Our experience with robotic-assisted thymic surgery.

Thoracic surgery is increasingly influenced by the development of minimally invasive approaches which have also influenced surgery in the area of the anterior mediastinum. The previously standard approach to the thymus via partial sternotomy was gradually replaced by the videothoracoscopic approach in most cases. In recent years, robotically assisted surgery has been gaining ground worldwide in this area, as well. The aim of our paper is to provide a comprehensive overview of procedures in the field of the thymus, including their indications, and to share our first experience with robot-assisted thymus surgery. At the 3rd Department of Surgery, since the start of the robot-assisted thymus surgery program, 23 thymectomies have been performed using this approach, of which 17 were performed for thymoma, 3 for myasthenia gravis, and 3 for parathyroid adenoma localized in thymus tissue. From our experience and the available data, it follows that the length of hospitalization, the rate of complications and the resulting effect of robot-assisted procedures is comparable to VTS procedures; however, the robot-assisted surgery also allows for mini-invasive treatment even in significantly obese patients and in patients with advanced thymic tumors who would otherwise be indicated for open thymectomy.

Surgical treatment of hyperparathyroidism with a pathologically changed parathyroid gland found in the mediastinum.

The most common indication for surgical treatment of parathyroid gland pathology is primary hyperparathyroidism where extirpation of the pathologically changed parathyroid gland is the first-choice treatment. Embryonic development of the lower pair of parathyroid glands is quite complex and is closely related to the tissue of the thymus; for this reason it is not uncommon for a parathyroid adenoma to be located in the mediastinum or directly in the tissue of the thymus. The treatment of primary hyperparathyroidism is becoming a multidisciplinary issue in which radiodiagnostics and nuclear medicine methods play a significant role as they are needed to accurately localize the affected gland and to plan an adequate surgery. In case of intrathoracic localization of parathyroid adenoma, the therapy belongs in the hands of thoracic surgery. At our department, the endocrine surgery program, including parathyroid gland surgery, has a long tradition, and complicated patients are concentrated here, often patients with refractory hyperparathyroidism after a previous procedure. In the last 10 years, almost 2,300 procedures for parathyroid pathology have been performed at the IIIrd Department of Surgery of the 1st Faculty of Medicine, Charles University and University Hospital in Motol, of which some pathologies with mediastinal localization were managed using minimally invasive methods, i.e. videothoracoscopy or robotic-assisted surgery.

Robotic distal pancreatectomy - the first experience.

INTRODUCTION: Minimally invasive distal pancreatectomy (MIDP) includes both laparoscopic and robotic distal pancreatectomy (RDP). MIDP is often adopted first due to the absence of the requirement of a complex reconstruction. In recent years, an increase in the use of robotic surgery has been noted. METHODS: The authors present initial experience with RDP and retrospective analysis of data from prospectively collected database. RESULTS: Between September 2021 and October 2022 five patients undergoing RDP with splenectomy performed in the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University and Motol University Hospital were included from a prospectively maintained database. The age was from 20 to 70 years. No conversion was required. One patient underwent reoperation due to staple-line hemorrhage. Postoperative hospital stay was from 4 to 14 days. The follow-up period was from 2 to 14 months. CONCLUSION: Our first experience demonstrates RDP is a safe and efficacious approach for tumors of pancreatic body and tail in selected patients. A larger number of patients is needed to obtain more accurate results.

Concomitant thyroid disease in patients operated for primary hyperparathyroidism.

INTRODUCTION: Parathyroid and thyroid diseases are ones of the most common endocrine diseases, but simultaneous surgical treatment of both endocrine systems is still under discussion. METHODS: We retrospectively evaluated 1,574 patients operated for primary hyperparathyroidism at the 3rd Department of Surgery, 1st Faculty Medicine, Charles University and University Hospital Motol in Prague with the thyroid and parathyroid ultrasound reports available. The patients were divided into two groups - with and without thyroid surgery. RESULTS: Thyroid surgery was performed in 34% of patients with primary hyperparathyroidism. Group 2, where thyroid surgery was performed, showed a higher proportion of reported abnormal thyroid sonographic findings (74%), a higher proportion of bilateral throat exploration (69%) and a longer hospital stay (3.3 days). CONCLUSION: A patient indicated for surgery for parathyroid disease should also be indicated for possible thyroid surgery.

Treatment of anastomotic leak after Ivor Lewis esophagectomy.

INTRODUCTION: Anastomotic leak (AL) is one of the most serious surgical complications after esophagectomy. Endoscopic, radiological and surgical methods are used in the treatment of AL. The aim of this study was to retrospectively evaluate our therapeutic procedures and results of AL treatment after Ivor Lewis esophagectomy (ILE). METHODS: Retrospective audit of all ILEs performed in the years 20052019. Evaluation of AL treatment results according to Esophagectomy Complication Consensus Group (ECCG) classification and according to the primary therapeutic procedure with a focus on the treatment with esophageal stent. RESULTS: Out of 817 patients with ILE, AL was detected in 80 patients (9.8%): ECCG type I 33 (41%), type II 23 (29%) and type III 24 (30%) patients. Some 33 patients (41%) were treated conservatively. Esophageal stents were used in 39 patients (49%), of which 18 (23%) had concomitant percutaneous drainage and 17 (21%) were reoperated. Reoperation without a stent insertion was performed in 7 patients (9%). Esophageal diversion with cervical esophagostomy was performed in a total of 16 patients (20%). Esophageal stent treatment was successful in 24/39 patients (62%). Airway fistula occurred in 4 patients treated with stent (10%). Endoscopic vacuum therapy was successfully used in three patients after stent failure. Eight patients (10%) died as a result of AL. Mortality of AL type I, II and III was 0%, 4% and 29%. CONCLUSION: Successful treatment of AL requires an individual and multidisciplinary approach. The primary effort should aim to preserve anastomosis using endoscopic and radiological methods. In case of insufficient clinical effect, we recommend not to hesitate with reoperation. If primary therapy fails, the life-saving procedure is a cervical esophagostomy.

[Videothoracoscopic excision of mediastinal parathyroid adenoma in primary hyperparathyroidism]. / Videothorakoskopické odstranení mediastinálne ulozeného adenomu prístítného telíska pri primární hyperparathyreóze.

INTRODUCTION: Primary hyperparathyroidism is a disease caused by elevated secretion of parathyroid hormone from pathological parathyroid glands. After the diagnosis, the success of its surgical solution depends predominantly on surgical management and experience of the surgeons. A special group is formed by ectopic localizations of pathologically enlarged parathyroid glands in the mediastinum, which require a modified surgical approach. When the adenoma is deep in the mediastinum, sternotomy or thoracotomy is indicated; alternatively, a minimally invasive approach can be used - videothoracoscopic thymectomy. CASE REPORT: We present a case of a patient with normocalcemic recurrent primary hyperparathyroidism. This patient underwent a minimally invasive video-assisted thymectomy after scintigraphic confirmation of parathyroid adenoma in the mediastinum. CONCLUSION: The removal of parathyroid adenoma in the mediastinum using the videothoracoscopic method is safe. Compared to sternotomy, this method improves the postoperative period, reduces the length of stay and provides more comfort to patients. We recommend considering the videothoracoscopic method in cases where the pathologically enlarged parathyroid gland is localized in the inferior and anterior mediastinum. KEY WORDS: primary hyperparathyroidism adenoma of glandula parathyroidea - mediastinum miniinvasive.

[Repeated surgery for parathyroid carcinoma]. / Opakované operace pro karcinom prístítného telíska.

INTRODUCTION: Carcinoma of the parathyroid glands is a rare cause of primary hyperparathyroidism with an incidence of 1%. MATERIAL AND METHODS: This article presents an up-to-date review of the literature illustrated by three clinical cases in the form of case reports. RESULTS: Parathyroid carcinoma is usually not detected before the first operation. Symptoms of carcinoma of the parathyroid glands are similar to those of benign adenoma. Patients with parathyroid carcinoma usually have a higher level of calcium in serum and a higher level of parathormone. Imaging methods such as neck ultrasound and 99mTc sestamibi scan can help localize pathologically enlarged glands, but they are not capable of distinguishing malignant disease. Fine needle aspiration is not recommended due to the possible associated risk of tumour seeding along the needle track. The radical excision of the tumour together with the ipsilateral thyroid gland removal remains the standard of treatment. Local recurrence is frequent. CONCLUSION: Parathyroid carcinoma is a very rare disease and should be managed surgically in a specialized centre.

Improvement of hypertension after parathyroidectomy of patients suffering from primary hyperparathyroidism.

Background. Primary hyperparathyroidism (PHPT) is one of the most common endocrine conditions and is accompanied by hypertension and increased cardiovascular mortality. The purpose of this study was to evaluate the effect of parathyroidectomy on systolic and diastolic blood pressure (BP) in hypertensive patients with PHPT and whether hypertension occurs more frequently in PHPT than in control group. Methods. A total of 1020 patients with proved PHPT who underwent surgery were compared with with 1020 age, sex, BMI, and smoking status matched controls. We evaluated changes in serum calcium, parathyroid hormone (PTH), uric acid, and BP before and 6 months after surgery. Results. Parathyroidectomy corrected PHPT and resulted in a substantial fall in both mean systolic (150 ± 3.8 to 138 ± 3.6 mmHg) and mean diastolic pressures (97 ± 3 to 88 ± 2.8 mmHg) of the hypertensive subjects; P < .01. In these patients, PTH, calcium, and uric acid normalized. 726 patients from 1020 with PHPT (69.8%) were found to be hypertensive whilst only 489 (47.8%) from 1020 of our control group. Conclusion. Parathyroidectomy in hypertensive patients reduces systolic and diastolic BP. PHPT is accompanied by a variety of metabolic complications, which are a risk factor for hypertension, and parathyroidectomy can improve these metabolic complications.

[Esophageal perforation]. / Perforace jícnu.

OBJECTIVE: Evaluation of patients with acute esophageal perforations with single institution experience. MATERIAL AND METHODS: The authors evaluate the set of 64 consecutive patients with esophageal perforation treated in our department between January 2000 and December 2010. In all patients were before decision making performed CT scans and X-ray examination with contrast agent administration. For selected patients was also accompanied upper endoscopy. Excluded were patients with malignant tracheoesophageal fistula and patients with perforation of malignant stenosis treated with palliative intent. RESULTS: The mean age was 62 years (range 24-90), of which one third (34.4%) were aged 70 years or more. We received the iatrogenic perforation in 45 (70%) patients, less than one quarter (n = 15; 23%) consisted of spontaneous perforation, in three patients we have failed to determine the cause of perforation (5%) and one patient experienced perforation during removal of foreign body. Perforation of the thoracic esophagus in 41 patients, in 20 (31%) cases in the upper and middle third and 21 (33%) in the distal third of the thoracic esophagus. Cervical perforation was noted in 14 patients (22%) and abdominal of the 9 patients (14%). 92% of patients were treated surgically (n = 59). 43% (n = 27) were treated by primary suture of the perforation, esophageal resection with primary reconstruction was performed in 4 patients, esophagectomy with terminal esophagostomy and nutritional jejunostomy in 7 patients, 4 patients were treated by surgical drainage and only 7 patients, we introduced endless lavage. In 9 cases we have resected affected portion of esophagus with stapler closure in the chest. Conservative management of esophageal perforation we proceeded in 5 patients in whom a stent was introduced and the perforation successfully healed. Overall mortality in our set of patients is 23.4%. CONCLUSION: Conservative procedure in carefully selected patients could be an alternative to radical and inherently surgical procedures. Published results and our little experience are encouraging, but this topic is still under study.

[Disadvantages of unilateral videothoracoscopic thymectomy]. / Nevýhody jednostranné videotorakoskopické tymektomie.

The authors highlight disadvantages of the unilateral videothoracic approach in thymectomy procedures. They present a case-review of a young female patient, indicated for the procedure for myastenia gravis. In these patients, the primary objective is to remove all the thymus tissue and the surrounding adipose tissue within the anterior mediastinum, which, using the above approach cannot always be guaranteed. Considering the number of patients indicated for the procedure based on the above diagnosis, it is inevitable to perform the procedures in specialized centres, experienced with these conditions.

[Stents--palliative and curative management of esophageal conditions. Seven-year surgical experience]. / Stenty--paliativní a kurativní osetrení jícnu. Sedmileté zkusenosti chirurgického pracoviste.

The authors present their experience with endoscopic introduction of stents into esophagus and cardia based on data collected from a group of 520 patients. Their study included both paliative management of stenoses in carcinomas of the esophagus and cardia, as well as management of other esophageal conditions, including fistules, perforations and various types of stenoses, including the use of novel absorbable stents.

[Paliative managment of oesophageal carcinomas--our experience]. / Paliativmní osetriení karcinomu jícnu--nase zkusenosti.

The authors of this presentation explain their experience with methods of paliative care of oesophagus carcinoma. The indication criteria are described and compared advantages and disadvantages of those methods. There is an accent in most frequent method--oesophagus stent implementation. The results in the group of patients after the stent implementation are described, also complications and other solutions.

[Our strategy in the therapy of myasthenia gravis]. / Unser Vorgehen in der chirurgischen Behandlung der Myasthenia gravis.

Surgical treatment of myasthenia gravis has at the 3 (rd) Department of Surgery, 1 (st) Medicine Faculty of Charles University in Prague a multiyear tradition which has originated in the 60's of the 20 (th) century. Since that time we carried out over 1 000 operations on the thymus, especially thymectomy for myasthenia gravis (MG) and with lesser frequency for thymomas. Thymectomy combined with exenteration of fatty tissue from the front mediastinum belongs to basic MG surgery. According to our experience an optimal approach to the thymus is given by partial sternotomy. A jugular approach is not regarded as enough radical. Videothoracoscopic approach and operation are possible but take more time, however they are the method of choice at some workplaces. The combined conservative and surgical treatment brings in 80 % of the cases an obvious improvement or deletion of the symptoms of the disease.

[Role of the surgeon in the treatment of myasthenia gravis and thymoma]. / Postavení chirurga v lécbe myasthenia gravis a tymomu.

Surgical treatment of myasthenia gravis at the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague, has long tradition. It originated in sixties of the 20th century. Over 1000 operations of a thymus has been carried out since that time, especially thymectomy for myasthenia gravis (MG) and for less frequent thymomas. The complete removal of thymus--thymectomy accompanied with exenteration of the fat in frontal mediastinum belongs to the principal MG surgery. According to our experience, the optimal approach to the thymus is a partial sternotomy. The jugular approach is not regarded as sufficiently radical. Videothoracoscopic approach and operation are possible but they are longer. They represent a method of choice at some workplaces. The combined MG treatment (conservative medicamentous and surgery treatment) brings in 80% a visible improvement and a deletion of symptoms of the disease.

Surgical contribution to the management of primary hyperparathyroidism.

Surgical management of primary hyperparathyroidism is a very effective method. The target is to cure primary hyperparathyroidism and to reach normal calcium levels. This results in an improvement of health condition and resolution or at least moderation of symptoms. Complications are infrequent and mortality is very low. Surgical management is definite, safe and effective. Authors of this article address the diagnosis of primary hyperparathyroidism, clarify bone, metabolic and biochemical syndromes and present series of 151 patients that have been operated on at the 3rd Department of Surgery of the Motol University Hospital, Prague, with the diagnosis of primary hyperparathyroidism. The survey is focused on the primary hyperparathyroidism concomitant diseases and on the possible sequelae in the postoperative period.

[Omentoplasty of the sternum--surgical solution in a sternal defect due to sternal osteomyelitis in a female patient with mediastinal localization of a parathyroid adenoma. Case report]. / Omentoplastika sterna--chirurgické resení defektu sterna pri osteomyelitide sterna u pacientky s mediastinálne ulozeným adenomem paratyreoidey. Kazuistika.

We report here the case report of patient with empyema of the thorax and sternal osteomyelitis, which undertool removal of ectopic mediastinal parathyroid adenoma with omentoplasty of sternal defect. Osteomyelitis was cured; though empyema persisted for several months and it's healing was complicated with central venous catheter sepsis.

[Personal experience with a bilateral approach in the surgical treatment of primary hyperparathyroidism. (A group of 222 patients with surgery for primary hyperparathyroidism from 1994 to 2000)]. / Nase zkusenosti s bilaterálním prístupem pri chirurgické lécbe primární hyperparatyreózy. (Soubor 222 pacientu operovaných pro primární hyperparatyreózu v letech 1994-2000.).

Surgical treatment offers a definite cure of patients with primary hyperparathyroidism. When making the diagnosis of primary hyperparathyroidism the success of a surgical solution depends on the experience and judgment of the surgeon. Our experience with 222 operations and re-operations convinced us on the preference of a bilateral approach, i.e. exploration of both sides of the neck. The ectopic localization of the parathyroid glands, the limited possibilities of an unequivocal interpretation of the histological examinations but also the frequent incidence of thyropathies leads the surgeon, in our opinion, to the complete exploration of both sides of the neck within the framework of the primary operation for primary hyperparathyroidism. This approach leads most probably to the best results. We use an aimed unilateral approach only in old patients who are in a very bad condition where we anticipate a benefit from a short operation.

[A rare case of necrotizing fasciitis and subsequent sepsis with multiorgan failure caused by Vibrio vulnificus]. / Vzácný prípad nekrotizující fasciitidy a následné sepse s multiorgánovým selháním zpusobený agens Vibrio vulnificus.

The authors report a rare case of necrotizing fasciitis, sepsis caused by a strain of Vibrio vulnificus rare in Czech Republic.

[An unusual complication after laparoscopic cholecystectomy]. / Neobvyklá komplikace po laparoskopické cholecystektomii.

The authors describe an interesting complication after laparoscopic cholecystectomy. During a complicated operation perforation of a gallbladder, severely altered by inflammation, occurred and part of the concrements escaped into the peritoneal cavity. Several concrements were left in the abdominal cavity. After several weeks of a complicated postoperative development the concrements penetrated into the subcutaneous layer in the lumbar region and finally they were eliminated spontaneously. In the discussion the authors deal with complications of laparoscopic cholecystectomy.