Treatment strategies for patients with colorectal carcinomaand synchronous liver metastases.

Multimodal approach in the management of patients with colorectal carcinoma and synchronous liver metastases allows for the application of various combinations of treatment modalities (colorectal resection, liver resection, chemotherapy, radiotherapy). The primary-first approach and simultaneous resection represent traditional strategies used because the primary tumor is thought to be the main source of subsequent metastases as well as the source of symptoms associated with local tumor progression (obstruction, perforation, colorectal bleeding). Poor long-term outcomes of traditional strategies have led to the proposal of reverse strategies (the liver-first approach and up-front hepatectomy approach). The idea behind reverse strategies is to give preference to liver resection over colorectal resection (prognosis of patients with stage IV colorectal cancer is determined mainly by the curability of liver metastases). According to available literature, reverse strategies are suitable mainly for patients with asymptomatic primary tumor. Treatment strategy for each patient should be individualized depending on the patients performance status, comorbidities, and tumor stage. In this paper, the authors offer an up-to-date review of treatment strategies for patients with colorectal carcinoma and synchronous liver metastases focusing on available data of evidence-based medicine. Key words: liver first - primary first - colorectal carcinoma - liver metastases - reverse strategies.

Advancement in liver laparoscopic resection - development of a new surgical device.

Liver resection is the standard treatment for any liver lesion. Laparoscopic liver resection is associated with lower intra-operative blood loss and fewer complications than open resection. Access to the posterior part of the right liver lobe is very uncomfortable and difficult for surgeons due the anatomic position, especially when employing laparoscopic surgery. Based on these experiences, a new laparoscopic device was developed that is capable of bending its long axis and allowing the application of radiofrequency energy in areas that were not technically accessible. The device is equipped with four telescopic needle electrodes that cause tissue coagulation after the delivery of radiofrequency energy. Ex vivo testing was performed in 2012 and 2014 at the University Hospital, Ostrava, on a porcine liver tissue. The main goal of this testing was to verify if the newly proposed electrode layout was suitable for sufficient tissue coagulation and creating a safety zone around lesions. During the ex vivo testing, the material of needle electrodes was improved to achieve the lowest possibility of adhesion. The power supply was adjusted from 20 to 120 W and the ablation time, which varied from 10 to 110 s, was monitored. Subsequently, optimal power delivery and time for coagulation was determined. This experimental study demonstrated the feasibility and safety of the newly developed device. Based on the ex vivo testing, LARA-K1 can create a safety zone of coagulation. For further assessment of the new device, an in vivo study should be performed.

Advancement in liver laparoscopic resection - development of a new surgical device

Liver resection is the standard treatment for any liver lesion. Laparoscopic liver resection is associated with lower intra-operative blood loss and fewer complications than open resection. Access to the posterior part of the right liver lobe is very uncomfortable and difficult for surgeons due the anatomic position, especially when employing laparoscopic surgery. Based on these experiences, a new laparoscopic device was developed that is capable of bending its long axis and allowing the application of radiofrequency energy in areas that were not technically accessible. The device is equipped with four telescopic needle electrodes that cause tissue coagulation after the delivery of radiofrequency energy. Ex vivo testing was performed in 2012 and 2014 at the University Hospital, Ostrava, on a porcine liver tissue. The main goal of this testing was to verify if the newly proposed electrode layout was suitable for sufficient tissue coagulation and creating a safety zone around lesions. During the ex vivo testing, the material of needle electrodes was improved to achieve the lowest possibility of adhesion. The power supply was adjusted from 20 to 120 W and the ablation time, which varied from 10 to 110 s, was monitored. Subsequently, optimal power delivery and time for coagulation was determined. This experimental study demonstrated the feasibility and safety of the newly developed device. Based on the ex vivo testing, LARA-K1 can create a safety zone of coagulation. For further assessment of the new device, an in vivo study should be performed.

Recent Development of Augmented Reality in Surgery: A Review.

INTRODUCTION: The development augmented reality devices allow physicians to incorporate data visualization into diagnostic and treatment procedures to improve work efficiency, safety, and cost and to enhance surgical training. However, the awareness of possibilities of augmented reality is generally low. This review evaluates whether augmented reality can presently improve the results of surgical procedures. METHODS: We performed a review of available literature dating from 2010 to November 2016 by searching PubMed and Scopus using the terms "augmented reality" and "surgery." Results. The initial search yielded 808 studies. After removing duplicates and including only journal articles, a total of 417 studies were identified. By reading of abstracts, 91 relevant studies were chosen to be included. 11 references were gathered by cross-referencing. A total of 102 studies were included in this review. CONCLUSIONS: The present literature suggest an increasing interest of surgeons regarding employing augmented reality into surgery leading to improved safety and efficacy of surgical procedures. Many studies showed that the performance of newly devised augmented reality systems is comparable to traditional techniques. However, several problems need to be addressed before augmented reality is implemented into the routine practice.

[Minimally invasive liver resections]. / Miniinvazivní resekce jater.

INTRODUCTION: Laparoscopic surgery is a standard and preferred modality of surgical treatment. Progress in laparoscopic procedures and the development of dedicated technology have made it possible to approach laparoscopic liver resections in selected patients. Initially operations were performed for benign and peripheral lesions, but nowadays more than 50% of total laparoscopic surgery is due to malignancy. METHOD: We conducted a literature search using Pubmed; by entering the keywords "Laparoscopic Liver Resection" we obtained a set of publications focused on this issue. We limited the selection to the period from 1991 to the present. Additionally, the selection was limited to reviews, prospective randomized trials or cohort studies. Also, we selected publications in the English and Czech languages. RESULTS: On the basis of the search, we identified 2345 publications, of which the abovementioned criteria were satisfied by 319 papers. Of these, 312 publications were in English and 7 in the Czech language. 59% of the searched publications were published in the last 5 years, which gives evidence of progression of the laparoscopic liver resection method. CONCLUSIONS: Laparoscopic liver resections are considered as safe for both benign and malignant lesions with comparable oncological outcomes compared to open resections. They also provide better short-term results such as a shorter hospital stay, lower overall costs, lower postoperative pain, reduced blood loss, earlier intestinal recovery, generally shorter convalescence of the patient, better cosmetic results and a lower rate of complications.Key words: laparoscopic liver resections - hand-assisted laparoscopy.

[Laparoscopic diverting ileostomy in rectal cancer surgery]. / Laparoskopická protektivní ileostomie v chirurgii karcinomu rekta.

INTRODUCTION: Low anterior resection (LAR) with total mesorectal excision (TME) represents the gold standard for patients with low rectal carcinoma. Protective ileostomy (PI) is commonly performed during LAR in an effort to protect low rectal anastomosis. The aim of this study is to analyse outcomes in our own patient population, focusing on morbidity associated with PI. METHOD: A retrospective clinical study of patients operated on between 2013 and 2015 was conducted in University Hospital Ostrava. All patients after LAR with PI due to low rectal cancer were included. The study design did not require randomisation. RESULTS: A total of 52 patients who underwent LAR with PI were included. Mean tumour height was 9.1±2.3 cm. 15.4% of the patients were classified as ASA I, 53.8% were classified as ASA II and 32.7% of the patients as ASA III. 30-day postoperative morbidity was 38.5%, and complications associated with PI (within 30 days after LAR) occurred in 7 (13.5%) patients. Three of these patients underwent urgent surgical revision due to small bowel obstruction (PI semirotation around its longitudinal axis in two patients and volvulus of the small bowel around PI in one patient). Mean time interval between PI creation and reversal was 252 days. During this period, complications associated with PI were detected in 25 (48.1%) patients; seven patients had more than one complication. Minor complications (such as peristomal dermatitis, stoma herniation or bleeding, wound infection after stoma reversal) were observed in 17 (32.7%) patients. Major complications (small bowel obstruction at the site of PI, dehydration due to high stoma output, intraabdominal abscess after stoma reversal) occurred in 8 (15.4%) patients. CONCLUSIONS: PI offers protection to low colorectal or coloanal anastomosis in rectal cancer surgery. However, this benefit is counterbalanced by a high risk of various complications which may occur during the whole period when PI is present. The decision for diversion should therefore be made only after careful consideration.Key words: rectal cancer - low anterior resection - laparoscopy - protective ileostomy - stoma complications.

[The risks of retroperitoneoscopic adrenalectomy]. / Rizika retroperitoneoskopické adrenalektomie.

INTRODUCTION: Minimally invasive adrenalectomy has become the gold standard for surgery of the suprarenal gland. Retroperitoneoscopic adrenalectomy with dorsal approach is preferred. The aim of our case report is to discuss potential complications that may arise from retroperitoneoscopic adrenalectomy, specifically an intra-operative injury of the inferior vena cava. CASE REPORT: A 47-year-old male patient was admitted to undergo elective adrenalectomy on the right side. The reason for the surgery was a hormonally active adenoma with clinical signs of Conns syndrome. Biochemistry revealed the typical signs of hyperaldosteronism. A one-year history of unsuccessful treatment for hypertension was known. Ultrasound examination showed an enlarged suprarenal gland on the right side with the diameter of 5.2 cm. A CT scan confirmed the results of the ultrasound examination. Retroperitoneoscopic adrenalectomy was performed. The inferior vena cava was intraoperatively injured. The high pressure in the retroperitoneal space prevented bleeding. The injury to the vena cava was treated using a continuous stitch without the necessity of conversion to open surgery. The patient was discharged on the third postoperative day without any other complications. CONCLUSIONS: Retroperitoneoscopic approach is regarded by many authors as the new gold standard for adrenalectomy. However, very serious complications such as an injury of the inferior vena cava may occur. It is possible to treat this injury using retroperitoneoscopy. The risk of air embolization due to elevated pressure in the retroperitoneum (20 mm Hg) and open lumen of the IVC needs to be taken seriously.Key words: adrenalectomy - retroperitoneoscopy - complication.

[Left hepatic vein injury during laparoscopic fundoplication for giant paraoesophageal hiatal hernia]. / Poranení levé hepatické vény v prubehu laparoskopické fundoplikace pro velkou paraezofageální hiátovou kýlu.

INTRODUCTION: After laparoscopic cholecystectomy, laparoscopic fundoplication has become another gold standard of minimal invasive surgery. The level of satisfaction of patients undergoing endoscopic surgery is almost 90%. Laparoscopic fundoplication, like other surgery methods, can also be burdened with grave complications, which could result in a fatal outcome even if the surgery is performed by a skilled surgeon. Even the authors themselves encounter complications despite their rich experience (more than 3,500 laparoscopic operations in the diaphragmatic hiatus area in more than 20 years). CASE REPORT: The authors report on a rare left hepatic vein injury during laparoscopic hiatoplasty and fundoplication according to Toupet for giant paraoesophageal hiatal hernia. CONCLUSION: For its low percentage of complications, laparoscopic fundoplication is considered as a safe operative method for gastroesophageal reflux disease and hiatal hernias. However, severe complications may still arise during the surgery and the surgeon should be familiar with them, be prepared for them and be able to manage such complications.Key words: gastroesophageal reflux disease hiatal hernia laparoscopic fundoplication left hepatic vein.

[Complete minimally invasive Ivor-Lewis esophageal resection]. / Kompletní miniinvazivní Ivor-Lewisova resekce jícnu.

INTRODUCTION: Minimally invasive esophagectomy is becoming a standard procedure in the treatment of esophageal cancer. We would like to present our experience with Ivor Lewis esophagectomy completed by minimally invasive technique. METHODS: The primary aim of the study was to analyse potential technical difficulties and intraoperative complications of thoracolaparoscopic Ivor Lewis esophagectomy with intrathoracic anastomosis. A secondary aim of the study was to evaluate postoperative complications according to the Clavien-Dindo classification. The inclusion criterion for the study was a history of thoracolaparoscopic esophagectomy. Multidisciplinary approach was employed in the diagnosis, surgery indications and perioperative care of all patients. RESULTS: Between January 2011 and January 2016, 19 patients underwent completely minimally invasive esophagectomy with intrathoracic anastomosis. There were 13 men and 6 women. Adenocarcinoma was confirmed by histopathological examination in all the patients. The cumulative postoperative morbidity was 68.4%. According to the Clavien-Dindo classification, we recorded grade I complications in 10.5% of the patients, grade II in 15.8%, grade III in 36.8% and grade IV in 5.3% of the patients. Anastomotic leak was the most serious complication; it was initially managed by negative pressure (vacuum) therapy followed by stent implantation. Postoperative mortality was 0%. Mean hospital stay was 12 days and mean stay at intensive care unit was 3.6 days. CONCLUSIONS: The basic oncosurgical principles of radicality need to be respected during minimally invasive procedures. However, functionality, safety, and cost effectiveness have to be preserved as well. In this paper, we present thoracolaparoscopic Ivor Lewis esophagectomy as one of feasible and accessible options of intrathoracic anastomosis. It seems to be safe with respect to technical obstacles, short-term and long-term complications.Key words: esophagectomy - intrathoracic - anastomosis - laparoscopy - thoracoscopy.

[Perforation of the right ventricle of the heart as a complication of CT guided percutaneous drainage of a subphrenic abscess - a case report]. / Perforace pravé srdecní komory jako komplikace CT navigované perkutánní drenáze subfrenického abscesu kazuistika.

INTRODUCTION: CT guided percutaneous drainage is currently the gold standard in the treatment of abdominal fluid collections, having substituted open surgical drainage in many cases. It burdens the patient less than surgical drainage. Its efficiency is comparable to standard surgical drainage when properly indicated. It is readily available even in smaller hospitals. However, this method can also have many complications, which originate most often from an improperly targeted drainage catheter. CASE REPORT: The authors describe a case report of a 55 years old man with a right-sided subphrenic abscess. The right ventricle of the heart was perforated during a CT guided percutaneous drainage. The bleeding was minimal, but the patient suffered a profound septic shock as a result of massive bacteremia during direct communication of the contents of the abscess cavity with blood circulation. He was operated immediately. The right ventricle was sutured, and the subphrenic abscess was drained. There were no complications after the operation, and the patient was discharged on day 17 after the surgery. CONCLUSION: The CT guided drainage of an abdominal abscess or a fluid collection in a risk area should be preferably done in hospitals whose therapeutic portfolio also includes the handling of serious complications. KEY WORDS: heart injury drainage.

[Primary malignant small bowel tumors]. / Primární zhoubné nádory tenkého streva.

INTRODUCTION: Small bowel presents 75% of the gut length and 90% of the gut surface. However, primary malignant tumors of the small bowel represent only 1-3% of all malignant gastrointestinal tumors. The aim of the present paper is to offer a current review of primary malignant small bowel tumors - their epidemiology, localization, symptoms, diagnostic and treatment options. METHODS: The authors have performed a comprehensive review of databases Medline, Scopus and Google Scholar focusing on studies regarding small bowel cancer. RESULTS: The most frequent small bowel tumors are adenocarcinoma (30-40%), neuroendocrine tumors (35-44%), lymphomas (10-20%) and gastrointestinal stromal tumors (12-18%). Symptomatology is non-specific and varies widely, which is why small bowel cancer is usually diagnosed in a locally advanced stage of the disease. Diagnosis is determined through standard methods (gastroscopy, colonoscopy, CT) and complementary special diagnostic modalities (capsule enteroscopy, enteroscopy, octreotide scan, etc.). Diagnostic process with a negative outcome frequently leads to diagnostic laparoscopy/laparotomy.The treatment of small bowel cancer in patients operated in acute settings is done according to acute abdomen management guidelines. Elective surgery of small bowel cancer differs with respect to the tumor type. Adenocarcinomas and neuroendocrine tumors should be treated with surgical R0 resection with radical lymphadenectomy (and multivisceral resection if necessary). Patients with GIST should undergo en bloc resection with 2-3cm safety resection margins (lymphadenectomy is not necessary). Palliative resection of neuroendocrine tumors can be associated with a significant clinical effect. On the other hand, palliative resection of adenocarcinomas of GIST is not advocated. CONCLUSION: Small bowel cancer is an infrequent condition. Symptoms are non-specific; patients are often diagnosed in an advanced stage of the disease. Achieving R0 surgical resection is usually difficult due to locally advanced stage of the disease. Besides the tumor type, patients prognosis is influenced by very late diagnosis of the tumor. KEY WORDS: primary tumor - small intestine - diagnostics - treatment options - surgical resection.

[Rare injury of perineum and anorectum - case report]. / Raritní poranení hráze a anorekta kazuistika.

UNLABELLED: Anorectal injuries, with the exception of iatrogenic damage, are rare. Considering the extensive range of causes and potential extent of damage, the diagnosis and treatment of these injuries requires an individual approach to every patient. Based on the extent of damage, the best way of treatment strategy has to be selected for successful treatment of the primary injury and elimination of frequent complications, especially fecal incontinence. The authors present a rare injury of the perineum and anorectum with anorectal sphincter damage in an elderly man after falling down from a stepladder. KEY WORDS: anorectum - anorectal trauma - anal sphincter.

[Laparoscopic resection rectopexy in the treatment of obstructive defecation syndrome]. / Laparoskopická resekcní rektopexe v lécbe obstrukcního defekacního syndromu.

INTRODUCTION: Obstructive defecation syndrome (ODS) presents a common medical problem, which can be caused by various pelvic disorders; multiple disorders are frequently diagnosed. At the present, a high number of corrective techniques are available via various surgical approaches. Laparoscopic resection rectopexy is a minimally invasive technique, which comprises redundant sigmoidal resection with rectal mobilisation and fixation. METHODS: The aim of this paper was to evaluate the safety and effectiveness of laparoscopic resection rectopexy in the treatment of patients with ODS. The evaluation was performed via our own patients data analysis and via literature search focused on laparoscopic resection rectopexy. RESULTS: In total, 12 patients with ODS undergoing laparoscopic resection rectopexy in University Hospital Ostrava during the study period (2012-2015) were included in the study. In our study group, mean age was 64.5 years and mean BMI was 21.9; the group included 11 women (91.6%). ODS was caused by multiple pelvic disorders in all patients. Dolichosigmoideum and rectal prolapse (internal or external) were diagnosed in all included patients. On top of that, rectocoele and enterocoele were diagnosed in several patients. Laparoscopic resection rectopexy was performed without intraoperative complications; mean operative time was 144 minutes. Mean postoperative length of hospital stay was 7 days. Postoperative 30-day morbidity was 16.6%. All postoperative complications were classified as grade II according to Clavien-Dindo classification. Mean preoperative Wexner score was 23.6 points; mean score 6 months after the surgery was 11.3 points. Significant improvement in ODS symptoms was noted in 58.3% of patients, and a slight improvement in 16.6% of patients; resection rectopexy provided no clinical effect in 25% of patients. CONCLUSION: It is fundamental to carefully select those patients with ODS who could possibly profit from the surgery. Our results, in accordance with published data, suggest that laparoscopic resection rectopexy is a valuable surgical technique in the treatment of patients with ODS caused by multiple pelvic disorders. KEY WORDS: obstructive defecation syndrome - constipation - resection rectopexy - operative techniques - pelvic floor disorders.

[Secondary angiosarcoma of the abdominal wall after adjuvant radiotherapy in a patient with uterine carcinoma - a case report]. / Sekundární angiosarkom brisní steny po adjuvantní radioterapii pacientky s karcinomem delohy kazuistika.

INTRODUCTION: Adjuvant radiotherapy is an integral part of the current treatment of many malignant tumours. However, this mode of treatment does not provide only benefits in the sense of lowering the risks of recurrence, but it is also associated with many undesirable side effects, from which one of the most serious is the development of secondary malignancies. CASE REPORT: The author describes a case report of 77 years old woman who underwent hysterectomy with bilateral adnexectomy and pelvic lymphadenectomy for uterine carcinoma pT1bN0M0, G1 in 2005. Adjuvant external radiotherapy with the dose 45Gy and brachytherapy 3x4Gy followed. Subsequently the patient was followed at the department of gynecology, which referred her in January 2015 with a quickly growing tumour of the skin and subdermal tissue in the hypogastric area, where previous radiation had been applied. Its excision was indicated with the diagnosis of suspected uterine carcinoma metastasis, but subsequent histological evaluation confirmed angiosarcoma. Despite negative resection margins the tumour quickly recurred and disseminated. CONCLUSION: Angiosarcoma as a side effect of irradiation is described increasingly more often nowadays. The vast majority of cases are related to the treatment of breast carcinoma. Its prognosis is very poor and therapeutic possibilities are limited. Surgical excision with negative margins remains the mainstay of the treatment. It is necessary to keep this diagnosis in mind and patients undergoing radiation treatment should be followed over a long period. KEY WORDS: angiosarcoma.

[10 years of sleeve gastrectomy in the Czech Republic in terms of the surgical procedure]. / 10 let sleeve gastrectomy - tubulizace zaludku v Ceské republice z hlediska operacního výkonu.

INTRODUCTION: Sleeve gastrectomy (SG) as a single bariatric/metabolic procedure has been performed since 2003 in the world, and since 2006 in the Czech Republic. We report 10 years experience with SG in the Czech Republic from 2006 to 2015. METHOD: Prospectively collected data from 14 surgical departments was evaluated retrospectively using descriptive statistics for every year from 2006 to 2015 and subsequently evaluated and compared for the entire period. The number of the patients, mean age, mean weight and BMI at the time of surgery, the number of patients with T2DM after SG, mean follow-up, mean %BMIL (% Body Mass Index Loss), distance of the starting point of the resection line from the pylorus, the size of the calibration bougie, the rate of complications, and the number and type of conversion procedures were evaluated. RESULTS: 4134 sleeve gastrectomies were done in the Czech Republic from 2006 to 2015 with the mean follow-up of 32.9 months (range 2145 months) from the procedure. The mean weight at the time of surgery fluctuated between 114.2 kg and 128.9 kg; mean BMI fluctuated between 42.3 and 46.7. Mean %BMIL was 63.2% for the entire evaluated period. The distance of the starting point of the resection line from the pylorus changed from the mean 6.1 cm (range 67 cm) to mean 4.2 cm (range 36 cm) and the size of the calibration bougie changed from the mean 39.2 F (range 3642 F) to mean 37.1 F (range 3542 F). As regards early postoperative complications, bleeding from the resection line occurred in 1.4% and a leak from the staple line occurred in 1.1%. The gastroesophageal reflux disease and hiatal hernia occurred in 17.3% as the most frequent late complications. Conversion to another bariatric procedure was approached in 3.8% in the event of an unsatisfactory effect of the SG. CONCLUSION: Bariatric or metabolic surgery, respectively, is a safe and effective surgical method for the treatment of severe obesity and T2DM in morbidly obese patients. Currently, SG is the most widely used bariatric/metabolic procedure in the Czech Republic as well as in most other countries and the long-time results are similar in comparison with other authors.Key words: bariatric surgery - sleeve gastrectomy - resection line - complications.

[Pruritus ani]. / Pruritus ani.

INTRODUCTION: Pruritus ani is defined as a dermatologic disease characterized by itching and/or burning in the perianal area. It occurs in 15% of the population. Men are affected more frequently than women, in the ratio 4:1. It is accompanied by an irresistible desire to scratch in the perianal area. Pruritus ani is divided into two subtypes: primary (idiopathic) and secondary. In idiopathic (primary) pruritus it is not possible to detect any other cause of itching. Secondary pruritus has an obvious causal origin.The aim of this paper is to offer a complex overview of possible causes, diagnostic procedures and treatment possibilities of this unpleasant and annoying disease. METHODS: We have researched available publications using PubMed and MEDLINE databases, focusing on articles on anal pruritus. At first the key word "Pruritus ani" was put in without any restrictions. Subsequently, we limited the selection by the time period of 5 years and 10 years; then we looked up articles in English, German and Czech languages, and finally review articles, clinical trials and others. RESULTS: 574 articles were found without entering any restrictions; 45 of them were review articles and 25 clinical trials. 437 articles were in the English language and 40 of them were review articles. 44 were in the German language and 1 of them was a review article. A total of 33 articles were found with a 5-year time limit. 6 of them were review articles and 4 were clinical trials. 66 articles from the last 10 years were found. 14 of them were review articles and 10 were clinical trials. In most of the other articles among the total number of articles found, pruritus ani was mentioned only marginally in articles focused on different topics. We have not found any summary articles on this topic in Czech publications. CONCLUSION: Pruritus ani is a common disease with a number of causes; therefore, effective treatment may be insufficient in the initial stages. The therapy is focused on the primary cause, if found. Broad differential diagnosis options need to be taken into consideration, and reevaluation of the therapy is a priority. When no obvious secondary cause is found, the empiric treatment is focused on an improvement of hygiene and change in the life style, removal of common irritators, and protection of perianal skin.

Laparoscopic sleeve gastrectomy for morbid obesity with natural orifice specimen extraction (NOSE).

OBJECTIVE: An experience with laparoscopic sleeve gastrectomy using the natural orifice specimen extraction (NOSE) technique. BACKGROUND: Bariatric surgery is nowadays the only long term effective obesity treatment method. METHODS: Twenty one consecutive patients underwent laparoscopic sleeve gastrectomy with the use of natural orifice specimen extraction (NOSE) in the Surgical Clinic of Faculty Hospital Ostrava between May 2012 and August 2012. Inclusion criteria were the body mass index (BMI) higher than 35 kg/m2 or higher than 32 kg/m2 accompanied with relevant comorbidities. RESULTS: Among 21 patients in this series, there were three men (14.3%) and 18 women (85.7%). Their mean age was 40.9±10.2 years. Their mean preoperative BMI was 40.4±4.6 kg/m2. No patient had previous bariatric surgery, one patient had laparoscopic fundoplication. All operations were completed laparoscopically with no conversions to an open procedure. In two cases, laparoscopic cholecystectomy was performed and the gallbladder was extracted along with the gastric specimen by transgastric approach. CONCLUSION: Laparoscopic sleeve gastrectomy is a safe and effective bariatric procedure with low morbidity and mortality. Based on our initial experiences it could be an indication for NOSE with transgastric approach. Obese patients would benefit from this approach due to the elimination of wound complications (Tab. 2, Fig. 3, Ref. 22).

Body Size, Bone Mineral Density, and Body Composition in Obese Women After Laparoscopic Sleeve Gastrectomy: A 1-Year Longitudinal Study.

Changes in body weight, waist and hip circumferences, body composition, and skeletal status in women after bariatric surgery were evaluated. Thirty-six women [mean age 41.2 ± (SD) 9.5 years, weight 115.7±18.0 kg, and BMI 42.1±5.3 kg/m(2)] underwent laparoscopic sleeve gastrectomy. Bone mineral density (BMD) at lumbar spine, femoral neck, total hip, and total body, and body composition were evaluated at baseline and 3, 6, and 12 months after surgery.Weight, BMI, waist and hip circumferences decreased significantly. Total body bone mineral content (TBBMC) increased by 2.5±3.5%, and fat, lean body mass, total mass and fat-% decreased significantly by 38.9±12.0%, 15.4±5.9%, 26.5±8.1%, and 17.6±8.9%, respectively. Slight decreases in total body (0.6±2.2%) and spine (1.2±7.1%) BMD were not significant, whereas total hip and femoral neck BMD decreased significantly by 5.3±8.2%, and 6.2±7.0% (p<0.001). Change (Δ) in TBBMC correlated only with Δ in weight (r=0.38, p<0.05) whereas Δ in all other body composition parameters correlated significantly with Δ in body weight and circumferences (r=0.46-0.98). The Δ in BMD (except total body BMD) correlated significantly with Δ in body composition parameters (r=0.34-0.59). Baseline fat and lean content besides changes in body fat and lean mass accounted for bone changes. In conclusion, bone loss after bariatric surgery is related to post-operative changes in body composition, as well as to weight loss and decrease in waist and hip circumferences.

[Acute abdominal surgery in pregnancy - as viewed by the surgeon]. / Operace v tehotenství pro náhlé príhody brisní z pohledu chirurga.

INTRODUCTION: Acute abdomen during pregnancy presents very specific problem on the boundary of surgery and gynaecology. Although gynaecologists provide healthcare to pregnant women, surgery indication because of acute abdomen during pregnancy should be done by surgeon (who has usually little knowledge and experience regarding pregnant women examination and management). There is therefore real opportunity for possible mistakes origin with serious consequences for mother and foetus. METHODS: Literature search in PubMed was done aimed at studies within the last 10 years dealing with appendectomy, cholecystectomy and laparoscopy during pregnancy in the context of acute abdomen. Surgical interventions done from obstetrics indications were excluded. RESULTS: Pregnancy is associated with many anatomical and physiological changes which have to be considered not only during clinical examination, but also when analysing laboratory findings and considering operative tactics. Imaging modalities employment during pregnancy is very limited due to harmful effect of ionising radiation and not clear impact of strong magnetic field on the foetus. Timing of surgical interventions because of acute abdomen during pregnancy should be the same as timing of acute abdomen interventions in non-pregnant patients. Minimally invasive surgery in acute abdomen during pregnancy presents standard technique nowadays. Many advantages of laparoscopic approach (lower rate of surgical site infections, quicker convalescence etc.) are valid also during pregnancy. CONCLUSION: Acute abdomen during pregnancy should be managed within a multidisciplinary cooperation between gynaecologist, surgeon, anaesthesiologist and neonatologist. With respect to results of published studies, laparoscopic approach in the management of acute abdomen during pregnancy should be considered safe and effective.

[Current standards of care in the management of patients with abdominal sepsis]. / Soucasné standardy v péci o pacienty s brisní sepsí.

INTRODUCTION: Abdominal sepsis patient management is an issue of high current importance, and the amount of knowledge keeps increasing and changing the approach to critically ill patients with abdominal sepsis. METHODS: Literature search (in MEDLINE, PubMed and Google Scholar databases) was done, focused on identification of relevant studies. The aim of this paper is to provide a review of current trends in diagnosing and predicting the prognosis of, and recommended treatment standards for patients with abdominal sepsis. RESULTS: Abdominal sepsis is defined as the Systemic Inflammatory Response Syndrome (SIRS) with an abdominal infection requiring a surgical intervention to control the source; or SIRS with an infection within 14 days after any major surgery. Although many different monitoring and scoring systems exist, daily careful clinical examination is the most reliable diagnostic tool in identification of septic patients. Whenever abdominal sepsis is suspected, the gold standard comprises immediate administration of broad-spectrum antibiotics, transferring the patient to the intensive care unit, with surgical intervention and supportive intensive care based on current guidelines of the Surviving Sepsis Campaign. Source control surgery is the principal therapeutic modality for patients with abdominal sepsis. The most relevant negative prognostic factors include clinical signs of septic shock and the necessity of high doses of catecholamines. CONCLUSION: Early identification of septic patients and prompt implementation of a complex, evidence-based interdisciplinary approach are the principal conditions for improving healthcare outcomes of care provided to patients with abdominal sepsis.