[Basic principles of diagnosis and treatment of secondary peritonitis - recommendations of experts with the support of SIS]. / Základní principy diagnostiky a lécby sekundární peritonitidy - doporucení odborníku s podporou SIS.

Secondary peritonitis is the most common cause of inflammatory acute abdomen treated at general surgery departments. Only early and correct diagnosis may improve the prognosis of these patients. The authors compiled an interdisciplinary review of the basic principles of diagnosis and treatment of secondary peritonitis, which reflects current findings supported by evidence-based medicine. The work is based on published international literature but also shares opinions and experiences of the selected specialists. The presented work in its extent is not meant to substitute an in-depth study of the issue, but to allow a basic and quick review of the topic.

[3D endorectal sonography in the diagnosis of periproctal fistulas]. / 3D endorektální sonografie v diagnostice perianálních pístelí

INTRODUCTION: Magnetic resonance (MRI) and endorectal sonography seem to be the most contributive methods in preoperative diagnostics of perianal fistula. The right interpretation of MRI requires the radiologist performing the evaluation to be very well acquainted with the issue of surgical treatment of perianal fistulas, or the surgeon to have experience with MRI findings interpretation. On the contrary, endorectal sonography is usually performed by surgeons who are able to transfer the findings to surgical practice and who also have the feedback during the description of the endorectal sonography findings in confrontation with the peroperative findings. MATERIAL AND METHODS: There were 482 patients with the clinical diagnosis of perianal fistula in our group who were examined and underwent surgery in the period between 1 January 2001 and 31 December 2011. In evaluating the findings, we used the basic Parks classification of perianal fistulas which is modified with respect to the specific features of ultrasound examination. RESULTS: In case of simple fistulas, the correspondence between preoperative diagnostics and peroperative finding was present in 304 cases (90%), in case of extrasphincteric fistulas there was correspondence in 36 patients (82%). In case of horseshoe fistulas, the correspondence was found in 16 patients (87%). The diagnosis of the fistulas with more than one sinus was accurate in 95 patients (76%). General correspondence between the preoperative examination and the peroperative finding was present in 419 patients (87%). CONCLUSION: Endorectal sonographic examination in the diagnosis of perianal fistulas is simple, cheap and less demanding for the patient, reaching at the same time high sensitivity and specificity. It is fully sufficient as a preoperative diagnostic method in most patients with perianal fistula.

[Treatment strategies of the colorectal anastomosis stricture]. / Strategie lécby striktury kolorektální anastomózy.

INTRODUCTION: The treatment of the stenoses of colorectal anastomoses represents a difficult area of colonic surgery. This is partly connected to the introduction of staplers and an increasing amount of sphincter-preserving surgeries. At our clinic, we solve the stenoses of colorectal anastomoses using a surgical rectoscope with a good effect. MATERIAL AND METHODS: We analysed retrospectively a group of 27 patients with benign stenosis of colorectal anastomosis of the medial and upper rectum who underwent surgery at our clinic in the period between January 2004 and December 2011. From the total amount of 27 patients, in 23 patients the stenosis was caused by the dehiscence of anastomosis, and in 4 patients the stenosis had a different etiology. RESULTS: In the group of 27 patients, in 14 patients the stenosis of colorectal anatomosis was solved radiologically using a high pressure balloon. Total of 13 patients underwent surgery, in 10 of them we used the surgical rectoscope and 3 patients underwent an open abdominal procedure. CONCLUSION: The first method of choice in treatment of the stenoses of the colorectal anastomoses is a balloon dilatation. If this is not successful we can use the surgical rectoscope as a minimally invasive though effective and safe method.

The significance of portal vein embolization in the treatment of colorectal liver metastases.

UNLABELLED: The first aim of the present paper was to evaluate hypertrophy of liver parenchyma after portal vein embolization in patients after systemic chemotherapy for colorectal carcinoma metastases and planned extensive liver resections. The second aim was to study whether hypertrophy of the liver parenchyma remnant after could influence the postoperative course large liver resections in long-term chemotherapy within complex therapy of colorectal carcinoma.The prospective study comprised of 43 patients with colorectal hepatic metastases in whom liver resections of 4-5 segments were planned (Table 1). All patients underwent complex therapy of colorectal carcinoma, including chemotherapy consisting of 6-12 therapeutic cycles. Time interval between chemotherapy and liver resection was 2-24 months (mean interval of 8 months). Twenty patients whose presumed liver parenchyma remnant was less than 40% of total liver volume were indicated for portal vein embolization (mean liver parenchyma remnant of 29%). This was always embolization of the right portal branch. Twenty-three patients were primarily indicated to liver resection. RESULTS: Hypertrophy of the left liver lobe occurred in all 20 patients. After portal vein embolization, the volume of left liver increased on average from 476 ml (282-754) to 584 ml (380-892) (P < 0.05). Mean hypertrophy of left liver lobe after portal vein embolization was 28.5%. The measured parenchyma remnant after tumor resection increased from 29% up to 38% by hypertrophy. Mean values of ALT and AST in the postoperative period were significantly different in the groups in this study. The values of alkaline phosphatase (ALP) and gamma glutamyl transpeptidase (GMT) were lower in patients after portal vein embolization (P < 0.05). Significant differences were in postoperative level of serum bilirubin, bilirubin levels in patients after portal vein embolization were 2-3 times lower than in the group of patients after immediate surgery (P < 0.05). he values of prothrombin time were also significantly lower in patients who underwent surgery without previous portal vein embolization (P < 0.05).

[Patient survival following radiofrequency ablation of liver metastases from colorectal cancer]. / Prezívání nemocných po radiofrekvecní ablaci jaterních metastáz kolorektálního karcinomu.

OBJECTIVE: The objective of the work was to evaluate five-year survival rates of patients with liver metastases from colorectal cancer following radiofrequency ablation (RFA). MATERIAL A METHOD: The authors prospectively evaluated a set of 32 patients indicated for radiofrequency ablation. RESULTS: Patients who were indicated for RFA and for a combination of liver resection with RFA for metastasis from colorectal cancer had a one-year, three-year and five-year survival of 81%, 31% and 13%, respectively. Therefore 10 patients survived 3 years following the procedure and of these 4 obtained five-year survival. CONCLUSION: Radiofrequency ablation has become a generally accepted technique in the treatment of liver metastases. It is indicated in cases of lesions unsuitable for surgical resection, either due to large number and location or in patients with comorbidities where an extensive resection is contraindicated. Radiofrequency ablation has minimal complications and is considered on the borderline between a palliative and radical procedure.

[Potential of transanal endoscopic microsurgery]. / Moznosti transanální endoskopické mikrochirurgické techniky.

AIM: Evaluate our more than seven year experience with transanal endoscopic microsurgical technique (TEM). MATERIALS AND METHODS: The authors prospectively evaluated a set of 393 patients who were operated using the TEM method. RESULTS: Out of 393 patients, 371 (94%) were indicated for the procedure for rectal tumor; 82 of these tumors were malignant. Nine patients underwent a rectoplasty for rectal stenosis, and in five patients drainage of a perirectal fluid collection was performed. Four patients underwent the surgical procedure for bleeding from the rectal tumor and in four patients an ulcerous lesion was removed from the rectum. Complications in the set of patients with malignant or benign tumors of the rectum occurred in 21 (6%) cases. Ten patients had bleeding, three patients underwent surgical revision for peritonitis with dehiscence of the intraabdominal bowel suture after transmural resection, periproctal abscess occurred in five patients, rectovaginal fistula was observed in three patients. There was no postoperative mortality. CONCLUSION: Transanal endoscopic microsurgery has become a standard therapeutic procedure. In oncosurgery, for early stages of rectal tumors, it is an equivalent alternative to conventional surgery with the advantages of minimal morbidity, mortality, postoperative complications, and sexual and urological dysfunctions. This, however, is only true when indication criteria are strictly adhered to and principles of resection radicality are maintained.

[Ambulatory excision of perianal duplicatures]. / Ambulantní excize perianálnich duplikatur.

For successful outpatient treatment of perianal duplicatures, it was necessary to solve two main problems. First was bleeding from wounds following excision of perianal duplicatures, which is often marked and "pulsating", as well as to accelerate defect healing after excision so as to eliminate or minimize sick leave following this outpatient procedure. To effectively stop acute bleeding we use Traumacel powder, which after applying to a tampon we apply to the bleeding site and by compression we facilitate its effect. Traumacel spray also has a significant haemostatic effect, which we spray directly onto the bleeding site, where it reacts and creates a strongly adhering coagulum, which has significant haemostatic properties. This effect may also be potentiated by applying compression in the form of tampon or longuette. After cessation of acute bleeding, as prevention against future seepage, surgical haemostatic materials are used, which adhere to the wound, or bleeding lesion, and are left in situ for approximately 12 hours. After stopping the bleeding, hydrocortisone and epithelializing cream is applied to the defects to support healing by significantly decreasing secretion from the wound and also significantly decreasing healing time by facilitating epithelization. At outpatient check-ups, wound surfaces treated as such are cleanly granulated without necrotic coating and with minimal surrounding redness. The total healing time is generally 2 weeks, whereas after 4 days the patients are almost without troubles. This effective healing not only lessens the patient's pain, but also improves the comfort of the patient and allows a more rapid return to daily activities.

[Risk of colorectal carcinoma in a patient with ulcerative colitis]. / Riziko kolorektálního karcinomu v terénu ulcerózní kolitidy.

Colorectal cancer, in patients with ulcerative colitis, is detected in the resected tissue of approximately 5% of patients, according to the literature. In our set of 82 patients operated on between the years 2000-2009, malignancy was confirmed in 9/82 patients (11%). In two young patients, the peroperative findings showed inoperable generalized carcinoma. The greater incidence of malignity is surely associated with inconsistent dispensarization of these patients.

Endorectal sonography in rectal cancer staging and indication for local surgery.

BACKGROUND/AIMS: Radical surgery still plays a decisive role in the therapy of rectal cancer. Besides classical abdominal operations, an alternative is transanal endoscopic resection of rectal tumor at T1 and T2 stages. Indication for local resection of malignant rectal tumor requires an accurate preoperative staging. METHODOLOGY: The paper evaluates the accuracy of 3D endorectal sonography in rectal cancer staging. In the group of 78 patients the staging of preoperative 3D endorectal sonography was compared with a final histopathologic of the operative sample. RESULTS: The results obtained indicate that the preoperative staging of malignant rectal tumor using 3D endorectal sonography represents 100% only in the pT1 stage. In the pT2 stage, the accuracy of 3D endorectal sonography is 72%, in pT3 and pT4 represents 92%. CONCLUSIONS: On the basis of our experience, complicated interpretation of findings obtained by 3D endorectal sonography occurs at limits of T2-T3 and T3-T4. In these localizations the peripheral reactive fibrous and inflammatory sections in the vicinity of tumor tissue often involve even the next layer of rectal wall and leads to overevaluation of invasion depth at endorectal sonography of rectal cancer.

[The intraabdominally located mesh in the laparotomy management of major hernias]. / Intraabdominálne ulozená sít'ka pri resení rozsáhlých kýl v laparotomii.

AIM: Major hernias in sutures following abdominal surgical procedures make the patients' quality of life significantly worse. Our aim is to prove that, even now, the surgical management of such hernias has its cons and in most cases requires a plastic mesh application. PATIENT SUBJECTS AND RESULTS: The authors operated 82 patients with hernias via the middle laparotomy. The patients had been primarily operated for their colorectal disorders. The incidence rate of the major hernias in sutures was 5.25% (82/1564). The defects of the abdominal wall were corrected using a prolene mesh placed intraperitoneally. Although in 11 patients the authors report postoperative complications in the sutures (1x absces, 6x seroma, a 4x infiltration), the long-term results of the above technique remain very positive. 2 patients had a relaps of the hernia and clinical manifestations of adhesions following the procedure were reported in 7 patients. CONCLUSION: The technique of the intraabdominally located mesh in the major postoperative hernias management enables tension-free procedures of the major defects of the abdominal wall to be conducted with very good long-term results.

Complex therapy of advanced colorectal carcinoma.

The present paper reports on a complex therapy of 18 patients with primary unresectable advanced carcinoma of the rectum and rectosigmoid. The results of surgery following complete chemoradiotherapy are evaluated. Radical surgery was successful in 15/18 patients. The authors describe a high incidence of postoperative complications and point out a high erudition of an oncosurgeon necessary for such intervention as well as for the indication of a patient to this extensive operation. (Tab. 2, Ref. 18.)

[Surgical treatment of the colorectal carcinoma synchronous with liver metastases]. / Chirurgická lécba synchronních jaterních metastáz kolorektálního karcinomu.

The authors present their results of the surgical treatment of the synchrone liver metastases in the second stage and following three courses of chemotherapy. Although the trial group is small, counting 25 patients operated between April 2002 and October 2003 (i.e. 18 months), the procedure's clinical benefits may be deducted, based on the immediate postoperative results.

Electron transfer in Paracoccus denitrificans with the modified fbc operon.

Membrane fragments of two mutant strains of Paracoccus denitrificans genetically modified in the bc(1) complex have been studied for comparison of enzymic activities of succinate-cytochrome-c reductase and its components, viz. succinate dehydrogenase (Complex II) and ubiquinol-cytochrome-c reductase (Complex III) and their response to changes in concentration of succinate, cytochrome c, ionic strength, pH, temperature and sensitivity to antimycin A. The mutants synthesized and assembled the b and c hemes in the ratio characteristic for the wild type strain. The mutant strain M 71 expressing the truncated copy of cytochrome c(1) (devoid of a stretch of 150 mainly acidic amino acids) was less sensitive to increasing concentration of cytochrome c and changes in ionic strength of the medium, but maintained the original affinity to succinate and sensitivity to antimycin A. The mutant strain M 36 with an overexpressed bc(1) content showed the highest response to changes in ionic strength and physical parameters, exhibited the lowest turnover number values with succinate-cytochrome-c reductase, but positively affected the succinate dehydrogenase. In view of the interaction of the redox components in native membranes the functional analyses of separated Complexes II and III should be regarded with caution.

[Radiofrequency ablation of colorectal liver metastases]. / Radiofrequenzablation von kolorektalen Lebermetastasen*

INTRODUCTION: Liver resection is the preferred treatment for colorectal liver metastases. About 30 to 40 % of the patients survive for five years after radical resection of liver metastases. In contrast to that, patients who are not fit enough for radical resection of metastases and two are treated by chemotherapy survive only for 18 months on average. The survival of patients with non-resectable liver metastases can be improved by metastases destruction and subsequent chemotherapy. At present, radiofrequency ablation (RFA) is widely used for the destruction of liver tumours. PATIENTS AND METHODS: In the four-year period (2000-2003), 190 patients with liver metastases of colorectal carcinoma have been operated upon at the 2 (nd) Surgical Department of University Hospital in Olomouc. Radical resection of metastases was carried out in 136 patients (71.5 %), RFA combined with liver resection was performed in 23 patients (12 %) and exclusive RFA of metastases was indicated in 31 patients (16 %). The patients were evaluated for the disease-free survival after one year and the survival rates at 12, 24 and 36 months after operation were determined. RESULTS: 12 months after the operation no tumour progression was found in 115 patients (85 %) subjected to radical resection of liver metastases, in 16 patients (52 %) after sole RFA of metastases and in 15 individuals (65 %) who underwent liver metastasis resection combined with RFA of the remaining cancer foci. The survival of patients after 12, 24 and 36 months was 124 / 136 (91 %) 103 / 136 (76 %) and 79 / 136 (58 %) in the group of radical metastasis resection; after sole RFA of the metastases and subsequent chemotherapy, the survival at 12, 24 and 36 months amounted to 27 / 31 (87 %), 19 / 31 (61 %) and 8 / 31 (26 %) of the patients; in the group undergoing metastases resection combined with RFA and adjuvant chemotherapy patient survival at 12, 24 and 36 months was as follows: 19 / 23 (83 %), 13 / 23 (57 %), and 7 / 23 (30 %). CONCLUSION: RFA combined with adjuvant chemotherapy considerably extends the survival of patients with liver metastases of colorectal carcinoma compared to chemotherapy alone. However, no difference in survival was found between our patients subjected to RFA of metastases and adjuvant chemotherapy and those patients undergoing resection of liver metastases combined with RFA of unresectable metastases and subsequent chemotherapy.

The isolation and some properties of the membrane-bound lactate dehydrogenase of Paracoccus denitrificans.

Membrane-bound lactate dehydrogenase was isolated from the cells of Paracoccus denitrificans by a combination of phase separation and chromatographic methods. It was NAD(+)-independent; phenazine methosulphate and 2,6-dichlorophenolindophenol could act as electron acceptors. It preferred D-lactate over the L-form (K(m) = 0.81 and 4.40 mM, respectively). Relative molecular weight estimations were 54000 +/- 3000 (electrophoresis) and 50000 +/- 5000 (gel chromatography) It was inhibited by thenoyltrifluoroacetone and diethyl pyrocarbonate, SH-reagents were without effect. No other lactate dehydrogenase activity was found in any subcellular fraction of cells grown on D,L-lactate, L-lactate, glucose or succinate.

Phosphate transport system in paracoccus denitrificans.

Pi uptake in cells or spheroplasts of Paracoccus denitrificans is biphasic; only the first rapid phase represents net Pi transport. The second phase is limited by the rate of Pi utilization inside the cell, i.e., mainly by its esterification, and as such it was inhibited by DCCD. The Pi/dicarboxylate antiporter does not seem to be operative, and its inhibitor n-butylmalonate did not exert specific inhibition. Pi transport is inhibited by SH reagents; the most potent inhibitor is PCMB, and mersalyl is much less effective. However, neither inhibitor affects efflux of accumulated Pi. The gradient of potassium ions may be involved in the Pi uptake, which is lowered in the presence of valinomycin. FCCP alone does not release accumulated Pi from spheroplasts unless they are preincubated with SCN-. The results indicate that Pi enters the cell by symport with protons.