[Innovated Judet Ribs Plates - Preclinical Study, First Clinical Experience]. / Inovované zeberní dlahy Judetova typu ­ preklinická studie, první klinické zkusenosti.

PURPOSE OF THE STUDY Based on the experience with using the Judet plates in stabilization of rib fractures an innovated Judet plate was constructed in cooperation with the Development Department of Medin company. During the preclinical part of the project, following the construction of the new Judet plate, a surgical technique was elaborated. Subsequently, the clinical application of rib osteosynthesis with innovated plates was commenced. MATERIAL AND METHODS In the course of the last three years the innovated Judet rib plate including the instruments were constructed by the Development Department of Medin company in cooperation with the Trauma Centre and the Department of Surgery of the University Hospital Královské Vinohrady. The goal of the innovation was the changes in technical parameters of rib plates which are compared with the new plates of other companies: 1. Adequate plate stability along the rib axis. 2. Creation of fixation clips for a stable, but not traumatized fixation of the plate around the rib. 3. Decreased robustness of the plate with sufficient stiffness. 4. Working out of a new technique of plate fixation with the use of new instruments. 5. Ensuring plate fixation with cortical locking screws. In the preclinical part of the project osteosynthesis of the broken rib was performed with a plate on a chest model for the basic types of rib fractures. Subsequently, the plate was used for rib osteosynthesis in a cadaver. The goal of the new instruments was besides temporarily maintaining the rib fracture reduction also the subsequent temporary application of plates with the assistance of fixation tongs before the final fixation of plates. In 2017, the clinical part of the project on the stabilisation of flail chest with the innovative Judet plates was launched. This type of innovative Judet plates has so far been used in 3 patients. RESULTS As to the surgical technique of ribs osteosynthesis: The profile of the plate has been adapted to the rib profile and can be further adjusted to rib curvature, also the fixation shoulders of the plates have been reshaped. The innovated plate has been complemented with a new configuration of fixation clips and the possibility to fix the plate with locking screws. The used cortical locking screws enable appropriate stabilisation of plates. They were tested on a laboratory model of ribs and on a cadaver using the new set of instruments. The plates can be easily shaped with tongs. The anchorage of fixation clips is adequately provided for also by means of tongs. The plates can be fixed to the rib without any significant compression of intercostal nerves. The essential change of the innovated Judet plate is its weight, which meets the contemporary trends in construction of rib plates designed for anatomical fixation. The first experience with the innovated plates in flail chest injury confirmed the safety of the procedure for stable osteosynthesis of rib fractures. Adequate stability of the chest wall facilitated an early withdrawal of ventilatory support. Osteosynthesis of rib fractures with innovated plates performed in the first three patient was without complications, including in the postoperative period. DISCUSSION A series of prospective studies prove the correctness of the indications of early rib osteosynthesis in flail chest. Further indications for rib osteosynthesis are postinjury chest deformity, dislocation of rib fracture fragments with a lung injury, and malunion of rib fracture. According to these studies the surgical stabilisation of the chest is a safe and efficient method resulting in pain reduction, decrease of ventilatory support time, and also in reduced morbidity. For rib osteosynthesis anatomical plates, Judet plates and intramedullary plates are used. Our innovation of the Judet plate aimed to improve the technical parameters of the plate. The innovative Judet plate means a significant improvement in technical parameters and stands comparison with the plates of others companies, which are used in the Czech Republic. This is also evidenced by preliminary clinical results. CONCLUSIONS Surgical stabilisation of the flail chest segment is considered to be he method of choice in treating selected patients, leading to the improvement of respiratory function and shortening of the ventilatory support time. The new technical parameters of the plate, including its weight, new fixation clips, locking screws and instruments are the priorities of the innovated Judet plates. The innovation of Judet plates represents an important step towards the extension of indications for surgical stabilisation of the chest. Key words:innovative Judet plates, preclinical study, osteosynthesis of rib fractures.

[Surgical Stabilisation of Flail Chest Injury: Indications, Technique and Results]. / Chirurgická stabilizace u blokové zlomeniny zeber: indikace, technika a výsledky.

PURPOSE OF THE STUDY: Multiple rib fractures with segmental chest wall instability are caused by high-energy chest trauma and are associated with significant morbidity and mortality. Flail chest injuries are mostly combined with lung injury (contusion, rupture, laceration) and subsequent pneumothorax or haemothorax. Early mechanical ventilation with internal pneumatic splinting is a conservative treatment for flail chest in patients with respiratory insufficiency. The surgical stabilisation of a flail chest is an effective method of treatment and is beneficial for selected patients. It shortens the duration of mechanical ventilation and thus reduces morbidity associated with prolonged ventilatory support. In addition, it decreases long-term pain and the inability of a flail chest to heal due to malunion, non-union or progressive collapse of the flail segment. Surgical stabilisation of a flail chest is indicated when the clinical examination shows progressive respiratory dysfunction confirmed by the results of multiple detector computer tomography (MDCT) of the thorax. MATERIAL AND METHODS: Thirty-three consecutive patients who underwent surgical stabilisation of a flail chest at the Trauma Centre between 2010 and 2014 were retrospectively evaluated. This included patient demographics, chest injury extent, results of pre-operative chest imaging (MDCT), surgical stabilisation technique and post-operative outcome. In addition to providing a radiographic finding of respiratory failure, the result of MDCT chest examination was considered an important criterion for surgical intervention. Surgical stabilisation of the chest wall was performed at an interval ranging from 2 hours to 11 days after injury. Intra-thoracic procedures were indicated in patients with lung injury (pulmonary laceration). The surgical procedure was completed by chest tube placement. RESULTS: Surgical stabilisation was carried out using 3 to 8 plates for flail segment fixation involving 3 to 4 ribs. The duration of post- operative mechanical ventilation was 5 days on the average. It was longer in patients with associated injuries such as craniocerebral trauma or severe pulmonary contusion. Tracheostomy was performed in seven patients requiring prolonged mechanical ventilation. Two patients had superficial surgical site infection. No death was recorded in the follow-up period. CONCLUSIONS: Surgical stabilisation of the flail chest segment is considered an effective procedure in selected patients, leading to improvement of respiratory function. By allowing for a shorter period of time on mechanical ventilation, it reduces the occurrence of complications due to ventilatory support. The result of MDCT chest examination in patients with fail chest is an important indication criterion for surgical fixation.

[The role of VATS in the treatment of thoracic empyema]. / Role VATS v lécení empyému hrudníku.

INTRODUCTION: Videothoracoscopy (VTS) and video-assisted thoracoscopic (VATS) decortication is commonly used in the treatment of early thoracic empyema. However, its conversion to thoracotomy is more frequent in chronic empyema cases. The authors evaluate the role of VTS/VATS in the pleural empyema therapy in the group of patients treated for thoracic empyema using VATS or thoracotomic decortication. PATIENTS, METHOD AND RESULTS: The retrospective study included 165 patients who underwent surgery for thoracic empyema. Pneumonia was the the commonest cause of pleural empyema (77%), while elective lung and esophageal surgery resulted in pleural empyema in 11% of the subjects, trauma in 9% and intraabdominal infection in 3% of the subjects. The subjects were diagnosed with thoracic empyema stage II or III either prior to the procedure on CT examination, or during the procedure. VTS/VATS was indicated in 52 subjects, and conversion to open decortication was required in 23 of them. Open thoracotomic decortication was performed in 113 subjects. VTS/VATS was successful in stage II disorders, in particular in the removal of pus and fibrin, with targeted chest drain insertion. VATS decortication was performed in 15 subjects with stage II or early stage III disorders. In open decortications, the procedure was extended to lung resection (8x lobectomy and 10x wedge non-anatomical resection) for residual abscess pneumonia or lung abscess. Conservatively managed postoperative complications included protracted chest drain air leak (11 patients) and fluidothorax relapses which were treated with redrainage (8 patients). Early postoperative rethoracotomy was indicated in 6 patients for hemothorax, resulting from hemocoagulation disorder in septic conditions. 4 patients were indicated for rethoracotomy for empyema relapses. During the postoperative period, 6 patients exited in the open decortication group. CONCLUSION: VTS is the method of choice in the treatment of stage II thoracic empyema, with a potential for the infectious focus removal, targeted drainage and lung reexpansion. VATS is an alternative thoracotomy method for decortication in the early stage III empyema. Decortication via thoracotomy is a standard treatment method for the management of chronic empyema.

[Penetrating thoracic and abdominal injuries: diagnostic and therapeutic approach]. / Penetrující poranení hrudníku a bricha: diagnostický a lécebný postup.

INTRODUCTION: Penetrating thoracic or abdominal or combined injuries are associated with high risk of life-threatening intraabdominal or intrathoracic organ injury. Most patients require acute surgery. When miniinvasive technique is available, thoracoscopic or laparoscopic intervention is indicated in hemodynamically stable patients to evaluate severity of the injury, as well as to treat the condition. AIM OF THE STUDY: Retrospective analysis of incidence, diagnostics and treatment of penetrating thoracic and abdominal injuries and combined thoracoabdominal injuries in a Trauma centre. PATIENTS, METHODS AND RESULTS: A total of 195 patients with penetrating thoracic, abdominal or combined injuries, who were hospitalized in the FNKV (Krilovské Vinohrady Faculty Hospital) Trauma centre in Prague from 1999 to 2010, were included in the study. The study group included 177 (91%) males. Out of the total, 102 patients (53%) suffered from penetrating abdominal injuries, 71 (36%) from thoracic injuries and 22 (11%) from combined, thoracoabdominal injuries. The majority of injuries were stab injuries (173, i.e. 89% of the patients). 22 subjects, the penetrating injury was caused by shot injuries. In stable patients, MDCT has been lately used to establish the diagnosis. In 171 subjects, acute thoracotomy or thoracotomy was indicated. Patients with combined injuries of the both cavities were indicated either for thoracotomy and laparotomy or thoracophrenolaparotomy. Videothoracoscopy or laparoskopy was conducted in 21 (11%) of the subjects. During the surgical revision, two subjects exited due to ireversible hemorrhagic shock, further 2 subjects died because of septic complications following shot abdominal injuries. CONCLUSION: Incidence of penetrating thoracic, abdominal or combined thoracoabdominal injuries is fairly rare in our country. Subjects with unstable hemodynamic conditions are indicated for acute thoracotomy or laparotomy. Miniinvasive procedures have diagnostic and therapeutic benefit in stable patients. Diagnostic thoracoscopy and laparocopy provides evidence of some injuries (diaphragm, alimentary tract). Therapeutically, miniinvasive methods may be used to manage the source of bleeding and for targeted drainage. Nonsurgical procedure is the method of choice in a selected group of hemodynamically stable patients with stab injuries, with monitoring of the patient's condition, including the use of x-ray imaging.

[A combination of dexmedetomidine with ketamine and opioids results in significant inhibition of hemodynamic changes associated with laparoscopic cholecystectomy and in prolongation of postoperative analgesia]. / Kombinace dexmedetomidinu s ketaminem a opioidy významne potlacuje hemodynamické zmeny zpusobené laparoskopickou cholecystektomií a prodluzuje trváiní pooperacní analgezie.

THE AIM OF THE STUDY: Recently, alpha2 sympathoadrenergic drugs are used in premedication to improve the perioperative course. The aim of our study was to compare a premedication with a new alpha2 sympathoadrenergic drug and standard premedication. METHODS: After ethic committee approval and written patient consent, in a randomised, double-blinded study, combination of dexmedetomidine 1.0 microg x kg(-1) + ketamine 0.5 mg x kg(-1) + fentanyl 1.0 microg x kg(-1) + atropine 0.5 mg (group FNT), dexmedetomidine 1.0 microg x kg(-1) + ketamine 0.5 mg x kg(-1) + alfentanil 5.0 microg x kg(-1) + atropine 0.5 mg (group ALFNT), or pethidine 1.0 mg x kg(-1) + atropine 0.5 mg (group Dolsin) was administered to a deltoid muscle 15 min. before anaesthesia (GA) in patients elicited for laparoscopic cholecystectomy (LCHE). GA was performed in a standard way, ECG, NIBP, respiration rate, SpO2, onset of effect, Observers Assessment of Alertness Sedation Score (OAASS) before GA, circulatory reaction to intubation and capnoperitoneum, fentanyl consumption during GA, time to the first request for post-operative analgesia and postoperative nausea and vomiting were measured. The data were processed by Kruskal-Wallis and Fisher tests. P-value < 0.05 was considered significant. RESULTS: There were 16 patients in FNT and Dolsin and 15 patients in ALFNT with no differences in demography except for younger age in ALFNT. The main differences were in hypertension during capnoperitoneum: 0/16 FNT and 1/15 ALFNT vs. 11/16 Dolsin, both p < 0.001, per-operative fentanyl consumption: FNT 31.5 microg vs. Dolsin 165.0 microg, p < 0.001 and ALFNT 50.0 microg, p < 0.05 (ALFNT vs. Dolsin, p < 0.01) and request to the first analgesic post surgery: FNT 1.3 h. vs. Dolsin 0.45 h., p < 0.05 vs. ALFNT 0.8 h., p < 0.01. There were no differences in side effects except for bradycardia in ALFNT (p < 0.05). CONCLUSIONS: Dexmedetomidine-ketamine-fentanyl-atropine combination is superior to pethidine-atropine combination in suppressing of adverse hemodynamic effects of capnoperitoneum, decreased need for analgesia during GA and prolonged postoperative analgesia.

[Leiomyoma of the abdomen wall. Case report]. / Leiomyom piední steny birisní.

Authors present the case report of the patient indicated to plastic of abdomen wall for large hernia. Per operation, tumor was found without communication with abdomen cavity and organs. Histopathologically, leiomyoma of the abdomen wall was identified.

[Contemporary approach to treatment of the posttraumatic empyema of the thorax]. / Soucasné moznosti lécení poúrazového empyému hrudníku.

INTRODUCTION: Empyema of the thorax is a serious morbidity and mortality causative factor in the postoperative period in severe blunt and penetrating thoracic injuries. The posttraumatic empyema of the thorax results, primarily, from secondary infections of the haemothorax. Current therapeutic management of the posttraumatic empyema of the thorax depends on the disease stage. AIM: A retrospektive analysis of the treatment procedures in patients with posttraumatic empyemas of the thorax. MATERIAL, METHODS, RESULTS: A study group included 118 patients with empyemas of the thorax, who were operated during the period from 1996 - June 2005. The commonest type of the empyema was a parapneumonic empyema, present in 86 (73%) subjects. 15 (13%) patients were operated for posttraumatic empyemas of the thorax. In 13 (11%) patients the empyema followed elective intrathoracic procedures (lung or oesophagus resection). In 4 (3%) cases the empyema resulted from intraabdominal inflammatory disorders. The cause of the posttraumatic empyema of the thorax was a secondary infection following repetitive drainages for the pneumothorax in three patients, infection of the retinated haemothorax in two patients and infection of the pleural exudate from a subphrenic absces following a stab injury of the abdomen in one patient. Another patient developed empyema as a complication of the oesophagus perforation by a foreign body. 8 injured patients with ventilation pneumonias developed parapneumonic empyemas. The patients were indicated for surgeries. Videothoracoscopic procedures (VTS, VATS) proved successful in 4 injured patients with empyemas, stage II. Thoracotomy with decortication was conducted in the remaining 11 injured patients (in 3 of them as a VTS conversion). The postoperative course following the decortication in the injured group with the posttraumatic empyema was complicated by a protracted air leak with a partial pneumothorax in two subjects and by a relaps of the pleural exudate in one operated subject. CONCLUSION: 1. Open thoracotomy with empyemectomy and decortication is a standard treatment method in the thoracic empyema, grade III. 2. The videothoracoscopic procedures (VTS, VATS) are indicated in early forms of the grade II of the disorder. 3. The quality and the result of the therapy depend on the following: the management of the focus of the infection, as well as a sufficient lung expansion while the residual pleural cavity is being minimized and also the management of the air leak from the lung.

[Surgical management of varicose ulcers]. / Chirurgická léba zilních bércových viedu.

One of the most often diseases of the European population is the venous chronic leg ulcer. It requires a long-term and expensive therapy. Basic elements of the therapy are elastic banding of the leg, diuretics, antibiotics and local treatment. In some cases a profit can be acquired from surgical procedure, which includes the stripping and/or crossectomy of the saphenous vein or the subfascial ligation of insufficient perforators and skin grafting (two phases operation). This procedure shorts the time of therapy and prevents the ulcer recurrence, because it resolves the reason and the results of the disease. We present 22 patients treated by this cure during the last 3 years at our surgery department of the 3rd faculty of medicine Charles University in Prague. 21 patients (95.5%) are healed.