Hepatocellular carcinoma--evaluation of a group of 74 patients treated at the surgical department.

The authors present their experience with treatment of 74 patients operated on for hepatocellular carcinoma. Resection could be performed only in 44 patients. In 19 cases, a catheter for regional chemotherapy was implanted. Tumor destruction with alcohol was performed 4 times and radiofrequency thermal ablation 5 times either as a single intervention or in addition to the resection. Liver cirrhosis was verified by histology in 29 operated patients. Hospital mortality: 2 operated patients. Median survival after the liver resection: 42 months, mean survival: 72 months. The importance of preoperative indocyanine green elimination test for the exact determination of functional capacity of the liver and the priority of radical resection as compared to the other treatment modalities are emphasized (Tab. 2, Ref. 12). Full Text (Free, PDF) www.bmj.sk.

Pedal bypass for limb salvage.

BACKGROUND: Pedal bypass grafting is often the only method of limb salvage in patients with chronic critical lower limb ischemia due to atherosclerotic obliteration of the crural arteries, including patients with diabetic foot gangrene. It involves arterial reconstruction with distal anastomosis to one of the pedal arteries. MATERIAL AND METHODS: Between January 2000 and June 2004, 54 pedal bypasses were performed in 53 patients with chronic critical lower limb ischemia. Forty-seven (87%) patients had gangrene or ischemic ulcer, 36 (68%) had diabetes. In some of the patients (16.7%), previous percutaneous transluminal angioplasty (PTA) of the crural arteries had failed. Preoperative angiographic findings were unsatisfactory in the majority of the patients; the plantar arch was not visualized in 36 (66.7%) limbs. RESULTS: In the period investigated (54 months) 11 grafts (20.4%) failed. Early thrombectomy resulting in long-term graft patency salvaged five limbs. One limb with graft occlusion occurring after foot ulcer healing was also salvaged. However, one amputation had to be performed despite a patent graft. The perioperative mortality rate was 3.8%. Cumulative primary and secondary graft patency rates and limb-salvage rates at 54 months were 76%, 78% and 81%, respectively. CONCLUSION: Pedal bypass grafting is a safe method with very good long-term outcomes. The absence of the pedal arteries or plantar arch on preoperative angiograms need not be taken as a contraindication to pedal vascular reconstruction. In discussions on the plantar arch it is recommended to discriminate between its actual absence and a mere "angiographic" absence.

[20-year experience in surgical treatment of popliteal aneurysm]. / 20 let zkuseností s operacemi pro aneuryzma podkolenní tepny.

We present our 20-year experience in surgical treatment of popliteal aneurysm in 67 patients. We conclude that popliteal aneurysms should be surgically treated as early as possible after its diagnosis, preferably before ischemic complications occur.

20-year experience with operations for popliteal artery aneurysm.

At the 2nd Department of Surgery, St. Anne's University hospital Brno, a total of 76 operations for popliteal artery aneurysm were performed in 67 patients in the last 20 years, in period 1985-2004. 63 operations were elective and 13 urgent. For reconstruction, autologous saphenous vein was used in 53 cases, vascular prosthesis in 15 cases, and a cryopreserved vein allograft in 3 cases. In 5 cases, amputation for advanced lower limb ischaemia was performed without arterial reconstruction. Elective operation is indicated in all patients with popliteal artery aneurysm, and it is associated with a relatively low risk for the patient. In fact, it is a preventive operation. In the acute stage, there is a higher risk of complications and (potential) amputation (Fig. 1, Ref. 8).

[The subclavian steal syndrome]. / Subclavian steal syndrom.

The aim of this work is to summarize the authors' experience gathered during surgical procedures for the subclavian steal syndrome. The authors put forward the method of anaesthesia with patient's vigility and mobility preserved, favouring the arterial transposition procedures against the prostheses implantation methods. The main common feature of the above approaches is to increase the procedure's safety.

[Importance of pedal bypass in limb salvage]. / Význam pedálního bypassu pri záchrane koncetiny.

In 2000 to 2002, we carried out "pedal" arterial reconstructions in 30 patients, performing a distal anastomosis to the dorsal pedal artery (47%) or the posterior tibial artery (53%). All patients suffered from critical ischemia of the lower extremity; 26 (86.7%) had gangrene or foot defect and 21 (70%) had diabetes mellitus. They all had atherosclerotic obliteration of the crural arteries and only a graft bypass of this segment offered good prospects for limb salvage. In 16.7% of the patients, previous percutaneous transluminar angioplasty had failed to treat the condition. Preoperative angiographic findings were unsatisfactory in the majority of patients because in 23 patients (76.7%) the plantar arch was not shown and, in 13 patients (43.3%), neither the plantar arch nor any of the pedal arteries were visualised. During 36 months of follow-up, one patient died (3.3%) and three had bypass graft occlusion (10%). Of these, one patient underwent early thrombectomy, which resulted in long-term graft patency and limb salvage. A further patient had the limb saved although occlusion occurred after the defect had healed. In the third patient, however, bypass occlusion eventually led to high amputation of the leg. The results were evaluated by Kaplan Meier analysis. At 36 months, cumulative probabilities were 87% and 90% for primary and secondary patency, respectively; cumulative probability for limb salvage was 93%. Our results are in agreement with those from major specialised foreign centres and support the view that patients with critical ischemia and unsatisfactory angiographic findings (obliteration of crural arteries) are indicated for pedal artery inspection with subsequent vascular reconstruction.

[An aorto-enteric fistula]. / Aorto-enterická pístel.

The most experienced surgeons should be called to conduct reoperations in the aorto-femoral region. It is always advisable to be aware of possible injuries to the urether and to prevent such cases by bandaging. A long-term follow-up of the patient in the same clinic, or at least consultation of his/hers condition helps to minimize any diagnostic hesitations as well as iatrogening harmings. Haemorrhaging aorto-enteric fistules must be surgically managed in clinics specialized in vascular surgery.

20-year experience in operations for subclavian steal syndrome.

The aim of this article is to summarize our experience in operations for subclavian steal syndrome. We recommend anaesthesia with preservation of patient's consciousness and mobility, and we prefer transposition of arteries to prosthesis implantation. The main characteristic of this approaches is an attempt to increase safety of operation. A feasible procedure is suggested also in the case of reconstruction occlusion: the axillo-axillary bypass. (Fig. 6, Ref. 3.)

[Pedal bypass versus PTA (percutaneous transluminal angioplasty) of the crural arteries]. / Pedální bypass versus PTA bércových tepen.

Diabetic foot syndrome in patients with atherosclerotic angiopathy of the crural arteries frequently develops in critical ischaemia and gangrene. Revascularization then may be the only approach to limb salvage. In the ongoing decade, pedal bypass grafting has become the method of choice for treatment of the most severe forms of chronic critical leg ischaemia caused by obliteration of the crural arteries. However, in patients in whom angiographic findings are favourable (short stenosis of the crural artery and the presence of suitable distal outflow arteries), percutaneous transluminal angioplasty (PTA), with stent placement, if indicated, is preferred. In multisegmental or diffuse disease or when PTA is associated with complications (occlusion or dissection) with subsequent limb ischaemia, bypass surgery is the method of treatment. In this study, the group of 30 patients undergoing bypass grafting showed 90% patency of the pedal bypasses at 12-month follow-up; in 18 patients treated by PTA, the patency of crural arteries at 6 months after angioplasty was 78%. Since either method has its advantage and disadvantages, an individual approach to each patient is recommended. In decision-making on the basis of angiographic findings, PTA is not confronted with pedal bypass grafting but the two methods are regarded as complementary in treatment of patients with crural artery disease.

Patient with percutaneous endoscopic gastrostomy.

INTRODUCTION: Since 1980, when percutaneous endoscopic gastrostomy was described and performed for the first time, the number of patients with this way of nutrition has been growing. At present, however, these patients are treated not only in intensive care units, but also in follow-up care institutions or in home care. AIM: We want to explain the problems of nutrition via endoscopic gastrostomy to those physicians who take long-term care of these patients. METHODS: In our department we introduced percutaneous endoscopic gastrostomy in 1994. A total of 78 PEGs were performed. In all cases the pull technique was used. A condition for percutaneous endoscopic gastrostomy insertion was an unaffected gastrointestinal tract from the stomach in aboral direction. The most frequent indications were: necessity of long-term enteral nutrition in patients during artificial ventilation, neurological patients with lost swallowing reflex, and patients with a tumor in the ENT area with preserved patency for the endoscope. RESULTS: In all cases, the intervention itself was without major complications and no death occurred relating to the intervention. Subsequently, mainly local complications such as decubitus ulcers or maceration around the tube and its accidental removal by a restless patient were noticed. CONCLUSION: In cases of more than 6-week inability to ingest food per os with otherwise unaffected gastrointestinal tract, it is appropriate to consider the nutrition via PEG. Using this method, it is possible to ensure an adequate access for enteral nutrition for a longer time without risk of complications associated with the nasoenteric tube, with minimum trouble to the patient. (Fig. 1, Ref. 9.).

[Pseudoaneurysms due to iatrogenic arterial injuries--observations at a vascular surgery worksite]. / Pseudoaneuryzma po iatrogenním postizení tepny--poznatky z angiochirurgického pracoviste.

With advancing care of patients with cardiovascular diseases the number of invasive cardiological operations is increasing. Although effective methods are involved, these procedures are also associated with certain risks for the patient. From the aspect of vascular surgery the most frequent complications include iatrogenic pseudoaneurysms and extensive haematomas. The objective of the present work is to evaluate the development of the number of pseudoaneurysms which occurred after puncture of the femoral artery during coronarography or PTCA, and verification of the hypothesis of the declining trend of the ratio of pseudoaneurysms in the total number of performed invasive cardiological diagnostic and therapeutic operations. The author submits in his paper the retrospectively assessed number of invasive operations performed at the 1st Medical Cardioangiological Clinic of the St. Ann Faculty Hospital Brno in 1996-2001. It summarizes the number of PA dealt with during the same period by physicians of the 2nd Surgical Clinic of the St. Ann Hospital in Brno. It analyzes also the treated complications of cardiological operations in 2001.

[Developments in surgery of the extracranial circulation--findings from a vascular surgery department]. / Vývoj v chirurgii extrakraniálního reciste--poznatky z angiochirurgického pracoviste.

The objective of the paper is to summarize hitherto assembled experience of the department with the application of new approaches to reconstruction operations of the extracranial circulation with emphasis on its most important part, i.e. the carotid circulation. The main feature of this approach is an effort to increase the safety of the operation for the patient at risk which implies among others extension of indications for reconstruction surgery.

Vascular collagen prosthesis of RaK type--long-term patency.

In 1990, the vascular prosthesis of RaK type (collagen-impregnated knitted prosthesis), produced by the Research Institute of Hosiery in Brno, was introduced into clinical practice. In 1998, we published our experience with this type of prosthesis in form of a clinical evaluating study performed according to the methods of the EN 540 European Norm. Now we inform about the results of the studied group followed during 3 years. The long-term patency of the prosthesis in the aortic-phemoral part is 88.8%; the incidence of infection of the vascular prosthesis in our group studied in the 3-year period is 2.5%. Thus we can say that even long-term results confirm our previous good experience with this vascular prosthesis produced in Brno. (Tab. 8, Fig. 1, Ref. 11.)

[Assessment of functional capability of liver parenchyma using indocyanine green before liver resection]. / Vysetrení funkcní zdatnosti jaterního parenchymu s pomocí indocyaninové zelene pred resekcí jater.

During the period from 1997 to 2000, the total of 129 liver operations were performed at the 2nd Surgical Department of the Masaryk's University in Brno. Malignant tumours were present in 91 cases. In-hospital mortality in patients operated on for malignant liver tumours was 2.1%. No case of death was caused by liver insufficiency. Examination of liver function by use of indocyanine green (ICG) enabling the determination of the extent of possible resection, contributes to the lowering of postoperative morbidity and mortality. The rate of indocyanine green retention up to 6% does not limit the extent of resection, the retention rate up to 15% allows bisegmentectomy or a minor surgery, the retention rate up to 20% allows segmentectomy at the most, and the retention rate up to 30% enables superficial excisions only.

Microsurgery in the diabetic foot.

The treatment of serious tissue defects on the diabetic foot is complicated and tedious because of a combination of pathogenetic mechanisms that influence healing. Diabetic neuropathies (sensory, motor, vegetative), ischaemia and microangiopathies contribute in varying degrees to the adverse healing. The submitted three-year prospective study was focused on an analysis of the pathogenetic factors with the objective of defining the indications for one of three types of microsurgical transfer: 1. a free flap sutured directly to the vessels at the site of the defect (in predominantly neuropathic defects); 2. a free flap sutured to a politeopedal bypass (in predominantly ischaemic defects); 3. a "nourishing" flap sutured by means of a long venous graft to vessels of the medial and upper leg (in patients in whom an inadequate outflow tract does not make revascularisation possible). In the first year of the investigation, thirteen patients were operated on by means of a free muscle flap incl. three "nourishing" and ten sutured at the site of the defect. Twelve flaps were flaped healed; one patient died from myocardial infarction on the second day after surgery.

[Personal experience with intra-arterial locoregional chemotherapy of liver metastases from colorectal carcinoma]. / Nase zkusenosti s intraarteriální lokoregionální chemoterapií metastatického kolorektálního karcinomu do jater.

Locoregional chemotherapy is one of the possible ways of treatment of inoperable metastatic affection of the liver by colorectal carcinoma. The advantage of regional administration of the cytostatic is the possibility to achieve a higher local concentration of the cytostatic associated with a higher percentage of therapeutic responses. In our department we preferred combined locoregional intraarterial chemotherapy (5-fluorouracil/Mitmycin C/Doxorubicin) combined with systemic intravenous chemotherapy (5-fluorouracil/leukovirin). Locoregional cghemotherapy was administered in the majority as chemotherapy of series 2 or 3 with a very good tolerance. In 2/19 patients we observed marked diminution of liver metastases and subsequent operability and with a duration of complete response for 13 and 18 months. In 7/19 patients a partial therapeutic response was achieved. The total therapeutic response (complete and partial) was 47%. Locoregional chemotherapy attains a higher therapeutic response as compared with systemic chemotherapy and is associated with an acceptable toxicity.

[Incidence of carcinomas in goiters and their combination with Hashimoto's thyroiditis]. / Incidence karcinomu ve strumách a jejich kombinace s Hashimotovou tyroiditidou.

In the investigated group 300 patients were operated for a thyropathy mostly struma nodosa, tumours were proved in 69 cases; 38 of them were carcinomas of various extent and 3 of them were combined with Hashinoto's lymphomatous goitre. The overwhelming majority of the carcinomas were papillary carcinomas (22 cases). The incidence of papillary carcinoma in Hashimoto's goitre was about 8%; this fact calls for more attention to autoaggressive thyroiditis both in examination of surgical material, and during autopsies in middle-aged women, where this thyroiditis is often clinically silent. Our results suggest an increase in the incidence of carcinoma in Hashimoto's goitre and the generally accepted rarity of this coincidence is questioned. We recorded also a lower incidence of medullary carcinoma than the worldwide average and a more frequent incidence of mixed-type carcinoma.

[Ruptured abdominal aortic aneurysms]. / Rupturující aneuryzma abdominální aorty.

The authors present the results of a retrospective study concerning 96 patients with an abdominal aortic aneurysm rupture who underwent surgery in the 2nd Department of Surgery in Brno in the time period from 1989 to 1999. In 30 cases (31.2%) there was an isolated retroperitoneal rupture, 66 patients (68.8%) also had haemoperitoneum. The mean age of the patients was 74 years and the male/female ratio was 76 (79.2%): 20 (20.8%). Twelve patients (40%) did not survive the retroperitoneal rupture, and 34 patients (51.5%) did not survive the intraabdominal rupture. Total mortality in the study group was 47.9%. The type of the rupture and the size of the haematoma that is in correlation with the time of diagnosis and operation, are among the most decisive prognostic factors. Patients with a small haematoma show higher survival rates. In large retroperitoneal haematomas accompanied by a haemorrhagic shock, the mortality was about 40% in the presented study group, in intraabdominal ruptures the mortality rate increases to values over 50%. The results are in accordance with foreign literature data, and the authors agree with the opinion that haemodynamically unstable patients with suspected abdominal aortic aneurysm rupture should be, after necessary preparations, urgently operated without complementary examinations.

[Ischemic disease of the lower extremity and lumbar sympathectomy]. / Ischemická choroba dolních koncetin a lumbální sympatektomie.

We consider lumbar sympathectomy (LSE) to be the last attempt to improve the condition of the limb. Though being aware of inconsistent opinions on LSE, we are not opponents of this method, particularly if it is carried out in a selected group of patients, that is in case of: 1) treatment of frostbites, 2) treatment of patients at an early stage of advanced ischemia whose main symptom is moderate night pain at rest, 3) desiccation of chronically moist ulcerations between the toes, 4) treatment of patients with reflex symptomatic dystrophy (causalgia), 5) Buerger's disease.

[A knit vascular prosthesis of RaK collagen--a clinical evaluation study]. / Pletená cévní protéza s kolagenem typu RaK--klinická zhodnocovací studie.

Vascular collagen prosthesis of RaK type (collagen-impregnated knitted prosthesis) made by Výzkumný ústav pletarský (Research Institute of Hosiery) in Brno was introduced into clinical practice in 1990. In comparison with previous type, the collagen-impregnated prosthesis has had a number of advantages and thus it gets into the interests of vascular surgeons. The report presented has given the results of clinical evaluating study carried out at the IInd Clinic of Surgery, Faculty of Medicine, Masaryk University, Brno according to the methods of EN 540 European Norm Proposal for clinical studies. The results obtained from evaluating a set of 107 patients created for this study (besides others, long-term patency of 90.7%, or 0.9% incidence of infection of the vascular prosthesis of Szilagyi III type) have shown that nowadays we have at disposal a very good, reliable and economically acceptable vascular prosthesis of our provenience.