Spigelian hernia.

INTRODUCTION: Spigelian hernia is a rare type of abdominal wall hernias which are often diagnosed when incarcerated. These hernias typically develop at the crossing point of the arcuate line and lateral portion of rectus abdominis muscle. CASE REPORT: We present the case of a 44-year-old female patient admitted to our surgery unit for a painful lump in her right mesogastrium. Incarcerated atypical hernia in the right mesogastrium was suspected based on completed imaging assessments. Spigelian hernia was confirmed by preoperative findings. Interestingly, the patient applied interferon (multiple sclerosis therapy) at the site of the lump, which is why the diagnosis of lipodystrophy had been considered. CONCLUSION: In general, the diagnosis of Spigelian hernia is difficult. From the anatomical point of view the clinical finding is not always specific. The risk of incarceration is relatively high, and thus even clinically silent findings are indicated for surgery.

Differential expression and processing of matrix metalloproteinase 19 marks progression of gastrointestinal diseases.

Matrix metalloproteinases (MMPs), responsible for extracellular matrix remodelling and processing of numerous soluble and cell-surface proteins, appear to play important roles in pathogenesis of gastrointestinal diseases. MMPs influence migration of inflammatory cells, mucosal destruction, matrix deposition and degradation. In this study, we analysed the expression of MMP-19 in the main forms of gastrointestinal diseases including inflammatory bowel diseases (IBD) such as ulcerative colitis and Crohn's disease, and colorectal carcinoma. We identified prominent MMP-19 expression in unaffected areas of intestinal epithelia and macrophages but not in other cells or tissues. Abundant expression of MMP-19 was also found in the endothelium of blood and lymphatic vessels of inflamed intestinal tissue. High MMP-19 immunoreactivity was also associated with macrophages in inflamed areas and myenteric plexuses. In comparison to the intestinal epithelium, all these cell types and compartments appeared to express MMP-19 irrespective of the disease pathogenesis and progression. Intestinal epithelia exhibited striking differential immunoreactivity for MMP-19. While immunoreactivity of monoclonal antibody recognizing the propeptide domain declined in virtually all IBD and colorectal carcinoma samples, other polyclonal antibodies against the hinge region and propetide domain did not show such an obvious decrease. Additional Western blotting analysis revealed that the antibodies against MMP-19 recognize differently processed forms of this MMP. The disappearance of immunoreactivity of the monoclonal anti-propeptide domain antibody does not mean down-regulation of MMP-19, but processing of the immature form. As this processing likely leads to the activation of this MMP, the differential staining pattern may be an important sign of disease progression.

[Erectile dysfunction after surgery for rectosigmoid tumors--diagnosis and therapy]. / Erektilní dysfunkce po operacích pro nádory rektosigmatu--diagnostika a moznosti lécby.

OBJECTIVE: To assess the standard diagnostic and therapeutic algorithm of erectile dysfunction (ED) after radical operations on account of rectosigmoid tumours. MATERIAL AND METHODS: At the Faculty Hospital in Plzen from Jan. 1995 till Oct. 1999 the mentioned operation was implemented in 167 men, incl. 98 who were sent a questionnaire concerning postoperative sexual complaints. 39 replied. Those interested were examined further and treatment of ED was started. RESULTS: Four men, mean age 75.3 +/- 1.0 years were before surgery sexually inactive. In the remaining 35 ED developed in 68.6% (24/35)--mean age 58.2 +/- 9.8 years (in men without ED it was 61.7 +/- 11.1 years), in 37.1% (13/35) ED was complete, in 31.4% (11/35) partial. A postoperative decline of libido was in recorded in 37.1% (13/35) and impaired ejaculation in 65.7% (23/35). In men with postoperative ED 66.7% (16/24) suffered also from another disease causing ED, in men without ED this ratio was only 18.1%. In the group of men with ED, on account of ED 40% were examined and treated (14/35) incl. 10 who were examined for the first time in conjunction with the questionnaire project. Sildenafil was administered to 10 men, an effect sufficient for intercourse was described by two (both with partial ED), a partial effect however inadequate for intercourse was described by four and four recorded no response. Only four men tried intracavernous PGE1 injections and in all instances with a favourable effect. CONCLUSION: ED which affects about two thirds of patients is not treated as a rule. For examination a rule anamnestic data and physical examination are sufficient. Oral sildenafil treatment is effective only in a small percentage of patients. Intracavernous injections are more effective but are usually refused.

[Surgery of a large ventral hernia using Gore-tex]. / Operace velké ventrální hernie s pouzitím Gore-texu.

Severe intraabdominal sepsis, i.e. perforating peritonitis or necrotizing pancreatitis with complications sometimes call for very aggressive surgery such as the method of temporary closure of the abdominal cavity with repeated revisions. This frequently leads to the development of extensive ventral hernia. The latter develops as a rule at a site where it is impossible to suture the aponeurotic part of the abdominal wall (it is too retracted or lacking) and the use of a synthetic mesh for its reconstruction is not possible for some reason. After elimination of the temporary closure thus only resuture of the skin and subcutaneous layer is made. The author demonstrates on two cases one of the possible operations of a thus developed major hernia, where a Gore-tex patch was used. This material meets best the demands laid on a permanent "substitute" of the abdominal wall. Its wider use is unfortunately prevented by its high price.

[Temporary closure of the abdominal cavity--surgical technique]. / Docasný uzáver brisní dutiny--príspevek k operacní technice.

Temporary closure of the abdominal cavity can be achieved by different means. The disadvantage of original devices (Ethzip, Velcro) is as a rule their high price. The author presents his own technique of temporary closure of the abdominal cavity which meets all contemporary demands laid on this method, while it uses materials of Czech origin the price of which is incomparably lower than that of foreign devices. He uses as a basis worldwide findings as well as his own long-standing experience with this method in the treatment of severe forms of haemorrhagic-necrotizing pancreatitis and diffuse peritonitis of varying etiology. The method was used at the Department of Surgery of the Faculty Hospital in Plzen since 1990 with favourable results in more than one hundred patients.

[A technique for treatment of extensive defects of the abdominal wall with gastrointestinal fistulae]. / Technika osetrování rozsáhlých defektu brisní steny s pístelemi GIT.

Under certain extreme conditions in abdominal surgery, such as in septic complications of resections of the GIT with dehiscence of the anastomosis the only possible surgical approach is classical laparostomy. In the latter, contrary to the technique of temporary closure, the abdominal cavity is left open. After control of the sepsis usually the greatest problem is treatment of the defect in the abdominal wall with a fistula of the GIT. Unfortunately special devices for the treatment of such wounds cannot be used in all cases. At the Department of Surgery in Plzen such situations are resolved by suction drainage led beyond the defect in the abdominal wall which is then covered with an incision foil. In this way treatment of the patient is greatly simplified.

Cancer in the anal canal (transitional zone) after restorative proctocolectomy with stapled ileal pouch-anal anastomosis.

The first case of an adenocarcinoma developing in the retained anal canal mucosa (transitional zone) after restorative proctocolectomy with a stapled ileal pouch anal anastomosis is presented. The cancer was detected during routine follow-up 16 months after pouch formation for long standing ulcerative colitis, complicated by a cancer in the upper rectum. The patient was treated with an abdominoperineal excision of the ileal pouch and anus.

[Initial experience with a new silicone drain made by Rubena Náchod]. / První zkusenosti s novými silikonovými drény z Rubeny Náchod.

At the Surgical Clinic in Plzen in 1992 clinical trials were made to test drains manufactured in Rubena Náchod (plant in Velké Porící). These soft silicone X-ray contrasting drains were used in 40 patients. A total of 70 drains were used, all in abdominal operations incl. acute abdominal surgery and injuries. The mean drainage period was 9.2 days, the longest period was 38 days. In all instances the drainage was effective, none of the patients developed a residual abscess or intestinal fistula. The material from which the drains are made was well tolerated by all patients and none of them developed a reaction.

[Esophageal injuries]. / Poranení jícnu.

The authors present an analysis of 33 oesophageal injuries treated at the surgical clinic of Faculty Hospital Plzen in 1976-1991. Iatrogenic injuries predominated (a total of 24 cases). Of these seven developed during oesophagoscopy performed on account of dysphagic complaints caused by benign or malignant disease. Ten injuries developed in conjunction with endoscopic extraction of a foreign body, three occurred during operation of hiatus hernia, two during sclerotization of oesophageal varices and one each during insertion of a nasogastric tube and oesophageal endoprosthesis. In the remaining cases perforation occurred during traumatic injury of the neck four times, twice as a result of a swallowed bone, and three perforations were spontaneous. The total mortality was 27.3%. The authors analyze factors which influence the morbidity and mortality--the site of injury, the time which elapsed between injury and treatment, the patient's age, mode of injury, associated diseases and method of treatment. They found that the most frequent complication and most frequent cause of death was septicaemia from mediastinitis and empyema of the chest.

[Mesenteric venous thrombosis as an unusual serious surgical complication in salmonellosis]. / Mezenteriální zilní trombóza jako neobvykle závazná chirurgická komplikace salmonelózy.

The authors describe a case of an extensive relapsing mesenterial thrombosis associated with an intestinal infection caused by Salmonella enteritidis. The disease had a fatal course, despite treatment based on contemporary knowledge. The authors discusses the method of treatment, emphasize the necessity of full heparinization and second look operation after extensive resection of the gut. They draw attention to the fact that a relapse of an apparently trivial salmonellosis can influence in a decisive way the results of treatment.