially in the experimental group (p < 0.05). The stone-free rate during 1-year follow-up in the experimental group (n = 71 (97.26%)) exceeded that of the control group (n = 61 (83.56%)) (p < 0.05). Conclusions External physical vibration combined with flexible ureteroscopy lithotripsy significantly increased the rate of finding stones in the urine the day after treatment, the clearance rate of upper urinary tract calculi, and the ameliorated renal function and reduced the stone re-formation rate.

Introduction A proactive approach is recommended in colorectal anastomosis leak treatment, and early diagnosis is very important. Early postoperative endoscopy would allow rapid diagnosis of anastomotic pathologies and consequent prompt intervention according to anastomotic disruption morphology. Aim To evaluate the effectiveness of close endoscopic follow-up of all patients (including asymptomatic ones) in improving diagnosis of acute leak (AL) and reducing its complications. Material and methods This study included 124 patients who had undergone rectum resection for rectal cancer with stapled anastomosis. Endoscopy was performed between the 7th and 10th postoperative day and 1 month postoperatively. For defect morphology assessment, a classification system was created based on four levels of severity. Photographic findings were evaluated by an independent, experienced gastroenterologist. Results Postoperative endoscopy revealed 28 (22.6%) patients with acute leakage. Initial endoscopy confirmed AL in 18 patients. Six (31.6%) patients were asymptomatic and 13 (68.4%) were symptomatic. The second endoscopy revealed another 9 (32.1%) leaks (4 (44.5%) asymptomatic and 5 (55.5%) symptomatic). Sixteen (57.1%) patients had grade A leakages, 7 (25.0%) had grade B leakages, and 5 (17.9%) had grade C leakages. Furthermore, 22 of 27 (81%) defects were located posterior and posterior-laterally. Fifteen (55.5%) defects were smaller than 1/3 the circumference, 7 (25.9%) affected 1/3-1/2 of the circumference, and 5 (18.5%) affected more than 1/2 of the circumference. Conclusions Incorporation of early endoscopy in postoperative management allows rapid diagnosis of AL and allows faster intervention, even in leaks that are clinically silent.

Introduction: Chest tube drainage is the first step in the management of complicated pleural effusions that have turned into empyema. In cases where adequate drainage cannot be provided or deloculation is required, intrapleural fibrinolytic therapy or surgical deloculation can be performed. Alteplase is a suitable agent for intrapleural fibrinolytic therapy. On the other hand, video-assisted surgery is an effective and minimally invasive treatment option for lung re-expansion. Aim: The effect of intrapleural alteplase irrigation applied through the thoracic tube in the treatment of pleural empyema was investigated and whether it could be an alternative technique to video-assisted thoracoscopic surgery was evaluated. Material and methods: The results of patients who were treated for empyema in our clinic were evaluated retrospectively. Twenty-one patients who underwent tube thoracostomy + intrapleural alteplase and 28 patients who underwent VATS deloculation were included in the study. Results: The study included 35 male and 14 female patients. There were 21 patients in group 1, and 28 patients in group 2. The mean age was 50.6. The average length of thoracic tube stay was determined as 7.1 and 6.96 days. The duration of hospital stay in this group was 6.73 and 6.35 days. In 17 (81%) patients in group 1, the treatment was discontinued without the need for surgery. Conclusions: VATS-D is an effective option in the treatment of pleural empyema. However, as seen in our study, intrapleural alteplase application is at least as effective as VATS-D in terms of treatment success. WOS:000700910200014 34691309 Q4

Aim The aim of the study was to compare the outcomes of robot-assisted (RAGD2) and laparoscopy-assisted gastrectomy with D2 lymphadenectomy (LAGD2) for patients with gastric cancer. Material and methods Relevant articles published up to September 2020 were searched. The weighted mean difference (WMD) was used to pool continuous variables, while risk ratio (RR) was calculated for dichotomous outcomes. Results RAGD2 required a longer operating time (WMD = 29.78, 95% confidence interval (CI): 15.97-43.59) and had less operative blood loss (WMD = -31.93, 95% CI: -44.03 to -19.83), shorter time to first flatus (WMD = -0.13, 95% CI: -0.22 to -0.04), shorter time to liquid diet (WMD = -0.20, 95% CI: -0.28 to 0.12), and fewer severe complications (RR = 0.62, 95% CI: 0.43-0.90) and overall complications (RR = 0.75, 95% CI: 0.62-0.91) than LAGD2. Conclusions RAGD2 could be beneficial in reducing operative blood loss and postoperative complications relative to LAGD2.

Introduction The rate of anastomotic leakage from intrathoracic esophagogastric anastomoses can be reduced by covering them with the mediastinal pleura. Whether anastomotic leakage can be reduced by covering the portion of the gastric tube in the upper mediastinum with the mediastinal pleura during minimally invasive McKeown esophagectomy (MIE McKeown) is unknown. Aim To evaluate the consequence of covering the mediastinal pleural during minimally invasive McKeown esophagectomy. Material and methods Consecutive patients who underwent MIE McKeown between January 2015 and December 2019 were retrospectively analyzed. Participants for whom the portion of the gastric tube in the upper mediastinum was not covered with the mediastinal pleura were assigned to group A; otherwise, they were assigned to group B. Chi-square analysis and univariable and multivariable logistic analyses were used to compare the differences between the two groups and explore the risk factors for anastomotic fistulae. Results A total of 267 patients with middle and lower esophageal cancer were included in this study (131 in group A and 136 in group B). Anastomotic leakage occurred in 5 patients (5/136) in group B compared with 13 patients (13/131) in group A (p = 0.042). Univariable and multivariable logistic analyses identified a gastric tube not covered with the mediastinal pleura as a risk factor for significantly greater anastomotic leakage (p = 0.042), but it was not an independent prognostic factor for anastomotic leakage (odds ratio = 0.585, 95% confidence interval: lower bound: 0.069, upper bound, 1.122). Conclusions This study provides preliminary evidence that covering the gastric tube with the mediastinal pleura during MIE McKeown can decrease the incidence of anastomotic leakage.

Introduction One of the most significant challenges nowadays is to educate and predict the predispositions of young surgeons taking into consideration that every ability has its own learning curve. Aim To determine the influence of selected factors and examine the shape and the length of the learning curve in performing simple tasks on an endoscopic simulator. Material and methods Twenty students took part in 4 training sessions with a one-week break between sessions. They were training 12 min and performed three tasks at every session on the endoscopic simulator. To identify whether selected factors influence the time of completing tasks, the participants were asked to fill in questionnaires. All participants also completed the Minnesota Manual Dexterity Test (MMDT) to assess hand-eye coordination. Results Our research reveals that regardless of activities performed in free time, the shape of the learning curve was logarithmic. Improvement after the fourth session ranged from 50% to 75%. Performing specific activities in the free time did not influence the results achieved on the simulator. No statistically significant correlation between MMDT results and the time to accomplish each task was found. Conclusions This study has shown that the length of the learning curve of performing simple tasks is quite short and the shape is logarithmic. It suggests that more complex exercises should be included in the training programme.

Aim Guide wire displacement in spinal pedicle screw implantation was analyzed in order to reduce or avoid the occurrence of this phenomenon and to reduce the complications associated with robot-assisted pedicle screw implantation surgery. Material and methods From April 2017 to December 2019, a retrospective study was conducted with 398 patients who underwent robot-assisted spinal pedicle screw implantation. The causes of guide wire displacement in 60 punctures were analyzed. Results There were 2,408 robot-assisted wire punctures of the pedicle, of which 2,348 wire punctures were located well within the pedicle, and 60 wire displacements occurred during robot-assisted wire puncture, with a displacement rate of 2.49%. There was 1 case of thoracic segmental artery injury and 1 case of spinal cord incomplete injury. Conclusions As it is a rare phenomenon in robot-assisted spinal pedicle screw implantation, guide wire displacement should be avoided as much as possible to improve the accuracy of screw placement and reduce surgical complications during the operation.

Introduction In women with abnormal uterine bleeding (AUB), endometrial polyps are a frequent finding, and the risk of a focal (pre)malignancy in a polyp is up to 6%. Because of this reported risk, the detection of polyps in these women is important. Aim To evaluate and compare the diagnostic accuracy of saline infusion sonohysterography, transvaginal sonography, and hysteroscopy in detecting endometrial polyps in women with AUB. Material and methods The searches were conducted by two independent researchers to find the relevant studies published from 1/1/2009 until the end of 30/06/2019. We searched for published literature in English language in MEDLINE, EMBASETM, The Cochrane Library, and Trip database. For literature published in other languages, we searched national databases (Magiran and SID), KoreaMed, and LILACS. The risk of bias of every article was evaluated by using QUADAS-2. Results After selection and quality assessment, 11 studies were included. Based on the random effect model the total prevalence of endometrial polyps in women with abnormal uterine bleeding was 38%. The sensitivity and specificity of saline infusion sonohysterography in diagnosis of endometrial polyps were 0.87 and 0.86, respectively. The sensitivity and specificity of transvaginal ultrasonography were 0.62 and 0.73 and the sensitivity and specificity of hysteroscopy were 0.92 and 0.85, respectively. Conclusions Although that sonohysterography is a safe and relatively cheap method, which allows ruling out or confirming endometrial polyps, it cannot be replaced with hysteroscopy due to the fact that hysteroscopy combined with biopsy is the gold standard for ruling out malignancies in an endometrial polyp.

Introduction Bariatric surgery has a significant impact on dietary intake, weight loss, patient's metabolism and also on defaecation stereotypes. Aim To investigate changes in bowel habits of morbidly obese patients after laparoscopic sleeve gastrectomy (LSG). Material and methods This was a prospective clinical cohort study conducted to assess changes in bowel habits after LSG in a single institution. Results In total, 124 patients were enrolled in the study (age 47.1 ±11.2 years, body mass index (BMI) 44.3 ±6.8 kg/m2). The mean weight loss 6 months after LSG was 29.1 ±11.1 kg; percentage excess weight loss was 56.2 ±20.4%. Before surgery, 35.5% of patients had constipation and 6.5% of patients had faecal incontinence (FI). No correlation was found between rising level of BMI and constipation or incontinence prevalence/severity. Data analysis has not confirmed increased prevalence/severity of postoperative constipation or incontinence 6 months after LSG. Out of the group of patients with preoperative constipation, clinically relevant improvement was noted in 45.5% of patients after the surgery. Among patients without constipation before surgery, impairment was noted in 21.2% of patients. Out of the group of patients with preoperative incontinence, improvement was found in 37.5% of patients; none of these patients reported clinically relevant impairment of incontinence symptoms. Conclusions The present study has not revealed increased prevalence/severity of postoperative constipation or anal incontinence 6 months after LSG. Our findings suggest that weight loss in patients after LSG might be associated with an improvement of constipation symptoms of individual patients.

Introduction Hysteroscopy is the gold standard for diagnosis and treatment of uterine pathologies. The office setting seems to be safe, reducing the anesthesia risks and also decreasing the overall costs of the procedure. Recent literature suggests that hysteroscopy performed without anesthesia may not be as painless as it was previously considered. Moreover, not every patient can be referred for a hysteroscopy in an office setting. Aim To analyze the factors correlated with a successful hysteroscopy in an office setting. Material and methods We analyzed the documentation of 1301 patients who underwent hysteroscopy at our department in the period 2013-2016. The impact of the type of the procedure and the various demographic factors on the need for general anesthesia was assessed. Results Almost 80% of all hysteroscopies were performed without analgesia in an office setting. The remaining patients underwent a hysteroscopy in general anesthesia. The key aspect for successful office hysteroscopy is the scope of the performed surgery. Over 91% of diagnostic hysteroscopies have been done without analgesia, but only about 30% of extensive endometrial scratching procedures were performed in an office setting. A previous vaginal delivery increases the chances for a successful office hysteroscopy by about 21%, and in the case of diagnostic procedures, multiparous patients were at an about 79% lower risk of analgesia necessity. Conclusions It is possible to perform nearly all diagnostic hysteroscopies in an office setting. In the case of operative hysteroscopy, the most crucial factor is the scope of the procedure.

Introduction Endoscopic resection for the treatment of gastrointestinal neuroendocrine tumors has a risk of resection margin residues. The related risk factors and prognosis of post-endoscopic resection margin residues have not been fully evaluated. Aim To investigate the associated risk factors and prognostic impact of resection margin residues after endoscopic resection of gastrointestinal neuroendocrine tumors. Material and methods We conducted a retrospective analysis of 129 patients who underwent endoscopic resection for the treatment of gastrointestinal neuroendocrine tumors. Sex, age, location, diameter of tumor, depth of invasion, endoscopic treatment methods, endoscopic ultrasonography (EUS) evaluation, and the work experience of endoscopists were evaluated as potential risk factors. In addition, the prognoses of patients with positive resection margins were analyzed. Results A total of 18 (18/129, 14.0%) patients exhibited positive resection margins after endoscopic resection. Among 16 successfully followed-up patients, 1 died due to rupture of pulmonary artery aneurysms, 2 underwent supplementary surgical operations, and 2 underwent additional endoscopic submucosal dissection. The remaining 11 patients were periodically followed up, and no recurrences were found. The results of univariate analysis suggested that endoscopic treatment method, the depth of invasion, and EUS evaluation correlated with positive resection margin. Multivariate regression analysis suggested that the depth of invasion and EUS evaluation were risk factors for resection margin residues. Conclusions The depth of invasion and EUS evaluation are independent risk factors for positive resection margins after endoscopic resection. This finding suggests that a greater depth of invasion increases the risk for positive resection margins, while EUS evaluation before resection decreases this risk.

Introduction Bispectral index (BIS) monitoring provides an objective, non-invasive measurement of the level of consciousness in a sedated patient. Aim In this prospective study, we aimed to investigate the hypothesis that risk of respiratory depression could be reduced and the desired level of sedation with minimal doses of propofol could be achieved by using BIS monitoring in endoscopic retrograde cholangiopancreatography (ERCP) procedures. Material and methods Sixty patients in the ASA 1–2 category, who were scheduled for an ERCP with sedation, were randomly divided into two groups. The procedure was performed, and sedation was administered so that the patient’s Ramsay Sedation Score (RSS) would be 4–5 in the first group (group 1) and the patient’s BIS value would be 65–75 in the second group (group 2). Cardiopulmonary complications, the total duration of the procedure, and the total amount of propofol administered were recorded. Results The mean SpO2 measurements at the third minute, fifth minute, and 10th minute were higher in the BIS group (p < 0.001) (p < 0.05). The mean number of respirations during the third, fifth, 10th, and 15th minute of sedation was significantly higher in the RSS group than in the BIS group (p < 0.05). There was no difference between the groups in terms of recovery time, total propofol amount, and additional doses of bolus propofol. Conclusions BIS monitoring during sedation with propofol for ERCP did not reduce total propofol use, but it may be an efficient guide for the timing of additional dose administration, which could reduce the risk of respiratory depression, and it could be used safely as an objective method in the follow-up of level of sedation.

Introduction The use of implants in inguinal hernia repair has reduced its recurrence rate. However, postoperative groin pain still remains an unresolved problem. There are suggestions that in totally extraperitoneal inguinal hernia repair (TEP-IHR) two of the likely factors responsible for pain are use of fixation and the type of fixation used. Aim To evaluate the impact of mesh fixation on the incidence of postoperative pain, restriction of physical activities, hernia recurrence risk, return to normal activities and demand for analgesics in patients after unilateral TEP-IHR. Material and methods Unilateral TEP-IHR was performed in 139 male patients randomized to three groups: self-gripping mesh (SG), lightweight mesh (L) and lightweight mesh with fixation (LF). Full study-inclusion criteria were met by 110 patients; 43, 18 and 49 in groups SG, L and LF respectively. Follow-up occurred on the 1st, 2nd, and 7th day and 3, 6, 12 months postoperatively. The numeric rating scale (NRS) was used to assess pain and the EuraHS-QoL (European Registry for Abdominal Wall Hernias Quality of Life Score) questionnaire to compare quality of life (QoL) prior to surgery and one year later. Results No statistically significant differences were observed between study groups with regard to the incidence rate and intensity of acute post-operative pain, chronic pain, analgesic demand, return to normal activity, hernia recurrence rate and post-operative QoL. Conclusions Lack of fixation in TEP-IHR does not increase the risk of hernia recurrence, and its presence does not significantly worsen the treatment results; especially it does not increase the incidence of chronic pain.

Introduction As a result of the growing number of people with obesity, the popularity of bariatric surgery has been systematically increasing. It has not yet been explored whether individual education of the patient can contribute to long-term success in weight reduction after bariatric treatment. Aim To implement and compare the effects of different education methods, versus receiving one-time written information in the form of a guidebook, on patient involvement in abiding by lifestyle recommendations after laparoscopic sleeve gastrectomy (LSG) bariatric treatment. Material and methods The study included 160 patients with morbid obesity. The education session study participants were 100 patients after sleeve gastrectomy, with whom three education sessions were planned, and who were enrolled in the study. The control group consisted of 60 patients who underwent sleeve gastrectomy, and before discharge from the department, they received one-time written recommendations in the form of a guidebook. Results We confirmed that the three education sessions we conducted with the study group after LSG had a significant impact on weight loss. The control group, which received only written information, achieved weight loss and abided by the written recommendations, although to a lesser extent than the study group. The differences were evident particularly in motivation to adhere to recommendations and check-ups, which was significantly lower (p < 0.001) after a year of observation in the control group. Conclusions This study results should encourage the establishment of education as a permanent element of the LSG procedure.

Introduction The prevalence of obesity is increasing according to the World Health Organization. Furthermore, global aging is increasing, especially in developed countries in Europe. Whether bariatric surgery should be performed in elderly people is still controversial. Aim To determine the clinical outcomes of sleeve gastrectomies (SG) in older central European patients. We compared the safety and efficacy of SG in patients older than 60 years with younger patients. Material and methods Eighty-nine patients older than 60 years, who underwent SG, were included in the study. Eighty-nine younger patients (aged 18-40 years) were matched according to body mass index (BMI) and comorbidities. The analyzed data included age, sex, total body weight, BMI, length of hospital stay, 30-day complications and improvement in comorbidities. Results There was no significant difference in the complication rate between the 2 age groups (p = 0.59). An improvement in hypertension was observed in 73.1% of older patients and in 69.2% of younger patients (p = 0.67). There was improvement in diabetes mellitus in 40% of older patients and in 31.1% of younger patients (p = 0.25). The ΔBMI after 12, 24 and 36 months was significantly lower in older patients than in younger patients (p = 0.002, p = 0.001; p = 0.043, respectively). Percent excess BMI loss (%EBMIL) after 12, 24, and 60 months was significantly lower in older than in younger patients (p = 0.001, p = 0.001, p = 0.028, respectively). Conclusions Better weight loss is achieved in younger than in older patients, while maintaining a similar effect on the risk of complications and improvement in comorbidities. Therefore, SG is safe and effective in older people.

Introduction Surgical treatment is always associated with tissue damage and the subsequent development of oxidative stress. Aim To compare the oxidative stress response in patients treated operatively for inguinal hernia with multi-trocar laparoscopic totally extraperitoneal technique (TEP) or single-incision laparoscopic totally extraperitoneal technique (TEP-SI). Material and methods A randomized group of 34 patients with one-sided inguinal hernia was enrolled in the study. Seventeen patients were treated with a standard TEP method (group 1) and the other 17 patients were treated with the TEP-SI technique (group 2). Thiobarbituric acid reactive substances (TBARS) and total antioxidant status (TAS) as the oxidative stress markers were measured before surgery (0), 1 day (1) and 4 days (2) after surgery. Results A decrease in TAS on the first day after surgery was observed in both groups. Sustained reduction on the fourth day after surgery was observed in group 1, whereas in group 2 an increase followed. A statistically significant difference was observed in TAS (2 : 0) ratio with a meaningful decrease in group 1. TBARS concentration was elevated 1 day after surgery in both groups. It remained at an elevated level on the fourth day after surgery in group 1, while it decreased in group 2. The duration of surgery was higher in group 2 (mean: 57.5 min) than in group 1 (mean: 50.0 min) (p = 0.0286). Conclusions Oxidative stress levels are lower in patients treated operatively by TEP-SI technique than by TEP. TEP-SI may be considered as a less invasive technique associated with less tissue injury.

Introduction Internal carotid artery (ICA) injury is the most dangerous and life-threatening complication in patients operated on due to parasellar tumors via a minimally invasive endoscopic endonasal approach. Sphenoid septal attachment to the ICA protuberance within the sphenoid sinus was found to be one of the anatomical risk factors for ICA injury during transsphenoidal surgery. Aim To determine the relationship between the sphenoid sinus septa and the parasellar or paraclival internal carotid artery prominence based on our own material and a literature review. Material and methods The axial plane scans of computed tomography angiography and a literature review of previously published papers on the septum variation and its connection with the ICA prominence are provided. Results Out of 100 sphenoid sinuses, 49 (49%) had at least one septum inserted at the ICA prominence. In the majority of cases 42 (86%) one septum was inserted at the prominence of one of the ICAs. In 7 (14%) cases, two separate septa were inserted at the prominences of both ICAs. Patients with multiple septa and those having an incomplete septum were at higher risk of at least one of them being inserted at the ICA prominence within the sinus. Including cases from the literature review, the average number of septa per patient was 1.42. The risk of intersection between the septum and the ICA prominence was 32%. Conclusions A significant percentage of the intrasphenoidal septa are inserted at the sphenoidal ICA protuberance.

Aim The aim of the study was to evaluate the incidence and severity of visually induced motion sickness (VIMS) during 3D laparoscopy, in operators without prior experience. Material and methods Design: A retrospective comparative study (Canadian Task Force classification II-2). Setting: A university hospital. Intervention: Gynecologic surgery. Main outcome measure: This is a prospective observational study, which enrolled 9 surgeons as participants. None of these surgeons had any prior experience with 3D laparoscopy. Each participant performed 10 consecutive cases of 3D laparoscopy in patients with benign or premalignant gynecological diseases. The primary outcome measure was the incidence and severity of VIMS, which was evaluated using the validated Simulator Sickness Questionnaire. Personal preferences, discomfort, and ease of 3D laparoscopy were also evaluated. Results Sixty-seven percent of surgeons experienced VIMS during their first 3D laparoscopy case. The incidence and severity of VIMS dramatically decreased from the second case onward. However, in some surgeons (22-44%), VIMS did not completely disappear until the tenth case. With respect to the discomfort using 3D laparoscopy, 84 self-reported responses after each surgery were "favor 3D laparoscopy," and "no" in 61 (72.6%) and 47 (55.9%) participants, respectively. Most participants found it easier to perform 3D laparoscopy than 2D laparoscopy. Conclusions The occurrence of visually induced symptoms in susceptible individuals during 3D laparoscopy is high, particularly during their first case. This suggests the need for increasing surgeons' awareness regarding the possibility of discomfort.

Introduction Laparoscopic resection has become an accepted approach to liver tumour surgery. However, it is considered difficult, especially in unfavourably located lesions. Aim To compare the outcomes of laparoscopic (LLR) and open liver resection (OLR) of posterolateral segments. Material and methods We searched the PubMed, EMBASE, and Scopus databases from inception to 30 September 2019. Full text articles and conference abstracts were included for further analysis. This review follows the PRISMA guidelines. Results From 643 articles, 15 studies (N = 1196 patients) were included in the meta-analysis. All of them were non-randomised. Our findings showed that LLR had significantly lowered overall morbidity compared to OLR (MD = 0.66; 95% CI: 0.51–0.86; p = 0.002). Length of hospital stay (MD = 2.48; 95% CI: –3.87, –1.08; p < 0.001) was also shorter in the LLR group. Operative time (MD = 55.65; 95% CI: 24.14–87.16; p < 0.001) was significantly shorter in the OLR group. In terms of blood loss, major complications, R0 resection rates, and resection margin, there were no significant differences. Conclusions Our meta-analysis showed that the laparoscopic approach to resections of posterolateral liver segments is beneficial. However, the results are based on non-randomised trials, and further research is needed to fully establish their clinical application.

Introduction Many publications detail the level and number of lymphadenectomies, whereas the timing of pelvic lymph node dissection (PLND) is infrequently discussed in the robot-assisted radical cystectomy (RARC) series. Aim To determine the effects of performing PLND before or after cystectomy in totally intracorporeal RARC on operative outcomes. Material and methods A total of 15 patients included in the study underwent RARC and intracorporeal orthotopic neobladder. Of these, 8 patients underwent PLND before cystectomy (group 1), whereas 7 underwent PLND after cystectomy (group 2). Demographic information, intraoperative data, and post-operative outcomes were recorded for each patient. Results The mean ± SD age was 61.87 ±6.76 years. Overall mean operation time (OT) was 537.33 ±63.07 min. The mean EBL and hospitalization time were 322.33 ±69.92 ml and 13.87 ±5.2 days. The number of LN removed was 23.75 ±3.454 for group 1 and 13.71 ±6.873 for group 2 (p = 0.007). The postoperative pathological stages were: pT2(5), pT3(2), pT4(1) for group 1, pT2(4), pT3(2), pT4(1) for group 2. Surgical margins were negative in all patient. Overall complications occurred in 7 (46.6%) patients. Only the number of LN removed was statistically significant in favor of group 1 (p = 0.007). Mean follow-up was 15.87 months. Conclusions Our initial experience with performing extended PLND (ePLND) before or after cystectomy in totally intracorporeal RARC appears to be favorable, with similar oncological results and acceptable complication rates. However, although the number of cases is too low for statistical evaluation, it seems to be advantageous to perform ePLND before cystectomy in terms of LN number and operation time.

Introduction The important part of radical prostatectomy (RP) for high risk (HR) is extended pelvic lymph node dissection (ePLND). This method consists of two stages of surgery usually performed at the compartment (pre- or transperineally). Aim We present our new combined technique of RP using two different approaches: a pre-peritoneal approach for laparoscopic radical prostatectomy (LRP) and a transperitoneal approach for ePLND. Material and methods This study included 30 patients aged 53 to 75 years (mean age: 64 years) with prostate cancer who underwent LRP and ePLND using a combined technique. After the pre-peritoneal LRP, transposition of the trocars into the peritoneal cavity was performed without changing their location, except the extreme left trocar, which was inserted through a new approach. Results The total duration of surgery was 155 to 290 min (mean: 215 min); ePLND lasted from 35 to 85 min (mean: 56 min). The movement of trocars into the peritoneal cavity was a very simple maneuver, taking up to 1 min without any complications. The number of removed lymph nodes (LNs) ranged from 13 to 28 (mean: 16.8). A positive margin was found in 5 (16%) patients. We recognized positive nodes in 9 (30%) patients. Conclusions The combined technique is both feasible and safe. Performing the most difficult maneuver, removal of the prostate, in the first stage appears to be more comfortable for the operator. The timing of the PLND stage in the combined technique and the number of removed LNs do not differ from the standard lenticular access.

Introduction Working on the institutional Enhanced Recovery After Surgery (ERAS Cardio) protocol for off-pump coronary artery bypass graft surgery (OP-CABG) we have noticed that patients treated according to the modified anesthesia protocol had not only significantly shorter time of respiratory support and intensive care unit stay but also lower postoperative troponin T concentration than patients who had standard fentanyl/sevoflurane-based anesthesia. Aim To compare the perioperative course of patients undergoing OP-CABG surgery and receiving standard fentanyl/sevoflurane anesthesia and those anesthetized according to the institutional ERAS Cardio protocol with remifentanil, sevoflurane, and bilateral extensor spinae plane (ESP) block. Material and methods Design: a prospective, open-label, observational study performed in a tertiary health center. Participants: 30 consecutive patients undergoing off-pump coronary bypass graft surgery. Interventions: 15 patients had standard anesthesia with etomidate, fentanyl, and rocuronium for induction and fentanyl/sevoflurane for maintenance (standard group); 15 others had bilateral single shot ESP block, then etomidate, remifentanil and rocuronium for induction, and remifentanil/sevoflurane for maintenance of anesthesia. Results Median time to extubation was 7.6 (5.5-12.5) h and 1.7 (1-3.25) h in "standard care" and ERAS groups, respectively (p = 0.00002). Length of stay in the intensive care unit was also shorter for patients in the ERAS group 20.5 (18-24) vs. 48 (42-48) h (p = 0.00001). Troponin concentration increased to a lesser extent in patients from the ERAS group: an increase of 151.8 (71.9-174.3) ng/ml vs. 253.8 (126.6-373.1) ng/ml, p = 0.008. Conclusions Remifentanil/sevoflurane anesthesia combined with bilateral ESP block shortens mechanical ventilation time and ICU stay, and decreases postoperative troponin-T concentration in patients undergoing off-pump coronary bypass graft surgery.

Introduction A trend towards robotic scarless surgery using remote site incisions has developed in head and neck surgery for better cosmetic outcomes. We have carried out robot-assisted excision of thyroglossal duct cysts (TGDC) by a postauricular facelift approach to avoid visible scars in the central neck related to the trans-cervical Sistrunk operation. Aim To evaluate the technical feasibility and safety of robot-assisted excision of TGDC by a postauricular facelift approach. Material and methods Six patients who underwent robot-assisted excision of TGDC by a postauricular facelift approach were analyzed. Results The robotic procedures were done successfully in all patients, without any conversion to a trans-cervical approach or incomplete removal of the lesions. In terms of cosmetic satisfaction, three patients were "very satisfied" and three were "satisfied". Conclusions Robot-assisted Sistrunk operations for TGDC by a postauricular facelift approach are feasible and safe and yield excellent postoperative cosmesis.

Introduction Cholecystectomy is associated with the risk of bile duct injury (BDI). The nature of the injury in laparoscopic cholecystectomy (LC) cases seems to be more serious. Aim We present an analysis of long-term results of the treatment of patients who underwent operations at our department due to iatrogenic excision of a part of the bile duct (EPBD). Material and methods Out of all 120 patients treated for BDI in our department we selected a group of 40 with EPBD. In all cases the corrective operation was hepaticojejunostomy. The median follow-up time was 157 (56–249) months. We evaluated risk factors for EPBD during LC compared to open cholecystectomy (OC). Results Among bile duct injuries referred to our centre, EPBD occurred more frequently during LC (46.7%) compared to OC (11%), p < 0.001. Injuries located in the hepatic hilum occurred more often in the case of LC (68.6%) than OC (20%), p = 0.056. We did not find a difference in the frequency of EPBD between LC and OC groups depending on the presence of acute or chronic cholecystitis. The narrow common hepatic duct was reported more frequently in the LC (68.6%) vs. OC (20%) group, p = 0.056. Satisfactory long-term reconstructive treatment results were observed in 36 (90%) of 40 patients. Conclusions Excision of a part of the bile duct occurs more often during LC than OC. It is often located in the hepatic hilum. Presence of a narrow common hepatic duct is a risk factor for EPBD during LC. Large diameter hepaticojejunostomy is a reconstructive procedure that promises good long-term results.

Introduction Transanal total mesorectal excision (TaTME) has been recently proposed to overcome the difficulties of the standard TME approach, allowing better visualization and dissection of the mesorectal fascia. Although TaTME seems very promising, the evidence and body of knowledge on achieving proficiency in performing it are still sparse. Aim To evaluate the learning curve of TaTME based on a single centre's experience. Material and methods Consecutive patients undergoing TaTME since 2014 in a tertiary referral department were included in the study. All procedures were performed by one experienced surgeon. CUSUM curve analyses were performed to evaluate learning curves. Results Sixty-six patients underwent TaTME. After analysis of postoperative morbidity rate, intraoperative adverse effects and operative time, we estimated that 40 cases are needed to achieve TaTME proficiency. Subsequently, patients were divided into two groups: before (40 patients) and after overcoming the learning curve (26 patients). Group 1 had higher readmission (p = 0.041) and complication rates (p = 0.019). There were no statistically significant differences in terms of intraoperative adverse effects, length of stay or pathological quality of the specimen. Conclusions Transanal total mesorectal excision is a promising yet technically demanding procedure and requires at least 40 cases to complete the learning curve. More data are needed to introduce it as a standard procedure for low rectal cancer treatment.

Introduction Although laparoscopic repair of inguinal hernia is associated with reduced postoperative pain, it is not entirely painless. In addition to reducing the need for analgesic medication, postoperative complications, and hospitalization, postoperative pain control enables early return to normal activity. Aim To evaluate the efficacy of bupivacaine instilled into the pre-peritoneal space and trocar incisions of patients undergoing laparoscopic totally extraperitoneal (TEP) repair of inguinal hernia. Material and methods Bupivacaine was instilled into the pre-peritoneal space and trocar incisions of the patients in group I (n = 23), whereas it was infiltrated only into the trocar incisions of the patients in group II (n = 21). No local anesthetic was administered to the patients in group III (n = 21). Postoperative pain was assessed using the Visual Analog Scale (VAS) at 4 and 24 h, and the dosage of analgesic medication was noted. Results No significant difference regarding age, gender, body mass index, ASA class, history of abdominal surgery, or smoking was noted between the three groups (p > 0.05). VAS score at 4 h was significantly higher in group III than in groups I and II (p < 0.05). The dosage of analgesic medication was significantly higher in group III than in groups I and II (p < 0.05), with no significant difference between groups I and II (p > 0.05). Conclusions Infiltration of long-acting local anesthetic into the pre-peritoneal space and trocar incisions of patients undergoing laparoscopic TEP repair of inguinal hernia reduces the need for analgesic medication by reducing early postoperative pain.

Introduction Ureteroscopic lithotripsy has become the first choice for the treatment of middle and lower ureteral stones, but it still has a certain rate of surgical failure. Here we aimed to determine the factors that may affect the success rate of holmium laser ureterolithotripsy (HLU) and provide the basis and guidance for its future use. Aim To evaluate the risk factors for HLU failure. Material and methods The clinical data of 385 patients undergoing holmium laser ureterolithotripsy from 2009 to 2012 were retrospectively reviewed to analyze the impact of gender, age, stone side, stone size, stone location, stone number, degree of hydronephrosis, stone impaction, previous extracorporeal shock lithotripsy (ESWL), and associated urinary tract infection (UTI) on the success or failure of surgery. Results Surgical success was achieved in 338 (87.8%) patients versus surgical failure in 47 (12.2%) patients. Univariate analysis revealed that the degree of hydronephrosis (p = 0.024), stone impaction (p = 0.003), stone location (p = 0.012), and previous ESWL (p = 0.037) were risk factors for surgical failure. Multivariate logistic regression revealed that stone impaction (odds ratio (OR) = 2.66; p = 0.018) and stone location (OR = 2.11; p = 0.013) were significantly associated with surgical failure. Since some cases of ureterostenosis developed postoperatively, we continued follow-up. The patients had the stent for a year and underwent regular follow-up checks until 5 years. No cases of ureterostenosis recurred. Conclusions Ureteroscopic lithotripsy is a safe procedure with few complications. Stone impaction and proximal location are the risk factors for its failure.

Introduction Incisional hernias can complicate up to one in four laparotomy procedures, and successful repair remains a significant clinical challenge for surgeons. Recently, the surgical technique of ventral hernia repair (eTEP-RS) has been introduced. Aim To present early results in treating patients with ventral hernia using the eTEP-RS technique and to discuss key technical aspects affecting the safety and efficiency of repair. Material and methods A prospective study of early outcomes was conducted for all ventral hernia patients (hernia orifice between 4 and 8 cm) who underwent eTEP-RS between March 2019 and July 2020. Results As of July 2020, we performed a total of 11 eTEP-RS procedures. The mean duration of the surgery was 204 min (158 to 295). The average size of the treated defect in the transverse dimension was 5.8 cm, and the defect area was 38.5 cm2. The average size of the mesh used was 486 cm2 (280 to 590). After an average follow-up of 7 months (1-17) there was no recurrence or major complication. Based on our initial experiences we present a detailed description of the main aspects of the surgical technique itself, as well as the essential nuances, to enable evaluation of the technique and future popularization. Conclusions The eTEP-RS technique is a safe alternative to open ventral hernia repair and allows for the placement of a large piece of mesh in accordance with current recommendations. Excellent knowledge of the detailed anatomy of the abdominal wall is essential for safe and effective hernia repair.

Introduction Robotic surgery is widely used in many surgical specialities, and there has been no study to assess the impact of sleep deprivation on the complex environment of robotic surgery. Aim To compare specific metrics of selected robotic simulator exercises on sleep-deprived and non-sleep-deprived surgical residents. Material and methods We enrolled 20 volunteers, residents in surgery, evaluated before and after an 18-hour overnight shift, regarding their results on virtual robotic surgery simulator – the sleep deprivation (SD) group. As a control group, the same subjects were evaluated 5–7 days after the post-shift evaluation, without having a shift overnight and at least 7 h of sleep the previous night – the non-sleep-deprivation (nSD) group. Results A statistically significant difference between the pre-shift and post-shift overall results for all exercises in the SD group and no statistical differences for the nSD group were observed. As the difficulty of the exercises increased, statistical differences were observed on specific metrics for all exercises between the pre-shift and post-shift as well as between the post-shift and the morning after a normal sleep period overnight. In a subgroup analysis, the overall results revealed a stronger statistical difference between pre-shift and post-shift for residents with more intense sleep deprivation (< 3 h of sleep vs. > 3 h of sleep). Conclusions Sleep deprivation leads to impairment of surgical skills assessed by robotic virtual simulator. The more complex and skill demanding the exercise, the higher the difference between sleep deprived and non-deprived residents.

Introduction: Bariatric procedures lead to changes in body composition. Desired fat loss may be accompanied by decrease of muscle mass, thus raising the risk of sarcopenia. Aim: To detect the risk of sarcopenia in patients 24 months after different bariatric/metabolic (B/M) procedures by DEXA. Material and methods: Consecutive patients scheduled for a B/M procedure underwent DEXA scan and anthropometric assessment before and 24 months after surgery in a prospective manner. Obtained data were tested for significant differences (p under 0.05) to detect body composition changes and occurrence of sarcopenia. The International Physical Activity Questionnaire (IPAQ) was answered at 24 months to assess physical activity. Results: Nineteen patients were enrolled, with no drop-off at follow-up. Body mass index dropped from 42.4 ±6.3 to 30.3 ±4.9 kg/m2, with excess weight loss of 72 ±25% and substantial improvement of all relevant anthropometric measurements (p under 0.001). Significant changes in DEXA parameters were observed: fat mass index (19.5 ±4.7 vs. 12.1 ±3.7 kg/m2), estimated visceral adipose area (235.8 ±70.0 vs. 126.5 ±50.4 cm2), lean mass index (22.1 ±2.4 vs. 18.1 ±2.3 kg/m2), appendage lean mass index (9.7 ±1.3 vs. 7.7 ±1.1 kg/m2), bone mineral content (1.22 ±0.1 vs. 1.12 ±0.1 kg), Z score (2.32 vs. 0.96) and T score (0.58 vs. –0.58). A low level of physical activity was recorded at 24 months. Conclusions: B/M procedures lead to significant changes in body composition at 24 months after surgery. DEXA detects these changes effectively. Desired fat loss is associated with significant reduction of skeletal muscle and bone mineral mass. As such, patients after B/M surgery are at risk of sarcopenia. A low level of physical activity may also play a negative role.

Introduction Gastroesophageal reflux is a major problem after sleeve gastrectomy. There is still insufficient understanding of how it occurs and whether it is due to the sphincter length, relaxation, or pressure differences. Aim This study evaluates the effect on the lower esophageal sphincter of the laparoscopic sleeve gastrectomy (LSG) technique applied in surgery in cases of morbid obesity using ambulatory 24-h pH monitoring (APM) and esophageal manometry (EM). Material and methods A retrospective examination was carried out on the APM and EM tests performed preoperatively and postoperatively in cases of LSG. The parameters examined were the body mass index (BMI), amplitude pressure of the esophagus (AP), total length of the lower esophageal segment (LESL), resting pressure of the LES (LESP), residual pressure of the LES (LESR), relaxation time of the LES, intragastric pressure, and the DeMeester score. Results A total of 62 cases with available data were evaluated. A statistically significant difference was determined between the preoperative values and the 3-month postoperative values of BMI, LESP, and relaxation time of the LES. A statistically significant increase was determined in the DeMeester score, and the increase in the total number of reflux episodes longer than 5 min was found to be the most responsible for this increase. No significant difference was determined in the other parameters. Conclusions The LSG was found to cause a reduction in LESP, and an increase in acid reflux causing an extended relaxation time of the LES. This was confirmed by the increase seen in the DeMeester score.

Introduction The worldwide outbreak of morbid obesity forced contemporary medicine to adopt a multidisciplinary approach, which led to the description of metabolic syndrome (MS): a disease with self-aggravating components and one of the most important causes of morbidity and mortality. The need for therapeutic methods provoked development of metabolic surgery, which nowadays give possibilities for safe and effective treatment of all MS aspects simultaneously and improves many obesity-related comorbidities. Aim To assess the laparoscopic sleeve gastrectomy (LSG) procedure's efficiency in resolving MS components, treating comorbidities and to analyze the influence on certain biochemical markers in 1-year follow-up. Material and methods The retrospective cohort study of 211 patients after an LSG operation relied on statistical analysis of clinical data collected prospectively in follow-up visits. All applicable guidelines and bioethical recommendations were respected in this study. Results Assessment of bariatric efficiency proved the LSG operation to be effective in inducing significant weight loss and treating obesity. Analysis on the influence on MS components, such as non-insulin dependent diabetes (NIDDM), arterial hypertension (AH) and dyslipidemia, showed substantial improvement in all observed cases of these diseases. In the present study, follow-up also proved a partial remission inducing effect of this bariatric operation in many comorbidities, especially in chronic obstructive pulmonary disease, obstructive sleep apnea, peptic ulcer disease and depression. A desirable reduction in creatinine, C-reactive protein, uric acid, alanine aminotransferase, asparagine aminotransferase, γ-glutamyltransferase serum levels has also been observed during the follow-up. Conclusions The LSG is an effective method of treatment in all areas of metabolic syndrome, provides a significant positive clinical outcome in obesity-related comorbidities and induces desirable changes in inflammatory, kidney and liver related biomarkers.