[CRASH--the first large randomized controlled study of head injuries]. / CRASH--první velká randomizovaná kontrolovaná studie u úrazu hlavy.

CRASH (www.crash.lshtm.ac.uk) is already today the most extensive randomized controlled study of patients with head injuries which was implemented, but its completion and statistical evaluation will be possible only when it achieves the planned and necessary 20,000 enlisted patients. This calls for unselfish cooperation of physicians and nurses world-wide. In the Czech Republic so far six departments participate in the study and we would be glad if this number would increase substantially.

[Changes in acid-base equilibrium, ventilation parameters and immunologic reactions in thoracoscopic operations]. / Zmeny acidobazické rovnováhy, ventilacních parametru a imunologická reakce pri torakoskopické operaci.

In the thoracoscopic operations it is usually necessary to deflate completely the ipsilateral lung. The aim of this study was to determine changes of blood gases and alterations of immune response mediators during thoracoscopic surgery with one-lung ventilation OLV. In the study 38 patients were included undergoing thoracoscopic or video-assisted thoracic surgery. Arterial blood gases, respiratory parameters, heart rate, blood pressure were determined before one-lung ventilation, at the peak of operation and after finishing OLV. The circulatory cytokines IL-1 beta, IL-2, IL-6, IL-8, TNF-alpha, and reactive oxygen species (ROS) were measured before and after operation, 3 h, 24 h and 48 h after operation. The obtained variables were statistically evaluated. One-lung ventilation caused a significant increase of PaCO2 (from 4.69 +/- 0.67 to 5.91 +/- 0.87 kPa) which was accompanied by an adequate decrease of pH (7.455 +/- 0.033-7.368 +/- 0.037) and a number of patients developed respiratory acidosis (34%). There were no significant changes in levels of the investigated cytokines, only a mild increase of IL-6, IL-8 and TNF during first 24 h after operation was observed. The activity of ROS was highest at the end of the operation, but did not differ significantly from the start, but then decreased significantly for a period of 24 h. The authors conclude that the observed increase of carbon dioxide levels and decrease of pH had no impact on the fate of the patients. Thoracoscopic or VATS procedures were a minimal load for patients causing no significant changes of proinflammatory cytokines. The operations did not significantly elevate the activity of ROS.

[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.

[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.

Recent position of transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension.

Transjugular intrahepatic portosystemic shunt (TIPS) is a side-to-side portocaval shunt for threatening complications of portal hypertension. TIPS effectively decreases portal hypertension connecting the hepatic and portal vein with an expandable metal stent without the mortality and morbidity of an open surgical procedure. Technical success can be achieved in over 90% of patients, with procedure related mortality of 1-2%. The main problem is stenosis or occlusion of the shunt by neo-intimal hyperplasia narrowing the lumen of the shunt in 20-80% of patients during 6-12 months, but fortunately, most stenotic stents can be revised successfully. Recent indications for TIPS are acute variceal hemorrhage refractory to endoscopic treatment and recurrent variceal bleeding despite sclerotherapy or band ligation. TIPS insertion in the treatment of refractory ascites seems to be promising.

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.

[Transjugular intrahepatic portosystemic shunt in the treatment of complications in portal hypertension]. / Transjugulární intrahepatická portosystémová spojka v lécbe komplikací portální hypertenze.

Transjugular intrahepatic portosystemic shunt (TIPS) is a side-to-side portocaval shunt for threatening complications of portal hypertension. The purpose of this study was to evaluate in first 33 patients indicated for TIPS insertion in our institution the efficacy, complications, and mortality. Indication was failure of sclerotherapy or ligation in control either of acute (n = 4) or repetitive (n = 25) variceal bleeding and refractory ascites (n = 4). The technical success rate was with 70% (21/30) lower than expected, but the complication rate was also very low. There were no fatal complications, only one subcapsular liver hematome, and in one patient repetitive punction of biliary tract. The 30-days mortality was 10% (2/21) and rebleeding was 15% (3/20), caused always by thrombosis of the shunt. TIPS seems to be a promising therapeutic procedure after failed endoscopic therapy of esophageal varices without the mortality and morbidity of an open surgical procedure. Recent indications for TIPS are acute variceal hemorrhage refractory to endoscopic treatment and recurrent variceal bleeding despite sclerotherapy or band ligation. Promising seems to be TIPS insertion in the treatment of refractory ascites.

[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.

[Thoracoscopic major pulmonary resection--pro and con]. / Torakoskopická velká plicní resekce--pro a proti.

The first reports of thoracoscopic video-assisted procedures are from 1993. The main reason for this new techniques was that they allow the performance of standard thoracic surgical procedures in a less invasive ways. The operation trauma is minimalised that could be a cause not only of postoperative pain but often also of chronic future problems. The other advantages are the shortened hospitalisation time and earlier end of disablement. On the other hand there are many objective arguments against here. Firstly, the operative technique is not standardised and thoracoscopic lobectomy and pneumonectomy are performed by many modified methods. No regular randomised studies are available that could confirm the positive contribution of thoracoscopy in these cases. It is possible to perform classic thoracotomy by very careful way saving muscles and contemporary observing the requirement of safe operation and to attain the maximally possible result. Resuming information from written and verbal reports in last 3 years we have necessary the impression that the main reason for thoracoscopic reactions was to demonstrate the technical feasibility of this operation which is entirely insufficient reason for acceptance of this technique. Authors suggest that thoracoscopy is in experienced hands and adequately equipped workplaces an accurate and safe method for the diagnosis and in some cases also for therapy of hemodynamic stabile patients with thoracic trauma.

[Trauma and emergency thoracoscopy]. / Trauma a casná torakoskopie.

Authors present their first experience with urgent videothoracoscopy in polytraumatism and in isolated thoracic trauma patients. During the prospective study in 1993-1995 thoracoscopically was treated 41 (18%) from 229 multiple trauma patients including thorax trauma, hospitalised in our Institute. Thoracoscopy underwent 62 (4%) from 1452 patients with simple thoracic trauma. Thoracoscopy has been indicated above all for continued bleeding into peritoneal cavity, for suspected diafragmatic injury and for the diagnosis and treatment of posttraumatic complications. Authors suggest that thoracoscopy is in experienced hands and adequatelly equipped workplaces an accurate and safe method for the diagnosis and in some cases also for therapy of hemodynamic stabile patients with thoracic trauma.

[Stress ulcers in patients with polytrauma]. / Výskyt stresového vredu u polytraumatizovaných.

Authors treat in their institution yearly 100-120 patients with polytrauma. In the Endoscopic Centre of the hospital approx. 20 gastroduodenal ulcers are diagnosed yearly in patients with supposed stress etiology. Authors analyze the pathophysiology of origin of stress ulcer, clinical symptoms and acute diagnostics. They evaluate results of early surgical treatment. Authors place the great importance on explicit treatment methods for prevention of stress ulcer origin.

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.

Our experience with early integration of laparoscopic cholecystectomy in surgical residency training.

Laparoscopic cholecystectomy is now a method of choice in treating symptomatic cholelithiasis. The aim of this study was to assess an early integration of surgical residents into performing laparoscopic cholecystectomies and the significance of the integration for their training. Since February 1992 laparoscopic cholecystectomy (LC) has been performed in our institutions. During the 1st year 253 LCs were done by 4 surgeons--2 residents (in postgraduate years 3 and 4) and 2 staff surgeons; the 2nd year the team was extended and 301 LCs were performed. The residents operated on 364 cases (66%); the overall conversion rate was 5.4%; in the group of patients operated by residents (R) it was 3.8%; in the group operated by staff surgeons (SS) it was 8.4%. The complication rates did not exceed literature reports. The overall complication rate was 3.4%, in the "R" group 3.0% and in the "SS" group 4.2%. It may be concluded that surgical residents can perform LC without additional complications after initial experience with the open technique and appropriate hands-on laboratory training period before starting LC. Continuous training in advanced open biliary procedures should be assured for senior surgical residents.

[Cytokine levels in patients with multiple injuries]. / Hladiny cytokinu u pacientu s polytraumaty.

BACKGROUND: The role of cytokines in trauma still has not been satisfactorily elucidated. Multiorgan failure (MOF) development should be also under the direction of cytokines, endotoxin, and other mediators. METHODS AND RESULTS: Therefore we prospectively studied 88 patients with multiple trauma admitted to Traumatological Hospital Brno from June 1, 1992 to May 31, 1993. Extent of the trauma was determined by Injury Severity Score (ISS), Revised Trauma Score (RTS), and TRISS methodology with probability of survival. In study patients was investigated concentrations of interleukin 1, 2, 6, and tumor necrosis factor (TNF). Of above mentioned cytokines were elevated only IL-6 levels at admission and significant correlation with ISS was found (r = 0.32; p < 0.01). MOF developed in 23 patients (12 of them died), but it was not possible to predict the MOF development nor surviving according to admission levels of cytokines. A significant difference was observed in IL-6 levels of MOF patients one day before death (439 +/- 111 ng/l) in comparison with MOF patients, who survived (132 +/- 88 ng/l, p < 0.001). None of 12 MOF patients with IL-6 concentrations above 400 ng/l survived. CONCLUSIONS: We conclude that IL-6, less TNF, seems to play an important role in organism response to multiple trauma, and later elevation in these cytokines levels, especially IL-6 level, in MOF patients mean poor prognosis. We had found a significant correlation between initial IL-6 level and ISS. Other cytokines did not show changes during the study.

[Serum levels of cytokines as a measure of response to stress after various types of elective gallbladder surgery]. / Sérové hladiny cytokinu jako merítko odpovedi organismu na zátez po elektivních operacích zlucníku ruzného typu.

The authors investigated the cytokine levels in patients after laparoscopic cholecystectomy (LCHE), conventional open cholecystectomy (OCHE) and complicated open cholecystectomy (KOMPL) in order to assess whether there is a relationship between cytokine levels and the general reaction of the organism, the type and extent of the operation. They did not find an increase of IL-1 or IL-2 levels in any of the patient groups. The IL-6 concentration was slightly raised only in three patients of the OCHE group three hours after surgery and this rise persisted for 24 hours. In the KOMPL group there was a more marked rise of IL-6 in 9 patients within 3 hours after surgery, persisting in 6 patients for 24 hours and in 2 patients for 48 hours. The TNF values were similar; in group OCHE they were slightly elevated in 2 patients 24 hours after operation. In the KOMPL group these values were elevated in 5 patients for 3 hours after surgery and this increase persisted in 2 for 24 hours after surgery. Based on the investigation of cytokine levels, which is a recent indicator for evaluating the reaction of the organism to stress, conclude that laparoscopic cholecystectomy is a minimal stress for the patient and is associated with a zero defence reaction of the organism, if evaluated according to serum cytokine concentrations.