[The spectrum of diaphragmatic injuries managed in a Prague traumatology centre]. / Spektrum poranení bránice osetrené v traumatologickém centru.

INTRODUCTION: Diaphragmatic injuries may result from blunt or penetrating injuries. The symptomatology is usually overlaid by symptoms of associated abdominal or thoracic injuries or by symptoms of other systems injuries in polytraumas. Multidetector computer tomography (MDTC) facilitates the improvement of preoperative diagnostics in blunt injuries. The retrospective study included analysis of a study group of subjects with blunt and penetrating diaphragmatic injuries. PATIENTS, METHODS AND RESULTS: From 1996 to 2009, a total of 44 injured patients with diaphragmatic injuries were operated in the FNKV (Faculty Hospital Kralovske Vinohrady) Traumatology Centre. The group included 17 blunt injuries and 27 penetrating injuries. There were 39 male and 5 female subjects, aged from 17 to 76 years. 32 subjects suffered from left-sided diaphragmatic injuries and 13 subjects from right-sided injuries. The commonest type of penetrating injuries were stab injuries in 21 subjects. 40 patients suffered from associated injuries. The commonest associated injuries included liver and splenic injuries. Simultaneous thoracotomy and laparotomy for associated injuries affecting the both cavities was performed in 21 patients. Left-sided diaphragmatic injury with associated abdominal injury was managed using laparotomy. Thoracoscopy or laparoscopy was used in 3 subjects with penetrating injuries. CONCLUSION: Penetrating injuries are the commonest cause of diaphragmatic injuries, with prevailing left-sided location of the injury. MDCT is an asset in the diagnostics of blunt diaphragmatic injuries. Surgical approach was selected based on the injury location and on the presence or absence of associated injuries. The miniinvasive approach contributes to the daignostics of penetrating diaphragmatic injuries in patients with stable hemodynamic conditions.

[Surgeries for blunt and penetrating thoracic injuries]. / Operace u tupého a pronikajícího poranení hrudníku.

INTRODUCTION: Up to 50% deaths due to fatal injuries result from thoracic injuries. Approximately 10-15 % of the injuries require thoracotomy. AIM OF THE STUDY: Indications and outcome of the surgery were assessed, based on the restrospective analysis data from subjects operated for blunt and penetrating thoracic injuries. SUBJECTS, METHODOLOGY AND RESULTS: 85 patients were operated for blunt or penetrating thoracic injuries during the period from 2000 to May, 2006. Urgent procedures for blunt thoracic injuries were performed in 13 subjects, and for penetrating injuries in 52 subjects. Immediate thoracotomy was indicated in 4 subjects suffering from stab injuries of the heart. 16 subjects were operated consequently for posttraumatic intrathoracic complications in blunt thoracic injuries. 4 subjects exited early postoperatively (4.7 %). CONCLUSION: The aim of urgent surgical interventions is to manage the major bleeding source (heart or large vascular injury), lungs, air leakage (tracheal or bronchial injuries) and diaphragmatic injuries. Irreversible hypovolemic shock in penetrating thoracic injuries and serious related injuries in blunt traumas resulted in peroperative and postoperative mortality.

[Indications for emergency surgery in thoraco-abdominal injuries]. / Soucasné indikace k neodkladným operacím u torakoabdominálních poranení.

PURPOSE OF THE STUDY: Under the conditions of an increasing number of car accidents and criminal injuries the thoracis and abdominal trauma is a source of a significant morbidity and mortality in blunt and penetrating mechanism of injury. On the basis of a group of patients operated on for blunt and penetrating injury of the chest and abdomen evaluation was made of the current indication and results of lifesaving surgery in case of these injuries. PATIENTS: The group included 68 patients requiring a lifesaving surgery for a blunt and penetrating injury of the chest and abdomen hospitalized between the beginning of 1966 and the end of April 2001. Forty-five patients sustained a blunt injury and 23 a penetrating injury. METHODS: In case of blunt injuries the indication for surgery was determined on the basis of clinical examination supplemented with a radiograph examination of the chest and spiral computer tomography. In case of penetrating stab wounds the surgery was indicated on the basis of clinical examination, in gunshot wounds by means of x-ray examination and spiral computer tomography performed in order to assess the scope of the injury of intraabdominal organs and the location of the projectile. Indicated on the basis of the examination in the blunt injury was thoracotomy in 6 cases, laporatomy in 34 cases and the combination of thoracotomy and laparotomy in 5 patients. In case of the penetrating injury thoracotomy was performed in 8 cases, laparotomy in 11 cases and the combination of thoracotomy and laparotomy in 4 patients. RESULTS: In the post-operative period 6 patients (9%) died: 3 patients with a polytrauma died from an irreversible damage caused by a protracted hemorrghagic shock, one female patient from the contusion of brain, one patient after splenectomy for an isolated injury died from cardiorespiratory failure and pneumonia, one patient with a stab wound of the left ventricle of the heart died from the heart failure by hypoxy. DISCUSSION: Indication for a lifesaving thoracotomy and laparotomy in our group of patients operated on corresponds to the overviews of surgeries in thoracoabdominal injuries presented in literature. The procedure in preoperative examination is identically limited by the stability of hemodynamics in the patient after the injury using mainly ultrasound and computer tomography of the stabilized patient. In contrast to a number of authors in our conditions we have not performed some of the intervention examinations such as diagnostic peritoneal lavage or thoracoscopy and laparoscopy. The improvement of results in patients operated on for thoracoabdominal injury is in our conditions given both by the timeliness of the operation in the availability of examination methods (US, spiral CT) and by adequate stabilization of the patient in the peroperative period at the emergency department. CONCLUSION: Priority indication for a lifesaving surgery in thoracoabdominal injuries is significant intraabdominal bleeding diagnosed on the basis of the result of the clinical examination in hemodynamically unstable patients. In a stabilized patient the lifesaving surgery is performed on the basis of the result of visualization methods (spiral computer tomography, ultrasound, angiography, endoscopy) revealing apart from significant bleeding also severe injuries of intrathoracic and intraabdominal organs. Protracted hypovolemic shock with the development of multi-organ failure or the occurrence of simultaneous severe associated injuries in polytrauma are the most frequent causes of mortality in patients operated on for thoracoabdominal injury.

[Diagnostic-therapeutic Algorithm in a Blunt Injury of the Thorax.]. / Diagnosticko-terapeutický algoritmus u tupého poranení hrudníku.

Based on the group of 22 patients operated on for a blunt injury of the thorax a diagnostic-therapeutic algorithm was evaluated in the procedure of the treatment of a severe trauma of the thorax. Acute thoracotomy or laparotomy was performed in 17 patients and in 5 of them thoracotomy was indicated only after some time interval. In the patients with acute surgery the indication was a rupture of diaphragm, massive hemotorax in case of lung laceration of bleeding from thoracic wall, rupture of bronchus and an associated injury of intra-abdominal parenchymal organs. Thoracotomy was after some time interval performed in case of empyema of thorax, post-injury paresis of diaphragm and residual hematoma in the lung parenchyma. Key words: blunt injury of thorax, diagnostic-therapeutic algorithm, indication to an acute or postponed operation.

[Empyema of the thorax]. / Empyém hrudníku.

The authors evaluated the therapeutic procedure and results in patients with empyema of the chest. From December 1996 till June 1998 at the Surgical Clinic of the Third Medical Faculty, Charles University Prague 21 patients with empyema of the chest were hospitalized. The most frequent cause of empyema of the chest was pneumonia in 13 patients (62%). In 16 patients (in 76%) the empyema was classified as the third stage of the disease. Decortication, the most frequent procedure, was performed in 16 patients, incl. three where it was done using videothoracoscopy. Surgical treatment was supplemented by antimicrobial treatment, either monotherapy or a combination of antimicrobial preparations. From the total number one patient died 25 days after thoracotomy and partial decortication with a mesiotheloma of the pleura. The other patients have no signs of relapse of empyema. According to the authors experience the selection of the surgical procedure depends on the stage of the disease. In the authors group decortication by the thoracotomic route was used most frequently.

[Percutaneous localization and marking of small solitary pulmonary nodules in CT imaging before video thoracoscopy surgery]. / Perkutánní lokalizace a znacení solitárních malých plicních uzlu pod CT kontrolou pred videotorakoskopickou operací.

BACKGROUND: The localization of small lung nodules by palpation is not possible when videothoracoscopic surgery is performed. Transparietal fine needle biopsy is frequently not successful in small lung nodules. METHODS AND RESULTS: The authors describe their experiences with percutaneous CT controlled marking of small lung parenchyma around small lung nodules by patent blue and contrast medium mixture. The method was used in 7 patients with nodule size from 7 mm to 25 mm. In all patients the surgeon was able to localize the nodule. Operation followed localization as soon as possible, the interval was from 60 to 120 minutes. Four of 7 nodules were benign, 3 nodules were malignant. CONCLUSIONS: New method of marking of small lung nodules makes a minimal invasive operation possible. The operation stress is lower and the time of hospitalization is shorter.

[Significance of blunt injury of thorax in polytrauma.]. / Význam tupého poranení hrudníku u polytraumatu.

Based on the analysis of a group of 100 patients with polytrauma evaluation was made of the impact of thoracic injury on post-injury period, including the incidence of complications, and on the outcome of the treatment. Blunt thoracic injury occurred in 64 patients. The most frequent complications of intrathoracic injury were pneumothorax, haemothorax and contusion of lungs. In the group of patients with polytrauma involving also the chest there was a more frequent incidence of respiratory insufficiency, higher morbidity (higher incidence of insufficiencies of organs and septic complications) and higher mortality (34%). The cause of mortality within 24 hours after admission was irreversible traumatic hemorrhagic shock, later the consequences of craniocerebral injury. The injury of chest in polytrauma deteriorates its prognosis. Key words: polytrauma, blunt thoracic injury, diagnostic - therapeutical algorithm, outcomes of the treatment.

[Use of collagen with gentamycin in abdominal and thoracic surgery]. / Pouzití kolagenu s gentamycinem v brisní a hrudní chirurgii.

Based on an analysis of a group of 16 patients operated at the Surgical Clinic of the Third Medical Faculty, Charles University Prague the indication of collagen with gentamycin was established. Collagen with gentamycin is used locally for prophylaxis and treatment of intraabdominal and intrathoracic infections. In a group of patients it was used for prophylaxis of postoperative infections in elective abdominal operations such as plastic operations of the abdominal wall, anastomoses in the aboral part of the GIT, in operations of fistulae as part of treatment of intraabdominal abscesses and advanced cholecystitis and appendicitis. In thoracic surgery for prophylaxis of postoperative infections in plastic operations of the thoracic wall and also after surgery on account of inflammatory complications (lung abscess, bronchopleural fistula).

[An unusual complication of establishing a capnoperiteoneum for laparoscopic cholecystectomy]. / Nezvyklá komplikace pri zakládání kapnoperitonea u laparoskopické cholecystektomie.

The authors describe the case history of a female patient indicated for laparoscopic cholecystectomy. In the patient with progressing muscular dystrophy and thickening of the peritoneum it did not prove possible to establish a capnoperitoneum at the onset of the operation.

[Videothorascopic surgery--initial experience]. / Video torakoskopické operace--nase první zkusenosti.

Practical experience with the miniinvasive laparoscopic technique in abdominal surgery logically led to extension of this method to thoracic surgery. Video-assisted thoracoscopic operations hold their place in the treatment of spontaneous pneumothorax, pleural syndrome, benign tumours of the thoracic wall etc. A curative solution of malignant diseases by this route is so far controversial and is reserved only for specially defined cases. Experience from the authors' department is based on nine-month use of a thoracoscopic apparatus. The authors operated a total of 21 patients thoracoscopically, incl. pneumothorax 6x, fluidothorax 10x and tumourous disease of the lungs or mediastinum 5x. The use of thoracoscopy is controversial in metastases of the lungs and in thymectomy. With regard to the authors are against thoracoscopic indications in the latter conditions contemporary technical possibilities.

[Importance of blunt injuries of the chest for assessment of the therapeutic procedure and prognosis in multiple injuries.]. / Význam tupého poranení hrudníku pro stanovení lécebného postupu a prognózy u polytraumat.

Based on analysis of a group of 62 casualties with multiple injuries where a blunt chest injury was found, the authors submit some principles for assessment of the priority of the therapeutic procedure. The patients were hospitalized at the intensive care unit of the Surgical Clinic of the Third Medical Faculty in Prague between 1989 and 1992. Craniocerebral injury was the most frequent associated injury, its sequelae were the cause of death in the majority of injured patients who died. In the treatment of chest injuries with an unstable thoracic wall, with contusion of the lungs and associated craniocerebral injury artificial ventilation is still the method of choice. Key words: multiple injuries, associated blunt injury of the chest, therapeutic procedure.

[Stab and gunshot thoracoabdominal injuries]. / Bodná a strelná poranení torakoabdominální.

The authors give an account of their experience with the treatment of punctures and gunshot injuries of the chest and abdomen in 43 patients hospitalized at the Surgical Clinic of the Third Medical Faculty, Charles University Prague 10 between 1989 and 1992. Injuries of the chest were recorded 15 times, abdominal injuries in 25 patients and concurrent injuries of the chest and abdomen in three patients. To ensure treatment of penetrating injuries the authors present an algorithm which comprises differentiated care as well as some non-interventional diagnostic methods (ultrasonography, computed tomography). Based on analysis of their own results and data in the literature, the authors recommend in casualties with penetrating chest injuries and abdominal injuries early indicated surgical revision which alone ensures adequate treatment with minimal diagnostic errors. They also draw attention to the necessity to ensure effective first aid and rapid transport of casualties to prevent the development of irreversible changes as a result of haemorrhage, as observed in a single patient who died after a piercing heart injury.

[Diagnostic and therapeutic approaches to spontaneous pneumothorax]. / Príspevek k diagnostickému a lécebnému postupu u spontánního pneumotoraxu.

Based on a retrospective study of 33 patients with spontaneous pneumothorax, the authors present their experience with the diagnostic and therapeutic procedure. In the majority of patients treatment was started by active suction drainage of the chest. After re-expansion of the lung another X-ray examination was made, incl. computed tomography of the chest, and endoscopic examination (bronchoscopy, thoracoscopy). On account of a relapse of pneumothorax in three patients thoracoscopy was performed and in seven patients thoracotomy. The operated patients recovered and are without signs of relapse of pneumothorax.

[Noxythiolin VUFB as part of antimicrobial prophylaxis and therapy in inflammatory intraabdominal complications in surgery]. / Noxythiolin VUFB jako soucást antimikrobní profylaxe a terapie nitrobrisních zánetlivých komplikací u chirurgických nemocných.

The author investigated the antimicrobial action of noxythioline, prepared by the Research Institute for Pharmacy and Biochemistry in Prague, in laboratory work as well as under clinical conditions. In the laboratory investigation the author assessed the minimal inhibitory concentration against aerobic and anaerobic bacteria within the range of 512-2048 mg/l, which is sufficient from the aspect of the noxythioline concentration (2.5%) used in clinical work. In the clinical part of the investigation noxythioline was administered to 58 patients hospitalized at the surgical clinic of the Medical Faculty of Hygiene in Prague in 1988-1989. In 13 patients it was used prophylactically in planned or acute intraabdominal operations. Therapeutically it was used in 45 patients operated mostly on account of intraabdominal diseases complicated by peritonitis or an abscess. Preliminary results confirmed the satisfactory effect of noxythioline VUFB which is comparable with Noxyflex S of Geistlich Co.

[Parenteral nutrition using branched-chain amino acids (Nutramin VLI Spofa) in the early postoperative period in patients with intra-abdominal inflammatory diseases]. / Parenterální výziva s pouzitím rozvetvených aminokyselin (Nutramin VLI Spofa) v casném pooperacním období u nemocných s nitrobrisními zánetlivými onemocneními.

In 19 patients with intraabdominal septic conditions hospitalized at the Surgical Clinic of the Medical Faculty of Hygiene, Charles University, Prague 10 in 1987-1988, the effect of the gradually increasing ratio of branched amino acids administered in parenteral nutrition was investigated. The administration of branched amino acids (Nutramin VLI Spofa) was started already on the first day after operation. By increasing the ratio to 43% of branched amino acids gradual normalization of metabolic changes occurred, incl. normalization of free amino acid plasma levels.

[Use of Nutramin VLI Spofa for parenteral nutrition in the early post-injury period in polytrauma]. / Pouzití Nutraminu VLI Spofa v parenterální výzive v casném poúrazovém období u polytraumat.

The solution of branched-chain amino acids of gradually increasing concertration ranging from 22.7 to 43 per cent was administered to 15 patients with polytrauma as part of parenteral nutrition. Parenteral nutrition was started with during 24 hours after the trauma. The effect of parenteral nutrition was objectified by a twenty-four hour balance of water, ions, energy and nitrogen and by a follow-up of kinetics of amino acids in the plasma. It was found out that the increase of the share of branched-chain amino acids up to 43 per cent resulted in a pharmacodynamically efficient level of valine. There occurred gradual adjustment both of the levels of other aminoacids in the plasma and other metabolic changes including the restoration of proteosynthesis.