Pancreatic head resections in the setting of celiac axis stenosis: Case report and review of literature.

INTRODUCTION: Ischemic complications are a notable cause of morbidity in patients after pancreatic head resections. Stenosis of celiac axis in patients undergoing pancreatoduodenectomy requires further perioperative attention. CASE REPORT: We present a patient with pancreatic head malignancy scheduled for Whipple procedure in the setting of hemodynamically significant celiac axis stenosis. Despite release of the artery from compression by median arcuate ligament, elevation of liver function tests on the first postoperative day was noted. Endovascular stenting was performed on the same day with significant radiological improvement and subsequent normalization of laboratory values. The patient had no further postoperative complications. CONCLUSION: Fast recognition of ischemic complications after pancreatic head resection is crucial. Even postoperatively, endovascular intervention might be a feasible treatment modality of celiac axis stenosis in selected patients who undergo pancreatoduodenectomy.

Neuromodulation in the treatment of postoperative epidural fibrosis: comparison of the extent of epidural fibrosis and the effect of stimulation.

The goal was to prove that when a cohort of patients is chosen precisely, dorsal column stimulation provides significant improvement to quality of life. We studied a cohort of 50 patients with the history of failed back surgery syndrome coupled with epidural fibrosis (EF). A percutaneous implantation technique was used in each of the 50 patients. The study group was composed of 20 women and 28 men aged 26-67 years (mean age 49). A prospective observational questionnaire-based study was used. According to the methods, Ross's classification was adjusted to four degrees of scar size for our study objective. Despite this adjustment, it was not possible to statistically evaluate our research, due to very similar results in Groups I, III and IV. Patients without epidural fibrosis were assigned to Group 0, and patients with EF of different ranges were assigned to Group 1. The mean change in visual analogue scale DeltaVAS after our division into Group 0 was 4.82; for Group 1 it was 6.13. Evaluation of EF and DeltaVAS correlation by paired t-test shows a statistically higher effect of spinal cord stimulation (SCS) in the epidural fibrosis group, compared to group 0 without postoperative epidural fibrosis (p=0.008). The extent of epidural fibrosis is an important factor for Failed back surgery syndrome (FBSS). FBSS is the basis for the existence of neuropathic pain after lumbar spinal surgery. There is clear evidence of a correlation between patients with epidural scar formation on MR scan and the effect of dorsal column stimulation.

Vertebral artery and osseous anomalies characteristic at the craniocervical junction diagnosed by CT and 3D CT angiography in normal Czech population: analysis of 511 consecutive patients.

There are numerous indications for stabilization using instrumentation of the upper cervical spine. This area is comprised of sophisticated anatomy. There is no study describing bony and vascular anomalies of this area in the middle European population. The main aim of this study was to investigate prevalence of any vertebral artery (VA) variations and osseous anomalies in the region of the craniocervical junction in a large sample of Czech patients based on three-dimensional computed tomographic angiography (3D CTA). The VA has a variable course through C2 before it passes above its groove on the posterior arch of C1. The artery can course more medially, more posteriorly or more superiorly, thus limiting the diameter of the bony elements used as landmarks for the safe insertion of metalwork. This is known as a high-riding VA (HRVA). The VA was considered HRVA in this study if the thickness of the C2 isthmus was less than 5 mm and/or the C2 internal height was less than 2 mm and/or the width of the C2 pedicle was less than 4 mm. The prevalence of ponticulus posticus (PP) was also identified. Following the VA variations in the V3 segment of the artery were persistent first intersegmental artery (FIA), fenestration (FEN) of the VA, and the posterior inferior cerebellar artery (PICA) branch originating from the C1/2 part of VA. Records of 511 patients from our institution were analyzed. The mean age of the patients was 63.6 years. One hundred and twenty-three (24.1 %) patients were identified to have HRVA, 30 (6 %) present on both sides. The age of patient over 70 years and female sex were found to be significant risk factors for HRVA presence. The prevalence of a nearby PICA branch was 4 %, FIA was 0.4 %, and FEN was 0.2 %. The presence of PP was identified in 14.3 % of patients. The HRVA and PP are common anomalies in the Czech population, and routine preoperative high-resolution CT evaluation is mandatory to prevent the VA injury when C1-C2 instrumentation is planned. The female sex and age over 70 years were found to be the most important factors for HRVA presence. The FIA and the FEN VA were rare in our study contrary to reports published from Asia, showing as many as a 10 % the VA presence over the starting point for C1 lateral screw. On the basis of the infrequent occurrence of these anomalies, we do not recommend routine CT angiography when upper cervical spine instrumentation in the normal population is planned.

Endovascular treatment of acute basilar artery occlusion: time to treatment is crucial.

AIM: To evaluate the safety and efficacy of multimodal endovascular treatment (EVT) of acute basilar artery occlusion (BAO), including bridging therapy [intravenous thrombolysis (IVT) with subsequent EVT], to compare particular EVT techniques and identify predictors of clinical outcome. MATERIALS AND METHODS: This retrospective, multi-centre study comprised 72 acute ischaemic stroke patients (51 males; mean age 59.1 ± 13.3 years) with radiologically confirmed BAO. The following data were collected: baseline characteristics, risk factors, pre-event antithrombotic treatment, neurological deficit at time of treatment, localization of occlusion, time to therapy, recanalization rate, post-treatment imaging findings. Thirty- and 90-day outcomes were evaluated using the modified Rankin scale with a good clinical outcome defined as 0-3 points. RESULTS: Successful recanalization was achieved in 94.4% patients. Stepwise binary logistic regression analysis identified the presence of arterial hypertension (OR = 0.073 and OR = 0.067, respectively), National Institutes of Health Stroke Scale (NIHSS) at the time of treatment (OR = 0,829 and OR = 0.864, respectively), and time to treatment (OR = 0.556 and OR = 0.502, respectively) as significant independent predictors of 30- and 90-day clinical outcomes. CONCLUSION: Data from this multicentre study showed that multimodal EVT was an effective recanalization method in acute BAO. Bridging therapy shortens the time to treatment, which was identified as the only modifiable outcome predictor.

[Irreversible electroporation in the treatment of locally advanced pancreatic cancer]. / Ireverzibilní elektroporatizace v lécbe lokálne pokrocilého karcinomu pankreatu.

INTRODUCTION: Irreversible electroporation (IRE) is a quite novel method of tissue ablation. Its mechanism of action that does not use thermal energy is the most important feature of the method. Current experience with IRE in animal studies and in clinical practice are summarized in the paper. In particular, the paper is focused on using IRE in locally advanced pancreatic carcinoma. METHOD: The basic principle of IRE is that it causes micropores in the phospholipid membrane of cells. This leads to an impairment of cellular homeostasis and programmed cell death - apoptosis. Because of absence of protein denaturation this method spares tubular structures like vessels and ducts. This is the key feature that allows to use IRE in the pancreas where common thermic ablative procedures cannot be used for difficult anatomic circumstances and resulting injury of surrounding structures. PRE-CLINICAL AND CLINICAL STUDIES: The ability to spare vascular structures and ducts was confirmed in many animal studies. Subsequently, IRE was safely utilized also in human liver, pancreas, lung and kidneys. IRE in the treatment of advanced pancreatic cancer: Most experience with IRE ablation has been gathered for locally advanced pancreatic carcinoma where clinical studies published in the recent 5 years have provided encouraging results. CONCLUSION: Irreversible electroporation is a safe method used to decrease tumour mass in pancreatic cancer. Further studies are needed to determine its therapeutic efficiency.

Carotid endarterectomy and carotid artery stenting: changing paradigm during 10 years in a high-volume centre.

BACKGROUND: We analysed the results of internal carotid artery (ICA) stenosis treatment at our institution over the last 10 years according to treatment modalities (carotid endarterectomy [CEA] vs carotid artery stenting [CAS]). Furthermore, we compared our results of treatment prior to the EVA-3S study being implemented into our practice (2003-2007) and after that (2008-2012). METHOD: During the years 2003-2012, a total of 1,471 procedures were performed for ICA stenosis. CEA was done in 815 cases and CAS in 656 cases. The primary outcome was disabling stroke (mRS > 2) or myocardial infarction (MI) within 30 days after treatment. Secondary outcomes were frequency of transient ischaemic attacks (TIAs), minor strokes (stroke without impaired activities of daily living [ADL]) and any other significant complication. Comparisons of the results before and after 2008 were performed. RESULTS: Major mortality and morbidity were divided according to treatment groups; reached 1.0 % in the CEA group and 3.0 % in the CAS group, p = 0.004. Minor stroke was recorded at 1.8 % and 2.7 % in the CEA and CAS, p = 0.245. TIAs in 1.0 % (CEA) and 4.7 % (CAS), p < 0.001. Any complication in 11.9 % (CEA) and 13.3 % (CAS), p = 0.401. In the overall results (i.e. CEA and CAS together), we found in 2008-2012 a decrease of incidence of TIAs (from 30/840 to 9/631, p = 0.011) and any complications (from 120/840 to 64/631, p = 0.017). CONCLUSIONS: CEA performed in a high-volume centre is a safe procedure in properly indicated patients. In all subgroup analyses, CEA fared better than or at least of equal benefit as CAS. Since 2008, the frequency of TIAs and other complications decreased significantly. This study supports an idea of CEA being the first choice of treatment and CAS being reserved for strictly selected cases, such as re-stenosis after a previous carotid procedure, carotid dissection, ICA stenosis after radiotherapy, previous major neck surgery, contralateral cranial nerve palsy or tandem stenosis.

[Multidisciplinary cooperation in the management of serious bleedings complicating necrotizing pancreatitis--a case review]. / Multioborová spolupráce pri osetrení závazného krvácení komplikující prubeh nekrotizující pankreatitidy--kazuistika.

Acute necrotising pancreatitis is connected with a high complication rate. The most serious ones are hemorrhagic complications with bleeding from vascular structures erosions. Authors report a case of endovascular treatment of surgically untreatable lesion of portal vein. In this case stentgraft was successfully implanted to cover the erosion and stop the bleeding. Percutaneous transhepatic route was used.

[The role of CT for indicating laparotomy in blunt abdominal trauma: comparing CT results and surgical findings in a group of 101 patients. Prospective study]. / Role CT v indikaci laparotomie u tupých úrazu bricha: porovnání CT záveru a operacních nálezu v souboru 101 pacientu.

BACKGROUND: The helical contrast CT plays an important role in the management of abdominal trauma. For surgeons its reliability and utilization remain questionable. OBJECTIVE: The study aimed at correlating CT results at admission with surgical findings in patients undergoing laparotomy for blunt abdominal trauma, detecting CT sensitivity for therapeutic laparotomy and uncovering organ injury. The group of patients is from one hospital; therefore mistakes from different result interpretations or data collecting are not present. METHOD: A rentgenologist's conclusion during patient admission, late independent CT evaluation by an experienced rentgenologist and surgical finding were statistically correlated. RESULTS: 101 out of 139 patients underwent laparotomy after initial CT. Mean ISS were 27.8. CT sensitivity (SE) for indicating therapeutic laparotomy was 88.77/ 89.88%, predictive value positive result (PVPR) 92.94/94.11%, and false negativity (FN) 11.23/10.11 %. SE in liver and spleen trauma was 88.76/95.50%, PVPR 96.34/93.41%, and FN 11.24%/ 4.50%. SE in bowel and mesenteric injury was 27.27/18.18 %, SE in diaphragm injury was 33.33 %. CONCLUSION: the study presented high SE of CT forecasting therapeutic laparotomy for blunt abdominal trauma. The high SE of CT in liver and spleen injuries is useful in indicating conservative therapy. The CT accuracy was not confirmed in bowel. mesenteric or diaphragm injury. It strongly recommend patient observation even with negative CT.