Myofibroblastic tumor of the esophagus - a case report of long-term follow-up and literature review.

BACKGROUND: Inflammatory myofibroblastic tumor (IMT) is a rare mesenchymal neoplasm with intermediate malignant potential. Although most often seen in the lungs, it can occur at multiple anatomical locations, including the gastrointestinal tract. An esophageal lesion is extremely rare, however. IMTs present most commonly in children and young adults. The main therapeutic approach is surgical resection. CASE REPORT: We report on the follow-up of a case in a 13-year-old boy with IMT in the esophagus. He underwent surgical resection in 2013 and is free of disease to date. CONCLUSION: Surgical resection is the most preferred therapy. If the resection is complete, the risk of recurrence is low. Nevertheless, every patient should be carefully followed up after the resection.

Correlation of survival length after pancreaticoduodenectomy for pancreatic head adenocarcinoma depending on tumor characteristics detected by means of computed tomography and resection margins status.

Pancreatic carcinoma is an aggressive tumor with a grim prognosis. Accurate staging is essential for indicating surgery in patients with borderline resectable tumors. This paper examines the correlation between pre-operation characteristics of tumors found on CT, infiltration of individual resection margins as confirmed by a pathologist, and the survival of patients with resectable pancreatic head ductal adenocarcinoma. This prospective cohort study involved patients operated on for pancreatic head adenocarcinoma, which was clearly resectable based on the staging CT and intraoperative observation between 2011-2014. Only patients without postoperative complications who underwent adjuvant chemotherapy were analyzed. Seventy-nine patients were assessed, of which 16 (20.3%) had R0 resection and 63 (79.7%) had R1 resection. Patients with R1 results had up to 2.7 times higher risk of death than patients with R0 resection. We found a trend towards shorter survival associated with a closer relationship of the tumor to the superior mesenteric vein/portal vein (SMV/PV) wall in the pre-operation CT examination. Patients with a tumor interface between the vein wall of up to 180 ° circumference had up to 1.97 times higher risk of death than patients without (p=0.131). The results of our work confirmed that in our center, even surgically treated, clearly resectable pancreatic head tumors still have a high occurrence of positive surgical margins (R1 resection) and that tumors with R1 resection had statistically significantly reduced survival compared to R0 resection. A trend for shorter overall survival was found after tumor resection depending on the increasing interface between the tumor and the SMV/PV wall, but this result was not statistically significant.

The role of the NOD2/CARD15 gene in surgical treatment prediction in patients with Crohn's disease.

PURPOSE: Crohn's disease (CD) belongs to chronic disorders with unpredictable disease course. The aim of this study was to identify how genetic testing (NOD2/CARD15) can be used in patients with CD to predict the need for surgical treatment (to define an aggressive type of disease where the patient can profit from early surgery). METHODS: The patients who were tested genetically had undergone a surgery due to CD at the Department of Surgery University Hospital Brno Bohunice between 2010 and 2016. The control group consisted of patients with CD who had been diagnosed with CD at least 5 years prior to the testing and had not required any surgical intervention. The second control group was healthy subjects. RESULTS: In total, there were 117 operated patients for CD, 77 patients with CD that had not undergone surgery for CD and 30 healthy subjects. For patients with at least one genetic mutation, the risk of the necessity of surgical treatment of CD is 1.96 times higher than for patients with no mutation. Patients with two or more mutations were generally operated on at a younger age, in a shorter time after being diagnosed and each patient had a partial resection of the ileum. CONCLUSION: The group of operated patients with CD had a significantly higher distribution of at least one genetic mutation as opposed to the non-operated group. In patients with two or more mutations, the disease course was more aggressive. This group of patients might profit from the conservative top-down or early surgical therapy.

Rare cases imitating acute appendicitis: Three case reports and a review of literature.

Acute appendicitis with its characteristic clinical course is one of the most common diagnoses that require urgent surgery. The following three case reports present patients with symptoms typical of acute appendicitis which was, however, not confirmed intraoperatively. Preoperative CT or MRI were not requested because symptoms clearly indicated acute appendicitis. The first case describes a male patient with right-sided diverticulitis, the second case report involves a pregnant woman in 33rd week of gestation with right adnexal torsion due to a dermoid cyst, and in the last report, a case of spontaneous perforation of appendiceal mucinous neoplasm is presented.Key words: right-sided diverticulitis - dermoid cyst - adnexal torsion - mucinous neoplasm - pseudomyxoma peritonei - appendicitis.

Quality of life after bowel resection for Crohn´s disease - first results.

INTRODUCTION: Crohn´s disease (CD) highly affects a patient´s quality of life. The aim of the study was to find out the impact of surgery on the quality of life (QoL) in CD patients and factors affecting their postoperative QoL. METHODS: 90 patients with CD who underwent surgery (bowel resection) filled out an EORTC QLQ-CR29 questionnaire preoperatively and again after the surgical procedure. RESULTS: 77% of the patients experienced a positive change (p<0.001), 22% negative and 11% no change. CONCLUSION: In this cohort, we proved that surgical treatment improves the overall QoL in patients with CD. To determine factors which affect postoperative QoL, more patients need to be enrolled in future studies.Key words: Crohn´s disease - quality of life - surgery - bowel resection - Czech cohort.

[The new blood test bio-marker SEPT9 and colorectal carcinoma screening]. / Nový krevní test bio-markeru SEPT9 a screening kolorektálního karcinomu.

Due to its high incidence and mortality rates, the colorectal carcinoma represents a crucial medical issue. However, when it is detected in early stage there is high rate of successful treatment. Thats why, early stage cancer screening programmes were introduced into the clinical practice. They focus on the finding of hidden bleeding, using various laboratory techniques, sigmoidoscopy, and, primarily, colonoscopy. However, screening programmes have not yet reached the effect required. New techniques are therefore being developed, such as the detection of blood bio-markers. This group includes also methylated SEPT9 (mSEPT9) detection in blood. We applied this test on 57 patients; we divided the group into two parts. There were 33 asymptomatic individuals in the first group. In this group, we were got only one positive mSEPT9 result. The consequent colonoscopies were negative. The other group had 24 proven carcinomas. Of them, two had negative mSEPT9 results. The remaining in all 22 patients was tested mSEPT9 positive. After its efficiency is tested by further studies, this test may be used especially for patients with low compliance, as it only requires routine blood drawing.

[Irritable bowel syndrome]. / Drázdivý tracník.

Irritable bowel syndrome is a frequent functional disorder of gastrointestinal tract. Its high incidence represents an important socioeconomic concern. The diagnosis of irritable bowel syndrome is indirect and requires exclusion of an organic lesion within as well as outside the gastrointestinal tract. No algorithms--so called treatment guidelines--are available for pharmacological or non-pharmacological treatment of the irritable bowel syndrome. Long-term and comprehensive care of patients with functional diseases is an important component of the management of patients with irritable bowel syndrome.

[Prokinetic agents--their contribution to practice of gastroenterology]. / Prokinetika--jejich prínos v klinické praxi gastroenterologické.

Motility plays a fundamental role in the functioning of the gastrointestinal tract. Prokinetic agents are thus an important treatment modality in patients with functional and certain organ diseases with underlying functional modifications. Gastro-oesophageal reflux disease is frequently associated with a disorder ofoesophageal motility, an alteration of gastric evacuation may manifest as an atypical dyspeptic complaint. Prokinetic agents may also be effective in other disease states, such as diabetic gastroparesis, malignant conditions associated with nausea and vomiting, motility disorders in preterm babies etc.

[The quality of life following laparoscopic fundoplication in correlation with preoperative symptomatology]. / Kvalita zivota po laparoskopické fundoplikaci v závislosti na predoperaní symptomatologii.

AIM: Gastroesophageal reflux disorder (GERD) is a serious health problem in the Western world, with prevalence rates between 9 and 42%. The correct preoperative diagnostics including assessment of symptomatology is a prerequisite for the establishment of adequate therapy, including surgery. The aim of this study was to assess the quality of life in patients with GERD, based on their preoperative symptomatology. METHODS: From IX/2004 to XII/2008, a total of 237 patients underwent antireflux procedures in the Brno Faculty Hospital (FN Brno) Surgical Clinic. The patients underwent preoperative and postoperative gastroenterological examination, including endoscopy, manometry, pH-metry. The patients were asked to fill in the GIQLI (GastroIntestinal Quality of Life Index) questionnaire. The results were statistically assessed and evaluated. RESULTS: The study included a total of 178 patients. 135 subjects (76.7%) presenting with typical symptomatology and 41 subjects (23.3%) with atypical symptomatology were indicated for surgery. The mean preoperative quality of life index, based on the GIQLI questionnaire, was 101.6 points, while at 6 months after the procedure, the quality of life was evaluated with 106.9 points. There is a statistically significant difference in the quality of life between the patients with atypical and the patients with typical symptomatology, both prior to the procedure (p = 0.002), as well as after the procedure (p = 0.006), with the atypicaly symptomatology patients declaring poorer quality of life than the typical symptomatology ones. The risk of prolonged dysphagia (over 6 weeks after the procedure) is higher in the atypical symptomatology subjects, with statistical significance of p < 0.001. CONCLUSION: Laparoscopic antireflux surgery increases the quality of life independent of the preoperative symptomatology. Patients with atypical symptoms must be carefully examined and indicated with caution, considering the higher risk of prolonged postoperative dysphagia.

[Risk of long-term antisecretory treatment]. / Rizika dlouhodobé antisekrecní terapie.

At present, pharmacotherapy leading to a reduction in hydrochloric acid production in the stomach constitutes the core treatment strategy for the majority of the upper intestinal tract diseases. Proton pump inhibitors (PPIs) are the predominant therapeutic group. Gastroesophageal reflux disease is the main indication for the long-term PPI use. Chronic use might be associated with adverse reactions. Potential risks take a form of malabsorption of certain food nutrients with their consequent deficiency, bacterial overgrowth and increased incidence of infections as well as altered regulation of proliferation of gastric as well as other mucosas. Individual risks are low; their assessment is mostly based on the results of population studies. Even though the treatment benefits outweigh any potential theoretical risks, it is wise to decide well on the correct indication and to prescribe the lowest effective dose.

Combined treatment of achalasia - botulinum toxin injection followed by pneumatic dilatation: long-term results.

Injection of botulinum toxin (BT) and pneumatic dilatation are available methods in nonsurgical treatment of achalasia. Authors anticipate beneficial effect of prior BT injection on the success of pneumatic dilatation and duration of its effect. There are no long-term data available to assess efficacy of combined treatment. From 1998 to 2007, 51 consecutive patients (20 men and 31 women, age 24-83) with achalasia were included and prospectively followed up. Each patient received injection of 200 IU of BT into the lower esophageal sphincter (LES) during endoscopy and 8 days later pneumatic dilatation (PD) under X-ray control was performed. The follow-up was established every 3 months first year and then annually. The efficacy was evaluated by a questionnaire concerning patient's symptoms and manometry. Results were compared with 40 historical controls (16 men and 24 women, age 26-80) treated by PD alone using the same method and follow-up. Fifty-one patients underwent combined treatment. Four patients failed in follow-up and were not included for analysis. The mean duration of follow-up was 48 months with range 12-96 months. Thirty-four of forty-seven (72%) patients were satisfied with results with none or very rare and mild troubles at the time of the last visit. Forty-one patients were followed up more than 2 years. Effect of therapy lasted in 75% (31/41) of them. In 17 patients, more than 5 years after treatment, effect lasted in 12 (70%). Mean tonus of LES before therapy was 29 mm Hg (10-80), 3 months after therapy decreased to 14 mmHg (5-26). The cumulative 5 years remission rate (+/-95% CI) in combined treated patients 69% +/- 8% was higher than in controls 50% +/- 9%; however it, was not statistically significant (P= 0.07). In control group 1, case of perforation (2.5%) occurred. Eight patients (17%) with relapse of dysphagia were referred to laparoscopic Heller myotomy with no surgical complication. The main adverse effect was heartburn that appeared in 17 patients (36%). Initial injection of BT followed by PD seems to be effective for long-term results with fewer complications. But the combined therapy is not significantly superior to PD alone.

Achalasia--which method of treatment to choose for senior patients?

BACKGROUND: Achalasia is an uncommon illness affecting 1 per 100,000 patients a year. It encompasses a rare, primary motor disorder of the distal esophagus. METHODS: Over the period 1998-2006, 115 patients underwent various treatments for achalasia; the subgroup of seniors consisted of 26 patients. Six patients of these (age 69.7 y) underwent a modified Heller cardiomyotomy due to failure of previous endoscopic interventions. Standard esophageal manometry and 24 hour pH metry were performed pre- and postoperatively. RESULTS: Six senior patients with achalasia underwent a laparoscopic Heller myotomy. Average preoperative tonus of the LES was 55 mmHg, postoperative tonus of the LES decreased to 11 mmHg. We performed Toupet partial fundoplication in all patients; no microperforation of the esophagus was found in the preoperative esophagoscopy. We recorded minimal pathological gastroesophageal reflux in pH metry - the average preoperative DeMeester score was 8, postoperatively 10.5. Prolonged dysphagia was not present in any patient--preoperative GIQLI score was 94, postoperative score was 106. There was no mortality or morbidity in the group of the operated patients. CONCLUSION: Our operational results and postoperative follow-up show that laparoscopic Heller myotomy with Toupet partial fundoplication is a safe and effective treatment and can be recommended as the method of first choice for senior patients with no contraindication for laparoscopic operation.

Tailored antireflux surgery.

BACKGROUND: With increasing age, the functional condition of the lower esophageal sphincter is getting weaker. Recent progress in peri-operative intensive care and the development of laparoscopic technique makes antireflux surgery a safe choice of GERD treatment in the elderly. AIM: This work evaluated the long-term results of tailored antireflux surgery in a group of elderly (more than 60 years old) patients. RESULTS: Five hundred and eighty one patients underwent antireflux surgery in our department from 1999 to 2005. Seventy of them (12.0%) were older than 60 years. Exclusion criteria of surgery were ASA IV classification and high grade esophageal dysmotility. Toupet's wrap was offered to patients with esophageal dysmotility or esophageal sphincter pressure higher than 15 mm Hg (16 cases). The rest were offered Nissen-Rossetti's complete wrap (54 cases). There was zero mortality and no further significant dysphagia. Pathological gastro-esophageal reflux after the surgery was detected in 6 patients (8.6%), which was a higher proportion than in the group of patients under 60 years. CONCLUSION: Good results of antireflux surgery with zero mortality and low morbidity can be achieved even in the elderly (more frequent use of incomplete Toupet's wrap).

[Higher incidence of thyropathy in patients with oesophageal achalasia. Genetic, autoimmune, regional or just a random association?]. / Vyssí výskyt tyreopatií u achalázie jícnu. Genetická, autoimunitní, regionální ci jen náhodná souvislost?

INTRODUCTION: The etiology of esophageal achalasia is still largely unknown. Inflammatory response to an initial stimulus on the level of genetic and/or immune predisposition may be the underlying cause of the disease. The final result is progressive disappearance of ganglion cells in the myenteric plexus and motility disorder. Autoimmune thyropathy (AIT) is a typical disease involving genetic background and immune response disorder. PATIENTS AND METHODS: 44 patients (of which 30 women and 14 men) with diagnosed esophageal achalasia and a control group of patients with esophageal reflux of corresponding age and sex were screened for thyroid disease. RESULTS: Thyroid disease was diagnosed in 15 out of 44 patients with achalasia (34%). Thyropathy was detected in 11 women (37%) and 4 men (28%). AIT was detected in 10 patients, in 4 of whom with hypfunction, nontoxic cystic or nodular goitre was detected in 4 patients, 1 patient was after strumectomy for benign node. Positive antithyroid antibody was newly detected in 4 patients with achalasia; subclinical hypothyreosis was found in one of them. There were two cases ofAIT with subclinical hypofunction and 1 case of nontoxic goitre in the control group (7%). The difference was statistically significant (p < 0.01). CONCLUSION: The incidence of thyroid disease proved higher in patients with achalasia than in the controls. The rate of occurrence of thyroid disease exceeded significantly the occurrence in the population. The association of achalasia with prevailingly autoimmune thyropathy may corroborate the importance of autoimmunity in the etiopathogenesis of the disease.

Intraoperative manometry of the lower esophageal sphincter pressure during laparoscopic antireflux surgery with a mechanical calibration--early results.

BACKGROUND/AIMS: Persistent postoperative dysphagia diminishes the good effect of laparoscopic anti-reflux surgery. An excessive increase of the intraoperative lower esophageal sphincter pressure (LESp) is supposed to be related to the persistent postoperative dysphagia and its knowledge could lead to the modification of the surgical technique followed by improved clinical outcomes. This study aims to describe the relation between the intraoperative LESp increase and the incidence of postoperative dysphagia and to find whether a combination of intraoperative manometry and mechanical calibration of the wrap is able to decrease the incidence of the persistent postoperative dysphagia. METHODOLOGY: The randomized, prospective, two-branch study included 39 patients suffering from symptoms of gastroesophageal reflux disease. All patients underwent pre- and postoperative manometry, 24-hour pH-metry and laparoscopic anti-reflux surgery. The intraoperative LESp was measured in the study arm only. RESULTS: A higher incidence of persistent postoperative dysphagia was revealed in patients with the intraoperative LESp increase more than 15 mmHg. This complication was not found in patients with the LESp increase under 8 mmHg with no impact on the efficacy of the surgery. The combination of the intraoperative manometry and the mechanical calibration of the wrap seems to bring the benefit only to a small number of the patients. CONCLUSIONS: According to our results, the intraoperative LESp measurement proved to be a useful supplementary method which was easy to perform, and which enables a modification of the surgical technique to decrease the incidence of the persistent postoperative dysphagia.

[Laparoscopic procedure according to Heller]. / Laparoskopická Hellerova operace.

Oesophageal achalasia is a rare disorder. For patients in good overall condition, surgical management--myotomy--is one of the treatment options. This study describes the technique of laparoscopic myotomy sured by partial antireflux cuff. 35 patients were operated. Only in 3 cases, further follow-up was required for dysphagia. None of the patients required re-operation. No serious peroperative or postoperative complications were recorded. Importance of peroperative oesophagogastroscopy in assessment of adequate extent of myotomy and in excluding perforations of the oesophageal mucosa is put forward.

[Could the peroperative manometry of the oesophagus be used for prediction of dysphagia following antireflux procedures?]. / Muze být peroperacní manometrie jícnu vyuzita v predikci dysfagie po antirefluxním výkonu?

A possible development of the postoperative persisting dysphagia, which decreases the quality of life of the operated, remains the main drawback of the laparoscopic antireflux surgery. Among several variations of the antireflux surgical procedures, there is none known to completely eliminate this risk. In this study, supported by the IGA MZ CR ND 7142-3 grant, peroperative measurements of the lower oesophageal sphincter (LES) tone with a concurrent mechanical callibration of the cuff using an oesophageal tube were taken. A complete Nissen-Rossetti cuff was applied in 39 patients. Peroperative increases in the LES tone following the completion of the antireflux cuffs were monitored. The patients continued to be monitored with the aim to detect the onset of dysphagia. In the patient group with the peroperative LES tone increase exceeding 15 mmHg, significantly higher rates of prolonged dysphagia were recorded. In cases of lower LES increases, the rates of dysphagia were low and good functioning to prevent any pathological gastrooesophageal reflux was maintained. No complication with respect to the peroperative oesophageal manometry was recorded. Duration of the antireflux operation conducted with the peroperative manometry was prolonged by 4 minutes, on average. Based on the assessment of the data, the authors demonstrate that the LES tone increase on its own, does not provide for the antireflux efect of the fundoplication procedures and that the patients cannot benefit from its extremely high values. On the contrary, its high values may indicate possible risks of dysphagia in the postoperative period.

[The relation of GERD, bronchial asthma and the upper respiratory tract]. / Vztah refluxní choroby jícnu k astmatu bronchiale a horním cestám dýchacím.

UNLABELLED: Gastroesophageal reflux disease (GERD) is one of the most common diseases affecting upper gastrointestinal tract. It is a chronic disease, whith stadily growing incidence and prevalence in west countries during last 30 years. GERD is caused by pathologic gastroesophageal reflux (GER). GERD includes endoscopically positive, endoscopically negative and extraesophageal reflux disease. Extraesophageal symptoms of GERD have been of a growing attention and discussion during last few years. The most discussed topics are the relation of GERD and bronchial asthma (BA), chronic cough and symptomatology from ear, nose and throught (ENT) regions, but also non - cardial chest pain and many others. AIM: In our clinic we ran a 5 years study which aim was to evaluate the presence of GERD in patients with bronchial asthma, chronic cough and affections from ENT regions. To assess if 3 months GERD treatment would improve lung function, subjective complaints (cough) and GERD control in asthmatics; if this treatment would allow to step - down with antiasthma medication. To assess if 3 months GERD treatment can improve objective and subjective assessments in patients with chronic cough and findings in ENT regions. As for GERD, we evaluated the improvement of pH and subjective complaints (pyrosis). METHODS: We examined 86 patients with different severity of bronchial asthma, 54 patients with chronic cough and 31 patients with ENT symptoms. All patients underwent 24 hour esophageal pH metry, spirometry with lung function evaluation and objective ENT examination by flexible laryngoscopy. In case of pathologic finding on 24 hour pH-metry 3 months full antireflux treatment with proton pump inhibitors (PPI) and prokinetics was introduced. After 3 months of GERD treatment we performed control 24 hour esophageal pH metry, control spirometry and ENT examination by flexible laryngoscopy. Patients were asked to make their subjective symptoms assessments. RESULTS: We found that GERD prevalence in patients with respiratory symptoms was very high. Three months GERD treatment improved lung function (FEV1) with statistical significance (p = 0.0319), and so improved GERD control (in 60.7% of patients with high statistical significance p = 0.0009). Subjective complaints (cough) also improved in most patients. 3 months GERD treatment did not allow to step down with maintenance BA therapy according to GINA guidelines, but it enabled to decrease the rescue medications in 50% of patients. Patients with chronic cough can benefit from GERD treatment as cough improved in 75.8% of patients. CONCLUSION: Objective findings as well as subjective complaints improved in 75% of patients with ENT symptomatology. GERD control (DeMeester score and pyrosis if present) was highly statistically significant in all three groups of patients. It is necessary to mention, that there is a high presence of nocturnal acid breakthrough (NAB) in patients with respiratory symptoms: 30.3 % in patients with bronchial asthma, 63.6 % in patients with chronic cough and 45 % of patients with ENT manifestations.

[Barrett's esophagus]. / Barrettuv jícen.

Barrett's oesophagus is a premalignant metaplastic change of the oesophageal mucosa. Due to its relationship with oesophageal reflux disease and the development of adenoma-carcinoma of the oesophagus the problem arouses increasing interest. In the wide pathogenesis of the disease most probably the composite effect of the refluxed HCl content and duodenal juices play a part. In the diagnosis in addition to fundamental methods--endoscopy and histology--increasingly chromoendoscopy and fluorescent endoscopy are involved. Dispensarization of patients is essential and depends on the degree of pathohistological epithelial changes. Treatment of Barrett's oesophagus can be divided into conservative, where the drug of choice are proton pump inhibitors, and surgical treatment. Promising is endoscopic ablation of the epithelium in combination with subsequent antisecretory therapy.

[Pathologic gastroesophageal reflux in patients with bronchial asthma]. / Patologický gastroezofageální reflux u pacientu s astmatem bronchiale.

Gastrooesophageal reflux (GER) and asthma bronchiale are frequent diseases. Asthma affects some 3-10% of adults. Gastrooesophageal reflux is present in some 45-89% asthmatic patients. Symptoms of GER are not only gastrooesophageal, and recently increased attention is focused on extraoesophageal symptoms where in particular the relationship of GER and asthma or chronic cough is investigated. At our clinic we implemented a pilot study with the objective to monitor the presence of pathological GER in patients with asthma and to assess whether antireflux therapy will influence the respiratory complaints of the patients. The group was formed by 14 patients selected at random with different severity of asthma and different symptoms of GER. The patients had a baseline examination evaluating the presence of GER (24-hour pH metry) and pulmonary function (FEV1). In case of a pathological GER the patients were treated by antireflux therapy and then check-up examinations were made. It was found that after treatment of GER in patients with asthma in particular subjective symptoms improved such as cough and pyrosis which leads to a substantial improvement of the quality of life. On the other hand reflux treatment did not exert a basic effect on pulmonary functions and it was not possible to reduce the medication of asthma.