[Development of structures of intestinal anastomosis and the actual state of their options]. / Vývoj konstrukcí strevních anastomóz a soucasný stav jejich mozností.

Colonic anastomosis is believed to be mostly performed in abdominal surgery. Since the 19th century has the enteric anastomosis technique process undergone through major changes as far as sewing materials, devices and the way of bowel reconnection are concerned. Anastomotic dehiscence risk is in some way a motor of constant technical and technological of artificial bowel connection improvement - both in elective and acute operations. In this review authors look back at the above mentioned techniques development of bowel connection and reparation regarding of oncoming experiments focused on ways of bowel anastomosis quality improvement.

[Optimizing the treatment procedure in crural ulcers - a pilot study of the surgical method]. / Optimalizace lécebného postupu u kozního trofického defektu bérce pilotní studie chirurgické metody.

INTRODUCTION: Current medical knowledge has provided us with a wide range of possibilities of treating chronic wounds. Over the recent decades, in particular, significant progress has been made in this field. The authors present an overview of current knowledge of chronic wound healing, pointing out the surgeons role in the process of chronic wound management. Using surgical therapy, we are able to heal a chronic wound in a shorter period of time, particularly if the treatment is accelerated by the application of platelet-rich plasma (PRP) as a source of growth factors. METHODS: The pilot randomized prospective study included four patients with chronic wounds of the lower leg after previous failure of conservative therapy who were indicated for skin transplantation. Following previous vacuum-assisted closure therapy, the patients undergoing skin transplantation were prospectively randomized into two groups. Autologous PRP was used in one of the groups and standard skin transplantation without PRP was performed in the other one. RESULTS: In the PRP group, 99% of the wound areas were healed on the 15th day after the operation. In the other group, 90% of the areas were healed on the 15th day following the operation. In the PRP group, complete healing of the defect occurred in both patients at 15 and 20 days post-surgery. In the second group, one patient completely healed within 28 days; the other one was not fully healed even at 3 months post-surgery. CONCLUSIONS: Most patient groups at great risk may benefit from the method using PRP, as well as patients with chronic wounds who have failed conventional methods available for both general and local therapy. This fact has been confirmed by the authors initial experience presented.Key words: platelet-rich plasma (PRP) - platelets wound healing chronic wound.

[Personalised antibiotic therapy in a surgical intensive care unit overview of current knowledge and the results of an observational kinetic study]. / Personalizovaná antibiotická terapie na chirurgické jednotce intenzivní péce prehled soucasných znalostí a výsledky observacní kinetické studie.

INTRODUCTION: The current efforts of intensivists focused on individual antibiotic treatment in patients suffering from sepsis has inspired us to conduct an open prospective clinical study to assess the relationship between body fluid retention (>10 L/24 hours) and the efficiency of hydrophilic time-dependent antibiotics used in critically ill patients. Polytrauma and abdominal catastrophes are the most frequent causes of systemic inflammatory response syndrome (SIRS). Consequent body liquid retention is taken for a pathophysiological covariate modifying the pharmacokinetics (PK) and pharmacodynamics (PD) of hydrophilic time-dependent antibiotics (betalactams and carbapenems). Not only body fluid retention but also changes in renal clearance are thought to be responsible for failure in PK/PD target attainment necessary for effective antimicrobial activity. To describe the importance of the pathophysiological covariates for the individual kinetic variables of a representative antibiotic (piperacillin) is the primary goal of this kinetic observational study. MATERIAL AND METHODS: Three patients with polytrauma and SIRS admitted at the ICU of the Surgical Department, Teaching Hospital Hradec Králové, whose condition was characterized by cumulative body fluid retention (>10 L), were eligible for enrolment. As per standard hospital protocol, the patients were administered with 4 g of piperacillin in combination with tazobactam 0.5 g intravenously by 1-hour (h) infusion every 8 h. A series of blood samples were taken 1, 2.5, and 5 h after the termination of the infusion. Urine was collected over each dosing interval and for 24 h. Piperacillin was detected using a previously validated HPLC method. Individual pharmacokinetic variables were estimated using non-compartmental pharmacokinetic analysis. Cumulative body fluid retention was calculated as the difference between fluid intake and output. Creatinine clearance (Cl) was used for renal function evaluation. PK/PD target attainment was analysed according to Carlier (2013). RESULTS: In three patients with polytrauma and SIRS, great interindividual and intraindividual differences in extravascular volume expansion, i.e. cumulative body fluid retention 2030 L and changes in renal function, were recorded. In 2/3 patients these pathophysiological changes as well as the clinical interventions administered resulted in augmented piperacillin clearance and an increase in distribution volume (Vd) (>20 L) with a maximum at Day 28 after initiation of therapy. In such patients treated with a standard dose of piperacillin, only minimum PK/PD target attainment (50% Ft >MIC) was obtained. In contrast, a patient suffering from renal dysfunction attained both minimum (50% ft >MIC) and maximum PK/PD target (100% ft >MIC). CONCLUSIONS: In three critically ill patients with polytrauma and SIRS, pathophysiological changes (covariates) had a profound effect on the key determinants of the pharmacokinetics (Cl and Vd), resulting in significant intraindividual variability in pharmacodynamic /pharmacokinetic target attainment necessary for therapeutic time-dependent antibacterial activity of piperacillin. Consequently, patients with augmented clearance of piperacillin may be at risk for treatment failure, and/or bacterial resistance without dose up-titration. A subsequent clinical study will be conducted to describe personalised kinetically guided antibiotic therapy.

[Abdominal compartment syndrome - review of current knowledge, diagnosis and management]. / Syndrom brisního kompartmentu - prehled soucasných znalostí, diagnostiky a resení.

This overview of the historical development in the definition of terms intra-abdominal hypertension and abdominal compartment syndrome focuses on the wide range of compartment syndromes and presents the issue of surgical or conservative management in the care for patients affected by the above-mentioned pathological abdominal conditions.

[Abdominal catastrophe--abdominal wall defect associated with gastrointestinal fistula--strategy of therapy]. / Abdominální katastrofa--defekt steny brisní komplikovaný strevní pístelí--strategie lécby.

BACKGROUND: Wound dehiscence complicated by gastrointestinal (GI) fistula to belong ,,abdominal catastrophe". Therapy is prolonged and connected with high morbidity and mortality rate. METHODS: In the period from October 2006 to July 2009 we performed 12 reconstructive surgical procedures on gastrointestinal tract in patients with abdominal catastrophe. Treatment of 12 consecutive patients (9 men, 3 women) was managed according to a standardize protocol. The protocol consists of treatment of septic complications, optimisation of nutritional state, special wound procedures, diagnosis of gastrointestinal fistulas and GI tract, timing of surgical procedures, reconstruction of GI tract and postoperative care. RESULTS: Reconstructive surgery of GI tract was successful on 11 patients. One patient developed recurrence of early GI fistula. In four patients we let open abdomen to heal per secundam. We observed no deaths after operation. CONCLUSION: With regard to complex character of therapy of abdominal catastrophe there is a need of multidisciplinary approach. Considering long-lasting and expensive therapy there is logical step to concentrate these patients into special centres which are experienced, equipped and their staff is trained in treatment of such a seriously impaired patients.

[The operation risks and the force of preoperative management]. / Operacní rizika a význam predoperacní péce.

The aim of this article is to summarize the current actual knowledge in possibilities of examination of patients' condition before surgery with respect to development of present operation risks and of a recovery phase in increased patients' co-morbidity and age. Not only a profile of our patients has changed partially as was mentioned above, but also the new diagnostics methods, non-invasive and miniinvasive techniques have appeared, too. Also the new methods of preparation of surgical patients for surgery are arising during the last few years. They answer the previously presented points witch are established on an increased interest in the patients during the perioperative time period (ERAS-enhanced recovery after surgery/fast track). New methods appreciated an operation trauma, which has a substantial influence on the result of an operation. The most frequent risks of an operation must be presented: anaesthetic, respiratory, cardial, nutritive, thromboembolic, and other specific risks subjecting to an individual case. A knowledge of patients' functional reserve is to be necessary and all these facts must not be underestimated in preparation of an operation type, mainly in wider reconstructions of gastrointestinal tract, at severe traumatic conditions, in vascular surgery, neurosurgery, cardiosurgery, urology and pediatric surgery.

[Peroperative diagnostics of acute bowel ischemia using ultraviolet light and fluorescein dye]. / Peroperacní diagnostika ischemie streva za pouzití fluoresceinu a ultrafialového svetla.

Acute bowel ischemia continues to have a high mortality rate. The main factor related to this poor outcome is considered to be the delay in diagnosis. The ability to detect ischemia early and to assess the extent of bowel involvement, are the most important aspects of successful treatment. The combination of ultraviolet (UV) light and fluorescein dye would be considered a simple, reliable and technically easy procedure for diagnosis of intestinal ischemia. The method can be used both for laparotomy when the source of UV light is a Wood's lamp as well for laparoscopy when the optical filters are placed to the light source of laparoscopic set to produce UV light. Present clinical experience shows that the method is precise, objective and accessible and that it gives a greater amount of independence to the surgeon allowing him to make the diagnosis of intestinal ischemia without having to rely on the assistance of other specialists.

Post-operative intraperitoneal adhesion prevention--the recent knowledge.

This article deals with the current knowledge on the possibilities of intraperitoneal adhesion prophylaxis in correlation with intraperitoneal interventions in abdominal surgery. The up-to-date experimental possibilities and other known methods are presented. These include: Intraperitoneal perfusion by certain special simple solutions--Dextran, Carboxymethycellulose, Crystalloid solutions, and Hyaluronidase. Intraperitoneal or other administration of certain drugs--Tetracyclines, Cephalosporins, Corticosteroids, Non-Steroidal Anti-inflammatory drugs, Histamine agonists, Ca-channel blockers, Heparin, Citrates and Oxalates, Streptokinase, Urokinase, Plasminogen activators, and application of special synthetic or natural materials intraperitoneally--Surgicel, Interceed, Gore-Tex, Fibrin Glue, or various combinations of the above mentioned. Rats, rabbits, and mousses were used, first of all, as an animal model in presented experiments.

[Preparation of patients for operation with per-oral intake on the day of the planned surgery]. / Príprava k operaci s perorálním príjmem v den plánovane operace.

INTRODUCTION: The clinical studies carried out leads to the hypothesis that the starvation of patients for several hours prior to a surgical procedure has a negative influence on the internal metabolic environment of a patient. It also has an impact on the psychosomatic disposition of the patient's physiology of metabolic processes and the proper functioning of vital organs and systems. This hypothesis was already stated by doctors specialized in Intensive Care Units in other European countries. In the frame of methodology, ERAS (enhancement recovery after surgery) also known as fast track, solves this problem not only on the level of clinical studies but also clinical practice. METHODOLOGY AND GROUP OF PATIENTS: The group of patients selected had been surgically treated for disease of the colon (both benign and malignant) and were divided into 3 groups: A--basically starving from mid-night of the day of operation, B--patients secured the night before the operation and on the day of the operation by a parenteral intake of 10% glucose solution with minerals, C--patients drinking a special drink, consisting basically of sugars (mainly maltodextrin) mixed in with minerals, the evening before the operation and on the day of the operation. Patients used in this study were required to fulfill several criteria to be included into the study: these criteria consisted of a co-morbidity of ASA 1-2, weight 60-90 kg, age 35-75 years, operating time of the procedure on the colon of 120 +/- 30 min. without complications. These patients also had not been given any transfusions of red blood cells or blood derivatives during or after the surgery (or during the time of hospitalization etc). The selected biochemical markers, muscular power, some cardial function, and subjective patients feelings were monitored in all patients during perioperative period. The basic statistical methods were used for evaluation of current results. RESULTS: The monitored parameters of the internal environment showed that the dynamics of the basic minerals had been roughly the same. The same scenario was found with serous concentrations of glucose, CRP, and albumin. In the group of patients given the sugar solution, there was a relative decrease in the serous concentration of insulin post-operatively (which is related to a lower insulin resistance) and serous concentration of myoglobin and creatin kinase. At the start of anesthesia, patient's stomachs contained the lowest volume of residual liquid with a low pH in the group that was drinking the fluid on the day of the operation. The results of the measurements of muscular power (force) and echocardiograph have not been elaborated in detail so far. Unpleasant feelings in patients on the day of the operation like thirst, hunger, nervousness, fear, etc. were mainly reduced in the group of drinking patients. CONCLUSION: Till date the findings documented by monitored indicators may prove that the implementation of per-oral intake on the day of an surgery will benefit and improve the quality of care of surgically treated patients and increase the number of successful operations.

Gastric banding: intraoperative and early postoperative complications and their prevention.

BACKGROUND: Intraoperative and early postoperative complications in patients operated for morbid obesity were assessed. METHODS: 114 morbidly obese patients underwnent gastric banding (non-adjustable or adjustable). The influence of body mass index (BMI), age and preoperative morbidity on the occurrence of postoperative ventilatory disturbances was evaluated. RESULTS: Risk of postoperative ventilatory disorders increased with preoperative cardiovascular disease (p < 0.01), diabetes (p < 0.05), and increasing BMI (p < 0.01). Age, hypertension and pulmonary disease did not influence significantly the risk of complication in this series. There have been no deaths. CONCLUSION: In patients undergoing banding for morbid obesity, the potential for ventilatory complications increases with higher BMI, diabetes and cardiovascular disease in the preoperative comorbidities. Principles for postoperative care were developed.

Pathomorphological changes in microcirculation of pancreas during experimental acute pancreatitis.

BACKGROUND/AIMS: Severe acute pancreatitis is prevalent in Eastern Bohemia (a part of the Czech Republic) and remains a very difficult problem to manage. Recent studies in treatment there are quite frequent but a direct view into the pancreas during its inflammatory process is very rare. Only information about a normal pancreatic microvascular bed appears to be available. This study was designed to explore pathomorphological changes in pancreatic microcirculation at the start and during the development of acute pancreatitis. METHODOLOGY: A group of 50 laboratory white rats was studied. The acute pancreatitis was induced by the modified method of Siech et al. The method of clamping of biliopancreatic duct and stimulation of external secretory tissue by a cholecystokinin and secretin and oral (orogastric tube) ethanol administration was performed. The pancreatic microvascular patterns were observed by using histochemical and corrosion casts methods. RESULTS: The study of the corrosion casts of pancreatic microcirculation in the scanning electron microscope and histochemical studies demonstrated the visible reduction of the pancreatic microvascular bed 18 hours after induction of acute pancreatitis. The microvascular bed is not fully destroyed until 48 hours of acute pancreatitis. CONCLUSIONS: The model of acute pancreatitis using postoperative application of ethanol to the digestive tract after stimulation of pancreas by cholecystokinine and secretin in the rats seems to be real and useful. The study of the corrosion casts of microcirculation in the scanning electron microscope and histochemical studies demonstrated the visible reduction of the pancreatic microvascular bed 18 hours after induction of acute pancreatitis. The microvascular bed is not fully destroyed until 48 hours of running acute pancreatitis, as some "islets" of the vital tissue still have undestroyed microvessels at this time. Despite the above-mentioned serious changes, restricted pancreatic microcirculation enables blood and medicament distribution to the still intact pancreatic tissue.

Exocellular proteases of Serratia marcescens and their toxicity to larvae of Galleria mellonella.

Out of 18 strains of Serratia marcescens producing exocellular proteases the strain Serratia marcescens CCEB 415 was selected according to preliminary experiments. It could be shown that the train exhibits proteolytic activity reaching up to 10 TU per 1 ml of the culture filtrate in a medium with gelatine and peptone. Two proteolytic enzyme could be demonstrated by means of specific inhibitors EDTA and diisopropyfluorophosphate: metalprotease with optimum activity at pH 7.5 and serine protease with pH optimum of 10.9. The enzymes were purified on Sephadex and DEAE cellulose columns and by means of gel electrophoresis. However, it was not possible to separate them. The optimum temperature for activity of the mixture of the two enzymes was 50degrees C, molecular weight varied around 37000 (according to gel filtration); certain kinetic characteristics of their activity were determined. Excess subtrate (casein) inhibited activity of the enzyme mixture. Toxicity of proteases expressed as LD50 units equals 78 - 10(3) TU per larva of Galleria mellonella.

[Surgical stress and biochemical indicators]. / Operacní zátez a nekteré biochemické ukazatele.

AIMS: An investigation of some relationships of routinely and rarely used biochemical markers to surgical (operating) trauma. PATIENTS AND METHODS: A group of 37 patients was divided to two subgroups according type of disease with need a resection of large bowel for malignant or benign malady. Large bowel adenocarcinoma was dominated in a subgroup of malignancies (23 patients, mean BMI 25.59, mean age 63.65 years) and Crohn's disease and complicated diverticullary disease were the reasons to operate in the second subgroup of benignities (14 patients, mean BMI 21.21, mean age 39.5 year). Blood samples were taken before an operation, postoperatively (immediately) and at 6:00 a.m. the 1st, 3rd and 5th postoperative day. The routine methods (albumin, CRP, cholinesterase, haptoglobin, cholesterol), special methods (SOD, glutathion) and ELISA methods (leptin, IL-2r, IL-8, TNF)were used for evaluation markers. The results were estimated by statistic methods Sigma-Stat, One Way ANOVA and linear regression test. RESULTS: The mean serum concentrations of albumin, leptin, cholesterol shifted down very clearly compared to preoperative values. The mean serum concentrations shifted up the 3rd day postoperatively to 722% in benignities and to 1814% in malignancies respectively. The values of cholinesterase, glutation, SOD, and haptoglobin didn't show any more serious dynamics perioperatively. The serum leptin concentrations correlated with BMI but other markers serum concentrations didn't correlate with BMI or with age. CONCLUSIONS: The serum leptin, albumin, haptoglobin, CRP concentrations demonstrated serious dynamics perioperatively. These concentrations are stabilized and they reach preoperative levels the 5th postoperative day. Each-other markers correlation is minimal.

[Serum leptin levels in the perioperative period in surgery patients]. / Sérové koncentrace leptinu u nekterých chirurgických nemocných v kolemoperacním období.

AIM: To assess dynamics of serum leptin concentrations (as a possible marker of stress) at some surgical patients during short perioperative period. PATIENTS AND METHODS: The serum leptin concentrations were estimated in group of patients with trauma or large bowel diseases in stress of both own disease and next elective or urgent surgery. The subgroups of patients were: a) monotrauma (13), b) polytrauma (10), c) malignant (20) or d) inflammatory disease (13) of large bowel. The serum leptin concentrations were evaluated preoperatively and during 16 hours postoperatively-immediately after surgery, after 8 and 16 hours after operation. The serum IL-6 concentrations were estimated immediately and 48 hours postoperatively. RESULTS: The serum leptin concentrations showed a time depending dynamic phase: they decreased postoperatively and increased during the first 16 hours postoperatively. It was more expressed in the malignant bowel disease subgroup. A correlation between age and serum leptin concentrations was not found in any subgroup. We found correlation between serum leptin concentrations preoperatively and postoperatively. CONCLUSIONS: The serum leptin concentrations demonstrated some dynamics in short perioperative periods. It was very considerably in patients with large bowel malignancy. Any significant difference in serum IL-6 concentrations was not discovered preoperatively and postoperatively in all subgroups.

[Severe acute pancreatitis]. / Tezká akutní pankreatitida.

The authors present a group of 31 patients with severe acute pancreatitis (SAP) treated by early or late surgery and prophylactic, symptomatic and causal medicamentous therapy of a different extent. The diagnosis of SAP is based above all on examination by CT after administration of a contrast substance into the digestive tract and vascular system. Surgical intervention during the first 2-5 days reduces the mortality substantially. It involves above all removal of necrotic masses and administration of multiple drainage. Repeated rapid revisions of the affected area make open packing possible or the use of Ethizip. In non-surgical treatment administration of broad spectrum antibiotics, vitamins, scavengers of free oxygen radicals, antiphlogistic agents, corticoids, immunopromoting preparations, extensive symptomatic individual medication, large volumes of fluids and adequate parenteral nutrition predominate. Controlled ventilation and haemodialysis are in many patients an integral part of treatment. The mortality was about 42% when treatment was early and adequate. In patients where treatment started late and was inadequate, the mortality was as much as twice as high!

[Jejunal diverticulosis as a rare cause of massive bleeding into digestive tract]. / Divertikulóza jejuna jako raritní zdroj masivního krvácení do gastrointestinálního traktu.

The authors present a case of an elderly man, who was admitted to the hospital due to unusual cause of massive bleeding into digestive tube. During diagnostic work-up the source of gastrointestinal bleeding was localized into jejunal divertuculum. The patient was operated on and resection of involved jejunal segment with primary anastomosis was performed. The possible complications ofjejunal diverticulosis are discussed.

[Diverticulosis of the small intestine--case report]. / Divertikulóza tenkého streva--kazuistika.

The authors describe the case of a 86-year-old female patient admitted to hospital with acute abdomen of the inflammatory type. The condition developed in the course of cca three days with sudden deterioration on the day of admission to hospital. Contrast X-ray examination revealed perforation of the distended jejunum and surgery revealed diffuse peritonitis the source of which was the mentioned perforation associated with mechanical ileus caused by malrotation and adhesions of the small intestine. An additional finding which, however, dominated on X-ray examination of the gastrointestinal tract when using contrast material and on revision of the peritoneal cavity was multiple diverticulosis of the small intestine. The uncommon finding on the small intestine and the relatively sparse data in the literature on diverticulosis of the jejunum and ileum made us submit the case-history for publication.

[Recurrent adhesive ileus after surgical treatment of ovarian teratoma, malposition of an intrauterine device and dolichosigmoid--case report] ]. / Recidivující adhezivní ileus po chirurgické terapii teratomu vajecníku, malpozice nitrodelozního telíska a dolichosigmatu--kazuistika.

A 30-year-old woman was operated for ovarian teratoma and repeatedly for adhesive ileus during 1995-1999. A partial left ovarectomy, extirpation of an intrauterine device (IUD) in malposition (greater omentum) and appendectomy were performed during the first operation. Early adhesive ileus developed on the fourth postoperative day. Adhesectomy was performed in the region of the terminal jejunum. A new adhesive ileus developed after twenty seven months when patient underwent laparoscopy for gynaecological problems with conversion to laparotomy because of greater adhesions intraperitoneally another adhesectomy was performed. During the next eleven months new adhesive obstructions of the bowel developed and a third operation had to be performed incl. resection of the dolichosigmoideum on account of chronic problems during defaecation. A special tube as a intraluminal splint was inserted as prophylaxis of mechanical ileus in the postoperative period. But during next thirteen months subileous conditions and mechanical ileus developed again (up to now). The picture of intraperitoneal conditions was disastrous: almost total fibrotic changes allowed only partial adhesectomy. The passage through bowel is limited and is restricted to dietetic and medicamentous preparations. This case-report demonstrates postoperative adhesions a very old and very serious problem at the beginning of the third millennium.