[The development of surgical treatment in liver and biliary tract diseases]. / Vývoj operativy onemocnení jater a zlucových cest.

INTRODUCTION: Surgical liver and biliary tract diseases remain to be among the most serious and the incidence of illnesses requiring surgical treatment has been increasing. It is therefore essential to consider the new possibilities of oncological and miniinvasive care, including ablation treatment, and to evaluate their importance and integration in the treatment system. MATERIAL AND METHODS: The article presents a retrospective analysis of three consecutive sets of patients from 1991-2011. Our monitoring focused primarily on bile duct lesions and on primary and secondary tumours of the liver. Assessments included the extent and method of the operation, neoadjuvant and adjuvant care, complications, lethality, and survival rate. RESULTS: Our study confirmed that the number of surgically treated secondary tumours (colorectal carcinoma metastases) rose by 9% as a result of downstaging (i.e., the combination of chemotherapy and oncological treatment or RFA) and the use of embolization via the portal vein and sequential resections. With no fundamental changes recorded in hepatocellular carcinoma treatment, resection or transplantation still appears to be the only curative treatment method. One-year survival is minimal without these procedures. We recorded a slight increase in the incidence of cholangiocarcinoma from 6 to 10.3%. The results of extrahepatic and hepatic form resections range from 0 to 90%, depending on the stage of the disease. Biliary duct lesions are treated more frequently at the time of laparoscopic surgery; they are diagnosed later or when stenosis has already developed, and hepaticojejunoanastomosis is the most widely applied procedure in treating the lesions. The authors indicate the ablation methods in hepatic and bile duct tumour treatment only when resection treatment is not possible. CONCLUSION: Surgical resection treatment in malignant diseases of the liver and biliary tract remains the primary treatment method with a high curative potential. Neoadjuvant combined treatment increases the eligibility of patients for such surgical procedures. In biliary tract lesions, we also regard the surgical approach as dominant. The overview of results for individual periods implies the necessity of interdisciplinary care in order to achieve better results in surgical management.

[Developments in pancreatic surgery at the 1st Surgical Department 1st Faculty of Medicine, Charles University and General University Hospital in Prague]. / Posuny v chirurgii pankreatu na I. chirurgické klinice 1. LF UK a VFN.

INTRODUCTION: Surgical treatment of pancreatic diseases has been going through certain changes and developments. This article aims to describe the changes in diagnosis and treatment that have occurred over the years. MATERIAL AND METHODS: Groups of patients from three different periods (1954-1999, 2002-2006 and 2007-2011), all of them having undergone elective follow-up for the diagnosis of acute or chronic pancreatitis (AP, CHP), pancreas and papilla tumours, terminal choledochus, and other less common tumours in this region, are described. Monitoring has focused on the indication criteria, the extent and method of the surgical procedure, perioperative lethality and morbidity, including complications, and also survival rate. RESULTS: In AP patients we recorded a significant drop in indications to surgery (38% vs. 16%), a shift in intervention time from 8.9 to 22.5 days, a decrease in lethality by 24%, or, as the case may be, by 3.5% (yet 7.9% during the first three months). The results show the domination of open abdominal procedures and a rising number of non-interventions. In CHP patients we detected a 30% increase in the number of resection procedures /Whipple/, a slight increase in drainage procedures (by 6%), and a decrease in drainage-resection procedures. The overall drop in the number of procedures in CHP patients probably relates to endoscopic and miniinvasive treatment. In pancreatic tumours we found domination of adenocarcinoma (92.6%), but also an increase in the number of cystic and endocrine tumours (2.6% and 4.8%) as a result of diagnostics and centralisation of care. We also recorded a decrease in exploratory laparotomy cases to 12%. In patients with resectable tumours we performed hemipancreatoduodenectomy in 90%, posterior approach in 2%, and vascular resection in only 4%. Perioperative lethality stagnates around 2.8%. Median survival rate has remained unchanged, as has long-term survival rate. CONCLUSION: Although treatment in general has not recorded any revolutionary and fundamental benefits, its surgical modality still represents the principal treatment and can be considered curative, even in tumours. Pancreatic diseases remain to be seen as a multidisciplinary issue and must be approached and dealt with as such, optimally in large-volume centres.

[Treatment outcomes in patients with toxic megacolon]. / Výsledky lécby nemocných s toxickým megakolon.

BACKGROUND: The aim of the study was to analyze data of patients threated by surgical intervention for toxic megacolon in period from 2005 till 2009 on 1st. dept. of Surgery of 1st. Faculty of Medicine, Charles University in Prague. Pre-disponding illness of toxic megacolon was studied intimately and evaluation of postoperative course especially for morbidity and letality was estimated. PATIENTS AND METHODS: Composit retrospective and prospective analysis of patients that underwent operation for diagnose of toxic megacolon. 19 patients were involved in the study and the method of surgical treatment was subtotal colectomy with formation of terminal ileostomy and rectal occlusion in macroscopically disease-free rectal segment in every case. RESULTS: Determined collection involved 19 patients, 13 male and 6 female patients with mean age of 51 years. The most frequent reason for toxic megacolon occurrence was ulcerative colitis (36.8%, 7 patients), then pseudomembranous colitis (26.3%, 5 patients) and ischemic colitis (15.8%, 3 patients). The method of surgical treatment was subtotal colectomy with formation of terminal ileostomy and rectal occlusion in macroscopically disease-free rectal segment in every case.

[Leiomyosarcoma of the inferior vena cava (case report)]. / Leiomyosarkom steny dolní duté zízzly (kazuistika).

The occur of resecable retroperitoneal tumours invading into inferiér vena cava is rare. The authors report in detail a case of fibrosarcoma of the inferior vena cava In article is presented case of 49-year-old female presented with echographic and computed tomographic evidence of solid formation below porta hepatis and ower head of pankreas, behinde duodenum, growed into inferior vena cava with trombus. Treatment of the abdominal and retroperitoneal tumours closely related to major blood vessels must be interdisciplinary, considering diagnostics, operability estimation and additional measures. The radical resection rate for involving important vesel may bee improved with vascular technique.

[Diagnostics and treatment of organic hyperinsulinism--experience in 105 cases]. / Diagnostika a lécba organického hyperinzulinismu--zkusenosti u 105 pacientu.

BACKGROUND: Organic hyperinsulinism causes hypoglycaemia manifesting mainly in the fasting state. We summarize our experience with diagnosis and treatment of 105 patients with organic hyperinsulinism. METHODS AND RESULTS: The diagnosis was confirmed in all patients by spontaneous hypoglycemia and neuroglycopenic symptoms, both developed during fasting test. Endoscopic ultrasonography was the most reliable method for the insulinoma localization (77% of insulinomas confirmed by surgery in the same location within the pancreas), less positive results were obtained by digital subtraction angiography (29%) and still less was found by computed tomography (18%). The localization remains unclear in about 20-25% of insulinomas despite of combined different exploring techniques. Surgical removal of insulinoma by enucleation is the best way of treatment, in some cases laparoscopic removal is a method of choice. From total number of 95 surgically treated patients the successful removal of insulinoma was performed in 84 patients (88%) and another 3 had histopathology diagnosis of micronodular polyadenomatosis. CONCLUSIONS: Insulinoma was not found during surgery and subsequent thorough histopathology investigation of the whole resecate in 8 patients which have to be treated like other non-surgically treated patients by diazoxide together with diabetic diet.

[Fulminant acute pancreatitis]. / Fulminantni akutní pankreatitida.

INTRODUCTION: Fulminant acute (FAP) and subfulminant pancreatitis (SFAP) represent the latterly defined subgroup within the severe acute pancreatitis (SAP) with rapidly progressing organ failure (OF) and multi-organ failure MOF high level of lethality and poor effect of both conservative and surgical treatment. AIM AND METHODS: Analysis of indigenous set of patients diagnosed with SAP, particularly with FAP and SFAP, and comparison of data with the literature. Retrospectively prospective study of data collected over the period 2003 to 2007. RESULTS: Mild form of AP (MAP) 128 p., etiology %: biliary/alcohol/other - 52/36/12; SAP 106 p., etiology %: biliary/alcohol/other - 51/41/9; ESAP 21 p. i.e. 20% of SAP, aetiology %: biliary/alcohol/other - 3/27/39. Age: MAP/SAP/ESAP - 43.2/45.8/46.1. Lethality %: MAP/SAP/ESAP: 0/19/71.5% (i.e. 78.5% of all deaths of TAP. ESAP 21 p., FAP 6 p., SFAP 15 p. FAP/SFAP: M/F 3/3 or 11/4, age 44.5 (17-81) or 46.8 (25-73). FAP etiology: 1x biliary, 1x alcohol, 4x?; SFAP: 6x biliary, 5x alcohol, 4x?. FAP: 4x severe hypercholesterolemia or hypertriglyceridemia, SFAP dtto 3x. FAP lethality: 83%, SFAP: 67%. Mean survival rate: FAP 4.1 d., SAP 9.2 d. FAP treatment: conservative 3 p., surgical 3 p., hemoelimination 2 p. SFAP treatment: conservative 9 p., surgical 6 p (reoperated 92% of all surgically treated, 7x on average), hemoelimination 8 p. DISCUSSION: Mortality prediction especially in FAP and SAP--progression and early occurrence of organ failure and its dynamics, existence of organ failure at the time of patient's admission and its rapid deterioration. Action of age, comorbidity and aetiology: insufficient data for meta-analysis; difference between ESAP and LAP has no statistic importance. Indigenous set of patients proves incidence, progression and lethality in FAP and SFAP, demonstrates higher incidence of hyperlididemia and hypercholesterolemia in FAP (60%) compared to SFAP with far more frequent biliary or alcohol aetiology. Among FAP, SAP and LSAP no age-dependent differences were proved. Absolute dominance of organ failure symptoms, suspicion to infected necrosis rather rarely expressed. Differences in prognosis in relation to applied treatment--either conservative or surgical (FAP surgery 50%, SFAP surgery 60%) were not observed. In section severe destructive findings in pancreas and its vicinity as well as extensive organ lesions were observed. CONCLUSION: Our own results are in concord with the results of other studies. It appears pretty useful to search for further ESAP predicting factors within meta-analytical studies. Intensive resuscitation care since the admission is a necessity, despite that, particularly in FAP, the results are unfavourable; surgical treatment has higher impact in SFAP than in AP, where often is ultimum refugium only.

[Serious complications following simple appendectomy]. / Závazné komplikace po prosté apendektomii.

Fulminant phlegmone of the abdominal wall is a very rare, however feared and severe complication, which may develop following open, as well as laparoscopic appendectomies. Most studies and the common opinion consider the open procedures to be of a greater risk of early infectious complications, while the laparoscopic procedures, compared to the open surgeries, show increased rates of intraabdominal complications. Based on their own studies, the authors came to similar conclusions. On their opinion, the different appendix stump management techniques in the both procedure variations (open x laparoscopic) have an important and sometimes underrated impact on the outcome. The above may explain such treatment failures, occassionaly with even fatal outcomes. Such deaths are viewed on particularly negatively by the involved lay public.

[Laparoscopic surgery in senior age]. / Laparoskopická chirurgie ve vysokém veku.

BACKGROUND: Surgery in the senior age has specific problems. Today many more people over 65 years need surgery in context with increasing age of the population. Development and practice of miniinvasive surgery allows performing operations also in elderly patients. The effect of insufflations of carbon dioxide and operation position of patients ware examined, namely at this group of risk patients. METHOD AND RESULTS: Analysis of literary reports and own experiences to define possibilities and limits of laparoscopic surgery (LS) in senior age. Negative influence of capnoperitoneum is manifested by alteration of blood circulation, but almost all old people tolerate it well. Only old patients with severe cardiopulmonary decompensation are not eligible for LS. Diagnostic LS manages to find the reason of right half abdomen symptoms in 90% cases. LS cholecystectomy is gold standard for treatment symptomatic cholecystolithiasis. Acute and elective LS are associated with the lower perioperative morbidity in comparison with open cholecystectomy. LS in the hiatus region has favourable long term results. Seniors have no limitation for intestine, colon, liver, spleen, stomach, and retroperitoneum LS. Disputable is LS in herniology. CONCLUSIONS: LS is a useful and safe diagnostic and therapeutic method in senior age.

[Infected brachial artery pseudoaneurysm--infrequent complication secondary to parenteral drug abuse]. / Infikovaná pseudoaneuryzma a. brachialis--raritní kazuistika u dlouholetého intravenózního narkomana.

INTRODUCTION: Intravenous drug abuse brings many infectious and surgical complications. Considering the duration of a drug scene in Czech Republic, pseudoaneurysms are not frequent complications, but we can expect their increased frequency with time. METHODS: A 27-year-old patient with known history of parenteral drug abuse (heroin, pervitin) was treated at our department during the autumn of 2006. He had self-injected heroin into an armpit four days before his appearance in our outpatient department. An abscess of his left arm and armpit resulting from cellulitis was his admission diagnosis based on a clinical ground. We did not validate that diagnosis with any radiology test. The operation made clear that pseudoaneurysm in a proximal part of brachial artery was a correct diagnosis. Because of severe inflammation of his left upper extremity, the pseudoaneurysm was dealt with resection, ligation of the brachial artery above and below the defect and leaving the incision to heal by secondary intention. RESULTS AND CONCLUSIONS: The pseudoaneurysm was treated with excision, tying the proximal and distal ends of brachial artery without urgent revascularization, extensive debridement of all necrotic tissues and leaving the incision to heal by secondary intention. Our approach did not threaten viability of the limb, which did not show any signs of ischemia during close postoperative monitoring. Our way seems to be appropriate and in agreement with current literature. The peroperative finding stresses the necessity of standard and Doppler ultrasound in every intravenous drug abuser with clinical picture of "a typical abscess" located in groin, elbow and armpit.

[Chronic appendicitis--vanishing or current diagnosis?]. / Chronická apendicitis--mizející ci bezná diagnóza?

BACKGROUND: Analysis of the literary findings and the clinical experiences of chronic appendicitis (CA) is presented. METHOD AND RESULTS: Analysis of the literary findings and study of our group of patients who were operated between years 2002 and 2004 is presented. The cohort includes 146 patients; 81% women, 19% men, aged between 14 to 72 years, average age 34 years, average age of men 46 years, women 29 years. The trend in the number of surgeries is decreasing in about 10% per year. Surgery findings: men--90% adhesions, atypical positions, findings of coprolites. Women--only 40% had macroscopical "findings". Medical history in the obscure cases (evaluable only in 50%), long-term hormonal contraception in 20%, 1-2 months after setting of hormonal contraception in 30%, intrauterine corpuscle in 10%, total negative in 40%. Effects of surgery in the group obscure surgery findings were practically always incomplete. Basic controversy in the diagnostic, in the range and in the appropriate time of surgical intervention is discussed. Surgeon also participates in the diagnostics, because the diagnosis of chronic appendicitis can come from some other medical specialists and the accuracy of indications can vary. Another aspect of the role of surgeon is the high evidence of laparoscopic methods for the diagnosis. Our results correspond with the literary sources. CONCLUSIONS: Chronic inflammation changes in the wall of the appendix bring about structural changes in the abdominal cavity. Clinical correlate exists only in the relation to the serious changes resulting from the inflammation of appendix for example: fixations, adhesions. That is why the chronic appendicitis as a clinical entity markedly receded. Problem is the restricted possibility, the range and level of investigation of right iliac region. From this point of view the rationality and professional opinion are essential in the indication to surgery.

[Pelvic infiltrations following amputation procedures for rectal carcinomas]. / Infiltráty v pánvi po amputacních výkonech pro karcinom rekta.

INTRODUCTION: The authors present anatomical division of the rectum and then give a short overview of the rectal surgery development. Currently, even in departments specialized in colorectal surgery, 25-30% of the rectal carcinoma cases must be managed by abdominoperineal amputations. COMPLICATIONS OF AMPUTATION PROCEDURES: The study deals with complications following extirpation of the rectum, like bleeding and its management, inflammatory complications during the healing process or following healing of the perineum. However, pelvic relapses, which in most cases cannot be managed surgically, remain the major therapeutic problem. These cases are indicated for systemic treatment with combinations of cytostatic drugs, eventually for radiotherapy. RESULTS: 324 patients with rectal carcinomas were operated at the 1st Surgical Clinic of the VFN in Prague. In 230 cases, resection was completed, in 94 cases, the rectum was amputated. In 78 cases, sutures of the pelvic floor was conducted, 64 cases healed per primam within 3 weeks, 11 healed per secundam within 3 months. In 16 cases, tamponade with surgical cover sheets and longettes was applied. 70% of these patients healed within 12 weeks of the surgery. In 3 cases, chronic fistules persisted for over 6 months. In 11 cases, locoregional relapses occurred. In 2 cases, radical excision was conducted, the other underwent systemic chemotherapy. CONCLUSION: Good preoperative care of the intestine, ATB prophylaxis and saving surgical technique were the precautions taken with the aim to prevent inflammatory complications. With respect to management difficulties of local relapses following amputations of the rectum, a requirement for total excisioning of the mesorectum on the first operation is substantial.

[Venous thrombosis prophylaxis in surgery--beginnings, contemporary state, ACCP consensus, future prospects]. / Profylaxe zilní trombózy v chirurgii--zacátky, dnesní stav, ACCP consensus, výhled.

Presentation and analysis basis questions and changes of thromboembolic disease prophylaxis in the surgical specialities from point of view the developments in last 30 years. Demonstration of the basic and modren methods of deep venous thrombosis prophylaxis. Recommendation of the 7th conference ACCP-CHEST 2004.

[Laparoscopic rectopexis]. / Laparoskopická rektopexe.

INTRODUCTION: Rektopexis is an effective treatment method of rectal prolapses. Our retrospective study assessed the laparoscopic rectopexis results. METHODOLOGY: From 01-01-2003 to 31-11-2005, 10 patients were indicated for the procedure of laparoscopic retropexis. A "Vypro" mesh (Johnson&Johnson) was used to suspend the rectum. We fix it to the sacrum and to the rectum with an anchor (Eanchr, Johnson&Johnson). The follow-up examinations were conducted 2-30 months after the procedure. We assessed mortality rates, morbidity rates, the prolaps relapses incidence rates, obstipation incidence rates. RESULTS: The laparoscopic procedure was completed in 9 patients. In one case, we converted. The mortality and serious postoperative morbidity rate was 0%. The mean duration of hospitalization was 7 days. During the follow-up, no patient relapsed. One female patient complained of mild postoperative obstipation, which, however, did not require surgical revision. CONCLUSION: Laparoscopic rectopexis is a modern, safe and effective method of the prolaps of the rectum treatment.

[Idiopatic bowel disease]. / Idiopatické strevní zánety--profil chirurgicky resených nemocných.

On the basis of retrospective five years analysis the authors process the problematic of idiopatic bowel disease--Morbus Crohn and ulcerative colitis. They pay main attention to surgical issue--types of operations, differences between acute and elective surgery, perioperative problems and results.

[Hydatic cysts--echinococcosis]. / Echinokoková nákaza--echinococcosis.

The case diagnosis and treatment of hydatic cyst in the right and left lobe of the liver in a 28 year old pregnant woman is described in the article.

[Robotic surgery]. / Robotika v chirurgii.

Installation first robotic system DaVinci in Prague in Czech Republic brought many questions. Surgery has rapidly changed during last 150 years. The progress in endoscopic surgery concerned namely the general surgery, thoratic and cardiovascular surgery. Present article gives and overview on the development of surgical techniques in the world from the laparoscopic to robotic surgery.

[Surgery in the elderly]. / Príspevek k chirurgii vyssího veku.

Among the steadily increasing population of surgical older patients than 65 yr are the fast growing group about 85 yr and older. Postoperative averse effects on the cardiac, pulmonary, cerebral and urinary systems are the main concerns for elderly surgical patients who are at high risk. The function capacity of organs reduces with age, resulting in decreased reserve and ability to endure stress. The effect of anesthetics on postoperative delirium has been studied and a leasing hyposthesis has been that offending druha aggravate an age-associated central cholinergic insufficiency. In additional to being linked to narcotics, sedative, and anticholinergics, delirium has been associated with urinary tract infection, pneumonia, hypoxia or hypercarbia, fever, blood loss, and electrolyte disturbances. In this review, we document the incidence of postoperative averse outcomes and discuss way of improving perioperative anaesthesia care for this vulnerable surgical population. There is present possibility anaesthesia in elderly.