Endoscopic pilonidal sinus treatment (E.P.Si.T.) - first experiences and results.

INTRODUCTION: The aim of our article is to present the results and experience with the method E.P.Si.T. - endoscopic pilonidal sinus treatment. METHODS: The operation is performed using a special endoscope - fistuloscope. In the first phase, we determine the extent and look for all the sinus tracts. In the second phase, the whole complex  is treated with a grasper, a brush and an electrode from the inside. RESULTS: A total of 21 operations were performed at our department from December 2018 through September 2019. In our sample, men predominated  6:1. Mean age of the patients was 27 years. Complete healing was achieved in 18 patients. Two patients were not healed primarily. One patient was lost to follow-up. CONCLUSION: According to the first experience and results, the E.P.Si.T. seems to be a very good method for treating pilonidal sinus. Compared to open procedures, the length of hospitalization, the need for analgesics and antibiotics were significantly reduced. The period of convalescence was shortened and the return to normal life was faster. The size of the cohort and the duration of post-operative follow-up do not allow us yet to statistically evaluate the results.

Is There a Benefit of HER2-Positive Breast Cancer Subtype Determination in Clinical Practice?

BACKGROUND: Breast cancer (BC) with increased expression of human epidermal growth factor receptor 2 with tyrosine kinase activity (HER2+) is a clinically and bio-logically heterogeneous dis-ease. In terms of gene expression, there are four major molecular subtypes - Luminal A, Luminal B, HER2-enriched (HER2-E), and Basal-like. The most common subtype is HER2-E (50- 60%). In hormone-dependent (HR+) HER2-positive tumors, the subgroup HER2-E represents 40- 50% of cases; others are luminal A and B subtypes. PURPOSE: The aim of this review is to provide information on the significance of the distribution of HER2-positive tumors accord-ing to subtype, which is considered a predictive parameter for guid-ing treatment decisions. For example, HER2-E subtype is characterized by a higher probability of achiev-ing complete pathological remission when treated with chemother-apy and antiHER2 ther-apy, and it is thought that it could be treated us-ing a dual HER2 blockade without chemother-apy. Currently, triple-positive tumors, a specific subtype of breast cancer characterized by HER2+ and HR+, are more often subjects of interest. Their unique bio-logical properties are due to complex interactions between HER2 and estrogen receptor (ER) signalling, which result in lower effectiveness of endocrine ther-apy in these patients than in HR+ and HER2-negative patients and, at the same time, the ER positivity in HER2+ tumors can result in resistance to antiHER2 ther-apy. This type of BC is a non-homogeneous group where the impacts of HER2 positivity on tumor malignant behavior and activity of the estrogen-driven signal-ing pathway are inconsistent. Current studies focus on test-ing new treatments such as dual HER2 block-ing or immunother-apy, in combination with antiHER2 targeted ther-apy with fulvestrant, aromatase inhibitors, cyclin dependent kinase 4/ 6 inhibitors, or inhibitors of the PI3K (phosphatidylinositol-3-kinase) pathway. CONCLUSION: The distribution of HER2+ BC accord-ing to individual subtype provides information that can contribute to achiev-ing more accurate decisions about the most appropriate ther-apy. Key words breast cancer - subtype - HER2 - trastuzumab - HER2 positive - triple positive - HER2 enriched The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers. Submitted: 27. 9. 2018 Accepted: 26. 11. 2018.

[Obstructed defecation syndrome - review article]. / ODS Obstrukcní defekacní syndrom - souhrnné sdelení.

INTRODUCTION: Obstructed defecation syndrome (ODS) is one of the main causes of primary constipation. It is caused by anatomical disorders in the pelvic floor region (rectocoele, en-terocoele, rectal intussusception, rectal prolapse), but it always occurs in combination with a functional defect of defecation. This review provides a comprehensive view of the diagnosis and treatment of the syndrome. METHOD: Treatment may be conservative or surgical. Conservative treatment involves a complex of approaches to the practice of defecation, regime and dietary measures together with pelvic floor rehabilitation and psychological support. The symptoms of ODS persist in some patients despite conservative treatment and this is why these patients are eligible for surgery. Surgical approaches can be divided into transvaginal, transabdominal and transanal. Transanal procedures, associated with good short-term results and low complication rates, are used most frequently. Long-term results are still under discussion. CONCLUSIONS: Since ODS is caused by the combination of functional and anatomical disorders, treatment has to be targeted at a wide range of causes. Therefore, only a multidisciplinary approach as well as a combination of conservative treatment and strictly and correctly indicated surgical procedures can lead to good long-term results.Key words: ODS - rectocoele - intussusception - STARR.

[Different impact of the laparoscopic and laparotomic approach on the immune response induced by surgical procedure]. / Rozdílný dopad laparoskopické ho a laparotomického prístupu na imunitní odpoved' navozenou chirurgickým zákrokem.

INTRODUCTION: The laparoscopic approach has been adopted to treat gastrointestinal tract malignities over the last decade. This approach has become a routine method. The laparoscopic approach has been proven to provide better short-term results. Its long-term results are similar. There has also been research into the affection of the local and systemic immune reaction following surgical procedures. Available findings reveal demonstrably diminished negative impacts on the systemic immune response after laparoscopic procedures. The research papers dealing with local immunity are only experimental and their results are heterogeneous. AIM: To give a literature review of the influence of a surgical procedure on the systemic and local immune response and to focus more closely on the comparison the immune response after laparoscopic and laparotomic approaches. REVIEW: Authors provide a summary of current knowledge and studies which deal with the affection of the immune system by surgical procedures. The summary is dividend into parts discussing systemic and local immune responses. The role of macrophages is elaborated on in detail depending on the type of surgical approach. The results and the above-mentioned of experimental studies and their possible impact on clinical practice are subjected to critical analysis. CONCLUSION: A great majority of studies support the hypothesis that the laparoscopic approach leads to less systemic immunosuppression and thus to the lower risk of the malignant spread of disease. Comparison of the impacts of laparoscopy and of open procedures on the local immune response has not been resolved yet.

[Peripheral nerve injury during laparoscopic procedures]. / Poranení periferních nervu pri laparoskopických operacích.

Laparoscopic approach predominates in almost all surgical procedures. In comparison with classical surgery the laparoscopic procedures are more considerable for most tissues. Nevertheless, after learning of laparoscopic surgical techniques, iatrogenic peripheral nerve lesions still occure. The authors present a review of the most frequent laparoscopic operations and occurrence of peripheral nerve injuries in particular procedures. They try to point to the situations leading to iatrogenic lesions, to identify different causes of nerve damage and to deduce necessary preventive measures.

[Gastrointestinal stromal and other mesenchymal gastric tumors--laparoscopic management?]. / Gastrointestinální stromální a jiné mezenchymilni tumory zaludku--laparoskopické resení?

INTRODUCTION: This study was aimed to evaluate a set of gastrointestinal stromal tumors (GIST) of the stomach managed with a laparoscopic technique (GIST). MATERIALS AND METHODS: The study covers a period from January 1,2007 until December 31, 2009 during which 12 patients underwent the laparoscopic removal of stomach tumors in the Regional Hospital in Pardubice. In all cases tumors were removed completely in a laparoscopic way, including the healthy border of the stomach tissue. The defect created in the stomach wall was sutured laparoscopically as well. On completion the sufficiency of the sutures was reviewed gastroscopically. RESULTS: No death was observed in our study. Two patients suffered from wound infection (secondary healing), one of them requiring repeat surgery owing to the excessive narrowing of the distal part of the stomach. The dehiscence of the laparoscopic suture or other intraabdominal complications was not observed. 3 patients underwent chemotherapy by Imitinib. During surveillance all patients were free of signs of tumor progression or local recurrence. DISCUSSION: Gastric GISTs are very rare tumors but their incidence is increasing. At this time the consensus about the necessity of preoperative unambiguous differentiation between malignant or less malignant variants is not available. The strict differentiation is very difficult and the determination to choose a more radical surgical approach for more malignant variants is not clear-cut. CONCLUSION: In case of gastric GIST the local removal of a tumor with the healthy border of the stomach tissue may be chosen as an adequate approach. Our results support this local surgical approach.

[The complication of a periproctal abscess--Fournièr's gangrene or necrotizing fasciitis? A case report]. / Komplikace periproktálního abscesu--Fournièrova gangréna nebo nekrotizující fasciitida? Kazuistika.

INTRODUCTION: Periproctal abscess is a routine diagnosis of everyday surgical practice. Fournièr's gangrene with progress to the sepsis is one of the most serious complication of this disease. CASE REPORT: The authors present a case review of fulminant surgical infection run as a Fournièr's gangrene and a necrotizig fasciitis of a right lower limb and body with the progress of severe septic status, which started on the strength of a contusion with formation of a periproctal absceding haematoma. A patienthood led to the long-term intensive care with a necessity of multiple surgeries and with subsequent rehabilitative care. This case is rare by the origin of thus extensive infection of soft tissue and its illustration of the heftiness of the patient's treatment with such a disease. CONCLUSION: Fournièr's gangrene and necrotizing fasciitis are loaded by a high-grade of mortality. It is one of the most serious surgical infection, which ends by death frequently. The therapy is primarily surgical, but it cannot be sufficient without aggressive intensive care of a patient.

[Inflammatory diseases of the thorax]. / Zánetlivá onemocnení hrudníku v chirurgii.

Inflammatory diseases of the thorax can affect its own lungs, pleural cavity, mediastinum or chest wall. They often complicate the treatment of traumatic injury of the thorax. Even infectious complication after intrathoracic surgery are not rare. The early removal of infectious substance (tissue, fluid) and relevant antibiotics therapy are basis of surgical treatment. This article deal about infection of the thorax in surgery and posibilities of treatment options. Contribution of well-timed surgical intervention is demonstrated on case report of patient with infectious complication after traumatic thorax injury.

[Traumatic perforation of the duodenum--a case review]. / Traumatická perforace duodena--kazuistika.

A blunt duodenal injuries are rare in spite of high-energetic injuries are common in this time. The diagnostic is very difficult not only for the reason of the little experience with this type of the injury but in term of the duodenal anatomic localization too. On the other side just late injury Identification of the retroperitoneal part of the duodenum leads to rapid development of the fatal retroperitoneal phlegmon. The development of the clinical symptoms and results of the paraclinical equipment examinations during blunt injury of the upper abdominal part with consequent perforation of the posterior retroperitoneal segment of the duodenum is well-documented by means of the mentioned case. The development of the retroperitonal phlegmon was not noticed despite of the slight diagnostic delayed and defect in the duodenal wall was treated by suture of the perforation aperture. The early detection of the duodenal injury is necessary premise for the good choice of the adequate surgical treatment.

[Natural orifice surgery. Hybrid transvaginal cholecystectomy]. / Operování prirozenými telními otvory. Hybridní transvaginální cholecystektomie.

OBJECTIVE: To review a current state of the natural orifice surgery. SUBJECT: Review article and case report. SETTING: Porodnicko-gynekologická klinika Pardubické krajské nemocnice, a.s. METHOD: The analysis of published data and case report. CONCLUSION: Natural orifice surgery makes it possible to perform intraperitoneal surgical procedures with a minimal number of access points in the abdominal wall entryways, so these procedures are hybrids. The aim is to reduce transabdominal assistance to be minimal or none at all.

[Massive hemothorax following canylation of the subcalvian vein--a case review]. / Masivní hemotorax po kanylaci v. subclavia--kazuistika.

INTRODUCTION: Cannulation v. subclavia is connected with many complications. Haemothorax is occurs approximately in 2% of cases. Surgical revision is indicated immediately if a major blood loss or a circulation insufficiency occur. Surgical treatment of bleeding in cupola of pleural cavity is due to its bad accesability difficult and conventional surgical methods aren't sufficient. In these cases one can use local haemostyptic. CASE REPORT: The authors present a case review of a 36-years old patient with a developed massive haemothorax on the left side post a catheterization of v. subclavia. During surgical revision it was found out that a source of bleeding in superior thoracic aperture is present. It wasn't able to be stopped by classical surgical procedure. TachoSil and Arista preparations were used in this case with a good effect.

[K-ras mutation as a prognostic factor in colorectal carcinoma]. / K-ras mutace u kolorektálního karcinomu jako prognostický faktor vývoje onemocnení.

INTRODUCTION: Colorectal carcinoma presents a serious problem in the Czech Republic: its incidence is on the increase and--according to some statistics takes first place among developed countries worldwide. Therefore, it is advised to incorporate examinational and the rapeutic algorithms with new modalities that will lead to early diagnostics or to a change in existing therapeutic procedures. CHARACTERIZATION OF K-RAS MUTATION: K-ras mutation belongs to the family of protooncogenes where a gene not having undergone mutation expresses proteins that regulate mitosis. Mutation cancels the regulatory function of these proteins, thus leading to the develop ment of tumors, especially carcinoma of the lungs, pancreas, and colorectum. PROJECT OBJECTIVE: The main objective of the project is to prove K-ras mutation in tumors of the colorectum: to detect tumor cells with K-ras mutation in peripheral blood; to detect K-ras mutation in liver metastases: and to verify the hypothesis claiming that tumors with K-ras mutation have a worse prognosis and often lead to disemination, mainly to the liver. METHODOLOGY AND COLLECTION OF DATA: The whole project is tied to an IGA grant and runs according to the strict rules of the protocol applied at the Surgical Clinic of the Pardubice Hospital, with its diagnostic part--PCR analysis being completed at the Biochemical Diagnostic Institute (UKBD) of the Teaching Hospital in Hradec Králové. RESULTS: The project has been running since June, 2004 to December 2006. 76 patients meeting defined parameters have been included in the file to date. K-ras mutation has been detected in the tumor tissue of 25 patients (33%). K-ras mutation hasn't been detected in the blood. DISCUSSION: Genetically analysis of a specific tumor has not yet become a standard part of the examinational and therapeutic algorithm. If an assumption of a worse course of illness and metastasizing--especially to the liver has been proven, the examination of Kras mutation in patients suffering from colorectal carcinoma should lead to the adjustment of their treatment and postoperative dispensarization, or the administration of chemotherapy and radiotherapy at stages when these modalities are not normally applied.

Preemptive antimycotic treatment in critically ill patients in the Czech Republic.

The incidence of Candida afflictions in critically ill patients is still growing in the Czech Republic. We looked for a method that not only decreases Candida afflictions but also decreases treatment expenses. This method is preemptive therapy. Critically ill patients were determined by a risk score system. This system was based on summarizing all the risk factors in one patient. Patients who reach the risk score were randomized into groups A and B. Patients in group A were administered itraconazole; patients in group B were not administered any antimycotics. Results of the study show that preemptive treatment decreases Candida infection and Candidemia. A decrease of treatment expenses was reached by identifying the specific group of patients at risk using the risk score system and administering antimycotics.

[Comparison of coated and bare metallic stents in inoperable carcinomas of the oesophagus and cardia]. / Srovnání potazených a nepotazených kovových stentu inoperabilních karcinomu jícnu a kardie.

INTRODUCTION AND AIM: The authors discuss paliative treatment using coated and bare metallic stents in a prospective randomized study for inoperable oesophageal carcinomas. The aim of this study is to assess the following parameters in both treatment groups: duration of the stents functionality, survival rates, complications rates and histological findings. METHODS: From 1999 to 2003, the total of 60 patients with oesophageal and cardial carcinomas were randomized. They had either bare (N-31 subjects) or coated (P-29 subjects) stents introduced. The patients were followed-up at one-month intervals. RESULTS: No statistical differences between the groups were found when the above parameters were assessed. DISCUSSION: The complications rate depended on the patients survival period in both stent types. Survival rates depended on the disease stage of the local tumorous process and on the individual patient's condition prior to the treatment. CONCLUSION: The study showed that the metallic selfexpandible stents treatment method may become a widely used paliative procedure in patients with malignant dysphagia, however, it has not proved any differences in complication rates depending on the stent coating.

[Do we always have the possibility to treat "lege artis"?]. / Máme vzdy moznost lécit "lege artis"?

The case-history occupies of a case of acute cardiac insufficiency in a patient at early postoperative period, who underwent a small surgical operation. Apparently the banal operation became the starting mechanism of life threatening cardiopulmonary insufficiency. Transthoracic echocardiografic diagnostic process not gave us the unambiguous response about a cause of that distressed state. The primary clinical consideration of the pulmonary embolization was not ambiguously acknowledged, though nor excluded. The clinical had to decided, whether the heparinization or the thrombolysing treatment was justified.

[Endoscopic solution of iatrogenic lesion of oesophagus]. / Endoskopické resení iatrogenního poskození jícnu.

The case report dissertates upon successful treatment of iatrogenic perforation of distal oesophagus with subcutaneous emphysema, pneumoperitoneum and pneumomediastinum. The endoclips and classic conservative treatment were used in therapy. The patient was treated 3 hours after the injury, no early or late complications related to perforation were noted.

[Surgical therapy options for bleeding gastroduodenal peptic lesions]. / Moznosti chirurgické terapie krvácejících peptických lézí gastroduodena.

INTRODUCTION: Mortality rate of bleeding into the upper GIT has remained relatively unchanged during the past 30 years, i.e. about 30%, even though the development of new technologies brought along substantial changes in diagnostic and therapeutic procedures. METHODOLOGY: This work deals with the surgical solution of bleeding into the upper GIT of peptic etiology. It covers a 5-year period (from January 1, 1999 until October 1, 2003) during which time the Regional Hospital in Pardubice admitted 1,310 patients with bleeding into the upper GIT of peptic etiology. 190 of them were hospitalized at the Surgical Clinic due to the developing hemorrhagic shock; the others were hospitalized at the Clinic of Internal Medicine. If it failed urgent endoscopy to stop the bleeding, the patient was referred to undergo an urgent surgery. If the bleeding was stopped by endoscopy yet it recurred after certain time, a second endoscopic homeostasis was attempted. If it failed, an urgent surgery was indicated. RESULTS: A total number of 24 patients underwent an acute surgery. A frequently used procedure was stomach resection, type BII, which was applied to a total number of 12 patients. However, this type of urgent surgery was accompanied with a relatively high number of complications. Reoperation had to be performed 4 times (33.3%). In one case (8.3%) for recurrent bleeding. In 12 patients one of the other procedures was performed: an injection and a trunkal vagotomy (3x), an injection and the ligation of the gastroduodenal artery (2x), proximal jejunum resection (1x), an injection accompanied with fundoplication according to Nissen-Rosseti (1x). Two of the patients who received this other group of procedures had to be reoperated for recurrent bleeding (16.7%). DISCUSSION: The decision about a suitable surgical procedure applicable to bleeding into the upper GIT after the failure of endoscopic homeostasis poses a substantial problem. It is necessary to choose from more radical procedures--resection--that stop bleeding reliably, yet their execution in an acute condition (often coinciding with the patient's hemorrhagic shock) results in a relatively large number of complications; and from less radical procedures that feature a smaller number of post-surgical complications yet that can be burdened with a larger percentile number of recurrent bleeding. Nearly the same number of serious recurrent bleeding in this study indicates that the appropriate choice of a procedure (according to the patient's current condition, ulcer localization, and associated diseases) makes both approaches (resection vs. a less radical procedure) similar as to the number of necessary reoperations after bleeding. CONCLUSION: The development of endoscopic methods introduced significant changes in the diagnostic-therapeutic algorithm of bleeding into the upper GIT. Nevertheless, the choice of an appropriate surgical procedure continues to present a relevant surgical issue.

[Complications after ERCP and their treatment]. / Komplikace po ERCP a jejich resení.

The aim of this article is to evaluate the occurrence of complications following diagnostic and therapeutic ERCP's and their treatment. It is based on data collected between January 1, 1998 and December 31, 2002, during which time period the Surgical Clinic in Pardubice completed 18 surgical procedures on patients experiencing post-ERCP complications. The article also provides an analysis of the individual types of complications, their specific surgical procedures, and the results. The discussion passage deals with the theoretical possibility of applying conservative treatment that is applicable in certain types of perforation occurrences, with special concern focused on the occurrence of fatal retroperitoneal phlegmona.

[Preemptive antimycotic therapy in critically ill patients]. / Preemptivní antimykotická terapie kriticky nemocných.

This article presents the results of the first year of the grant study that deal with preemptive treatment of yeast infection in surgical ICU. This research included patients with a large number of risk factors (ten and more). These risk factors indicated in the chart. 147 patients reached a score of ten and more points. This number was divided in two groups. In the first group there were 87 patients who received treatment of itraconazol by prescribed scheme. They were hospitalized in ICU for 11.6 days, on average. The first group did not display any positive hemoculture and also other microbial culture from intravenous cannula. No patients fell from ill candida sepsis. Itraconazol was not administered to the 60 patients, who were hospitalizated 11.8 days, on average. Positive hemoculture or yeast sepsis with connection invasive yeast infection was proven in six cases (10%). No patient died in direct connection with yeast infection in either groups. The presented results show a reduction in the number of developing yeast infections and mainly yeast sepsis in patients undergoing preemptive treatment with itraconazol.

[Dysphagia in patients with disorders of the nervous system--comparison of a nasogastric tube with percutaneous endoscopic gastrostomy]. / Dysfagie u nemocných s poruchou nervového systému--srovnání nazogastrické sondy s perkutánní endoskopickou gastrostomií.

Dysphagia is frequently encountered in patients with acute affections of the nervous system (cerebrovascular attacks, craniocerebral injuries) and in chronic nervous diseases (amyotrophic lateral sclerosis, Parkinson s disease, dementia). To these patients enteral nutrition must be administered. If the perspective of dysphagia is short (several days) then nutrition by a nasogastric tube is fully indicated and sufficient. In cases of more prolonged dysphagia and in patients with a long perspective of dysphagia percutaneous endoscopic gastrostomy (PEG) is indicated. Both these methods of enteral nutrition have their advantages and disadvantages which are manifested in different ways in patients with disorders of the nervous system. The authors compared 62 patients hospitalized in the course of 4.5 years at the neurological department who had PEG with 72 patients who had nasogastric tubes and were hospitalized at the neurological intensive care unit in the course of one year. The authors evaluated the different indications for application, the incidence of complications and the advantages and disadvantages of the two methods.