Radicality of mediastinal lymphadenectomy in minimally invasive pulmonary resection: a comparative analysis of uniportal and multiportal thoracoscopic approaches.

INTRODUCTION: Lung cancer is a serious health problem with a high mortality rate. In the context of surgical management, minimally invasive approaches, including uniportal thoracoscopic techniques, offer potential benefits such as faster recovery and increased patient cooperation. The aim of this study was to compare the accessibility of the mediastinal lymph nodes between uniportal and multiportal thoracoscopic approaches and to verify whether the use of the uniportal approach affects the radicality of the lymphadenectomy. METHODS: A comparative study conducted from January 2015 to July 2022 at the University Hospital Ostrava focused on evaluating the radicality of mediastinal lymphadenectomy between subgroups of patients undergoing surgery using the uniportal thoracoscopic approach and the multiportal thoracoscopic approach. RESULTS: A total of 278 patients were included in the study. There were no significant differences in the number of available lymphatic stations between the subgroups. The mean number of lymph node stations removed was 6.46 in the left hemithorax and 6.50 in the right hemithorax. Thirty-day postoperative morbidity for the entire patient population was 24.5%, with 18.3% having minor complications and 3.6% having major complications. The overall mortality rate in the study population was 2.5%, with a statistically significant difference in mortality between uniportal and multiportal approaches (1.0% vs 6.4%, p=0.020). CONCLUSIONS: The uniportal approach demonstrated comparable accessibility and lymph node yield to the multiportal approach. There was also no difference in postoperative morbidity between the two approaches. The study suggests the possibility of lower mortality after uniportal lung resection compared with multiportal lung resection, but this conclusion should be interpreted with caution.

Metastatic potential of T1a and T1b non-small cell lung cancer: analysis in the Czech population.

INTRODUCTION: Lung cancer is the most common cause of cancer death in the Czech Republic, in part due to its significant metastatic potential. The aim of this study was to collect real data on the metastatic potential and clinical characteristics of T1a and T1b lung cancer in the Czech population and to investigate potential factors that would predict an increased risk of lymph node metastasis. METHODS: Prospective-retrospective study conducted at the Department of Surgery of the University Hospital Ostrava during the period from January 1, 2015, to July 31, 2022. The study included patients who underwent lobectomy or bilobectomy for T1a and T1b non-small cell lung carcinoma. RESULTS: Out of a total of 165 patients with T1a and T1b lung carcinoma, 17.6% of patients were confirmed to have metastatic involvement of the lymph nodes (with 9.1% classified as N2 lymph node involvement). The highest percentage of positive lymph nodes was observed in patients with tumors located in the upper left lobe (29.5%) and lower right lobe (23.3%). Adenocarcinoma was the most commonly metastasizing carcinoma, with 21.1% of patients showing positive lymph nodes. Neuroendocrine carcinoma metastasized in 19.4% of cases, while squamous cell carcinoma did so in 6.8% of cases. The cumulative risk of having positive lymph nodes in T1a and T1b adenocarcinoma located in the upper left lobe reached 40.0%, of which the risk of N2 lymph node involvement was 25.0%. CONCLUSION: T1a/b non-small cell lung cancer exhibits significantly lower metastatic potential than T1c tumors and higher. Adenocarcinoma showed a 3-fold higher metastatic potential than squamous cell carcinoma, indicating the need for increased attention in the treatment of lung adenocarcinoma, especially in tumors localized in the upper left lobe, where a cumulative risk of lymph node metastasis of up to 40% was observed.

Innovative trends in surgery: a robotic approach to retrotracheal goitre.

The retrotracheal form is a rare variant of retrosternal goitre. The incidence is low, representing approximately 4% of all retrosternal goitres. The traditional approach to the treatment of this type of pathology is the cervical approach combined with high thoracotomy. Recently, however, new methods and technologies have begun to emerge that also open new possibilities for the surgical management of these conditions. The aim of this case report was to present the potential of a video-robotic approach in the treatment of retrotracheal goitre. The authors have successfully used this innovative method in the treatment of retrotracheal lesions, bringing hope for more effective and less invasive surgical interventions in this difficult-to-access area.

Laparoscopic repair of perforated peptic ulcer - routine procedure or targeted patient selection?

INTRODUCTION: Peptic ulcer is one of the most common diseases of the proximal gastrointestinal tract. Its complications are relatively common, the most serious one being peptic ulcer perforation with the incidence of about 10 cases per 100,000 population per year and the mortality rate of 10-40%. Surgical suture via laparoscopy or laparotomy is the only treatment option. The aim of the study was to compare the short-term results of laparoscopic and open repair of acute peptic ulcer perforation and evaluate the accuracy of the Boey scoring system in the Czech population. METHODS: Retrospective study conducted at the surgical department of the University Hospital Ostrava. The patients underwent laparoscopic or open repair of perforated peptic ulcer in 2017-2021. RESULTS: The study included 60 patients; laparoscopic repair was performed in 43.3% of the patients, and open repair in 56.7%. Postoperative morbidity was 70.0%, mild complications were reported in 23.3% of the patients, and severe complications in 16.7%. Patients undergoing the laparoscopic repair showed a higher incidence of mild as well as severe complications (26.9% vs 20.6% and 19.2% vs 14.7%) but also a higher incidence of an uncomplicated postoperative course. Overall postoperative mortality was 30.0% (laparoscopy 15.4%, laparotomy 41.2%). The study results confirmed the estimated baseline risk of mortality based on the Boey score. CONCLUSION: Laparoscopic repair may be the procedure of choice for patients with no or low risk factors. Patients undergoing laparoscopy showed a higher incidence of mild and severe complications. The higher mortality of patients after open repair is related to their worse initial clinical condition. Preoperative determination of mortality risk using the Boey score is accurate and appropriate in terms of choosing the surgical approach.

Our technique of thoracoscopic first rib resection - case report.

INTRODUCTION: First rib resection is a standard surgical treatment for decompressing the neurovascular structures in thoracic outlet syndrome (TOS). Historically, open approaches were used. In this report, we present technical details of thoracoscopic first rib resection. CASE REPORT: This year, we performed two operations in a row using this mini-invasive technique. Three ports were introduced. The used equipment included a laparoscopic camera (30 degree), endoscopic grasper, harmonic scalpel, long neurosurgical bone punch and a long intervertebral disc rongeur. The first rib was cut, separated and removed under thoracoscopic control. CONCLUSION: Thoracoscopic first rib resection for TOS is a safe and promising technique.

Sebaceous carcinoma of the breast area a case report.

INTRODUCTION: Sebaceous carcinoma is a rare malignant tumor of the sebaceous glands. Sebaceous carcinoma occurs mainly in the head and neck region, rarely in trunk.  Case report: We present a case report of 63-year-old patient, operated on for sebaceous carcinoma in the right breast area. The patient underwent radical surgery, removal of the tumor with the skin, subcutaneous tissue, and the large pectoral muscle. The patient is in good clinical condition eight months after the surgery. She is being constantly monitored and so far, there are neither signs of local recurrence nor tumor progression.  Conclusion: Patients with rare tumors should be treated comprehensively with subsequent lifelong dispensarisation in specialized centers. Multidisciplinary medical teams are able to eruditely diagnose, recognize, treat and dispense patients.

[Circumferential resection margin in the modern treatment of rectal cancer]. / Cirkumferencný resekcný okraj v modernej liecbe karcinómu rekta.

INTRODUCTION: In the last decades, the assessment of circumferential resection margin (CRM) has gained enormous importance in the management of patients with rectal carcinoma, not only in predicting the prognosis, but also in precise cancer staging, in multimodal treatment indications and in quality assessment of provided care. METHODS: The authors present a review article containing CRM definition, describing the technique of CRM assessment, the effect of CRM status on the prognosis and quality of provided therapy. CRM assessment in the context of a multidisciplinary team is especially emphasised. The aspect of CRM has to be considered by the radiologist during cancer staging, the surgeon in the course of the operation, the pathologist during precise macroscopic and histopathological specimen evaluation, and the oncologist when deciding on neoadjuvant/adjuvant therapy administration. CONCLUSION: CRM nowadays represents a fundamental aspect in modern treatment of patients with rectal carcinoma. The introduction of CRM assessment into clinical practice has lead to more precise staging, better multimodal therapy indications, more precise surgical technique (total mesorectal excision), an increased rate of sphincter-saving resections, lowered local recurrence rates and improved patient survival.

[Surgical treatment of complicated hepatic echinococcosis in two Bulgarian citizens at two surgical departments in the Czech Republic]. / Chirurgické resení komplikované jaterní echinokokózy u dvou bulharských obcanu na dvou pracovistích v Ceské republice.

Echinococcosis, also referred to as hydatidosis, is a parasitic infection caused by the tapeworm Echinococcus in its larval stage. It has worldwide distribution and endemic areas in Europe include especially the regions surrounding the Mediterranean Sea. In the Czech Republic, its incidence tends to be quite rare. Although it may affect any organ or tissue in the human body, the liver (60%) and lungs (20%) are the most frequently affected sites. The authors present two cases of Bulgarian patients with hepatic echinococcosis operated on the same day at two different surgical departments in the Czech Republic. Treatment is based on the surgical removal of the cysts in combination with anti-parasite treatment by benzimidazoles (Albendazol, Mebendazol). Treatment with anti-parasitic drugs needs to be started preoperatively and should continue for at least 1-2 months after surgery. The success of the treatment can be monitored by imaging methods, especially PET/CT and serology. Patients after surgical as well as conservative therapy need to be followed up on an outpatient basis due to the long-term risk of recurrence.

[Nuss miniinvasive procedure for pectus excavatum in adolescents and adults]. / Miniinvazivní operace pectus excavatum u adolescentu a dospelých dle Nusse.

Pectus excavatum is a congenital chest wall deformity with depression of the sternum and adjacent costal cartilages. Severe forms of this deformity lead not only to psychosocial deprivation but also limit physical performance due to lung volume reduction and cardiac compression. Open surgical correction using stemochondroplasty represented the gold standard of surgical treatment of pectus excavatum. Miniinvasive technique of corrective steel bar insertion was published in 1998. Since then, so called Nuss operation has become widely accepted. Good experience with this type of the pectus excavatum correction have encouraged us to adopt this procedure. We use this technique not only in children and adolescencents but also in adults suffering from depressed anterior chest wall. We present our initial experience with the treatment of nine patients. We describe the benefits and pitfalls of the method which are known to us.

[An optimum miniinvasive approach in esophageal replacement with stomach]. / Optimální miniinvazivní prístup pri náhrade jícnu zaludkem.

Esophagectomy was performed by transhiatal approach from laparotomy or laparotomy combinated with thoracotomy till the beginning of 90th of 20th century. These procedures are associated with high morbidity (40-80%) and mortality (5-15%) rate. There is a tendency of using minimally invasive approach in esophageal surgery with preserving oncological radicality. Based on our experiences with minimally invasive esophagectomy and gastric replacement we would like to introduce a technique which is considered optimal in our department.

[Diagnostics of intestinal ischemia. Influence of surgery on plasma levels of I-FABP as the marker of enterocyte injury]. / Diagnostika strevní ischemie. Vliv operacního výkonu na plazmatické hladiny I-FABP jako specifického ukazatele poskození enterocytu.

BACKGROUND: Intestinal fatty acid binding protein (I-FABP) deriving from the cytoplasm of the intestinal epithelial cells is a new biochemical marker with potential to indicate intestinal mucosal injury early in the phase of enterocyte damage. I-FABP is thought to be promising marker for detection of the systemic inflammatory response syndrome (SIRS) and sepsis before its onset. AIMS OF THE STUDY: The aim of the study was to consider the influence of surgery on I-FABP plasma levels. METHODS: Fifty-six consecutive patients undergoing elective surgery were prospectively studied. Only patients with major surgical procedure were involved in the study. Patients were divided into three groups: group A (n=19) patients with open abdominal surgery, group B (n=19) patients with laparoscopic abdominal surgery and group C (n=15) patients with thoracic surgery. From every patient in the study six samples of venous blood were taken in these intervals: preoperatively, immediately postoperatively and 4, 12, 24 and 48 hours after the surgery. Plasma samples were analysed for I-FABP levels by enzyme linked immunosorbent assay. RESULTS: There were no differences in the mean plasma I-FABP levels within the groups (ANOVA, p > 0.05), except significant decrease of the I-FABP level 48 hours after the surgery in contrast to preoperative plasma concentration in group B (82.60 pg/ml vs. 229.00 pg/ml; p = 0.025) and group C (88.99 pg/ml vs. 194.96 pg/ml; p = 0.0347). There were no differences in the mean I-FABP plasma concentrations among the groups preoperatively, immediately postoperatively and 4, 12. 24 and 48 hours after the surgery (ANOVA, p > 0.05). No differences were found in the I-FABP plasma levels related to preoperative laxative drug use, duration of surgery, small bowel resection and SIRS in postoperative period (t-test, p > 0.05). CONCLUSIONS: There were no differences in the mean plasma I-FABP levels preoperatively and in the postoperative period after the major surgery. Because surgery alone probably has no influence on I-FABP plasma levels we can say that the concept of l-FABP as the early marker of the intestinal mucosal injury is also viable in postoperative period.

[Thoracoscopic thymectomy--initial experience]. / Torakoskopická tymektomie--iniciální zkusenosti.

Video-assisted thymectomy and its variations is not generally accepted approach in surgical treatment of myasthenia gravis yet. Authors present their initial experience with videothoracoscopic technique in surgery for thymic cysts and myasthenia gravis. Authors prefer left thoracoscopic approach which allows good view to the thymus in mediastinum and neck. Recent studies confirm generally known advantages of miniinvasive surgery and show no differences between open and thoracoscopic thymectomy in terms of treatment outcome of myasthenia gravis. Nevertheless, prospective randomized study comparing open and thoracoscopic thymectomy in myasthenia gravis is not known.

[Spontaneous pneumomediastinum]. / Spontáinní pneumomediastinum.

Spontaneous pneumomediastinum is a presence of free air in the mediastinum without previous injury and without previously known lung disease. Spontaneous pneumomediastinum is infrequent and little known by physicians. Authors present a case report of three young men with spontaneous pneumomediastinum. There was no evident causation in two cases. In one case there was previous excessive sport activity. Main presenting symptoms were chest and neck pain, odynophagia, dysphonia, vomiting, and neck subcutaneous emphysema. Esophageal perforation was ruled out. All patients recovered spontaneously. Spontaneous pneumomediastinum is the benign disease. Its main importace is in differential diagnosis concerning especially esophageal perforation.

[Small bowel perforation as a late complication after laparoscopic hernioplasty]. / Perforace tenkého streva jako pozdní komplikace laparoskopické hernioplastiky.

The authors present a case report of a 44-years old male after laparoscopic onlay mesh technique repair of the right inguinal hernia. Patient underwent three open and laparoscopic reoperations because of the neuralgic pain of the right leg, febrilia, and abdominal tenderness. Multiple adhesions of the coecum and the small bowel to the mesh and penetration of the onlay mesh to the adhered small bowel was revealed during the last laparoscopic revision. The mesh was removed and the affected small bowel was resected. Patient had no other complications again. Such serious complications on the basis of the mesh hernioplasty are probably rare or remain simply unpublished.

[Comparison various types of artificial nutrition on postoperative complications after major surgery]. / Porovnání vlivu ruzných druhu umelé výzivy na pooperacní komplikace po velkých chirurgických výkonech.

BACKGROUND: The present rationale appears to prefer early postoperative enteral nutrition to total parenteral nutrition. But no clear conclusions exist for demonstrating the clinical benefit of early postoperative enteral nutrition in patients after the major surgical resections of upper gastrointestinal tract. AIM: To compare the clinical impact of various types of the artificial nutrition by comparison of the postoperative complications. METHODS: Prospective, randomized, controlled clinical trial. Sixty-two patients were analyzed. In the group I (21 patients) the total parenteral nutrition was received, in the group II (20 patients) the standard enteral nutrition was received, in the group III (21 patients) the enteral nutrition enriched with glutamin, arginin and omega-3 fatty acids was received. Both enteral feedings were given early. All three nutritional regiments were isocaloric and isoproteinaceus. RESULTS: The postoperative complications were in 31 patients overall (11, 11, 9 patients in the each group I, II, III). Three patients died in the group I, 2 patients in the group II, and 1 patient in the group III. There were no significance differences (p < 0,05) in postoperative complications, both infectious and non-infectious reasons. CONCLUSION: The study has shown no impact of various type of artificial nutrition on clinical outcome in patients after major resections of upper gastrointestinal tract. There was no significant difference in infectious complications in the groups with enteral feeding. The combination of enteral and parenteral nutrition appears as optimum after major surgery of the upper gastrointestinal tract. It is necessary to realize more extensive studies of homogenous patients to find out the benefit of various types of arteficial nutrition in postoperative period.

[Subhepatic drainage in laparoscopic cholecystectomy--a necessity or an overused tradition?]. / Subhepatální drenáz pri laparoskopické cholecystektomii--nutnost nebo prekonaná tradice?

The subhepatic drainage is mandatorily used in the end of laparoscopic cholecystectomy in the majority of departments of surgery in Czech republic. The preoperative finding of advanced inflammatory alteration or bleeding in operative field is certainly the reason to do so. But it seems that obligatory drainage after uncomplicated laparoscopic cholecystectomy has no real foundation and it is suspiciously an expression of antiquated tradition. From January 1, 2001 to December 31, 2002 the prospective non-randomized study was performed: in the first group of patients the drainage of subhepatic space was used mandatorily (324 patients), in the second group the drainage was used only in indicated cases (365 patients). No statistically significant difference was found between the two groups in postoperative complications (biliary leak, intraabdominal abscess, reoperation). There was the significant difference in surgery times (55 min. in the group with mandatory drainage, 50 min. in the group with indicated drainage, p < 0.05), in term of hospital stay--the patients with mandatory drainage stayed longer in hospital (3.2 day, resp. 2.4 day, p < 0.05). In summary, the mandatory drainage of subhepatic space after laparoscopic cholecystectomy is not associated with lower incidence of postoperative complications. On the other hand, the mandatory drainage has significantly longer surgery time and longer length of hospital stay. The drainage is exceptionally indicated but not mandatorily in uncomplicated operations.

[A large ovarian teratoma mimicking acute abdomen--case report]. / Velký ovariální teratom imitující náhlou príhodu brisní--kazuistika.

Authors present case report of an adolescent girl with the large ovarian teratoma. Teratoma of the ovary was surprising finding during laparotomy which was indicated on the basis of acute abdomen. Tumorectomy was performed. Microscopic examination revealed differentiated mature teratoma. There were no signs of recurrence. Authors present short review of the literature concerning this rare diagnosis and the reason of acute abdomen.

[Metastatic choriocarcinoma as a cause of hemorrhage in the digestive tract and abdominal cavity]. / Metastatický choriokarcinom jako prícina krvácení do trávicí trubice a brisní dutiny.

Authors present a case report of an young woman with metastatic choriocarcinoma. Clinical presentation of the disease was intracerebral bleeding concurring with intestinal bleeding and bleeding from ruptured spleen according to metastatic spread. Physicians firstly didn't think of choriocarcinoma because of small incidence of the disease and long period after the patient's latest pregnancy. At last the aggressive treatment was successful. Authors would like to bring out the reality that the surgeon could be the first who is faced with diagnosis and treatment of serious complications of choriocarcinoma.