From adjustable gastric banding to Roux-en-Y gastric bypass - case report.

INTRODUCTION: Adjustable gastric banding (AGB) used to be a popular bariatric procedure. However, it fails in more than half of those operated on in the long term, becomes ineffective and must be removed. Therefore, the use of AGB has been in decline globally. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are the most used bariatric revision surgeries when AGB is removed. CASE REPORT: We present the case of a woman after AGB removal and conversion to SG who developed a stenosis of the sleeve. Therefore, a decision was made to convert to RYGB with a good effect. CONCLUSION: Revisional procedures are more technically challenging than primary procedures and have higher complication rates. The most performed revisional operations include SG and RYGB. Stenosis of the sleeve can occur after SG, with a negative impact on the patient's nutritional status and quality of life. This can be managed by endoscopic dilatation, and where this solution proves ineffective, RYGB can be indicated.

Randomized experimental study of two novel techniques for transanal repair of dehiscent low rectal anastomosis.

BACKGROUND: Anastomotic leak after low anterior rectal resection is a dreadful complication. Early diagnosis, prompt management of sepsis followed by closure of anastomotic defect may increase chances of anastomotic salvage. In this randomized experimental study, we evaluated two different methods of trans-anal anastomotic repair. METHODS: A model of anastomotic leak was created in 42 male pigs. Laparoscopic low anterior resection was performed with anastomosis created using a circular stapler with half of the staples removed. Two days later, animals were randomized into a TAMIS (trans-anal minimally invasive surgery) repair, endoscopic suture (ENDO) or control group with no treatment (CONTROL). Signs of intraabdominal infection (IAI), macroscopic anastomotic healing and burst tests were evaluated to assess closure quality after animals were sacrificed on the ninth postoperative day. RESULTS: Closure was technically feasible in all 28 animals. Two animals had to be euthanized due to progressive sepsis at four and five days after endoscopic closure. Healed anastomosis with no visible defect was observed in 10/14 and 11/14 animals in TAMIS and ENDO groups, respectively, versus 2/14 in CONTROL (p < 0.05). Overall IAI rate was significantly lower in TAMIS (4/14; p = 0.006) and ENDO (5/14; p = 0.018) compared to CONTROL (12/14). Burst tests confirmed sealed closure in healed anastomosis with a median failure pressure of 190 (110-300) mmHg in TAMIS and 200 (100-300) mmHg in ENDO group (p = 0.644). CONCLUSION: In this randomized experimental study, we found that both evaluated techniques are effective in early repair of dehiscent colorectal anastomosis with a high healing rate.

Robotic-assisted surgery for rectal cancer results of a non-randomized study.

INTRODUCTION: The Czech Republic belongs to countries in which colorectal cancer significantly contributes to the overall oncological burden. Radical removal of tumor-affected tissues plays a key role in the multimodal therapy of rectal cancer. In the first decade of the third millennium the mini-invasive approach in rectal cancer surgery gradually expanded to include robotic-assisted surgeries. The aim of this paper is to present the results of a non-randomized study with prospectively collected data from robotically assisted rectal cancer surgeries. METHODS: 204 patients with rectal cancer (.

Ten years of laparoscopic sleeve gastrectomy at the Military University Hospital in Prague.

INTRODUCTION: The aim of this study was to evaluate a group of bariatric patients operated at the Military University Hospital in Prague during the last 10 years (20112020), in whom laparoscopic sleeve gastrectomy was performed. METHODS: Retrospective survey of the internal operation database. The search used the following combination of keywords: “sleeve“, “LSG“ and the diagnosis “E6*“. A total of 279 operated patients were enrolled. We evaluated the sex, age at the time of surgery, complications, need for drainage, weight, BMI, presence of type two diabetes mellitus and any effect of the surgery on its improvement, length of hospital stay, follow-up duration and % excess weight loss. RESULTS: A total of 279 patients, including 195 women and 84 men, underwent laparoscopic sleeve gastrectomy in the period of 10 years. The mean age was 44.46 years. The average operating time was 111 minutes. The mean BMI of the patients before surgery was 42.24 and the weight was 123.4 kg. The mean BMI one year after the surgery corresponded to a decrease of approximately 10 and the mean weight of 93.8 kg. Rather severe acute postoperative complications occurred in 2.87% patients. An improvement or complete cure of type two diabetes mellitus was observed in 57.8% patients. CONCLUSION: Currently, laparoscopic sleeve gastrectomy is the most common bariatric operation at the Military University Hospital in Prague. This study demonstrates a satisfactory effect of bariatric surgery in terms of long-term significant weight loss and an improvement or even cure of associated diseases such as type two diabetes mellitus, arterial hypertension and others.

Multidisciplinary team in colorectal cancer treatment - analysis of our patients in 2017.

INTRODUCTION: Multidisciplinary teams (MDTs) have become a standard part of treating oncological patients. Based on the available data, they have lead to significantly higher survival rates in the treatment of colorectal cancer (CRC). Reported negatives include potentially longer times between diagnoses and the start of appropriate treatment, and the lack of quality controls over the MTDs actions. This report aims to assess the benefits of MDTs using our own data set for 2017. METHODS: Year 2010 saw the institution of an MDT at the Central Military University Hospital in Prague, with the obligation to refer CRC patients to the MDT before the start of treatment. Having standardized the registration, we have implemented a simple procedure to track the quality of our MDTs involvement and its patient benefits: number of patients, number of referrals with proposed diagnostic and therapeutic procedure, frequency and reason of changes to original strategies, and the frequency of variations from the MDTs conclusions. RESULTS: 405 CRC patients were referred to the MDT in 2017; we have found 499 referrals in this group. The data set was formed predominantly by men (61%), with the mean age of 63 (21-91), and the median age of 64.5 years. Surgical treatment was the most commonly proposed procedure (59%), followed by systemic treatment or, as the case may be, radiotherapy. In 24% of the cases, the conclusion did not match the originally proposed procedure. The decision not to go through with the proposed surgical treatment was the most common change (66 %). We have found a difference in the quality of referral in patients examined specifically by the referring doctor, as opposed to patients whose medical records have just been sent in. We have found therapeutic variation in the MTDs conclusions in less than 5% of patients. CONCLUSION: Having analyzed our data for CRC patients referred to the MDT in 2017, we have found out that in 24% of the patients, the MDT referral leads to a change in the originally proposed diagnostic and therapeutic procedure. Consensus among the MDTs members on the CRC patients treatment guarantees an optimum procedure. What is fundamental is that the referring doctor knows the patient. Constant tracking of the MDTs outputs forms a condition for sustaining the quality of its work and a base for assessing its benefits to the patients.

SADIS Single anastomosis duodeno-ileal bypass with sleeve gastrectomy as a second step after sleeve gastrectomy.

INTRODUCTION: Sleeve gastrectomy (SG) is the most popular bariatric method at present. In case of unsatisfactory effect of the SG, i.e. in case of insufficient weight loss, improving or threatening diabetes or metabolic syndrome or regain of weight, bariatry offers a second possible step. One of the possible methods is biliopancreatic diversion type SADIS (BPD/SADIS). METHOD: Between the years 2009 and 2017, 327 morbidly obese patients underwent laparoscopic sleeve gastrectomy at our surgical department. Between mid-2011 to the end of 2017, 37 (11.3 %) patients after SG with unsatisfactory effect on diabetes or on metabolic syndrome or in case of weight regain in 23.7 (1548) months after the SG underwent the second step - BPD/SADIS. The weight loss, change of the BMI and level of the HbA1c were evaluated during two years after procedure. RESULTS: 31 (83.7 %) patients were evaluated, the others were rejected due to an incomplete follow-up (FU) or a short time elapsed since the procedure. Two years after the SADIS, the average %EBMIL was 47.1 (41.552.7) %, average %EWL was 73.9 (65.183.7) %, average final BMI was 29.4 (24.6-38.2) kg/m2, which means average decrease of the BMI was 9.3 (2.914.1) kg/m2. Average level of the HbA1c was 37.9 (2842) mmol/mol, type 2 diabetes was cured in 20 (64.5 %) cases. CONCLUSION: Biliopancreatic diversion type SADIS offers a satisfactory weight loss effect as well as an improvement of the metabolic syndrome in morbidly obese patients after SG with unsatisfactory result. In comparison with the classic BPD/DS, SADIS is a technically easier method with lesser incidence of complications along with acceptable rate of malnutrition.

Postoperative monitoring of colorectal anastomosis - experimental study.

INTRODUCTION: Inadequate blood supply is one of the major risk factors for colorectal anastomotic leak. Early postoperative detection of local ischemic changes can predict complicated healing and lead to better outcome. Microdialysis (MD) offers real-time evaluation of adequate bowel perfusion through monitoring of tissue metabolism. The aim of this study was to assess the feasibility of MD for early detection of ischemic changes in colorectal anastomosis. METHOD: Five pigs with end-to-end colorectal anastomosis were included. MD catheter was placed intramurally 5mm from anastomotic edge. Occlusive ischemia was induced after 3 measurements and followed by another 3 hours of monitoring. Tissue levels of different metabolites were measured every 60 minutes before and after ischemia induction. Mann-Whitney test was used to compare pre and post ischemic changes. RESULTS: The monitoring of colorectal anastomosis using MD was technically feasible and associated with no complications. Significant changes caused by local ischemia were observed in decreased levels of glucose or pyruvate and increased levels of lactate and glycerol. All metabolic changes were detectable already in first samples 60 minutes after ischemia induction. CONCLUSION: Postoperative ischemic changes in colorectal anastomosis can be detected by means of microdialysis.Key words: colorectal anastomosis anastomotic leak microdialysis.

[Rare situations in treatment of polytraumatised patients - case reports]. / Raritní situace pri osetrování polytraumatizovaných pacientu - kazuistická sdelení.

Polytrauma is one of the leading causes of mortality in people at productive age. Prompt activation of the rescue system is most important in the treatment. In cases of severe injuries, primary transport to a specialized hospital - trauma center is crucial. Our report is focused on two cases of polytraumatized patients whose treatment was associated with relatively rare situations. One of the patients suffered a pancreatic injury that required pancreaticoduodenectomy. The other patient had a liver injury, which was treated with right lobectomy with a rare complication. The necessity of a multidisciplinary approach to the management of severely injured patients is also emphasized in our report.

[Superficial thrombophlebitis of the lower limbs from the surgeons point of view]. / Povrchní tromboflebitida dolních koncetin z hlediska chirurga.

INTRODUCTION: A new consensus on the management of superficial thrombophlebitis (STP) from the Central European Vascular Forum (CEVF) for the diagnosis and treatment of STP recommends anticoagulation treatment either with Fondaparinux 2.5 mg for at least 45 days or with low molecular weight heparin (LMWH) for 4 weeks in patients with thrombosis of GSV/SSV proven by duplex ultrasonography (DUS) and with thrombus length exceeding 5 cm. The dosage and duration of anticoagulation treatment depend on the associated diseases and other risk factors for TVE. Many options for doses an duration of treatment are referred to in the literature. Emergency surgery is not recommended. The aim of this study is to demonstrate the role of DUS examination in acute ascending thrombophlebitis (ASTP) of the GSV, and demonstrate the efficiency of surgical treatment - crossectomy and phlebectomy of thrombosed GSV/SSV. MATERIAL AND METHODS: The authors present their clinical experience with DUS diagnosis and surgical treatment of acute ascending thrombophlebitis in GSV/SSV on 66 patients with 68 operations. In two of them bilateral crossectomy was performed. In the diagnosis it is necessary to perform DUS examination after clinical diagnosis of acute thrombophlebitis. It should be done bilaterally, not only in the affected limb. DUS confirms the measure, progression and eventually ascension of the thrombosis on the trunk of the GSV/SSV and perforating veins. Progress of the thrombotic process from the thigh to the SF/SP junction is usually a matter of a few hours. Daily ultrasound assessment should therefore be performed in acute thrombophlebitis, even during anticoagulation therapy. Thrombus near the SF/SP junction is a reason for urgent surgery - crossectomy and phlebectomy. RESULTS: 66 patients were operated on under general anaesthesia without any complications. A large hematoma in the subinguinal region developed in one patient after surgery. A 50-year-old patient returned with colliquation of the residual varicose vein on the lower leg. Outpatient incision and evacuation had to be performed 3 weeks after surgery. Anticoagulation therapy with warfarin was started in two patients. The other patients were discharged 4 to 6 days following surgery without any problems. Post-operative anti-coagulation in other patients was not longer than 2 weeks. CONCLUSION: Urgent crossectomy and phlebectomy represent a reliable method of treatment in the management of acute ascending thrombophlebitis of GSV/SSV, guaranteeing prophylaxis of complications, especially in pregnant women with PT in the later phase of pregnancy. Surgical treatment destroys the damaged vein with crossectomy as a potential cause of deep vein thrombosis (DVT), pulmonary embolism (PE) and STP recurrence. After anticoagulation therapy the affected vein remains in situ. It can potentially cause the recurrence of STP, and DVT and PE may develop.