[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.

[Clostridial myonecrosis of the abdominal wall - case report]

The authors present a case report of a forty-five-year-old patient operated on for acute appendicitis who developed gas gangrene of the abdominal wall within 48 hours after an appendectomy and subsequently also clostridial sepsis. Due to early diagnosis and intensive care, the patient survived. Clostridial myonecrosis is a rare complication after abdominal surgery and may be fatal in many cases. In our literature, there are only a few publications describing cases of patients who survived this rare postoperative complication.

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.

[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.

[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.

[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.

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.

[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.

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.

[Radiofrequency assisted liver resection in non-cirhotic liver. Initial clinical experience]

AIM OF THE STUDY

To evaluate the radiofrequency assisted liver resection using Habib sealer (RITA Medical System, Inc., Mountain View, CA).

METHODS

The operation time, liver transection time, transfusion units used, and postoperative complications were recorded in a prospective way.

RESULTS

22 liver resections were performed between July 2005 and December 2005, 15 of them were done using radiofrequency technique. Twelve anatomical resections and three non-anatomical resections were performed in total. The mean operation time equalled 155 (120-240) minutes. An average of 0.6 (0-4) transfusion units was used. In 13 of the 15 operations, which represent 86% of the patients, no transfusions were used. Postoperatively, no major bleeding from the resection plane was noted and no biliary fistula was observed.

CONCLUSIONS

Radiofrequncy assisted liver resection is a safe technique with the major benefit of minimal perioperative blood lost.

A rare cause of mediastinal expansion with a massive pleural effusion

The authors present a case of a 53 year old woman, who was admitted to hospital because of an unusual cause of massive pleural effusion. During diagnostic examination the mediastinal propagation of the pancreatic pseudocyst was discovered as a complication of the chronic calcifying pancreatitis. The patient was operated on and the pseudocyst was resolved by Roux-en-Y cystjejunostomy. The diagnostics and treatment of this unusual pancreatic pseudocyst spreading is discussed.

[Elective standard appendectomy versus elective laparoscopic appendectomy in women. A retrospective study]

AIM

Comparison of open appendectomy and laparoscopic appendectomy with focus on the wound infectious complications.

METHODS

Retrospective comparison of the early postoperative complications of the elective open and elective laparoscopic appendectomy in the Surgical Clinics of the Teaching Hospital Hradec Králové in period January 2001-July 2004.

RESULTS

250 elective appendectomies in women were performed in followed period. 187 (75%) were done by laparoscopic approach, 63 (25%) by open procedure. Conversion was necessary in 18 cases (9.6%). The average hospital stay was statistically significantly shorter following laparoscopic than open appendectomy, 4.6 +/- 1.5 days counter to 6.1 +/- 1.6. The global morbidity was comparable in both groups 15%, one patient died (0.5%) in laparoscopic appendectomy group. The incidence of early postoperative complications was not statistically different in both groups.

CONCLUSIONS

The average hospital stay was statistically significantly shorter following laparoscopic appendectomy. Laparoscopic appendectomy did not improve the results regarding infectious complications and was a cause of serious complications. Some of them required operational revision.

[Jejunal diverticulosis as a rare cause of massive bleeding into digestive tract]

The authors present a case of an elderly man, who was admitted to the hospital due to unusual cause of massive bleeding into digestive tube. During diagnostic work-up the source of gastrointestinal bleeding was localized into jejunal divertuculum. The patient was operated on and resection of involved jejunal segment with primary anastomosis was performed. The possible complications ofjejunal diverticulosis are discussed.

[Sharp transsection of the parenchyma in liver resection]

Extended clinical application of total vascular isolation (TVI) in resection liver surgery made a more radical and invasive liver interventions possible as well as the application of new so far non-standard technique. The sharp transsection of liver parenchyma in vascular isolation represents a technique that could provide some advantages as compared with classical technique of finger fracture. AIMS OF THE WORK: To verify the safety of the sharp liver transsection and total vascular isolation in non-anatomical liver resection.

MATERIAL AND METHODS

The experiments were performed in minipigs (N = 9). The surgical intervention was performed under aseptic conditions in general endotracheal anesthesia. After TVI the authors performed non-anatomical resection of the right liver lobe in a sharp way by the scalpel. Individual structures, i.e. branches of protobiliary triad and branches of hepatic vein were treated by stitches. In the course of operation the authors evaluated the diameter and the number of the treated structures in the resection surface, duration of the operation and duration of TVI. The blood loss during the operation, changes in blood count and hepatic enzymes were evaluated.

RESULTS

The surgical intervention lasted 88.7 min (55-139 min) on the average, vascular isolation of the liver lasted 24 min (19-33 min) on the average. The mean blood loss was 193.7 ml (40-400 ml). The decrease in Hb values was 8.25 mg/l (6-11 g/l) on the average. In one resection surface the authors treated 9 (6-11) tubular structures on the average, as soon as the clamp was removed, a branch of hepatic artery had to be subsequently treated three times and a branch of portobiliary triad once.

CONCLUSION

The combination of total vascular isolation and sharp transsection of liver parenchyma enable a safe management of branches of portobiliary triad smaller than 1 mm in the case of vessels as well as biliary pathways. The management of small hepatic veins, smaller than 1 mm and the branches of hepatic artery pose greater problems which are, however, related to the anatomical difference of the model.