Laparoscopic sleeve gastrectomy for morbid obesity with natural orifice specimen extraction (NOSE).

OBJECTIVE: An experience with laparoscopic sleeve gastrectomy using the natural orifice specimen extraction (NOSE) technique. BACKGROUND: Bariatric surgery is nowadays the only long term effective obesity treatment method. METHODS: Twenty one consecutive patients underwent laparoscopic sleeve gastrectomy with the use of natural orifice specimen extraction (NOSE) in the Surgical Clinic of Faculty Hospital Ostrava between May 2012 and August 2012. Inclusion criteria were the body mass index (BMI) higher than 35 kg/m2 or higher than 32 kg/m2 accompanied with relevant comorbidities. RESULTS: Among 21 patients in this series, there were three men (14.3%) and 18 women (85.7%). Their mean age was 40.9±10.2 years. Their mean preoperative BMI was 40.4±4.6 kg/m2. No patient had previous bariatric surgery, one patient had laparoscopic fundoplication. All operations were completed laparoscopically with no conversions to an open procedure. In two cases, laparoscopic cholecystectomy was performed and the gallbladder was extracted along with the gastric specimen by transgastric approach. CONCLUSION: Laparoscopic sleeve gastrectomy is a safe and effective bariatric procedure with low morbidity and mortality. Based on our initial experiences it could be an indication for NOSE with transgastric approach. Obese patients would benefit from this approach due to the elimination of wound complications (Tab. 2, Fig. 3, Ref. 22).

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).

[Impact of anastomotic leakage on oncological outcomes after rectal cancer resection]. / Vliv dehiscence anastomózy na onkologické výsledky u resekcních výkonu pro karcinom rekta.

INTRODUCTION: The aim of the study was to determine the impact of anastomotic leakage on long-term outcomes after curative surgery for rectal cancer. MATERIAL AND METHODS: The study included 174 patients who underwent elective, potentially curative open or laparoscopic resection with anastomoses for rectal cancer at the Department of Surgery of the University Hospital Ostrava from 1 January 2001 to 31 December 2009. Anastomotic leakage was defined as clinically or radiologically confirmed signs of local or diffuse peritonitis, gas, pus or stool from the drain, rectoscopy signs of anastomotic insufficiency, or rectovesical or rectovaginal fistula. The Cox proportional hazards model with forward selection was used to determine the influence of predefined baseline characteristics on overall, disease-free survival and recurrence. The results are presented as Hazard Ratio (HR) with 95% Confidence Interval (CI). RESULTS: Based on the Cox model, anastomotic leakage was not identified as a factor with a significant impact on overall or disease-free survival. Anastomotic leakage, however, has remained an independent risk factor for a higher local recurrence rate (Hazard Ratio: 6.621, 95% CI 1.289-34.020, p=0.024). On the contrary, anastomotic leakage was not identified as a statistically significant prognostic factor for the incidence of distant metastases. CONCLUSION: Anastomotic leakage represents an independent risk factor for a higher local recurrence rate after curative resection for rectal cancer.

Long-term results of laparoscopic versus open surgery for nonmetastatic colorectal cancer.

PURPOSE: Laparoscopic surgery for colon cancer has been proven safe, but controversy continues over implementation of laparoscopic technique for rectal cancer. The aim of this study was to compare the long-term outcomes of laparoscopically assisted and open surgery for nonmetastatic colorectal cancer. MATERIAL AND METHODS: From January 2001 to December 2006 all patients with nonmetastatic adenocarcinoma of the colon and rectum were considered for inclusion in this prospective non-randomised trial. The primary endpoint was overall survival, disease free survival and recurrence rate. Analysis was by intention to treat. RESULTS: A total of 365 resections were performed for nonmetastatic adenocarcinoma of the colon and rectum during the study period. Of those resections, 220 were colonic and 145 were rectal. In the patients with colon cancer 119 (54.1%) were operated laparoscopically and 101 (45.9%) by open surgery, in the patients with rectal cancer 75 (51.7%) were treated by laparoscopy and 70 (48.3%) by open technique. No statistically significant difference was found between the laparoscopic and open group regarding 5-year overall survival (p = 0.17 for colon cancer, p = 0.60 for rectal cancer), 5-year disease free survival (p = 0.25 for colon cancer, p = 0.81 for rectal cancer) and overall recurrence (p = 0.78 for colon cancer, p = 0.79 for rectal cancer). With respect to the tumor stage, in rectal cancer the probability of 5-year disease free survival was significantly higher in the laparoscopic group in stage III (p = 0.03). CONCLUSION: Laparoscopic surgery for colorectal cancer is an oncologically safe procedure that is associated with a survival and recurrence rate equal to open surgery.

[A giant gastrointestinal stromal tumour - a case report]. / Obrovský gastrointestinální stromální tumor - kazuistika.

Gastrointestinal stromal tumours represent a group of non-epithelial gastrointestinal tumours that have both benign and malignant character. Most frequently, they occur in the stomach and the intestine; however, as regards their overall incidence, they are rather infrequent tumour lesions. The present case report describes a rare bulky extragastrointestinal stromal tumour originating from the mesenterium in a young patient. Its anatomical and histological picture, diagnosis and treatment are described. Our work points to the necessity for physicians to also bear in mind the less likely options and highlights the role of surgery in the treatment of such voluminous findings.

[Nuss miniinvasive procedure for pectus excavatum in adolescents and adults]. / Miniinvazivní operace pectus excavatum u adolescentu a dospelých dle Nusse.

Pectus excavatum is a congenital chest wall deformity with depression of the sternum and adjacent costal cartilages. Severe forms of this deformity lead not only to psychosocial deprivation but also limit physical performance due to lung volume reduction and cardiac compression. Open surgical correction using stemochondroplasty represented the gold standard of surgical treatment of pectus excavatum. Miniinvasive technique of corrective steel bar insertion was published in 1998. Since then, so called Nuss operation has become widely accepted. Good experience with this type of the pectus excavatum correction have encouraged us to adopt this procedure. We use this technique not only in children and adolescencents but also in adults suffering from depressed anterior chest wall. We present our initial experience with the treatment of nine patients. We describe the benefits and pitfalls of the method which are known to us.

[Prevention of parastomal hernia using laparoscopic introduction of a prosthetic mesh--initial experience]. / Prevence parastomální hernie primoimplantací sít'ky laparoskopicky--první zkusenosti.

INTRODUCTION: Parastomal hernia is a very common complication after stoma formation. Current surgical procedures for repairing parastomal hernia have unsatisfactory results. The aim of this study was to evaluate our initial experience with laparoscopic prophylactic mesh placement at the time of stoma formation. MATERIAL AND METHODS: Four patients underwent laparoscopic abdominoperineal rectal cancer resection with prophylactic parastomal mesh placement. A specially designed mesh made of polyvinylidene fluoride with central funnel (Dynamesh IPST) was implanted using an intraperitoneal onlay technique. The surgical data, the frequency of mesh-related complications as well as the rate of parastomal henias were evaluated. RESULTS: The mean operating time for mesh placement was 15 min (10-25 min.). No mesh- related complications or infection was observed and no parastomal hernia could be detected clinically. To this date, the mean follow up time has been six months (4-8 months). CONCLUSION: Laparoscopic prophylactic parastomal mesh placement might be a safe and effective procedure with a potential to reduce the risk of parastomal hernia, at least in the short run. However, our experience is limited due to the small number of patients included in the study. Additional large trials with long term follow up are necessary.

[NOSE (Natural Orifice Specimen Extraction) in laparoscopic colorectal surgery]. / NOSE (Natural Orifice Specimen Extraction) v kolorektální chirurgii.

INTRODUCTION: The aim of this study was to asses our initial first experience with NOSE techniques in laparoscopic colorectal surgery with both transanal and transvaginal extraction. MATERIAL AND METHODS: In this prospective study, the authors analyzed data from patients in whom NOSE laparoscopic sigmoid, rectosigmoid and rectal resections were performed in the Department of Surgery, University Hospital Ostrava, from May 2011 to October 2011. A group of 7 patients was analyzed based on demographic characteristics (sex,age and BMI). Tumor localization, type of extraction (transanal/transvaginal), the number of removed lymph nodes, tumor size, histology and length of the specimen were also assessed. Furthermore, the following intraoperative data were evaluated: duration of the procedure, frequency of intraoperative complications and conversion rate. During the postoperative period, duration of hospitalization and morbidity rates were evaluated. RESULTS: The patient group included 2 male (28.6%) and 5 female (71.4%) subjects, their median age was 70 years (61-80), BMI 26,76 (24.76-34.67). The pathology was located in the sigmoid colon in 4 cases (57.1%) and in the proximal rectum in 3 cases (42.9%). Transanal extraction was performed in 5 patients (71.4%) and transvaginal extraction in 2 patients (28.6%). The average number of harvested lymph nodes was 13 (10-15), the average lenght of specimen was 16 cm (13-20) and the average tumor size was 4 cm (2-6). Histologically, adenocarcinoma was confirmed in 6 cases (85.7%), and low grade adenoma in 1 case (14.3%). The median duration of surgery was 205 min (140-300) and no intraoperative complications were recorded. No surgical conversion was required. No postoperative complications occured and the median duration of of hospital stay was 7 days (5-11). CONCLUSION: In the selected group of patients, NOSE technique proved to be a safe technique for laparoscopic colorectal procedures, reducing the risk of incisional complications while maintaining the principles of oncological radicality. Therefore, it may be considered a bridge towards NOTES (Natural Orifice Transluminal Endoscopic Surgery), surgery without scars.

[Is age a risk factor for laparoscopic colorectal surgery?]. / Ist das Alter ein Risikofaktor für laparoskopische kolorektale Operationen?

BACKGROUND: The aims of this study were to evaluate the results of laparoscopic colorectal surgery in elderly patients and compare them with the results of open procedures. METHODS: An analysis of a prospectively collected database of 705 patients who underwent in the period between January 2001 and December 2006 elective laparoscopic (LAC) or open (OC) colorectal surgery was performed. The primary end point was the morbidity rate, which was analysed in relation to the age (≤ 75 years, > 75 years) and operative technique (laparoscopic, open). RESULTS: During the study period, 360 elective laparoscopic and 345 elective open colorectal operations were performed. 140 patients (20%) were older than 75 years (geriatrics), 60 of whom underwent laparoscopic and 80 open surgery. Both groups of patients (laparoscopic vs. open) were comparable in basic parameters. Mean operative time for laparoscopic colorectal resections was not longer (LAC 141 ± 46 min vs. OC 137 ± 57 min, n. s.); even in cases of simple stoma formation it was significantly shorter (LAC 42 ± 19 min vs. OC 78 ± 32 min, p = 0.004). In the group of younger patients (≤ 75 years) the open approach was associated with a statistically significant increase of postoperative morbidity (LAC 26% vs. OC 34%, p = 0.039). In the group of geriatric patients (> 75 years) the open approach was associated with a significantly high incidence of postoperative morbidity (LAC 27% vs. OC 48%, p = 0.012) too. In the laparoscopically operated patients, the morbidity rate did not differ in both age groups (older than 75 years 27% vs. younger than 75 years 26%, n. s.). Conversely, open procedures in elderly patients were associated with a significant increase of postoperative complications (morbidity) compared to younger patients (older than 75 years 48% vs. younger than 75 years 34%, p = 0.033). CONCLUSION: On account of the lower incidence of post-operative complications, the laparoscopic approach should be indicated in colorectal surgery for geriatric patients.

[Giant Zenker's diverticulum--case report]. / Obrovský Zenkeruv divertikl--kazuistika.

Zenker's diverticulum is one of the most common esophageal diverticuli. The reported prevalence in Czech population is approx. 0.5%, typically presents in the elderly. A small Zenker's diverticulum can be asymptomatic. When a diverticulum increases in size, it can cause regurgitation and dysphagia and the condition is often complicated by aspiration and reccurent pneumonia. The diagnosis can be made on a barium esophagogram and CT scan. Surgical therapy is the treatment most commonly offered and the prognosis is excellent. Here we report a 66-years-old male presenting with bleeding from large Zenker's diverticulum. He was immediately admitted to hospital. A computed tomography scan showed a large Zenker's diverticulum protruding into the right superior hemithorax. Resection was chosen as a therapeutic option. Due to the size of the diverticuli his recovery post operation was complicated by fever, bleeding into mediastinum from the place of resection and temporary functional esophagi disorder. Histological examination confirmed ulceration inside the diverticulum as the source of bleeding. Three weeks after the surgery the patient was discharged home in a stable condition with recovered swallowing and phonation.

[Laparoscopic total gastrectomy]. / Laparoskopická totálni gastrektomie.

AIM: Laparoscopic total gastrectomy for cancer have been rarely adopted in Czech Republic. The aim of this study is to assess results of these procedures analyzing our series of patients. MATERIAL AND METHODS: From May 2002 to June 2010 43 laparoscopic total gastrectomies with lymphadenectomy were performed for patients with gastric cancer. Clinical and tumor parameters, perioperative characteristics, short term and long term results were analyzed retrospectively. RESULTS: Males were 27 (63%) and females were 16 (37%). Mean age was 65 years (range 48-80), mean BMI was 25.7 (range 18.7-37.0). 27 patients (63%) had an ASA score III and 16 patients (37%) had an ASA score II. The patologic stage (UICC) was 10 stage I (23%), 10 stage II (23%), 19 stage III (44%) and 4 stage IV (9%). The mean operation time was 292 minutes (range 180-400). Conversion was necessary in four cases (9%) and hand assisted technique was used in four cases (9%). The number of retrieved lymph node were 18 (range 4-32). Five laparoscopic total gastrectomies were estimated as palliative. Median time of hospitalization was 12 days (range 7-86). Overall morbidity was 37%, 5 patients (12%) were died related with postoperative complications. The 3-years overall survival was 50% and 5-years overall survival was 45%. CONCLUSION: Laparoscopic total gastrectomy is feasible and acceptable clinically and oncologically. Surgical skill and patient's selection are necessary.

["Low volume" laparoscopic nephrectomy for relative-to-relative transplantation]. / "Low volume" laparoskopická nefrektomie pro príbuzenskou transplantaci.

AIM: Worldwide, the number of suitable cadaverous donors is limited. Therefore, as a solution for patients with chronic renal failure appears to extend the group of living donors of healthy individuals who voluntarily donate kidney to relatives or emotionally related recipients. Given the altruistic circumstances of these operations, the main monitored parameters are security for donors and excellent graft function for recipients. Currently published works show that minimally invasive technique can guarantee comparable results with open access in both monitored parameters. The aim of this study is to asses our results with laparoscopic assisted living donor nephrectomy for transplantation. PATIENTS AND METHODS: In retrospective study we analyzed data of patients in whom laparoscopic donor nephrectomy was performed on the Surgical Clinic, University Hospital Ostrava in the period from May 13, 2002 to June 30, 2010. Group of 34 donors were analyzed according to demographic characteristics (sex, age, ASA classification and BMI). From the perioperative data were monitored length of operation and warm ischemia, blood loss, frequency of intraoperative complications and conversion rate. In the postoperative period were evaluated in donors length of postoperative hospitalization, frequency of early and late reoperations, causes of morbidity and mortality, dynamics of the levels of creatinine and in the recipients was monitored 1-year survival of the graft. RESULTS: There were 14 men (41%) and 20 women (59%), median age was 48 years (25-77 years), BMI 26.9 (18.7-37.0), 53% of patients were ASA II, 44% ASA I, 1 patient (3%) ASA III. Median length of operation was 180 min (90-300 min), warm ischemia 120 s (58-240 s), blood loss 50 ml (30-1000 ml). There was no conversion. Intraoperative complications occured in 3 donors (8.8%). The length of hospital stay was 7 days (3-26 days), morbidity rate was 14.7%, without mortality. Early reoperations were in 2 patients (5.9%), late reoperations were performed in 4 patients (11.8%). In donors an average increase of creatinine value was 35.5 micromol/l the first postoperative day. One-year graft survival in our cohort was 94.1%. CONCLUSION: For patients with terminal renal insufficiency the living donor kidney transplantation offers possibility to shorten time in waiting list and to ensure a better graft function with its longer survival. Minimally invasive laparoscopic technique (we prefer transperitoneal approach), represents a safe alternative to open operation.

[1000 laparoscopic colorectal operations]. / 1000 laparoskopických operací na kolorektu.

AIM: The aim of this study was to asses the role of laparoscopy based on experiences with 1000 miniinvasive colorectal procedures. MATERIAL AND METHODS: The prospective study of 1000 patients after elective laparoscopic procedures for colorectal diseases at Municipal Hospital Ostrava Fifejdy and the Surgical Clinic of University Hospital Ostrava between February 1993 and December 2010 was undertaken. Patients with both benign and malignant colorectal pathologies were included in the study. Except of baseline demographic data, the types of surgical procedure, conversion rates, peroperative complications, blood loss, operating time, number and reasons for reoperations, postoperative morbitidy and mortality, number of blood transfusions and length of hospital stay were analysed. For the analysis descriptive statistics methods were used. RESULTS: There were 609 men (60.9%) and 391 women (39.1%). The mean age was 64 years (range 15-97 years), mean BMI was 26.7 (range 14.6-48.0). The most frequent operations were on the right colon (22.2%), sigmoid colon (21.7%) and low anterior resections of the rectum (20.4%). Peroperative complications were in 44 patients (4.4%). Reoperations were necessary in 105 patients (10.5%), postoperative morbidity was 22.6% and 30-day mortality was 4.1%. CONCLUSION: Laparoscopy is safe and effective method in the treatment of both malignant and benign diseases of colon and rectum.

[Effects of infrainguinal bypasses on long-term patency in pelvic procedures--the significance of hybrid procedures]. / Vliv infrainguinálních bypassu na dlouhodobou pruchodnost pánevních intervencí--význam hybridních výkonu.

OBJECTIVE: The hitherto published data did not provide clear answer to whether the adjustment of poor runoff through infrainguinal by-pass can improve long-term patency of iliac interventions in patients with multiple-stage arterial lesion. Our intent was to respond to this question. MATERIAL AND METHODS: In the period since 1st January 2003 until 31st May 2005 we evaluated two groups of revascularized patients with similar angiographic affection of the iliac and femoropopliteal arteries and statistically comparable input parameters. In the first group incorporating 38 procedures the vascular surgeon performed hybrid intervention (group 1)--one-step iliac intervention with infrainguinal ipsilateral bypass, in the second group incorporating 43 patients angioradiologist performed single percutaneous iliac intervention in catheterization laboratory (group 2). RESULTS: Observation median was 71 months (60-86). Three-year primary patency of iliac interventions was 83% in the hybrid group (group 1) and 72% in single angioplasty group (group 2). Five-year patency was 77% in group 1 and 69% in group 2. In secondary patency the three-year and five-year patency was 94% in group 1 and 83% in group 2. Statistically we did not prove that poor infrainguinal runoff is negative factor of primary patency of iliac intervention (K-M, log rank test, p = 0.58628), as well as secondary patency (p = 0.11474). CONCLUSION: From the long-term perspective it is not possible to consider poor runoff to be independent risk factor of patency of iliac intervention. Infrainguinal bypass within the hybrid procedures shall not improve the results of iliac intervention.

[Surgical management of perforations during colonoscopy]. / Chirurgické resení perforací pri kolonoskopii.

INTRODUCTION: Colonoscopy is an effective both diagnostic and therapeutic method. Despite its wide use, however, colonoscopy may be associated with complications occurrence, of which the most serious is bleeding and perforation. Iatrogenic perforation can lead to the peritonitis with high morbidity and mortality. The relative frequency of perforation in diagnostic colonoscopies is 0.03-0.8%, for therapeutic colonoscopy 0.15-3%. The most iatrogenic perforations are located on sigmoid colon. PATIENTS AND METHODS: The endoscopic unit of University Hospital Ostrava performed a total of 7800 colonoscopy in the period between 1st January 2006 to 31st December 2010. In 8 patients (0.1%) occurred perforation of the colorectum. In all patients, this complication arose during diagnostic colonoscopy and was treated by surgery. Six patients (75%) were operated on within 24 hours from the performance of colonoscopy, 2 patients (25%) were operated after more than 24 hours. In 5 patients (62.5%) the left colon including rectum was perforated, in 3 patients (37.5%) perforation occurred in right colon. RESULTS: Postoperative complications occurred in 7 patients, postoperative morbidity was 87.5%. In 1 patient (12.5%) surgical revision was necessary. 2 patients died within 30 days after surgery, mortality was 25%. CONCLUSION: Iatrogenic perforation of the colorectum is one of the most serious complications during colonoscopy. Early and optimal treatment is crucial for the subsequent reduction of serious complications and mortality.

[Czech bariatry in 2010]. / Ceská bariatrie v roce 2010.

INTRODUCTION: It is only during the past two decades, when obesity has become to be considered a pandemic disorder. However, in 1953 Varco performed jejunoileal bypass as the world's first bariatric surgical procedure. 30 years later, Pesková performed the first bariatric surgery--a gastroplasty--in Czechoslovakia. From 1984 she started to perform fixed gastric bandages, through laparotomic app- roach at that time. The first laparoscopic fixed bandage in Czechoslovakia was performed in 1993. Over the years, the number of surgical procedures to treat morbid obesity, as well as the number of bariatric surgeons, continued to increase. In 2004, Czech Bariatric Section of the Czech Surgical Society and the Czech Society of Obesitology of the Czech Medical Association of J. E. Purkyne, were established. MATERIAL AND METHODS: 170 bariatric surgeries were performed in the Czech Republic in 1999. The majority of procedures included fixed gastric bandage, rarely, adjustable bandage was performed. At that time, bariatric procedures were performed at five sites only. However, over the past 10 years, bariatric surgery has largely developed in the Czech Republic. The exact number of bariatric procedures completed per year was unknown, therefore, 21 surgical clinics, at which bariatric procedures are performed, were contacted from January to June 2010. Heads of the clinics were asked to provide basic data on surgical treatment of obesity. The aim of the study was to analyze the situation in bariatric surgery in the Czech Republic at the end of 2009. A total of 18 clinics (85.8%) joined the study and provided their own statistical data. 14 of them perform over 20 bariatric procedures a year. RESULTS: The analysis data showed that, in 2009, a total of 1558 bariatric procedures were completed at 18 surgical clinics and approximately 1600 procedures were performed in the whole Czech Republic. However, out of the total, over 230 patients were foreigners. In 99% of bariatric procedures in morbid obese subjects, laparoscopic approach was used. CONCLUSION: Over the ten year period, the number of clinics performing over 20 bariatric procedures a year increased from five to 14 clinics and the number of bariatric procedures increased from 170 to 1600 procedures a year. It is 900% increase, compared to the year 1999! Nevertheless, compared to other countries, e.g. Austria, the number of bariatric procedures does not correspond with prevalence rates of obesity in the Czech Republic.

[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.

[Advanced age--indication or contraindication for laparoscopic colorectal surgery?]. / Pokrocilý vek--indikace nebo kontraindikace laparoskopické kolorektilni chirurgie?

AIM: The aim of this study was to evaluate the results of laparoscopically-assisted (LAC) and open (OC) colorectal surgery in elderly patients (a 75 years) and to compare them to a cohort of younger patients (<75 years) undergoing similar surgical procedures. METHODS: Patients who underwent elective laparoscopically-assisted or open colorectal surgery in the period between January 2001 and December 2009 were included in the analysis. The primary end point was the incidence of short-term postoperative morbidity and mortality, long-term overall and colorectal cancer specific survival which were analyzed in relation to the age and operative technique. RESULTS: During the study period, 557 elective laparoscopic and 404 elective open colorectal operations were performed. 190 patients (20 %) were older than 75 years, 99 of which underwent laparoscopic and 91 open surgery. In geriatric patients, the open approach was associated with increase of postoperative morbidity, statistically nonsignificant (LAC > or = 75 years 30% vs. OC < 75 years 40%, p = 0,151). In the laparoscopic procedures, the morbidity rate did not differ in both age groups (LAC > or = 75 years 30% vs. LAC < 75 years 28%, p = 0,702). Conversely open procedures in elderly patients were associated with a significant increase of postoperative complications compared to younger patients (OC > or = 75 years 40% vs. OC < 75 years 29%, p= 0,033). There was no difference in postoperative mortality rate between laparoscopic and open approach in geriatric patients (LAC > or = 75 years 5% vs. OC > or = 75 years 3%, p=0,548). Mortality rate did not differ in both age groups operated laparoscopically (LAC > or = 75 years 5% vs. LAC < 75 years 3%, p = 0,322) even by open approach (OC > or = 75 years 3% vs. OC <75 years 2%, p = 0,433). Although five year overall survival was significantly lower in the older age group (LAC > or = 75 years 43 +/- 8% vs. LAC < 75 years 58 +/- 4 %, p = 0,049; OC - 75 years 35 +/- 7% vs. OC < 75 years 56 +/- 4%, p = 0,006), five year colorectal cancer specific survival was not different between both age groups (LAC > or = 75 years 76 +/- 9% vs. LAC < 75 years 75 +/- 4%, p = 0,693; OC > or = 75 years 67 +/- 7% vs. OC < 75 years 69 +/- 4%, p = 0,824). In the elderly patients surgical technique did not influenced overall five year survival (LAC > or = 75 years 43 +/- 8% vs. OC > or = 75 years 35 +/- 7%, p = 0,428), even five year colorectal cancer specific survival (LAC . or = 75 years 76 +/- 9% vs. OC a 75 years 69 +/- 7%, p = 0,393). CONCLUSION: Laparoscopically-assisted colorectal surgery should be particularly considered in geriatric patients, for the reason of lower incidence of postoperative complications. Oncological safety of miniinvasive approach in the treatment of colorectal cancer is valid also for the specific group of elderly patients.

[Comparison of oncological outcomes between laparoscopic and open procedures in non-metastazing colonic carcinomas]. / Srovnání onkologických výsledku laparoskopického a otevreného prístupu u nemetastazujícího karcinomu kolon.

AIM: The aim of our study was to compare oncological results of laparoscopic assisted coloctomy and open colectomy in the treatment of nonmetastatic colon cancer. MATERIAL AND METHODS: In this prospective nonrandomised clinical trail a group of elective laparoscopic or open resections in patients with the colon adenocarcinom was evaluated in the period between January 2001 and December 2006. The primary endpoint was overall survival, disease free survival and recurrence. RESULTS: A total of 220 patients were included in the analysis, of which 119 were operated laparoscopically and 101 by open technique. The median follow up period was 59 months (range 25-91) in the laparoscopic group and 68 months (range 25-96) in the open group (p = 0.0003). No statistically significant difference was found between the two treatment modalities regarding combined overall and disease-free survival for all stages (p = 0.16 resp. p = 0.27). With a respect of the tumor stage, there was a tendency of higher overall survival in favour of the laparoscopic group in the stage III, however the difference was not statistically significant (p = 0.07). During the follow up period the disease recurred in the laparoscopic and open group in 22 (18%), respective 20 (20%) patients (p = 0.78). The regression analysis showed that operative technique didn't influence neither overall or disease-free survival (p = 0.16, respective p = 0.27). CONCLUSION: Long-term results support laparoscopic colon cancer surgery as a safe and effective alternative to open surgery.

[Laparoscopic surgery for rectal carcinoma--long-term outcomes]. / Laparoskopická chirurgie karcinomu rekta--dlouhodobé výsledky.

INTRODUCTION: Laparoscopic surgery for rectal cancer is still debated. The aim of this study was to compare long-term results for patients undergoing laparoscopic or open surgery for rectal cancer. MATERIAL AND METHODS: The study included a group of 196 patients who underwent elective operation for rectal cancer using laparoscopic (103 patients) or open technique (93 patients) from 1 January 2001 to 31 December 2006. It was a unicentric, comparative, nonrandomized clinical study. Monitored data included characteristics of patients, surgery data, tumour characteristics and long-term outcomes. The main objective was the comparison of long-term outcomes. Three- and five-year overall survival, Kaplan-Meier curves of cumulative survival and recurrence rate were compared. P-value < 0.05 was interpreted as statistically significant result. RESULTS: Long-term results were obtained from, 180 patients, 8 patients of the laparoscopic group and 8 patients of the open surgery were lost. Although the study was not a randomised one, both groups were comparable in terms of sex, age, body mass index, tumour characteristics, types of procedure, neoadjuvancy and proportion of curative an palliative surgeries. Total three-year survival after open or laparoscopic procedure for all patients was 57% and 62% respectively, curative operations 71% and 79% respectively, stage I 100% and 90% respectively, stage II 89% and 80% respectively, stage III 54% vs. 75%, stage IV 8% vs. 15%. Total five-year survival after open or laparoscopic technique for all patients was 46% and 55% respectively, curative operations 60% and 75% respectively, stage I 88% and 86% respectively, stage II 87% and 83% respectively, stage III 41% vs. 72%, stage IV 0% in both groups. Except for significantly better five-year survival in group of laparoscopic technique and stage III (p = 0.0381), we reported no difference in long-term survival. The same results, i.e. no difference in long-term survival, with better outcomes in group of patients with laparoscopy and stage III (p = 0.01677) were obtained by analysis of cumulative survival curves. We proved no difference in incidence of local recurrence, distant recurrence and generalisation of the disease. CONCLUSION: In this nonrandomized single centre study the long-term oncologic outcomes were not significantly different in group of patients undergoing laparoscopic surgery for rectal cancer. The probability of survival in the laparoscopic group for stage III carcinoma was conversely significantly better.