[Splenectomy via the Transdiaphragmatic Approach]. / Splenektomie transdiafragmaticky.

The spleen is one of the most commonly injured organ in blunt traumas to the chest and abdomen. Splenic injury can be a serious complication of fracture of the left 9th to 11th rib. The authors present a case report of a 65-year-old male patient with a blunt trauma to the left chest and abdomen, diagnosed with multiple left rib fractures, left hemothorax and splenic injury with a small subcapsular hematoma with no signs of active splenic bleeding. Due to hemodynamic instability and a large volume of blood loss via the chest drain, the patient was indicated for emergency left thoracotomy. A perforation in the lower lobe of the left lung caused by rib fractures was found, which was treated with sutures. Furthermore, the diaphragm was examined, two ruptures were identified from which blood was coming out, and thus a phrenotomy was performed. The bleeding central splenic rupture came as a big surprise. A spleen preserving surgery was impossible, therefore a splenectomy had to be performed, followed by chest wall stabilization with splints. Transthoracic approach to manage the splenic injury through phrenotomy should not be used as a standard. In a selected group of patients with concomitant chest and upper abdominal organ injuries, the use of this surgical approach appears to be highly beneficial. Key words: splenic injury, splenectomy, thoracotomy, rib fractures, diaphragmatic rupture.

Pancreaticoduodenectomy in patients with an unusual course of the hepatic artery.

INTRODUCTION: Variations in hepatic artery anatomy are very common in the population. The aim of this study is to evaluate the rates of individual types of hepatic artery variants in the population of patients undergoing pancreaticoduodenectomy (PD), assess the accuracy of preoperative staging CT imaging to identify hepatic artery variants, and evaluate the impact of the hepatic artery variants on perioperative and postoperative morbidity of PD patients. METHODS: A prospective observation study of 147 patients undergoing PD for a pancreatic head pathology at the 1st Department of Surgery, University Hospital Olomouc between 1/2015-12/2018. Preoperative diagnosis of the course of the hepatic artery was made based on staging CT imaging analysis of the abdomen. The result was classified according to the Michels' scale and correlated with the final perioperative finding. Demographic, histopathological and clinicopathological data were included in a prospectively maintained database. RESULTS: A total of 147 patients were included in the study, 83 (56.5%) males and 64 (43.5%) females, median age 65.0 (37-83) years. A variant course of the hepatic artery was found in 37 (25.2%) patients. The accuracy of preoperative CT imaging in determining the variant was 100%. The presence of a hepatic artery variant was not statistically significant as a factor in terms of postoperative complications - CD I-II (50.0% vs 47.2%), CD III-IV (8.3% vs 13.8%). Similarly, the 30-day (4.2% vs 2.4%) and 90-day mortality rates (4.2% vs 3.3%) were comparable in both groups. CONCLUSION: Preoperative diagnosis of vascular variants based on multidetector CT imaging of the abdomen is routinely available and shows high detection accuracy. There was no difference in postoperative morbidity and mortality in patients with and without a variant hepatic artery undergoing PD.

Middle and distal bile duct carcinoma, retrospective analysis & short-term and long-term outcomes of surgical therapy.

INTRODUCTION: The prognosis of extrahepatic cholangiocarcinoma is dismal and the only way to achieve long-term survival is surgical resection. While pancreatoduodenectomy (PD) is the standard procedure for distal cholangiocarcinoma (distal bile duct cancer; DBDC), bile duct segmental resection (BDR) can be used as an alternative approach for middle bile duct cholangiocarcinoma (middle bile duct cancer; MBDC). The aim of the study was to calculate the short-term and long-term outcomes of curative-intent surgery in distal bile duct cholangiocarcinoma patients. METHODS: A retrospective cohort study of consecutive patients treated for MBDC and DBDC with PD or BDR between 1/2009-12/2019. The patients were divided according to the type of surgical resection (PD and BDR group). Demographic, clinicopathological and histopathological data and overall survival (OS) were evaluated in both groups. OS was estimated using the Kaplan-Meier analysis. RESULTS: The study comprised a total of 62 patients - 45 patients (72.6%) in the PD group and 17 (27.4%) in the BDR group. Patients undergoing BDR were significantly older than those receiving PD (p=0.048). Men predominated in the PD group (N=34/45; 75.6%) while more women were included in the BDR group (N=10/17; 58.8%). Median age was higher in the BDR group (p=0.048). Serious morbidity (Clavien-Dindo III-V) (33.3% vs 11.8%), 30-day and 90-day mortality (4.4% vs 0.0% and 8.9% vs 5.9%, respectively) predominated in the PD group although the differences were not statistically significant, as well as a longer hospital stay (16.0 days vs 11.0 days; p=0.002). Pathological assessments revealed comparable numbers of positive lymph nodes in both groups, but a significantly higher number of total resected lymph nodes in the PD group (p.

Antibiotic therapy of postoperative bronchopneumonia in patients after lung resections - single-site experience.

INTRODUCTION: Infectious complications after lung surgery are the most important factor that affects mortality and morbidity, prolongs hospital stays and increases financial costs. According to various sources, 30-day mortality after lung resections reaches 123%. Infectious complications account for 2075% of overall mortality. The infections most often present as postoperative pneumonia (POP), and their treatment is based on empirical and targeted antibiotic therapy. Any time lag in initiating effective antibiotic therapy significantly increases morbidity and mortality. Postoperative pneumonia is defined according to current guidelines of the American Thoracic Society of 2016 as nosocomial or ventilator pneumonia in patients after surgery. METHODS: Evaluation of risk factors, infectious agents, morbidity and mortality in patients after lung resections at a single site in the period from 1 January 2018 to 31 December 2019. RESULTS: Of our group of 190 patients, 21 (11.1%) patients had POP which was severe in 6 (33% with POP) patients, and 11 patients with POP required artificial oxygenation for saturation below 92%. Two patients with POP had to be intubated for respiratory failure, and 3 patients required noradrenaline circulatory support. One patient with severe POP died of multiorgan failure after developing refractory sepsis. CONCLUSION: Early identification of lung infection and early initiation of POP therapy are critical points for reducing morbidity and mortality after lung resections. Advanced antibiotic regimens for POP stratify the risk of mortality and infection with multidrug-resistant bacterial strains. However, the regimes require modification according to the epidemiological situation at the site with individualization of the specific procedure. Other research tasks include identification of valid markers of the initial stages of infection, and targeting of antibiotic therapy according to risk stratification and the relationship with physiological flora.

Enzyme replacement following total pancreatectomy; population analysis

Introduction: Total pancreatectomy (TPE) inevitably leads to absolute exocrine pancreatic insufficiency (EPI). No specific recommendations are available for enzyme replacement in such cases. The aim of our analysis was to explore the actual EPI replacement rates among patients following TPE after a certain period of time from the surgery. Methods: This retrospective analysis of living patients who had undergone TPE more than 2 years ago was done using a simple questionnaire to investigate the following: BMI prior to TPE, 3 months after TPE and at the time of data collection (in 2022), together with the actual number of daily bowel movements; and the replacement characteristics ­ the daily dose, its scheme and subjective satisfaction evaluation. Results: In total, we obtained data from 26 living patients with the history of TPE with their median follow up of 56 months (30­157). Malignant disease was confirmed in 69% patients based on histology; a benign tumor was present in the rest, although malignancy had been suspected preoperatively. Median BMI decreased from preoperative 27.4 (19.1­41.1) to 24.1 (19.8­33.7) 3 months following TPE, and median BMI value of 25.5 (21.2­34.5) was established at 30­157 months from TPE. The mean number of daily bowel movements was 2.2 (median 2, range 1­8) and the mean daily replacement dose was 182,000 units of lipase (median 175,000 u., range 0­250,000 u.) at the time of our investigation. Subjective satisfaction was reported by 85% responders and a lack of satisfaction despite maximum EPI replacement was expressed by 15% responders. Conclusion: BMI decreased shortly after TPE. In the long term, up to 80% of the patients achieved preoperative BMI values ±10% after TPE. Due to persistent steatorrhea and more frequent bowel movements despite enzyme replacement, 15% of the patients remained subjectively dissatisfied after TPE, but 85% of the patients did not perceive even more frequent bowel movements as unpleasant and were satisfied with their condition. The need of individualized enzyme replacement therapy of EPI following TPE is evident.

[Negative Pressure Wound Therapy as a Treatment Option for Extensive Post-Trauma Subcutaneous Emphysema]. / Moznosti lécby rozsáhlého poúrazového podkozního emfyzému pomocí podtlakové terapie.

Subcutaneous emphysema can be a secondary complication of chest trauma or one of the complications of ruptured bullae in advanced chronic obstructive pulmonary disease. Massive subcutaneous emphysema impairs the respiratory mechanics and affects the venous returns of the head and neck. It can lead to respiratory insufficiency with the need for mechanical ventilation. The treatment should focus on the primary pathology. Nonetheless, in patients with subcutaneous emphysema as the only but serious symptom, the treatment can zero in solely on this complication. The standard procedure consists in the insertion of chest drain which does not necessarily have to lead to successful treatment results. The authors present a case study of a 77-year-old man with major comorbidities, with extensive subcutaneous emphysema after blunt chest wall trauma, in which respiratory insufficiency developed. The chest drain was ineffective. The solution was to apply subfascial negative pressure therapy infraclavicularly to the area of the pectoral muscle, which made the subcutaneous emphysema almost immediately subside and which substantially improved the clinical condition of the patient. Local negative pressure therapy can be used as the method of choice for treating massive subcutaneous emphysema in patients, in whom the standardised treatment by chest drain with active suction mechanism failed and the lung is expanded in the pleural cavity, and for whom surgery is far too risky. Key words: negative pressure wound therapy, subcutaneous emphysema, rib fracture.

[Evolution of Opinions on Chest Wall Stabilisation and Our Experience]. / Vývoj názoru na stabilizace hrudní steny a nase zkusenosti.

PURPOSE OF THE STUDY Rib fractures represent one of the most common fractures sustained by 10-40% of all patients with blunt chest trauma, their incidence increases with age. In the current literature, however, new indication criteria continue to emerge. The purpose of this study is to assess the indication criteria, the timing of surgery and the use of individual plates in dependence on fracture location in our patients after the chest wall stabilisation in a retrospective analysis. MATERIAL AND METHODS Our group of patients (n = 349) included the patients who were hospitalised in the Trauma Centre of the University Hospital Olomouc from 1 January 2015 to 31 January 2019, of whom 16 patients were indicated for a surgery. In case of polytrauma, spiral CT was performed, while all patients with a more serious wall chest trauma underwent 3D CT chest wall reconstruction. The surgical approach was chosen based on the fracture location, most frequently posterolateral thoracotomy was opted for. The type of plates was chosen based on the location and type of the fracture. The most common was the lateral type of fracture. RESULTS The most common indication for surgery was multiple rib fractures with major chest wall disfiguration with the risk of injury to intrathoracic organs, present hemothorax or pneumothorax. The age of patients ranged from 44 to 92 years. 8 patients sustained a thoracic monotrauma, the remaining patients suffered multiple injuries, mostly craniocerebral trauma, pelvic or long bone fractures or parenchymal organ injury. The patients were indicated for surgery between 1 hour and 7 days after the hospital admission, on average 3 plates per patient were used and the most commonly used type of plate was the newly modified Judet plate made by Medin. All the patients underwent a surgical revision of pleural cavity, in 3 patients diaphragmatic rupture was found despite a negative preoperative CT scan. The duration of mechanical ventilation in polytrauma patients was 16 days, in thoracic monotrauma patients it was 2 days. CONCLUSIONS Prevailing majority of patients with a blunt chest trauma with rib fractures is still treated non-operatively, which is confirmed also by our group of patients. Nonetheless, correctly and early indicated stabilisation of the chest wall based on accurate indication criteria is of a great benefit to the patients. The aim of each and every trauma centre should be to develop a standardised protocol for the management of blunt chest trauma (the so-called "rib fracture protocol"), which comprises precisely defined criteria for patient admission, multimodal analgesia, indications for surgery, comprehensive perioperative and postoperative care and a subsequent rehabilitation of patients. Key words: rib fracture protocol, chest wall stabilisation, flail chest.

Successfull therapy of grade III leak after thoracic oesophagectomyusing endoscopic vacuum assisted closure therapy - a case study.

INTRODUCTION: Post-oesophagectomy leakage occurs in 1-30% of cases as a significant factor in postoperative morbidity and mortality, accounting for 40% of postoperative deaths. Endoscopic vacuum therapy (EVAC) is, besides stent therapy, clips and surgical therapy, a new endoscopic thera-peutic modality. CASE REPORT: A 72-year-old polymorbid female patient with Siewert type II adenocarcinoma of the distal esophagus (T1b, N0, M0) was indicated for resection of the upper stomach and lower thoracic esophagus from laparotomy and thoracotomy with reconstruction using double-stapling anastomosis. On postoperative day 12, a 3rd degree leakage with propagation into the right pleural cavity was proven on CT. Endoscopy showed a defect affecting 30% of the circumference with a 7×3×3 cm cavity. Because of the leak morphology, EVAC was indicated. The therapy comprised 12 sessions with 3-4-day intervals for a total duration of 40 days with 5 extraluminal and 7 intraluminal applications and negative pressure of 100-125 mmHg. The condition was complicated by global respiratory failure due to severe pneumonia. Artificial ventilation was terminated on the 58th postoperative day. The patient was discharged to a rehabilitation facility on the 90th postoperative day. The follow-up 3 months after discharge confirms satisfactory performance results with full replenishment. CONCLUSION: The therapy of complications of intrathoracic anastomoses after oesophagectomy has shown a trend toward reduced invasiveness and wider implementation of endoscopic methods. In spite of its shortcomings, the use of EVAC is a safe and highly effective therapeutic option even for extensive anastomotic defects. The future use, indications as well as relation to other therapeutic options require further evaluation. Key words: endoscopic vacuum therapy - esophageal leakage - esophagectomy complications - intraoperative endoscopy.

[Multiple organ resection for extensive lymphoma in the abdominal cavity]. / Multiorgánová chirurgická resekce pro rozsáhlý lymfom dutiny brisní.

Extranodal lymphomas are quite rare, and they usually present as non-Hodgkin lymphomas. The most common localization is the gastrointestinal tract, mainly the stomach - primary gastric lymphoma; histologically, diffuse large B-cell lymphoma (DLBCL) is the most frequent type. The diagnosis is established based on endoscopic examination with biopsy of the tumor. It is an aggressive tumor, highly chemosensitive, which is why primary systemic chemotherapy is indicated in early, as well as late, stages of the disease. Surgery is indicated to treat complications such as perforation, bleeding or gastrointestinal obstruction. The authors present the case of a chemoresistant patient with hemodynamically significant bleeding, indicated for surgical revision after unsuccessful endoscopic treatment. Multiple organ resection was performed due to the large size of the tumor in the abdominal cavity.Key words: gastric lymphoma - surgical treatment.