[Is accurate preoperative assessment of pancreatic cystic lesions possible?]. / Je presná predoperacní diagnostika cystických lézí pankreatu mozná?

INTRODUCTION: Cystic lesions of the pancreas (CLP) are of different origin and behaviour. Mucinous lesions with the risk of invasive cancer represent an important subgroup. The key point in differential diagnosis of CLP is to distinguish malignant and benign lesions and also correct indication for surgery in order to minimize the impact of serious complications after resection. Different and unsatisfying predictive values of each of the examinations make proper diagnosis challenging. We focused on overall diagnostic accuracy of preoperative imaging and analytic studies. We studied the accuracy of distinguishing between non-neoplastic vs. neoplastic and bening vs. malignant lesions. MATERIAL AND METHODS: We retrospectively analyzed all of the patients (N=72) with CLP (median of age 58 years, range 22-79) recommended for surgery. CT, EUS, ERCP, MRCP findings, cytology and aspirate analysis were used to establish preoperative diagnosis. Finally, preoperative diagnoses were compared with postoperative pathological findings to establish overall accuracy of preoperative assessment. RESULTS: During 5 years, 72 patients underwent resection for CLP. We performed 66 (92%) resection and 6 (8%) palliative procedures with 32% morbidity and 7% of one hospital stay mortality. All the patients were examined by CT and EUS. FNA was performed in 44 (61%) patients. Cytology was evaluable in 39 (88%) cases. ERCP was done in 40 (55%) patients. Pathology revealed non-neoplastic CLP in 25 (35%) and neoplastic lesions in 47 (65%) specimens. Mucinous lesions accounted for 25%. Malignant or potentially malignant CLP were found in 37 (51%) patients. Sensitivity, specificity and diagnostic accuracy of preoperative diagnosis for distinguishing between inflammatory and neoplastic, and benign and malignant was 100%, 46%, 85% and 61%, 61%, 44%, respectively. CONCLUSION: Correct and accurate preoperative assessment of CLP remains challenging. Despite the wide range of diagnostic modalities, the definitive preoperative identification of malignant or high-risk CLP is inaccurate. Because of this, a significant portion of the patients undergo pancreatic resection for benign or inflammatory lesions that are not potentially life-threatening. Possible serious complications after pancreatic surgery are the main reason for precise selection of patients with cystic affections recommended for surgery.

[Biliary complications after major liver resection]. / Biliární komplikace po velkých resekcích jater.

INTRODUCTION: Major liver resection involves operations where three or more liver segments are resected. The decrease of perioperative and early lethality enlarged indicator conditions, especially in patients with colorectal cancer liver metastasis. Bile leakage belongs to major postoperative complications. AIM: Authors present literary experience and retrospective analysis of patients with emphasis on biliary complications and their treatment. RESULTS: 96 patients underwent major hepatic resections between April 2004 and December 2009 at the Surgery Department of the Central Military Hospital in Prague. The average age of patients was 61 (25-84). Patients with an oncology disease dominated the set, representing 78% of all the patients. One half of the patients were formed by patients with colorectal cancer liver metastasis. Fourteen patients (14.6%) suffered from postoperative biliary complications. Non-surgical treatment was successful in nine cases. Surgical treatment was necessary in five cases. Combinations of these methods were essential in half of the patients. Two patients died (2.1%). CONCLUSION: Bile leakage after major liver resection is a quite common and serious postoperative complication. Conservative treatment (ERCP, CT - navigated drainage) is the method of choice. Surgical treatment is necessary where conservative management fails or where the size of the bile leakage is large. Multidisciplinary approach to treatment of these patients is essential.

[Screening of the sporadic colorectal cancer]. / Skrínink sporadického kolorektálního karcinomu v Ceské republice.

The epidemiology of colorectal cancer (CRC) in the Czech Republic is extremely unfavourable. The alarmingly high rates of incidence (78/100,000--in 2004) and mortality (43/100,000--in 2004) have practically remained unchanged in recent years. It is unclear to what extent this reflects a generally unfavourable genetic heritage, environmental factors or the dietary habits of the Czech population. The Czech Society of Gastroenterology launched a population-based CRC screening program in 2000. The FOBT became the standard procedure for a biannual screening examination performed by the general practitioners. A colonoscopy follows in the event of a positive FOBT result. In three screening rounds in 2003, 2004 and 2005, the number of FOBT performed was 207,636, 232,930 and 239,795, respectively, the number of adenomas found was 4623, 2612 and 6272, respectively. The acceptance and detection rates doubled between 2001 and 2005. In 2005 every sixth case of colorectal cancer was found due to screening programme.

Endoscopic treatment of chronic pancreatitis: a multicenter study of 1000 patients with long-term follow-up.

BACKGROUND AND STUDY AIMS: Endoscopic ductal decompression therapy has become an established method of treating patients with painful obstructive chronic pancreatitis. Smaller series, mostly with a medium-term follow-up period, have reported encouraging results. The present analysis presents long-term follow-up data from a large multicenter patient cohort. PATIENTS AND METHODS: Patients with painful chronic pancreatitis and with ductal obstruction due to either strictures and/or stones treated endoscopically at eight different centers underwent follow-up after 2 - 12 years (mean 4.9 years). The patients' clinical data, the rate of technical success, and complications were recorded from the charts. Follow-up data were prospectively obtained using structured questionnaires; the main parameter for evaluating treatment success was a significant reduction in pain (no pain or only weak pain). RESULTS: Follow-up data were obtained from 1018 of 1211 patients treated (84%) with mainly strictures (47%), stones (18%), or strictures plus stones (32%). At the long-term follow-up, 60% of the patients had their endotherapy completed, 16% were still receiving some form of endoscopic treatment, and 24% had undergone surgery. The long-term success of endotherapy was 86% in the entire group, but only 65% in an intention-to-treat analysis. There were no significant differences between the patient groups with regard to either strictures, stones, or both. Pancreatic function was not positively affected by endoscopic therapy. CONCLUSIONS: Endoscopic ductal decompression therapy offers relief of pain in two-thirds of the patients when it is used as the only form of treatment. One-quarter of the patients have to undergo surgery.

[Primary adenocarcinoma of the duodenum]. / Primární adenokarcinom dvanáctníku.

The authors describe a case of 60-year-old man with primary adenocarcinoma of the distal duodenum. The first, ex post assumed symptom, was haemorrhage into the gastrointestinal tract almost two years before the final diagnostic conclusion. The diagnosis was not correctly established even during subsequent examinations during progression of the disease and not even during the first surgical revision. The reason is, no doubt, the rareness of the diagnosis and the adverse site of the tumour. An asset was was enteroscopy, although its conclusion was not accurate as regards the site. The tumour was radically removed only during the second operation by segmental resection of the distal duodenum with a duodenojejunal anastomosis in the region of D2. The patient was then referred to the care of an oncologist. The case shows the diagnostic difficulties and the unique operation that was performed. Possible success of treatment is always conditioned by coordinated gastroenterological, surgical and oncological care.

[Etiopathogenesis of chronic pancreatitis--present state]. / Etiopatogeneze chronické pankreatitidy--soucasný stav.

Chronic pancreatitis is in advanced European and North American countries the statistically most important source of morbidity and mortality among benign pancreatopathies. It is defined as affection of the pancreas by chronic inflammation whereby the secretory parenchyma is gradually replaced by fibrous tissue. The fibrosis is irreversible and the disease has a progressing trend. In advanced countries the main pathogenetic factor has been for some centuries alcohol consumption. Chronic pancreatitis can be classified with regard to its morphology, etiology or pathogenesis. Most frequently the classification of chronic pancreatitis with regard to morphological changes is used, whereby the latter are based on different pathogenetic mechanisms. The present Marseille-Rome classification is valid from 1988 and divides chronic pancreatitis according to morphological changes into three groups. 1. Chronic calcifying pancreatitis. 2. Obstructive chronic pancreatitis. 3. Primarily inflammatory chronic pancreatitis. In some publications pancreatic fibrosis is listed as a special category. The submitted paper gives an up to date picture of chronic pancreatitis from the aspect of etiopathogenesis, it draws attention to the weak points of the contemporary classification and provides information on the genetic diagnosis of some rare forms of this highly prevalent disease.

Penetration of antibiotics into the pancreas in rats: an effect of acute necrotizing pancreatitis.

BACKGROUND: Penetration of antibiotics into the pancreas is considered to be an important criterion in determining the most appropriate antibiotic treatment during severe acute pancreatitis. Our study investigated pancreatic penetration of five antibiotics in rats with and without acute necrotizing pancreatitis (ANP) (non-pancreatitis rats (NR), pancreatitis rats (AP)). METHODS: ANP was induced by intraductal bile acid injection, and 3 h later the antibiotic was administered. In both NR and AP the antibiotic concentrations were evaluated in blood and pancreatic tissue 90 min after antibiotic administration. RESULTS: The tissue/serum (T/S) ratios for NR were 16% with amikacin, 24% with amoxycillin/clavulanic acid, 27% with piperacillin, 59% with ofloxacin, and 108% with cefoperazone. The ratios for AP were 7%, 23%, 26%, 52%, and 70%, respectively. T/S ratios were similar for NR and AP except for amikacin, for which the T/S ratio was lower in AP than in NR (P = 0.02). Pancreatic tissue concentrations of antibiotics with high penetration rates (cefoperazone and ofloxacin) were sufficient to inhibit most of the pathogens expected during acute pancreatitis. The concentrations of the other antibiotics were less than the minimal inhibitory concentrations (MIC) for common potential pathogens in pancreatic infection. CONCLUSIONS: Cefoperazone and ofloxacin showed the best pancreatic penetration of the five antibiotics tested. The high concentrations of these antibiotics in the pancreatic tissue would have enabled efficient antibacterial activity against most of the potential pathogens causing pancreatic infection. An early stage of acute necrotizing pancreatitis did not have a major effect on the pancreatic concentrations of the antibiotics.