Liver regeneration during the associating liver partition and portal vein ligation for staged hepatectomy procedure in Sus scrofa is positively modulated by stem cells

This present study investigated the impact of the application of stem cells to liver regeneration following the first stage of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). The experiment was conducted on a pig model (n=6, 3 that did not receive application of stem cells, 3 that received application stem cells). Collected samples of liver (day 0 and 9 following surgery) were subjected to complete transcriptome sequencing. In total, 39 differentially expressed genes were found in the group without the application of the stem cells (genes of unwanted processes such as fibrosis and inflammation). In the group that did receive application of stem cells, no significantly differentially expressed genes were found, indicating a properly regenerated liver remnant. The present study therefore demonstrated, to the best of our knowledge for the first time, the positive effect of stem cells application in the liver regeneration process during ALPPS procedure in the pig model.

Treatment strategies for patients with colorectal carcinomaand synchronous liver metastases

Multimodal approach in the management of patients with colorectal carcinoma and synchronous liver metastases allows for the application of various combinations of treatment modalities (colorectal resection, liver resection, chemotherapy, radiotherapy). The primary-first approach and simultaneous resection represent traditional strategies used because the primary tumor is thought to be the main source of subsequent metastases as well as the source of symptoms associated with local tumor progression (obstruction, perforation, colorectal bleeding). Poor long-term outcomes of traditional strategies have led to the proposal of reverse strategies (the liver-first approach and up-front hepatectomy approach). The idea behind reverse strategies is to give preference to liver resection over colorectal resection (prognosis of patients with stage IV colorectal cancer is determined mainly by the curability of liver metastases). According to available literature, reverse strategies are suitable mainly for patients with asymptomatic primary tumor. Treatment strategy for each patient should be individualized depending on the patients performance status, comorbidities, and tumor stage. In this paper, the authors offer an up-to-date review of treatment strategies for patients with colorectal carcinoma and synchronous liver metastases focusing on available data of evidence-based medicine. Key words: liver first - primary first - colorectal carcinoma - liver metastases - reverse strategies.

Anatomic Peculiarities of Pig and Human Liver

Many investigations on surgical methods and medical treatment are currently done on pigs. This is possible because the pig is sufficiently close genetically to humans. In recent years, progress in liver surgery has opened new possibilities in surgical treatment of liver diseases. Because the methods are relatively novel, various improvements are still needed, and it is thus helpful to conduct experimental surgeries on pig livers. We reviewed the literature to compare the anatomic and functional features of pig and human livers, information that will be of great importance for improving surgical techniques. During the literature review, we used various sources, such as PubMed, Scopus, and veterinary journals. Our results were summarized in diagrams to facilitate understanding of the vascular structure and biliary systems. We conclude that, although the shapes of the human and pig livers are quite different, the pig liver is divided into the same number of segments as the human liver, which also shows a common structure of the vascular system. Thus, with the anatomic and structural features of the pig liver taken into account, this animal model can be used in experimental hepatic surgery.

[Laparoscopic diverting ileostomy in rectal cancer surgery]

INTRODUCTION

Low anterior resection (LAR) with total mesorectal excision (TME) represents the gold standard for patients with low rectal carcinoma. Protective ileostomy (PI) is commonly performed during LAR in an effort to protect low rectal anastomosis. The aim of this study is to analyse outcomes in our own patient population, focusing on morbidity associated with PI.

METHOD

A retrospective clinical study of patients operated on between 2013 and 2015 was conducted in University Hospital Ostrava. All patients after LAR with PI due to low rectal cancer were included. The study design did not require randomisation.

RESULTS

A total of 52 patients who underwent LAR with PI were included. Mean tumour height was 9.1±2.3 cm. 15.4% of the patients were classified as ASA I, 53.8% were classified as ASA II and 32.7% of the patients as ASA III. 30-day postoperative morbidity was 38.5%, and complications associated with PI (within 30 days after LAR) occurred in 7 (13.5%) patients. Three of these patients underwent urgent surgical revision due to small bowel obstruction (PI semirotation around its longitudinal axis in two patients and volvulus of the small bowel around PI in one patient). Mean time interval between PI creation and reversal was 252 days. During this period, complications associated with PI were detected in 25 (48.1%) patients; seven patients had more than one complication. Minor complications (such as peristomal dermatitis, stoma herniation or bleeding, wound infection after stoma reversal) were observed in 17 (32.7%) patients. Major complications (small bowel obstruction at the site of PI, dehydration due to high stoma output, intraabdominal abscess after stoma reversal) occurred in 8 (15.4%) patients.

CONCLUSIONS

PI offers protection to low colorectal or coloanal anastomosis in rectal cancer surgery. However, this benefit is counterbalanced by a high risk of various complications which may occur during the whole period when PI is present. The decision for diversion should therefore be made only after careful consideration.Key words: rectal cancer - low anterior resection - laparoscopy - protective ileostomy - stoma complications.

[The risks of retroperitoneoscopic adrenalectomy]

INTRODUCTION

Minimally invasive adrenalectomy has become the gold standard for surgery of the suprarenal gland. Retroperitoneoscopic adrenalectomy with dorsal approach is preferred. The aim of our case report is to discuss potential complications that may arise from retroperitoneoscopic adrenalectomy, specifically an intra-operative injury of the inferior vena cava.

CASE REPORT

A 47-year-old male patient was admitted to undergo elective adrenalectomy on the right side. The reason for the surgery was a hormonally active adenoma with clinical signs of Conns syndrome. Biochemistry revealed the typical signs of hyperaldosteronism. A one-year history of unsuccessful treatment for hypertension was known. Ultrasound examination showed an enlarged suprarenal gland on the right side with the diameter of 5.2 cm. A CT scan confirmed the results of the ultrasound examination. Retroperitoneoscopic adrenalectomy was performed. The inferior vena cava was intraoperatively injured. The high pressure in the retroperitoneal space prevented bleeding. The injury to the vena cava was treated using a continuous stitch without the necessity of conversion to open surgery. The patient was discharged on the third postoperative day without any other complications.

CONCLUSIONS

Retroperitoneoscopic approach is regarded by many authors as the new gold standard for adrenalectomy. However, very serious complications such as an injury of the inferior vena cava may occur. It is possible to treat this injury using retroperitoneoscopy. The risk of air embolization due to elevated pressure in the retroperitoneum (20 mm Hg) and open lumen of the IVC needs to be taken seriously.Key words: adrenalectomy - retroperitoneoscopy - complication.

[Minimally invasive liver resections]

INTRODUCTION

Laparoscopic surgery is a standard and preferred modality of surgical treatment. Progress in laparoscopic procedures and the development of dedicated technology have made it possible to approach laparoscopic liver resections in selected patients. Initially operations were performed for benign and peripheral lesions, but nowadays more than 50% of total laparoscopic surgery is due to malignancy.

METHOD

We conducted a literature search using Pubmed; by entering the keywords "Laparoscopic Liver Resection" we obtained a set of publications focused on this issue. We limited the selection to the period from 1991 to the present. Additionally, the selection was limited to reviews, prospective randomized trials or cohort studies. Also, we selected publications in the English and Czech languages.

RESULTS

On the basis of the search, we identified 2345 publications, of which the abovementioned criteria were satisfied by 319 papers. Of these, 312 publications were in English and 7 in the Czech language. 59% of the searched publications were published in the last 5 years, which gives evidence of progression of the laparoscopic liver resection method.

CONCLUSIONS

Laparoscopic liver resections are considered as safe for both benign and malignant lesions with comparable oncological outcomes compared to open resections. They also provide better short-term results such as a shorter hospital stay, lower overall costs, lower postoperative pain, reduced blood loss, earlier intestinal recovery, generally shorter convalescence of the patient, better cosmetic results and a lower rate of complications.Key words: laparoscopic liver resections - hand-assisted laparoscopy.

[Left hepatic vein injury during laparoscopic fundoplication for giant paraoesophageal hiatal hernia]

INTRODUCTION

After laparoscopic cholecystectomy, laparoscopic fundoplication has become another gold standard of minimal invasive surgery. The level of satisfaction of patients undergoing endoscopic surgery is almost 90%. Laparoscopic fundoplication, like other surgery methods, can also be burdened with grave complications, which could result in a fatal outcome even if the surgery is performed by a skilled surgeon. Even the authors themselves encounter complications despite their rich experience (more than 3,500 laparoscopic operations in the diaphragmatic hiatus area in more than 20 years).

CASE REPORT

The authors report on a rare left hepatic vein injury during laparoscopic hiatoplasty and fundoplication according to Toupet for giant paraoesophageal hiatal hernia.

CONCLUSION

For its low percentage of complications, laparoscopic fundoplication is considered as a safe operative method for gastroesophageal reflux disease and hiatal hernias. However, severe complications may still arise during the surgery and the surgeon should be familiar with them, be prepared for them and be able to manage such complications.Key words: gastroesophageal reflux disease hiatal hernia laparoscopic fundoplication left hepatic vein.

[Complete minimally invasive Ivor-Lewis esophageal resection]

INTRODUCTION

Minimally invasive esophagectomy is becoming a standard procedure in the treatment of esophageal cancer. We would like to present our experience with Ivor Lewis esophagectomy completed by minimally invasive technique.

METHODS

The primary aim of the study was to analyse potential technical difficulties and intraoperative complications of thoracolaparoscopic Ivor Lewis esophagectomy with intrathoracic anastomosis. A secondary aim of the study was to evaluate postoperative complications according to the Clavien-Dindo classification. The inclusion criterion for the study was a history of thoracolaparoscopic esophagectomy. Multidisciplinary approach was employed in the diagnosis, surgery indications and perioperative care of all patients.

RESULTS

Between January 2011 and January 2016, 19 patients underwent completely minimally invasive esophagectomy with intrathoracic anastomosis. There were 13 men and 6 women. Adenocarcinoma was confirmed by histopathological examination in all the patients. The cumulative postoperative morbidity was 68.4%. According to the Clavien-Dindo classification, we recorded grade I complications in 10.5% of the patients, grade II in 15.8%, grade III in 36.8% and grade IV in 5.3% of the patients. Anastomotic leak was the most serious complication; it was initially managed by negative pressure (vacuum) therapy followed by stent implantation. Postoperative mortality was 0%. Mean hospital stay was 12 days and mean stay at intensive care unit was 3.6 days.

CONCLUSIONS

The basic oncosurgical principles of radicality need to be respected during minimally invasive procedures. However, functionality, safety, and cost effectiveness have to be preserved as well. In this paper, we present thoracolaparoscopic Ivor Lewis esophagectomy as one of feasible and accessible options of intrathoracic anastomosis. It seems to be safe with respect to technical obstacles, short-term and long-term complications.Key words: esophagectomy - intrathoracic - anastomosis - laparoscopy - thoracoscopy.

J-pouch versus Roux-en-Y reconstruction after gastrectomy: functional assessment and quality of life (randomized trial)

Purpose

The aim of this study was to evaluate the quality of life and functional emptying of J-pouch versus Roux-en-Y reconstruction after total gastrectomy for malignancy.

Methods

This study was designed as a prospective, nonblinded, randomized, parallel clinical trial (Trial Number: MN Ostrava, 200604). With informed consent, patients undergoing gastrectomy for malignancy were randomized to J-pouch or Roux-en-Y reconstruction. The time taken for a test semisolid meal labeled with ^99mTc-sulfur colloid to exit the reconstructed parts was measured by dynamic scintigraphy 1 year after resection. Quality of life was measured using the Eypasch questionnaire at the same time as functional emptying assessment. This trial was investigator-initiated.

Results

In all, 72 patients were included into the study. The time taken for the test meal to exit the postgastrectomy reconstruction was 16.5±10.0 minutes (mean ± standard deviation) in the Roux-en-Y group and 89.4±37.8 minutes in the “J-pouch” group; the difference was statistically significant (P<0.001). Emptying of the J-pouch appeared to be a linear decreasing function compared to the exponential pattern seen in the Roux-en-Y group. The quality of life measurement showed scores of 106±18.8 points (mean ± standard deviation) in the Roux-en-Y group compared to 122±22.5 points in the J-pouch group; the difference was statistically significant (P=0.0016). There were no important adverse events.

Conclusion

After total gastrectomy, a J-pouch reconstruction empties more slowly and is associated with higher quality of life compared to Roux-en-Y reconstruction. Whether these two observations have a direct causative link remains unanswered.

Intrathoracic splenosis - lesson learned: a case report

BACKGROUND

Intrathoracic splenosis presents an extremely rare thoracic lesion occurring after a simultaneous rupture of the spleen and diaphragm as a consequence of heterotopic autotransplantation and implantation of splenic tissue. Intrathoracic splenosis is usually an asymptomatic, incidental finding, which should be ideally managed without surgical intervention.

CASE PRESENTATION

We present a case of 68-year old woman with intrathoracic splenosis. Patient presented with a 2-month history of a dry cough unresponsive to administered antibiotics and antimycotics. Computed tomography (CT) of the chest revealed two homogeneous pleural nodules (diameters of 2 and 4 cm) in the left upper lung field. Two consequent CT-assisted transthoracic core-cut biopsies were performed. Histopathology examination of both biopsy specimens was inconclusive (haemorrhagic and non-specific tissue). After that, patient was referred to the department of thoracic surgery with a suspicion of malignant mesothelioma or metastatic lesions. Thoracoscopic revision of the left pleural cavity was performed and the presence of pleural nodules was confirmed. Bloody looking nodules were resected (standard thoracoscopic resection). Postoperative recovery was uneventful. The histopathology examination of the specimen showed normal splenic tissue. Only with the histopathology report in hand, a detailed medical history was taken. It revealed a gunshot injury requiring splenectomy (without known diaphragm or lung injury) 44 years ago (one of the longest time periods in the literature).

CONCLUSIONS

We would like to point out that following the recommendations regarding splenosis may be very difficult in daily routine practice. The simple question regarding abdominal trauma in a patient's history can lead the clinician to the diagnosis of splenosis, which can be unequivocally established via scintigraphy. The importance of thorough medical history taking, therefore, cannot be underestimated.

The influence of methods of bariatric surgery for treatment of type 2 diabetes mellitus

The constantly growing incidence of obesity represents a risk of health complications for individuals, and is a growing economic burden for health care systems and society. The aim of this study was to evaluate the efficacy of bariatric surgery, specifically laparoscopic greater curve plication, laparoscopic sleeve gastrectomy, and Roux-en-Y gastric bypass, in patients with type 2 diabetes mellitus. The effect of bariatric surgery on the changes in blood pressure before, and 12 months after, surgery and in pharmacotherapy in the 12 months after surgery was analyzed. For achieving this purpose, 74 patients from the Obesity and Surgery Department of Vitkovice Hospital in Ostrava in the Czech Republic, were monitored. They were operated in 2011 and 2012. The Bonferroni method was used to test hypotheses about the impact of surgery on blood pressure and pharmacotherapy. One year after the surgery, systolic and diastolic blood pressure values decreased, both with no statistically significant difference between surgery types. Improvement was observed in 68% of cases, with 25% of patients discontinuing pharmacotherapy entirely.

[Secondary angiosarcoma of the abdominal wall after adjuvant radiotherapy in a patient with uterine carcinoma - a case report]

INTRODUCTION

Adjuvant radiotherapy is an integral part of the current treatment of many malignant tumours. However, this mode of treatment does not provide only benefits in the sense of lowering the risks of recurrence, but it is also associated with many undesirable side effects, from which one of the most serious is the development of secondary malignancies.

CASE REPORT

The author describes a case report of 77 years old woman who underwent hysterectomy with bilateral adnexectomy and pelvic lymphadenectomy for uterine carcinoma pT1bN0M0, G1 in 2005. Adjuvant external radiotherapy with the dose 45Gy and brachytherapy 3x4Gy followed. Subsequently the patient was followed at the department of gynecology, which referred her in January 2015 with a quickly growing tumour of the skin and subdermal tissue in the hypogastric area, where previous radiation had been applied. Its excision was indicated with the diagnosis of suspected uterine carcinoma metastasis, but subsequent histological evaluation confirmed angiosarcoma. Despite negative resection margins the tumour quickly recurred and disseminated.

CONCLUSION

Angiosarcoma as a side effect of irradiation is described increasingly more often nowadays. The vast majority of cases are related to the treatment of breast carcinoma. Its prognosis is very poor and therapeutic possibilities are limited. Surgical excision with negative margins remains the mainstay of the treatment. It is necessary to keep this diagnosis in mind and patients undergoing radiation treatment should be followed over a long period.

KEY WORDS

angiosarcoma.

Diverting ileostomy in laparoscopic rectal cancer surgery: high price of protection

BACKGROUND

Anastomotic leakage presents the most feared complication after low anterior resection (LAR). A proximal diversion of the gastrointestinal tract is recommended to avoid septic complications of anastomotic leakage. The aim of the present study was to evaluate the benefits and risks of diverting ileostomy (DI) created during laparoscopic LAR because of low rectal cancer.

METHODS

This was a retrospective clinical cohort study conducted to assess outcomes of laparoscopic LAR with/without DI in a single institution within a 6-year period.

RESULTS

In total, 151 patients were enrolled in the study (73 patients without DI, 78 patients with DI). There were no significant differences between both groups regarding demographic and clinical features. Overall 30-day morbidity rates were significantly lower in patients without DI (23.3 vs. 42.3 %, P = 0.013). Symptomatic anastomotic leakage occurred more frequently in patients without DI (9.6 vs. 2.5 %, P = 0.090); surgical intervention was needed in 6.8 % of patients without DI. Post-operative hospital stay was significantly longer in the group of patients with DI (11.3 ± 8.5 vs. 8.1 ± 6.9 days, P = 0.013). Stoma-related complications occurred in 42 of 78 (53.8 %) patients with DI; some patients had more than one complication. Acute surgery was needed in 9 patients (11.5 %) because of DI-related complications. Small bowel obstruction due to DI semi-rotation around its longitudinal axis was seen in 3 patients (3.8 %) and presents a distinct complication of DI laparoscopic construction. The mean interval between LAR and DI reversal was more than 8 months; only 19.2 % of patients were reversed without delay (≤4 months). Morbidity after DI reversal was 16.6 %; re-laparotomy was necessary in 2.5 % of patients.

CONCLUSIONS

The present study indicates that DI protects low rectal anastomosis from septic complications at a cost of many stoma-related complications, substantial risk of acute surgery necessity and long stoma periods coupled with decreased quality of life.

[Primary malignant small bowel tumors]

INTRODUCTION

Small bowel presents 75% of the gut length and 90% of the gut surface. However, primary malignant tumors of the small bowel represent only 1-3% of all malignant gastrointestinal tumors. The aim of the present paper is to offer a current review of primary malignant small bowel tumors - their epidemiology, localization, symptoms, diagnostic and treatment options.

METHODS

The authors have performed a comprehensive review of databases Medline, Scopus and Google Scholar focusing on studies regarding small bowel cancer.

RESULTS

The most frequent small bowel tumors are adenocarcinoma (30-40%), neuroendocrine tumors (35-44%), lymphomas (10-20%) and gastrointestinal stromal tumors (12-18%). Symptomatology is non-specific and varies widely, which is why small bowel cancer is usually diagnosed in a locally advanced stage of the disease. Diagnosis is determined through standard methods (gastroscopy, colonoscopy, CT) and complementary special diagnostic modalities (capsule enteroscopy, enteroscopy, octreotide scan, etc.). Diagnostic process with a negative outcome frequently leads to diagnostic laparoscopy/laparotomy.The treatment of small bowel cancer in patients operated in acute settings is done according to acute abdomen management guidelines. Elective surgery of small bowel cancer differs with respect to the tumor type. Adenocarcinomas and neuroendocrine tumors should be treated with surgical R0 resection with radical lymphadenectomy (and multivisceral resection if necessary). Patients with GIST should undergo en bloc resection with 2-3cm safety resection margins (lymphadenectomy is not necessary). Palliative resection of neuroendocrine tumors can be associated with a significant clinical effect. On the other hand, palliative resection of adenocarcinomas of GIST is not advocated.

CONCLUSION

Small bowel cancer is an infrequent condition. Symptoms are non-specific; patients are often diagnosed in an advanced stage of the disease. Achieving R0 surgical resection is usually difficult due to locally advanced stage of the disease. Besides the tumor type, patients prognosis is influenced by very late diagnosis of the tumor.

KEY WORDS

primary tumor - small intestine - diagnostics - treatment options - surgical resection.

[Laparoscopic resection rectopexy in the treatment of obstructive defecation syndrome]

INTRODUCTION

Obstructive defecation syndrome (ODS) presents a common medical problem, which can be caused by various pelvic disorders; multiple disorders are frequently diagnosed. At the present, a high number of corrective techniques are available via various surgical approaches. Laparoscopic resection rectopexy is a minimally invasive technique, which comprises redundant sigmoidal resection with rectal mobilisation and fixation.

METHODS

The aim of this paper was to evaluate the safety and effectiveness of laparoscopic resection rectopexy in the treatment of patients with ODS. The evaluation was performed via our own patients data analysis and via literature search focused on laparoscopic resection rectopexy.

RESULTS

In total, 12 patients with ODS undergoing laparoscopic resection rectopexy in University Hospital Ostrava during the study period (2012-2015) were included in the study. In our study group, mean age was 64.5 years and mean BMI was 21.9; the group included 11 women (91.6%). ODS was caused by multiple pelvic disorders in all patients. Dolichosigmoideum and rectal prolapse (internal or external) were diagnosed in all included patients. On top of that, rectocoele and enterocoele were diagnosed in several patients. Laparoscopic resection rectopexy was performed without intraoperative complications; mean operative time was 144 minutes. Mean postoperative length of hospital stay was 7 days. Postoperative 30-day morbidity was 16.6%. All postoperative complications were classified as grade II according to Clavien-Dindo classification. Mean preoperative Wexner score was 23.6 points; mean score 6 months after the surgery was 11.3 points. Significant improvement in ODS symptoms was noted in 58.3% of patients, and a slight improvement in 16.6% of patients; resection rectopexy provided no clinical effect in 25% of patients.

CONCLUSION

It is fundamental to carefully select those patients with ODS who could possibly profit from the surgery. Our results, in accordance with published data, suggest that laparoscopic resection rectopexy is a valuable surgical technique in the treatment of patients with ODS caused by multiple pelvic disorders.

KEY WORDS

obstructive defecation syndrome - constipation - resection rectopexy - operative techniques - pelvic floor disorders.

[Rare injury of perineum and anorectum - case report]

Anorectal injuries, with the exception of iatrogenic damage, are rare. Considering the extensive range of causes and potential extent of damage, the diagnosis and treatment of these injuries requires an individual approach to every patient. Based on the extent of damage, the best way of treatment strategy has to be selected for successful treatment of the primary injury and elimination of frequent complications, especially fecal incontinence. The authors present a rare injury of the perineum and anorectum with anorectal sphincter damage in an elderly man after falling down from a stepladder.

KEY WORDS

anorectum - anorectal trauma - anal sphincter.

[Faecal incontinence - serious medical and social issue]

Faecal incontinence presents gastrointestinal disorder with high prevalence (more than 2% of population) and serious impact on the quality of life. General practitioners, gastroenterologists and colorectal surgeons play the principal role in screening, diagnostics and providing health care to patients who suffer from faecal incontinence. Insufficient knowledge about faecal incontinence and minimal training aimed at its diagnostics and therapy lead to the low quality of provided health care.Authors offer comprehensive up-to-date review focused on faecal incontinence - its definition, prevalence, seriousness, consequences, pathophysiology, diagnostics and management. Detailed anatomical and physiological assessment of each patient is fundamental in determining correct cause of faecal incontinence and consequent selection of the most appropriate therapeutic modality.Broad spectrum of available therapeutic options comprises conservative management (lifestyle modification, diet, medications, and absorbent tools), biofeedback and surgical interventions (sphincter augmentation, sphincter reconstruction, sacral nerve stimulation, sphincter substitution and stools diversion). Application of the most appropriate treatment can lead in majority of patients to significant improvement in faecal incontinence and quality of life. Early diagnosis prevents possible complications, which would possibly deteriorate patients quality of life.

[10 years of sleeve gastrectomy in the Czech Republic in terms of the surgical procedure]

INTRODUCTION

Sleeve gastrectomy (SG) as a single bariatric/metabolic procedure has been performed since 2003 in the world, and since 2006 in the Czech Republic. We report 10 years experience with SG in the Czech Republic from 2006 to 2015.

METHOD

Prospectively collected data from 14 surgical departments was evaluated retrospectively using descriptive statistics for every year from 2006 to 2015 and subsequently evaluated and compared for the entire period. The number of the patients, mean age, mean weight and BMI at the time of surgery, the number of patients with T2DM after SG, mean follow-up, mean %BMIL (% Body Mass Index Loss), distance of the starting point of the resection line from the pylorus, the size of the calibration bougie, the rate of complications, and the number and type of conversion procedures were evaluated.

RESULTS

4134 sleeve gastrectomies were done in the Czech Republic from 2006 to 2015 with the mean follow-up of 32.9 months (range 2145 months) from the procedure. The mean weight at the time of surgery fluctuated between 114.2 kg and 128.9 kg; mean BMI fluctuated between 42.3 and 46.7. Mean %BMIL was 63.2% for the entire evaluated period. The distance of the starting point of the resection line from the pylorus changed from the mean 6.1 cm (range 67 cm) to mean 4.2 cm (range 36 cm) and the size of the calibration bougie changed from the mean 39.2 F (range 3642 F) to mean 37.1 F (range 3542 F). As regards early postoperative complications, bleeding from the resection line occurred in 1.4% and a leak from the staple line occurred in 1.1%. The gastroesophageal reflux disease and hiatal hernia occurred in 17.3% as the most frequent late complications. Conversion to another bariatric procedure was approached in 3.8% in the event of an unsatisfactory effect of the SG.

CONCLUSION

Bariatric or metabolic surgery, respectively, is a safe and effective surgical method for the treatment of severe obesity and T2DM in morbidly obese patients. Currently, SG is the most widely used bariatric/metabolic procedure in the Czech Republic as well as in most other countries and the long-time results are similar in comparison with other authors.Key words: bariatric surgery - sleeve gastrectomy - resection line - complications.

[Perforation of the right ventricle of the heart as a complication of CT guided percutaneous drainage of a subphrenic abscess - a case report]

INTRODUCTION

CT guided percutaneous drainage is currently the gold standard in the treatment of abdominal fluid collections, having substituted open surgical drainage in many cases. It burdens the patient less than surgical drainage. Its efficiency is comparable to standard surgical drainage when properly indicated. It is readily available even in smaller hospitals. However, this method can also have many complications, which originate most often from an improperly targeted drainage catheter.

CASE REPORT

The authors describe a case report of a 55 years old man with a right-sided subphrenic abscess. The right ventricle of the heart was perforated during a CT guided percutaneous drainage. The bleeding was minimal, but the patient suffered a profound septic shock as a result of massive bacteremia during direct communication of the contents of the abscess cavity with blood circulation. He was operated immediately. The right ventricle was sutured, and the subphrenic abscess was drained. There were no complications after the operation, and the patient was discharged on day 17 after the surgery.

CONCLUSION

The CT guided drainage of an abdominal abscess or a fluid collection in a risk area should be preferably done in hospitals whose therapeutic portfolio also includes the handling of serious complications.

KEY WORDS

heart injury drainage.

[Hepatic pseudolesions adjacent to the falciform ligament]

INTRODUCTION

Accurate detection of hepatic pseudolesions using multi-detector CT and MRI examinations is crucial for the differentiation of benign alterations from primary and secondary malignant lesions in hepatic parenchyma.

METHOD

The authors conducted a systematic literature review in PubMed. "Liver" and "pseudolesion" were used as keywords in English and Czech, and papers/articles published from 2000 to 2014 were retrieved.

RESULTS

The authors presented a literature review. In addition, the authors performed a retrospective evaluation of a group of patients treated for liver disease at University Hospital Ostrava where this anomaly was encountered in 7 cases.In 3 of the patients, diagnostic laparoscopy was done, with visual examination of the lesion accompanied by intraoperative ultrasound exam (IOUS) and partial excision, to establish the diagnosis. Subsequent histological assessment of the specimens confirmed the diagnosis of a steatotic lesion in each of these 3 patients. Additional 2 of the 7 patients underwent liver surgery for concurrent metastatic lesions of colorectal cancer and an open-access revision of the suspected lesions was performed. Visual inspection and intraoperative ultrasound (IOUS) was followed by excisional biopsy. The histology revealed macro- and micro-vesicular steatosis and excluded malignant changes. The last 2 patients still continue to be followed-up regularly on a 6-month routine check-up basis at our hepatology unit.

CONCLUSION

The authors presented their own experience gained through inter-disciplinary cooperation at Multidisciplinary conferences. A literature overview of this unusual subject is also included. Particularly in oncologic patients, correct interpretation of these pseudolesions may help to avoid unnecessary biopsies, further imaging examinations and diagnostic laparoscopies and/or explorative laparotomies.

Body Size, Bone Mineral Density, and Body Composition in Obese Women After Laparoscopic Sleeve Gastrectomy: A 1-Year Longitudinal Study

Changes in body weight, waist and hip circumferences, body composition, and skeletal status in women after bariatric surgery were evaluated. Thirty-six women [mean age 41.2 ± (SD) 9.5 years, weight 115.7±18.0 kg, and BMI 42.1±5.3 kg/m(2)] underwent laparoscopic sleeve gastrectomy. Bone mineral density (BMD) at lumbar spine, femoral neck, total hip, and total body, and body composition were evaluated at baseline and 3, 6, and 12 months after surgery.Weight, BMI, waist and hip circumferences decreased significantly. Total body bone mineral content (TBBMC) increased by 2.5±3.5%, and fat, lean body mass, total mass and fat-% decreased significantly by 38.9±12.0%, 15.4±5.9%, 26.5±8.1%, and 17.6±8.9%, respectively. Slight decreases in total body (0.6±2.2%) and spine (1.2±7.1%) BMD were not significant, whereas total hip and femoral neck BMD decreased significantly by 5.3±8.2%, and 6.2±7.0% (p<0.001). Change (Δ) in TBBMC correlated only with Δ in weight (r=0.38, p<0.05) whereas Δ in all other body composition parameters correlated significantly with Δ in body weight and circumferences (r=0.46-0.98). The Δ in BMD (except total body BMD) correlated significantly with Δ in body composition parameters (r=0.34-0.59). Baseline fat and lean content besides changes in body fat and lean mass accounted for bone changes. In conclusion, bone loss after bariatric surgery is related to post-operative changes in body composition, as well as to weight loss and decrease in waist and hip circumferences.

Bone mineral density and body composition after laparoscopic sleeve gastrectomy in men: A short-term longitudinal study

INTRODUCTION

Longitudinal changes in bone and body composition occurring in obese men after laparoscopic sleeve gastrectomy (LSG) has been evaluated.

METHODS

In short-term longitudinal study, 25 obese men in mean baseline age 44.8 ± 10.9 years and mean body mass index (BMI) 43.3 ± 4.4 kg/m(2)were assessed after undergoing LSG for obesity. Bone mineral density (BMD) (spine, femoral neck [FN], total hip [TH], and total body [TB]) and body composition (TB bone mineral content [BMC], fat, % of fat, lean, lean BMC, total mass) were assessed at baseline, and after three and six months.

RESULTS

Mean body measurements, including weight, BMI, waist and hips, decreased significantly over the study period (p < 0.0001). FN BMD (p < 0.01) and TH BMD (p < 0.001) decreased, and spine BMD increased significantly (p < 0.001). TB BMD did not change. Weight decreased by 21.3 ± 7.3%, BMI by 21.2 ± 7.3%, FN BMD by 3.32 ± 6.35%, TH BMD by 3.51 ± 3.95% whereas spine BMD increased by 2.89 ± 5.1%. TB BMC increased by 2.4 ± 4.62%; all other variables relating to body composition decreased: fat by 33.0 ± 9.6%, lean mass by 12.8 ± 6.1%, lean BMC by 12.3 ± 5.9%, total mass by 20.1 ± 6.4%, and % fat by 15.8 ± 7.2%.

CONCLUSIONS

After LSG, body size and variables related to body composition (except for TB BMC) decreased with an accompanying decrease in FN BMD in the men in this study. Spine BMD increased, and TB BMD did not change.

The impact of standard protocol implementation on the quality of colorectal cancer pathology reporting

BACKGROUND

The aim of the study is to assess the influence of standardized protocol implementation on the quality of colorectal cancer histopathology reporting.

METHODS

A standardized protocol was created based on the recommendations of The College of American Pathologists. The impact of this protocol was measured by comparing frequencies of assessed parameters in histopathology reports before and after implementation.

RESULTS

In total, 177 histopathology reports were included in this study. The numbers of harvested lymph nodes were 12.4 ± 5.2 (colon) and 12.6 ± 5.4 (rectum) before protocol; and 17.1 ± 6.5 (colon), and 16.6 ± 7.0 after protocol implementation; differences were statistically significant. The recommended minimum of 12 lymph nodes was not achieved in 42.8 % (colon) and 45.7 % (rectum) of specimens before, and in 10.4 % (colon) and 17.7 % (rectum) of specimens after protocol implementation; differences were statistically significant. There were no differences in histopathology assessment of proximal and distal resection margins, grading assessment, TNM staging recording, and number of positive findings of microscopic tumor aggressiveness. The findings of tumor budding, tumor satellites, and assessment of microscopic tumor aggressiveness were more frequent after protocol implementation. Histopathology reports of rectal specimens contained assessments of the macroscopic quality of mesorectum, circumferential resection margin, and neoadjuvant therapy effect (if administered) only after protocol introduction.

CONCLUSIONS

A standardized protocol is a valuable and effective tool for improving the quality of histopathology reporting. Its implementation is associated with more precise specimen evaluation, higher numbers of harvested lymph nodes, and improved completeness of histopathology reports.

[Pruritus ani]

INTRODUCTION

Pruritus ani is defined as a dermatologic disease characterized by itching and/or burning in the perianal area. It occurs in 15% of the population. Men are affected more frequently than women, in the ratio 4:1. It is accompanied by an irresistible desire to scratch in the perianal area. Pruritus ani is divided into two subtypes: primary (idiopathic) and secondary. In idiopathic (primary) pruritus it is not possible to detect any other cause of itching. Secondary pruritus has an obvious causal origin.The aim of this paper is to offer a complex overview of possible causes, diagnostic procedures and treatment possibilities of this unpleasant and annoying disease.

METHODS

We have researched available publications using PubMed and MEDLINE databases, focusing on articles on anal pruritus. At first the key word "Pruritus ani" was put in without any restrictions. Subsequently, we limited the selection by the time period of 5 years and 10 years; then we looked up articles in English, German and Czech languages, and finally review articles, clinical trials and others.

RESULTS

574 articles were found without entering any restrictions; 45 of them were review articles and 25 clinical trials. 437 articles were in the English language and 40 of them were review articles. 44 were in the German language and 1 of them was a review article. A total of 33 articles were found with a 5-year time limit. 6 of them were review articles and 4 were clinical trials. 66 articles from the last 10 years were found. 14 of them were review articles and 10 were clinical trials. In most of the other articles among the total number of articles found, pruritus ani was mentioned only marginally in articles focused on different topics. We have not found any summary articles on this topic in Czech publications.

CONCLUSION

Pruritus ani is a common disease with a number of causes; therefore, effective treatment may be insufficient in the initial stages. The therapy is focused on the primary cause, if found. Broad differential diagnosis options need to be taken into consideration, and reevaluation of the therapy is a priority. When no obvious secondary cause is found, the empiric treatment is focused on an improvement of hygiene and change in the life style, removal of common irritators, and protection of perianal skin.

Treatment strategies for colorectal carcinoma with synchronous liver metastases: Which way to go?

AIM: To offer an up-to-date review of all available treatment strategies for patients with synchronous colorectal liver metastases (CLM).

METHODS: A comprehensive literature search was performed to identify articles related to the management of patients with synchronous CLM. A search of the electronic databases PubMed, MEDLINE, and Google Scholar was conducted in September 2014. The following search terms were used: synchronous colorectal liver metastases, surgery, stage IV colorectal cancer, liver-first approach, and up-front hepatectomy. These terms were employed in various combinations to maximize the search. Only articles written in English were included. Particular attention was devoted to studies and review articles that were published within the last six years (2009-2014). Additional searches of the cited references from primary articles were performed to further improve the review. The full texts of all relevant articles were accessed by two independent reviewers.

RESULTS: Poor long-term outcomes of patients with synchronous CLM managed by a traditional treatment strategy have led to questions about the timing and sequence of possible therapeutic interventions. Thus, alternative paradigms called reverse strategies have been proposed. Presently, there are four treatment strategies available: (1) primary first approach (or traditional approach) comprises resection of the primary colorectal tumor followed by chemotherapy; subsequent liver resection is performed 3-6 mo after colorectal resection (provided that CLM are still resectable); (2) simultaneous resection of the primary colorectal tumor and CLM during a single operation presents intriguing options for a highly select group of patients, which can be associated with significant postoperative morbidity; (3) liver-first (or chemotherapy-first) approach comprises preoperative chemotherapy (3-6 cycles) followed by liver resection, adjuvant chemotherapy, and resection of the primary colorectal tumor (it is best suited for patients with asymptomatic primary tumors and initially unresectable or marginally resectable CLM); and (4) up-front hepatectomy (or “true” liver-first approach) includes liver resection followed by adjuvant chemotherapy, colorectal resection, and adjuvant chemotherapy (strategy can be offered to patients with asymptomatic primary tumors and initially resectable CLM).

CONCLUSION: None of the aforementioned strategies appears inferior. It is necessary to establish individual treatment plans in multidisciplinary team meetings through careful appraisal of all strategies.

[Current standards of care in the management of patients with abdominal sepsis]

INTRODUCTION

Abdominal sepsis patient management is an issue of high current importance, and the amount of knowledge keeps increasing and changing the approach to critically ill patients with abdominal sepsis.

METHODS

Literature search (in MEDLINE, PubMed and Google Scholar databases) was done, focused on identification of relevant studies. The aim of this paper is to provide a review of current trends in diagnosing and predicting the prognosis of, and recommended treatment standards for patients with abdominal sepsis.

RESULTS

Abdominal sepsis is defined as the Systemic Inflammatory Response Syndrome (SIRS) with an abdominal infection requiring a surgical intervention to control the source; or SIRS with an infection within 14 days after any major surgery. Although many different monitoring and scoring systems exist, daily careful clinical examination is the most reliable diagnostic tool in identification of septic patients. Whenever abdominal sepsis is suspected, the gold standard comprises immediate administration of broad-spectrum antibiotics, transferring the patient to the intensive care unit, with surgical intervention and supportive intensive care based on current guidelines of the Surviving Sepsis Campaign. Source control surgery is the principal therapeutic modality for patients with abdominal sepsis. The most relevant negative prognostic factors include clinical signs of septic shock and the necessity of high doses of catecholamines.

CONCLUSION

Early identification of septic patients and prompt implementation of a complex, evidence-based interdisciplinary approach are the principal conditions for improving healthcare outcomes of care provided to patients with abdominal sepsis.

[Acute abdominal surgery in pregnancy - as viewed by the surgeon]

INTRODUCTION

Acute abdomen during pregnancy presents very specific problem on the boundary of surgery and gynaecology. Although gynaecologists provide healthcare to pregnant women, surgery indication because of acute abdomen during pregnancy should be done by surgeon (who has usually little knowledge and experience regarding pregnant women examination and management). There is therefore real opportunity for possible mistakes origin with serious consequences for mother and foetus.

METHODS

Literature search in PubMed was done aimed at studies within the last 10 years dealing with appendectomy, cholecystectomy and laparoscopy during pregnancy in the context of acute abdomen. Surgical interventions done from obstetrics indications were excluded.

RESULTS

Pregnancy is associated with many anatomical and physiological changes which have to be considered not only during clinical examination, but also when analysing laboratory findings and considering operative tactics. Imaging modalities employment during pregnancy is very limited due to harmful effect of ionising radiation and not clear impact of strong magnetic field on the foetus. Timing of surgical interventions because of acute abdomen during pregnancy should be the same as timing of acute abdomen interventions in non-pregnant patients. Minimally invasive surgery in acute abdomen during pregnancy presents standard technique nowadays. Many advantages of laparoscopic approach (lower rate of surgical site infections, quicker convalescence etc.) are valid also during pregnancy.

CONCLUSION

Acute abdomen during pregnancy should be managed within a multidisciplinary cooperation between gynaecologist, surgeon, anaesthesiologist and neonatologist. With respect to results of published studies, laparoscopic approach in the management of acute abdomen during pregnancy should be considered safe and effective.

Quality of life after laparoscopic and open resection of colorectal cancer

BACKGROUND

The aim of the study was to evaluate quality of life (QOL) outcomes after colorectal surgery for cancer from a 6-month perspective at a single institution.

METHODS

Cohort study to prospectively assess postoperative QOL in patients who underwent elective colorectal resection at the University Hospital Ostrava. QOL was assessed using the validated Short Form 36 (SF-36v2™) questionnaire at fixed time points.

RESULTS

A total of 148 patients were enrolled in the study (83 and 65 patients underwent laparoscopic and open colorectal resection, respectively). Operative time was significantly longer (161 vs. 133 min; p = 0.0073) and length of hospital stay was significantly shorter (10.7 vs. 13.1 days; p = 0.0451) in the laparoscopic group. Overall 30-day morbidity rates were lower in the laparoscopic group, but the difference was not significant (27.7 vs. 33.8%; p = 0.2116). QOL scores were comparable in both study groups before surgery (p ≥ 0.05). QOL was statistically significantly lower 2 days and 1 week after open colorectal surgery compared with laparoscopic surgery. One month and 6 months after surgery, there were no statistically significant differences between groups.

CONCLUSION

The present study suggests a higher postoperative QOL during the first month after laparoscopic colorectal resection could be one of the benefits of laparoscopy.

[A new strategy in the surgical treatment of multiple liver tumors - ALPPS]

INTRODUCTION

This systematic review was performed to introduce the two-staged hepatectomy procedure (Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy - ALPPS) and present its current results.

MATERIAL AND METHODS

We conducted a systematic literature search using the PubMed database with key words "ALPPS" or "staged liver resection". The inclusion criteria were randomized trials or cohort studies. Case reports were excluded. The primary end-point was the assessment of liver tissue hypertrophy after the ALPPS procedure. Morbidity and mortality evaluation were the secondary end-point.

RESULTS

After an electronic data search of PubMed with the selected key words, six cohort studies evaluating 96 patients met the inclusion criteria. There was no prospective randomised trial. Based on the results of the individual studies, liver hypertrophy ranged from 74 to 87%. Morbidity and mortality ranged from 53 to 71% and 0 to 13% respectively.

CONCLUSIONS

Despite the higher morbidity and mortality the ALPPS procedure could be a promising technique for a selected group of patients with multiple liver tumors. However long term results are not yet available.

[Surgical rectocele repair - many techniques, few unambiguous conclusions]

INTRODUCTION

Surgical treatment of rectocele represents a controversial issue on the boundary between medical specialisations with many different corrective surgical techniques. Is it possible, based on the available knowledge, to determine an optimal operative technique for rectocele repair?

METHODS

Complex literature search focusing on the identification of rectocele surgical repair studies in the MEDLINE, PubMed and Google Scholar databases. The aim of this paper is to offer a comprehensive review of the contemporary situation as regards rectocele surgical repair.

RESULTS

There are four main possible approaches for rectocele repair - transvaginal, transanal, transperineal and transabdominal. Posterior colporrhaphy with levatoroplasty is the traditional transvaginal technique, performed at most gynaecological departments in various modifications. Defect-specific rectocele repair and mesh repair represent newer transvaginal techniques which offer better postoperative functional results, although with the risk of possible serious complications. Traditional transanal rectocele repair (vertical and horizontal plication of the rectovaginal septum) is currently performed only rarely due to its worse results in comparison with the transvaginal approach. Rectal resection using endostaplers (STARR and TRANSTAR techniques) is a modern transanal technique. Stapled rectocele repair leads to the correction of anorectal anatomical conditions and to the improvement of obstructive defecation symptoms with acceptable morbidity. Transperineal approach is usually used in patients with rectocele and anal incontinence due to a proven sphincter defect. Transabdominal laparoscopic approach is based on vaginorectopexy by means of mesh implantation, and it is indicated especially in patients with rectocele and enterocele.

CONCLUSION

Based on the results of published studies, it is not possible to determine clear guidelines for rectocele surgical repair. Posterior colporrhaphy and stapled transanal repair are the most common techniques in practice. Prospective randomized studies focusing on the comparison between transvaginal and stapled transanal approach for rectocele repair are needed.

[Transtibial amputation: sagittal flaps in patients with diabetic foot syndrome]

INTRODUCTION

Diabetic foot syndrome is defined by ulcer or destruction of leg tissues in patients with diabetes (diabetics) associated with infection, neuropathy and various degree of ischaemia (peripheral vascular disease). In Czech Republic in 2010 were registrated over 45 000 patients with diabetic foot syndrome. 8500 (diabetics) patients with diabetes undergone the surgery (any type of amputation).

MATERIAL AND METHODS

In retrospective non randomized trial we evaluated the population of patients with lower limb amputation admitted to Clinic of Surgery FNO between 2010-1012. We introduce current (present) view to possibilities of lower limb amputations, historical problems and development of surgical methods. Special aspect is dedicated to sagital shank amputation. Detail description of operative (surgical) technique itself and crural region (area) anatomy.

RESULTS

In 2010-2012 we achieved 146 lower limb amputations in shank, from that 27 sagital shank amputations( sagital operative method). We observed ( followed up) the number of reoperations, reasons that led to amputation, wounds healing by secondary intention, itęs sources and necessity of revision due to postoperative hemorrhage.

CONCLUSION

Effects of amputations on patientęs quality of life. Social and socioeconomical impacts. Provably lower number of complications in sagital shank amputations compared to (in comparison with) conventional methods. Authors would like to point out and introduce interesting operation method to the general public.

[Improving the quality of histopathological examination of colorectal cancer specimens through standard protocol implementation]

INTRODUCTION

Detailed, high-quality histopathological examination of colorectal carcinoma is an essential component of accurate disease staging. The aim of this study was to evaluate the influence of standard pathological protocol implementation on the quality of colorectal cancer specimen evaluation.

MATERIAL AND METHODS

The standard protocol for colorectal cancer specimens evaluation was created on the basis of the NCCN guidelines for colorectal carcinoma and in accordance with the American Joint Committee on Cancer (AJCC) recommendations. The protocol has been implemented into the practice of University Hospital Ostrava since 1 January 2013. All patients who underwent resection for colorectal cancer in University Hospital Ostrava between 1 January 2011 and 30 June 2013 were included into the study. Histopathological reports (before and after protocol implementation) were analysed with a focus on the presence of the parameters being monitored; the differences underwent statistical analysis.

RESULTS

In total, 235 patients who underwent resection of colorectal cancer (184 patients before and 51 patients after protocol implementation) were included into the study. The mean number of investigated lymph nodes was 12.5±6.3 (colon) and 12.6±6.2 (rectum) before protocol implementation. The mean number of lymph nodes was 15.0±4.6 (colon) and 16.8±6.7 (rectum) after protocol implementation; the differences are statistically significant. Before protocol implementation, the limit of 12 investigated lymph nodes was not reached in 49 patients with colon carcinoma (43.8%) and in 32 patients with rectal carcinoma (44.4%). Statistically significant improvement was noted after protocol implementation - the limit of 12 lymph nodes was not reached in 5 patients (18.5%) with colon and 4 patients (16.7%) with rectal carcinoma. There were also differences in the number of macroscopic mesorectal excision quality evaluation, circumferential resection margin reports and signs of microscopic tumour aggressiveness, in favour of histopathological reports after standard protocol implementation.

CONCLUSIONS

Our retrospective study proved that the implementation of the standard protocol for colorectal cancer resection specimens leads to an improved quality of definitive histopathological reports.

[Overall survival: is it an objective endpoint for assessing the quality of surgical treatment for colorectal cancer?]

The monitoring of the quality of surgical treatment is the basic condition for improving the results of medical care. There are various endpoints available to assess the quality of surgical care. Survival time traditionally represents the key parameter for patients with colorectal cancer. Overall survival should not, however, be the only standard accepted measure of surgical care quality. Disease free survival in the early stages, neoadjuvant or adjuvant settings has been validated as a better option. Progression free survival, alone or aggregated with the quality of life, provides a useful, more sensitive parameter for advanced or metastatic colorectal cancer. The selection of appropriate, valid end-points is the basic prerequisite for improving the quality of surgical care for patients with colorectal cancer.

[Heparin-induced thrombocytopenia in a patient with acute thrombosis, acute aortic dissection and acute lower limb ischaemia]

This case report presents the course of illness, as well as the diagnosis and therapy, of acute thrombosis and abdominal aortic dissection after Fogarty thrombectomy with the symptoms of acute limb ischaemia in a 42-year-old female patient suffering from heparin-induced thrombocytopenia. HIT is a severe iatrogenic complication emerging after unfractionated or low molecular weight heparin administration, with rather easy diagnosis; however, it is often neglected due to the rarity of its occurrence.

[Laparoscopic lavage and drainage in the management of acute diverticulitis: is it time to move on?]

INTRODUCTION

Diverticular disease management represents a very topical issue with many unanswered questions as yet. Laparoscopic lavage and drainage in patients with acute diverticulitis is one of the controversial areas. Miniinvasive approach presents a possible treatment alternative for CT-guided percutaneous drainage and also for radical colon resection in the form of Hartmanns procedure or resection with primary anastomosis. MATERIAL A METHODS: The authors aim was the evaluation of patients with Hinchey II, III or IV diverticulitis treated by laparoscopic lavage and drainage, or by laparoscopic suture of the perforation, in a retrospective cohort study. The inclusion criterion for the study was laparoscopic lavage and drainage indication in patients with Hinchey II, III or IV diverticulitis. The primary aim of the study was laparoscopic treatment evaluation focused on leakage, if applicable, and on postoperative morbidity and mortality.

RESULTS

During the study period (2007-2012), 12 patients operated on at our department (with a mean age of 71.7 years) were included into the study. The group comprised 7 men and 5 women with a BMI of 28.1 kg/m2. Laparoscopic exploration, lavage and drainage of the abdominal cavity with purulent peritonitis finding were performed in 10 patients. The site of bowel perforation was not located unambiguously in these patients. Two patients with faecal peritonitis and identified place of perforation underwent laparoscopic lavage, drainage and suture of the perforation. Postoperative leakage was not detected in any of the patients. The mean operating time was 65 minutes, postoperative morbidity reaching 27.7%, and postoperative mortality 0%. The mean length of hospital stay was 8.8 days. Elective laparoscopic resection was performed 6-15 weeks after the primary operation in 8 patients.

CONCLUSION

Laparoscopic exploration with thorough lavage, suture of the perforation and drainage presents a possible alternative in modern management of acute diverticulitis. The miniinvasive approach indication should be based both on careful, highly individualised and complex patient evaluation and on the departments experience.

[The staple line in sleeve gastrectomy]

INTRODUCTION

Postoperative leak and bleeding from the staple line are potentially serious early complications following laparoscopic sleeve gastrectomy.

AIM

This study aims to assess the significance of oversewing the staple line after laparoscopic sleeve gastrectomy in preventing leak and bleeding in our group of patients.

MATERIAL AND METHODS

Patients after laparoscopic sleeve gastrectomy were included in the trial. Two different principles of oversewing the staple line (selective vs. mandatory) were analyzed. The design of the trial was retrospective-prospective, non-randomized. Postoperative complications were recorded.

RESULTS

Between October 2006 and December 2011, 638 laparoscopic sleeve gastrectomies were carried out using standard laparoscopic technique. 297 of the patients belonged to the group with selective oversewing of the staple line. The remaining 341 patients belonged to the group in which the staple line was oversewn in all cases. Both groups of patients were comparable in the basic parameters. Early postoperative leak affected one patient in both groups, 0.30% versus 0.29% (p = 0.9203), respectively. The rates of postoperative bleeding were 2.7% (selective oversewing) versus 0% (mandatory oversewing) (p = 0.0023), respectively.

CONCLUSION

Our study did not demonstrate the impact of oversewing the staple line on the occurrence of postoperative leak. The rates of postoperative bleeding from the resection site were statistically significantly lower in the group with the mandatory oversewing of the staple line.

[Anatomic-surgical study of intercostobrachial nerve (ICBN) course in axilla during I. and II. level of axilla clearance in breast cancer and malignant melanoma]

INTRODUCTION

The aim of this paper is to offer results of anatomic study of axillary course of intercostobrachial nerve (ICBN) and the effort of its saving in primary axilla clearance (PE), secondary clearance (SE) after previous positive sentinel nodes detection (SLN) and in re-clearance (RE) after previous axilla clearance in breast cancer and malignant melanoma. The correlation between possibility of ICBN saving and anatomic variant of ICBN and type of previous surgery was observed.

MATERIAL AND METHODS

A total of 113 surgeries with the effort of description and preservation of ICBN were done between September 2007 and August 2011. Patients were divided into three groups according to type of surgery: primary clearance (PE), secondary clearance (SE) and re-clearance (RE). Results have been statistically tested using licensed statistical software Statgraphics.

RESULTS

ICBN was found in 107 patients (94.7%), it wasnt found in six cases. There were eight different types of ICBN branching. Two most frequent variants formed majority of cases - 87 out of 107 (81.3%). The successful preservation of intact ICBN was in 86 patients (76.1%). ICBN was interrupted or not found in 10 patients (8.8%), partial injury of ICBN branches was detected in 17 cases (15.0%). If the most frequent variant of ICBN branching was present, the nerve was not injured in 42 out of 45 cases (93.3%). Statistical testing showed that non-standard anatomical branches are associated with higher risk of perioperative injury. The risk of injury was lowest in PE (21.6%) and the highest in RE (42.9%). The difference wasnt statistically significant because of low number of re-clearance cases in our study.

CONCLUSION

The anatomy of ICBN in axilla is variable. The standard variant of ICBN course is the most frequent (the trunk coming out of second intercostal space; no branches in axillary course). If other variants are present, there is significantly higher risk of perioperative injury. ICBN preservation is possible also after previous axilla clearance. Preparation is more difficult and the risk of injury is increasing with the degree of previous surgery radicality.

[Circumferential resection margin in the modern treatment of rectal cancer]

INTRODUCTION

In the last decades, the assessment of circumferential resection margin (CRM) has gained enormous importance in the management of patients with rectal carcinoma, not only in predicting the prognosis, but also in precise cancer staging, in multimodal treatment indications and in quality assessment of provided care.

METHODS

The authors present a review article containing CRM definition, describing the technique of CRM assessment, the effect of CRM status on the prognosis and quality of provided therapy. CRM assessment in the context of a multidisciplinary team is especially emphasised. The aspect of CRM has to be considered by the radiologist during cancer staging, the surgeon in the course of the operation, the pathologist during precise macroscopic and histopathological specimen evaluation, and the oncologist when deciding on neoadjuvant/adjuvant therapy administration.

CONCLUSION

CRM nowadays represents a fundamental aspect in modern treatment of patients with rectal carcinoma. The introduction of CRM assessment into clinical practice has lead to more precise staging, better multimodal therapy indications, more precise surgical technique (total mesorectal excision), an increased rate of sphincter-saving resections, lowered local recurrence rates and improved patient survival.

Radiofrequency energy in surgery: state of the art

Over a period of more than 100 years, radiofrequency energy has been introduced in many fields and applications in medicine. At present, radiofrequency constitutes the basis of numerous medical devices employed in almost all medical specialties. It is particularly applicable and valuable in various minimally invasive procedures for its locally focused effects. Radiofrequency energy is a technical term established to describe high-frequency alternating electrical currents (with a frequency ranging from 300 kHz to 3 MHz) and their impact on biological tissue. The application of RF energy causes controlled tissue heating with consequent cell protein denaturation and desiccation, which leads to cell death and tissue destruction. The primary principle of radiofrequency is that the generated heat can be used to cut, coagulate or induce metabolic processes in the target tissue. The authors of this paper offer a comprehensive and compact review of the definition, history, physics, biological principles and applications of radiofrequency energy in current surgery.

[Impact of anastomotic leakage on oncological outcomes after rectal cancer resection]

INTRODUCTION

The aim of the study was to determine the impact of anastomotic leakage on long-term outcomes after curative surgery for rectal cancer.

MATERIAL AND METHODS

The study included 174 patients who underwent elective, potentially curative open or laparoscopic resection with anastomoses for rectal cancer at the Department of Surgery of the University Hospital Ostrava from 1 January 2001 to 31 December 2009. Anastomotic leakage was defined as clinically or radiologically confirmed signs of local or diffuse peritonitis, gas, pus or stool from the drain, rectoscopy signs of anastomotic insufficiency, or rectovesical or rectovaginal fistula. The Cox proportional hazards model with forward selection was used to determine the influence of predefined baseline characteristics on overall, disease-free survival and recurrence. The results are presented as Hazard Ratio (HR) with 95% Confidence Interval (CI).

RESULTS

Based on the Cox model, anastomotic leakage was not identified as a factor with a significant impact on overall or disease-free survival. Anastomotic leakage, however, has remained an independent risk factor for a higher local recurrence rate (Hazard Ratio: 6.621, 95% CI 1.289-34.020, p=0.024). On the contrary, anastomotic leakage was not identified as a statistically significant prognostic factor for the incidence of distant metastases.

CONCLUSION

Anastomotic leakage represents an independent risk factor for a higher local recurrence rate after curative resection for rectal cancer.