[Endoscopic retrograde cholangiography with a single-balloon enteroscope in patients with Roux-en-Y hepatico jejunal anastomosis]. / Endoskopická retrográdní cholangiografie pomocí jednobalónkového enteroskopu u pacientu s Roux-Y hepatikojejunoanastomózou.

AIMS OF THE STUDY: The aim of this retrospective study was to evaluate our experience with using a single-balloon enetroscope for diagnostic and therapeutic endoscopic retrograde cholangiography (ERC) in patients with Roux-en-Y hepatico jejunal anastomosis (HJA). Due to the considerably changed anatomic circumstances after the surgery, ERC is, in comparison to the standard endoscopic retrograde cholangiopancraeaticography (ERCP), significantly more difficult to perform. PATIENT SAMPLE AND METHODOLOGY: The sample was followed up from January 2009 to September 2011. The study retrospectively reviewed 14 patients with Roux-en-Y HJA with symptoms of biliary obstruction. A total of 21 ERCs were performed in these 14 Roux-en-Y HJA patients using the single-balloon videoenetroscope Olympus SIF Q 180. RESULTS: Diagnostic ERC cannulation was successful in 11 of the 14 patients (79% success rate for the diagnostic ERC). One of the 11 patients had a normal finding on the ERC. The remaining 10 patients had a pathological finding on ERC that, in one patient (cystic dilatation of bile duct), was subsequently managed surgically. Endoscopic treatment was initiated in the remaining 9 patients (HJA stenosis in 4, choledocholithiasis in 2 and concurrent HJA stenosis and choledocholithiasis in 3) immediately after the diagnostic ERC; the surgery was successful in 8 of the 9 patients (89% success rate for the therapeutic ERC). The performed endoscopic therapeutic procedures included: balloon dilatation of HJA stenosis 9 times (6 patients), choledocholithiasis extraction - 5 times (5 patients), biliary plastic stent placement - 5 times (3 patients), removal of biliary stents placed by us - 5 times (3 patients). We did not observe any complications in our sample of 14 patients. CONCLUSIONS: ERC using a single-balloon enteroscope in patients with Roux-Y HJA is significantly more difficult than the standard ERCP due to different post-surgical anatomy. In our sample of patients, we achieved 79% success rate for the diagnostic ERC and 89% success rate for the therapeutic ERC. Additional time should be allowed for the individual procedures. Furthermore, the presence of an anaesthesiologist during these operations (deep analgosedation) is essential. This is a technically very demanding technique that, however, is effective and safe and importantly extends the options available for the management of biliary pathologies in these patients.

[Buried bumper syndrome (BBS) as a complication of percutaneous endoscopic gastrostomy]. / Buried bumper syndrom (BBS) jako komplikace perkutánní endoskopické gastrostomie.

"Buried bumper syndrome" is a less frequent but potentially serious complication of percutaneous endoscopic gastrostomy. We present case reports of two patients in whom buried bumper syndrome was diagnosed by means of X-ray examination and endoscopic examination. In both cases the original gastrostomy was surgically removed and classical gastrostomy was performed.

[Rare tumors of the gallbladder and bile ducts. A case review]. / Vzácné tumory zlucníku a zlucových cest. Kazuistika.

The authors deal with the problem of benigh tumours of the bile duct which might occur as a very suprising intraoperative finding instead of preoperatively diagnosed "gallstones". This situation can happen because of possible mistakes that might accompany today's modern practical investigative techniques. The presented report is an example of the pre-operatirely assumed choledocholithiasis which was not confirmed during the operation. Instead a rare bile duct tumour was found.

[Endoscopic diagnostics and management of pancreatic-biliary disorders in patients after Billroth II gastric resection]. / Endoskopická diagnostika a lécba pankreatobilárních onemocnení u pacientu po resekci zaludku podle Billrotha II.

AIMS OF THE STUDY: The aim of this retrospective study was to analyse diagnostic and therapeutic success of endoscopic retrograde cholangiopancreatography (ERCP) in our sample of patients following Billroth II gastric resection, where, due to significantly modified anatomic ratios, this surgery represents a specific and often extremely difficult technical problem when performing ERCP. MATERIALS AND METHODOLOGY: The sample was followed up for 13 years (November 1994-December 2007). The data on 112 patients after Billroth II gastric resection were assessed retrospectively; indications for ERCP included cholestasis in 92 patients, acute biliary pancreatitis in 12 patients, acute cholangitis in 6 patients and suspected bile leak following laparoscopic cholecystectomy (LCE) in 2 patients. RESULTS: Cannulation success during ERCP in the 112 patients following Billroth II gastric resection was 90.2% (i.e. 101 of the 112 patients). Normal ERCP finding was recorded in 4 patients. The remaining 97 patients had pathological results on ERCP (choledocholitiasis was found in 78 patients, malignant biliary stenosis in 14, benign biliary stenosis in 3 a bile leak following LCE in 2). Endoscopic treatment was initiated immediately after diagnostic ERCP in all these 97 patients, the initial step was in all cases endoscopic papillotomy using one of the special papillotomes (diathermy wire). Overall, therapeutic ERCP was completely successful in 83 of the 97 patients (85.6% of 97) in whom the originally endoscopic treatment had been initiated. CONCLUSIONS: ERCP following Billroth II gastric resection is, due to modified post-surgery anatomy, markedly more challenging then the conventional procedure. Availability of a variety of tools as well as, understandably, extensive experience and skill of an endoscopist are prerequisite to ERCP success in these patients. Correctly performed ERCP in patients following Billroth II gastric resection is a highly effective and safe method for diagnostics and, in particular, treatment of pancreatic-biliary diseases, in which similar success as under standard anatomic conditions can be achieved.

[Treatment of vascular prosthesis infection and aorto-enteric fistula as a late complication after reconstructive surgery of the abdominal aorta--a case report]. / Lécba infekce cévní protézy a aorto-enterické pístele jako pozdní komplikace rekonstrukcního výkonu na abdominální aorte--kazuistika.

Vascular prosthesis infection is a serious diagnostic and therapeutic problem. Timely diagnosis and adequate treatment are essential for the patient's future condition. We present a case report of a 60-year-old man with aortobifemoral prosthesis infection and with an aortoduodenal fistula. The prosthesis infection was confirmed by fluorodeoxyglucose positron emission tomography. Urgent surgery was indicated due to massive gastrointestinal bleeding. Because of lower limb Ischaemia after removal of the infected bifurcation prosthesis, an implantation of an axillobifemoral bypass was performed in a one stage procedure. 8 months after the surgery, the patient is in good condition without walking limitation.

[Laparoscopic liver resection]. / Laparoskopická resekce jater.

Rapid development of liver surgery in the last 25 years results from introduction of new procedures entailing an increase in the number of operated patients, and simultaneously a reduction in risk of the surgery and subsequent postoperative morbidity and mortality. They include standard preoperative examination completed by new high-resolution diagnostic methods (duplex ultrasound, spiral CT, liver scintigraphy, PET) which can better reveal the pathological focus in relation to liver anatomy and largely contribute to the consideration of resecability of the liver affection . Standard resection technique is, in addition to the advantage of an anatomical resection, completed with modern technology which helps to reduce the blood loss and ischemic damage to the remaining liver parenchyma especially in non-anatomical resections. Nowadays, liver resections are performed by a combination of various techniques. One of them is a liver parenchyma resection using a harmonic scalpel in the classical surgical procedure. There are also mini-invasive laparoscopic operations, and recently robotic resections which can't be done without the harmonic scalpel. The authors present a case report of a 25-year-old woman who developed spastic pain in the epigastrium three years ago. Sonography, CT, MR, liver scintigraphy and, last but not least, diagnostic laparoscopy were used for accurate diagnostics. Diagnostic laparoscopy was performed in order to confirm the diagnosis, extent of surgery and especially the possibility of performing laparoscopic liver resection. This was carried out using the harmonic scalpel which is the method of choice especially in non-anatomical resection for better control of bleeding and safer isolation of bile ducts and vessels.

[Retromuscular mesh repair of a hernia in a scar according to Rives--our first experience]. / Retromuskulární plastika kýly v jizve podle Rivese--nase první zkusenosti.

The authors present a group of 24 patients with hernias in scars operated from February 2004 to January 2005 (12 months) using a retromuscular reconstruction procedure according to Rives. 20 procedure following central laparotomies and 4 procedures following lateral laparotomies were conducted. The defect sizes ranged from 5 to 16 cm. A polypropylene mesh was used which was placed between the rectus abdominis muscle and the posterior leaf of the rectus abdominis sheath. The mesh was covered by the fascia with a minimum overlap of 5 cm in all directions. The mean follow- up period was six months (1-12 months) and no early relapses were recorderd. The complications rate was acceptable--1x secondary wound healing, 2x seroma, 1x non-transmural MI in a patient with a cardiac ischemic disorder. The retromuscular reconstruction procedure according to Rives appears to be an appropriate method for management of large ventral hernias with excellent results and minimum complications.

[20-year experience in surgical treatment of popliteal aneurysm]. / 20 let zkuseností s operacemi pro aneuryzma podkolenní tepny.

We present our 20-year experience in surgical treatment of popliteal aneurysm in 67 patients. We conclude that popliteal aneurysms should be surgically treated as early as possible after its diagnosis, preferably before ischemic complications occur.

The laparoscopic ventral and incisional hernia repair.

We retrospectively reviewed the first twenty laparoscopic ventral and incisional hernia repairs performed at the 2nd Department of Surgery, St. Anne's Teaching Hospital, Brno from March 2003 till April 2004. Laparoscopic repairs were performed using Biomesh mesh (Cousin Biotech, France) with a minimum of 3 cm overlap circumferentially with normal fascia and secured with spiraltacks every 3-4 cm and transparietal sutures. All adhesions on the parietal defect are released, using scissors, and whenever possible we attempted to reduce the hernia sac. The mean follow-up period was 7 months with a range of 2 to 13 months. There was no recurrence in the group. There were two hematomas and one seroma in our group, which disappeared without treatment. Two patients experienced transient pain, which was resolved by analgesic treatment over time. By this date, no chronic infection, bowel obstruction, or enterocutaneous fistula have been reported. In conclusion our results are encouraging and suggest that laparoscopic ventral and incisional hernia repair is a safe, feasible, and effective alternative to open techniques. (Ref. 10.)

20-year experience with operations for popliteal artery aneurysm.

At the 2nd Department of Surgery, St. Anne's University hospital Brno, a total of 76 operations for popliteal artery aneurysm were performed in 67 patients in the last 20 years, in period 1985-2004. 63 operations were elective and 13 urgent. For reconstruction, autologous saphenous vein was used in 53 cases, vascular prosthesis in 15 cases, and a cryopreserved vein allograft in 3 cases. In 5 cases, amputation for advanced lower limb ischaemia was performed without arterial reconstruction. Elective operation is indicated in all patients with popliteal artery aneurysm, and it is associated with a relatively low risk for the patient. In fact, it is a preventive operation. In the acute stage, there is a higher risk of complications and (potential) amputation (Fig. 1, Ref. 8).

[The subclavian steal syndrome]. / Subclavian steal syndrom.

The aim of this work is to summarize the authors' experience gathered during surgical procedures for the subclavian steal syndrome. The authors put forward the method of anaesthesia with patient's vigility and mobility preserved, favouring the arterial transposition procedures against the prostheses implantation methods. The main common feature of the above approaches is to increase the procedure's safety.

20-year experience in operations for subclavian steal syndrome.

The aim of this article is to summarize our experience in operations for subclavian steal syndrome. We recommend anaesthesia with preservation of patient's consciousness and mobility, and we prefer transposition of arteries to prosthesis implantation. The main characteristic of this approaches is an attempt to increase safety of operation. A feasible procedure is suggested also in the case of reconstruction occlusion: the axillo-axillary bypass. (Fig. 6, Ref. 3.)

Patient with percutaneous endoscopic gastrostomy.

INTRODUCTION: Since 1980, when percutaneous endoscopic gastrostomy was described and performed for the first time, the number of patients with this way of nutrition has been growing. At present, however, these patients are treated not only in intensive care units, but also in follow-up care institutions or in home care. AIM: We want to explain the problems of nutrition via endoscopic gastrostomy to those physicians who take long-term care of these patients. METHODS: In our department we introduced percutaneous endoscopic gastrostomy in 1994. A total of 78 PEGs were performed. In all cases the pull technique was used. A condition for percutaneous endoscopic gastrostomy insertion was an unaffected gastrointestinal tract from the stomach in aboral direction. The most frequent indications were: necessity of long-term enteral nutrition in patients during artificial ventilation, neurological patients with lost swallowing reflex, and patients with a tumor in the ENT area with preserved patency for the endoscope. RESULTS: In all cases, the intervention itself was without major complications and no death occurred relating to the intervention. Subsequently, mainly local complications such as decubitus ulcers or maceration around the tube and its accidental removal by a restless patient were noticed. CONCLUSION: In cases of more than 6-week inability to ingest food per os with otherwise unaffected gastrointestinal tract, it is appropriate to consider the nutrition via PEG. Using this method, it is possible to ensure an adequate access for enteral nutrition for a longer time without risk of complications associated with the nasoenteric tube, with minimum trouble to the patient. (Fig. 1, Ref. 9.).

[Pseudoaneurysms due to iatrogenic arterial injuries--observations at a vascular surgery worksite]. / Pseudoaneuryzma po iatrogenním postizení tepny--poznatky z angiochirurgického pracoviste.

With advancing care of patients with cardiovascular diseases the number of invasive cardiological operations is increasing. Although effective methods are involved, these procedures are also associated with certain risks for the patient. From the aspect of vascular surgery the most frequent complications include iatrogenic pseudoaneurysms and extensive haematomas. The objective of the present work is to evaluate the development of the number of pseudoaneurysms which occurred after puncture of the femoral artery during coronarography or PTCA, and verification of the hypothesis of the declining trend of the ratio of pseudoaneurysms in the total number of performed invasive cardiological diagnostic and therapeutic operations. The author submits in his paper the retrospectively assessed number of invasive operations performed at the 1st Medical Cardioangiological Clinic of the St. Ann Faculty Hospital Brno in 1996-2001. It summarizes the number of PA dealt with during the same period by physicians of the 2nd Surgical Clinic of the St. Ann Hospital in Brno. It analyzes also the treated complications of cardiological operations in 2001.

[Endoscopic gastric polypectomy--personal experience]. / Endoskopická polypektomie zaludku--nase zkusenosti.

In the time period from August 1986 to August 2001, a total of 10,260 gastrofibroscopic examinations were performed in our department. Gastric polyps were found in 28 patients--in 15 men and 13 women. Polypoid foveolar hyperplasia was present in 67.8% patients, hyperplasiogenic polyps in 21.5%, and adenomatous polyps in 10.7% of patients. Multiple gastric polyposis was found in 3 patients: in two of them all polyps were removed and one patient has regular gastrofibroscopic checkups. We did not encounter complications after endoscopic polypectomy of the stomach in our study group. Polypectomy via gastrotomy was not performed in any of our patients.

[Ischemic disease of the lower extremity and lumbar sympathectomy]. / Ischemická choroba dolních koncetin a lumbální sympatektomie.

We consider lumbar sympathectomy (LSE) to be the last attempt to improve the condition of the limb. Though being aware of inconsistent opinions on LSE, we are not opponents of this method, particularly if it is carried out in a selected group of patients, that is in case of: 1) treatment of frostbites, 2) treatment of patients at an early stage of advanced ischemia whose main symptom is moderate night pain at rest, 3) desiccation of chronically moist ulcerations between the toes, 4) treatment of patients with reflex symptomatic dystrophy (causalgia), 5) Buerger's disease.

[Emergency ERCP and acute biliary pancreatitis]. / Urgentní ERCP a akutní biliární pankreatitida.

In the period from 1992 to 1997, a total of 130 urgent therapeutic ERCPs were performed at the 2nd Department of Surgery of the Faculty of Medicine in Brno. The examination was indicated because of acute pancreatitis, acute septic cholangitis, and papillary ileus. Fifty nine patients with proven acute biliary pancreatitis and successful endoscopic papillosphincterotomy were followed up subsequently. Information on 44 patients could be retrieved (75%). The results were evaluated and compared with a group of patients treated for acute biliary pancreatitis at the 2nd Department of Surgery in Brno before introduction of urgent therapeutic ERCPs. In addition to lower mortality, in the group of patients who underwent endoscopy a decrease in the percentage of surgical revisions needed was reached, and in the group with conservative treatment, statistically significant reduction of hospitalization was duration achieved. (Tab. 3, Fig. 1, Ref. 14.)

[100 emergency ERCPs performed at a surgery department]. / 100 urgentních ERCP na chirurgickém pracovisti.

Since the year 1989 the authors, surgeons, performed more then 1600 ERCP. In the period of 1992 to 1995 urgent ERCP was indicated in one hundred cases when block of papila Vateri, cholangitis or acute pancreatitis were suspected. Our results in ERCP were: cholangitis with common bile duct stones 14, pancreatitis acuta biliaris 53, pancreatitis acuta nonbiliiaris 28, other diagnosis 1. In 4 cases, ERCP was unsuccessful. Endoscopic papillosphincterotomy (EPS) was indicated in all patients after the successful ERCP with pancreatitis or cholagitis. We achieved success in urgent EPS in 92%. No patient died owing to ERCP or EPS. From our point of view urgent ERCP and EPS are important diagnostical and therapeutical methods in patients with cholangitis and pancreatitis biliaris which may be performed as soon as possible. (in our cases all patients undergo ERCP and EPS no later than six hours after their admission to the hospital). In case of nonbiliaris pancreatitis we prefer and have good results with EPS too, but our number of these patients is too small to be generalized. (Tab. 5, Ref. 13.).

[Initial experience with percutaneous endoscopic gastrostomy in a surgery department]. / První zkusenosti chirurgického pracoviste s perkutánní endoskopickou gastrostomií.

The authors present their initial experience with percutaneous endoscopic gastrostomy and draw attention to its advantages and risks. As a basis they use their own group of patients, most of them in a very poor condition where it proved possible to ensure by this method enteral nutrition on a long-term basis.

Our experience in the surgical treatment of liver tumors in the years 1994-1996.

The study is based on the evaluation of a study group consisting of 61 patients who underwent surgery for liver tumors in the 2nd Surgical Clinic in Brno between 1994 and 1996. Liver resections were carried out in 39 patients, port-systems for regional chemotherapy were implanted in 29 patients. In recent years, port-systems have been inserted even in liver resections in indicated cases. The median survival after liver resection for hepatocellular carcinoma was 43 months, for colorectal carcinoma metastases it was 32 months. The in-hospital mortality was 3.4%.