Delayed diagnosis of diaphragmatic rupture after blunt chest trauma - 2 case reports.

INTRODUCTION: Diaphragmatic rupture is a rare but life-threatening condition that occurs in 0.85% of surgically managed thoracoabdominal injuries. In most cases, the condition is accompanied by associated traumas responsible for poor prognosis. Signs of diaphragmatic rupture are often masked by more serious manifestations of the associated trauma. The rupture is usually revealed by an X-ray of the chest or CT scan. However, a minor defect may be missed, especially if the patient is not indicated for urgent surgery. METHODS: The authors present 2 case reports of patients treated for chronic diaphragmatic rupture at the Department of Surgery of the Faculty of Medicine, Charles University and University Hospital in Pilsen between 01 January 2009 and 31 December 2021. The aim was to analyze the clinical data and to compare this data with literature. RESULTS: Both patients with the chronic diaphragmatic rupture were men in their productive age. The mechanism of their primary trauma was a traffic accident. In the first case, the rupture was diagnosed 6 years after the trauma. The second case was diagnosed 14 years after the primary trauma. The diaphragmatic rupture was present on the left side in the first case and on the right in the other. Both patients underwent suture of the diaphragmatic defect via thoracotomy. CONCLUSION: Unrecognized diaphragmatic rupture is a severe condition that can result in a life-threatening complication, namely incarceration of abdominal organs dislocated to the chest. It is necessary to keep this diagnosis in mind in patients with gastrointestinal or respiratory problems after a previous high-energy, blunt-force abdominal and thoracic injury, even many years after the trauma.

Pleural empyema - single center experience.

INTRODUCTION: Retrospective analysis of a group of patients treated for pleural empyema in the Department of Surgery, University Hospital Pilsen, over the last ten years. METHOD: We evaluated a group of patients treated for pleural empyema in the Department of Surgery, University Hospital in Pilsen, during the period 2007-2016. We focused on the demographic data of this group, the causes of empyema in these patients, surgical procedures performed in connection with empyema, the microbial species found in empyema, and, last but not least, on morbidity and lethality. RESULTS: We treated 103 patients with pleural empyema during the above period - 80 men (77.7%) and 23 women (22.3%) aged 23-83 years (average age 59.4 years). 64 patients had a history of surgical or invasive procedure (62.1%). The length of history was traceable in 55 patients (53.4%) and was 23.1 days on average, remaining unclear in the rest of the group. 1/3 of cases were metapneumonic empyemas, 1/3 postoperative empyemas and 1/3 of the cases were due to other reasons. The most commonly cultivated bacterial genus was Streptococcus, species Staphylococcus aureus. The most common surgery was chest drainage (51%). 13 patients died (lethality 12.6%) after surgery, the most common cause of death being sepsis; postoperative morbidity was 34%. CONCLUSION: Pleural empyema is a serious condition with very high morbidity and lethality. Surgical procedures done to manage empyema are associated with a very high risk of necessary reoperation. Positive mycological culture from empyema seems to be associated with a higher risk of complications and death. Key words: empyema - thoracic drainage - thoracotomy - lung decortication - videothoracoscopy.

Can the One-Step Nucleic Acid Amplification method of lymph nodes examination make the staging of pulmonary tumours more precise?

INTRODUCTION: The aim of this article is to compare the sensitivity of detecting micrometastases in hilar and mediastinal lymph nodes in case of primary (non-small cell) and secondary (metastases of colorectal carcinoma) pulmonary tumours using standard histopathological examination with haematoxylin-eosin staining, immunohistochemistry examination with Anti-Cytokeratin 19 antibody and examination based on the One-Step Nucleic Acid Amplification method. METHOD: During radical surgical treatment of primary non-small cell lung carcinoma and pulmonary metastases of colorectal carcinoma, hilar and mediastinal lymph nodes of 100 patients enrolled in the study in the period from 2015 to 2017 were extracted based on a standard classification. These lymph nodes were subsequently divided along the longitudinal axis into 4 identical parts where part one and three on the left were intended for examination based on the One-Step Nucleic Acid Amplification method, whereas parts two and four were subjected to histopathological examination. In evaluating the respective parts of the nodes by histological examination, the nodes were first examined by a standard procedure that involves haematoxylin-eosin staining, followed by immunohistochemistry examination with Anti-Cytokeratin 19 antibody. The One-Step Nucleic Acid Amplification method was performed in the kit supplied by Sysmex (Kobe, Japan) and is based on the detection of cytokeratin 19 mRNA (messenger ribonucleic acid) by reverse transcription coupled with isothermal amplification. RESULTS: A total of 1,426 lymph nodes of the patients enrolled in the study were extracted and examined using the above mentioned methodology. In 78 patients (78%), identical results were obtained using haematoxylin-eosin staining, immunohistochemistry with Anti-Cytokeratin 19 and One-Step Nucleic Acid Amplification. Micrometastases in the lymph nodes using the One-Step Nucleic Acid Amplification method in the absence of the other methods were proven in 16 patients (16%). Only in 3 cases (3%), the examination by haematoxylin-eosin staining, or immunohistochemistry with Anti-Cytokeratin 19, was positive while One-Step Nucleic Acid Amplification was negative. The results obtained by immunohistochemistry with Anti-Cytokeratin 19 antibody were practically the same as those obtained by haematoxylin-eosin staining (97%). CONCLUSION: The results of the study have demonstrated a higher percentage of metastases detected in hilar and mediastinal lymph nodes if the One-Step Nucleic Acid Amplification method of examination was used compared to haematoxylin-eosin staining and immunohistochemistry with Anti-Cytokeratin 19 antibody (upstaging in 16%). This shows that the examination of lymph nodes using the One-Step Nucleic Acid Amplification method can have a certain potential to make the pulmonary tumours staging more accurate. On the other hand, immunohistochemistry with Anti-Cytokeratin 19 antibody seems to be not so useful. However, it is necessary to prove this hypothesis in follow-up studies, or where applicable, in a larger cohort of patients. Another task is to ascertain, by careful patient monitoring, the influence of the micrometastases detected in their lymph nodes using the One-Step Nucleic Acid Amplification method on these patients' follow-up. Key words: lung cancer - lymph nodes - H&E - IHC CK19 - OSNA assay.

[Traumatic pneumothorax - diagnosis and treatment of 322 cases over a five-year period]. / Traumatický pneumotorax - diagnostika a lécba 322 prípadu v petiletém období.

INTRODUCTION: Retrospective analysis of a set of patients treated for traumatic pneumothorax in the Trauma Centre of Teaching Hospital in Pilsen over a period of five years. METHOD: In total, 322 patients with traumatic pneumothorax were treated in the study period 20122016. The set included subjects whose injury fell within the definition of traumatic pneumothorax and who underwent either primary treatment or secondary transport to the Trauma Centre following basic treatment in another health facility on the day that the trauma occurred. The exclusion criterion was a pneumothorax <1 cm; in addition, patients with inconclusive findings from imaging screening were not included in the set. Basic demographic information, the mechanism, type and laterality of the traumatic pneumothorax, the Injury Severity Score, associated injuries, diagnostic procedures, timing, method and outcome of the treatment, as well as any complications and reoperations, were identified in the set. Other assessed information included deaths of patients with traumatic pneumothorax, including the cause and time of death in relation to the time of admission to the Trauma Centre. RESULTS: The vast majority of traumatic pneumothoraces (94.1%) occurred as a result of blunt chest trauma, car accidents being the most common mechanism (about 28%). Closed pneumothoraces dominated (91.3%). Traumatic pneumothorax was part of a polytrauma in about one half of the injured. The average Injury Severity Score within the set was 20 points. Traumatic pneumothorax was diagnosed in more than three quarters of the patients based on clinical examination and computed tomography. The most common therapeutic procedure was drainage of the relevant pleural cavity (259 patients - 80.5%). Almost two thirds of surgical procedures were carried out within 1 hour of admission to the Trauma Centre. Complications associated with traumatic pneumothorax treatment were reported in 10.2% of the cases, and 33 reoperations were carried out. 15 patients (4.7%) in the set died, out of which 12 on the day of the trauma, all of them as a result of decompensated traumatic shock. CONCLUSION: Traumatic pneumothorax is a relatively frequent type of chest trauma found in up to half of the patients with chest trauma as part of a polytrauma. It usually occurs as closed pneumothorax as a result of blunt chest trauma. The diagnostic process is based on clinical examination and chest radiogram. However, ultrasound examination could be an alternative to chest radiogram in emergency situations. Computed tomography is the method of first choice for more serious traumas and inconclusive findings. To manage this condition, proper drainage of the relevant pleural cavity is sufficient in the vast majority of the patients. With timely diagnosis and adequate therapeutic intervention, the prognosis for patients with traumatic pneumothorax is favourable.Key words: traumatic pneumothorax - diagnosis - chest drainage.

[Penetrating chest trauma - experience of the Pilsen University Hospital Trauma Centre]. / Penetrující poranení hrudníku - zkusenosti Traumacentra Fakultní nemocnice Plzen.

INTRODUCTION: Retrospective analysis of a set of patients treated for penetrating chest trauma in the Trauma Centre at University Hospital Pilsen over seventeen years. METHOD: Overall, 96 injured with penetrating chest trauma were treated in the study period 2000-2016. Basic demographics, the mechanism, type, location and extent of the penetrating chest trauma, Injury Severity Score, existence of associated injuries, diagnostic procedures, timing and method of the chest trauma treatment as well as any complications and reoperations were identified in the set. Other collected information included deaths of the injured, and the cause and time of death in relation to the time of admission to the Trauma Centre. RESULTS: The most common mechanism of injury was attack by a stabbing weapon (54%) and the most common type of injury was pulmonary laceration (33%). The average Injury Severity Score within the set was 24 points. The most common therapeutic procedure was pleural cavity drainage (47 patients), and less than 40% of the cases required revision surgery by means of thoracotomy or sternotomy. One patient died immediately after being admitted to the Trauma Centre without a chance to apply any therapy; three other patients died during resuscitative thoracotomy or laparotomy. Post-operative complications occurred in 13 patients (13.5%) and required 14 reoperations. CONCLUSIONS: The diagnostic and therapeutic algorithm of penetrating chest trauma is primarily determined by the condition of the injured. Adequate drainage of the relevant pleural cavity is sufficient to treat one half of the patients; on the other hand, 40% of traumas, injuries of the heart, large vessels and gunshot wounds in particular, require urgent revision surgery by means of thoracotomy or sternotomy. If the injured patient is transported to a specialized centre for timely treatment, the prognosis of penetrating chest traumas is quite favourable.Key words: penetrating chest trauma - diagnosis - chest drainage - thoracotomy - sternotomy.

[Thyroid carcinoma, ten-years file]. / Karcinom stítné zlázy, desetiletý soubor.

INTRODUCTION: Even though thyroid carcinoma has, in general, a good prognosis and low mortality rate, its incidence, especially the incidence of early forms of the disease has been growing. METHOD: Retrospective analysis of the file of surgeries of documented thyroid carcinoma within the years of 2006-2015. RESULTS: Thyroid carcinoma was recorded in 145 of 1820 patients operated for thyreopathy (8%); microcarcinoma (<10mm) was recorded in 64 cases (44.1%). The carcinoma was mostly detected accidentally during total thyroidectomy, which was in 70 cases (48.3%). The carcinoma was expected in 35 cases (24.1%) on the basis of prior puncture and total thyroidectomy was carried out straight away. Perioperative histology after hemithyroidectomy was requested in 31 cases (21.4%), and it was found positive only in 13 cases; thyroidectomy was finished in the second period in the other cases. Due to advanced carcinoma, tumour exploration/debulking was performed in 3 cases (2.1%) - for anaplastic carcinoma in all these cases. A permanent unilateral lesion - n. laryngeus recurrens - occurred in 3 cases (2.1%); a permanent bilateral lesion was recorded twice (1.4%).The most frequently manifested carcinoma was the papillary carcinoma in 114 patients (78.6%; 83 women/31 men; age of 1284 years; mean age of 50.6), the second most frequent carcinoma was the follicular carcinoma in 16 patients (11.0%; 15/1; 1969; 55.3), followed by the medullary carcinoma in 10 patients (6.9%; 6/4; 2576; 58.1). Anaplastic carcinoma was detected only in 4 cases (2.8%; 2/2; 6487; 75.5), and lymphoma of the thyroid gland occurred twice as well as Hürtle cell carcinoma. CONCLUSION: Thyroid carcinoma is mostly found accidentally during surgery in the early phase of the disease. This proves the high quality of endocrinology care and the correctness of the tendency to indicate early surgical treatment of thyroidal pathology.Key words: thyroid carcinoma - thyroidectomy complications.

[Chest Injury and its Surgical Treatment in Polytrauma Patients. Five-Year Experience]. / Poranení hrudníku a jeho operacní lécba u polytraumatizovaných nemocných v petiletém období.

UNLABELLED: PURPOSE OF THE STUDY Thoracic trauma, one of the most frequent injuries in patients with multiple traumata, is found in 50 to 80% of these patients and it is crucial for the patient's prognosis. It accounts for 25% of all death from polytraumatic injuries. The aim of this retrospective study was an analysis of the occurrence of chest injuries in polytrauma patients and their surgical treatment in the Trauma Centre or Department of Surgery of the University Hospital Pilsen in a five-year period. MATERIAL AND METHODS Patients with injuries meeting the definition of polytrauma and an Injury Severity Score (ISS) ≥16 were included. The demographic characteristics, mechanism of multiple trauma, ISS value and chest injury were recorded in each patient. The number of injured patients in each year of the study was noted. In the patients with chest injury, the type of injury and method of treatment were assessed. The therapy was further analysed including its timing. The number of deaths due to polytrauma involving chest injury, the cause of death and its time in relation to the patient's admission to the Trauma Centre were evaluated. RESULTS In the period 2010-14, 513 polytrauma patients were treated; of them 371 (72.3%) were men with an average age of 40.5 years. The most frequent cause of injury was a traffic accident (74%). The average ISS of the whole group was 35 points. Chest injury was diagnosed in 469 patients (91.4%) of whom only five (1.1%) had penetrating injury. Pulmonary contusion was most frequent (314 patients; 67%). A total of 212 patients with chest injury underwent surgery (45.2%); urgent surgery was performed in 143 (67.5%), acute surgery in 49 (23.1%) and delayed surgery in 63 (29.7%) patients. Chest drainage was the major surgical procedure used in the whole group. Of 61 patients who died, 52 had chest injury. In this subgroup the most frequent cause of death was decompensated traumatic shock (26 patients; 50%). In the whole group, 32 polytrauma patients died within 24 hours of injury (61.5%). CONCLUSIONS Chest injury, almost always blunt, is often diagnosed in polytrauma patients. A prevalent cause of multiple trauma is a traffic accident. Chest injury most frequently involves pulmonary contusion. Nearly half of chest injuries require surgery, of which 2/3 are urgent procedures. The procedure most frequently performed in polytrauma patients with chest injury is chest drainage and this is also a sufficient procedure in 75% of surgically treated patients. KEY WORDS: polytrauma, chest injury, pulmonary contusion, surgical treatment, chest drainage.

[Pulmonary metastases - 12-year experience with surgical therapy]. / Plicní metastázy - dvanáctileté zkusenosti s chirurgickou lécbou.

INTRODUCTION: Nowadays, radical surgical therapy of selected secondary pulmonary tumours is a generally accepted therapeutic procedure that has been proven to extend long-term survival of the patients with acceptable perioperative morbidity and mortality. The authors present a retrospective analysis of a set of patients who underwent surgery for pulmonary metastases of various tumours in a 12-year period. MATERIAL AND METHODS: In 2001-2012, 159 patients with secondary pulmonary tumours were operated on at the authors department, of whom 80 were men; the median age was 65 years. Solitary metastases were present in 112 patients (70.4%); the other patients had multiple metastases; 24 patients (15.1 %) suffered from bilateral involvement, and 6 patients (3.8%) suffered from relapsed metastatic disease after previous radical surgery. Colorectal carcinoma metastases were diagnosed in most cases (75 people - 47.2%). The median disease-free period from the surgery of the primary tumour was 27 months in the patient set. RESULTS: In total, 166 unilateral (87.4%) and 24 bilateral surgeries were performed using one- or two-stage procedure (12.6%). Precise laser excisions represented the most common type of surgery (59 procedures - 31.1%). In total, 296 metastases were radically resected, and 13 were treated using radiofrequency ablation. Perioperative morbidity was 13.2% with a zero lethality rate. 90 operated patients (56.6%) still survive after the metastasectomy, with median survival of 44 months. The overall 3-year survival in the set was 59%, and 5-year survival was 39%. The number of metastases is a statistically significant factor affecting survival in the patient cohort with colorectal carcinoma metastases, the risk of death being 2.7 times higher in patients with 2 and more colorectal carcinoma metastases. 68 patients (42.8%) live without progression of the disease after the metastasectomy, with the median disease-free interval of 29 months. In total, 43% of the patients were free of any signs of relapse or disease progression for 3 years, and 27% for 5 years. The risk of disease progression is 2.1 times higher in patients with 2 and more metastases of any tumour, and for colorectal carcinoma this risk is 2.3 times higher. CONCLUSION: The achieved results confirm the positive role of pulmonary metastasectomy in disseminated tumour therapy. The number of metastases is the decisive prognostic factor affecting both long-term survival of operated patients and their DFI.

[Liver and pulmonary metastases of the colorectal carcinoma - the experience of the Department of Surgery, University Hospital in Pilsen]. / Jaterní a plicní metastázy kolorektálního karcinomu - zkusenosti Chirurgické kliniky FN v Plzni.

INTRODUCTION: Liver and pulmonary metastases of the colorectal carcinoma develop in about 20-70%, resp. in 10-22% patients with the colorectal carcinoma. Their treatment is still a matter of discussion. The aim of our study was to evaluate the results of surgical treatment as a part of the multimodal approach. MATERIAL AND METHODS: 30 patients with liver and pulmonary colorectal metastases were operated on between 2002 and 4/2013. The average age was 62.8 ± 10.7 years. 19 patients had metachronous and 11 synchronous metastases. The liver metastases preceded pulmonary in 14 cases, and vice versa in 5 patients. Both types of metastases developed in seven patients simultaneously. Liver resection was performed in 23, radiofrequency ablation (RFA) in 7 patients. Laser pulmonary metastasectomy was performed in 15, pulmonary resection in 14 and RFA in one patient. The liver procedure preceded pulmonary in 25 patients. 73.3% patients had adjuvant oncological treatment. RESULTS: 30 days mortality rate was 3.3% (N=1) for the actinomycotic sepsis complicated with MRSA infection. Morbidity rate was 10%. Recurrence of liver metastases developed in 6 patients. RFA was performed in all patients. The median of overall and disease free survival was 6.9, resp. 1.1 years. CONCLUSION: Surgical treatment as a part of the multimodal treatment is the only radical treatment for patients with liver and pulmonary metastases. It offers good long-term results.

[Mediastinitis after esophageal perforation]. / Mediastinitida po perforaci jícnu.

INTRODUCTION: Assessment of therapy in patients with mediastinal infection resulting from esophageal perforation. MATERIAL AND METHODS: Retrospective (2008-2012) processing of a group of surgically treated patients. The aspects assessed were aetiology, the surgical methods applied and the length of therapy. RESULTS: The total number of patients treated was 16. In 8 cases, the aetiology was iatrogenic (3 cases of leaking esophageal anastomosis in consequence of resection of the esophagus, 2 cases of perforation after fundoplication, 1 case of esophageal cardiomyotomy, and 2 cases of perforation during endoscopy). In 4 patients, the aetiology was spontaneous perforation, impacted foreign bodies caused difficulties to 3 patients, and the last cause was acid corrosive esophagitis. A stent was applied in all the patients at the site of the defect. The mediastinitis was drained through the access from thoracotomy or left thoracolaparotomy, respectively (8 cases), or by combination of laparotomy/laparostomy and pleural drainage (5 cases). Pleural (in 3 cases) and neck (1 case) drainage meant minimum intervention. Esophagectomy was not carried out in any of the patients. 4 patients died. The average period of time for which the stent was left in situ was 53.7 days; the average time of hospitalization in surviving patients was 53.4 days. CONCLUSION: Stent application does not show any difference regarding patients' survival (25% mortality), but enables shortening the total therapy time and, predominantly, preserving the native esophagus.

Surgical therapy of pulmonary metastases - 10-year results.

INTRODUCTION: The surgical therapy of selected secondary pulmonary tumors, including both solitary and multiple or bilateral tumours, is currently a generally accepted therapeutic procedure demonstrably extending the long term survival of these patients. PURPOSE: The purpose of the present study is a ten-year retrospective analysis of a group of patients who underwent surgery due to pulmonary metastases of various primary tumors. METHODS: In 2000-2009, 87 patients (of which 44 were male with a median age of 64 years) with secondary pulmonary tumors underwent surgery at the departments of the authors of this study. Solitary metastases were found in 60 patients, multiple metastases in the remaining patients, while 13 patients had bilateral metastases. The median disease-free period from surgery of the primary tumor was 31 months. RESULTS: In total, 74 unilateral and 13 bilateral surgeries were performed in one or two periods. The most common type of surgery included anatomical pulmonary resections (32 procedures), wedge resections (29 procedures) and laser excisions (24 procedures). In total, the radical resection was performed in 156 metastases. Post-operative morbidity was 17.2 % with zero mortality. A proportion of 50.6 % of operated patients survived after resection of metastases with median survival of 39 months. The overall three-year and five-year survivals in the group were 57 % and 38 %, respectively. A proportion of 35.6 % of patients live after resection of metastases without disease progression, and the median is 15 months. CONCLUSION: The achieved results confirm the positive role of pulmonary metastasectomy in the therapy of disseminated cancer disease (Tab. 1, Fig. 5, Ref. 34).

[Catamenial pneumothorax - case studies from our department in a ten-year period]. / Katameniální pneumotorax - kazuistiky z vlastního pracoviste v období 10 let.

Catamenial pneumothorax is defined as spontaneous pneumothorax in women of reproductive age occurring in conjunction with the menstrual cycle. The authors present 4 cases of this condition treated in our department during the past ten years. The causes leading to the development of this condition and optimal treatment procedures are also discussed.

[Descending necrotising mediastinitis - surgical management]. / Descendentní nekrotizující mediastinitida - chirurgická lécba.

INTRODUCTION: Descending necrotising mediastinitis (DNM) is a less common form of infection in the mediastinum caused by downward spread from the cervical, oral and pharyngeal regions. MATERIAL AND METHODS: We retrospectively evaluate a group of patients who underwent surgical management of DNM at our department between 2007 and 2011. RESULTS: We operated on 7 patients (1 female, 6 males) with the mean age of 56.3 years. In 3 cases the infection was of odontogenic origin and in 4 cases of tonsillar origin. Except for one patient with permanent immunosuppression, after kidney transplantation, swab culture showed the original, inciting pathogen to be Streptococcus in all cases; as for anaerobic organisms it was mostly Fusobacterium. In all cases we performed external cervical drainage and mediastinal drainage through a cervical approach. In 3 cases it was necessary to perform mediastinal drainage through thoracotomy. Mean hospital stay was 45.7 days, 30-day mortality was zero. CONCLUSION: The results confirm a better prognosis of DNM compared to mediastinitis caused by oesophageal perforation or oesophageal surgery complication.

[Surgical therapy of pulmonary metastases of colorectal cancer--ten-year results]. / Chirurgická léba plicních metastáz kolorektálního karcinomu--desetileté výsledky.

INTRODUCTION: Nowadays, surgical therapy of pulmonary metastases of colorectal cancer is a generally accepted therapeutic approach that has been proven to extend long term patient survival with acceptable perioperative morbidity and mortality rates. The aim of the study is to retrospectively analyse a group of patients who underwent surgery for pulmonary metastases of colorectal cancer over a period of ten years. MATERIALS AND METHODS: From 2000 to 2009, 39 patients with pulmonary metastases of colorectal cancer underwent surgical therapy at the site of the authors, out of whom 21 were males (53.8%), with a mean age of 60.4 years. Out of the total, 24 patients (61.5%) presented with solitary metastases, multiple metastases were found in the remaining patients. 8 patients (20.5%) bileral affection was detected. 34 patients (87.2%) underwent adjuvant oncological therapy of a radically surgically curable primary tumor before metastasectomy and 6 patients (15.4%) underwent surgery for liver metastases. Five patients in the group (12.8%) had both pulmonary and secondary liver affections at the same time. The median disease-free period after the primary tumor surgery was 27 months in the whole group. RESULTS: In total, we performed 31 unilateral (79.5%) and 8 bilateral (20.5%) one- or two- step surgeries. The most common type of surgery included anatomical pulmonary resections (18 procedures), laser excisions (13 procedures) and wedge resections (9 procedures). In total, we performed 73 radical resections of metastases and 5 metastases were treated by radiofrequency ablation (RFA). Metastatic affection of hilar lymph nodes was found in three patients (7.7%). Perioperative morbidity reached 12.8%, mortality was zero, and two re-operations were required because of complications (5.1%). 53.8% of patients with metastasectomy are still alive, the median survival time is 38 months. The three-year survival rate is 52% and the five-year survival rate is 41% five years. Pre-operatively increased value of tissue polypeptid specific antigen (TPS) was the only statistically significant factor that had a negative impact on the overall survival. 30.7% of patients with metastasectomy show no disease progression, the median disease- free interval is 14 months. There is a statistically significant correlation between DFI (Disease Free Interval) following metastasectomy and the type of surgery and the lowest value of DFI was achieved with radiofrequency ablation. The risk of disease progression is 3.4-times higher in patients with two and more metastases of colorectal cancer up to 3.9-times higher in subjects with three and more metastases. CONCLUSION: The positive effect of pulmonary metastasectomy on the long-term survival is evident. However, careful selection of patients with individual evaluation of each single case is required. In particular, indication for metastasectomy should be carefuly considered in cases of multiple affection, which are associated with higher risk of disease progression. The essential requirement is to achieve complete resection of the pathological focus, with a maximum effort aimed at sparing healthy pulmonary tissue, which allows for potential necessary reoperations in case of the disease recurrence. Systematic mediastinal lymphadenectomy (SMLA) should be an integral part of any pulmonary metastasectomy.

[Penetrating laryngotracheal injury during a suicide attempt]. / Penetrierende laryngotracheale Verletzung beim Suizid.

The authors present a case of a 40-year-old man who intentionally stabbed himself several times in the trachea and larynx during a suicide attempt, and also inflicted other penetrating injuries of the stomach and liver upon himself. The preoperative examination using fiber-optic tracheoscopy and CT revealed only transection of the ligamentum cricothyroideum; the remaining two defects were discovered later, during the surgical revision. All three injuries were successfully treated with sutures, in one case using the transtracheal approach.

[Pulmonary metastases of the clear cell (conventional) renal cell carcinoma--options and results of surgical treatment]. / Moznosti a výsledky chirurgické lécby plicních metastáz svetlobunecného (konvencního) renálního karcinomu.

BACKGROUNDS: At the diagnosis, up to one third of patients with clear cell (conventional) renal cell carcinoma have metastases, and the disease will progress in a half of patients with localized disease; the lungs are the most frequently affected organ. Despite clear advances in targeted biological treatment, radical surgery of organ, mainly pulmonary, metastases is a justified treatment approach with good results. AIM: A nine-year retrospective analysis of patients with clear cell renal cell carcinoma undergoing surgical treatment of pulmonary metastases. MATERIALS AND METHODS: At our centre, 13 patients with the mean age of 65 years, 9 of which were men, underwent surgical treatment between 2001 and 2009. Surgery was only indicated in patients after renal tumour resection without extrapulmonary metastases in whom presurgical assessment suggested that the pulmonary metastases were resectable (with respect to their number and location) and in whom the benefits of performing the surgery outweighed any potential risks. Metastases were solitary in 9 patients and multiple in the rest, 2 patients had bilateral involvement. Median disease-free interval following nephrectomy was 28 months. RESULTS: A total of 11 unilateral and 2 bilateral resections were performed during one or two surgical operations. Most frequently, wedge resection was performed (7 patients). A total of 23 metastases were resected. Perisurgical morbidity was 15.4%, zero mortality. Of those undergoing metastasectomy, 53.8% are still surviving with a median survival of 24.3 months. Three-year survival in the sample was 66%, 5-year survival was 53%. Five patients (38.5%) have had no disease progression for a median of 8.8 months. CONCLUSION: Our results confirm the positive role of metastasectomy in the treatment of pulmonary metastases of clear cell (conventional) renal cell carcinoma. Long-term survival after pulmonary metastasectomy might be expected in patients with solitary metachrone small metastases with DFI after nephrectomy > 1 year, without tumour involvement of the relevant lymph nodes and R0 resection.

[Mediastinal cysts, surgical management]. / Mediastinální cysty, chirurgické resení.

INTRODUCTION: Mediastinal cysts are common lesions, affecting children, as well as adults. They account for 20-30 % pathological mediastinal masses. The treatment is surgical, including extirpation, respectively enucleation of the cyst. AIM OF THE STUDY: Assessment of the author's patient group and overview of current literature data. MATERIAL AND METHODS: Retrospective analysis of a group of 11 patients (9 female and2 male subjects, the mean age was 47.6 years) indicated for scheduled procedures for mediastinal cysts from 2006 to 2010. RESULTS: Histological examination confirmed pericardial cysts in 7 subjects (63.6%), brochogenic cysts in 3 (27.3%) subjects and a thymic cyst in one subject (9.1%). The commonest location was anterior mediastinum - 7 subjects (63.6%), whereas upper mediastinum was the cyst site in 3 (27.3%) subjects and posterior mediastinum in 1 (9.1%) subject. Thoracotomy was indicated in 3 subjects, one subject was indicated for lung resection for carcinoma using thoracotomy and the pericardial cyst was a secondary known diagnosis, one patient was operated using sternotomy. 6 patients were indicated for videothoracoscopic (VTS) procedures and a decision to convert to thoracotomy was taken in 2 of these subjects. The patients were discharged from hospital 4-12 days after thoracotomy (the mean of 6.67 days), 3-4 days after VTS (the mean of 3.25 days), while the patient undergoing sternotomy was discharged on the postoperative Day 8. The mean size of the cysts removed using thoracotomy was 78 x 55 mm and the mean size of the cysts removed using VTS was 50 x 29 mm. CONCLUSION: The surgical technique for expected mediastinal cysts should be selected based on the cysts location, rather than on their size. The main objective is to indicate each mediastinal cyst for VTS (shorter duration of hospitalization) and eventual conversion to thoracotomy does not cause any delays or complications. Also asymptomatic cysts should be indicated for surgery.

[Surgical treatment of pulmonary carcinoids - ten-year results]. / Chirurgische Behandlung von Lungenkarzinoiden - Zehnjahresergebnisse.

INTRODUCTION: Carcinoids are malignant neuro-endocrine tumours occurring in the bronchopulmonary location in about 25 %, and accounting for approximately 2 % of all pulmonary tumours. MATERIAL AND METHODS: Our retrospective analysis included 27  patients, 14  men and 13  women, mean age 58.4  years, treated from 2000 to 2009 for carcinoids in bronchopulmonary locations. The tumour manifested clinically in 52 % of the cases, the most common symptom being cough; one tumour manifested as carcinoid syndrome. All patients underwent fibrobronchoscopy that was positive in 20  cases (74.1 %). Pre-surgery histological diagnoses were made in 13  patients (48.1 %). Chest CT scans were carried out in 26  patients, and the investigation failed to detect the expected pathological process in 2  of the patients. Octreoscans were carried out in 12  patients, and were successful in identifying a primary neuroendocrine tumour in 75 %. RESULTS: All patients in the sample underwent rad-ical surgical therapy; the most common surgical procedure was lobectomy (70.4 %). Perioperative morbidity and mortality were zero. Typical carcinoids were found in 20  cases while 7  cases were atypical carcinoids, 20  tumours were located centrally. 74 % of the tumours were consistent with stage  I A disease. Mean follow-up period was 47 (range: 6-134)  months. Local recurrences were observed in 2  patients (7.4 %), but the tumour disseminated in 4  patients (14.8 %). Two patients (7.4 %) died during the follow-up period. Overall five-year survival in the sample was 92.3 %, 90.9 % in the typical carcinoid group and 100 % for atypical carcinoids. We found a statistically significant association between disease-free interval and histological type of the tumour; the risk of progression was 8  times higher in -patients with atypical carcinoids compared to patients with typical carcinoids (Log-Rank-Test: p-value = 0.0049). CONCLUSION: Radical surgical treatment of bronchopulmonary carcinoids is the optimum therapeutic approach that results in the best results both regarding perioperative morbidity and mortality and regarding long-term survival of the patients.

[Pancreatic trauma]. / Poraneni slinivky brisní.

Injuries to the pancreas are relatively rare, occurring in around 10% of case involving serious trauma to the abdominal cavity, with 65% of such injuries resulting trauma occurs only exceptionally, involving only 5% of all injuries. The mortality of this entity is influenced by many factors, especially the age of the injured person, the seriousness of the injury, the duration of the shock, the potentially associated trauma, early diagnosis and correct selection of suitable treatment. The authors present here 4 case reports describing injuries to the pancreas and documenting the diagnostic and therapeutic approaches in cases of this very serious trauma.

[Surgical treatment of liver and pulmonary metastases of colorectal carcinoma]. / Chirurgickái lécba jaterních a plicních metastáz kolorektálního karcinomu.

THE AIM: The aim of the work was to evaluate the set of 10 patients, who were operated on hepatic and pulmonary metastases of colorectal carcinoma at the Surgical Clinic of Medical Faculty of Charles University and Faculty Hospital in Plzen in years from 2005 till 2009. With regard to limited experience with the patients who underwent hepatic as well as pulmonary resection, we focused on the evaluation of a long-term survival of the patients and their mortality and morbidity. THE SET OF THE PATIENTS: In years from 2005 till 12/2009 we operated 10 patients during whose affection there occurred hepatic and pulmonary metastases of colorectal carcinoma and these were solved surgically. This concerned 5 men and 5 women at an average age of 62.4 years (42-71 years). In 10% it was hepatic resection in the first period after the operation of primary carcinoma, it was the first performance on the hepatic parenchyma in 90%. THE RESULTS: Morbidity of the set was 20.1% regarding hepatic resections and 5.6% regarding pulmonary resections. A 30-day postoperative mortality was 0%. In three cases a hepatic involvement was bilateral, in two cases in the left lung and 5 patients had an involvement of the right pulmonary lobe. In 4 cases primary carcinoma was in the rectum and in 6 cases in the large intestine. The period of three months was an average time between hepatic and pulmonary resection. Resection on liver parenchyma was the most often performance and metastasectomy with the help of laser on the pulmonary parenchyma. Rectal carcinoma spread into lungs in 50%. An average time of a 5-year survival in the patients after resection of hepatic and pulmonary metastases of colorectal carcinoma was 26%. THE CONCLUSION: Hepatic and pulmonary resection in the selected patients with generalized colorectal carcinoma extends the period of a survival and does not worsen the quality of the life. The patients after resection of both--hepatic and pulmonary metastases have got a worse long-term survival than the patients being only after hepatic resections.