[Innovated Judet Ribs Plates - Preclinical Study, First Clinical Experience]. / Inovované zeberní dlahy Judetova typu ­ preklinická studie, první klinické zkusenosti.

PURPOSE OF THE STUDY Based on the experience with using the Judet plates in stabilization of rib fractures an innovated Judet plate was constructed in cooperation with the Development Department of Medin company. During the preclinical part of the project, following the construction of the new Judet plate, a surgical technique was elaborated. Subsequently, the clinical application of rib osteosynthesis with innovated plates was commenced. MATERIAL AND METHODS In the course of the last three years the innovated Judet rib plate including the instruments were constructed by the Development Department of Medin company in cooperation with the Trauma Centre and the Department of Surgery of the University Hospital Královské Vinohrady. The goal of the innovation was the changes in technical parameters of rib plates which are compared with the new plates of other companies: 1. Adequate plate stability along the rib axis. 2. Creation of fixation clips for a stable, but not traumatized fixation of the plate around the rib. 3. Decreased robustness of the plate with sufficient stiffness. 4. Working out of a new technique of plate fixation with the use of new instruments. 5. Ensuring plate fixation with cortical locking screws. In the preclinical part of the project osteosynthesis of the broken rib was performed with a plate on a chest model for the basic types of rib fractures. Subsequently, the plate was used for rib osteosynthesis in a cadaver. The goal of the new instruments was besides temporarily maintaining the rib fracture reduction also the subsequent temporary application of plates with the assistance of fixation tongs before the final fixation of plates. In 2017, the clinical part of the project on the stabilisation of flail chest with the innovative Judet plates was launched. This type of innovative Judet plates has so far been used in 3 patients. RESULTS As to the surgical technique of ribs osteosynthesis: The profile of the plate has been adapted to the rib profile and can be further adjusted to rib curvature, also the fixation shoulders of the plates have been reshaped. The innovated plate has been complemented with a new configuration of fixation clips and the possibility to fix the plate with locking screws. The used cortical locking screws enable appropriate stabilisation of plates. They were tested on a laboratory model of ribs and on a cadaver using the new set of instruments. The plates can be easily shaped with tongs. The anchorage of fixation clips is adequately provided for also by means of tongs. The plates can be fixed to the rib without any significant compression of intercostal nerves. The essential change of the innovated Judet plate is its weight, which meets the contemporary trends in construction of rib plates designed for anatomical fixation. The first experience with the innovated plates in flail chest injury confirmed the safety of the procedure for stable osteosynthesis of rib fractures. Adequate stability of the chest wall facilitated an early withdrawal of ventilatory support. Osteosynthesis of rib fractures with innovated plates performed in the first three patient was without complications, including in the postoperative period. DISCUSSION A series of prospective studies prove the correctness of the indications of early rib osteosynthesis in flail chest. Further indications for rib osteosynthesis are postinjury chest deformity, dislocation of rib fracture fragments with a lung injury, and malunion of rib fracture. According to these studies the surgical stabilisation of the chest is a safe and efficient method resulting in pain reduction, decrease of ventilatory support time, and also in reduced morbidity. For rib osteosynthesis anatomical plates, Judet plates and intramedullary plates are used. Our innovation of the Judet plate aimed to improve the technical parameters of the plate. The innovative Judet plate means a significant improvement in technical parameters and stands comparison with the plates of others companies, which are used in the Czech Republic. This is also evidenced by preliminary clinical results. CONCLUSIONS Surgical stabilisation of the flail chest segment is considered to be he method of choice in treating selected patients, leading to the improvement of respiratory function and shortening of the ventilatory support time. The new technical parameters of the plate, including its weight, new fixation clips, locking screws and instruments are the priorities of the innovated Judet plates. The innovation of Judet plates represents an important step towards the extension of indications for surgical stabilisation of the chest. Key words:innovative Judet plates, preclinical study, osteosynthesis of rib fractures.

[Complicated intraabdominal infections in surgical patients-empiric antimicrobial therapy management]. / Komplikované nitrobrisní infekce u chirurgického nemocného - postup v empirické antimikrobní lécbe.

Any intraabdominal infection (IAI) is a complex disease that requires an assessment of a number of various aspectsimportant for determining proper therapeutic management, including an appropriate antimicrobial regimen. Current classifications of intraabdominal infections recognize various types of peritonitides (primary, secondary, tertiary); however, for clinical needs the cases are most commonly divided as non-complicated and complicated intraabdominal infections. In any intraabdominal infection, the surgical intervention includes perioperative empiric choice of antibiotics, which should take into account - in addition to the severity level of the infection - the epidemiological situation and risk factors of the presence of resistant bacteria in the patient. The article presents a current overview of the choice of antimicrobial agents indicated in individual groups of intraabdominal infections (biliary, extrabiliary) caused by community-acquired or hospital-acquired pathogens. Recent guidelines for choosing antimicrobial drugs against multiresistant bacteria provide very important information, particularly with respect to the increasing incidence of multiresistant strains as causal agents of intraabdominal infections in surgical patients. However, surgical departments need to be familiar with current sensitivity of pathogens in order to provide individualized antimicrobial therapy via empiric administration.Key words: intraabdominal infection multiresistant bacteria antimicrobial therapy.

[Damage control surgery in thoracic trauma]. / Damage control operace u poranení hrudníku.

Damage control surgery (DCS) is an integral part of management in critically injured patients. These usually involve patients with profound hemorrhagic shock with the development of acidosis, hypothermia and coagulopathy. Three stages of DCS are widely accepted: 1) Limited operation to control bleeding and contamination. 2) Continued resuscitation in intensive care unit. 3) Reoperation. Besides DCS in intraabdominal trauma, DCS techniques are currently employed also in thoracic injuries. DCS techniques in heart, lung, internal thoracic vessel and esophagus injuries are presented.Key words: damage control surgery thoracic trauma.

[Surgical Stabilisation of Flail Chest Injury: Indications, Technique and Results]. / Chirurgická stabilizace u blokové zlomeniny zeber: indikace, technika a výsledky.

PURPOSE OF THE STUDY: Multiple rib fractures with segmental chest wall instability are caused by high-energy chest trauma and are associated with significant morbidity and mortality. Flail chest injuries are mostly combined with lung injury (contusion, rupture, laceration) and subsequent pneumothorax or haemothorax. Early mechanical ventilation with internal pneumatic splinting is a conservative treatment for flail chest in patients with respiratory insufficiency. The surgical stabilisation of a flail chest is an effective method of treatment and is beneficial for selected patients. It shortens the duration of mechanical ventilation and thus reduces morbidity associated with prolonged ventilatory support. In addition, it decreases long-term pain and the inability of a flail chest to heal due to malunion, non-union or progressive collapse of the flail segment. Surgical stabilisation of a flail chest is indicated when the clinical examination shows progressive respiratory dysfunction confirmed by the results of multiple detector computer tomography (MDCT) of the thorax. MATERIAL AND METHODS: Thirty-three consecutive patients who underwent surgical stabilisation of a flail chest at the Trauma Centre between 2010 and 2014 were retrospectively evaluated. This included patient demographics, chest injury extent, results of pre-operative chest imaging (MDCT), surgical stabilisation technique and post-operative outcome. In addition to providing a radiographic finding of respiratory failure, the result of MDCT chest examination was considered an important criterion for surgical intervention. Surgical stabilisation of the chest wall was performed at an interval ranging from 2 hours to 11 days after injury. Intra-thoracic procedures were indicated in patients with lung injury (pulmonary laceration). The surgical procedure was completed by chest tube placement. RESULTS: Surgical stabilisation was carried out using 3 to 8 plates for flail segment fixation involving 3 to 4 ribs. The duration of post- operative mechanical ventilation was 5 days on the average. It was longer in patients with associated injuries such as craniocerebral trauma or severe pulmonary contusion. Tracheostomy was performed in seven patients requiring prolonged mechanical ventilation. Two patients had superficial surgical site infection. No death was recorded in the follow-up period. CONCLUSIONS: Surgical stabilisation of the flail chest segment is considered an effective procedure in selected patients, leading to improvement of respiratory function. By allowing for a shorter period of time on mechanical ventilation, it reduces the occurrence of complications due to ventilatory support. The result of MDCT chest examination in patients with fail chest is an important indication criterion for surgical fixation.

[Basic principles of diagnosis and treatment of secondary peritonitis - recommendations of experts with the support of SIS]. / Základní principy diagnostiky a lécby sekundární peritonitidy - doporucení odborníku s podporou SIS.

Secondary peritonitis is the most common cause of inflammatory acute abdomen treated at general surgery departments. Only early and correct diagnosis may improve the prognosis of these patients. The authors compiled an interdisciplinary review of the basic principles of diagnosis and treatment of secondary peritonitis, which reflects current findings supported by evidence-based medicine. The work is based on published international literature but also shares opinions and experiences of the selected specialists. The presented work in its extent is not meant to substitute an in-depth study of the issue, but to allow a basic and quick review of the topic.

[Importance of interdisciplinary cooperation in multiple trauma management]. / Význam mezioborové spolupráce v osetrení polytraumat.

Multiple trauma represents the most serious type of trauma in which the result of the treatment depends on the quality of pre-hospital care according to ATLS (Advanced Trauma Life Support) as well as on the availability of emergency specialized care in traumatology centres. Resuscitation in the early post-injury phase involves prevention of the lethal triad (hypothermia, acidosis, coagulopathy) development, as early as during pre-hospital care and also during admission to a traumatology department (damage control resuscitation). Damage control resuscitation involves permissive hypotension and coagulopathy correction with red blood cells (RBCs), fresh frozen plasma and platelets administration with crystalloid solutions restriction. Management in a traumatology centre involves : 1. Determining the sequence for treating each of the injuries step by step: a) control of external and intracavitary bleeding, b) operation for craniocerebral injuries, c) external fixation of fractures. 2. Phased management of intracavitary injuries (damage control surgery) and injuries of the extremities (damage control orthopaedics). 3. Non-operative management of solid organs injuries including radiointervention procedures. 4. Post-injury intensive care after the primary operation (treatment of the lethal triad). 5. Treatment regimen extension in craniocerebral injuries (stabilisation of cerebral perfusion pressure with sufficient oxygenation). 6. Modern therapeutic strategies in mechanical ventilation (protective, non-invasive ventilation). 7. Integration of new imaging methods such as MDCT (Multidetector Computed Tomography). Ensuring complex management in polytrauma treatment requires active cooperation of numerous clinical disciplines, already in the early post-injury period.

[The spectrum of diaphragmatic injuries managed in a Prague traumatology centre]. / Spektrum poranení bránice osetrené v traumatologickém centru.

INTRODUCTION: Diaphragmatic injuries may result from blunt or penetrating injuries. The symptomatology is usually overlaid by symptoms of associated abdominal or thoracic injuries or by symptoms of other systems injuries in polytraumas. Multidetector computer tomography (MDTC) facilitates the improvement of preoperative diagnostics in blunt injuries. The retrospective study included analysis of a study group of subjects with blunt and penetrating diaphragmatic injuries. PATIENTS, METHODS AND RESULTS: From 1996 to 2009, a total of 44 injured patients with diaphragmatic injuries were operated in the FNKV (Faculty Hospital Kralovske Vinohrady) Traumatology Centre. The group included 17 blunt injuries and 27 penetrating injuries. There were 39 male and 5 female subjects, aged from 17 to 76 years. 32 subjects suffered from left-sided diaphragmatic injuries and 13 subjects from right-sided injuries. The commonest type of penetrating injuries were stab injuries in 21 subjects. 40 patients suffered from associated injuries. The commonest associated injuries included liver and splenic injuries. Simultaneous thoracotomy and laparotomy for associated injuries affecting the both cavities was performed in 21 patients. Left-sided diaphragmatic injury with associated abdominal injury was managed using laparotomy. Thoracoscopy or laparoscopy was used in 3 subjects with penetrating injuries. CONCLUSION: Penetrating injuries are the commonest cause of diaphragmatic injuries, with prevailing left-sided location of the injury. MDCT is an asset in the diagnostics of blunt diaphragmatic injuries. Surgical approach was selected based on the injury location and on the presence or absence of associated injuries. The miniinvasive approach contributes to the daignostics of penetrating diaphragmatic injuries in patients with stable hemodynamic conditions.

[A contribution of multidetector computed tomography to indications for chest wall stabilisation in multiple rib fractures]. / Prínos multidetektorové výpocetní tomografie hrudníku k indikaci stabilizace hrudní steny u blokové zlomeniny zeber: první zkusenosti.

PURPOSE OF THE STUDY: Multidetector computed tomography (MDCT) is more sensitive for the detection of injury to the thoracic wall and intra-thoracic organs than a plain chest radiograph. The chest wall deformity and instability following multiple rib fracture involves fractures of four or more adjacent ribs at two levels, sometimes including a sternal fracture. It may also be associated with lung trauma (pneumothorax, haemothorax, rupture, laceration or pulmonary contussion). An isolated multiple-rib fracture can successfully be treated conservatively. Early intubation and mechanical ventilation are indicated in patients with progressive respiratory insufficiency. Indications for surgical stabilisation of this fracture are based on the signs of respiratory failure and the results of imagining methods (MDCT at the present time). MATERIAL AND METHODS: Examination by MDCT was carried out in patients with severe thoracic trauma. In five patients with multiple rib fractures, the CT findings were included in indication criteria for open rib osteosynthesis and thoracotomy. A clinical indication criterion was respiratory insufficiency after the patient's weaning from a ventilator, manifested by paradoxical chest motion. A radiographic indication included an extensive chest deformity with rib displacement into the pleural cavity in 3D reconstruction from MDCT images. Surgery was performed within one hour to five days of admission. Access was gained through an oblique skin incision and by cutting though the chest wall muscles to release fractured ribs. To explore the thoracic cavity, a defect in the intercostal muscles was extended by an incision at the site of rib fracture. Suction of a haemothorax was done and lung ruptures were sutured in three patients. After chest drain insertion, the fractured ribs were stabilized by plate osteosynthesis (fy Medin). RESULTS: In the post-operative period, mechanical ventilation was continued for 3 to 6 days in four patients. There were no complications. In the patients with flail chest, the 3D reconstruction from MDCT images allowed us to make more exact pre- operative decisions concerning the extent of rib osteosynthesis and the method of exposure. If lung injury was also shown, this was an indication for thoracic cavity exploration. DISCUSSION: The pathophysiological effects of flail chest involve several factors including the size of a flail segment, change in intra-thoracic pressure during spontaneous breathing and multiple injuries to the intra-thoracic organs. Therapy is related to the seriousness of respiratory disorder associated with flail chest, the degree of chest wall deformity and other complications of conservative treatment (dependence on mechanical ventilation with no possibility of weaning). Surgical stabilization of the chest wall is the most reliable method of treatment which allows us to avoid or interrupt the adverse effect of rib displacement and chest instability. A contribution of MDCT examination to the indication for surgical stabilization lies in that MDCT provides imagining of the details decisive for the classification of fracture types including their tendency to displacement. MDCT permits a better visualisation of chest injury and a better understanding of the respiratory disorder. CONCLUSIONS: Based on 3D reconstruction from MDCT images, it is possible to make the pre-operative considerations for rib osteo- synthesis more specific and to choose the best approach. At the same time MDCT enables us to diagnose associated intra-thoracic injuries and provides indications for their treatment. In addition, it gives us a possibility to evaluate the role of a flail segment in breathing dysfunction and to establish indications for surgical stabilization in multiple rib fractures. Rib osteosynthesis allowed for early stabilization of the chest wall and improved the mechanics of breathing, thus requiring a shorter period of mechanical ventilation. The evaluation of statistical significance of these facts will be made when a larger group of patients examined by MDCT is available.

[The role of VATS in the treatment of thoracic empyema]. / Role VATS v lécení empyému hrudníku.

INTRODUCTION: Videothoracoscopy (VTS) and video-assisted thoracoscopic (VATS) decortication is commonly used in the treatment of early thoracic empyema. However, its conversion to thoracotomy is more frequent in chronic empyema cases. The authors evaluate the role of VTS/VATS in the pleural empyema therapy in the group of patients treated for thoracic empyema using VATS or thoracotomic decortication. PATIENTS, METHOD AND RESULTS: The retrospective study included 165 patients who underwent surgery for thoracic empyema. Pneumonia was the the commonest cause of pleural empyema (77%), while elective lung and esophageal surgery resulted in pleural empyema in 11% of the subjects, trauma in 9% and intraabdominal infection in 3% of the subjects. The subjects were diagnosed with thoracic empyema stage II or III either prior to the procedure on CT examination, or during the procedure. VTS/VATS was indicated in 52 subjects, and conversion to open decortication was required in 23 of them. Open thoracotomic decortication was performed in 113 subjects. VTS/VATS was successful in stage II disorders, in particular in the removal of pus and fibrin, with targeted chest drain insertion. VATS decortication was performed in 15 subjects with stage II or early stage III disorders. In open decortications, the procedure was extended to lung resection (8x lobectomy and 10x wedge non-anatomical resection) for residual abscess pneumonia or lung abscess. Conservatively managed postoperative complications included protracted chest drain air leak (11 patients) and fluidothorax relapses which were treated with redrainage (8 patients). Early postoperative rethoracotomy was indicated in 6 patients for hemothorax, resulting from hemocoagulation disorder in septic conditions. 4 patients were indicated for rethoracotomy for empyema relapses. During the postoperative period, 6 patients exited in the open decortication group. CONCLUSION: VTS is the method of choice in the treatment of stage II thoracic empyema, with a potential for the infectious focus removal, targeted drainage and lung reexpansion. VATS is an alternative thoracotomy method for decortication in the early stage III empyema. Decortication via thoracotomy is a standard treatment method for the management of chronic empyema.

[Penetrating thoracic and abdominal injuries: diagnostic and therapeutic approach]. / Penetrující poranení hrudníku a bricha: diagnostický a lécebný postup.

INTRODUCTION: Penetrating thoracic or abdominal or combined injuries are associated with high risk of life-threatening intraabdominal or intrathoracic organ injury. Most patients require acute surgery. When miniinvasive technique is available, thoracoscopic or laparoscopic intervention is indicated in hemodynamically stable patients to evaluate severity of the injury, as well as to treat the condition. AIM OF THE STUDY: Retrospective analysis of incidence, diagnostics and treatment of penetrating thoracic and abdominal injuries and combined thoracoabdominal injuries in a Trauma centre. PATIENTS, METHODS AND RESULTS: A total of 195 patients with penetrating thoracic, abdominal or combined injuries, who were hospitalized in the FNKV (Krilovské Vinohrady Faculty Hospital) Trauma centre in Prague from 1999 to 2010, were included in the study. The study group included 177 (91%) males. Out of the total, 102 patients (53%) suffered from penetrating abdominal injuries, 71 (36%) from thoracic injuries and 22 (11%) from combined, thoracoabdominal injuries. The majority of injuries were stab injuries (173, i.e. 89% of the patients). 22 subjects, the penetrating injury was caused by shot injuries. In stable patients, MDCT has been lately used to establish the diagnosis. In 171 subjects, acute thoracotomy or thoracotomy was indicated. Patients with combined injuries of the both cavities were indicated either for thoracotomy and laparotomy or thoracophrenolaparotomy. Videothoracoscopy or laparoskopy was conducted in 21 (11%) of the subjects. During the surgical revision, two subjects exited due to ireversible hemorrhagic shock, further 2 subjects died because of septic complications following shot abdominal injuries. CONCLUSION: Incidence of penetrating thoracic, abdominal or combined thoracoabdominal injuries is fairly rare in our country. Subjects with unstable hemodynamic conditions are indicated for acute thoracotomy or laparotomy. Miniinvasive procedures have diagnostic and therapeutic benefit in stable patients. Diagnostic thoracoscopy and laparocopy provides evidence of some injuries (diaphragm, alimentary tract). Therapeutically, miniinvasive methods may be used to manage the source of bleeding and for targeted drainage. Nonsurgical procedure is the method of choice in a selected group of hemodynamically stable patients with stab injuries, with monitoring of the patient's condition, including the use of x-ray imaging.

[Principles of the thoracic wall injury management]. / Principy osetrení poranení hrudní steny.

The overview presents the current situation in the diagnostics and therapy of unstable thoracic wall injuries. The diagnostic spectrum is enlarged by multidetector computed tomography with 3D reconstruction imaging in rib fractures. The use of MDCT in routine examination of blunt thoracic injuries proved to bet the most sensitive imaging method in rib fractures detection, including their dislocations and assessment of the extent of thoracic wall deformity. MDCT improves visualization of the thoracic wall injuries, thus facilitating assessment of the potential respiratory disorder significance. Non-surgical therapy is, as a standard, indicated in patients with thoracic wall injuries. The treatment includes respiratory tract hygiene, pain management and selective ventilatory support. Relative indications for surgical stabilization of fractures include block and serial rib fractures, thoracic deformities and defects and rib fractures healing disorders combined with other limiting criteria. Surgical stabilization is technically managed using metal or absorbable plasters. Surgery with open reduction and internal rib fixation, in particular in block or serial rib fractures, is associated with reduction of ventilation support time and reduction in the risk of infection.

[Abdominal catastrophe--surgeon's view]. / Abdominálni katastrofa--pohled chirurga.

Abdominal catastrophe is a serious clinical condition, usually being a complication arising during treatment of intraabdominal nontraumatic disorders or abdominal injuries. Most commonly, inflamation- secondary peritonitis, is concerned. Abdominal catastrophe also includes secondary signs of sepsis, abdominal compartment syndrome and enterocutaneous fistules. Most septic abdominal disorders which show signs of abdominal catastrophy, require surgical intervention and reinterventions--planned or "on demand" laparotomies. During the postoperative period, the patient requires intensive care management, including steps taken to stabilize his/hers condition, management of sepsis and metabolic and nutritional support measures, as well as adequate indication for reoperations. New technologies aimed at prevention of complications in laparostomies and to improve conditions for final laparotomy closure are used in phase procedures for surgical management of intraabdominal infections. Despite the new technologies, abdominal catastrophe has higher morbidity and lethality risk rates.