Robotic-assisted minimally invasive esophagectomy - our first experience.

INTRODUCTION: Minimally invasive esophagectomy is associated with lower postoperative morbidity and better quality of life compared to open esophagectomy in patients with comparable oncological outcomes. Robotic-assisted surgery represents the next step in the development of mini- mally invasive surgery. We aim to present the results of a pilot cohort of patients undergoing robotic-assisted minimally invasive esophagectomy (RAMIE). METHODS: An initial cohort of patients with RAMIE was retrospectively analyzed. Operative characteristics, histopathological results, postoperative course, incidence of complications, and postoperative mortality were evaluated. RESULTS: From 3/2022 to 6/2023, a total of 31 patients underwent RAMIE at our institution, including hybrid RAMIE (robotic abdomen, open chest) in 11 and total RAMIE in 20 patients. Most patients were male, had locally advanced tumors, predominantly adenocarcinoma and neoadjuvant treat- ment. Thirty patients had Ivor-Lewis and one patient had McKeown esophagectomy. The median total operative time was 495 minutes and median blood loss was 200 mL. R0 resection was achieved in 87% of patients. A median of 26 lymph nodes were removed. Postoperative Clavien-Dindo ≥3 complications occurred in 9 (29%) patients. Four (13%) patients required reoperation. Anastomotic leak was found in 5 (16%) and pneumonia in 9 (29%) patients. The median hospital stay was 9 days. One patient died in the postoperative period. Thirty-day and 90-day mortality rates were 0% and 3.2%, respectively. CONCLUSION: Our initial experience shows that RAMIE is a safe surgical procedure and we consider its implementation at our institution to be success- ful. After overcoming the learning curve, we hope to reduce the operative time and increase the medical benefit for the patient.

Treatment of anastomotic leak after Ivor Lewis esophagectomy.

INTRODUCTION: Anastomotic leak (AL) is one of the most serious surgical complications after esophagectomy. Endoscopic, radiological and surgical methods are used in the treatment of AL. The aim of this study was to retrospectively evaluate our therapeutic procedures and results of AL treatment after Ivor Lewis esophagectomy (ILE). METHODS: Retrospective audit of all ILEs performed in the years 20052019. Evaluation of AL treatment results according to Esophagectomy Complication Consensus Group (ECCG) classification and according to the primary therapeutic procedure with a focus on the treatment with esophageal stent. RESULTS: Out of 817 patients with ILE, AL was detected in 80 patients (9.8%): ECCG type I 33 (41%), type II 23 (29%) and type III 24 (30%) patients. Some 33 patients (41%) were treated conservatively. Esophageal stents were used in 39 patients (49%), of which 18 (23%) had concomitant percutaneous drainage and 17 (21%) were reoperated. Reoperation without a stent insertion was performed in 7 patients (9%). Esophageal diversion with cervical esophagostomy was performed in a total of 16 patients (20%). Esophageal stent treatment was successful in 24/39 patients (62%). Airway fistula occurred in 4 patients treated with stent (10%). Endoscopic vacuum therapy was successfully used in three patients after stent failure. Eight patients (10%) died as a result of AL. Mortality of AL type I, II and III was 0%, 4% and 29%. CONCLUSION: Successful treatment of AL requires an individual and multidisciplinary approach. The primary effort should aim to preserve anastomosis using endoscopic and radiological methods. In case of insufficient clinical effect, we recommend not to hesitate with reoperation. If primary therapy fails, the life-saving procedure is a cervical esophagostomy.

[18 F]Fluorodeoxyglucose PET/CT and prediction of histopathological response to neoadjuvant chemotherapy for adenocarcinoma of the oesophagus and oesophagogastric junction.

BACKGROUND: The aim of this prospective study was to assess whether [18 F]fluorodeoxyglucose PET can be used to predict histopathological response early in the course of neoadjuvant chemotherapy in patients with adenocarcinoma of the oesophagus and oesophagogastric junction. METHODS: Following the PET response criteria in solid tumours (PERCIST 1.0) as a standardized method for semiquantitative assessment of metabolic response, FDG-PET/CT was performed before (PET1) and after (PET2) initiation of the first cycle of chemotherapy. The relative changes in the peak standardized uptake value (ΔSUL) and total lesion glycolysis (ΔTLG) between PET1 and PET2 were correlated with histopathological response, defined as less than 50 per cent viable tumour cells in the resection specimen. A receiver operating characteristic (ROC) curve analysis was used to identify the optimal cut-off value with the highest accuracy of histopathological response prediction. RESULTS: PET2 was performed a median of 16 (range 12-22) days after the start of chemotherapy. Some 27 of 90 patients who underwent surgery had a histopathological response. There was no association between the median ΔSUL or median ΔTLG and the histopathological response. A post hoc analysis in 47 patients with PET2 performed 16 days or less after the start of chemotherapy showed that ΔTLG, but not ΔSUL, was associated with the histopathological response (P = 0·009). The optimal cut-off value of ΔTLG was 66 per cent or more. CONCLUSION: FDG-PET/CT after the first cycle of chemotherapy does not predict histopathological response in patients with adenocarcinoma of the oesophagus and oesophagogastric junction.

[Intramural haematoma of the oesophagus - a case report and literature review]. / Intramurální hematom jícnu - kazuistika a prehled literatury.

Intramural hematoma of the oesophagus is a rare diagnosis presenting with retrosternal pain, dysphagia and haematemesis. It is caused by barotrauma or direct injury to the esophagus, or it may occur spontaneously without apparent cause, which is more common in patients taking antiplatelet or anticoagulant medications. In most cases, treatment is conservative. Rarely, endoscopic, endovascular or surgical treatment is effective. This article presents a case report of a female patient with spontaneous haematoma of the oesophagus solved conservatively and discusses further possibilities of the course and treatment of the disease.Key words: intramural haematoma of the oesophagus IHE.

Outcomes of patients with oesophageal cancer treated with preoperative chemoradiotherapy, followed by tumor resection: influence of nutritional factors.

PURPOSE: To assess the impact of clinical and nutritional factors on overall survival (OS) and time to disease progression of oesophageal cancer patients treated with neoadjuvant chemoradiotherapy (CRT) and surgery. METHODS: We retrospectively studied and analysed several clinical and nutritional factors, such as performance status, weight changes before and during CRT, dysphagia, nutritional support, and serum albumin to see whether they exerted any impact on OS and time to disease progression. RESULTS: In 107 patients the average weight loss was 9.7% from the onset of signs of disease to the beginning of therapy and 3% during CRT. In univariate analysis, significant unfavorable impact on survival was proved for low performance status, severe dysphagia, need for nasogastric tube insertion, above-average weight loss before treatment, weight loss >5% during CRT, and serum albumin ≤ 35 g/l before or after CRT. Patients supported by oral nutritional supplements (ONS) had higher probability to attain full dosage of CRT and radical resection than did those obtaining dietary advice alone. In multivariate analysis, serum albumin level, nasogastric (NG) tube insertion and pretreatment body weight loss were independent prognostic factors for OS, while serum albumin level after CRT and NG tube insertion were prognosticators for time to progression. CONCLUSION: Serum albumin level can serve as a useful prognostic factor for the outcome of patients with oesophageal cancer treated with neoadjuvant CRT and surgery. Appropriate nutritional support of these patients increased the probability of attaining full dosage of CRT and radical disease resection.

[Esophageal perforation]. / Perforace jícnu.

OBJECTIVE: Evaluation of patients with acute esophageal perforations with single institution experience. MATERIAL AND METHODS: The authors evaluate the set of 64 consecutive patients with esophageal perforation treated in our department between January 2000 and December 2010. In all patients were before decision making performed CT scans and X-ray examination with contrast agent administration. For selected patients was also accompanied upper endoscopy. Excluded were patients with malignant tracheoesophageal fistula and patients with perforation of malignant stenosis treated with palliative intent. RESULTS: The mean age was 62 years (range 24-90), of which one third (34.4%) were aged 70 years or more. We received the iatrogenic perforation in 45 (70%) patients, less than one quarter (n = 15; 23%) consisted of spontaneous perforation, in three patients we have failed to determine the cause of perforation (5%) and one patient experienced perforation during removal of foreign body. Perforation of the thoracic esophagus in 41 patients, in 20 (31%) cases in the upper and middle third and 21 (33%) in the distal third of the thoracic esophagus. Cervical perforation was noted in 14 patients (22%) and abdominal of the 9 patients (14%). 92% of patients were treated surgically (n = 59). 43% (n = 27) were treated by primary suture of the perforation, esophageal resection with primary reconstruction was performed in 4 patients, esophagectomy with terminal esophagostomy and nutritional jejunostomy in 7 patients, 4 patients were treated by surgical drainage and only 7 patients, we introduced endless lavage. In 9 cases we have resected affected portion of esophagus with stapler closure in the chest. Conservative management of esophageal perforation we proceeded in 5 patients in whom a stent was introduced and the perforation successfully healed. Overall mortality in our set of patients is 23.4%. CONCLUSION: Conservative procedure in carefully selected patients could be an alternative to radical and inherently surgical procedures. Published results and our little experience are encouraging, but this topic is still under study.

Prospective non-randomized study of preoperative concurrent platinum plus 5-fluorouracil-based chemoradiotherapy with or without paclitaxel in esophageal cancer patients: long-term follow-up.

Combined modality treatment for esophageal carcinoma seems to improve survival over surgery alone. Different combinations of cytotoxic drugs have been studied to improve antitumor efficacy and limit the toxicity of chemoradiotherapy (CRT) with inconsistent results. We present a prospective study of neoadjuvant CRT with or without paclitaxel in chemotherapy schedule. One hundred seven patients (93 males, 14 females), median age 59 years (range 44-76), with operable esophageal cancer were enrolled. They received the following neoadjuvant therapy: Carboplatin, area under curve (AUC) = 6, intravenously on days 1 and 22, 5-fluorouracil (5-FU), 200 mg/m(2)/day, continuous infusion on days 1 to 42, radiation therapy 45 grays/25fractions/5 weeks beginning on day 1. Forty-four patients (41%) were furthermore non-randomly assigned to paclitaxel 200 mg/m(2)/3 h intravenously on days 1 and 22. Nutritional support from the beginning of the treatment was offered to all patients. Surgery was done within 4-8 weeks after completion of CRT, if feasible. All patients were evaluated for grade 3 plus 4 toxicities: leukopenia (28%), neutropenia (30%), anemia (6%), thrombocytopenia (31%), febrile neutropenia (6%), esophagitis (24%), nausea and vomiting (7%), pneumotoxicity (8%). Seventy-eight patients (73%) had surgery and 63 of them were completely resected. Twenty-two patients (20%) achieved pathological complete remission, and additional 20 (19%) had node-negative and esophageal wall-positive residual disease. There were 10 surgery-related deaths, mostly due to pulmonary insufficiency. Twenty-nine patients were not resected, 15 for early progression, 14 for medical reasons or patient refusal. After a median follow-up of 52 months (range 27-80), median survival of 18.0 months and 1-, 2-, 3- and 5-year survival of 56.7, 37.5, 27.0 and 21% was observed in the whole group of 107 patients. Addition of paclitaxel to carboplatin and continual infusion of FU significantly increased hematologic and non-hematologic toxicity, but treatment results as overall survival or time to progression did not differ significantly in groups with and without paclitaxel. Patients achieving pathological complete remission or nodes negativity after neoadjuvant therapy had favorable survival prognosis, whereas long-term prognosis of node positive patients was poor. Distant metastases prevailed as a cause of the treatment failure. Factors significant for survival prognosis in multivariate analysis were postoperative node negativity, performance status, and grade of dysphagia. Addition of paclitaxel to carboplatin and continual FU significantly increased hematologic and non-hematologic toxicity without influencing efficacy of the treatment. This study confirmed improved prognosis of patients after achieving negativity of nodes. Distant metastases prevailed as cause of the treatment failure. Prospectively, it is important to look for a therapeutic combination with better systemic effect.

[Stents--palliative and curative management of esophageal conditions. Seven-year surgical experience]. / Stenty--paliativní a kurativní osetrení jícnu. Sedmileté zkusenosti chirurgického pracoviste.

The authors present their experience with endoscopic introduction of stents into esophagus and cardia based on data collected from a group of 520 patients. Their study included both paliative management of stenoses in carcinomas of the esophagus and cardia, as well as management of other esophageal conditions, including fistules, perforations and various types of stenoses, including the use of novel absorbable stents.

[Our experience with diverticulectomy in symptomatic Zenker's diverticulum]. / Unsere Erfahrungen mit der Zenkerdivertikelresektion.

INTRODUCTION: The frequency of endoscopic procedures for management of Zenker's diverticulum has increased rapidly in the last years. Endoscopic methods are highly effective. We tried to answer the question whether the development of endoscopic methods means the end of open surgery. PATIENTS AND METHODS: In this retrospective study 30 patients (11 men, 19 women) with an average age of 70.9 (49-88) years with Zenker's diverticulum (ZD) were included. All patients were treated with an open transcervical approach between October 2000 and July 2005. In all cases the region of ablation of the diverticulum was closed with a primary handmade suture. In two cases an additional myotomy was performed. For evaluation of the long-term results the patients were sent a questionnaire. To objectify the findings, all patients underwent postoperatively an X-ray examination of the esophagus. The literature was searched by PubMed. RESULTS: 30 patients underwent 32 operations. 91 % of the inquired patients evaluated the operation as successful. An anastomotic leakage was observed in 3 patients, a lesion of the recurrent laryngeal nerve occurred in 2 patients. CONCLUSION: Despite the rapid development of endoscopic methods the open surgical approach remains a reliable and minimal invasive solution of ZD with excellent results and low complication rate. In patients that cannot undergo endoscopic procedures the surgical approach represents the only therapeutic option. Therefore surgical training for repairing ZD is also necessary for the future.

[Paliative managment of oesophageal carcinomas--our experience]. / Paliativmní osetriení karcinomu jícnu--nase zkusenosti.

The authors of this presentation explain their experience with methods of paliative care of oesophagus carcinoma. The indication criteria are described and compared advantages and disadvantages of those methods. There is an accent in most frequent method--oesophagus stent implementation. The results in the group of patients after the stent implementation are described, also complications and other solutions.

[The cystadenocarcinoma of the appendix]. / Kystadenokarcinom apendixu.

The authors present a case-review of a patient with a large retroperitoneal tumor. A right-sided hemicolectomy with a removal of a large retroperitoneal cyst extending behind the liver up to the diaphragm on the right side, was conducted. Histology confirmed a mucous cystadenocarcinoma of the appendix. Furthermore, the authors discuss this fairly rare type of the GIT carcinoma. This tumor is low-invasive, mucus producing and rarely metastazing. During the tumor progression, the tumorous cells enter the peritoneal cavity and cause, so called, pseudomyxoma peritonei. The treatment principle is to complete a radical surgical removal of the tumor and, furthermore, in case of the pseudomyxoma periotenei, also application of the local peroperative chemotherapy.

[Oesophageal perforations]. / Perforace jícnu.

The subject of oesophageal perforations is wide enough to make any comparison of therapeutical methods and their respective results very difficult, if not impossible. Therefore, the authors aim to specify individual perforation types and their therapeutical management.

[Liver metastases of colorectal carcinoma]. / Jaterní metastázy kolorektálního karcinomu.

The surgical resection of liver metastasis is still rather rare in the Czech Republic. The survey of literature indicates that correctly indicated metastasectomy is the method of the first choice. Five years after metastasectomy one third of patients who underwent surgical intervention still lives.

[Appendectomy--classical or laparoscopic?]. / Apendektomie--klasicky nebo laparoskopicky?

The authors demonstrate on a group of 219 patients, who had in last two years the appendectomy performed, results of care while using open and laparoscopic technique. They compare these depending on chosen parameters, which is the usage of analgetic, the time patients have to stay in hospital after performed operation and comparison of spirometry within specific patients before and after operation. Based on these parameters the authors did not prove clear advantages of laparoscopic appendectomy.

[Lymphoma of the small intestine]. / Lymfom tenkého streva.

The authors analyze on a case-history the problem of lymphomas of the gastrointestinal tract. The patient was a female who was operated on account of a suspected perforation. On operation multiple perforations of the small intestine were found. A resection was performed. According to the histological results it was a giant-cell B-lymphoma of the small intestine. The postoperative course was without major complications. The patient was referred to the oncological department without further treatment.

[Surgery of esophageal achalasia--possible complications]. / Operace achalázie jícnu--mozné komplikace.

The authors demonstrate on a group of patients operated by a miniinvasive method possible complications of treatment of achalasia of the oesophagus. On a group of 61 patients they analyze all complications and try to detect their causes. They divide complications into peroperative, early and late postoperative ones. The most frequent peroperative complications are perforation of the oesophagus which are as a rule treated by the laparoscopic route. After surgery the most frequent problem is a relapse of achalasia. The latter is sometimes due to inadequate myotomy. This can be prevented by careful surgical technique along with peroperative endoscopic control.

[Aspergillus osteomyelitis of the sternum]. / Aspergilová osteomyelitida sterna.

The objective of the work was to describe experience with the treatment of Aspergillus osteomyelitis of the sternum. Radical resection of the affected portion of the bone with subsequent filling of the defect of the part of the omentum majus proved useful. Complete healing occurred after 4 months. Based on their own experience the authors assume that resection therapy is the method of choice in pulmonary aspergilloma. In the described case with affection of the thoracic wall its resection with subsequent filling of the defect by the omentum majus proved useful. The operation was implemented in a single stage.

[An unusual complication after laparoscopic cholecystectomy]. / Neobvyklá komplikace po laparoskopické cholecystektomii.

The authors describe an interesting complication after laparoscopic cholecystectomy. During a complicated operation perforation of a gallbladder, severely altered by inflammation, occurred and part of the concrements escaped into the peritoneal cavity. Several concrements were left in the abdominal cavity. After several weeks of a complicated postoperative development the concrements penetrated into the subcutaneous layer in the lumbar region and finally they were eliminated spontaneously. In the discussion the authors deal with complications of laparoscopic cholecystectomy.