Laparoscopic versus open liver resections for colorectal cancer liver metastases: short term results

INTRODUCTION

Analysis and comparison of short-term results of laparoscopic liver resections (LLR) and open liver resections (OLR) for colorectal cancer liver metastases (CRCLM).

METHODS

Retrospective analysis of patients operated for CRCLM in the time period from May 2007 to May 2019 (12 years) at the department of surgery, University Hospital Hradec Králové and University Hospital Královské Vinohrady.

RESULTS

206 liver resections were performed; 167 (81.1%) OLR and 39 (18.9%) LLR procedures. Conversion to open surgery was necessary in 6 cases (15.4%). LLR was associated with a longer operation time (194±107 min) vs (129±58 min) for OLR. The ICU stay, 3.5±4.3 days for OLR and 4.1±8.1 days for LLR, and the hospital stay, 11.9±8.3 days (OLR) vs 12.1±11.3 days (LLR), were comparable. Perioperative blood loss was lower in the LLR group, 189±166 ml vs 360±410 ml. Total transfusion rate was similar, 10.8% (OLR) vs 12.8% (LLR). Oncologic radicality was also comparable in both groups; negative resection margin was achieved in 78% (OLR) and 80% (LLR). Postoperative morbidity and mortality was comparable in both groups; morbidity was 33% (OLR) vs 31% (LLR), while mortality was 1.8% (OLR) vs 2.6% (LLR).

CONCLUSION

LLR for CRCLM provided comparable short-term results compared to OLR in our group of patients even in the learning curve period. However, it should be noted that the study group is a highly selected group of patients.

[An uncommon case of purulent mesenteric lymphadenitis]

The authors present a case of a middle-aged female with large isolated mesenteric lymphadenitis. Abdominal ultrasonography undertaken as a preventive assessment revealed a solid tumour mass in the left mesogastrium, sized 70x55x55 mm. A solid abdominal tumour such as a GIST or sarcoma was considered and the patient underwent elective laparoscopic surgery. The tumour was completely removed. Histopathological examination confirmed an unexpected result of nonspecific purulent mesenteric lymphadenitis. The authors discuss potential causes of mesenteric lymphadenitis.Key words: abdominal tumour mesenteric lymphadenopathy purulent lymphadenitis - solitary lymphadenopathy.

[Parametric monitoring of the quality of total mesorectal excision and surgical treatment of rectal carcinoma results of a multicenter study]

INTRODUCTION

Tumour size and the quality of its complete surgical removal are the main prognostic factors in rectal cancer treatment. The number of postoperative local recurrences depends on whether the mesorectum has been completely removed - total mesorectal excision (TME) - and whether tumour-free resection margins have been achieved. The surgery itself and its quality depend on the accuracy of preoperative diagnosis and detection of risk areas in the rectum and mesorectum, on the surgeons skills, and finally on pathological assessment evaluating whether complete tumour excision has been accomplished including circumferential margins of the tumour, and whether mesorectal excision is complete. The aim of our study was to implement and standardize a new method of evaluation of the quality of the surgical procedure - TME - in rectal cancer treatment using an assessment of its circumferential margins (CRO) and completeness of the excision.

METHODS

The study consisted of two parts. The first, multi-centre retrospective phase with 288 patients analysed individual partial parameters of the diagnosis, operations and histological examinations of the rectal cancer. Critical points were identified and a unified follow-up protocol was prepared. In the second, prospective part of this study 600 patients were monitored parametrically focusing on the quality of the TME and its effect on the oncological treatment results.

RESULTS

The proportion of patients with restaging following neoadjuvant therapy increased from 60.0% to 81.7% based on preoperative diagnosis. The number of specimens missing an assessment of the mesorectal excision quality decreased from 52.9% in the retrospective part of to the study to 22.8% in the prospective part. The proportion of actually complete TMEs rose from 22.6% to 26.0%, and that of nearly complete TMEs from 10.1% to 24.0%.

CONCLUSION

The introduction of parametric monitoring into routine clinical practice improved the quality of pre-treatment and preoperative diagnosis, examination of the tissue specimen, and consequently improved quality of the surgical procedure was achieved.

KEY WORDS

rectal cancer TME - parametric monitoring - quality control.

[Technical background of data collection for parametric observation of total mesorectal excision (TME) in rectal cancer]

INTRODUCTION

Improvement in any human activity is preconditioned by inspection of results and providing feedback used for modification of the processes applied. Comparison of experts experience in the given field is another indispensable part leading to optimisation and improvement of processes, and optimally to implementation of standards. For the purpose of objective comparison and assessment of the processes, it is always necessary to describe the processes in a parametric way, to obtain representative data, to assess the achieved results, and to provide unquestionable and data-driven feedback based on such analysis. This may lead to a consensus on the definition of standards in the given area of health care.

METHOD

Total mesorectal excision (TME) is a standard procedure of rectal cancer (C20) surgical treatment. However, the quality of performed procedures varies in different health care facilities, which is given, among others, by internal processes and surgeons experience. Assessment of surgical treatment results is therefore of key importance. A pathologist who assesses the resected tissue can provide valuable feedback in this respect.

RESULTS

An information system for the parametric assessment of TME performance is described in our article, including technical background in the form of a multicentre clinical registry and the structure of observed parameters.

CONCLUSION

We consider the proposed system of TME parametric assessment as significant for improvement of TME performance, aimed at reducing local recurrences and at improving the overall prognosis of patients.

KEY WORDS

rectal cancer total mesorectal excision parametric data clinical registries TME registry.

Small carcinomas involving less than one-quarter of the rectal circumference: local excision is still associated with a high risk of nodal positivity

AIM

A study was carried out to determine the relationship between mesorectal lymph nodal involvement and T stage in a group of patients with a rectal cancer involving less than one-quarter of the rectal circumference, such as might be selected for local excision.

METHOD

The data of patients having rectal resection between 2010 and 2014 were prospectively entered in a rectal carcinoma registry. A model for describing tumours involving less than one quadrant of the rectal circumference was created to facilitate the evaluation process.

RESULTS

In all, 304 patients were included in the study. In 68 (22.4%) a small tumour (< 1 quadrant involved) was found. Of these, 26.5% had positive mesorectal lymph nodes (N+). In lesions of Stage ypT0 cancer 12.5% patients were node positive, in Stage Tis and T1 tumours there was no case of node positivity, but in Stage T2 and Stage T3 cancers the incidence of node positivity was 27.5% and 64%.

CONCLUSION

The study demonstrated that, even for small tumours involving only one rectal quadrant, the risk of lymph nodal involvement was about 25%. Had the patients undergone local excision the treatment would have been incomplete.

Endovascular Management of Acute Embolic Occlusion of the Superior Mesenteric Artery: A 12-Year Single-Centre Experience

PURPOSE

Retrospective evaluation of 12-year experience with endovascular management of acute mesenteric ischemia (AMI) due to embolic occlusion of the superior mesenteric artery (SMA).

MATERIALS AND METHODS

From 2003 to 2014, we analysed the in-hospital mortality of 37 patients with acute mesenteric embolism who underwent primary endovascular therapy with subsequent on-demand laparotomy. Transcatheter embolus aspiration was used in all 37 patients (19 women, 18 men, median age 76 years) with embolic occlusion of the SMA. Adjunctive local thrombolysis (n = 2) and stenting (n = 2) were also utilised.

RESULTS

We achieved complete recanalization of the SMA stem in 91.9 %. One patient was successfully treated by surgical embolectomy due to a failed endovascular approach. Subsequent exploratory laparotomy was performed in 73.0 % (n = 27), and necrotic bowel resection in 40.5 %. The total in-hospital mortality was 27.0 %.

CONCLUSION

Primary endovascular therapy for acute embolic SMA occlusion with on-demand laparotomy is a recommended algorithm used in our centre to treat SMA occlusion. This combined approach for the treatment of AMI is associated with in-hospital mortality rate of 27.0 %.

[Current status in the treatment of rectal cancer in the Czech Republic regarding the rate of complete pathological response after neoadjuvant therapy--PATOD C20 study 2011-2012]

INTRODUCTION

Deciding on the strategy in rectal cancer´s treatment requires a complex and multidisciplinary approach. The primary rectal resection is indicated in early stages, while locally advanced tumors should be pretreated by one of the modes of neoadjuvant (chemo) radiotherapy. The main goal of this study was to explore the therapeutic strategy in patients with rectal cancer in the Czech Republic. The second aim was to determine the incidence of the pathological complete response after neoadjuvant therapy.

METHODS

This is a retrospective multicenter clinical study, which includes data from all patients with rectal cancer who were treated at participating centers in the period from 01/01/2011 to 31/12/2012. The required data has been passed into the online registry PATOD C20.Three issues have been set up: 1. Characteristics of the center and cooperation with the oncological department; 2. Characteristics of the treatment of patients with rectal cancer; and 3. Detailed analysis of the group of patients with complete pathological response. The analysis was performed with regard to the nature of individual departments, i.e. departments of surgery in university hospitals with complex oncological centres, departments of surgery within complex oncologic centers, and departments of surgery outside complex oncologic centers.

RESULTS

In total, 21 departments of surgery in the Czech Republic provided data about 1860 patients with rectal cancer for the study. The treatment strategy for rectal cancer was determined at multidisciplinary seminars at 19 centers (90.5%). Statistically significant differences between the centers were found in the indication for neoadjuvant treatment (p<0.001), rectal resection with anastomosis (p=0.048), and resection without anastomosis (p=0.022). Complete pathological response was found in 61 (8.7%) patients. Positivity of mesorectal lymph nodes (ypN+) was found in the case of ypT0 stage in 7 (9.7%) patients.

CONCLUSION

PATOD study showed that therapy of rectal cancer is highly heterogeneous in the Czech Republic. Despite the best conditions provided, university hospitals and large departments within complex oncologic centers do not fully utilize this benefit.

[Popliteal artery entrapment syndrome]

Popliteal artery entrapment syndrome is a rare cause of lower limb ischaemia. It is caused by an abnormal relationship between popliteal artery and its surrounding musculotendineous structures (anatomic entrapment). Functional popliteal entrapment is characterized by normal anatomic relationships within popliteal fossa. The true incidence is unknown, it usually affects young patients, typically men, and is clinically presented with symptoms of calf claudication, calf cramping, coldness and paresthesia. CT angiography and MR angiography have become an imaging technique of choice. The mainstay surgical procedure is popliteal artery release. In cases of popliteal artery damage autologous saphenous vein bypass grafting offers the best long-term results. Authors on the basis of two case reports describe the clinical course, diagnosis and surgical technique used in the treatment of patients with advanced popliteal artery entrapmentsyndrome.

[Complicated mesenteric ischaemia]

Acute mesenteric ischaemia is a serious condition associated with high morbidity and mortality. Atherosclerosis is one of the most frequent etiologic factors. This case report presents a patient suffering from acute mesenteric ischaemia complicated by acute lower limb ischaemia and post-ischaemic stenosis of the ileum. Such a patient requires a multidisciplinary, comprehensive, and, in some cases, phased approach to solve complications brought about especially by generalized atherosclerosis.

[Predicting pN positivity in T3 rectal cancer]

INTRODUCTION

Stage pN+ is a factor which determines the strategy for treatment of T3 rectal cancer. The sensitivity of preoperative imaging examinations revealing N+ is not entirely satisfactory. Risk factors that are associated with pT3pN+ stage and that are detectable by preoperative examination have not been reliably identified. The aim of the study is to analyze the predictive factors determining lymph node involvement in T3 rectal cancer.

MATERIAL AND METHODS

Patients with rectal resection for (y)pT3 rectal cancer were analysed. All of the surgical interventions were performed at the Department of Surgery, University Hospital in Hradec Kralove, from 1 January 2011 to 28 February 2014. Data were prospectively collected and saved in the Rectal Cancer Oncologic Register. The parameters studied were age, gender, tumour localisation and its circumferential topography, preoperative chemoradiotherapy, absolute number of harvested lymph nodes and the number of positive lymph nodes in each specimen, tumour grading, presence of lymphovascular invasion and perineural invasion, and the depth of tumour penetration.

RESULTS

After selection, 89 patients with T3 rectal cancer were included into the study. Resection for cancer of the upper rectum was performed in 22 (24.7%) patients, middle rectum in 37 (41.6 %) and lower rectum in 30 (33.7%) patients. 38 (42.7%) patients underwent primary operation, 41 (46.1%) patients received neoadjuvant chemoradiotherapy, and radiation therapy was administered to only 10 (11.2%) patients. Stage pN+ was found in 51 (57.3%) patients. Statistical analysis was used to identify the risk factors for pN+: lymphovascular invasion (p0.001), angioinvasion (p=0.030) and perineural invasion (p=0.010). On the border of statistical significance for pN+, low grading of the tumour (p=0.084) was found. The depth of penetration of the tumour into the mesorectum was not statistically significant (p=0.230).

CONCLUSION

Our study has shown that pN positivity is associated with lymphovascular invasion, perineural invasion and low grading of the tumour. Accurate identification of these factors before treatment, however, remains very difficult.

[Influence of preoperative chemoradiotherapy on changes of epidermal growth factor receptor expression in patients treated by preoperative chemoradiotherapy for local advanced rectal carcinoma]

AIM

The aim of this retrospective study was to determine the prognostic impact of expression of epidermal growth factor receptor (EGFR) changes during neoadjuvant chemoradiotherapy in patients with locally advanced rectal adenocarcinoma.

MATERIAL AND METHODS

One hundred and three patients with locally advanced rectal adenocarcinoma of stage II and III were evaluated. All patients were administered the total dose of 44 --  50.4 Gy. Concomitantly, the patients received capecitabine in the dose 825 mg/ m² in two daily oral administrations or 5- fluorouracil in the dose 200 mg/ m² in continuous infusion. Surgery was indicated at intervals of 4-8 weeks from chemoradiotherapy completion. EGFR expression in the pretreatment biopsies and in resected specimens was assessed with immunohistochemistry.

RESULTS

All of 103 patients received radiotherapy without interruption up to the total planned dose. Downstaging was described in 64 patients. Six patients had complete pathologic remission. Recurrence occurred in 49 patients. Local recurrence was found in 22 patients, generalization of disease was reported in 27 patients. A total of 51 patients died. Increased EGFR expression was found in 26 patients. The statistically significantly shorter overall survival (p < 0.001) and disease-free survival (p < 0.001) was found in patients with increased expression of EGFR compared with patients where no increase in the expression of EGFR was observed during neoadjuvant chemoradiotherapy.

CONCLUSIONS

The overexpression of EGFR during neoadjuvant chemoradiotherapy for locally advanced rectal adenocarcinoma is associated with significant shorter overall survival and disease-free survival.

[Pilonidal sinus - possibilities surgical treatment]

INTRODUCTION

Pilonidal sinus is a skin disease affecting the sacrococcygeal region caused by chronic irritation of the skin by ingrowing hairs that get pushed into skin sinuses and follicles. The acute form of the disease which is presented by subcutaneous abscesses very often develops into chronic suppurative subcutaneous fistula. The incidence of pilonidal sinus is approximately 26/100,000 people. Radical surgical excision using skin flaps is essential for successful treatment.

MATERIALS AND METHODS

The results of surgical treatment were analysed retrospectively. All surgical procedures evaluated were performed at the Department of Surgery, University Hospital in Hradec Kralove, from January 2010 to June 2014. The parameters analysed were gender, age, method used to close the defect, length of hospital stay, overall morbidity including pilonidal sinuses recurrence.

RESULTS

141 patients undergoing radical excision for pilonidal sinus were analysed. Primary suture was used in 101 (71.6%) patients. Limberg flap reconstruction was performed in 16 (11.3%) patients and Karydakis procedure was used in 24 (17.0%) patients. The length of hospital stay was 4.2 days. 19 operations were performed for recurrent pilonidal sinus. Norecurrence occurred after Karydakis procedure, there were 3 cases of recurrence after Limberg flap reconstruction, and 8 patients experienced recurrence after primary suture. The overall incidence of recurrence was 7.8%. Surgical site complications were recorded mostly after primary suture (37 patients, 26.2%). Conversely, surgical site complications appeared in the Limberg flap group in 2 patients (12.5%) and in theKarydakis procedure group in 1 patient (4.2%).

CONCLUSION

Limberg flap reconstruction and Karydakis procedure lead to better results in pilonidal sinus surgery, especially as regards lower recurrence rates and overall morbidity. Both of these procedures are relatively easy to perform and technically undemanding.

[The role of drains in pancreatic surgery]

Pancreatic fistula is a significant complication following pancreatic resection. Several methods aimed at lowering the postoperative pancreatic fistula rate were studied in the past. These methods mainly include pharmacological prophylaxis and technical modifications of pancreatic remnant management. Another method which can influence postoperative pancreatic fistula rate is the use of and the manipulation with intra-abdominal drains following pancreatic resection. Recent studies have shown that the use of the drains, the type of drain and manipulation with the drains can influence the outcomes. The aim of this review is to summarize current knowledge about the use of drains in pancreatic surgery. There are three questions to ask when studying the use of drains in pancreatic surgery: 1) Whether to use the drains at all 2) When to remove the drains? 3) Which type of the drain is more appropriate? Ad 1) Despite the growing number of studies showing comparable or even better results in patients without intra-abdominal drains following pancreatic resection, the latest randomized study proved that avoiding the use of drains is associated with more clinically significant postoperative complications and higher postoperative mortality. It is also important to consider the risk factors of pancreatic fistula development, especially pancreatic texture and the main pancreatic duct diameter. Currently, pancreatic resection without intra-abdominal drains cannot be routinely recommended. Ad 2) Two studies addressed the question when to remove the drains after pancreatic resection, and both studies clearly showed that early removal brings better results. Ad 3) No study has specifically addressed the question whether the type of drain can influence the rate of postoperative pancreatic fistula and of other complications. Gravity drains and closed-suction drains are most commonly used nowadays. The closed-suction drains are more effective due to the active suction. On the other hand, active suction can cause leak of the amylase-rich fluid through the pancreatic anastomosis or suture line and thus promote the development of pancreatic fistula or even worsen its clinical significance. There are no data in the literature so far regarding the type of drain. Therefore, we have commenced a randomized control trial which aims to compare closed-suction drains and closed gravity drains.

[Basic principles of diagnosis and treatment of secondary peritonitis - recommendations of experts with the support of SIS]

Secondary peritonitis is the most common cause of inflammatory acute abdomen treated at general surgery departments. Only early and correct diagnosis may improve the prognosis of these patients. The authors compiled an interdisciplinary review of the basic principles of diagnosis and treatment of secondary peritonitis, which reflects current findings supported by evidence-based medicine. The work is based on published international literature but also shares opinions and experiences of the selected specialists. The presented work in its extent is not meant to substitute an in-depth study of the issue, but to allow a basic and quick review of the topic.

[Evaluation of safe resection margins in rectal carcinoma]

The fact that surgically well performed total mesorectal excision with negative circumferential resection margin represents one of the most important prognostic factors in colorectal carcinoma is already well known. These parameters significantly affect the incidence of local tumour recurrence as well as distant metastasis, and are thus related to the duration of patient survival. The surgeons task is to perform mesorectal excision as completely as possible, i.e., to remove the rectum with an intact cylinder of mesorectal fat. The approach of the pathologist to evaluation of total mesorectal excision specimens differs greatly from that of resection specimens from other parts of the large bowel. Besides evaluation of the usual parameters for colon cancer staging, it is essential to assess certain additional factors specific to rectal carcinomas, namely tumour distance from circumferential (radial) resection margins and the quality of the mesorectal excision. In order to accurately evaluate these parameters, knowledge of a wide range of clinical data is indispensable (results of preoperative imaging, intraoperative findings). For objective evaluation of these parameters it is necessary to introduce standardized procedures for resection specimen processing and macro and microscopic examination. This approach is based mainly on standardized macroscopic photo-documentation of the integrity of the mesorectal surface. Parallel transverse sections of the resection specimens are made with targeted tissue sampling for histological examination. It is essential to have close cooperation between surgeons and pathologists within a multidisciplinary team enabling mutual feedback.

Solid pseudopapillary tumour of the pancreas: diagnosis, treatment, and prognosis

BACKGROUND

Solid pseudopapillary tumour (SPT) of the pancreas is a relatively rare entity which most commonly occurs in young women. In this paper we report our clinical experience together with the current knowledge on the diagnostics, treatment and prognosis of this rare tumour.

METHODS

We reviewed hospital records of patients diagnosed with a solid pseudopapillary tumour of the pancreas between January 2002 and December 2011 at the Department of Surgery, University Hospital Hradec Králové, Czech Republic. Clinical, operative, pathological data were obtained on all the patients.

RESULTS

Over the 10-year period of the study we performed 181 planned pancreatic resections in our department. Overall, the 30-day postoperative mortality rate in this series of patients was 2.2%. SPT was diagnosed in 4 cases. All the patients were women and the average age was 34 years. Preoperative endosonography with biopsy sample was performed in all the patients and the diagnosis of SPT was known in all the patients before the surgical procedure.

CONCLUSIONS

The current knowledge of SPT is based only on case reports and small series. It typically occurs in young women and therefore the presence of a large pancreatic mass in a young woman may suggest a diagnosis of SPT. SPT has a low malignant potential and the prognosis is excellent following complete surgical resection in the majority of the cases.

[Rectal cancer within 10 cm. Comparison of the radicality of laparoscopic and open surgical techniques with regard to the circumferential resection margin and the completeness of mesorectal excision]

INTRODUCTION

The issue of achieving radical circumferential margin in laparoscopic rectal surgery has not yet been satisfactorily clarified. In this paper we have focused on circumferential margin assessment and the quality of the mesorectal excision, comparing laparoscopic and open resection for cancer of the middle and lower rectum.

MATERIAL AND METHODS

The results of surgical procedures for middle and low rectal cancer were analysed. All the interventions were performed at the Department of Surgery, Teaching Hospital in Hradec Kralove, during the period from January 2011 to December 2012. The data were prospectively collected and entered in the Rectal Cancer Registry. Age, gender, BMI, tumour localisation and topography, the clinical stage, preoperative chemoradiotherapy and response to it, the type of surgery, distal and circumferential margin characteristics, mesorectal excision quality, pT and pN were compared for laparoscopic and open surgery.

RESULTS

A total of 161 patients were operated on for rectal cancer during the abovementioned period. 94 patients were included in the trial following selection. Laparoscopy was used in 40 patients and open surgery in 54 patients. Laparoscopic approach was performed in 33 (82.5%) low anterior resections (including four intersphincteric resections), 6 (15%) abdominoperineal amputations and 1 (2.5%) Hartmanns procedure. Open surgery was used for 26 (48.1%) low anterior resections, 21 (38.9%) APR and 7 (13%) Hartmanns procedures. Complete mesorectal excision was achieved in 45% of the laparoscopic resections vs. 46.3% of open resections. Nearly complete excision was performed in 22.5% and 11.1%, respectively. Finally, incomplete excision was described in 30% vs. 38.9%. No available data for TME was detected in three patients. The differences in TME were not statistically significant. Positive circumferential margin was found in 5 (12.5%) patients in the laparoscopy group; on the contrary, in the group undergoing open surgery, pCRO+ was found in 15 (27.8%) patients. Here, too, the results were not statistically significant. When patients without preoperative chemoradiotherapy were excluded, the relationship between ypCRM in the laparoscopy and open surgery group was on the border of statistical significance (Fischer=0.0556).

CONCLUSION

As has been shown in our trial, the outcomes of laparoscopic and open approach in rectal cancer treatment are very similar. Particularly, mesorectal excision quality and negative CRM results have proven that the laparoscopic technique is safe and comparable to open surgery in rectal cancer treatment.

[The radicality of surgical resection in rectal cancer. Analysis of factors associated with incomplete mesorectal excision]

INTRODUCTION

Circumferential resection margin (pCRM) and the completeness of mesorectal excision (ME) are two independent prognostic factors significantly associated with the radicality of surgical treatment. Positive pCRM and incomplete mesorectal excision are associated with a significantly higher incidence of local recurrence and worse patient prognosis. The aim of this article is to analyze the risk factors associated with incomplete mesorectal excision.

MATERIAL AND METHODS

Patients operated on at the Department of Surgery, University Hospital Hradec Kralove between January 2011 and February 2013 were included in the study. The patients data were prospectively collected and entered in the Dg C20 registry. The following factors were analyzed: sex, age, BMI, cN, pT, clinical stage, the involved segment of the rectum, neoadjuvant therapy, circumferential tumour location, the type of surgical approach and the type of surgery.

RESULTS

168 patients were operated on during the above period. 9 (5.3%) palliative stomas and 159 (94.6%) resection procedures were performed in this group of 168 patients. 7 (4.4%) patients were excluded because the quality of excision was not assessed in them. 114 (75%) resections, including 5 intersphincteric resections, were performed in the group of the remaining 152 patients. 10 (7%) were Hartmanns procedures a 28 (18%) were amputation procedures. Out of 152 procedures, 69 (45%) were performed laparoscopically. Positive (y)pCRO was recorded in 26 (17%) patients, predominantly after abdominoperineal resection (APR) - 11 out of 27 (41%), and Hartmanns operation - 6 out of 10 (60%). Incomplete ME was observed in 45 patients (30%), complete ME in 81 patients (53%) and partially complete in 26 patients (17%). Univariate analysis confirmed statistically significant factors associated with incomplete mesorectal excision: (y)pT (P = 0.00027), type of surgery (P = 0.00001) and tumour location (P = 0.00001). Multivariate analysis then confirmed two independent prognostic factors associated with incomplete mesorectal excision. It was the location of the tumour in the distal third of the rectum and the (y)pT stage of the tumour.

CONCLUSION

Distal rectum tumor location and higher (y)pT are associated with a higher risk of incomplete mesorectal excision with worse patient prognosis.

[Pancreatic fistula - definition, risk factors and treatment options]

Pancreatic fistula is a common complication after pancreatic resections. Its incidence oscillates between 10 and 30%. The differences in the incidence cited in the studies are due to the various fistula definitions. According to ISGPF, pancreatic fistula is an output -via an operatively placed drain (or a subsequently placed percutaneous drain) - of any measurable volume of drain fluid on or after postoperative day 3, with an amylase content higher than 3 times the upper normal serum value. The fistula is then classified according to the clinical impact in grades A, B, and C. There are known three risk factor categories for the development of pancreatic fistula: the risk related to the pancreatic disease, to the patient, and to the surgical procedure. Most of the risk factors for the development of pancreatic fistula cannot be influenced either prior to or during the surgery. There are two basic options for the prevention of pancreatic fistula: pharmacological intervention (administration of somatostatin and its analogues) and technical modifications of the pancreatic remnant treatment. However, the routine administration of somatostatin and its analogues is not advisable in all pancreatic surgical procedures. In high risk cases the selective administration is preferred. The second option is modification of pancreatic remnant treatment. Most of the studies dealing with various modifications of the pancreatic remnant treatment were retrospective with lower level of evidence. There were only a few properly designed randomized trials, and most of them did not prove benefit of one method over another. It has been shown that the results depend on the experience of a given surgical department, and above all on the experience of an individual surgeon who performs the pancreatic resection. The therapy of pancreatic fistula is based on the clinical severity. Conservative approach is warranted in most patients. In cases when reoperation is required, there are two basic strategies: surgical drainage of the collections, and completion of total pancreatectomy. Total pancreatectomy was preferred in the past, however, this procedure is technically very demanding with mortality up to 80 per cent. Nowadays, most of the authors prefer surgical drainage; this procedure is technically less demanding, has lower mortality, the endocrine function of pancreas is protected, and the patients usually need no further interventions.

[Classification of surgical complications: analysis of the group of consecutive patients]

INTRODUCTION

The aim of the work was to evaluate the implementation of Clavien - Dindo classification of surgical complications into a routine clinical praxis and to evaluate the results achieved at the university department of surgery.

MATERIAL AND METHODS

Prospectively collected data of patients hospitalized at the Clinic of Surgery of the University Hospital in Hradec Králové between January 2010 and September 2012 were retrospectively evaluated. Incidence, spectrum and severity of postoperative complications were evaluated according to individual surgical specializations.

RESULTS

9039 patients were operated and enrolled into the database during the time period from January 2010 to October 2012. A surgical complication was recorded in 1248 (12.9%) patiens, grade I. in 284 (3.4%) cases, grade II. in 384 (4.3%) cases, grade III in 370 (4.1%) cases, grade IV. in 67 (0.7%) patients. Death,i.e. grade V., occurred in 143 (1.43%) patients.

CONCLUSION

Clavien - Dindo classification of surgical complications was successfully implemented into a routine clinical praxis at the department of surgery, University Hospital Hradec Králové. Wider use of this classification system would improve conditions for evaluation and comparison of results between different surgical approaches, surgeons or departments.

[STARR surgery in the treatment of rectocele and rectal intussusception]

INTRODUCTION

Rectocele and intussusceptions are amongst the most frequent causes of Obstructed Defecation Syndrome (ODS). ODS diagnostics has been constantly improving which results in more precise indication criteria for individual surgical approaches. The work discusses indications for Stapled TransAnal Rectal Resection (STARR) as well as the results of the seven-year follow-up.

MATERIAL AND METHODS

Female patients with ODS score over 7 were indicated for STARR procedure after all conservative treatment possibilities failed. The proper indication requires that other causes of ODS be excluded. The retrospective analysis of prospectively collected data was employed.

RESULTS

Between January 2005 and October 2012 29 STARR procedures for rectocele were performed. Morbidity rate of the set of our patients was 6.9%. None of the patients died. We recorded bleeding from the staple line in seven patients (without surgical revision), and urinary infection in two patients. Bleeding from staple line was present in seven causes and urinary infection was present twice.

CONCLUSION

The STARR procedure seems to be an effective and safe treatment for ODS associated with rectocele and intussusception. The overall morbidity rate is low. Further investigation is required to optimize patient's selection and to reduce the potential complications and failure during postoperative period.

Hepatic arterial infusion of oxaliplatin, 5-fluorouracil and leucovorin in patients with liver metastases from colorectal carcinoma

PURPOSE

Limited data are available regarding the efficacy of hepatic arterial infusion (HAI) of oxaliplatin in patients with liver metastases from colorectal carcinoma (CRC). The aim of the present study was to evaluate the results of HAI of oxaliplatin combined with 5-fluorouracil (5-FU) and leucovorin (LV) in patients with such metastases.

METHODS

A retrospective analysis of 22 CRC patients treated with HAI of combination of oxaliplatin and 5-FU and LV was performed.

RESULTS

Partial response (PR) was observed in 4 (18%) patients and stable disease (SD) in 7, with an overall disease control rate of 50%. The median progression-free (PFS) and overall survival (OS) were 7 and 11 months, respectively. Two patients treated with first-line treatment underwent subsequent liver resection. In 2 patients, HAI of oxaliplatin, 5-FU and LV was combined with systemic administration of bevacizumab.

CONCLUSION

Our data demonstrate reasonable efficacy of HAI with oxaliplatin, 5-FU and LV in patients with liver metastases from CRC.

[Palliative surgical treatment of tumors of pancreas and periampullary region]

BACKGROUNDS

Pancreatic cancer is an aggressive malignant disease with increasing incidence. Radical resection, the only potentially curative method, is possible in only 20-30% of patients. The main symptoms of advanced non-resectable pancreatic head tumors include obstructive jaundice, caused by stenosis of distal common bile duct, duodenal obstruction and pain, especially in the epigastric region and back. The aim of palliative treatment is to relieve these complaints. This paper evaluates our own palliative surgical treatment results in patients with pancreatic head and periampullary region cancer.

PATIENTS AND METHODS

This study included all patients with pancreatic head and periampullary region cancer who underwent surgery at the Department of Surgery, University Hospital in Hradec Kralove from 1st January 2006 to 31st December 2010. The aim of the surgery in all patients was to resect the tumor. Palliative surgical procedure was performed in patients witn an inoperable tumor. We performed gastro-entero anastomosis in all the patients. When perioperative situation allowed, hepatico-jejuno anastomosis was performed in patients with obstructive jaundice. Surgical splanchnicectomy was performed in patients with back pain.

RESULTS

Over five years, we performed a surgery in 94 patients for malignant disease of pancreas and periampullary region. Radical resection was performed in 45 patients. Palliative bypass procedure was performed in 42 patients. Exploration only was performed in 7 patients. Postoperative complications after palliative bypass procedures were noted in 15 patients (30.6%), the majority of these complications were minor.

CONCLUSION

The advantage of surgical hepatico-jejuno anastomosis over endoscopically placed stent is particulary in superior long-term patency. Therefore, it is advisable to perform these procedures in patients with longer expected survival. Morbidity associated with palliative surgical procedures was relatively low and there was no mortality.

[Gun-shot injuries to the abdomen involving the pancreas]

PURPOSE OF THE STUDY

The aim of the study is to present our experience with the diagnosis and therapy of penetrating abdominal injury involving the pancreas caused by a gun shot.

MATERIAL AND METHODS

The group included patients with gun-shot abdominal injuries involving the pancreas who were treated at the Department of Surgery and the Department of Emergency Medicine at the University Hospital Hradec Králové. The extent of pancreatic injury was assessed using the American Association for the Surgery of Trauma (AAST) classification. The factors evaluated included the timing of surgery, operative strategy, operative time, blood loss, post-operative complications with pancreatic fistulas in particular, and the length of hospital stay. Pancreatic fistula was assessed according to the ISGPF (International Study Group for Pancreatic Fistula). RESULTS During the period of study lasting 10 years, three patients with gun-shot abdominal injuries involving the pancreas were treated.

DISCUSSION

Pancreatic trauma due to a gun shot is a rare injury, but has also been reported in the Czech Republic. In any penetrating injury to the abdomen due to a gun shot, surgical exploration is always indicated and pancreatic trauma is usually found during the surgery. The first step in the procedure is to check all potential sources of bleeding because uncontrolled bleeding is the most frequent cause of intra-operative death. In a seriously injured patient, the technique of damage control surgery must be employed. After the major sources of bleeding have been checked, a thorough exploration of all abdominal organs should be performed to ascertain whether the main pancreatic duct has not been injured and, if so, in which part of the pancreas and to what extent. The correct classification of pancreatic injury according to the AAST is necessary to indicate appropriate therapy. Exploration for injury to other organs that often accompanies pancreatic trauma is a necessity.

CONCLUSIONS

Penetrating pancreatic trauma is almost always associated with injury to the adjacent organs. All patients with gun-shot injuries to the abdomen are indicated for surgical exploration, thus the pancreatic injury is often found at the surgical exploration. After bleeding has been controlled, for treatment of the injured pancreas, simple drainage, or suture of the pancreatic capsule, or pancreatic resection or a patch with an excluded jejunal loop can be used. Partial duodenopancreatectomy is the last option because this procedure is associated with high morbidity and mortality.

Giant biliary cystadenoma: a case report

Biliary cystadenoma is a very rare benign cystic tumour of the liver. Fewer than 150 cases have been described in the literature so far. The authors present a case of a 29-year-old female with a giant intrahepatic biliary cystadenoma who presented with abdominal pain and obstructive jaundice. The patient was treated with left hepatectomy and now 12 months after the surgery she is in good condition with no signs of recurrence of the disease. Clinical presentation of biliary cystadenoma is not specific. Diagnosis is based on imaging methods, mainly ultrasound and CT scan. However, it is often misdiagnosed. For treatment, radical resection is advocated because a biliary cystadenoma is considered to be a premalignant lesion. The prognosis of biliary cystadenoma after complete resection is excellent. Nevertheless, there is a risk of recurrence or malignant transformation after incomplete resection.

Radiofrequency-assisted liver resection: higher incidence of infectious complications?

AIM

To evaluate clinical experience with radiofrequency (RF)-assisted liver resection in non-cirrhotic and non-cholestatic patients with metastatic liver disease.

METHODS

A group of consecutive patients who underwent RF-assisted liver resection for metastatic liver disease was prospectively followed.

RESULTS

Between July 2005 and April 2008, 95 liver RF-assisted liver resections were performed, 71 of them for metastatic liver disease. The mean hospital stay was 14 (range 5-40) days. The mean operation time was 141 (range 64-233) minutes. The mean duration of RF coagulation was 10 (range 9-12) minutes. A total of 37 complications in 24 (33%) patients were recorded, including 12 (16.9%) infected collections in resection line that had to be drained percutaneously. The 30-day postoperative mortality was zero.

CONCLUSION

This study indicates that RF-assisted resection may have a benefit in decreasing peroperative blood loss and the number of blood transfusions. Nevertheless, an increased incidence of infectious complications and pleural effusions that required evacuation was noted.

[Current trends of surgical therapy of focal liver and pancreatic lesions]

Focal liver and pancreatic lesions represent important therapeutic problem in a relatively huge group of patients. Secondary liver tumors are the crucial factor affecting morbidity and mortality in patients with malignancies. Radical surgery is the only therapeutic option that gives the chance of long-term survival. The authors present current trends in surgical therapy of liver and pancreatic tumors as a review article.

[Laparoscopic pancreatic resections in experimental setting and clinical practice]

INTRODUCTION

Pancreatic fistula is a major postoperative complication after pancreatic resection. One of the main risk factors of developing the pancreatic fistula after distal pancreatectomy is the method employed for the management of the pancreatic remnant.

AIM OF THE STUDY

The aim of the experimental part of this work was to test a novel method of management of the pancreatic remnant after distal pancreatectomy on a large laboratory animal. Furthermore, based on the experience with the experimental work to introduce the laparoscopic approach to human clinical practice.

METHODS

In the experimental part of the work laparoscopic distal pancreatectomy with spleen and splenic vessels preservation was performed in ten female domestic pigs. The experimental animals were divided into two groups. In the first group the pancreas was transected using an EndoGIA Universal Stapler and in the second group, the pancreas was transected using a Ligasure device and the pancreatic remnant was reinforced with hydrogel sealant Pleuraseal. We introduced the laparoscopic distal pancreatectomy to clinical practice in the Department of Surgery in Hradec Králové in 2009. Transection of the pancreas was performed with staplers.

RESULTS

In the experimental part of the work the postoperative course was uneventful in all the animals. All animals gained weight. Only minor macroscopic and microscopic alterations of the healing process were found. Statistical differences between the groups were not significant. In the clinical part of the work we performed laparoscopic distal pancreatectomy in 6 patients. We performed two distal pancreatectomies with splenectomy, one distal pancreatectomy with splenectomy and left nephrectomy and 3 distal pancreatectomies with the spleen and splenic vessels preservation. We did not have to convert to open procedure in any of the cases.

CONCLUSIONS

In the experimental part of the work we showed that the novel technique using Ligasure transection reinforced by the hydrogel sealant Pleuraseal is feasible and safe technique, which seems to be comparable with the standard transection technique using stapler. Our initial experience with laparoscopic distal pancreatectomy in the clinical practice cannot be used to compare various methods of management of the pancreatic stump or to evaluate the rate of pancreatic fistula in such small group of patients.

[Abdominal catastrophe--abdominal wall defect associated with gastrointestinal fistula--strategy of therapy]

BACKGROUND

Wound dehiscence complicated by gastrointestinal (GI) fistula to belong ,,abdominal catastrophe". Therapy is prolonged and connected with high morbidity and mortality rate.

METHODS

In the period from October 2006 to July 2009 we performed 12 reconstructive surgical procedures on gastrointestinal tract in patients with abdominal catastrophe. Treatment of 12 consecutive patients (9 men, 3 women) was managed according to a standardize protocol. The protocol consists of treatment of septic complications, optimisation of nutritional state, special wound procedures, diagnosis of gastrointestinal fistulas and GI tract, timing of surgical procedures, reconstruction of GI tract and postoperative care.

RESULTS

Reconstructive surgery of GI tract was successful on 11 patients. One patient developed recurrence of early GI fistula. In four patients we let open abdomen to heal per secundam. We observed no deaths after operation.

CONCLUSION

With regard to complex character of therapy of abdominal catastrophe there is a need of multidisciplinary approach. Considering long-lasting and expensive therapy there is logical step to concentrate these patients into special centres which are experienced, equipped and their staff is trained in treatment of such a seriously impaired patients.

Papillary adenoma of the extrahepatic biliary tract--a rare cause of obstructive jaundice

The authors present a case of papillary adenoma of the extrahepatic biliary tract presenting as obstructive jaundice. The diagnosis was based on the endoscopic retrograde cholangiopancreatography (ERCP), and above all cholangioscopy findings. The patient was treated by bile duct resection with Roux-en-Y hepaticojejunostomy. Adenoma of the bile duct is a rare entity. Only a few cases have been described in the world literature so far.

[Numbers of lymph nodes in large intestinal resections for colorectal carcinoma]

INTRODUCTION

Precise evaluation of lymph nodes in the surgical specimen is crucial for the staging and subsequent decision about the adjuvant therapy in colorectal cancer. Prognosis of the patients can be assessed only in cases when at least 12 lymph nodes in the surgical specimen are examined.

AIM OF THE WORK

To evaluate the radicalism of resections for colorectal carcinoma after introducing laparoscopic approach.

METHODS

We compared all resections for primary colorectal cancer and rectal cancer (C 18-C20) performed in the Department of Surgery in University Hospital Hradec Králové in the years 2005 and 2008 and we evaluated numbers of examined lymph nodes in the surgical specimens. The patients with recurrent tumours and the patients with complete pathological response (negative histology) after neoadjuvant therapy were excluded from the study.

RESULTS

117 patients were included in the study in 2005, 2 of them were operated laparoscopically. 155 patients (more by 32.5%) were included in the study in 2008, 53 of them (34.2%) were operated laparoscopically. In tumours of the right part of the colon (C180-C184) treated by right hemicolectomy: on an average 7.9 (+/- 5.3) lymph nodes were examined in the specimens in 2005, and 15.3 (+/- 7.0) lymph nodes in 2008. In tumours of the left part of the colon (C185-C186) treated by left hemicolectomy: 6.5 (+/- 5.1) lymph nodes were examined in 2005, and 19.6 (+/- 15.6) in 2008. In tumours of the sigmoid colon (C187) 9.1 (+/- 6.9) lymph nodes were examined in 2005,and 15.4 (+/- 7.9) in 2008. In tumours of the rectosigmoid junction (C19) 8.0 (+/- 6.9) lymph nodes were examined in 2005, and 17.8 (+/- 11.2) in 2008. In rectal cancer (C20) 5.2 (+/- 4.5) lymph nodes were examined in 2005, and 13.6 (+/- 12.5) in 2008. There is a significant difference in a number of examined lymph nodes in patients without neodadjuvant treatment compared to those with neoadjuvant chemoradiotherapy and neoadjuvant radiotherapy. In 2005, in an average 3.7 (+/- 3.3) lymph nodes were removed in rectal resections after neoadjuvant chemoradiotherapy, in 2008 in an average 7.6 (+/- 6.1) lymph nodes were removed. In 2005, in an average 5.1 (+/- 3.7) lymph nodes in rectal resections after neoadjuvant radiotherapy were removed, in 2008 6.3 (+/- 4.3) lymph nodes were removed. In 2005, in an average 7.0 (+/- 5.5) lymph nodes in rectal resections without neoadjuvant therapy were removed, in 2008 20.9 (+/- 14.1) lymph nodes were removed. Laparoscopic resections were comparable with open resections regarding the number of examined lymph nodes in our group of patients.

CONCLUSION

Introducing the laparoscopic approach to resections of colorectal carcinomas did not decrease radicalism of the operation as to the number of removed lymph nodes.

[Peritonitides caused by gastrointestinal perforations--analysis of an elderly patient group]

AIM

The aim of this study was to assess causes of peritonitides resulting from acute abdominal perforations in a group of elderly patients and to evaluate the yield of common classification systems in predicting the risks of postoperative complications, in particular of postoperative death rates.

PATIENTS AND METHODS

The retrospective analysis included 123 patients aged 70 y.o.a. and over (65 males, 58 females, the mean age was 78.7 y.o.a.), who underwent surgical revision for signs of peritonitis due to urgent GIT perforation, over a five-year period. The patients were assigned to groups based on their baseline diagnosis and on the procedure performed. The PSS (Peritonitis Severity Score) and MPI (Mannheim Peritonitis Index) classification systems factors were assessed. Statistical significance of the classification systems was evaluated, as well as their relation.

RESULTS

Overall death rate of the studied group was 30% (37 patients). The highest death rate related to the baseline diagnosis was observed in the GIT ischemia group (67%). Based on the procedure, the highest death rate was observed in the enterostomy group (75%). Overall morbidity related to a known wound infection was 24% (29 patients). Significant correlation between the both classification systems was demonstrated (Spearman's correlation coefficient 0.86). Of the all studied factors creating classification schemes, the following proved statistically most significant: ASA IV, peritonitis Hinchey grade III-IV, existing immunosuppression and signs of organ failure (p < 0.0001).

CONCLUSION

Perforation peritonitis remains a high risk condition, considering the postoperative morbidity rates, as well as the death rates. Perforation of the sigmoid diverticle was the commonest cause of GIT perforations in the elderly. The highest death rate was observed in those with ischemic ethiology. The PSS and MPI scoring systems are of high prediction value in the assessment of the risk of postoperative death.

[Peroperative diagnostics of acute bowel ischemia using ultraviolet light and fluorescein dye]

Acute bowel ischemia continues to have a high mortality rate. The main factor related to this poor outcome is considered to be the delay in diagnosis. The ability to detect ischemia early and to assess the extent of bowel involvement, are the most important aspects of successful treatment. The combination of ultraviolet (UV) light and fluorescein dye would be considered a simple, reliable and technically easy procedure for diagnosis of intestinal ischemia. The method can be used both for laparotomy when the source of UV light is a Wood's lamp as well for laparoscopy when the optical filters are placed to the light source of laparoscopic set to produce UV light. Present clinical experience shows that the method is precise, objective and accessible and that it gives a greater amount of independence to the surgeon allowing him to make the diagnosis of intestinal ischemia without having to rely on the assistance of other specialists.

[Laparoscopic liver resections. Successes and failures associated with the technique introduction--case reports]

The authors present initial clinical experience with laparoscopic liver resections as a case report series. The operation time, hospital and ICU stay length, perioperative blood loss, transfusion units used, and postoperative complications were recorded in a prospective way. The reasons for conversion to open surgery were also evaluated. 15 laparoscopic liver resections were completed between May 2006 and February 2009. There were 11 anatomical resections including hemihepatectomies and 4 non-anatomical laparoscopicaly completed liver resections. The initial experience shows that laparoscopic liver resection is feasible and safesate approach that requires advances experience in laparoscopic operative technique and liver surgery. Introduction of the laparoscopic technique is not easy and is associated with high risk of hilar bile duct injuries and perioperative bleeding.

[Distal pancreatic resections: indications, surgical technique, and complications]

INTRODUCTION

Distal pancreatic resections are relatively less frequent surgical procedures than duodenopancreatectomies. This is due to lower incidence and later onset of lesion symptoms in this part of the pancreas. The aim of our work was to evaluate retrospectively the results of distal pancreatic resections performed at the Department of Surgery, University Hospital in Hradec Králové from 1996 to 2008.

METHODS

We retrospectively evaluated the indications, surgical procedure (including complications) and the postoperative course. All procedures were done through transverse laparotomy. The pancreas was transected sharply with a scalpel and the resection line was oversewn. Staplers were not used. All the patients were given Sandostatin postoperatively.

RESULTS

We performed 51 distal pancreatic resections at our department from 1996 to 2008, 40 of which were distal pancreatic resections with splenectomy (78%). We performed 149 duodenopancreatectomies in the same time period. Benign lesions or borderline lesions (chronic pancreatitis, benign tumours, borderline tumours) were found in 67% of the surgical specimens. Malignant tumours were found in 33%, most of which were adenocarcinoma. Severe pancreatic fistula developed in two patients (3.9%). Two reoperations (3.9%) were necessary due to postoperative complications. Postoperative mortality was nil.

CONCLUSION

We assume that our technique resulted in a relatively low morbidity and zero mortality. However, we used this technique in all cases, and therefore cannot compare it to other techniques.

[Truncus coeliacus stenosis in duodenopancreatectomy]

INTRODUCTION

Patients with celiac axis stenosis are asymptomatic due to the rich collateral blood supply through superior mesenteric artery. Ligating and dividing gastroduodenal artery during pancreatoduodenectomy can cause ischemic threat especially to liver, less frequently stomach and spleen, or failure of anastomoses.

CASE REPORT

The authors present a case of 27-year-old female who underwent duodenopancreatectomy for pseudopapillary tumour of the head of pancreas. Celiac axis stenosis was found peroperatively and proven during angiography. Although an attempt of endovascular dilatation of celiac axis was unsuccessful, blood supply to the liver was sufficient and therefore we did not perform any other intervention to improve blood flow to the liver. Postoperative course was uneventful.

DISCUSSION

Celiac axis stenosis can be caused by tumour infiltration or lymphadenopathy in malignant disease, atherosclerosis or compression of the median arcuate ligament. The stenosis can be managed by endovascular treatment or arterial reconstruction. In conclusion the authors propose a management algorithm to prevent the consequences of celiac axis stenosis.

[Our experience with pancreatic resection procedures. Retrospective analysis]

INTRODUCTION

Pancreatic resections are highly demanding surgical procedures, which require higher specialization of the surgical teams and concentration of the patients into the specialized centers. The aim of our study was to analyze our results of the surgical therapy at a center which performs approximately 15 resections and 20 other procedures on pancreas a year.

METHODS

A group of patients with pancreatic resection operated on at the Department of Surgery, University Hospital in Hradec Králové between 1996 and 2006 was analyzed retrospectively. Postoperative mortality and postoperative complications were recorded. Long-term survival was evaluated only in patients with carcinoma.

RESULTS

158 pancreatic resections were performed in the referred period, 116 partial duodenopancreatectomies, 1 total duodenopancreatectomy and 41 distal resections of pancreas. 30-day postoperative mortality after duodenopancreatectomy was 4.3%. There was no postoperative death after the distal resection. Severe complications were recorded in 22 patients (13.9 %). Median survival of the patients was 11 months. 15 out of 68 patients (22.1%) survived 5 years, 30 out of 89 patients (33.7%) survived 3 years.

CONCLUSION

Our results of surgical therapy are comparable with the results of other hospitals with similar frequency of the pancreas resection, regarding postoperative mortality and morbidity, also regarding long-term results.

Temporary liver blood-outflow occlusion increases effectiveness of radiofrequency ablation: An experimental study on pigs

AIM

To evaluate the feasibility of liver blood outflow (LBOF) occlusion and its impact on the effectiveness of radiofrequency ablation (RFA).

METHODS

The experiment was performed on 10 pigs. The animals were divided into groups A and B according to RFA protocol. In group A (n=5) the RFA time was that taken to reach the target temperature of 105 degrees C, whereas group B (n=5) had a constant RFA temperature of 105 degrees C and constant time of 8min. The liver blood flow (LBF) was quantified using Doppler ultrasonography before LBOF occlusion and after that. RFA were performed using an expandable 3cm RF needle. Two liver ablations created in different liver lobes were compared; the first ablation was created before balloon inflation and the second one was created under LBOF occlusion. The time required for RFA procedure, liver ablation volumes, shape and microscopic changes of the thermoablated zones were recorded.

RESULTS

The LBF dropped significantly in all liver vessels after balloon inflation. The volume of the ablated area was 8.2+/-2.2cm(3) and increased significantly after LBOF occlusion to 17.4+/-3.8cm(3) (p<0.001), in group A. A significant enlargement of the ablated area with occluded LBF was registered in group B, it was 6.7+/-2.8cm(3) versus 19.4+/-1.8cm(3) respectively (p<0.01).

CONCLUSIONS

Temporary LBOF occlusion led to a significant reduction in liver blood flow, enlargement of the thermoablated area volume and homogeneity of the coagulated zones.

Comparison of Sutured versus Non-Sutured Subcutaneous Fat Tissue in Abdominal Surgery

PURPOSE

The aim of this prospective randomized study was to investigate the necessity of suturing subcutaneous fat tissue in elective abdominal surgery.

METHODS

415 patients undergoing elective abdominal surgery were admitted to the trial. The patients were divided into two basic groups according to wound contamination: clean operations (n = 201) and clean-contaminated operation (n = 214). Subcutaneous suturing of the subcutaneous fat tissue was performed in half of the patients in each group, determined using the envelope method ('Suture Yes' or 'Suture No'). Wounds were checked on postoperative days 3, 7, 14, and 30. Infectious and non-infectious wound complications were charted in the records. Data were statistically analyzed. The percentages of complications in groups with and without subcutaneous suturing were statistically compared using Yates' corrected chi(2) two-tailed test.

RESULTS

There were no statistically significant group differences in infectious and non-infectious wound complications.

CONCLUSION

These results suggest that omission of subcutaneous fat tissue suturing does not increase the occurrence of infectious or non-infectious wound complications.

[Radiofrequency-assisted liver resection. Analysis of a group of consecutive patients treated at a single centre]

AIM

To evaluate clinical experience with radiofrequency (RF)-assisted liver resection in patients with metastatic liver disease.

METHODS

A group of consecutive patients who underwent liver resection using the RF-assisted technique were prospectively followed.

RESULTS

Between July 2005 and September 2006, 65 liver resections were performed, among these, 40 procedures were performed using the RF technique for metastatic disease. The mean operative time was 141 (range 64-233) minutes, and the mean duration of RF parenchyma coagulation of the resected surface was 17.5 (range 2-32.5) minutes; mean 10 (range 9-12) minutes in the case of right hemihepatectomy. Blood transfusions associated with the operation were administered in 3 (7.5%) patients. The mean number of transfusion units of red blood cells administered was 0.2 (range 0-3). Liver resection was complicated by biliary fistula in 1 patient (2.5%) after mesohepatectomy, hepatic abscess was observed in 1 patient (2.5%) and subdiaphragmatic abscess was observed in 2 patients (5%).

CONCLUSION

This study indicates that RF-assisted resection may have a benefit in decreasing perioperative blood loss and the volume of transfused blood, without a higher incidence of wound and infectious complications. An increased incidence of pleural effusions that required evacuation was noted.

[Laparoscopic diagnostics of the acute bowel ischemia--first experimental experience]

AIM

Aim of the study was to prove possibilities of laparoscopic diagnostics of an acute bowel ischemia when using fluorescein dye and the ultra-violet (UV) light.

MATERIAL AND METHODS

There were five animals (domestic pigs) included into the experiment in the year 2005. The endoluminal embolization of the peripheral branch of superior mesenteric artery (SMA) was made. Optical filters were placed to laparoscopic set to produce UV light. Fluorescein was administered intravenously and bowel inspection and applying the clips on the border of ischemia visualized by fluorescein was performed.

RESULTS

In all cases, the combination of laparoscopy, UV light and fluorescein dye distinguished ischemic part of bowel from the viable remnant.

CONCLUSION

Combination of the UV light and fluorescein dye is able to reliable differentiate the viable segments of the bowel from the ischemic ones.

[Insufficient anastomoses in sigmoideal and rectal resections. A retrospective study conducted in a surgical clinic in Hradec Králové]

INTRODUCTION

Anastomotic insufficiency is the primary cause of postoperative morbidity and mortality following resection procedures of the large intestine and rectum.

MATERIAL AND METHODOLOGY

In the retrostpective study, the authors analysed rates of rectal and sigmoideal anastomotic insufficiencies in patients operated for rectal and sigmoideal carcinomas in the Faculty Hospital Surgical Clinic in Hradec Králové from 2000 to 2004. At the same time, the authors analysed risk factors of the insufficiencies. The subject of protective derivation stomies is discussed.

RESULTS

In the group with primary colorectal anastomosis, the anastomotic insufficiency occured in 11% of the group subjects, in the group with primary sigmoideal anastomosis in 9.1% of the group subjects. Out of the total of 215 subjects, the anastomotic insufficiency occurred in 23 subjects (10.7 %), 6 cases were fatal and the overall postoperative mortality was 1.56 % . In the anastomotic insufficiency group, it reached 13.04 %. The difference between the studied groups is significant (p<0,001, OR = 10.5).

CONCLUSION

Postoperative mortality in sigmoideal and rectal resection procedures correlates with anastomotic insufficiency.

Intraoperative enteroscopy: ten years' experience at a single tertiary center

BACKGROUND AND METHODS

Intraoperative enteroscopy is an invasive technique for small bowel investigation. It enables us to investigate the entire small intestine and to treat pathological findings by endoscopic or surgical means at the same time. The investigation is invasive and that is why the proper indication is mandatory.

RESULTS

Forty-one intraoperative enteroscopies were performed at our center within a 10-year period. The procedure was diagnostic in 37/41 patients (90.2%); in 3 patients no pathology was found, and in 1 patient we found only previously diagnosed celiac disease. The investigation was therapeutic in 35/41 (85.4%) patients; 2 patients with small bowel ulcers did not require any intraoperative therapy. The pathological findings were arteriovenous malformations (found in 12 patients), small bowel NSAID-induced or Crohn's ulcers (8 patients)--ulcerations and arteriovenous malformations were simultaneously found in three patients; carcinoid of the small intestine (5 patients); Peutz-Jeghers syndrome (5 patients); bleeding polyps (2 gastrointestinal stromal tumors, 1 paraganglioma, and 1 lipoma--in 4 patients); Rendu-Osler-Weber disease (2 patients); multiple cavernous hemangiomas in blue rubber bleb nevus syndrome (1 patient); Henoch-Schönlein purpura (1 patient); aortoenteral fistula (1 patient); and retrograde intussusception of Meckel's diverticulum (1 patient). In five patients with Peutz-Jeghers syndrome, 6-22 hamartomas (median of 18 per session) were removed by means of endoscopic polypectomy during intraoperative enteroscopy. There were no major procedure-related complications in our series.

CONCLUSIONS

Intraoperative enteroscopy is accepted as the ultimate diagnostic procedure for complete investigation of the small bowel. Despite the introduction of double-balloon enteroscopy into clinical practice, intraoperative enteroscopy will be reserved for those cases where double-balloon enteroscopy cannot be performed or fails to investigate the entire small intestine, especially to prevent excessive bowel resection.

[Soft tissue infection classification issues]

The authors give the summary on classification of soft tissues infections. Besides aetiopathogenesis and classification, separate clinical units are mentioned with the emphasis given on necrotizing processes and basic principles of their treatment. At the end own clinical material is presented with the results of microbiological analysis at the Departments of Surgery and Orthopedic surgery in University Hospital.

A modified radiofrequency-assisted approach to right hemihepatectomy

AIMS

To evaluate a modified radiofrequency-assisted approach to right hemihepatectomy.

METHODS

Following a bilateral subcostal incision and intraoperative ultrasonography, the liver was mobilized in the standard manner, and a cholecystectomy was performed. The portal vein was isolated, encircled, and ligated. After demarcating the liver parenchyma, coagulation necrosis was achieved using a radiofrequency-assisted device along the line demarcated for transecting the liver parenchyma. The actual transection of the liver parenchyma and the right portal vein was done using a surgical scalpel along the radiofrequency-coagulated line. The right hepatic vein was coagulated using the radiofrequency sealer or by stitching in the resection plane. The hepatic artery was not dissected and was sealed together with the bile ducts in the resection plane using the radiofrequency instrument. The hepatic vein was not divided.

RESULTS

Between July 2005 and July 2006, a total of 49 liver resections were performed in our unit. Of these, the radiofrequency-assisted technique was used in 33 cases with metastatic disease; 14 of these cases had right hemihepatectomies, including 2 repeat resections. The mean operation time was 180min (range, 120-240min), and the average blood transfusion was 0.14U (range, 0-2U). Postoperatively, there was no morbidity, such as bleeding, infection, or biliary fistula, related to the liver resection technique, and no patients died as a result of surgery. In 8 out of the 14 right hemihepatectomies, a right-sided pleural effusion was observed; 3 of them required evacuation.

CONCLUSION

This paper describes a modified radiofrequency-assisted hemihepatectomy, which allows one to obtain control of the portal blood flow going into the resected part of liver. The modified approach appears to be simple and safe.