Fresh arterial allograft as a replacement for an infected common femoral prosthetic graft and recurrent false aneurysm.

Replacing an infected vascular prosthetic conduit with an allograft is a possible solution of this complication given the low recurrence of infection. It is most commonly utilized for cases where the use of autologous tissue is not an option. We present the case of a 70-year-old patient who had undergone repeated vascular reconstructions in the right lower limb. He was admitted to our department due to a progressively growing mass in the right groin and subsequently placed on the waiting list for a fresh allograft. The patient had the infected false aneurysm and prosthetic material of the femoral bifurcation replaced with an arterial allograft. The previous femoral popliteal autovenous bypass graft was reimplanted into the allograft. There were signs of sepsis during the operation; however, the blood culture was negative. Cultures from neither the wound nor the drain revealed the presence of any bacteria. The patient was discharged on the seventh post-operative day with prophylactic antibiotics. An early followup confirmed that there were no signs of recurrent infection and that the reconstruction remained patent. Seven and half months after the surgery, the femoral popliteal bypass graft became occluded and a conservative approach was chosen. A small thrombosed false aneurysm of the graft was revealed two years after the surgery due to transient non-compliance of the patient to immunosuppression therapy. It was treated conservatively. Two and a half years after the surgery, the allograft still remains open and the limb is preserved.

Retroperitoneal tumour resection in fifteen consecutive cases: Single centre experience.

INTRODUCTION: Retroperitoneal tumours (RTs) in adults are a rare heterogeneous group of neoplasms arising from the retroperitoneal space. RTs'clinical manifestations are nonspecific and depend on their anatomical positioning and relation with bordering structures. Our study aimed to retrospectively evaluate our patients' diagnosis, length of hospital stay, disease-free period and postoperative metastasis occurrence. METHODS: From 2011 to 2019, fifteen suspected RT resections were performed at our centre. Retrospective analysis of patients' hospital stays, follow-up, histological and immunological tumour profile, and metastasis occurrence/ re-occurrence was performed. RESULT: All of the 15 (100%) patients were males. The average age of our patients was 44 years (SD ± 11.2 years), average hospital stay was 7.4 days (SD±3.4 days) (Tab.1). All resected tumours underwent histological and immunological evaluation. Based on histological examination of the resected tumours, nonseminomatous germ cell tumours were present in 12 (80%) patients - including teratoma in 4 (26.6%) patients, seminoma in 2 (13.3%) patients, and malignant B-cell lymphoma in 1 (6.6%) patient. The average patient follow-up was 42.7 months (SD±31.4.9 months). Complete remission after the surgery was achieved in 11 (76.9%) patients, and 2 (13.3%) patients were lost in follow-up. CONCLUSION: RT is a rare heterogeneous group of neoplasm. The patient's prognosis dramatically depends on the type of tumour, metastasis occurrence and re-occurrence, and the surgeons' ability to resect the tumour completely.

Open revascularization in a patient with chronic mesenteric ischemia and a history of aorto-bifemoral bypass - a case report.

INTRODUCTION: This case report describes surgical treatment of chronic mesenteric ischemia in a polymorbid patient with the history of an aorto-bifemoral bypass implant. CASE REPORT: The patient suffered from chronic occlusions of the mesenteric arteries. He experienced postprandial pain and significant weight loss. Endovascular repair of the occlusions failed. Open single retrograde bypass from the left branch of the aorto-bifemoral graft to the superior mesenteric artery was implanted successfully. CONCLUSION: The discussion briefly mentions current trends in the treatment of chronic mesenteric ischemia. Despite the development of interventional radiology, surgical treatment remains a relevant alternative for the management of chronic mesenteric ischemia.

Minimally-invasive pancreatic surgery in high volume centers in the Czech Republic - current status and possible implementations.

INTRODUCTION: Minimally-invasive surgical methods have been becoming ever more common also in the segment of pancreatic surgery. The aim of this paper was to analyze the current state of minimally-invasive surgery in the Czech Republic and the justification and potential of implementing such procedures. METHODS: Analysis of high volume centers using healthcare providers´ and payers´ data. RESULTS: Thirteen pancreatic surgical centers meet the proposed criteria for being called a high volume center - a center of highly specialized care in pancreatic surgery based on the annual number of at least 17 major resections of the pancreas. According to data from healthcare payers, laparoscopy was used in 0.6%-65.7% of procedures in individual centers. However, these are not resection procedures. The centers themselves report a significantly smaller number of minimally-invasive pancreatic resection procedures. The actual numbers of minimally-invasive resection procedures in the current system are practically impossible to verify. The potential for implementing minimally-invasive pancreatic surgery in the Czech Republic can be estimated based on the identification of candidate patients. CONCLUSION: Due to the fragmentation of this operative segment, its costs and small numbers of patients suitable for minimally-invasive pancreatic surgery even among high volume centers, the implementation rate of these methods is very slow. The need to centralize this segment of care appears to be very urgent from all points of view.

Giant aggressive intra-abdominal desmoid-type fibromatosis - case report.

INTRODUCTION: Aggressive fibromatosis, also known as desmoid tumour (DT), is a locally invasive soft tissue malignancy originating from fascial planes, connective tissue, and musculoaponeurotic structures of the muscles. The symptoms greatly depend on the location and size of the tumour. CASE REPORT: A 68-year-old male patient without any comorbidities with a large, palpable mass in the abdomen underwent computed tomography (CT) of the abdomen during diagnostic examination in September 2017 in another centre. The CT scan revealed a giant intraperitoneal 30×40cm tumour without signs of infiltrating the surrounding organs and large vessels. The tumour biopsy revealed an aggressive DT. The patient was scheduled for tumour resection. Midline laparotomy was performed in the supine position under general anaesthesia. After gaining access to the abdominal cavity, 8 litres of clear ascites were evacuated. The tumour was not attached to the abdominal wall. Large omentum was freed from the DT. The perioperative finding confirmed the CT images of DT encapsulation of the medial colic artery, part of the small intestine, and transverse colon. The tumour was resected with part of the mesenteric radix, 30 cm of small intestine, and 2/3 of the transverse colon. After the DT was removed entirely, the small intestine was re-anastomosed end to end. The abdominal cavity and the liver were carefully checked for bleeding. The abdominal cavity was closed in a standard manner. RESULTS: The postoperative hospital stay was uneventful. The patient was discharged on the 7th postoperative day with prophylactic low weight molecular heparin for one month. Currently, we have five months of follow-up with no signs of DT recurrence based on CT examination. The histology of the resected tumour confirmed the diagnosis of a desmoid tumour (aggressive abdominal fibromatosis). CONCLUSION: Desmoid tumours are benign neoplasms with no metastatic potential. However, their treatment is challenging due to their aggressive growth, infiltrative behaviour, and a high tendency to recur.

Finding Eden - alternative transplantation sites for pancreatic islets.

Pancreatic islets transplantation is an established treatment method for type 1 diabetic patients with the hypoglycemia unawareness syndrome in whom a therapy with modern technologies fails. Islet transplantation is most commonly done using an interventional radiology method: a tissue suspension of pancreatic islets is applied into a branch of the portal vein through a percutaneously installed catheter. Although being minimally invasive unlike pancreas organ transplant, this method is associated with many technical difficulties. Possible complications of the procedure include hemorrhage and portal vein thrombosis. Unlike their natural dispersed localization in exocrine pancreas, isolated pancreatic islets are exposed to hypoxia, toxins and immunosuppressive drugs in the liver parenchyma. Direct contact with the recipients blood causes an instant blood mediated inflammatory reaction (IBMIR) resulting in the death of more than half of the pancreatic islets shortly after their application. Therefore the size of the islet graft is often insufficient and a number of transplanted patients require administration of exogenous insulin. All of these are reasons for seeking an alternative transplantation site with more hospitable conditions for long-term islet survival. Various transplantation sites have been tested in experimental and clinical research. The advantages and disadvantages of some of them are summarized in this paper. Currently, transplantation into the greater omentum seems most promising, which has already been used in clinical practice at several institutions.

Migration of a mesh into the colon after inguinal hernia repair - a case report.

INTRODUCTION: Mesh migration is one of the least common complications that arise after inguinal hernia repair with a mesh. Only small case series have been reported, and an understanding of this issue is limited due to a lack of data. Most of the cases were treated surgically. In this paper, we wish to present the potential of treating this condition using endoscopic techniques. CASE REPORT: A male patient underwent transabdominal preperitoneal repair of a primary inguinal hernia in 1999. In 2003, the patient required the same procedure for a recurrent inguinal hernia. Twenty years after the primary hernia repair, the patient had a positive faecal occult blood test but was completely asymptomatic. A colonoscopy revealed mesh migration into the sigmoid colon. Despite multiple attempts to remove the mesh endoscopically, endoscopic treatment was unsuccessful. The migrated mesh was surgically removed and obligatory resection of the sigmoid colon was carried out. Apart from wound infection (Clavien-Dindo IIIb), the postoperative course was uneventful. CONCLUSION: In our case, the mesh that had penetrated the colon could not be removed endoscopically. Despite our experience, it is advisable to attempt endoscopic removal of mesh that has migrated into a hollow intra-abdominal viscus.

Thrombolysis as a treatment for transplant renal artery thrombosis - a report of three unsuccessful cases and an overview of reported cases.

INTRODUCTION: Thrombolysis has been suggested as a feasible method to treat arterial renal transplant thrombosis under conditions of short duration of ischemia. Data on maximal duration of ischemia that are still feasible to treat are scarce. METHODS: We retrospectively analysed our experience involving three attempts to utilize thrombolysis to treat transplant renal artery thrombosis. We searched through literature on PubMed and compared the data we found with our own experience. RESULTS: In case number 1 of our cohort, thrombolysis was initiated 12 hours after the onset of thrombosis and had to be ceased after five hours due to the formation of a haematoma. Perfusion of the graft was restored but it did not regain function, most likely due to long ischemia time. In case number 2, an attempt to use thrombolysis was unsuccessful due to failure to cross the graft artery occlusion with a guidewire. Thrombosis was most likely caused by chronic rejection of the graft. In case number 3, thrombolysis restored arterial patency but, due to an onset of ischemia, which lasted 2 to 3 days, did not lead to restoration of graft function. The prolonged ischemia period in case three occurred, at least in part, due to failure to perform an ultrasound scan when the patient was first admitted. CONCLUSION: We can confirm that thrombolysis for transplant renal artery thrombosis seems to be feasible only when the condition has a short duration. In the event of sudden deterioration of graft function, the absence of perfusion must always be ruled out by ultrasound scan.

Extensive bile duct injury resulting from a laparoscopic cholecystectomy resolved by a Roux-en-Y tri-hepaticojejunostomy: a case report.

INTRODUCTION: Bile duct injuries (BDIs) that occur after a laparoscopic cholecystectomy (LC) are among the most serious iatrogenic injuries and have high morbidity and mortality. They significantly impact the quality of life of the patient. They are one of the most common causes of benign biliary strictures, which can result in serious complications such as recurrent cholangitis or secondary biliary cirrhosis. Although LC is a common operation today, the incidence of BDIs associated with LC is twice that of BDIs resulting from open cholecystectomies. CASE REPORT: In this paper, we present a case report of a patient after LC with the Class III-D injury according to the Stewart-Way classification. The injury was a result of a misleading description from a preoperative ultrasonography and a subsequent misunderstanding of the anatomical conditions of a patient with congenital gallbladder agenesis. The BDI was recognised first day after surgery. Thanks to a prompt transfer to our centre the patient was in a good condition. Biliary reconstruction could be done because there was no serious inflammation or biliary peritonitis at the time of reoperation. Due to the extent of the injury a Roux-en-Y tri-hepaticojejunostomy combined with external transhepatic biliary drains was performed. CONCLUSION: Iatrogenic BDI after a LC is a rare, but potentially life-threatening complication. The main risk factor is the presence of anatomical variants of the biliary tract. Early recognition and treatment in a department with adequately experienced hepatobiliary specialists are crucial for a positive outcome. The most frequent surgical treatment is a Roux-en-Y hepaticojejunostomy.

Liver transplantation using grafts from donors after circulatory death - the first Czech Republic experience.

INTRODUCTION: Liver transplantation is established as a lifesaving procedure for patients with acute and chronic liver failure, as well as certain selected malignancies. Due to a continuing organ shortage and ever-growing patient waiting lists, donation after cardiac death (DCD) is becoming more frequently utilized in order to close the gap between “supply and demand”. METHODS: A retrospective analysis of DCD and subsequent liver transplantations was performed. RESULTS: From May 2016 to September 2019, a total of 9 DCD liver transplantations were performed in our institution. All cases except one were primary liver transplantations. The recipients comprised 5 (56%) males and 4 (44%) females. The mean DCD donor age was 41±12 (22-57) years, with ventilation duration of 7±1 days and warm ischemia time 19±3 minutes. The average recipient age was 51±22 (4-73) years, with an average cold ischemia 3h:59m±27m and manipulation time of 23±5 minutes. Periprocedural mortality was 1 (11%). Hepatitis C recurrence was documented in 1 (11%) patient. The mean follow-up time was 19±13 (7-37) months. Until now, we have not observed any signs of ischemic cholangiopathy. CONCLUSION: DCD liver transplantation allows us to enlarge the pool of potential liver grafts, thus decreasing the time spent on the liver recipient waiting list. This paper documents the first series of DCD liver transplantations in the Czech Republic.

The most recent recommendations for the surgical treatment of inguinal hernia.

INTRODUCTION: The publication of new guidelines in recent years shows that surgical treatment of inguinal hernia remains topical. The main goal is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain. The main purpose of this article is to summarize the latest recommendations in surgical treatment of the groin hernias, especially in the case of strangulation. METHODS: The authors made literature review of all the guidelines published by the hernia societies, including related articles, in the last ten years. RESULTS: The use of the EHS classification system is suggested. In elective operations, mesh repair is recommended. The Lichtenstein technique is the standard in open inguinal hernia repair. Transabdominal preperitoneal and totally extraperitoneal approach have comparable outcomes. Their clear advantages include minimal invasiveness. Mesh repair is recommended also in the case of strangulation, but only in clean and clean-contami-nated operations. A laparoscopic approach should be considered as well. Inter alia, it allows an assessment of bowel viability during the whole procedure. The need of bowel resection is hence lower compared to open surgery. If it is not possible to use the mesh, the Shouldice method is regarded as the best non-mesh repair technique. If there is concern about bowel viability, visualization, either by formal laparoscopy, hernia sac laparoscopy or laparotomy, is recommended. Hernioscopy is a simple and safe procedure that uses the hernia sac for insertion of a port following insufflation and diagnostic examination. It requires less advanced laparoscopic skills than does emergency laparoscopic hernia repair. It can be performed even by surgeons who lack sufficient experience with laparoscopy. CONCLUSION: In elective procedures, the mesh repair is recommended. It is recommended also in the case of strangulation, but not in a contaminated-dirty surgical field. If there is concern about bowel viability, visualization, either by formal laparoscopy, hernia sac laparoscopy or laparotomy, is needed.

Adipose tissue collection from a living kidney donor; an experimental model for the research of atherosclerosis.

Thanks to an increased number of living-donor kidney transplants the IKEM transplant program offers the possibility of obtaining adipose tissue for scientific purposes from patients with varying degrees of atherosclerosis. Surgery mainly addresses vascular complications of this disease. On the other hand, surgery may also be the reason for the development and acceleration of atherosclerosis - for instance, acceleration of atherosclerosis in the living kidney donor, particularly if, although meeting internationally recognized donation criteria, the donor actually suffers from metabolic syndrome. The effort to refine the examinations of living kidney donors in terms of eliminating the risk of developing atherosclerosis is a long-term project. The aims are to determine the risk factors for living kidney donors and to prevent long-term complications after donation. The paper gives a detailed description of the technique of adipose tissue collection from a living kidney donor and of the experimental model for the research of atherosclerosis.The project has the potential to increase the safety of living kidney donation and to enhance our present knowledge of atherosclerosis development mechanisms.

[Pregnancy in women with solid-organ transplants]. / Tehotenství u zen po transplantacích solidních orgánu.

OBJECTIVE: Evaluation of pregnancies and deliveries in women after solid organ transplantations with respect to the maternal and fetal risks. DESIGN: Overview article. SETTING: Department of Obstetrics and Gynaecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague. METHODS: Literature search using the Web of Science, Ovid, Cochrane, Google Scholar and Medline databases with keywords (transplantation, pregnancy, immunosuppression) and analysis of articles published in impact and reviewed journals from 1958 to 2017. RESULTS: Pregnancy in patients after solid organ transplantions is associated with the higher risk of complications, particularly preeclampsia, and high incidence of comorbidities. Women after transplantation have an increased risk of premature deliveries and low birth weight newborns. The highest risk of complications is documented after lung transplantation. For immunosuppression in pregnancy inhibitors of calcineurin, azathioprine and prednisone are used. CONCLUSION: Pregnancies and deliveries in women after solid organ transplants are in a high risk. With early transplantation, adequate patient health compensation, properly planned pregnancy, adequate immunosuppressive therapy and specialized prenatal and obstetric care, women can give birth to healthy newborns after transplantation.

Orthotopic liver transplantation with reduced and rotated graft in adult situs inversus recipient: a case report and a review of reported cases.

INTRODUCTION: Situs inversus is a rare congenital anomaly characterized by a mirror-image orientation of abdominal and mostly also thoracic organs. Liver transplantation in these patients is a demanding procedure due to the difficulties pertaining to positioning of the graft and the presence of frequently associated vascular abnormalities. Several reports have been published regarding successful liver transplantation in adult situs inversus recipients with different proposed positions of the graft. Relevant experience remains limited. CASE REPORT: In this paper we present a case of successful transplantation of a reduced-size cadaverous left hemi-liver graft to an adult situs inversus recipient in a 90-degree clockwise rotation. A complex arterial reconstruction was established. A review of published liver transplantations in adult situs inversus recipients along with the techniques employed is provided. RESULTS: No vascular or spatial problems were encountered using this technique. The graft function is perfect at 27 months from the transplant procedure. The first liver transplantation with a reduced-size left hemi-liver graft from a situs solitus cadaveric donor to the situs inversus adult recipient is presented. CONCLUSION: The devised method of 90-degree clockwise rotation provides perfect spatial adjustment. Relatively smaller grafts are to be preferred as they allow maximum flexibility. Vascular conduits should be readily available.

Aorto-iliac endarterectomy: Old-fashioned or re-newed method?

INTRODUCTION: Aorto-iliac occlusive disease is best treated with endovascular angioplasty/stenting or surgical bypass, depending on disease severity. Aorto-iliac endarterectomy was frequently used until the 1980s. However, it can still be performed in cases of previous failure or contraindication of standard methods. The aim was a retrospective evaluation of a single-center case series of aorto-iliac endarterectomy. METHODS: Seven patients at mean age 60±8 years (5768 years) were treated by aorto-iliac endarterectomy between 2013 and 2018. Rutherford categories of leg ischemia were 2 (moderate claudication) 3x, 3 (severe claudication) 2x, 4 (rest pain) and 5 (toe gangrene). The reasons for endarterectomy approach were: late in-stent iliac occlusion in an oncology patient, failure or complication of previous endovascular treatment of short iliac stenosis 2×, high infection risk of prosthesis use in long iliac-femoral occlusion, and short iliac occlusions 3x. Two patients after previous organ transplant were on immunosuppression. RESULTS: Technical success rate was 100%. There was no peri-operative (30 days) death or amputation. Mean follow-up was 17 months (1.1 month3.3 year). One patient required additional tibial bypass 1 month after endarterectomy to heal foot gangrene. One patient developed symptomatic re-stenosis which was treated with iliac stenting 8 months after procedure. All patients clinically improved and recovered from leg ischemia. Two patients died of tumor with preserved limb 1.1 month and 3.1 years after procedure, respectively. Five remaining patients are asymptomatic with patent revascularization to date. CONCLUSION: Aorto-iliac endarterectomy is a vital alternative technique for revascularization in selected patients when other methods seem inappropriate. Key words: endarterectomy - peripheral arterial disease - iliac artery - abdominal aorta.

Two-stage surgical treatment of inferior vena cava traumatic rupture including urgent transport to a specialized unit.

Inferior vena cava injury as well as major liver injury remains a formidable treatment challenge. The most imminent danger is life-threatening bleeding. In this report, we present a case of polytrauma (Injury Severity Score 35) with arupture of the juxtahepatic inferior vena cava which was successfully treated using two-stage approach. The first part of the treatment consisted of damage control laparotomy at a level I trauma center. After stabilization, the patient was air-transported to receive the definitive treatment at a tertiary care facility experienced in hepatopancreatobiliary and transplantation surgery. As the level of injury was not clear prior to the second stage surgery, a cardiac team also assisted the operation. The second stage procedure was uneventful. The patient is doing well and is preparing to return to work. We believe that experience with major abdominal, thoracic and liver transplantation surgery is beneficial in such cases.

Liver resection for recurrent sarcoma with allogenic aortic patch as partial inferior vena cava replacement - case report and review of literature.

In this case report, we discuss the topic of hepatic sarcomas, their occurrence and treatment options. We present a case of successful radical resection in a young man with recurrent sarcoma of the liver with inferior vena cava infiltration. We describe the surgical procedure in steps and point out the severity of the disease with frequent recurrences. We also review evidence behind the topic aimed to support our treatment approach.Key words: hepatectomy - sarcoma - inferior vena cava - blood vessel prosthesis - allograft.

[Recurrent retroperitoneal sarcoma]. / Recidiva sarkomu retroperitonea.

Retroperitoneal sarcomas are rare malignant neoplasms that are often diagnosed late because of their typical nonspecific symptomatology. Radical surgical resection, if possible given the local anatomical conditions, is the most important treatment modality. However, even if the surgery is feasible and successful, the prognosis of retroperitoneal sarcoma is not good. The most frequent type of recurrence is local recurrence, and radical surgical resection remains the most important treatment modality even in such cases.Our study presents a case report of a patient with a retroperitoneal leiomyosarcoma that was radically (R0) removed. Two years later a local recurrence developed, which was eventually diagnosed by MRI. Again, radical (R0) surgical resection was approached (because of tumor invasion into inferior caval vein, the vein had to be partially resected as well and substituted with a vascular prosthesis).The report describes a relatively typical case of retroperitoneal sarcoma, while pointing out the importance of timely diagnosis (which is definitely not easy to achieve) and especially of radical surgical treatment.Key words: retroperitoneal sarcoma recurrence surgery.

Deceased donor uterus retrieval - The first Czech experience.

INTRODUCTION: Uterus transplantation is the youngest solid organ transplantation described in the literature. This procedure is the only treatment method for congenital or acquired Absolute Uterine Factor Infertility. METHOD: The method is not recognised as standard clinical care yet, there were only some 13 cases performed worldwide so far. There is only one clinical trial worldwide, which has proven both feasibility and also healthy child delivery. RESULTS: Czech Republic Ministry of Health permitted the uterus transplant clinical trial in 2015. The first phase of the surgical part includes performance and description of the uterus retrieval from a deceased donor. CONCLUSIONS: The first uterus retrieval from a deceased donor as a part of multi-organ retrieval was performed in the Czech Republic on January 13th, 2016; the case is described in the paper. KEY WORDS: uterus - transplantation - deceased - donor - retrieval.

Kidney transplant early venous complications managed by reperfusion and re-transplantation - salvage procedure.

We report five cases of early venous complications, all successfully rescued by graft removal, re-perfusion and re-transplantation, these kidneys would have been lost otherwise. All kidneys were from deceased donors, mean donor age was 39 years (range 29-55), with serum creatitine levels on harvesting being 81 µmol/l (65-108), glomerular filtration of 1.46 ml/s (0.82-1.83). Reasons for venous complications were following: Two cases of renal vein stenosis, another two with renal vein laceration, one renal vein thrombosis for unknown reason. All the five kidney grafts have been rescued successfully. One year's results in this group comes as mean serum creatinine level of 127 µmol/l. The described approach gives a chance to the patients with early vein thrombosis and offers the kidney graft salvage (Ref. 4).