[Thymectomy at the 2nd Surgical Clinic of the Comenius University Medical School Hospital]. / Tymektómia na II. chirurgickej klinike LF UKo a dnes.

Based on comparison of two groups of thymectomies (46 in 1955-1975 and 158 in 1990-1998) the authors found a marked improvement of the results of thymectomy. During the former period thymectomies had a severe postoperative course with a high lethality and low percentage of remissions. Due to the introduction of immunosuppressive treatment the lethality of thymectomies declined to almost zero and clinical and pharmacological remission resp. was recorded in 70% patients.

[Determination of prognostic factors in surgical treatment of myasthenia gravis]. / Stanovenie významu prognostických faktorov pri chirurgickej liecbe myasténia gravis.

The authors evaluated, using statistical analysis, the importance of prognostic factors in patients subjected to thymectomy on account of myasthenia gravis. The results revealed a better prognosis of the disease, if the history was less than 6 months, preoperative treatment less than 1.5 years, a histological finding of thymus hyperplasia, second clinical stage according to Ossermann and the patients age below 30 years. From the statistical analysis ensues that the prognosis of myasthenia gravis is more favourable when the case-history is shorter as a result of rapid diagnosis and when preoperative treatment is reduced to a minimum.

[Comprehensive treatment of crural ulcers]. / Komplexná liecba vredov predkolenia.

The authors present 65 patients treated in the stage C6 of chronic venous insufficiency. Conservative therapy was performed in the cases with large ulcers associated with crural edema. Recovery was observed in 47 cases (73%) during 5 months. Recurrence authors in 3 patients (5%) and the treatment was not successful in 7 cases (10%). In 8 patients primary or secondary surgical treatment was performed. The average period of treatment was 1.6 months. (Tab. 1, Ref. 24.)

[Transjugular biopsy of the liver]. / Transjugulárna biopsia pecene.

Transjugular liver biopsy is an alternative of percutaneous biopsy in collection of hepatic tissue for histological examination. It is used when percutaneous biopsy is contraindicated, or involves great risk, i.e. in particular in patients with severe ascites and severely impaired blood coagulation. According to worldwide statistics it occurs in about one third of hepatological patients. The authors present a group of 16 patients who had transjugular biopsy and report on the high yield and low risk of the method. A representative histological sample was obtained in 100%, there were no complications in the investigated group. The authors give an account of the indications and description of the method, its possible complications. They compare their results with data in the literature. Their initial experience confirms that the inclusion of transjugular biopsy among hepatological examination methods is justified.

[Care of the diabetic foot]. / Koncepcia staroslivosti o diabetickú nohu.

BACKGROUND: The diabetic foot is the most frequent complication of diabetes requiring hospitalization. According to large sets of patients, as many as 25% of diabetic patients develop damage to their feet during their life. Regarding the growing number of diabetic patients it is necessary to elaborate a prospective conception of the treatment of patients afflicted by this complication. OBJECTIVE: The study's aim is to respond to the question of differentiation of treatment of patients with the diabetic foot. METHODS: A retrospective analysis of two sets of patients hospitalized at the surgical clinic. RESULTS: The group I (1989-1993) included 264 patients treated by "classical surgical management". The group II (October 1994-January 1996) included 142 patients subdued to "intensified therapy" with maximum possible use of revascularization procedures, 52-57% of patients were admitted with extensive gangrene, 65-68% with ischaemic disease of the lower extremities in the stage of CLI. The proportion of revascularizations was 26% vs 68%, the proportion of large amputations was 60% vs 38%. Despite maximum surgical forcefullness, a large proportion of large amputations reaching 38%, perseveres. The authors additionally surveyed the patients of group II as to the degree of their knowledge on the possible chronic complications of diabetes. The predominant majority of patients (63%) had insufficient knowledge about the prevention of the diabetic foot. CONCLUSIONS: Even a maximum use of surgical procedures is not sufficient in procuring a decrease in the proportion of large amputations of lower limbs in diabetic patients who have been hospitalized with their disease being in a progressed stage caused by neglection. Therefore it is necessary to transfer the emphasis of treatment of the diabetic foot into the period preceding the stage of manifestant infectious and necrotic complications. It would be most appropriate to delegate this "frontman" task to diabetologists. USE IN PRACTICE: Even though the only definitive solution of this dissatisfying situation resides in the establishment of specialized centres focused on the therapy of the diabetic foot, certain progress can be achieved also under current conditions by a consequent use of the existing net of diabetologic out-patients clinics, improvement of the quality of the diagnostic process and enhancement of educational activities. (Tab. 5, Ref. 18.)

[Atypical abdominal abscesses]. / Atypické abscesy brucha.

In case-histories of four patients the authors present an account on atypical abdominal abscesses which are late symptoms of advanced malignity of the large bowel or inflammatory intestinal disease. They discuss whether it is suitable to use percutaneous drainage or surgery. The latter holds despite the higher mortality a permanent place in the solution of serious intraabdominal infections, in particular if combined with malignity.

[Aneurysm of the left hepatic artery--a rare cause of hemobilia after laparoscopic cholecystectomy: case report]. / Aneuryzma arteria hepatica sinistra--zriedkavá prícina hemobílie po laparosko-pickej cholecystektómii: kazuistika.

The authors draw attention to a rare case when haemobilia was manifested as a complication after laparoscopic cholecystectomy and its source was an aneurysm of the branch of the left hepatic artery in the region of the third hepatic segment.

[Amputation of the lower extremities for non-traumatic causes in Slovakia in 1995]. / Amputácie dolných koncatín pre neúrazové príciny na Slovensku v roku 1995.

The authors submit a questionnaire-based epidemiological study from 61 surgical departments in Slovakia, focused on the problem of amputation of the lower extremities. The objective of the study was to evaluate indirectly the standard of care of diabetic feet in Slovakia. In the study 61 surgical departments participated with a catchment area comprising 4,814,000 insured persons, i.e. 85% of the Slovak population. In these patients a total of 2116 amputations on account of non-traumatic causes were performed (44/100000 population). This number included 1578 diabetic patients (74.6%). Minor amputations were performed 1044 times, incl. 92.2% in diabetic subjects. Major amputations were made 1072 times, incl. 57.3% in diabetics. The prevalence of major amputations in 1995 was 21.8/100000 population. The authors recorded a 2.65 fold increase of the total number of amputations since 1985. They recorded dissatisfaction with the small number of revascularization operations-total 294 (13.9%) which is only one quarter of the desirable number. The authors submit their study as the basis for a systemic solution of care of the diabetic foot in Slovakia and as a challenge for its improvement.

[Results of long-term follow-up of surgical treatment of pulmonary metastases of testicular germ cell tumors]. / Vysledky dlhodobych sledovaní chirurgickej liecby plúcnych metastáz germinatívnych nádorov testis.

The authors analyse 34 cases of surgeries performed due to residual pulmonary metastases with germinative testicular tumours. Good results in the length of survival are ascribed to thoracotomy, or sternotomy with the resection of metastatic foci, i.e. the only method which reliably ascertains the biological nature of residual pulmonary lesion after chemotherapy. (Tab. 1, Fig. 2, Ref. 17.)

Management of germ cell testicular cancer with pulmonary metastases.

Twenty eight patients with germ cell testicular cancer pulmonary metastases received primary chemotherapy including bleomycin, etoposide, and cisplatin (BEP). Complete response was achieved in 21 (75%) patients, in 11 of them CR was achieved following chemotherapy alone. Postchemotherapy surgery of residual mass was performed in 12 (42.9%) patients with normalized serum tumor markers. Retroperitoneal lymph node dissection was performed in one patient, pulmonary surgery in four, and both postchemotherapy treatments in 7 patients. Overall cure rate was 89.3%, 26 (92.9%) patients are still alive at a mean follow-up of 19.7+ months (range, 3-34+ months) after the treatment start. Two (7.1%) patients died: one of them due to disease progression during chemotherapy, and the second one due to postoperative complication (acute respiratory failure). Relapse of disease was observed in one patient 21 months following CR achievement, and sequential chemotherapy was introduced. Authors recommend surgical remove of all radiologically detected residual deposits, because the available imaging methods are not adequate for determining the histologic composition of residual mass, which is decisive for further therapy and has prognostic value.

Postchemotherapy surgery in nonseminomatous testicular tumors.

Two hundred and twenty patients with metastatic nonseminomatous germ cell testicular tumors received primary chemotherapy including cisplatin, vinblastine and bleomycin (PVB). Complete response was achieved with chemotherapy alone in 108 (49.1%) patients. Postchemotherapy surgery of the residual mass was done in 85 (38.6%) patients with normalized serum tumor markers. Laparotomy was done in 62 patients, 19 patients underwent thoracic surgery, and 4 patients had both postchemotherapy treatments. Thirteen (5.9%) patients had persistently elevated serum tumor markers, they died despite salvage second-line chemotherapy. Fourteen (6.4%) patients died during primary PVB chemotherapy. The masses removed at laparotomy consisted of necrotic and/or fibrotic tissue in 25.8%, mature teratoma in 61.3% and viable cancer was detected in 12.9% of cases. In contrast, resected pulmonary masses consisted of necrotic and/or fibrotic tissue in 42.1%, mature teratoma in 26.3% and viable cancer in 31.6%. The total therapeutic outcome in 220 patients was as follows: 159 (72.3%) patients are alive and free of disease; 4 (1.8%) patients live with disease, and 57 (25.9%) died of the disease.

[Myasthenia gravis and 93 thymectomies. Therapeutic strategies and results 1990-1994]. / Myasténia gravis a 93 tymektómií. Stratégia liecby a výsledky v rokoch 1990-1994.

The authors evaluate 93 thymectomies they performed in the course of five years. Indication for surgery was in all instances myasthenia gravis. Surgery was used only after conservative treatment, the patients had to be asymptomatic or have only minimal myasthenic manifestations. Thymectomy was associated with a 6.4% morbidity and zero mortality. On long-term follow-up the results were excellent or very good in 66.7% of patients and marked improvement was recorded in 30.1%. Thymectomy is part of comprehensive treatment of patients with myasthenia gravis.

[Carcinoids of the appendix]. / Karcinoidy apendixu.

Based on a group of six patients with carcinoid of the appendix treated at the Surgical Clinic of Dérer's Hospital in Bratislava in 1988/93, the authors discuss the diagnosis and treatment of clinically silent carcinoids (< 2 cm). Appendectomy was performed and the mesoappendix was removed. The prognosis of these patients is good, after five years 100% of the patients survive. The carcinoid syndrome is a symptom of an advanced tumour or secondaries in the liver where comprehensive treatment (surgery + metastasectomy + chemotherapy) is indicated. One third of the patients survive after five years.

[Postchemotherapy surgery in patients with non-seminomatous testicular tumors]. / Postchemoterapeutická chirurgia u pacientov s neseminomatóznymi nádormi testis.

From 1982 to 1993, 220 patients with metastatic nonseminomatous germ cell testicular tumours were treated with a combination of cisplatin, vinblastine and bleomycin. Complete remission was achieved in 108 (49.1%) pts. on chemotherapy alone. Residual abdominal or pulmonary masses persisted on completion of chemotherapy in 85 (38.6%) pts. All of them had normal serum levels of tumour markers. In 13 (5.9%) pts tumour markers were positive. Fourteen (6.4%) pts died during primary chemotherapy. The pts with residual masses and normal tumour markers were treated by surgical exploration and masses removal. In 62 pts the masses were resected through laparotomy, in 19 pts through pulmonary surgery and in four pts laparotomy was followed later by pulmonary surgery. The masses removed at laparotomy consisted of necrotic and fibrotic tissue in 25.8%, mature teratoma in 61.3% and viable cancer was detected in 12.9% cases. In contrast, resected pulmonary masses consisted of necrotic and fibrotic tissue in 42.1%, mature teratoma in 26.3% and viable cancer in 31.6%. The total therapeutic outcome in 220 pts was as follows: 159 pts (72.3%) are alive and free of disease. Four pts (1.8%) live with the disease and 57 pts (25.9%) died from the disease. On the basis of their results the authors advocate: 1. Primary chemotherapy should be indicated for IIA and IIB stages of nonseminomatous testicular tumours. 2. Surgical exploration should be reserved for pts with residual abdominal and pulmonary masses bigger than 15 mm in diameter. 3. Operation should include a complete removal of all residual masses. 4. No reliable criteria indicating necrotic and fibrotic changes preoperatively were identified. (Tab. 4, Ref. 17.)

Chemotherapy of testicular cancer: 10-year experience.

A total of 250 patients with germ cell testicular tumors were treated by PVB chemotherapy between 1982 and 1992. Mean age of patients was 28.9 years (range 15-52). Thirty-four patients in clinical Stage II (11 patients IIA, 13 patients IIB, and 10 patients IIC) underwent primary retroperitoneal lymphadenectomy (RPL) with subsequent chemotherapy. They were followed-up for a mean of 106.3 months (range 85-125). CR was achieved in 30 patients (88.2%). Three patients relapsed. Twenty-seven patients (79.4%) are alive with no evidence of disease (NED) after a minimum of 5 years since the start of therapy. One hundred and twenty-two patients underwent primary chemotherapy for clinical Stages IM (15 patients), IIA (31 patients, IIB (48 patients) and IIC (28 patients) with RPL in cases with residual mass in the retroperitoneum. They were followed-up for a mean of 47.7 months (range 6-122). CR was achieved in 115 patients (92.7%) (75 of them received chemotherapy alone, 40 patients achieved CR following combined cytostatic-surgical treatment). Eleven patients relapsed. One hundred and nine patients (89.3%) are alive with NED. Ninety-four patients in Stages III and IV (8 patients III, 86 patients IV) underwent primary chemotherapy with additional surgical removal of residual metastases. They were followed-up for a mean of 50.5 months (range 6-125). CR was achieved in 65 patients (69.1%) (32 of them received chemotherapy alone, 33 patients achieved CR following combined cytostatic-surgical treatment). Eleven patients relapsed. Fifty-seven patients (60.6%) are alive NED. There were 11 patients with advanced germ cell testicular cancer (Stages IIC and IV) who underwent initial PVB chemotherapy without previous orchiectomy. Delayed orchiectomy was done simultaneously with surgical removal of residual mass in the retroperitoneum or in the lungs or at completion of chemotherapy alone. The toxicity of chemotherapy was moderate. There were drug-related deaths in ten patients (4%).

[Combined therapy in patients with testicular germ cell tumors in the dissemination stage (pulmonary metastasis)]. / Kombinovaná liecba pacientov s germinatívnymi nádormi testis v stádiu diseminácie (pl'úcne metastázy).

The efficacy of combined cytostatic-surgical treatment was evaluated in a prospective study involving 70 patients with germinal tumors of the testis metastasizing into the lungs. Complete remission was achieved in 50 (71.4%) patients, 30 of these received only chemotherapy. Thoracotomy was performed in 14 patients with residual pulmonary CT finding, 6 of them underwent bilateral operations. Of the total 21 operations of the lungs residual malignant tumor was found 4 times. After a mean follow up period of 29.8 months since onset of treatment 48 patients (68.6%) survived. Within a mean of 11.4 months after onset of treatment 22 patients (31.4%) died. The authors consider thoracotomy with resection of the metastatic focus to be the only method for determining reliably the biological nature of the residual pulmonary lesion after chemotherapy. The result of the procedure determines the further measures, i.e. sequential chemotherapy or regular check ups. (Tab. 1, Fig. 6, Ref. 15.).

Germ cell testicular tumours with lung metastases: chemotherapy and surgical treatment.

Eighty patients with stage IV testicular germ cell tumours with lung metastases were treated with PVB chemotherapy and subsequent surgery in cases of residual disease. Out of 80 patients 28 (35%) achieved complete response following chemotherapy alone. Thirty-six patients (45%) with partial response underwent surgery: 17 had lymphadenectomy because of residual mass in the retroperitoneum, 15 had pulmonary surgery alone and 4 had both operations. Of these 36 patients 27 achieved complete response following cytostatic and surgical treatment. Sixteen patients died following PVB chemotherapy, 10 of them due to progression of disease, and there were six (7.5%) drug-related deaths. The authors refer to the importance of surgical treatment of residual metastatic mass in the lungs following PVB chemotherapy. Germ cell tumours of the testis are the most curable solid neoplasms treated by the oncologist. Advances in their management are due to the introduction of cisplatin-based combination chemotherapy and surgical removal of the residual mass [8]. Progress in chemotherapy of testicular tumours has changed the attitude towards thoracotomy and surgical removal of lung metastases. The aim of this study is to evaluate combined cytostatic and surgical treatment of disseminated testicular tumours with emphasis on surgical removal of residual lung metastases following chemotherapy.

[Is it necessary to begin therapy with orchiectomy in patients with advanced stage testicular tumors?]. / Je potrebné zacat liecbu pacientov s testikulárnym nádorom v pokrocilom stádiu orchiektómiou?

Seven patients with germ cell tumours of the testis in advanced stages of the disease were treated by primary chemotherapy without previous orchidectomy. To achieve complete remission it was necessary to remove the residual tumour in five patients (in two from the lungs and in three from the retroperitoneal space). Two of the seven patients had a persisting vital tumour in the ectomized testis. Five patients survive in complete remission for an average period of 9.6 months (range 3-18 months) after termination of treatment. In patients with germ cell tumours of the testis in advanced stages of the disease primary chemotherapy should be preferred and treatment should not be started by orchidectomy. Contemporary methods of visualization and laboratory examinations provide adequate evidence of the presence of germ cell tumours and the asset of a rapid effect of chemotherapy on metastases is greater than the advantages of accurate histopathological classification of the tumour. After termination of chemotherapy orchidectomy is indicated because even in patients with complete remission of secondaries a vital malignant tumour may persist.