Study of the X-ray radiation interaction with a multislit collimator for the creation of microbeams in radiation therapy.

Microbeam radiation therapy (MRT) is a developing radiotherapy, based on the use of beams only a few tens of micrometres wide, generated by synchrotron X-ray sources. The spatial fractionation of the homogeneous beam into an array of microbeams is possible using a multislit collimator (MSC), i.e. a machined metal block with regular apertures. Dosimetry in MRT is challenging and previous works still show differences between calculated and experimental dose profiles of 10-30%, which are not acceptable for a clinical implementation of treatment. The interaction of the X-rays with the MSC may contribute to the observed discrepancies; the present study therefore investigates the dose contribution due to radiation interaction with the MSC inner walls and radiation leakage of the MSC. Dose distributions inside a water-equivalent phantom were evaluated for different field sizes and three typical spectra used for MRT studies at the European Synchrotron Biomedical beamline ID17. Film dosimetry was utilized to determine the contribution of radiation interaction with the MSC inner walls; Monte Carlo simulations were implemented to calculate the radiation leakage contribution. Both factors turned out to be relevant for the dose deposition, especially for small fields. Photons interacting with the MSC walls may bring up to 16% more dose in the valley regions, between the microbeams. Depending on the chosen spectrum, the radiation leakage close to the phantom surface can contribute up to 50% of the valley dose for a 5 mm × 5 mm field. The current study underlines that a detailed characterization of the MSC must be performed systematically and accurate MRT dosimetry protocols must include the contribution of radiation leakage and radiation interaction with the MSC in order to avoid significant errors in the dose evaluation at the micrometric scale.

The importance of sentinel lymph node biopsy following neoadjuvant chemotherapy in patients with breast cancer: prospective multicentre trial.

INTRODUCTION: The role of sentinel lymph node biopsy (SLNB) in patients with breast cancer after neoadjuvant chemotherapy (NAC) is currently under discussion. The aim of our study was to determine the false negativity rate (FNR) of SLNB, the accuracy of ultrasound examination in the evaluation of the status of lymph nodes and the accuracy of perioperative cryobiopsy of the sentinel lymph node (SLN). METHODS: Prospective multicentre study, which took place in years 20182020 at three centres in the Czech Republic. A total of 59 patients were evaluated. RESULTS: The FNR of SLNB in the group of patients with cN1 before NAC and ycN0 after NAC was 12.5%. The FNR of perioperative histological examination of the SLN was 38.5%. The FNR of ultrasound examination of axillary lymph nodes in patients after NAC was 35.5%, and the false positivity rate was 16.7%. The incidence of inflammatory complications in our cohort was 3.3%. CONCLUSION: The FNR of SLNB in the group of patients with cN1 before NAC and ycN0 after NAC exceeds the tolerable limit of 10%. The FNR of perioperative histological examination of the SLN is high; definitive histological examination of the SLN may change the original diagnostic-therapeutic plan. Ultrasound examination of the axillary lymph nodes in patients after NAC is a method with high false negativity and positivity and may not correspond with the perioperative finding. The incidence of inflammatory complications in our cohort in patients after NAC is comparable to literature data on the frequency of complications in patients without NAC.

[Surgical procedures for the correction and stabilization of pes planovalgus]. / Stabilisierung und Korrektur der medialen Säule im Rahmen der operativen Pes-planovalgus-Therapie.

The medial column of the foot is a relevant factor of the pathogenesis of pes planovalgus. Crucial anatomic structures are the tibiocalcaneonavicular ligament complex, the naviculocuneiform joints, including the ossa cuneiformia, and the first tarsometatarsal joint. A combination of bony and soft tissue reconstructive techniques must, therefore, be taken into account when treating pes planovalgus. The present article presents stabilizing and correcting surgical procedures for the medial column of the foot, including basic anatomy and biomechanics.

Harmonic scalpel versus traditional ligation in axillary dissection for breast cancer: a retrospective multivariate analysis.

INTRODUCTION: The aim of this pilot retrospective study is to evaluate the complication rate in patients after axillary dissection comparing preparation with harmonic scalpel vs traditional ligation technique, and to analyse risk factors for complications occurrence. METHODS: 144 patients with 148 axillary dissections operated in a single centre between January 2014 and 2019 were included into the study. Axillary dissection was performed using harmonic scalpel in 73 and absorbable ligations in 70 cases. RESULTS: Seroma formation was observed in 41 patients (56.2%) in the harmonic scalpel group and in 21 patients (30.0%) in the ligations group (p=0.003). The mean period from the surgery to drain removal was 4.0 days in the harmonic scalpel group and 3.0 days in the ligations group (p<0.001). The mean amount of the drained fluid after mastectomy was 300.9 ml in the harmonic scalpel group and 168.7 ml in the ligations group (p=0.005); after breast conserving surgery, it was 241.9 ml and 107.4 ml, respectively (p =0.023). CONCLUSION: In comparison with traditional ligations with absorbable material, axillary dissection using harmonic scalpel significantly increases the risk of postoperative seroma formation, prolongs the time from the surgery to drain removal, and increases the amount of drained fluid.

Identification of Cystic Lesions by Secondary Screening of Familial Pancreatic Cancer (FPC) Kindreds Is Not Associated with the Stratified Risk of Cancer.

OBJECTIVES: Intraductal papillary mucinous neoplasms (IPMNs) are associated with risk of pancreatic ductal adenocarcinoma (PDAC). It is unclear if an IPMN in individuals at high risk of PDAC should be considered as a positive screening result or as an incidental finding. Stratified familial pancreatic cancer (FPC) populations were used to determine if IPMN risk is linked to familial risk of PDAC. METHODS: This is a cohort study of 321 individuals from 258 kindreds suspected of being FPC and undergoing secondary screening for PDAC through the European Registry of Hereditary Pancreatitis and Familial Pancreatic Cancer (EUROPAC). Computerised tomography, endoscopic ultrasound of the pancreas and magnetic resonance imaging were used. The risk of being a carrier of a dominant mutation predisposing to pancreatic cancer was stratified into three even categories (low, medium and high) based on: Mendelian probability, the number of PDAC cases and the number of people at risk in a kindred. RESULTS: There was a median (interquartile range (IQR)) follow-up of 2 (0-5) years and a median (IQR) number of investigations per participant of 4 (2-6). One PDAC, two low-grade neuroendocrine tumours and 41 cystic lesions were identified, including 23 IPMN (22 branch-duct (BD)). The PDAC case occurred in the top 10% of risk, and the BD-IPMN cases were evenly distributed amongst risk categories: low (6/107), medium (10/107) and high (6/107) (P = 0.63). CONCLUSIONS: The risk of finding BD-IPMN was independent of genetic predisposition and so they should be managed according to guidelines for incidental finding of IPMN.

Accuracy of ultrasonography in the assessment of liver fat compared with MRI.

AIM: To investigate the accuracy of ultrasonography in the assessment of hepatic steatosis using magnetic resonance imaging (MRI) as standard of reference and to explore the influence of additional hepatic iron overload. MATERIAL AND METHODS: A total of 2,783 volunteers (1,442 women, 1,341 men; mean age, 52.3±13.8 years) underwent confounder-corrected chemical-shift-encoded MRI of the liver at 1.5 T. Proton-density fat fraction (PDFF) and transverse relaxation rate (R2*) were calculated to estimate hepatic steatosis and liver iron overload, respectively. In addition, the presence of hepatic steatosis was assessed by B-mode ultrasonography. The sensitivity, specificity, and accuracy of hepatic ultrasonography were determined for different degrees of hepatic steatosis and different amounts of liver iron. RESULTS: MRI revealed hepatic steatosis in 40% of participants (n=1,112), which was mild in 68.9% (n=766), moderate in 26.7% (n=297), and severe in 4.4% (n=49) of patients. Ultrasonography detected hepatic steatosis in 37.8% (n=1,052), corresponding to 74.5% sensitivity and 86.6% specificity. The sensitivity of ultrasound increased with the amount of hepatic fat present and was 65.1%, 95%, and 96% for low, moderate, and high fat content; whereas the specificity was constantly high at 86.6%. The diagnostic accuracy of ultrasound for detection of hepatic steatosis did not vary significantly with the amount of liver iron present. CONCLUSION: Ultrasonography is an excellent tool to assess hepatic steatosis in the clinical setting with some limitations in patients with a low liver fat content. The detection of hepatic steatosis by ultrasonography is not influenced by liver iron.

Intratumoural expression of deoxycytidylate deaminase or ribonuceotide reductase subunit M1 expression are not related to survival in patients with resected pancreatic cancer given adjuvant chemotherapy.

BACKGROUND: Deoxycytidylate deaminase (DCTD) and ribonucleotide reductase subunit M1 (RRM1) are potential prognostic and predictive biomarkers for pyrimidine-based chemotherapy in pancreatic adenocarcinoma. METHODS: Immunohistochemical staining of DCTD and RRM1 was performed on tissue microarrays representing tumour samples from 303 patients in European Study Group for Pancreatic Cancer (ESPAC)-randomised adjuvant trials following pancreatic resection, 272 of whom had received gemcitabine or 5-fluorouracil with folinic acid in ESPAC-3(v2), and 31 patients from the combined ESPAC-3(v1) and ESPAC-1 post-operative pure observational groups. RESULTS: Neither log-rank testing on dichotomised strata or Cox proportional hazard regression showed any relationship of DCTD or RRM1 expression levels to survival overall or by treatment group. CONCLUSIONS: Expression of either DCTD or RRM1 was not prognostic or predictive in patients with pancreatic adenocarcinoma who had had post-operative chemotherapy with either gemcitabine or 5-fluorouracil with folinic acid.

Expression of dihydropyrimidine dehydrogenase (DPD) and hENT1 predicts survival in pancreatic cancer.

BACKGROUND: Dihydropyrimidine dehydrogenase (DPD) tumour expression may provide added value to human equilibrative nucleoside transporter-1 (hENT1) tumour expression in predicting survival following pyrimidine-based adjuvant chemotherapy. METHODS: DPD and hENT1 immunohistochemistry and scoring was completed on tumour cores from 238 patients with pancreatic cancer in the ESPAC-3(v2) trial, randomised to either postoperative gemcitabine or 5-fluorouracil/folinic acid (5FU/FA). RESULTS: DPD tumour expression was associated with reduced overall survival (hazard ratio, HR = 1.73 [95% confidence interval, CI = 1.21-2.49], p = 0.003). This was significant in the 5FU/FA arm (HR = 2.07 [95% CI = 1.22-3.53], p = 0.007), but not in the gemcitabine arm (HR = 1.47 [0.91-3.37], p = 0.119). High hENT1 tumour expression was associated with increased survival in gemcitabine treated (HR = 0.56 [0.38-0.82], p = 0.003) but not in 5FU/FA treated patients (HR = 1.19 [0.80-1.78], p = 0.390). In patients with low hENT1 tumour expression, high DPD tumour expression was associated with a worse median [95% CI] survival in the 5FU/FA arm (9.7 [5.3-30.4] vs 29.2 [19.5-41.9] months, p = 0.002) but not in the gemcitabine arm (14.0 [9.1-15.7] vs. 18.0 [7.6-15.3] months, p = 1.000). The interaction of treatment arm and DPD expression was not significant (p = 0.303), but the interaction of treatment arm and hENT1 expression was (p = 0.009). CONCLUSION: DPD tumour expression was a negative prognostic biomarker. Together with tumour expression of hENT1, DPD tumour expression defined patient subgroups that might benefit from either postoperative 5FU/FA or gemcitabine.

Comparative measurements of bone mineral density and bone contrast values in canine femora using dual-energy X-ray absorptiometry and conventional digital radiography.

BACKGROUND: Aseptic loosening due to bone remodelling processes after total hip replacement is one common cause for revision surgery. In human medicine, dual-energy X-ray absorptiometry (DEXA) is the gold standard for quantitative evaluation of bone mineral density, whereas in veterinary medicine conventional radiography is used for follow-up studies. Recently, a method has been described using digital X-ray images for quantitative assessment of grey scale values of bone contrast. Therefore, the aim of the present study was to evaluate the correlation of bone mineral density (BMD) measured by DEXA with grey scale values (GV) measured in digital X-ray images (RX50, RX66) ex vivo. RESULTS: The measured GV in the chosen X-ray settings showed on average a good correlation (r = 0.61) to the measured BMD with DEXA. Correlation between the two X-ray settings was very good (r = 0.81). For comparisons among regions of interests (ROIs) a difference of 8.2% was found to be statistically significant, whereas in the case of RX50 and RX66 differences of 5.3% and 4.1% were found to be statistically significant. CONCLUSIONS: Results indicate that measuring absolute changes in bone mineral density might be possible using digital radiography. Not all significant differences between ROIs detectable with DEXA can be displayed in the X-ray images because of the lower sensitivity of the radiographs. However, direct comparison of grey scale values of the periprosthetic femur in one individual patient during the follow-up period, in order to predict bone remodelling processes, should be possible, but with a lesser sensitivity than with DEXA. It is important that the same X-ray settings are chosen for each patient for follow-up studies.

[Distal osteotomy for the treatment of hallux valgus (Chevron osteotomy)]. / Distale Korrekturosteotomie zur Behandlung des Hallux valgus (Chevron-Osteotomie).

Distal osteotomies, like the Chevron osteotomy, is indicated for mild to moderate hallux valgus deformities. Splayfoot, painful pseudoexostosis, and transfer metatasalgia are observed in the clinical examination. Radiographic examination should be done with weight bearing in two planes. Preoperatively the intermetatarsal (IM), hallux valgus, and distal metatarsal articular (DMAA) angles should be measured. The operative technique is based on soft tissue and bony correction. Modifications of the osteotomy allow a shortening, lengthening, or neutral correction of the first metatarsal. With a modified Chevron osteotomy, an increased DMAA can be also corrected.

[Left hepatic vein injury during laparoscopic fundoplication for giant paraoesophageal hiatal hernia]. / Poranení levé hepatické vény v prubehu laparoskopické fundoplikace pro velkou paraezofageální hiátovou kýlu.

INTRODUCTION: After laparoscopic cholecystectomy, laparoscopic fundoplication has become another gold standard of minimal invasive surgery. The level of satisfaction of patients undergoing endoscopic surgery is almost 90%. Laparoscopic fundoplication, like other surgery methods, can also be burdened with grave complications, which could result in a fatal outcome even if the surgery is performed by a skilled surgeon. Even the authors themselves encounter complications despite their rich experience (more than 3,500 laparoscopic operations in the diaphragmatic hiatus area in more than 20 years). CASE REPORT: The authors report on a rare left hepatic vein injury during laparoscopic hiatoplasty and fundoplication according to Toupet for giant paraoesophageal hiatal hernia. CONCLUSION: For its low percentage of complications, laparoscopic fundoplication is considered as a safe operative method for gastroesophageal reflux disease and hiatal hernias. However, severe complications may still arise during the surgery and the surgeon should be familiar with them, be prepared for them and be able to manage such complications.Key words: gastroesophageal reflux disease hiatal hernia laparoscopic fundoplication left hepatic vein.

CEA response is associated with tumor response and survival in patients with KRAS exon 2 wild-type and extended RAS wild-type metastatic colorectal cancer receiving first-line FOLFIRI plus cetuximab or bevacizumab (FIRE-3 trial).

BACKGROUND: To examine the relation of carcinoembryonic antigen (CEA) response with tumor response and survival in patients with (K)RAS wild-type metastatic colorectal cancer receiving first-line chemotherapy in the FIRE-3 trial comparing FOLFIRI plus cetuximab versus FOLFIRI plus bevacizumab. PATIENTS AND METHODS: CEA response assessed as the percentage of CEA decrease from baseline to nadir was evaluated for its association with tumor response and survival. Receiver operating characteristic analysis revealed an optimal cut-off value of 75% using the maximum of sensitivity and specificity for CEA response to discriminate CEA responders from non-responders. In addition, the time to CEA nadir was calculated. RESULTS: Of 592 patients in the intent-to-treat population, 472 were eligible for analysis of CEA (cetuximab arm: 230 and bevacizumab arm: 242). Maximal relative CEA decrease (%) significantly (P = 0.003) differed between the cetuximab arm (median 83.0%; IQR 40.9%-94.7%) and the bevacizumab arm (median 72.3%; IQR 26.3%-91.0%). In a longitudinal analysis, the CEA decrease occurred faster in the cetuximab arm and was greater than in the bevacizumab arm at all evaluated time points until 56 weeks after treatment start. CEA nadir occurred after 3.3 months (cetuximab arm) and 3.5 months (bevacizumab arm), (P = 0.49). In the cetuximab arm, CEA responders showed a significantly longer progression-free survival [11.8 versus 7.4 months; hazard ratio (HR) 1.53; 95% Cl, 1.15-2.04; P = 0.004] and longer overall survival (36.6 versus 21.3 months; HR 1.73; 95% Cl, 1.24-2.43; P = 0.001) than CEA non-responders. Analysis of extended RAS wild-type patients revealed similar results. CONCLUSION: In the FIRE-3 trial, CEA decrease was significantly faster and greater in the cetuximab arm than in the bevacizumab arm and correlated with the prolonged survival observed in patients receiving FOLFIRI plus cetuximab. CLINICAL TRIALS NUMBER: NCT00433927 (ClinicalTrials.gov); AIO KRK0306 FIRE-3.

Prospective cohort study comparing transient EUS guided elastography to EUS-FNA for the diagnosis of solid pancreatic mass lesions.

BACKGROUND: Semiquantitative EUS-elastography has been introduced to distinguish between malignant and benign pancreatic lesions. This study investigated whether semiquantitative EUS-guided transient real time elastography increases the diagnostic accuracy for solid pancreatic lesions compared to EUS-FNA. PATIENTS AND METHODS: This single centre prospective cohort study included all patients with solitary pancreatic lesions on EUS during one year. Patients underwent EUS-FNA and semiquantitative EUS-elastography during the same session. EUS and elastography results were compared with final diagnosis which was made on the basis of tissue samples and long-term outcome. RESULTS: 91 patients were recruited of which 68 had pancreatic malignancy, 17 showed benign disease and 6 had cystic lesions and were excluded from further analysis. Strain ratios from malignant lesions were significantly higher (24.00; 8.01-43.94 95% CI vs 44.00; 32.42-55.00 95% CI) and ROC analysis indicated optimal cut-off of 24.82 with resulting sensitivity, specificity and accuracy of 77%, 65% and 73% respectively. B-mode EUS and EUS-FNA had an accuracy for the correct diagnosis of malignant lesions of 87% and 85%. When lowering the cut-off strain ratio for elastography to 10 the sensitivity rose to 96% with specificity of 43% and accuracy of 84%, resulting in the least accurate EUS-based method. This was confirmed by pairwise comparison. CONCLUSION: Semiquantitative EUS-elastography does not add substantial value to the EUS-based assessment of solid pancreatic lesions when compared to B-mode imaging.

Real-time eye lens dose monitoring during cerebral angiography procedures.

OBJECTIVES: To develop a real-time dose-monitoring system to measure the patient's eye lens dose during neuro-interventional procedures. METHODS: Radiation dose received at left outer canthus (LOC) and left eyelid (LE) were measured using Metal-Oxide-Semiconductor Field-Effect Transistor dosimeters on 35 patients who underwent diagnostic or cerebral embolization procedures. RESULTS: The radiation dose received at the LOC region was significantly higher than the dose received by the LE. The maximum eye lens dose of 1492 mGy was measured at LOC region for an AVM case, followed by 907 mGy for an aneurysm case and 665 mGy for a diagnostic angiography procedure. Strong correlations (shown as R(2)) were observed between kerma-area-product and measured eye doses (LOC: 0.78, LE: 0.68). Lateral and frontal air-kerma showed strong correlations with measured dose at LOC (AKL: 0.93, AKF: 0.78) and a weak correlation with measured dose at LE. A moderate correlation was observed between fluoroscopic time and dose measured at LE and LOC regions. CONCLUSIONS: The MOSkin dose-monitoring system represents a new tool enabling real-time monitoring of eye lens dose during neuro-interventional procedures. This system can provide interventionalists with information needed to adjust the clinical procedure to control the patient's dose. KEY POINTS: Real-time patient dose monitoring helps interventionalists to monitor doses. Strong correlation was observed between kerma-area-product and measured eye doses. Radiation dose at left outer canthus was higher than at left eyelid.

[Fracture of the Anatomical Neck of the Humerus Associated with Posterior Shoulder Dislocation. Case Report]. / Zlomenina anatomického krcku humeru spojená se zadní luxací ramene ­ kazuistika.

A rare case of a fracture of the anatomical neck of the humerus associated with a posterior dislocation of the shoulder in a 43-year-old man is presented. It was managed by immediate surgery using locking plate osteosynthesis. The shoulder was immobilised for 5 weeks in a Gilchrist brace. The outcome was very good with a full range of motion and a stable shoulder at 1 year after injury, with no signs of avascular necrosis of the humeral head. The aetiology of this injury and possibilities of its treatment are discussed. Key words: shoulder dislocation, humeral fractures.

[Perforation of the right ventricle of the heart as a complication of CT guided percutaneous drainage of a subphrenic abscess - a case report]. / Perforace pravé srdecní komory jako komplikace CT navigované perkutánní drenáze subfrenického abscesu kazuistika.

INTRODUCTION: CT guided percutaneous drainage is currently the gold standard in the treatment of abdominal fluid collections, having substituted open surgical drainage in many cases. It burdens the patient less than surgical drainage. Its efficiency is comparable to standard surgical drainage when properly indicated. It is readily available even in smaller hospitals. However, this method can also have many complications, which originate most often from an improperly targeted drainage catheter. CASE REPORT: The authors describe a case report of a 55 years old man with a right-sided subphrenic abscess. The right ventricle of the heart was perforated during a CT guided percutaneous drainage. The bleeding was minimal, but the patient suffered a profound septic shock as a result of massive bacteremia during direct communication of the contents of the abscess cavity with blood circulation. He was operated immediately. The right ventricle was sutured, and the subphrenic abscess was drained. There were no complications after the operation, and the patient was discharged on day 17 after the surgery. CONCLUSION: The CT guided drainage of an abdominal abscess or a fluid collection in a risk area should be preferably done in hospitals whose therapeutic portfolio also includes the handling of serious complications. KEY WORDS: heart injury drainage.

[Secondary angiosarcoma of the abdominal wall after adjuvant radiotherapy in a patient with uterine carcinoma - a case report]. / Sekundární angiosarkom brisní steny po adjuvantní radioterapii pacientky s karcinomem delohy kazuistika.

INTRODUCTION: Adjuvant radiotherapy is an integral part of the current treatment of many malignant tumours. However, this mode of treatment does not provide only benefits in the sense of lowering the risks of recurrence, but it is also associated with many undesirable side effects, from which one of the most serious is the development of secondary malignancies. CASE REPORT: The author describes a case report of 77 years old woman who underwent hysterectomy with bilateral adnexectomy and pelvic lymphadenectomy for uterine carcinoma pT1bN0M0, G1 in 2005. Adjuvant external radiotherapy with the dose 45Gy and brachytherapy 3x4Gy followed. Subsequently the patient was followed at the department of gynecology, which referred her in January 2015 with a quickly growing tumour of the skin and subdermal tissue in the hypogastric area, where previous radiation had been applied. Its excision was indicated with the diagnosis of suspected uterine carcinoma metastasis, but subsequent histological evaluation confirmed angiosarcoma. Despite negative resection margins the tumour quickly recurred and disseminated. CONCLUSION: Angiosarcoma as a side effect of irradiation is described increasingly more often nowadays. The vast majority of cases are related to the treatment of breast carcinoma. Its prognosis is very poor and therapeutic possibilities are limited. Surgical excision with negative margins remains the mainstay of the treatment. It is necessary to keep this diagnosis in mind and patients undergoing radiation treatment should be followed over a long period. KEY WORDS: angiosarcoma.

[Rare injury of perineum and anorectum - case report]. / Raritní poranení hráze a anorekta kazuistika.

UNLABELLED: Anorectal injuries, with the exception of iatrogenic damage, are rare. Considering the extensive range of causes and potential extent of damage, the diagnosis and treatment of these injuries requires an individual approach to every patient. Based on the extent of damage, the best way of treatment strategy has to be selected for successful treatment of the primary injury and elimination of frequent complications, especially fecal incontinence. The authors present a rare injury of the perineum and anorectum with anorectal sphincter damage in an elderly man after falling down from a stepladder. KEY WORDS: anorectum - anorectal trauma - anal sphincter.

[Laparoscopic resection rectopexy in the treatment of obstructive defecation syndrome]. / Laparoskopická resekcní rektopexe v lécbe obstrukcního defekacního syndromu.

INTRODUCTION: Obstructive defecation syndrome (ODS) presents a common medical problem, which can be caused by various pelvic disorders; multiple disorders are frequently diagnosed. At the present, a high number of corrective techniques are available via various surgical approaches. Laparoscopic resection rectopexy is a minimally invasive technique, which comprises redundant sigmoidal resection with rectal mobilisation and fixation. METHODS: The aim of this paper was to evaluate the safety and effectiveness of laparoscopic resection rectopexy in the treatment of patients with ODS. The evaluation was performed via our own patients data analysis and via literature search focused on laparoscopic resection rectopexy. RESULTS: In total, 12 patients with ODS undergoing laparoscopic resection rectopexy in University Hospital Ostrava during the study period (2012-2015) were included in the study. In our study group, mean age was 64.5 years and mean BMI was 21.9; the group included 11 women (91.6%). ODS was caused by multiple pelvic disorders in all patients. Dolichosigmoideum and rectal prolapse (internal or external) were diagnosed in all included patients. On top of that, rectocoele and enterocoele were diagnosed in several patients. Laparoscopic resection rectopexy was performed without intraoperative complications; mean operative time was 144 minutes. Mean postoperative length of hospital stay was 7 days. Postoperative 30-day morbidity was 16.6%. All postoperative complications were classified as grade II according to Clavien-Dindo classification. Mean preoperative Wexner score was 23.6 points; mean score 6 months after the surgery was 11.3 points. Significant improvement in ODS symptoms was noted in 58.3% of patients, and a slight improvement in 16.6% of patients; resection rectopexy provided no clinical effect in 25% of patients. CONCLUSION: It is fundamental to carefully select those patients with ODS who could possibly profit from the surgery. Our results, in accordance with published data, suggest that laparoscopic resection rectopexy is a valuable surgical technique in the treatment of patients with ODS caused by multiple pelvic disorders. KEY WORDS: obstructive defecation syndrome - constipation - resection rectopexy - operative techniques - pelvic floor disorders.

[Economic burden of Clostridium difficile enterocolitis in German hospitals based on routine DRG data]. / Ökonomische Auswirkungen einer Clostridium-difficile-Enterokolitis in deutschen Krankenhäusern auf der Basis von DRG-Kostendaten.

BACKGROUND: Clostridium difficile associated diarrhea (CDAD) is not only a increasing medical but also economical problem. METHODS: Data from the DRG project group of the German society for digestive and metabolic diseases (DGVS) were analyzed for CDAD. Out of 430,875 cases from 37 German hospitals 2,767 cases were grouped by having CDAD either as primary (PD) or secondary diagnosis (SD; likely to be from a hospital source) in an initial or recurring hospital stay (RD). For comparison non-CDAD cases from the same hospitals from that year where matched using propensity score matching. As endpoints we defined LOS (length of stay), difference of LOS to national average LOS, total costs per case and difference between costs and revenue for all three groups. RESULTS: Patients from the PD group (n = 817) showed a mean LOS of 11.2 days compared to 8.5 days for the control group, 4,132 € mean cost per case (536 € more than control) and a mean loss of -1,064 € per case compared to -636 €. In the SD group (n = 1,840) patients stayed in the hospital for 28.8 days (control: 18.1 days), had costs of 19,381 € (control: 13,082 €) and a loss of -3,442 € compared to -849 € in the control group. Recurring cases (RD; n = 110) showed a LOS of 37.3 days (control: 21.3 days), had even higher costs (20.755 € vs. 13,101 €) and higher losses (-4,196 € vs. -1,109 €). CONCLUSION: By extrapolating these findings CDAD not only harms patients but generates a yearly cost burden of 464 million € for the German healthcare system including a loss of 197 million € for German hospitals. To the authors' opinion sufficient measures against CDAD should include pre hospital risk reduction programs, introduction of effective therapeutic and hygienic strategies in hospitals as well as improvements in documentation for these cases to support further developments of the German DRG system.