Fasciitis necrotisans - duplicitas casuum.

Necrotizing fasciitis is a dangerous bacterial infectious disease that is not commonplace in Czech society. On the other hand, neither is it so rare that the majority of surgeons should not come across it occasionally. In the early stages, pathological changes in fascia, subcutaneous tissue and even skin may run an inconspicuous course. However, this can rapidly deteriorate into shock and sepsis which may lead to multi-organ failure and an imminent life-threatening condition. The fatality rate of necrotizing fasciitis among high-risk groups (e.g. diabetics, patients who are immuno-compromised, obese and/or elderly, malnourished, or with a history of drug use), is particularly steep, reaching as high as 73%. Treatment for this condition consists of early, radical surgical intervention in conjunction with targeted antibiotherapy. Complex resuscitative and intensive care, including rehabilitation, are standard components of post-surgical management. Use of hyperbaric oxygen therapy, if such an opportunity exists, is also recommended. Interdisciplinary collaboration is a vital prerequisite for successful treatment. This article describes two case-studies of necrotizing fasciitis that occurred in men of similar age during a three-year period. Both patients presented with very similar and complicated disease courses, and both were successfully treated by the same interdisciplinary team comprised of clinicians from various specialized departments. Key words: necrotizing fasciitis - radical necrectomy - antibiotherapy - hyperbaric oxygen therapy - complex resuscitative and intensive care.

[Optimizing the treatment procedure in crural ulcers - a pilot study of the surgical method]. / Optimalizace lécebného postupu u kozního trofického defektu bérce pilotní studie chirurgické metody.

INTRODUCTION: Current medical knowledge has provided us with a wide range of possibilities of treating chronic wounds. Over the recent decades, in particular, significant progress has been made in this field. The authors present an overview of current knowledge of chronic wound healing, pointing out the surgeons role in the process of chronic wound management. Using surgical therapy, we are able to heal a chronic wound in a shorter period of time, particularly if the treatment is accelerated by the application of platelet-rich plasma (PRP) as a source of growth factors. METHODS: The pilot randomized prospective study included four patients with chronic wounds of the lower leg after previous failure of conservative therapy who were indicated for skin transplantation. Following previous vacuum-assisted closure therapy, the patients undergoing skin transplantation were prospectively randomized into two groups. Autologous PRP was used in one of the groups and standard skin transplantation without PRP was performed in the other one. RESULTS: In the PRP group, 99% of the wound areas were healed on the 15th day after the operation. In the other group, 90% of the areas were healed on the 15th day following the operation. In the PRP group, complete healing of the defect occurred in both patients at 15 and 20 days post-surgery. In the second group, one patient completely healed within 28 days; the other one was not fully healed even at 3 months post-surgery. CONCLUSIONS: Most patient groups at great risk may benefit from the method using PRP, as well as patients with chronic wounds who have failed conventional methods available for both general and local therapy. This fact has been confirmed by the authors initial experience presented.Key words: platelet-rich plasma (PRP) - platelets wound healing chronic wound.

[Intestinal diverticulum localized in antimesenterial side of jejunum as a reason of perforation peritonitis--case report]. / Divertikl lokalizovaný na mezenteriální strane jejuna jako prícina perforacní peritonitidy--kazuistika.

Authors present the case of patient with perforation of atypicaly localised diverticula of small intestine. The most important in clinical picture of patient was the sudden progress of sepsis and symptoms of organ failure. This status was progreding after the first operative revision of abdominal cavity when no explanation for peritonitis was found. During the second operation revision we found the perforated diverticula of the mesenterial side of distal jejunum. In the period after operation several complications such as wound healing failure and organs failure were occurred.

[Peritonitides caused by gastrointestinal perforations--analysis of an elderly patient group]. / Peritonitidy zpusobené perforací trávicí trubice--analýza gerontologické skupiny pacientu.

AIM: The aim of this study was to assess causes of peritonitides resulting from acute abdominal perforations in a group of elderly patients and to evaluate the yield of common classification systems in predicting the risks of postoperative complications, in particular of postoperative death rates. PATIENTS AND METHODS: The retrospective analysis included 123 patients aged 70 y.o.a. and over (65 males, 58 females, the mean age was 78.7 y.o.a.), who underwent surgical revision for signs of peritonitis due to urgent GIT perforation, over a five-year period. The patients were assigned to groups based on their baseline diagnosis and on the procedure performed. The PSS (Peritonitis Severity Score) and MPI (Mannheim Peritonitis Index) classification systems factors were assessed. Statistical significance of the classification systems was evaluated, as well as their relation. RESULTS: Overall death rate of the studied group was 30% (37 patients). The highest death rate related to the baseline diagnosis was observed in the GIT ischemia group (67%). Based on the procedure, the highest death rate was observed in the enterostomy group (75%). Overall morbidity related to a known wound infection was 24% (29 patients). Significant correlation between the both classification systems was demonstrated (Spearman's correlation coefficient 0.86). Of the all studied factors creating classification schemes, the following proved statistically most significant: ASA IV, peritonitis Hinchey grade III-IV, existing immunosuppression and signs of organ failure (p < 0.0001). CONCLUSION: Perforation peritonitis remains a high risk condition, considering the postoperative morbidity rates, as well as the death rates. Perforation of the sigmoid diverticle was the commonest cause of GIT perforations in the elderly. The highest death rate was observed in those with ischemic ethiology. The PSS and MPI scoring systems are of high prediction value in the assessment of the risk of postoperative death.

[Peroperative diagnostics of acute bowel ischemia using ultraviolet light and fluorescein dye]. / Peroperacní diagnostika ischemie streva za pouzití fluoresceinu a ultrafialového svetla.

Acute bowel ischemia continues to have a high mortality rate. The main factor related to this poor outcome is considered to be the delay in diagnosis. The ability to detect ischemia early and to assess the extent of bowel involvement, are the most important aspects of successful treatment. The combination of ultraviolet (UV) light and fluorescein dye would be considered a simple, reliable and technically easy procedure for diagnosis of intestinal ischemia. The method can be used both for laparotomy when the source of UV light is a Wood's lamp as well for laparoscopy when the optical filters are placed to the light source of laparoscopic set to produce UV light. Present clinical experience shows that the method is precise, objective and accessible and that it gives a greater amount of independence to the surgeon allowing him to make the diagnosis of intestinal ischemia without having to rely on the assistance of other specialists.

Gastrointestinal stromal tumors: review on morphology, molecular pathology, diagnostics, prognosis and treatment options.

Gastrointestinal stromal tumors (GISTs) are the most common non-epithelial mesenchymal tumors of the gastrointestinal tract. GISTs represent a specific group of mesenchymal tumors with uncertain biological behaviors. These tumors are assumed to originate from progenitor cells, usually unable to self-regenerate, which differentiate towards Cajal cells. Apart from common GISTs that occur predominantly in adulthood, a heterogeneous group of tumors has been described that are morphologically identical with GIST, but have a specific clinical presentation and biological properties. Approximately 30% of newly diagnosed GISTs are malignant or have a high potential for malignancy. Currently, GISTs are routinely identified with histological, immunohistochemical, and molecular genetic assays. However, clinical diagnoses, particularly of small or intramural GISTs, might be difficult. The most useful techniques for imaging and monitoring disease progression are endoscopic examinations and fused PET/CT imaging. Surgical treatment is the first-line treatment and the only method that might lead to full remission in patients with a primary GIST. There is currently no consensus on the issues of whether to perform resections in patients with positive margins or resections of metastases. Endoscopic resection could represent a relatively simple and less aggressive alternative as compared to traditional surgery in the treatment of small sized GISTs. Biological therapy with imatinib mesylate is recommended for patients with newly diagnosed, locally advanced, inoperable, or metastasizing gastrointestinal GISTs that express the c-KIT protein. Treatment may reduce a primary tumor to a size small enough for surgical excision. Current research is focusing on the development of new therapies for the treatment of advanced disease and/or disease prophylaxis.