Peroral endoscopic myotomy (POEM) in the treatment of severe postfundoplication dysphagia.

Although uncommon, chronic postfundoplication dysphagia (PFD) is a serious complication of antireflux surgery. Currently, reoperation is the only possible solution as endoscopic pneumatic or hydraulic dilation are not effective. At present, POEM represents a standard method for the treatment of esophageal achalasia; however, in patients with PFD it is an experimental approach whose clinical effectiveness is unknown. Our case report describes a female patient who suffered from severe PFD after two surgeries (fundoplication and subsequent reoperation). Dysphagia and progressive weight loss had developed over the years and all treatment attempts (several sessions of dilation) were unsuccessful. Subsequently, esophageal resection was considered as the last resort. After a discussion in a multidisciplinary team and additional examinations (EndoFLIP), POEM was performed without any complications, and the procedure had an excellent effect without any adverse events.

Endoscopic clips versus overstitch suturing system device for mucosotomy closure after peroral endoscopic pyloromyotomy (G-POEM): a prospective single-center study.

BACKGROUND AND AIMS: G-POEM is an emerging method for treatment of severe gastroparesis. Safe mucosal closure is necessary to avoid adverse events. The aim of this study was to compare the efficacy of two closure methods: clips and endoscopic suturing (ES) after G-POEM. METHODS: We performed a single center, prospective study. The closure method was assigned at the discretion of an endoscopist prior to the procedure. The main outcome was the proportion of subjects with successful closure. Unsuccessful closure was defined as a need for a rescue method, or a need for an additional intervention or incomplete closure-related adverse events. Secondary outcomes were the easiness of closure (VAS score 1 = very difficult, 10 = easy), closure time, and cost. RESULTS: A total of 40 patients [21 female; mean age, range 47.5; (20-74)] were included; 20 received ES and 20 clips [mean number of clips 6; range (4-19)]. All 20 patients with ES (100%, 95% CI 84-100%) and 18 patients with clips (89%, 95% CI 70-97%) had successful closure (p = 0.49). One patient needed a rescue method (KING closure) and the other patient an additional clipping on POD1. Closure with clips was quicker [mean time 9.8 (range 4-20) min vs. 14.1 (5-21) min; p = 0.007] and cheaper [mean cost 807 USD (± 402) vs. 2353 USD (± 145); p < 0.001]. Endoscopist assessed the easiness of ES and clips as comparable [mean VAS, range 7.5 (3-10) (ES) vs. 6.9 (3-10) (clips); p = 0.3]. CONCLUSIONS: Both ES and clips are effective methods for mucosal closure in patients undergoing G-POEM. However, centres using clips should have a rescue closure method available as clips may fail in some patients. Closure with ES is more costly than with clips.

The experience with colorectal cancer screening in the Czech Republic: the detection at earlier stages and improved clinical outcomes.

OBJECTIVES: Colorectal cancer (CRC) remains a major health burden. Although screening is recommended and considered beneficial, further data on its positive effects are needed for worldwide implementation. STUDY DESIGN: The aim of our national multicentre prospective observational study was to reveal and document clinicopathological differences in CRC diagnosed by screening and presented by disease symptoms as well as assess the efficiency of the screening programme in the Czech Republic. METHODS: Between March 2013 and September 2015, a total of 265 patients were enrolled in 12 gastroenterology centres across the Czech Republic. Patients were divided into screening and symptomatic groups and compared for pathology status and clinical characteristics. Screening was defined as a primary screening colonoscopy or a colonoscopy after a positive faecal occult blood test in an average-risk population. RESULTS: The distribution of CRC stages was significantly (statistically and clinically) favourable in the screening group (predominance of stages 0, I and II) compared with the non-screening group (P < 0.001). The presence of distant and local metastases was significantly less frequent in the screening group than in the symptomatic group (P < 0.001). Patients in the screening group had a higher probability of radical surgery (R0) than those diagnosed based on symptoms (P < 0.001). Systemic palliative treatment was indicated in two patients in the screening group compared with 23 patients in the non-screening group (P = 0.018). CONCLUSION: CRC diagnosed by screening disclosed less advanced clinicopathological characteristics and results in patients with a higher probability of radical surgery (R0) than diagnoses established based on symptoms, with subsequent management differing accordingly between both groups. These results advocate the implementation of a suitable worldwide screening programme.

Per-oral endoscopic pyloromyotomy (g-poem) for the treatment of gastroparesis - a pilot single-centre study with mid-term follow-up.

INTRODUCTION: Endoscopic pyloromyotomy (G-POEM) is an emerging therapeutic method for the treatment of gastroparesis (GP). So far, only limited case-series suggesting its effectivity have been published. The aim of our study was to assess the effectivity of G-POEM in patients with refractory GP. METHODS: Consecutive patients with severe and refractory GP were offered the procedure. An abnormal gastric emptying study (GES) was necessary for inclusion. The main outcome was treatment success defined as a decrease of the total GSCI symptom score by at least 40% from baseline at 3, 6, 12 and 24 months. RESULTS: G-POEM was performed in 9 patients (5 women, mean age 56.3): 5 post-surgical, 2 diabetic, 1 idiopathic and 1 combined post-surgical and diabetic. The median follow-up was 23M (range 12-31). All procedures were successfully completed. One patient experienced delayed bleeding from gastric ulceration, which was successfully treated endoscopically; all remaining patients recovered uneventfully. Treatment success was achieved in 8/9 patients (88.9%) at 3, 6 and 12M and in 3/4 (75%) at 24M. The mean GSCI decreased from 3.16 to 0.86 (p=0.008), 0.74 (p=0.008), 1.07 (p=0.008) and 1.31 (p=0.11) at 3, 6, 12 and 24M after the procedure. The Quality of Life Index improved from the baseline value of 77 (range 48102) to 113 (86-138, p=0.03) and 96 (50-124, p=0.4) at 12 and 24M. In patients with treatment success, no recurrences have occurred so far. GES improved/normalized in all the patients. CONCLUSION: G-POEM was effective in 88.9% of patients with refractory GP and the effect seems to be long-lasting.

Confocal laser endomicroscopy in diagnosing indeterminate biliary strictures and pancreatic lesions a prospective pilot study.

INTRODUCTION: An accurate histopathological diagnosis of indeterminate biliary strictures and pancreatic lesions is challenging because of insufficient quali-ty of tissue specimen taken during ERCP (brush cytology), cholangioscopy (biopsies) or endosonography (EUS, FNAB). Confocal laser endomicroscopy (CLE) allows virtual histopathological diagnosis with the potential to either replace or increase the diagnostic yield of standard histopathological diagnosis in patients presenting with biliary strictures and pancreatic lesions. The aims of our prospective pilot study were to: 1. Assess the diagnostic yield of standard histopathology compared to CLE in patients referred for cholangioscopy or for EUS of the pancreas; 2. Evaluate the cost of CLE in these indications. METHODS: CLE was performed (during cholangioscopy or EUS), followed by standard tissue sampling. CLE-based diagnosis was compared with standard histopathology/cytology. CLE probe was introduced through the working channel of the cholangioscope or through the FNAB needle. RESULTS: A total of 23 patients were enrolled (12 women, mean age 61 years); 13 patients underwent cholangioscopy and 10 patients underwent EUS. Cholangioscopy: CLE diagnosed correctly all 4 malignant strictures (histology 2 of them only as 2 patients had insufficient quality of the tissue specimen). Agreement between standard histopathology and CLE was achieved in 85 %. EUS: All 3 cases of pancreatic cancer were correctly diagnosed by both CLE and FNAB. All remaining (premalignant and benign) lesions were also correctly diagnosed by both methods. The cost of CLE examination is higher compared to FNAB but comparable with tissue sampling during digital cholangioscopy. CONCLUSION: CLE demonstrated sufficient diagnostic accuracy in patients with indeterminate biliary strictures or pancreatic lesions and, therefore, might improve diagnostic accuracy or even replace standard histopathology in these indications.

Confocal laser endomicroscopy in the diagnostics of gastrointestinal lesions literary review and personal experience.

INTRODUCTION: Confocal laser endomicroscopy (CLE) is a new method enabling real-time histopathological diagnosis. Two platforms of CLE are used standardly: the so called probe-based CLE in which an endomicroscopic probe is inserted through an endoscope, and so-called needle-based CLE inserted through a needle. METHODS: CLE enables evaluation of epithelial and subepithelial structures with 1000x magnification in any part of the gastrointestinal system. The main advantage over conventional biopsies can be immediate diagnosis and larger area evaluated. CLE might play a promising role in indeterminate biliary lesions where biopsies are often not sufficient and fail to allow for accurate diagnosis. CLE can also have a promising potential in pancreatic lesions where it is used along with the needle designed for tissue aspiration during endosonography. It is also possible to use CLE in other organ systems and medical specialties, e.g. in pneumology, neurosurgery, ENT and others. CONCLUSION: CLE is a promising diagnostic method; however, it is unlikely to replace standard biopsies currently since these are still considered a gold standard of histopathological diagnosis. High purchase price is a main disadvantage of the method, hampering its expansion in medicine. Key words: confocal laser endomicroscopy CLE biliary strictures pancreatic lesions esophageal carcinoma Rozhl Chir 2018;97:531-538.

[Molecular Pathogenesis of Colorectal Cancer]. / Molekulární genetika kolorektálního karcinomu.

BACKGROUND: Colorectal cancer (CRC) remains a major health burden with an incidence of 1.3 million new cases worldwide and a mortality of almost 8.5%. It is the 2nd most common cancer in women (1st breast carcinoma) and 3rd most common in men (1st lung carcinoma, 2nd prostate carcinoma). CRC alongside breast, lung, prostate and stomach cancer is in the top five most common cancers in men and women worldwide. There are still more than 50% of CRC patients diagnosed with advanced disease (stage III and IV) in the Czech Republic. Genetically, CRC is a very heterogeneous disease with many factors playing key roles in pathogenesis. There are two types of CRC, hereditary with an incidence of between 5% and 10% with APC (FAP, aFAP) or MMR (HNPCC) genes affected, and sporadic colorectal cancer with an incidence of 90-95% with a lot of mutations in variable genes that accumulate during pathogenesis (APC, KRAS, MMR, microRNA, CIMP etc.). Knowledge of the molecular pathogenesis of CRC (hereditary, sporadic) is crucial for treatment, assessment of risk, prognosis, and patient follow-up. CONCLUSION: This article summarizes the molecular pathogenesis of sporadic and hereditary CRC.

NOTES in Europe: summary of the working group reports of the 2012 EURO-NOTES meeting.

The sixth EURO-NOTES workshop (4 - 6 October 2012, Prague, Czech Republic) focused on enabling intensive scientific dialogue and interaction between surgeons, gastroenterologists, and engineers/industry representatives and discussion of the state of the practice and development of natural orifice transluminal endoscopic surgery (NOTES) in Europe. In accordance with previous meetings, five working groups were formed. In 2012, emphasis was put on specific indications for NOTES and interventional endoscopy. Each group was assigned an important indication related to ongoing research in NOTES and interventional endoscopy: cholecystectomy and appendectomy, therapy of colorectal diseases, therapy of adenocarcinoma and neoplasia in the upper gastrointestinal tract, treating obesity, and new therapeutic approaches for achalasia. This review summarizes consensus statements of the working groups.

[Acute pancreatitis -  new developments in treatment]. / Akutní pankreatitida -  novinky v lécbe

Acute pancreatitis continues to be a potentially very severe disease. According to new classification schemes, a severe pancreatitis (up to 20%) is conditioned by structural changes and organ failures. The first critical moment concerns a fast development of pancreatic necrosis, followed by delayed infection. The most common complications of pancreatitis include infections, bleeding, compartment syndrome and decompensation of comorbidities. At the early stage the most important measure concerns the active expansion of blood volume and treatment of organ dysfunction. General antibiotic prophylaxis has been rejected; it is indicated only if there are signs of persistent circular failure and inflammatory response syndrome. The choice of antibiotic regimens usually includes Ciprofloxacin plus Metronidazole, Imipenem and Propene, administered for at least 10 to 14 days. After that the prophylaxis should be assessed and it may be continued under a changed regimen. The lab tests as well as imaging methods are continuously monitored and the administration of antibiotics is adequately adjusted. If infection is demonstrated antibiotics are indicated based on standard microbiological parameters and clinical relationships. Any surgical intervention (nephrectomy) is delayed as long as possible. Indication would concern impaired condition despite intensive care, e.g. newly developed sepsis, pains, food intake inability or other complications, such as bleeding. Recently the open surgical nephrectomy is confronted with derivations of infected necrosis via mini-invasive procedures, such as transcutaneous drainage, laparoscopic video-assisted nephrectomy or endoscopic transgastric nephrectomy. The methods may be combined. Mortality and morbidity of mini-invasive procedures are comparably significantly lower.

[A detailed study of colon polyps]. / Podrobná studie o polypech tlustého streva.

UNLABELLED: INTRODUCTION, STUDY AIM: Colorectal carcinoma is one of the most frequent malignancies. Most frequently, neoplasms, including malignant precursors, are in the form of polyps, although these might be of a non-tumour origin. The aim of this prospective multicentre study was to provide an overview of coloscopic identification and biological nature of polyps. RESULTS: 3,400 consecutive coloscopies performed between 2009 and 2010 were analyzed. At different centres, the top of the cecum was reached in 89% to 93% and terminal ileum in 73% to 87% of cases. In the above 40 age group, 26.6% were screening coloscopies. The mean age of the above 40 patients was 56 years. The incidence of potential neoplastic lesions (polyps, carcinomas), advanced adenomas and carcinomas were: 7.8 %, 0.8 % and 0.16 %, respectively, in the above 40 age group, 41.5 %, 9.8 % and 1.6 %, respectively, in the 40-50 years age group and 70.5 %, 31.3 % and 6.8 %, respectively, in the above 50 age group. The incidence of tubular adenoma and hyperplastic polyps was 23.9% and 66.2%, respectively, in the below 40 age group and 53.1% and 26.1% in the above 50 age group. 57.8% of advances neoplasms were located in the rectosigmoid a descendent colon. The incidence ratio for adenomas and hyperplastic polyps was 76.6% and 14%, respectively, for rectosigmoid colon, 63.6 and 17.4 %, respectively, for descendent colon, 63.6 and 11.4 % for traverse colon and 63,4 a 17,9 %, respectively, for cecum and ascendant colon. The incidence of tubulovillous adenomas and hyperplastic polyps in pedunculated polyps larger than 1 cm was 19.4 % and 20.4 %, respectively, and 34.2 % and 13.1 %, respectively, in other polyps. The incidence of potential lesions (polyps and carcinomas), advanced adenomas, carcinomas and advanced neoplasms was 66.7 %, 23.1 %, 5.8 % and 28.9 %, respectively, in women and 63.1 %, 30.0 %, 5.7 % and 34.7 %, respectively, in men. CONCLUSION: The top of the cecum was reached in a higher proportion of cases than required, although this was lower than in the majority of other recent studies. Terminal ileum was reached in high number of cases. The incidence of polyps and neoplasms rose sharply from 40 years of age. Therefore, the screening threshold should be extended to the below 50 age group. Hyperplastic polyps predominated in younger age and adenomas in the above 40 age group. Histological profile was similar and did not suggest importantly different pathogenesis with respect to localization. There were relatively fewer adenomas and more hyperplastic polyps in pedunculated polyps and vice verse in other types of polyps, suggesting a higher risk associated with non-pedunculated lesions. Both sexes differed less than suggested based on epidemiological statistics.

[Evaluation of variants of unknown significance in the BRCA2 gene]. / Hodnocení variant nejasného významu v genu BRCA2.

BACKGROUND: Endogenous processes and exogenous agents cause constant DNA damage. DNA double-strand breaks are among the most serious types of damage. They are mainly repaired by homologous recombination, where the BRCA2 protein plays a dominant role. Heterozygous germline BRCA2 mutations predispose to breast, ovarian, pancreatic and other types of cancer. The presence of a pathogenic mutation in patients or their family members warrants close surveillance and prophylactic surgery. Apart from clearly pathogenic mutations, variants leading only to a single amino acid substitution are often identified. Since the influence of these variants on cancer risk is unknown, they represent a major clinical problem. AIMS: The aim of this paper is to summarize the current possibilities of predicting pathogenicity of BRCA2 variants. In some cases, genetic methods are able to classify variants with high probability; however, their use is often limited by low frequency of the variants or inaccessibility of samples for mRNA isolation or DNA from family members. Alternatively, functional assays performed in various cellular models may be employed. Multiple functional tests and cellular models are presented and characterized, including their advantages and limitations. A new model of human syngeneic cell lines developed by the authors is presented, in which one BRCA2 allele is deleted and the variant is introduced into the other allele by homologous recombination. This model has the potential to evaluate function of variants without some of the unwanted effects of the other models. Currently, this model is being applied to variants identified in patients with hereditary cancer predisposition in the Masaryk Memorial Cancer Institute. CONCLUSION: Functional assays in cellular models including a new model of syngeneic cell lines described by the authors have a great potential in evaluating clinical importance of unclassified variants in the BRCA2 gene, especially in cases where genetic tests are not applicable.

[Sorafenib in the treatment of hepatocellular carcinoma]. / Sorafenib v lécbe hepatocelulárního karcinomu.

Hepatocellular carcinoma (HCC) is the 5th most frequent tumour disease and, at the same time, the 3rd most frequent cause of death from cancer worldwide. More than 600 000 new patients are diagnosed every year and more than 80% are diagnosed at an advance stage where surgical treatment is not indicated and systemic chemotherapy does not provide longer survival time. Sorafenib is the first substance that provides proven significant prolongation of survival time of HCC patients. This is a multikinase inhibitor with anti-proliferative and anti-angiogenic properties. Its efficacy was shown in the SHARP study that enabled licensing of sorafenib for the therapy of inoperable, metastasizing hepatocellular carcinoma, including patients with liver cirrhosis, functional class Child-Pugh A or B, in more than 60 countries worldwide, including the Czech Republic. The aim of this paper is to provide a comprehensive summary of the current treatment of HCC and, at the same time, to point out some new therapeutic approaches that, in the near future, shall certainly play a major role in the treatment of HCC.

[The coincidence of alcoholic liver cirrhosis and chronic pancreatitis]. / Soubezný výskyt alkoholické jaterní cirhózy a chronické pankreatitidy.

UNLABELLED: INTRODUCTION, STUDY AIM: Health consequences of alcoholism vary and include a wide range of pathological conditions from mental disorders to disorders of various parenchymatous organs. There are many differences between alcohol abusers, from the way they abuse alcohol to the nature of bodily harm. The aim of this prospective study was to map and correlate organ involvement with the type of alcohol abuse and smoking and dietary habits. METHODS: A prospective study analyzing a questionnaire on alcoholism, smoking, diet and lifestyle habits completed by 146 patients with liver cirrhosis and chronic pancreatitis. RESULTS: Of the 80 liver cirrhosis patients with the mean age of47.5 year (23-60 years, SD 8.58), 64 were men and 16 (20%) were women. Of the 60 chronic pancreatitis patients with the mean age of 37.8 year (23-60 years, SD 9.66), 60 were men and 6 (9.1%) were women. The mean daily alcohol intake was 57.7 g in patients with cirrhosis and 63.7 g per day in patients with pancreatitis. The first contact with alcohol before 15th year of age was reported by 25.8% of patients with pancreatitis and 8.8% of patients with cirrhosis. Age under 30 years as the period with the largest intake of alcohol was reported by 43.6% of patients with pancreatitis and 20.3% of patients with cirrhosis. There was a statistically significant difference in the type of alcohol used; patients with pancreatitis predominantly drank beer. 16.7% of patients with pancreatitis and 3.7% of patients with cirrhosis started to smoke before 15th year of age. 66.7% of patients with pancreatitis and 40% of patients with cirrhosis left education before achieving collage state exam, 9.1% of patients with pancreatitis and 25% of patients with cirrhosis had university education. Cirrhosis was diagnosed in 11 (16.7%) patients with chronic pancreatitis. In all patients, this was functional disorder Child-Pugh stage A, decompensation occurred in 54.5% of patients. Portal hypertension was diagnosed in 72.7% of patients and thrombosis of v. portae orv. lieanlis in 12 patients. Bleeding from gastroesophageal varices occurred in 1 patient with chronic pancreatitis, liver cirrhosis and v. portae thrombosis. Chronic pancreatitis was diagnosed in 2 (2.5%) patients with livercirrhosis. With respect to comorbidities, chronic obstructive bronchopulmonary disease and ischemic heart disease was significantly more frequent in patients with chronic pancreatitis. CONCLUSION: There are differences in social-behavioural background of both relatively common organ disorders. Chronic pancreatitis is more prevalent in people with lower education. The first contact with alcohol and regular abuse occur at younger age, smoking is also more frequent, with earlier onset. Both diseases rarely occur concurrently and simultaneous decompensation of both organs is not seen. We could speculate that early exposition to the known aetiopathogenic factors affect primarily pancreas. The rare concurrence of both diseases, particularly of their advanced stages, opposes all known theories.

[Early biliary complications following liver transplantation]. / Casné biliární komplikace po transplantaci jater.

INTRODUCTION: Biliary complications (BC) after liver transplantation (LTx) are serious problems with an incidence rate of 6-35%. There are two types of BC, early and late. Early BC is observed for 30 days post LTx or during the entire period of the patient's first hospital stay after LTx. The main causes of early BC are ischemia of the biliary tree (the bile duct of the transplanted liver is supplied only from the right hepatic artery descendingly; the supply from the gastroduodenal artery is lacking) as well as implementation of the biliary anastomosis surgical technique. Treatment of BC is administered by a surgeon, a gastroenterologist and a radiologist. AIM: To evaluate early biliary complications after LTx PATIENTS AND METHODS: We reviewed patients with early BC after LTx from 4/2004 - 12/2009. We defined early BC as a complication that is present during the first 30 days post LTx or during the entire period of the patient's first hospital stay after LTx. RESULTS: We performed 384 LTx during the above-mentioned period. We carried out reconstruction of the biliary tree in the form of a choledochocholedochostomy (CDD) in 312 cases and in the form of a choledochojejunostomy (CDJ) in 72 cases. Sixty-eight patients had early BC (17.7%), 25 patients experienced biliary leak (6.5%), 40 patients had anastomotic stenosis (10.4%) and 3 patients (0.8%) experienced both complications (biliary leak and stenosis). Most complications were eliminated by ERCP with a papilosfincterotomy, a balloon dilatation of stenosis, and a biliary stent implant with repeated stent replacements (45 cases in total- all patients with biliary stenosis). Twenty-two patients were reoperated on (16x CDJ, 3x re-CDD, 2x suture of aberrant bile duct, 1x suture common bile duct) and 1 patient was treated by percutaneous transhepatic bilary drainage (PTD). The mortality rate was zero. CONCLUSION: BC after LTx continue to pose a serious surgical problem. The treatment of choice when dealing with BC is ERCP, which has more than a 70% success rate. If ERCP or PTD are not successful, or when biliary peritonitis is present, we perform a reanastomosis of the bile duct. The combined effort of the surgeon, gastroenterologist and radiologist is the most important factor for successful treatment. The incidence of BC after LTx at IKEM is similar to that of treatment centers all over the world.

Portal hypertension is the main driver of liver stiffness in advanced liver cirrhosis.

Liver stiffness (LS) is a novel non-invasive parameter widely used in clinical hepatology. LS correlates with liver fibrosis stage in non-cirrhotic patients. In cirrhotic patients it also shows good correlation with Hepatic Venous Pressure Gradient (HVPG). Our aim was to assess the contribution of liver fibrosis and portal hypertension to LS in patients with advanced liver cirrhosis. Eighty-one liver transplant candidates with liver cirrhosis of various aetiologies underwent direct HVPG and LS measurement by 2D shear-wave elastography (Aixplorer Multiwave, Supersonic Imagine, France). Liver collagen content was assessed in the explanted liver as collagen proportionate area (CPA) and hydroxyproline content (HP). The studied cohort included predominantly patients with Child-Pugh class B and C (63/81, 77.8%), minority of patients were Child-Pugh A (18/81, 22.2%). LS showed the best correlation with HVPG (r=0.719, p< 0.001), correlation of LS with CPA (r=0.441, p< 0.001) and HP/Amino Acids (r=0.414, p< 0.001) was weaker. Both variables expressing liver collagen content showed good correlation with each other (r=0.574, p<0.001). Multiple linear regression identified the strongest association between LS and HVPG (p < 0.0001) and weaker association of LS with CPA (p = 0.01883). Stepwise modelling showed minimal increase in r2 after addition of CPA to HVPG (0.5073 vs. 0.5513). The derived formula expressing LS value formation is: LS = 2.48 + (1.29 x HVPG) + (0.26 x CPA). We conclude that LS is determined predominantly by HVPG in patients with advanced liver cirrhosis whereas contribution of liver collagen content is relatively low.

[One-year survival outcomes in patients with pancreatic head and portomesenteric veins resection]. / Výsledky jednorocního prezití u nemocných po resekci hlavy slinivky brisní resekcí zil portomezenterické oblasti (PMO).

INTRODUCTION: Hemipancreatoduodenectomy is a standard technique for surgical management of pancreatic head carcinomas. However, so far, mesenteric and/or portal vein resections have not been commonly indicated. This original report presents one-year survival outcomes in a group of operated subjects. METHODOLOGY: From 7/2005 to 7/2008, 13 pancreatic resections with concomitant resection of the mesenteric or portal vein were performed in the IKEM Transplant Surgery Clinic. The study objective was to assess the perioperative complications and 30-day mortality rates, and the overall survival period. RESULTS: The study group included 13 patients, 8 males and 5 females, the mean age was 66 (48 to 85) years. Concomitantly, resection of the portal vein (6x) or the superior mesenteric vein (3x), or of the both veins (4x) was performed. In 11 subjects of this patient group, the time period between the surgical procedure and the assessment was over a year. During the portomesenteric reconstruction phase, end-to-end anastomoses were performed in eight subjects, and the resected vein was replaced with the internal jugular vein in two subjects. In three subjects, the venous wall excision site was closed using a simple defect suture. Out of the study group, 5 subjects were surviving at 12 months. Three patients exited due to their primary diagnosis and the fourth one for internal complications two months after the procedure. CONCLUSION: The authors belive that hemipancreatoduodenectomy with concomitant resection of portomesenteric veins should become a standard treatment method in indicated patients, performed in specialized centres.

Low incidence of adenocarcinoma and high-grade intraepithelial neoplasia in patients with Barrett's esophagus: a prospective cohort study.

BACKGROUND AND STUDY AIMS: Barrett's esophagus is a premalignant condition. The risk of developing high grade intraepithelial neoplasia (HGIN) or adenocarcinoma is currently a matter of debate. Due to several shortcomings, previous studies have probably overestimated the risk. The main aim of our study was to investigate the incidence of HGD and adenocarcinoma in a cohort of patients with Barrett's esophagus. PATIENTS AND METHODS: In a prospective, cohort study, all patients had intestinal metaplasia and macroscopic evidence of short- or long-segment (< 3 cm or > or = 3 cm) Barrett's esophagus. All patients underwent a standard protocol including regular endoscopies with biopsies and were treated with a proton pump inhibitor or antireflux surgery. RESULTS: A total of 135 patients underwent 623 endoscopies during 700 patient-years (mean follow-up 5.2 +/- 2.3 years). Simultaneous HGIN and adenocarcinoma were detected in two patients with long-segment Barrett's esophagus (1.5%; 2 and 6 years after the index endoscopy). Low grade intraepithelial neoplasia (LGIN) was detected in 25 patients (18.5%); in 11 of these patients (44%), LGIN was not confirmed in later biopsies. Our study shows an incidence of HGIN/adenocarcinoma of 1/350 patient-years. Endoscopic regression of Barrett's esophagus was seen in 20.7% of patients. CONCLUSION: The incidence of HGIN/adenocarcinoma is low in patients with adequately treated Barrett's esophagus. The annual risk of developing HGIN/adenocarcinoma is 0.21% (1.6% in long-segment Barrett's esophagus).

[Surgical treatment of gastrointestinal complications after the heart transplantation]. / Chirurgické výkony na gastrointestinálním traktu po transplantaci srdce.

BACKGROUND: Orthotopic heart transplantation (OHT) is standard treatment of patients with end-stage heart failure. Long-term immunosuppressive therapy leads to the increased risk of the infection and cancer. METHODS AND RESULTS: Our retrospective study was aimed to evaluate gastrointestinal surgery procedures after OHT. The retrospective study was carried out at the Institute of clinical and experimental medicine (IKEM), between January 1, 1996 and December 31, 2006. Our group of patients includes 587 transplant recipients and 22 gastrointestinal surgery procedures. CONCLUSIONS: Results from our department did not show statistical differences in the length of hospital stay, morbidity and mortality in comparison with patients after OHT and control group.

Systematic review: the efficacy of treatments for irritable bowel syndrome--a European perspective.

BACKGROUND: Irritable bowel syndrome (IBS) is a common, chronic disorder, characterized by abdominal pain/discomfort, bloating and altered bowel habit. AIM: To conduct a systematic evidence-based review of pharmacological therapies currently used, or in clinical development, for the treatment of IBS in Europe. The safety and tolerability of these therapies are the subject of an accompanying review. METHODS: A literature search was completed for randomized controlled studies which included adult patients with IBS and an active or placebo control, assessed IBS symptoms, and were published in English between January 1980 and June 2005. The level of evidence for efficacy was graded according to the quality of the trial design and the study outcome. RESULTS: There is some evidence for improvement of individual IBS symptoms with antidiarrhoeals (diarrhoea), antispasmodics (abdominal pain/discomfort), bulking agents (constipation), tricyclic antidepressants (abdominal pain/discomfort) and behavioural therapy. In contrast, there is strong evidence for the improvement of global IBS symptoms with two new serotonergic agents: the 5-HT4 selective agonist tegaserod (IBS with constipation) and the 5-HT3 antagonist alosetron (IBS with diarrhoea). Further data are required for the 5-HT3 antagonist, cilansetron, and the mixed 5-HT3 antagonist/5-HT4 agonist renzapride before their utility in IBS can be appraised. CONCLUSIONS: There is limited evidence for the efficacy, safety and tolerability of therapies currently available in Europe for the treatment of IBS. Overall, there is an absence of pharmacological agents licensed specifically for the treatment of IBS subtypes, and new agents are awaited in Europe that will allow changes in clinical practice to focus on and improve global IBS symptoms.