Multiple organ resection for large paraganglioma a case report.

Paragangliomas represent a group of neuroendocrine tumours which occur in various localizations. Most of them produce catecholamines, and in advanced cases present with typical symptoms and signs such as palpitations, headache and hypertension. The only curative treatment is radical resection. About one-quarter of paragangliomas are malignant, defined by the presence of distant metastases. There are multiple treatment options for unresectable metastatic tumours. They include radionuclid therapy, chemotherapy, and radiotherapy, although none of them are curative. Cytoreductive surgery can also be considered, especially when the goal is to decrease symptoms related to advanced disease. We present a rare case of a large paraganglioma of the left retroperitoneum. Despite radical surgery, early recurrence of the disease was observed.

[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.

Hepatocellular carcinoma - prognostic criteria of individualized treatment.

BACKGROUND: Though the sixth most frequent malignancy, hepatocellular carcinoma (HCC) is the third most common cause of death amongst solid tumours. Only surgery in the early stages may provide the cure; however, HCC still has a high recurrence rate. Non-surgical treatment lacks comparable efficacy. It was not sooner than in 2017 that the therapy galore started to extend. Thus prognostic factors driving the therapy have been gaining importance. MATERIAL AND METHODS: All relevant literature was checked for aetiology, epidemiology, dia-gnostic means, and individualised treatment of HCC. Cytochrome P-450 expression data from 22 patients operated in the University Hospital Brno in the period 2017-2020 were included. RESULTS: Screening the population at risk (presence of cirrhosis) with the transabdominal ultrasound lies at the centre of the dia-gnostic algorithm. Making the dia-gnosis does not require a bio-psy in most cases. Only a few parameters are thus known before the treatment - a size and number of lesions, and AFP level. These drive the indication to surgery. Relapses after surgery and response to palliative treatment depend on the expression of MET and AXL that directly affect anti-VEGF therapy. High AFP predicts a good response to regorafenib but early relapse after surgery. The pattern of P450 expression was found linked with tumour differentiation. The differentiation correlates with the size and number of lesions. We also found a link between the P450 expression and some mi-RNAs possibly detectable using liquid bio-psy techniques. CONCLUSION: The share of deaths from HCC overweighs its incidence. The risk population to screen is well-defined (cirrhosis). The BCLC staging system probably gives the best complication/efficacy results. This system does not require any bio-psy and does not comprise all predictive factors important in the expanding targeted molecular therapy. According to our results, small molecules to treat HCC should work better in poorly differentiated tumours. Surgery is more effective in those well-differentiated. It isnt easy to get all relevant information before therapy. Some factors need macrobio-psy (surgical). The pretreatment workup will probably require a mandatory bio-psy in BCLC B and C stages to get the information. This opens up a way for the liquid bio-psy that could use some specific mi RNAs.

[Complications of radical oncogynecological operations]. / Komplikace radikálních onkogynekologických operací.

OBJECTIVE: Information sheet about the most frequently complications of radical oncogynecological operations. DESIGN: Literature review with case reports. SETTING: Department of Gynaecology and Obstetrics, Faculty of Medicine, Masaryk's University and Faculty Hospital, Brno. METHODS: Literature review about complications of radical oncogynecological operations with illustrative case reports. CONCLUSIONS: Radical oncogynecological operations, due to their size, associated with a higher morbidity compared with traditional gynecological surgery. The literature states morbidity parameters between 25-45% depending on the center of erudition and range of out performance. Basic division of surgical complications is on perioperative complications and postoperative complications, which are further divided into early and late. The most frequently intraoperative complication is large blood loss requiring the application of blood substitutes. Less common complications are injury to the urinary bladder, ureter, rarely bowel or neural structures, especially nerve obturatorius. Among early postoperative complications are dominated urological complications, particularly urinary bladder hypotonia, another important group are the vascular complications, ie trombembolia and bleeding. Between late postoperative complications is possible to define several basic groups, ie urology, intestinal, lymphovascular and complications associated with laparotomy wound suture. Prevention of complications should be based on several basic assumptions. These include adequate erudition and composition of the operating team, perfect knowledge of anatomical conditions in the pelvic retroperitoneum, the paraaortic, the paracaval and inguinal area, implementation radicality adequate performance in relation to the extent of the disease and developing new surgical techniques (eg nerve sparing surgery). Absolute necessity is also the possibility of interdisciplinary cooperation with other surgical disciplines, which is important both in terms of preventing complications, and for their event subsequent solutions.

Gastrointestinal Stromal Tumours of the Rectum - Evaluating the National Registry Data with Respect to its Use in Clinical Practice.

BACKGROUND: Gastrointestinal stromal tumours (GIST) are rare malignant mesenchymal tumours with an incidence of 1 in 100,000. They represent only 5% of gastrointestinal tumours. The GISTs are mainly located in the stomach (60-70%) and in the rectum in < 5% of cases. In the case of localized, resectable tumours, the treatment is surgical resection. Depending on the size and localization of the tumour in the rectum, either a local excision, rectal resection with anastomosis, or abdominoperitoneal amputation with permanent stoma can be performed. In contrast to carcinomas, the metastasis of GISTs into lymph nodes is rare; therefore, from an oncological point of view, lymphadenectomy in the form of mesorectal excision is not required. Neoadjuvant treatment using tyrosine-kinase inhibitors (TKI) is recommended for tumours larger than 5 cm and in case of tumours infiltrating surrounding organs or sphincters in order to achieve complete resectability, less mutilating and continent procedure. In GISTs with a positive resection line, re-resection can be attempted. Adjuvant TKI therapy can be considered in cases of CD117 positivity and after resections of GISTs with medium and high-risk malignant behaviour. The TKI treatment is also indicated in cases of unresectable and metastatic GISTs. METHODS: Data obtained from the GIST registry by the 1st January 2017, when 10 centres in the Czech Republic were contributing to the registry, were analysed. RESULTS: We analysed 1,095 patients out of which 45 (4.1%) had GIST localized in the rectum. The average age of the patients was 60 years. There were significantly more males (68.9%; p = 0.0007) and symptomatic patients (62.2%; p = 0.034). In total, 82% of the patients underwent surgery. Local excision was performed in 37.8%, resection of the rectum with anastomosis in 29.7%, and Miles operation in 29.7%. In the cohort, most tumours were 2-5 cm in size and almost half of the tumours presented a high risk of malignant behaviour. Systemic treatment was reported in 73% of patients. A complete remission was achieved in 80% of patients with GIST of the rectum. The median survival rate was 11.3 years and the 5-year survival rate is 90.6%. CONCLUSION: Despite the success of TKI treatment, the only potentially curative method of rectal GISTs is a surgical R0 resection. Given the relatively rare frequency of these tumours, proper diagnosis and treatment is demanding. Therefore, these patients should be preferably treated in specialised centres. This work was supported by grant MH CZ - RVO (FNBr, 65269705).  The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers. Submitted: 19. 12. 2018 Accepted: 2. 2. 2019.

Tailored antireflux surgery.

BACKGROUND: With increasing age, the functional condition of the lower esophageal sphincter is getting weaker. Recent progress in peri-operative intensive care and the development of laparoscopic technique makes antireflux surgery a safe choice of GERD treatment in the elderly. AIM: This work evaluated the long-term results of tailored antireflux surgery in a group of elderly (more than 60 years old) patients. RESULTS: Five hundred and eighty one patients underwent antireflux surgery in our department from 1999 to 2005. Seventy of them (12.0%) were older than 60 years. Exclusion criteria of surgery were ASA IV classification and high grade esophageal dysmotility. Toupet's wrap was offered to patients with esophageal dysmotility or esophageal sphincter pressure higher than 15 mm Hg (16 cases). The rest were offered Nissen-Rossetti's complete wrap (54 cases). There was zero mortality and no further significant dysphagia. Pathological gastro-esophageal reflux after the surgery was detected in 6 patients (8.6%), which was a higher proportion than in the group of patients under 60 years. CONCLUSION: Good results of antireflux surgery with zero mortality and low morbidity can be achieved even in the elderly (more frequent use of incomplete Toupet's wrap).

[Experience with treatment of thoracic empyema during seven years period]. / Zkusenosti s lébou empyému hrudníku behem sedmiletého období.

The authors prospectively assembled group of 157 patients treated for empyema thoracic during seven years period. They followed applied methods of the diagnostics and therapy, the length of hospital stay after surgical intervention and its successfulness. The parameters were statistically evaluated. The results showed that surgical intervention substantially influences shortening of the hospital stay and successful cure. In the early stages of the disease thoracoscopic treatment is often sufficient to eliminate the infection. When is indicated later then three weeks after onset of the effusion, then facilitates early decontamination of the empyema cavity and possibility to perform lung decortication. In patients with thoracic empyema, where adequate effusion evacuation can not be reached, the conservative treatment results in prolongation of the hospitalization. Surgical intervention on the contrary the hospital stay, without increase in morbidity or mortality, shortens.

Intraoperative manometry of the lower esophageal sphincter pressure during laparoscopic antireflux surgery with a mechanical calibration--early results.

BACKGROUND/AIMS: Persistent postoperative dysphagia diminishes the good effect of laparoscopic anti-reflux surgery. An excessive increase of the intraoperative lower esophageal sphincter pressure (LESp) is supposed to be related to the persistent postoperative dysphagia and its knowledge could lead to the modification of the surgical technique followed by improved clinical outcomes. This study aims to describe the relation between the intraoperative LESp increase and the incidence of postoperative dysphagia and to find whether a combination of intraoperative manometry and mechanical calibration of the wrap is able to decrease the incidence of the persistent postoperative dysphagia. METHODOLOGY: The randomized, prospective, two-branch study included 39 patients suffering from symptoms of gastroesophageal reflux disease. All patients underwent pre- and postoperative manometry, 24-hour pH-metry and laparoscopic anti-reflux surgery. The intraoperative LESp was measured in the study arm only. RESULTS: A higher incidence of persistent postoperative dysphagia was revealed in patients with the intraoperative LESp increase more than 15 mmHg. This complication was not found in patients with the LESp increase under 8 mmHg with no impact on the efficacy of the surgery. The combination of the intraoperative manometry and the mechanical calibration of the wrap seems to bring the benefit only to a small number of the patients. CONCLUSIONS: According to our results, the intraoperative LESp measurement proved to be a useful supplementary method which was easy to perform, and which enables a modification of the surgical technique to decrease the incidence of the persistent postoperative dysphagia.

Laparoscopically assisted subtotal colectomy for idiopathic pneumatosis cystoides intestinalis.

Pneumatosis cystoides intestinalis (PCI) is a rare entity in which gas filled cysts are found within the intestinal wall. Conservative management and the treatment of underlying illnesses are recommended in most patients and surgery is usually indicated when acute and life-threatening complications such as bowel necrosis, perforation or peritonitis appear. The authors report a case of idiopathic pneumatosis cystoides intestinalis which, after repeated failure of conservative treatment including the oxygen therapy in hyperbaric chamber, was successfully treated by laparoscopic subtotal colectomy. A laparoscopically assisted approach proved to be a good indication in subtotal colectomy in cases of PCI that are non-responsive to standard conservative treatment.

[Could the peroperative manometry of the oesophagus be used for prediction of dysphagia following antireflux procedures?]. / Muze být peroperacní manometrie jícnu vyuzita v predikci dysfagie po antirefluxním výkonu?

A possible development of the postoperative persisting dysphagia, which decreases the quality of life of the operated, remains the main drawback of the laparoscopic antireflux surgery. Among several variations of the antireflux surgical procedures, there is none known to completely eliminate this risk. In this study, supported by the IGA MZ CR ND 7142-3 grant, peroperative measurements of the lower oesophageal sphincter (LES) tone with a concurrent mechanical callibration of the cuff using an oesophageal tube were taken. A complete Nissen-Rossetti cuff was applied in 39 patients. Peroperative increases in the LES tone following the completion of the antireflux cuffs were monitored. The patients continued to be monitored with the aim to detect the onset of dysphagia. In the patient group with the peroperative LES tone increase exceeding 15 mmHg, significantly higher rates of prolonged dysphagia were recorded. In cases of lower LES increases, the rates of dysphagia were low and good functioning to prevent any pathological gastrooesophageal reflux was maintained. No complication with respect to the peroperative oesophageal manometry was recorded. Duration of the antireflux operation conducted with the peroperative manometry was prolonged by 4 minutes, on average. Based on the assessment of the data, the authors demonstrate that the LES tone increase on its own, does not provide for the antireflux efect of the fundoplication procedures and that the patients cannot benefit from its extremely high values. On the contrary, its high values may indicate possible risks of dysphagia in the postoperative period.

[Role of mini-invasive surgery in the treatment of patients with neoplasms, particularly in colorectal carcinoma]. / Postavení miniinvazivní chirurgie v lécbe onkologického nemocného, predevsím u kolorektálního karcinomu.

Laparoscopic surgery has found its firm position in the treatment of benign diseases. Yet, oncologic laparoscopy remains a controversial technique. Its indication is discussed, especially its specific complication in oncologic diseases--recurrence of malign tumors within the scar after the trocar. The authors have performed an extensive recherché on the incidence of local recurrences of malign tumors after laparotomy or laparoscopy. They compare the functional results of both techniques, radical measure of intervention and their technical limits. They analyse the causes of local recurrences as well as possibilities of their reduction. They evaluate also their own experience in laparoscopy performed in coincidence with malign diseases, especially in palliative surgery. They suggest indications of laparoscopy in cases with colorectal carcinoma which is currently, as well as prospectively the most frequent malign disease of the gastrointestinal tract in our region.

[Gastroesophageal reflux disease from the viewpoint of the surgeon]. / Gastroezofageální refluxní choroba z pohledu chirurga.

Surgical treatment of patients with gastroesophageal reflux disease (GERD) represents an alternative approach in relation to the long-term pharmacologic therapy of prokinesis, and secretoinhibitory therapy. It must be considered in cases where the conservative approach has failed. The success of surgical treatment depends on an individual approach to the patient. The factors determining the surgical indication and especially the type of surgery, include age, anatomy of the hiatus and the results of pre-operational examinations of the esophagus. The type of operation depends on the ability of the esophagus to contract and to transfer the propulsion activity. According to the authors, the key examination is represented by the detection of esophageal contractility by use of esophageal manometry. The alternative option is represented by scintigraphic measurement of esophageal transit time by use of a tagged bolus. The patients with disappeared contractility are preferentially treated by conservative therapy due to the high risk of post-operational dysphagia. 80% of patients are treated by the standard procedure of laparoscopic fundoplication by a 360-grade cuff. The cases with decreased contractility or esophageal dysmotility are preferentially treated by partial fundoplication in Toupet's modification. The shortening of the esophagus requires consideration as to chest approach, or Collis' operation. Intestinal metaplasia of the esophagus requires specific procedures. Severe dysplastic changes require the consideration of resection treatment. The gained therapeutic results are evaluated by both, the subjective point of view of the authors, as well as by standard pH measurement and manometry of the esophagus performed 6 weeks after surgery.

[Combined surgical treatment of portal hypertension]. / Kombinovaná chirurgická lécba portální hypertenze.

The bleeding from esophageal varices is at 85-90% cases stopped by conservative (i.e. non surgical) approach. The method of choice is endoscopic sclerotisation or ligation. Less often is necessary to perform TIPS. The rest of cases is necessary to resolve by one of surgical techniques of hemorrhage control--devascularisation operation or perform emmergently porto-systemic shunt. The authors stress the importance of devascularisation operations for theirs simplicity. On the case report they illustrate the advantage of combination of both surgical techniques.

Small-bowel tumors in the elderly 65+ years: 10 years of experience.

UNLABELLED: Primary, secondary, benign or malignant tumorous diseases of the small intestine are rare. They are very often diagnosed by accident or as a cause of acute abdomen. Less serious symptoms can be overseen mainly in older patients. This work represents a prospective evaluation of a diagnostic and therapeutic algorithm in the management of the small-intestine tumor below the ligamentum Treitzi in patients over 65 years of age. RESULTS: A population of 96 patients who underwent surgery for a small-intestinal tumor in our hospital from 1996 to 2006 is presented. Thirty-four of these patients were older than 65 years. Ultrasound of the small intestine was sufficient to make the diagnosis in 21 of them. Elective surgery (laparoscopy was highly preferred) could be offered to 31 of these older patients. Perioperative mortality was zero. CONCLUSION: The small-bowel ultrasound can be recommended as the first choice method. All complaints regarding the gastrointestinal tract should be verified. Older patients can be safely offered an elective laparoscopic surgery with acceptable morbidity and mortality.