Gigantic intra-abdominal tumors the experience of one center.

A complex review of surgery treatment of unusually giant intra-abdominal and retroperitoneal tumors regardless of their origin and histological findings. The therapy of such neoplasms requires a multidisciplinary approach which is necessary to make a reasonable and responsible decision concerning not only the indication of surgery, but also its extent. The authors describe 5 case reports, highlighting specific aspects and pitfalls of the diagnosis and treatment of these rare cases.

Benefits of hybrid methods (PET/CT, PET MRI) in the diagnosis of abdominal aortic pathology.

INTRODUCTION: Ultrasound and CT angiography are common diagnostic methods of abdominal aortic pathologies. In the last decade, hybrid methods (PET/CT, PET/MRI) have become more common in this diagnostic algorithm. Originally they were indicated in malignancies or inflammatory processes. Currently, efforts are developed to visualize possible local inflammatory activity in the aortic wall and thus to assess a certain “disease activity” with the goal to anticipate further development of aortic pathology. The aim of our study was to analyze potential benefits of hybrid methods in predicting abdominal aortic pathology progression. METHODS: In this prospective, open-label, observational study we examined 75 patients referred to PET/CT (N=61) or PET/MRI (N=14) due to any aortic pathology in 2015-2017. The patients included those with abdominal aortic aneurysm (AAA) (N=48; 64%), aortitis (N=5; 6.7%), aortic dissection (N=4; 5.3%), patients undergoing EVAR (N=6; 8%), patients with excessive atherosclerosis (N=7; 9.3%), patients with concomitant AAA and retroperitoneal fibrosis (N=4; 5.3%) and patient with an intramural hematoma (N=1; 1.3%). The minimum follow-up period was 6 months (0.5-2.5 years). Clinical symptoms, aortic diameter, growth rate and CRP levels were analyzed during the follow-up and correlation with PET/CT or PET/MRI findings was evaluated. RESULTS: Increased metabolic activity in the aorta was found in 25 of the 75 examined patients (33.3%). Based on statistical analysis there were no associations between increased activity based on PET/CT or PET/MRI in the aortic wall and disease symptoms or progression. CONCLUSION: Our results provide no evidence that hybrid methods can predict further development of pathological findings in the abdominal aorta. PET/CT- or PET/MRI-based activity did not correlate with disease symptoms, AAA progression rate or dissection, either. Our results are also supported by some recent literature data.

Indications to open surgical revascularization of visceral arteries in the endovascular era.

INTRODUCTION: Due to the high success rate of endovascular procedures, open surgical treatment of visceral arteries has become rarer worldwide. Yet, open surgical techniques remain essential for cases of chronic mesenteric ischemia as well as in other clinical instances. METHODS: Drawing on their own experience and literary data, the authors summarize the indications to open surgical repair of the visceral arteries. They point out the situations in which surgical management is the method of choice even in the endovascular era. Discussing the advantages and disadvantages of various vascular reconstructions, they point out their technical challenges. CONCLUSION: Although used less frequently, open surgical repair of the visceral arteries needs to remain among the vascular surgeons tools. Not only for situations when an endovascular technique fails, but also for elective procedures in patients in whom an endovascular approach is contraindicated or not possible. Key words: mesenteric ischemia aorto-mesenteric bypass endovascular approach.

[Extragenital malignant Müllerian carcinosarcoma with invasion of inferior vena cava - a case report]. / Extragenitální maligní Müllerianský karcinosarkom infiltrující dolní dutou zílu - kazuistika.

UNLABELLED: The authors present the case of a 57-year-old woman with a very rare extragenital malignant retroperitoneal Müllerian carcinosarcoma invading the inferior vena cava. Tumor resection with partial resection of the vena cava wall and resection of metastases in the pelvic area is described. The authors further discuss diagnostic options of metastases of this tumour and the recommended adjuvant chemotherapy. KEY WORDS: extragenital Müllerian carcinosarcoma malignant mixed Müllerian tumour - diagnosis therapy.

Determination of the Middle Cerebral Artery Occlusion Length in Acute Stroke: Contribution of 4D CT Angiography and Importance for Thrombolytic Efficacy Prediction.

PURPOSE: To assess the benefit of 4D-CT angiography (4D-CTA) in determination and precise measurement of middle cerebral artery (MCA) occlusion in comparison to CTA. Possible relationship of measured occlusion lengths with recanalization after intravenous thrombolysis was analysed as a second objective. METHODS: Detailed evaluation of complete MCA occlusions in 80 patients before intravenous thrombolysis using temporal maximum intensity projection (tMIP) dataset, calculated from 4D-CTA and conventional single-phase CTA was performed. Further, manual measurement technique was compared to results of semiautomatic procedure (vessel analysis) as reference. Statistical analysis of correlation between MCA occlusion length and IVT efficacy (24 h recanalization rate according modified Thrombolysis In Myocardial Infarction criteria-mTIMI) was performed. RESULTS: The distal end of occlusion was identified in all patients using tMIP, but only in 48 patients (60%) using CTA. The manual measurement method was not statistically different and well correlated with reference tMIP-vessel analysis. (15.4 vs. 16.3 mm; p = 0.434; r = 97). In measurable occlusions by CTA, no significant difference was proved in manually measured lengths using tMIP and CTA (14.5 vs. 13.3 mm; p = 0.089). Favorable recanalization (mTIMI 2-3) was achieved in 37 patients (47%). Length of occlusion in M1 segment (p = 0.002) and M2 segment involvement (p = 0.017) were proved as independent negative predictors of recanalization. Using receiver operating characteristics analysis, the cutoff length of the M1 segment occlusion for favorable recanalization was found to be 12 mm. CONCLUSION: The feasibility of MCA occlusion assessment using tMIP datasets and benefit over conventional CTA were confirmed. The manual measurement method was proved as feasible and simple with good correlation to reference semiautomatic analysis. The significant correlation of the MCA occlusion length and early recanalization was found. The length of 12 mm was recognized as cut-off length for favorable recanalization.

[A study of the morphology of the descending branch of the lateral circumflex femoral artery (DBLCFA) as a possible vascular graft for the reconstruction of coronary arteries using angio CT]. / Studie morfologie r. descendens a. circumflexae femoris lateralis jako mozné cévní náhrady pro rekonstrukci koronárního reciste pomocí angio CT vysetrení

INTRODUCTION: Due to the need for alternative arterial grafts suitable for the reconstruction of the coronary bloodstream, we conducted a morphological analysis of the descending branch of the lateral circumflex femoral artery (DBLCFA) using an AGCT scan. MATERIAL AND METHODS: Not only anatomical variations and the quantitative representation of sclerotic changes, but also the presence of a collateral system in the event of significant stenosis of the pelvic and femoral artery system were analysed. RESULTS: The results revealed favorable findings in the sense of the studied arteries length (9.3 cm on average), a relatively low anatomical variability and a very small percentage of the studied blood vessels participating in collateral blood flow, despite that 72% of tests revealed significant stenotic disease (stenosis of more than 50%) of the upper branch of lower limb arteries. CONCLUSION: According to the defined criteria, 68% of vessels were found to be suitable for grafting. We suppose that this number would be considerably higher in patients with only insignificant or no ischemic disease of the lower extremities.

[Retroperitoneal neuroectodermal tumors]. / Neurogenní tumory retroperitonea.

Various types of neurogenous tumours occur in the retroperitoneum. Hormonally inactive tumours are often asymptomatic and their diagnosis is mostly accidental. Authors are presenting their recent experience with three cases. They discuss diagnostic options and the therapy of retroperitoneal schwannoma, ganglioneuroma and paraganglioma.

Focal histopathological progression of porcine experimental abdominal aortic aneurysm is mitigated by atorvastatin.

AIM: Observational studies in human patients and animal experiments suggested that statins have a potential in slowing the growth of small abdominal aortic aneurysms (AAA). Our aim was to quantify histological postoperative changes of AAA in porcine experimental model of AAA with and without administration of atorvastatin. METHODS: The AAA was induced by intraaortic infusion of porcine pancreatic elastase and subrenal application of plastic cuff. The AAA statin group (N.=14) received atorvastatin 1 mg/kg daily for 28 days, the other AAA group (N.=13) did not. The aortic diameter was measured by ultrasonography. Aortic samples were described using eleven quantitative histological parameters and compared with healthy aortae. RESULTS: There was no difference in aortic diameter between the AAA with statin when compared to AAA without statin. Administration of atorvastatin led to a better postoperative histological condition of the aortic elastin network, preservation of contractile phenotype of vascular smooth muscle, a higher density of vasa vasorum, it prevented thickening of intima and media. The increase in wall thickness in AAA without atorvastatin has not been accompanied by a proportional increase in number of vasa vasorum. CONCLUSION: The effects of atorvastatin seem to prevent the histopathological progression of AAA.

[Primary aortoduodenal fistula (PADF)]. / Primární aortoduodenální pístel (PADF).

Primary aortoduodenal fistula is very rare acute abdomen with high mortality. Serious problem is often late diagnosis. Authors present case report from their University Hospital. Diagnosis and therapy options are discussed. Key words:primary aortoduodenal fistula - late diagnosis.

[Pharmacological influencing of abdominal aortic aneurysm model - animal experimental study, primary results]. / Farmakologické ovlivnení modelového aneuryzmatu brisní aorty - experiment na zvíreti, prvotní výsledky.

INTRODUCTION: The aim of our work was to influence growth and histological changes in the wall of an experimentally induced aneurysm of the abdominal aorta in a large laboratory animal (domestic pig) by administering atorvastatin (3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor). MATERIAL AND METHODS: Within the scope of the above mentioned experimental work, we compared the growth rate of the aneurysm between the group influenced by statin administration (n=14) and the group without any pharmacological treatment (n=13). We also compared histological changes in the structure of the aortic wall in both groups with aneurysm and the wall of the aorta without aneurysm (n=6). RESULTS: During the 4-week follow-up, we did not prove a statistically significant difference in the growth rate of aneurysms between the above mentioned groups. The histological structure of the aneurysm walls, however, differed between the two groups. The structure of the wall in the group of animals influenced by statin administration resembled the structure of the aortic wall without aneurysm. CONCLUSION: The results presented demonstrate that statins do influence the composition of the aortic wall. In our opinion, the administration of statins could lead to changes resulting in a more stable aneurysmatic wall. We believe that patients with smaller aneurysms who are not indicated for surgery or endovascular treatment could be treated with statins. Stabilization of the aneurysmal wall could slow down the growth of the aneurysm and prevent its rupture.

[Vascular system injuries]. / Poranení cévního systému.

PURPOSE OF THE STUDY: The aim of this retrospective study is to present our experience with the management of injuries to the vascular system at the Trauma Centre, University Hospital in Plzen. We show the most frequent mechanisms of injury, diagnostic pitfalls, therapeutic options and evaluate both the short-term and long-term results of surgical treatment and interventional radiology procedures. MATERIAL AND METHODS: We evaluated a group of patients with a serious vascular injury who were treated at the Traima Centre during the five-year period from January 2006 to December 2010. The group included 82 patients, 59 men and 23 women, with the average age of 34.5 years. We assessed the success rate of vascular reconstruction, primary and secondary graft patency and mortality and morbidity rates. Recovery of function in the injured extremities and return of the patient to normal daily activities were considered the most important parameters. In 28 patients (34%) vascular injury was due to polytrauma, in nine (11%) it was part of a combined injury, and 45 patients (55 %) sustained monotrauma. Most of the patients (68; 83%) were managed surgically. The most frequent procedures included direct suture of a lesion, resection and replacement of an injured artery or bypass grafting. In 13 patients we used interventional radiology procedures (in most cases it was for thoracic endovascular aortic repair). In one patient we were able to use a conservative treatment. RESULTS: The 30-day mortality rate was 8.5%, i.e., seven patients died of polytrauma. The morbidity rate was 35% (29 patients). The most frequent complications included respiratory failure in polytrauma (13%), transient leg/arm swelling (6%) and wound infection (4%). Primary and secondary graft patencies were 100% and 95.5%, respectively. Vascular reconstruction failed in three patients and, in two of them, we had to carry out limb amputation. CONCLUSIONS: From the viewpoint of vascular surgery, even very serious injuries of upper and lower extremities can be managed, if possible associated injuries of the skeletal and nerve structures allow for it. The key to success is good co-operation of the orthopaedic trauma surgeon, vascular surgeon and neurosurgeon.

Impact of mycophenolate mofetil (MMF)-related gastrointestinal complications and MMF dose alterations on transplant outcomes and healthcare costs in renal transplant recipients.

Mycophenolate mofetil (MMF), a mycophenolic acid prodrug, is a highly effective adjunct immunosuppressive agent in transplant therapy. Although MMF is generally well tolerated, optimal therapy may be limited by adverse effects, in particular gastrointestinal (GI) toxicity, which has been reported to occur in up to 45% of MMF-treated patients. MMF dose changes resulting from these adverse events may lead to sub-therapeutic dosing and impaired clinical outcomes. This retrospective study analyzed clinical records from 772 renal transplant patients from 10 US transplant centers who were initiated on MMF. The analysis revealed that 49.7% (n = 382) of patients experienced at least one GI complication within the first 6 months post-transplant, with 66.8% (n = 255) of these having multiple GI complications. Of the patients with GI complications, 39.0% experienced MMF dose adjustments or discontinuation of MMF therapy. Patients with GI complications who experienced MMF dose adjustments/discontinuation had a significantly increased incidence of acute rejections compared with patients without GI complications (30.2% vs. 19.4%; p = 0.005). Mean treatment costs were higher in patients with GI complications than in those with no GI complications, particularly in those who experienced MMF dose adjustments/discontinuation (p = 0.0001). The mean incremental cost for patients experiencing GI complications was US$3700 per patient during the 6 months post-transplant (p < 0.001), which was mainly attributable to hospitalization costs. In summary, GI complications and MMF dose adjustments/discontinuations are associated with a significant negative impact on transplant outcomes and markedly increase short-term treatment costs.