[A pilot study: correction of the levator hiatus using an anal sling as a surgical treatment of faecal incontinence]. / Pilotní studie: korekce levátorového hiátu anální páskou jako chirurgická metoda lécby strevní inkontinence.

INTRODUCTION: Faecal incontinence is a significantly depressing and mentally devastating disability. Surgical treatment, as a first choice method, is indicated for incontinence originating as a result of traumatic or iatrogenic infliction of the sphincter apparatus, particularly of the external sphincter. In case of idiopathic (neurogenic) incontinence, it is indicated very exceptionally, if ever. The authors present a pilot study to verify the possibility of surgical treatment of anal incontinence with the support of a puborectal muscle loop by means of the absorbable STRATASIS® TF mesh. MATERIAL AND METHODS: In the years 2010-2012, eight experimental surgical procedures were performed. Female patients with a history of faecal incontinence of the third stage longer than one year and with EMG-verified neurological lesion were recruited. The evaluating criteria were the Wexner score and changes in the levator and anorectal angle acquired from a MR defecographic examination performed before and six months after the operation. RESULTS: The complaints improved distinctly in six patients; in the two remaining cases, the method failed completely. The failures were associated with an inflammatory complication in both cases. In one patient, the authors do not rule out an incorrect indication, too. The Wexner score decreased from 18 to 10 in improved patients. Changes in the levator and anorectal angle were not significant. CONCLUSION: The results confirm the possibility of successful surgical influence on incontinence of the third stage by correcting the levator hiatus with biodegradable mesh. Continence improvement persists even after the mesh transforms into scar tissue.

[Micturition, sexual and defecation disorders in middle-aged women after pelvic fractures. A comparative study]. / Mikcní, sexuální a defekacní problémy u zen v aktivním veku po zlomenine pánve: srovnávací studie.

PURPOSE OF THE STUDY: To present the results of a three-year study on micturition, defecation, gynecological and sexual disorders in middle-aged women who sustained pelvic fractures. MATERIAL AND METHODS: A group of 33 female patients who were treated for unstable pelvic fractures (AO types B or C) in the 2004-2009 period were evaluated (treated group) and compared with 31 women who had given vaginal birth at least once and went to see a urologist because of urinary problems in the period from 2009 to 2010 (control group). The questionnaires used in the study included ICIQ, UIQ, UDI and PISQ12 instruments. Urodynamic tests included flow cystometry, urethral pressure profile at rest and under stress and uroflowmetry. For a comparison of continuous variables of normal distribution, the t-test for independent samples was used. In the questionnaire study when responses were classified as nominal-ordinal variables, the Mann-Whitney U-test was used. Differences between the two patient groups in qualitative variables were tested by Pearson s 2 test. When the expected number of answers in contingency table was lower than 5, Fisher s exact test was used; when the number of answers was 0, Haldane s correction was employed. The results in all tests were considered significant when the level of significance was lower than 5%, i.e. p-value < 0.05. RESULTS: The age of patients in the treated group ranged from 17 to 55 years (average, 32 years), the age in the control group was between 30 and 78 years (average, 58 years). The difference was significant (p<0.001). The control group patients had significantly more serious urination disorders than the treated group patients. Some micturition problems were reported by 25 patients (75%) of the treated group and by all patients of the control group (p<0.001). Intestinal disorders were more frequent in the treated group, in which 19 (61%) patients reported problems as against seven (21%) in the control group. Gynaecological problems involving feelings of genital prolapse had 13 (39%) control patients (p = 0.041). Sexual disorders were markedly worse in the treated group, with 16 (52%) of the patients having problems in comparison with only seven (21%) in the control group. DISCUSSION: A comparison of patient groups composed using the method described here is disputable. The first difficulty lay with a low compliance of the treated patients, of whom only 33 underwent examination out of 52 originally enrolled. The other problem was the necessity of having an exactly defined control group of patients willing to undergo urological and gynaecological examination including urodynamic testing. The groups composed by our method were comparable only in the micturition disorder characteristic. A significantly higher age of the control group affected the comparison of defecation, gynaecological and sexual problems. CONCLUSIONS: The results of this study showed a high occurrence of micturition, defecation and sexual disorders in middle-aged women after pelvic injury. However, the problems are usually not serious enough to make the patients seek help of a specialist. The authors recommend that these problems should be looked for by disorder-directed inquiry in the final period of pelvic fracture treatment and help of a specialist in urology, gynaecology, sexuology or proctology should be offered to the patients in whom disorders have been identified. Key words: urinary incontinence, voiding dysfunction, stool incontinence, obstipation, unstable pelvic fracture.

[The spectrum of diaphragmatic injuries managed in a Prague traumatology centre]. / Spektrum poranení bránice osetrené v traumatologickém centru.

INTRODUCTION: Diaphragmatic injuries may result from blunt or penetrating injuries. The symptomatology is usually overlaid by symptoms of associated abdominal or thoracic injuries or by symptoms of other systems injuries in polytraumas. Multidetector computer tomography (MDTC) facilitates the improvement of preoperative diagnostics in blunt injuries. The retrospective study included analysis of a study group of subjects with blunt and penetrating diaphragmatic injuries. PATIENTS, METHODS AND RESULTS: From 1996 to 2009, a total of 44 injured patients with diaphragmatic injuries were operated in the FNKV (Faculty Hospital Kralovske Vinohrady) Traumatology Centre. The group included 17 blunt injuries and 27 penetrating injuries. There were 39 male and 5 female subjects, aged from 17 to 76 years. 32 subjects suffered from left-sided diaphragmatic injuries and 13 subjects from right-sided injuries. The commonest type of penetrating injuries were stab injuries in 21 subjects. 40 patients suffered from associated injuries. The commonest associated injuries included liver and splenic injuries. Simultaneous thoracotomy and laparotomy for associated injuries affecting the both cavities was performed in 21 patients. Left-sided diaphragmatic injury with associated abdominal injury was managed using laparotomy. Thoracoscopy or laparoscopy was used in 3 subjects with penetrating injuries. CONCLUSION: Penetrating injuries are the commonest cause of diaphragmatic injuries, with prevailing left-sided location of the injury. MDCT is an asset in the diagnostics of blunt diaphragmatic injuries. Surgical approach was selected based on the injury location and on the presence or absence of associated injuries. The miniinvasive approach contributes to the daignostics of penetrating diaphragmatic injuries in patients with stable hemodynamic conditions.

[Comparison of micturition, sexual and defecation disorders in females following type B and C pelvic fractures]. / Porovnání mikcních, sexuálních a defekacních poruch u zen v aktivním veku po zlomeninách pánve typu B a C.

INTRODUCTION: The objective of this work is to present results obtained in a three-year study focussed on micturition, defecation and sexual disorders in women of active age. METHODS: The monitored set consisted of 33 female patients treated in 2004-2009 for unstable pelvic fracture (B-type or C-type according to AO classification). Out of them 25 patients suffered B-type fracture and 8 patients suffered C-type fracture. Their age ranged between 17 and 55 years (the average age was 32 years). Anamnestic data were obtained based on UIQ, UDI and PISQ12 questionnaires. The non-parametric Mann-Whitney U-test was used for answers to individual questions representing nominal/ordinal variables. After finding a statistically significant difference in answers between both groups of patients, it was investigated by means of Pearson Chi2-test which answers are behind this statistically significant difference. If the number of answers to any question was less than 5, the exact Fisher test was used. In the event the rate equalled 0, Haldane correction was applied. All tests were considered statistically significant if the significance level was below 5%. RESULTS: The occurrence of urologic problems was higher in the B-type fracture patients (84% vs. 50%), however, afflictions were more severe in the C-type fracture patients. Intestinal problems were more frequent in the C-type fracture patients (75% vs. 52%) and they were also more severe. Also sexual problems were more frequent in the C-type fracture patients (75% vs. 40%), although according to individual answers it was not possible to state that their sexual life was unequivocally worse. CONCLUSION: The analysis of comparison of micturition, sexual and defecation problems in patients one year after the unstable pelvic fracture showed in some respects higher problems in the patients who had suffered the C-type fracture. However, more important are the following observations, generally related to unstable pelvic fracture patients: 1. The occurrence of micturition, sexual and defecation problems was unexpectedly high; 2. Without active examination by a traumatologist during the after-treatment "minor" problems may escape his/her attention and may negatively affect life of each individual patient in the longer run; 3. A targeted method of detection of problems by means of questionnaires could lead to their disclosure; 4. A urologist, urogynaecologist, sexologist and proctologist have an indisputable place in the treatment of women who suffered a severe pelvic trauma.

[Damage control laparotomy in blunt abdominal injury]. / Damage control laparotomie u tupého poranení bricha.

PURPOSE OF THE STUDY: Damage control surgery is one of the major advances in surgical techniques used in polytrauma patients in the past 25 years. It is based on a foreshortened pre-operative examination during ongoing resuscitation which includes surgical intervention in an injured patient with severe hypotension due to haemorrhage. In this seven-year retrospective study the authors evaluate the results of damage control laparotomy in patients with injury to the abdominal organs, retroperitoneum and pelvis. MATERIAL AND METHODS: The evaluated group included 21 patients with blunt abdominal trauma who underwent damage control laparotomy in the 2001-2007 period. There were 17 men and four women; the age range was 17 to 69 years, with an average of 36 years. Damage control laparotomy was indicated in the patients with blunt abdominal trauma, or with closed or open pelvic fracture, who developed a progressive haemorrhagic shock. RESULTS: Between 2001 and 2007, a total of 21 922 patients were admitted to the Trauma Centre and 12 392 operations were performed. However, only in 21 of them (0.1 %) damage control laparotomy was indicated. The procedure was most frequently performed for liver injury (16 patients), which was associated with multiple injury to the other abdominal organs and retroperitoneum in five patients. Further three patients were operated on for haemoperitoneum at continual bleeding due to type C fracture of the pelvis. In the remaining two patients the damage control procedure was chosen to stop persistent bleeding following splenectomy and nephrectomy for traumatic rupture. In these 21 patients blunt trauma was part of polytrauma (ISS > 15). Repeat surgery was carried out within 48 to 96 hours (average, 58 h). Four patients (19 %) died; two due to progressive traumatic haemorrhagic shock and two because of brain oedema after concussion. DISCUSSION: Damage control surgery has become a fundamental component of surgical strategy for severe trauma and has been accepted by surgeons although it cannot be evaluated in randomized clinical studies. Survival after damage control laparotomy in serious intra-abdominal injuries involved in polytrauma is reported in relation to the scoring system values (ISS, GCS), but depends, first of all, on blood loss, degree of acidosis and severity of associated injuries, with craniocerebral trauma in the first place. CONCLUSIONS: Damage control laparotomy is an effective procedure in the treatment of severe trauma to the abdominal organs and retroperitoneum in critically injured patients. This time-limited, staged surgical intervention is included in resuscitation of patients with hypothermia, metabolic acidosis and coagulopathy. The outcome of damage control surgery is related to not only the severity of injury, but also experience with comprehensive acute care in trauma centres.

[Antimicrobial treatment of nosocomial intra-abdominal infections--new treatment options with tygecycline]. / Antimikrobní lécba nozokomiálních nitrobrisních infekcí--nové lécebné moznosti tygecyklinem.

INTRODUCTION: Nosocomial, intra-abdominal infections are extremely serious conditions, considering possibilities for their early diagnosis, as well as for their effective therapy. Multiresistant bacteria (Enterobacteriacae producing extended-spectrum beta-lactamases - ESBL Escherichia coli, Klebsiella species, vancomycin-resistant enterococci [VRE], and methicillin-resistant Staphylococcus aureus [MRSA]) are frequently isolated as pathogens of these infections. Tygecycline is among the novel wide- spectrum antibiotics affecting multiresistant bacteria, which are being introduced in clinical practice. AIM: The aim of this study is to assess actual sensitivity of tygecycline to the commonest pathogens of intra-abdominal infections, generated in hospitalized surgical patients. Based on the sensitivity tests, tygecycline was indicated for targeted antibiotic therapy in intraabdominal infections. METHODS: Sensitivity to tygecycline, aminopenicillins, fluorochinoloni and gentamycine was established for the following bacteria: Escherichia coli, Klebsiella pneumonie, Enterobacter cloacea, Proteus mirabilis. Sensitivity to oxacillin, clincamycine and tygecycline was tested in Staphylococcus aureus, and to fluorochinolini, gentamycine and tygecycline in Enterococcus faecalis, and to fluorochinoloni, gentamycine, ceftazidime and gentamycine in Pseudomonas aeruginosa. Based on the sensitivity results, tygecycline was administered in two patients with postsurgical intra-abdominal infections caused by ESBL Escherichia coli and Klebsiella pneumonie. The initital dose of tygecycline was 100 mg i.v., followed by tygecycline 50 mg i.v. every 12 hours for 7 days. RESULTS: The isolated bacteria showed 98-100% sensitivity to tygecycline, except Psudomonas aeruginosa, where 100% resistance was demonstrated. Targeted antimicrobial medication with tygecycline proved effective in postoperative nosocomial intra-abdominal infections, the both concerned patients recovered. CONCLUSION: The choice of antimicrobial medication in nosocomial intra-abdominal infections requires through evaluation considering various factors including prior antibiotic therapy, co-morbidities and the current status of sensitivity with respect to potential multiresistant pathogens. Tygecycline shows significant in vitro efficacy against resistant gram-positive and key gram-negative facultative bacteria, which are a common cause of intra-abdominal infections in surgery patients. Clinical experience has shown that tygecycline is safe and effective in the treatment of complicated intra-abdominal infections.

Transrectal stent in endoscopic palliative therapy of malignant stenosis of the rectum.

BACKGROUND/AIMS: To check the feasibility and safety of endoscopic stent introduction in colorectal cancer therapy. METHODOLOGY: A total of 62 patients with inoperable tumors of the rectum and rectosigmoid were treated by introducing stents. Stents were also introduced in 3 patients with advanced prostate tumors obturating (narrowing) the rectum. In 3 cases, the stents were introduced under X-ray control. In all other cases, an endoscopic approach to the stent introduction was employed. RESULTS: Stents could not be introduced in 4 patients. In 1 case, the bowel was perforated above the malignant (tumorous) stenosis. In 4 patients, it was necessary to remove the stents because of dislocation. Growth of the tumor into the stent was not experienced. Experience with acute obstruction treatment was minimal as only two patients were treated for this indication. CONCLUSIONS: Endoscopic stent introduction is a safe palliative procedure making it possible to improve the quality of life of patients with inoperable tumors of the rectum and rectosigmoid.

[Surgical site infection following proximal GIT procedures]. / Infekce chirurgického místa po operacích na aborální cásti GIT.

INTRODUCTION: Surgical site infections (ICHM) remain a serious problem in the proximal GIT surgery, with incidence rates from 5% to 26% in planned procedures, and up to 40% in urgent procedures. Surgical site infections result in increased postooperative morbidity and mortality rates, prolonged hospitalization and increased treatment costs. Minimalization of the surgical site infection rates is an important epidemiological and therapeutical objective. AIM: A retrospective study assessed surgical site infections rates in urgent and elective procedures on the proximal GIT, and in a selected group of elective procedures on the large intestine and rectum. The significance of some risk factors was assessed based on analyses of surgical site infections in all subjects operated during the two-year study period. PATIENTS AND METHODS: Infection rates following urgent procedures were analysed in 545 subjects operated for acute abdomen during 2003-2004. In another study group of 4667 subjects operated during 2005-2006, surgical site infection rates were analysed based on assessment of some risk factors. In this group, incidence of surgical site infections in 640 patients following proximal GIT procedures was studied. In a selected group of 192 elective colorectal procedures, incidence rates of surgical site infections and peritoneal infections were evaluated. RESULTS: Surgical site infections occurred in 71 (13 %) of the subjects in the group of 545 patients operated for acute abdomen. In 48 patients, the microbiological findings in surgical site infections were positive with the following commonest pathogens: Escherichia coli, staphylococci and Enteroccocus faecalis. Surgical site infections were demonstrated in 217 subjects (4.6%) out of the total of 4667 patients included in the study group. The surgical site infections risk factors, which were found statistically significant (p < 0.05), included the procedure's duration over 2 hours (p = 0.042) and the age > 50 (p = 0.047). Surgical site infections occurred most frequently in the group of 640 subjects with proximal GIT procedures, classified as septic procedures (surgical site infections in 28.5% and in the peritenal cavity in 8%). In the group of 192 subjects with colorectal procedures, the surgical site infections occurred in 6.8%, peritoneal cavity infections in 3.1% of the subjects. CONCLUSION: Surgical site infections are the commonest postoperative infections in proximal GIT surgeries. The surgical site is the commonest location. The principal pathogens following urgent procedures include Enterobacteriacae, enterococci and staphylococci. The following risk factors were found statistically significant: the procedure's duration (> 2 hours) and the patient's age (< 50 years).

[Postoperative nutritional support in liver surgery. Effects of specialized parenteral nutrition enriched with branched-chain amino acids following liver resections for colorectal carcinoma metastases]. / Pooperacní nutricni podpora v chirurgii jater. Ucinek specializované parenterální vyzivy obohacen o rozvetvene aminokyseliny po resekci jater pro metastázy kolorektálního karcinomu.

INTRODUCTION: Perioperative nutritional support in liver surgery remains specific regarding the role of the liver in the metabolism regulation. The loss of functional liver tissue following resection procedures may result in significant metabolic disorders, particularly in patients with preoperative liver impairment in chronic conditions. Perioperative nutritional support is indicated in patients suffering from malnutrition, chronic liver disorders and also following liver resections with limiting residual parenchyma. AIM OF THE STUDY: The retrospective study assessed the effect of complete parenteral nutrition enriched with branched chain amino acids on liver function and the rate of postoperative complications following liver resections (of at least two segments) for colorectal carcinoma metastases. SUBJECTS AND METHODOLOGY: 142 subjects following liver resections for colorectal carcinoma metastases were included in the study. In 42 subjects with anatomical resections of at least two segments, complete parenteral nutrition enriched with branched chain amino acids (3.8 g) was administered postoperatively from Day 1. The parenteral nutrition was maintained for 5 to 7 days, from Day 3, additional oral diet regime was indicated. In 100 subjects with a single segment resections or wedge resections, a combination of glucose 10% and crystalloid solutions was administered from Day 1, and early oral diet was added from Day2. Liver tests were performed during the first postoperative week and protein electrophoresis 14 days postoperatively. RESULTS: During the first postoperative week, the liver test values reached normal values in patients with specialized complete parenteral nutrition. In subjects, where the specialized parenteral nutrition was not administered, increased alcaline phosphatase levels and gamma glutamyl transpherase levels were recorded through the postoperative Day 7. No significant differences were detected in protein electrophoresis values and in rates of postoperative complications (14% in both patient groups). Liver test values in specialized nutritional support patients were negatively affected by the extent of their liver resections and occurrence of additional extra hepatic disorders. Administration of complete parenteral nutrition enriched with branched- chain amino acids proved a positive effect on the liver test values recovery. CONCLUSION: Postoperative parenteral nutrition with solutions enriched with branched-chain amino acids in major liver resections (at least 2 segments) has a positive impact on the liver test values recovery during the early postoperative period.

[Polytraumas in injured patients over 65 years of age]. / Polytrauma u zranených starsích 65 let.

INTRODUCTION: Geriatric trauma is most commonly defined as a trauma in patients of 65 years of age and over. These patients represent a specific problem due to their vulnerability, limited physiological response to the traumatic stress and high frequency of associated disorders, complicating the treatment. The aim of this report is to assess polytrauma patients of 65 years of age and older, compared to a group of younger patients. PATIENTS, METHODOLOGY AND RESULTS: 198 polytrauma patients, hospitalized from 2005 to 2006 were included in the retrospective study. Out of the total, 27 subjects (13.6%) were 65+ years old. Upon their admission, the difference in APACHE II between the groups was highly statistically significant (19-27.2, p = 0.0001). The ISS (the mean value) score was higher in the elderly patients (29-38). Traffic injuries, including pedestrian-vehicle collisions (61-73%), were the commonest mechanism of injuries in the both groups. There was a significant difference in the rates of craniocerebral injuries (80-96%, p = 0.041). During the early posttraumatic period, 99 (57%) urgent surgical procedures were performed in younger patients, compared to 11 (79%) procedures in the elderly. The difference in death rates was statistically significant (25-44%, p = 0.031). CONCLUSION: Polytraumas in the elderly (65 years of age and over) injured is characterized by higher severity scores and higher rates of craniocerebral injuries. Traffic injury was the commonest mechanism of injury. The death rate was higher in the elderly patients.

Comparison of photodynamic therapy with phthalocyanine and photofrin in human colorectal carcinoma.

Photodynamic therapy (PDT) has been developed in recent years as a new modality for the treatment of various neoplastic and non-neoplastic lesions. Although the method of combining light with photosensitizers for treatment has been around for a century, further understanding has been evolved over the past decades. The method is based on the phenomenon involving the combination of photosensitizer and light. Neither drug nor light alone are effective as therapeutic agents. The antitumour effects result from direct cell damage, destruction of tumor vasculature and activation of a nonspecific immune response. The more accepted use of PDT is still restricted for ophthalmology, dermatology and treatment of some stages of esophageal, lung and urinary bladder cancer. In our experiments, the effect of phototherapy with disulfonated hydroxyaluminium phthalocyanine (Al(OH)S2Pc) and photofrin (control group) on the growth of human colorectal carcinoma on nude mice was studied. We chose colorectal carcinoma, because the Czech population has the highest incidence and it is still increasing. We try to offer a new possibility of treatment for patients with this severe disease.

[Technical aspects of the liver resection procedure--options for combinations of individual methods]. / Technické aspekty resekce jater--moznosti kombinace jednotlivých metod.

INTRODUCTION: The liver resection procedure as a treatment method of benign and malignant hepatobiliary disorders grows more important due to the fact, that its postoperative morbidity and mortality rates have been reduced, a result of the patients selection method, surgical techniques and perioperative care improvements. The aim of this report was to assess combinations of recent liver transsection techniques, based on the authors' own experience and results of recent studies. MATERIAL, METHODS AND RESULTS: From 1999 to May 2005, in the Surgical Clinic of the Faculty Hospital Královské Vinohrady in Prague, the liver resection procedure was completed in 133 patients with benign or primary and secondary malignant tumors. In the liver transsection procedure, the following instrumentation was used, starting from 1999: harmonic scalpels, ultrasonographic dissectors, water jet scalpel, bipolar diathermia, argon coagulation and radiofrequency. The liver tissue dissection using the ultrasonographic dissector or the water jet scalpel in combination with the harmonic scalpel or bipolar diathemic coagulation, reduced the postoperative blood loss in extensive non-anatomical liver resections. This dissection method was also used in some "centrally" located tumors for their non-anatomical resections. The benefit of the combination of the methods is based on sufficient coagulation and interruption of minor vascular branches and bile ducts in the resection line, without intermittent closure of the blood influx to the liver, using a Pringle manoeuvre. The radiofrequency, as a novel method for the liver tumors ablation, was used in anatomical and non-anatomical liver resections to coagulate the liver tissue prior to its transection prior to the R0 resection. The postoperative morbidity rate was 14% (19 patients). Within 30 postoperative days, no death was recorded. CONCLUSION: 1. The above listed liver transsection techniques, employing the ultrasonographic dissector or water jet scalpel, are safe alternative liver resection methods, reducing the blood loss. 2. Diathermic coagulation is an alternative to the harmonic scalpel for intersecting minor intraparenchymatous vascular branches and bile ducts. 3. A combination of the ultrasonographic dissector technique or water jet scalpel with the harmonic scalpel or diathermic coagulation technique, aids the liver resection by closing and interrupting the vessels and bile ducts in the resection line. 4. Radiofrequency and pre-transsectional coagulation of the liver parenchyma reduces the bleeding during the resection procedure and is a method of choice in resections of centrally located tumors, reducing the loss of the functional parenchyma.

[Anatomical resection for liver metastases of the carcinoma of the large intestine and the rectum]. / Anatomická resekce u jaterních metastáz karcinomu tlustého streva a konecníku.

UNLABELLED: Resection of the colorectal carcinoma liver metastases is an effective therapeutical procedure with a five-year survival rate in 20-50% of the operated. Opinions on the most optimal type of the resection procedure remain to be controversial. The aim of this study was to assess all indication criteria for anatomical resections of the colorectal carcinoma liver metastases. SUBJECTS AND METHODOLOGY: This retrospective study analyzed 98 patients with liver resection for colorectal metastases. In 31 patients, extensive anatomical resections of the liver were conducted, segmentotomie were conducted in 20 patients and nonanatomical wedge resections in 47 patients. Extensive anatomical resections were conducted in cases of tumorous foci larger than 2cm and located marginally between individual segments of a single lobe, and in cases of multiple tumorous foci affecting a single liver lobe. The nonanatomical resections were conducted in cases of metastases smaller than 2 cm, localized on the liver surface or in cases of multiple peripheral foci, including cases when both liver lobes were affected. RESULTS: In the group with the wedge-type resections, a histologically positive border was found in 4 cases. Postoperative complications were recorded in 10 (19.6%) patients with the anatomical resection and in 9 (19.1%) with the wedge resection. CONCLUSION: 1. Anatomical resection of the liver for the colorectal carcinoma metastases is indicated in cases of larger foci (over 2 cm), located marginally between segments or in multiple metastases affecting a single liver lobe. 2. Anatomical approach to the resection lowers the rates of histologicaly non-radical resections (R 1). 3. The new surgical technique of the liver transsection lowered, even in cases of anatomical resections, the postoperative morbidity rates.

[Diverticulosis of the small intestine--the authors study group and a case review]. / Divertikulární onemocnení tenkého streva--vlastní soubor a kazuistika.

Our case review describes an unusual case of an acute GIT haemorrhaging, caused by multiple diverticulosis of the proximal jejunum. The disorder is rare, rarely reported in literature worldwide. The typical course of the disease is asymptomatic, manifesting itself late as acute complications, most commonly urgent abdominal disorders. Chronic symptoms are less frequent, e.g. unspecific abdominal pain or occult haemmorhage. Inspired by literature data, the authors set up their own group of patients, who had been operated by the team for diverticles located in the small intestine, in the last 9 years.

[Non-surgical aproach in blunt injuries to the liver and spleen]. / Neoperacní postup u tupých poranení jater a sleziny.

INTRODUCTION: Non-surgical approach in blunt injuries of the liver and spleen in patients haemodynamically stable, is widely accepted as their therapeutical method of choice. Based on a retrospective analysis, the aim of this study is to assess the injured patients with blunt injuries of the liver and spleen who were treated non-surgically. SUBJECTS AND METHODOLOGY: 75 injured patients with blunt intraabdominal injuries were hospitalized from 2001 to 2003. The spleen injuries were diagnosed in 40 patients, out of which 12 of them suffered from concomittent injuries of other intraabdominal organs, the liver injuries were diagnosed in 37 cases, out of which 24 injuries were isolated. The non-surgical approach was indicated in haemodynamically stable patients with isolated injuries of the spleen and the liver of the ISt-IVth grade with haemoperitoneum up to 300 ml, diagnosed on a spiral CT examination. RESULTS: 47 (63%) patients were urgently operated for intraabdominal injuries, 7 of them (15%) exited within 30 days after the surgery. The non-surgical approach was indicated in 28 (37%) cases. In this group, 19 patients suffered from liver injuries, 7 from spleen injuries and 2 from pancreatic injuries. The severity of the injury was classified as the It degree in 7 patients, as the IInd degree in 7 patients, as the IIIrd degree in 7 patients and as the IVth degree in 5 patients. The non-surgical procedure failed in 5 (19%) cases of patients with IIIrd or IVth degree liver or spleen injuries. The failure was caused by a delayed bleeding from the injured spleen in 3 patients and by a continuous bleeding in the IVth degree liver injury and the bile collection from the biliary bladder rupture in the patient with the IIIrd degree liver injury. The spleen injury was treated using splenectomy. In the IVth degree liver injury a debridement of the dilacerated tissue of the 7th segment and a ligature of the injured branch of the right hepatic vein, were conducted. The patient with the IIIrd degree injury was treated using cholecystectomy with a suture of the liver rupture. CONCLUSION: The non-surgical approach to the treatment of the isolated blunt liver and spleen injuries is indicated for the injured patients who are haemodynamicaly stable, with Ist-IVth degree injuries, without or with minor (up to 300 ml) haemoperitoneum and with continuous intensive care. The non- surgical approach to the higher degree blunt liver and spleen injuries has higher treatment failure risk rates.

[What are indications for hepatic resection in metastases?]. / Kdy je indikována resekce jater u metastáz.

INTRODUCTION: In the last 20 years the resection of liver metastases became the method of choice in the therapy of malignant tumors, particularly of colorectal cancer. The study was aimed at evaluating indication criteria and operation tactics in liver metastases resection. MATERIALS AND METHODS: The authors retrospectively analyzed a group of 154 patients subjected to liver resection for metastases, having been operated on since 1980 to May 2003. The preoperative indication procedure included a) imaging examination of the liver (CT, NMR, DSA--radiological staging), b) evaluation of tolerance to liver resection to liver resection (ASA, hem-coagulation tests, liver tests, nutritional state), c) examination to exclude the occurrence of extrahepatic tumor (imaging and endoscopic methods). In addition to peroperative examination (surgical staging) and selective vascular exclusion in anatomical resection, the standard operation procedure was supplemented in the last five years with transaction of the liver by means of the harmonic scalpel. From the total number, metastases of colorectal cancer were resected in 116 patients, in 20 gall bladder cancers, in 6 stomach cancers, in 4 breast cancers, in three carcinoids of colon and intestine and in two kidney cancers. Individual patients suffering from metastases of adrenal cancer, pancreas cancer and melanoma, respectively, were also operated on. More extensive anatomical resections were performed in 44 patients, segmentectomy was made in 43 subjects and non-anatomical wedge-shaped resections in 67 individuals. RESULTS: Postoperative complications occurred in 15 (9.8%) patients (subphrenic hematoma, abscess, cholascos, fluidothorax, pulmonary or early infection). Two patients died within 30 days (1.3%) for hemorrhagic shock due to bleeding from duodenal ulcer and from hepatorenal failure). CONCLUSION: 1. Liver resection is indicated is resectable metastases of colorectal cancer. 2. The resection exerts a therapeutic effect in non-colorectal metastases in neuroendocrine tumors, tumor of uropoetic and genital system, breast cancer, sarcoma and melanoma. 3. The preoperative diagnosis should include: a) imaging examination of the liver and the site of primary tumor and possible occurrence of other metastases, b) determination of tolerance to liver resection. 4. The operation tactics includes the peroperative evaluation of operability, radical resection of metastases with 1 cm border of unaffected liver tissue and procedures leading to diminished blood loss and biliary stasis. 5. Anatomical resection is indicated in larger metastases affecting segments of one lobe. Non-anatomical wedge-shaped resection is aimed at removal of peripheral foci.

[Current diagnostic and therapeutic approaches in liver injuries]. / Postupy pri poranení jater z pohledu soucasných diagnostických a lécebných mozností.

PURPOSE OF THE STUDY: The recent improvements in hospital care system (centralized specialized care) and the use of new imaging methods and modern technologies in surgical treatment have greatly enhanced successful outcomes of therapy in liver injury. The aim of the study was to evaluate the contribution of procedures included in the diagnostic-therapeutic algorithms to the treatment of blunt injury to the liver in our patient population. MATERIAL: Our group consisted of 43 patients with blunt injury to the liver who were treated at the Emergency Department between 1998 and 2002. In 28 patients, blunt injury was part of polytrauma, in 7 patients it was associated with thoraco-abdominal injury and, in 8 patients, it was the only trauma sustained. METHODS: The diagnosis and therapy were based on the algorithm currently used for treating liver injury at the Emergency Department. In addition to clinical examination and assessment of the actual status of hemodynamics, spinal computed tomography was carried out to establish the therapeutic procedure. Fourteen patients were treated conservatively according to the criteria of a non-surgical approach and 29 patients underwent urgent surgery. Indications for revision surgery included, apart from signs of ongoing abdominal bleeding related to liver injury, combined spleen and kidney trauma. All patients with thoraco-abdominal involvement had laparotomy; in addition, four underwent thoracotomy including repair of the lacerated lung by suturing and three patients required suturing of a rupture of the right part of the diaphragm. RESULTS: In the patients treated conservatively, 10 showed spontaneous regression of parenchymal hematomas and four had to be treated by suction drainage. Out of 29 patients operated on, five died with signs of an irreversible hemorrhagic shock from multiple trauma and one died of multiple organ failure. DISCUSSION: The principal criterion determining therapy in blunt liver injury is the patient's hemodynamic status; laparotomy is mandatory in intra-abdominal trauma with severe hemoperitoneum or when unstable hemodynamics is due to intraperitoneal bleeding. Non-surgical treatment of blunt liver injury, on condition that the established criteria are observed, has several advantages such as less stress for the patient, fewer intra-abdominal complications and fewer blood transfusions needed. The modern technologies used in the operative procedure are related to both a transient vascular occlusion and a strategy for selective care in liver trauma. CONCLUSION: 1. The treatment strategy in a patient with blunt liver trauma is determined by the patient's hemodynamic status; in a stable patient, spinal CT examination of the thorax and abdomen is mandatory. 2. Urgent laparotomy is indicated when the patient with blunt liver trauma is hemodynamically unstable due to diagnosed hemoperitoneum or suspected intraperitoneal bleeding. 3. Conservative therapy is applied when the criteria for non-surgical treatment are fulfilled. 4. Surgical strategy for blunt liver trauma is based on the extent and localization of the injury, the patient's overall status and severity of associated injuries. Resection of the injured parenchyma is indicated when laceration of a liver lobe occurs. 5. The prognosis of blunt liver injury is influenced, apart from hemorrhagic shock reversibility, by the severity of associated injuries in multiple trauma.

[Traumatic rupture of the diaphragm in blunt injuries]. / Traumatická ruptura bránice u tupého poranení.

The authors present a group of 12 casualties operated on account of a traumatic rupture of the diaphragm. The rupture of the diaphragm was part of an associated thoracoabdominal injury or multiple injury. The casualties were examined within the framework of the diagnostic algorithm, in 11 of them rupture of the diaphragm was proved by spiral computed tomography. The diaphragm was injured in 7 subjects on the left and in 5 on the right. In 8 casualties during injury of the diaphragm also a serious intrathoracic injury was treated (in 5 laceration of the lungs) and of intraabdominal organs (in 4 laceration of the liver and in 2 laceration of the spleen). On the left side injuries of the diaphragm were always treated from laparotomy, on the right in 4 patients from thoracotomy. In 4 patients with concurrent injury of the intrathoracic and intraabdominal organs a thoracoabdominal approach was selected. During the postoperative period one female patient with multiple injuries died. The cause of death was contusion of the brain. According to the authors' experience it is useful to apply for early diagnosis of diaphragmatic injuries modern non-invasive imaging methods (spiral post-contrast computed tomography). The surgical approach depends on the presence of associated intrathoracic and intraabdominal injuries. The therapeutic results are limited by the presence of serious associated injuries.

[When is resection indicated in primary liver tumors?]. / Kdy je indikována resekce u primárních nádoru jater?

The development of hepatic surgery involved also definition of indications for resection in primary liver tumours. Based on an analysis of a group of 76 patients with primary liver tumours operated in 1978-2001 (up to the end of October) the authors evaluated the indication criteria for resection of primary hepatic tumours. As to benign tumours most frequently haemangiomas were resected (in 35 patients) and follicular nodular hyperplasia in 10 patients. Indication for resection was the symptomatology of the tumour (40x), signs of progression during a check-up examination (13x) or doubts as regards preoperative ruling out of malignity (16x). Hepatocellular adenoma was resected in 8 patients, incl. 7 where the preoperative diagnosis was assessed by bioptic examination. The extent of resection depended on the size and site of the tumour, in haemangiomas and follicular nodular hyperplasia non-anatomical resections predominated (in 27 patients). On account of hepatocellular carcinoma resections were made in 18 patients, incl. 8 who suffered also from cirrhosis which limited the extent of resection. In patients without cirrhosis with carcinoma in one of the lobes an anatomical resection was implemented. Postoperative complications developed in 14 patients (18%), two died (3%) from hepatic failure and pulmonary embolism.

[Liver transection with the harmonic scalpel in elective liver surgery]. / Transekce jater harmonickým skalpelem u elektivních jaterních operací.

More procedures used in transection of the liver parenchyma include also resection by means of a harmonious scalpel with an enhanced haemostatic effect. Based on analysis of 51 patients operated on account of liver disease using a harmonious scalpel, the authors evaluate its asset to the liver resection technique. The harmonious scalpel was used in transection of the liver in seven patients with benign liver disease (inborn cysts, follicular nodular hyperplasia, haemangioma, hepatocellular adenoma) and in 44 with malignant disease (hepatocellular carcinoma, metastases, most frequently, i.e. 34x of colorectal carcinoma). Anatomical liver resection (hemihepatectomy, lateral bisegmentectomy, segmentectomy) was implemented in 34 patients, and in 17 a wedge-shaped resection. Transection of the parenchyma by a harmonious scalpel was made using 10 mm coagulation scissors, i.e. their blunt blade with a lower oscillation grade. The preoperative blood loss was from 30 to 300 ml. As to postoperative complications 2 patients developed cholascos, 2 fluidothorax, 1 respiratory failure and 2 early infection. Liver resection by means of a harmonious scalpel is a new method of parenchyma transection with adherence to the resection line without damage of the deeper structures, reducing preoperative haemorrhage and minimalizing the extent of resection in liver diseases with impaired regeneration of the parenchyma (cirrhosis). Liver transection by a harmonious scalpel is a safe method where it is essential to respect recommended technical parameters, incl. the necessary time.