Surgical management of colorectal injury in war

The rate of colorectal trauma is 5-10 % in modern war conflicts. The most common causes include gunshots or shrapnel injuries; the contusion-laceration mechanism occurs in sporadic cases in the war zone. Despite modern surgical procedures, however, it is associated with a high rate of morbidity, especially if it is not diagnosed and treated in time. Surgical management is specified by simple scoring schemes - the colon injury scale, rectal injury scale and the Flint grading system. Colonic resection with primary or delayed anastomosis is not associated with a higher risk of complicated healing and is nowadays preferred over the construction of terminal stomas. These are indicated only for cases with severe hemodynamic instability in traumatic-hemorrhagic or septic shock with severe diffuse peritonitis. Trauma to the intraperitoneal segment of the rectum is treated in the same way as trauma to the colon. An extraperitoneal rectal injury without soft tissue devastation can be treated with or without a transanal suture. On the contrary, devastating injuries to the rectum including the pelvic soft tissues should be primarily controlled with a stoma with delayed reconstruction. Presacral drainage or rectal stump lavage are no longer recommended.

Military surgery and field surgical care in the Czech Army

Military surgery is one of the basic branches of military medicine. It is based on the principles of surgery performed in peacetime, but is significantly different when performed under specific conditions. The aim of the article is to describe these differences and present the current state of providing surgical care in the field in the Czech Army. Medical support in the field, or the treatment and evacuation system of medical services of the armies of NATO member countries, is organized on four levels, matched by medical facilities designated as Role 1-4. Surgical care in the field usually takes place at the level of Role 2 and Role 3. While in the conditions of a foreign military mission, surgical treatment aims to achieve a definitive standard, in a typical war conflict the only goal is to save life and limb and prepare casualties for further evacuation. Additionally, triage of the wounded is an important part of health care in the field at individual levels, the importance of which increases especially in the case of mass casualties. In the military medical service of the Army of the Czech Republic, goals are defined as part of the construction and development of capabilities, which should expand and reinforce the current potential of providing surgical care in the field - currently encompassing two field hospitals capable of Role 2 or 3. The ambitious plan to construct additional field medical elements is difficult to achieve in the expected time horizon and, in addition, it also faces a significant shortage of military surgeons due to the planned scope of capacity increase. Despite all the objective difficulties, however, Czech military surgeons have a high credit in the eyes of the NATO allies, gained during the deployment of the Czech field hospital or of the Czech field surgical team within multinational military units.

Pneumatosis cystoides intestinalis as a rare cause of non-surgical pneumoperitoneum

Pneumoperitoneum as a finding on imaging examinations is not always a sign of acute abdomen due to gastrointestinal perforation. These findings must be viewed in connection with the clinical condition and personal history of each patient because they may also indicate a non-surgical or spontaneous pneumoperitoneum. This condition is repeatedly described but very often neglected. This paper presents the case report of a patient with non-surgical pneumoperitoneum where, despite proceeding according to the guidelines, no expected intra-abdominal pathology explaining the patient's problems was found.

[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.

[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.

[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.

[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.