Risk factors and post-operative complications after gastrectomy for cancer.

INTRODUCTION: Gastric resections due to carcinoma belong to the most demanding procedures in visceral surgery. This is due to the requirements for the extent of resection and lymphadenectomy, coupled with the need for functional reconstruction of the digestive tract. The procedure is associated with 18-46% morbidity, which delays administration of adjuvant therapy and worsens oncological results. Identification of risk factors for potential complications may play an important role in the indication and perioperative care. The aim of our study is to (i) evaluate the morbidity a mortality of a patient group with post-gastrectomy complications and to (ii) identify associated risk factors. METHOD: This retrospective analysis comprises patients treated in 2005-2016. Gastric resection was performed in 266 adenocarcinoma patients, 172 men and 94 women (median age 66 years). Early post-operative complications following gastrectomy were observed within 60 days. Complications and their severity were evaluated according to the extended form of the Accordion Severity Grading System. Selected demographic risk factors, operative factors and malignancy-related factors were analyzed. Multivariate regression (orthogonal projections to latent structure) was used for statistical processing. RESULTS: Overall morbidity and mortality was 34.6% and 3.4%. Serious complications occurred in 51 operated patients (19.2%). 24 patients had two or three complications (9%). The most common grades of severity were grade 2 in 31 patients (11.7%) and grade 4 in 20 patients (10.9%). The duration of hospital stay correlated with the severity of the complication. Most common surgical complications were: intra-abdominal abscess (16.4%, 17 cases), wound complications (5.3%, 14 cases), pancreatitis (4.9%, 13 cases), anastomotic leakage (3.4%, 9 cases), postoperative ileus (3.4%, 9 cases). Respiratory and cardiac complications were the most common non-surgical complications (8.6%, 23 cases and 3.8%, 20 cases, respectively). In the derived statistical model, BMI, the presence of more comorbidities, lesser surgical experience, the length of hospital stay and hospitalization at ICU were identified as risk factors associated with the grade of complication, morbidity, presence of serious complication and multiple complications. CONCLUSION: Gastrectomy plays a fundamental role in the curative treatment of gastric carcinoma; it is, however, associated with substantial morbi-dity and mortality. The best management of complications is their prevention. Preoperatively, the greatest attention should be paid to patients with several comorbidities and higher BMI. Resections should be performed by experienced surgeons. During resection, consideration should be given to the extent of resection and lymphadenectomy. In the postoperative period, the length of hospital stay, especially at ICU, should be reduced to minimum. Analyses of these risk factors may decrease the incidence of complications. Key words: gastric cancer - gastrectomy - risk factors - complications.

Hybrid thoracoscopic esophagectomy for cancer - retrospective analysis and comparison with transhiatal resection.

INTRODUCTION: Minimally invasive methods for esophagectomy have been introduced to reduce postoperative complications. This paper compares open transhiatal esophagectomy and minimally invasive hybrid esophagectomy. Both methods have different extents of lymphadenectomy, transhiatal esophagectomy being considered less radical. METHOD: A single-centre retrospective study comprised 39 patients subjected to transhiatal esophagectomy and 25 patients subjected to hybrid esophagectomy combining thoracoscopy with laparotomy and cervical anastomosis. All patients were operated for middle and distal third carcinoma of the esophagus, including cardia (Siewert II), in the period of 2006-2016 at the Surgery department of Nový Jicín hospital. The data of both groups, in particular the incidence of early postoperative complications and the number of dissected lymph nodes, were statistically compared. Complications are reported according to the International Consensus on Standardization of Data Collection for Complications Associated with Esophagectomy. RESULTS: The duration of operation was significantly longer in the group that underwent hybrid resections (345 vs. 240 min, p<0.001). The number of dissected lymph nodes was comparable in both groups (15 vs. 16, p=0.072). Postoperative pulmonary complications were lower for hybrid operations (16% vs. 30.8%, p=0.243). The most common complication of transhiatal esophagectomy was pleural effusion requiring drainage, which occurred in 7 patients. The most common pulmonary complication of hybrid procedures was respiratory failure, which occurred in 3 patients. Anastomotic leak occurred in 5 patients after transhiatal esophagectomy and in one after thoracoscopic resection (12.8% vs. 4%, p=0.391). 30-day and 90-day mortality was nonsignificantly lower for hybrid resections (0% vs. 5.1%, p=0.516 and 4% vs. 10.3%, p=0.64). Following transhiatal esophagectomy, two patients died as a result of respiratory complications, one died from necrosis of the gastric tube and one from acute myocardial infarction. In the hybrid group, one patient died from respiratory failure. Hybrid resection exhibited lower morbidity (36% vs. 59%, p=0.123). The number of overall complications, irrespective of their severity according to the Clavien-Dindo classification, was statistically in favor of hybrid resection (11 vs. 30, p=0.015). CONCLUSION: In our study, we found that thoracoscopic hybrid resection was a feasible and well-executable method, with a statistically lower incidence of postoperative complications. Thoracoscopy allows lymphadenectomy to be performed to sufficient extent. The large number and various combinations of esophagectomy techniques make it difficult to evaluate and compare the outcomes of individual methods. Preference for a specific resection technique within a given surgical department remains an important factor as clear recommendations for esophageal resections do not yet exist. However, the use of minimally invasive techniques in esophageal resections is gradually becoming a standard. Key words: minimally invasive esophagectomy - thoracoscopy - postoperative complications - lymphadenectomy.

Prophylactic ligation of the thoracic duct in the prevention of chylothorax after esophagectomy.

INTRODUCTION: Chylothorax after esophageal resection is an uncommon but serious complication with a reported incidence of 1-10%. It occurs after the injury of the thoracic duct or its tributaries. Chylothorax may cause an overall loss of several liters per day and may lead to dehydration, malnutrition and immunosuppression. Therapeutic approach has not been standardized. Prophylactic ligation of the thoracic duct during primary resection has been introduced to decrease the overall incidence of chylothorax. Its oncological benefit is unknown. METHOD: A retrospective single-center study of patients who underwent transthoracic esophagectomy from 2008-2016 for esophageal carcinoma at the Department of Surgery, Hospital Nový Jicín. 58 patients underwent transthoracic esophagectomy (Ivor-Lewis and McKeown). Prophylactic ligation of the thoracic duct was performed in 31 patients (53%). The incidence of chylothorax and the amount of harvested lymph nodes was analysed in the group with thoracic duct ligation (A PTDL 31 patients) and in the non-ligation group (B 27 patients). RESULTS: Overall incidence of chylothorax after transthoracic esophagectomy was 3.4%. Chylothorax occurred in two men (type 3B) in the prophylactic group (6.5%) and it was not observed in the non-ligation group. Statistically significant difference was not confirmed (p=0,494). Chylous leak was successfully treated thoracoscopically and by thoracotomy with repeat ligation of the thoracic duct. Non-significantly more lymph nodes were harvested in the prophylactic group (18 A PTDL vs. 15 B, p=1). CONCLUSION: Prophylactic ligation of the thoracic duct in our study did not reduce the incidence of chylothorax. Redo thoracotomy and redo thoracoscopy for chylothorax is feasible. In patients with high-output and long lasting leaks the indication for redo surgery should be early. Key words: chylothorax - esophageal resection - prophylactic thoracic duct ligation.

Current state of surgical treatment of cancer of the stomach and gastro-esophageal junction in the Czech Republic.

INTRODUCTION: Analysis of the epidemiology and treatment of cancer of the stomach (CS) and gastro-esophageal junction (GEJ) in the Czech Republic (CR). METHOD: Analysis from the National Cancer Registry (NCR) of the CR examined data up to the year 2013. RESULTS: In CS and GEJ, the incidence is 14.3, mortality is 10.5 and prevalence is 51.1 per 100,000 population. The Karlovy Vary, Olomouc and Moravian-Silesian regions had the highest incidences. The median age at diagnosis is 69 years for men and 72 years for women. Location in the stomach prevails in 85% of the patients, cancer of the gastric cardia occurring in 15%. In men, this ratio is 81 to 19%, in women 90 to 10%. The disease is usually diagnosed late; in 2013, 36% of CS and 32% of GEJ tumors were stage I and II. 53% of CS and 56% of tumors of the GEJ were diagnosed as stage III and IV, and in 11% and 12%, the stage was not determined. In the years 2009-2013 (1,580 patients with CS and GEJ), only 22% were treated surgically, surgery and oncological treatment was given to 21.3%, only non-surgical treatment was received by 15.7% and 41% of patients received no oncological treatment. Overall five-year survival in patients treated between 2010 and 2013 was 32%. At stage I it was 69%, at stage II 41%, at stage III 23% and at stage IV it was 6%. Five-year survival rates according to disease stage and type of treatment given and median of survival were analysed on 8,348 patients with CS and GEJ between 2004 and 2013. Surgery only was performed in 4,116 patients, surgery and radiotherapy was administered to 113 patients, surgery and chemotherapy to 1,855 patients, and 1,125 patients received chemotherapy alone. In 98% of the treated patients, chemotherapy and/or radiotherapy was administered adjuvantly after the surgery. Primary operations were performed at a total of 175 surgical centers, only 22 of them performing more than 10 operations annually. The median of survival differed depending on the number of operations performed: at enters performing more than 20 operations, the median was 24.8 months (m); at enters performing 10-19 operations, the median was 18.2 m; at centers performing 6-9 operations the median was 18.1 m; and at centers performing less than 6 operations, the median was 13.1 m. CONCLUSION: Early diagnosis is key for five-year survival. Treatment is based on surgery; greatest improvement is seen when surgery is combined with chemoradiotherapy, which is usually administered adjuvantly in the CR. At stage I in CS +9.5%, GEJ cancer +26.5%, at stage II in CS +14.7%, GEJ cancer +16.4% and at stage III in CS +13.3%, GEJ cancer +2.6%. Palliative chemo and/or radiotherapy does not prolong five-year survival and must be selected on an individual basis with regard to the expected benefit for the patient. Facilities performing a greater number of surgical procedures have better long-term results. Key words: malignant esophageal tumors - epidemiology - treatment - results.

[Sternal resection for metachronous metastasis from renal carcinoma]. / Resekce sterna pro metachronní metastázu karcinomu ledviny.

In this report, the authors describe a rare case of complete sternal resection for a metachronous metastasis from renal carcinoma in a 59-year-old female patient 12 years after primary left nephrectomy. Due to the large extent of resection, a polyester double layer mesh with bone cement was used for chest wall reconstruction. The postoperative course was uneventful without any indication for adjuvant treatment. The patient has been followed up for 20 months without any signs of complications and recurrence of her malignancy.Key words: sternum resection bone metastases renal carcinoma.

[Gastric stump cancer--unicentric analysis of 7 patients]. / Karcinom zaludecního pahýlu--unicentrická analýza 7 pacientu.

INTRODUCTION: Gastric stump cancer accounts for 14% of all gastric carcinomas. Originally this term included patients who previously underwent surgery due to peptic ulcer disease but today gastric stump cancer also includes patients diagnosed some time after primary gastric resection due to gastric cancer. The incidence is increasing. Gastric stump cancer is associated with poor prognosis and its reported resecability is around 40%. METHODS: We retrospectively analyzed the data of 7 patients with a preoperatively histologically confirmed stump cancer who had been operated at the Department of Surgery at Nový Jicín Hospital during 2006-2014. RESULTS: We operated 5 men and 2 women with the median age of 70 years (5580). The primary surgical resection in all our patients was BII gastric resection due to peptic ulcer disease, and GSC had evolved within a median of 38 years (3246) after primary intervention. None of the patients had been regularly screened by endoscopy following primary surgery. We performed five curative resections (four total gastrectomies, one subtotal gastrectomy). Our resecability rate was 71%. In two cases, only explorative laparotomy was performed due to generalisation of the malignancy. Two patients from the resected group died after 30 and 34 months due to progression of their disease; the other three patients are still alive after 17, 19 and 88 months. CONCLUSION: Gastric stump cancer is a malignancy often diagnosed in its late stages. Regural endoscopic screening after primary gastric resection for benign disease can lead to diagnosis at an earlier stage, thereby improving the resection rate and overall survival. This also applies to long-term follow-up of patients with primary subtotal gastrectomy for cancer. Lymphatic metastasizing of the carcinoma can often be different due to the previous surgical intervention and altered anatomy. This must be taken into account during operations.

[Colon cancer - evaluation of complications and risks of planned resections]. / Karcinom tlustého streva - zhodnocení komplikací a rizik plánovaných resekcních výkonu

INTRODUCTION: Resection procedures for colorectal cancer are burdened with a relatively high number of complications. The aim of this study is to define risk factors associated with the development of postoperative complications based on retrospective data analysis. MATERIAL AND METHODS: From January 1 st 2007 to December 31st 2012, 1093 patients underwent surgery for colorectal cancer. Retrospectively, we selected a group of 406 patients who underwent planned, elective colon resection for colon cancer. Open surgery was performed in 158 patients (38.9%), laparoscopic resection in 248 patients (61.1%). Based on initial staging of the disease, there were 85 patients (20.9%) in stage I, 137 patients (33.8%) in stage II, 110 patients (27.1%) in stage III and 74 patients (18.2%) in stage IV. Postoperative complications were evaluated according to Clavien - Dindo classification. RESULTS: Grade I complications were observed in 34 patients (8.4%), grade II in 25 patients (6.2%), grade III in 43 patients (10.6%), grade IV in 7 patients (1.7%) and grade V in 8 patients (2.0%). The highest incidence of complications was observed in left colon resection procedures (41.1%), open resections (39.8%), procedures lasting longer than 301 minutes (50%), patients older than 81 years (41.6%) and in procedures performed by the youngest, less experienced surgeon (40.6%). CONCLUSION: Our results confirmed that the type and approach of surgical procedure, patients age and surgeons experience are risk factors associated with a higher incidence of postoperative complications. High-risk surgical patients should be operated on by experienced surgeon who regularly performs a high number of resection procedures.

[Acceptable risks in surgery from the perspective of the evidence-based medicine and an evaluation of the quality of surgical care]. / Prípustná rizika v chirurgii z pohledu Medicíny zalozené na dukazech a hodnocení kvality chirurgické péce.

A qualified assessment of the risks of surgical treatment and especially operations is based on the evaluation of morbidity, mortality and long-term results of surgeons work. These analyses should be conducted based on the principles of the evidence-based medicine (EBM) and, in recent years, an assessment of the risks that surgical treatment has been included into a broader complex of evaluating the quality of surgical care. Surgery, other surgical specializations, and the urgent medicine belong among medical fields which most often carry a risk of unsuccessful outcomes and complications. Taking into account the complexity of medicine, the diagnostic and therapeutic processes are burdened necessarily by a certain number of complications. It is never possible to completely eliminate human errors, but what is possible is to continuously decrease their numbers and repair them on time. EBM is defined as a method of treating for patients based on the best scientific evidence resulting from clinical and epidemiological scientific research publications. From an EBM perspective, surgery compared with pharmaceutical treatment is usually at a disadvantage because the studies with the highest level of evidence (the controlled randomized studies) are usually not possible to be performed in surgery. In various situations it is only possible to obtain certain kinds of evidence and in surgery the highest level of evidence is most often obtained from cohort studies and case control studies as a possible means of sorting our information. Currently, evaluating the quality of surgical care should be in the forefront of interest of every surgeon. Traditional criteria include the evaluation of operative and postoperative complications, mortality, the number of re-operations, the evaluation of the satisfaction of the patient with the procedure performed, the length of survival of oncological patients, the number of recurrences and a number of other criteria. The term "High Volume Hospital" represents a newly developing concept of evaluating quality in surgery, which arises from the assumption that with the increasing number of procedures (operations) performed the quality of the results attained increases as well. The evaluation of quality in surgery is a topic which should be addressed more thoroughly among surgeons. The creation of indicators of quality of surgical care and their application into clinical practice has great significance for the development of surgery and it is not possible to leave it beyond the control of surgeons.

[Complications and risks of the surgery of tumors of the upper digestive tract (Foregut) Part I: Esophagus]. / Komplikace a rizika chirurgie nádoru horní cásti zazívacího traktu (Foregut) I. cást: Jícen.

INTRODUCTION: The aim of the work is to evaluate acceptable mortality and morbidity associated with the esophageal resections for carcinoma. METHOD: The work analyses the data of patients with esophageal cancer from the Czech National Cancer Registry and it compares personal experience with complications and risks associated with the esophagectomy for carcinoma with the data from specialized literature published in recent years. RESULTS: Despite improvements in the surgical technique and the perioperative intensive care, the esophagectomy maintains a relatively high morbidity and mortality. Published studies present mortality up to 10% and total morbidity between 40-60%. Respiratory complications are most frequent and significant and they reach up to 40% and the anastomotic dehiscence ranges from 0 to 25%. At the authors workplace in Nový Jicín, a total of 193 patients with the esophageal carcinoma were examined since 2007; 38% of these patients were indicated for operation and 62 esophageal resections with replacement were performed. The postoperative mortality within 30 days was 3.2% and the total morbidity was approximately 50%. Respiratory and cardiac complications were 28% and 18% respectively, fistula in the cervical anastomosis was seen in 5% and in the gastric tube in 3%, only one patient died from this surgical complication. The paralysis of the recurrent nerve occurred in 10%, and chylothorax in 3%. In almost all patients, the operation began with a laparoscopic revision to confirm operability and in 37% of the operated patients a video-assisted approach was used, most often the thoracoscopic mobilization of the esophagus. CONCLUSION: The surgical treatment of tumors of the esophagus is a highly specialized domain of thoracic surgeons specialized in the issuesof the esophagus. General trends for improving the morbidity and mortality include the use of minimally-invasive approaches, fast-track programs after the esophagectomy, and the application of principles of High-volume centres. The long-term prognosis of patients with esophageal cancer is principally dependent on the degree of advancement of the disease.

[Complications and risks in the surgery of tumors of the upper digestive tract (Foregut) Part II : Stomach]. / Komplikace a rizika chirurgie nádoru horní cásti zazívacího traktu (Foregut) II. cást: Zaludek.

INTRODUCTION: The aim of the work is to evaluate acceptable mortality and morbidity associated with stomach resections for carcinoma. METHOD: The work analyzes data of patients with gastric cancer from the Czech National Cancer Registry and compares personal experience with complications and risks associated with stomach resections for carcinoma with the data from specialized literature from recent years. RESULTS: The incidence of gastric cancer in the Czech Republic is presently 15.1/100 000 inhabitants, the mortality 11.6 and the prevalence 48.3. Stomach resections for carcinoma are complicated operations. Despite improving surgical techniques and tactics, as well as the perioperative intensive care, this procedure remains associated with significant morbidity and mortality. At the Department of Surgery of the Oncological Center and Hospital Nový Jicín, 286 patients with gastric cancer were operated between the years 2005 and 2012. In the group of 172 radical R0 resections, the mortality was 3.5% and the total morbidity was 33.7%. The most frequent and significant postoperative surgical complications were the pancreatitis (4.7%) and the anastomotic dehiscence (3.5%). The most frequent non-surgical ones were respiratory complications (4.7%). The mortality and morbidity frequency is comparable with the data published in specialized literature. Surgical treatment also utilized laparoscopy. All operations began with a diagnostic laparoscopy to specify the stage of the disease and to select the laparoscopic approach, most often a laparoscopically-assisted resection, which was used in 60 patients (30%). Laparoscopy was preferred even for the palliative anastomoses. No significant differences in morbidity and mortality were seen between open and laparoscopic procedures and statistical analysis is planned to gain greater experience. CONCLUSION: In the Czech Republic, surgical treatment of tumors of the stomach is currently performed at a large number of workplaces with a low frequency. General trends for improving the morbidity and mortality include the use of minimally-invasive approaches, a fast-track program, and the application of principles of High-volume centres. The long-term prognosis of patients with gastric cancer is principally dependent on the degree of advancement of the disease.

[Malignant tumors of the esophagus in the Czech Republic]. / Zhoubné nádory jícnu v Ceské republice.

INTRODUCTION: Data analysis of the incidence, mortality and basic data regarding therapy of esophageal cancer in the Czech Republic and determining possible ways to improve the current situation. MATERIAL AND METHODS: Analysis was performed using data obtained from the Czech National Cancer Registry and from the Registry of Thoracic Procedures from the Section of Thoracic Surgery of the Czech Surgical Society. Analysis of specialized literature provided generally accepted risk factors for the development of esophageal cancer. RESULTS: Esophageal cancer represents 0.7% of all solid malignant tumours in the Czech Republic (1.1% in males and 0.2% in females). During 1977 to 2008, the incidence increased from 2 to 5.4 cases per 100.000 inhabitants and mortality from 1.9 to 4.1 cases per 100.000 inhabitants. In absolute numbers, the incidence was 561 cases (5.4 per 100.000 inhabitants) in 2008. Absolute mortality rate was 452 deaths (4.3 per 100.000 inhabitants) and absolute prevalence (number of patients living with cancer or with its medical history) was 791 subjects(7.6 per 100.000 inhabitants). When compared to international data, the incidence in the Czech Republic is the 84th highest in the world and 17th highest in Europe (mortality rates are at the 85th place in the world and the 18th place in Europe). In the Czech Republic, the highest incidence is in the Moravian-Silesian and Zlin regions (6.1 per 100.000), the lowest in the Plzen (4.2) and Vysocina (4.1) regions. The average age at the time of diagnosis is 62 years in males and 68 years in females, the maximum incidence is between 55 and 69 years in males and between 58 and 79 years in females. Upon diagnosis, advanced stages of the disease predominate. In 2008, 28% of the detected esophageal cancer cases were stage I and II disorders, 60 % were stage III and IV disorders, and in 12% of the cases the stage was not determined. In the treated patient group, the five-year survival rate was 15.5% in total, based on an analysis of data from 2004 - 2007. The five-year survival was 30% in stage I and II diosease cases, 12% in stage III disorders and 2% in stage IV cases. When comparing the analysis of data from 2004 to 2007 with the analysis of data from 2000 to 2003, there is a 10% improvement in stages I and II and a 4% improvement in stage III disorders. According to the Thoracic Surgery Registry of Thoracic Procedures data covering the period 2007 to 2010, thoracic procedures are performed at 19 to 22 surgical departments, esophageal resections are performed at 13 to 14 surgical departments, but only in 8 to 9 of these departments is the frequency of such procedures more than 10 operations per year. At the authors' department, 53 esophageal resections have been performed in the past five years with a 3.8% postoperative mortality rate and a 23 % total postoperative morbidity rate. Forty-nine percent of the cases were adenocarcinomas. CONCLUSION: Based on its incidence in our population, esophageal cancer can be considered an unfrequent tumour. This analysis shows regions of the Czech Republic with higher incidence and the most at-risk age group in males. Significant risk factors for squamous cell cancer such as smoking and alcohol consumption have already been previously identified; in adenocarcinoma it is primarily Barrett's esophagus. Other risk groups include patients with achalasia and with strictures after corrosion injury to the esophagus. Acceptable treatment results may only be achieved in patients with less severe stages of the disease and it would therefore be appropriate to actively search for such patients in at-risk regions and among the risk groups as part of the preventive programs. To date, universally accepted guidelines for monitoring of such patients have not been defined. Surgical treatment is a highly specialized domain of thoracic surgeons focused on esophageal surgery and patients should be concentrated in specialized centres.

[Intraoperative radiotherapy in multimodality treatment of locally advanced rectal carcinoma]. / Intraoperacní radioterapie v multimodalitní lécbe lokálne pokrocilého karcinomu rekta.

Multimodality treatment of locally advanced rectal cancer combines radical surgery, radiotherapy and chemotherapy. This method leads to improvement of local control and overall survival. However, some of the patients incur local failure of disease, which are localized predominantly in presacral region. The integration of intraoperative radiotherapy as part of a multimodal treatment approach helps to a further dose escalation without increasing toxicity, and reduces the likelihood of otherwise difficult curable local failure.

[Modern radiotherapy in the complex management of soft tissue and bone sarcomas in adults--current overview and the author's experience]. / Moderní radioterapie v komplexní lécbe sarkomu mekkých tkání a kostí u dospelých--aktuální prehled a vlastní zkusenosti.

Soft tissue sarcomas and primary bone tumours constitute very heterogenic group. Gold treatment standard is surgery in most of them. Nowadays the combination surgery with radiotherapy is preferred, because thanks new radiotherapeutic technology is possible to apply very high dose of radiation which necessary for local control of these tumours. The goal of our article is to describe new possibilities of radiotherapy, including neoadjuvant and adjuvant setting, intraoperative radiotherapy, interstitial brachytherapy and the combination with surgery. But very important is multidisciplinary cooperation to until recently in prognostic bad group of patients, concentration these patients to centers with modern technique and clinical experience with treatment of soft tissue sarcomas and bone tumours.

Intra-operative liver ultrasound--a contribution to colorectal carcinoma staging.

BACKGROUND: Laparoscopic resection of colorectal carcinoma is now a well-established surgical technique with oncology treatment outcome similar to open surgery, yet performing better in some short-term variables. The technique, however, does not allow palpation of intra-abdominal organs and the liver in particular. This prospective study aims to assess the performance of laparoscopic intra-operative ulrasonography of the liver (L-IOUS) and compare its findings with pre-operative staging data. METHODS: In total 70 patients, 53 men and 17 women, who were recruited into the study, were indicated for primary laparoscopic resection for colorectal carcinoma, with laparoscopic intra-operative ulrasonographic examination of the liver (L-IOUS) being used during the initial part of the operation. Before surgery, all patients underwent abdominal and pelvic contrast CT examinations. Ultrasonographic examination of the liver was included. RESULTS: In 14 patients L-IOUS detected a synchronous metastatic lesion of the liver as opposed to only six patients with pre-operative CT-positive findings. Furthermore, CT-positive metastases in three patients were not confirmed by L-IOUS. Several patients were diagnosed with benign lesions not disclosed during pre-operative assessment, e.g. haemangioma in 5 vs 2 patients, focal nodular hyperplasia in 3 vs 1 patient and liver cysts in 7 vs 5 patients. CONCLUSION: Results of the presented prospective study substantiate the use of laparoscopic intra-operative ultrasound of the liver (L-IOUS) within the standard staging protocol, as this seems to appropriately supplement the results of the pre-operative staging. In cases of colorectal carcinoma the method allows highly sensitive detection of occult synchronous liver metastases that could finally alter a therapeutic strategy.

[Laparoscopic resection of rectal cancer: evaluation of perioperative results of the primary resection and resection after preoperative chemoradiotherapy]. / Laparoskopická resekcia karcinómu rekta: zhodnotenie perioperacných výsledkov primárnej resekcie a resekcie po neoadjuvantnej chemorádioterapii.

AIMS: To evaluate and compare perioperative results of laparoscopic resection for low and middle third rectal cancer subgroup of patients intended for primary resection (PR) with those operated after chemoradiotherapy (CHRT). METHODS: 291 patients were operated for rectal cancer during the years 2005-2007 in Department of Surgery, J. G. Mendel Oncological Centre Nový Jicín. 155 patients (49 women and 106 men, mean age 65 +/- 9.7, range 27-87) having laparoscopic resection for low and middle rectal cancer were included in the present prospective single centre study. Primary surgical approach was adopted in 74 patients and 81 patients had a preoperative chemoradiotherapy. RESULTS: Both groups were comparable regarding intraoperative (p = 0.632) and postoperative surgical complications (p = 0.179) and nonsurgical complications (p = 0.654) too. Operative time and postoperative stay were similar in both groups. Number of harvested lymphnodes was higher for PR group (p < 0.001). CONCLUSION: In summary, after short term results evaluation, there is no significant difference for PR and CHRT groups in laparoscopic rectal resection. Neoadjuvant chemoradiotherapy did not lead to worsening of the perioperative results of our patients.

[The role of interstitial brachytherapy in multimodality management of solid tumors]. / Role intersticiální brachyterapie v multimodalitní lécbe solidních tumoru.

Although being used for several decades, interstitial brachytherapy remains a modern radiotherapeutic method. Over the time, it has been highly improved, including the latest technologies. Its broad use has been facilitaed by the use of high dose rate (HDR) afterloadings. The method is fast and fairly inexpensive. Its prons include, in particular, a possibility to apply a dose, in addition to external radiotherapy, directly into the tumor region or its focus, which may improve treatment success rates in patients with localized tumors. The commonest diagnoses, where interstitial brachytherapy is employed, include the following: breast carcinomas, soft tissue sarcomas, head and neck tumors, gynaecological tumors, penile and anal tumors and prostate tumors. In the article, the authors aimed to highlight potential and benefits of intersitital brachytherapy in individaual diagnoses. Only multidisciplinary management of these patients may improve their prognosis or quality of life.

[Laparoscopic cholecystectomy in outpatient surgery clinic]. / Laparoskopická cholecystektómia v ambulantnej chirurgii.

AIM: Based on literature data and their own experience, the authors present a view that, in a selected group of patients, ambulatory laparoscopic cholecystectomy may be performed with no increased risks and with good outcomes. MATERIAL AND METHODS: The retrospective study presents a group of 93 patients, 72 females and 21 males, who underwent ambulatory laparoscopic procedures for symptomatic cholecystolithiasis in the Podlesí Hospital Centre of Miniinvasive Surgery, from January 2003 to the end of June 2006. 61.3% of the patients were in their forties and fifties, 69.9% of the patients were classified as ASA II, according to the surgical risk. Half of the patients had an ideal body weight, according to their body mass index (BMI) assessment. RESULTS: No peroperative or postoperative complications were recorded in the above, closely selected group of patients. 84 patients (90.3%) were discharged to homecare on the day of the procedure. Nine patients (9.7% required hospitalization for the first postoperative night and they were discharged the following morning, i.e. within 24 hours after the procedure. None of the subjects, discharged after the ambulatory procedure, required rehospitalization. CONCLUSION: Similarly to studies presented in the literature worldwide, the authors concluded that laparoscopic cholecystcctomy performed in the outpatient regime appears an appropriate surgical method in closely selected patient groups. In our setting, out of the total of 618 operated patients, who underwent laparoscopic cholecystectomy during the studied period, 15.4% could be managed using the above method.

[Appendectomy--comparison of results of laparoscopy versus open surgery]. / Apendektómia - porovnanie výsledkov laparoskopickej a otvorenej techniky operácie.

AIM: The authors present results of laparoscopy versus open appendectomy in patients indicated for urgent procedures. MATERIALS AND METHODS: 214 patients, who underwent urgent appendectomy during a 18-month period (November 2004 - April 2006) were included in the retrospective study. The subjects were assigned to two main study groups according to the chosen abdominal approach - laparoscopic versus classical method. Within the respective study groups, duration of the procedure, histopathological findings, peroperative and postoperative complications, duration of postoperative hospitalization were assessed. Furthermore, in the laparoscopic subgroup, requirement for conversion to open surgery is assessed. RESULTS: The results proved that the laparoscoic approach reduced hospitalization period in patients with histopathologicaly advanced findings. The positive effect of miniinvasive methods on hospitalization duration is diminished in subjects with less advanced findings. CONCLUSION: Considering overall benefits of the laparoscopic procedures, the authors themselves prefer the laparoscopic method as the method of choice in management of acute appendicitis.

[The Peutz-Jeghers syndrome--a case review]. / Peutz-Jeghersov syndróm - kazuistika.

INTRODUCTION: The authors present a case review of a localized Peutz-Jeghers syndrome of the caecum, emulating a carcinoma. METHODS: The patient who presented with insignificant family history with a diagnosed stenosing tumor of his appendix and histological findings of highly suspected adenocarcinoma, was indicated for surgical revision and right-sided hemicolectomy. RESULTS: The patient underwent laparoscopically assissted right-sided hemicolectomy and his postoperative course was adequate. The final histological finding diagnosed solitary hamartoma of the Peutz-Jeghers polyp. CONCLUSION: Differential diagnostic reasoning in patients with negative family history and unclear case history with findings of polypous tumorous lesions of the GIT, should also consider the Peutz-Jeghers syndrome. The syndrome is related to a high risk of malignancies in the elderly.

[Da vinci robotic surgery in gynaecological oncology: a critical interim appraisal]. / Da Vinci robotická chirurgie v gynekologické onkologii: kritické hodnocení úvodních zkuseností.

OBJECTIVE: Benefit evaluation of robot-assisted surgery in gynecological oncology. The parameters observed were feasibility, safety, overal surgery length and economic aspects. DESIGN: Prospective study analysing our experience in 10 patients operated due to gynaecological malignancy, adnexal tumors or planned for the procedure used as a part of extensive oncological surgery. SETTINGS: Department of Gynecology and Minimally Invasive Surgery Na Homolce Hospital, Prague. METHODS: The surgeries were performed with Da Vinci robotic system (Intuitive Surgical, inc., USA) including surgeon's console with stereoscopic viewer with hand and foot controls. The second component of the system was In Site vision system with 3D 12 mm endoscope. The third part comprised of 3 telerobotic arms with Endowrist instruments. From 2/2006 to 9/2006 10 patients were operated upon. 2 patients with early invasive cervical cancer, 2 patients with cervical cancer in situ (CIS), 3 patients with complex ovarian tumors, 2 patients with symptomatic atypical endometrial glandular hyperplasia and 1 patient underwent necessary gynecological surgery as a part of oncological treatment of breast cancer. The range of surgery included Total robotic hysterectomy, Robot-assisted vaginal hysterectomy with adnexectomy and frozen section, Robot-assisted radical vaginal trachelectomy with pelvic lymphadenectomy and unilateral adnexectomy with frozen section. The average age of patients was 52 years (range 32-58 years). 30% of patients had a previous laparotomy in their history. RESULTS: All procedures were finished with robot-assisted system. In 2 patients a temporary conversion to laparoscopy was made. In 3 patients a technical fault of the robotic system was noticed. This was corrected during the surgery. The overal surgery time was significantly longer (29 hours for robot-assisted versus 12 hours for laparoscopy). This represented operation time increase of 59% in comparison to identical laparoscopic procedures in our department in 2006. This was caused by lengthy assembly and disassembly time of the robotic system. No patients experienced any peroperative or postoperative comlications. The costs in our setting were approximately 10 times higher in comparison to laparoscopy. CONCLUSION: Our preliminary experience shows that Robot-assisted surgery is comparable to the standard laparoscopic procedure in terms of feasibility and outcome, but costs are considerably higher owing to longer operating time and the use of more expensive instruments. A major limitation is the lack of a large operation field. The enormous costs and the lack of appropriate instruments can be a major problem in the further expansion of robotic surgery. The use of robotic system in gynecologic oncologic surgery and in abdominal surgery in general offers, at this stage, no relevant benefit and thus is not justified. Clinical data demonstrating improved outcomes are so far lacking for robotic surgical application within the abdomen.