Inferior pancreaticoduodenal artery aneurysm rupture as a cause of haemoperitoneum - case report and review of the literature.

INTRODUCTION: Arterial aneurysms of the pancreaticoduodenal arcade (PDA) represent approximately 2% of all aneurysms of visceral arteries. Despite a low incidence, this group of aneurysms is clinically significant due to its high risk of rupture. CASE REPORT: A 45 years old patient presented with a pancreaticoduodenal arcade aneurysm rupture along with a tight stenosis at the origin of the coeliac trunk. Retrograde blood flow from the superior mesenteric artery (SMA) to the hepatic artery (HA) via PDA limited our therapeutic options due to the necessity to maintain liver perfusion. The patient was indicated for an interventional radiology procedure, which consisted of percutaneous transluminal angioplasty (PTA) with stent placement at the origin of the coeliac trunk and subsequent transarterial embolisation (TAE) - trapping of the aneurysm using coils. Due to clinical signs of the intra-abdominal compartment syndrome, within 24 hours of the radiological treatment, the patient was indicated for surgical revision (laparotomy). During the surgery, no signs of active bleeding were found; coagula were evacuated from the abdominal cavity (800 ml) and laparostomy was performed with a temporary closure using a grid. Final closure of the abdominal cavity was performed on postoperative day 20 from the initial procedure. Follow-up abdominal CT performed 22 months after TAE showed no recurrence of the aneurysm. CONCLUSION: Aneurysm rupture represents a serious case of acute abdomen which requires urgent treatment. The preferred method of treatment for ruptured PDA aneurysms is the endovascular intervention using TAE, which is associated with lower morbidity and mortality than the surgical intervention. Concurrent coeliac trunk stenosis requires consideration given the need to maintain sufficient liver perfusion after TAE of the PDA aneurysm, acting up to this point as a collateral circulation of the liver. The choice of the therapeutic approach should be individualised taking into account the above mentioned recommendations.

[Treatment strategies of the colorectal anastomosis stricture]. / Strategie lécby striktury kolorektální anastomózy.

INTRODUCTION: The treatment of the stenoses of colorectal anastomoses represents a difficult area of colonic surgery. This is partly connected to the introduction of staplers and an increasing amount of sphincter-preserving surgeries. At our clinic, we solve the stenoses of colorectal anastomoses using a surgical rectoscope with a good effect. MATERIAL AND METHODS: We analysed retrospectively a group of 27 patients with benign stenosis of colorectal anastomosis of the medial and upper rectum who underwent surgery at our clinic in the period between January 2004 and December 2011. From the total amount of 27 patients, in 23 patients the stenosis was caused by the dehiscence of anastomosis, and in 4 patients the stenosis had a different etiology. RESULTS: In the group of 27 patients, in 14 patients the stenosis of colorectal anatomosis was solved radiologically using a high pressure balloon. Total of 13 patients underwent surgery, in 10 of them we used the surgical rectoscope and 3 patients underwent an open abdominal procedure. CONCLUSION: The first method of choice in treatment of the stenoses of the colorectal anastomoses is a balloon dilatation. If this is not successful we can use the surgical rectoscope as a minimally invasive though effective and safe method.

[Risk of colorectal carcinoma in a patient with ulcerative colitis]. / Riziko kolorektálního karcinomu v terénu ulcerózní kolitidy.

Colorectal cancer, in patients with ulcerative colitis, is detected in the resected tissue of approximately 5% of patients, according to the literature. In our set of 82 patients operated on between the years 2000-2009, malignancy was confirmed in 9/82 patients (11%). In two young patients, the peroperative findings showed inoperable generalized carcinoma. The greater incidence of malignity is surely associated with inconsistent dispensarization of these patients.

[Potential of transanal endoscopic microsurgery]. / Moznosti transanální endoskopické mikrochirurgické techniky.

AIM: Evaluate our more than seven year experience with transanal endoscopic microsurgical technique (TEM). MATERIALS AND METHODS: The authors prospectively evaluated a set of 393 patients who were operated using the TEM method. RESULTS: Out of 393 patients, 371 (94%) were indicated for the procedure for rectal tumor; 82 of these tumors were malignant. Nine patients underwent a rectoplasty for rectal stenosis, and in five patients drainage of a perirectal fluid collection was performed. Four patients underwent the surgical procedure for bleeding from the rectal tumor and in four patients an ulcerous lesion was removed from the rectum. Complications in the set of patients with malignant or benign tumors of the rectum occurred in 21 (6%) cases. Ten patients had bleeding, three patients underwent surgical revision for peritonitis with dehiscence of the intraabdominal bowel suture after transmural resection, periproctal abscess occurred in five patients, rectovaginal fistula was observed in three patients. There was no postoperative mortality. CONCLUSION: Transanal endoscopic microsurgery has become a standard therapeutic procedure. In oncosurgery, for early stages of rectal tumors, it is an equivalent alternative to conventional surgery with the advantages of minimal morbidity, mortality, postoperative complications, and sexual and urological dysfunctions. This, however, is only true when indication criteria are strictly adhered to and principles of resection radicality are maintained.

[Ambulatory excision of perianal duplicatures]. / Ambulantní excize perianálnich duplikatur.

For successful outpatient treatment of perianal duplicatures, it was necessary to solve two main problems. First was bleeding from wounds following excision of perianal duplicatures, which is often marked and "pulsating", as well as to accelerate defect healing after excision so as to eliminate or minimize sick leave following this outpatient procedure. To effectively stop acute bleeding we use Traumacel powder, which after applying to a tampon we apply to the bleeding site and by compression we facilitate its effect. Traumacel spray also has a significant haemostatic effect, which we spray directly onto the bleeding site, where it reacts and creates a strongly adhering coagulum, which has significant haemostatic properties. This effect may also be potentiated by applying compression in the form of tampon or longuette. After cessation of acute bleeding, as prevention against future seepage, surgical haemostatic materials are used, which adhere to the wound, or bleeding lesion, and are left in situ for approximately 12 hours. After stopping the bleeding, hydrocortisone and epithelializing cream is applied to the defects to support healing by significantly decreasing secretion from the wound and also significantly decreasing healing time by facilitating epithelization. At outpatient check-ups, wound surfaces treated as such are cleanly granulated without necrotic coating and with minimal surrounding redness. The total healing time is generally 2 weeks, whereas after 4 days the patients are almost without troubles. This effective healing not only lessens the patient's pain, but also improves the comfort of the patient and allows a more rapid return to daily activities.

[Patient survival following radiofrequency ablation of liver metastases from colorectal cancer]. / Prezívání nemocných po radiofrekvecní ablaci jaterních metastáz kolorektálního karcinomu.

OBJECTIVE: The objective of the work was to evaluate five-year survival rates of patients with liver metastases from colorectal cancer following radiofrequency ablation (RFA). MATERIAL A METHOD: The authors prospectively evaluated a set of 32 patients indicated for radiofrequency ablation. RESULTS: Patients who were indicated for RFA and for a combination of liver resection with RFA for metastasis from colorectal cancer had a one-year, three-year and five-year survival of 81%, 31% and 13%, respectively. Therefore 10 patients survived 3 years following the procedure and of these 4 obtained five-year survival. CONCLUSION: Radiofrequency ablation has become a generally accepted technique in the treatment of liver metastases. It is indicated in cases of lesions unsuitable for surgical resection, either due to large number and location or in patients with comorbidities where an extensive resection is contraindicated. Radiofrequency ablation has minimal complications and is considered on the borderline between a palliative and radical procedure.

[Radiofrequency ablation of colorectal liver metastases]. / Radiofrequenzablation von kolorektalen Lebermetastasen*

INTRODUCTION: Liver resection is the preferred treatment for colorectal liver metastases. About 30 to 40 % of the patients survive for five years after radical resection of liver metastases. In contrast to that, patients who are not fit enough for radical resection of metastases and two are treated by chemotherapy survive only for 18 months on average. The survival of patients with non-resectable liver metastases can be improved by metastases destruction and subsequent chemotherapy. At present, radiofrequency ablation (RFA) is widely used for the destruction of liver tumours. PATIENTS AND METHODS: In the four-year period (2000-2003), 190 patients with liver metastases of colorectal carcinoma have been operated upon at the 2 (nd) Surgical Department of University Hospital in Olomouc. Radical resection of metastases was carried out in 136 patients (71.5 %), RFA combined with liver resection was performed in 23 patients (12 %) and exclusive RFA of metastases was indicated in 31 patients (16 %). The patients were evaluated for the disease-free survival after one year and the survival rates at 12, 24 and 36 months after operation were determined. RESULTS: 12 months after the operation no tumour progression was found in 115 patients (85 %) subjected to radical resection of liver metastases, in 16 patients (52 %) after sole RFA of metastases and in 15 individuals (65 %) who underwent liver metastasis resection combined with RFA of the remaining cancer foci. The survival of patients after 12, 24 and 36 months was 124 / 136 (91 %) 103 / 136 (76 %) and 79 / 136 (58 %) in the group of radical metastasis resection; after sole RFA of the metastases and subsequent chemotherapy, the survival at 12, 24 and 36 months amounted to 27 / 31 (87 %), 19 / 31 (61 %) and 8 / 31 (26 %) of the patients; in the group undergoing metastases resection combined with RFA and adjuvant chemotherapy patient survival at 12, 24 and 36 months was as follows: 19 / 23 (83 %), 13 / 23 (57 %), and 7 / 23 (30 %). CONCLUSION: RFA combined with adjuvant chemotherapy considerably extends the survival of patients with liver metastases of colorectal carcinoma compared to chemotherapy alone. However, no difference in survival was found between our patients subjected to RFA of metastases and adjuvant chemotherapy and those patients undergoing resection of liver metastases combined with RFA of unresectable metastases and subsequent chemotherapy.

Endorectal sonography in rectal cancer staging and indication for local surgery.

BACKGROUND/AIMS: Radical surgery still plays a decisive role in the therapy of rectal cancer. Besides classical abdominal operations, an alternative is transanal endoscopic resection of rectal tumor at T1 and T2 stages. Indication for local resection of malignant rectal tumor requires an accurate preoperative staging. METHODOLOGY: The paper evaluates the accuracy of 3D endorectal sonography in rectal cancer staging. In the group of 78 patients the staging of preoperative 3D endorectal sonography was compared with a final histopathologic of the operative sample. RESULTS: The results obtained indicate that the preoperative staging of malignant rectal tumor using 3D endorectal sonography represents 100% only in the pT1 stage. In the pT2 stage, the accuracy of 3D endorectal sonography is 72%, in pT3 and pT4 represents 92%. CONCLUSIONS: On the basis of our experience, complicated interpretation of findings obtained by 3D endorectal sonography occurs at limits of T2-T3 and T3-T4. In these localizations the peripheral reactive fibrous and inflammatory sections in the vicinity of tumor tissue often involve even the next layer of rectal wall and leads to overevaluation of invasion depth at endorectal sonography of rectal cancer.

[The intraabdominally located mesh in the laparotomy management of major hernias]. / Intraabdominálne ulozená sít'ka pri resení rozsáhlých kýl v laparotomii.

AIM: Major hernias in sutures following abdominal surgical procedures make the patients' quality of life significantly worse. Our aim is to prove that, even now, the surgical management of such hernias has its cons and in most cases requires a plastic mesh application. PATIENT SUBJECTS AND RESULTS: The authors operated 82 patients with hernias via the middle laparotomy. The patients had been primarily operated for their colorectal disorders. The incidence rate of the major hernias in sutures was 5.25% (82/1564). The defects of the abdominal wall were corrected using a prolene mesh placed intraperitoneally. Although in 11 patients the authors report postoperative complications in the sutures (1x absces, 6x seroma, a 4x infiltration), the long-term results of the above technique remain very positive. 2 patients had a relaps of the hernia and clinical manifestations of adhesions following the procedure were reported in 7 patients. CONCLUSION: The technique of the intraabdominally located mesh in the major postoperative hernias management enables tension-free procedures of the major defects of the abdominal wall to be conducted with very good long-term results.

Complex therapy of advanced colorectal carcinoma.

The present paper reports on a complex therapy of 18 patients with primary unresectable advanced carcinoma of the rectum and rectosigmoid. The results of surgery following complete chemoradiotherapy are evaluated. Radical surgery was successful in 15/18 patients. The authors describe a high incidence of postoperative complications and point out a high erudition of an oncosurgeon necessary for such intervention as well as for the indication of a patient to this extensive operation. (Tab. 2, Ref. 18.)

Oncologic markers in patients with colorectal cancer after a complex therapy.

The authors present a prospective study on a value of oncologic markers CEA and CA 19-9 in patients after curative therapy for colorectal adenocarcinoma. During a five-year follow-up in 320 patients, a significant elevation of CEA or CA 19-9 was documented in 71 patients (22.8 %), and resulted in tumour detection in 39/71 patients (55 %). Although the levels were defined as false positive in 32 patients (45 %), the importance of CEA and CA 19-9 monitoring is documented by elevated levels of oncomakers in 39/55 patients (71%) with metastases or local-regional recurrence of colorectal adenocarcinoma. (Tab. 3, Ref: 21.)

[Surgical treatment of the colorectal carcinoma synchronous with liver metastases]. / Chirurgická lécba synchronních jaterních metastáz kolorektálního karcinomu.

The authors present their results of the surgical treatment of the synchrone liver metastases in the second stage and following three courses of chemotherapy. Although the trial group is small, counting 25 patients operated between April 2002 and October 2003 (i.e. 18 months), the procedure's clinical benefits may be deducted, based on the immediate postoperative results.

[Quo vadis laparoscopic appendectomy?]. / Quo vadis appendectomia laparoscopica?

The authors evaluated a group of 282 patients subjected between January 1993 and December 1998 to appendectomy, either by the open or laparoscopic route. They compared the period of work incapacity in the two groups to confirm or rule out the fact that after laparoscopic appendectomy the return to work is faster. The results are more favourable in the group of patients operated by the mini-invasive procedure, but even then the period of work incapacity is twice as long, as compared with other countries.