Chylothorax treatment with thoracic duct embolization

The authors present a case of a patient with non-traumatic right-sided chylothorax which was successfully treated by thoracic duct embolization. The procedure was performed through the cisterna chyli which was visualised by intranodal lymphography. The coils and acrylic tissue glues were used for embolization. The patient has been followed for 5 months and is free of recurrence of chylothorax.

Pulmonary arteriovenous malformation managed by VATS lobectomy

Pulmonary arteriovenous malformation (PAVM) is formed by abnormal connections between pulmonary arteries and veins that bypass the pulmonary capillaries and transport deoxygenated blood through pulmonary veins to the left heart. This causes insufficient oxygenation of blood in the lungs. This condition remains symptomless for a long period of time. The most common symptoms include shortness of breath on exertion, nosebleeds, increased fatigue and a gradual development of cyanosis. Paradoxical embolism in the brain is a serious complication; it can present with a stroke or a brain abscess. Treatment of the disease consists of embolization of the pathological vascular connections, surgical resection of the affected pulmonary parenchyma and management of concomitant manifestations of the disease. PAVM in most common cases arises as a result of an autosomal dominant hereditary disorder referred to as hereditary hemorrhagic telangiectasia.  Case report: In our communication, we document the diagnostic and therapeutic management in a young patient diagnosed with PAVM after falling off his bicycle. Based on comprehensive assessments, AV malformations with a 40% shunt of the pulmonary circulation were detected. An angiographic procedure was not an appropriate option considering the type and extent of the condition. Therefore, video-assisted thoracic resection of the affected pulmonary lobe was indicated. Conclusion: PAVM is a rare finding. PAVM should be ruled out in all patients with hereditary hemorrhagic telangiectasia (HHT) signs in the oral cavity. Contrast sonography of the heart and contract CT of the chest are the methods of choice for the diagnosis. Conservative or pharmacological treat-ment fails to improve the patients status.  The condition is usually managed by embolization. Cases where PAVM is rather extensive or diffuse, where endovascular management would be inappropriate, can be well managed using endoscopic resection adequate to the extent of the condition.

[Chest drain injury of the heart]

INTRODUCTION

Injury to the heart during chest drainage is a very rare but potentially fatal complication of the procedure.

CASE REPORT

A 56-year-old, polymorbid, poorly co-operative and extremely obese patient with chronic cardiac subcompensation and pleural effusion was admitted to a district hospital. A drain was inserted into the left pleural cavity in order to evacuate the pleural effusion. Fresh oxygenated blood was flowing out from the drain. The drain was clamped immediately. Echocardiography showed drain insertion into the left ventricle. A cardiac surgeon was contacted and indicated patient transfer to a cardiac surgery department followed by an emergency surgery. During the surgery performed through a left thoracotomy, a defect in the left ventricular wall was sutured. The patient was then stabilized, transferred back to the district hospital and, after achieving cardiopulmonary compensation, discharged home.

CONCLUSION

Injury to the heart in chest drainage is a very serious iatrogenic complication. If it is to be managed successfully, the site of the insertion of the drain tip needs to be correctly identified and the drain must not be extracted. A surgical department capable of adequately addressing this complication needs to be contacted promptly, as emergency surgery may be the only lifesaving possibility.Key words: chest drainage - complication - heart injury.

Castlemans disease - surgical treatment, case reports

The authors describe their experience with surgical treatment of benign rare lymph proliferation - Castlemans disease (CD). It occurs in unicentric and multicentric forms. The very low incidence of the disease makes it very difficult to design larger prospective studies. Cases of two leading localizations of the unicentric form of CD - intrathoracic and retroperitoneal with special emphasis on the preoperative diagnosis and imaging options are described. This article underlines the curative potential of surgical treatment where a complete resection of the affected lymph node leads to eradication in almost 100% of the cases. The discussion is focused on the forms of CD - different localization, clinical symptoms and course of disease. It discusses the differential diagnosis, particularly difficult in the multicentric form, emphasizing the need to exclude malignant lymphoma. The etiopathogenesis of the disease is presented, mentioning its association with HIV (Human Immunodeficiency Virus) infection and HHV-8 (Human herpers virus 8) infection and the importance of overproduction of proinflammatory cytokines. The importance of surgical therapy for the unicentric form of CD is highlighted as compared to the multicentric form, where the surgeon´s task involves taking a biopsy - required for an accurate diagnosis.Key words: Castlemans disease - lymphoproliferation - lymphadenopathy - surgical treatment.

[PET-CT documented fast onset of treatment response to cyclophosphamide, thalidomide and dexamethasone in patients with multicentric Castlemans disease. Case description and treatment information overview]

Castlemans disease (also called angiofollicular lymph node hyperplasia) can take two forms with different prognosis: the localized form can usually be treated by a surgical intervention and has therefore a favourable prognosis. On the other hand, the multicentric form has an unfavourable prognosis and requires systemic treatment. Classic manifestations of multicentric Castlemans disease are multiple sites of lymphadenopathy, sometimes hepatomegaly and also splenomegaly or serous cavity effusions. Typical pathological laboratory levels measured in patients with this disease include an increased CRP level, anaemia of chronic diseases, and many patients have an increased total protein concentration, in some cases exceeding even 100g/ l. It is caused by a high concentration of polyclonal immunoglobulins. Typical clinical symptoms include fluctuating subfebrile or febrile temperatures, increased night sweats and fatigue usually related to anaemia. In some patients, the disease is manifested as vasculitis, frequently also affecting cerebral arteries, i.e. leading to cerebrovascular accidents. The aetiology of this disease is unclear; it is a polyclonal lymphocyte proliferation, often with differentiation into plasma cells. It is not a clonal malign disease; however, it can transform into a clonal lymphoproliferative disease. Even though it is not a malign disease in the histomorphological sense, the disease symptoms are so acute that systemic treatment is required. In the past, the treatment method of this disease used to be based on corticoids and cytostatics; however, such treatment was not always successful in achieving its objective, i.e. complete remission. In the past few years, an improvement of treatment results was accomplished by adding a new drug to the basic medication, i.e. to cytostatics and dexamethasone. Many publications describe the benefi t of adding a third drug from the IMiDs group (immunomodulatory drugs), such as thalidomide or lenalidomide. These drugs affect the formation of cytokines and block the angiogenesis, which in turn positively influences the speed of the treatment response. The second new drug that has helped in combination with classical treatment is the anti-CD20 antibody, rituximab. The third new drug to add this list is the monoclonal antibody against the interleukin-6 receptor, tocilizumab. This paper describes a rapid treatment response after combined treatment with cyclophosphamide 500mg/ m2 i.v. infusion 1st and 15th day in a 28- day cycle, dexamethasone 20mg p.o. cycle day 1- 4 and cycle day 15- 18, and thalidomide 100mg daily. In the course of the two-month treatment, the accumulation of fl uorodeoxyglucose during the PET-CT imaging has normalized; the originally pathologically enlarged nodes have become smaller, the originally elevated CRP level has normalized and the originally signifi cantly lower haemoglobin level has risen. This is the second patient with multicentric Castlemans disease in the last three years who showed a rapid response to treatment with thalidomide combined with cyclophosphamide and dexamethasone. Therefore, we consider such treatment suitable for newly diagnosed patients with multicentric Castlemans disease.

[The role of PET-CT in decision making on the treatment of localized nodular form of pulmonary AL-amyloidosis]

Depending on the extent of organism affected, there is a systemic (amyloid is deposited in the interstitial space of multiple tissues and organs) and localized (amyloid is deposited in one or a few solitary lesions) form of amyloidosis. Localized forms of amyloidosis have a significantly better prognosis than the systemic ones. The respiratory tract might be affected by diffuse interstitial involvement, associated with systemic AL-amyloidosis, as well as localised involvement of respiratory tract (localised laryngotracheobronchial amyloidosis) or pulmonary parenchyma called nodular form of localized pulmonary amyloidosis. Tracheobronchial form may affect larynx and bronchial tree, and forms plaques or nodules in the epithelium of the respiratory tract. Nodular form causes spherical or irregular lesions in the pulmonary parenchyma, indistinguishable from pulmonary parenchyma metastases. We describe a two-year follow up of a patient with nodular form of pulmonary amyloidosis. The patient had multiple lesions in both lungs, clearly visible on HRCT (High Resolution Computer Tomography) that intensively accumulated fluorodeoxyglucose (FDG) during the first PET-CT. At the time of diagnosis, the largest lesion SUV for FDG accumulation was 8.2. Histochemical analysis showed that amyloid consisted of the light λ chains, i.e. AL-amyloid. Investigations to detect a systemic form of amyloidosis, if present, were negative. The patient had no monoclonal immunoglobulin either in the urine or serum (negative immunofixation) and had normal levels of free light chains in the serum. Her symptoms were previously suggestive of the Sjögrens syndrome. However, the rheumatologist consulted at the time of diagnosis of the nodular form of pulmonary amyloidosis did not find any signs of an active systemic connective tissue disorder. CRP was repeatedly normal. When systemic AL-amyloidosis was excluded, we decided to only monitor lesion development with no treatment intervention. The patient had 3 PET-CTs. CT showed that no lesions enlarged, some lesions decreased in size slightly. It should be emphasized that follow-up PET-CTs did not show increased FDG accumulation. We assume that the increased FDG accumulation in pulmonary lesions seen during the first PET-CT was due to the activity of the cells that formed this amyloid and that this activity spontaneously ceased, leading to normalization of FDG accumulation in pulmonary nodules. PET-CT is useful for monitoring of the development of pulmonary nodular amyloidosis. Normalization of originally increased FDG accumulation in amyloid lesions suggests cessation of the process of amyloid formation and is a positive prognostic sign.

[Amyand's hernia -- a rare cause of acute abdomen]

BACKGROUND

Amyand's hernia is a rare condition in which the appendix is positioned in the inguinal hernia sac. Acute appendicitis in this situation is a extremely rare and only a few reports are found in the literature.

METHODS

Case report

RESULTS AND CONCLUSION

We report a case of acute gangrenous appendicitis with the perforation at the tip of the appendix, which was incarcerated in the right groin. We conduct a review of the literature, emphasizing possible causes and suggesting a predisposing factor for the condition.

[Pulmonary Langerhans cell histiocytosis--evaluation of the disease activity and treatment response using PET-CT (SUV(max) Pulmo/SUV(max) Hepar index). Description of own experience and literature review]

Pulmonary Langerhans cell histiocytosis (LCH) manifests with dyspnoea and a cough with no significant expectoration, with spontaneous pneumothorax being the first symptom in some patients. The disease is caused by multiple granulomas in terminal bronchioles, visible on high resolution CT (HRCT) as nodules. During the further course of the disease, these nodules progress through cavitating nodules into thick-walled and, subsequently, thin-walled cysts. LCH may affect the lungs only or multiple organs simultaneously. Pulmonary LCH may continually progress or remit spontaneously. Treatment is indicated in patients in whom pulmonary involvement is associated with multi-system involvement or when a progression of the pulmonary lesions has been confirmed. To document the disease progression, examination of the lungs using HRCT is routinely applied. Increasing number of nodules suggests disease progression. However, determining the number of nodules is extremely difficult. Measuring radioactivity of the individual small pulmonary loci (nodules) using PET is not possible due to the high number and small size of the nodules. Our centre has a register of 23 patients with LCH; the pulmonary form had been diagnosed in 7 patients. A total of 19 PET and PET-CT examinations were performed in 6 of these patients. PET-CT was performed using the technique of maximum fluorodeoxyglucose accumulation in a defined volume of the right lung--SUV(max) Pulmo. In order to compare the results of examinations performed using the same and different machines over time as well as in order to evaluate pulmonary activity, the maximum fluorodeoxyglucose accumulation in a defined volume of the right lung (SUV(max) Pulmo) to maximum fluorodeoxyglucose accumulation in a defined volume of the liver tissue (SUV(max) Hepar) ratio (index) was used. The disease progression was evaluated using the SUV(max) Pulmo/SUV(max) Hepar index in the six patients with pulmonary LCH. The index value was compared to other parameters characterising the disease activity (HRCT of the lungs, examination of pulmonary function and clinical picture). The SUV(max) Pulmo/SUV(max) Hepar index correlated closely with other disease activity parameters. The traditional PET-CT examination is useful in detecting the LCH loci in the bone, nodes and other tissue but not in the presence of diffuse involvement of pulmonary parenchyma. Measuring the maximum fluorodeoxyglucose accumulation in a defined volume of the right lung and expressing this activity as the SUV(max) Pulmo/SUV(max) Hepar index appears to be a promising approach. Our initial experience suggests that the results obtained using this method correlate well with other parameters that characterise activity of pulmonary LCH. However, this is a pilot study and further verification is required.

Significance of urban and agricultural land use for biocide and pesticide dynamics in surface waters

Biocides and pesticides are designed to control the occurrence of unwanted organisms. From their point of application, these substances can be mobilized and transported to surface waters posing a threat to the aquatic environment. Historically, agricultural pesticides have received substantially more attention than biocidal compounds from urban use, despite being used in similar quantities. This study aims at improving our understanding of the influence of mixed urban and agricultural land use on the overall concentration dynamics of biocides and pesticides during rain events throughout the year. A comprehensive field study was conducted in a catchment within the Swiss plateau (25 km(2)). Four surface water sampling sites represented varying combinations of urban and agricultural sources. Additionally, the urban drainage system was studied by sampling the only wastewater treatment plant (WWTP) in the catchment, a combined sewer overflow (CSO), and a storm sewer (SS). High temporal resolution sampling was carried out during rain events from March to November 2007. The results, based on more than 600 samples analyzed for 23 substances, revealed distinct and complex concentration patterns for different compounds and sources. Five types of concentration patterns can be distinguished: a) compounds that showed elevated background concentrations throughout the year (e.g. diazinon >50 ng L(-1)), indicating a constant household source; b) compounds that showed elevated concentrations driven by rain events throughout the year (e.g. diuron 100-300 ng L(-1)), indicating a constant urban outdoor source such as facades; c) compounds with seasonal peak concentrations driven by rain events from urban and agricultural areas (e.g. mecoprop 1600 ng L(-1) and atrazine 2500 ng L(-1) respectively); d) compounds that showed unpredictably sharp peaks (e.g. atrazine 10,000 ng L(-1), diazinon 2500 ng L(-1)), which were most probably due to improper handling or even disposal of products; and finally, e) compounds that were used in high amounts but were not detected in surface waters (e.g. isothiazolinones). It can be safely concluded that in catchments of mixed land use, the contributions of biocide and pesticide inputs into surface waters from urban areas are at least as important as those from agricultural areas.

[Complications in patients undergoing pulmonary oncological surgery]

AIM

A survey evaluating incidence and risk factors of complications in persons underwent complete open lung resection because of primary or secondary lung malignancy.

MATERIAL AND METHODS

Retrospective study of 189 open surgery procedures in 128 males and 61 females, mean age males 61 years (range 21-78), females 64 years (range 33-80) during a five-years period (2003-2007). Data processing and analysis were performed with the statistical software system Statistica and compared by parametres odds ratio a chi2 test.

RESULTS

Complications were divided into five groups. First group was defined as complications in perioperative period and was composed of three events 1.5%: endotracheal tube dysfunction (i.e. 0.5%), heavy cardiac arrhytmia 0.5% and serious haemorrhage, that occurred immediately after operation 0.5%. Second group includes complications within period of 7 days after surgery: prolonged air leak (PAL > 7 days) 7.4%, bronchopneumonia 6.9%, cardiac arrhythmia 6.9%, postoperative delirium 4.2%, atelectasis 2.6%, wound infection 1.1%, bleeding 1.1% and chylothorax 0.5%. Third group contains events between 8th and 30th postoperative days: thoracic empyema 2.1%, dysphonia 2.1%, painfull shoulder 1.1%, alimentary tract infection 0.5% and bronchial closure insufficiency 0.5%. Fourth group contains patients with severe complications, that led to death during 30 days after operation: ischemic stroke 0.5% and pulmonary embolism 0.5%. Patients without any complication formed the fifth group of 60.5%.

CONCLUSION

Main risk factors for complications in postoperative period after lung resection due to primary or secondary lung malignancy in our group of patients are COPD, corticotherapy, time of operation over 3 hours, BMI over 25, left side tumor localization and bronchoplastic procedure. For cardiac arrhytmia seems to be risk factor pneumonectomy and previous neoadjuvant radiochemotherapy.

[Spontaneous pneumothorax--management, therapy]

OBJECTIVE

Spontaneous pneumothorax (SPNO) is a surgical disease, which belongs to surgical emergencies. It is divided into a primary, secundary, katamenial and neonatal. A young and healthy men are affected by primary SPNO, usually on the right side of the thorax, recurrence is common. A secondary SPNO typically occurs in patients between the 5th and 7th decenium. These patients usually suffer from some lung disease. A major complications are more common in this type of pneumothorax.

METHODS

At Department of surgery, University Hospital Brno, 73 patients were treated for spontaneous pneumothorax from the January, 2006 till August, 2008. We divided patients in two groups. The first one with primary SPNO, and the second one with secondary SPNO. Hospital stay, age distribution, type of operation, duration of drainage, postoperative complication, histological findings and laterality were followed up retrospectively.

RESULTS

In group of primary SPNO, 24 patients were operated without major complication. The most frequent cause was bullate emphysema, hospital stay was 8 days, duration of drainage 6 days. The second group with secondary SPNO, five patients were operated, hospital stay was 16.5 days, duration of drainage 10 days. Haemothorax as a postoperative complication occured in one case. In both groups we proved the bullate emphysema as the most frequent cause, as well as a right - sided involvement.

CONCLUSION

Spontaneous pneumothorax is a surgical disease. It's treatment has to be provided by surgeon, if possible by a thoracic specialist. The first occurrence of spontaneous pneumothorax is treated by drainage, the recurrence by operation. The principal is to combine an atypical resection of affected lung with a mechanical pleurodesis. Postoperative complications are not frequent.

[Antibiotic prophylaxis in colorectal surgery]

OBJECTIVE

Antibiotic (ATB) prophylaxis is generaly recommended in surgery. There is an important role in colorectal surgery especially. Colorectal surgery is associated with a particularly high risk of post-operative infection because of contamination of the wound with faecal bacteria. ATB prophylaxis decreases surgical wound infection, morbidity and mortality as well. Morbidity and mortality are associated with longer hospital stays and increased costs of care.

METHOD

At surgical department of Faculty hospital Brno, during March-June 2008 an 88 patients were operated because of different diagnoses in colorectum. Both an emergent and schedule operations were made. Type of ATBs, time of application before operation, reapplication after operation and surgical site infection (SSI), in - hospital stay were followed up prospectively. SSI were divided into superficial, deep and intraabdominal. Data were analyse statistically.

RESULTS

The most used combination of ATBs, almost in 91%, were Cefazoline and Metronidazole. In 50% were time of application till 20 minutes before incision. Only in 17% were time of application in interval 20-30 minutes before incision, which is recommended. We noticed 25 SSI. We prove that patients with SSI has almost two-times longer in-hospital stay. Enterococcus and enterobacterias were the most common etiological agents.

CONCLUSION

ATB prophylaxis is indicated in colorectal surgery. It has to be applied in correct dose and right time before operation to decrease SSI.

[Experience with treatment of thoracic empyema during seven years period]

The authors prospectively assembled group of 157 patients treated for empyema thoracic during seven years period. They followed applied methods of the diagnostics and therapy, the length of hospital stay after surgical intervention and its successfulness. The parameters were statistically evaluated. The results showed that surgical intervention substantially influences shortening of the hospital stay and successful cure. In the early stages of the disease thoracoscopic treatment is often sufficient to eliminate the infection. When is indicated later then three weeks after onset of the effusion, then facilitates early decontamination of the empyema cavity and possibility to perform lung decortication. In patients with thoracic empyema, where adequate effusion evacuation can not be reached, the conservative treatment results in prolongation of the hospitalization. Surgical intervention on the contrary the hospital stay, without increase in morbidity or mortality, shortens.

[Our experience with treatment of postoperative pain in Crohn's disease]

When conservative options for the treatment of Crohn's disease are exhausted, surgical treatment of complications is indicated. Based on our experience, it appears that the pain thershold is reduced in these patients and, compared to other patients undergoing comparable procedures, they poorly tolerate postoperative algesia. In the report, the authors concentrated on postoperative analgesia, considering the altered pain perception of the subjects, with the aim to define the best analgesic procedure.

[Aortointestinal fistula--a serious complication of surgery on aortic and pelvic arteries]

Aortoenteral fistula (AEF) is a rare, but a serious complication in the vascular surgery. It may occur as a primary or a secondary fistula. The principal sign of the condition is bleeding from the gastrointestinal tract (GIT), which, depending on its severity, may present with various symptoms (anemia, melena, hematemesis). The authors describe three cases of patients who experienced AEF. In all the cases, signs of massive GIT bleeding were present with a rapid development of hemorrhagic shock. In a single case, the primary fistula was concerned, in two cases the fistula was secondary. The perioperative mortality rate reached 66%. The surgical management approach is discussed in the article, and early diagnosis and prevention of the complication is emphasized.

[Utilization of continuous elimination methods at the surgical ICU]

The authors inform about the causes of introduction and use of continuous veno-venous hemofiltration at theirs intensive care unit. They describe in details this technique. They present theirs experience in this field and give the overview of the development of its indication in the last years. Based on group of 46 patient results, they recommend implementation of this technique to intensive care units, where surgical patients with organ insufficiency are treated as highly positive and essential.

Changes of vertical skeletal morphology in patients with complete unilateral and bilateral cleft lip and palate

OBJECTIVE

The aim of this retrospective investigation was to qualify and quantify changes of the vertical skeletal morphology during puberty in cleft patients compared with an age-matched noncleft control.

METHODS

Patients with unilateral cleft lip and palate (UCLP; n = 12) and bilateral cleft lip and palate (BCLP; n = 11) who fulfilled strict inclusion criteria according to the Hanover treatment protocol were evaluated by means of cephalometric analysis. Lateral cephalograms were analyzed for each cleft patient at age 10 and 15 and compared with corresponding data of a noncleft control (n = 20).

RESULTS AND CONCLUSIONS

It was concluded that a vertical growth impairment of the maxilla is found in patients with cleft lip and palate. The maxilla of cleft patients shows a significant clockwise rotation, whereas the inclination of the mandible shows little difference. Consequently, there is a skeletal superposition of the jaws. The posterior height of the maxilla is significantly shorter in patients both with UCLP and BCLP at T(0) and T(1). An increase of the anterior height of the mandible is found in the cleft groups.

Vertical Changes in Patients with Complete Unilateral and Bilateral Cleft Lip, Alveolus and Palate

AIMS AND METHODS

Twelve UCLP and eleven BCLP patients who had been treated according to the Hanover treatment protocol were evaluated by means of cephalometric analysis and cast measurements. The aim of this investigation was to demonstrate changes in the vertical plane and in incisor position in the course of craniofacial growth compared to age-matched non-cleft controls. Lateral cephalograms and casts were analyzed for each cleft patient at age 10 and 15 and compared with corresponding data of a non-cleft control group (n = 20).

RESULTS

A vertical growth impairment of the maxilla was registered in patients with cleft lip, alveolus and palate. The maxilla of the cleft patients showed a significant clockwise rotation while the inclination of the mandible remained virtually unchanged. Both upper and lower incisors, which were significantly retruded at the beginning of the late mixed dentition, could be protruded in the course of craniofacial growth, development of the dentition and treatment, but remained retruded in comparison with the non-cleft controls. The posterior midfacial height was highly significantly shorter in both UCLP and BCLP patients at both evaluation timepoints, whereas the anterior lower jaw height was greater than in the control group

Laparoscopic resection of surface metastases in liver--description of the technique

Recently, the laparoscopic approach has been used more frequently for liver resection. The authors describe the method of laparoscopic resection of surface as well as subcapsulary metastases, which had previously been destroyed by radiofrequency ablation. This technique provides relatively easy, complete removal of the tumorous tissue. The disadvantages of the described technique are limited use (it is suitable only for surface lesions) and increased financial costs.

[Personal experience with intra-arterial locoregional chemotherapy of liver metastases from colorectal carcinoma]

Locoregional chemotherapy is one of the possible ways of treatment of inoperable metastatic affection of the liver by colorectal carcinoma. The advantage of regional administration of the cytostatic is the possibility to achieve a higher local concentration of the cytostatic associated with a higher percentage of therapeutic responses. In our department we preferred combined locoregional intraarterial chemotherapy (5-fluorouracil/Mitmycin C/Doxorubicin) combined with systemic intravenous chemotherapy (5-fluorouracil/leukovirin). Locoregional cghemotherapy was administered in the majority as chemotherapy of series 2 or 3 with a very good tolerance. In 2/19 patients we observed marked diminution of liver metastases and subsequent operability and with a duration of complete response for 13 and 18 months. In 7/19 patients a partial therapeutic response was achieved. The total therapeutic response (complete and partial) was 47%. Locoregional chemotherapy attains a higher therapeutic response as compared with systemic chemotherapy and is associated with an acceptable toxicity.

[Combined surgical treatment of portal hypertension]

The bleeding from esophageal varices is at 85-90% cases stopped by conservative (i.e. non surgical) approach. The method of choice is endoscopic sclerotisation or ligation. Less often is necessary to perform TIPS. The rest of cases is necessary to resolve by one of surgical techniques of hemorrhage control--devascularisation operation or perform emmergently porto-systemic shunt. The authors stress the importance of devascularisation operations for theirs simplicity. On the case report they illustrate the advantage of combination of both surgical techniques.

[Laparoscopic resection of a mesenteric cyst]

The authors report a case of an unusual abdominal tumor-mesenteric cyst. When it is found active surgical approach is recommended. Laparoscopic resection of the cyst is considered as the method of choice.

[Cholestasis--an indication for surgical treatment]

Disorders of common bile duct function are among adults relatively frequent. Formal treatment schemes are gradually transformed, and the interdisciplinary co-operation becomes the basic principle. The goal is to recognise the type of the mechanic jaundice, followed by elimination of the obstruction or to ensure biliary drainage without delay. The authors describe indication criteria used on Surgery Department at Bohunice Hospital in Brno. They present their results of treatment of the obstructive jaundice at a group of 576 patients followed during five year period.

[Coagulopathy as an unusual manifestation of splenic artery aneurysm. Case report]

Meticulous examination of patient treated for infertility with clinical signs of coagulopathy reveals lienal artery aneurysm. Such presentation of mentioned pathology is very rare. Surgical resection of aneurysm enabled to cure coagulopathy and very probably infertility as well.

[Metal stents in patients with malignant and benign esophageal stenoses]

The authors used between October 1993 and January 1997 in 131 patients with inoperable malignant or benign stenosis of the oesophagus an expansible metal stent. In 25 patients the stenosis was in the upper third of the oesophagus, in 44 in the medium part, in 53 in the lower third of the oesophagus and in 9 patients in the area of the anastomosis. All patients suffered at the time when the stent was introduced from marked dysphagia (stage 3-4 according to the international classification). In 45 patients the authors introduced more than one stent. 112 patients suffered from malignant stenosis (67 squamous cell carcinoma, 27 adenocarcinoma, 9 pulmonary or bronchogenic carcinoma, in two instances lymphoma, in two instances leiomyosarcoma and in five patients another type of tumour). Seventeen patients suffered from benign stenosis (8 complications of reflux oesophagitis, 3 stenosis in the anastomosis, in two instances corrosion by acid, 2 cases of epidermolysis bullosa oesophagi and one post-radiation stenosis). In these patients repeatedly before introduction of the stent dilatation of the stenosis by means of a balloon dilatation catheter was attempted. In two instances the etiology of the stenosis was obscure. Complications related to the procedure proper or after insertion of the stent were recorded in 49 patients-dislocation of the stent 23x, occlusion of the stent 17x, development of a fistula 6x, ulceration 16x, haemorrhage 4x, hyperplasia of the mucosa 21x, ileus 2x, inadequate expansion of the stent 8x.

[A rare cause of ileus and its laparoscopic treatment]

Stenting is a modern method making possible to open malignant oesophageal stenosis. The technique is associated with various complications. The authors describe the management of a rare stent migration to the aboral part of the GI tract, causing an acute abdomen. Based on their own experience with dislocated stents they recommend, contrary to the literature, an active approach when migration to the aboral of the GI tract occurs. Early stent extraction even when the course is uneventful is advantageous.

[Surgery of inguinal hernia in a clinical department]

The authors stress on the academic surgical departments the necessity of the development of both traditional and minimally invasive techniques of the groin hernia repair. They suggest to make patient selection based on the hernia type (Nyhus Classification) and patient's will and take account of an internal-anesthesiologic aspects. From four currently most often applied minimally invasive techniques they bring attention to the hernioplasty by exclusively extraperitoneal approach, till now seldom used by us.

[Retroperitoneoscopy--a new era]

Retroperitoneoscopy is a minimal invasive surgical technique enabling the diagnostics of the disease, as well as operative treatment of retroperitoneal organs. It is a very promising method especially for urologist, but of interest for general, vascular surgeon or gynecologist. The method is known since the end of sixties. Its routine introduction was enabled by technical advancement of laparoscopic surgery.

[Retroperitoneoscopic lumbar sympathectomy]

The development of revascularization techniques of the distal lower extremity dramatically diminished the need of lumbar sympathectomy. Which is indicated when patient with rest pain or with a profound gangrene of toes (which does not exceed the line of metatarsal articulation) could not be treated by vascular reconstruction. Lumbar sympathectomy could be done surgically or chemically, the efficiency of which is about 50%. The second to the fourth lumbar sympathetic ganglion could be resected with minimal invasivity, retroperitoneoscopically. This approach to lumbar sympathectomy opens further possibilities for operating in retroperitoneal space. Retroperitoneoscopy is well tolerated by patients.

[A modified technic in laparoscopy-assisted appendectomy--a transumbilical approach through a single port]

The authors describe fast, inexpensive and safe technique of appendicectomy enabling them to solve majority of all patients undertaking surgery for acute or chronic inflammation. It is very careful procedure performed through one umbilical port. This method combines the advantages of the minimal invasive surgery with the safe classic way of the appendix base closure.

Diagnostic video-assisted thoracoscopic procedures

OBJECTIVE

The authors evaluated the effectiveness and the limitations of video-assisted diagnostic thoracoscopy.

SUMMARY BACKGROUND DATA

The initial successes achieved with the use of video-assisted diagnostic thoracoscopic techniques has lead to an enthusiastic propagation of its use by thoracic surgeons as well as by some pulmonologists. However, detailed analyses of the diagnostic yield and potential limitations of this technique in relation to the roentgenographic and pathologic presentations of the patients are necessary to ensure its safe and effective application.

METHODS

From July 1991 to December 1993, 102 diagnostic video-assisted thoracoscopic procedures were performed. All patients received other preoperative diagnostic workups without a definitive diagnosis. The initial roentgenographic presentations of these patients included 42 pulmonary nodules, 23 interstitial processes, 11 parenchymal infiltrates, 6 pleural effusions, 10 mediastinal tumors, and 10 mediastinal lymphadenopathies. If the procedure was completed without minithoracotomy or extension of any port site, then it was defined as an exclusive thoracoscopic biopsy (ETB); if the procedure was completed with the assistance of minithoracotomy (4-6 cm), then it was defined as a supplementary thoracoscopic biopsy (STB).

RESULTS

Ninety-two of the pathology reports (90.2%) were interpreted as conclusive. Of these, 35 tumors were malignant and 67 benign. Ten pathology reports were inconclusive and on initial roentgenography had presented as pulmonary infiltrates (4 cases), pulmonary nodule (2), pleural effusion (2), interstitial process (1), and mediastinal lymphadenopathy (1). Seventy-six procedures (74.5%) were completed thoracoscopically and were classified as ETB. The remaining 26 procedures (25.5%) were completed with minithoracotomy and were classified as STB. The underlying diseases in the STB group were carcinoma (8 cases), Hodgkin's lymphoma (3), sarcoidosis (3), tuberculosis (2), interstitial pneumonitis (2), organizing pneumonia (2), mesothelioma (1), and miscellaneous disease (5). The reasons given for minithoracotomy were diffuse intrapleural adhesion (10 cases), technical inexperience (8), inability to localize the lesion (5), problems with anesthesia (1), poor patient tolerance (1), and unknown (1). Four patients (3.9%) experienced complications and three (2.9%) died while in the hospital.

CONCLUSIONS

Diagnostic thoracoscopy provides high diagnostic yield with very low risk. However, 25.5% of the procedures require minithoracotomy to obtain adequate tissue for definitive diagnosis. This finding supports the assertion that diagnostic thoracoscopy should be performed only by experienced thoracic surgeons who can extend the procedure when indicated.

[A technic for laparoscopic gastrostomy]

The authors describe the technique of laparoscopic gastrostomy and laparoscopic assisted gastrostomy. It is an alternative method for patients, when PEG (percutaneous endoscopic gastronomy) or other more physiologic way of food administration is not possible to perform.

[Composite carcinoma-carcinoid of the large intestine]

The authors give an account of a bioptically revealed adenocarcinoma of the large bowel which was combined with a carcinoid. The carcinoid constituent of the tumor had massive metastases as revealed by the postmortem examination.