Giant inguinoscrotal hernia repair.

Giant inguinoscrotal hernia is defined as an inguinal hernia extending below the midpoint of inner thigh in standing position. The authors describe giant inguinoscrotal hernia and small umbilical hernia with 12 years history of this uncommon disease. After preoperative evaluation, US and CT examination he was operated on. It was very difficult to return the hernia sac contents back to the abdomen and additional infraumbilical incision was needed. Hernioplasty suo modo without mesh was done. Patient recovered uneventfully. In the discussion the authors present the newer classification of giant inguinal hernia, the current treatment options and known serious complications of surgery. Finally, it indicates that good treatment results can only be achieved by close cooperation of concerned professionals in the treatment and intensive intraoperative and postoperative patient monitoring (Fig. 9, Ref. 31).

[A rare case of an acute abdomen patient with gangrene of the colon as a complication of systemic lupus erythematosus]. / Zriedkavá náhla brusná príhoda - gangréna kolonu ako komplikácia systémového lupus erythematosus.

The authors present a case report of a 39-year-old woman with acute abdomen - a comorbid patient with systemic lupus erythematosus, chronic renal insufficiency as a complication of lupus nephritis, included in a haemodialysis programme. The patient had also undergone transplantation of the left kidney in the past. She was initially admitted to the Department of Traumatology for a total endoprosthesis procedure due to bionecrosis of the head of the thigh bone. Postoperatively, the patients condition was complicated by gangrene of the colon confirmed by CT scan and during the operation. The patient was operated on - subtotal colectomy, terminal ileostomy and left-sided ovariectomy was performed. The postoperative course was complicated by perforation of the jejunum which was sutured. The patient was admitted to ICU and, after recovery, to our surgical department. Because of the metabolic disturbance she was treated in the internal medicine department. After 60 days she was discharged in a good condition, walking and with full per os realimentation.Key words: lupus erythematosus gangrene of the colon acute abdomen.

Use of intraabdominal VAC (Vacuum Assisted Closure) lowers mortality and morbidity in patients with open abdomen.

OBJECTIVE: Authors compare two groups of patients with open abdomen. The objective is to compare and evaluate two treatment modalities, namely Kern laparostomy and vacuum-assisted closure in terms of mortality, closure of abdominal wound, and fistula management, all these stratified by BMI and CRP. BACKGROUND: Open abdomen can be considered a "patient salvage technique", used in patients with abdominal sepsis, as well as in patients with abdominal compartment syndrome, and in damage control surgery. Various management techniques are known, of which Kern laparostomy is most widely used. Newer techniques using negative pressure have emerged, still waiting for their wider acceptance and use. The authors present their study, in which they compare Kern laparostomy and intraabdominal VAC in patients with open abdomen. MATERIAL AND METHODS: Study consists of 44 patients treated at the authors´ clinics, while group KERN consisted of patients managed by Kern laparostomy, and group VAC was managed by intraabdominal VAC. The groups were compared in terms of mortality, abdominal closure, appearance of enteroatmospheric fistulas, primary closure of fistulas, and possibility of diversion of enteral contents. All outputs were stratified by CRP (C-reactive protein) and BMI (Body Mass Index). RESULTS: In VAC group, a significant decrease in mortality was seen, as well as significantly higher closure of abdominal wall, and significantly higher possibility of diversion of enteral content from fistulas. No statistically significant findings were observed in stratification with CRP and BMI. CONCLUSION: Intraabdominal VAC offers patients lower morbidity and mortality and should be defined as a treatment of choice in patients with open abdomen (Tab. 4, Fig. 3, Ref. 15).

Intra-abdominal hypertension and acute pancreatitis.

Intra-abdominal hypertension (IAH) contributes to organ dysfunction and leads to the development of the abdominal compartment syndrome (ACS). IAH and ACS are relatively frequent findings in patiens with severe acute pancreatitis (SAP) and are associated with deterioration in organ functions. The most affected are cardiovascular, respiratory and renal functions. The incidence of IAH in patients with SAP is approximately 60-80%. There is an accumulating evidence in human and animal studies that changes of perfusion, particularly to the microvasculature, are crucial events in the progression of acute pancreatitis (AP). The perfusion of the small and large intestine is impaired due to reduced arterial pressure, increased vascular resistence and diminished portal blood flow. Bacterial translocation has been described in patients with ACS, and this may apply to patients with SAP. Approximately 30-40% of SAP patients develop ACS because of pancreatic (retroperitoneal) inflammation, peripancreatic tissue edema, formation of fluid collections or abdominal distension. Surgical debridement was the preferred treatment to control necrotizing pancreatitis in the past. However, the management of necrotizing pancreatitis has changed over the last decade. The main objective of this article is to describe the association between IAH and AP and to emphasize this situation in clinical praxis as well (Fig. 1, Ref. 38).

[Diverticulum of the greater curvature of the stomach as a cause of anaemia]. / Divertikul velkej kurvatúry zalúdka ako prícina anemizácie.

Gastric diverticula represent a rare pathological condition. They are usually asymptomatic and are often found only by accident during radiologic or endoscopic examination, or during autopsy. Their incidence is low and evenly distributed between men and women. Gastric diverticula are most frequently located on the posterior wall of the cardia and on the lesser curvature of the stomach. The authors present a case study of a 58-year-old patient with severe sideropenic anaemia, a marked weight loss and non-specific dyspeptic symptoms. The suspicion of a diverticulum was raised by a gastroenterologist during gastrofibroscopy and confirmed by a radiologist following a dynamic CT examination of the stomach. The diverticulum had an atypical location beneath the cardia on the greater curvature. The patient was indicated for surgery. During conventional laparotomy, resection of the diverticulum was performed using a linear stapler. The postoperative course was uneventful. Histology confirmed a false diverticulum. The patient is doing well, is asymptomatic, has put on 7 kg since the operation and her blood count is normal.

[Cholecystoduodenal fistule as a consequence of calculouse cholecystitis in a female elderly patient]. / Cholecystoduodenálna fistula ako dôsledok kalkulóznej cholecystitídy pacientky vysokého veku (Kazuistika).

Bilioenteric fistules are fairly rare, cholecystoduodenal fistules are the commonest type, accounting for 70-80% of cases. Cholecystoduodenal fistules usually occur as a consequence of cholecystolithiasis and cholecystitis. Their symptomatology is atypical and fistules are frequently detected during surgery. Preoperative diagnostic procedures include visualization methods, such as US, CT, MRI, resp.ERCP. Both conventional laparotomy, as well as laparoscopy may be used in the treatment of the disease. Each of the methods has its pros and cons. The authors present a case review of a 85-year old female patient with a cholecystoduodenal fistule, diagnosed prior to the surgical procedure. Conventional laparotomy was elected as a method of treatment and the outcome was successful.

Rectal prolapse.

It is not so much the diagnosis that offers the surgeon a wide range of opportunities in the technical solutions of rectal prolapse. Currently there are at least 130 different techniques used in the surgical treatment of rectal prolapse and in fact none of these procedures has been shown most effective for any one patient. In this study, our intent is to describe the experiences of the authors with the treatment of rectal prolapse, to estimate the actual level of expertise of the surgeons in treatment of rectal prolapse, and to describe in which way to proceed in the future (Tab. 4, Fig. 3, Ref. 27). Full Text (Free, PDF) www.bmj.sk.

Diagnosis and management of local and locoregional recurrence of colorectal carcinoma.

All intraabdominal forms of recurrence of colorectal carcinoma, other than metastases in the liver, are considered a locoregional treatment failure. Maximum frequency of local recurrence of CRC occurs in the first two years following the initial potentially curative resection. Intensive follow-up in this period is therefore reasonable. It should be based on case history, clinical examination and examination of tumor markers (particularly CEA). Other examinations are indicated only for patients with abnormal findings or during normal annual check-ups. The salvage surgery for CRC recurrence covers a large scale of surgical performances from limited local resections up to extensive surgery including pelvic exenteration and peritonectomy. The potentially curative resection (R0 and R1) of colorectal carcinoma is a sole confirmed factor that has a direct positive influence on the overall survival of patients (Fig. 5, Ref. 21).

Gastrointestinal stromal tumors.

In the last 3 years 9 patients with gastrointestinal stromal tumors (GIST) underwent surgery at our department. All cases were with very atypical process. From these patients 3 interesting cases are described in more details. A 75-years-old woman with gastroscopically verified endoluminal tumour in the proximal third of stomach, 6x7 cm, 76-years-old man with a large endoluminal tumour in D2-D3 part of the duodenum, 4x4 cm, and 62-years-old man with verified extraluminal tumour by CT examination in the middle part of stomach. In all cases, gastrointestinal stromal tumour was histologically confirmed. Work is well photo-documented pre-surgically with endoscopic and CT-findings and during surgery: individual steps during the removal of these tumours. In assessment of the size and number of mitoses, tumours belonged to a group with highly malignant potential. Patients are regularly checked in 3-months intervals and also examination by positron emission tomography was performed--it seems to have the best demonstrability of possible relapse. All three patients live and are subjectively and objectively without significant problems (Tab. 5, Fig. 5, Ref. 7). Full Text (Free, PDF) www.bmj.sk.

[Short bowel syndrome and limits of small intestinal resections]. / Short bowel syndróm a limity resekcnej chirurgie tenkého creva.

Short bowel syndrome (SBS) is a malabsorption syndrome resulting from anatomical or functional loss of a significantly long small intestinal segment. A loss over 80% of the small intestinal length is associated with increased urgency for supportive parenteral nutrition and results in reduced overall survival of the patients. The ileocaecal valve (valvula Bauhini) loss results in bacterial contamination of the small intestine, affecting tolerability of the oral, ev. enteral nutrition. The authors present a case review of a 27-year-old patient with repetitive small intestinal resections. The last procedure included the Bauhini valve and, finally, the patient has only 70 cm of the jejunum preserved.

[Biliary ileus--potential complication of cholecystolithiasis]. / Biliárny ileus-- nad'alej reálna komplikácia cholecystolitiázy.

Biliary ileus is a rare complication of cholecystolithiasis. The condition occurs predominantly in the elderly with incidence rates of 1-4%, according to the literature data. Most commonly, it develops as a complication of cholelithiasis which remained untreated or was managed conservatively, or as a complication of a gallbladder decubitus necrosis. The condition results in a cholecysto-duodenal fistula. In this case, the cholecystolithiasis is latent or is clinically manifested in a third of the patients. A total of 1560 cholecystectomies (1345 L-CHE and 215 conventional CHE) were performed in our clinic during a five-year period. Biliary ileus was an indication for operation only in two subjects, during the studied period. In the both cases, the diagnosis was established intraoperatively, although upon re-examination of the visualization modalities views (upright native abdominal views, CT scans) the authors concluded that the primary cause of the ileus could have already been identified, based on the above views.

[Intususception of appendical cystadenoma imitating a caecal tumor]. / Intususcepcia cystadenómu apendixu imitujúca tumor céka.

Appendical cystadenoma is one of the histological forms of the appendical mucocele. Preoperative diagnostics is difficult, however, due to potential iatrogennic rupture during a surgical procedure, is very important. The authors present a case review of a 62-year-old patient with itususception of the appendical cystadenoma, until now rarely reported in literature. Upon the preoperative diagnosis the appendical cystadenoma appeared as a caecal tumor or a tumor of the terminal ileum. A histological, intraoperative, diagnosis was established, followed by a final histological examination of the resected tissue. The authors discuss contemporary options of the preoperative diagnostic measures of the appendical tumors, stressing up all risks of aspiration cytology as well as risks of laparoscopic approach in this pathology management

[Endovascular and vascular surgical reconstruction in the treatment of ischemia of the lower extremities]. / Postavenie endovaskulárnych a cievnochirurgických rekonstrukcií v liecbe ischémie dolných koncatín.

The authors analyze the importance of PTA, EAE and vascular reconstructive surgery of obliterative atherosclerosis on lower extremities. According to their own experiences the advantages and also negatives of particular treatment methods are discussed and studied group of patients is presented. On the basis of the achieved results the authors suppose that ischemic syndrome of lower extremities is attractive not only for vascular surgeon, but also for interventional radiologist. When properly indicated, particular treatment modalities can have substantiation in the treatment of obliterative atherosclerosis. (Tab. 9, Fig. 5, Ref. 29.)

[Treatment of choledocholithiasis in the era of laparoscopic cholecystectomy]. / Liecba choledocholitiázy v ére laparoskopickej cholecystektómie.

Laparoscopic cholecystectomy (L-CHE) is currently considered to be the optimal standard in the therapy of cholecystolithiasis. However, it is choledocholithiasis which is problematic, especially the timing of the solution in relation to L-CHE. In general, the opinion predominates that in preoperatively verified choledocholithiasis the ERCP with EPS and extraction of choleliths should be performed 24-28 hours prior to the elective L-CHE. Surgical removal of choleliths from the main biliary ducts indicated only in a small group of patients. The authors of the study reflect upon the current trends of the choledocholithiasis therapy in the era of laparoscopic cholecystectomy. They present their own set of patients and recommend the procedure of the choledocholithiasis therapy concommitted with cholecystolithiasis with the subjective of the full use of endoscopic methods in the therapy of this disease. (Ref. 14.).

[Crohn's disease and symptoms of appendicitis]. / Crohnova choroba a príznaky apendicitídy.

Retrospective analysis of 47 patients surgically treated at the IInd Surgical Clinic LFUK due to Crohn's disease and its complications indicates that in 16.3% of patients the diagnosis of Crohn's disease was stated in coincidence with laparotomy which had been indicated due to the suspicion of appendicitis. The reasons of this situation, as well as the recommendation of surgical tactics are analysed. (Tab. 3, Ref. 11.)

[Endoanal transrectal ultrasonography in the diagnosis and care of patients with rectal carcinoma]. / Endoanálna transrektálna usg v diagnostrike a dispenzarizácii pacientov s karcinómom rekta.

Endoanal sonography in rectal tumor is diagnostically significant. This method helps to specify the prognosis of patients with malignant rectal tumor. Endoanal sonography examination before the operation corresponds with postoperative histopathological findings (endoanal sensitivity uT--91.6%). The method is most important during the follow-up of patients after surgery and in ascertainment of local recurrence (endoanal sensitivity recidivation uT--86%). The authors present their experience with 402 patients. The advantages of endoanal transrectal sonography are possibilities of determination of staging the tumors which can not be reached physically, information of the way of spreading and penetration depth of the tumor, information about their growth, simplicity and easy repetition of the process and economical convenience. (Tab. 2, Fig. 2, Ref. 14.)

[The short bypass in the treatment of popliteal artery occlusion]. / "Short bypass" v liecbe oklúzie a. poplitea.

Authors present in case report a patient with occlusion of proximal section of popliteal artery which was resolved by the reconstructive vascular surgical procedure--short femoropopliteal bypass using autolognal saphenous vein as a graft. In discussion they deal with the problem of short bypass in traumatic injured lower extremities and also in atherosclerotic or other degenerative diseases of lower extremities arteries. On the account of particulars from literature they refer to the possibility of using various autolognal venous grafts and also artificial vascular protheses. They also deal with the adjuvant medical treatment from the point of view of prevention of a favourable closure of graft and its longterm patency. They presume that the short bypass is in indicated cases mainly in highly at risk patients fully justifiable.

[Medical and economic advantages of percutaneous transluminal angioplasty]. / Medicínske a ekonomické výhody perkutánnej transluminálnej angioplastiky.

Percutaneous transluminal angioplasty (PTA) has been used for nearly 30 years. This method was refused in the past because of lack of knowledge of its effectiveness, and insufficient technical equipment for its safe realization. The further factor negatively affecting usage of this method in common clinical practice in occlusive diseases of the lower limbs arteries was an essentially shorter long-term patency than that after reconstructive arterial surgery. Currently this method is widespread in common clinical practice and with the help of angioscopy, argon-laser angioplasty and rotary transluminal catheter system (RO-TACS) it can still be improved. In this study the authors deal in detail with medical and economical advantages of this widely used method.

[Massive hemorrhage from duodenal adenocarcinoma]. / Masívne krvácanie z adenokarcinómu duodéna.

The authors report the case of a 48 year old patient with duodenal adenocarcinoma. The patient was hospitalized at the internal clinic and due to massive bleeding into GIT was removed into the surgical clinic in a state of shock. The operation revealed a Tu formation on the border between D3 and D4, and a palliative resection was performed. The histologic examination verified the diagnosis of the duodenal carcinoma, WHO gr.II. During the postoperative period the patient received 4 chemotherapeutic treatments, although literature generally refers to chemotherapy as having no effect on the time of survival in patients with duodenal adenocarcinoma. The authors conclude that in patients with a long termed history of atypical abdominal symptoms including bleeding into GIT which are inexplicable owing to fibroscopy and x-ray, it is necessary to take into consideration the possible presence of neoplasms in the small intestine, and hence in the duodenum. In cases with massive bleeding they recommend palliative resection and subsequent chemotherapy. (Fig. 6, Ref. 11.).

[What are the costs of septic complications in surgery?]. / Co stojí septická komplikácia v chirurgii?

Infectious complications have remained the most frequent cause of morbidity in surgical patients, and that despite the constantly broadening range of up-to-date antimicrobial drugs administered prophylactically and therapeutically, the improved methods of cultivating microorganisms and of establishing sensitivity to antibiotics. Infections in surgical patients lead to prolonged hospitalization, prolonged working disability, and to increased cost of treatment. Considerable economic consequences of infections in surgical patients are demonstrated on the basis of the authors' clinical material and possibilities of preventing infections and of their treatment are also discussed. (Fig. 1, Tab. 2, Ref. 21.)