Achalasia - position of surgery in current management.

Oesophageal achalasia is a serious cause of dysphagia. Therapeutic options for achalasia include endoscopic and surgical methods. Indications for individual methods overlap to a certain extent and require careful diagnosis. The review article describes individual methods, focusing particularly on the issues of indications of pneumatic dilatation, peroral endoscopic myotomy (POEM) and laparoscopic or robotic Hellers myotomy. Special attention is paid to revision procedures after Hellers myotomy. The main added value of POEM is the treatment of spastic disorders of the oesophagus and re-do myotomy. Type 2 achalasia can be treated with dilatation, POEM and HM; type 1 achalasia can be treated using the same modalities. For type 3, POEM is the current method of choice. Despite the current emphasis on endoscopic myotomy, surgical therapy, especially laparoscopic or robotically assisted Hellers myotomy, remains a safe therapeutic option. It is indicated especially in patients who are not suitable for endoscopic therapy or those with advanced achalasia findings. In the future, identification of the risk of postoperative complications (perforation, reflux) should lead to differentiation of the indication of the laparoscopic (robotic) approach and POEM, or it may lead to a synchronous or metachronous indication of the cuff construction.

Current possibilities of minimally invasive therapy of oesophageal diverticula.

Oesophageal diverticula represent a relatively rare pathology of the oesophagus requiring a specific diagnostic and therapeutic approach. Interventional therapy is indicated for symptomatic diverticula, diverticula with other pathologies (tumour in the diverticulum, gastroesophageal reflux disease, low-malignancy gastroesophageal junction tumours). The open surgical approach is being increasingly replaced by minimally invasive surgical, endoscopic and combined methods. Surgical mini-invasive methods use transaxillary, thoracoscopic or transhiatal laparoscopic approach, often with endoscopic assistance. Endoscopic and transoral surgical procedures include various diverticulotomy techniques and submucosal tunnelling techniques (variants of peroral endoscopic myotomy). The primary concern in therapy is the reduction of symptoms, improvement of the quality of life and the patient´s safety. The resulting quality of life is affected by the frequent presence of functional diseases of the oesophagus (achalasia, hypercontractile oesophagus). Although surgical minimally invasive therapy using the laparoscopic or thoracoscopic approach is safe, it nevertheless does not exclude serious risk of complications. Randomized and observational studies comparing endoscopic and surgical methods are still missing. It is, therefore, necessary to extend the records in order to update the indication algorithm of intervention therapy, focusing mainly on safety with a clear imperative for patient centralization.

Iatrogenic thoracic aortic injury in esophagectomy - a case report and literature review.

INTRODUCTION: This case report describes bleeding from an iatrogenic thoracic aortic injury in minimally invasive thoracoscopic esophagectomy. CASE REPORT: A 53-year-old man underwent neoadjuvant radiochemotherapy for adenocarcinoma of the esophagus with positive lymph nodes. PET/CT showed only a partial response after neoadjuvant therapy. Minimally invasive thoracoscopic esophagectomy in the semi-prone position with selective intubation of the left lung was performed. However, massive bleeding from the thoracic aorta during separation of the tumor resulted in conversion from minimally invasive to conventional right thoracotomy. The bleeding was caused by a five millimeter rupture of the thoracic aorta. The thoracic aortic rupture was treated by suture with a gore prosthesis in collaboration with a vascular surgeon. Esophagestomy was not completed due to hypovolemic shock. Hybrid transhiatal esophagectomy was performed on the seventh day after the primary operation. Definitive histological examination showed T3N3M0 adenocarcinoma. CONCLUSION: Esophagectomy for cancer of the esophagus is one of the most difficult operations in general surgery in which surgical bleeding from the surrounding structures cannot be excluded. Aortic hemorrhage is hemodynamically significant in all cases and requires urgent surgical treatment.

Complications and mortality of surgical therapy for esophageal cancer: 10 years single center experience.

A single-center retrospective study the complication and mortality of surgical treatment of esophageal cancer 2006 to 2015 is presented. A total of 212 patients with esophageal cancer were operated at the First Department of Surgery University Hospital Olomouc, Czech Republic in the period between 2006 and 2015. Adenocarcinoma was histologically described in 127 patients (59.9%), squamous cell carcinoma in 82 patients (38.7%), and other types of carcinoma were described in 3 cases. According to the preoperative staging of esophageal cancer, the patients with early stage disease (T1-2N0M0) had primary surgery, while the patients with advanced stage (T3-4N0-2M0) were indicated for neoadjuvant chemoradiation with the surgery being performed subsequently. Transhiatal laparoscopic esophagectomy was performed in 183 patients, and Orringer esophagectomy in 4 patients. Thoracoscopic esophagectomy was performed in 17 patients and thoracotomy in 30 patients. Respiratory failure with the development of ARDS syndrome accompanied by multiple-organ failure occurred in 21 patients. Statistically significant association between mortality and ASA (p = 0.009) and between respiratory complications and ASA (p = 0.006) was demonstrated. The majority of patients who died were under 60 years of age (p = 0.039). Further, significant association between 30-day mortality and tumor stage (p = 0.021), gender (p = 0.022) and age (p = 0.018) was evident. A significant association between tumor stage and fistula in anastomosis, (p = 0.043) was observed. Esophagectomy is a procedure, which should be performed in specialized high-volume centers experienced in treatment of this serious malignancy and by certified oncology surgeons with long time experience in esophageal surgery.

Risk factors and post-operative complications after gastrectomy for cancer.

INTRODUCTION: Gastric resections due to carcinoma belong to the most demanding procedures in visceral surgery. This is due to the requirements for the extent of resection and lymphadenectomy, coupled with the need for functional reconstruction of the digestive tract. The procedure is associated with 18-46% morbidity, which delays administration of adjuvant therapy and worsens oncological results. Identification of risk factors for potential complications may play an important role in the indication and perioperative care. The aim of our study is to (i) evaluate the morbidity a mortality of a patient group with post-gastrectomy complications and to (ii) identify associated risk factors. METHOD: This retrospective analysis comprises patients treated in 2005-2016. Gastric resection was performed in 266 adenocarcinoma patients, 172 men and 94 women (median age 66 years). Early post-operative complications following gastrectomy were observed within 60 days. Complications and their severity were evaluated according to the extended form of the Accordion Severity Grading System. Selected demographic risk factors, operative factors and malignancy-related factors were analyzed. Multivariate regression (orthogonal projections to latent structure) was used for statistical processing. RESULTS: Overall morbidity and mortality was 34.6% and 3.4%. Serious complications occurred in 51 operated patients (19.2%). 24 patients had two or three complications (9%). The most common grades of severity were grade 2 in 31 patients (11.7%) and grade 4 in 20 patients (10.9%). The duration of hospital stay correlated with the severity of the complication. Most common surgical complications were: intra-abdominal abscess (16.4%, 17 cases), wound complications (5.3%, 14 cases), pancreatitis (4.9%, 13 cases), anastomotic leakage (3.4%, 9 cases), postoperative ileus (3.4%, 9 cases). Respiratory and cardiac complications were the most common non-surgical complications (8.6%, 23 cases and 3.8%, 20 cases, respectively). In the derived statistical model, BMI, the presence of more comorbidities, lesser surgical experience, the length of hospital stay and hospitalization at ICU were identified as risk factors associated with the grade of complication, morbidity, presence of serious complication and multiple complications. CONCLUSION: Gastrectomy plays a fundamental role in the curative treatment of gastric carcinoma; it is, however, associated with substantial morbi-dity and mortality. The best management of complications is their prevention. Preoperatively, the greatest attention should be paid to patients with several comorbidities and higher BMI. Resections should be performed by experienced surgeons. During resection, consideration should be given to the extent of resection and lymphadenectomy. In the postoperative period, the length of hospital stay, especially at ICU, should be reduced to minimum. Analyses of these risk factors may decrease the incidence of complications. Key words: gastric cancer - gastrectomy - risk factors - complications.

The use of retrosternally placed colon in esophageal replacement.

The authors present a review article evaluating the use of the colon as a replacement for the esophagus. We present current indications for both benign and malignant conditions and compare the advantages and disadvantages of the technical possibilities of esophageal reconstruction. The surgical technique utilizing the vascular bundle of the left colic artery and retrosternal location of the colonic conduit is discussed and documented in detail. Furthermore, we describe both early and late complications, including their management. We conclude that the colon is a safe technical possibility for esophageal replacement with satisfactory early and long-term results in cases where gastric conduit is not available. Key words: esophageal replacement with colonic interposition - esophageal replacement complications - colon interposition for esophageal replacement technique - coloplasty - esophageal replacement surgery.

Successfull therapy of grade III leak after thoracic oesophagectomyusing endoscopic vacuum assisted closure therapy - a case study.

INTRODUCTION: Post-oesophagectomy leakage occurs in 1-30% of cases as a significant factor in postoperative morbidity and mortality, accounting for 40% of postoperative deaths. Endoscopic vacuum therapy (EVAC) is, besides stent therapy, clips and surgical therapy, a new endoscopic thera-peutic modality. CASE REPORT: A 72-year-old polymorbid female patient with Siewert type II adenocarcinoma of the distal esophagus (T1b, N0, M0) was indicated for resection of the upper stomach and lower thoracic esophagus from laparotomy and thoracotomy with reconstruction using double-stapling anastomosis. On postoperative day 12, a 3rd degree leakage with propagation into the right pleural cavity was proven on CT. Endoscopy showed a defect affecting 30% of the circumference with a 7×3×3 cm cavity. Because of the leak morphology, EVAC was indicated. The therapy comprised 12 sessions with 3-4-day intervals for a total duration of 40 days with 5 extraluminal and 7 intraluminal applications and negative pressure of 100-125 mmHg. The condition was complicated by global respiratory failure due to severe pneumonia. Artificial ventilation was terminated on the 58th postoperative day. The patient was discharged to a rehabilitation facility on the 90th postoperative day. The follow-up 3 months after discharge confirms satisfactory performance results with full replenishment. CONCLUSION: The therapy of complications of intrathoracic anastomoses after oesophagectomy has shown a trend toward reduced invasiveness and wider implementation of endoscopic methods. In spite of its shortcomings, the use of EVAC is a safe and highly effective therapeutic option even for extensive anastomotic defects. The future use, indications as well as relation to other therapeutic options require further evaluation. Key words: endoscopic vacuum therapy - esophageal leakage - esophagectomy complications - intraoperative endoscopy.

Esophageal cancer results of surgical treatment at the Department of Surgery I. at the University Hospital Olomouc.

The authors present the results of surgical treatment of esophageal cancer at Department of Surgery I, University Hospital Olomouc between 20062016. The aim of the study was to use retrospective analysis to evaluate the results of patients operated for esophageal cancer and statistically evaluate the results based on the type of surgical approach (transhiatal, transthoracic). Method: A total of 240 patients with esophageal cancer were operated at Department of Surgery I between the beginning of 2006 and the end of 2016. We evaluated respiratory complications, the incidence of anastomotic fistula and complications based on the Clavien-Dindo classification of complications, based on the type of surgical approach selected (transhiatal or transthoracic esophagectomy). Results: The patient set included 207 men (86.3%) and 33 women (13.7%). The mean patient age was 60.4 years. The histological type was adenocarcinoma in 145 (60.4%) and squamous cell carcinoma in 90 (37.5%) patients; another type of carcinoma was observed in 5 cases. Transhiatal esophagectomy was performed in 194 patients (80.2%) (transhiatal laparoscopic in 190 and classic Orringer in 4 patients). Transthoracic approach was used in 46 patients (19.2%), thoracoscopic in 16, and thoracotomic in 30 patients. A gastric conduit was used in 236 patients and coloplasty was performed in 4 patients. The mean duration of surgery was 217 min for the transhiatal approach, 239 min for the thoracoscopic approach and 277 min for the thoracotomic approach. Total blood loss per patient was 562 ml on average for all the operated patients. Peri- or postoperative blood transfusions were administered to 148 patients. Lymphadenectomy was performed as part of the procedure in all patients; the mean of 16.1 lymph nodes were removed. The average hospital stay was 20.7 days. In the patient set, 30-day mortality included 12 patients (respiratory complications 10, MI 1, conduit necrosis 1) and 90-day mortality included 4 (multi organ failure during ARDS). Based on statistical analysis, the incidence of respiratory complications significantly correlated with ASA classification (p=0.0001) and Clavien-Dindo classification (p.

[Multiple organ resection for extensive lymphoma in the abdominal cavity]. / Multiorgánová chirurgická resekce pro rozsáhlý lymfom dutiny brisní.

Extranodal lymphomas are quite rare, and they usually present as non-Hodgkin lymphomas. The most common localization is the gastrointestinal tract, mainly the stomach - primary gastric lymphoma; histologically, diffuse large B-cell lymphoma (DLBCL) is the most frequent type. The diagnosis is established based on endoscopic examination with biopsy of the tumor. It is an aggressive tumor, highly chemosensitive, which is why primary systemic chemotherapy is indicated in early, as well as late, stages of the disease. Surgery is indicated to treat complications such as perforation, bleeding or gastrointestinal obstruction. The authors present the case of a chemoresistant patient with hemodynamically significant bleeding, indicated for surgical revision after unsuccessful endoscopic treatment. Multiple organ resection was performed due to the large size of the tumor in the abdominal cavity.Key words: gastric lymphoma - surgical treatment.

[Proximal gastrectomy for adenocarcinoma of the gastroesophageal junction in a selected set of patients immediate and long-term results]. / Proximální gastrektomie u selektovaných pacientu s adenokarcinomem gastroezofageální junkce, bezprostrední a dlouhodobé výsledky operacní terapie.

INTRODUCTION: The authors present the results of surgical resection in the form of proximal gastrectomy in a selected set of patients with adenocarcinoma of the gastroesophageal junction. The selection criteria included: ASA III-IV, internal comorbidities and elderly patients. METHODS: Between 2007 and 2015, 28 patients with adenocarcinoma of the gastroesophageal junction underwent proximal gastrectomy at the 1st Department of Surgery. The patient set consisted of 19 (67.8%) men and 9 (32.3%) women aged 5289 years with the median age of 72.5 years. Endoscopic examination revealed a tumour of the gastroesophageal junction, which was evaluated according to the Siewert classification: type I was present in 4 (16.7%) cases, type II in 12 (42.3%), and type III in 12 (42.3%). Histological analysis revealed adenocarcinoma in all cases. Proximal gastrectomy with lymphadenectomy was performed in all patients. Splenectomy was performed in eleven patients. The continuity of the gastrointestinal tract was ensured by esophagogastroanastomosis, and pyloromyotomy was performed as a standard procedure. Cryostatic examination revealed positive resection margins in the esophagus in five patients, which led to the resection of the distal esophagus from the right-sided thoracotomy. RESULTS: Injury to the biliary tract was observed in one case in the perioperative period, which was treated by hepaticojejunoanastomosis onto an excluded jejunal loop. The following complications were observed postoperatively: bleeding, respiratory complications, anastomotic dehiscence, laparotomy wound dehiscence, and inflammatory infiltration in the abdominal cavity. Thirty-day mortality was 10.7% in our patient set. CONCLUSION: Proximal gastrectomy with lymphadenectomy is an appropriate alternative for polymorbid patients with adenocarcinoma of the gastroesophageal junction and provides good short- and long-term results.Key words: cancer of gastroesophageal junction proximal gastrectomy complications of therapy.

[Tumor cells transfer between the patient and laboratory animal as a basic methodological approach to the study of cancerogenesis and identification of biomarkers]. / Transfer nádorových bunek mezi pacientem a laboratorním zvíretem jako základní metodický prístup ke studiu kancerogeneze a identifikace biomarkeru.

INTRODUCTION: The investigation of prognostic and predictive factors for early diagnosis of tumors, their surveillance and monitoring of the impact of therapeutic modalities using hybrid laboratory models in vitro/in vivo is an experimental approach with a significant potential. It is preconditioned by the preparation of in vivo tumor models, which may face a number of potential technical difficulties. The assessment of technical success of grafting and xenotransplantation based on the type of the tumor or cell line is important for the preparation of these models and their further use for proteomic and genomic analyses. METHODS: Surgically harvested gastrointestinal tract tumor tissue was processed or stable cancer cell lines were cultivated; the viability was assessed, and subsequently the cells were inoculated subcutaneously to SCID mice with an individual duration of tumor growth, followed by its extraction. RESULTS: We analysed 140 specimens of tumor tissue including 17 specimens of esophageal cancer (viability 13/successful inoculations 0), 13 tumors of the cardia (11/0), 39 gastric tumors (24/4), 47 pancreatic tumors (34/1) and 24 specimens of colorectal cancer (22/9). 3 specimens were excluded due to histological absence of the tumor (complete remission after neoadjuvant therapy in 2 cases of esophageal carcinoma, 1 case of chronic pancreatitis). We observed successful inoculation in 17 of 28 tumor cell lines. CONCLUSION: The probability of successful grafting to the mice model in tumors of the esophagus, stomach and pancreas is significantly lower in comparison with colorectal carcinoma and cell lines generated tumors. The success rate is enhanced upon preservation of viability of the harvested tumor tissue, which depends on the sequence of clinical and laboratory algorithms with a high level of cooperation.Key words: proteomic analysis - xenotransplantation - prognostic and predictive factors - gastrointestinal tract tumors.

[Postpancreatectomy haemorrhage (PPH), prevalence, diagnosis and management]. / Krvácení po pankreatektomii (PPH), prevalence, diagnostika a resení.

INTRODUCTION: Postpancreatectomy haemorrhage (PPH) is considered to be the most severe specific postoperative complication following pancreatic resections and its treatment is difficult and requires coordinated interdisciplinary collaboration. PPH causes 11-38% of all post-pancreatectomy deaths. The aim of this study was to determine the prevalence of PPH in a set of patients operated on within the last 10 years, and to analyze the diagnostic methods, treatment modalities and the outcomes. METHODS: A retrospective analysis of patients undergoing pancreatic resections between 2006 and 2015. Clinically relevant PPH (types B and C) were the subject of interest. The onset, location and severity of PPH were analysed. Other factors analysed included operation diagnosis of PPH, diagnostic methods along with signs of sentinel bleeding, treatment options undertaken including the number of transfusions. 30-day, 90-day and in-hospital mortality, as well as the length of hospital stay and readmission rate were calculated. A descriptive statistical method was used. RESULTS: A total of 449 patients were operated on. Pancreatoduodenectomy (DPE) or pylorus-preserving pancreatoduodenectomy (PPPD) was done in 76.4%, left sided pancreatectomy (LPE) in 19.8% and total pancreatectomy (TPE) in 3.8%. 190 of the patients (42.3%) were women and 259 (57.7%) men, with the mean age of 61.5±11.1 years. A total of 23 (5.1%) PPH cases were identified, 21 (4.7%) were clinically relevant. Eight patients (35%) developed early PPH with direct reoperation, late PPH was seen in 14 patients after DPE and in one after LPE. Sentinel bleeding was present in 53.3% of late PPH cases. CT/CTA was performed in four patients with subsequent DSA performed in three. DSA identified a gastroduodenal artery stump pseudoaneurysm in one patient, which was resolved using a stent. Surgical intervention for late PPH was required in 10 patients in total, six of whom needed direct surgery due to the rapid development of circulatory instability and 3 due to inconclusive radiological management. One patient needed surgical drainage of both an abscess and haematoma. In two patients the origin of bleeding was due to a gastric ulcer, which was proven and solved endoscopically and 2 patients required conservative treatment only. The specific mortality for PPH was 17.4%. In the group of patients that suffered with any PPH following DPE and PPDPE the mortality rate was 22.2%, and 28.6% for late PPH. If late PPH developed coincidentally with postoperative pancreatic fistula (POPF), the mortality was 44%. In the early PPH group, an average of 10.1±2.5 transfusion units (TUs) were used with an average length of hospital stay 17.5±4.8 days and zero mortality in comparison to an average of 11.7±10 TUs and 29.9±14.6 days in hospital and 26.6% mortality in the late PPH group. CONCLUSION: PPH is a severe complication, which has a high mortality rate. It also often coincidentally develops with POPFs. Early clinical diagnosis with identification of its cause plays a key role in management. The use of interventional radiology in the treatment of PPH has begun to dominate other treatment modalities due to a very high success rate, and close collaboration with interventional radiologists is necessary in order to reduce the rate of surgical intervention required in PPH. KEY WORDS: haemorrhage - pancreas - resection - complications - mortality.

The benefit of PET/CT in the diagnosis and treatment of esophageal cancer.

INTRODUCTION: To evaluate the significance of PET/CT for the initial staging of esophageal cancer with emphasis on metastatic lymph node affection and detection of distant metastases. Furthermore, the aim of the work was to analyze the significance of PET/CT examination when evaluating the effect of neoadjuvant therapy. METHODS: A set of 354 patients with esophageal cancer treated at the 1st Department of Surgery, University Hospital Olomouc and Medical Faculty at Palacky University in Olomouc between the years 20062012 were analyzed in a prospective study. The initial PET/CT examination was performed in 349 patients. We analyzed the benefit of this examination in regard to disease staging and based on the result, therapeutic strategy was determined. The initial PET/CT showed varying degrees of disease generalization in 102 patients, these patients were indicated for palliative or symptomatic therapy. In 247 patients, the disease was limited only to the esophagus and /or regional lymph nodes. After considering the patients overall condition and taking into account the wishes of the patient, 188 patients were indicated for neoadjuvant chemoradiotherapy (CRT); 32 patients did not complete this treatment. In 156 patients a follow-up PET/CT scan was performed after an average of 8.4 weeks following completion of neoadjuvant therapy. Based on this examination, a complete response- CR, was observed in 38 patients (24.4%), regression of the tumor in 89 (57.0%), stationary findings were seen in 10 (6.4%), and progression in 19 (12.2%). Ninety-seven patients were indicated for surgical resection; however, esophagectomy was only possible in 85 patients, in the remaining 12 patients only an explorative laparotomy was performed due to disease progression. RESULTS: The initial PET/CT examination performed in 349 patients correctly described the extent of the disease in accordance with the histologically confirmed diagnosis in virtually all patients. A false positive result was seen in only 5 patients (1.43%). When evaluating the effect of neoadjuvant therapy, the patients were divided into groups based on the findings of the follow-up PET/CT after neoadjuvant therapy and their overall survival was evaluated. A significant difference (p=0.0004) in survival was observed between the groups based on the different reactions to neoadjuvant therapy (CR (n=38), regression (n=89), stationary findings (n=10), progression (n=19)) without taking into account the following treatment the patient received after neoadjuvant therapy. Patients who had a better response to neoadjuvant therapy had better survival results. There was also a significant difference in survival between the group of patients who completed neoadjuvant therapy and underwent radical surgical resection (n=85) versus those patients who completed neoadjuvant therapy but did not undergo subsequent surgery (n=59). The operated group had a significantly higher overall survival (p=0.003). The longest mean survival, 38.6 months (median 29.0 months), was achieved by the group of patients who completed neoadjuvant therapy, showed a complete response on the follow-up PET/CT, and underwent surgical resection. However, a significant difference was not observed (p=0.587) between the groups who underwent surgical resection and whose follow-up PET/CT results differed (regression or stationary findings). To date, the number of cases in the individual groups is not great enough to consider the obtained results conclusive, and we will continue to include more patients into the study and continue with the analysis. CONCLUSION: The work documents the significance and benefit of PET/CT in the initial staging of esophageal cancer, especially in detecting metastatic disease- positive lymph nodes as well as distant metastases. PET/CT has great importance in determining therapeutic strategy. Furthermore, the significance of PET/CT in evaluating the effect of neoadjuvant therapy was also studied.Key words: esophageal cancer PET/CT neoadjuvant therapy esophagectomy.

[Pancreatic metastases--diagnosis, radical surgery, complications and survival]. / Metastázy do pankreatu--diagnostika a moznosti radikální lécby, komplikace, prezívání.

INTRODUCTION: Although generally uncommon, pancreatic metastases are increasingly encountered in clinical practice. The benefit of pancreatic resections in this setting is unclear and still being discussed. Renal cell carcinoma is the most frequent primary tumour metastasing to the pancreas--R0 resections in cases of solitary metastases can be performed. Resections in malignant melanoma and ovarian cancer are rather considered as palliative. The aim of this study is to analyse our own set of patients operated on for metastases into the pancreas and evaluate the results of their surgical treatment. METHODS: We identified the patients operated on for metastases to the pancreas. Patient and tumour characteristics were summarized using descriptive statistics. RESULTS: A total of 9 patients (out of 312 patients undergoing resection for malignancy in the period of 2006-2014) with pancreatic metastases were analysed. All but one were asymptomatic; the symptomatic patient suffered from GI bleeding. All patients had a metachronous lesion with a median length of 12 years (421 years) between the initial operation and pancreatic resection. The most common metastasing tumour was renal cell carcinoma (77%) with the highest incidence occurring at the head of the pancreas (44%). The most frequent procedure used was the pylorus-preserving pancreatic head resection (44%). The median operating time was 247 min, (126375 min). Six patients were complication free, the median of their hospital stay was 9.5 days (812 days). Complications included PPH type C and PF type B both of which required surgical intervention; however, PF type A required no intervention. No postoperative deaths occurred, multiple metastases were found in 4 patients with renal cell carcinoma metastases. The median of follow-up has been 11.5 months, (334 months). CONCLUSION: Survival after pancreatic resections due to renal cell carcinoma is favourable. Mortality is low and morbidity is similar to that associated with pancreatic resections due to other aetiologies, making surgery a valid and safe treatment option. Lifelong follow-up of patients after nephrectomy is advised. Resections in pancreatic metastases of malignant melanoma or ovarian carcinoma are considered as palliative, their indication being individual following interdisciplinary consultation.

[Synchronous cancer duplicities of pancreas and stomach/kidney and their surgical treatment]. / Synchronní nádorové duplicity pankreatu a zaludku/ledviny a jejich lécba.

INTRODUCTION: The occurence of synchronous pancreatic cancer and other primary cancer is not frequent and reaches about 5.6% as reported in autoptic studies. Double resections of the pancreas with another organ due to synchronous malignancies have been published only in quite sporadic sets of cases or individual case reports. The authors present three cases of synchronous pancreatic malignancies and stomach or renal cancers treated with surgery, including results and survival. CASES: Three patients with synchronous double cancer were identified in a series of 400 pancreatic resections (20062014). Two patients presented with symptoms of pancreatic periampullary tumors (bile duct obstruction, weight loss and abdominal pain). The second malignancies were identified as incidental during diagnostic work-up (asymptomatic cancer of the stomach, kidney). Pancreatoduodenectomies (PDE) with lymphadenectomies were performed due to ductal adenocarcinomas (pT2N1M0 G3 and pT3N1M0 G2). The second procedures included subtotal gastrectomy with lymphadenectomy (gastric adenocarcinoma pT1N1M0, G2) and nephrectomy (renal papillary carcinoma pT1bN0M0, G3). Postoperative adjuvant chemotherapy with gemcitabine was given in both patients. Survival rates were 12 and 19 months, respectively. The third patient suffered from abdominal pain and weight loss. Diagnostic work-up revealed stomach carcinoma and early pancreatic adenocarcinoma. Double resection - subtotal gastrectomy with lymphadenectomy and pancreatoduodenectomy with lymphadenectomy - was performed. Gastric adenocarcinoma pT2N2M0, G3 and pancreatic ductal papillary-mucinous adenocarcinoma pT2N0M0, G1 were found in the specimens. Adjuvant radiochemotherapy with 5-fluorouracil and leukovorine was given postoperatively. This patient is still alive nearly 5 years after the surgery, without any reccurence. CONCLUSION: The survival of patients with double synchronous pancreatic malignancies and other primary tumors in our set seems to be influenced by the stage and biology of pancreatic cancer. The survival was worse when the duplicity was presented with symptoms of pancreatic cancer. Pancreatic cancer found incidentally when another malignancy is presented has more favourable results.

[Surgical therapy of pancreatic cancer - 5 years survival]. / Resekabilní karcinom pankreatu 5leté prezití.

INTRODUCTION: The purpose was to identify 5-year survivors among a group of radically resected patients with pancreatic cancer and analyse the characteristics and factors associated with their 5-year survival. Single tertiary centre experience. METHOD: A prospectively maintained database of 155 pancreatic resections from January 2006 to June 2010 was scanned to identify patients after curative radical resections for pancreatic ductal adenocarcinoma. The clinical and pathological data was analysed retrospectively. The outcomes of the PDAC group were evaluated using Kaplan-Meier analysis (survival) with the Log-rank test and Cox regression analysis (evaluation of prognostic factors). Characteristics of the survivors were discussed. Significance level of 0.05 was used. Those factors were used as independent variables for Cox regression analysis whose significant effect on survival was shown based on Kaplan-Meier analysis. RESULTS: Among 155 patients undergoing a curative pancreatic resection, 73 had a pancreatic ductal adenocarcinoma. Fifteen patients (20.5%) after radical surgery survived over 5 years, 13 of whom are still alive. In the group of the survivors, the mean overall survival was 77.1 months (60110) and the median survival was 74 months. The mean relapse-free interval in the group of the survivors was 63.3 months (14110) with the median of 65 months. Factors associated with a longer survival included the absence of lymph node infiltration (p=0.031), uncomplicated postoperative course (p=0.025), absence of vascular invasion (p=0.017), no blood transfusions (p=0.015) and the use of postoperative therapy - predominantly chemotherapy (p=0.009). Significant independent predictors of survival included vascular invasion HR=2.239 (95%CI: 1.0934.590; p=0.028), postoperative chemotherapy HR=2.587 (95%CI: 1.3015.145; p=0.007) and blood transfusion HR=2.080 (95%CI: 1.0274.212; p=0.042). The risk of death was increased 2.2 times in patients with vascular invasion, 2.1 times in patients with transfusions, and finally 2.6 times in those with no chemotherapy. CONCLUSION: Factors associated with an improved overall survival included: the absence of lymph node infiltration, an uncomplicated postoperative course, absence of vascular invasion, no need of blood transfusions, and finally the use of postoperative chemotherapy. Vascular invasion, use of blood transfusions and postoperative adjuvant chemotherapy were significant independent prognostic factors of survival.

[Results of limited resection of carcinoma of the gastroesophageal junction]. / Výsledky limitované resekce karcinomu gastroezofageální junkce.

INTRODUCTION: The authors present results of surgical therapy in adenocarcinoma of gastroesophageal junction. MATERIAL AND METHODS: The patient set included 14 patients, 7 men and 7 women. The average age of the patients was 72 years. The study only included patients in initial phases of malignant disease, according to EUS category T1, 2, N0. PET/CT ruled out generalization in all patients. Another criterion for this type of resection was general polymorbidity and older patient age. Resection of gastroesophageal junction and lymphadenectomy were performed in all patients. Splenectomy was performed in six patients. Reconstruction of the upper part of the GIT was performed by esophagogastroanastomosis; pyloromyotomy was standard procedure. In two cases resection of the distal esophagus was performed from a right thoracotomy. RESULTS: No serious complications were observed during the operation. In one patient a cholecystectomy was performed for empyema of the gallbladder together with the resection of the GE junction during which injury of common bile duct occurred. A hepaticojejunostomy was performed. Fistula in anastomosis after the operation was described in four patients, conservative therapy was successful in two cases, in one case surgical treatment was necessary. One woman patient died after fistula complications with development of septic shock and pulmonary failure. CONCLUSION: Resection of the gastroesophageal junction is surgical therapy for patients in initial stages of adenonocarcinoma of the GE junction if the required criteria of RO resection are fullfilled.

[Endosonography of the oesophagus in the diagnosis and treatment of oesophageal tumours]. / Endosonografie jícnu v diagnostice a lécbe tumoru jícnu.

Endoscopic ultrasound examination (EUS) in oesophageal tumours is a widely used method with the need for further study of its benefits and indication. EUS plays an important role in the staging and management of further therapy. Following on from current world literature, we review the current importance of EUS in oesophageal tumours. We point out contemporary technical possibilities and comment on the importance of endosonography for early oesophageal carcinoma management, T-staging of primary tumour, benefits for N-stage diagnosis, the potential for the detection of generalised disease in comparison with CT and PET/CT, and the possibilities of histological evaluation. We mention in particular the impact of EUS on mesenchymal oesophageal tumour management. We consider EUS to be the golden standard for submucosal oesophageal tumour diagnosis. EUS has a special importance for early oesophageal carcinoma evaluation and the detection of celiac trunk lymph node involvement. Furthermore, EUS is a complementary method for higher-stage oesophageal carcinoma diagnostics. The benefits of the method, however, need further scientific evaluation. Key words: oesophageal endoscopic ultrasound - early oesophageal carcinoma - oesophageal carcinoma staging - submucosal oesophageal tumour.

[Gastric carcinoma--rates and management of surgical treatment complications]. / Karcinom zaludku--výskyt a resení komplikací chirurgické lécby.

The authors present a study on rates and management of complications of gastric carcinoma surgeries. During a five-year period, a total of 149 patients with gastric carcinomas were operated in the Ist Surgical Clinic (Charles University Faculty Hospital). Radical resections were performed in 121 subjects. In 7 subjects, upper pole resections were performed. 21 subjects underwent paliative therapy or surgical exploration. In the authors' study group, no serious perioperative complications were recorded. The following postoperative complications were observed: fistulas in esophagojejunal anastomosis (8x), duodenal stub fistula (lx), subphrenic abscess (2x), adhesive ileus (1x). In two subjects, esophagojejunal stricture was diagnosed during the late postoperative period. Incisional hernia was diagnosed in two subjects. Two subjects exited- the first one from respiratory failure with ARDS syndrome in esophagojejunal dehiscence, the second subject died of hepatorenal failure in liver cirrhosis. Complications cannot be excluded in any surgical procedure. Should they occur, their timely diagnosis and adequate treatment is required.

[Video-assisted esophageal resection for carcinoma--ten-year experience]. / Videoasistovaá resekce jícnu pro karcinom--desetileté zkusenosti.

INTRODUCTION: Esophageal procedures belong to the most complicated gastrointestinal procedures. Therefore, esophageal carcinoma patients have been and still are concentrated into specialized centres, equipped with all diagnostic and therapeutic means. At the Ist Surgical Clinic of the LF UP (Medical Faculty of the Palacky University) in Olomouc, esophageal surgery has a long lasting tradition. In the management of malignant esophageal disorders, the clinic prefers the use subtotal esophageal resection, attaching the esophagus transplant to a cervical esophageal stud, to the use of more saving resection with the anastomosis site in the mediastinum. In order to substitute for the resected esophagus, the authors normally use a tubulized gastric flap. In cases, where the stomach cannot be used, the authors use transverse colon to replace the resected esophagus. Classical esophageal procedures have nearly entirely been replaced by video-assisted procedures. Most esophageal resections are performed using video-assisted laparoscopic transhiatal approach. In the management of esophageal tumors which are located at the level of tracheal bifurcation, or below it, the authors use right- sided thoracoscopic approach. MATERIAL AND METHODS: During the past 10 years, 178 patients have undergone subtotal esophageal resection for esophageal carcinoma. In 81 patients (45.5%), the esophagus was resected using classical approach. 35 subjects underwent transhiatal "blind"extirpation according to Orringer, in 46 subjects right-sided thoracotomy was used (subjects with tumors located in the middle third of the thoracic esophagus and higher). Video-assisted approach was used in 97 patients, which included 88 subjects with laparoscopic transhiatal modification of the procedure and 9 subjects, who underwent video-thoracoscopy. OUTCOMES: The mean procedure duration was 242 minutes. The authors recorded the following complications: pneumothorax in 29 patients (16%) and n. laryngeus recurrens palsy in 16 subjects (9%). 13 patients (7%) developed a fistule in anastomosis, which was managed by drainage of the cervical wound. Pulmonary complications were recorded in 55 patients (31%). The mean duration of hospitalization was 12 days, intraoperative death rate was 4.5%. Only 2 out of 8 deaths occurring during the early postoperative period, were surgery-related. In the both cases, mediastinitis developed, resulting from a transponate necrosis in one of the cases and from a bronchial fistule in the other subject. Five subjects exited because of ARDS, which included one case of myocardial infarction. CONCLUSION: When esophageal carcinoma is managed at a clinic equipped with the latest modern diagnostic and therapeutical means, the procedure of esophageal resection is a fairly safe procedure with low death and morbidity rates.