[Predictive factors for non-sentinel lymph nodes affection in breast carcinoma--outcomes of a Czech multicenter study of sentinel lymph nodes]. / Prediktivní faktory postizení nonsentinelových uzlin u karcinomu prsu--závery ceské multicentrické studie sentinelových uzlin.

BACKGROUND: The aim of the study was to assess positivity nonsentinel lymph nodes in patients with macro, micro and submicrometastases in sentinel lymph nodes and find predictive factors of positivity nonsentinel lymph nodes. Study was conducted at the Department of Surgery in Pardubice, Pilsen, Ostrava and Zlín. MATERIAL AND METHODS: Sentinel lymph nodes were assessed based on standards of Czech Pathological Society. Detection of sentinel lymph nodes was performed based on radionavigation or combination of radionavigation and blue dye method. RESULTS: In group N1 (macrometastases) there was found positivity of nonsentinel lymph nodes in 50% (45 from 90 patients). In group N1 Mi (micrometastases) there was found positivity of nonsentinel lymph nodes in 26.7% (16 from 60 patients). In group NO I+ (sub-micrometastases) there was found positivity of nonsentinel lymph nodes in 6.7% (1 from 15 patients). Predictive factors were size of metastasis, number of positive sentinel lymph nodes and grading. Size of tumor was not found to be a predictive factor of positivity nonsentinel lymph nodes. DISCUSSION: High positivity of nonsentinel lymph nodes in pacients with macro and micrometastases in sentinel lymph nodes advocates to perform axillary lymph nodes dissection. Due to small number of patients with submicrometastases it is not possible to assess if axillary dissection is necessary or not. Predictive factors of positivity of nonsentinel lymph nodes are size of metastasis in sentinel lymph nodes, number of positive sentinel lymph nodes and grading. Size of tumor was not found to be a predictive factor due to small tumors in the study. In spite of this it is necessary to consider it like a predictive factor of positivity nonsentinel lymph nodes. CONCLUSION: In patients with macro and micrometastases it is necessary to perform axillary dissection. In patients with submicrometastases in sentinel lymph nodes it is necessary to consider predictive factors.

[Haemothorax after blunt thoracic trauma]. / Hemotorax pri tupém poranení hrudníku.

BACKGROUND: Haemothorax is frequent consequence of blunt and penetrating thoracic trauma and is usually associated with pneumothorax. The occurence of haemothorax in blunt thoracic trauma patients is estimated between 25-75%. The reason of bleeding is impairment of intercostal arteries or lung parenchyma after trauma of the ribs. Uncontrolled bleeding is the main cause of the death. The article is focused on the treatment of this injury. MATERIAL AND METHODS: There were enrolled 238 patients with thoracic trauma, who were admitted into our department, into the study. The average age of the patients was 42.5 years. The ISS > or = 16 were in 101 patients. Forty two patients were artefitially ventilated. Conservative treatment prevails, almost in 65%. Special care was indicated in patients with haemothorax (fluidotoraxem). RESULTS: Clinically and based on other screening methods the presence of the fluid in thoracic cavity was in 131 patients. Surgical treatment (punction, drainage, videothoracoscopy and thoracotomy) was necessary in 47 (35.0%). Thoracotomy for the bleeding was indicated in seven cases (5.3 %). CONCLUSION: In diagnostics and in treatment of the bleeding in thoracic trauma patients the most important factor is clinical status of the patient. Indication for thoracotomy must be unambigous. Massive haemotorax leads to restrictive ventilation disorder with decreased preload and can be activator of the haemocolaguation disorders. This fact decreases chance for the survival of the patient.

[Traumatic perforation of the duodenum--a case review]. / Traumatická perforace duodena--kazuistika.

A blunt duodenal injuries are rare in spite of high-energetic injuries are common in this time. The diagnostic is very difficult not only for the reason of the little experience with this type of the injury but in term of the duodenal anatomic localization too. On the other side just late injury Identification of the retroperitoneal part of the duodenum leads to rapid development of the fatal retroperitoneal phlegmon. The development of the clinical symptoms and results of the paraclinical equipment examinations during blunt injury of the upper abdominal part with consequent perforation of the posterior retroperitoneal segment of the duodenum is well-documented by means of the mentioned case. The development of the retroperitonal phlegmon was not noticed despite of the slight diagnostic delayed and defect in the duodenal wall was treated by suture of the perforation aperture. The early detection of the duodenal injury is necessary premise for the good choice of the adequate surgical treatment.

[Massive hemothorax following canylation of the subcalvian vein--a case review]. / Masivní hemotorax po kanylaci v. subclavia--kazuistika.

INTRODUCTION: Cannulation v. subclavia is connected with many complications. Haemothorax is occurs approximately in 2% of cases. Surgical revision is indicated immediately if a major blood loss or a circulation insufficiency occur. Surgical treatment of bleeding in cupola of pleural cavity is due to its bad accesability difficult and conventional surgical methods aren't sufficient. In these cases one can use local haemostyptic. CASE REPORT: The authors present a case review of a 36-years old patient with a developed massive haemothorax on the left side post a catheterization of v. subclavia. During surgical revision it was found out that a source of bleeding in superior thoracic aperture is present. It wasn't able to be stopped by classical surgical procedure. TachoSil and Arista preparations were used in this case with a good effect.

[Haemobilia, the rare case of bleeding into GIT]. / Hemobilie, vzácná prícina krvácení do GIT.

AIM OF THE WORK: Bleeding into GIT is still serious problem with not low lethality. Especially, acute bleeding needs fast diagnostics and treatment. The aim of our work is to present the rare case of bleeding into GIT--haemobilia. GROUP OF THE PATIENTS: There is presented casuistics of the patient who was successfully treated on our department for bleeding from erosion of cystic artery as a consequence of acute cholecystitis. CONCLUSION: Nowadays there is dominantly preferred endoscopic approach in diagnostics and treatment of the bleeding into GIT. But surgical approach is in some cases the only one method in treatment of these complications.

[K-ras mutation as a prognostic factor in colorectal carcinoma]. / K-ras mutace u kolorektálního karcinomu jako prognostický faktor vývoje onemocnení.

INTRODUCTION: Colorectal carcinoma presents a serious problem in the Czech Republic: its incidence is on the increase and--according to some statistics takes first place among developed countries worldwide. Therefore, it is advised to incorporate examinational and the rapeutic algorithms with new modalities that will lead to early diagnostics or to a change in existing therapeutic procedures. CHARACTERIZATION OF K-RAS MUTATION: K-ras mutation belongs to the family of protooncogenes where a gene not having undergone mutation expresses proteins that regulate mitosis. Mutation cancels the regulatory function of these proteins, thus leading to the develop ment of tumors, especially carcinoma of the lungs, pancreas, and colorectum. PROJECT OBJECTIVE: The main objective of the project is to prove K-ras mutation in tumors of the colorectum: to detect tumor cells with K-ras mutation in peripheral blood; to detect K-ras mutation in liver metastases: and to verify the hypothesis claiming that tumors with K-ras mutation have a worse prognosis and often lead to disemination, mainly to the liver. METHODOLOGY AND COLLECTION OF DATA: The whole project is tied to an IGA grant and runs according to the strict rules of the protocol applied at the Surgical Clinic of the Pardubice Hospital, with its diagnostic part--PCR analysis being completed at the Biochemical Diagnostic Institute (UKBD) of the Teaching Hospital in Hradec Králové. RESULTS: The project has been running since June, 2004 to December 2006. 76 patients meeting defined parameters have been included in the file to date. K-ras mutation has been detected in the tumor tissue of 25 patients (33%). K-ras mutation hasn't been detected in the blood. DISCUSSION: Genetically analysis of a specific tumor has not yet become a standard part of the examinational and therapeutic algorithm. If an assumption of a worse course of illness and metastasizing--especially to the liver has been proven, the examination of Kras mutation in patients suffering from colorectal carcinoma should lead to the adjustment of their treatment and postoperative dispensarization, or the administration of chemotherapy and radiotherapy at stages when these modalities are not normally applied.

Preemptive antimycotic treatment in critically ill patients in the Czech Republic.

The incidence of Candida afflictions in critically ill patients is still growing in the Czech Republic. We looked for a method that not only decreases Candida afflictions but also decreases treatment expenses. This method is preemptive therapy. Critically ill patients were determined by a risk score system. This system was based on summarizing all the risk factors in one patient. Patients who reach the risk score were randomized into groups A and B. Patients in group A were administered itraconazole; patients in group B were not administered any antimycotics. Results of the study show that preemptive treatment decreases Candida infection and Candidemia. A decrease of treatment expenses was reached by identifying the specific group of patients at risk using the risk score system and administering antimycotics.

[New aspects in enteral nutrition in critical patients at the surgical intensive care unit]. / Nové aspekty v enterální nutricní podpore kriticky nemocných na chirurgické JIP.

INTRODUCTION: Nutritional support in critically ill patients has an impact on both prevention and treatment. Development of complications and organ failure can be prevented, good status of gut mucosa kept and positive nitrogen balance induced. Inflammatory response can be modulated. NUTRITIONAL SCREENING: Patients undergoing major surgery should be actively screened for the nutritional risk level according to described parameters since it is considered to be very important for the postoperative period. Enteral nutrition (EN) versus parenteral nutrition (PN): Current study findings do not show any difference in mortality of critically ill patients with regard to the administration route. Inflammatory complications rate is significantly lower in EN patients. ESPEN Guidelines on Enteral Nutrition: The most recent recommendations for surgery patients are based on the evidence. CONCLUSION: There is a need for an active nutritional screening to find patients in the risk. Other important points are the following: a progressive approach to early enteral nutrition combined with PN, multiprofessional cooperation and protocol implementation.

[Neovascularisation as a cause of recurrence after varicose veins operation]. / Neovaskularizace jako prícina recidivy po operaci varixu dolních koncetin.

AIMS: Following surgical therapy, new varicose veins may develop, in particular at the site of the previous saphenofemoral junction. The objective of this study is the appreciation of the causes of the bad results of surgical procedures in the treatment of varicose veins and the proposal of the possibilities of their prevention. MATERIAL AND METHODS: Retrospective study of the group of 404 patients (573 procedures) with the diagnosis of the recurrence after previous radical surgery was performed. After exclusion of perforator refluxes, the most frequently, the great saphenous vein territory was affected (86%), followed by the small saphenous vein territory (14%). The group of 30 consecutive patients (35 limbs) with saphenofemoral or saphenopopliteal recurrence was selected for this study. Based on preoperative ultrasound and per-operative morphological findings, in 12 patients (14 limbs) - 8 women and 4 men, meticulous histopathological examination of the venous tissue block from the saphenofemoral or saphenopopliteal region, VEGF (Vascular endothelial growth factor) and protein S-100 investigation were performed. RESULTS: In 14 limbs with sonographic and clinical suspition for neovascularisation, this entity was confirmed in 11 of them (79%) which represents 31.42% of the whole group. CONCLUSIONS: The varicose veins recurrences can be observed not only after technically or tactically imperfect primary procedure (which is surely the most common cause of the varicose veins recurrence), but also after the operations performed by the experienced venous surgeon in the perfect way. Neovascularisation explains a certain number of postoperative recurrences despite correctly conducted disconnection of the saphenous termination. The endovascular procedures (endovenous laser or radiofrequency saphenous obliteration) without open groin access can minimise the possibility of this complication.

[SIRS and serious blunt thoracic injuries]. / SIRS u závazných tupých poranení hrudníku.

INTRODUCTION: Serious blunt injuries are accompanied with the worsening of the mechanics of ventilation due to the chest and lung injuries alone as well as with a systemic inflammatory response (SIRS) that always affects the lungs. The development of an injury-induced respiratory failure is multifactorial and timely pharmacological intervention is likely to contribute to the treatment algorithm, thus improving prognosis in some patients with a serious chest trauma. THE OBJECTIVE OF THE STUDY: The objective of this study is to verify the efficacy of the pharmacological blockade of the systemic inflammatory response of the body (SIRS) in serious blunt chest injuries. The study also intends to identify whether the administration of indomethacin could reduce SIRS score and prevent multiorgan dysfunction and multiorgan failure. METHODS: 126 patients with blunt chest injuries were evaluated during 33 months. The patients were divided into four groups, depending on the extent of trauma severity assessed by means of ISS (Injury Severity Score). Randomly selected patients in each group were administered--in addition to standard therapy--indomethacin in usual doses. All tests were carried out at a significance level alpha of 0.05. RESULTS: The onset of SIRS in the subgroup with indomethacin was statistically significantly postponed in groups I. and II. Groups ISS I to III showed a statistically markedly shorter time of SIRS duration in the subgroup with indomethacin. The first increase in inflammatory markers (acute phase proteins) was statistically significantly postponed in the group ISS I without the administration of indomethacin. Groups ISS II through IV did not show a statistically significant differences in the first onsets of inflammatory markers. The evaluation of all four groups did not detect any statistically significant differences in the duration of the inflammatory markers increase in the subgroup with indomethacin and in a control group. There was no statistical significance in the average time of ventilation support. An average hospitalization time was shorter in the subgroup ISS II with indomethacin. There was found statistically significant difference. Of the patients included in our file seven died during the monitored period. Lethality is thus 5.6%. A multiorgan failure was the cause of death in two patients in the non-indomethacin subgroup and in one patient in the indomethacin subgroup. CONCLUSION: We proved that the factors that can be affected by the blockade of cyclooxygenase display statistically significant changes in subgroups with the administration of indomethacin. No changes were recorded with regard to acute phase proteins whose synthesis is not mediated by prostaglandins. The administration of indomethacin positively affects the development of SIRS, reduces and diminishes its effects as well as impact on the impaired body.

[Comparison of coated and bare metallic stents in inoperable carcinomas of the oesophagus and cardia]. / Srovnání potazených a nepotazených kovových stentu inoperabilních karcinomu jícnu a kardie.

INTRODUCTION AND AIM: The authors discuss paliative treatment using coated and bare metallic stents in a prospective randomized study for inoperable oesophageal carcinomas. The aim of this study is to assess the following parameters in both treatment groups: duration of the stents functionality, survival rates, complications rates and histological findings. METHODS: From 1999 to 2003, the total of 60 patients with oesophageal and cardial carcinomas were randomized. They had either bare (N-31 subjects) or coated (P-29 subjects) stents introduced. The patients were followed-up at one-month intervals. RESULTS: No statistical differences between the groups were found when the above parameters were assessed. DISCUSSION: The complications rate depended on the patients survival period in both stent types. Survival rates depended on the disease stage of the local tumorous process and on the individual patient's condition prior to the treatment. CONCLUSION: The study showed that the metallic selfexpandible stents treatment method may become a widely used paliative procedure in patients with malignant dysphagia, however, it has not proved any differences in complication rates depending on the stent coating.

[Acute extremity ischemia based on the popliteal artery aneurysm thrombosis--combined thrombolytic and surgical management]. / Akutní koncetinová ischemie na podklade trombózy aneuryzmatu popliteální tepny--kombinovaná trombolytická a chirurgická lécba.

Authors present their experience with combined trombolytic-surgical treatment of acute ischaemia of low extremity based on trombosis of popliteal artery aneurysm. This treatment was performed in three patients. Authors compare results of intraarterial catheter pharmacological trombolysis of infrapopliteal arteries with indirect surgical trombolysis.

[An axillary metastasis as the first sign of the breast carcinoma--a case review]. / Axilární metastáza jako první projev karcinomu prsu--kazuistika.

BACKGROUND: Carcinoma of the breast is the most commonly diagnosed women cancer. Less than 1% of the patients diagnosed with breast cancer initially present with axillary metastases as their only clinical manifestation. CASUISTIC: We report case of 58 years old woman with occult breast carcinoma in which extensive axillary node metastasis was the first manifestation. DISCUSSION: Breast cancer presenting with axillary metastases and no clinical apparent primary tumour in the breast is an uncommon form of stage II or IV of this disease. Ultrasonography, mammography, MRI and excisional biopsy are indicated for detecting occult primary tumours. The appropriate treatment of the breast after an axillary presentation of occult breast carcinoma continues to be a controversial issue. Complete axillary lymph node dissection is indicated in all patients. As a local treatment of the breast is indicated irradiation of the breast or total mastectomy or subcutaneus mastectomy with application of the breast prothesis. CONCLUSION: Axillary metastasis is rare first sign of breast cancer. Diagnostics of the occult breast carcinoma is difficult. The treatment of occult breast carcinoma is still controversial.

[Endoscopic solution of iatrogenic lesion of oesophagus]. / Endoskopické resení iatrogenního poskození jícnu.

The case report dissertates upon successful treatment of iatrogenic perforation of distal oesophagus with subcutaneous emphysema, pneumoperitoneum and pneumomediastinum. The endoclips and classic conservative treatment were used in therapy. The patient was treated 3 hours after the injury, no early or late complications related to perforation were noted.

[The glomus caroticum tumor--an unusal case]. / Tumor glomus caroticum--neobvyklý prípad.

There is discussed case of malignant paraganglioma with cervical lymph node metastasis that was complicated by mistake during peroperative histology. Peroperative histological examination revealed metastasis of medular carcinoma of thyroid gland. Total thyroidectomy was performed. Postoperative histological assessment revealed metastasis of carotic paraganglioma. Tumour was resected together with carotic arteries. Their reconstruction was performed during second procedure.

[Postoperative complications of a perforated aneurysm of the abdominal aorta--a case review]. / Pooperacní komplikace perforovaného aneuryzmatu abdominální aorty--kazuistika.

There discussed casuistics of the 64 years old man, who underwent urgent resection of perforated subrenal aortic aneurysm that expanded to both iliac arteries. Aortobifemoral bypass and packing of retroperitoneum were performed. The patient was operated for periprothetic abscess and aorto-enteric phistula three months later. Phistula was closed, infected prothesis was resected and replaced by new prothesis. Omentoplasty was added.

[Gas in the portal and mesenteric venous bed in a vascular ileus]. / Plyn v portálním a mezenteriálním venózním recisti pri cévním ileu.

Mesenteric artery embolisation is serious complication of heart diseases. Its mortality is almost 95%. Diagnostics of mesenteric artery embolisation is based not only on clinical examination, but also on CT scan. Presence of the gas in portal and mesenteric venous basin is very suspected from vascular ileus. This sign can be very helpful in diagnostics and consequently in treatment of this disease. Late diagnostics and treatment of vascular ileus has fatal prognosis.

[Surgical therapy options for bleeding gastroduodenal peptic lesions]. / Moznosti chirurgické terapie krvácejících peptických lézí gastroduodena.

INTRODUCTION: Mortality rate of bleeding into the upper GIT has remained relatively unchanged during the past 30 years, i.e. about 30%, even though the development of new technologies brought along substantial changes in diagnostic and therapeutic procedures. METHODOLOGY: This work deals with the surgical solution of bleeding into the upper GIT of peptic etiology. It covers a 5-year period (from January 1, 1999 until October 1, 2003) during which time the Regional Hospital in Pardubice admitted 1,310 patients with bleeding into the upper GIT of peptic etiology. 190 of them were hospitalized at the Surgical Clinic due to the developing hemorrhagic shock; the others were hospitalized at the Clinic of Internal Medicine. If it failed urgent endoscopy to stop the bleeding, the patient was referred to undergo an urgent surgery. If the bleeding was stopped by endoscopy yet it recurred after certain time, a second endoscopic homeostasis was attempted. If it failed, an urgent surgery was indicated. RESULTS: A total number of 24 patients underwent an acute surgery. A frequently used procedure was stomach resection, type BII, which was applied to a total number of 12 patients. However, this type of urgent surgery was accompanied with a relatively high number of complications. Reoperation had to be performed 4 times (33.3%). In one case (8.3%) for recurrent bleeding. In 12 patients one of the other procedures was performed: an injection and a trunkal vagotomy (3x), an injection and the ligation of the gastroduodenal artery (2x), proximal jejunum resection (1x), an injection accompanied with fundoplication according to Nissen-Rosseti (1x). Two of the patients who received this other group of procedures had to be reoperated for recurrent bleeding (16.7%). DISCUSSION: The decision about a suitable surgical procedure applicable to bleeding into the upper GIT after the failure of endoscopic homeostasis poses a substantial problem. It is necessary to choose from more radical procedures--resection--that stop bleeding reliably, yet their execution in an acute condition (often coinciding with the patient's hemorrhagic shock) results in a relatively large number of complications; and from less radical procedures that feature a smaller number of post-surgical complications yet that can be burdened with a larger percentile number of recurrent bleeding. Nearly the same number of serious recurrent bleeding in this study indicates that the appropriate choice of a procedure (according to the patient's current condition, ulcer localization, and associated diseases) makes both approaches (resection vs. a less radical procedure) similar as to the number of necessary reoperations after bleeding. CONCLUSION: The development of endoscopic methods introduced significant changes in the diagnostic-therapeutic algorithm of bleeding into the upper GIT. Nevertheless, the choice of an appropriate surgical procedure continues to present a relevant surgical issue.