Endoscopic approaches in head and neck endocrine surgery introduction of TOETVA (TransOral Endoscopic Thyroidectomy by Vestibular Approach) into clinical use at the Department of Surgery of the University Hospital in Brno.

Transoral endoscopic surgery of the thyroid and parathyroid glands is a modification of neck surgery using natural orifices. The classic approach in neck surgery is the gold standard, which we modified in 2007 by introducing Minimally Invasive Video-Assisted Thyroidectomy/Parathyroid-ectomy (MIVAT/P). We have been using TransOral Endoscopic Thyroidectomy/Parathyroidectomy by Vestibular Approach (TOETVA/TOEPVA) since the end of the last year and have operated on four patients. This method is more attractive for patients because it does not leave a visible scar on the neck, which is common in MIVAT/P. TOETVA is a promising procedure with many advantages, such as healing without visible scars, less pain, minimally invasive dissection and a clear operating field to both thyroid lobes and parathyroid glands. Presentation of the first case. Patients indicated for TOETVA must meet certain criteria - nodule(s) up to 3.5 cm, gland volume up to 30 ml, benign FNAB, papillary, follicular carcinoma not advanced, well differentiated, up to the nodule size of 10 mm with 1 lymph node up to 10 mm. The contraindications include a large goiter, previous neck surgery, history of thyroiditis, lymphadenopathy of the neck, advanced thyroid cancer. Relative contraindications include previous radiotherapy to the throat, Grave´s disease, and obese patients with a short neck. Intraoperative findings may result in a modification of the procedure. TOETVA is an excellent choice for selected patients who want to avoid a neck incision. This method provides the benefit of using standard endoscopic instruments and techniques. It is a safe and effective procedure that provides a good cosmetic result and considerable comfort in terms of clarity of the operating field by zooming in with an endoscopic camera. Longer operating times become shorter due to the learning curve effect.

Our experience with transanal total mesorectal excision (TaTME) procedures in middle and distal rectal tumors.

INTRODUCTION: Transanal total mesorectal excision (TaTME) is a relatively new approach in surgical treatment of rectal cancer. There are no clear indications when to choose this strategy. It is a technically demanding procedure for the surgeon with a long learning curve, which should also be taken into account in evaluation of this method. The results of both oncological and postoperative complications must be properly evaluated to explore the benefit of TaTME. The aim of this study is to assess the potential benefit of TaTME compared to other alternatives in middle and distal rectal tumors. METHODS: Retrospective evaluation of patients undergoing TaTME procedure performed by one team of surgeons between October 2014 and June 2019. The authors analyzed demographic indicators of the group of patients, tumor characteristics, specimen quality, early postoperative complications and the possibility of stoma reversal. RESULTS: A total of 93 patients underwent TaTME procedure for middle and distal rectal cancer. Mean BMI was 27.6 (4.8). T3 or T4 tumor was found in 73 (78.5%) patients, 68 (73.1%) patients had positive lymph nodes and 12 (12.9%) patients were treated for synchronous metastatic rectal cancer. Neoadjuvant therapy was used in 80 (86%) patients. Conversion to open laparotomy was necessary in one case (1%). Stapled anastomosis was performed in 37 (39.7%) cases, handsewn in 56 (60.2%). A positive circumferential resection margin (CRM) was found in 10 (10.7%) cases. Distal resection margin (DRM) was positive in 3 (3.2%) patients. Pathological analysis showed a complete mesorectum in 18 patients (19.4%), nearly complete in 39 (41.9%) and an incomplete mesorectum in 36 (38.7%). Complications in the first 30 days after primary surgery were observed in 38 (40.8%) patients, mainly for anastomotic leak (19 patients, 20.4%). Reoperation was required in 7 (7.5%) patients. Permanent colostomy had to be performed in 4 (4.3%) cases. No patient died after surgery. CONCLUSION: In a selected group of patients it is possible to perform resection using this approach with acceptable postoperative morbidity and quality of the specimen. We used TaTME procedure in patients expected to have difficult TME due to obesity, size and distal localization of tumor. The incidence of conversion to open surgery was very low. Further studies for long term oncological outcomes are needed.

Lymphomas and acute abdomen - a set of case reports.

Surgical treatment of gastrointestinal solid tumors is the basic method with a curative potential. However, the first-line treatment modalities in lymphomas are systemic oncology therapy (chemotherapy, immunotherapy and hematopoietic stem cell transplantation), radiotherapy or their combination. Surgery in lymphomas is predominantly associated with acute disease and dominantly, surgery is still used mainly in diagnosing lymphomas. Acute abdomen associated with lymphoma can be divided into 3 groups: bleeding, obstruction and perforation of GIT due to lymphoma. All these conditions might be caused by both gastrointestinal (extranodal) lymphomas or advanced nodal lymphomas that directly infiltrate or compress gastrointestinal tract (GIT) as well. Perforation is also often associated with the effect of systemic chemotherapy administration. When treating acute abdomen conditions caused by lymphomas, multidisciplinary cooperation with all participating experts is necessary. From the surgical point of view, minimizing the risk of postoperative complications is crucial to ensure the possibility of early systemic oncological treatment administration.

Spontaneous retroperitoneal hematoma - our experience with surgical approach.

Spontaneous retroperitoneal hematoma is a serious complication of anticoagulation and antiplatelet therapy. Its incidence has increased in recent years due to an increasing number of patients on this treatment. A number of case series have been described in the literature. In the vast majority of cases, the hemodynamically stable patients were treated either conservatively or by selective radiological embolization of the bleeding source. A surgical approach is reported as a last choice in the cases where the conservative therapy fails, radiological intervention is unavailable, in patients with continuous bleeding or in patients who develop abdominal compartment syndrome. In our case report, we present a patient on anticoagulation therapy for deep venous thrombosis complicated by massive retroperitoneal bleeding: surgery was used as the method of first choice and the treatment was successful. Key words: retroperitoneal hematoma bleeding anticoagulation treatment surgery.

Acute hiatal hernias.

INTRODUCTION: In surgical practice, hiatal hernias are often related to gastro esophageal reflux disease treatment in which continuous proton pump inhibitor administration is very successful. In large hiatal hernias, life threatening complications may occur. However, planned surgical repair of hiatal hernias is associated with very good functional outcomes with a low risk of postoperative complications. The incidence of large hiatal hernias grows with increasing age of the patient. In geriatric patients, internal comorbidities are also more frequent, including serious conditions. In these patients, one may hesitate whether to perform surgery with regard to the possible risk of postoperative complications. Conservative treatment of hiatal hernias is associated with a higher risk of stomach volvulus or severe bleeding as the most frequent complications. METHODS: We performed a retrospective study of patients operated on for a large hiatal hernia at the Department of Surgery, University Hospital Brno, between 2010 and 2016 (86 months). The patients were divided into 2 groups depending on the type of operation: acute (A) and elective (B). We evaluated demographic data, the nature of preoperative symptoms, type of surgery and postoperative complications. RESULTS: 120 patients were operated on for large hiatal hernia in this period of time. Group A involved 22 operated patients, group B 98 patients. There was a significantly higher number of laparotomies in the acute patient group compared to the elective group B (72.7 % vs. 23.5%, p.

Results of minimally invasive esophagectomy for esophageal cancer performed after ischemic gastric conditioning

INTRODUCTION: Esophageal tumor resections are extensive procedures with high postoperative complication rates including anastomotic leak. An anastomotic leak occurs when microcirculation in the proximal gastric wall used for esophageal replacement is impaired. Preoperative occlusion of certain gastric vessels (ischemic gastric conditioning) may lead to changes in vascularization and can potentially reduce the occurrence and severity of anastomotic leak after esophageal resection. METHOD: This is a retrospective data analysis of patients with esophageal cancer operated on in the Department of Surgery at University Hospital in Brno after previous ischemic gastric conditioning. RESULTS: Preoperatively, IC was performed by means of a radiological method in 7 patients (embolisation of the left gastric artery). In another 68 patients, a diagnostic laparoscopy was performed and the left gastric artery was surgically divided. During the laparoscopy, a nutritional jejunostomy was performed to enhance nutrition supply in 44 patients with food intake issues due to a stenotizing tumor. In 15 cases, a biopsy from suspicious formations in the abdominal cavity was harvested. In 5 patients, the biopsies revealed malignant disease which had not been discovered with staging radiologic diagnostic methods. After radiological ischemic conditioning, spleen ischemia was found in 2 patients after esophageal resection, and therefore we did not continue to use this method. After surgical gastric ischemic conditioning, 39 mini-invasive esophageal resections were performed. 2 of the resected patients died after the operation (5.1%). Anastomotic leak was found in a total of 8 patients after the resection. In 6 patients with anastomotic leak, management was not complicated and no reoperation was needed. No patient had complete necrosis of the gastric conduit due to ischemia. CONCLUSION: Staging laparoscopy is a safe method beneficial for patients with esophageal cancer. It offers exploration of the abdominal cavity to rule out small peritoneal and liver metastases and nutritional jejunostomy for nutrition intake improvement can be done. Ischemic conditioning can also be performed during laparoscopy which may enhance vascularization of the gastric conduit used for esophageal replacement and, despite the fact that it does not reduce the incidence of anastomotic leak, it may reduce its severity. There are no exact recommendations about adequate time delay between ischemic conditioning and esophageal resection. Performing esophageal resection is not altered by previous ischemic gastric conditioning.

[Gallbladder volvulus]. / Volvulus zlucníku.

INTRODUCTION: Volvulus of the gallbladder is one of very rare diseases ranked among acute abdomen conditions. Only case reports are described in the literature. The disease presents with acute biliary ailments, often reminiscent of acute cholecystitis. It is more common in frail elderly women and its preoperative diagnosis is very difficult, and therefore this finding is encountered intraoperatively in most cases. CASE REPORT: In our case report we present the case of a female patient where the volvulus of the gallbladder was found as a surprising discovery during surgery. CONCLUSION: Gallbladder volvulus is a rare disease that presents as acute abdomen. It is most often diagnosed intraoperatively. Cholecystectomy is the most appropriate therapeutic method.Key words: gallbladder volvulus - acute abdomen - floating gallbladder.

Rare cases imitating acute appendicitis: Three case reports and a review of literature.

Acute appendicitis with its characteristic clinical course is one of the most common diagnoses that require urgent surgery. The following three case reports present patients with symptoms typical of acute appendicitis which was, however, not confirmed intraoperatively. Preoperative CT or MRI were not requested because symptoms clearly indicated acute appendicitis. The first case describes a male patient with right-sided diverticulitis, the second case report involves a pregnant woman in 33rd week of gestation with right adnexal torsion due to a dermoid cyst, and in the last report, a case of spontaneous perforation of appendiceal mucinous neoplasm is presented.Key words: right-sided diverticulitis - dermoid cyst - adnexal torsion - mucinous neoplasm - pseudomyxoma peritonei - appendicitis.

[Transanal endoscopic microsurgery (TEM) our experience]. / Transanální endoskopická mikrochirurgie (TEM) nase zkusenosti.

INTRODUCTION: The purpose of this paper is to present our experience with transanal endoscopic microsurgery (TEM) as an operative approach in a selected group of patients with rectal tumours. METHODS: We present a retrospective study of 80 patients operated for rectal tumour using TEM. Specific preoperative and postoperative indicators were gathered and statistically evaluated. We assessed histological examination before the surgery and definitive histology of the resected tumour, resection depth and basic demographic data of our patients. RESULTS: Our experience suggests that there is no significant difference between the age of patients according to sex, even if malignant and benign tumours are assessed separately. The majority of our operated patients were male patients, mean age of 64 years who were primarily referred to our department because of bleeding low-grade adenomas of the rectum. In 17 patients a malignant tumour was diagnosed based on final histopathologic examination. None of them had signs of malignancy before the surgery. CONCLUSION: In the hands of an experienced surgeon, TEM is a feasible option of radical removal of rectal, locally not advanced malignancies if within reach of TEM rectoscope. TEM is a safe procedure that does not result in any alteration of rectal sphincter functions. Possible false negative preoperative benign diagnosis leads us to approach radical removal of the tumour with full wall thickness resection. Although the posterior aspect of the rectum is an optimal location for the rectoscope, anterior tumours were found in almost one half of our patients. Considering technical feasibility of the rectal wall suture, the base of the tumour should not extend beyond one half of the rectal circumference. Low non-stenotising noninvasive tumours of the rectum are suitable for TEM. Our good results are particularly due to strict patient selection criteria, mastering the operating technique and long-time experience. KEY WORDS: transanal endoscopic microsurgery (TEM) benign rectal tumours rectal cancer.

Quality of life after bowel resection for Crohn´s disease - first results.

INTRODUCTION: Crohn´s disease (CD) highly affects a patient´s quality of life. The aim of the study was to find out the impact of surgery on the quality of life (QoL) in CD patients and factors affecting their postoperative QoL. METHODS: 90 patients with CD who underwent surgery (bowel resection) filled out an EORTC QLQ-CR29 questionnaire preoperatively and again after the surgical procedure. RESULTS: 77% of the patients experienced a positive change (p<0.001), 22% negative and 11% no change. CONCLUSION: In this cohort, we proved that surgical treatment improves the overall QoL in patients with CD. To determine factors which affect postoperative QoL, more patients need to be enrolled in future studies.Key words: Crohn´s disease - quality of life - surgery - bowel resection - Czech cohort.

Intestinal resection of a porcine model under thermographic monitoring.

OBJECTIVE: Surgical resection of a part of the intestine is a standard procedure in gastrointestinal surgery and in order to perform this type of surgery successfully, tissue blood flow must be evaluated clearly. There exists a theoretical indication that it would be possible to use infrared thermography (IRT) for this purpose. Therefore, the main objective of the study is the qualitative evaluation of the infrared thermography method as an ancillary method for determining the resection lines and forming an optimal intestinal anastomosis on the porcine model. APPROACH: Blood circulation rate has a close relationship with temperature difference and is also very important for identifying the resection lines on the bowel, the formation of anastomoses, and, subsequently, their adequate healing. Therefore, IRT could be helpful in determining the nonvascular part of the intestine. In order to make a qualitative evaluation of this method, the study also focuses on a comparison of IRT with the contrasting indocyanine green (ICG) imaging method, which is commonly used. MAIN RESULTS: The comparison of two independent imaging methods (IRT and ICG) revealed similar, but not identical, results. Subjective evaluation of the anastomosis performed by the team of three surgeons was more in agreement with the area detected by contactless thermography imaging. Moreover, the proceeding 'dynamic temperature return test', when the particular intestinal part was cooled and its subsequent temperature return was measured, revealed significant results. The time taken to return to the original intestinal temperature was greater for the devascular part of the intestine. SIGNIFICANCE: A thermographic examination could help to detect the correct location of the intestine resection line for further/continuing anastomosis creation.

TCDB: the Transporter Classification Database for membrane transport protein analyses and information.

The Transporter Classification Database (TCDB) is a web accessible, curated, relational database containing sequence, classification, structural, functional and evolutionary information about transport systems from a variety of living organisms. TCDB is a curated repository for factual information compiled from >10,000 references, encompassing approximately 3000 representative transporters and putative transporters, classified into >400 families. The transporter classification (TC) system is an International Union of Biochemistry and Molecular Biology approved system of nomenclature for transport protein classification. TCDB is freely accessible at http://www.tcdb.org. The web interface provides several different methods for accessing the data, including step-by-step access to hierarchical classification, direct search by sequence or TC number and full-text searching. The functional ontology that underlies the database structure facilitates powerful query searches that yield valuable data in a quick and easy way. The TCDB website also offers several tools specifically designed for analyzing the unique characteristics of transport proteins. TCDB not only provides curated information and a tool for classifying newly identified membrane proteins, but also serves as a genome transporter-annotation tool.

Lysophospholipid flipping across the Escherichia coli inner membrane catalyzed by a transporter (LplT) belonging to the major facilitator superfamily.

The transfer of phospholipids across membrane bilayers is protein-mediated, and most of the established transporters catalyze the energy-dependent efflux of phospholipids from cells. This work identifies and characterizes a lysophospholipid transporter gene (lplT, formally ygeD) in Escherichia coli that is an integral component in the 2-acylglycerophosphoethanolamine (2-acyl-GPE) metabolic cycle for membrane protein acylation. The lplT gene is adjacent to and in the same operon as the aas gene, which encodes the bifunctional enzyme 2-acyl-GPE acyltransferase/acyl-acyl carrier protein synthetase. In some bacteria, acyltransferase/acyl-ACP synthetase (Aas) and LplT homologues are fused in a single polypeptide chain. 2-Acyl-GPE transport to the inside of the cell was assessed by measuring the Aas-dependent formation of phosphatidylethanolamine. The Aas-dependent incorporation of [3H]palmitate into phosphatidylethanolamine was significantly diminished in deltalplT mutants, and the LplT-Aas transport/acylation activity was independent of the proton motive force. The deltalplT mutants accumulated acyl-GPE in vivo and had a diminished capacity to transport exogenous 2-acylglycerophosphocholine into the cell. Spheroplasts prepared from wild-type E. coli transported and acylated fluorescent 2-acyl-GPE with an apparent K(d) of 7.5 microM, whereas this high-affinity process was absent in deltalplT mutants. Thus, LplT catalyzes the transbilayer movement of lysophospholipids and is the first example of a phospholipid flippase that belongs to the major facilitator superfamily.

Phylogeny as a guide to structure and function of membrane transport proteins.

Protein phylogeny, based on primary amino acid sequence relatedness, reflects the evolutionary process and therefore provides a guide to structure, mechanism and function. Any two proteins that are related by common descent are expected to exhibit similar structures and functions to a degree proportional to the degree of their sequence similarity; but two independently evolving proteins should not. This principle provides the impetus to define protein phylogenetic relationships and interrelate families when possible. In this mini-review, we summarize the computational approaches and criteria we use to establish common evolutionary origin. We apply these tools to define distant superfamily relationships between several previously recognized transport protein families. In some cases, available structural and functional data are evaluated in order to substantiate our claim that molecular phylogeny provides a reliable guide to protein structure and function.

Web-based programs for the display and analysis of transmembrane alpha-helices in aligned protein sequences.

We developed novel programs for displaying and analyzing the transmembrane alpha-helical segments (TMSs) in the aligned sequences of homologous integral membrane proteins. TMS_ALIGN predicts the positions of putative TMSs in multiply aligned protein sequences and graphically shows the TMSs in the alignment. TMS_SPLIT (1). predicts the positions of TMSs for each sequence; (2). allows a user to select proteins with a specified number of TMSs, and (3). splits the sequences into groups of TMSs of equal numbers. TMS_CUT works like TMS_SPLIT, but it can cut sequences with any combination of TMSs. The BASS program similarly allows comparison of protein repeat elements, equivalent to TMS_SPLIT plus IC, but it provides the comparison data expressed in BLAST E values. These programs, together with the IntraCompare program, facilitate the identification of repeat sequences in integral membrane proteins. They also facilitate the estimation of protein topology and the determination of evolutionary pathways.