Tumors of the rectum and anus.

Within a ten year period we have performed 433 radical operations on the rectum. An anterior resection of rectum was done in 110 cases, low anterior resection in 60 patients, very low anterior resection was done by stapler in 32 patients and was sewn by hand in 10 patients. Colo-anal anastomoses were performed 86 times and abdominoperineal amputation of rectum sec. Miles 20 times. Local transsphincteric procedures were used 14 times. In 12 patients the colo-anal anastomosis was performed either for recurrence of tumor or after a Hartmann's procedure. In the carcinoma of the lower half of the rectum there is still an unsolved question: whether to perform a low or a very deep low anastomosis or whether an extirpation of rectum with sparing the sphincters and sewing a colo-anal anastomosis is more beneficial. In the years 1980-1995 we treated surgically 64 patients with a tumor in anal area. All patient underwent preoperative radio- and chemotherapy. In our group adenocarcinoma was demonstrated in 6 patients, squamous carcinoma in 48 patients and squamous cells of the carcinoma in situ in 10 patients.

[Carcinoma of the lower half of the rectum]. / Karcinom dolní poloviny rekta.

Authors analyze the group of patients surgically treated for rectal carcinoma during ten-years long period. While the surgical tactic in upper part of the rectum is solved by the resection with straight anastomosis, in carcinomas of lower part of the rectum there is an open question there, to use the deep pelvic anastomosis after radical resection or to perform the rectal extirpation with saving of sphincters and using the coloanal anastomosis. The necessary requirement is complex preoperative examination of the tumor and of pelvic fundus physiology. For application of coloanal anastomosis the rigid indications are determined. Authors used this method in 107 patients of the monitored group. Early and delayed complications of these interventions are analysed, indication for temporary stomy and application of pouchs. In the group of patients with coloanal anastomosis no local recurrence was noted, in the group with deep pelvic anastomosis the locoregional anastomosis was found in 8% of patients.

[Does insufflation of the abdomen in laparoscopic surgery affect acid-base and ventilatory parameters?]. / Ovlivnuje insuflace bricha pri laparoskopické operaci acidobazické a ventilacní parametry?

The cardiopulmonary and metabolic changes experienced by patients undergoing laparoscopic cholecystectomy with CO2 pneumoperitoneum are not well understood. The purpose of this study is to determine changes of basal parameters during laparoscopy and evaluate their prognostic value. One hundred patients (26 obese, 39 older than 60 years, 7 obese and older than 60) undergoing laparoscopic cholecystectomy for uncomplicated cholecystolithiasis were included in the study. Arterial blood gases, respiratory and ventilatory parameters, heart rate, blood pressure were determined before the induction of pneumoperitoneum, at the peak of operation and after exsufflation. The obtained variables were statistically evaluated. Pneumoperitoneum caused significant hypercapnia and a decrease of pH accompanied with increase of expiratory CO2 concentration, which continued after exsufflation (p < 0.001). The changes were more expressed in older and obese patients and were solely of a respiratory type. No significant changes were observed in the heart rate, blood pressure, minute ventilation, PaO2, SaO2, base excess. Although changes were highly significant, there was no impact on clinical status--all patients survived without problems. The authors conclude that observed increase of carbon dioxide levels and decrease of pH had no impact on survival of patients. Changes were caused mostly by CO2 absorption from the abdominal cavity. Laparoscopic cholecystectomy is a safe and effective procedure even in older and obese patients, especially when insufflation is as low as possible.

[Preventive sclerotherapy of esophageal varices with a high risk of hemorrhage: a prospective randomized controlled study]. / Preventivní skleroterapie jícnových varixu s vysokým rizikem krvácení: prospektivní randomizovaná kontrolovaná studie.

Endoscopic sclerotherapy (ES) is known to be effective in the treatment of bleeding esophageal varices, but the efficacy in the prophylaxis of first variceal bleeding has not been clear yet. The aim of this study was to investigate the frequency of first variceal bleeding, eradication and recurrence of varices, and survival after treatment with ES compared to non-treated control group. A total of 104 patients with liver cirrhosis and advanced esophageal varices with no previous history of upper gastrointestinal bleeding were randomly assigned to either endoscopic sclerotherapy group--SKL n = 56, or non-treated control group--KON n = 48. After eradication of esophageal varices in SKL group and in all control patients, the endoscopic examination was performed in 3 month intervals. The complete eradication of esophageal varices was achieved in 45 (83%) patients of SKL group. The mean number of sessions required to obtain eradication was 7.8 +/- 2.5. The recurrence of esophageal varices occurred in 9 (17%) patients. Total mortality was significantly lower in SKL patients as compared to controls (21.4% vs. 39.6%; p = 0.047, 95% CI 0.5-35.5). The significant decrease of variceal bleeding we observed in sclerotherapy (21%) versus controls (52%; p = 0.002, 95% CI 13-49%). Serious complications of ES were not observed. Endoscopic sclerotherapy is effective in the prevention of first variceal bleeding and in experienced hand, if the complication rate is low, is able to reduce total mortality of treated patients. The newer endoscopic method, variceal ligation, must be examined in this indication.

A prospective randomized controlled trial of sclerotherapy vs ligation in the prophylactic treatment of high-risk esophageal varices.

BACKGROUND: Endoscopic ligation (EVL) and endoscopic sclerotherapy (EIS) are both effective in the treatment of bleeding esophageal varices, but the efficacy of the two techniques in the prophylaxis of first variceal bleeding has not been investigated. The aim of this study was to investigate the frequency of first variceal bleeding, the recurrence of varices, and survival after treatment with the two techniques, as compared to a nontreated control group. METHODS: A total of 157 patients with liver cirrhosis and advanced esophageal varices with no previous history of upper gastrointestinal bleeding were randomly assigned to either an EIS group (n = 55), an EVL group (n = 52), or a nontreated control group (n = 50). After the eradication of esophageal varices in the EIS and in EVL groups and in all control patients, the endoscopic examination was performed at 3-month intervals. RESULTS: There were no significant differences between EIS and EVL in the eradication rate of esophageal varices (85% in the EIS group versus 81% in the EVL group). The mean number of sessions required to obtain eradication was lower in the EVL group than in the EIS group (4.8 +/- 1.8 versus 6.2 +/- 2.0; p = 0.0003), but the recurrence of esophageal varices was higher in the EVL group (31% versus 11%; p = 0.01). Total mortality was significantly lower in the EIS patients than in the controls (20% versus 38%; p = 0.04). It was also lower, but not significantly, in the EVL patients than in the controls (23% versus 38%; p = 0.10). A significant decrease in variceal bleeding was observed both in sclerotherapy cases (20%) and controls (54%; p = 0.0005) and in ligation cases and controls (29%; p = 0.01). No significant difference in bleeding episodes was observed between the sclerotherapy and ligation cases (p = 0.29). No serious complications were observed either in the EIS or EVL groups. CONCLUSIONS: EIS and EVL are similarly effective in the prevention of first variceal bleeding. The choice between EIS and EVL depends on the skill of the endoscopic unit. For highly experienced surgeons facing no complications, sclerotherapy seems to be preferable; for all others, it is technically easier to perform ligation.

[Loss injuries of the biliary tract in laparoscopic cholecystectomy-- possibilities of reconstruction]. / Ztrátová poranení zlucových cest pri laparoskopické cholecystektomii--moznosti rekonstrukcí.

Authors analyze occurrence of injuries of external biliary tract relating to the increasing number of laparoscopic cholecystectomies, especially of loss injuries, very demanding for its reconstruction. The early diagnosis of these injuries is emphasized and the necessity of their surgical revision as soon as possible, best still during the primary intervention. Authors present the own reconstruction method by high intrahepatic anastomoses in loss injuries of the common hepaticus and its branches.

[Laparoscopy in abdominal injuries]. / Laparoskopia pri úrazoch brucha.

Application of laparoscopy in trauma was studied in Traumatological Hospital in Brno, within a more widely concipated project of grant IGA, Ministry of Health in Czech Republic. In the series of 28 patients there was detected neither a single complication, nor a reoperation nor any significant damage to the patient in connection with the use of the endoscopic method detected. Results of the research and author's observations act as a guide for use of more precise indication criteria and adequate selection of patients and for the proper evaluation of the method. Provided that basic principles and priorities of the urgencies management are kept, the application of this minimally invasive method in the management of patients with selected both the blunt and the penetrating abdominal trauma is justified, including associated extraabdominal injuries and polytrauma. It's diagnostic contribution exceeds the therapeutic one.

Benefit of prophylactic endoscopic sclerotherapy of esophageal varices. A retrospective analysis.

BACKGROUND: The therapeutic schedule in bleeding esophageal varices is today established: emergency endoscopy with sclerotherapy or ligation combined with somatostatin and decreasing portal pressure drug followed by repetitive sclerotherapy or ligation. But the approach to varices that do not bleed is not clear. METHODS: The authors submit the results of a 6-year sclerotherapeutic program. Since January 1989 they have treated 421 patients with varices and have together performed 4,115 endoscopic sclerotherapeutic procedures. Among the 421 patients 95 were treated during acute bleeding and 254 were treated after first bleeding; in 72 patients prophylactic sclerotherapy (PSG) was performed. RESULTS: The procedure was indicated, when grade III or IV varices or high-risk signs and/or hepatic venous pressure gradient (HVPG) > 15 in grade II varices were observed. Prophylactic therapy (not-treated group-NTG) refused next 31 selected patients. The mean follow-up time was 32 months in the PS group and 28 months in NTG (n.s.). Fifteen PSG patients died (21%), while the mortality among the NTG patients (13 = 42% patients) was significantly higher (P < 0.02). CONCLUSIONS: We recommend prophylactic sclerotherapy with 1% polidocanol in patients with advanced varices in liver cirrhosis of varied etiology. We emphasize the need to perform these procedures in a department with adequate experience, where at least 100-200 sclerotherapies per year are performed.

[Laparoscopic inguinal hernioplasty--results in the initial group 2 years after surgery]. / Laparoskopická inguinální hernioplastika--výsledky v iniciálním souboru dva roky po operaci.

The authors evaluate retrospectively after a two-year interval the results of laparoscopic inguinal hernioplasty (L.I.H.) in an initial group of 49 patients (52 hernias) operated by three surgeons using the method of transabdominal preperitoneal plastic operation (TAPP) in 1993, 1994 and 1995. They confirmed the expected favourable results, except for the very high incidence of relapses (6.7%). In view of the small number of patients other conclusions cannot be drawn except analyse the three early failures of L.I.H., indicate technical mistakes made when introducing the new operation and emphasize the necessity to adhere to the known basic technical details when performing this relatively pretentious laparoscopic operation.

Pantoprazole-based dual and triple therapy for the eradication of Helicobacter pylori infection: a randomized controlled trial.

BACKGROUND/AIMS: The eradication of Helicobacter pylori (Hp) infection in duodenal ulcer and dyspepsia has been achieved using various therapy regimens. The efficacy of protein pump inhibitor pantoprazole as part of these regimens has not been widely studied. METHODOLOGY: During a prospective randomized trial, 250 Hp positive patients with either duodenal ulcer, erosive bulbitis, or gastritis and dyspepsia were treated using 14 days of therapy 1) pantoprazole 40 mg daily and clarithromycin 500 mg b.i.d. (PC), 2) pantoprazole 40 mg daily and clarithromycin 500 mg b.i.d. plus amoxicillin 1 g b.i.d. (PCA), or 3) bismuth subcitrate 120 mg t.i.d., roxithromycin 150 mg b.i.d., metronidazole 250 mg b.i.d. plus ranitidin 300 mg (BRMR). Hp status was assessed on 3 tests at the inclusion (2-specimen rapid urease test, 2-specimen histology, serology) and 2 tests (2-specimen rapid urease test, 2-specimen histology) 4 weeks after the end of the treatment. RESULTS: The entry criteria was fulfilled in 250 patients, of whom 13 missed the control endoscopy. The treatment had to be discontinued for adverse effects in 8 (10%) BRMR patients, and 1 (1%) PCA patients. Compliance was 100% in the PC group. All ulcers were healed at the end of the study with one exception in the BRMR group. The best eradication rate of Hp was shown by the PCA group with 94.8% (n = 73/77) followed by the PC group with 82.5% (n = 66/80) and finally the BRMR with 67.6% (n = 48/71)-PCA:BRMR - p < 0.001; PC:BRMR-p < 0.001; PCA:PC-p < 0.05. CONCLUSION: This study showed that triple therapy using PPI pantoprazole combined with antibiotics clarithromycin and amoxicillin was very effective in the eradication of Hp and treatment of duodenal ulcer with rare side effects. The dual pantoprazole and clarithromycin therapy had the highest rate of patient compliance, but is less effective than triple therapy. The combination of ranitidin with bismuth based triple therapy had the highest number of adverse events and the lowest rate of Hp eradication and therefore, should not be recommended.

[Repeat laparoscopy in the management of biliary leaks after laparoscopic cholecystectomy]. / Moznosti relaparoskopie pri osetrení biliární sekrece po laparoskopické cholecystektomii.

The incidence of bile leaks increased with the introduction of laparoscopic cholecystectomy in surgery. The present paper is focused on biliary leaks-their diagnosis and treatment in a large group of patients, with special emphasis on a miniinvasive approach. Nine biliary leaks were found (i.e. 0.72%). Four leaks resolved spontaneously, five were treated surgically with good results.

[Recurrent source of bleeding in patients with esophageal varices]. / Duplicita zdroje krvácení u pacientu s jícnovými varixy.

During last 7 years were in Endoscopic Centre of Brno Traumatologic Hospital treated 824 patients (624 male, 200 female) with esophageal varices, indicated to endoscopic sclerotherapy, ligation, or tissue adhesive injection. For one or more episodes of bleeding were treated 659 patients and resting 165 received therapy prophylactically. Recurrent acute bleeding from upper GIT occurred from 1 January 1990 to 30 April 1997 in 212 of them. In patients with previously proved esophageal varices were investigated for repetitive acute bleeding in this period 212 of them. In 157 (74%) patients endoscopy confirmed expected repetitive bleeding from esophageal varices, but in 55 (26%) was found bleeding from other source of upper gastrointestinal tract. The bleeding from gastroduodenal ulcers in 18 (8%) patients, in 22 (10%) from apths, Mallory-Weiss syndrome was source of bleeding in 8 (4%) patients, and hemorrhagic gastropathy in 7 (3%) was found. The authors draw attention to the fact that, in their big group patients with esophageal varices, duplicity of source of bleeding occurred in 1/4 patients. They concluded, that in patients with previously proved esophageal varices in necessary to perform in case of recurrent bleeding emergency of urgent endoscopy not only of esophagus, but even of whole upper GIT. Therapeutic mistake can happen in 1/4 of patients, if repetitive bleeding from varices would be expected and automatically treated by balloon tube. The patients could be damaged by delay in the treatment of bleeding from other source.

The role of relaparoscopy in the management of bile leaks after laparoscopic cholecystectomy.

The incidence of bile leaks has increased with the advent of laparoscopic cholecystectomy. The present paper is focused on bile leaks--their diagnosis and management approaches with special consideration to relaparoscopy. From February 1992 to May 1995 a total of 1223 laparoscopic cholecystectomies were performed in two hospitals. Eight biliary leaks were found in the series under study (i.e. 0.65%). The diagnosis was confirmed by means of ultrasound, CT scans and ERCP. Three leaks resolved spontaneously on external drains placed during the operation. Two and three patients underwent laparotomy and relaparoscopy, respectively. The etiology of the leakage included three cases of ducts of Luschka, one cystic duct leak, and one retained CBD stone. the source of the remaining leaks was not determined. In all cases the management approaches comprised relaparoscopy and laparotomy. It may be concluded that an early diagnosis and management of bile leaks after laparoscopic cholecystectomies would prevent further complications.