[Hemorrhagic complications of warfarin therapy]. / Hemoragické komplikace lécby warfarinem.

INTRODUCTION: Introduction of warfarin use in prevention and treatment of thromboembolic diseases resulted in lower rates of thromboembolic complications, however, on the other hand, it has been associated with increased incidence of hemorrhagic complications,which often require surgical management. AIM, MATERIAL, METHODS: The aim of the study was a retrospective analysis of hemorrhagic complications in 184 patients, hospitalized in the FNKV (Královské Vinohrady Faculty Hospital) Surgical Clinic during 2000-2008, following warfarin overdose. The following diagnostic or treatment methods were used: endoscopy of the upper or lower GIT in GIT hemorrhages and spiral CT when peritoneal bleeding was suspected. RESULTS: GIT bleeding, such as hematemesis, melena, enterorrhagy, was the commonest complication observed in 147 patients, ie. 79.9%. Upper GIT was identified as the source of bleeding in 76 subjects, i.e. 51.7%, lower GIT was the identified source in 26 subjects, ie. 17.7%, and the source remained unidentified in 45 patients, ie. in 30.6%. 10 patients suffered from soft tissue bleeding, m. rectus abdominis hematoma was detected in 7 subjects, hemoperitoneum and/or retrohemoperitoneum was identified in 8 subjects. Intestinal wall or its intestinal peritoneum was affected in 3 subjects and 3 patients suffered from liver or splenic intraparenchymal hematoma. Out of the total of 184 patients, 165 subjects were treated conservatively (89.7%), 19 subjects underwent surgery (10.3%), including 14 laparotomies for acute abdomen symptoms and 5 incisions with removal of hematomas. Overall lethality rate was 7/184, ie. 3.8%, 5 subjects undergoing conservative treatment and 2 subjects undergoing surgery exited. CONCLUSION: Uncontrolled warfarin administration may cause serious, even life- threatening complications. Therefore, patients undergoing warfarin therapy should be adequately informed about potential complications and regular INR monitoring is required.

[Traumatic rupture of the diaphragm in blunt injuries]. / Traumatická ruptura bránice u tupého poranení.

The authors present a group of 12 casualties operated on account of a traumatic rupture of the diaphragm. The rupture of the diaphragm was part of an associated thoracoabdominal injury or multiple injury. The casualties were examined within the framework of the diagnostic algorithm, in 11 of them rupture of the diaphragm was proved by spiral computed tomography. The diaphragm was injured in 7 subjects on the left and in 5 on the right. In 8 casualties during injury of the diaphragm also a serious intrathoracic injury was treated (in 5 laceration of the lungs) and of intraabdominal organs (in 4 laceration of the liver and in 2 laceration of the spleen). On the left side injuries of the diaphragm were always treated from laparotomy, on the right in 4 patients from thoracotomy. In 4 patients with concurrent injury of the intrathoracic and intraabdominal organs a thoracoabdominal approach was selected. During the postoperative period one female patient with multiple injuries died. The cause of death was contusion of the brain. According to the authors' experience it is useful to apply for early diagnosis of diaphragmatic injuries modern non-invasive imaging methods (spiral post-contrast computed tomography). The surgical approach depends on the presence of associated intrathoracic and intraabdominal injuries. The therapeutic results are limited by the presence of serious associated injuries.

[Laparoscopic surgery of gastric diverticula with secondary adhesiolysis]. / Laparoskopická divertikulektomie zaludku se sekundární adheziolýzou.

The authors present the case-history of a rare cause of gastric diverticulum. On account of a very painful symptomatology and X-ray evidence of a diverticulum the authors decided on laparoscopic excision of the diverticulum. The resection was made using a Endo GIA II stapler. The gradual, one-year development of adhesions and a new different algic symptomatology which impeded the subject's occupational activities led the authors to make another laparoscopic operation. After releasing the adhesion between the stomach and the collateral peritoneum the condition improved completely. The patient is now 16 months after re-operation completely free of complaints and performs his physically pretentious work and ingests food without dyspeptic phenomena.

[The harmonic scalpel and surgery of the thyroid gland]. / Harmonický skalpel a chirurgie stítné zlázy.

UNLABELLED: The objective of the investigation was to test the effects and properties of a harmonious scalpel in operations of the thyroid gland. During a three-year period (1999-2001) for this indication at the Surgical Clinic of the Third Medical Faculty Charles University Prague on account of this indication 306 patients were operated, 133 with a harmonious scalpel and 173 by the classical technique. In the experimental part the authors made sure first that the necrotic changes in tissues surrounding the thyroid gland caused by the ultrasonic blade do not reach further than 1 mm from the line of resection. If this demand is respected, then the operations with a harmonious scalpel are safe, anatomically clear and physiological to a maximum extent. As compared with the classical approach, the authors did not observe a statistically significant difference as regards complications (i.e. early postoperative haemorrhage, paresis of the laryngeal recurrent nerve or permanent hypocalcaemia). After mastering of the surgical technique the time of operation is reduced as compared with the classical operation, the operation is almost bloodless and in the surgical wound no foreign material is left. The pathologist confirms that thyroid specimens obtained by the harmonious scalpel are more easily evaluated for assessment of the final diagnosis. CONCLUSION: The authors outline the asset of a harmonious scalpel for thyroid surgery. They recommend its use in these operations, they consider however preliminary training of work with the harmonious scalpel an essential prerequisite for correctly performed work.

[Infiltration of local anesthetics into the thyroid gland capsule for surgery and the postoperative period]. / Prínos infiltrace pouzdra stítné zlázy lokálním anestetikem pro operacní a bezprostrední pooperacní prubeh.

In a prospective randomized study the hypothesis was tested whether infiltration of the thyroid capsule by a local anaesthetic will reduce the haemodynamic response to surgical trauma, consumption of anaesthetics and opioids during surgery and will shorten the time of arousal. A total of 64 patients indicated for planned goitre surgery were divided at random into a control group (C, n = 32) and experimental group (LA, n = 32). The preoperative medication and anesthesia did not differ in the two groups. In group C into the thyroid capsule a maximum of 40 ml saline was administered, in LA the same volume of 0.5% trimecain. A highly significant difference was found (p < 0.001) in the incidence of hypertension during surgery (21 C vs. 5 LA) and the need of further pharmacological interventions (21 vs. 8). In the control group was a higher consumption (p < 0.95) of the opioid phentanyl (167.5 +/- 111 micrograms vs. 125 +/- 93.5 micrograms), a trend of longer arousal and the need to antagonize the effect of opioid (p < 0.1). The substitution of saline by a local anaesthetic for infiltration of the thyroid capsule is a safe and simple method leading to a reduction of cardiovascular complications during surgery.

[Personal experience with surgery of retrosternal goiter]. / Nase zkusenosti s operacemi retrosternálních strum.

BACKGROUND: Retrosternal goitre has its specific features: a clinical picture with elements of compression, an increased percentage of malignant conversion, a technically more pretentious operation with an increased number of complications etc. Data in the literature are not uniform. The objective of the presented work was to assemble information in a large group of operated patients. METHODS AND RESULTS: The authors evaluated retrospectively operations of retrosternal goitres from two clinical departments. Of 716 patients operated on account of goitre 87 (21.1%) had retrosternal goitre. Women were affected more frequently (84%) than men (16%), ratio 5.2:1; the mean age of women was 66 years, of men 56 years. A malignant finding was confirmed in 4.6% of the operated patients. The most frequent finding was benign adenomatous colloid goitre (8.5%) and Hashimoto's thyroiditis (80.4%). Hyperthyroidism of the Graves-Basedow type (4.6%) and benign hyperthyroidism of the Plummer type (2.3%) were not frequent. Type of malignity: papillary carcinoma (3.45%) and follicular carcinoma (1.15%); medullary carcinoma, anaplastic carcinoma or lymphoma were not found. The most frequent surgical approach was cervical incision (Kocher) in 95.4%; it had to be supplemented by sternotomy only in 4.6% of the operated patients. As far as the extent of surgery is concerned, almost total thyroidectomy was performed in 60.9%, total lobectomy in 2.3%, subtotal thyroidectomy in 32.2% and subtotal lobectomy in 4.6% of the patients. 24.1% of the patients developed complications, only in 5.7% they were permanent. One female patient died (1.2%). CONCLUSIONS: Retrosternal goitre accounted for cca 20% of patients operated on account of goitre. In cca 5% histology confirmed a malignant form (papillary and follicular carcinoma). Sternotomy was necessary only in less than 5% of the operated patients. The results of surgery are very good.

[Principles and possibilities in the treatment of multiple injuries]. / Zásady a moznosti lécby polytraumat.

The authors describe the therapeutic results in 135 patients with multiple injuries hospitalized at the Surgical Clinic of the Third Medical Faculty, Charles University in 1981-1990. The authors analyze the procedure in the treatment of these patients which is provided by the most experienced surgeon in collaboration with his assistant. A stage-by-stage procedure and early indication of operation is the most important aspect of treatment.