Robotic distal pancreatectomy - the first experience.

INTRODUCTION: Minimally invasive distal pancreatectomy (MIDP) includes both laparoscopic and robotic distal pancreatectomy (RDP). MIDP is often adopted first due to the absence of the requirement of a complex reconstruction. In recent years, an increase in the use of robotic surgery has been noted. METHODS: The authors present initial experience with RDP and retrospective analysis of data from prospectively collected database. RESULTS: Between September 2021 and October 2022 five patients undergoing RDP with splenectomy performed in the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University and Motol University Hospital were included from a prospectively maintained database. The age was from 20 to 70 years. No conversion was required. One patient underwent reoperation due to staple-line hemorrhage. Postoperative hospital stay was from 4 to 14 days. The follow-up period was from 2 to 14 months. CONCLUSION: Our first experience demonstrates RDP is a safe and efficacious approach for tumors of pancreatic body and tail in selected patients. A larger number of patients is needed to obtain more accurate results.

Volvulus 8 years after bariatric surgery.

INTRODUCTION: Bariatric surgery is a widespread branch of surgery because of the increase in obesity in population. It is one way to achieve long-term weight loss effect in obese patients. Like other surgeries, bariatric surgery has many complications including ileus and volvulus in small intestine. It is an acute state in surgery and usually leads to a revision surgery. CASE REPORT: 58 years old woman who underwent mini-gastric bypass in 2014. She was admitted to our department because of manifestation of ileus on the second day after TEP of the hip joint. There was a typical sign of volvulus on the CT scan. She was operated on the same day. The reinsertion of enteroenteroanastomosis and denotation of the small intestine, desufflation of the large intestine, and reconstruction of new enteroenteroanastomosis was needed. After the surgery, the patient was without any complications. The bowel function recovery was slower postoperatively. CONCLUSION: Diagnosis of volvulus is not easy because of non-specific clinical symptoms. In this case report, the volvulus occurred 8 years after the primary surgery. Symptoms developed because of paralytic ileus after hip replacement.

Triple neurectomy following Lichtenstein repair of inguinal hernia.

INTRODUCTION: Chronic pain is a distressing complication that can occur after inguinal hernia repair, affecting between 5% and 20% of patients as reported in literature. There are several reasons for chronic pain, including peripheral nerve irritation caused by surgical mesh or stitches. Preoperative pain is a risk factor for chronic pain. CASE REPORT: We present the case of a 59-year-old man who experienced chronic inguinal pain following Lichtenstein hernia repair. Conservative therapy was ineffective, and he subsequently underwent triple neurectomy without removal of the original polypropylene mesh. The patient experienced significant pain relief immediately after the surgery. There was no reported pain 1 month and 1 year post-surgery. CONCLUSION: The management of patients with chronic pain following hernia repair should be comprehensive and, ideally, centralized. Conservative procedures should be attempted first, but neurectomy and mesh removal may be necessary in cases where conservative measures are unsuccessful.

Minimally-invasive pancreatic surgery in high volume centers in the Czech Republic - current status and possible implementations.

INTRODUCTION: Minimally-invasive surgical methods have been becoming ever more common also in the segment of pancreatic surgery. The aim of this paper was to analyze the current state of minimally-invasive surgery in the Czech Republic and the justification and potential of implementing such procedures. METHODS: Analysis of high volume centers using healthcare providers´ and payers´ data. RESULTS: Thirteen pancreatic surgical centers meet the proposed criteria for being called a high volume center - a center of highly specialized care in pancreatic surgery based on the annual number of at least 17 major resections of the pancreas. According to data from healthcare payers, laparoscopy was used in 0.6%-65.7% of procedures in individual centers. However, these are not resection procedures. The centers themselves report a significantly smaller number of minimally-invasive pancreatic resection procedures. The actual numbers of minimally-invasive resection procedures in the current system are practically impossible to verify. The potential for implementing minimally-invasive pancreatic surgery in the Czech Republic can be estimated based on the identification of candidate patients. CONCLUSION: Due to the fragmentation of this operative segment, its costs and small numbers of patients suitable for minimally-invasive pancreatic surgery even among high volume centers, the implementation rate of these methods is very slow. The need to centralize this segment of care appears to be very urgent from all points of view.

Successful Restoration of Elbow Extension Using the Latissimus Dorsi Flap: Case Report.

The latissimus dorsi (LD) myocutaneous flap is heavily used in reconstructive plastic surgery as either a local or distant flap, and mostly for coverage of large defects. To date, only a limited number of studies have described the use of an LD flap for functional reconstruction. Restoration of the extensor mechanism remains an unexplored area, and several issues remain to be addressed. First, generally accepted recommendations for the surgical technique do not include specific steps to achieve functional qualities of the upper extremity after complete removal of the triceps brachii muscle. Second, to date, it has not been clarified whether elbow extension requires correction because the movement can be naturally compensated for by gravity. To contribute to the current knowledge base in this field, the authors describe a technique for the reconstruction of an extensor mechanism of the elbow by transferring a pedicled functional LD flap while maintaining an intact insertion. Reconstruction was performed in a patient who experienced a second recurrence of a malignant peripheral nerve sheath tumor and underwent complete excision of the triceps brachii muscle. After excision, a meshed epidermal graft was used for wound closure. The patient's postoperative course was uneventful. His elbow was immobilized for 3 weeks using an elbow splint, followed by intensive rehabilitation. The functional result was excellent, with an Enneking limb function score of 26. During the 16-month follow-up, no signs of local recurrence or systemic spread were observed.

[Surprising histological findings on the resected specimen of the omentum due to a strangulated umbilical hernia]. / Prekvapivý histologický nález v resekátu omenta pro uskrinutou pupecní kýlu.

INTRODUCTION: Gastrointestinal stromal tumor, GIST, is the most common mesenchymal tumor of the digestive system. It most often grows from the stomach or the small intestine and tends to be asymptomatic. The basic and the only curative therapy is an attempt at R0 resection. If the tumor is inoperable, metastatic or when neoadjuvant or adjuvant therapy is needed, patients are treated with a tyrosine kinase inhibitor - imatinib. It was discovered in 2000 on the basis of GIST molecular behavior. CASE REPORT: The case report describes a female patient who had been without any clinical symptoms for a long time until she presented with acute abdominal pain due to squeezed umbilical hernia. She underwent an acute operation, resection of the strangulated omentum and reconstruction of the abdominal wall. The omentum was sent for definitive histology. However, the pathologist described nonspecific sarcoma. A subsequent CT scan showed a large tumor mass in the abdominal cavity and in the small pelvis. A multidisciplinary team of the Motol Teaching Hospital indicated the patient for an attempt at radical tumor extirpation. Omentectomy, resection of the jejunum, hysterectomy, right adnexectomy, low anterior resection of the rectum and omphalectomy were performed. The result of the definitive histological examination was high-risk, malignant GIST, c-kit-positive, growing from the jejunum.Key words: GIST gastrointestinal stromal tumor KIT imatinib.

[Synovial sarcoma of the liver - case report]. / Synoviální sarkom jater - kazuistika.

Synovial sarcoma is malignant mesenchymal fuso-cellular tumor with variable epithelial differentiation. We present the rare case of young female patient with primary synovial sarcoma of the liver. Molecular diagnosis was done by detection of SYT/SSX fusion transcript. Patients with sarcoma should be treated only in high specialized centres.Key words: synovial sarcoma of the liver.

Postoperative rectal anastomotic complications.

Colorectal cancer represents the most common tumour of the gastrointestinal tract and the second most common tumour in men as well as women. The trend of increasing incidence of colorectal cancer is alerting. We undertook a retrospective study on 588 patients with rectal cancer and operated by rectal resection with anastomosis between the years 2002-2012. In our sample, we observed 54 (9.2 %) cases of anastomosis insufficiencies requiring reoperation. Out of 54 insufficient anastomoses, 36 (66 %) were in the lower two thirds of the rectum and only 18 (34 %) in the oral one. Although we have observed similar occurrences of anastomosis insufficiency in both groups - classical vs. staple suture (9.5 % and 9.0 %, respectively), the majority of stapler anastomoses (94 %) were made in the aboral part of the rectum. However, we can state that a majority of authors prefer the staple anastomosis as the one with lowest risk, mainly in the distal region of anastomosis. The high ligation of inferior mesenteric artery was performed in 182 (31 %) patients; out of these, we observed anastomosis insufficiency in 12 cases (22 %), which is exactly similar to that in the group of patients without high ligation of the inferior mesenteric artery. We did not observe the use of antibiotics in therapeutical doses as a positive factor for anastomosis insufficiencies, and neither was oncological therapy observed as a risk factor. In our group of patients we agreed that age, level of anastomosis and corticosteroids are high-risk factors. The purpose of these reports, is for the sake of future to share and reference our experiences with cases of rectal and rectosigmoideal resection over the last 11 years. We consider it important to reference our results, especially the risk factors regarding the healing of rectal anastomosis, because anastomotic healing is a surgical problem with potentially deadly consequences for patients (Tab. 4, Ref. 24).

Intraoperative enteroscopy: ten years' experience at a single tertiary center.

BACKGROUND AND METHODS: Intraoperative enteroscopy is an invasive technique for small bowel investigation. It enables us to investigate the entire small intestine and to treat pathological findings by endoscopic or surgical means at the same time. The investigation is invasive and that is why the proper indication is mandatory. RESULTS: Forty-one intraoperative enteroscopies were performed at our center within a 10-year period. The procedure was diagnostic in 37/41 patients (90.2%); in 3 patients no pathology was found, and in 1 patient we found only previously diagnosed celiac disease. The investigation was therapeutic in 35/41 (85.4%) patients; 2 patients with small bowel ulcers did not require any intraoperative therapy. The pathological findings were arteriovenous malformations (found in 12 patients), small bowel NSAID-induced or Crohn's ulcers (8 patients)--ulcerations and arteriovenous malformations were simultaneously found in three patients; carcinoid of the small intestine (5 patients); Peutz-Jeghers syndrome (5 patients); bleeding polyps (2 gastrointestinal stromal tumors, 1 paraganglioma, and 1 lipoma--in 4 patients); Rendu-Osler-Weber disease (2 patients); multiple cavernous hemangiomas in blue rubber bleb nevus syndrome (1 patient); Henoch-Schönlein purpura (1 patient); aortoenteral fistula (1 patient); and retrograde intussusception of Meckel's diverticulum (1 patient). In five patients with Peutz-Jeghers syndrome, 6-22 hamartomas (median of 18 per session) were removed by means of endoscopic polypectomy during intraoperative enteroscopy. There were no major procedure-related complications in our series. CONCLUSIONS: Intraoperative enteroscopy is accepted as the ultimate diagnostic procedure for complete investigation of the small bowel. Despite the introduction of double-balloon enteroscopy into clinical practice, intraoperative enteroscopy will be reserved for those cases where double-balloon enteroscopy cannot be performed or fails to investigate the entire small intestine, especially to prevent excessive bowel resection.

[Retroperitoneal hemangioma--a case report]. / Hemangiom retroperitonea--kazuistika.

Localization of hemangioma in retroperineum causes late diagnosis of the disease. The tumour is usually detected only when the clinical symptoms caused by the pressure of the surrounding tissues occur. This article presents the case of retroperitoneal hemangioma preoperatively diagnosed as suspect feochromocytoma.

[Paliative managment of oesophageal carcinomas--our experience]. / Paliativmní osetriení karcinomu jícnu--nase zkusenosti.

The authors of this presentation explain their experience with methods of paliative care of oesophagus carcinoma. The indication criteria are described and compared advantages and disadvantages of those methods. There is an accent in most frequent method--oesophagus stent implementation. The results in the group of patients after the stent implementation are described, also complications and other solutions.

[Small bowel carcinoid]. / Karcinoid tenkého streva.

Tumors of the small intestine can be fatal from the oncologic point of view. Its quite sporadic incidence and absence of early clinical symptoms lead to its very difficult diagnosis. Carcinoid stays as the second most often tumor of the small intestine and it is qualified by some authors as semimalignant. The case report presented is aimed at that issue.

[Unusual cause of the acute appendicitis]. / Neobvyklá prícina akutní apendicitidy.

Exogenous foreign particles in the appendix rarely case appendicitis. Their prevalence is reported to be 0.0005%. This fact makes both lay and medical community underestimate possible complications related to the presence of foreign particles in the appendix lumen. Our case review documents risks related with swallowing a sharp foreign particle. The particle concerned was a tooth root--on prosthesis with an acrylic crown, which caused acute appendicitis with the appendical wall perforation by the above mentioned foreign body.

[Laser palliative destruction of rectum carcinoma--case reports]. / Laserová paliativní destrukce nádoru rekta--kazuistiky.

The palliative treatment of developed primary or recurrent rectum carcinoma is still an important issue in treatment of this disease. The aim of the surgery is in such case to remove the tumorous obstacle and to prevent the development of ileus, to reduce pain, to limit the volume of tumorous tissue, to prevent bleeding and possible incontinence or mucous secretion. The transanal laser thermodestruction of the tumor represents one of the possible ways of palliative treatment of rectum carcinoma. The method is very considerate even for the high risk patients. On the other hand it requires a short-term hospitalization. The method of transanal laser evaporisation of carcinoma is also important from the ethical point of view: in many cases it may prevent the creation of palliative derivative colostomy. This fact is very important especially in patients with the terminal stage of the malign carcinoma because they live the rest of their lives in acceptable conditions. The important benefits are described in three case histories. The method is presented as an urgent surgery in solution of ileus which is based on tumorous rectum stenosis.

[Liver metastases of colorectal carcinoma]. / Jaterní metastázy kolorektálního karcinomu.

The surgical resection of liver metastasis is still rather rare in the Czech Republic. The survey of literature indicates that correctly indicated metastasectomy is the method of the first choice. Five years after metastasectomy one third of patients who underwent surgical intervention still lives.

[Cholestatic icterus during parenteral nutrition and the therapeutic effect of enteral feeding--case report]. / Cholestatický ikterus na parenterální výzive a lécebný vliv enterální aplikace--kazuistika.

An acute operation was made on a 56-year woman for inflammatory perforation of colon. A series of repeated operations followed due to relapsing iatrogenic intestinal fistula and peritonitis. From the day 70 the patient was treated at the Intensive Metabolic Care Unit of the Gerontological and Metabolic Clinic of Faculty Hospital in Hradec Králové. Having cured the septic shock the authors prepared the patient to a reconstruction operation on alimentary tract by administering parenteral nutrition, treating the wounds and by motion rehabilitation. From day 150 on the patient was treated with low doses of enteral nutrition into the segment of intestine between the fistulas, in connection with the subsequent decrease of two-month lasting hyperbilirubinemia of 200-260 mumol/l. A successful reconstruction of the alimentary tract was performed on the day 205 of the treatment with the time lapse of 146 days after the last surgical intervention. A three-fold anastomosis on small intestine and a resection of the fistula on the transversal colon was made. The post-operation fistula was healed-up conservatively, while the parenteral nutrition continued, as verified on day 246 by enteroclysis. The paper draws attention to the importance of conservative metabolic care in the therapy of dishiscences of intestinal anastomoses not treated by acute surgery in time. A favourable additive effect of enteral nutrition on the persisting cholestasis during parenteral nutrition is discussed.

[Intraoperative enteroscopy--personal experience from 1995 to 2002]. / Intraoperacní enteroskopie--vlastní zkusenosti z období 1995-2002.

Authors present their experience with the intraoperative enteroscopy method--an invasive technique of small bowel examination. It is performed under narcosis at an operating theatre (i.e. in co-operation with surgeon and anaesthesiologist). The endoscopy-performing physician becomes one of the members of the operating team. The advantage of the method is the possibility to examine of the whole small intestine and to solve immediately the pathological findings by endoscopic or surgical intervention. The examination is invasive and the correct indication is mandatory. Authors report their results of 18 intraoperative panendoscopies of small intestine.

[A simple peritoneovenous shunt in the treatment of chronic ascites]. / Jednoduchá peritoneovenózní spojka v lécbe chronického ascitu.

The authors describe their own initial experience with a peritoneo-venous shunt in otherwise incurable ascites. It is a simple procedure which is more satisfactory than the formerly used technique of implantation of Le Veen's system.

Immunoscintigraphy and intra-operative radioimmunodetection in the treatment of colorectal carcinoma.

PURPOSE: Intra-operative radioimmunodetection of malignant involved lymph nodes follows the pre-operative immunoscintigraphy in the treatment of patients with colorectal carcinoma. The aims of this clinical study were to determine the sensitivity of the method, to compare the results in study when using Oncoscint and CEA-Scan and to evaluate the importance of the method of surgery and postoperative adjuvant therapy. PATIENTS AND METHODS: 121 patients with colorectal tumours (106 primary and 15 recurrent) were operated on using radioimmunoguided surgery (RIGS). The study compared results of pre-operative immunoscintigraphy, intra-operative radioimmunodetection and postoperative histological examination. Histological investigation used classical H&E staining. In histologically negative and RIGS positive cases the immunohistochemical investigation was supplemented. Two radiopharmaceuticals were used Oncoscint CR 103 (MAb B72.3, Satumomab Pendetide), labelled with 111In in 56 patients and CEA-Scan (IMMU 4-Fab' fragments MAb against CEA, Arcitumomab), labelled with 99mTc in 65 patients. RESULTS: The relationship between RIGS positive results and histological examination was statistically assessed after 38 operations and the most acceptable RIGS evaluating index was determined. All subsequent results were evaluated by this index. Immunoscintigraphy of tumour was positive in 112 cases (92.6%). Fifty-five RIGS positive cases of malignant infiltrated lymph nodes were confirmed by 43 histologically positive examinations (78%). In this group 9 cases were discovered only by immunohistochemistry. Sixty-six remaining RIGS negative results were confirmed in 62 (94%) cases by negative histology. CONCLUSIONS: Both immunoscintigraphy and RIGS enable one to make a more accurate diagnosis. While treating the primary disease the use of RIGS may help in assessment of necessary extent of operation performance and in staging of the disease by revealing occult lymph nodes involved. Pre-operative immunoscintigraphy seems to be a useful diagnostic method for detection of tumour recurrence. When comparing two radiopharmaceuticals used, CEA-Scan seems to be more suitable for diagnostic studies, but using the Oncoscint for tumour recurrence detection had some specific benefit, too.

Importance of the anorectal manometry in chronic anal fissure.

This publication presents the results of postoperative manometric investigations of 77 patients with anal fissure treated within the time span 1985-1997 by lateral sphincterotomy (LS). Results of manometric investigations are compared with digital anal examinations and subjective complaints of patients. Digital anal examination correlated with manometry results in 52 cases (68%). The correspondence between these two results was proved in 48 cases when normal finding was present. An increased sphincter tonus was found in 3 patients, all of them having the anal fissure recurrences. A marked sphincters insufficiency, which had been manifested by stool and gas incontinence was found in one case. When searching for the reason of this complication we found out that this operation procedure had been performed by an unexperienced team of surgeons. In 25 cases (32%) the digital anal assessment and manometric measurement were different. Nevertheless, the clinical symptoms in this group of patients were rather poor. To conclude we may state that manometry provides important data for preoperative evaluation of anal sphincter function and should be performed prior to lateral sphincterotomy operation at least in women.