Our experience with transanal total mesorectal excision (TaTME) procedures in middle and distal rectal tumors.

INTRODUCTION: Transanal total mesorectal excision (TaTME) is a relatively new approach in surgical treatment of rectal cancer. There are no clear indications when to choose this strategy. It is a technically demanding procedure for the surgeon with a long learning curve, which should also be taken into account in evaluation of this method. The results of both oncological and postoperative complications must be properly evaluated to explore the benefit of TaTME. The aim of this study is to assess the potential benefit of TaTME compared to other alternatives in middle and distal rectal tumors. METHODS: Retrospective evaluation of patients undergoing TaTME procedure performed by one team of surgeons between October 2014 and June 2019. The authors analyzed demographic indicators of the group of patients, tumor characteristics, specimen quality, early postoperative complications and the possibility of stoma reversal. RESULTS: A total of 93 patients underwent TaTME procedure for middle and distal rectal cancer. Mean BMI was 27.6 (4.8). T3 or T4 tumor was found in 73 (78.5%) patients, 68 (73.1%) patients had positive lymph nodes and 12 (12.9%) patients were treated for synchronous metastatic rectal cancer. Neoadjuvant therapy was used in 80 (86%) patients. Conversion to open laparotomy was necessary in one case (1%). Stapled anastomosis was performed in 37 (39.7%) cases, handsewn in 56 (60.2%). A positive circumferential resection margin (CRM) was found in 10 (10.7%) cases. Distal resection margin (DRM) was positive in 3 (3.2%) patients. Pathological analysis showed a complete mesorectum in 18 patients (19.4%), nearly complete in 39 (41.9%) and an incomplete mesorectum in 36 (38.7%). Complications in the first 30 days after primary surgery were observed in 38 (40.8%) patients, mainly for anastomotic leak (19 patients, 20.4%). Reoperation was required in 7 (7.5%) patients. Permanent colostomy had to be performed in 4 (4.3%) cases. No patient died after surgery. CONCLUSION: In a selected group of patients it is possible to perform resection using this approach with acceptable postoperative morbidity and quality of the specimen. We used TaTME procedure in patients expected to have difficult TME due to obesity, size and distal localization of tumor. The incidence of conversion to open surgery was very low. Further studies for long term oncological outcomes are needed.

[The importance of pre-operative MRI-detected extramural vascular invasion in the treatment of rectal carcinoma]. / Význam predoperacne zjistené extramurální vaskulární invaze v lécbe karcinomu rekta.

INTRODUCTION: Extramural vascular invasion (EMVI) is associated with a poor prognosis in patients with rectal carcinoma. Patients with proven vascular invasion have a shorter progression-free survival and overall survival. Until recently, vascular invasion had been identified primarily by pathologists. Currently, EMVI can be detected preoperatively by magnetic resonance imaging used for rectal cancer staging. Our study aimed at verifying the effect of pre-operative EMVI detection on PFS after resection and comparing this interval (PFS) to the group of patients with vascular invasion identified and confirmed by pathologists. METHODS: Patients who underwent surgery for rectal carcinoma at our Surgical Department in the years 20122016 were included in the group and were followed for local recurrence or systemic progression of the disease. The median follow-up was 36 months. In this group, we then retrospectively evaluated MR EMVI and at the same time the presence of tumor vascular invasion from the resected specimen. The relationship of both prognostic markers to PFS was compared. RESULTS: Tumor vascular invasion as well as positive extramural vascular invasion on MRI found preoperatively in our group had a statistically significant negative effect on the progression-free survival compared to the group without evidence of EMVI or vascular invasion. CONCLUSION: Positive extramural vascular invasion found on MRI during rectal cancer staging is associated with a poor prognosis. It is one of the prognostically negative factors and referral of these patients for outpatient care should receive special attention because even after radical resection with a negative resection line there is a risk of early progression of the disease.Key words: rectal carcinoma extramural vascular invasion - progression-free survival.

[Comparison of laparotomic and laparoscopic techniques for implantation of the peritoneal part of the shunt in the treatment of hydrocephalus]. / Srovnání laparotomické a laparoskopické techniky pri implantaci peritoneální cásti shuntu v terapii hydrocefalu.

INTRODUCTION: Implantation of a ventriculoperitoneal shunt is a standard procedure in the treatment of hydrocephalus. Shunt malfunction can be due to various causes, such as failure of the peritoneal (distal) part of the shunt with a frequency of 5% to 47%. OBJECTIVE: The aim of this study was to compare laparoscopic and laparotomic techniques for implantation of a ventriculoperitoneal shunt. MATERIAL AND METHODS: We considered a cohort of 304 patients with hydrocephalus, acquired during a 10-year period, who underwent surgical intervention at the Neurosurgical and Surgical Clinics of the University Hospital Brno. RESULTS: The 304 patients underwent a total of 392 operations, of which 67 (17.1%) were performed using a laparoscopic approach and 325 (82.9%) using a laparotomic approach. In the laparotomy group, 59 (18.2%) interventions were repeated due to complications of the peritoneal part of the shunt, while in the laparoscopy group revisions accounted for only 3 cases (4.5%). CONCLUSIONS: The laparoscopic technique significantly reduces the risk of complications of the peritoneal part of the shunt, and thus the overall complications associated with the implantation of the ventriculoperitoneal shunt. Laparoscopy is indicated in the case of migration of the peritoneal catheters into the abdominal cavity and is also very helpful in revisions in the case of malfunction of the peritoneal part of the shunt or in the case of previous abdominal surgery. It can explain the anatomical conditions in the abdominal cavity and it is able to treat any incidental pathology.

[Laparoscopic adrenalectomy--indications and selection criteria]. / Laparoskopická adrenalektomie--indikace a selekcní kritéria.

INTRODUCTION: Laparoscopic adrenalectomy has become a standard surgical procedure for the most of adrenal gland disorders. Hormonal active adenomas, feochromocytomas even some malignant tumors are the most frequent indications. The number of operations for accidentally diagnosed foci has grown rapidly. It has been suggested to revise recommendations specifying criteria, based on which incidentaloma is indicated for adrenalectomy. The aim of this work is to compare the results of adrenalectomies for hormonal active lesions and incidentalomas. MATERIAL AND METHODS: An analysis of 65 patients who underwent adrenalectomy in the Department of Surgery University Hospital Brno Bohunice from 2005 to 2010. Correlation between preoperative examination outcomes and postoperative histology findings was performed. Furthermore, findings in patients indicated for surgery for hormonally active versus for hormonally inactive suprarenal tumors were compared. RESULTS: Thirty-eight patients underwent laparoscopic surgery for hormonally active adrenal tumors, one for bilateral metastasses of bronchogenic carcinoma. In 26 cases adrenalectomy was indicated for incidentaloma. Adrenal hyperplasia was the commonest histological finding in the group with hormonally inactive tumors. No carcinoma was detected in this group. In 5 of 19 patients operated for suspective feochromocytoma, the procedure did not result in blood pressure adjustment and feochromocytoma was histologically confirmed in 11 out of the 19 subjects. The size of the tumors was significantly higher in incidentalomas, compared to hormonally active pathologies. No incidentaloma and hypertension subjects experienced alteration in their clinical condition after the procedure. CONCLUSION: Laparoscopic adrenalectomy is a standard procedure in the majority of hormonally active focal suprarenal conditions. Patients with accidentally detected suprarenal tumors should be carefully indicated, taking into consideration internal comorbidities and any surgical procedures in a patient's history. The benefit of adrenalectomy for the clinical condition alteration is arguable in incidentalomas. The National Institutes of Health U.S.A. (NIH) consensus guidlines should be strictly followed during the decision making proces. Indication for adrenalectomy in tumors of less than 6 cm and with benign appearance on CT or MRI is not considered rational.

[Bouveret's syndrome--a rare case of proximal ileus of biliary etiology]. / Bouveretuv syndrom--raritní prípad vysokého ileu biliární etiologie.

Bouveret's syndrome is gastric outlet obstruction caused by impaction of large gallstone in the duodenal bulb which penetrated through a cholecystoduodenal fistula. A 56-years-old lady suffered from right upper abdominal pain and vomiting. Investigations, including abdominal radiograph, ultrasonography and computed tomography, revealed pneumobilia and a large stone impacted in the duodenal bulb. She underwent upper GIT endoscopy, where was found a large stone in the duodenal bulb and cholecystoduodenal fistula on frontal wall of pars descendens duodeni. A stone was too large for endoscopic treatment. She underwent laparotomy with cholecystectomy, the stone was removed and the cholecystoduodenal fistula was closed with omentoplastic.