Analysis of postoperative complications after open scar hernia hernioplasty - a retrospective analysis of a patient cohort.

INTRODUCTION: The aim of this study was to analyse complications associated with inicisional hernia repair surgery and to assess individual risk factors for surgical site infections occurring at the Department of Surgery of the University Hospital Kralovske Vinohrady in 2015. METHODS: We analysed 138 patients with a focus on risk factors that potentially increase the risk of postoperative infectious complications such as mesh implantation, smoking, diabetes mellitus, ischemic heart disease, malignancies, immunosuppressive therapy and urgency of the procedure. RESULTS: Based on multivariate logistic regression analysis, acute surgery proved to be a risk factor for infection, and in the ad hoc Fisher test, the ratio was 2.73. Diabetes mellitus as a risk factor reached the limit of significance (p=0.071). No other variables were associated with an increased risk of surgical site infections. CONCLUSION: Acute surgery was assessed as a significant risk factor for postoperative wound infection. On the contrary, mesh repair was not associated with an increased risk of infection.

Surgery of extrahepatic bile duct cancer - current evidence and recommendations.

Extrahepatic cholangiocarcinoma is a rare disease with poor prognosis, requiring comprehensive multidisciplinary management. Only radical resection gives hope for long-term survival. Most patients have either an unresectable disease or their condition does not allow for radical surgery. The method of choice for resectable perihilar cholangiocarcinoma is en-block liver resection including the extrahepatic bile duct, or pancreatoduodenectomy for distal cholangiocarcinoma. Hepatopancreatoduodenectomy can be performed in selected patients if the entire hepato-choledochus is affected. Liver transplantation after neoadjuvant treatment can be also considered in highly selected patients with unresectable perihilar cholangiocarcinoma. These procedures are technically demanding, are associated with high morbidity and relevant mortality, and must be concentrated in tertiary hepatobiliary centers. Preoperative optimization (bile duct drainage, nutrition, portal venous embolization, etc.) plays a crucial role in reducing postoperative morbidity and mortality.

Surgery of iatrogenic bile duct injuries.

Iatrogenic bile duct injury still represents a serious complication mostly connected with minimally invasive cholecystectomy. This complication has an important impact both on short- and long-term morbidity and is associated with non-negligible mortality. The objective of our study was to provide a comprehensive summary of information based on the most recent guidelines with recommendations for how to prevent a bile duct injury, how to reach an early diagnosis and finally, how to proceed should they occur in order to minimize further damage. We also present ATOM, a new classification of bile duct injuries that provides clear information not only about the extent of anatomical damage, but also about the time and mechanism of its occurrence.

Intrahepatic cholangiocarcinoma: risk factors affecting survival of operated patients.

INTRODUCTION: The aim of this study was to evaluate the results of surgical treatment of intrahepatic cholangiocarcinoma (IHCHCA) in terms of overall survival and disease-free survival, and to analyse and find potential prognostic factors affecting overall survival and disease-free survival. METHODS: Retrospective evaluation was performed of consecutively enrolled patients operated for IHCHCA from January 2005 to January 2022 (17 years) had undergone surgery. During the monitored period, 38 surgical procedures were performed, of which liver resection was done in 25 cases (65.8%). RESULTS: The 5-year survival in the radically resected group was 44%, and the 5-year disease-free survival was 32%. Based on univariate and multivariate analysis, radicality of surgery (p=0.01116) and lymph node involvement (p=0.00576) were assessed as negative prognostic factors for overall survival. Radicality of surgery (p=0.018) and administration of adjuvant chemotherapy (p=0.044) were significant negative prognostic factors affecting disease-free survival. However, they lost their significance in the multivariate analysis. CONCLUSION: Radical surgical resection of the liver remains an essential treatment option for intrahepatic cholangiocarcinoma aimed at achieving a radical procedure with microscopically negative margins. KEY WORDS: cholangiocarcinoma, resection, recurrence, survival.

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

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

Monitoring EBV infection, MSI, PDL-1 expression, Her-2/neu amplification as a biomarker for PD-1 inhibition in gastric cancer.

BACKGROUND: The anti-PD-1 monoclonal antibody pembrolizumab has been shown to be associated with a good response in patients with metastatic gastric cancer. Excellent therapeutic results of pembrolizumab have been shown in patients with tumours showing a high microsatellite instability (MSI) and Epstein-Barr virus (EBV) positivity. GOAL: This is a retrospective study of 40 bioptic specimens from the patients, who underwent gastrectomy for gastric carcinoma. The goal of the study was to identify biomarkers (EBV, MLH-1, PDL-1 expression) that are potentially relevant for selecting the patients, who may benefit from PD-1 inhibition therapy. METHODS: Immunohistochemical (IHC) expression of PDL-1 and MSI, cytogenetic FISH amplification of the HER-2/neu gene and polymerase chain reaction of EBV RNA, including charge quantification, were performed in selected patients with metastatic or advanced gastric cancer. RESULTS: EBV-encoded RNA was detected in nine patients. None of them exhibited Her-2 overexpression or CMV infection. PD-L1 was detected in twelve patients. Ten patients were MLH1 positive. All nine cases of EBV infection showed a high expression of PD-L1 and MLH-1 (Tab. 1, Ref. 14).

Introducing in vivo pancreatic cancer models for the study of new therapeutic regimens

Introduction: Pancreatic cancer is a severe oncological disease with an ever-increasing incidence and a high rate of morbidity and mortality. Therapeutic options are limited and the five-year overall survival rate is 7­20%, depending on the possibility of surgical resection and the earliness of detection. Most patients with this diagnosis die due to the resistance of tumour cells and their microenvironment to the used treatment regimes. Methods: In our study, we focused on the implementation of two in vivo models, which are the cell-line derived xenograft (CDX) and the patient-derived xenograft (PDX). These two models differ significantly from each other methodologically, technically, financially, but also in their achieved results. Results: In a pilot study, we managed to successfully implement the CDX model with a very aggressive and resistant PaCa-44 line of pancreatic cancer in a total of 30 NU/NU strain mice. Furthermore, we created three PDX models with various subtypes of pancreatic cancer from patients operated at the University Hospital Kralovske Vinohrady, Department of General Surgery. These tumours were re-transplanted into subsequent generations of 23 individuals of NOD/SCID strain and 47 NU/NU strain mice. The established CDX and PDX models are then used to compare conventional and experimental chemotherapy regimens. Conclusion: The next steps will be to evaluate the effects of treatment regimens by using imaging and molecular genetic methods and to optimise the entire process for further use in precise personalised medicine for patients with pancreatic cancer. The upcoming goal is to create a library of PDX models of the most common pancreatic ductal adenocarcinoma and other rare subtypes of pancreatic cancer.

Autoimmune pancreatitis ­ a surgical mistake?

Autoimmune pancreatitis is a specific type of chronic pancreatitis. Its clinical manifestation mimics pancreatic cancer. A multidisciplinary approach is necessary to establish the correct diagnosis. Autoimmune pancreatitis can be diagnosed on the basis of symptomatology, imaging methods, endoscopy, serology and histopathological examination. There are two different forms of autoimmune pancreatitis ­ type 1 and type 2. Type 1 is lymphoplasmacytic sclerosing pancreatitis and type 2 is idiopathic centroductal sclerosing pancreatitis. The disease most often takes a chronic form with acute exacerbations. In this paper we present two case reports of patients operated on for suspected malignancy of the pancreas, who were subsequently diagnosed with autoimmune pancreatitis based on histopathological examination. The aim of this communication is to point out the diagnostic pitfalls of this disease. Surgical treatment is not considered as a standard therapeutic method according to the current guidelines.

Expression of selected microRNAs in pancreatic ductal adenocarcinoma: is there a relation to tumor morphology, progression and patient's outcome?

Pancreatic ductal adenocarcinoma (PDAC) remains a disease with extremely poor prognosis and limited effective available treatment. Differential expression of miRNAs isolated from tumor tissue has been proposed as a marker for tumor diagnosis, progression, and prognosis. Nevertheless, the prognostic value of miRNAs expression in PDACs for patient outcome still remains unclear. Expression of 7 selected miRNAs, isolated from FFPE samples of 54 PDAC patients, was quantified using RT-qPCR. The relationship of miRNA expression levels with tumor histology, clinicopathological characteristics, patient overall survival (OS), and progress-free survival (PFS), was subsequently evaluated. Overexpression of miR-21, miR-155, and miR-210 was observed in PDACs (up to 72.62, 232.36, and 181.38-fold, respectively), in comparison with non-neoplastic tissues. On the other hand, miR-96 and miR-217 were significantly downregulated in PDACs (up to one hundred times). No differences were, however, noticed between cancer and normal tissues for the expression levels of miR-148a and miR-196a. On the other hand, expression levels of all 7 miRNAs failed to demonstrate a significant correlation with parameters of tumor progression, such as tumor stage, grade, nodal involvement, perineural, and vascular invasion. The positive correlation of miR-210 levels was, however, observed with patient age (ρ=0.35). Additionally, miR-148a and miR-217 expressions have shown a positive association with tubular tumor growth pattern (ρ=0.39; ρ=0.28). The negative correlation of miR-148a values was also demonstrated with dissociative growth pattern and nuclear atypia (ρ=-0.30; ρ=-0.27). Finally, no statistically significant correlation could be demonstrated with the expression levels of all 7 tested miRNAs and PDAC patient survival; neither for OS nor for PFS (p>0.05). Our data have confirmed abnormal miRNAs expression in PDACs in comparison with adjacent non-neoplastic tissue. On the other hand, no correlation was discovered between miRNA expression and parameters of tumor progression. We have found a significant association between histologic tumor growth patterns and miRNA expression, making this work the first study, which analyses this aspect of PDAC. Finally, in our group of patients, no relationship of miRNA levels and patient prognosis could be demonstrated. Therefore, further investigation is required to evaluate the predictive and prognostic potential of miRNAs in a clinical setting.

Molecular and IHC analysis of head and neck carcinomas associated with HPV infection.

Head and neck squamous cell carcinomas (HNSCC) are a highly heterogenous disease which can be induced by two main carcinogens - tobacco and/or alcohol, or by HR HPV infection. This work examined 60 paraffin-embedded biopsies of head and neck carcinomas after histological verification. HPV infection, including its specific types in various HNSCC areas, was studied using multiplex qPCR. Expression levels of p16INK4A and p53 were detected by subsequent IHC analysis as being potential diagnostic markers. Based on the assumption that patients with HNSCC could benefit from anti-EGFR therapy (cetuximab), but the predictors are not yet defined, analyses of point mutations of ras genes (Kras, Nras) were carried out using multiplex qPCR and sequence analysis of the Braf gene. All statistical data were processed by Chí-x2 test.HPV infection was detected in 23.34 % of cases with HNSCC, of which 100 % were HPV 16, which is the most frequently infection found in the oropharyngeal region. Using IHC analysis, a positive expression of P16INK4A was detected in 100 % of HPV-positive HNSCC while this expression was discovered to be highly correlated with HPV infection. Furthermore, a correlation between p53 and HPV-negative HNSCC was proved. The mutation incidence was the highest in the Kras gene (codon 12 and codon 146), Nras (codon 12) and Braf. A correlation between tumor location in the oropharyngeal region and Kras mutations was proved. The HPV infection correlated with Kras mutations in case of codon 146 but on the grounds of low amount of output data, these figures could be irrelevant. In one case, c.1808 G>A, protein 603 Arg>Gln mutation was found in the Braf gene but its correlation with head and neck carcinomas has not been described yet (Tab. 2, Fig. 2, Ref. 24). Keywords: head and neck carcinomas, biopsy, HPV types, PCR, p16INK4A, p53, molecular predictors, Kras, Nras, Braf.

Current view on prostheses in herniology (hernia meshes) - classifications, indications, advantages and disadvantages of different implants, complications J. Skach, M. Slamborova, V. Blecher, P. Hromadka, R. Gurlich.

Hernia repair is one of the most commonly performed surgical procedures worldwide. Reinforcement of the tissue with a surgical mesh requires the implantation of much over 1 million meshes per year worldwide. Implant design remains a critical challenge for the prevention of hernia recurrence. Currently available implants exhibit a wide spectrum of different characteristics. This review summarizes the specifics, advantages, limitations, complications and functionalities of commonly accessible prostheses. There is still no ideal mesh for every surgery.

Laparoscopic versus open liver resections for colorectal cancer liver metastases: short term results.

INTRODUCTION: Analysis and comparison of short-term results of laparoscopic liver resections (LLR) and open liver resections (OLR) for colorectal cancer liver metastases (CRCLM). METHODS: Retrospective analysis of patients operated for CRCLM in the time period from May 2007 to May 2019 (12 years) at the department of surgery, University Hospital Hradec Králové and University Hospital Královské Vinohrady. RESULTS: 206 liver resections were performed; 167 (81.1%) OLR and 39 (18.9%) LLR procedures. Conversion to open surgery was necessary in 6 cases (15.4%). LLR was associated with a longer operation time (194±107 min) vs (129±58 min) for OLR. The ICU stay, 3.5±4.3 days for OLR and 4.1±8.1 days for LLR, and the hospital stay, 11.9±8.3 days (OLR) vs 12.1±11.3 days (LLR), were comparable. Perioperative blood loss was lower in the LLR group, 189±166 ml vs 360±410 ml. Total transfusion rate was similar, 10.8% (OLR) vs 12.8% (LLR). Oncologic radicality was also comparable in both groups; negative resection margin was achieved in 78% (OLR) and 80% (LLR). Postoperative morbidity and mortality was comparable in both groups; morbidity was 33% (OLR) vs 31% (LLR), while mortality was 1.8% (OLR) vs 2.6% (LLR). CONCLUSION: LLR for CRCLM provided comparable short-term results compared to OLR in our group of patients even in the learning curve period. However, it should be noted that the study group is a highly selected group of patients.

Timing of cholecystectomy as the therapy for acute calculous cholecystitis.

INTRODUCTION: Acute calculous cholecystitis is a common disease treated mostly by surgical therapy - laparoscopic cholecystectomy (CHE), particularly upon the common failure of conservative therapy. Timing of the surgery is essential for the development of perioperative complications. METHODS: We carried out a retrospective study with patients hospitalised at our Department of Surgery, University Hospital Královské Vinohrady between January 2013 and December 2015 for the treatment of acute calculous cholecystitis. We had a set of 209 patients. We looked for the presence of perioperative complications in relation to the time of surgery - cholecystectomy. RESULTS: Having compared patients with primary surgical treatment of acute calculous cholecystitis we found that twice as many patients after acute cholecystectomy done within 24 hours from admission developed 26% perioperative complications compared to those who had the surgery later than within 24 hours from their admission to the hospital (43.9%). We also found that there was a higher number of conversions from laparoscopic to open cholecystectomy in the group of patient undergoing cholecystectomy within 24 hours from admission. CONCLUSION: Timing of the surgical treatment of acute calculous cholecystitis is essential for the development of postoperative complications. Acute laparoscopic cholecystectomy done by an experienced surgeon within 24 hours from admission of the patient to the hospital should be the golden standard, irrespective of the duration of the symptoms or severity of the acute cholecystitis. The sooner, the better.

Tumor grade as significant prognostic factor in pancreatic cancer: validation of a novel TNMG staging system.

Aim of the study was to asses the tumor grade prognostic value in the Czech pancreatic cancer patients and to evaluate the accuracy of TNMG prognostic model. Retrospective analysis of 431 pancreatic cancer patients undergoing pancreatic resection in seven Czech oncological centers between 2003 and 2013 was performed. The impact of tumor grade and the accuracy of TNMG prognostic model were evaluated. Lymph node status, tumor size, tumor stage and grade were proved as statistically significant survival predictors. The lower tumor differentiation (grade 3 and 4) was associated with poorer prognosis in all stages (stage I: HR 2.23 [1.14; 4.36, CI 95%] p=0.019, stage II: HR 3.09 [2.01; 4.77, CI 95%] p=0.001, stage III and IV: HR 3.52 [1.73; 7.18, CI 95%] p=0.001). Kaplan-Meier analysis verified statistically significant impact of new TNMG stages on survival after resection for pancreatic cancer (p=0.001). In conclusion, we can state that the tumor grade was confirmed as statistically significant prognostic factor in pancreatic cancer. Its incorporation into the current TNM classification enables more accurate prognosis prediction within particular clinical stages. That is why an inclusion of the grade to the standard TNM classification should be discussed.

[Damage Control Surgery in Polytrauma Patients with Pelvic Fractures. Is It Possible to Use Internal Fixation?] / Damage Control Surgery u polytraumatizovaných pacientu s poranením pánve. Je mozné pouzít vnitrní osteosyntézu?

Current polytrauma management is multidisciplinary, with Damage Control Surgery (DCS), Damage Control Orthopaedics (DCO) and Damage Control Resuscitation (DCR) being applied in the first few hours after injury. The most severe group of polytrauma patients are those with circulatory instability and massive blood loss as a consequence of unstable pelvic fractures. In treating these patients, of crucial importance is the speed and quality of stabilisation of pelvic fracture fragments. The authors present two case reports of polytrauma patients with unstable pelvic fractures, in whom open reduction and internal fixation was performed on the anterior fracture segment through extended laparotomy in order to stop bleeding into the abdominopelvic cavity as part of the DCS approach. Key words: exsanguination, polytrauma, unstable pelvic fracture, plate fixation.

[Synchronous colorectal carcinoma and non-Hodgkin lymphoma - two case reports]. / Synchronní kolorektální karcinom a nehodgkinský lymfom - popis dvou prípadu.

Colorectal carcinoma represents an important cause of morbidity and mortality in adults, and its incidence in the Czech Republic is one of the world´s highest. The basic therapeutic approach is surgery: surgical removal of the affected part of the bowel together with regional lymph nodes dissection. The lymph nodes are routinely examined by means of histopathology. In this paper, we present two patients whose histological examination of mesocolic lymph nodes revealed an infiltration by synchronous malignant B-non-Hodgkin-lymphoma. Mantle cell lymphoma was present in the first case, and small cell lymphoma CLL/SLL in the other. Relevant literature is reviewed. KEY WORDS: synchronous - malignancy - colorectal - lymphoma - lymph node.

Dilemmas in autoimmune pancreatitis. Surgical resection or not?

Surgical treatment is not commonly recommended in the management of autoimmune pancreatitis. The article describes a dilemma in diagnostics and treatment of a 68-year old man with the mass in the head of the pancreas that mimicked pancreatic cancer and that was diagnosed as a type 1 autoimmune pancreatitis (IgG4-related pancreatitis) after a surgical resection. Diagnosis of the autoimmune pancreatitis is a real clinical challenge, as in the current diagnostic criteria exists some degree of overlap in the findings between autoimmune pancreatitis and pancreatic cancer (indicated by the similarity in radiologic findings, elevation of IgG4, sampling errors in pancreatic biopsy, and the possibility of synchronous autoimmune pancreatitis and pancreatic cancer). Despite the generally accepted corticosteroids as the primary treatment modality in autoimmune pancreatitis, we believe that surgical resection remains necessary in a specific subgroup of patients with autoimmune pancreatitis (Fig. 4, Ref. 37).

[Skin and soft tissue infections (SSTIs)]. / Infekce kuze a mekkých tkání.

UNLABELLED: Skin and Soft Tissue Infections (SSTIs) encompass a wide spectrum of inflammatory diseases of the skin, subcutis, fascia and muscles. Recent national trends indicate increasing rates of patients treated for these diagnoses at outpatient surgical department, but also of patients hospitalized with severe forms of SSTIs. Up to 90% fatality rates are reported in the literature for the most severe forms, resulting from underestimation of initial symptoms and therefore delayed onset of radical therapy only the phase of septic shock. The paper provides an interdisciplinary review of essential principles of the diagnosis and therapy of SSTIs, reflecting present knowledge supported by evidence-based medicine. KEY WORDS: skin and soft tissue infections - SSTIs - necrotizing fasciitis - diagnosis - therapy.

[Current status regarding surgical treatment of pancreatic cancer in the Czech Republic]. / Aktuální stav chirurgické lécby karcinomu pankreatu v Ceské republice.

INTRODUCTION: The aim is to map the current situation in the surgical treatment of pancreatic cancer in the Czech Republic. This information has been obtained from surgical treatment providers using a simple questionnaire and by identifying the so called high volume centres. The information has been collected in the interest of organizing and planning research projects in the field of pancreatic cancer treatment. METHOD: We addressed centres known to provide surgical treatment of pancreatic cancer. A simple questionnaire formulated one question about the total number of pancreatic resections, also separately for the diagnoses PDAC - C25, in the last two years (2014 and 2015). Other questions focused on the use of diagnostic methods, neoadjuvant therapy, preoperative assessment of risks, the possibility of rapid intraoperative histopathology examination, Leeds protocol, monitoring of morbidity and mortality including long-term results, and the method of postoperative follow-up and treatment. ÚZIS (Institute of Health Information and Statistics of the Czech Republic) was addressed with a request to analyze the frequency of reported total numbers for DPE, LPE, TPE and to do the same with respect to diagnosis C 25 for the last two years, available for the entire Czech Republic (2013, 2014). RESULTS: Altogether 19 institutions were identified by the preceding audit, which reported more than 10 pancreatic resections annually; these institutions were addressed with the questionnaire. Sixteen institutions responded to the questions, 13 of them completely. CONCLUSION: The majority of potentially radical surgeries for PDAC in the Czech Republic are carried out at 6 institutions. All of the institutions that participated in the survey collect data about morbidity and mortality and monitor their results. KEY WORDS: pancreas cancer outcomes surgery.

Heme oxygenase is not involved in the anti-proliferative effects of statins on pancreatic cancer cells.

BACKGROUND: Pancreatic cancer is recognized as one of the most fatal tumors due to its aggressiveness and resistance to therapy. Statins were previously shown to inhibit the proliferation of cancer cells via various signaling pathways. In healthy tissues, statins activate the heme oxygenase pathway, nevertheless the role of heme oxygenase in pancreatic cancer is still controversial. The aim of this study was to evaluate, whether anti-proliferative effects of statins in pancreatic cancer cells are mediated via the heme oxygenase pathway. METHODS: In vitro effects of various statins and hemin, a heme oxygenase inducer, on cell proliferation were evaluated in PA-TU-8902, MiaPaCa-2 and BxPC-3 human pancreatic cancer cell lines. The effect of statins on heme oxygenase activity was assessed and heme oxygenase-silenced cells were used for pancreatic cancer cell proliferation studies. Cell death rate and reactive oxygen species production were measured in PA-TU-8902 cells, followed by evaluation of the effect of cerivastatin on GFP-K-Ras trafficking and expression of markers of invasiveness, osteopontin (SPP1) and SOX2. RESULTS: While simvastatin and cerivastatin displayed major anti-proliferative properties in all cell lines tested, pravastatin did not affect the cell growth at all. Strong anti-proliferative effect was observed also for hemin. Co-treatment of cerivastatin and hemin increased anti-proliferative potential of these agents, via increased production of reactive oxygen species and cell death compared to individual treatment. Heme oxygenase silencing did not prevent pancreatic cancer cells from the tumor-suppressive effect of cerivastatin or hemin. Cerivastatin, but not pravastatin, protected Ras protein from trafficking to the cell membrane and significantly reduced expressions of SPP1 (p < 0.05) and SOX2 (p < 0.01). CONCLUSIONS: Anti-proliferative effects of statins and hemin on human pancreatic cancer cell lines do not seem to be related to the heme oxygenase pathway. While hemin triggers reactive oxygen species-induced cell death, cerivastatin targets Ras protein trafficking and affects markers of invasiveness.