Portal vein embolization and application of autologous stem cells in patients with primary unresectable liver tumours.

BACKGROUND: Only 15-20 % of patients with liver tumours can undergo radical surgery. Insufficient future liver remnant volume (FLRV) is one of the main causes of tumours unresectability. Portal vein embolization (PVE) together with administration of haematopoietic stem cells (HSC) may expand the operability of primary unresectable liver tumours. METHODS: In this pilot study, the authors reported on five patients (1 hepatocellular carcinoma, 4 colorectal cancer metastases) with FLRV <30 %, who underwent PVE on the side of the tumour with a subsequent application of HSC to the non-embolized branch of portal vein. RESULTS: PVE with HSC application was without any complications. In three patients, a sufficient increase of FLRV occurred within 2-4 weeks followed by a liver resection. All patients were between 5-12 months after the surgery in good condition; one of them was diagnosed with pulmonary metastasis after nine months that was successfully treated with laser metastasectomy. In one patient with hepatocellular carcinoma, an increase of FLRV and progression of the tumour in the liver occurred following the PVE with administration of HSC and the patient was treated only symptomatically. Despite an adequate increase of FLRV, severe intraabdominal adhesions hampered liver resection in one patient. CONCLUSIONS: Combination of PVE with HSC administration appeared to be a promising method that stimulated growth of FLRV with a subsequent possibility of an early radical liver resection. The issue is a danger of tumour progression in the liver parenchyma following the PVE with HSC. The current randomized study should answer these questions (Tab. 1, Fig. 4, Ref. 38).

[Late failure of the endovascular infrarenal aortic aneurysm solutions - diagnosis and treatment]. / Pozdní selhání endovaskulárního resení aneuryzmatu subrenální aorty - diagnostika a lécba.

INTRODUCTION: Nowadays, there are two possible solutions to aneurysms of the abdominal aorta. One is an open resection, which is undoubtedly one of the major surgeries and endovascular solutions, and which represents a smaller operating load for the patient. Long-term monitoring of patients after the endovascular solutions showed late failure in 7-17% of cases. The late incidence of endoleaks and the migration of stents are explained by changing the anatomy of the aneurysm and the resulting change in the mechanical pressure on the stent graft. If these conditions cannot be solved by an endovascular procedure the situation may present a technical challenge for the vascular surgeon. MATERIAL AND METHODS: Our report on the five case studies points to possible late complications of EVAR and solutions to their individual states. CONCLUSIONS: In the future, it should be recognized that if the endoleak is not proven it does not mean that it cannot occur over the years and massively fill the excluded aneurysm with the risk of rupture. Undoubtedly, re-operating the open patch is a challenging exercise. Nevertheless, it is possible even with the patients who were, primarily in terms of polymorbidity, indicated EVAR.

[Traumatic rupture of thoracic aorta]. / Traumatická ruptura hrudní aorty.

INTRODUCTION: Thoracic aortic injury (TAI) is burdened with high mortality (80-90%). The diagnostic and therapeutic algorithm has changed radically over the last couple of years. The authors present their experience with diagnosis and treatment of TAI at the University Hospital Trauma Centre. MATERIAL AND METHODS: 24 TAIs were evaluated in a retrospective study, in 20 (83.3%) cases they were part of a polytrauma. The average age of the patients was 39.4 years (20-67). Traffic accidents formed the majority of TAIs (87.5%). Multi-detector computed tomography was used as a basic examination to detect TAI. Thoracic endovascular aortic repair (TEVAR) was the treatment of choice in 21 and open surgery in 3 injured patients. RESULTS: The 30-day postoperative mortality was 12.5%, in one case it was associated with TEVAR. 30-day morbidity was 37.5% (circulatory instability, respiratory insufficiency, bronchopneumonia, type I endoleak). CONCLUSION: MDCT and TEVAR are currently the methods of first choice in the diagnosis and treatment of TAI. TAI requires a highly specialized multidisciplinary approach within Trauma Centres providing complex cardiovascular services.

[Non-tumor bile duct strictures]. / Nenádorové stenózy zlucových cest.

The authors rectrospectively evaluate the possibilities of the solutions and the complications regarding benign stenoses of the biliary tract in 10 patients, who were treated within the years 2008 - 4/2011 at the Surgical Clinic of Medical Faculty of Charles University and the Faculty Hospital in Plzen. The injury of the biliary tree at cholecystectomy - 6 cases - was the most often cause of the benign stenosis of the biliary tree development in our collection. Once it was the case of a rare incidence of M. Crohn's disease of the biliary tract, once it was the case of stenosis in Mirrizi syndrome and two times it was the case of stenosis after the repeated instrumental procedures at ERCP after choledocholithiasis. Three times stenosis was solved by help of the repeated dilations of stenosis in the way of ERCP procedure. In other 7 cases stenosis was solved surgically by help of hepaticojejunalanastomosis to the excluded Roux-en-Y gastric bypass. The dilation of stenosis of the biliary tree requested two sessions on average, the surgical solution had a minimal peri-operative morbidity - 0% and within a 30-day peri-operative period there was noted 1 death in connection with the solution of stenosis of the biliary tract with the massive bleeding at decubitus of the stent of the left biliary duct into hepatic artery. Long-term results with respect to a short-time period were not evaluated.

[Can tumor markers predict outcomes of portal vein branch embolization in patients with primary inoperable liver tumors?]. / Mohou nádorové markery predpovídat výsledek embolizace vetve portální zíly u nemocných s primárne inoperabilním nádorem jater?

INTRODUCTION: Portal vein embolization (PVE) is one of the options to increase the number of resecable cases in patients with primary inoperable liver tumors. However, insufficient growth of liver parenchyma or postoperative tumor progression remains problematic in PVE procedures. Generally, tumor markers are of significance in patient postoperative monitoring for the disease recurrence. The aim of this study is to assess the potential of tumor markers in predicting PVE outcomes. METHOD: The study group included 43 subjects with primary or secondary tumors, in whom serum alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), thymidine kinase (TK), tissue polypetide antigen (TPS) and MonoTotal levels were assessed 28 days following PVE. The liver parenchyma growth or tumor progression were assessed based on computer tomography. RESULTS: Sufficient liver parenchyma hypertrophy was recorded in 27 (62.8 %) patients with subsequent liver resection. Insufficient post-PVE liver parenchyma growth was recorded in 5 (11.6 %) patients and tumor progression was recorded in 11 (25.6 %) subjects. The following tests were considered significant predictive tumor markers of PVE outcomes: serum levels of CEA, TPA, Mono Total prior to PVE, and serum levels of TK, TPA, Mono Total within 28 days following PVE. CONCLUSION: Tumor markers may be significant in predicting PVE outcomes in patients with primary inoperable liver tumors. However, in order to make final conclusions on their clinical significance, larger patient group studies should be performed.

Chemo-embolization of inoperable liver tumors.

A small percentage of patients suitable for radical surgery require us to introduce alternative palliative methods prolonging the good quality of life in patients with malignant liver tumors. Apart from thermoablation or cryo-ablation, one of the alternative methods with palliative influence on tumors is the chemoembolization of tumors. A group of 18 patients, who underwent chemo-embolization at the Surgical Clinic and Radiodiagnostic Clinic, Medical Faculty, Charles University in Pilsen from 2007 to 2008, were assessed from the point of view of complications, overall survival and the patients' life quality. The most common complication was temperature and pain in the right infracostal area in connection with the performed procedure. The patients' quality of life after chemo-embolization was very good and the time of hospitalization was only 3.5 days on average. We had to perform the procedure repeatedly in 30% of cases. The chemo-embolization was done on inoperable liver metastases of colorectal carcinoma and on inoperable hepatocellular carcinoma (Tab. 1, Fig. 2, Ref. 5).

[Portal vein branch embolization in patients with primary inoperable liver tumors]. / Problematika embolizace vetve portální zíly u nemocných s primárne neoperabilními nádory jater.

INTRODUCTION: Portal vein embolization (PVE) is indicated in patients with insufficient liver remnants following liver resections for tumor disorders. Therefore, due to PVE, the number of primary operable patients is higher. Insufficient growth of the liver parenchyma or malignant progression remain the PVE cons. AIM OF THE STUDY: To date outcomes of PVE are assessed based on the authors' own experience and literature data. In particular, the authors focus on difficulties with PVE, i.e. its failures. METHODS: 40 patients (35 with colorectal carcinoma metastases, 2 with breast carcinoma metastases and one with ovarian carcinoma metastases, 2 with hepatocellular carcinoma) were indicated for PVE due to insufficient liver reserve following planned liver resection. RESULTS: Liver resections were completed in 22 subjects, 42.6 days (mean value) after PVE. In 14 (35%) subjects, the liver resection could not be performed (11x tumor progression, 3x insufficient liver tissue growth). In four subjects, only radiofrequency ablation was performed. At year one, two and three after the procedure, the survival rate is 83.7, 69.7 and 52.3% (resp.) of the subjects, while the survival rate following exploration and in unoperated subjects was 22.2% (25 subjects) (p < 0.001). A one-year, resp. two-year relapse--free survival rate was 30.3, resp. 7%. CONCLUSION: PVE has become an established procedure in stage liver procedures, due to its potential to facilitate operability of primary and secondary liver tumors. In order to improve the outcomes, attention must be paid to the post- PVE growth of the liver parenchyma and further assessment of oncological treatment approaches during the pre- and post- PVE period, with the aim to reduce liver and extra-liver malignant progression rates prior to the liver resection procedure.

[Abdominal aortic aneurysms--long-term treatment results]. / Aneuryzma abdominální aorty--dlouhodobé výsledky lécby.

OBJECTIVE: To evaluate the single center experience in the treatment of patients with AAA. METHODS: 586 patients undergoing open resection (OR) and EVAR (2000-2009). The average age was 72.2 +/- 7.7 years. AAA diameter was 8.3 cm (range 5.0-13.1 cm). 451 (76.9%) patients had asymptomatic AAA, 135 (23.1%) RAAA. 448 patients (76.5%) suffered from various co-morbidities. 430 (73.4 %) OR, 156 (26.6%) EVAR and 52 (8.9%) one staged procedure (for concomitant diseases) was performed. RESULTS: 30 days mortality rate of elective OR and EVAR was 6.2, resp. 2.9% (n.s.) versus 36.6% of RAAA (p < 0.0001). 30 days mortality rate of one staged and single procedure was 19.5, resp. 3.6% (p < 0.0001). 30 days morbidity rate was in the whole group 52.1% (80.7% in RAAA x 43.4% in asymptomatic AAA - p < 0.0001), in one-stage procedures 60.8% x 51.1% in single procedures - n.s., 45.1% in OR x 39.0% in EVAR - n.s. Redo procedures were significantly higher in EVAR x OR in the long-term period after primary procedure. 1-, 3-, 5-, and 8 years survival of patients with asymptomatic AAA and RAAA was 91.6, 85.9, 81.1 and 73.6%, resp. 54.9, 48.9, 45.9 and 43.5 years (p < 0.0001). 1-, 3-, and 5 years patients survival with single versus one staged procedures was 85.5, 80.5 and 71.0% versus 71.1, 68.0 and 74.6% (n.s.). 1-, 3-, and 5- years patients survival after OR or EVAR was 91.2, 87.1 and 80.6%, resp. 90.7, 79.9 and 74.6 % (n.s.). The significant influence on patients long-term survival had RAAA, age of patients, postoperative complications and one stage procedures. CONCLUSION: High percentage of polymorbidity was the cause of the significant 30 days postoperative mortality of patients after OR. EVAR and OR have similar long-term results. One staged procedures should be used very carefully in selected patients due to the higher mortality rate and worse long-term patients survival.

Hybrid procedures in the treatment of pseudoaneurysms of the aortic arch--case report.

Classical surgical therapy of dilatation disorders of the aortic arch require extracorporeal circulation, selective brain perfusion and/or deep hypothermia and it is still associated with very high mortality and morbidity. Endovascular therapy has until recently indicated only been in cases when the disease did not affect the area of the origins of the main branches within the aortic arch. We are presenting a case report of a 68 year female patient with a vascular anomaly (arteria lusoria) and 2 pseudoaneurysms of the aortic arch between the origins of arteria carotis communis on the right and arteria carotis communis on the left, respectively between a. carotis communis on the left and arteria subclavia on the left, when we took advantage of a hybrid procedure in the therapy. The patient was treated by creating a new branching of the aortal arch using a prosthesis from the ascendant aorta and subsequently by an introduction of 2 stent-grafts to the aortic arch using femoral arteries.

[Portal vein embolization--increased chance for liver resecability for malignancies]. / Embolizace portální zíly - zvýsení resekability jater pro maligní onemocnení.

INTRODUCTION: Liver surgery for liver malignancy is recently limited not by technical possibilities but by physiological reserves of liver parenchyma. Portal vein embolization (PVE) is performed to increase future liver remnant volume (FLRV) to extend the possibilities of liver resections. The authors evaluate the cohort of patients, that underwent PVE and confront them with the cohort of patients that underwent liver resection without PVE. METHODOLOGY: At the Department of Surgery and Departement of Radiology, University Hospital Pilsen there were performed successfully PVE at 24 patients between January 2001 and August 2006. The increase of FLRV was sufficient at 17 patients. The mean period between PVE and computed tomography volumetry was 29 days. The mean period between PVE and surgical procedure was 54 days. 8 patients underwent radical liver surgery (right hepatectomy, extended right hepatectomy, combination of right hepatectomy with RFA in left lobe), 3 patients underwent radiofrequency ablation, the rest of patients was explored. For comparison we used cohort of 107 patients that underwent one step radical surgery for malignancy. RESULTS: 1 year survival rate after liver operation was 85.7%, 3 years survival rate 42.9%. Disease free interval (DFI) was counted only for group of radicaly operated patients. One year DFI was 40%, two year DFI was 20%. The number of leasions was not proved as statistically significant for DFI or survival rate. In non PVE group 1 year survival rate was 78.9%, 3 years survival rate was 34.0%, one year DFI was 60.2%, two years DFI was 36.6%. DISCUSSION: The survival rate was higher in PVE group, the DFI was shortened in PVE group. In our cohort we could conclude, the PVE increase survival rate instead of shortened DFI. PVE spreads possibilities for liver resections at patients with small FLVR and enables radical surgical therapy for patients, that will be leaved a palliative surgery or oncological therapy.

[Role of pulse spray thrombolysis in acute ischemia of the extremities--comparison of results with the low dose technique of local thrombolysis, embolectomy and thrombectomy]. / Postavení pulsní sprayové trombolýzy u akutní koncetinové ischemie--porovnání výsledku s "low dose" technikou lokální trombolýzy, embolektomií a trombektomií.

BACKGROUND: The reported mortality of patients suffering from acute limb ischemia is in the range of 10% to 30%, as is the incidence of amputation in the survivors. MAIN PURPOSE: The evaluation of the pulse spray thrombolysis (PST) role in the treatment of acute extremity ischemia originating from thrombosis or embolism of native artery or bypass graft. The comparison of PST with low dose technique thrombolysis (LD), thrombectomy (TE) and embolectomy (EE). METHODS: Ninety nine consecutive patients were evaluated during a two year interval (1994-1996). PST, resp. LD, TE and EE were the method of choice in 22, resp. 11, 35 and 31 patients of average age 58.3 +/- 13.7; resp. 60.0 +/- 8.9; 74.2 +/- 11.7; 76.9 +/- 9.3 years. The native artery was occluded in 15 (68.2%), resp. 8 (72.7%), 31 (88.6%) and 30 (96.8%) patients with PST, resp. LD, TE and EE treatment. The vascular reconstruction was occluded in the rest of the cases. The lower limb extremity arteries were occluded in 20 (90.9%) of patients indicated for PST, 10 (90.9%) for LD, 33 (94.3%) for TE and 26 (83.9%) for EE. The contraindication for local fibrinolysis was severely ischemic limb in which viability was imminently threatened. RESULTS: PST was successful in 19 (86.4%), LD in seven (63.4%), TE in 13 (37.1) and EE in 27 (87.1%) patients. The failure of procedure required amputation in one patient (4.5%) with PST, one (9.1%) with LD, nine (25.7%) with TE-p < 0.001 and two (6.5%) with EE. The mortality was 4.5% (one patient), resp. 0%, 28.6% (10 patients)-p < 0.001 and 3.2% (one patient) in PST, resp. LD, TE and EE. The long term results were better if the successful local fibrinolysis was combined with percutaneous transluminal angioplasty (PTA), stent implantation or small vascular reconstruction. CONCLUSION: PST is the method of choice in the treatment of thrombotic or embolic occlusion of native artery or bypass graft in condition of good limb viability where there is no danger of time delay. EE is indicated in limb embolism where the viability of extremity is threatened. Thrombectomy alone has no place in the treatment of artery or bypass graft thrombosis.

[Aneurysm of an anomalous common celiac-mesenteric trunk]. / Aneuryzma anomálního spolecného céliakomezenterického trunku.

The authors describe the successful surgical treatment of a very rare aneurysm of the common coeliacomesenteric trunk in a 68-year-old woman. They mention the symptoms, diagnostic procedure and possibilities of surgical treatment of aneurysms of visceral branches of the abdominal aorta.

[Dysphagia lusoria]. / Dysphagia lusoria.

In a 44-year-old female patient with dysphagia persisting for 30 years it was found that the cause of the complaints was an abnormal insertion of the right subclavian artery (arteria lusoria). After simple severing of the artery without reconstruction dysphagia disappeared, the right upper extremity is not ischaemic and does not handicap the patient. So far symptoms of the steal syndrome did not develop.

[Arterial thrombosis of the upper extremity treated with a combined approach]. / Tepenná trombóza horní koncetiny resená kombinovaným prístupem.

The authors present the case-history of a 49-year-old female patient with arterial thrombosis of the upper extremity with compression of the first rib. The patient was successfully treated by combined continual and pulsed spray thrombolysis with subsequent resection of the first rib.

[Injuries of extremity blood vessels, personal experience and results]. / Poranení koncetinových cév, nase zkusenosti a výsledky.

The authors evaluated the results achieved in 47 patients with injuries of the acral vesels where they performed a total of 50 vascular operations during the five-year period from 1998-2001. 21.3% injuries were part of multiple injuries. The mean period of hospitalization was 14.7 days. The 30-day mortality was 6.4% and the morbidity 12.8%. The upper extremity was saved in all instances (100%), the lower extremity in 77.3% of the injured. The reason for high amputations of the lower extremity were most frequently injuries of the popliteal artery associated with skeletal injury and extensive contusion of the soft tissues of the extremity. The authors discuss the optimal diagnostic and therapeutic procedures in injuries of the acral vessels. They emphasize a multidisciplinary approach without delay with early, frequently during the primary operation indicated fasciotomy, to prevent the development of compartment syndrome. The order of operations in concurrent injuries of the acral skeleton depends on the stage of ischaemia, type of injury and solution of the skeletal fractures. This type of injury frequently calls for repeated redressing in the operation theatre with repeated necrectomies of soft tissues to prevent infection which may prove fatal for the extremity. Injuries of the acral vessels should be nowadays treated in specialized departments with a 24-hour diagnostic and therapeutic traumatological service which comprises a highly specialized team of vascular surgeons.

[Surgical treatment of benign liver tumours--indications and results]. / Wann sollte man benigne Lebertumoren chirurgisch behandeln?*

The authors present their results on the treatment of benign liver tumors. 65 patients were operated upon in the University Hospital in Pil-sen from 2000 until July 2006. Benign liver lesions were rather rare compared to malignant tumours, for which 273 patients were treated within the same period. The most often found benign -lesions were hepatocellular adenoma, focal nodular hyperplasia (FNH) and hemangioma. Sometimes, it was not possible to make a correct diagnosis preoperatively. The surgical procedures used for benign tumours were mostly enucleation and non-anatomic parenchyma-saving resection (55.4 %). Morbidity in this group was 26.5 %, mortality 0 %.

[Manifestation of popliteal aneurysm during pulse spray thrombolysis (PST)]. / Manifestierung eines Poplitealaneurysmas während der Puls-Spray-Thrombolyse (PST).

We report the case of a 32-year-old woman presenting with acute extremity ischemia due to thrombosis of a previously undetected popliteal artery aneurysm. The popliteal artery aneurysm was revealed by PST which was indicated for the treatment of thrombosis of the superficial femoral artery. PST was complicated by a peripheral embolism with subsequent severe extremity ischaemia. Immediate embolectomy and reconstructive vascular surgery led to a successful result. This case illustrates the diagnostic problems of a thrombosed popliteal artery aneurysm and warns of embolic complications during PST.

[Penetrating aortic ulcer with severe gastrointestinal bleeding]. / Penetrierendes atherosklerotisches Ulkus der Aorta mit massiver gastrointestinaler Blutung.

Primary aortointestinal fistula is a rare reason for gastrointestinal bleeding and mainly caused by a communication between the digestive tract and an aortic aneurysm. The penetrating aortic ulcer has been recently recognized as an independent pathological entity. It may penetrate through the aortic wall, leading to fistula into adjacent organs. We report the case of a 78-year-old woman who was admitted to our department with massive gastrointestinal hemorrhage. Endoscopy did not reveal the cause of hemorrhage. The diagnosis was made by computed tomography showing a primary aortoduodenal fistula without aortic aneurysm. The patient was successfully operated on. During urgent operation we found the penetrating atherosclerotic ulcer as the cause of the aortoduodenal communication. Primary aortoenteric fistula has a fatal outcome unless it is diagnosed accurately and urgently treated by surgical intervention. Contrast-enhanced computed tomography is the primary imaging modality to specify the diagnosis.