Our experience with transanal total mesorectal excision (TaTME) procedures in middle and distal rectal tumors.

INTRODUCTION: Transanal total mesorectal excision (TaTME) is a relatively new approach in surgical treatment of rectal cancer. There are no clear indications when to choose this strategy. It is a technically demanding procedure for the surgeon with a long learning curve, which should also be taken into account in evaluation of this method. The results of both oncological and postoperative complications must be properly evaluated to explore the benefit of TaTME. The aim of this study is to assess the potential benefit of TaTME compared to other alternatives in middle and distal rectal tumors. METHODS: Retrospective evaluation of patients undergoing TaTME procedure performed by one team of surgeons between October 2014 and June 2019. The authors analyzed demographic indicators of the group of patients, tumor characteristics, specimen quality, early postoperative complications and the possibility of stoma reversal. RESULTS: A total of 93 patients underwent TaTME procedure for middle and distal rectal cancer. Mean BMI was 27.6 (4.8). T3 or T4 tumor was found in 73 (78.5%) patients, 68 (73.1%) patients had positive lymph nodes and 12 (12.9%) patients were treated for synchronous metastatic rectal cancer. Neoadjuvant therapy was used in 80 (86%) patients. Conversion to open laparotomy was necessary in one case (1%). Stapled anastomosis was performed in 37 (39.7%) cases, handsewn in 56 (60.2%). A positive circumferential resection margin (CRM) was found in 10 (10.7%) cases. Distal resection margin (DRM) was positive in 3 (3.2%) patients. Pathological analysis showed a complete mesorectum in 18 patients (19.4%), nearly complete in 39 (41.9%) and an incomplete mesorectum in 36 (38.7%). Complications in the first 30 days after primary surgery were observed in 38 (40.8%) patients, mainly for anastomotic leak (19 patients, 20.4%). Reoperation was required in 7 (7.5%) patients. Permanent colostomy had to be performed in 4 (4.3%) cases. No patient died after surgery. CONCLUSION: In a selected group of patients it is possible to perform resection using this approach with acceptable postoperative morbidity and quality of the specimen. We used TaTME procedure in patients expected to have difficult TME due to obesity, size and distal localization of tumor. The incidence of conversion to open surgery was very low. Further studies for long term oncological outcomes are needed.

Use of preperitoneal wound catheter for continuous local anaesthesia after laparoscopic colorectal surgery.

INTRODUCTION: The main cause of postoperative pain after abdominal surgery is the wound where laparotomy is made. Recently, laparoscopic procedures have become common in colorectal surgery. Although improving the tolerance of the surgery, postoperative pain management still remains a discussed problem. The use of an epidural catheter used to be generally recommended in the open surgery era; however, an ideal strategy for postoperative analgesic therapy after laparoscopy remains unclear. Reduced administration of opioid analgesic drugs after colorectal resection is a generally accepted goal. Preperitoneal catheter insertion for continuous local anaesthetic (LA) infusion in the wound after surgery is a simple alternative to other pain management methods. METHODS: Retrospective analysis of analgotherapy outcomes in patients undergoing laparoscopic colorectal resection procedures, divided in three patient groups according to the type of analgesia: Group 1: use of a catheter for local wound infusion (KAT) n=73; group 2: epidural analgesia (EPI) n=23; and control group 3 with combined parenteral and subcutaneous analgesia (CON) n=66. The main objective of this study was to analyse postoperative pain and the consumption of opioid analgesics in the first three days from the surgery and the incidence of any complications related to the analgesic therapy. RESULTS: Opioid consumption in KAT and EPI groups was significantly lower compared to CON in the first 72 hours from the surgery. The lowest postoperative pain was measured in the EPI group. Subjective perception of pain, measured using VAS, was not significantly different between the KAT and CON groups. In KAT patients, vomiting was statistically less frequent than in CON patients. There was no significantly different incidence of paralytic ileus in the KAT and CON groups and no paralytic ileus was observed in the EPI group. There was no increased incidence of SSI (surgical site infections) in the KAT group compared to the other groups. CONCLUSION: The use of the catheter was assessed as safe. Insertion and management of the catheter is unsophisticated, and we did not observe any complications in terms of application of the catheter or toxic side effects of the LA. The use of the catheter clearly reduced opioid administration in the postoperative period compared to the control group (CON) with combined parenteral and subcutaneous analgesics. The best pain control measured using the visual analog scale (VAS) was observed in the EPI group.

The timing of ERCP in acute biliary pancreatitis.

Despite several studies, the role and timing of endoscopic retrograde cholangiopancreatography (ERCP) in the case of acute biliary pancreatitis (ABP) remains a subject of discussion.There is a clear indication of early ERCP within 72 hours in patients with ABP andcholedochal obstruction, moreover the ERCP within 24 hours in cases of cholangitis. However, the role of ERCP in patients with ABP without symptoms of cholangitis or concrements obstructing the bile duct is controversial. If ABP is indicated for the ERCP, the earlier the ERCP is performed the less complications it is associated with. The decision to perform ERCP is often based on findings from a biochemical and transabdominal ultrasound examination. The results of these examinations may, but may not, confirm the presence of stones in the choledochus. An effective and safe method approaching the sensitivity of ERCP in the diagnosis of concrements in the choledochus is endoscopic ultrasonography (EUS) and magnetic resonance cho-langiopancreatography (MRCP). The cholecystectomy should be performed to prevent a recurrence of pancreatitis and biliary problems after the successfully treatment of ABP. Key words: acute biliary pancreatitis choledocholithiasis cholangitis endoscopic retrograde cholangiopancreatography.

Acute hiatal hernias.

INTRODUCTION: In surgical practice, hiatal hernias are often related to gastro esophageal reflux disease treatment in which continuous proton pump inhibitor administration is very successful. In large hiatal hernias, life threatening complications may occur. However, planned surgical repair of hiatal hernias is associated with very good functional outcomes with a low risk of postoperative complications. The incidence of large hiatal hernias grows with increasing age of the patient. In geriatric patients, internal comorbidities are also more frequent, including serious conditions. In these patients, one may hesitate whether to perform surgery with regard to the possible risk of postoperative complications. Conservative treatment of hiatal hernias is associated with a higher risk of stomach volvulus or severe bleeding as the most frequent complications. METHODS: We performed a retrospective study of patients operated on for a large hiatal hernia at the Department of Surgery, University Hospital Brno, between 2010 and 2016 (86 months). The patients were divided into 2 groups depending on the type of operation: acute (A) and elective (B). We evaluated demographic data, the nature of preoperative symptoms, type of surgery and postoperative complications. RESULTS: 120 patients were operated on for large hiatal hernia in this period of time. Group A involved 22 operated patients, group B 98 patients. There was a significantly higher number of laparotomies in the acute patient group compared to the elective group B (72.7 % vs. 23.5%, p.

[Necrotizing fasciitis--a rare complication of laparoscopic appendectomy]. / Nekrotizující fasciitida, vzácná komplikace laparoskopické apendektomie.

Necrotizing fasciitis is a bacterial infectious disorder affecting the fascia and the dermis, however sparing the muscle layer. Initial, difficult to detect, fast-progressing subcutaneous spread with rapid progression to shock, conduces to the high mortality rates of the disorder. In risk patient groups, such as in diabetes patients, immunocompromized patients or the elderly, the mortality rate even exceeds 80%. The majority of infections is caused by common skin, rectal or urethral bacteria. The commonest paths of entry into the body include minor skin lesions, including surgical wounds. Fever, pain, skin redness and edema, crepitus and, later even skin necrosis mimicking grade III burns, are the symptoms suggestive of necrotizing fasciitis. Among depicting methods, CT examination is irreplacable. Only early and sufficiently radical surgical management with adjunctive antibiotic therapy may result in successful outcomes. The authors present a rare case of necrotizing fasciitis, which developed as a complication of laparoscopic appendectomy in a young healthy subject. Considering the rarity of the complication, a summary of available medical literature data related to the problematics is included in this presentation.

Gastrointestinal Stromal Tumours of the Rectum - Evaluating the National Registry Data with Respect to its Use in Clinical Practice.

BACKGROUND: Gastrointestinal stromal tumours (GIST) are rare malignant mesenchymal tumours with an incidence of 1 in 100,000. They represent only 5% of gastrointestinal tumours. The GISTs are mainly located in the stomach (60-70%) and in the rectum in < 5% of cases. In the case of localized, resectable tumours, the treatment is surgical resection. Depending on the size and localization of the tumour in the rectum, either a local excision, rectal resection with anastomosis, or abdominoperitoneal amputation with permanent stoma can be performed. In contrast to carcinomas, the metastasis of GISTs into lymph nodes is rare; therefore, from an oncological point of view, lymphadenectomy in the form of mesorectal excision is not required. Neoadjuvant treatment using tyrosine-kinase inhibitors (TKI) is recommended for tumours larger than 5 cm and in case of tumours infiltrating surrounding organs or sphincters in order to achieve complete resectability, less mutilating and continent procedure. In GISTs with a positive resection line, re-resection can be attempted. Adjuvant TKI therapy can be considered in cases of CD117 positivity and after resections of GISTs with medium and high-risk malignant behaviour. The TKI treatment is also indicated in cases of unresectable and metastatic GISTs. METHODS: Data obtained from the GIST registry by the 1st January 2017, when 10 centres in the Czech Republic were contributing to the registry, were analysed. RESULTS: We analysed 1,095 patients out of which 45 (4.1%) had GIST localized in the rectum. The average age of the patients was 60 years. There were significantly more males (68.9%; p = 0.0007) and symptomatic patients (62.2%; p = 0.034). In total, 82% of the patients underwent surgery. Local excision was performed in 37.8%, resection of the rectum with anastomosis in 29.7%, and Miles operation in 29.7%. In the cohort, most tumours were 2-5 cm in size and almost half of the tumours presented a high risk of malignant behaviour. Systemic treatment was reported in 73% of patients. A complete remission was achieved in 80% of patients with GIST of the rectum. The median survival rate was 11.3 years and the 5-year survival rate is 90.6%. CONCLUSION: Despite the success of TKI treatment, the only potentially curative method of rectal GISTs is a surgical R0 resection. Given the relatively rare frequency of these tumours, proper diagnosis and treatment is demanding. Therefore, these patients should be preferably treated in specialised centres. This work was supported by grant MH CZ - RVO (FNBr, 65269705).  The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers. Submitted: 19. 12. 2018 Accepted: 2. 2. 2019.

[Outcomes of pancreatic resections in the elderly and geriatric patients]. / Výsledky resekcní lécby pankreatu u starsích a geriatrických pacientu.

As a result of the population aging, we are confronted with the problematics of geriatric patients more and more frequently. The aim of this retrospective study was to compare outcomes of pancreatic resections in patients of three different age groups. During 2000-2007, 150 pancreatic resections were performed in our clinic, including 34 (22.7%) patients aged 65 and over at the time of the procedure and 5 (3.3%) patients over 75 y.o.a. The procedures were heterogenous, including indications for oncologic diagnoses, as well as for chronic pancreatitis. Our assessment demonstrated no significant differences in the 30-day postoperative mortality between the group of subjects over 65 y.o.a, geriatric group (i.e. over 75 y.o.a) and the group of subjects below 54 y.o.a. (8.8% vs. 0% vs. 5.2%). Furthermore, the postoperative morbidity showed no statistically significant differences between the all three groups (30.2% vs. 29.4% vs. 20%). The commonest postoperative complications included secondary healing of the surgical wound (7.8%) and pancreatic fistules (6.9%) in the group of subjects below 65 y.o.a., and insufficiency of the pancreatic-jejunal anastomosis (5.8%) and hepatic- jejunal anastomosis (5.88%) in the group aged 65 and over. Pancreatic-jejunal anastomosis insufficiency, complicated by consecutive bleeding, contributed to postoperative mortality most significantly. Significant increase in postoperative complication rates connected to proximal pancreatoduodenectomies and total pancreatoduodenectomies, was recorded in patients over 65, compared to those in the young patient group (p = 0.014). No statistically significant relation was found between a particular comorbidity and onset of postoperative complications or deaths in patients over 65 or geriatric patients. Based on the results, the authors do not consider the patient's age a contraindication for pancreatic resection procedures. Radical resections can be performed with acceptable mortality and morbidity rates in geriatric patients.

Comparison of cervical anastomotic leak and stenosis after oesophagectomy for carcinoma according to the interval of the stomach ischaemic conditioning.

Background Stomach preparation by ischaemic conditioning prior to oesophageal resection represents a potential method of reducing the risk of anastomotic complications. This study compares the results of the anastomotic complications of cervical anastomosis after oesophagectomy with a short interval after ischaemic conditioning (group S) and a long interval (group L). Methods Subjects undergoing oesophagectomy for carcinoma after ischaemic conditioning were divided into two groups. Group S had a median interval between ischaemic conditioning and resection of 20 days, while for group L the median interval was 49 days. Anastomotic leak and anastomotic stenosis in relation to the interval between ischaemic conditioning and actual resection were followed. Results After ischaemic conditioning, 33 subjects in total underwent surgery for carcinoma; 19 subjects in group S and 14 subjects in group L. Anastomotic leak incidence was comparable in both groups. Anastomotic stenosis occurred in 21% of cases in group S and 7% of cases in group L (not statistically significant). Conclusions A long interval between ischaemic conditioning and oesophagectomy does not adversely affect the postoperative complications. A lower incidence of anastomosis stenoses was found in subjects with a longer interval, however, given the size of our sample, the statistical significance was not demonstrated. Both groups seem comparable in surgical procedure course and postoperative complications.