Postoperative delirium

Postoperative delirium is a serious complication occurring mainly in patients over 65 years. This complication is common in the above mentioned age group and has been described in up to 50% of patients. Postoperative delirium has a significant impact both on postoperative morbidity and mortality. Systematic and early detection of at-risk patients is essential to reduce the risk of postoperative delirium. Targeted efforts are then developed in thus identified patients to reduce the risk factors for developing delirium. An individualized approach to anesthesia is adopted during the surgery. Procedures that contribute to reducing the risk of developing delirium are preferred in the postoperative period. If this complication does occur, it is primarily preferred to manage any potential cause of the condition using non-pharmacological procedures. Pharmacological interven- tion should be reserved only for patients with a hyperactive form of delirium. The aim of the article was to shed more light on measures that help to prevent the delirium and on the therapeutic procedures used.

A rare case of urothelial carcinoma metastasizing to the gallbladder wall with manifestations as acute cholecystitis

BACKGROUND

Metastasis to the gallbladder is very rare. This case report highlights a rare cause of acute cholecystitis, which should be considered by the surgeon and other treating physicians in the differential diagnosis of patients with urothelial carcinoma.

CASE

We report the case of a 73 year-old man with follow-up oncology care. He was diagnosed with infiltrating urothelial carcinoma in 2019, received neoadjuvant chemotherapy, and subsequently underwent radical cystectomy with ureteroileostomy in April 2020. Histology confirmed complete regression of bladder cancer, the lymphonodes were also free of tumour infiltration. In July 2021, the patient was examined for intermittent abdominal pain, predominantly of the right upper quadrant. On clinical examination, the gallbladder hydrops was palpable and a positive Murphy's sign was present. Due to the signs of acute cholecystitis, the patient was indicated for acute cholecystectomy. Gallbladder histology revealed metastatic involvement of the gallbladder wall by urothelial carcinoma.

CONCLUSION

If patients with bladder cancer present with intermittent right subcostal pain or signs of acute cholecystitis and diagnostic imaging shows a thickened gallbladder wall, clinicians and radiologists should consider the possibility of metastatic origin of lesion.

Ischemic Colitis in a Patient with Severe COVID-19 Pneumonia

At the time of the current COVID-19 pandemic, on a daily basis, we encountered patients suffering from various manifestations of this infection. The most common are respiratory symptoms. Many of the patients require acute hospital care, and a smaller group of them are hospitalized in intensive care units. A subset of these critically ill patients demonstrates clinically remarkable hypercoagulability and thus a predisposition to venous and arterial thromboembolism, manifested by thrombotic events ranging from acute pulmonary embolism and splanchnic vascular ischemia to extremity ischemia. The article describes a case of a patient with COVID-19 pneumonia complicated by massive bleeding into the gastrointestinal tract due to ischemic enterocolitis in connection with COVID-19 infection.

Radiofrequency ablation in pancreatic cancer

INTRODUCTION

Clinical study evaluating the impact of intraoperative radiofrequency ablation in pancreatic cancer.

METHODS

Patients with histologically proved pancreatic cancer were included. Two groups were defined. In the RFA group (n=24) intraoperative RFA of the pancreatic tumour was performed. In the control group (n=24) only the bypass procedure was indicated (gastroenteric and hepaticojejunal anastomosis). No patient received neoadjuvant chemotherapy. Three-month morbidity and mortality, overall survival, quality of life, pain relief and radiological response were studied.

RESULTS

Overall three-month morbidity and mortality were 41.7% and 8.3%, respectively. RFA related morbidity and mortality reached 16.6% and 8.3%, respectively. The overall median survival time was 9.9 and 8.3 months in the RFA group and in the control group, respectively. The survival difference was not of statistical significance (p=0.758). QoL improvement after RFA was not proved. There was no statistically significant analgesic effect of RFA. Postoperative CT scan assessed as per RECIST criteria displayed progressive disease, stable disease, partial response and complete response in 41.6%, 45.8%, 8.3% and 0% cases, respectively.

CONCLUSION

Intraoperative RFA of locally advanced and metastatic pancreatic cancer is a feasible palliative method. A survival benefit of this method remains doubtful, even though some positive results have been achieved in patients with localized, well-differentiated tumours. Although RFA was not associated with any impairment of the quality of life, no convincing evidence of a positive impact thereof on QoL was shown, either, during the three-month postoperative period. Pain relief was not achieved during the first 3 months after RFA.

Lymphomas and acute abdomen - a set of case reports

Surgical treatment of gastrointestinal solid tumors is the basic method with a curative potential. However, the first-line treatment modalities in lymphomas are systemic oncology therapy (chemotherapy, immunotherapy and hematopoietic stem cell transplantation), radiotherapy or their combination. Surgery in lymphomas is predominantly associated with acute disease and dominantly, surgery is still used mainly in diagnosing lymphomas. Acute abdomen associated with lymphoma can be divided into 3 groups: bleeding, obstruction and perforation of GIT due to lymphoma. All these conditions might be caused by both gastrointestinal (extranodal) lymphomas or advanced nodal lymphomas that directly infiltrate or compress gastrointestinal tract (GIT) as well. Perforation is also often associated with the effect of systemic chemotherapy administration. When treating acute abdomen conditions caused by lymphomas, multidisciplinary cooperation with all participating experts is necessary. From the surgical point of view, minimizing the risk of postoperative complications is crucial to ensure the possibility of early systemic oncological treatment administration.

Spontaneous retroperitoneal hematoma - our experience with surgical approach

Spontaneous retroperitoneal hematoma is a serious complication of anticoagulation and antiplatelet therapy. Its incidence has increased in recent years due to an increasing number of patients on this treatment. A number of case series have been described in the literature. In the vast majority of cases, the hemodynamically stable patients were treated either conservatively or by selective radiological embolization of the bleeding source. A surgical approach is reported as a last choice in the cases where the conservative therapy fails, radiological intervention is unavailable, in patients with continuous bleeding or in patients who develop abdominal compartment syndrome. In our case report, we present a patient on anticoagulation therapy for deep venous thrombosis complicated by massive retroperitoneal bleeding: surgery was used as the method of first choice and the treatment was successful. Key words: retroperitoneal hematoma bleeding anticoagulation treatment surgery.

Synchronous liver metastases of rectal cancer and the possibility of simultaneous resection

Treatment of metastatic rectal cancer and liver metastases continues to pose a major challenge. Synchronous liver metastases are present in up to one fifth of patients diagnosed with rectal carcinoma. Multidisciplinary cooperation is essential for determination of the consequent diagnostic and therapeutic plan. Only tight collaboration of experts from different medical fields allows for optimal timing of various medical procedures leading to a maximal benefit for the patient. Given the complexity of the problem, different specific methods and combinations thereof are applied in the course of the therapy, making the design of straightforward guidelines impossible. Since open surgery is complicated by the vastly distant locations of the rectum and liver, minimally invasive approach brings more perspectives in simultaneous surgery. A novel possibility of robotic and/or laparoscopic surgery performed by two teams is currently being developed. Despite the progress in surgical technology, optimal strategy has not yet been established.

Meckel's Diverticulum in Children-Parameters Predicting the Presence of Gastric Heterotopia

BACKGROUND

The presence of gastric ectopic mucosa in Meckel's diverticulum is associated with a higher risk of development of complications. The aim of the present study was to investigate which demographic/clinical parameters predict the presence of gastric heterotopia in Meckel's diverticulum.

METHODS

This was a retrospective cohort study conducted in a single institution (University Hospital Ostrava, Czech republic). All children who underwent laparoscopic/open resection of Meckel's diverticulum within a 20-year study period were included in the study.

RESULTS

In total, 88 pediatric patients underwent analysis. The mean age of the children was 4.6 ± 4.73 years; the male-female ratio was approximately 2:1. There were 50 (56.8%) patients with asymptomatic Meckel's diverticulum in our study group. Laparoscopic resection was performed in 24 (27.3%) patients; segmental bowel resection through laparotomy was performed in 13 (14.8%) patients. Gastric heterotopia was found in 39 (44.3%) patients; resection margins of all patients were clear of gastric heterotopia. No correlation was found between the presence of gastric heterotopia and the following parameters: age, gender, maternal age, prematurity, low birth weight, perinatal asphyxia, distance from Bauhin's valve and length of Meckel's diverticulum. The width of the diverticulum base was significantly higher in patients with gastric heterotopia (2.1 ± 0.57 vs. 1.2 ± 0.41 cm; p < 0.001).

CONCLUSIONS

According to the study outcomes, the width of the diverticulum base seems to be a significant predictive factor associated with the presence of gastric heterotopia in Meckel's diverticulum. The laparoscopic/open resection of asymptomatic MD with a wide base should therefore be recommended.

Obesity paradox in patients undergoing lung lobectomy - myth or reality?

Background

The aim of the present study was to evaluate the impact of BMI on the short-term outcomes of patients undergoing lung lobectomy.

Methods

This was a retrospective clinical cohort study conducted in a single institution to assess the short-term outcomes of obese patients undergoing lung resection. Intraoperative and postoperative parameters were compared between the two study subgroups: obese (BMI ≥30 kg/m2) and non-obese patients (BMI < 30 kg/m2).

Results

In total, 203 patients were enrolled in the study (70 obese and 133 non-obese patients). Both study subgroups were comparable with regards to demographics, clinical data and surgical approach (thoracoscopy vs. thoracotomy). The surgery time was significantly longer in obese patients (p = 0.048). There was no difference in the frequency of intraoperative complications between the study subgroups (p = 0.635).

The postoperative hospital stay was similar in both study subgroups (p = 0.366). A 30-day postoperative morbidity was higher in a subgroup of non-obese patients (33.8% vs. 21.7%), but the difference was not significant (p = 0.249). In the subgroup of non-obese patients, a higher frequency of mild and severe postoperative complications was observed. However, the differences between the study subgroups were not statistically significant due to the borderline p-value (p = 0.053). The 30-day postoperative mortality was comparable between obese and non-obese patients (p = 0.167).

Conclusions

Obesity does not increase the incidence and severity of intraoperative and postoperative complications after lung lobectomy. Slightly better outcomes in obese patients indicate that obesity paradox might be a reality in patients undergoing lung resection.

Stereotactic body radiotherapy using the CyberKnife® system in the treatment of patients with liver metastases: state of the art

Background

The management of patients with liver metastases presents a challenging problem in clinical oncology. Patients with limited involvement of the liver may be suitable for surgical resection or local ablative techniques. Stereotactic body radiotherapy (SBRT) presents an emerging new technology that has shown high efficacy in ablating tumors at various disease sites.

Methods

A comprehensive literature search was performed to identify articles in regard to the SBRT in the treatment of patients with liver metastases.

Results

SBRT allows for the delivery of high-dose radiation in few fractions to the tumor with extreme accuracy, while minimizing the damage to normal surrounding tissue. The CyberKnife^® system is an image-guided robotic system that delivers SBRT, tracks tumors during respiration, and automatically adjusts treatment for any patient movement. The most frequently used indications for CyberKnife^® therapy are ≤5 liver metastases with maximum tumor sizes of 6 cm, no extrahepatic disease, good performance status, and adequate hepatic functions. Local control rates range from 70%-100% at 1 year and from 60%-90% at 2 years. Severe toxicity related to SBRT is uncommon - grade three side effects occur in less than 5% of cases. Despite excellent local control rates, out-of-field metastatic progression (out-of-field hepatic metastases and extrahepatic metastases) develops in a substantial proportion of patients after SBRT. Therefore, it seems essential to improve the selection of patients with liver metastases for SBRT.

Conclusion

The CyberKnife^® system presents an effective minimally invasive treatment modality for patients with hepatic oligometastases who are not suitable candidates for radical liver resection. The available data suggest that liver metastases can be treated by CyberKnife therapy with very low toxicity and excellent local control rates.

[Radiotherapy in the treatment of rectal cancer is it time to move on?]

Multidisciplinary treatment approach in accordance with current guidelines represents a gold standard of care for patients with rectal cancer. Radical surgical resection is a fundamental and the only curative treatment modality. Patients with locally advanced rectal cancer (cT3-4N0M0 or anyTN1-2M0) are indicated for neoadjuvant radiotherapy or radiochemotherapy. However, there are many controversies regarding neoadjuvant radiotherapy indications in the available literature. Evidence-based medicine data suggest that neoadjuvant radiotherapy is associated with improved local control of the disease, but has no impact on patients survival. Moreover, neoadjuvant radiotherapy is associated with less favorable perioperative outcomes and significantly deteriorates anorectal function of patients after sphincter-preserving rectal resections.Key words: rectal cancer - radiotherapy - postoperative morbidity - survival - functional outcome.

[The importance of pre-operative MRI-detected extramural vascular invasion in the treatment of rectal carcinoma]

INTRODUCTION

Extramural vascular invasion (EMVI) is associated with a poor prognosis in patients with rectal carcinoma. Patients with proven vascular invasion have a shorter progression-free survival and overall survival. Until recently, vascular invasion had been identified primarily by pathologists. Currently, EMVI can be detected preoperatively by magnetic resonance imaging used for rectal cancer staging. Our study aimed at verifying the effect of pre-operative EMVI detection on PFS after resection and comparing this interval (PFS) to the group of patients with vascular invasion identified and confirmed by pathologists.

METHODS

Patients who underwent surgery for rectal carcinoma at our Surgical Department in the years 20122016 were included in the group and were followed for local recurrence or systemic progression of the disease. The median follow-up was 36 months. In this group, we then retrospectively evaluated MR EMVI and at the same time the presence of tumor vascular invasion from the resected specimen. The relationship of both prognostic markers to PFS was compared.

RESULTS

Tumor vascular invasion as well as positive extramural vascular invasion on MRI found preoperatively in our group had a statistically significant negative effect on the progression-free survival compared to the group without evidence of EMVI or vascular invasion.

CONCLUSION

Positive extramural vascular invasion found on MRI during rectal cancer staging is associated with a poor prognosis. It is one of the prognostically negative factors and referral of these patients for outpatient care should receive special attention because even after radical resection with a negative resection line there is a risk of early progression of the disease.Key words: rectal carcinoma extramural vascular invasion - progression-free survival.

Anorectal dysfunction after laparoscopic low anterior rectal resection for rectal cancer with and without radiotherapy (manometry study)

BACKGROUND AND OBJECTIVES

The aim was to evaluate the impact of radiotherapy (RT) on anorectal function of patients with low rectal cancer undergoing low anterior resection (LAR).

METHODS

Prospective clinical cohort study conducted to assess the functional outcome by means of high-resolution anorectal manometry and LARS score.

RESULTS

In total, 65 patients were enrolled in the study (27 patients underwent LAR without RT, 38 patients underwent RT and LAR). There were no statistically significant differences between study subgroups regarding demographic and clinical data; postoperative morbidity was significantly higher in irradiated patients. One year after the surgery, mean LARS score was significantly higher in patients who underwent RT and surgery. Major LARS was detected in 37.0% of irradiated patients and in 14.8% of patients after surgery alone. Anorectal manometry revealed significantly lower resting pressures in patients after RT and LAR; the squeeze pressures were similar. Rectal compliance and all volumes describing rectal sensitivity (first sensation, urge to defecate, and discomfort volume) were significantly lower in irradiated patients.

CONCLUSIONS

RT significantly deteriorates the functional outcome of patients after LAR. Manometry revealed internal sphincter dysfunction, reduced capacity, and compliance of neorectum, which seem to have a significant correlation with LARS presence/seriousness.

Functional outcome of low rectal resection evaluated by anorectal manometry

BACKGROUND

Low anterior resection syndrome (LARS) covers disordered bowel function after rectal resection, leading to deterioration in patients' quality of life. The aim of this study was to evaluate anorectal function after laparoscopic low anterior resection (LAR) by means of standardized instruments.

METHODS

This was a prospective clinical cohort study conducted in a single institution to assess functional outcome of patients 1 year after laparoscopic LAR by means of LARS score and high-resolution anorectal manometry.

RESULTS

In total, 65 patients were enrolled in the study. Mean tumour height was 9.4 ± 1.8 cm; total mesorectal excision during laparoscopic LAR with low end-to-end colorectal anastomosis was performed in all patients. One year after the surgery, minor LARS was detected in 33.9% of patients, major LARS in 36.9% of patients. Anorectal manometry revealed decreased resting pressure and normal squeeze pressure of the anal sphincters in the majority of our patients. Rectal compliance and rectal volume tolerability (first sensation, urge to defaecate and discomfort volume) were significantly reduced. The statistical testing of the correlation between LARS and manometry parameters showed that with increasing seriousness of LARS, values of some parameters (resting pressure, first sensation, urge to defaecate, discomfort volume and rectal compliance) were reduced.

CONCLUSION

This study indicates that the majority of patients after laparoscopic LAR experience symptoms of minor or major LARS. These patients have decreased resting anal sphincter pressures, decreased rectal volume tolerability and decreased rectal compliance.

[Confocal Laser Endomicroscopy in the Diagnostics of Malignancy of the Gastrointestinal Tract]

In confocal laser endomicroscopy (CLE), a type of optical microscope that uses a laser beam as its light source and processes the acquired image by processor unit is used. Although the principle behind the device has been known since 1957, its use in clinical practice has only recently been enabled by technical developments, and it is therefore a relatively new modality in differential diagnosis. CLE enables real-time microscopic imaging of the tissue under investigation and in fact non-invasive in vivo biopsy. First experiences with CLE have primarily been obtained in the field of endoscopy, in particular in the pathology of the esophagus, stomach, bile duct, pancreas, and colon. Further to its use in endoscopy, CLE was recently developed for perioperative use, with the most experience gained in neurological, breast, and prostate surgery. Numerous prospective randomized trials have confirmed the benefits of CLE in tumor screening, differential diagnosis of tumors or inflammatory diseases, earlier diagnostics of diseases, and reducing the number of required endoscopic examinations. In addition, CLE is associated with minimal side effects. A known possible side effect is allergy to the fluorescein used to stain tissues during the examination. Extending of endoscopic examination or surgery is minimal in the hands of trained personnel. Current limiting factors of CLE include insufficient clinical experience, the price of the CLE device and probes, and the subjectivity inherent in the evaluation of microscopic images by the endoscopist or surgeon. This article summarizes published studies of CLE in the diagnostics of oncological diseases of the gastrointestinal tract.Key words: confocal microscopy - gastrointestinal tract - neoplasms The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 9. 2. 2017Accepted: 26. 2. 2017.

Rare cases imitating acute appendicitis: Three case reports and a review of literature

Acute appendicitis with its characteristic clinical course is one of the most common diagnoses that require urgent surgery. The following three case reports present patients with symptoms typical of acute appendicitis which was, however, not confirmed intraoperatively. Preoperative CT or MRI were not requested because symptoms clearly indicated acute appendicitis. The first case describes a male patient with right-sided diverticulitis, the second case report involves a pregnant woman in 33rd week of gestation with right adnexal torsion due to a dermoid cyst, and in the last report, a case of spontaneous perforation of appendiceal mucinous neoplasm is presented.Key words: right-sided diverticulitis - dermoid cyst - adnexal torsion - mucinous neoplasm - pseudomyxoma peritonei - appendicitis.

[Treatment of 14 cases of Castlemans disease: the experience of one centre and an overview of literature]

Castlemans disease is the term for reactive lymphocytary and plasmocytary proliferation which occurs in the unicentric (localized) form, usually without systemic symptoms, or in the generalized/multicentric form, typically with systemic symptoms (www.vzacne-diagnozy.cz). Over the past 25 years we diagnosed, treated and followed 14 histologically proven cases of Castlemans diseases. Seven patients had the localised form of the disease. In 5 of 7 cases the pathological lesion was located intrathoracically or intraabdominally and in only 2 cases it was on the surface of the body. No clinical symptoms were present in any of the patients with the unicentric form of the disease and surgical treatment led to the total removing of the disease in all of them. As opposed to that, all 7 patients with the multicentric form of Castlemans disease experienced febrile or subfebrile temperatures. Three of the 7 patients complained of severe troubling night sweats. Clinical expressions of vasculitis which was the cause of stroke, were present in 1 of 7 patients. Osteosclerotic changes on the skeleton were detected in 1 patient, who also suffered from fluid retention likely associated with this disease. Polyclonal propagation of immunoglobulins, predominantly immunoglobulin IgG type, was present in 5 of 7 patients with the multicentric form. In one case there was one complete molecule of monoclonal imunoglobuline present and in one case loose light chains κ were increased More than 1 sampling of material for histological examination of enlarged lymph nodes were needed in 6 of 7 patients for diagnosing the multicentric form of the disease. It has turned out beneficial with respect to diagnosing the disease to carry out surgical removal and histological examination of the nodes which accumulated the most fluorodeoxyglucose within PET-CT examination. The text describes experience of the treatment. In recent years the basis for the treatment has been the monoclonal antibody antiCD20 rituximab, or thalidomide and lenalidomide, or possibly their combination. The new medicine for these patients is interleukin-6 antibody called siltuximab (Sylvant), of which we have no own experience so far. Five of our seven patients with the multicentric form received treatment, 1 patient refused treatment and in one patient the signs of the disease activity are not expressed to such extent that would require treatment. The therapy containing rituximab reached complete remission in 2 patients and the therapy containing thalidomide and lenalidomide achieved the complete remission of the disease in 3 patients. In one of the above described cases the disease did not respond to the initial treatment with rituximab and remission was reached by thalidomide and lenalidomide and in one case the disease did not respond to the initial treatment with thalidomide and complete remission was reached with rituximab. Following the treatment, no patient with the multicentric form of Castlemans disease has had a relapse until now.

Castlemans disease - surgical treatment, case reports

The authors describe their experience with surgical treatment of benign rare lymph proliferation - Castlemans disease (CD). It occurs in unicentric and multicentric forms. The very low incidence of the disease makes it very difficult to design larger prospective studies. Cases of two leading localizations of the unicentric form of CD - intrathoracic and retroperitoneal with special emphasis on the preoperative diagnosis and imaging options are described. This article underlines the curative potential of surgical treatment where a complete resection of the affected lymph node leads to eradication in almost 100% of the cases. The discussion is focused on the forms of CD - different localization, clinical symptoms and course of disease. It discusses the differential diagnosis, particularly difficult in the multicentric form, emphasizing the need to exclude malignant lymphoma. The etiopathogenesis of the disease is presented, mentioning its association with HIV (Human Immunodeficiency Virus) infection and HHV-8 (Human herpers virus 8) infection and the importance of overproduction of proinflammatory cytokines. The importance of surgical therapy for the unicentric form of CD is highlighted as compared to the multicentric form, where the surgeon´s task involves taking a biopsy - required for an accurate diagnosis.Key words: Castlemans disease - lymphoproliferation - lymphadenopathy - surgical treatment.

[Juxtapapillary duodenal diverticulum causing pancreatobiliary problems - case report and literature review]

Juxtapapillary duodenal diverticula are reported as a potential cause of many pancreatobiliary diseases. However, data concerning this association is inconsistent and the role of the diverticulum is often underestimated or even denied in clinical practice. This case report and literature review is aimed at pointing out this problem.Obstruction of the diverticulum with a food bezoar can be considered as an important clinical clue of the etiological role of the diverticulum in pancreatobiliary disease development.Endoscopic sphincterotomy is considered to be the treatment of the first choice, with surgery (diverticulectomy and/or biliodigestive anastomosis) reserved for cases where the minimally invasive approach fails.

KEY WORDS

juxtapapillary duodenal diverticulum obstructive jaundice acute pancreatitis endoscopic papilosphincterotomy biliodigestive anastomosis.

Quality of life after bowel resection for Crohn´s disease - first results

INTRODUCTION

Crohn´s disease (CD) highly affects a patient´s quality of life. The aim of the study was to find out the impact of surgery on the quality of life (QoL) in CD patients and factors affecting their postoperative QoL.

METHODS

90 patients with CD who underwent surgery (bowel resection) filled out an EORTC QLQ-CR29 questionnaire preoperatively and again after the surgical procedure.

RESULTS

77% of the patients experienced a positive change (p<0.001), 22% negative and 11% no change.

CONCLUSION

In this cohort, we proved that surgical treatment improves the overall QoL in patients with CD. To determine factors which affect postoperative QoL, more patients need to be enrolled in future studies.Key words: Crohn´s disease - quality of life - surgery - bowel resection - Czech cohort.

[Standardization of pancreatic cancer specimen pathological examination]

INTRODUCTION

The frequency of R1 resections for pancreatic cancer in studies where a non-standardized protocol of pathological evaluation of the specimen is used varies from 17 to 30%. The aim of our study is to apply the standardized (so-called Leeds) protocol of resected pancreatic specimen pathological examination, and to evaluate the frequency of R1 resections for pancreatic cancer using this new protocol.

MATERIAL AND METHODS

Ninety-one patients who underwent pancreatoduodenectomy for pancreatic cancer were included in the study. This group was divided into two subgroups: patients examined by the Leeds protocol (n=20) and those examined by a non-standardized pathological protocol (n=71). The R1 resection rate was evaluated separately in each group. The positivity rate of every individual resection margin was specified in the Leeds protocol group. The correlation of R1 resection rate and "tumour - resection margin distance" parameter was evaluated. The tumour infiltration of peripancreatic adipose tissue was assessed in the non-standardized group.

RESULTS

In the Leeds protocol subgroup, R1 and R0 resection rate was 60% (12/20) and 40% (8/20), respectively. Resection line positivity rates were as follows: dorsal 45% (9/20), ventral 35% (7/20), VMS 20% (4/20), cervical 20% (4/20), AMS 15% (3/20). The correlation between the tumour - resection line distance and R1 resection frequency was the following: direct infiltration 30% R1, tumour-resection margin border 0.5 mm 50% R1, 1mm 60%, 1.5 mm 75% R1, 2 mm 80% R1, >2 mm 80% R1. If the criterion of resection line positivity ( 1mm) was set, the R1 resection rate difference between the two groups was of statistical significance. In the subgroup where the non-standardized protocol was used (n=71), R1 resection was recorded in 25 (35.2%) patients. The main cancer-positive areas were peripancreatic adipose tissue in 26.8% (19/71) of cases, and VMS, AMS or retroperitoneal line in 8.5% (6/71), respectively. R0 resection was achieved in 46 (64.8%) patients. The statistically significant (p=0.046) difference in R0 and R1 resection rates was detected (Leeds protocol and non-standardized one: R0 40.0% vs. 64.8% and R1 60.0% vs. 35.2%, respectively) in the studied groups.

CONCLUSION

The rate of R1 resections for pancreatic cancer increased in all studies, including ours, where the standardized (Leeds) protocol of pancreatic specimen pathological examination was used. The higher R1 resection rate when using the Leeds protocol is approaching to the local recurrence rate of pancreatic cancer. Therefore, the Leeds protocol can provide more realistic evaluation of local radicality of pancreatoduodenectomy and can also offer more accurate evaluation of the surgical and adjuvant therapy of pancreatic cancer.

[PET-CT documented fast onset of treatment response to cyclophosphamide, thalidomide and dexamethasone in patients with multicentric Castlemans disease. Case description and treatment information overview]

Castlemans disease (also called angiofollicular lymph node hyperplasia) can take two forms with different prognosis: the localized form can usually be treated by a surgical intervention and has therefore a favourable prognosis. On the other hand, the multicentric form has an unfavourable prognosis and requires systemic treatment. Classic manifestations of multicentric Castlemans disease are multiple sites of lymphadenopathy, sometimes hepatomegaly and also splenomegaly or serous cavity effusions. Typical pathological laboratory levels measured in patients with this disease include an increased CRP level, anaemia of chronic diseases, and many patients have an increased total protein concentration, in some cases exceeding even 100g/ l. It is caused by a high concentration of polyclonal immunoglobulins. Typical clinical symptoms include fluctuating subfebrile or febrile temperatures, increased night sweats and fatigue usually related to anaemia. In some patients, the disease is manifested as vasculitis, frequently also affecting cerebral arteries, i.e. leading to cerebrovascular accidents. The aetiology of this disease is unclear; it is a polyclonal lymphocyte proliferation, often with differentiation into plasma cells. It is not a clonal malign disease; however, it can transform into a clonal lymphoproliferative disease. Even though it is not a malign disease in the histomorphological sense, the disease symptoms are so acute that systemic treatment is required. In the past, the treatment method of this disease used to be based on corticoids and cytostatics; however, such treatment was not always successful in achieving its objective, i.e. complete remission. In the past few years, an improvement of treatment results was accomplished by adding a new drug to the basic medication, i.e. to cytostatics and dexamethasone. Many publications describe the benefi t of adding a third drug from the IMiDs group (immunomodulatory drugs), such as thalidomide or lenalidomide. These drugs affect the formation of cytokines and block the angiogenesis, which in turn positively influences the speed of the treatment response. The second new drug that has helped in combination with classical treatment is the anti-CD20 antibody, rituximab. The third new drug to add this list is the monoclonal antibody against the interleukin-6 receptor, tocilizumab. This paper describes a rapid treatment response after combined treatment with cyclophosphamide 500mg/ m2 i.v. infusion 1st and 15th day in a 28- day cycle, dexamethasone 20mg p.o. cycle day 1- 4 and cycle day 15- 18, and thalidomide 100mg daily. In the course of the two-month treatment, the accumulation of fl uorodeoxyglucose during the PET-CT imaging has normalized; the originally pathologically enlarged nodes have become smaller, the originally elevated CRP level has normalized and the originally signifi cantly lower haemoglobin level has risen. This is the second patient with multicentric Castlemans disease in the last three years who showed a rapid response to treatment with thalidomide combined with cyclophosphamide and dexamethasone. Therefore, we consider such treatment suitable for newly diagnosed patients with multicentric Castlemans disease.

[Laparoscopic adrenalectomy--indications and selection criteria]

INTRODUCTION

Laparoscopic adrenalectomy has become a standard surgical procedure for the most of adrenal gland disorders. Hormonal active adenomas, feochromocytomas even some malignant tumors are the most frequent indications. The number of operations for accidentally diagnosed foci has grown rapidly. It has been suggested to revise recommendations specifying criteria, based on which incidentaloma is indicated for adrenalectomy. The aim of this work is to compare the results of adrenalectomies for hormonal active lesions and incidentalomas.

MATERIAL AND METHODS

An analysis of 65 patients who underwent adrenalectomy in the Department of Surgery University Hospital Brno Bohunice from 2005 to 2010. Correlation between preoperative examination outcomes and postoperative histology findings was performed. Furthermore, findings in patients indicated for surgery for hormonally active versus for hormonally inactive suprarenal tumors were compared.

RESULTS

Thirty-eight patients underwent laparoscopic surgery for hormonally active adrenal tumors, one for bilateral metastasses of bronchogenic carcinoma. In 26 cases adrenalectomy was indicated for incidentaloma. Adrenal hyperplasia was the commonest histological finding in the group with hormonally inactive tumors. No carcinoma was detected in this group. In 5 of 19 patients operated for suspective feochromocytoma, the procedure did not result in blood pressure adjustment and feochromocytoma was histologically confirmed in 11 out of the 19 subjects. The size of the tumors was significantly higher in incidentalomas, compared to hormonally active pathologies. No incidentaloma and hypertension subjects experienced alteration in their clinical condition after the procedure.

CONCLUSION

Laparoscopic adrenalectomy is a standard procedure in the majority of hormonally active focal suprarenal conditions. Patients with accidentally detected suprarenal tumors should be carefully indicated, taking into consideration internal comorbidities and any surgical procedures in a patient's history. The benefit of adrenalectomy for the clinical condition alteration is arguable in incidentalomas. The National Institutes of Health U.S.A. (NIH) consensus guidlines should be strictly followed during the decision making proces. Indication for adrenalectomy in tumors of less than 6 cm and with benign appearance on CT or MRI is not considered rational.

Surgical treatment of Clostridium colitides

INTRODUCTION

Infection with Clostridium difficile (CDI) is the most frequent cause of nosocomial diarrhoeas. Most cases are successfully treated by antibiotic therapy, but nearly 10% may progress to the fulminative form of this condition. The objective of the work is retrospective evaluation of the results of surgical treatment in patients with the fulminative form of Clostridium colitis with revealing of risk factors leading to serious post-operative morbidity and mortality.

PATIENTS AND METHODOLOGY

Retrospective evaluation of the results of surgical treatment in patients with the fulminative form of Clostridium colitis between 2008 and 4/2012.

RESULTS

Between 2008 and 4/2012 Clostridium toxins were positively detected in 1,088 patients in total, 21 of whom underwent operations due to the fulminative form of Clostridium colitis. The operations included 4 total colectomies with terminal ileostomy, 15 subtotal colectomies with terminal ileostomy, 1 caecostomy and 1 axial ileostomy. The 30-day mortality was 23.8%, and morbidity reached 66.6%. High leukocytosis is a statistically significant predictor of post-operative mortality and morbidity (p = 0.008).

CONCLUSION

Early indication for a colectomy operation with terminal ileostomy in patients with the fulminative form of Clostridium colitis leads to lower morbidity and mortality.

[Surgical management of jejunal diverticulosis complications]

Jejunal diverticulosis is a rare disorder and the course of the disease is mostly asymptomatic. A surgeon meets the patients only in the acute phase of the disease, when the disease symptoms most commonly include bleeding and perforation. Jejunum is difficult to examine using the common visaulization methods and endoscopic methods, therefore, the diagnostics of the disease is difficult and the disease may often mask other disorders. The authors present two case reviews of patients operated for perforation and bleeding from jejunal diverticles.

[Amyand's hernia -- a rare cause of acute abdomen]

BACKGROUND

Amyand's hernia is a rare condition in which the appendix is positioned in the inguinal hernia sac. Acute appendicitis in this situation is a extremely rare and only a few reports are found in the literature.

METHODS

Case report

RESULTS AND CONCLUSION

We report a case of acute gangrenous appendicitis with the perforation at the tip of the appendix, which was incarcerated in the right groin. We conduct a review of the literature, emphasizing possible causes and suggesting a predisposing factor for the condition.

[Complications in patients undergoing pulmonary oncological surgery]

AIM

A survey evaluating incidence and risk factors of complications in persons underwent complete open lung resection because of primary or secondary lung malignancy.

MATERIAL AND METHODS

Retrospective study of 189 open surgery procedures in 128 males and 61 females, mean age males 61 years (range 21-78), females 64 years (range 33-80) during a five-years period (2003-2007). Data processing and analysis were performed with the statistical software system Statistica and compared by parametres odds ratio a chi2 test.

RESULTS

Complications were divided into five groups. First group was defined as complications in perioperative period and was composed of three events 1.5%: endotracheal tube dysfunction (i.e. 0.5%), heavy cardiac arrhytmia 0.5% and serious haemorrhage, that occurred immediately after operation 0.5%. Second group includes complications within period of 7 days after surgery: prolonged air leak (PAL > 7 days) 7.4%, bronchopneumonia 6.9%, cardiac arrhythmia 6.9%, postoperative delirium 4.2%, atelectasis 2.6%, wound infection 1.1%, bleeding 1.1% and chylothorax 0.5%. Third group contains events between 8th and 30th postoperative days: thoracic empyema 2.1%, dysphonia 2.1%, painfull shoulder 1.1%, alimentary tract infection 0.5% and bronchial closure insufficiency 0.5%. Fourth group contains patients with severe complications, that led to death during 30 days after operation: ischemic stroke 0.5% and pulmonary embolism 0.5%. Patients without any complication formed the fifth group of 60.5%.

CONCLUSION

Main risk factors for complications in postoperative period after lung resection due to primary or secondary lung malignancy in our group of patients are COPD, corticotherapy, time of operation over 3 hours, BMI over 25, left side tumor localization and bronchoplastic procedure. For cardiac arrhytmia seems to be risk factor pneumonectomy and previous neoadjuvant radiochemotherapy.

[Outcomes of pancreatic resections in the elderly and geriatric patients]

As a result of the population aging, we are confronted with the problematics of geriatric patients more and more frequently. The aim of this retrospective study was to compare outcomes of pancreatic resections in patients of three different age groups. During 2000-2007, 150 pancreatic resections were performed in our clinic, including 34 (22.7%) patients aged 65 and over at the time of the procedure and 5 (3.3%) patients over 75 y.o.a. The procedures were heterogenous, including indications for oncologic diagnoses, as well as for chronic pancreatitis. Our assessment demonstrated no significant differences in the 30-day postoperative mortality between the group of subjects over 65 y.o.a, geriatric group (i.e. over 75 y.o.a) and the group of subjects below 54 y.o.a. (8.8% vs. 0% vs. 5.2%). Furthermore, the postoperative morbidity showed no statistically significant differences between the all three groups (30.2% vs. 29.4% vs. 20%). The commonest postoperative complications included secondary healing of the surgical wound (7.8%) and pancreatic fistules (6.9%) in the group of subjects below 65 y.o.a., and insufficiency of the pancreatic-jejunal anastomosis (5.8%) and hepatic- jejunal anastomosis (5.88%) in the group aged 65 and over. Pancreatic-jejunal anastomosis insufficiency, complicated by consecutive bleeding, contributed to postoperative mortality most significantly. Significant increase in postoperative complication rates connected to proximal pancreatoduodenectomies and total pancreatoduodenectomies, was recorded in patients over 65, compared to those in the young patient group (p = 0.014). No statistically significant relation was found between a particular comorbidity and onset of postoperative complications or deaths in patients over 65 or geriatric patients. Based on the results, the authors do not consider the patient's age a contraindication for pancreatic resection procedures. Radical resections can be performed with acceptable mortality and morbidity rates in geriatric patients.

Use of radiofrequency ablation in the treatment of malignant liver lesions

BACKGROUND/AIMS

The authors present their experience with the option of using radiofrequency ablation (RFA) in the treatment of malignant focal liver lesions.

METHODOLOGY

In a prospective study conducted in the period from 2002-2005, 60 patients were treated using RFA during a total of 72 sessions and treating 108 lesions of various size, number and localisation. The method of RFA was applied either percutaneously under computed tomography (CT) or ultrasonographic (USG) navigation (22 patients) or surgically--during opened laparotomy or laparoscopy (42 patients).

RESULTS

Median observation time was 12.7 months (with the range 3-36 months). Authors did not observe any serious complications after RFA treatment in the study population. Median time of local recurrence in the ablated lesion position was 13.5 months in the observed population, median time of metastatic progression in the residual liver parenchyma was 12 months, and overall median survival was 22 months. Percutaneous RFA application demonstrated significantly worse results when compared with surgical application in previously the mentioned parameters. Lesions larger than 3cm in diameter also showed statistically more frequent local recurrence.

CONCLUSIONS

RFA is appreciated as minimally invasive method of treatment for liver malignancies with promising perspectives of therapeutic effects.

[An unusual cause of the chronic ileus state--the absence of the intestinal wall muscularis layer]

In this study the authors describe a rare histological finding in the resected small intestine, which was a cause of continuous ileal difficulties in a young female patient, and which increased in their intensity and finally resulted in an acute state which had to be solved by an urgent surgical procedure. The situation was defined as "absence of the muscularis layer" of the intestinal wall by a pathologist. The pathologist also stated that he had never come across such a case, neither in our literature, nor in the foreign one and that the condition was diagnosed with difficulties when using a standard visualization examination methods.

[Sentinel node biopsy in colorectal carcinoma--pilot study]

BACKGROUND

Sentinel lymph node biopsy is a widely accepted method for staging melanoma and breast cancer in indicated cases. However, the use of the method in colorectal cancer is under clinical investigation. The aim of the pilot study was to introduce the technique into the surgical practice in colon carcinoma, to determine the feasibility and potential problems and to evaluate the first experience.

METHODS

Twenty patients with colon cancer underwent lymphatic mapping and sentinel node biopsy using blue dye, fluorescein or lymphoscintigraphy followed by standard surgical resection. The acquired sentinel nodes were investigated with both standard hematoxylin-eosin staining and immunohistochemical staining for cytokeratin.

RESULTS

Lymphatic mapping adequately identified at least one sentinel node (SN) intraoperatively or by a modified ex vivo technique in 20 patients (100%). The average number of SN was 1.5 (range 1-3), non-SN 13.6 (range 1-38) per patient. SN correctly predicted the regional lymphatic basin status in 14 cases (70%). The false negative rate was 40%. No patient has been upstaged on the basis of immunohistochemical staining.

CONCLUSIONS

Lymphatic mapping and sentinel node biopsy in colon cancer is feasible and safe method with a high SN identification rate. The role and significance of sentinel node biopsy in colon cancer is not as clear as its role in other tumors and remains controversial. Further large prospective studies with standardized techniques are needed to evaluate the potential benefit of this new method.

[Segmental absence of intestinal musculature]

Herein we describe a case of 33-year old woman repeatedly affected by incomplete ileus. Primary segmental absence of lamina muscularis propria has been found in this patient. Histological examination revealed areas of small intestine with total absence of muscularis propria followed by areas of the intestinal wall characterised by normal histological structure. No necrosis, inflammation, and fibrosis supporting the secondary origin of this lesion was found.

[Do we comply with the standard classification of staging in colorectal carcinoma after curative resection?]

BACKGROUND

Lymph node status is the most important prognostic and predictive factor in curatively resected colorectal cancer. According to TNM staging system, a minimum number of 12 regional lymph nodes is to be examined for the correct staging. In addition to the status of lymph nodes other important prognostic factors should be reported by the pathologist.

METHODS

A retrospective study was performed to analyze how many of regional lymph nodes were examined in colorectal cancer specimens in two hospitals (Czech Republic) during the last few years. Availability of other prognostic factors important for the management of the disease after surgery was always investigated.

RESULTS

In the hospital "A", the examination of lymph nodes were not sufficient in 43.8% of 121 cases analyzed, in the hospital "B", the number of examined lymph nodes was less than a minimum of 12 in all 162 cases. There were often no data available regarding to a histological examination of resection margins, grading and angioinvasion.

CONCLUSION

Reporting of the standard and most important prognostic factors in colorectal cancer was not sufficient in two selected hospitals and it may not be much better in others. It might have a deteriorating influence on the outcomes despite of successfully performed primary surgery. Search for the new prognostic and predictive factors, that would help us to stratify the patients for the optimal tailored therapy is surely needed, but the standard staging parameters, as are the lymph node involvement, resection margins, grading and angioinvasion, must not be forgotten as occurred to be in many cases of our study.

[Lymphatic mapping and sentinel lymph node biopsy in selected carcinomas of the digestive tract]

The current status of lymphatic mapping and sentinel node biopsy in patients with selected carcinomas of the digestive tract is described. The possible future use of the method in patients with gastric, small bowel and colorectal malignancies is considered. Preoperative lymphatic mapping and reliable identification of sentinel node (nodes) in patients with gastrointestinal cancers may lead to tailored resections or limited surgical procedures. On the other hand, extended lymph node dissection may be performed in those patients in whom the sentinel node(s) contains tumour cells or in cases where skip lymphatic nodes metastases appear. The method offers the opportunity of improving staging (ultrastaging) by identification of patients with early dissemination in lymphatic nodes where conventional methods are not sensitive enough. These patients should be considered for traditional adjuvant treatment or be included in trials with more effective adjuvants regimens. Large prospective multicenter studies are needed to find out if the sentinel node concept is valid in gastrointestinal cancer. If the answer is yes, several basic diagnostic and therapeutic measures may be changed in favour of cancer patients.

[Effect of carbon dioxide pneumoperitoneum on selected parameters of the acid-base equilibrium in laparoscopic cholecystectomy]

The authors focused attention on a hitherto less well known area of the effect of capnoperitoneum during laparoscopic cholecystectomy on homeostasis of the internal environment, i.e. values of the acid-base balance and its changes during surgery and the early postoperative period. From a randomized perspective study ensued that intraabdominal pressure and the reduction of the intraabdominal CO2 pressure from 15 mmHg to 10 mmHg did not have a significant effect on parameters of the acid-base balance in the investigated group of patients as compared with a control group. From the results it is apparent that possible danger of acidosis as a result of CO2 absorption from the abdominal cavity, deterioration of the splanchnic blood supply or a negative impact of the intraabdominal overpressure on the cardiovascular apparatus is sufficiently compensated by the respiratory system during artificial pulmonary ventilation. There is however a certain danger of acidosis during the immediate postoperative period after extubation when the patients are not yet able to compensate possible fluctuations of the acid-base balance and are according to the authors' measurements in a state of mixed or respiratory acidosis. But even in this respect no statistically significant difference was observed between the two groups. These assessments were made in relatively healthy patients, i.e. group I and II according to the ASA classification, therefore these results will apply even mor in groups of risk patients of higher ASA categories. In particular in these patients it is useful to adjust the insufflation pressure individually to lower values in order to reduce to a minimum possible negative impacts of the capnoperitoneum.

[Adenocarcinoma of the appendix--case report]

The authors describe a case with a rare diagnosis of adenocarcinoma of the appendix in an adult female patient. The patient was indicated for surgical revision on account of acute appendicitis with a peroperative finding suspect of malignity of the vermiform appendix. A radical resection of the ileocoecal area was performed along with part of the ascendant colon and appropriate mesocolon as a primary operation. According to the postoperative histological evaluation of the resected portion the diagnosis of adenocarcinoma of the appendix was confirmed.

[Endoscopic stricturotomy--possible treatment of stenoses of colorectal anastomoses based on a stapling technique]

The authors present the possibility of using colonoscopic stricturotomy by means of a papillotomy commonly used for sphinctertomy of the Papilla Vateri in order to influence a stenosis of a colorectal anastomosis implemented by the stapler technique. The operation proper and postoperative course were without any complications.

[Late postoperative colonic stenosis caused by the biofragmentable anastomosis ring (BAR)]

The authors focused their attention on the prevalence of late postoperative stenoses of anastomoses following resection of the colon. In 42 patients the anastomosis was implemented by means of a Valtrac ring--i.e. by compressive biofragmentable seamless technique. Within an interval of 6 months after surgery the majority of these patients were subjected to colonoscopic examination with direct visualization of the intestinal anastomosis. The authors did not record any late postoperative stenoses of the BAR anastomosis of the colon. Moreover on colonoscopic examination in the majority of patients the original intestinal anastomosis was only difficult to detect.

[Carcinoma of the colon invading the duodenum and pancreas]

In the submitted case-history the authors present the case of a 60-year-old woman with an extensive tumour of the transverse colon penetrating into the duodenum and head of the pancreas with an intimate relation to the upper mesenteric vein. An extensive curative en bloc resection included right-sided hemicolectomy, hemi-pancreatoduodenectomy and partial parietal resection of the upper mesenteric vein. The pathologist identified in the resected tissue a medium differentiated adenocarcinoma of the large intestine damaging the head of the pancreas and infiltrating the duodenal wall. The lymph nodes were negative and no metastatic affections were revealed. The postoperative course was without serious complications. The few cases of this type reported in the literature illustrate the possibility of successful resection and thus a substantially improved prognosis of the affected patient.

[Compression anastomosis in acute resection of the colon]

The authors draw attention to the possible use of a biofragmentable anastomotic ring (BAR) for anastomosis of the gut, used by the authors for construction of an anastomosis after acute resection of the colon under particularly risky conditions with infection and advanced deterioration of the intestinal wall. In both instances when this alternative method was used the postoperative course was uneventful and the patients were discharged without complications into domiciliary treatment.

[The BAR-Valtrac for the colon]

The authors present their experience with biofragmentable anastomosis in the area of the colon in 42 patients where they used a biofragmentable ring Valtrac, Davis-Geck Co. to restores continuity after resection. The authors focus their attention on the peroperative technical difficulty of construction of the anastomosis proper and on complications encountered during the immediate postoperative course. The most serious among them is, no doubt, dehiscence of the anastomosis. Based on this experience, the authors express their opinion on the simplicity of the implementation proper of a BAR anastomosis and problems of postoperative complications.

[Endoscopic visualization of BAR (biofragmentable anastomotic ring)]

The authors present information on the use of a modern sutureless anastomotic connection by means of a biofragmentable ring--BAR (Biofragmentable Anastomotic Ring) which was used in patients to restore the continuity of the GIT after resections in the upper portions of the digestive tract. The authors present their initial clinical experience and emphasize the importance of visualization of biofragmentable anastomoses by gastroscopic examination in case of postoperative complications with the possibility of therapeutic provisions, if necessary.

[Incidental laparoscopic orchiectomy of intra-abdominal testis]

The authors present an incidental finding of intraabdominal testicle during laparoscopic operation for another diagnosis in an adult man. The surprising finding was managed by laparoscopy without conversion to an open procedure, adhering to rules of oncologic prevention because possible testicular cancer. Had an open approach been chosen in this patient, the intraabdominal testicle would have remained undetected.

[Pitfalls of biofragmentable anastomotic ring construction]

The authors describe the main problems of the technical implementation and construction of biofragmentable anastomoses by means of the Valtrac ring, used for anastomosis after resections in the area of the gastrointestinal tract in a total of 72 patients. The authors evaluate postoperative technical difficulties and the main aspects of the implementation proper which may be the cause of serious complications during the immediate postoperative period.

[Bar-Valtrac--a modern alternative to conventional intestinal anastomosis?]

The authors describe a modern method of intestinal anastomoses without suture after resections of the gastrointestinal tract, by means of a biofragmentable ring used in 62 patients where the continuity of the digestive tract was restored by means of BAR-Valtrac (Davis Geck Co, USA). The perspective alternative of the common manual and stapler technique BAR anastomosis is evaluated on the basis of data from the literature and the authors own clinical exoerience with regard to the main parameters of healing of the anastomosis and immediate postoperative complications, among which dehiscence of the anastomosis is, no doubt, most important.