[Atypical portocaval anastomosis for hemorrhage in portal hypertension]. / Atypické portokavální anastomózy pro krvácení pri portální hypertenzi.

The success of endoscopy in treating esophageal varices and the later introduction of liver transplantation into the algorithm of therapy for liver failure shifted surgery of portal hypertension out of sight of hepatologists and surgeons. This decline from surgical treatment was further confirmed by introduction of TIPS into clinical practice. It is completely out of question that only liver transplantation is the causal solution of decompensated liver disease and a series of reliable and less invasive methods may be selected for acute treatment of bleeding from varices. However, even at the present time the portal-systemic shunt may be used in its own indication in repeatedly bleeding patients with a good liver capacity, where it can play a role by bridging the time to liver transplantation in a way similar to TIPS or even to provide a final solution, which makes it possible to live the life expectancy in adequate comfort without the risk of bleeding complications. However, it is not always possible to place a surgical shunt on some of the main branches of the portal vein. In such cases, devascularization is often successfully applied. Atypical shunts represent an exceptional alternative, because side feeder veins of the portal vein are rarely of sufficient caliber for placing a hemodynamically significant shunt. The authors describe two cases, in which stubborn anemia-causing bleeding events in portal hypertension were treated with left-side epiploic-renal shunt or anastomosis between the mesenteric and left-side iliac vein.

[Effect of portosystemic anastomosis on the degree of splenic inhibition]. / Vliv portosystemické spojky na míru splenického útlumu.

UNLABELLED: Secondary hypersplenism is a well-known complication of portal hypertension. Reduced platelet count is a more alarming sign for the physician than risk for the patient. Improvement of thrombocytopenia is urgent, when portal hypertension with splenomegaly and thrombocytopenia presents with life-threatening haemorrhage from gastroesophageal varices. In this case, treatment aimed at stopping the bleeding may be more beneficial than any intervention on the spleen. In this study, we evaluated long-term effects of an elective distal splenorenal shunt or small diameter H-shunt on splenomegaly and thrombocytopenia in 26 patients with portal hypertension operated for repeated bleeding from oesophageal varices. 25 patients had splenomegaly and 16 patients had thrombocytopenia before shunting. Surgery corrected splenomegaly in 16 patients (64%), platelet counts increased in 13 of 16 patients with thrombocytopenia (81.2%). CONCLUSION: Selective or partial portal decompression is sufficient to alleviate thrombocytopenia and splenomegaly associated with portal hypertension.

Decreasing process variation in the care of carotid endarterectomy patients.

Avoidable complications after successful carotid endarterectomy surgery typically occur in the immediate postoperative period; most of these complications are related to hemodynamic instability. At Saint Agnes Medical Center, process variation resulted from 22 anesthesiologists and 11 surgeons doing the same process 242 ways. We introduced a Post-Anesthesia Care Unit Carotid Order Set to standardize the process, drug sequence, and drug choices for postoperative carotid endarterectomy patients. Ongoing monitoring demonstrated that this reduction in process variability resulted in a lower complication rate for stroke and wound hematoma.

[Are problems with portosystemic shunts still a reality and is shunt selectivity the deciding factor for justifying its use?]. / Je problém portosystémové spojky stále aktuální? A je selektivita spojky rozhodujícím faktorem pro její oprávnenost?

OBJECTIVE: The objective of the work is detailed evaluation of portosystemic shunts. The criterium of suitability and justification is their selectivity and preservation in the course of time. METHODS: The authors used a clinical group of patients who had either a Warren shunt or a mesocaval H-shunt with a limited blood flow (diameter 8 mm). In these patients the blood flow was assessed by dopplerometry in the portal vein and before the shunt, i.e. in the lienal or possibly mesenterial vein. RESULTS: Of 32 shunts made during the last five years it was possible to make 12 assessments (8 Warren and 4 H-mesocaval shunts). An adequate decline in the blood flow in the portal vein was recorded and a corresponding increase in the lienal or mesenteric vein. Even after one year no marked drop in the flow through the portal vein was recorded. CONCLUSION: A distal Warren shunt and H-mesocaval shunt with a restricted blood flow preserve the signs of selectivity even after one year. An adequate blood flow through the liver is also preserved. From this aspect selective shunts are still suitable treatment of portal hypertension. Obviously correct indication is the basic prerequisite of success.

Dextrocardia and Marfan's syndrome.

It is described the occurrence of dextrocardia together with the congenital cyanotic heart disease in 20 year old man included in the fruste forme of the Marfan's syndrome. The diagnosis was made by the physical examination with the evidence of the arachnodactyly by the metacarpal indices and confirmed by autopsy with the following results: dextrocardia, large atrial septal defect, common ventricle, atresia of the pulmonary artery with the collateral lung perfusion from the descending aorta. There were found neither ocular manifestations, nor unambiguous manifestations of the aortic lesions. The ultrastructural examinations showed only greater accumulation of the PAS positive substances. Dextrocardia as the cardiovascular manifestation of the Marfan's syndrome has not yet been reported in the available literature.

[Foreign bodies in the deglutition tract and their complications]. / Cizí telesa v polykacích cestách a jejich komplikace.

The authors demonstrate some pitfalls of the diagnosis of foreign bodies wedged in the hypopharynx (drawing instrument) and oesophagus (beef bone) in two children who developed extensive retropharyngeal abscesses. Both foreign bodies were endoscopically extracted on the eighth day after the event. The affected area recovered without sequelae.