Current management of diffuse peritonitis - is postoperative continuous lavage still a relevant method of choice?

INTRODUCTION: Diffuse peritonitis is a serious disease with rather poor therapeutic results. Management traditionally consists in the surgical treatment of its etiology, combined with targeted antibiotic therapy and complex intensive care of the patient. The basic procedure includes the identification and treatment of the origin of peritonitis, followed by thorough abdominal cavity toilet, lavage and drainage. There are currently two major procedures for carrying out complex surgical care of a patient suffering from diffuse peritonitis. The first one is primary sanation of the abdominal cavity, in which toilet, peroperative lavage and postoperative drainage is performed. The second procedure involves similar steps, but postoperative irrigation with saline or another solution is performed, usually over 2448 hours - continuous lavage. Both procedures, albeit often modified, are still used in most surgical departments in the Czech Republic; therefore, we decided to compare them in terms of morbidity, mortality and hospital length of stay. METHOD: We conducted a prospective randomized study involving 55 patients with peritonitis operated on from 10/2012 to 4/2014. Whenever possible, we tried to use both methods alternately method regularly to enable randomization and ensure presentable outcomes. RESULTS: No statistically significant difference related to morbidity, mortality and hospital length of stay was recorded in our group. CONCLUSION: Based on our results, we can state that both methods are equal and suitable for all types of diffuse peritonitis without any impact on mortality, morbidity and hospital length of stay. Key words: peritonitis - drainage peritoneal lavage.

[Circumscribed and diffuse peritonitis: severe complications in bariatric and metabolic surgery; specifics related to their diagnosis and therapy]. / Cirkumskriptní a difuzní peritonitis: závazné komplikace po operacích bariatrické a metabolické chirurgie, specifika pri jejich diagnostice a terapii.

INTRODUCTION: Cases of localized and diffuse peritonitis are severe surgical conditions. Despite expanding possibilities for the diagnosis and therapy, patients with peritonitis, its diffuse form in particular, still suffer from high morbidity and mortality. The management of this condition, both in the healthy and especially seriously ill population, is not satisfactory. Recently, we have witnessed an increase in bariatric and metabolic surgery in response to an ever rising number of extremely obese patients worldwide. Bariatric patients belong to a group of seriously ill patients with a significant risk of post-operative complications due to an infection. Although their treatment is identical to that of the normal population, a great emphasis is put on early recognition of complications, and the decision on any potential surgical revision should be actively approached, often necessitating the absence of frequently lengthy paraclinical assessments. METHODS: We conducted a retrospective analysis of 346 obese bariatric patients undergoing surgical treatment for morbid obesity between August 2011 and August 2015. RESULTS: A total of 6 patients experienced severe complications including two cases of diffuse peritonitis, two cases of localized peritonitis and two cases of intraperitoneal bleeding. One patient died after her discharge from hospital due to toxic shock caused by stomach perforation. We describe two case reports in greater detail to highlight the importance of early detection of complications and a timely surgical intervention. CONCLUSION: In principle, bariatric patients are a severely ill population where standard diagnostic procedures for post-operative complications often fail. Clinical findings and the surgeons experience are commonly the only diagnostic signs that trigger a surgical revision. In contrast, surgical treatment of post-operative complications in obese patients with peritonitis is virtually identical to that in patients with normal or slightly increased BMI. It involves thorough toilette of the abdominal cavity, lavage and drainage. Due to high morbidity and large peritoneal surface, obese patients may deteriorate rapidly. Timely surgical intervention is thus the only proper therapeutic approach, even without any, often lengthy paraclinical assessments. KEY WORDS: peritonitis - bariatric surgery - complications in bariatric surgery.

[10 years of sleeve gastrectomy in the Czech Republic in terms of the surgical procedure]. / 10 let sleeve gastrectomy - tubulizace zaludku v Ceské republice z hlediska operacního výkonu.

INTRODUCTION: Sleeve gastrectomy (SG) as a single bariatric/metabolic procedure has been performed since 2003 in the world, and since 2006 in the Czech Republic. We report 10 years experience with SG in the Czech Republic from 2006 to 2015. METHOD: Prospectively collected data from 14 surgical departments was evaluated retrospectively using descriptive statistics for every year from 2006 to 2015 and subsequently evaluated and compared for the entire period. The number of the patients, mean age, mean weight and BMI at the time of surgery, the number of patients with T2DM after SG, mean follow-up, mean %BMIL (% Body Mass Index Loss), distance of the starting point of the resection line from the pylorus, the size of the calibration bougie, the rate of complications, and the number and type of conversion procedures were evaluated. RESULTS: 4134 sleeve gastrectomies were done in the Czech Republic from 2006 to 2015 with the mean follow-up of 32.9 months (range 2145 months) from the procedure. The mean weight at the time of surgery fluctuated between 114.2 kg and 128.9 kg; mean BMI fluctuated between 42.3 and 46.7. Mean %BMIL was 63.2% for the entire evaluated period. The distance of the starting point of the resection line from the pylorus changed from the mean 6.1 cm (range 67 cm) to mean 4.2 cm (range 36 cm) and the size of the calibration bougie changed from the mean 39.2 F (range 3642 F) to mean 37.1 F (range 3542 F). As regards early postoperative complications, bleeding from the resection line occurred in 1.4% and a leak from the staple line occurred in 1.1%. The gastroesophageal reflux disease and hiatal hernia occurred in 17.3% as the most frequent late complications. Conversion to another bariatric procedure was approached in 3.8% in the event of an unsatisfactory effect of the SG. CONCLUSION: Bariatric or metabolic surgery, respectively, is a safe and effective surgical method for the treatment of severe obesity and T2DM in morbidly obese patients. Currently, SG is the most widely used bariatric/metabolic procedure in the Czech Republic as well as in most other countries and the long-time results are similar in comparison with other authors.Key words: bariatric surgery - sleeve gastrectomy - resection line - complications.

[The ONSTEP inguinal hernia repair technique]. / Operace tríselné kýly technikou ONSTEP.

The ONSTEP (Open New Simplified Totally Extraperitoneal) inguinal/femoral hernia repair technique is an innovative procedure presented by Portuguese surgeons Augusto Lourenço and Rui Soares da Costa within the EHS/AHS Congress in March 2012. The first institutions to perform this kind of hernia surgery in the Czech Republic are the Department of Surgery at Prostejov Hospital and the Department of Surgery at Frydlant Hospital. The ONSTEP technique represents a minimally traumatizing frontal approach to inguinal hernia repair using a special self-expanding mesh patch (an oval, anatomically-shaped moderate-pore polypropylene mesh with the circumferential memory-ring consisting of polyethylene terephthalate). The main advantages of this method are: short duration of surgery, the possibility of performing the procedure under local anaesthesia, short recovery time and rapid return to daily activities, low incidence of chronic post-operative groin pain, low recurrence rate, short hospital stay, good cosmetic effect and a low price. It is suitable for institutions performing outpatient surgery.

[Foreign bodies--uncommon causes of GIT injuries]. / Cizí telesa--méne obvyklá prícina poranení zazívacího traktu.

Injuries to various parts of the digestive tract caused by foreign bodies, frequently deliberately swallowed or inserted using various practics, are less common, however serious injuries. The symptomatology may be vague, credibility is often limited or anamnestic data may be intentionaly missing, which makes the diagnostic process tricky. Undefined, vague signs are related to specificities during the GIT perforation, so called hidden perforation. The recovery is commonly complicated, with a resulting handicap of stool incontinence or of colostomy. This is demonstrated on several subjects, treated in our surgical department.

Postcoital pneumoperitoneum after hysterectomy.

Usually, pneumoperitoneum is a serious condition suggesting a perforation of the abdominal viscus. Nonsurgical pneumoperitoneum accounts for approximately 10% of all cases. The authors present a case of postcoital pneumoperitoneum after a hysterectomy. A 46-year-old woman presented to the emergency department 4 months after an abdominal hysterectomy with complaints of abdominal discomfort and radiographic evidence of free air under the diaphragm. The clinical finding did not support the radiographic evidence. An unclear peptic ulcer history led us at first to mistakenly diagnose a covered perforation of gastroduodenal ulcer. Diagnostic perplexity forced us to perform a laparoscopy after 30 h. The abdominal cavity was surprisingly normal, and no perforation was found. Nonsurgical postcoital pneumoperitoneum is rare. We solved such a case for the first time. By means of laparoscopy, we could exclude perforation of the viscus and peritonitis, and the operation was carried out in a minimally invasive way.

Esophageal dysfunction in a female patient with diabetes mellitus and achalasia.

BACKGROUND: Achalasia is an infrequent disorder of esophageal motility. Diabetes mellitus is an endocrine metabolic disease, the complication of which can afflict the motor activity of gastroenteral tract. The combination of these diseases in one patient is also very rare. In this study we introduce one patient suffering from this scarce coincidence of diseases. CASE HISTORY: A 54-year-old diabetic patient who lost weight of 26 kg in one month with repeated hypoglycaemic collapse states and regurgitation of poorly digested food and saliva with maintained appetite and thirst. The diagnosis of esophageal achalasia II was proved. A standard surgical performance was chosen, namely the laparoscopic myotomy. The extent of myotomy was verified by preoperative manometry. Approximately 1 month after the surgery, intermittent mild dysphagia especially after the consumption of solid food and some sorts of fruit appeared. The suspicion of stricture in the site of myotomy led us to the performance of endoscopic and radiologic examinations. The balloon calibration of cardia did not reveal any residual muscular fibres. The supplementation of a prokinetic drug of itoprid three times a day resulted in a significant improvement of difficulties. CONCLUSION: Despite the sufficient extent of surgical treatment in a patient suffering from these two diseases, the resulting effect was not fully satisfactory. It is apparent that despite the correctly indicated and performed operation in patients suffering from a metabolic disease, the complications of which afflict the motility of upper digestive tract, the ideal response to treatment cannot be expected. The supplemented prokinetic therapy is inevitable, and informing the patient on the expected result and particular residual disorders can save both the patient and surgeon from disappointment. (Fig. 3, Ref. 8.).

[Present status of minimally invasive surgery in the Czech Republic]. / Soucasný stav miniinvazivní chirurgie v Ceské republice.

OBJECTIVE: The authors evaluate the contemporary state of miniinvasive surgery in the Czech Republic. METHOD: The authors made a questionnaire survey in surgical departments of the Czech Republic. Some 58% of the addressed departments (118 departments) replied. They evaluated the prevalence and use of miniinvasive techniques in 1997 in the following areas: flexible endoscopy, sonography, intervention radiology and endoscopic surgery. RESULTS: 40% of the surgical departments possess flexible endoscopes and 14% surgeons use endoscopy. Interdisciplinary collaboration is being enforced. In 54% departments endoscopy is ensured in collaboration by surgeons and gastroenterologists. Single-handed sonography was recorded among 3.2% surgeons, but 80% feel that surgeons should do sonography single-handed. Intervention radiology as an alternative to surgery is indicated by 88% surgeons. However only 1.2% surgeons participate actively in these examinations. The era of endoscopic surgery was started in the Czech Republic in 1991. At present these operations are made at all departments. The number of operations increases steadily. Thoracoscopy is used in 21% departments. In addition to cholecystectomy (100%) most frequently the following operations are made: appendenctomy--81%, inguinal hernia--67%, acute abdomen--55% and in a smaller number of departments (cca 10%) some more pretentious operations are made in the region of the oesophageal hiatus, intestinal resection etc. CONCLUSION: Endoscopic surgery replaced in some areas classical surgery. The importance of flexible endoscopy and sonography induced an ever increasing numbers of surgeons to use these methods actively. Intervention radiology is also of increasing importance and in many cases it is the preferred alternative of classical operations.

[Surgery of gastroduodenal ulcers in the Czech Republic]. / Chirurgie gastroduodenálního vredu v Ceské republice.

OBJECTIVE: Evaluation of surgical treatment of gastroduodenal ulcers during the past 20 years and its importance at the present time. METHOD: During the past 20 years three questionnaire surveys were implemented in surgical departments in the Czechoslovak Republic (1975-57 departments, 1989-80 departments) and in the Czech Republic (1994-80 departments) focused on surgery of gastroduodenal ulcers. The authors analysed also a group of patients from their own department covering a five-year period (1990-89 operations and 1995-27 operations). RESULTS: In surgical departments of the Czechoslovak and Czech Republic the ratios of different operations during the mentioned years were as follows: 1975: resections 85%, vagotomy 9%, suture of perforation 6%. 1989: 71%, 10%, 19% and 1995: 48%, 8%, 31% and other operations 13%. In the authors department the ratio of these operations in 1990 was as follows: 23%, 23%, 10% and in 1995: 59%, 7%, 23%, 11%. The surgical approach declined in the course of five years by 70%. During the last two years in the Czech Republic and in the authors department first experience was assembled with laparoscopic suture of perforated ulcers and with superselective vagotomy. The initial results are very encouraging. CONCLUSION: The basis of treatment of gastroduodenal ulcers is modern medicamentous treatment, surgery is indicated most frequently if conservative treatment fails or in case of haemorrhage (78% of haemorrhages are controlled endoscopically). In gastric ulcers resection is indicated most frequently, similarly as in complications of duodenal ulcers. In non-complicated duodenal ulcers superselective vagotomy is an equivalent alternative of long-term conservative treatment.

[Retroperitoneoscopic lumbar symathectomy]. / Retroperitoneoskopická lumbální sympatektomie.

During the period between August 1995 and February 1996 at the Second Surgical Clinic of the Faculty Hospital in Olomouc 12 retroperitonescopic lumbar sympathectomies were performed on account of different indications. The authors present an elaborate technique of access into the retroperitoneum and their own technique of lumboscopic sympathectomy. The success of the method was evaluated clinically and by histological evidence of sympathetic ganglia in the collected material. Retroperitoneoscopic lumbar sympathectomy is considered a gentle and safe method which can be used also in other patients where the risk of open surgery would be excessive.

[Peroperative diagnostic methods during esophageal achalasia surgery. Initial experience]. / Peroperacní diagnostické metody pri operaci achalázie jícnu. První zkusenosti.

AIM OF THE STUDY: The authors present their first experience with the application of esophageal manometry during the operation on achalasia of esophagus. The completeness of performed myotomy is evaluated on the basis of decreased pressure in the region of lower esophageal sphincter (LES). METHODS: Stationary pull-through four-channel manometry was performed twice during the operation: before the application of capnoperitoneum to localize LES with evaluation of its length and tonus and after the myotomy was performed after capnoperitoneum was abolished to verify sufficient extent of myotomy. The subsequent endoscopic control was used to exclude damage of esophagus mucous membrane. RESULTS: In the period of one year during 2002/2003 the authors operated on four patients with achalasia, when manometry was used for peroperative localization of LES and evaluation of the extent of myotomy. The peroperation manometry demonstrated decreased tonus of LES (the mean 42.06 mmHg before myotomia and the mean 20.03 mmHg after myotomia) and in one case the finding resulted in necessary extension of myotomia. CONCLUSIONS: Based on our preliminary experience with peroperation manometry in operations on achalasia of esophagus it may be stated that it is a useful method for objectivization of the completeness of myotomy, which does not significantly prolong the period of operation. It contrast, it makes it possible to respond to lasting hypertonic area in LES subjected to myotomy, which may be the cause of lasting complaints of patients after the operation.

[Complications after laparoscopic surgery of inguinal hernias]. / Komplikace po laparoskopických operacích tríselných kýl.

AIMS: The authors describe the occurrence of complications in laparoscopic approach to treat inguinal hernias in patients operated on at 2nd Surgical Clinic in Olomouc from May 1991 to the end of the year 2002. METHODS: The occurrence of preoperation and postoperation complications and relapses in inguinal hernias treated with laparoscopy in the period of May 1991 to the end of 2002. The TAPP method was used for operation on 98% of inguinal hernias, the IPOM method for 0.9% of inguinal hernias, TEP method in 0.4% and a simple suture in operation on 0.7% of inguinal hernias. RESULTS: Five hundred and thirty four (56% of all surgically treated inguinal hernias) were treated with laparoscopy in adult patients in the period of May 1991 to the end of 2002. Eight preoperation and postoperation complications (1.4%) were encountered. These included two cases of hematoma in the wound after port (0.3%), one hematoma of scrotum (0.2%), two artificial perforations of intestine (0.3%), one case of neuralgia of n. genitofemoralis, one artificial perforation of urinary bladder (0.2%), and one postoperation hydrocele (0.2%). There were 14 relapses (2.6%) in the 534 inguinal hernias operated on with laparoscopy. CONCLUSION: Based on our experience in the solution of inguinal hernias with laparoscopy the method of transabdominally-preperitoneally localized grid (TAPP). In this method we have used three-point fixation--by a screw to pected ossis pubis and the upper margins of the grip with two transparietal stitches fixed permanently in subcutaneous tissue.

[CHS 100P surgical mesh in inguinal hernioplasty in adults using the Lichtenstein tension-free method]. / Vyuzití chirurgické sít'ky CHS 100 P k plastikám tríselných kýl u dospelých metodou bez napetí podle Lichtensteina.

AIMS: The authors present their initial experience with surgical grid CHS 100 P with strengthened middle strip for the intestinal hernioplasty by the method without tension according to Lichtenstein. METHODS: In the inguinal hernioplasty by anterior transinguinal way in adult patients the authors use prolene grid and a surgical grid CHS 100 P with strengthened middle strip having been developed in collaboration with the Research Knitting Institute in Brno. RESULTS: From November 2001 to May 2003 56 adult patients were operated on inguinal hernia by the tensionless plasty according to Lichtenstein using a surgical grid CHS 100 P. No preoperation of postoperation complication or relapse were encountered. The patients were subject to load in the first postoperation day. CONCLUSION: Based on our first experience with flexible surgical grid with strengthened middle band CHS 100 P used for tensionless inguinal hernioplasty in adult patients according to Lichtenstein it may be concluded that the grid is well tolerated by the patients. Flexibility of the grid makes it possible to fully load inguinal area during the first postoperation day.

[Surgical treatment of patients with paraesophageal and mixed hiatal hernias]. / Chirurgické lécení nemocných s paraezofageálními a smísenými hiátovými herniemi.

In 1948-1990 the authors operated 112 patients with paraoesophageal and mixed hiatus hernias. 100 patients operated in 1988 were followed up on a long-term basis. Gastroesophageal reflux was recorded before operation in 52%, haemorrhage in 18%, an ulcer in the neck in 7% an incarceration and obstruction in 9%. Before the onset of the seventies hiatorrhaphy and gastropexy were performed. During check-up examinations in these patients relapses were recorded in 47%, reflux in 43%, subjective complaints in 26%. This made the authors change the surgical procedure and in subsequent years they performed hiatorrhaphy, fundoplication, fundophrenopexy and anterior gastropexy. The incidence of relapses of hernia during check-up examinations declined to 21%, of gastroesophageal reflux to 9% and subjective complaints to 10%. The follow-up period varied between 1 and 19 years. The surgical lethality was 2%.

[Manometry in esophageal achalasia]. / Manometrie u achalázie jícnu.

OBJECTIVE: Manometric findings in achalasia are pathognomic already in early clinical stages of the disease. The authors evaluate the importance of manometry in the diagnosis and therapy, in particular in early stages of the disease. METHOD: During manometry we obtain data on the function of the lower oesophageal sphincter and the body of the oesophagus. Impaired relaxation of the sphincter is evaluated, as well as increased tonus of the sphincter and tertiary contraction of the body of the oesophagus. In patients with achalasia we implement laparoscopically extramucous myotomy. RESULTS: In 1997 we started a prospective manometric study of dysphagic complaints. We examined 304 patients on account of different diseases of the oesophagus incl. 16(5.2%) where we proved or confirmed achalasia in stage I, II or III according to the radiological classification. These patients were indicated for laparoscopic myotomy. In one instance we had to convert the operation to an open one. In two instances we added partial fundoplasty according to Thal on account of perforation of the oesophageal mucosa. Four patients were subjected after a 5-12-month interval to remyotomy. Twice because of the development of a fibrous stricture at the site of myotomy and twice for an obviously inadequate original myotomy. The history of dysphagia in patients with primary operations was on average 37.3 months. CONCLUSIONS: Manometric examination of patients with functional dysphagia makes it possible to detect achalasia in early stages and to indicate in time surgical treatment. In case of a relapse or persistence of complaints manometry makes it possible to express objectively the cause which is most frequently an atonic oesophagus with inadequate evacuating capacity, stricture at the site of myotomy or inadequate myotomy.

[Palliative treatment of inoperable esophageal stenoses using stents: long-term results, complications]. / Paliativní lécba inoperabilních stenóz jícnu stenty: dlouhodobé výsledky, komplikace.

The authors evaluate the effectiveness of palliative treatment of inoperable oesophageal stenoses by means of self-expandable stents in a group of 102 patients and discuss complications. In all patients after implantation of the stent dysphagia improved by at least two degrees. Eighty nine patients of the group died, the mean period of survival was 107 days. At the time of evaluation 13 patients survive, the mean survival period being 175 days. As to complications the authors recorded incomplete expansion of the stent (n = 1), fissuring of the tumour (n = 1), migration of the stent (n = 8), oesophagorespiratory decubital fistula (n = 4), ingrowth of the tumour into the stent (n = 4), obstruction of the stent by food (n = 7) and arterial haemorrhage (n = 1). The effectiveness of palliative treatment of inoperable oesophageal stenoses by self-expanding stents is high and prompt. The total number of complications is 22%, the mortality after surgery is zero. The majority of complications is easily resolved by methods of interventional radiology.

[Treatment of perforating mediastinitis]. / Lécba perforacní mediastinitidy.

In 1986-1994 at the Second Surgical Clinic in Olomouc Faculty Hospital and Medical Faculty 23 patients with perforating mediastinitis were treated. The treatment of this serious disease is associated with a 30% lethality. The cause of its development are complications after surgery of the oesophagus, more frequently operations in the area of the cardia but also damage during instrumental treatment of the upper digestive tract. The analysis draws attention to the risk of perforation of the oesophagus in different types of operations. The author emphasize the importance of early comprehensive intensive treatment, incl. support of respiratory functions.