[Splenectomy via the Transdiaphragmatic Approach]. / Splenektomie transdiafragmaticky.

The spleen is one of the most commonly injured organ in blunt traumas to the chest and abdomen. Splenic injury can be a serious complication of fracture of the left 9th to 11th rib. The authors present a case report of a 65-year-old male patient with a blunt trauma to the left chest and abdomen, diagnosed with multiple left rib fractures, left hemothorax and splenic injury with a small subcapsular hematoma with no signs of active splenic bleeding. Due to hemodynamic instability and a large volume of blood loss via the chest drain, the patient was indicated for emergency left thoracotomy. A perforation in the lower lobe of the left lung caused by rib fractures was found, which was treated with sutures. Furthermore, the diaphragm was examined, two ruptures were identified from which blood was coming out, and thus a phrenotomy was performed. The bleeding central splenic rupture came as a big surprise. A spleen preserving surgery was impossible, therefore a splenectomy had to be performed, followed by chest wall stabilization with splints. Transthoracic approach to manage the splenic injury through phrenotomy should not be used as a standard. In a selected group of patients with concomitant chest and upper abdominal organ injuries, the use of this surgical approach appears to be highly beneficial. Key words: splenic injury, splenectomy, thoracotomy, rib fractures, diaphragmatic rupture.

Appendiceal tumors and pseudomyxoma peritonei: current recommendations for clinical practice.

Appendiceal tumors and pseudomyxoma peritonei (PMP) are rare tumors. Perforated epithelial tumors of the appendix are the most common source of PMP. This disease is characterized by the presence of mucin of varying degrees of consistency, partially adherent to the surfaces. Appendiceal mucoceles themselves are also very rare and usually their treatment involves only a simple appendectomy. The aim of this study was to provide an up-to-date review of the recommendations for the diagnosis and treatment of these malignancies according to the current guidelines of The Peritoneal Surface Oncology Group International (PSOGI) and the Blue Book of the Czech Society for Oncology of the Czech Medical Association of J. E. Purkyne (COS CLS JEP).

Pancreaticoduodenectomy in patients with an unusual course of the hepatic artery.

INTRODUCTION: Variations in hepatic artery anatomy are very common in the population. The aim of this study is to evaluate the rates of individual types of hepatic artery variants in the population of patients undergoing pancreaticoduodenectomy (PD), assess the accuracy of preoperative staging CT imaging to identify hepatic artery variants, and evaluate the impact of the hepatic artery variants on perioperative and postoperative morbidity of PD patients. METHODS: A prospective observation study of 147 patients undergoing PD for a pancreatic head pathology at the 1st Department of Surgery, University Hospital Olomouc between 1/2015-12/2018. Preoperative diagnosis of the course of the hepatic artery was made based on staging CT imaging analysis of the abdomen. The result was classified according to the Michels' scale and correlated with the final perioperative finding. Demographic, histopathological and clinicopathological data were included in a prospectively maintained database. RESULTS: A total of 147 patients were included in the study, 83 (56.5%) males and 64 (43.5%) females, median age 65.0 (37-83) years. A variant course of the hepatic artery was found in 37 (25.2%) patients. The accuracy of preoperative CT imaging in determining the variant was 100%. The presence of a hepatic artery variant was not statistically significant as a factor in terms of postoperative complications - CD I-II (50.0% vs 47.2%), CD III-IV (8.3% vs 13.8%). Similarly, the 30-day (4.2% vs 2.4%) and 90-day mortality rates (4.2% vs 3.3%) were comparable in both groups. CONCLUSION: Preoperative diagnosis of vascular variants based on multidetector CT imaging of the abdomen is routinely available and shows high detection accuracy. There was no difference in postoperative morbidity and mortality in patients with and without a variant hepatic artery undergoing PD.

Minimally-invasive pancreatic surgery in high volume centers in the Czech Republic - current status and possible implementations.

INTRODUCTION: Minimally-invasive surgical methods have been becoming ever more common also in the segment of pancreatic surgery. The aim of this paper was to analyze the current state of minimally-invasive surgery in the Czech Republic and the justification and potential of implementing such procedures. METHODS: Analysis of high volume centers using healthcare providers´ and payers´ data. RESULTS: Thirteen pancreatic surgical centers meet the proposed criteria for being called a high volume center - a center of highly specialized care in pancreatic surgery based on the annual number of at least 17 major resections of the pancreas. According to data from healthcare payers, laparoscopy was used in 0.6%-65.7% of procedures in individual centers. However, these are not resection procedures. The centers themselves report a significantly smaller number of minimally-invasive pancreatic resection procedures. The actual numbers of minimally-invasive resection procedures in the current system are practically impossible to verify. The potential for implementing minimally-invasive pancreatic surgery in the Czech Republic can be estimated based on the identification of candidate patients. CONCLUSION: Due to the fragmentation of this operative segment, its costs and small numbers of patients suitable for minimally-invasive pancreatic surgery even among high volume centers, the implementation rate of these methods is very slow. The need to centralize this segment of care appears to be very urgent from all points of view.

Achalasia - position of surgery in current management.

Oesophageal achalasia is a serious cause of dysphagia. Therapeutic options for achalasia include endoscopic and surgical methods. Indications for individual methods overlap to a certain extent and require careful diagnosis. The review article describes individual methods, focusing particularly on the issues of indications of pneumatic dilatation, peroral endoscopic myotomy (POEM) and laparoscopic or robotic Hellers myotomy. Special attention is paid to revision procedures after Hellers myotomy. The main added value of POEM is the treatment of spastic disorders of the oesophagus and re-do myotomy. Type 2 achalasia can be treated with dilatation, POEM and HM; type 1 achalasia can be treated using the same modalities. For type 3, POEM is the current method of choice. Despite the current emphasis on endoscopic myotomy, surgical therapy, especially laparoscopic or robotically assisted Hellers myotomy, remains a safe therapeutic option. It is indicated especially in patients who are not suitable for endoscopic therapy or those with advanced achalasia findings. In the future, identification of the risk of postoperative complications (perforation, reflux) should lead to differentiation of the indication of the laparoscopic (robotic) approach and POEM, or it may lead to a synchronous or metachronous indication of the cuff construction.

Enzyme replacement following total pancreatectomy; population analysis

Introduction: Total pancreatectomy (TPE) inevitably leads to absolute exocrine pancreatic insufficiency (EPI). No specific recommendations are available for enzyme replacement in such cases. The aim of our analysis was to explore the actual EPI replacement rates among patients following TPE after a certain period of time from the surgery. Methods: This retrospective analysis of living patients who had undergone TPE more than 2 years ago was done using a simple questionnaire to investigate the following: BMI prior to TPE, 3 months after TPE and at the time of data collection (in 2022), together with the actual number of daily bowel movements; and the replacement characteristics ­ the daily dose, its scheme and subjective satisfaction evaluation. Results: In total, we obtained data from 26 living patients with the history of TPE with their median follow up of 56 months (30­157). Malignant disease was confirmed in 69% patients based on histology; a benign tumor was present in the rest, although malignancy had been suspected preoperatively. Median BMI decreased from preoperative 27.4 (19.1­41.1) to 24.1 (19.8­33.7) 3 months following TPE, and median BMI value of 25.5 (21.2­34.5) was established at 30­157 months from TPE. The mean number of daily bowel movements was 2.2 (median 2, range 1­8) and the mean daily replacement dose was 182,000 units of lipase (median 175,000 u., range 0­250,000 u.) at the time of our investigation. Subjective satisfaction was reported by 85% responders and a lack of satisfaction despite maximum EPI replacement was expressed by 15% responders. Conclusion: BMI decreased shortly after TPE. In the long term, up to 80% of the patients achieved preoperative BMI values ±10% after TPE. Due to persistent steatorrhea and more frequent bowel movements despite enzyme replacement, 15% of the patients remained subjectively dissatisfied after TPE, but 85% of the patients did not perceive even more frequent bowel movements as unpleasant and were satisfied with their condition. The need of individualized enzyme replacement therapy of EPI following TPE is evident.

Antibiotic therapy of postoperative bronchopneumonia in patients after lung resections - single-site experience.

INTRODUCTION: Infectious complications after lung surgery are the most important factor that affects mortality and morbidity, prolongs hospital stays and increases financial costs. According to various sources, 30-day mortality after lung resections reaches 123%. Infectious complications account for 2075% of overall mortality. The infections most often present as postoperative pneumonia (POP), and their treatment is based on empirical and targeted antibiotic therapy. Any time lag in initiating effective antibiotic therapy significantly increases morbidity and mortality. Postoperative pneumonia is defined according to current guidelines of the American Thoracic Society of 2016 as nosocomial or ventilator pneumonia in patients after surgery. METHODS: Evaluation of risk factors, infectious agents, morbidity and mortality in patients after lung resections at a single site in the period from 1 January 2018 to 31 December 2019. RESULTS: Of our group of 190 patients, 21 (11.1%) patients had POP which was severe in 6 (33% with POP) patients, and 11 patients with POP required artificial oxygenation for saturation below 92%. Two patients with POP had to be intubated for respiratory failure, and 3 patients required noradrenaline circulatory support. One patient with severe POP died of multiorgan failure after developing refractory sepsis. CONCLUSION: Early identification of lung infection and early initiation of POP therapy are critical points for reducing morbidity and mortality after lung resections. Advanced antibiotic regimens for POP stratify the risk of mortality and infection with multidrug-resistant bacterial strains. However, the regimes require modification according to the epidemiological situation at the site with individualization of the specific procedure. Other research tasks include identification of valid markers of the initial stages of infection, and targeting of antibiotic therapy according to risk stratification and the relationship with physiological flora.

Middle and distal bile duct carcinoma, retrospective analysis & short-term and long-term outcomes of surgical therapy.

INTRODUCTION: The prognosis of extrahepatic cholangiocarcinoma is dismal and the only way to achieve long-term survival is surgical resection. While pancreatoduodenectomy (PD) is the standard procedure for distal cholangiocarcinoma (distal bile duct cancer; DBDC), bile duct segmental resection (BDR) can be used as an alternative approach for middle bile duct cholangiocarcinoma (middle bile duct cancer; MBDC). The aim of the study was to calculate the short-term and long-term outcomes of curative-intent surgery in distal bile duct cholangiocarcinoma patients. METHODS: A retrospective cohort study of consecutive patients treated for MBDC and DBDC with PD or BDR between 1/2009-12/2019. The patients were divided according to the type of surgical resection (PD and BDR group). Demographic, clinicopathological and histopathological data and overall survival (OS) were evaluated in both groups. OS was estimated using the Kaplan-Meier analysis. RESULTS: The study comprised a total of 62 patients - 45 patients (72.6%) in the PD group and 17 (27.4%) in the BDR group. Patients undergoing BDR were significantly older than those receiving PD (p=0.048). Men predominated in the PD group (N=34/45; 75.6%) while more women were included in the BDR group (N=10/17; 58.8%). Median age was higher in the BDR group (p=0.048). Serious morbidity (Clavien-Dindo III-V) (33.3% vs 11.8%), 30-day and 90-day mortality (4.4% vs 0.0% and 8.9% vs 5.9%, respectively) predominated in the PD group although the differences were not statistically significant, as well as a longer hospital stay (16.0 days vs 11.0 days; p=0.002). Pathological assessments revealed comparable numbers of positive lymph nodes in both groups, but a significantly higher number of total resected lymph nodes in the PD group (p.

Pancreatic cancer in chronic pancreatitis ­ the diagnostic and therapeutic dilemma; an overview of cases

Introduction: Any mass in chronic pancreatitis (CP) is a difficult diagnostic and therapeutic problem. The aim of the study is a) to use our own group to determine the actual incidence of non-malignant masses in CP where any mass is highly suspected of being malignant; and b) to determine the actual incidence of malignant tumors in CP. Methods: We present a retrospective analysis of our group of patients operated in 2015­2019 for CP, a mass in CP and suspected malignancy in the mass in CP. Additionally, we present difficult cases in terms of preoperative diagnosis. Results: Thirty-three of 340 (9.7%) pancreatic resection were done due to any form of chronic pancreatitis in 2015­2019. A mass in the pancreatic head was present in 16 (48%) patients; of these, pancreatic ductal adenocarcinoma (PDAC) was suspected in 10 (62%) patients based on EUS, CT or PETCT, and also based on positive tissue diagnosis using EUS-FNA in 6 cases. Bypass or Frey procedure were done in 59 patients (HJA, PJA, Frey). Preoperative tissue sampling was done in 8 (13%) patients and malignancy was suspected in 25%. Intraoperatively, malignancy was confirmed only in one patient assessed as non-malignant in the preoperative period. The clinical course in 3 other patients undergoing HJA, although tumor-free at the time of the surgery, indicated PDAC in CP. Conclusion: The ability to detect malignant cells in a mass in CP remains poor even using all of the available sophisticated methods and the success depends on many variable factors. The rate of "unnecessary" right-sided resections of a mass in CP reached 48% in our patient group, while the rate of resections which should have been performed instead of bypass procedures was 7%. A certain percentage of the so-called excessive pancreatic resections, as well as the failure to perform a resection due to an undetected/unrecognized pancreatic tumor in CP should continue to be expected.

Inferior pancreaticoduodenal artery aneurysm rupture as a cause of haemoperitoneum - case report and review of the literature.

INTRODUCTION: Arterial aneurysms of the pancreaticoduodenal arcade (PDA) represent approximately 2% of all aneurysms of visceral arteries. Despite a low incidence, this group of aneurysms is clinically significant due to its high risk of rupture. CASE REPORT: A 45 years old patient presented with a pancreaticoduodenal arcade aneurysm rupture along with a tight stenosis at the origin of the coeliac trunk. Retrograde blood flow from the superior mesenteric artery (SMA) to the hepatic artery (HA) via PDA limited our therapeutic options due to the necessity to maintain liver perfusion. The patient was indicated for an interventional radiology procedure, which consisted of percutaneous transluminal angioplasty (PTA) with stent placement at the origin of the coeliac trunk and subsequent transarterial embolisation (TAE) - trapping of the aneurysm using coils. Due to clinical signs of the intra-abdominal compartment syndrome, within 24 hours of the radiological treatment, the patient was indicated for surgical revision (laparotomy). During the surgery, no signs of active bleeding were found; coagula were evacuated from the abdominal cavity (800 ml) and laparostomy was performed with a temporary closure using a grid. Final closure of the abdominal cavity was performed on postoperative day 20 from the initial procedure. Follow-up abdominal CT performed 22 months after TAE showed no recurrence of the aneurysm. CONCLUSION: Aneurysm rupture represents a serious case of acute abdomen which requires urgent treatment. The preferred method of treatment for ruptured PDA aneurysms is the endovascular intervention using TAE, which is associated with lower morbidity and mortality than the surgical intervention. Concurrent coeliac trunk stenosis requires consideration given the need to maintain sufficient liver perfusion after TAE of the PDA aneurysm, acting up to this point as a collateral circulation of the liver. The choice of the therapeutic approach should be individualised taking into account the above mentioned recommendations.

Hyperthermic intraoperative intrapleural chemotherapy and surgical cytoreduction as part of multimodal treatment of malignant pleural mesothelioma - case report M. Szkorupa1, D. Klos1, J. Chudacek1, J. Hanuliak1, M. Stasek1, O. Fischer2, R. Lemstrova3.

Malignant pleural mesothelioma is one of the most aggressive malignancies with a very poor prognosis. Multimodal treatment consisting of three modalities - chemotherapy, radiotherapy and cytoreductive surgery is optimal. The use of new therapeutic modalities, such as hyperthermic intraoperative intrapleural chemotherapy or photodynamic therapy can improve the current results of mesothelioma treatment. Combined hyperthermic intraoperative chemotherapy and cytoreductive surgery as part of multimodal therapy of malignant mesothelioma has been used since 2017 at the 1st Department of Surgery of University Hospital Olomouc. The authors report the case of a 47-year-old man with malignant epithelioid mesothelioma of the left pleural cavity. Following neoadjuvant chemotherapy, this patient underwent extrapleural pneumonectomy with intraoperative intracavitary hyperthermic chemotherapy. The postoperative period was complicated by circulatory instability and later by tension fluidothorax with signs of heart failure. Currently, 8 months have elapsed from the surgery and the patient remains without any signs of recurrence.

Successfull therapy of grade III leak after thoracic oesophagectomyusing endoscopic vacuum assisted closure therapy - a case study.

INTRODUCTION: Post-oesophagectomy leakage occurs in 1-30% of cases as a significant factor in postoperative morbidity and mortality, accounting for 40% of postoperative deaths. Endoscopic vacuum therapy (EVAC) is, besides stent therapy, clips and surgical therapy, a new endoscopic thera-peutic modality. CASE REPORT: A 72-year-old polymorbid female patient with Siewert type II adenocarcinoma of the distal esophagus (T1b, N0, M0) was indicated for resection of the upper stomach and lower thoracic esophagus from laparotomy and thoracotomy with reconstruction using double-stapling anastomosis. On postoperative day 12, a 3rd degree leakage with propagation into the right pleural cavity was proven on CT. Endoscopy showed a defect affecting 30% of the circumference with a 7×3×3 cm cavity. Because of the leak morphology, EVAC was indicated. The therapy comprised 12 sessions with 3-4-day intervals for a total duration of 40 days with 5 extraluminal and 7 intraluminal applications and negative pressure of 100-125 mmHg. The condition was complicated by global respiratory failure due to severe pneumonia. Artificial ventilation was terminated on the 58th postoperative day. The patient was discharged to a rehabilitation facility on the 90th postoperative day. The follow-up 3 months after discharge confirms satisfactory performance results with full replenishment. CONCLUSION: The therapy of complications of intrathoracic anastomoses after oesophagectomy has shown a trend toward reduced invasiveness and wider implementation of endoscopic methods. In spite of its shortcomings, the use of EVAC is a safe and highly effective therapeutic option even for extensive anastomotic defects. The future use, indications as well as relation to other therapeutic options require further evaluation. Key words: endoscopic vacuum therapy - esophageal leakage - esophagectomy complications - intraoperative endoscopy.

[The survival of patients with radically non-resectable pancreatic cancer]. / Prezívání pacientu s radikálne neresekabilním karcinomem pankreatu.

INTRODUCTION: Pancreatic cancer (PDAC) is one of the most aggressive malignancies. Its poor prognosis is due to a combination of various factors, mainly aggressive biology of the tumour, non-specific symptoms in early stages, their underestimation, prolonged time to diagnosis and late onset of treatment. The majority of patients are diagnosed in an advanced stage of the disease. Median survival of these patients ranges from 211 months. The most common consequences of locally advanced disease that require intervention include obstruction of the duodenum and biliary obstruction. The purpose of our study was to analyze the survival of patients with radically inoperable PDAC undergoing palliative surgery or exploration with biopsy, and to evaluate the influence of patient and tumour factors and treatment modalities on survival. METHODS: In our retrospective study we included all patients with radically inoperable PDAC undergoing a non-radical surgical intervention between 01 January 2006 and 31 December 2014. Patient age, histopathological findings, surgical and oncological treatment and survival were included in the analysis. The results were statistically processed and evaluated using IBM SPSS Statistics software version 22 (USA). RESULTS: 184 patients with radically inoperable PDAC, 105 males and 79 females, were included in our study. Mean age of the patients was 64 years and most patients presented with stage IV of the disease. Mean survival time was 7.04 months and median 4.7 months. CONCLUSION: We determined a statistically significant influence of the following factors on patient survival: sex, stage, presence of distant metastases at the time of surgery and oncological treatment administration. Mean and median survival of patients with radically inoperable tumours matches global statistics. KEY WORDS: pancreatic cancer - radically non-resectable - palliative surgery - survival.

[Postpancreatectomy haemorrhage (PPH), prevalence, diagnosis and management]. / Krvácení po pankreatektomii (PPH), prevalence, diagnostika a resení.

INTRODUCTION: Postpancreatectomy haemorrhage (PPH) is considered to be the most severe specific postoperative complication following pancreatic resections and its treatment is difficult and requires coordinated interdisciplinary collaboration. PPH causes 11-38% of all post-pancreatectomy deaths. The aim of this study was to determine the prevalence of PPH in a set of patients operated on within the last 10 years, and to analyze the diagnostic methods, treatment modalities and the outcomes. METHODS: A retrospective analysis of patients undergoing pancreatic resections between 2006 and 2015. Clinically relevant PPH (types B and C) were the subject of interest. The onset, location and severity of PPH were analysed. Other factors analysed included operation diagnosis of PPH, diagnostic methods along with signs of sentinel bleeding, treatment options undertaken including the number of transfusions. 30-day, 90-day and in-hospital mortality, as well as the length of hospital stay and readmission rate were calculated. A descriptive statistical method was used. RESULTS: A total of 449 patients were operated on. Pancreatoduodenectomy (DPE) or pylorus-preserving pancreatoduodenectomy (PPPD) was done in 76.4%, left sided pancreatectomy (LPE) in 19.8% and total pancreatectomy (TPE) in 3.8%. 190 of the patients (42.3%) were women and 259 (57.7%) men, with the mean age of 61.5±11.1 years. A total of 23 (5.1%) PPH cases were identified, 21 (4.7%) were clinically relevant. Eight patients (35%) developed early PPH with direct reoperation, late PPH was seen in 14 patients after DPE and in one after LPE. Sentinel bleeding was present in 53.3% of late PPH cases. CT/CTA was performed in four patients with subsequent DSA performed in three. DSA identified a gastroduodenal artery stump pseudoaneurysm in one patient, which was resolved using a stent. Surgical intervention for late PPH was required in 10 patients in total, six of whom needed direct surgery due to the rapid development of circulatory instability and 3 due to inconclusive radiological management. One patient needed surgical drainage of both an abscess and haematoma. In two patients the origin of bleeding was due to a gastric ulcer, which was proven and solved endoscopically and 2 patients required conservative treatment only. The specific mortality for PPH was 17.4%. In the group of patients that suffered with any PPH following DPE and PPDPE the mortality rate was 22.2%, and 28.6% for late PPH. If late PPH developed coincidentally with postoperative pancreatic fistula (POPF), the mortality was 44%. In the early PPH group, an average of 10.1±2.5 transfusion units (TUs) were used with an average length of hospital stay 17.5±4.8 days and zero mortality in comparison to an average of 11.7±10 TUs and 29.9±14.6 days in hospital and 26.6% mortality in the late PPH group. CONCLUSION: PPH is a severe complication, which has a high mortality rate. It also often coincidentally develops with POPFs. Early clinical diagnosis with identification of its cause plays a key role in management. The use of interventional radiology in the treatment of PPH has begun to dominate other treatment modalities due to a very high success rate, and close collaboration with interventional radiologists is necessary in order to reduce the rate of surgical intervention required in PPH. KEY WORDS: haemorrhage - pancreas - resection - complications - mortality.

[Tumor cells transfer between the patient and laboratory animal as a basic methodological approach to the study of cancerogenesis and identification of biomarkers]. / Transfer nádorových bunek mezi pacientem a laboratorním zvíretem jako základní metodický prístup ke studiu kancerogeneze a identifikace biomarkeru.

INTRODUCTION: The investigation of prognostic and predictive factors for early diagnosis of tumors, their surveillance and monitoring of the impact of therapeutic modalities using hybrid laboratory models in vitro/in vivo is an experimental approach with a significant potential. It is preconditioned by the preparation of in vivo tumor models, which may face a number of potential technical difficulties. The assessment of technical success of grafting and xenotransplantation based on the type of the tumor or cell line is important for the preparation of these models and their further use for proteomic and genomic analyses. METHODS: Surgically harvested gastrointestinal tract tumor tissue was processed or stable cancer cell lines were cultivated; the viability was assessed, and subsequently the cells were inoculated subcutaneously to SCID mice with an individual duration of tumor growth, followed by its extraction. RESULTS: We analysed 140 specimens of tumor tissue including 17 specimens of esophageal cancer (viability 13/successful inoculations 0), 13 tumors of the cardia (11/0), 39 gastric tumors (24/4), 47 pancreatic tumors (34/1) and 24 specimens of colorectal cancer (22/9). 3 specimens were excluded due to histological absence of the tumor (complete remission after neoadjuvant therapy in 2 cases of esophageal carcinoma, 1 case of chronic pancreatitis). We observed successful inoculation in 17 of 28 tumor cell lines. CONCLUSION: The probability of successful grafting to the mice model in tumors of the esophagus, stomach and pancreas is significantly lower in comparison with colorectal carcinoma and cell lines generated tumors. The success rate is enhanced upon preservation of viability of the harvested tumor tissue, which depends on the sequence of clinical and laboratory algorithms with a high level of cooperation.Key words: proteomic analysis - xenotransplantation - prognostic and predictive factors - gastrointestinal tract tumors.

[Parametric monitoring of the quality of total mesorectal excision and surgical treatment of rectal carcinoma results of a multicenter study]. / Parametrické sledování kvality totální mezorektální excize a chirurgické lécby karcinomu rekta výsledky multicentrické studie.

INTRODUCTION: Tumour size and the quality of its complete surgical removal are the main prognostic factors in rectal cancer treatment. The number of postoperative local recurrences depends on whether the mesorectum has been completely removed - total mesorectal excision (TME) - and whether tumour-free resection margins have been achieved. The surgery itself and its quality depend on the accuracy of preoperative diagnosis and detection of risk areas in the rectum and mesorectum, on the surgeons skills, and finally on pathological assessment evaluating whether complete tumour excision has been accomplished including circumferential margins of the tumour, and whether mesorectal excision is complete. The aim of our study was to implement and standardize a new method of evaluation of the quality of the surgical procedure - TME - in rectal cancer treatment using an assessment of its circumferential margins (CRO) and completeness of the excision. METHODS: The study consisted of two parts. The first, multi-centre retrospective phase with 288 patients analysed individual partial parameters of the diagnosis, operations and histological examinations of the rectal cancer. Critical points were identified and a unified follow-up protocol was prepared. In the second, prospective part of this study 600 patients were monitored parametrically focusing on the quality of the TME and its effect on the oncological treatment results. RESULTS: The proportion of patients with restaging following neoadjuvant therapy increased from 60.0% to 81.7% based on preoperative diagnosis. The number of specimens missing an assessment of the mesorectal excision quality decreased from 52.9% in the retrospective part of to the study to 22.8% in the prospective part. The proportion of actually complete TMEs rose from 22.6% to 26.0%, and that of nearly complete TMEs from 10.1% to 24.0%. CONCLUSION: The introduction of parametric monitoring into routine clinical practice improved the quality of pre-treatment and preoperative diagnosis, examination of the tissue specimen, and consequently improved quality of the surgical procedure was achieved. KEY WORDS: rectal cancer TME - parametric monitoring - quality control.

[Synchronous cancer duplicities of pancreas and stomach/kidney and their surgical treatment]. / Synchronní nádorové duplicity pankreatu a zaludku/ledviny a jejich lécba.

INTRODUCTION: The occurence of synchronous pancreatic cancer and other primary cancer is not frequent and reaches about 5.6% as reported in autoptic studies. Double resections of the pancreas with another organ due to synchronous malignancies have been published only in quite sporadic sets of cases or individual case reports. The authors present three cases of synchronous pancreatic malignancies and stomach or renal cancers treated with surgery, including results and survival. CASES: Three patients with synchronous double cancer were identified in a series of 400 pancreatic resections (20062014). Two patients presented with symptoms of pancreatic periampullary tumors (bile duct obstruction, weight loss and abdominal pain). The second malignancies were identified as incidental during diagnostic work-up (asymptomatic cancer of the stomach, kidney). Pancreatoduodenectomies (PDE) with lymphadenectomies were performed due to ductal adenocarcinomas (pT2N1M0 G3 and pT3N1M0 G2). The second procedures included subtotal gastrectomy with lymphadenectomy (gastric adenocarcinoma pT1N1M0, G2) and nephrectomy (renal papillary carcinoma pT1bN0M0, G3). Postoperative adjuvant chemotherapy with gemcitabine was given in both patients. Survival rates were 12 and 19 months, respectively. The third patient suffered from abdominal pain and weight loss. Diagnostic work-up revealed stomach carcinoma and early pancreatic adenocarcinoma. Double resection - subtotal gastrectomy with lymphadenectomy and pancreatoduodenectomy with lymphadenectomy - was performed. Gastric adenocarcinoma pT2N2M0, G3 and pancreatic ductal papillary-mucinous adenocarcinoma pT2N0M0, G1 were found in the specimens. Adjuvant radiochemotherapy with 5-fluorouracil and leukovorine was given postoperatively. This patient is still alive nearly 5 years after the surgery, without any reccurence. CONCLUSION: The survival of patients with double synchronous pancreatic malignancies and other primary tumors in our set seems to be influenced by the stage and biology of pancreatic cancer. The survival was worse when the duplicity was presented with symptoms of pancreatic cancer. Pancreatic cancer found incidentally when another malignancy is presented has more favourable results.

[Pancreatic metastases--diagnosis, radical surgery, complications and survival]. / Metastázy do pankreatu--diagnostika a moznosti radikální lécby, komplikace, prezívání.

INTRODUCTION: Although generally uncommon, pancreatic metastases are increasingly encountered in clinical practice. The benefit of pancreatic resections in this setting is unclear and still being discussed. Renal cell carcinoma is the most frequent primary tumour metastasing to the pancreas--R0 resections in cases of solitary metastases can be performed. Resections in malignant melanoma and ovarian cancer are rather considered as palliative. The aim of this study is to analyse our own set of patients operated on for metastases into the pancreas and evaluate the results of their surgical treatment. METHODS: We identified the patients operated on for metastases to the pancreas. Patient and tumour characteristics were summarized using descriptive statistics. RESULTS: A total of 9 patients (out of 312 patients undergoing resection for malignancy in the period of 2006-2014) with pancreatic metastases were analysed. All but one were asymptomatic; the symptomatic patient suffered from GI bleeding. All patients had a metachronous lesion with a median length of 12 years (421 years) between the initial operation and pancreatic resection. The most common metastasing tumour was renal cell carcinoma (77%) with the highest incidence occurring at the head of the pancreas (44%). The most frequent procedure used was the pylorus-preserving pancreatic head resection (44%). The median operating time was 247 min, (126375 min). Six patients were complication free, the median of their hospital stay was 9.5 days (812 days). Complications included PPH type C and PF type B both of which required surgical intervention; however, PF type A required no intervention. No postoperative deaths occurred, multiple metastases were found in 4 patients with renal cell carcinoma metastases. The median of follow-up has been 11.5 months, (334 months). CONCLUSION: Survival after pancreatic resections due to renal cell carcinoma is favourable. Mortality is low and morbidity is similar to that associated with pancreatic resections due to other aetiologies, making surgery a valid and safe treatment option. Lifelong follow-up of patients after nephrectomy is advised. Resections in pancreatic metastases of malignant melanoma or ovarian carcinoma are considered as palliative, their indication being individual following interdisciplinary consultation.

[Surgical therapy of pancreatic cancer - 5 years survival]. / Resekabilní karcinom pankreatu 5leté prezití.

INTRODUCTION: The purpose was to identify 5-year survivors among a group of radically resected patients with pancreatic cancer and analyse the characteristics and factors associated with their 5-year survival. Single tertiary centre experience. METHOD: A prospectively maintained database of 155 pancreatic resections from January 2006 to June 2010 was scanned to identify patients after curative radical resections for pancreatic ductal adenocarcinoma. The clinical and pathological data was analysed retrospectively. The outcomes of the PDAC group were evaluated using Kaplan-Meier analysis (survival) with the Log-rank test and Cox regression analysis (evaluation of prognostic factors). Characteristics of the survivors were discussed. Significance level of 0.05 was used. Those factors were used as independent variables for Cox regression analysis whose significant effect on survival was shown based on Kaplan-Meier analysis. RESULTS: Among 155 patients undergoing a curative pancreatic resection, 73 had a pancreatic ductal adenocarcinoma. Fifteen patients (20.5%) after radical surgery survived over 5 years, 13 of whom are still alive. In the group of the survivors, the mean overall survival was 77.1 months (60110) and the median survival was 74 months. The mean relapse-free interval in the group of the survivors was 63.3 months (14110) with the median of 65 months. Factors associated with a longer survival included the absence of lymph node infiltration (p=0.031), uncomplicated postoperative course (p=0.025), absence of vascular invasion (p=0.017), no blood transfusions (p=0.015) and the use of postoperative therapy - predominantly chemotherapy (p=0.009). Significant independent predictors of survival included vascular invasion HR=2.239 (95%CI: 1.0934.590; p=0.028), postoperative chemotherapy HR=2.587 (95%CI: 1.3015.145; p=0.007) and blood transfusion HR=2.080 (95%CI: 1.0274.212; p=0.042). The risk of death was increased 2.2 times in patients with vascular invasion, 2.1 times in patients with transfusions, and finally 2.6 times in those with no chemotherapy. CONCLUSION: Factors associated with an improved overall survival included: the absence of lymph node infiltration, an uncomplicated postoperative course, absence of vascular invasion, no need of blood transfusions, and finally the use of postoperative chemotherapy. Vascular invasion, use of blood transfusions and postoperative adjuvant chemotherapy were significant independent prognostic factors of survival.

[Determination of CEA, EGFR and hTERT expression in peritoneal lavage in patients with pancreatic adenocarcinoma using RT - PCR method]. / Stanovení exprese CEA, EGFR a hTERT v peritoneální lavázi u pacientu s adenokarcinomem pankreatu metodou RT-PCR.

INTRODUCTION: The aim of this study is to assess the significance of CEA, EGFR and hTERT as markers of occult tumor cells for predicting treatment outcomes in pancreatic cancers, as well as determining the cut-off values of these markers individually in peritoneal lavage. METHOD: The study compared 87 patients undergoing palliative operations (bypass surgery, biological sampling for subsequent oncological treatment) for either stage III or IV (UICC) pancreatic ductal adenocarcinomas with a control group of 24 healthy patients. Abdominal cavity lavage was performed at the beginning of the surgery in both groups, using 100 ml of physiological solution (phosphate buffered saline, pH 7.2). The samples were transported in bottles containing 1.5 ml 0.5 M EDTA and 10 ml of fetal bovine serum. Total RNA samples were all processed and purified by reverse transcription. Occult tumor cells in the peritoneal lavage were detected by the real-time RT-PCR method using CEA, EGFR and hTERT as markers of tumor cells. Another aim was to calculate the cut-off values of these markers. Statistical analysis was done using software R (www.r-project.org) and Statistica (StatSoft, Inc. USA). RESULTS: Mean expression of CEA, EGFR and hTERT in peritoneal lavage in the control group was 2501, 716749 and 104 copies of mRNA / mg RNA. Threshold, cut-off values were determined as the "mean + 2 times standard deviation". Absolute expression values were further normalized to expression of the house-keeping gene glyceraldehyde-3-phosphate dehydrogenase (GAPDH). After normalization, cut-off values of the tested markers were 4.89, 115.88 and 0.02 copies of mRNA/GAPDH mRNA. As regards absolute expression of the markers tested, only hTERT was able to statistically significantly (p<0.001) distinguish the analysed groups, where patients with advanced pancreatic adenocarcinoma had a higher expression of hTERT. Absolute expression of CEA or EGFR was not able to discriminate between the two groups. The more accurate normalized expression values of the test markers demonstrated a statistically significantly higher expression of hTERT (p<0.005) and CEA (p<0.001) in patients with advanced adenocarcinoma compared to the control group. CONCLUSION: Absolute hTERT expression in peritoneal lavage of patients with advanced pancreatic cancer was significantly higher compared to the control group.