[Risk factors for anastomotic leakage following rectal resection - multicenter study]. / Rizikové faktory anastomotické insuficience po resekcích konecníku - Multicentrická studie.

INTRODUCTION: Anastomotic insufficiency (anastomotic leakage) is one of the most serious complications of the sphincter-saving rectal resections, with significant impact on patient morbidity and mortality. The risk rate of anastomotic leakage may be influenced by local anatomic conditions - tumour localisation and stage, possible technical problems in anastomosis construction (ischaemia, anastomosis under tension), and by complex factors associated with the patient - malnutrition, obesity, smoking, corticosteroid therapy and preoperative chemoradiation. MATERIAL AND METHODS: All sphincter-saving rectal resections that were performed between September 2011 and April 2014 in three centres of colorectal surgery, i.e. at Atlas Hospital in Zlín, the Czech Republic, and at Kosice-Saca Hospital and Dérers University Hospital in Bratislava, Slovakia, were included in the present multicentric prospective study. The incidence of anastomotic leakage in laparoscopic and open surgery was compared and the risk factors resulting in leakage occurrence were analyzed. RESULTS: Anastomotic leakage developed in 12 (10.9%) out of the total number of 110 patients. In the laparoscopic group (58 patients), the insufficiency occurred 4x (6.9%), in the 17 converted patients 3x (17.6%), and in the open surgery group (35 patients) the leakage occurred 5x (14.3%). There was no statistically significant difference between these groups. Nevertheless, patients with anastomotic leakage were only males (P=0.006), they had significantly lower pre-operative albumin levels (35.8 g/l vs. 38.3 g/l; P=0.03), as well as a lower pre-operative total protein level (60.8 g/l vs. 64.1 g/l; P=0.07), when compared to patients without insufficiency. Tumour distance from the anal verge in patients with anastomotic leakage was also significantly lower (10.8 cm vs. 12.8 cm; P=0.05). CONCLUSION: The following risk factors for anastomotic insufficiency after rectal surgery were identified: male gender, low pre-operative albumin and total protein levels, as well as decreasing tumour distance from the anal verge. The difference in the incidence of anastomotic insufficiency between laparoscopic and open surgery groups was not statistically significant.

Significance of the resection margin and risk factors for close or positive resection margin in patients undergoing breast-conserving surgery.

PURPOSE: While positive resection margin (RM) in women undergoing breast-conserving surgery (BCS) represents a clear indication for re-resection, there is no unequivocal recommendation regarding the extent of the clear RM. The aim of this study was to define the optimal extent of the RM and the risk factors for close or positive RM. METHODS: Patients scheduled for BCS had diagnosis confirmed before BCS (lumpectomy and quadrantectomy) by core biopsy. Sentinel lymph node biopsy followed BCS, and in case of positive findings axillary lymph node dissection followed. According to RM patients were categorized into 4 groups: 1) Patients with positive RM; 2) Clear RM < 2 mm; 3) Clear RM of 2-5 mm; and 4) RM > 5 mm. In the first 3 groups where re-resection was indicated, the presence of tumor cells in the re-resection specimen was determined. All patients were followed for local recurrence. RESULTS: 330 patients undergoing BCS were studied. Median follow up was 39.6 months (range 12-70). Lumpectomy was performed in 111 cases and quadrantectomy in 219. In 19 cases the final procedure was mastectomy due to the impossibility to achieve negative RM. In 78 cases re-resection followed the primary procedure due to close or positive RM. Clear RM was < 2 mm in 12 cases (15%), 2-5 mm in 56 (72%) and positive margin in 10 (13%). Positive re-resection specimen was detected in 31 cases (39.7%) (in 10 cases with positive RM after primary procedure, in 3 with negative margin < 2 mm and in 18 with 2-5 mm margin). The re-resection rate according to the location of the primary tumor was 77% (n=60) in the upper outer quadrant, 8% (n=6) in the lower outer quadrant, 6% (n=5) in the upper inner quadrant, 4% (n=3) in the lower inner quadrant, and 5% (n=4) in centrally located tumors. Multicentric/ multifocal tumor was diagnosed in 16 cases from which re-resection was indicated in 12 cases (75%). The number of re-resection according to tumor size was as follows: Tis 8 cases (30.7%), T1a none, T1b 14 (20.2%), T1c 34 (22.5%), T2 22 (28%). Re-resection was performed in 8 cases (31%) of ductal carcinoma in situ (DCIS), in 53 (22%) of ductal carcinoma, in 10 (37%) of lobular carcinoma, and in 7 (15%) of other histology. Five cases with local relapse were detected during follow up. CONCLUSION: The generally recommended clear RM of 1-5 mm is not sufficient because of the high number of positive specimens in the case of clear RM of 2-5 mm. The risk factors for close or positive RM are multicentric tumors and upper outer location of the primary tumor. Longer follow up will be needed to analyze local relapse rate according to RM status.

[Lymphadenectomy in papillary thyroid cancer]. / Lymfadenektomie u papilárního karcinomu stítné zlázy.

INTRODUCTION: Papillary carcinoma is the most frequent malign tumour of the thyroid with rising incidence and metastasising in lymphatic veins. AIM: Diagnosing our patients and comparing the TNM stages to metastases found in lymphatic nodes. MATERIALS, METHODS: A retrospective study of 1,353 patients treated at our department between 2005 and 2008. RESULTS: 220 (16.3%) malign thyroid tumours have been found among 1,353 patients. Papillary carcinoma has been found in 180 cases, according to the TNM classification T1 mic 80x (44.4%), T1 58x (32.2%), T2 29x (16.1%), T3 8x (4.4%), T4 5x (2.8%). Multifocal incidence of papillary carcinoma has been observed in 42 patients (23.3%). Lymphadenectomy cervicocentral 18x, ipsicervicolateral 52x, contracervicolateral 1x. In total, 351 nodes were removed and 113 nodes had metastasis of papillary carcinoma. 2 patients had permanent paresis of the NLR (1.11%), nerve at risk 0.56%, transitory paresis 5.56%. CONCLUSION: The basic surgical treatment of the thyroid with papillary carcinoma is total thyroidectomy with cervicocentral lymphadenectomy. Ipsilateral lympadenectomy is indicated in the case of nodes found sonographically or tumour size T2.

[Locoregional recurrences after conservative surgery in early breast cancer]. / Lokoregionální recidivy po konzervativních výkonech u casného karcinomu prsu.

INTRODUCTION: Conservative surgery is considered as standard and alternative mastectomy in early stage breast cancer but number of local recurrence is higher. Aim of the study was to detect number of local recurrences after conservative surgery and to identify risk factors of local recurrence especially importance of resection margins. MATERIALS AND METHODS: Local recurrences were evaluated in patients after conservative surgery in early breast cancer at department of surgery Atlas hospital in Zlin between January 2004 and December 2008. T1-2 (only one T3) breast cancers were included in study. Diagnostic biopsy, lumpectomy and quadrantectomy were performed. In all patients axillary nodes were examined. Study guidelines required microscopic distance between resection line and tumor margin 5mm. Specimen after surgery was marked with black ink and from June 2006 with six colors ink. Radiotherapy and chemotherapy in additions to character of cancer followed surgery. RESULTS: Conservative surgery was performed in 330 patients. Mean age was 59 years. Follow-up was 39.6 month. Stage of the tumor: 0 19x, I 101x, IIA 163x, IIB 33x, IIIA 5, IIIB 0, IIIC 9. Lumpectomy was made 11 lx including 11 diagnostic biopsies and quadrantectomy 219x. Final conservative surgery was 331x and mastectomy 19x. Positive axillary nodes were 98x. In breast local recurrence appeared in 5 (3.6%) patients and one had regional recurrence without in breast recurrence. Distant metastases were 8x (2.4%) and ten patient died on primary disease without locoregional recurrence. CONCLUSION: Local recurrence appeared only 5x. Clear margins after breast conserving surgery are very important factor in prevention local recurrence. We recommend keeping 5 mm resection distance.