Preparation of a pig experimental model of defective colon anastomosis - review.

Anastomotic leak is a serious complication in colorectal surgery. The problem of intestinal anastomosis healing disorders is dealt with by a number of experimental studies, especially in applied research. The design of animal models is diverse and the results of individual studies are difficult to compare. This paper summarizes the main issues of planning animal models of intestinal anastomoses, which are discussed individually. The main part of the text is a description of the defective intestinal anastomosis model of the pig. The anastomosis is constructed in the model with a localized mucosal protrusion. The animals are monitored for 3 weeks postoperatively, the clinical condition and changes in vital values and laboratory parameters are monitored, and CT examinations are performed at defined points. At the end of the observation period, samples are taken, macroscopic findings in the abdominal cavity are evaluated, adhesions are scored, and signs of leakage or passage disorders are assessed. The preparations are evaluated histologically both by standard methods analyzing vascularity, inflammatory infiltration and the proportion of collagen, and by methods developed de novo for the needs of the experiment, such as the analysis of the integrity of the intestinal wall at the site of the mucosal protrusion. We value the experimental model for the possibility of a systematic and detailed analysis of the healing state of the anastomosis in combination with a detailed observation protocol, which produces clinically relevant results.

Transhepatic perforation of the gallbladder with massive intraperitoneal hemorrhage as a rare complication of acute cholecystitis.

INTRODUCTION: Perforation of the gallbladder into the hepatic parenchyma with massive bleeding into the abdominal cavity is a very rare but life-threatening complication of acute cholecystitis. Initially, the clinical finding may not differ significantly from the normal course of acute cholecystitis, but later there is a significant deterioration associated with hemorrhagic shock. Monitoring of the patients clinical condition as well as radiological methods have a crucial role in early and accurate diagnosis. CASE REPORT: We present the case of a 55-year-old patient who was admitted to our clinic with the clinical finding of acute cholecystitis. During the third day of hospitalization, there was a significant deterioration in his clinical condition with circulatory instability. Computed tomography (CT) scans revealed massive hemoperitoneum with a large hematoma reaching into the liver parenchyma and the gallbladder bed. Based on this finding, the patient was indicated for urgent laparotomy. The perioperative finding confirmed intrahepatic perforation of the gallbladder with a stone collapsed into the hepatic parenchyma and secondary perforation of the hepatic capsule with massive bleeding into the abdominal cavity. The authors present an unusual complication of acute cholecystitis, its diagnosis and surgical solution. CONCLUSION: Massive intraperitoneal bleeding associated with transhepatic perforation of the gallbladder is very rare, occurring only in single-digit percent of acute cholecystitis cases. It is essential to evaluate not only the clinical and laboratory findings, but above all to complete an appropriate imaging assessment. The timing of the assessment is crucial for proper preoperative diagnosis and for reducing the risks of urgent surgical treatment.

Spontaneous retroperitoneal bleeding in COVID-19 patients - two case reports.

INTRODUCTION: COVID-19 disease is associated with a high risk of thromboembolic events, especially in patients with a severe course of the disease. At the same time, however, there is a risk of bleeding. These complications have a significant impact on patient morbidity and mortality. Thus, determining an optimal approach to thromboembolic disease prophylaxis can be challenging. CASE REPORTS: This paper presents two cases of polymorbid female patients suffering from COVID-19. Both patients experienced retroperitoneal hemorrhage while on low molecular weight heparins in the process of deintensification of the treatment of their moderate to severe disease. Although both patients were treated surgically with a good local effect on the hemorrhage, their deterioration progressed, finally resulting in death in both the cases. CONCLUSION: Despite the proven benefit of prophylaxis of thromboembolic events using low molecular weight heparins in patients with COVID-19, care should be taken to monitor coagulation laboratory parameters in proper time intervals. The risk of a fatal course of bleeding complications is extremely high in critically ill patients and patients with multiple comorbidities.

Tumor mimicking gastric ulcer penetrating asymptomatically into the pancreas.

Gastroduodenal ulcer disease is characterized by ulceration of the stomach or duodenum, with ulcer lesions occurring more frequently in the duodenum. Serious complications of this disease include bleeding, perforation of the ulcer and penetration into surrounding organ. Our report presents the case of an older man who had a gastric ulcer penetrating into the pancreas. This was not diagnosed at the time of the penetration. The patient came to our care for recurrent hematemesis without a proven source of bleeding. During the diagnostic process, the presence of an intramural gastric tumor was suspected. An excision of the suspected lesion was successfully performed at our clinic, followed by histological confirmation of perforated ulcer. The postoperative course was complicated by the development of a pancreatic fistula. However, conservative treatment resulted in complete recovery of the patient.

Sternotomy in thyroid surgery

Introduction: A bulky retrosternal goiter means for the surgeon to consider an extracervical approach, usually from a partial sternotomy. Methods: Retrospective evaluation of a group of thyroid operations requiring sternotomy in a ten-year period (year 2012­2021), in an attempt to predict the need for sternotomy. Results: We performed a total of 1254 thyroid operations, with partial sternotomy required in 11 cases (0.88%): in 6 women and 5 men aged 43­84 years (mean 73.1 years). For these, 3 total thyroidectomies and 6 hemithyroidectomies (lobectomies) were performed. In 2 cases, we operated on the mediastinal residue, or regenerate, after a previous thyroidectomy from the cervical approach. The duration of hospitalization was 5­14 days, once there was bleeding with the need for operative revision, otherwise the procedures were without complications, including phonation. The border of the lower part of the thyroid gland in relation to the upper border of the aortic arch was in the range of +20 to -22 mm. The mean was -8.5 mm. Conclusion: All sternotomy thyroidectomies performed by us had a close relationship to, or overlapped with the upper line of the aortic arch. Significantly retrosternal propagating goiters are mostly eufunctional (81.9 % in our group) and develop in patients in the seventh or eighth decade of life. Therefore, if only one lobe propagates intrathoracically, a hemithyroidectomy is sufficient. A carcinoma is rarely present; in one case in our group. We believe that the necessity of sternotomy cannot be accurately predicted, but it is necessary to be prepared for it, especially in the case of a goiter exceeding the level of the aortic arch. In case of greater retrosternal propagation, it is certainly appropriate to perform a CT, for surgical reasons (possibility of sternotomy, risk of leaving part of the gland) and anesthetic reasons (compression and deviation of the trachea).

Delayed diagnosis of diaphragmatic rupture after blunt chest trauma - 2 case reports.

INTRODUCTION: Diaphragmatic rupture is a rare but life-threatening condition that occurs in 0.85% of surgically managed thoracoabdominal injuries. In most cases, the condition is accompanied by associated traumas responsible for poor prognosis. Signs of diaphragmatic rupture are often masked by more serious manifestations of the associated trauma. The rupture is usually revealed by an X-ray of the chest or CT scan. However, a minor defect may be missed, especially if the patient is not indicated for urgent surgery. METHODS: The authors present 2 case reports of patients treated for chronic diaphragmatic rupture at the Department of Surgery of the Faculty of Medicine, Charles University and University Hospital in Pilsen between 01 January 2009 and 31 December 2021. The aim was to analyze the clinical data and to compare this data with literature. RESULTS: Both patients with the chronic diaphragmatic rupture were men in their productive age. The mechanism of their primary trauma was a traffic accident. In the first case, the rupture was diagnosed 6 years after the trauma. The second case was diagnosed 14 years after the primary trauma. The diaphragmatic rupture was present on the left side in the first case and on the right in the other. Both patients underwent suture of the diaphragmatic defect via thoracotomy. CONCLUSION: Unrecognized diaphragmatic rupture is a severe condition that can result in a life-threatening complication, namely incarceration of abdominal organs dislocated to the chest. It is necessary to keep this diagnosis in mind in patients with gastrointestinal or respiratory problems after a previous high-energy, blunt-force abdominal and thoracic injury, even many years after the trauma.

Rupture of a large aneurysm of common hepatic artery - case report.

Visceral artery aneurysms are rare findings in the practice of vascular surgeons. Their inaccessibility to physical examination, asymptomatic nature in many cases, but also an inherent risk of rupture that can be life threatening, make them a complex diagnostic and therapeutic problem. By presenting a case report of a ruptured common hepatic artery aneurysm the authors summarize basic characteristics of these aneurysms, as well as diagnostic and treatment options.

Infections associated with vascular reconstruction procedures at the Department of Surgery in Pilsen in retrospect.

INTRODUCTION: Vascular graft infection is a rare but serious complication in vascular surgery, associated with high morbidity and mortality. Early diagnosis of vascular graft infection is important for proper and timely surgical and antibiotic treatment that improves the outcome. The tactic and techniques of surgical treatment of vascular graft infection have changed over the last two decades, and this trend can also be observed in our retrospective study. METHODS: We evaluated a group of patients with prosthetic vascular reconstructions performed at the Department of Surgery, University Hospital in Pilsen in the period of 2003-2021 using retrospective analysis. In the analyzed 19-year period, 23 infected vascular grafts were managed out of a total of 2090 performed peripheral bypasses, and 27 infected vascular grafts were managed out of a total set of 1940 central reconstructions. RESULTS: The incidence of peripheral vascular graft infections at our Department of Surgery in the period of 2003-2021 reached 1.1% with the early mortality rate of 8.7%; 1.4% central vascular graft infections occurred in the same time period with 33% early mortality. CONCLUSION: The results of our retrospective study are comparable virtually in all parameters with the experience of other departments. Consistently, our department switched to in situ replacements for explanted vascular grafts and we can confirm good experience with silver impregnated grafts.

Massive intrathoracic haemorrhage as a complication of pulmonary parenchymal haemorrhage and anticoagulant treatment of lung embolization during COVID-19 - two case reports.

INTRODUCTION: The medical and social interest in the SARS-CoV-2 infection is currently high. This infection can, in severe cases, be accompanied by a series of complications, such as thromboembolic disease or pulmonary parenchymal haemorrhage. CASE REPORTS: The paper presents two rare cases of massive intrathoracic haemorrhage caused by pulmonary parenchymal haemorrhage and exacerbated by full anticoagulant treatment of thromboembolic disease. RESULTS: In both cases, the haemorrhage originated in the left lower lobe and was life threatening, requiring urgent anatomical lung resection - left lower lobectomy. CONCLUSIONS: The combinaion of anticoagulant therapy and thromboembolic events related to COVID-19 can cause, in rare cases, massive pulmonary haemorrhage. This rare complication proved lethal in one out of two of the cases described in this paper. An imminent and adequate reaction is necessary when the first signs of haemorrhage appear.

Diagnosis and treatment of surgical skin and soft tissue infections - current status.

Surgical skin and soft tissue infections (SSTIs) result from microbial invasion of the skin and underlying soft tissues, often requiring surgical treatment. SSTIs encompass a variety of pathological conditions, ranging from frequent simple superficial skin infections with very good outcomes to rare, rapidly progressive necrotizing infections associated with long-lasting morbidity and high mortality. The document summarizes current knowledge of the diagnosis and therapy of these diseases and provides clinicians with current standards of care of these patients based on international guidelines. Additionally, regional specific aspects are also reflected, and thus in all cases, this paper on diagnostic-therapeutic management of individual clinical forms respects the actual clinical practice and epidemiology in the Czech Republic. The document has been prepared based on multidisciplinary consensus of experts from universities all over the Czech Republic.

Extrahepatic bile duct malignancies.

INTRODUCTION: Biliary tract malignancies belong to very aggressive malignancies of the gastrointestinal tract. The only radical treatment is surgical resection which is possible only in a limited number of cases due to late diagnosis. The aim of this report was to present the experience of our own department with the diagnosis and treatment of these tumours. METHODS: In the years 2005-2021 radical (R0) resection was performed in 27 (28.4%) patients, the same number were managed only symptomatically and in 41 (43.2%) patients we used biliary stenting and external-internal drainage as the definitive procedure. Adjuvant oncological treatment was indicated in 16 (59.3%) of the radically operated and 49 (72.1%) of the non-operated patients. RESULTS: Median overall survival and median progression-free survival in the operated patients were 19.9 months and 15.7 months, respectively. Overall survival in the operated patients was significantly better (p.

Permanent intravenous access in experimental surgery ­ our experience

Introduction: Permanent intravenous access is usually required in pigs used for surgical experiments, not only to enable repeated blood sample collections. The aim of this study was to evaluate the patency and complications of vascular access ports (VAP) implanted in pigs included in different surgical experiments. Methods: VAPs were implanted via the external jugular vein in a total of 211 pigs from 7 different experiments. All observed complications were retrospectively evaluated. Results: No complications were observed in 157 animals (74.4%). Complications of the least severity were edema or seroma around the port which were observed in 12 (5.7%) and 3 (1.4%) animals, respectively. Temporary problems with aspiration of blood via the port occurred in 13 animals (6.2%). The most severe complications which prevented the use of the VAP for aspiration and application were recorded in 26 animals (12.3%). These complications included: abscess formation around the port (12 animals), skin necrosis over the port (2 animals), partial wound dehiscence (2 animals) and loss of the VAP function due to an unspecified cause (10 animals). Removal of the VAP was not needed in any of the animals and none of the animals had to be excluded from the experiment due to the complications. The VAP can also be used for safe administration of iodine contrast agent during CT examination. Conclusion: Despite the observed complications the VAP is suitable as permanent intravenous access in pigs used for surgical experiments. This method helps to minimize the stress of the animals in the postoperative period and to reduce the number of experimental animals.

Experimental surgery as part of the development of degradable biomaterials for cardiovascular surgery

Introduction: Cardiovascular diseases are responsible for significant morbidity and mortality in the population. Artificial vascular grafts are often essential for surgical procedures in radical or palliative treatment. Many new biodegradable materials are currently under development. Preclinical testing of each new material is imperative, both in vitro and in vivo, and therefore animal experiments are still a necessary part of the testing process before any clinical use. The aim of this paper is to present the options of using various experimental animal models in the field of cardiovascular surgery including their extrapolation to clinical medicine. Methods: The authors present their general experience in the field of experimental surgery. They discuss the selection process of an optimal experimental animal model to test foreign materials for cardiovascular surgery and of an optimal region for implantation. Results: The authors present rat, rabbit and porcine models as optimal experimental animals for material hemocompatibility and degradability testing. Intraperitoneal implantation in the rat is a simple and feasible procedure, as well as aortic banding in the rabbit or pig. The carotid arteries can also be used, as well. Porcine pulmonary artery banding is slightly more difficult with potential complications. The banded vessels, explanted after a defined time period, are suitable for further mechanical testing using biomechanical analyses, for example, the inflation-extension test. Conclusion: An in vivo experiment cannot be avoided in the last phases of preclinical research of new materials. However, we try to strictly observe the 3R concept ­ Replacement, Reduction and Refinement; in line with this concept, the potential of each animal should be used as much as possible to reduce the number of animals.

Gigantic intra-abdominal tumors the experience of one center.

A complex review of surgery treatment of unusually giant intra-abdominal and retroperitoneal tumors regardless of their origin and histological findings. The therapy of such neoplasms requires a multidisciplinary approach which is necessary to make a reasonable and responsible decision concerning not only the indication of surgery, but also its extent. The authors describe 5 case reports, highlighting specific aspects and pitfalls of the diagnosis and treatment of these rare cases.

Aorto-caval fistula - case report.

Aorto-caval fistula can be associated with abdominal aortic aneurysm. The fistula can manifest with nonspecific symptoms. The rupture of abdominal aortic aneurysm is one of the leading symptoms. The symptoms and the necessity of treatment are related to these acute conditions. This article describes the case of a 78 years old man with a huge abdominal aortic aneurysm and aorto-caval fistula that was presented with a sudden onset of abdominal pain, dyspnoea, hypotension and cardiac insufficiency with an acute cor pulmonale. Urgent surgery was performed - aneurysm resection with transaortic suture of the fistula and aortic replacement using a Dacron graft. Resuscitation and defibrillation were needed during the surgery due to fibrillation cardiac arrest, which were successful. The post-operative period was complicated with a persisting consciousness disorder of the patient and persisting myocardial ischaemia, resulting in the patients death 3 weeks after the surgery. The aim of this report is to point out the severity of this condition, the various treatment options of this uncommon disease with an uncertain prognosis, and also the importance of a multidisciplinary approach, essential in the entire treatment process as well as in the primary diagnosis.

Differentiated thyroid microcarcinoma current perspective.

INTRODUCTION: Differentiated thyroid cancer (DTC) has a good prognosis and low mortality despite its growing incidence, which is particularly the case of microcarcinomas (T1a - up to 10 mm). METHODS: Retrospective analysis of overall survival of patients in the group of thyroid gland surgeries for differentiated forms of microcarcinoma in the period of 2006-2015 up to the present. An overview of contemporary therapeutic methods is included. RESULTS: Thyroid cancer was detected in 144 cases out of the total of 1820 patients with thyreopathy undergoing surgery (8%); DTC microcarcinoma was detected in 65 cases (45.1%) of all carcinomas. The papillary form was diagnosed in 59 cases (51.8% of all papillary cases), and the follicular form was found in 6 cases (37.5% of all follicular cases). Two cases of Hürthle cells cancer were found, both in a stage higher than T1. Overall 10-year survival of carcinomas >T1 was 86%, reaching 90% in the microcarcinoma group (Gehan Wilcoxon test: p=0.10675). CONCLUSION: Differentiated microcarcinoma shows a very good overall survival. Provided that other criteria are satisfied, particularly unifocal occurrence without spreading through the gland casing and without any suspicion of nodal involvement, hemithyroidectomy is considered to be a sufficient procedure or the method of choice, respectively.

Clear cell renal carcinoma metastases to the pancreas.

INTRODUCTION: To date, clear cell renal carcinoma (Grawitz tumour) remains the most frequent malignant tumour of the kidney in adults. It metastasises in more than 25% of cases, most frequently to the bones (osteolytic metastases), lungs, brain, liver, adrenal glands and the contralateral kidney. Metastases to the pancreas are rare and represent 1-4% of all malignant tumours of the pancreas. METHODS: This is a retrospective analysis of patients who were operated at the Department of Surgery in Pilsen between 2010 and 2018 for histologi-cally verified metastasis of clear cell carcinoma (Grawitz tumour) to the pancreas. RESULTS: We operated 12 patients (8 men and 4 women). The metastases appeared on average 8 years and 8 months following the primary urolo-gical surgery. The mean age of the male patients was 66.5 years and that of the female patients was 67.4 years. In our sample, the diagnostic specificity of the CT scan was 50%, the diagnostic specificity of endoscopic ultrasound (EUS) was 75% and subsequent EUS-guided fine needle aspiration biopsy performed in 100% of cases yielded a specificity of 75%. Resectability was 92%. The average length of hospitalisation was 11.5 days. Post-operative complications according to Clavien-Dindo were grade 1 in 66%, grade 2 in 1.25% and grade 5 in 8.3% of the cases. The 30-day post-operative mortality was 8.3% (one patient).  Conclusion: Clear cell renal carcinoma metastases to the pancreas are very rare. However, if radically removed, the patient has a good prognosis with regards to long-term survival.

Morgagni hernia - case reports.

Morgagni hernia is a rare form of diaphragmatic hernia. It is a congenital defect of the diaphragm, often asymptomatic in adulthood and thus usually found only incidentally. Its treatment is predominantly surgical. This article presents three case reports of patients operated in our department.

Acute abdomen in pregnancy: a retrospective study of pregnant patients hospitalised for abdominal pain.

INTRODUCTION: Abdominal emergencies occur in pregnant women with the rate of 1:500635 pregnancies. Such conditions usually develop from full health and worsen rapidly. Symptoms are often similar to those in physiological pregnancy (abdominal pain, vomiting, constipation). The diagnostic process is thus difficult and both the mother and her child are at risk. Our aim was to evaluate the frequency of abdominal emergencies in the Department of Surgery, University Hospital in Pilsen and to consider their impact on pregnancy and on the newborn. METHODS: We acquired a set of patients by retrograde collection of data. We searched for pregnant patients suspected of developing an abdominal emergency admitted to the Department of Surgery, Faculty of Medicine, Pilsen between 2004 and 2015. We evaluated a number of clinical signs to statistically describe the set. RESULTS: The set included 121 patients; 42 of the patients underwent a surgical procedure and 79 received conservative treatment. 38 patients underwent appendectomy; 6 appendixes were with no pathologies. McBurneys incision was an approach of choice in most cases. The most frequent symptom was pain in the right lower abdominal quadrant. The foetus has been lost in none of the cases. CONCLUSION: Acute appendicitis was the most frequent abdominal emergency in our set and also the most frequent reason for surgical intervention. The most specific sign was pain in the right lower abdominal quadrant. No impact of appendicitis or appendectomy on the health of the newborn has been observed. Even though abdominal emergencies in pregnancy are relatively rare, the results of the department are very good.

Perioperative acute internal carotid thrombosis after general surgery.

INTRODUCTION: The average incidence of perioperative stroke during major non-cardiac surgery is less than 1%, suggesting that it is rarely a major problem for the vast majority of patients. METHODS: In our paper we present a 46-year-old patient undergoing acute right hemicolectomy who developed right-sided hemiparesis in the perioperative setting. Immediate CTAg examination showed an ischemic stroke in the left hemisphere as a result of left internal carotid thrombosis. A surgical procedure to recanalize the left carotid artery was performed 14 hours from the onset of neurological symptomatology and the neurological deficit gradually recovered fully. CONCLUSION: Our case report supports studies showing that a thorough diagnostic assessment allows the selection of patients who may benefit from urgent revascularization of acute internal carotid occlusion during the phase of acute brain ischemia.