Oncology wounds - recommendations for care based on multidisciplinary cooperation.

BACKGROUND: Oncology wounds and wounds of other etiology are rare but serious complications, which significantly impair patients quality of life. Preventive and curative interventions and education of healthcare personnel and patients reduce the risk of either their occurrence or their impact and consequences. A working group of authors from professional groups (the Supportive Care Group of the Czech Society for Oncology, the Czech Society for Wound Healing, the Society for Radiation Oncology, Biology and Physics, and the Czech Nurses Association) prepared recommendations for care. A comprehensive approach to the treatment of oncological wounds, including symptomatic treatment of associated healing complications, prevention, early detection, interdisciplinary cooperation and education are essential to deal with wounds related to chemotherapy administration, radiotherapy and oncological treatment in general. The proper choice of local care products and the eventuality of active oncological treatment are important elements of care in ulcerating tumors. PURPOSE: A basic summary of recommended interventions to prevent and treat oncology wounds in daily practice, defined based on expert societies guidelines, trials and literature data, proven practice and on the consensus opinions of the authors group members. The recommended procedures contribute to the reduction of the development, severity and consequences of oncological wounds and wounds of other etiology in oncological  patients.

Diagnosis and treatment of surgical skin and soft tissue infections - current status.

Surgical skin and soft tissue infections (SSTIs) result from microbial invasion of the skin and underlying soft tissues, often requiring surgical treatment. SSTIs encompass a variety of pathological conditions, ranging from frequent simple superficial skin infections with very good outcomes to rare, rapidly progressive necrotizing infections associated with long-lasting morbidity and high mortality. The document summarizes current knowledge of the diagnosis and therapy of these diseases and provides clinicians with current standards of care of these patients based on international guidelines. Additionally, regional specific aspects are also reflected, and thus in all cases, this paper on diagnostic-therapeutic management of individual clinical forms respects the actual clinical practice and epidemiology in the Czech Republic. The document has been prepared based on multidisciplinary consensus of experts from universities all over the Czech Republic.

Occult breast cancer: a case report and current management of treatment.

Occult breast cancer is a very rare type of cancer which presents with axillary lymphadenopathy with no visible mass in the breast. Advances in imaging methods (MRI, PET/CT, PET/MRI, etc.) have enabled the detection of a large number of lesions which are not visible using basic imaging methods, such as mammography and ultrasound. To date, optimal management of this type of cancer is lacking. Generally, treatment of occult breast cancer is that of primary breast cancer with axillary lymph node involvement. This includes neoadjuvant oncological therapy, axillary dissection with adjuvant radiation therapy and either mastectomy or radiation to the breast. However, several recent studies have shown that similar results may be achieved with less radical treatment. The paper describes the case of a 62-year-old patient with occult breast cancer, the procedure and results of imaging assessments, and subsequently the treatment management. Furthermore, the paper reports on current treatment trends published in the literature.

Nutrition in open abdomen.

Open abdomen is known as a serious consequence of various intra-abdominal pathologies. Initially, patients often have a life-threatening condition, sepsis or septic shock. Severe stress related malnutrition, mineral and fluid imbalance develop as metabolic consequences. Intestinal fistulas also occur as a frequent complication in patients with open abdomen. In such patients, a comprehensive approach is needed, including rehabilitation, nutritional support using optimal formulas, and local care for the open abdomen. Our case report presents a patient with open abdomen and enterocutaneous fistulation. A complex nutritional approach in the course of the disease is described and its importance is discussed. Finally, a summary of nutritional care for open abdomen patients is provided based on current recommendations.

Metastatic Clear Cell Renal Carcinoma Without Evidence of a Primary Renal Tumour Mimicking Advanced Stage of Malignant Lung Tumour.

BACKGROUND: Clear cell renal carcinoma (ccRC) accounts for 65-70% of renal carcinomas with peak occurrence at the 6th and 7th age decade, predominantly in males. At the time of diagnosis, especially pulmonary metastases can be found in one-third of patients. There have also been described as late metastases for several decades after nephrectomy. In our case report, clinical course indicated primary lung tumour. Histological differential diagnosis included malignant pleural mesothelioma, lung adenocarcinoma and squamous cell carcinoma with clear cell differentiation or primary clear cell adenocarcinoma of the lung. However, using immunohistochemistry, all these possible diagnoses were excluded. CASE REPORT: We present a case of 62-year old man with 3 months history of progressive dyspnea accompanied with a cough and recurrent pleural effusions. PET/CT scan revealed metastatic tumour spread with right-sided pleural thickening, multiple pulmonary tumour foci, mediastinal, cervical, abdominal para-aortic and pelvic lymph node involvement and skeletal metastasis. The patient died one day after administration of palliative chemotherapy. The autopsy showed the majority of changes in the right hemithorax, was caused by a diffuse yellowish, extremely tough tumour infiltrating parietal and visceral pleura with adhesions and obliteration of truncus pulmonalis. In left lung and both renal cortices we could see scant nodules, mimicking primary lung tumour metastasis. In close proximity to the left renal hilum we found unusual homogeneous white round to oval tissue of 80 × 86 × 72mm in diameter, with identical histological pattern. Extensive immunohistochemical profile (positivity of CK18, PAX8, vimentin, androgen receptor, napsin A; negativity of mesothelial markers, TTF-1, CK7, CK20, CDX-2, CD10, PSA, CK34B12 and PAS-D) was compatible with metastatic ccRC. CONCLUSION: We present an extremely rare case of morphologically verified metastatic ccRC without evidence of primary lesion in the kidneys. There is speculated the possibility of spontaneous regression of primary tumour. In our case, however, we cannot exclude the possibility of generalized primary tumour of ectopic kidney. This hypothesis is based on the finding of isolated tumour mass adjacent to left renal hilum.

[Our experience with chest wall stabilization]. / Nase zkusenosti se stabilizací hrudníku.

INTRODUCTION: An unstable chest wall is defined as a fracture of at least three adjacent ribs broken at least in two planes. As a result of impaired mechanical strength of the chest wall, paradoxical movements occur, resulting in insufficient pulmonary ventilation with the development of respiratory insufficiency with typical consequences - hypoxia, hypercapnia and acidosis. METHODS: In this paper we describe a group of 16 patients who underwent stabilization of the chest wall. The average age of the group was 56 years, the youngest patient was 23 and the oldest one 76 years old. There was an average of 6.1 broken ribs per patient, individually ranging from 4 to 8. In 11 cases, the stabilization was performed for a block fracture, in 5 cases for a serial fracture with a thoracic wall deformity. RESULTS: The average length of hospital stay was 19 days, the time from admission to surgery was 4.46 days, and the average duration of mechanical ventilation was 2.63 days. In our group, we had only one deep wound infection that was healed using vacuum therapy. Concerning other complications, there was one case of bronchopneumonia and one patient developed delirium. No redrainage for fluido- or pneumothorax was necessary. CONCLUSION: The main focus of this paper is on the active surgical approach to treatment of serial and block fractures of ribs with deformation or manifest instability of the chest wall. Not all patients with block fracture required stabilization, whereas 5 patients with serial fracture of the ribs were indicated for surgical revision for chest wall deformity and other complications.Key words: flail chest treatment indications.

[Initial experience with using uniportal VATS (SITS) to treat the implications of thoracic trauma in the 1st Department of Surgery of the Faculty of Medicine at Masaryk University and St. Annes Teaching Hospital in Brno]. / Iniciální zkusenosti s pouzitím "uniportal VATS (SITS)" prístupu pri osetrování dusledku hrudních traumat na I. chirurgické klinice LFMU a FNUSA v Brne.

Thoracic trauma represents a multidisciplinary therapeutic challenge requiring individualized approach to every patient. Continuous development and implementation of mini-invasive techniques in thoracic surgery pave way to so far unique attempts to establish video-assisted thoracic surgery for thoracic trauma as well. The indication is limited by hemodynamic stability of the patient, extent of the trauma, as well as by time required for the treatment. However, proper indication provides an unequivocal benefit in terms of postoperative pain, early mobilization and excellent cosmetic effect. Continuous reduction of the number of incisions down to monoportal approach is currently the peak of mini-invasive approach in thoracic trauma management. The aim of this work is to provide 3 case reports documenting the current spectrum of monoportal video-assisted surgery indication for thoracic trauma.Key words: uniportal VATS thoracic trauma.

[Assessment of thoracic trauma at the 1st Department of Surgery in Brno (1 January 2011 - 31 December 2015)]. / Poranení hrudníku na I. chirurgické klinice LF MU a FN USA v Brne (vyhodnocené období 1. 1. 2011 az 31. 12. 2015).

INTRODUCTION: The number of cases of thorax injury increased steadily between 2011 and 2015. This is probably related to a more active lifestyle of the younger generations and also to the increasing average age of citizens. The aim of the study was to show problems connected with thorax injury. METHOD: Our retrospective study evaluated a group of patients with thoracic injury (diagnosis codes S20-S29) in the period from 1 January 2011 to 31 December 2015 who were treated in our Department. RESULTS: We evaluated a group of 1,697 patients with thoracic injury were divided into five subgroups: 1) simple contusion of the thorax, 2) simple rib fractures, 3) contusion of the thorax with vertebral fractures, 4) serial, multiple rib fractures, 5) stab and gunshot injuries of the thorax. Each subgroup was analyzed independently and in detail. The number of thoracic injuries increased steadily, year on year. More than 40% of the patients were older than 60 years. In the group with simple rib fractures, the authors found 14 cases of pneumothorax (5.1%), which was drained in only 8 cases. The most common complications in the serial rib fractures group included pneumothorax (33 cases, 20%), hemothorax (28 cases, 16.9%) and lung contusion (15 cases, 9%). Stabilization of the thoracic wall was performed 16 times, out of the total of 26 multiple rib fracture cases (61.5%). CONCLUSIONS: Thorax injury is routinely encountered by surgeons. The authors recommend to pay particular attention not only to serious, but also to simple thorax injuries in very old patients, for instance those on anticoagulation therapy. Adequate caution also needs to be taken with serial rib fractures and flail chest and their treatment.Key words: thorax injury - rib fractures - hemothorax - pneumothorax.

[Intraoperative sentinel lymph node detection in colon cancer resection - preliminary results]. / Peroperacní detekce sentinelové uzliny pri resekci pro karcinom kolon - predbezné výsledky.

INTRODUCTION: The aim of this paper is to evaluate the results of intraoperative sentinel node detection in colon cancer patients and to compare the number of nodes retrieved per specimen in comparison with standard resection. METHODS: Patients undergoing elective colon cancer resection were included in the study. The specimen and the sentinel lymph node were sent for histopathological examination. A group of patients from 2011 who underwent elective resection served as the study control. RESULTS: The control group comprised 56 patients. The average node count was 12.73 (4-27). The study group included 102 patients; 29 patients had to be excluded because of protocol deviation. Out of the remaining 73 (46 male and 27 female) patients, 24 were N-positive and 2 of them were pN1c. In the remaining 22 patients, the sentinel node was positive in 8 cases, corresponding to a sensitivity of 36.36%. The average lymph node count was 15.97(3-30) after patent blue dye injection. CONCLUSION: Intraoperative sentinel lymph node detection is an easy and feasible method. Despite the low sensitivity, the main positive effect of the method is the increased lymph node count per resection specimen.

[Ten years of endovenous ablation - achievements, failures and future]. / Deset let endovenózní ablace varixu, úspechy, neúspechy a budoucnost.

Endovenous ablation of varicose veins is a very frequent treatment method which has more or less replaced the classic stripping method. It has its limitations, advantages as well as disadvantages. The authors present a summarizing article and their own experience with these methods. Histology examinations performed prove differences in the reaction of the endothelium to the individual types of endovenous therapy. Causes of varicose veins treatment failures are discussed.

[Repeated resection for recurrent pulmonary metastases]. / Opakované plicní resekce v chirurgii plicních metastáz.

INTRODUCTION: Repeated pulmonary resections are predominantly used in sarcomas, colorectal cancer, Grawitz tumours, and at a young age in general. Patients with the recurrence of pulmonary metastases within a period of six months have a poor prognosis. MATERIAL AND METHODS: During the period from I/1997 to XII/2011, a total of 165 operations were performed in 149 patients. 11patients had multiple pulmonary resections. According to histological origin, sarcomas were found in 6 cases, Grawitz tumours in 2 cases, Schwannoma malignum in 1 case and laryngeal carcinoma in 1 case. There was synovialosarcoma, osteosarcoma, rhabdomyosarcoma, alveolar sarcoma and uterine sarcoma in the group of sarcomas. RESULTS: In our retrospective study, the most commonly used approach was muscle-sparing vertical thoracotomy in 14 patients, posterolateral thoracotomy in 8 patients, VATS in 3 patients and clamshell thoracotomy in 3 patients. We performed 22 extraanatomic resections - of which 3 times VATS, 6 times lobectomy (of which 1 completion pneumonectomy). We observed complications in 6 cases (small air leak in 3 patients, wound infection in 3 patients) in the postoperative period. No rethoracotomy for complications was needed, lethality was 0. The overall 5-year survival that we observed was 45.4%. CONCLUSION: Surgery is an integral part of complex oncological care. What is extremely important is strict selection of patients eligible for surgery for repeated resections and, of course, an experienced team of thoracic surgeons, but also other physicians. When performed by experienced specialists, surgical treatment of lung metastases is a safe and very useful procedure.

[Wound microbial sampling methods in surgical practice, imprint techniques]. / Metody odberu vzorku na kultivacní vysetrení v chirurgické praxi, otiskové metody.

The wound is a damage of tissue. The process of healing is influenced by many systemic and local factors. The most crucial and the most discussed local factor of wound healing is infection. Surgical site infection in the wound is caused by micro-organisms. This information is known for many years, however the conditions leading to an infection occurrence have not been sufficiently described yet. Correct sampling technique, correct storage, transportation, evaluation, and valid interpretation of these data are very important in clinical practice. There are many methods for microbiological sampling, but the best one has not been yet identified and validated. We aim to discuss the problem with the focus on the imprint technique.

[Resection and reconstruction of the chest wall for primary or metastatic tumours]. / Resekce a rekonstrukce hrudní steny pro primární ci metastatické nádorové onemocnení.

PURPOSE OF THE STUDY: The aim of the study was to assess mortality and the complication rate after the extensive resection of chest wall tumour and subsequent soft tissue reconstruction. We wanted to evaluate the justification for major surgery in the group of patients with primary or secondary tumours, including those with an advanced stage of disease. MATERIALS AND METHODS: A total of 35 patients after major chest wall resection within an eight-year period (2000-2008) were analysed retrospectively. A major resection was defined as resection of 75 cm2 or more of full thickness of the chest wall. There were 19 cases of primary malignant tumour of the chest wall, 10 cases of secondary tumour, and 6 cases of benign or semi-malignant lesions. The chest was stabilised with the help of either polypropylene or a double layer mesh of polyester covered with polyurethane. For soft tissue reconstruction, a musculocutaneous flap was used in 18 cases. The number of resected ribs ranged from two to seven. The vertebral body was partially resected in four cases, and total sternectomy was performed in two cases. This surgery was carried out with potentially curative intent in 30 (85.7%) and with palliative intent in five patients (14.3%). RESULTS: No post-operative mortality occurred. The complication rate was 17.1 %. The one-year survival rate was 88.6 %. There were seven long-term survivors at 5 or more years after resection of the chest wall for soft tissue sarcoma. Local recurrence occurred in six patients (17.1%). Neither the type of prosthesis nor the type of surgical procedure influenced the complication rate. DISCUSSION: Chest wall resection is an established surgical procedure in the treatment of primary chest wall tumours and, occasionally, solitary metastatic disease. The groups of patients reported in the literature have been heterogeneous and usually small, and thus an estimation of the true risk of the major procedure is difficult. Three studies involving large patient groups published in the last 11 years have shown morbidity in 24.4%, 33.2% and 46.0% of patients and mortality in 7.0%, 3.8% and 4.1% of patients, respectively. The results in our group of unselected patients are comparable with these studies; however, we did not perform extensive procedures like pneumonectomy and chest wall resection, or extended fore quarter amputation. CONCLUSIONS Complete resection of the chest wall is feasible even in advanced tumours without significant peri-operative morbidity and mortality. Major chest wall resection as a palliative procedure remains selective for motivated patients in a good physical condition but with low quality of life caused by a chest wall tumour.

The anatomical relationship between the saphenous nerve and the great saphenous vein.

OBJECTIVE: Damage to the saphenous nerve (SN) has been a known complication during varicose vein surgeries. We tested whether a better knowledge of the anatomy of the SN and the great saphenous vein (GSV) can prevent such damage. METHODS: We conducted a morphological and histological examination on 86 limbs from 43 cadavers in order to analyse the anatomical interrelation between the SN and the GSV in the lower leg and we also measured the distance between the nerve and the vein in a sample of 42 sections from three parts of the lower leg. RESULTS: The anatomical relationship between the SN and the GSV is varied and the two structures run close to each other so a better knowledge of their anatomy in itself proved insufficient in preventing damage to the SN. CONCLUSION: However, in the case of endovenous laser therapy and radiofrequency ablation tumescent anaesthesia decreases the risk of damage to the SN.

[Is pneumonectomy justified in the management of lung metastases?]. / Je oprávnené provedení pneumonektomie v lécbe plicních metastáz?

The authors discuss about questions of possibility pneumonectomy in concept of lung metastasis therapy. They analysed in detail indications, surgery, complications, survival and factors of survival. The authors also introduce case report of one patient with pneumonectomy in your group of patients.

[Rare tumors of the gallbladder and bile ducts. A case review]. / Vzácné tumory zlucníku a zlucových cest. Kazuistika.

The authors deal with the problem of benigh tumours of the bile duct which might occur as a very suprising intraoperative finding instead of preoperatively diagnosed "gallstones". This situation can happen because of possible mistakes that might accompany today's modern practical investigative techniques. The presented report is an example of the pre-operatirely assumed choledocholithiasis which was not confirmed during the operation. Instead a rare bile duct tumour was found.

[Axilloscopy--an option in axillary lymph nodes dissections in breast carcinomas]. / Axiloskopie--alternativa v disekci axilárních lymfatických uzlin pri karcinomu mammy.

Authors in this randomised prospective study, which occurred in years 2007 to 2008 on the St. Anne's First Surgical Clinic in 56 breast cancer female patients, compare the results of minimally invasive axillary dissection to those of the classical axillary dissection and point to the advantages and setbacks of this new method both for the patient and surgeon.

[Malignant mediastinal teratoma--a case review]. / Maligni teratom mediastina--kazuistika.

In this case report the authors present a case of mediastinal malignant teratoma of a 23 years old patient, who suddenly suffers form chest pain as the only symptom. During examination is a huge mediastinal tumor diagnosed. After histological diagnosis is a radical surgery performed. According to the definitive histology is an adjutant oncological treatment indicated. The aim of our report is to think always about the mediastinal tumors as one of the possible cause of thoracic pain.

[Open pleural window at treatment of the advanced thoracic empyema: 20 high-risk patients' treatment experience]. / Otevrené pleurální okénko v lécbe pokrocilého empyému hrudníku: zkusenosti s lécbou dvaceti rizikových pacientu.

UNLABELLED: The aim of the retrospective clinical study was the analysis of the 20 high-risk patients operated in our department within years 2000-2008 by the modified Eloesser procedure for the serious thoracic empyema. MATERIAL AND METHODS: We have analyzed the data of the 17 men and 3 women. The most important objectives were the cause of the disease, type of procedure, perioperative mortality, length of stay and subsequent procedures. The underlying disease was the malignant intrathoracic disease in 40%, diabetes mellitus was found in 25%. The cause of empyema was pleuropneumonia in 45%, postresectional empyema occurred in 35%. RESULTS: There were two perioperative deaths (10%), remaining patients were all dismissed in a stabilized condition the 22nd postoperative day at average. Six subsequent reconstructive procedures were performed. There was no early death for the postpneumonectomy empyema. CONCLUSION: In case of the serious pleural empyema in a high-risk patient is the modified Eloesser procedure safe and life saving surgical operation. The timing of the procedure and correct indication for surgery are essential.

[Mediastinal lymphadenectomy in surgery of pulmonary metastasis]. / Mediastinální lymfadenektomie v chirurgii plicních metastáz.

The effect of lymphadenectomy in pulmonary metastasectomy is unceratain. Good indication and right radicality of resection are to-days surgery possibilities to manage the best patient survival. Next possibility is performance of systematic mediastinal lymphdenecomy for currative effect and increasing of staging quality for indication of adjuvant therapy by metatatic lymphnode involvement. The answer about performance of mediastinal lyphadenectomy and its kind was seeked by authors in retrospective study in years 1999-2008. Hundred and six patient underwent pulmonary metastasectomy, 34% patients were of sarcomatous origin. Mediastinal lymhadenectomy was made in 31% patients. There were found the lyphnode involvement in five cases. The group of own patiens is non homogenous for exact conclusion of impact mediastinal lymphadenectomy on survival after pulmonary metastasectomy. The comparison of patient survival with diferent kind of lymphadenectomy isn't acceptable because sampling of lymphonodes may be false negative. For exact comparison of mediastinal lymphadenectomy importance is necessary to do systematic mediastinal lymphadenectomy in prospective multicentric study.