Successful treatment of gastrosplenic fistula after sleeve gastrectomy.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is one of the most performed bariatric procedures. But it is also associated with serious and potentially life-threatening staple line-related complications, such as stomach leak and bleeding. CASE REPORT: The article describes a case of surgical treatment of an early fistula between the stomach and the spleen 3 weeks after LSG. We have focused our attention on the diagnosis and possible treatment options for this potentially life-threatening complication. CONCLUSION: Efforts to reduce the frequency of leakage after LSG include a number of different measures. It is advisable to have expert knowledge not only in primary bariatric surgery, but also in the management of problems and reoperations in gastrointestinal surgery. An individualized approach and multidisciplinary teamwork are essential for successful therapy.

The Impact of High Protein Nutritional Support on Clinical Outcomes and Treatment Costs of Patients with Colorectal Cancer.

BACKGROUND: The primary objective of this study was to investigate the impact of high protein oral nutrition support (ONS) on clinical outcomes in patients with colorectal cancer (CRC). The secondary aim was to compare the cost of treatment and length of stay (LoS) for CRC patients taking high protein ONS vs. patients on conventional nutritional support. MATERIALS AND METHODS: The study was conducted on adult patients with CRC undergoing colorectal surgery. Informed consent was obtained before the study. The study group (SG; n = 52) was instructed to take high protein ONS (600 kcal, 40 g protein per day) in addition to a normal diet for at least 10 days before and two weeks after surgery. Data from the comparative group (CG; n = 105) were collected retrospectively. RESULTS: A relative reduction in the frequency of the following complications was observed in SG: wound dehiscence (2.2 times lower), infections (4.3 times lower), anastomosis dehiscence (2.0 times lower), and rehospitalization (1.7 times lower). The mean LoS was shorter in SG (9.4 ± 4.97 vs. CG 12 ± 6.4 days), which resulted in significantly lower treatment costs during hospitalization (SG 479 vs. CG 538 EUR; p = 0.01) and at six months after surgery (SG 4,862 vs. CG 6,456 EUR). CONCLUSION: Pre- and postoperative high protein ONS reduces LoS, treatment costs, postoperative complications, and re-hospitalizations in CRC, regardless of initial nutritional status.Key words: high protein oral nutritional support - colorectal cancer - perioperative care.

[Lumbar sympathectomy literature review over the past 15 years]. / Lumbálna sympatektómia prehlad svetovej literatúry za posledných 15 rokov.

INTRODUCTION: Lumbar sympathectomy (LS) irreversibly damages a part of the sympathetic trunk and adjacent ganglia between L1 and L5, typically between L2 and L4. The first LS was performed in 1923. Initially, it used to be performed very often; however, with the progress of vascular and endovascular surgery its importance gradually continues to decline. The aim of the paper is to present literature review focusing on LS over the past 15 years. METHOD: Literature review of 113 academic articles found in academic journal databases. PATHOPHYSIOLOGY: Irreversible interruption of the efferent innervation leads to relative vasodilation of small vessels in lower extremities (α1-receptors blockade), and it reduces the volume of sweat due to inactivation of eccrine glands and nociception from lower limbs. INDICATION: Raynaud´s phenomenon, thromboangitis obliterans, non-revascularizable peripheral arterial disease (PAD) (Fontain grade III-IV), hyperhidrosis, persistent pain in lower extremities, chronic pain of amputation stump, frostbites, chilblains.Effect: The three largest studies showed a positive effect in 63.6-93.4% cases of PAD and in 97%100% cases of hyperhidrosis. The positive effect was defined as warmer lower extremities, increased blood flow, acceleration of chronic defects healing, sweating disappearance and pain reduction. CONCLUSION: Lumbar sympathectomy still remains a useful method in the treatment of above mentioned diseases if properly indicated. KEY WORDS: lumbar sympathectomy - Raynaud´s phenomenon - thromboangitis obliterans -peripheral arterial disease - hyperhidrosis.

[Transtibial amputation: sagittal flaps in patients with diabetic foot syndrome]. / Sagitální typ bércové amputace u pacientu se syndromem diabetické nohy.

INTRODUCTION: Diabetic foot syndrome is defined by ulcer or destruction of leg tissues in patients with diabetes (diabetics) associated with infection, neuropathy and various degree of ischaemia (peripheral vascular disease). In Czech Republic in 2010 were registrated over 45 000 patients with diabetic foot syndrome. 8500 (diabetics) patients with diabetes undergone the surgery (any type of amputation). MATERIAL AND METHODS: In retrospective non randomized trial we evaluated the population of patients with lower limb amputation admitted to Clinic of Surgery FNO between 2010-1012. We introduce current (present) view to possibilities of lower limb amputations, historical problems and development of surgical methods. Special aspect is dedicated to sagital shank amputation. Detail description of operative (surgical) technique itself and crural region (area) anatomy. RESULTS: In 2010-2012 we achieved 146 lower limb amputations in shank, from that 27 sagital shank amputations( sagital operative method). We observed ( followed up) the number of reoperations, reasons that led to amputation, wounds healing by secondary intention, ites sources and necessity of revision due to postoperative hemorrhage. CONCLUSION: Effects of amputations on patientes quality of life. Social and socioeconomical impacts. Provably lower number of complications in sagital shank amputations compared to (in comparison with) conventional methods. Authors would like to point out and introduce interesting operation method to the general public.

[The staple line in sleeve gastrectomy]. / Staplerová linie u sleeve resekce zaludku.

INTRODUCTION: Postoperative leak and bleeding from the staple line are potentially serious early complications following laparoscopic sleeve gastrectomy. AIM: This study aims to assess the significance of oversewing the staple line after laparoscopic sleeve gastrectomy in preventing leak and bleeding in our group of patients. MATERIAL AND METHODS: Patients after laparoscopic sleeve gastrectomy were included in the trial. Two different principles of oversewing the staple line (selective vs. mandatory) were analyzed. The design of the trial was retrospective-prospective, non-randomized. Postoperative complications were recorded. RESULTS: Between October 2006 and December 2011, 638 laparoscopic sleeve gastrectomies were carried out using standard laparoscopic technique. 297 of the patients belonged to the group with selective oversewing of the staple line. The remaining 341 patients belonged to the group in which the staple line was oversewn in all cases. Both groups of patients were comparable in the basic parameters. Early postoperative leak affected one patient in both groups, 0.30% versus 0.29% (p = 0.9203), respectively. The rates of postoperative bleeding were 2.7% (selective oversewing) versus 0% (mandatory oversewing) (p = 0.0023), respectively. CONCLUSION: Our study did not demonstrate the impact of oversewing the staple line on the occurrence of postoperative leak. The rates of postoperative bleeding from the resection site were statistically significantly lower in the group with the mandatory oversewing of the staple line.

["Low volume" laparoscopic nephrectomy for relative-to-relative transplantation]. / "Low volume" laparoskopická nefrektomie pro príbuzenskou transplantaci.

AIM: Worldwide, the number of suitable cadaverous donors is limited. Therefore, as a solution for patients with chronic renal failure appears to extend the group of living donors of healthy individuals who voluntarily donate kidney to relatives or emotionally related recipients. Given the altruistic circumstances of these operations, the main monitored parameters are security for donors and excellent graft function for recipients. Currently published works show that minimally invasive technique can guarantee comparable results with open access in both monitored parameters. The aim of this study is to asses our results with laparoscopic assisted living donor nephrectomy for transplantation. PATIENTS AND METHODS: In retrospective study we analyzed data of patients in whom laparoscopic donor nephrectomy was performed on the Surgical Clinic, University Hospital Ostrava in the period from May 13, 2002 to June 30, 2010. Group of 34 donors were analyzed according to demographic characteristics (sex, age, ASA classification and BMI). From the perioperative data were monitored length of operation and warm ischemia, blood loss, frequency of intraoperative complications and conversion rate. In the postoperative period were evaluated in donors length of postoperative hospitalization, frequency of early and late reoperations, causes of morbidity and mortality, dynamics of the levels of creatinine and in the recipients was monitored 1-year survival of the graft. RESULTS: There were 14 men (41%) and 20 women (59%), median age was 48 years (25-77 years), BMI 26.9 (18.7-37.0), 53% of patients were ASA II, 44% ASA I, 1 patient (3%) ASA III. Median length of operation was 180 min (90-300 min), warm ischemia 120 s (58-240 s), blood loss 50 ml (30-1000 ml). There was no conversion. Intraoperative complications occured in 3 donors (8.8%). The length of hospital stay was 7 days (3-26 days), morbidity rate was 14.7%, without mortality. Early reoperations were in 2 patients (5.9%), late reoperations were performed in 4 patients (11.8%). In donors an average increase of creatinine value was 35.5 micromol/l the first postoperative day. One-year graft survival in our cohort was 94.1%. CONCLUSION: For patients with terminal renal insufficiency the living donor kidney transplantation offers possibility to shorten time in waiting list and to ensure a better graft function with its longer survival. Minimally invasive laparoscopic technique (we prefer transperitoneal approach), represents a safe alternative to open operation.

[The dependence of weight loss on the dimensions of neoventriculus in patients after gastric banding]. / Závislost úbytku hmotnosti na velikosti neozaludku po laparoskopické bandázi zaludku.

BACKGROUND: At present the surgical procedure is accepted in the physicians' opinion of the cases of morbid obesity in patients where the conservative therapy has failed. Bariatric surgery offers an effective, standardized, and safe way to radical and long-term loss of weight. The laparoscopic gastric banding is the most frequent procedure in patients with morbid obesity. AIM OF THE STUDY: The aim of the study was to consider if the statistic dependence exits between the weight loss and the dimensions of neoventriculus in patients after gastric banding or between the weight loss and the width of artificial stenosis created operatively. METHODS: One hundred and eighty four patients with morbid obesity underwent the laparoscopic gastric banding from January 1, 2001 to July 30, 2006. The dimensions of neoventriculus and the width of artificial stenosis were measured after the operation. The patients were divided into three subgroups according to the dimensions of neoventriculus and the width of artificial stenosis. The patients were followed 2 years and the weight loss was registred. The results were statistically evaluated by correlative ratio. RESULTS: The correlative ratio were calculated between weight loss and the dimensions of neoventriculus and between the weight loss and the width of artificial stenosis created operatively. The analysis showed that there was no statistic difference between the tested parameters. CONCLUSIONS: The study has showed that the success of gastric banding does not depend on the dimensions of neoventriculus and on the width of artificial stenosis but it depends on orderliness of patients. It means the adherence of dietary limitations and recommandations.

[Comparison various types of artificial nutrition on postoperative complications after major surgery]. / Porovnání vlivu ruzných druhu umelé výzivy na pooperacní komplikace po velkých chirurgických výkonech.

BACKGROUND: The present rationale appears to prefer early postoperative enteral nutrition to total parenteral nutrition. But no clear conclusions exist for demonstrating the clinical benefit of early postoperative enteral nutrition in patients after the major surgical resections of upper gastrointestinal tract. AIM: To compare the clinical impact of various types of the artificial nutrition by comparison of the postoperative complications. METHODS: Prospective, randomized, controlled clinical trial. Sixty-two patients were analyzed. In the group I (21 patients) the total parenteral nutrition was received, in the group II (20 patients) the standard enteral nutrition was received, in the group III (21 patients) the enteral nutrition enriched with glutamin, arginin and omega-3 fatty acids was received. Both enteral feedings were given early. All three nutritional regiments were isocaloric and isoproteinaceus. RESULTS: The postoperative complications were in 31 patients overall (11, 11, 9 patients in the each group I, II, III). Three patients died in the group I, 2 patients in the group II, and 1 patient in the group III. There were no significance differences (p < 0,05) in postoperative complications, both infectious and non-infectious reasons. CONCLUSION: The study has shown no impact of various type of artificial nutrition on clinical outcome in patients after major resections of upper gastrointestinal tract. There was no significant difference in infectious complications in the groups with enteral feeding. The combination of enteral and parenteral nutrition appears as optimum after major surgery of the upper gastrointestinal tract. It is necessary to realize more extensive studies of homogenous patients to find out the benefit of various types of arteficial nutrition in postoperative period.

[Subhepatic drainage in laparoscopic cholecystectomy--a necessity or an overused tradition?]. / Subhepatální drenáz pri laparoskopické cholecystektomii--nutnost nebo prekonaná tradice?

The subhepatic drainage is mandatorily used in the end of laparoscopic cholecystectomy in the majority of departments of surgery in Czech republic. The preoperative finding of advanced inflammatory alteration or bleeding in operative field is certainly the reason to do so. But it seems that obligatory drainage after uncomplicated laparoscopic cholecystectomy has no real foundation and it is suspiciously an expression of antiquated tradition. From January 1, 2001 to December 31, 2002 the prospective non-randomized study was performed: in the first group of patients the drainage of subhepatic space was used mandatorily (324 patients), in the second group the drainage was used only in indicated cases (365 patients). No statistically significant difference was found between the two groups in postoperative complications (biliary leak, intraabdominal abscess, reoperation). There was the significant difference in surgery times (55 min. in the group with mandatory drainage, 50 min. in the group with indicated drainage, p < 0.05), in term of hospital stay--the patients with mandatory drainage stayed longer in hospital (3.2 day, resp. 2.4 day, p < 0.05). In summary, the mandatory drainage of subhepatic space after laparoscopic cholecystectomy is not associated with lower incidence of postoperative complications. On the other hand, the mandatory drainage has significantly longer surgery time and longer length of hospital stay. The drainage is exceptionally indicated but not mandatorily in uncomplicated operations.

[Manually-assisted laparoscopic nephrectomy in a living donor]. / Manuálne asistovaná laparoskopická nefrektomie od zivého dárce.

Manually assisted laparoscopic nephrectomy from a live donor combines the advantage of a mini-invasive approach with the advantage of the assisting hand in the abdominal cavity to which the surgeon is used from classical operations. The authors performed the first nephrectomy from a live donor by this method on May 13, 2002. Our initial experience with five nephrectomies by this method indicate that every subsequent operation was shorter and the period of warm ischemia was also shorter. There was no postoperative complication. In the second operation suppuration of the minilaparotomy occurred which protracted hospitalization and the convalescent period. The prerequisite of these operations is a certain amount of experience with laparoscopic operations. This type of nephrectomy has the general advantages of a miniinvasive approach, i.e. greater postoperative comfort and a shorter convalescence as compared with an open operation. The period of warm ischaemia does not differ markedly from nephrectmies by the classical procedure.

[Hand-assisted laparoscopic surgery of the colorectum]. / Manuálne asistovaná laparoskopická chirurgie kolorekta.

Hand-assisted laparoscopic surgery extends the possibilities of laparoscopic operations while preserving the miniinvasive character of the operation. The objective of the work is, based on the authors' experience with a group of 28 patients operated by this method for diseases of the colorectum to describe the surgical technique, present their results and emphasize the indications and advantages of this procedure.

[Metastatic choriocarcinoma as a cause of hemorrhage in the digestive tract and abdominal cavity]. / Metastatický choriokarcinom jako prícina krvácení do trávicí trubice a brisní dutiny.

Authors present a case report of an young woman with metastatic choriocarcinoma. Clinical presentation of the disease was intracerebral bleeding concurring with intestinal bleeding and bleeding from ruptured spleen according to metastatic spread. Physicians firstly didn't think of choriocarcinoma because of small incidence of the disease and long period after the patient's latest pregnancy. At last the aggressive treatment was successful. Authors would like to bring out the reality that the surgeon could be the first who is faced with diagnosis and treatment of serious complications of choriocarcinoma.

[Ureteroureteral end-to-side anastomosis in kidney transplantation--personal experience]. / Uretero-uretero anastomóza end to side u transplantací ledvin--nase zkusenosti.

The most widely used way of reconstruction of the urinary pathways in transplantations of the kidney is at present a ureteroneocysto anastomosis. In some patients this type of reconstruction is difficult, if not impossible (adhesions in the lesser pelvis of the recipient, atrophic urinary bladder, short ureter of the graft, transplantation of child kidneys). In these instances the authors indicated a uretero-uretero end-to-side anastomosis. The authors performed in 13 patients a total of 17 uretero-uretero end-to-side anastomoses. In six transplantation of child kidneys en bloc was involved. During the postoperative period one female patient developed a urinary fistula from the renal pelvis of the graft which healed after conservative treatment. End-to-side uretero-uretero anastomosis is a simple and safe way of reconstruction of the urinary pathways in renal transplantations.