Strangulation ileus caused by malposition of the ureter.

Ileus is one of the most severe diagnoses of the group of acute abdomen events. Some patients with certain forms of bowel obstruction respond well to conservative therapy. However, the diagnosis of strangulation ileus can be delayed in some situations, resulting in high morbidity and mortality in such cases. Our paper presents the case of an 81-year-old female patient who developed an ileus shortly after ureteral stent placement due to obstructive hydroureteronephrosis. The strangulation of the small intestine was caused by an atypical position of the right ureter in the abdominal cavity.

Different cardiac loading conditions and haemodynamic monitoring in animal models.

OBJECTIVE: To develop models of various cardiac loading conditions in an experimental study. MATERIALS AND METHODS: A total of 78 piglets, average weight 24 kg were divided into 4 groups under different cardiac loading conditions: Group A were spontaneously breathing pigs without haemodynamic changes, Group B were ventilated animals with increased left ventricular afterload, Group C ventilated with increased right ventricular preload and Group D ventilated with increased afterload of both heart ventricles. Haemodynamic parameters were invasively measured at 60 and 120 minutes. RESULTS: Groups B, C and D demonstrated higher preload of both ventricles, compared with Group A. Group C demonstrated higher preload and afterload of both ventricles in comparison with Groups B and D. CONCLUSION: Haemodynamic measured data confirmed the expected changes in cardiac loading and corresponded to human clinical situations. These models may be used for future experimental haemodynamic studies (Tab. 1, Fig. 3, Ref. 8).

[Penetrating laryngotracheal injury during a suicide attempt]. / Penetrierende laryngotracheale Verletzung beim Suizid.

The authors present a case of a 40-year-old man who intentionally stabbed himself several times in the trachea and larynx during a suicide attempt, and also inflicted other penetrating injuries of the stomach and liver upon himself. The preoperative examination using fiber-optic tracheoscopy and CT revealed only transection of the ligamentum cricothyroideum; the remaining two defects were discovered later, during the surgical revision. All three injuries were successfully treated with sutures, in one case using the transtracheal approach.

Comparison of Doppler flow Tei-indexes with pulmonary artery thermodilution measurement of cardiac output in an experimental porcine model.

The objective of our study was to compare Doppler echocardiography imaging with pulmonary artery thermodilution measurement during mechanical ventilation. Total 78 piglets (6 weeks old, average weight 24 kg, under general anesthesia) were divided into 4 groups under different cardiac loading conditions (at rest, with increased left ventricular afterload, with increased right ventricular preload, and with increased afterload of both heart ventricles). At 60 and 120 min the animals were examined by echocardiography and simultaneously pulmonary artery thermodilution was used to measure cardiac output. Tei-indexes data were compared with invasively monitored hemodynamic data and cardiac output values together with calculated vascular resistance indices. A total of 224 parallel measurements were obtained. Correlation was found between values of right Tei-index of myocardial performance and changes in right ventricular preload (p<0.05) and afterload (p<0.01). Significant correlation was also found between left index values and changes of left ventricular preload (p<0.001), afterload (p<0.001), stroke volume (p<0.01), and cardiac output (p<0.01). In conclusion, echocardiographic examination and determination of the global performance selectively for the right and left ventricle can be recommended as a suitable non-invasive supplement to the whole set of methods used for monitoring of circulation and cardiac performance.

Diffuse alveolar damage due to inappropriate strategy of mechanical ventilation in an experimental porcine model.

BACKGROUND: The aim of the study was to determine how tidal volumes may affect the lung and haemodynamics during mechanical ventilation. MATERIALS AND METHODS: With the approval of the Ethics Committee, the study included a total of 24 healthy piglets, average weight 30 kg (range 28-33 kg). The animals were ventilated for 90 minutes under general anaesthesia with two different tidal volume strategies and allocated into three groups. Group A, animals were healthy controls, Group B, animals comprised 8 piglets with an abdominal aortic aneurysm and ventilated with a low tidal volume strategy (VT(exp) 7 ml/kg). Group C comprised 8 animals seven days after kidney transplantation, ventilated with a high tidal volume strategy (VT(exp) 12 ml/kg). Changes in lung mechanics and hemodynamics were assessed at 30th and 90th minutes. Lung tissue samples were examined histologically. RESULTS: Protective ventilation in Group A and B did not confer any haemodynamic and lung mechanic differences. Significant differences were only found in Group C at 90 minutes for increased preload of both heart ventricles (CVP; t-test 4.07, p<0.01 and PAoP; t-test 8.43, p<0.01), pulmonary vascular resistance (t-test 3.11, p<0.05), and decreased expiratory tidal volume (t-test 6.07, p<0.01), dynamic lung compliance (t-test 3.83, p<0.01) and cardiac output (t-test 2.07, p<0.01). Diffuse alveolar damage was detected histologically. CONCLUSION: Mechanical ventilation at high tidal volumes reaching 12 ml/kg caused functional changes in the lungs, diffuse alveolar damage and reduction of cardiac output within 90 minutes.

[Abdominal aortic aneurysms--long-term treatment results]. / Aneuryzma abdominální aorty--dlouhodobé výsledky lécby.

OBJECTIVE: To evaluate the single center experience in the treatment of patients with AAA. METHODS: 586 patients undergoing open resection (OR) and EVAR (2000-2009). The average age was 72.2 +/- 7.7 years. AAA diameter was 8.3 cm (range 5.0-13.1 cm). 451 (76.9%) patients had asymptomatic AAA, 135 (23.1%) RAAA. 448 patients (76.5%) suffered from various co-morbidities. 430 (73.4 %) OR, 156 (26.6%) EVAR and 52 (8.9%) one staged procedure (for concomitant diseases) was performed. RESULTS: 30 days mortality rate of elective OR and EVAR was 6.2, resp. 2.9% (n.s.) versus 36.6% of RAAA (p < 0.0001). 30 days mortality rate of one staged and single procedure was 19.5, resp. 3.6% (p < 0.0001). 30 days morbidity rate was in the whole group 52.1% (80.7% in RAAA x 43.4% in asymptomatic AAA - p < 0.0001), in one-stage procedures 60.8% x 51.1% in single procedures - n.s., 45.1% in OR x 39.0% in EVAR - n.s. Redo procedures were significantly higher in EVAR x OR in the long-term period after primary procedure. 1-, 3-, 5-, and 8 years survival of patients with asymptomatic AAA and RAAA was 91.6, 85.9, 81.1 and 73.6%, resp. 54.9, 48.9, 45.9 and 43.5 years (p < 0.0001). 1-, 3-, and 5 years patients survival with single versus one staged procedures was 85.5, 80.5 and 71.0% versus 71.1, 68.0 and 74.6% (n.s.). 1-, 3-, and 5- years patients survival after OR or EVAR was 91.2, 87.1 and 80.6%, resp. 90.7, 79.9 and 74.6 % (n.s.). The significant influence on patients long-term survival had RAAA, age of patients, postoperative complications and one stage procedures. CONCLUSION: High percentage of polymorbidity was the cause of the significant 30 days postoperative mortality of patients after OR. EVAR and OR have similar long-term results. One staged procedures should be used very carefully in selected patients due to the higher mortality rate and worse long-term patients survival.

[Mucinous adenocarcinoma of the appendix--case report]. / Mucinózni adenokarcinom apendixu--kazuistika.

The authors are describing a case of a patient with the diagnosis of the appendicular cancer. The 66-year-old patient underwent appendectomy because of signs of acute appendicitis, and than in the next step right-sided hemicolectomy because of histological finding of the mucinous adenocarcinoma of the appendix. Mucinous adenocarcinoma is the most common type of appendicular cancer, none the less this diagnosis is very rare.

[Procedures on internal carotid performed under locoregional anesthesia in the Plzen Surgical Clinic, over a seven-year period. A discussion on AHA and ESVS guidelines]. / Operace na vnitrrních karotidách v lokoregionální anestezii na chirurgické klinice v Plzni za uplynulých 7 let. Diskuse nad AHA a ESVS guidelines.

During a seven-year period (2002-2008), 830 patients underwent internal carotid surgery in the Plzen Surgical Clinic. The mean age of the patients was 68 y.o.a. (range 48-86 years). A total of 916 internal carotid procedures were performed, the male/female ratio was 667/249. 639 procedures were performed for asymptomatic and 277 for symptomatic conditions. 677 patients suffered from unilateral carotid disorders and 153 subjects from bilateral carotid disorders. All the procedures were performed under locoregional anesthesia. The 30-day mortality rate was 1% (9 subjects) of all the procedures.

Ischemia-reperfusion injury in kidney transplantation from non-heart-beating donor--do antioxidants or antiinflammatory drugs play any role?

BACKGROUND: Ischemia reperfusion injury (IRI) is a serious problem of transplanted kidneys from a non-heart-beating donor (NHBD). IRI is probably the main cause of primary disfunction or delayed graft function. The aim of this study was to demonstrate the reduction of IRI by intravenous application of antioxidants or immunosuppressives to the recipient before the kidney transplantation in an experimental model. METHOD: Piglets weighing between 20-25 kg were used (n=45) for the experiment. Intravenous application of multivitamins (GI) and a combination of immunosuppressives (GII) was tested one hour before the kidney transplantation from the NHBD. In control group (GIII) simple NHBD modelling was used. Plasma levels of malondiadehyde (MDA) and reduced glutathione (GSH) were assessed at intervals of 0, 20, 60 and 120 minutes after the kidney transplantation. Concentrations of both MDA and GSH were also assessed in the transplanted kidney before and 120 minutes after transplantation. RESULTS: A permanent increase in MDA plasma concentrations occurred in GIII. In GI and GII, after a transient increase in MDA plasma levels within the first 20 minutes after reperfusion, it decreased permanently (p<0.05, p<0.01). MDA plasma levels were not significantly different between GI and GII groups, but both groups differed from GIII (p<0.001). GSH plasma levels and tissue concentrations of MDA and GSH were not statistically significant in any group in the course of the experiment. CONCLUSION: Intravenous application of multivitamins or immunosuppressives before kidney transplantation could have a significant influence on the immediate function of transplanted kidneys from a NHBD (Tab. 3, Fig. 1, Ref. 13). Full Text (Free, PDF) www.bmj.sk.

[Ischemia-reperfusion injury in kidney transplantation from non-heart beating donor--do antioxidants or antiinflammatory drugs play any role?]. / Ischemicko-reperfuzní poskození ledvin transplantovaných z nebijícího dárce (NHBD)--mají antioxidanty nebo protizánetlivé léky význam v jeho prevenci?

BACKGROUND: Ischemia reperfusion injury (IRI) represents a serious problem of transplanted kidneys from a non-heart-beating donor (NHBD). It is probably the main cause of primary a function or delayed graft function. The aim of the experimental study was to demonstrate on an experimental model the possibilities of reduction of IRI by intravenous application of antioxidants or immunosuppressives to the recipient before the kidney transplantation. METHOD: Piglets weighing between 20-25 kg were used (N = 45) for the experiment. Intravenous application of multivitamins (GI) and a combination of immunosuppressives (GII) was tested one hour before the kidney transplantation from the NHBD. As a control a group (GIII) with simple NHBD modelling was used. At intervals of 0, 20, 60 and 120 minutes after the kidney transplantation, plasma levels of malondiadehyde (MDA) and reduced glutathione (GSH) were assessed. Before and 120 minutes after transplantation tissue concentrations of both factors were assessed in the transplanted kidney. RESULTS: A permanent increase in MDA plasma concentrations occurred in GIII. In GI and GII, after a temporary increase of MDA plasma levels in the first 20 minutes after reperfusion, there was their permanent decrease then. (p < 0.05, resp. p < 0.01). The differences in the MDA plasma levels of GI and GII groups did not reach statistical significance. The both groups differed from GIII (p < 0.001). GSH plasma levels and also tissue concentrations of MDA and GSH were not statistically significant in any group in the course of the experiment. CONCLUSION: Intravenous application of multivitamins or immunosuppressives before kidney transplantation could have a significant influence on the immediate function of transplanted kidneys from a NHBD.

[Management of unstable pelvic fracture in the acute phase (pelvic damage control surgery)]. / Osetrení nestabilní zlomeniny pánve v akutní fázi (Pelvic Damage Control Surgery).

Pelvic fractures are serious injuries. For the diagnosis and treatment of unstable pelvic ring fracture in a haemodynamically unstable patient, it is necessary to use standard procedures with the objective to stabilise both blood circulation and the pelvic ring. According to the state of the patient, the choice is between life-saving surgery, damage control surgery and procedures of early or delayed stabilisation of the pelvic ring. The survival of injured patients as well as their further health condition will depend on the method of treatment used in the first hours after injury.

Hybrid procedures in the treatment of pseudoaneurysms of the aortic arch--case report.

Classical surgical therapy of dilatation disorders of the aortic arch require extracorporeal circulation, selective brain perfusion and/or deep hypothermia and it is still associated with very high mortality and morbidity. Endovascular therapy has until recently indicated only been in cases when the disease did not affect the area of the origins of the main branches within the aortic arch. We are presenting a case report of a 68 year female patient with a vascular anomaly (arteria lusoria) and 2 pseudoaneurysms of the aortic arch between the origins of arteria carotis communis on the right and arteria carotis communis on the left, respectively between a. carotis communis on the left and arteria subclavia on the left, when we took advantage of a hybrid procedure in the therapy. The patient was treated by creating a new branching of the aortal arch using a prosthesis from the ascendant aorta and subsequently by an introduction of 2 stent-grafts to the aortic arch using femoral arteries.

[Management of the lienal artery aneurysms in the Plzen Surgical Clinic during 2002-2007]. / Resení aneuryzmat lienálni tepny na Chirurgické klinice v Plzni v letech 2002-2007.

The authors present their experience with the management of the lienal artery aneurysms. Individual types of aneurysms are presented according to their pathogenesis. Furthermore, the diagnostic options, indication criteria and treatment options are discussed.

Adverse effects of the high tidal volume during mechanical ventilation of normal lung in pigs.

INTRODUCTION: The "open lung concept" theory of mechanical ventilation is correct, but an unsuitable setting of the machine is not appropriate in children. TYPE OF STUDY: This experimental study is a comparative, closed, randomized, double-blind study. The aim of the study was to verify the hypothesis that even a short-term high tidal volume during the course of mechanical ventilation damages the lung parenchyma as well as extra-pulmonary organs. MATERIAL AND METHODS: The inappropriate strategy of mechanical lung ventilation was simulated on an animal model. The study was performed on 30 healthy white domestic piglets (25 kg). Using a random selection, the piglets with healthy lungs were ventilated for 120 minutes under general anaesthesia with two different strategies of mechanical ventilation, i.e. 15 animals achieving alveolar hyperinflation with a high tidal volume (14 ml.kg(-1)), and 15 animals according to the "lung protective strategy" principle. Lung tissue samples were examined morphologically using the blind test method, and the proinflammatory cytokines levels were assessed in the piglets' serum. RESULTS: The study demonstrated that a high tidal volume during mechanical lung ventilation with permanent positive pressure after 120 minutes induced very important morphological and functional lung changes that unfavourably influenced blood circulation, reduced cardiac output and induced a systemic inflammatory reaction (Fig. 9, Ref. 11).

Internal carotid artery surgery in regional anesthesia at the Clinic of Surgery in Pilsen during the past 5 years.

A low percentage of perioperative complications and excellent long-term outcome following carotid artery surgery in Vascular Centers demonstrate the priority of surgical solutions in patients with significant findings on carotid arteries, in the prevention and treatment of ischemic cerebrovascular accidents. The group of patients from the Clinic of Surgery in Pilsen demonstrates the benefits of regional anesthesia during internal carotid artery surgery, both in terms of the patients' health and the financial costs incurred by the hospital.

[The ruputured abdominal aortic aneurysm--a multifactorial study]. / Das rupturierte Bauchaortenaneurysma--eine multifaktorielle Studie.

AIM OF THE STUDY: We examined the outcome of patients with ruptured abdominal aortic aneurysm and analysed factors that were responsible for the mortality. PATIENTS AND METHODS: From January 1 (st), 1999 to March 1 (st), 2005 82 patients with ruptured abdominal aortic aneurysm were registered in the University Hospital of Pilsen. 61 men, 21 women entered the hospital, the average age of the patients ranged to 73.5+/-6.8 years. The average time interval between first symptoms and admission to the hospital ranged to 23.9 hours. In 74 patients (90,3%) a reconstruction of the vascular system was performed, in 8 patients the reconstruction was no more possible, these patients died in the operating theatre. RESULTS: The peri- and postoperative mortality (30-day-mortality) ranged to 37.8% (31 of 82 patients). The patients were on average for 2.3+/-4 days artificially ventilated postoperatively, the mean time of hospital stay ranged to 14.5+/-16,7 days. Respiratory failure, multiple organ failure, the necessity of cardiocirculatory resuscitation, patient age and ischemic heart disease, and the hemoglobin value on admission correlated significantly with the mortality. CONCLUSION: The present study demonstrates that the severe situation of ruptured abdominal aortic aneurysm is not without a chance, many patients can be successfully managed. The success of treatment depends partly on factors which cannot be influenced by the surgeon, but other factors (for example hemoperitoneum und decreasing hemoglobin level) can be managed by quick diagnostics and expensive postoperative intensive care.

Does the administration of antioxidants as scavengers of reactive oxygen species in kidney transplantation really have sense?

BACKGROUND: The aim of the study was to evaluate the degree of ischemia reperfusion syndrome (IRS) in serious ischemic insult of a kidney transplant and to try to mitigate the production of reactive oxygen substances (ROS) and inflammatory response. METHODS: The study was performed on 14 white pigs (20 kg). The pigs were divided in couples using a negative cross-matching and the couples were divided into the two groups. Each animal from the compatible couple was a donor/recipient of a kidney to/from the counterpart. Group II (TxII) received the intravenous antioxidants. Group I (TxI) was a control group. L-ascorbic acid 125 mg, selenium 4.4 mg, tocoferol 50 mg and N-acetyl-cysteine 200 mg were used as the antioxidants. They were applied intravenously to the TxII animals for 20 minutes before reperfusion of a kidney transplant. A serious ischemic insult was created by the left kidney hilum's cross-clamping for 30 min before donation. After the kidneys' removal, the left ones were flushed with Histidine Tryptophan Ketoglutarate (HTK) preservation solution and transplanted after the 1.5 hour (in the meantime stored in melted ice). Venous blood samples were taken for the assessment of malondialdehyde (MDA), reduced glutathione (GSH), glutathioneperoxidase (GSHPx), antioxidative capacity of plasma (AOC), interleukin 6 (IL-6), and tumor-necrosis factor alfa (TNFalfa) prior to the nefrectomy, before application of ROS scavengers (TxII), and during the 120-minute period after the transplantation (TxL+TxII). RESULTS: There wasn't a significant difference neither in production of MDA, nor in the levels of GSH, GSHPx, AOC, IL6 and TNFalfa between the TxI and TxII groups. CONCLUSIONS: Based on our results, we cannot conclude that the intravenous application of ROS scavengers in given combination and amount, administered to the recipient in the period just before transplantation, is a useful protective mechanism against kidney damage during IRS (Fig. 3, Ref. 17). Full Text (Free, PDF) www.bmj.sk.

[Giant bilateral adrenal myelolipoma associated with congenital adrenal hyperplasia]. / Ein bilaterales Riesenmyelolipom der Nebennieren in Kombination mit kongenitaler adrenaler Hyperplasie.

BACKGROUND: Myelolipoma is a rare benign tumor formed by mature fat tissue with strata of haematopoiesis. It is mainly asymptomatic, only large myelolipomas manifest themselves by abdominal discomfort, bleeding or by symptoms of oppressing adjacent organs. It is usually localized in the region of the adrenal gland. Myelolipomas are mostly clinically inert, only a small number of them are associated with Cushing's type of endocrine disorders, Conn's syndrome, Addison's disease, etc. PATIENT AND METHODS: The authors present a rare case of a giant bilateral myelolipoma emerging out of the adrenal gland cortex in a congenital adrenal hyperplasia, with steroid 21-hydroxylase deficiency, in a woman with pronounced virilism. The principal diagnostic methods include sonography and computer tomography. The therapy available is either a surgical extirpation in the case of large or growing myelolipomas or observation in the case of small ones (< 5 cm). RESULTS: The condition was resolved by bilateral adrenalectomy with extirpation of both myelolipomas and subsequent hormonal substitution treatment during which there was a gradual regression of virilising symptoms. CONCLUSIONS: The coincidence of myelolipoma and congenital disorder with subsequent overproduction of the adrenocorticotropin hormone and androgens, might be explained by the incipient of myelolipoma through chronic hormonal stimulation of the adrenal gland cortex. However, the etiopathogenesis of myelolipoma is still unclear.

[An inflammatory aneurysm of the abdominal aorta]. / Zánetlivé aneuryzma brisní aorty.

Inflammatory aneurysm of the abdominal aorta is a rare disorder, affecting approximately 3-10% of the population with a diagnosis of the abdominal aortic aneurysm. The principal etiological agents of the disorder include bacterial microorganisms, primarily Salmonella, Staphylococcus aureus, and Escherichia coli. However, in many cases the etiology od the disorder remains unclear and, likely, autoimmune and genetic dispositions may play a certain role, as well. The principal diagnostic procedures include ultrasound, CT and MRI examinations. The principal therapeutic procedures include open resection of the inflammatory aneurysm with complete removal of the infectious tissue and its replacement by a prosthesis or a vascular allograft "in situ" or through an extraantomical reconstructive procedure. New procedures also include endovascular therapy which is technically much simpler, less demanding for a patient, however, it may leave a potential infectious focus in the organism with a risk of further septic complications to follow. Therefore, the authors recommend a strictly individual treatment strategy in each patient with this serious disorder. In case of positive cultivation bacteriological findings, extended (a minimum of 6 weeks) antibiotic therapy and regular, long-term patient follow-up with regular visits, are essential.