Analysis of postoperative complications after open scar hernia hernioplasty - a retrospective analysis of a patient cohort.

INTRODUCTION: The aim of this study was to analyse complications associated with inicisional hernia repair surgery and to assess individual risk factors for surgical site infections occurring at the Department of Surgery of the University Hospital Kralovske Vinohrady in 2015. METHODS: We analysed 138 patients with a focus on risk factors that potentially increase the risk of postoperative infectious complications such as mesh implantation, smoking, diabetes mellitus, ischemic heart disease, malignancies, immunosuppressive therapy and urgency of the procedure. RESULTS: Based on multivariate logistic regression analysis, acute surgery proved to be a risk factor for infection, and in the ad hoc Fisher test, the ratio was 2.73. Diabetes mellitus as a risk factor reached the limit of significance (p=0.071). No other variables were associated with an increased risk of surgical site infections. CONCLUSION: Acute surgery was assessed as a significant risk factor for postoperative wound infection. On the contrary, mesh repair was not associated with an increased risk of infection.

Intrahepatic cholangiocarcinoma: risk factors affecting survival of operated patients.

INTRODUCTION: The aim of this study was to evaluate the results of surgical treatment of intrahepatic cholangiocarcinoma (IHCHCA) in terms of overall survival and disease-free survival, and to analyse and find potential prognostic factors affecting overall survival and disease-free survival. METHODS: Retrospective evaluation was performed of consecutively enrolled patients operated for IHCHCA from January 2005 to January 2022 (17 years) had undergone surgery. During the monitored period, 38 surgical procedures were performed, of which liver resection was done in 25 cases (65.8%). RESULTS: The 5-year survival in the radically resected group was 44%, and the 5-year disease-free survival was 32%. Based on univariate and multivariate analysis, radicality of surgery (p=0.01116) and lymph node involvement (p=0.00576) were assessed as negative prognostic factors for overall survival. Radicality of surgery (p=0.018) and administration of adjuvant chemotherapy (p=0.044) were significant negative prognostic factors affecting disease-free survival. However, they lost their significance in the multivariate analysis. CONCLUSION: Radical surgical resection of the liver remains an essential treatment option for intrahepatic cholangiocarcinoma aimed at achieving a radical procedure with microscopically negative margins. KEY WORDS: cholangiocarcinoma, resection, recurrence, survival.

Laparoscopic versus open liver resections for colorectal cancer liver metastases: short term results.

INTRODUCTION: Analysis and comparison of short-term results of laparoscopic liver resections (LLR) and open liver resections (OLR) for colorectal cancer liver metastases (CRCLM). METHODS: Retrospective analysis of patients operated for CRCLM in the time period from May 2007 to May 2019 (12 years) at the department of surgery, University Hospital Hradec Králové and University Hospital Královské Vinohrady. RESULTS: 206 liver resections were performed; 167 (81.1%) OLR and 39 (18.9%) LLR procedures. Conversion to open surgery was necessary in 6 cases (15.4%). LLR was associated with a longer operation time (194±107 min) vs (129±58 min) for OLR. The ICU stay, 3.5±4.3 days for OLR and 4.1±8.1 days for LLR, and the hospital stay, 11.9±8.3 days (OLR) vs 12.1±11.3 days (LLR), were comparable. Perioperative blood loss was lower in the LLR group, 189±166 ml vs 360±410 ml. Total transfusion rate was similar, 10.8% (OLR) vs 12.8% (LLR). Oncologic radicality was also comparable in both groups; negative resection margin was achieved in 78% (OLR) and 80% (LLR). Postoperative morbidity and mortality was comparable in both groups; morbidity was 33% (OLR) vs 31% (LLR), while mortality was 1.8% (OLR) vs 2.6% (LLR). CONCLUSION: LLR for CRCLM provided comparable short-term results compared to OLR in our group of patients even in the learning curve period. However, it should be noted that the study group is a highly selected group of patients.

[The role of drains in pancreatic surgery]. / Význam drénu v pankreatické chirurgii.

Pancreatic fistula is a significant complication following pancreatic resection. Several methods aimed at lowering the postoperative pancreatic fistula rate were studied in the past. These methods mainly include pharmacological prophylaxis and technical modifications of pancreatic remnant management. Another method which can influence postoperative pancreatic fistula rate is the use of and the manipulation with intra-abdominal drains following pancreatic resection. Recent studies have shown that the use of the drains, the type of drain and manipulation with the drains can influence the outcomes. The aim of this review is to summarize current knowledge about the use of drains in pancreatic surgery. There are three questions to ask when studying the use of drains in pancreatic surgery: 1) Whether to use the drains at all 2) When to remove the drains? 3) Which type of the drain is more appropriate? Ad 1) Despite the growing number of studies showing comparable or even better results in patients without intra-abdominal drains following pancreatic resection, the latest randomized study proved that avoiding the use of drains is associated with more clinically significant postoperative complications and higher postoperative mortality. It is also important to consider the risk factors of pancreatic fistula development, especially pancreatic texture and the main pancreatic duct diameter. Currently, pancreatic resection without intra-abdominal drains cannot be routinely recommended. Ad 2) Two studies addressed the question when to remove the drains after pancreatic resection, and both studies clearly showed that early removal brings better results. Ad 3) No study has specifically addressed the question whether the type of drain can influence the rate of postoperative pancreatic fistula and of other complications. Gravity drains and closed-suction drains are most commonly used nowadays. The closed-suction drains are more effective due to the active suction. On the other hand, active suction can cause leak of the amylase-rich fluid through the pancreatic anastomosis or suture line and thus promote the development of pancreatic fistula or even worsen its clinical significance. There are no data in the literature so far regarding the type of drain. Therefore, we have commenced a randomized control trial which aims to compare closed-suction drains and closed gravity drains.

[Clostridial myonecrosis of the abdominal wall - case report]. / Klostridiová myonekróza brisní steny - kazuistika.

The authors present a case report of a forty-five-year-old patient operated on for acute appendicitis who developed gas gangrene of the abdominal wall within 48 hours after an appendectomy and subsequently also clostridial sepsis. Due to early diagnosis and intensive care, the patient survived. Clostridial myonecrosis is a rare complication after abdominal surgery and may be fatal in many cases. In our literature, there are only a few publications describing cases of patients who survived this rare postoperative complication.

Solid pseudopapillary tumour of the pancreas: diagnosis, treatment, and prognosis.

BACKGROUND: Solid pseudopapillary tumour (SPT) of the pancreas is a relatively rare entity which most commonly occurs in young women. In this paper we report our clinical experience together with the current knowledge on the diagnostics, treatment and prognosis of this rare tumour. METHODS: We reviewed hospital records of patients diagnosed with a solid pseudopapillary tumour of the pancreas between January 2002 and December 2011 at the Department of Surgery, University Hospital Hradec Králové, Czech Republic. Clinical, operative, pathological data were obtained on all the patients. RESULTS: Over the 10-year period of the study we performed 181 planned pancreatic resections in our department. Overall, the 30-day postoperative mortality rate in this series of patients was 2.2%. SPT was diagnosed in 4 cases. All the patients were women and the average age was 34 years. Preoperative endosonography with biopsy sample was performed in all the patients and the diagnosis of SPT was known in all the patients before the surgical procedure. CONCLUSIONS: The current knowledge of SPT is based only on case reports and small series. It typically occurs in young women and therefore the presence of a large pancreatic mass in a young woman may suggest a diagnosis of SPT. SPT has a low malignant potential and the prognosis is excellent following complete surgical resection in the majority of the cases.

[Pancreatic fistula - definition, risk factors and treatment options]. / Pankreatická pístel - definice, rizikové faktory a moznosti lécby.

Pancreatic fistula is a common complication after pancreatic resections. Its incidence oscillates between 10 and 30%. The differences in the incidence cited in the studies are due to the various fistula definitions. According to ISGPF, pancreatic fistula is an output -via an operatively placed drain (or a subsequently placed percutaneous drain) - of any measurable volume of drain fluid on or after postoperative day 3, with an amylase content higher than 3 times the upper normal serum value. The fistula is then classified according to the clinical impact in grades A, B, and C. There are known three risk factor categories for the development of pancreatic fistula: the risk related to the pancreatic disease, to the patient, and to the surgical procedure. Most of the risk factors for the development of pancreatic fistula cannot be influenced either prior to or during the surgery. There are two basic options for the prevention of pancreatic fistula: pharmacological intervention (administration of somatostatin and its analogues) and technical modifications of the pancreatic remnant treatment. However, the routine administration of somatostatin and its analogues is not advisable in all pancreatic surgical procedures. In high risk cases the selective administration is preferred. The second option is modification of pancreatic remnant treatment. Most of the studies dealing with various modifications of the pancreatic remnant treatment were retrospective with lower level of evidence. There were only a few properly designed randomized trials, and most of them did not prove benefit of one method over another. It has been shown that the results depend on the experience of a given surgical department, and above all on the experience of an individual surgeon who performs the pancreatic resection. The therapy of pancreatic fistula is based on the clinical severity. Conservative approach is warranted in most patients. In cases when reoperation is required, there are two basic strategies: surgical drainage of the collections, and completion of total pancreatectomy. Total pancreatectomy was preferred in the past, however, this procedure is technically very demanding with mortality up to 80 per cent. Nowadays, most of the authors prefer surgical drainage; this procedure is technically less demanding, has lower mortality, the endocrine function of pancreas is protected, and the patients usually need no further interventions.

[Gun-shot injuries to the abdomen involving the pancreas]. / Strelná poranení dutiny brisní zasahující pankreas.

PURPOSE OF THE STUDY: The aim of the study is to present our experience with the diagnosis and therapy of penetrating abdominal injury involving the pancreas caused by a gun shot. MATERIAL AND METHODS: The group included patients with gun-shot abdominal injuries involving the pancreas who were treated at the Department of Surgery and the Department of Emergency Medicine at the University Hospital Hradec Králové. The extent of pancreatic injury was assessed using the American Association for the Surgery of Trauma (AAST) classification. The factors evaluated included the timing of surgery, operative strategy, operative time, blood loss, post-operative complications with pancreatic fistulas in particular, and the length of hospital stay. Pancreatic fistula was assessed according to the ISGPF (International Study Group for Pancreatic Fistula). RESULTS During the period of study lasting 10 years, three patients with gun-shot abdominal injuries involving the pancreas were treated. DISCUSSION: Pancreatic trauma due to a gun shot is a rare injury, but has also been reported in the Czech Republic. In any penetrating injury to the abdomen due to a gun shot, surgical exploration is always indicated and pancreatic trauma is usually found during the surgery. The first step in the procedure is to check all potential sources of bleeding because uncontrolled bleeding is the most frequent cause of intra-operative death. In a seriously injured patient, the technique of damage control surgery must be employed. After the major sources of bleeding have been checked, a thorough exploration of all abdominal organs should be performed to ascertain whether the main pancreatic duct has not been injured and, if so, in which part of the pancreas and to what extent. The correct classification of pancreatic injury according to the AAST is necessary to indicate appropriate therapy. Exploration for injury to other organs that often accompanies pancreatic trauma is a necessity. CONCLUSIONS: Penetrating pancreatic trauma is almost always associated with injury to the adjacent organs. All patients with gun-shot injuries to the abdomen are indicated for surgical exploration, thus the pancreatic injury is often found at the surgical exploration. After bleeding has been controlled, for treatment of the injured pancreas, simple drainage, or suture of the pancreatic capsule, or pancreatic resection or a patch with an excluded jejunal loop can be used. Partial duodenopancreatectomy is the last option because this procedure is associated with high morbidity and mortality.

[Palliative surgical treatment of tumors of pancreas and periampullary region]. / Paliativní chirurgická lécba nádoru pankreatu a periampulární oblasti.

BACKGROUNDS: Pancreatic cancer is an aggressive malignant disease with increasing incidence. Radical resection, the only potentially curative method, is possible in only 20-30% of patients. The main symptoms of advanced non-resectable pancreatic head tumors include obstructive jaundice, caused by stenosis of distal common bile duct, duodenal obstruction and pain, especially in the epigastric region and back. The aim of palliative treatment is to relieve these complaints. This paper evaluates our own palliative surgical treatment results in patients with pancreatic head and periampullary region cancer. PATIENTS AND METHODS: This study included all patients with pancreatic head and periampullary region cancer who underwent surgery at the Department of Surgery, University Hospital in Hradec Kralove from 1st January 2006 to 31st December 2010. The aim of the surgery in all patients was to resect the tumor. Palliative surgical procedure was performed in patients witn an inoperable tumor. We performed gastro-entero anastomosis in all the patients. When perioperative situation allowed, hepatico-jejuno anastomosis was performed in patients with obstructive jaundice. Surgical splanchnicectomy was performed in patients with back pain. RESULTS: Over five years, we performed a surgery in 94 patients for malignant disease of pancreas and periampullary region. Radical resection was performed in 45 patients. Palliative bypass procedure was performed in 42 patients. Exploration only was performed in 7 patients. Postoperative complications after palliative bypass procedures were noted in 15 patients (30.6%), the majority of these complications were minor. CONCLUSION: The advantage of surgical hepatico-jejuno anastomosis over endoscopically placed stent is particulary in superior long-term patency. Therefore, it is advisable to perform these procedures in patients with longer expected survival. Morbidity associated with palliative surgical procedures was relatively low and there was no mortality.

[Classification of surgical complications: analysis of the group of consecutive patients]. / Klasifikace chirurgických komplikací: analýza vlastní skupiny nemocných.

INTRODUCTION: The aim of the work was to evaluate the implementation of Clavien - Dindo classification of surgical complications into a routine clinical praxis and to evaluate the results achieved at the university department of surgery. MATERIAL AND METHODS: Prospectively collected data of patients hospitalized at the Clinic of Surgery of the University Hospital in Hradec Králové between January 2010 and September 2012 were retrospectively evaluated. Incidence, spectrum and severity of postoperative complications were evaluated according to individual surgical specializations. RESULTS: 9039 patients were operated and enrolled into the database during the time period from January 2010 to October 2012. A surgical complication was recorded in 1248 (12.9%) patiens, grade I. in 284 (3.4%) cases, grade II. in 384 (4.3%) cases, grade III in 370 (4.1%) cases, grade IV. in 67 (0.7%) patients. Death,i.e. grade V., occurred in 143 (1.43%) patients. CONCLUSION: Clavien - Dindo classification of surgical complications was successfully implemented into a routine clinical praxis at the department of surgery, University Hospital Hradec Králové. Wider use of this classification system would improve conditions for evaluation and comparison of results between different surgical approaches, surgeons or departments.

Radiofrequency-assisted liver resection: higher incidence of infectious complications?

AIM: To evaluate clinical experience with radiofrequency (RF)-assisted liver resection in non-cirrhotic and non-cholestatic patients with metastatic liver disease. METHODS: A group of consecutive patients who underwent RF-assisted liver resection for metastatic liver disease was prospectively followed. RESULTS: Between July 2005 and April 2008, 95 liver RF-assisted liver resections were performed, 71 of them for metastatic liver disease. The mean hospital stay was 14 (range 5-40) days. The mean operation time was 141 (range 64-233) minutes. The mean duration of RF coagulation was 10 (range 9-12) minutes. A total of 37 complications in 24 (33%) patients were recorded, including 12 (16.9%) infected collections in resection line that had to be drained percutaneously. The 30-day postoperative mortality was zero. CONCLUSION: This study indicates that RF-assisted resection may have a benefit in decreasing peroperative blood loss and the number of blood transfusions. Nevertheless, an increased incidence of infectious complications and pleural effusions that required evacuation was noted.

Giant biliary cystadenoma: a case report.

Biliary cystadenoma is a very rare benign cystic tumour of the liver. Fewer than 150 cases have been described in the literature so far. The authors present a case of a 29-year-old female with a giant intrahepatic biliary cystadenoma who presented with abdominal pain and obstructive jaundice. The patient was treated with left hepatectomy and now 12 months after the surgery she is in good condition with no signs of recurrence of the disease. Clinical presentation of biliary cystadenoma is not specific. Diagnosis is based on imaging methods, mainly ultrasound and CT scan. However, it is often misdiagnosed. For treatment, radical resection is advocated because a biliary cystadenoma is considered to be a premalignant lesion. The prognosis of biliary cystadenoma after complete resection is excellent. Nevertheless, there is a risk of recurrence or malignant transformation after incomplete resection.

[Laparoscopic pancreatic resections in experimental setting and clinical practice]. / Laparoskopická resekce pankreatu v experimentu a klinické praxi.

INTRODUCTION: Pancreatic fistula is a major postoperative complication after pancreatic resection. One of the main risk factors of developing the pancreatic fistula after distal pancreatectomy is the method employed for the management of the pancreatic remnant. AIM OF THE STUDY: The aim of the experimental part of this work was to test a novel method of management of the pancreatic remnant after distal pancreatectomy on a large laboratory animal. Furthermore, based on the experience with the experimental work to introduce the laparoscopic approach to human clinical practice. METHODS: In the experimental part of the work laparoscopic distal pancreatectomy with spleen and splenic vessels preservation was performed in ten female domestic pigs. The experimental animals were divided into two groups. In the first group the pancreas was transected using an EndoGIA Universal Stapler and in the second group, the pancreas was transected using a Ligasure device and the pancreatic remnant was reinforced with hydrogel sealant Pleuraseal. We introduced the laparoscopic distal pancreatectomy to clinical practice in the Department of Surgery in Hradec Králové in 2009. Transection of the pancreas was performed with staplers. RESULTS: In the experimental part of the work the postoperative course was uneventful in all the animals. All animals gained weight. Only minor macroscopic and microscopic alterations of the healing process were found. Statistical differences between the groups were not significant. In the clinical part of the work we performed laparoscopic distal pancreatectomy in 6 patients. We performed two distal pancreatectomies with splenectomy, one distal pancreatectomy with splenectomy and left nephrectomy and 3 distal pancreatectomies with the spleen and splenic vessels preservation. We did not have to convert to open procedure in any of the cases. CONCLUSIONS: In the experimental part of the work we showed that the novel technique using Ligasure transection reinforced by the hydrogel sealant Pleuraseal is feasible and safe technique, which seems to be comparable with the standard transection technique using stapler. Our initial experience with laparoscopic distal pancreatectomy in the clinical practice cannot be used to compare various methods of management of the pancreatic stump or to evaluate the rate of pancreatic fistula in such small group of patients.

[Current trends of surgical therapy of focal liver and pancreatic lesions]. / Soucasné moznosti chirurgické lécby loziskového postizení jater a pankreatu.

Focal liver and pancreatic lesions represent important therapeutic problem in a relatively huge group of patients. Secondary liver tumors are the crucial factor affecting morbidity and mortality in patients with malignancies. Radical surgery is the only therapeutic option that gives the chance of long-term survival. The authors present current trends in surgical therapy of liver and pancreatic tumors as a review article.

Papillary adenoma of the extrahepatic biliary tract--a rare cause of obstructive jaundice.

The authors present a case of papillary adenoma of the extrahepatic biliary tract presenting as obstructive jaundice. The diagnosis was based on the endoscopic retrograde cholangiopancreatography (ERCP), and above all cholangioscopy findings. The patient was treated by bile duct resection with Roux-en-Y hepaticojejunostomy. Adenoma of the bile duct is a rare entity. Only a few cases have been described in the world literature so far.

[Distal pancreatic resections: indications, surgical technique, and complications]. / Levostranné resekce pankreatu: indikace, chirurgická i technika a komplikace.

INTRODUCTION: Distal pancreatic resections are relatively less frequent surgical procedures than duodenopancreatectomies. This is due to lower incidence and later onset of lesion symptoms in this part of the pancreas. The aim of our work was to evaluate retrospectively the results of distal pancreatic resections performed at the Department of Surgery, University Hospital in Hradec Králové from 1996 to 2008. METHODS: We retrospectively evaluated the indications, surgical procedure (including complications) and the postoperative course. All procedures were done through transverse laparotomy. The pancreas was transected sharply with a scalpel and the resection line was oversewn. Staplers were not used. All the patients were given Sandostatin postoperatively. RESULTS: We performed 51 distal pancreatic resections at our department from 1996 to 2008, 40 of which were distal pancreatic resections with splenectomy (78%). We performed 149 duodenopancreatectomies in the same time period. Benign lesions or borderline lesions (chronic pancreatitis, benign tumours, borderline tumours) were found in 67% of the surgical specimens. Malignant tumours were found in 33%, most of which were adenocarcinoma. Severe pancreatic fistula developed in two patients (3.9%). Two reoperations (3.9%) were necessary due to postoperative complications. Postoperative mortality was nil. CONCLUSION: We assume that our technique resulted in a relatively low morbidity and zero mortality. However, we used this technique in all cases, and therefore cannot compare it to other techniques.

[Truncus coeliacus stenosis in duodenopancreatectomy]. / Stenóza truncus coeliacus pri duodenopankreatektomii.

INTRODUCTION: Patients with celiac axis stenosis are asymptomatic due to the rich collateral blood supply through superior mesenteric artery. Ligating and dividing gastroduodenal artery during pancreatoduodenectomy can cause ischemic threat especially to liver, less frequently stomach and spleen, or failure of anastomoses. CASE REPORT: The authors present a case of 27-year-old female who underwent duodenopancreatectomy for pseudopapillary tumour of the head of pancreas. Celiac axis stenosis was found peroperatively and proven during angiography. Although an attempt of endovascular dilatation of celiac axis was unsuccessful, blood supply to the liver was sufficient and therefore we did not perform any other intervention to improve blood flow to the liver. Postoperative course was uneventful. DISCUSSION: Celiac axis stenosis can be caused by tumour infiltration or lymphadenopathy in malignant disease, atherosclerosis or compression of the median arcuate ligament. The stenosis can be managed by endovascular treatment or arterial reconstruction. In conclusion the authors propose a management algorithm to prevent the consequences of celiac axis stenosis.

[Laparoscopic liver resections. Successes and failures associated with the technique introduction--case reports]. / Laparoskopické resekce jater. Uspechy a nezdary spojené se zavedením techniky--soubor kazuistik.

The authors present initial clinical experience with laparoscopic liver resections as a case report series. The operation time, hospital and ICU stay length, perioperative blood loss, transfusion units used, and postoperative complications were recorded in a prospective way. The reasons for conversion to open surgery were also evaluated. 15 laparoscopic liver resections were completed between May 2006 and February 2009. There were 11 anatomical resections including hemihepatectomies and 4 non-anatomical laparoscopicaly completed liver resections. The initial experience shows that laparoscopic liver resection is feasible and safesate approach that requires advances experience in laparoscopic operative technique and liver surgery. Introduction of the laparoscopic technique is not easy and is associated with high risk of hilar bile duct injuries and perioperative bleeding.