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.

Transversus abdominis release in the management of a large, chronic defect of the abdominal wall.

INTRODUCTION: Chronic defects and hernias of the abdominal wall are a common complication of repeated surgical procedures and/or their accompanying complications. Reconstruction of the abdominal wall is difficult in these defects/hernias and debates of an ideal method of treatment have not reached a conclusion. Primary suture is usually impossible. Onlay, inlay, sublay, underlay and IPOM plasty procedures have their limits and often lead to unsatisfactory results. CST (component separation technique) technique is a new therapeutic approach enabling a solution of large defects and hernias of the abdominal wall with very good short-term results. TAR (transversus abdominis release) is a posterior approach in CST. It releases transversus abdominis muscle (MTA) to mobilize the posterior sheath of the rectus abdominis muscle (MRA). TAR preserves MRA and its neurovascular bundle, creates a large space for mesh insertion and allows complex reconstruction of the abdominal wall. CASE REPORT: A 55-year-old patient underwent surgery for perforated diverticulitis of colon sigmoideum with diffuse peritonitis. Hartmans operation was performed. The patient was reoperated for colostomy necrosis and fascia dehiscence on the 7th postoperative day. After healing 6 months later, colostomy occlusion was indicated. The operation itself - colorectal anastomosis using an end-to-end circular stapler - was without complications. However, complications occurred in the postoperative period including an intra-abdominal abscess in the lesser pelvis and subsequent destructive phlegmona and necrosis of the abdominal wall, resulting in a non-healing extensive chronic abdominal wall defect. After the failure of conservative treatment, the chronic defect was excised and the abdominal wall was reconstructed using the TAR method. CONCLUSION: TAR is an acceptable method in the treatment of large defects and hernias of the abdominal wall, associated with low perioperative morbidity and low recurrence rates.

An alternative method of surgical treatment in refractory GERD following laparoscopic sleeve gastrectomy.

Obesity has become a global problem with increasing prevalence. Undoubtedly, bariatric surgery is the most effective way to treat morbid obesity. Laparoscopic sleeve gastrectomy (LSG) is currently the most commonly performed bariatric procedure worldwide. The prevalence of gastroesopha-geal reflux disease (GERD) is also increasing, a close association with increasing prevalence of obesity being regarded as the main cause of this trend. The relationship between LSG and GERD is still unclear, at least controversial. If GERD occurs in the postoperative period, the first therapeutic intervention is initiation of proton pump inhibitors (PPI) treatment, which is effective in the vast majority of patients. In patients resistant to this treatment, conversion to laparoscopic Roux en Y gastric bypass (LRYGB) is usually necessary. The authors present the case report of a patient who developed GERD in the longer postoperative period and conversion to LRYGB was not appropriate due to previous complications and surgical procedures. Therefore, this patient was managed operatively by an alternative method - hiatoplasty with partial posterior fundoplication. The success of the treatment was confirmed clinically by disappearance of GERD symptomatology postoperatively even after PPI discontinuation. LRYGB is the method of choice for GERD after restrictive bariatric procedures. However, some patients are not suitable for conversion to LRYGB, and alternative treatment options are therefore needed.

Treatment strategies for patients with colorectal carcinomaand synchronous liver metastases.

Multimodal approach in the management of patients with colorectal carcinoma and synchronous liver metastases allows for the application of various combinations of treatment modalities (colorectal resection, liver resection, chemotherapy, radiotherapy). The primary-first approach and simultaneous resection represent traditional strategies used because the primary tumor is thought to be the main source of subsequent metastases as well as the source of symptoms associated with local tumor progression (obstruction, perforation, colorectal bleeding). Poor long-term outcomes of traditional strategies have led to the proposal of reverse strategies (the liver-first approach and up-front hepatectomy approach). The idea behind reverse strategies is to give preference to liver resection over colorectal resection (prognosis of patients with stage IV colorectal cancer is determined mainly by the curability of liver metastases). According to available literature, reverse strategies are suitable mainly for patients with asymptomatic primary tumor. Treatment strategy for each patient should be individualized depending on the patients performance status, comorbidities, and tumor stage. In this paper, the authors offer an up-to-date review of treatment strategies for patients with colorectal carcinoma and synchronous liver metastases focusing on available data of evidence-based medicine. Key words: liver first - primary first - colorectal carcinoma - liver metastases - reverse strategies.

[Breast angiosarcoma induced by radiotherapy - surgical treatment options and review of literature]. / Radiací indukovaný (postiradiacní) angiosarkom prsu - moznosti chirurgické lécby a prehled literatury.

INTRODUCTION: Radiation-induced angiosarcoma is a rare but very aggressive tumour. The highest risk of sarcoma development is in patients after breast-conserving surgery.Case 1: The 66 years old patient underwent radical mastectomy with axillary dissection because of ductal carcinoma with consequent radiotherapy, chemotherapy and hormonal therapy. After 6 years, high-grade angiosarcoma was diagnosed and resected with negative resection margins. Within subsequent 24 months, additional three radical re-excisions were performed because of repeated sarcoma recurrence. 29 months from the diagnosis of the first sarcoma, another radical re-excision was performed, this time with positive resection margins and with consequent disease progression. The patient died three years after the first angiosarcoma diagnosis.Case 2: The 68 years old patient underwent breast-conserving surgery with axillary dissection because of ductal carcinoma and radiotherapy. Breast colour changes were observed 6 years later; radical mastectomy was performed after additional 16 months due to locally advanced angiosarcoma. Given positive resection margin, radical re-excision with musculocutaneous musculus latissimus dorsi flap was done. 24 months later, a small sarcoma recurrence was detected near the upper resection margin, which was managed by radical re-excision. 52 months after radical operation, a metastasis was diagnosed by means of PET/CT in the contralateral axilla. Radical axillary dissection was performed (two metastases were found in axillary lymph nodes). According to follow-up, the patient has been free of any recurrence for 66 months from the radical surgery. CONCLUSION: Recommendations regarding the management of radiotherapy induced breast angiosarcoma are very vague due to limited evidence. Radical surgical excision with negative resection margins (potentially with complementary flap reconstruction) presents the fundamental approach to breast angiosarcoma.Key words: radiation-induced angiosarcoma - breast cancer - surgery.

[The risks of retroperitoneoscopic adrenalectomy]. / Rizika retroperitoneoskopické adrenalektomie.

INTRODUCTION: Minimally invasive adrenalectomy has become the gold standard for surgery of the suprarenal gland. Retroperitoneoscopic adrenalectomy with dorsal approach is preferred. The aim of our case report is to discuss potential complications that may arise from retroperitoneoscopic adrenalectomy, specifically an intra-operative injury of the inferior vena cava. CASE REPORT: A 47-year-old male patient was admitted to undergo elective adrenalectomy on the right side. The reason for the surgery was a hormonally active adenoma with clinical signs of Conns syndrome. Biochemistry revealed the typical signs of hyperaldosteronism. A one-year history of unsuccessful treatment for hypertension was known. Ultrasound examination showed an enlarged suprarenal gland on the right side with the diameter of 5.2 cm. A CT scan confirmed the results of the ultrasound examination. Retroperitoneoscopic adrenalectomy was performed. The inferior vena cava was intraoperatively injured. The high pressure in the retroperitoneal space prevented bleeding. The injury to the vena cava was treated using a continuous stitch without the necessity of conversion to open surgery. The patient was discharged on the third postoperative day without any other complications. CONCLUSIONS: Retroperitoneoscopic approach is regarded by many authors as the new gold standard for adrenalectomy. However, very serious complications such as an injury of the inferior vena cava may occur. It is possible to treat this injury using retroperitoneoscopy. The risk of air embolization due to elevated pressure in the retroperitoneum (20 mm Hg) and open lumen of the IVC needs to be taken seriously.Key words: adrenalectomy - retroperitoneoscopy - complication.

[Left hepatic vein injury during laparoscopic fundoplication for giant paraoesophageal hiatal hernia]. / Poranení levé hepatické vény v prubehu laparoskopické fundoplikace pro velkou paraezofageální hiátovou kýlu.

INTRODUCTION: After laparoscopic cholecystectomy, laparoscopic fundoplication has become another gold standard of minimal invasive surgery. The level of satisfaction of patients undergoing endoscopic surgery is almost 90%. Laparoscopic fundoplication, like other surgery methods, can also be burdened with grave complications, which could result in a fatal outcome even if the surgery is performed by a skilled surgeon. Even the authors themselves encounter complications despite their rich experience (more than 3,500 laparoscopic operations in the diaphragmatic hiatus area in more than 20 years). CASE REPORT: The authors report on a rare left hepatic vein injury during laparoscopic hiatoplasty and fundoplication according to Toupet for giant paraoesophageal hiatal hernia. CONCLUSION: For its low percentage of complications, laparoscopic fundoplication is considered as a safe operative method for gastroesophageal reflux disease and hiatal hernias. However, severe complications may still arise during the surgery and the surgeon should be familiar with them, be prepared for them and be able to manage such complications.Key words: gastroesophageal reflux disease hiatal hernia laparoscopic fundoplication left hepatic vein.

[Complete minimally invasive Ivor-Lewis esophageal resection]. / Kompletní miniinvazivní Ivor-Lewisova resekce jícnu.

INTRODUCTION: Minimally invasive esophagectomy is becoming a standard procedure in the treatment of esophageal cancer. We would like to present our experience with Ivor Lewis esophagectomy completed by minimally invasive technique. METHODS: The primary aim of the study was to analyse potential technical difficulties and intraoperative complications of thoracolaparoscopic Ivor Lewis esophagectomy with intrathoracic anastomosis. A secondary aim of the study was to evaluate postoperative complications according to the Clavien-Dindo classification. The inclusion criterion for the study was a history of thoracolaparoscopic esophagectomy. Multidisciplinary approach was employed in the diagnosis, surgery indications and perioperative care of all patients. RESULTS: Between January 2011 and January 2016, 19 patients underwent completely minimally invasive esophagectomy with intrathoracic anastomosis. There were 13 men and 6 women. Adenocarcinoma was confirmed by histopathological examination in all the patients. The cumulative postoperative morbidity was 68.4%. According to the Clavien-Dindo classification, we recorded grade I complications in 10.5% of the patients, grade II in 15.8%, grade III in 36.8% and grade IV in 5.3% of the patients. Anastomotic leak was the most serious complication; it was initially managed by negative pressure (vacuum) therapy followed by stent implantation. Postoperative mortality was 0%. Mean hospital stay was 12 days and mean stay at intensive care unit was 3.6 days. CONCLUSIONS: The basic oncosurgical principles of radicality need to be respected during minimally invasive procedures. However, functionality, safety, and cost effectiveness have to be preserved as well. In this paper, we present thoracolaparoscopic Ivor Lewis esophagectomy as one of feasible and accessible options of intrathoracic anastomosis. It seems to be safe with respect to technical obstacles, short-term and long-term complications.Key words: esophagectomy - intrathoracic - anastomosis - laparoscopy - thoracoscopy.

Semi-spherical Radiofrequency Bipolar Device - A New Technique for Liver Resection: Experimental In Vivo Study on the Porcine Model.

The incidence of colorectal carcinoma is still growing in the Czech Republic and also all around the world. With success of oncological treatment is also growing a number of potential patients with liver metastases, who can profit from surgical therapy. The aim of this study was to confirm on porcine models that this method by using new surgical device is effective and safe for patients who have to undergo liver resection. The primary hypothesis of the study was to evaluate whether this new device is able to consistently produce homogeneous and predictable areas of coagulation necrosis without the Pringle maneuver of vascular inflow occlusion. The secondary hypothesis of the study was to compare the standard linear radiofrequency device and a new semi-spherical bipolar device for liver ablation and resection in a hepatic porcine model. Twelve pigs were randomly divided into two groups. Each pig underwent liver resection from both liver lobes in the marginal, thinner part of liver parenchyma. The pigs in first group were operated with standard using device and in the second group we used new developed semi-spherical device. We followed blood count in 0(th), 14(th) and 30(th) day from operation. 14(th) day from resection pigs underwent diagnostic laparoscopy to evaluate of their state, and 30(th) day after operation were all pigs euthanized and subjected to histopathological examination. Histopathological evaluation of thermal changes at the resection margin showed strong thermal alteration in both groups. Statistical analysis of collected dates did not prove any significant (p < 0.05) differences between standard using device and our new surgical tool. We proved safety of new designed semi-spherical surgical. This device can offer the possibility of shortening the ablation time and operating time, which is benefit for patients undergoing the liver resection.

[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.

[Anatomic-surgical study of intercostobrachial nerve (ICBN) course in axilla during I. and II. level of axilla clearance in breast cancer and malignant melanoma]. / Anatomicko-chirurgická studie prubehu interkostobrachiálních nervu (ICBN) v axile pri exenteraci I. a II. etáze axily u karcinomu prsu a maligního melanomu.

INTRODUCTION: The aim of this paper is to offer results of anatomic study of axillary course of intercostobrachial nerve (ICBN) and the effort of its saving in primary axilla clearance (PE), secondary clearance (SE) after previous positive sentinel nodes detection (SLN) and in re-clearance (RE) after previous axilla clearance in breast cancer and malignant melanoma. The correlation between possibility of ICBN saving and anatomic variant of ICBN and type of previous surgery was observed. MATERIAL AND METHODS: A total of 113 surgeries with the effort of description and preservation of ICBN were done between September 2007 and August 2011. Patients were divided into three groups according to type of surgery: primary clearance (PE), secondary clearance (SE) and re-clearance (RE). Results have been statistically tested using licensed statistical software Statgraphics. RESULTS: ICBN was found in 107 patients (94.7%), it wasnt found in six cases. There were eight different types of ICBN branching. Two most frequent variants formed majority of cases - 87 out of 107 (81.3%). The successful preservation of intact ICBN was in 86 patients (76.1%). ICBN was interrupted or not found in 10 patients (8.8%), partial injury of ICBN branches was detected in 17 cases (15.0%). If the most frequent variant of ICBN branching was present, the nerve was not injured in 42 out of 45 cases (93.3%). Statistical testing showed that non-standard anatomical branches are associated with higher risk of perioperative injury. The risk of injury was lowest in PE (21.6%) and the highest in RE (42.9%). The difference wasnt statistically significant because of low number of re-clearance cases in our study. CONCLUSION: The anatomy of ICBN in axilla is variable. The standard variant of ICBN course is the most frequent (the trunk coming out of second intercostal space; no branches in axillary course). If other variants are present, there is significantly higher risk of perioperative injury. ICBN preservation is possible also after previous axilla clearance. Preparation is more difficult and the risk of injury is increasing with the degree of previous surgery radicality.

Radiofrequency-assisted liver resection: short-term results in a single institution.

OBJECTIVES: The main goal of the study was to evaluate the effectiveness and safety of radiofrequency-assisted liver resection. BACKGROUND: Liver resection is the "gold standard" for patients with resectable liver tumors. In the past years, the role of radiofrequency in liver surgery has been expanded from simple tumor ablation to its use in the technique of radiofrequency-assisted liver resection. METHODS: Patients with primary or secondary liver tumors, who underwent radiofrequency-assisted liver resection have been included into the prospective study. The acquired data underwent statistical analysis and were compared with the published results of liver resections. RESULTS: Between January 1, 2007 and September 30, 2009, 53 patients underwent radiofrequency-assisted liver resection. Seventy-six tumours were resected with the mean diameter of 38±19 mm. Mean peroperative blood loss was 170.8±285.4 mL and transfusions were needed postoperatively in 9.4 % cases. The mean hospital stay was 10.6±7.2 days. Postoperative complications were noted in 16.9 % patients; postoperative mortality was 1.9 %. CONCLUSION: The radiofrequency-assisted liver resection represents a safe and effective way of hepatic parenchyma transaction and to hepatobiliary surgeon it offers a new way of effective transection of liver parenchyma (Tab. 2, Ref. 23).

[Surgical treatment of complicated hepatic echinococcosis in two Bulgarian citizens at two surgical departments in the Czech Republic]. / Chirurgické resení komplikované jaterní echinokokózy u dvou bulharských obcanu na dvou pracovistích v Ceské republice.

Echinococcosis, also referred to as hydatidosis, is a parasitic infection caused by the tapeworm Echinococcus in its larval stage. It has worldwide distribution and endemic areas in Europe include especially the regions surrounding the Mediterranean Sea. In the Czech Republic, its incidence tends to be quite rare. Although it may affect any organ or tissue in the human body, the liver (60%) and lungs (20%) are the most frequently affected sites. The authors present two cases of Bulgarian patients with hepatic echinococcosis operated on the same day at two different surgical departments in the Czech Republic. Treatment is based on the surgical removal of the cysts in combination with anti-parasite treatment by benzimidazoles (Albendazol, Mebendazol). Treatment with anti-parasitic drugs needs to be started preoperatively and should continue for at least 1-2 months after surgery. The success of the treatment can be monitored by imaging methods, especially PET/CT and serology. Patients after surgical as well as conservative therapy need to be followed up on an outpatient basis due to the long-term risk of recurrence.

[Predictive factors for non-sentinel lymph nodes affection in breast carcinoma--outcomes of a Czech multicenter study of sentinel lymph nodes]. / Prediktivní faktory postizení nonsentinelových uzlin u karcinomu prsu--závery ceské multicentrické studie sentinelových uzlin.

BACKGROUND: The aim of the study was to assess positivity nonsentinel lymph nodes in patients with macro, micro and submicrometastases in sentinel lymph nodes and find predictive factors of positivity nonsentinel lymph nodes. Study was conducted at the Department of Surgery in Pardubice, Pilsen, Ostrava and Zlín. MATERIAL AND METHODS: Sentinel lymph nodes were assessed based on standards of Czech Pathological Society. Detection of sentinel lymph nodes was performed based on radionavigation or combination of radionavigation and blue dye method. RESULTS: In group N1 (macrometastases) there was found positivity of nonsentinel lymph nodes in 50% (45 from 90 patients). In group N1 Mi (micrometastases) there was found positivity of nonsentinel lymph nodes in 26.7% (16 from 60 patients). In group NO I+ (sub-micrometastases) there was found positivity of nonsentinel lymph nodes in 6.7% (1 from 15 patients). Predictive factors were size of metastasis, number of positive sentinel lymph nodes and grading. Size of tumor was not found to be a predictive factor of positivity nonsentinel lymph nodes. DISCUSSION: High positivity of nonsentinel lymph nodes in pacients with macro and micrometastases in sentinel lymph nodes advocates to perform axillary lymph nodes dissection. Due to small number of patients with submicrometastases it is not possible to assess if axillary dissection is necessary or not. Predictive factors of positivity of nonsentinel lymph nodes are size of metastasis in sentinel lymph nodes, number of positive sentinel lymph nodes and grading. Size of tumor was not found to be a predictive factor due to small tumors in the study. In spite of this it is necessary to consider it like a predictive factor of positivity nonsentinel lymph nodes. CONCLUSION: In patients with macro and micrometastases it is necessary to perform axillary dissection. In patients with submicrometastases in sentinel lymph nodes it is necessary to consider predictive factors.