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To achieve clinical impact in daily oncological practice, emerging AI-based cancer imaging research needs to have clearly defined medical focus, AI methods, and outcomes to be estimated. AI-supported cancer imaging should predict major relevant clinical endpoints, aiming to extract associations and draw inferences in a fair, robust, and trustworthy way. AI-assisted solutions as medical devices, developed using multicenter heterogeneous datasets, should be targeted to have an impact on the clinical care pathway. When designing an AI-based research study in oncologic imaging, ensuring clinical impact in AI solutions requires careful consideration of key aspects, including target population selection, sample size definition, standards, and common data elements utilization, balanced dataset splitting, appropriate validation methodology, adequate ground truth, and careful selection of clinical endpoints. Endpoints may be pathology hallmarks, disease behavior, treatment response, or patient prognosis. Ensuring ethical, safety, and privacy considerations are also mandatory before clinical validation is performed. The Artificial Intelligence for Health Imaging (AI4HI) Clinical Working Group has discussed and present in this paper some indicative Machine Learning (ML) enabled decision-support solutions currently under research in the AI4HI projects, as well as the main considerations and requirements that AI solutions should have from a clinical perspective, which can be adopted into clinical practice. If effectively designed, implemented, and validated, cancer imaging AI-supported tools will have the potential to revolutionize the field of precision medicine in oncology.

Laparoscopic appendectomy (LA) for treatment of acute appendicitis has gained acceptance with its considerable benefits over open appendectomy. LA, however, can involve some adverse outcomes: morbidity, prolonged length of hospital stay (LOS) and hospital readmission. Identification of predictive factors may help to identify and tailor treatment for patients with higher risk of these adverse events. Our aim was to identify risk factors for serious morbidity, prolonged LOS and hospital readmission after LA. A database compiled information of patients admitted for acute appendicitis from eighteen Polish and German surgical centers. It included factors related to the patient characteristics, peri- and postoperative period. Univariate and multivariate logistic regression models were used to identify risk factors for serious perioperative complications, prolonged LOS, and hospital readmissions in acute appendicitis cases. 4618 laparoscopic appendectomy patients were included. First, although several risk factors for serious perioperative complications (C-D III-V) were found in the univariate analysis, in the multivariate model only the presence of intraoperative adverse events (OR 4.09, 95% CI 1.32-12.65, p = 0.014) and complicated appendicitis (OR 3.63, 95% CI 1.74-7.61, p = 0.001) was statistically significant. Second, prolonged LOS was associated with the presence of complicated appendicitis (OR 2.8, 95% CI: 1.53-5.12, p = 0.001), postoperative morbidity (OR 5.01, 95% CI: 2.33-10.75, p 0.001), conversions (OR 6.48, 95% CI: 3.48-12.08, p 0.001) and reinterventions after primary procedure (OR 8.79, 95% CI: 3.2-24.14, p 0.001) in the multivariate model. Third, although several risk factors for hospital readmissions were found in univariate analysis, in the multivariate model only the presence of postoperative complications (OR 10.33, 95% CI: 4.27-25.00), reintervention after primary procedure (OR 5.62, 95% CI: 2.17-14.54), and LA performed by resident (OR 1.96, 95% CI: 1.03-3.70) remained significant. Laparoscopic appendectomy is a safe procedure associated with low rates of complications, prolonged LOS, and readmissions. Risk factors for these adverse events include complicated appendicitis, postoperative morbidity, conversion, and re-intervention after the primary procedure. Any occurrence of these factors during treatment should alert the healthcare team to identify the patients that require more customized treatment to minimize the risk for adverse outcomes.

Introduction According to meta-analyses laparoscopic appendectomy is associated with many benefits. However, in comparison to open surgery an increased rate of intraabdominal abscesses (IAA) has been reported. Identification of predictive factors for this complication may help to identify patients with higher risk of IAA. Aim To identify potential risk factors for intraabdominal abscess after laparoscopic appendectomy (LA). Material and methods Eighteen surgical units in Poland and Germany submitted data of patients undergoing LA to the online web-based database created by the Polish Videosurgery Society of the Association of Polish Surgeons. It comprised 31 elements related to the pre-, intra- and postoperative period. Surgical outcomes were compared among the groups according to occurrence of IAA. Univariate and multivariate logistic regression models were used to identify potential risk factors for IAA. Results 4618 patients were included in the analysis. IAA were found in 51 (1.10%) cases. Although several risk factors were found in univariate analysis, in the multivariate model, only the presence of complicated appendicitis was statistically significant (OR = 2.98, 95% CI: 1.11-8.04). Moreover, IAA has a significant influence on postoperative reintervention rate (OR = 126.95, 95% CI: 67.98-237.06), prolonged length of stay > 8 days (OR = 41.32, 95% CI: 22.86-74.72) and readmission rate (OR = 33.89, 95% CI: 18.60-34.73). Conclusions Intraabdominal abscesses occurs relatively rarely after LA. It is strongly associated with complicated appendicitis. Occurrence of this complication has a great influence on the postoperative period and due to the nature of its treatment is associated with the need for reintervention, prolonged length of stay and by extension possible readmission.

Laparoscopic appendectomy (LA) for treatment of acute appendicitis has gained acceptance with its considerable benefits over open appendectomy. LA, however, can involve some adverse outcomes: morbidity, prolonged length of hospital stay (LOS) and hospital readmission. Identification of predictive factors may help to identify and tailor treatment for patients with higher risk of these adverse events. Our aim was to identify risk factors for serious morbidity, prolonged LOS and hospital readmission after LA. A database compiled information of patients admitted for acute appendicitis from eighteen Polish and German surgical centers. It included factors related to the patient characteristics, peri- and postoperative period. Univariate and multivariate logistic regression models were used to identify risk factors for serious perioperative complications, prolonged LOS, and hospital readmissions in acute appendicitis cases. 4618 laparoscopic appendectomy patients were included. First, although several risk factors for serious perioperative complications (C-D III-V) were found in the univariate analysis, in the multivariate model only the presence of intraoperative adverse events (OR 4.09, 95% CI 1.32–12.65, p = 0.014) and complicated appendicitis (OR 3.63, 95% CI 1.74–7.61, p = 0.001) was statistically significant. Second, prolonged LOS was associated with the presence of complicated appendicitis (OR 2.8, 95% CI: 1.53–5.12, p = 0.001), postoperative morbidity (OR 5.01, 95% CI: 2.33–10.75, p

Breast cancer has high metastatic potential with distant metastases involving mainly lungs, liver and bones. Less frequently it gives distant spread to other organs. Herein we would like to present a very rare case of an acute cholecystitis which turned out to be a metastatic breast cancer in previously healthy woman. A female patient, 64-years old, presented to the emergency department with symptoms of biliary colic and acute abdomen. During the emergency cholecystectomy, we diagnosed the gallbladder empyema with thickened wall. There were also multiple metastatic nodules in the peritoneal cavity and an excessive amount of free fluid. The emergency physicians diagnosing female patient with the acute abdominal symptoms and a breast cancer history might suspect malignant spread into abdominal organs including gallbladder. On the other hand, acute cholecystitis symptoms might be the first symptoms of metastatic process in the gallbladder from the unknown primary source, which may be breast.

Colorectal carcinoma (CRC) is one of the leading causes of cancer-related deaths worldwide. Alterations in keratin expression, including keratin 7 (K7), are frequent findings in multiple cancers, and they constitute a prognostic factor. The aim of our study was to evaluate the prognostic significance of K7 in the primary tumour and lymph node metastases in two separate cohorts of patients: the first one with lymph node involvement (LN+, 129 cases) and the second one free of LN metastases (LN–, 85 cases). Keratin 7 expression in CRC was analysed on tissue microarrays with immunohistochemistry and evaluated using the h-score. In the LN+ group K7 positivity was identified in 7/129 (5.4%) of primary tumours (PT) and lymph node metastases (LNM); concordance between them was 94% ( 0.396). Keratin 7 was expressed in 8/85 cases (9.4%) in the LN– group. K7 expression in LNM of the LN+ cohort correlated with shorter overall survival (OS) (p = 0.047) and presence of distant metastases at diagnosis (p = 0.005). Expression of K7 in the primary tumour in both cohorts did not correlate with survival. We conclude that the status of K7 expression in metastatic lymph nodes from CRC is a poor prognostic factor.

Preoperative classification of complicated and uncomplicated appendicitis (AA) is challenging. However, the differences in surgical outcomes necessitate the establishment of risk factors in developing, complicated AA. This study was an analysis of the clinical outcomes of laparoscopic appendectomies (LA), as well as preoperative risk factors for the development of complicated AA.The data of 618 patients who underwent LA in 18 surgical units across Poland and Germany were collected in an online web-based database created by the Polish Videosurgery Society. The surgical outcomes of patients with complicated and uncomplicated appendicitis were compared. Uni- and multivariate logistic regression models were used to establish risk factors for the development of complicated appendicitis.In all, 1269 (27.5%) patients underwent LA for complicated appendicitis (Group 1) and 3349 (72.5%) for uncomplicated appendicitis (Group 2). The conversion rate, number of intra-operative adverse events, re-intervention rate, postoperative complications, and readmission rate was greater in Group 1. The preoperative risk factors associated with complicated appendicitis were: female sex (Odds ratio [OR]: 1.58), obesity (OR: 1.51), age50 years (OR: 1.51), symptoms48 hours (OR: 2.18), high Alvarado score (OR: 1.29 with every point), and C-reactive protein level100 mg/L (OR: 3.92).Several demographic and clinical risk factors for complicated AA were identified. LA for complicated appendicitis was associated with poorer outcomes.

Background: In general, the three main options for stump closure in laparoscopic appendectomy are clips, endoscopic staplers and endoloops. However, there is no gold standard, especially regarding ...

The role of adjuvant chemotherapy in stage T2-T3N0 colon cancer (CC) is controversial and there are currently no reliable factors allowing for individual selection of patients with high risk of relapse for such therapy. We searched for microRNA-based signature with prognostic significance in this group. We assessed by qRT-PCR expression of 754 microRNAs (miRNAs) in tumour samples from 85 stage pT2-3N0 CC patients treated with surgery alone. MiRNA expression was compared between two groups of patients: 40 and 45 patients who did and did not develop distant metastases after resection, respectively. Additionally, miRNA expression was compared between CC and normal colon mucosa samples and between the mismatch repair (MMR) competent and deficient tumours. Low expression of miR-1300 and miR-939 was significantly correlated with shorter distant metastasis-free survival (DMFS) in Cox univariate analysis (p.adjusted = 0.049). The expression signature of five miRNAs (miR-1296, miR-135b, miR-539, miR-572 and miR-185) was found to be prognostic [p = 1.28E−07, HR 8.4 (95 % CI: 3.81–18.52)] for DMFS and cross-validated in a leave-one-out analysis, with the sensitivity and specificity of 74 and 78 %, respectively. The expression of miR-592 was significantly associated with the MMR status (p.adjusted

Acute appendicitis (AA) is the most common surgical emergency and can occur at any age. Nearly all of the studies comparing outcomes of appendectomy between younger and older patients set cut-off point at 65 years. In this multicenter observational study, we aimed to compare laparoscopic appendectomy for AA in various groups of patients with particular interest in the elderly and very elderly in comparison to younger adults. Our multicenter observational study of 18 surgical units assessed the outcomes of 4618 laparoscopic appendectomies for AA. Patients were divided in 4 groups according to their age: Group 1—8 days. Logistic regression models comparing perioperative results of each of the 3 oldest groups compared with the youngest one showed significant differences in odds ratios of symptoms lasting >48 hours, presence of complicated appendicitis, perioperative morbidity, conversion rate, prolonged LOS (>8 days). The findings of this study confirm that the outcomes of laparoscopic approach to AA in different age groups are not the same regarding outcomes and the clinical picture. Older patients are at high risk both in the preoperative, intraoperative, and postoperative period. The differences are visible already at the age of 40 years old. Since delayed diagnosis and postponed surgery result in the development of complicated appendicitis, more effort should be placed in improving treatment patterns for the elderly and their clinical outcome.

BACKGROUND Preoperative classification of complicated and uncomplicated appendicitis (AA) is challenging. However, the differences in surgical outcomes necessitate the establishment of risk factors in developing, complicated AA. This study was an analysis of the clinical outcomes of laparoscopic appendectomies (LA), as well as preoperative risk factors for the development of complicated AA. METHODS The data of 618 patients who underwent LA in 18 surgical units across Poland and Germany were collected in an online web-based database created by the Polish Videosurgery Society. The surgical outcomes of patients with complicated and uncomplicated appendicitis were compared. Uni- and multivariate logistic regression models were used to establish risk factors for the development of complicated appendicitis. RESULTS In all, 1269 (27.5%) patients underwent LA for complicated appendicitis (Group 1) and 3349 (72.5%) for uncomplicated appendicitis (Group 2). The conversion rate, number of intra-operative adverse events, re-intervention rate, postoperative complications, and readmission rate was greater in Group 1. The preoperative risk factors associated with complicated appendicitis were: female sex (Odds ratio [OR]: 1.58), obesity (OR: 1.51), age >50 years (OR: 1.51), symptoms >48 hours (OR: 2.18), high Alvarado score (OR: 1.29 with every point), and C-reactive protein level >100 mg/L (OR: 3.92). CONCLUSION Several demographic and clinical risk factors for complicated AA were identified. LA for complicated appendicitis was associated with poorer outcomes.

Introduction Absent today is a simple numerical system of outcomes assessment that recognizes that bariatric surgery is metabolic surgery and incorporates weight loss, hypertension control, and type 2 diabetes control. Aim To introduce a simple, new Numerical Scale to Assess the Outcomes of Metabolic Surgery (NOMS). Material and methods For the stratification of weight outcomes, we used the percentage excess weight loss (%EWL); for hypertension, the systolic blood pressure (SBP) and diastolic blood pressure (DBP) combined with medication usage; and for type 2 diabetes, the hemoglobin A1c (HbA1c) value combined with medication usage. Results Utilizing the guidelines of the American Diabetes Association, the Working Group of the European Society of Hypertension, the European Society of Cardiology, and the American College of Cardiology/American Heart Association, we propose for %EWL: W1 ≥ 50, W2 > 25 and < 50, and W3 ≤ 25; for hypertension H1 SBP/DPB < 140/90 mm Hg on no medication, H2 SBP/DBP ≥ 140/90 mm Hg with improvement of SBP or possible reduction of antihypertensive medication, and H3 no change or SBP higher than before surgery; for diabetes mellitus D1 HbA1c ≤ 7% and no medication, D2 HbA1c > 7% with a decrease of the HbA1c level or possible reduction of medication, D3 no change in HbA1c or HbA1c higher than before surgery. Designations of H0 and D0 are given if hypertension or diabetes was not present before surgery. Patient examples for numerical scores are provided. Conclusions The introduction of our numerical scale (NOMS) can be of benefit in metabolic/bariatric outcomes assessment; communications among metabolic/bariatric surgery centers, physicians, and patients; and for more precise reporting in the evidence-based literature.

We describe an extracorporeal staple technique used to treat severe colostomy stenosis under analgo-sedation, thus avoiding relaparotomy. The surgery is performed under short-term sedation. The orifice of the stoma is widened and overgrowing skin is excised. The volume and diameter of the stoma are assessed. The anvil of a circular stapler device is inserted into the lumen of the colostomy. First bowel layers and then skin are closed with purse-string sutures. One firing of the stapler is used to reshape the stoma. The procedure takes around 20–30 min. One circular stapler is used. The patient can be discharged the same day or a day after surgery. No complications were noted in operated patients. At 6- and 12-month follow-ups, a slight narrowing of the colostomy was visible, but no recurrence of the stricture was noted. The described technique is an interesting, easy and safe alternative to previous methods of treatment for stenosed end-colostomy. Importantly, it is an extra-abdominal procedure and may be offered to patients with a history of multiple abdominal operations or with serious coexisting medical conditions in the one-day surgery setting.

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.

Introduction: Hemorrhoidal disease is one of the commonest anorectal disorders worldwide. Stapled hemorrhoidopexy (SH) is a treatment modality associated with low postoperative pain and early mobilization. Aim: To assess long-term outcomes after SH. Material and methods: All 326 patients who underwent SH in 1999–2003 were invited by mail to participate. For each patient we analyzed their medical records, and conducted a questionnaire survey and a digital rectal examination. Results: Only 91 patients attended the final examination and the mean ± SD follow-up time was 8.7 ±1.2 years. Recurrences were diagnosed in one third of the 91 subjects. There were correlations between recurrences and: the duration of disease (p = 0.047); female gender (p = 0.037); and childbirth (vaginal delivery) (p = 0.026). Sixty-seven patients (73.6%) were satisfied with the outcomes. In the group of dissatisfied patients symptoms such as pain (p = 0.0001), burning (p = 0.0002) and itching (p = 0.014) were most common. Long-term outcomes were good with 75% and 88% reductions in pain sensation and severe and moderate hemorrhoidal bleeding. Pruritus, burning and discomfort resolved in more than 50% of patients. Flatus incontinence, fecal incontinence, or soiling occurred in 21%, 11%, and 32% of patients. Conclusions: Long-term results of stapled hemorrhoidopexy are satisfactory in most patients. The 36% recurrence rate correlates with the degree of hemorrhoidal prolapse before the operation, duration of the disease, female gender, and previous vaginal delivery.

Wprowadzenie. Rak pecherzyka zolciowego (gallbladder cancer — GBC) jest piątym z kolei, najczestszym rakiemw obrebie przewodu pokarmowego. Celem naszego badania bylo określenie wlaściwej rozleglości leczenia chirurgicznegou chorych na raka pecherzyka zolciowego w zalezności od wielkości guza pierwotnego, określenie wlaściwegopostepowania z przewodem zolciowym wspolnym, zakresu resekcji wątroby i usuniecia wezlow chlonnych.Material i metody. Badanie przeprowadzono w oparciu o ocene grupy 16 chorych operowanych z powodu rakapecherzyka zolciowego w Oddziale Chirurgii Onkologicznej Wojewodzkiego Szpitala Specjalistycznego im. JanuszaKorczaka w Slupsku w latach 2006–2009.Wyniki. Średni wiek w badanej grupie 16 chorych na raka pecherzyka zolciowego wynosil 67 (55–87) lat. Bylo 15 kobieti 1 mezczyzna. U 15 chorych stwierdzono kamice zolciową, 1 mial pecherzyk porcelanowy. Badana grupa stanowila1% chorych, u ktorych wykonano cholecystektomie. Badanie histopatologiczne u 14 chorych wykazalo obecnoścadenocarcinoma, u 1 — carcinoma mucinosum, a u 1 — oba te utkania. Ceche G1 stwierdzono u siedmiu chorych,G2 — u pieciu, G3 — u czterech. Ceche T1 stwierdzono u pieciu chorych (T1a u 4 i T1b — u 1), ceche T2 — u trzech,T3 — u siedmiu i T4 — u jednego. Dziesieciu chorych zakwalifi kowano do rozszerzenia resekcji (4 konwersje, 6 relaparotomii).Ceche N1 stwierdzono u sześciu chorych, M1 synchronicznie — u dziesieciu, metachronicznie — u czterech.5-letnie przezycie obserwowano u 3/16 (18%) chorych, średni okres przezycia wyniosl 6 miesiecy.Podsumowanie. Podstawowym zadaniem operacyjnego leczenia chorych na raka pecherzyka zolciowego jest osiągniecieresekcji R0. Powtorne wkroczenie i poszerzenie zakresu resekcji jest wskazane we wszystkich guzach ≥ pT1b(pT1a+); grupa o zaawansowaniu T4 wymaga indywidualnych decyzji. W wiekszości przypadkow wystarczającymzakresem leczenia operacyjnego jest resekcja klinowa wątroby i regionalna limfadenektomia; nie stwierdzono korzyściw postaci dluzszego przezycia po resekcji przewodu zolciowego wspolnego i zyly wrotnej.

Introduction: With the introduction of new surgical equipment, there is always the need for new, more advanced train - ing. The authors try to answer whether the use of the newest generation tools has an impact on achieving better results in single incision laparoscopic surgery (SILS) technique during the exercises in the surgical skills laboratory. Material and methods: There were 51 participants in the study: 44 'novices' and 7 'experts'. All subjects performed the 'advanced grasping' exercise according to the FLS programme manual using four types of laparoscopic approach including two SILS ports and SILS-dedicated instruments. The outcome measures involved task completion time and the number of errors. Results: Tasks using straight laparoscopic instruments set together with classic three-port access as well as SILS access ports were finished significantly faster when compared with SILS-dedicated instruments (p < 0.05). There were no significant differences in performance times between the two setups with straight instruments (p < 0.05) and both setups with SILS-dedicated instruments, irrespective of the use of curved or dynamic articulated tools. Students with no previous laparoscopic experience had significantly worse task completion times in all tasks in comparison to stu - dents with laparoscopic laboratory training and the 'experts' group. Conclusions: The use of the straight instruments in the SILS technique remain similar to its performance in full trian - gulation. SILS-dedicated instruments paradoxically increase the task completion time irrespective of possessed skills. The study showed the necessity of a SILS-dedicated tools training programme.

Patients with gastric tumors usually present with symptoms of discomfort or pain in the epigastrium, regurgitations, nausea, vomiting or melena. Treatment options include open and laparoscopic total or partial gastrectomy and recently endoscopic mucosal resection. A case of successful endoscopic submucosal dissection is described with the unusual pathological finding of heterotopic pancreatic tissue forming a gastric tumor. The 67-year-old male patient was operated on due to the initial diagnosis of gastro-intestinal stromal tumor of the gastric trunk. Two intra-operative biopsies were negative for cancer cells. Submucosal endoscopic dissection was performed with IT and Hook knives (Olympus). A literature review was performed. The operative time was 180 min with hospital stay of 6 days. During the injection of the carmine dye and the air insufflation pneumoperitoneum occurred and remained clinically silent during the observation period. The pathology result showed a heterotopic pancreatic tissue type 2 according to Heinrich's classification with microfoci of intestinal metaplasia. Preoperative diagnostics of gastric masses might be misleading and such tumors not necessarily should be excised. There are several surgical options with endoscopic submucosal dissection being probably the safest one and a non-disabling approach. Patients tolerate that kind of surgery well with good postoperative functional outcomes.

More than 1 million inguinal hernia repairs are performed in Europe and the US annually. Although antibiotic prophylaxis is not required in clean, elective procedures, the routine use of implants (90% of inguinal hernia repairs are performed with mesh) makes the topic controversial. The European Hernia Society does not recommend routine antibiotic prophylaxis for elective inguinal hernia repairs. However, the latest randomized controlled trial, published by Mazaki et al., indicates that the use of prophylaxis is effective for the prevention of surgical site infection. Unnecessary prophylaxis contributes to the development of bacterial resistance and significantly increases healthcare costs. This review documents clinical trials on inguinal hernia repairs with mesh and summarizes the current knowledge. It also tries to solve certain problems, namely: what constitutes a real risk factor, late-onset infection, and how the “surgical environment” impacts on the need to use antibiotic prophylaxis.

In recent years, multiple studies have proved laparoscopic total mesorectal excision (TME) to be as safe and as effective in rectal cancer treatment as open surgery, with the undeniable benefit of perioperative trauma reduction. Decreasing the number of incisions and performing single-port surgery could have further reduced the trauma. A new access device, QuadPort™ Olympus, enables operations from just one small transumbilical incision, leaving a barely visible scar afterwards. This is one of the first reports of transumbilical laparoendoscopic single-site TME for rectal carcinoma. A 73-year-old woman presented with tubulo-villous adenoma with high-grade dysplasia and focal adenocarcinoma in situ at 7 cm from the anal verge. She had TME performed via a QuadPort™, Olympus, in line with principles of laparoscopic TME. The operating time was 80 min. There were no adverse events during the procedure. Total blood loss was less than 100 ml. There were no complications in the postoperative period. The patient required only non-opioid analgesia, during the first 2 days. The patient was discharged on the 3rd postoperative day with standard recommendations. Feasibility and safety of the proposed transumbilical laparoendoscopic single site TME for rectal carcinoma was proved. It is a technically demanding procedure, requiring appropriate laparoscopic skills. The QuadPort provided good oncological protection of the wound and easy specimen extraction. Reduced operative trauma resulted in no opioid administration in the perioperative period. Hospital stay was comparable with laparoscopic TME but the cosmetic effect was much better.

Introduction: Laparoscopic sleeve gastrectomy (LSG) as a stand-alone or a first step in the biliopancreatic diversion - duodenal switch (BPD-DS) procedure is frequently the surgery of choice for the 21st century's epidemic of morbid obe- sity. To date, LSG as a relatively new method has few complications reported and analysed. Aim: The article describes splenic infarction, not reported so far, a potentially serious complication of LSG, analyses its causes, and suggests a considerate treatment and follow-up protocol. Material and methods: During the observation period between March and November 2008, 24 LSG patients (20 female and 4 male) were enrolled with mean body mass index of 44 kg/m 2 . All LSG procedures were recorded. Computerized statistical software Statistica 7 StatSoft, Krakow, Poland was used for analysis. Statistical significance was calculated with nonparametric tests (p < 0.05). Results: In 4 patients (17%) splenic infarction was diagnosed intraoperatively. Consecutive angio-CT scan confirmed infarction of the upper splenic pole with 12% to 33% of the splenic pulp affected. Two out of 4 patients had one minor perioperative complication. There were no significant differences between patients. Video analysis excluded possible technical errors. Conclusions: The described analysis suggests short gastric vessels and upper terminal splenic artery branch dissection as possible causative factors of splenic infarction in the course of LSG. We suggest a considerate protocol with abdom- inal cavity inspection at the beginning and end of the procedure, angio-CT scans, prophylactic LMWH, initial broad spectrum intravenous antibiotics, and appropriate follow-up with neither splenectomy nor related immunization.

Laparoscopic adjustable gastric banding (LAGB) remains the most popular surgical modality for obesity management in Europe. The aim of this publication is to present a 5-year experience in obesity treatment with LAGB operation with the assessment of outcomes, frequency of complications, and their management. Management of the band-related complications is crucial for continuous obesity treatments, despite the fact of initial failure, allowing further excess weight loss in patients with morbid obesity.One hundred sixty patients underwent the LAGB procedure with standard pars flaccida technique during the years 2005-2009. A retrospective analysis of the data was performed; chi-squared test and Student's t test at the level of significance of p 0.05 were used. Information on reoperations was gathered from hospital case notes.In the presented group, the mean body mass index (BMI) was 48.13 kg/m(2) (33.46-83.04 kg/m(2); standard deviation [SD] ±8.45). Of the patients, 36.2% had super morbid obesity with BMI50 kg/m(2). The mean observation period reached 549 days (31-2,026 days; SD ±390.1), with the mean number of control visits of 4.2 (1-12). The mean percentage of excess weight loss during the observation period was 34% (from -9.9% to 85.1%; SD ±20.6), with the mean body mass reduction of 24.4 kg. Complications appeared in 30 patients (20.1%). Twenty-four patients (16.1%) required reoperation. There were no mortalities recorded.The mean operative time of 59 min was relatively short. Morbidity and mortality rates were comparable to many published series. Failure or complications of LAGB did not stop the obesity treatment. Most of the band-related complications occurred late and could be provided for laparoscopically.

In oncological patients with upper gastrointestinal tract tumours, dysphagia and cachexy necessitate gastrostomy or jejunostomy as the only options of enteral access for long-term feeding. In this article the authors describe a modified technique of laparoscopic feeding jejunostomy applied during the staging laparoscopy. A 48-year-old male patient with gastroesophageal junction tumour and a 68-year-old male patient with oesophageal tumour were operated on using the described technique. Exploratory laparoscopy was performed. Then the feeding jejunostomy was made using a Cystofix® TUR catheter. The jejunum was fixed to the abdominal wall with four 2.0 Novafil™ transabdominal stitches. Two additional sutures were placed caudally about 4 cm and 8 cm from the jejunostomy, aiming at prevention of jejunal torsion. Total operating time was 45 min. There was no blood loss. There were no intraoperative complications. The only adverse event was one jejunostomy wound infection that responded well to oral antibiotics. There were no mortalities. The described technique has most of the benefits of laparoscopic feeding jejunostomy with some steps added from the open operation making the procedure easier to perform as part of a staging operation with a relatively short additional operating time. The proposed transabdominal stitches make the technique easier to apply. Two additional ‘anti-torsion sutures’ prevent postoperative volvulus. Use of the Cystofix catheter allows easy introduction of the catheter into the peritoneal cavity and the jejunal lumen, providing a good seal at the same time. Further studies on larger groups of patients are required to assess long-term outcomes of the proposed modified technique.

Despite their current limitations, metabolic surgery and natural orifice transluminal endoscopic surgery (NOTES), set new horizons. In this article, the first three cases of adjustable gastric banding (AGB) through transvaginal access in obese women are described.In the General and Vascular Surgery Department, Ceynowa Hospital, Poland, three cases of AGB through the transvaginal access in hybrid, laparoscopically assisted NOTES technique were performed. All patients were female with BMI range 35-37. A dual-channel endoscope and regular laparoscopic instruments were used.The mean operating time was 110 min. Indometacin was given intravenously PRN for postoperative pain. None of the patients required more than 3 g of indometacin and for longer than 24 h postoperatively. None required opioids either. There was one major complication of iatrogenic damage to the ureter, which required subsequent hospitalisation and laparoscopic repair. Hospitalisation time was 2 days. During 2 months follow up, the mean weight loss was 15 kg. There were no malpositions of the band. There was no early mortality in the study group.Feasibility of the proposed hybrid laparoscopically assisted NOTES adjustable gastric banding was proved. It is a technically demanding procedure, requiring appropriate endoscopic and laparoscopic skills. To avoid ureteric damage one should acquire safe colpotomy skills before commencing transvaginal NOTES operations.

Aim: To present a novel technique of a laparo-endoscopic single site (LESS) distal pancreatic resection via the umbilicus with use of the QuadPort TM Access System. Material and methods: The technique of distal pancreatic resection through a 30 mm longitudinal incision in the umbilicus is described. Medial to lateral approach of pancreas preparation using a harmonic scalpel and regular laparoscopic instruments is applied. The described technique was successfully applied in a 26-year-old female patient with tumour of the pancreatic body and tail (90/41/27 mm). Pancreatectomy was followed by splenectomy due to infiltration of the splenic vessels. Results: Total operative time was 160 min. Blood loss was 800 ml. Initial wound size was 30 mm. Splenic vein and artery infiltration forced augmentation of the wound to 80 mm. The patient required only per request medication. Peristalsis returned spontaneously on the first postoperative day. Hospital stay was 4 days. There were no early perioperative complications. The patient required readmission due to electrolyte imbalance 7 weeks after the operation. Conclusions: The proposed operative technique of single incision laparoscopic distal pancreatectomy is difficult and challenging. Nonetheless, the authors proved that it is safe and feasible when performed by an experienced laparoscopic team.

The aim of this study was to develop a less-invasive transanal endoscopic microsurgery (TEM) operative technique that could be applied in severely ill patients. Modified technique of TEM operation with use of the TriPort Access System in place of the operative rectoscope was designed. Harmonic scalpel and regular laparoscopic instruments were used. Resection of the rectal stump tumor was performed. A 71-year-old male patient with recurrent adenocarcinoma T2N0M0 in rectal stump and ASA 4 was operated using presented technique with good outcome. Total operating time was 25 minutes. There were no adverse events during or after the procedure. Patient was fully mobilized directly after the procedure. Proposed technique can be performed in severely ill patients as it avoids anal sphincter divulsion and therefore general anesthesia. Standard laparoscopic instruments can be used at no extra cost and no need for additional skills.

Natural orifice transluminal endoscopic surgery (NOTES) is a natural consequence of evolution in minimally invasive surgery. It allows one to reduce surgical trauma and the number of complications and to improve cosmetic outcomes. It also shortens the patient’s recovery time. So far there have been only nine NOTES procedures performed in Poland and around 200 NOTES interventions performed worldwide. In this paper a transgastric diagnostic NOTES procedure in a critically ill patient is described. A 60-year-old male patient with multi-organ failure (circulatory, respiratory and renal insufficiency, with co-morbid hypothyroidism and diabetes mellitus) hospitalized in the intensive therapy unit (ITU) with unknown cause of his condition was qualified for transgastric diagnostic NOTES procedure. This intervention revealed the diagnosis of metastatic neoplastic disease and allowed persistent therapy to be avoided. Diagnostic NOTES in selected patients seems to be a very useful. It provides fast diagnosis with relatively small perioperative trauma. It is an easy procedure that requires a regular or operative endoscope, one surgeon and an endoscopic nurse. It can be done anywhere, including at the patient’s bedside. It provides specimens for histopathology and speeds up diagnostics and decision making, especially in terminally ill patients.

Introduction: Pleural empyema is the most serious, life-threatening postoperative complication of pneumonectomy, observed after 1-12% of all pneumonectomies, with bronchopleural fistula being its main cause. Aim: The aim of this publication is to present early outcomes of minimally invasive surgical management of pleural empyema. Patients were subjected to a single, complex procedure, consisting of the laparoscopic mobilization of the greater omentum and its transposition via the diaphragm into the pleural cavity to fill in the empyema cavity with the consecutive pleuro-cutaneous fistuloplasty (thoracoplasty). Material and methods: Between May 2011 and April 2013, 8 patients were qualified to undergo the procedure. The mean age was 61 years (range: 46-77 years). Presence of bronchopleural fistula was confirmed in 3 cases. The median time of treatment with thoracostomy was 14.5 months. Results: The mean operative time was 125 min. The mean duration of post-operative hospital stay was 13.5 days (range: 7-31 days). In 6 patients (75%) the objective of permanent resolution of pleural empyema was achieved. In total, 4 patients had complications: pleural empyema recurrence (2 patients), splenic injury, hiatal hernia, gastroin- testinal bleed. Two patients with empyema recurrence had Staphylococcus aureus infections prior to surgery. They were successfully managed both with prolonged thoracic drainage and antibiotics. Conclusions: Use of the greater omentum that was laparoscopically mobilized and transpositioned into the pleural cavity allows simultaneous management of the pleural empyema cavity and thoracostomy. The procedure is safe, with few direct complications. It is well tolerated and has at least a satisfactory cosmetic effect. The minimally inva- sive approach allows faster recovery and return to daily activities in comparison to the fully open technique.

UNLABELLED Over the last decade, gastric cancer treatment has changed from extensive multiorgan resections towards less invasive approaches with limited resections and a more selective lymphadenectomy. Despite all available trials, the conclusions on the extent of necessary resections still remain debatable. The aim of the study was to assess the short term outcomes (morbidity and mortality) of a total gastrectomy depending on the simultaneous splenectomy status. MATERIAL AND METHODS We performed a retrospective analysis of the records of all patients treated with a curative intent using a total gastrectomy for gastric cancer between 1997 and 2003. 49 patients fulfilled the inclusion criteria. Patients were divided into two groups: S(+) gastrectomy with splenectomy group (29 patients) and S(-) total gastrectomy with spleen preservation (20 patients). RESULTS Survival analysis at one year showed that there was no difference in survival between the two groups (p=0.84). There were six recurrences, one in the group S(+) and five in group S(-) (p>0.05). Dissemination was observed in three patients in group S(-) (p>0.05). Other complications including infectious complications, exenteration, subileus, cardiovascular insufficiency, multiorgan failure were more frequent in the S(+) group (31% v 15%) although the difference was not significant (p=0.17). CONCLUSIONS Splenectomy during gastrectomy for cancer has no statistically significant impact on short-term morbidity and mortality. Even though it does not show benefit in terms of 5-year overall survival rates it might be performed when needed in more advanced cases in properly selected patients (e.g. upper gastric T3/4 gastric cancer).

We describe a case of cardiac tamponade caused by ProTacks Autosuture used for mesh fixation during a laparoscopic Nissen operation with giant paraesophageal hernia repair. Perforations of the posterior descendent artery and epicardial vein of the right ventricle were caused by ProTacks used for Parietex Composite Mesh fixation. Protruding ProTacks were secured from inside the pericardiac sac with a synthetic vascular patch during emergency sternotomy. Quick and multidisciplinary cooperation ended with emergency cardiothoracic procedure saving the patient's life and preventing further damage to the heart muscle and its vessels.