The impact of body mass index and gender on the development of infectious complications in polytrauma patients.

PURPOSE: The aim was to test the impact of body mass index (BMI) and gender on infectious complications after polytrauma. METHODS: A total of 651 patients were included in this retrospective study, with an Injury Severity Score (ISS) ≥16 and age ≥16 years. The sample was subdivided into three groups: BMI <25 kg/m(2), BMI 25-30 kg/m(2), and BMI >30 kg/m(2), and a female and a male group. Infectious complications were observed for 31 days after admission. Data are given as mean ± standard errors of the means. Analysis of variance, Kruskal-Wallis test, χ(2) tests, and Pearson's correlation were used for the analyses and the significance level was set at P < 0.05. RESULTS: The overall infection rates were 31.0 % in the BMI <25 kg/m(2) group, 29.0 % in the BMI 25-30 kg/m(2) group, and 24.5 % in the BMI >30 kg/m(2) group (P = 0.519). The female patients developed significantly fewer infectious complications than the male patients (26.8 vs. 73.2 %; P < 0.001). The incidence of death was significantly decreased according to the BMI group (8.8 vs. 7.2 vs. 1.5 %; P < 0.0001) and the female population had a significantly lower mortality rate (4.1 vs. 13.4 %; P < 0.0001). Pearson's correlations between the Abbreviated Injury Scale (AIS) score and the corresponding infectious foci were not significant. CONCLUSION: Higher BMI seems to be protective against polytrauma-associated death but not polytrauma-associated infections, and female gender protects against both polytrauma-associated infections and death. Understanding gender-specific immunomodulation could improve the outcome of polytrauma patients.

[Pneumosurgery in the management of colorectal carcinomas]. / Pneumochirurgie v resení karcinomu kolorekta.

OBJECTIVE: Surgically solved lung involvement in patients after surgery of colorectal cancer. MATERIALS AND METHODS: Altogether 15 patients, 9 men (median age in the time of lung diagnosis 67 years) and 6 women (median age 59 years) underwent classical open pulmonary surgery during 2003-2008 years from the follow-up cohort of 836 persons after operation due to colorectal cancer in the time period of 1996-2008 years. The indication for lung surgery: solitary pulmonary lesion. Procedures distribution: pulmonary lobectomy 7, bilobectomy 2, segmentectomy 4, wedge resection 2. The requirement of the European Society of Thoracic Surgeons (ESTS) guidelines of complete pulmonary resection has been met by 10 operations (66.7%) with lobe specific lymphadenectomy. Histopathology investigation: Formalin fixed, paraffin embedded samples were investigated after hematoxylin-and-eosin staining, supplemented in case of need by immunohistochemistry of CK7, CK20 and TTF1. RESULTS: Eleven pulmonary metastases were found, in two cases with interlobar lymfatics involvement. Two metachronous primary adenocarcinomas of the lung (ADL) were diagnosed, one of them with metastases into hilar lymphatics. In remaining two patients pulmonary chondrohamartoma was discovered. CONCLUSION: Solitary pulmonary opacity in patient after colorectal surgery might not represent simple metastasis explicitly. Complete resection is needed.

[Complications in patients undergoing pulmonary oncological surgery]. / Komplikace u pacientu po operaci pro plicní malignitu.

AIM: A survey evaluating incidence and risk factors of complications in persons underwent complete open lung resection because of primary or secondary lung malignancy. MATERIAL AND METHODS: Retrospective study of 189 open surgery procedures in 128 males and 61 females, mean age males 61 years (range 21-78), females 64 years (range 33-80) during a five-years period (2003-2007). Data processing and analysis were performed with the statistical software system Statistica and compared by parametres odds ratio a chi2 test. RESULTS: Complications were divided into five groups. First group was defined as complications in perioperative period and was composed of three events 1.5%: endotracheal tube dysfunction (i.e. 0.5%), heavy cardiac arrhytmia 0.5% and serious haemorrhage, that occurred immediately after operation 0.5%. Second group includes complications within period of 7 days after surgery: prolonged air leak (PAL > 7 days) 7.4%, bronchopneumonia 6.9%, cardiac arrhythmia 6.9%, postoperative delirium 4.2%, atelectasis 2.6%, wound infection 1.1%, bleeding 1.1% and chylothorax 0.5%. Third group contains events between 8th and 30th postoperative days: thoracic empyema 2.1%, dysphonia 2.1%, painfull shoulder 1.1%, alimentary tract infection 0.5% and bronchial closure insufficiency 0.5%. Fourth group contains patients with severe complications, that led to death during 30 days after operation: ischemic stroke 0.5% and pulmonary embolism 0.5%. Patients without any complication formed the fifth group of 60.5%. CONCLUSION: Main risk factors for complications in postoperative period after lung resection due to primary or secondary lung malignancy in our group of patients are COPD, corticotherapy, time of operation over 3 hours, BMI over 25, left side tumor localization and bronchoplastic procedure. For cardiac arrhytmia seems to be risk factor pneumonectomy and previous neoadjuvant radiochemotherapy.

[Pulmonary segmentectomy for tumour]. / Plicní segmentektomie pro nádor.

BACKGROUND: An analysis of outcome data of pulmonary segmentectomy focused on local efficacy in primary non small cell lung cancer and true or seeming lung metastasis. PATIENTS AND METHODS: Miscellaneous series of twenty patients treated with classical open procedure involving individuals with primary or metachronous non small cell lung cancer, solitary pulmonary metastasis of extrapulmonary cancer and/or benign pulmonary lesions, lung metastasis mimicing. Thirteen patients after segmentectomy because of malignancy are separated into a group of 7 cases with NSCLC up to 20 mm in diameter, and a group of 6 persons with solitary pulmonary opacity up to 38 mm treated previously surgically for extrapulmonary cancer. Both without enlargement of hilar and/or mediastinal lymphatics proven on preoperative CT imaging. Third part of the group collects benign pulmonary lesions: chondrohamartoma, pneumonitis and pulmonary infarct. Persons involved through a ten years period are followed up at 3 (4)-months intervals. RESULTS: No perioperative and thirty day mortality was registered. Six cases of distant recurrence were recorded, three in NSCLC and three in extrapulmonary cancer patients. Five patients died within the follow-up period, three of them through the general progression of the oncological disease. Two deaths were non-cancer related. One R1 disease was discovered in a patient with primary lung adenocarcinoma. No local recurrence was recorded in both cancer series with median age of 63 yrs (range 45-79 yrs) and median duration of follow up 35 months. CONCLUSION: Lung segmentectomy seems to accomplish local control of early stage non small cell lung cancer and pulmonary metastasis of extrapulmonary cancer in selected patients.

[Spontaneous pneumothorax--management, therapy]. / Spontáinní pneumotorax--management, terapie.

OBJECTIVE: Spontaneous pneumothorax (SPNO) is a surgical disease, which belongs to surgical emergencies. It is divided into a primary, secundary, katamenial and neonatal. A young and healthy men are affected by primary SPNO, usually on the right side of the thorax, recurrence is common. A secondary SPNO typically occurs in patients between the 5th and 7th decenium. These patients usually suffer from some lung disease. A major complications are more common in this type of pneumothorax. METHODS: At Department of surgery, University Hospital Brno, 73 patients were treated for spontaneous pneumothorax from the January, 2006 till August, 2008. We divided patients in two groups. The first one with primary SPNO, and the second one with secondary SPNO. Hospital stay, age distribution, type of operation, duration of drainage, postoperative complication, histological findings and laterality were followed up retrospectively. RESULTS: In group of primary SPNO, 24 patients were operated without major complication. The most frequent cause was bullate emphysema, hospital stay was 8 days, duration of drainage 6 days. The second group with secondary SPNO, five patients were operated, hospital stay was 16.5 days, duration of drainage 10 days. Haemothorax as a postoperative complication occured in one case. In both groups we proved the bullate emphysema as the most frequent cause, as well as a right - sided involvement. CONCLUSION: Spontaneous pneumothorax is a surgical disease. It's treatment has to be provided by surgeon, if possible by a thoracic specialist. The first occurrence of spontaneous pneumothorax is treated by drainage, the recurrence by operation. The principal is to combine an atypical resection of affected lung with a mechanical pleurodesis. Postoperative complications are not frequent.

[Benign lymphoepithelial cyst of the pancreas: a case report]. / Benigní lymfoepiteliální cysta pankreatu--kazuistika.

Lymphoepithelial cyst of the pancreas represents an extremely rare and benign entity of undetermined pathogenesis. This lesion must be taken into consideration in the differential diagnosis of pancreatic cystic lesions. A case of resected lymphoepithelial cyst of pancreas in 59-year-old man with an attack of acute pancreatitis in anamnesis is reported. The postoperative period was uneventful, and the histolopathological examination revealed the structures of lymphoepithelial cyst. The aim of this report is to describe the clinical and pathological features of this unusual true cyst of the pancreas.

[Preoperative radiotherapy in hypoxia in the complex treatment of the rectal carcinoma--complications]. / Predoperacná rádioterapia v hypoxii v komplexnej liecbe karcinómu rekta--komplikácie.

INTRODUCTION: Preoperative radiotherapy is considered to be the standard approach in the treatment of the rectal carcinoma. Acute hypoxia decreases partial pressure of oxygen in healthy tissues immediately, but in the tumor after 30 min of duration. There is a higher radioresistance of healthy tissues in this interval because of lower oxygenation compared with normooxic status and the tumor is still relatively good oxygenated. This fact theoretically enables higher doses of radiotherapy and lower adverse effects. The aim of this study was to evaluate short and long term complications after preoperative radiotherapy of rectal carcinoma in hypoxia. PATIENTS AND METHODS: Between April 1991 and October 2000, 127 patients with the rectal carcinoma were treated preoperatively with locoregional accelerated hypofractionated radiotherapy in hypoxic conditions in Masaryk Memorial Cancer Institute. The dosis was up to 8 x 4 Gy. Acute hypoxia was induced during irradiation by ventilation of a hypoxic gas mixture containing 7.8-8.0% oxygen for totally 7-8 min. Operation was performed till 24 hours. RESULTS: There was no complication concerning with breathing of hypoxic gas mixture. A 30 day postoperative mortality was 0.8%. A 30 day postoperative morbidity was 31.7%. An anastomotic leakage occurred in 6.5%. Chronic gastrointestinal disorders occurred in 16.1% patients. CONCLUSION: Preoperative irradiation in hypoxic conditions is safe and efficient procedure. It permits safe administration of doses higher than those tolerated by normooxic conditions. Type and frequency of complications are comparable with other preoperative regimens.

[Preoperative radiotherapy in hypoxia in the complex treatment of the rectal carcinoma--long term results]. / Predoperacná rádioterapia v hypoxii v komplexnej liecbe karcinómu rekta - dlhodobé výsledky.

INTRODUCTION: The aim of this study was to evaluate long term results of patients with rectal carcinoma which were irradiated in hypoxic conditions. PATIENTS AND METHODS: Of all patients which were irradiated in hypoxic conditions in Masaryk Memorial institute, 93 patients were followed up longer time than five year. RESULTS: The most common surgical procedure was resection in 60%, overall five year survival was 73.1%, systemic relapse of disease occurred in 33.3% and local recurrence rate was 13.9%. CONCLUSION: Preoperative irradiation in hypoxic conditions permits safe administration of doses higher than those tolerated by normooxic conditions, without increase of complication. Long term results are comparable with crucial trials.

Autofluorescence (safe) bronchoscopy and p21/ki-67 immunostaining related to carcinogenesis.

Archival biopsy materials from 20 randomly selected asymptomatic volunteers from the Czech uranium miners (CZ UM) risk group (n=98) were examined for p21 and ki-67 immunostatning. There were 16 areas with normal respiratory epithelium and 22 areas with bronchial intra-epithelial neoplasia (IEN). Normal and IEN areas were identified by autofluorescence (System Autofluorescence Endoscopy, SAFE-1000) and monitored during 1998-2002. The majority of specimens from areas with normal autofluorescence intensity with ciliated columnar bronchial epithelium showed strong predominantly cytoplasmic p21 positivity. The SAFE monitoring divided areas of decreased autofluorescence intensity with early stage IEN lesions into two groups. Persistent lesions (P)-showing a spectrum of p21 cytoplasmic staining ranging from negative or isolated negativity to weak or moderate positivity combined with higher proliferative capacity proved by ki-67 nuclear staining. Disappearing lesions (D)-showing strong cytoplasmic p21 positivity and negative ki-67 staining. The IEN lesions were classified into three groups based on p21/ki-67 immunostaining: proliferative lesions at risk (R) with low or without p21 plasma immunostaining combined with high ki-67 nuclear reactivity; ambiguous lesions (A) including cases combining strong p21 cytoplasmic positivity with high ki-67 nuclear reactivity or p21 cytoplasmic negativity with ki-67 negativity staining patterns; the quiescent lesion group (Q) was characterized by strong p21 cytoplasmic positivity and negative ki-67 immunostaining.

[Ulnar-carpal impingement after fractures of the distal radius]. / Ulnokarpální impingement po zlomeninách distálního radia.

The authors describe the group of 23 patients (16 women, 7 men), who were operated during 2000-2003 on ulna-carpal impingement or the syndrome of ulna impact on the basis of "plus variant" of ulna or also "long ulna". There was a fracture of distal radius in anamnesis of all these patients. The condition was solved in 18 patients (mean age 51 years) by reducing the ulna by 4.5 cm on the average (range 2-10 mm). In five patients (mean age 49 years), the radius-ulna desis sec. Sauvé-Kapandij was performed. The results are evaluated with the time lapse of 6 months on the average (range 3-26). The resulting evaluation indicates that in all patients, who were not affected by radius-ulna arthrosis, a simple reduction of ulna resulted in an improvement of the extent of movements and improved subjective complaints. Patients with radius-ulna arthrosis, where the ulna-carpal impingement was solved by radius-ulna desis, suffer from worse long-term functional results. The authors also analyze complications of the interventions. Posttraumatic deformations in the area of distal forearm should be solved early before degenerative changes develop. The is the only way how to expect good results of the operation and favorable effect for the patient.

Severe complications following intravesical BCG instillation.

In patients with urinary bladder carcinoma, the intravesical BCG instillation is widely used. We present two cases of severe pulmonary afflictions developed during this treatment. The possible mechanisms of etiology are discussed and the classification of the intravesical BCG treatment side effects is suggested.

[Gastroesophageal reflux disease from the viewpoint of the surgeon]. / Gastroezofageální refluxní choroba z pohledu chirurga.

Surgical treatment of patients with gastroesophageal reflux disease (GERD) represents an alternative approach in relation to the long-term pharmacologic therapy of prokinesis, and secretoinhibitory therapy. It must be considered in cases where the conservative approach has failed. The success of surgical treatment depends on an individual approach to the patient. The factors determining the surgical indication and especially the type of surgery, include age, anatomy of the hiatus and the results of pre-operational examinations of the esophagus. The type of operation depends on the ability of the esophagus to contract and to transfer the propulsion activity. According to the authors, the key examination is represented by the detection of esophageal contractility by use of esophageal manometry. The alternative option is represented by scintigraphic measurement of esophageal transit time by use of a tagged bolus. The patients with disappeared contractility are preferentially treated by conservative therapy due to the high risk of post-operational dysphagia. 80% of patients are treated by the standard procedure of laparoscopic fundoplication by a 360-grade cuff. The cases with decreased contractility or esophageal dysmotility are preferentially treated by partial fundoplication in Toupet's modification. The shortening of the esophagus requires consideration as to chest approach, or Collis' operation. Intestinal metaplasia of the esophagus requires specific procedures. Severe dysplastic changes require the consideration of resection treatment. The gained therapeutic results are evaluated by both, the subjective point of view of the authors, as well as by standard pH measurement and manometry of the esophagus performed 6 weeks after surgery.

[Use of the Miller-Abbott tube in treatment of early postoperative ileus]. / Uzití Millerovy-Abbottovy sondy pri resení casného pooperacního ileu.

The authors present an account on the use of an intraluminal intestinal stent to treat early postoperative ileus. They demonstrate on a case-history the possibility to combine the tube inserted via jejunostomy and with laparostomy. In the discussion they deal also with the historical development of intubation of the small intestine and support of controlled adhesion formation.

[Cholestasis--an indication for surgical treatment]. / Cholestáza--indikace chirurgické lécby.

Disorders of common bile duct function are among adults relatively frequent. Formal treatment schemes are gradually transformed, and the interdisciplinary co-operation becomes the basic principle. The goal is to recognise the type of the mechanic jaundice, followed by elimination of the obstruction or to ensure biliary drainage without delay. The authors describe indication criteria used on Surgery Department at Bohunice Hospital in Brno. They present their results of treatment of the obstructive jaundice at a group of 576 patients followed during five year period.

[Aspergilloma]. / Aspergillom.

The authors present the case-history of a patient operated on account of a pulmonary aspergilloma, incl. analysis of postoperative infectious complications. The course is confronted with data in the literature. Based on the professional literature on the subject the authors discuss the contemporary approach to surgical treatment of this disease.

[Indications for laparoscopic adrenalectomy]. / Indikace k chirurgické laparoskopické adrenalektomii.

Endocrinological indication for surgical adrenalectomy is relatively rare. There is relatively little information on possibilities how to perform adrenalectomy by a minimally invasive procedure. Minimal invasive surgery made it possible to implement some operations sparing the patient. Adrenalectomy is one of these procedures. Laparoscopic adrenalectomy, which is extremely rare in other countries, as practiced in the Czech Republic, is the subject of the submitted paper.

[Metal stents in patients with malignant and benign esophageal stenoses]. / Kovové stenty u nemocných s maligní a benigní stenózou jícnu.

The authors used between October 1993 and January 1997 in 131 patients with inoperable malignant or benign stenosis of the oesophagus an expansible metal stent. In 25 patients the stenosis was in the upper third of the oesophagus, in 44 in the medium part, in 53 in the lower third of the oesophagus and in 9 patients in the area of the anastomosis. All patients suffered at the time when the stent was introduced from marked dysphagia (stage 3-4 according to the international classification). In 45 patients the authors introduced more than one stent. 112 patients suffered from malignant stenosis (67 squamous cell carcinoma, 27 adenocarcinoma, 9 pulmonary or bronchogenic carcinoma, in two instances lymphoma, in two instances leiomyosarcoma and in five patients another type of tumour). Seventeen patients suffered from benign stenosis (8 complications of reflux oesophagitis, 3 stenosis in the anastomosis, in two instances corrosion by acid, 2 cases of epidermolysis bullosa oesophagi and one post-radiation stenosis). In these patients repeatedly before introduction of the stent dilatation of the stenosis by means of a balloon dilatation catheter was attempted. In two instances the etiology of the stenosis was obscure. Complications related to the procedure proper or after insertion of the stent were recorded in 49 patients-dislocation of the stent 23x, occlusion of the stent 17x, development of a fistula 6x, ulceration 16x, haemorrhage 4x, hyperplasia of the mucosa 21x, ileus 2x, inadequate expansion of the stent 8x.

[A rare cause of ileus and its laparoscopic treatment]. / Raritní prícina ileózního stavu a její laparoskopické resení.

Stenting is a modern method making possible to open malignant oesophageal stenosis. The technique is associated with various complications. The authors describe the management of a rare stent migration to the aboral part of the GI tract, causing an acute abdomen. Based on their own experience with dislocated stents they recommend, contrary to the literature, an active approach when migration to the aboral of the GI tract occurs. Early stent extraction even when the course is uneventful is advantageous.

[Surgery of inguinal hernia in a clinical department]. / Operace tríselné kýly na klinickém pracovisti.

The authors stress on the academic surgical departments the necessity of the development of both traditional and minimally invasive techniques of the groin hernia repair. They suggest to make patient selection based on the hernia type (Nyhus Classification) and patient's will and take account of an internal-anesthesiologic aspects. From four currently most often applied minimally invasive techniques they bring attention to the hernioplasty by exclusively extraperitoneal approach, till now seldom used by us.

[Retroperitoneoscopy--a new era]. / Retroperitoneoskopie--nová éra.

Retroperitoneoscopy is a minimal invasive surgical technique enabling the diagnostics of the disease, as well as operative treatment of retroperitoneal organs. It is a very promising method especially for urologist, but of interest for general, vascular surgeon or gynecologist. The method is known since the end of sixties. Its routine introduction was enabled by technical advancement of laparoscopic surgery.