Methodology for implementing early recovery after surgery protocols in colorectal surgery.

INTRODUCTION: Enhanced recovery after surgery (ERAS) protocols in colorectal surgery leads to improved quality of care and more efficient resource utilization. Despite these positive outcomes, the penetration of ERAS protocols in the Czech Republic is low. The aim of this study is to present a general methodology for implementing an ERAS protocol in colorectal surgery. METHODS: The methodology is based on the authors' extensive experience in implementing clinical protocols at various institutions in the Czech Republic, as well as published international experiences. This methodology is described in detail and supplemented with data obtained during implementation of an ERAS program at the author's institution. RESULTS: The preparatory phase includes in-depth quality of care audits and preparation of an ERAS protocol. The purpose of the audits is to identify areas of care where standardization or targeted changes in clinical practice are desirable. The implementation phase involves staff training, technical implementation support, protocol dissemination, adherence monitoring, and evaluation of a pilot phase with subsequent protocol adjustments. The evaluation phase involves data collection, maintaining a prospective database, and regular assessments. CONCLUSION: The presented methodology describes the individual steps in the process of implementing a clinical protocol into practice. This text can serve as a manual for implementing an ERAS protocol in colorectal surgery at any institution.

Robotic resection of the rectum - what are the advantages?

INTRODUCTION: Surgical treatment is the most important part of multimodal management of rectal cancer. In recent years, minimally invasive surgery has been preferred. Minimally invasive procedures include laparoscopy and more recently robotic surgery. Robotic surgery has been developed to eliminate the shortcomings of laparoscopy, especially the parallel position of instruments and their limited movement. The advantages of a robotic system should be most apparent in narrow and deep spaces, i.e. the lesser pelvis. The aim of this study was to analyze the short-term results of robot-assisted surgery for rectal tumors. METHODS: The study is a retrospective analysis of a cohort of 220 patients with robotic-assisted surgery for rectal cancer. The cohort was analyzed in terms of length of surgery, blood loss, number of conversions to open surgery, completeness of TME, distal and circumferential resection margin positivity, length of hospital stays and number of 30-day rehospitalizations. In addition, 30-day postoperative morbidity and mortality were assessed using the Clavien-Dindo score. RESULTS: Robotic-assisted surgeries lasted an average of 184 minutes. In total, 5 operations were converted, i.e. 2.3%. Complete mesorectum was achieved in 90% of the patients. Severe postoperative complications, Clavien-Dindo score 3-4, were observed in 14% of the patients. Anastomotic complications occurred in 9.6% of the patients. The mean length of the hospital stay was 8.4 days. CONCLUSION: Robotic surgery for rectal tumors is a safe method with an acceptable rate of complications. An established training method and a high degree of standardization of the surgical procedures are indisputable advantages of robotic systems, making it possible to achieve very good results in a short time. In terms of perioperative and early postoperative outcomes, robotic surgery outperforms laparoscopic surgery in some parameters.

Enhanced recovery after surgery and mini-invasive approaches in rectal cancer surgery - short-term outcomes.

INTRODUCTION: The aim of this study was to evaluate short-term outcomes of patients undergoing mini-invasive rectal resection within an ERAS (enhanced recovery after surgery) protocol. METHODS: A prospectively managed database of patients undergoing rectal operations performed at our department between January 2015 and April 2020 was retrospectively analyzed. An ERAS protocol was implemented into clinical practice at our department in April 2016 and mini-invasive rectal procedures in May 2016. The ERAS group consisted of all patients who underwent mini-invasive rectal resections or amputations within the ERAS protocol. The control group consisted of patients who underwent open procedures and received standard perioperative care. The extracted data included basic patient characteristics, surgical data, postoperative recovery parameters, 30-day morbidity, length of postoperative stay and 30-day rehospitalization. RESULTS: A total of 110 patients were included in the study: 67 patients in the ERAS group and 43 in the control group. Within the ERAS group 47 patients underwent robotic procedures and 20 had laparoscopic procedures. Patients in the ERAS group had significantly better clinical and laboratory recovery parameters except for postoperative nausea and vomiting. A significantly lower incidence of paralytic ileus (20.9% vs. 3%) and a shorter length of postoperative stay (13 days vs. 9 days) was found in the ERAS group. The rehospitalization rate and 30-day morbidity were not different between the ERAS and control group. CONCLUSIONS: Implementation of the ERAS protocol in combination with mini-invasive approaches leads to better short-term postoperative outcomes after rectal surgery.

Management and outcome of colorectal cancer during pregnancy: report of 41 cases.

BACKGROUND: Colorectal cancer in pregnancy is rare, with an incidence of 0.8 per 100,000 pregnancies. Advanced disease (stage III or IV) is diagnosed more frequently in pregnant patients. We aimed to review all cases of colorectal cancer in pregnancy from the International Network on Cancer, Infertility and Pregnancy database in order to learn more about this rare disease and improve its management. METHODS: Data on the demographic features, symptoms, histopathology, diagnostic and therapeutic interventions and outcomes (obstetric, neonatal and maternal) were analysed. RESULTS: Twenty-seven colon and 14 rectal cancer cases were identified. Advanced disease was present in 30 patients (73.2%). During pregnancy, 21 patients (51.2%) received surgery and 12 patients (29.3%) received chemotherapy. Thirty-three patients (80.5%) delivered live babies: 21 by caesarean section and 12 vaginally. Prematurity rate was high (78.8%). Eight babies were small for gestational age (27.6%). Three patients (10.7%) developed recurrence of disease. Overall 2-year survival was 64.4%. CONCLUSION: Despite a more frequent presentation with advanced disease, colorectal cancer has a similar prognosis in pregnancy when compared with the general population. Diagnostic interventions and treatment should not be delayed due to the pregnancy but a balance between maternal and foetal wellbeing must always be kept in mind.

[Intra-operative fluorescence angiography of colorectal anastomotic perfusion: a technical aspects]. / Technické aspekty fluorescencní angiografie pro peroperacní hodnocení perfuze anastomózy v kolorektální chirurgii.

INTRODUCTION: Anastomotic leak after colorectal surgery is a serious complication. Tissue perfusion plays a key role for anastomotic healing. Fluorescence angiography with indocyanine green under near-infrared excitation allows a real-time perfusion assessment. The aim of this study was to evaluate the feasibility and the potential benefit of intraoperative assessment of anastomotic perfusion in colorectal surgery using indocyanine green-enhanced fluorescence in near-infrared light. METHODS: 53 patients with primary anastomosis after elective colon or rectum resection were enrolled between 1 January 2016 and 31 January 2017. Near-infrared fluorescence angiography with indocyanine green was performed to assess tissue perfusion. The data of patient characteristics, data of surgery, data related to perioperative fluorescence angiography and postoperative complications were collected prospectively. RESULTS: Intraoperative fluorescence angiography was successful in 52 patients (98%). There were no adverse effects related to procedure. The mean time from indocyanine green application to visible fluorescence was 35 seconds, the mean added procedure time was 5 minutes. The best contrast was achieved by reducing the dose to 0.1 mg/kg. In 5 patients (9%), fluorescence angiography resulted in a change of the surgical plan. In two cases, the resection line was moved proximally, in two cases the anastomosis was corrected and in one case perfect perfusion of the anastomosis contributed to the decision to abandon the planned protective ileostomy. There was no postoperative anastomotic leak. CONCLUSIONS: Perioperative assessment of anastomotic perfusion in colorectal surgery by use of indocyanine green in near-infrared light is technically feasible with the potential to alter surgical strategy (including avoidance of defunctioning stoma) and to reduce the anastomotic leak rate.Key words: anastomotic leak colorectal surgery fluorescence angiography indocyanine green.

[Bouveret syndrome: a case report and literature review]. / Bouveretuv syndrom - kazuzistika a prehled literatury.

UNLABELLED: Bouveret syndrome is a gastric outlet obstruction caused by impaction of a gallstone that passes through a cholecystoduodenal or cholecystogastric fistula. It is a rare disease, most common in elderly women with multiple comorbidities and high surgical risk. The diagnosis can be made either radiologically or endoscopically. Endoscopic extraction is the preferred therapeutic option. Surgical intervention is indicated when endoscopic methods fail. We describe a case of Bouveret syndrome in a 79 years old woman. The report is followed by a review of literature on the diagnostics and treatment of this rare syndrome. KEY WORDS: gallstones bilioenteric fistula gallstone ileus duodenal obstruction Bouveret syndrome.

Critical complications of intestinal tuberculosis--a case report.

Intestinal tuberculosis is a rare disease in developed countries, affecting mainly immigrants and immunocompromised patients. Clinical presentation may mimic many other abdominal diseases such as intra-abdominal infections, tumors, and Crohn´s disease. Differential diagnosis of Crohn´s disease and intestinal tuberculosis poses a dilemma to clinicians and pathologists as both are chronic granulomatous disorders with similar clinical features. We report the case of a 53 year-old man presenting with perforated intestinal tuberculosis in which the initial diagnostic work-up suggested Crohn´s disease. The severity of the findings resulted in critical complications during the course of treatment. This case points out the need for awareness of intestinal tuberculosis in the differential diagnosis of chronic intestinal disease.

[Perspective of patients undergoing surgery for secondary peritonitis]. / Perspektiva pacientu operovaných pro sekundární peritonitidu.

INTRODUCTION: Peritonitis is a life-threatening disease with high mortality and morbidity. The prognosis depends on patient factors, the nature of the disease, and on diagnostic and therapeutic methods. The goal of our study was to perform a retrospective analysis of a group of patients with secondary peritonitis and to compare patients with non-stercoral peritonitis and those with stercoral peritonitis, and finally, to determine the prognostic value of the MPI prognostic index. METHODS: We analysed 124 patients who had undergone surgery for secondary peritonitis during the years 2012-2013. We divided the patients into two groups. Group A comprised patients with non-stercoral peritonitis and group B consisted of patients with stercoral peritonitis. We compared the two groups and predicted the peritonitis outcome using the Mannheim Peritonitis Index (MPI). RESULTS: The complete sample of 124 patients consisted of 70 men and 54 women. The average age of the patients was 63 years and the average length of hospitalization was 18 days. In total, 18 patients (15%) died during their hospitalization. The average MPI score was 19, which correlates to an 18% mortality rate prediction. In group A, which consisted of 68 patients with non-stercoral peritonitis, the average age was 59 years and the average length of hospitalization was 12 days. Two patients (3%) from this group died during hospitalization. The average MPI score was 9, which correlates to a 9% mortality rate prediction. In group B, which consisted of 56 patients with stercoral peritonitis, the average age was 67 years and the average length of hospitalization was 25 days. 16 patients (29%) from this group died during hospitalization. The average MPI score was 29, which correlates to a 31% mortality rate prediction. CONCLUSIONS: The outcome of our comparison between the two groups is that group A with non-stercoral peritonitis had a significantly lower mortality, lower number of complications and a shorter length of hospitalization. Both basic clinical data and sophisticated scoring systems can be used for mortality prediction in peritonitis. The Mannheim Peritonitis Index, a simple scoring system, proved to be useful in our study.

[Sigmoid colon cancer in pregnancy - a case report].

Colorectal cancer in pregnancy is a rare but life-threatening disease. The authors present a case of early-stage sigmoid colon cancer in pregnancy, discussing the issue in the light of the current literature.

[Low anterior resection syndrome]. / Funkcní poruchy po resekci rekta.

UNLABELLED: The most important quality parameters of rectal cancer surgery are oncological radicality, postoperative complications, recurrence rate and survival. Rectal dysfunction following low anterior resection occurs in up to 25-50% of patients. Despite its high frequency, however, it does not receive enough attention. Rectal dysfunction after surgery includes frequent bowel movements, urgency, incomplete evacuation, incontinence or sexual and urinary dysfunctions. The complex of symptoms is collectively referred to as the low anterior resection syndrome - LARS. In this review, we discuss the alterations in anorectal physiology after low anterior resection, the etiology and risk factors of LARS, different types of neorectal reservoir construction, and various options for prevention and treatment of LARS. Furthermore, sexual and urinary dysfunction is briefly reviewed. KEYWORDS: low anterior resection bowel dysfunction incontinence anorectal physiology.

[Fluid therapy and surgical outcomes after low anterior resection]. / Tekutiny, nízká resekce rekta a zase tekutiny.

INTRODUCTION: Fluid therapy is a fundamental component of surgical care. Recent data regarding fluid restriction has shown an association with improved outcomes. The aim of this study is to determine whether the use of restrictive approaches in perioperative fluid administration improves patient outcomes following low anterior resection. MATERIAL AND METHODS: 89 patients undergoing low anterior resection included in this study were divided by the median 14.9 mL/kg/h into group A (7.4-14.7 mL/kg/h) and group B (14.9-36.8 mL/kg/h) within intraoperative fluid administration, and by the median 3.3 mL/kg/h into group C (2.0-3.3 mL/kg/h) and group D (3.3-6.9 mL/kg/h) for fluid administration on the day of surgery. The main outcomes measured were cardiac and pulmonary complications, the incidence of anastomotic leak and wound infections, gastrointestinal function recovery, laboratory inflammatory markers and the length of hospital stay. RESULTS: The restricted perioperative fluid regimen significantly reduced the risk of pleural effusion and anastomotic leak in patients after low anterior resection. The overall incidence of anastomotic leak was 9.0%. Another significant risk factor for anastomotic leak was neoadjuvant radiochemotherapy (15.9% vs. 2.2%, p=0.03). CONCLUSION: The restricted perioperative fluid regimen reduces postoperative morbidity in patients after low anterior resection. Hospital stay remains unchanged.

[Dissection and coagulation technique in thyroid surgery - is it the key to a successful outcome?]. / Disekcní a koagulacní technika - má vliv na výsledky totální tyreoidektomie?

INTRODUCTION: This study analyzes the impact of coagulation instrument devices used during thyroid gland removal in which careful dissection and perfect haemostasis represent very important aspects. Standard electrocautery is compared to the use of bipolar forceps. The aim is to determine whether the use of different modes of coagulation is the key to the frequency and severity of postoperative complications following total thyroidectomy. MATERIAL AND METHODS: This study included 82 patients undergoing total thyroidectomy with haemostasis by conventional suture ligation technique combined with monopolar electrocauterization and 36 patients undergoing total thyroidectomy with complete haemostasis by bipolar forceps. The main outcomes measured were postoperative bleeding, recurrent laryngeal nerve palsy and post-thyroidectomy hypocalcaemia and hypoparathyroidism. Patients were followed up for 6 months. RESULTS: The results of our study showed that the use of bipolar forceps for vessel ligation in thyroid surgery is as safe and effective as the use of monopolar electrocautery and ligatures. Statistical analysis showed no significant differences in the rate of the individual postoperative complications between the two cohorts. Complication rates in the entire cohort were comparable with data reported in the literature. CONCLUSION: Both approaches are safe and reliable and both represent valid options. The choice might depend on the surgeons preferences and experience, the nature of the thyroid condition and the nature and extent of the surgical procedure.

[K-ras mutational status and tumour-infiltrating lymphocytes in human colon cancer: state of the art and future perspectives]. / K-ras mutace a nádory infiltrující lymfocyty u karcinomu kolon, soucasnost a výhledy.

INTRODUCTION: Nowadays, the prognosis of newly diagnosed colorectal cancer patients relies mostly on the tumour-node-metastasis (TNM) classification which is also a determining criterion for the indication of adjuvant oncological treatment. Currently, new prognostic and predictive biomarkers are sought after in order to more precisely define prognosis and better predict the benefits of adjuvant treatment in colorectal cancer. Besides several molecular biomarkers, such as mutations in the proto-oncogene K-ras, analyses of tumour-infiltrating lymphocytes have shown promising prognostic value. The aim of the study is to examine the correlations between K-ras mutational status and tumour-infiltrating immune cells in colon cancer patients with respect to colon cancer recurrence. MATERIAL AND METHODS: Formalin-fixed paraffin-embedded specimens were obtained from 44 patients with surgically resected colon cancer (R0 resection) treated between 2004 and 2009. K-ras mutational status was detected using PCR amplification of exon 1 followed by direct sequencing and K-ras StripAssay. Tumour-infiltrating immune cells were detected by immunofluorescence staining using monoclonal antibodies against CD3, CD8, FoxP3, CD1a and DC-LAMP. RESULTS: All 44 patients in our cohort underwent radical resection of colon cancer. In 16 patients the tumour relapsed (36.4%). K-ras mutations were found in 45.5% (n=20) of the primary carcinomas: 65% in codon 12 and 35% in codon 13. Although codon 13 K-ras mutations were associated with disease relapse, they were present in both disease-free and relapsed patients. However, disease-free and relapsed patients differed markedly in their patterns of tumour-infiltrating immune cells. There was a trend towards decreased density of tumour-infiltrating lymphocytes within the group of relapsed patients. In addition, relapsed patients with codon 13 mutations had markedly lower levels of tumour-infiltrating mature DC-LAMP+ dendritic cells and higher frequency of CD1a+ cells compared to disease-free patients. CONCLUSION: Colon cancer patients with low levels of tumour-infiltrating lymphocytes, a high CD1a+/DC-LAMP+ tumour-infiltrating DC ratio and a K-ras mutation in codon 13 are at a high risk of disease recurrence.

Short-term binding of fibroblasts to fibronectin: optical tweezers experiments and probabilistic analysis.

The biophysical properties of the interaction between fibronectin and its membrane receptor were inferred from adhesion tests on living cells. Individual fibroblasts were maintained on fibronectin-coated glass for short time periods (1-16 s) using optical tweezers. After contact, the trap was removed quickly, leading to either adhesion or detachment of the fibroblast. Through a stochastic analysis of bond kinetics, we derived equations of adhesion probability versus time, which fit the experimental data well and were used to compute association and dissociation rates (k+ = 0.3-1.4 s(-1) and koff = 0.05-0.25 s(-1), respectively). The bond distribution is binomial, with an average bond number < or = 10 at these time scales. Increasing the fibronectin density (100-3000 molecules/microm2) raised k+ in a diffusion-dependent manner, leaving koff relatively unchanged. Increasing the temperature (23-37 degrees C) raised both k+ and koff, allowing calculation of the activation energy of the chemical reaction (around 20 kBT). Increasing the compressive force on the cell during contact (up to 60 pN) raised k+ in a logarithmic manner, probably through an increase in the contact area, whereas koff was unaffected. Finally, by varying the pulling force to detach the cell, we could distinguish between two adhesive regimes, one corresponding to one bond, the other to at least two bonds. This transition occurred at a force around 20 pN, interpreted as the strength of a single bond.

Static compression is associated with decreased diffusivity of dextrans in cartilage explants.

The chondrocytes of adult articular cartilage rely upon transport phenomena within their avascular extracellular matrix for many biological activities. Therefore, changes in matrix structure which influence cytokine transport parameters may be an important mechanism involved in the chondrocyte response to tissue compression. With this hypothesis in mind, partitioning and diffusion of 3-, 10-, and 40-kDa dextrans conjugated to tetramethylrhodamine, and 430-Da tetramethylrhodamine itself, were measured within statically compressed bovine articular cartilage explants using a novel experimental apparatus and desorption fluorescence method. Partitioning and diffusion were examined as functions of solute molecular weight and matrix proteoglycan density, and diffusion was measured versus static compression up to 35% volumetric strain. In general, partition coefficients and diffusivities were found to decrease with increasing solute molecular weight. In addition, for a given solute, diffusivities decreased significantly with increasing static compression. Results therefore suggest a possible role for transport limitations of relatively large molecular weight solutes within the extracellular matrix in mediating the biological response of chondrocytes to cartilage compression.