Can the prophylactic administration of tranexamic acid reduce the blood loss after robotic-assisted radical prostatectomy? Robotic Assisted Radical Prostatectomy with tranEXamic acid (RARPEX): study protocol for a randomized controlled trial

Background

The prophylactic administration of tranexamic acid reduces blood loss during procedures at high risk of perioperative bleeding. Several studies in cardiac surgery and orthopedics confirmed this finding. The aim of this prospective, double-blind, randomized study is to evaluate the effect of tranexamic acid on peri-and postoperative blood loss and on the incidence and severity of complications.

Methods/design

Based on the results of our pilot study, we decided to conduct this prospective, double-blind, randomized trial to confirm the preliminary data. The primary endpoint is to analyze the effect of tranexamic acid on perioperative and postoperative blood loss (decrease in hemoglobin levels) in robotic-assisted radical prostatectomy. The additional endpoint is to analyze the effect of tranexamic acid on postoperative complications and confirm the safety of tranexamic acid in robotic-assisted radical prostatectomy.

Discussion

No study to date has tested the prophylactic administration of tranexamic acid at the beginning of robotic-assisted radical prostatectomy. This study is designed to answer the question of whether the administration of tranexamic acid might lower the blood loss after the procedure or increase the rate and severity of complications.

Trial registration

ClinicalTrials.gov NCT04319614. Registered on 25 March 2020

Tumor grade as significant prognostic factor in pancreatic cancer: validation of a novel TNMG staging system

Aim of the study was to asses the tumor grade prognostic value in the Czech pancreatic cancer patients and to evaluate the accuracy of TNMG prognostic model. Retrospective analysis of 431 pancreatic cancer patients undergoing pancreatic resection in seven Czech oncological centers between 2003 and 2013 was performed. The impact of tumor grade and the accuracy of TNMG prognostic model were evaluated. Lymph node status, tumor size, tumor stage and grade were proved as statistically significant survival predictors. The lower tumor differentiation (grade 3 and 4) was associated with poorer prognosis in all stages (stage I: HR 2.23 [1.14; 4.36, CI 95%] p=0.019, stage II: HR 3.09 [2.01; 4.77, CI 95%] p=0.001, stage III and IV: HR 3.52 [1.73; 7.18, CI 95%] p=0.001). Kaplan-Meier analysis verified statistically significant impact of new TNMG stages on survival after resection for pancreatic cancer (p=0.001). In conclusion, we can state that the tumor grade was confirmed as statistically significant prognostic factor in pancreatic cancer. Its incorporation into the current TNM classification enables more accurate prognosis prediction within particular clinical stages. That is why an inclusion of the grade to the standard TNM classification should be discussed.

Solid pseudopapillary tumour of the pancreas: diagnosis, treatment, and prognosis

BACKGROUND

Solid pseudopapillary tumour (SPT) of the pancreas is a relatively rare entity which most commonly occurs in young women. In this paper we report our clinical experience together with the current knowledge on the diagnostics, treatment and prognosis of this rare tumour.

METHODS

We reviewed hospital records of patients diagnosed with a solid pseudopapillary tumour of the pancreas between January 2002 and December 2011 at the Department of Surgery, University Hospital Hradec Králové, Czech Republic. Clinical, operative, pathological data were obtained on all the patients.

RESULTS

Over the 10-year period of the study we performed 181 planned pancreatic resections in our department. Overall, the 30-day postoperative mortality rate in this series of patients was 2.2%. SPT was diagnosed in 4 cases. All the patients were women and the average age was 34 years. Preoperative endosonography with biopsy sample was performed in all the patients and the diagnosis of SPT was known in all the patients before the surgical procedure.

CONCLUSIONS

The current knowledge of SPT is based only on case reports and small series. It typically occurs in young women and therefore the presence of a large pancreatic mass in a young woman may suggest a diagnosis of SPT. SPT has a low malignant potential and the prognosis is excellent following complete surgical resection in the majority of the cases.

[Current trends of surgical therapy of focal liver and pancreatic lesions]

Focal liver and pancreatic lesions represent important therapeutic problem in a relatively huge group of patients. Secondary liver tumors are the crucial factor affecting morbidity and mortality in patients with malignancies. Radical surgery is the only therapeutic option that gives the chance of long-term survival. The authors present current trends in surgical therapy of liver and pancreatic tumors as a review article.

[Laparoscopic pancreatic resections in experimental setting and clinical practice]

INTRODUCTION

Pancreatic fistula is a major postoperative complication after pancreatic resection. One of the main risk factors of developing the pancreatic fistula after distal pancreatectomy is the method employed for the management of the pancreatic remnant.

AIM OF THE STUDY

The aim of the experimental part of this work was to test a novel method of management of the pancreatic remnant after distal pancreatectomy on a large laboratory animal. Furthermore, based on the experience with the experimental work to introduce the laparoscopic approach to human clinical practice.

METHODS

In the experimental part of the work laparoscopic distal pancreatectomy with spleen and splenic vessels preservation was performed in ten female domestic pigs. The experimental animals were divided into two groups. In the first group the pancreas was transected using an EndoGIA Universal Stapler and in the second group, the pancreas was transected using a Ligasure device and the pancreatic remnant was reinforced with hydrogel sealant Pleuraseal. We introduced the laparoscopic distal pancreatectomy to clinical practice in the Department of Surgery in Hradec Králové in 2009. Transection of the pancreas was performed with staplers.

RESULTS

In the experimental part of the work the postoperative course was uneventful in all the animals. All animals gained weight. Only minor macroscopic and microscopic alterations of the healing process were found. Statistical differences between the groups were not significant. In the clinical part of the work we performed laparoscopic distal pancreatectomy in 6 patients. We performed two distal pancreatectomies with splenectomy, one distal pancreatectomy with splenectomy and left nephrectomy and 3 distal pancreatectomies with the spleen and splenic vessels preservation. We did not have to convert to open procedure in any of the cases.

CONCLUSIONS

In the experimental part of the work we showed that the novel technique using Ligasure transection reinforced by the hydrogel sealant Pleuraseal is feasible and safe technique, which seems to be comparable with the standard transection technique using stapler. Our initial experience with laparoscopic distal pancreatectomy in the clinical practice cannot be used to compare various methods of management of the pancreatic stump or to evaluate the rate of pancreatic fistula in such small group of patients.

Papillary adenoma of the extrahepatic biliary tract--a rare cause of obstructive jaundice

The authors present a case of papillary adenoma of the extrahepatic biliary tract presenting as obstructive jaundice. The diagnosis was based on the endoscopic retrograde cholangiopancreatography (ERCP), and above all cholangioscopy findings. The patient was treated by bile duct resection with Roux-en-Y hepaticojejunostomy. Adenoma of the bile duct is a rare entity. Only a few cases have been described in the world literature so far.

[Numbers of lymph nodes in large intestinal resections for colorectal carcinoma]

INTRODUCTION

Precise evaluation of lymph nodes in the surgical specimen is crucial for the staging and subsequent decision about the adjuvant therapy in colorectal cancer. Prognosis of the patients can be assessed only in cases when at least 12 lymph nodes in the surgical specimen are examined.

AIM OF THE WORK

To evaluate the radicalism of resections for colorectal carcinoma after introducing laparoscopic approach.

METHODS

We compared all resections for primary colorectal cancer and rectal cancer (C 18-C20) performed in the Department of Surgery in University Hospital Hradec Králové in the years 2005 and 2008 and we evaluated numbers of examined lymph nodes in the surgical specimens. The patients with recurrent tumours and the patients with complete pathological response (negative histology) after neoadjuvant therapy were excluded from the study.

RESULTS

117 patients were included in the study in 2005, 2 of them were operated laparoscopically. 155 patients (more by 32.5%) were included in the study in 2008, 53 of them (34.2%) were operated laparoscopically. In tumours of the right part of the colon (C180-C184) treated by right hemicolectomy: on an average 7.9 (+/- 5.3) lymph nodes were examined in the specimens in 2005, and 15.3 (+/- 7.0) lymph nodes in 2008. In tumours of the left part of the colon (C185-C186) treated by left hemicolectomy: 6.5 (+/- 5.1) lymph nodes were examined in 2005, and 19.6 (+/- 15.6) in 2008. In tumours of the sigmoid colon (C187) 9.1 (+/- 6.9) lymph nodes were examined in 2005,and 15.4 (+/- 7.9) in 2008. In tumours of the rectosigmoid junction (C19) 8.0 (+/- 6.9) lymph nodes were examined in 2005, and 17.8 (+/- 11.2) in 2008. In rectal cancer (C20) 5.2 (+/- 4.5) lymph nodes were examined in 2005, and 13.6 (+/- 12.5) in 2008. There is a significant difference in a number of examined lymph nodes in patients without neodadjuvant treatment compared to those with neoadjuvant chemoradiotherapy and neoadjuvant radiotherapy. In 2005, in an average 3.7 (+/- 3.3) lymph nodes were removed in rectal resections after neoadjuvant chemoradiotherapy, in 2008 in an average 7.6 (+/- 6.1) lymph nodes were removed. In 2005, in an average 5.1 (+/- 3.7) lymph nodes in rectal resections after neoadjuvant radiotherapy were removed, in 2008 6.3 (+/- 4.3) lymph nodes were removed. In 2005, in an average 7.0 (+/- 5.5) lymph nodes in rectal resections without neoadjuvant therapy were removed, in 2008 20.9 (+/- 14.1) lymph nodes were removed. Laparoscopic resections were comparable with open resections regarding the number of examined lymph nodes in our group of patients.

CONCLUSION

Introducing the laparoscopic approach to resections of colorectal carcinomas did not decrease radicalism of the operation as to the number of removed lymph nodes.

[Peroperative diagnostics of acute bowel ischemia using ultraviolet light and fluorescein dye]

Acute bowel ischemia continues to have a high mortality rate. The main factor related to this poor outcome is considered to be the delay in diagnosis. The ability to detect ischemia early and to assess the extent of bowel involvement, are the most important aspects of successful treatment. The combination of ultraviolet (UV) light and fluorescein dye would be considered a simple, reliable and technically easy procedure for diagnosis of intestinal ischemia. The method can be used both for laparotomy when the source of UV light is a Wood's lamp as well for laparoscopy when the optical filters are placed to the light source of laparoscopic set to produce UV light. Present clinical experience shows that the method is precise, objective and accessible and that it gives a greater amount of independence to the surgeon allowing him to make the diagnosis of intestinal ischemia without having to rely on the assistance of other specialists.

[Laparoscopic liver resections. Successes and failures associated with the technique introduction--case reports]

The authors present initial clinical experience with laparoscopic liver resections as a case report series. The operation time, hospital and ICU stay length, perioperative blood loss, transfusion units used, and postoperative complications were recorded in a prospective way. The reasons for conversion to open surgery were also evaluated. 15 laparoscopic liver resections were completed between May 2006 and February 2009. There were 11 anatomical resections including hemihepatectomies and 4 non-anatomical laparoscopicaly completed liver resections. The initial experience shows that laparoscopic liver resection is feasible and safesate approach that requires advances experience in laparoscopic operative technique and liver surgery. Introduction of the laparoscopic technique is not easy and is associated with high risk of hilar bile duct injuries and perioperative bleeding.

[Distal pancreatic resections: indications, surgical technique, and complications]

INTRODUCTION

Distal pancreatic resections are relatively less frequent surgical procedures than duodenopancreatectomies. This is due to lower incidence and later onset of lesion symptoms in this part of the pancreas. The aim of our work was to evaluate retrospectively the results of distal pancreatic resections performed at the Department of Surgery, University Hospital in Hradec Králové from 1996 to 2008.

METHODS

We retrospectively evaluated the indications, surgical procedure (including complications) and the postoperative course. All procedures were done through transverse laparotomy. The pancreas was transected sharply with a scalpel and the resection line was oversewn. Staplers were not used. All the patients were given Sandostatin postoperatively.

RESULTS

We performed 51 distal pancreatic resections at our department from 1996 to 2008, 40 of which were distal pancreatic resections with splenectomy (78%). We performed 149 duodenopancreatectomies in the same time period. Benign lesions or borderline lesions (chronic pancreatitis, benign tumours, borderline tumours) were found in 67% of the surgical specimens. Malignant tumours were found in 33%, most of which were adenocarcinoma. Severe pancreatic fistula developed in two patients (3.9%). Two reoperations (3.9%) were necessary due to postoperative complications. Postoperative mortality was nil.

CONCLUSION

We assume that our technique resulted in a relatively low morbidity and zero mortality. However, we used this technique in all cases, and therefore cannot compare it to other techniques.

[Truncus coeliacus stenosis in duodenopancreatectomy]

INTRODUCTION

Patients with celiac axis stenosis are asymptomatic due to the rich collateral blood supply through superior mesenteric artery. Ligating and dividing gastroduodenal artery during pancreatoduodenectomy can cause ischemic threat especially to liver, less frequently stomach and spleen, or failure of anastomoses.

CASE REPORT

The authors present a case of 27-year-old female who underwent duodenopancreatectomy for pseudopapillary tumour of the head of pancreas. Celiac axis stenosis was found peroperatively and proven during angiography. Although an attempt of endovascular dilatation of celiac axis was unsuccessful, blood supply to the liver was sufficient and therefore we did not perform any other intervention to improve blood flow to the liver. Postoperative course was uneventful.

DISCUSSION

Celiac axis stenosis can be caused by tumour infiltration or lymphadenopathy in malignant disease, atherosclerosis or compression of the median arcuate ligament. The stenosis can be managed by endovascular treatment or arterial reconstruction. In conclusion the authors propose a management algorithm to prevent the consequences of celiac axis stenosis.

[Our experience with pancreatic resection procedures. Retrospective analysis]

INTRODUCTION

Pancreatic resections are highly demanding surgical procedures, which require higher specialization of the surgical teams and concentration of the patients into the specialized centers. The aim of our study was to analyze our results of the surgical therapy at a center which performs approximately 15 resections and 20 other procedures on pancreas a year.

METHODS

A group of patients with pancreatic resection operated on at the Department of Surgery, University Hospital in Hradec Králové between 1996 and 2006 was analyzed retrospectively. Postoperative mortality and postoperative complications were recorded. Long-term survival was evaluated only in patients with carcinoma.

RESULTS

158 pancreatic resections were performed in the referred period, 116 partial duodenopancreatectomies, 1 total duodenopancreatectomy and 41 distal resections of pancreas. 30-day postoperative mortality after duodenopancreatectomy was 4.3%. There was no postoperative death after the distal resection. Severe complications were recorded in 22 patients (13.9 %). Median survival of the patients was 11 months. 15 out of 68 patients (22.1%) survived 5 years, 30 out of 89 patients (33.7%) survived 3 years.

CONCLUSION

Our results of surgical therapy are comparable with the results of other hospitals with similar frequency of the pancreas resection, regarding postoperative mortality and morbidity, also regarding long-term results.