Sacral neuromodulation for faecal incontinence - 10 years experience and long-term outcomes of a specialized centre.

INTRODUCTION: Sacral neuromodulation/sacral nerve stimulation (SNM/SNS) has become the most successful method for treatment of faecal incontinence (FI) in the last 10 years. The high efficiency of SNM is based on the electrical stimulation of the external anal sphincter and moreover the mechanism of action of SNS can be explained by the modulation of somatovisceral reflexes and perceptions of afferent information. Therefore the mechanism of action is more complex in contrast to other methods of treatment. In the Czech Republic, the SNM was implemented for the first time in 2010 with the financial support of the IGA grant of the Ministry of Health of the Czech Republic. Since 2018, two specialized centres for the treatment of FI using the SNM method have been established in the Czech Republic. METHODS: In the years 20102020, 35 patients were indicated for SNM. The ratio of women to men was 34:1. The mean age at implantation was 62 years (range 4675). Most patients were in the 6th and 7th decade. Two diagnostic procedures were performed in all patients, percutaneous evaluation of the S2S4 sacral nerves, implantation of the Medtronic 3889 28cm stimulation tined lead electrode and its connection to an external stimulator and subsequent subchronic stimulation for 24 weeks. The criteria for permanent neurostimulator implantation were a minimum 50% reduction in the number of FI episodes per week or a 50% reduction in incontinence score. Patients were then implanted with a Medtronic InterStim II 3058 permanent neurostimulator. RESULTS: A permanent neurostimulator was implanted in 33 of 35 patients (94%). No patient died. The complication rate was 11.4%. In 2 patients it was an infectious complication. In one patient malposition of the stimulator occurred after falling down and in one patient we observed lead breakage with subsequent malfunction of the stimulator after falling down. All complications were successfully resolved by reoperation. The longterm effect of SNM was evaluated in the group of the first 15 implanted patients from 20102011. Of these, 9 patients were available, in whom a new neurostimulator was reimplanted due to loss of battery power in 20182020. The mean length of follow-up was 112 months (99124). The mean number of FI episodes per week was 1.9 (013) after neurostimulator implantation compared to 13.6 (325) before implantation. The Cleveland Clinic Incontinence Score (CCIS) was 8.3 (316) after neurostimulator implantation compared to CCIS 18.8 (1520) before implantation. Both FI episode counts and CCIS scores were significantly lower (p.

Peritoneal surface malignancy spread reoperations after cytoreductive surgery + HIPEC.

INTRODUCTION: Peritoneal malignancies (PM) are observed in about 1030% of patients suffering from gastrointestinal malignant diseases, both in connection with the primary surgical management or as metachronous metastases due to cancer recurrence. METHODS: In the 1980s a new method of cytoreductive surgery (CRS) + HIPEC (hyperthermic intraperitoneal chemotherapy) was introduced. Today, we consider this method to be the gold standard for treatment of pseudomyxoma peritonei and peritoneal mesothelioma. The method increases overall survival (OS) of patients diagnosed with colorectal cancer, primary peritoneal and ovarian cancers. However, the disease recurs after this demanding treatment in the certain group of patients, approximately in 2544% of patients treated for pseudomyxoma peritonei, and in 40% and up to 82% of those treated for mesothelioma and colorectal cancer, respectively. Based on literary data (PubMed-Medline, last 5 years) and our own experience we present the basic factors associated with tumor recurrence, possibility of treatment using repeated CRS + HIPEC, data regarding second-look operations, and as applicable, prophylactic HIPEC. CONCLUSION: The method CRS + HIPEC provides an effective treatment of peritoneal carcinomatosis even in cases of recurrence. The second-look operations and prophylactic HIPEC may favorably affect the prognosis after primary R0 resections.

Is high age a contraindication to pulmonary resection?

INTRODUCTION: As the population ages, there are increasing numbers of elderly patients diagnosed with operable primary pulmonary malignancy or other lesions requiring pulmonary resection. The objective of the study was to evaluate post-operative outcomes in the elderly group and compare them with younger patients undergoing the same surgery. METHODS: Retrospectively, we evaluated our own set of 424 patients undergoing anatomical pulmonary resection for primary lung cancers and other resectable lesions in 20112020. 328 patients underwent open procedures, and VATS lobectomy was performed 96 times. We evaluated the set of patients in terms of 30-day morbidity and mortality using Clavien-Dindo classification modified for pulmonary resections. We compared the patient subgroups by age (under 55, 5564 years old, 6574 years and over 75 years). RESULTS: A non-biometric Kruskal-Wallis test was used to compare the groups. We have not shown a statistically significant difference in the number of complications (p=0.220). CONCLUSION: Standard surgical treatment for non-small cell lung carcinoma, lobectomy with systematic mediastinal lymphadenectomy, is safe also for a well-indicated group of seniors. With careful preoperative assessments and consideration of the extent of resection, we can expect a comparable rate of complications in the elderly compared to younger patients. Sublobar resection or radiotherapy should be considered in case of patients at risk. For seniors over 70 years of age, comparable outcomes of oncological treatment can be reached, taking into account their shorter life expectancy.

Delirious conditions in surgical ICU - case report.

Delirious conditions are encountered in daily practice in the surgical ward, especially in intensive care units (ICUs). An ordinary surgeon must deal with these conditions very often. The case report of a patient with alcoholic delirium is presented. For a comprehensive view of the issue, we present a simple communication on delirious situations in the ICU. Deliria are classified according to their manifestations, and their etiology is briefly described. For practice, an outline of examinations and treatments is provided which is fundamentally different for alcoholic and nonalcoholic delirium.

Peritoneal carcinomatosis of colorectal origin treated by cytoreductive surgery and hyperthermic intraoperative peritoneal chemotherapy at the Bulovka University Hospital.

INTRODUCTION: Peritoneal carcinomatosis (PK) of colorectal origin is a malignant tumour of the peritoneum caused by spreading of colorectal carcinoma (KRK) over the peritoneal surface of the abdominal cavity and its organs. PK occurs as a synchronous tumour in 1520% of patients, and as metachronous disease in 2550% of patients. METHODS: A group of 66 patients operated on for PK was retrospectively evaluated; 18 patients were excluded due to insufficient data. We evaluated 48 patients in total (22 men and 26 women) with mean age of 58 and 53 years, respectively; 12 patients (25%) were aged over 65 years. The patients were operated on between 2000 and 2019 using the Sugarbaker´s method of maximal cytoreduction (CRS) + HIPEC (Hyperthermic Intraoperative Peritoneal Chemotherapy). We evaluated the length, median survival, the incidence of complications and lethality in relation to the Peritoneal Carcinoma Index (PCI) and the Completeness of Cytoreduction (CC) score. The patients were divided into two subgroups according to the PCI score (012 and >12, respectively) and the CC score (CC 01 and CC 23, respectively). RESULTS: The mean survival was 26.3 months in the group with PCI up to 12 and 21.4 months in patients with PCI above 12 (p=0.02). In the group with CC 01 the mean survival was 27.1 months, while in the patients with the CC 23 it reached 12.6 months (p=0.06). The morbidity rate requiring an intervention was 18.7% and the lethality rate was 6.25% in the entire group. The median survival of the entire group was 22 months (1334 months). CONCLUSION: Literary references and our results are comparable, confirming the high efficiency of this method both in our country and worldwide. The use of CRS and HIPEC, associated with acceptable mortality and morbidity in selected patients with PK of colorectal origin, results in a significant extension of overall survival (OS).

NF-κB/p65 expression before and after treatment in rectal cancer patients undergoing neoadjuvant (chemo)radiotherapy and surgery: prognostic marker for disease progression and survival.

Nuclear factor-kappaB (NF-κB), especially p65 subunit, has been associated with origin and progression of cancer as well as with the resistance to radiotherapy and chemotherapy in experimental models. The aim of the present study was to determine expression of NF-κB/p65 in tumor specimens before and after treatment of rectal cancer patients and to evaluate possible relationship between expression of NF-κB/p65 before and after (chemo)radiotherapy, other tumor characteristics and the clinical outcome. Furthermore, NF-κB/p65 was studied in relationship to pathologic response to preoperative (chemo)radiotherapy. Fifty patients with rectal cancer undergoing neoadjuvant (chemo)radiotherapy and surgery were included in the study. Pre-treatment rectal cancer specimens were obtained from diagnostic colonoscopy. Post-treatment rectal cancer specimens were obtained from surgically removed part of the rectum with the tumor. NF-κB/p65 expression was determined by immunohistochemistry and analysis was performed both in biopsies and in post-treatment tumor samples. Cytoplasmic positivity in tumor cells and nuclear positivity in lymphocytes were detected. High NF-κB/p65 positivity in pre-treatment tumor samples was significantly associated with shortened overall survival (OS). Disease-free survival (DFS) tends to be shortened as well. In post-treatment tumor samples, high NF-κB/p65 positivity was neither associated with shortened OS nor with shortened DFS. In post-treatment samples residual tumor cells deeply infiltrating the wall of the rectum with high NF-κB/p65 expression were found. The cells were linked to significantly worse clinical outcome in terms of shortened OS and DFS. NF-κB/p65 positivity did not correlate with pathologic response to preoperative (chemo)radiotherapy. In conclusion, our data suggest that high level of NF-κB/p65 subunit may be associated with more aggressive features of the tumor, higher metastatic potential, and shortened overall survival, but it does not correlate with resistance to (chemo)radiotherapy. Consequently, the level of NF-κB/p65 may help to select those patients who have poor prognosis and are candidates for more intensive anticancer therapy. For these purposes both pre-treatment and post-treatment tumor samples may be used.

Sensitization of colorectal cancer cells to irradiation by IL-4 and IL-10 is associated with inhibition of NF-kappaB.

The efficiency of radiotherapy for rectal cancer treatment is limited because of radioresistance. Transcription factor nuclear factor-kappaB (NF-kappaB), which has antiapoptotic properties, may play an important role in this process. Recent studies indicate that behavior of the tumor is done not only by oncogenic events in tumor cells but also by microenvironment surrounding the tumor. Therefore we tested anti-inflammatory cytokines IL-4 and IL-10 occurring in tumor stroma whether they can modulate response of colorectal cancer cells to irradiation and whether this potential effect is associated with NF- kappaB. SW620 colorectal cancer cells were used for all experiments. Cell growth and clonogenicity were determined by cell proliferation assay and clonogenic assay, respectively. Activation of NF-kappaB was assessed by ELISA-based transcription factor assay and luciferase reporter assay. Apoptosis was determined by measuring caspase 3 activity. Irradiation (2-8 Gy) inhibited growth and clonogenicity of SW620 cells, induced apoptosis, and activated NF-kappaB, predominantly its subunits p50, p65, and RelB. IL-4 or IL-10 (1, 10, 100 ng/ml) neither inhibited growth and clonogenicity nor activated NF-kappaB, but they sensitized cells to irradiation in a dose dependent manner. Radiosensitization by IL-4 or IL-10 was associated with inhibition of NF-kappaB, predominantly its subunits p50 and p65 and increased apoptosis. In conclusion, modulation of the intestinal microenvironment, high local concentration of anti-inflammatory cytokines such as IL-4 and IL-10 may help to overcome resistance of colorectal tumors to radiotherapy. In this process NF-kappaB may be employed.

[NF-kappaB, colorectal carcinoma and radiotherapy: results of a clinical and experimental study]. / NF-kappaB, kolorektální karcinom a radioterapie: výsledky klinické a experimentální studie.

Resistance to radiotherapy often seen in rectal cancer patients requires intensive study of mechanisms taking part in this process. It seems that nuclear factor-kappaB (NF-kappaB), especially its subunit p65, could play an important role in radioresistance. The aims of this study were: 1. to assess expression of p65 in rectal cancer patients and to evaluate its possible predictive role; 2. to determine in in vitro experiments possibilities of p65 modulation and to evaluate, whether this modulation can result in enhacement of efficiency of radiation therapy. We found that the level of NF-kappaB expression may serve as a predictive marker of overall survival. Further we found that inhibition of NF-kappaB activity caused by radiation improves impact of radiation therapy.

Constitutive NF-kappaB activity in colorectal cancer cells: impact on radiation-induced NF-kappaB activity, radiosensitivity, and apoptosis.

Constitutive NF-kappaB activity has been found in many cancer cells of different origin. In our study we focused on constitutive NF-kappaB activity and its impact on radiation-induced NF-kappaB activity, intrinsic radiosensitivity, and apoptosis. Using colorectal cancer cell lines (Caco-2, SW480, SW620) we demonstrated that each cell line expresses different level of constitutive NF-kappaB activity. Moreover, irradiation caused secondary NF-kappaB activation which differed in each cell line. The cell lines tested displayed also different intrinsic radiosensitivities as was determined by clonogenic assay, and different spontaneous and radiation-induced apoptosis determined by activity of caspase 3. Complex analysis of our results revealed that there was a strong correlation between constitutive NF-kappaB activity and radiation-induced NF-kappaB activity (r=0.835), the level of constitutive NF-kappaB activity predicted the level of secondary, radiation-induced NF-kappaB activity. Furthermore, SW620 cells with the highest level of constitutive NF-kappaB activity displayed the lowest radiosensitivity and the lowest level of spontaneous apoptosis; Caco-2 cells with almost undetectable level of constitutive NF-kappaB activity displayed the highest radiosensitivity and even highest level of spontaneous apoptosis. SW480 cells showed intermediate level of constitutive NF-kappaB activity, intermediate radiosensitivity and intermediate level of spontaneous apoptosis. Our data suggest that the level of constitutive NF-kappaB activity may predict radiosensitivity of colorectal cancer cells. Such prediction may allow the individualization of patient treatment by radiotherapy.

[The molecular screening of the stool for the colorectal carcinoma]. / Molekulární screening stolice pro kolorektální karcinom.

BACKGROUND: Current screening methods of colorectal carcinoma are based on examination of occult bleeding in the stool, and further on endoscopic and irrigographical (barium enema) examinations. Population-based non-invasive screening method having high sensitivity and specificity is needed. METHODS: Detection of molecular alterations in colonocytes from the stool may be a promising new diagnostic tool for such screening. Determination of mutations in APC, K-ras, DCC, p53 genes and "long" DNA may serve for early detection of colorectal cancer from stool samples. Multi-target DNA-assays employing all these markers suggest high sensitivity and specificity, unfortunately also expensiveness. Therefore finding a marker characteristic for all tumor cells would be desirable. Nuclear faktor-kappaB (NF-kappaB) could be such marker suitable for determination in colonocytes shed into the stool. CONCLUSION: Molecular testing of stool for early detection of colorectal cancer may be a promising screening method for this disease. Large multicenter trials are required to validate results obtained from preliminary clinical studies.

Pneumatosis cystoides intestinalis--a review.

Pneumatosis cystoides intestinalis is a rare disease characterized by presence of multilocular cysts in the gastrointestinal wall. Idiopathic and secondary forms of the disease can be distinguished. There are presented several theories explaining pneumatogenesis in this article. The specific and non-specific symptoms are described. Attention is drawn to the pneumoperitoneum without signs of peritoneal irritation, what is a typical complication of this disease. The suspicion of pneumatosis cystoides intestinalis may be based on plain abdominal X-ray, and is usually confirmed by computer tomography or magnetic resonance imaging. The therapy can be conservative or surgical. In conclusion, although pneumatosis cystoides intestinalis is a rare disease, it may represent a problem in differential diagnosis of abdominal pain.

[Mycophenolate mofetil, a possible new immunosuppresant]. / Mycophenolat mofetil, nové perspektivní imunosupresivum.

The mycophenolate mofetil, a prodrug of mycophenolic acid, is a new immunosuppressive drug with a specific mechanism of action consisting in the inhibition of T- and B-lymphocytes proliferation. A series of animal experiments showed efficiency of the mycophenolate mofetil administered in monotherapy or in combination with other immunosuppressants to prolong the survival of different allo- and xenotransplanted grafts. In clinical trials, the mycophenolate mofetil, cyclosporine, and steroids demonstrated high efficacy in the prevention of acute rejection in the solid allotransplanted organs. The mycophenolate mofetil seems to be a suitable candidate for the treatment of many other, e.g., autoimmune and inflammatory diseases.

[Cervical lymphangiectasia--case report]. / Krcní lymfangiektázie--kazuistika.

A case-report of a patient with paraesthesia of the left upper extremity caused by a tumor localized in the left supraclavicular area is presented. The patient underwent an operation. Two formations--a lipoma and cyst--were found. Both were removed and histologically examined. The diagnosis of lipoma and neck lymphangiectasia was made. On the third postoperative day the patient was discharged home with no more paraesthetic complaints. A check-up after three months did not reveal any complaints present before operation. In the paper the differential diagnosis of neck tumors with a view to resistance associated with the lymphatic system especially lymphangioma, lymphangiectasia and hygroma coli cysticum is discussed. Lymphangioma is a benign oncogenic affection of lymphatic vessels developing during the postnatal period of life. Lymphangiectasia is a congenital disease without proliferating activity. Hygroma coli cysticum is a congenital extensive multioccular formation localized in the neck area. All three affections are often incorrectly mistaken for each other. Histological examination is decisive for the correct diagnosis.

[Spontaneous rupture of an abdominal aortic aneurysm into the inferior vena cava--case report]. / Spontánní ruptura aneuryzmatu abdominální aorty do dolní duté zíly--kazuistika.

A 76-year-old man was admitted to the surgical department with acute abdominal pain and impaired sensation of the lower extremities. An aneurysm of the abdominal aorta (AAA) was diagnosed already in the past. There were no signs of cardiovascular failure. Examination (sonography, CT) did not show intraabdominal bleeding. Nevertheless AAA rupture was suspected. A decision on an urgent operation was taken. Despite permanent resuscitation the patient died on the table before the operation began. In the discussion four type of AAA rupture are mentioned: into the open abdominal cavity, into the retroperitoneum, into surrounding organs such as gut or vena cava and so-called "sealed rupture". In every symptomatic AAA connected with circulatory instability rupture is suspected. An urgent operation is necessary in these cases. Rupture of AAA into the vena cava inferior is rare. A syndrome including a history of aneurysm, abdominal pain, continuous abdominal murmur and heart failure is pathognomic for this type of rupture. Computer tomography, sonography or arteriography could be helpful the diagnose determination. However, correct preoperative diagnosis is difficult. Other causes of circulatory failure, especially heart attack, must be differentiated. Treatment of such cases is surgical, using a stent graft is rare and determined only for indicated cases.

[Pneumatosis cystoides intestinalis as a cause of obstructive ileus]. / Pneumatosis cystoides intestinalis jako prícina obstrukcního ileu.

The authors present the case-history of a 83-year-old patient hospitalized and operated on account of ileus caused by pneumatosis cystoides intestinalis. In the discussion the authors pay attention to the etiology, pathogenesis, clinical picture and possible treatment of this disease.

[Cooperation between a surgeon and an interventional radiologist in cases of internal bleeding]. / Spolupráce chirurga a intervencního radiologa pri vnitrních krváceních.

INTRODUCTION: Internal bleeding still remains a serious condition, which must be urgently diagnosed and treated. In the Faculty Hospital in Hradec Králové the diagnosis of the internal bleeding source and its consequent treatment is managed under cooperation between a surgeon and an interventional radiologist. A CASE-REVIEW: In the case-review section of this report, a total number of five patients with serious cases of internal bleeding, the source of which was diagnosed and treated under cooperation between the above mentioned specialists is presented. The patients concerned suffered from the following: a trauma to the liver parenchyma, posttraumatic arterioportal shunts, an intraheparic aneurysm, a relaps of the uterine carcinoma with hemorrhaging into the colon and the vagina, bleeding into retroperitoneum. In all the cases the lesion was successfully treated and the hemorrhage was managed. DISCUSSION: Exact location of the bleeding artery during an arteriogragraphic examination is a prerequisite of a successful treatment of the condition. Both, the absorbable materials which allow gradual recanalization of the embolized vessel, and the non-absorbable materials may be used to conduct embolization of the affected vessel. It is necessary to haemodynamically stabilize the patient prior to the procedure. CONCLUSION: In many cases, the cooperation between a surgeon and an interventional radiologist allows for the source of the internal bleeding to be located and managed. It is indicated in certain cases of benign and malignant disorders and in some cases of the parenchymatose organs trauma.

[The position of the aortic bifurcation in humans]. / Ulození aortální bifurkace u cloveka.

We followed the position of aorta bifurcation in the arteriograms of 253 persons of known sex and age and in four human foetus. There exists a statistically relevant difference between sex and age. Bifurcation has a higher position in women than in men. In foetus the bifurcation position is placed relatively high--in the 3rd lumbal vertebra--in adults the bifurcation position is in the 4th lumbal vertebra. We can observe a slow decrease of aortal bifurcation to the distal direction in humans after 50 years of age. This descent is statistically significant.

Note on variability of the arteries of the lower extremities in man.

The organization of the arterial bed was evaluated in the arteriograms of 253 lower extremities of subjects of a known sex and age. High origination of the a. profunda femoris from the a. iliaca ext. was observed in 0.4% of the cases; in 0.8% the a. profunda femoris arose from the transition of the a. iliaca ext. to the femoral artery. The crural segment was the most variable part of the arterial bed of the lower limbs. Most frequently, in 21.7% of the subjects, anomalies of the crural arteries were unilateral; in 4.6% they were bilateral. In 2.3%, bilaterally different anomalies were present. The a. tibialis post. is the most variable crural artery and the a. peronea is the most stable.

[Location of the aortic bifurcation in man and its practical significance in vascular surgery]. / Die Lage der aortalen Bifurkation beim Menschen und ihre praktische Bedeutung für die Gefässchirurgie.

Based on analysis of arteriography in 300 subjects of different age and sex, as well as 4 human fetuses, we demonstrated that in the course of an individual's life aortal bifurcation moves caudally. In a fetus, bifurcation is located at the level of L3, while in an adult it moves to the level of L4. After the age of 50, the position of bifurcation moves gradually caudally and can reach--in the advanced age--as far as the level of L5/S1 disc. The changes of position during a lifetime are statistically significant. A shift in the position of the bifurcation of abdominal aorta can be of significance for surgical interventions on the abdominal aorta.

Endovascular brachytherapy potentiated by hyperthermia in the prevention of vascular restenosis. A case report.

BACKGROUND: The combination of hyperthermia and radiotherapy has additive or synergistic effects. This combination has been studied extensively in radiation oncology, but not in the prevention of vascular restenosis. CASE REPORT: A patient with restenosis of cephalic vein underwent percutaneous transluminal angioplasty (PTA) followed by endovascular irradiation with 192Iridium (12 Gy) using a high dose rate afterloading technique. After endovascular irradiation, one fraction of external ultrasound hyperthermia was administered to the irradiated segment. There was no restenosis in the treated vessel segment according to duplex sonography performed 192 days after treatment. No radiation or hyperthermia associated side effects were observed. CONCLUSIONS: Present observations suggest that endovascular brachytherapy of restenosis potentiated by hyperthermia is a technically feasible and well-tolerated treatment. The additive and synergistic effects of hyperthermia, in conjunction with radiation, could be of benefit in the prevention of vascular restenosis.