Latex and silicone drains in surgery − is the ban on rubber drains really a step forward or rather a step back?

The use of silicone and latex drains is an integral part of surgical practice. Experience and the review of the world literature show that silicone drain is characterized by a much lower rate of fibrotic reaction of the tissue around the drain. The ability of a latex, or rubber, or popularly called rubber drain, to induce the formation of ligaments in its surroundings is advantageously used in situations where the targeted formation of scar tissue is desired. This feature is absent in silicone drains. However, nowadays the rule in most surgical departments is to use almost exclusively silicone drains, which is based on prevention of latex allergy. This article is devoted to the description of the different and mutually irreplaceable use of silicone and latex drains. Subsequently, he also discusses the question of whether the twilight of the use of latex drains in modern medicine is really progress, or rather retrogression.

Granulomatous mastitis treatment options and our experience.

Granulomatous mastitis (GM) is a rare benign inflammatory disease of the breast, first described by Kessler and Wolloch in 1972. Clinically, it can present as unilateral, sometimes painful, increasing breast resistance, or as a hard, irregular mass. Sonography is the most useful diagnostic method for GM evaluation. The only method for definitive diagnosis is the use of biopsy. In histological findings, GM is characterized by non-caseifying granulomas, often associated with microabscess and fistula formation. There is considerable heterogeneity in treatment options; this may explain the high recurrence rate which is close to 50%. Such a high recurrence rate is alarming and proves that current treatments are suboptimal. Two treatment options are discussed worldwide: conservative strategies involving drug therapy with corticosteroids versus a surgical approach involving partial or total mastectomy. All conservative treatment options are associated with a high risk of recurrence, and most patients require surgery in the end. Thorough excision of inflammatory tissue is crucial for successful treatment while negative surgical margins are associated with a low recurrence rate. The surgical approach to GM requires sufficient radicality and presumes knowledge in the field of reconstructive breast surgery, similarly to oncosurgical breast conservation operations. However, alternatives to GM treatment with oral steroids may be acceptable for patients concerned about surgery. This article presents six case reports of patients treated at our department.

Sebaceous carcinoma of the breast area a case report.

INTRODUCTION: Sebaceous carcinoma is a rare malignant tumor of the sebaceous glands. Sebaceous carcinoma occurs mainly in the head and neck region, rarely in trunk.  Case report: We present a case report of 63-year-old patient, operated on for sebaceous carcinoma in the right breast area. The patient underwent radical surgery, removal of the tumor with the skin, subcutaneous tissue, and the large pectoral muscle. The patient is in good clinical condition eight months after the surgery. She is being constantly monitored and so far, there are neither signs of local recurrence nor tumor progression.  Conclusion: Patients with rare tumors should be treated comprehensively with subsequent lifelong dispensarisation in specialized centers. Multidisciplinary medical teams are able to eruditely diagnose, recognize, treat and dispense patients.

Technical modifications of appendiceal transection during laparoscopic appendectomy.

INTRODUCTION: Appendiceal transection is the most critical part of laparoscopic appendectomy (LAPPE). The aim of our study was to evaluate post-operative and economic outcomes of laparoscopic appendectomy with different technical modifications of transection of the appendix. METHODS: This was a prospective, randomized, unicenter clinical study comparing different techniques of appendiceal transection in patients with acute appendicitis during the study period (18 months). The patients were randomized to one of three arms - endoloop, hem-o-lok clips and the stapler. RESULTS: In total, 120 patients were enrolled in the study. The shortest operative time was noted in the hem-o-lok arm (37.3 minutes); mean length of hospital stay (3.7 days) was comparable in all study arms. Postoperative morbidity was 6.6%; all recorded complications were SSIs (Surgical Site Infections). The number of postoperative complications was comparable in all study arms. Mean direct costs of laparoscopic appendectomy were lowest in the hem-o-lok arm. According to our findings, LAPPE is not a profit making surgery irrespective of the type of appendiceal transection (mean profit in the study patients was CZK -4019). CONCLUSION: The rate of postoperative complications was similar for all the technical modifications of appendiceal stump closure. As indicated by the study outcomes, hem-o-lok clips have the potential of becoming the method of choice in securing the appendix base during LAPPE.

Anus perinei ventralis in adulthood - case report.

Anorectal malformations present a type of the most serious congenital malformations, either in terms of treatment or treatment outcomes. Anorectal atresia can be subdivided into three categories: the supralevator form, the intermediate type of atresia and the low translevator type. One of the clinical forms of low translevator type in girls is a perineal fistula opening just behind the vaginal entrance on the perineum, with a fully developed sphincter complex dorsally from the fistula (so called anus perinei ventralis). The golden standard of surgical treatment of anus perinei ventralis in children is Peñas procedure, which was used as a guideline for anorectal reconstruction in our adult patient, as well.

An alternative method of surgical treatment in refractory GERD following laparoscopic sleeve gastrectomy.

Obesity has become a global problem with increasing prevalence. Undoubtedly, bariatric surgery is the most effective way to treat morbid obesity. Laparoscopic sleeve gastrectomy (LSG) is currently the most commonly performed bariatric procedure worldwide. The prevalence of gastroesopha-geal reflux disease (GERD) is also increasing, a close association with increasing prevalence of obesity being regarded as the main cause of this trend. The relationship between LSG and GERD is still unclear, at least controversial. If GERD occurs in the postoperative period, the first therapeutic intervention is initiation of proton pump inhibitors (PPI) treatment, which is effective in the vast majority of patients. In patients resistant to this treatment, conversion to laparoscopic Roux en Y gastric bypass (LRYGB) is usually necessary. The authors present the case report of a patient who developed GERD in the longer postoperative period and conversion to LRYGB was not appropriate due to previous complications and surgical procedures. Therefore, this patient was managed operatively by an alternative method - hiatoplasty with partial posterior fundoplication. The success of the treatment was confirmed clinically by disappearance of GERD symptomatology postoperatively even after PPI discontinuation. LRYGB is the method of choice for GERD after restrictive bariatric procedures. However, some patients are not suitable for conversion to LRYGB, and alternative treatment options are therefore needed.

Comparison of surgical intervention to Cyberknife® radiotherapy in the treatment of liver malignancies.

INTRODUCTION: Surgical resection is the method of choice in treating liver malignancies. In patients who are not suitable for radical surgical treatment, the radiotherapeutic system Cyberknife® is a viable treatment option. The aim of this study is to compare short- and long-term results of both treatment methods. METHODS: A retrospective analysis of prospectively collected data was performed, focused on patients undergoing treatment of liver malignancies either by surgical resection or by the Cyberknife® system from 2013 to 2016. Only patients treated using a single treatment method were included in the study. RESULTS: A total of 260 patients were analysed; 142 were treated by performing surgical resection and the remaining 118 using Cyberknife® radiotherapy. Median survival was 30.65 months for the surgical resection and 22.93 for the Cyberknife® therapy; median overall survival was 27.63 months. Three-year cumulative survival was 47.4% for the resection and 19.9% for radiotherapy. Kaplan-Meier analysis did not demonstrate a statistically significant difference in disease-specific survival between both groups (p=0.082, CI 95%). Results limited only to colorectal liver metastases showed a statistically significant difference in disease-specific survival (p=0.031, CI 95%). CONCLUSIONS: Results of this study show statistically indifferent overall disease-specific survival of both groups. However, the significant difference in 3-year survival still indicates a predominant position of surgery in the diagnostic and therapeutic management of patients with liver malignancies. Nevertheless, Cyberknife® radiotherapy may actually represent a viable treatment alternative, particularly in patients unable to undergo surgical resection, although a longer follow-up period is necessary to obtain more robust results.

Treatment strategies for patients with colorectal carcinomaand synchronous liver metastases.

Multimodal approach in the management of patients with colorectal carcinoma and synchronous liver metastases allows for the application of various combinations of treatment modalities (colorectal resection, liver resection, chemotherapy, radiotherapy). The primary-first approach and simultaneous resection represent traditional strategies used because the primary tumor is thought to be the main source of subsequent metastases as well as the source of symptoms associated with local tumor progression (obstruction, perforation, colorectal bleeding). Poor long-term outcomes of traditional strategies have led to the proposal of reverse strategies (the liver-first approach and up-front hepatectomy approach). The idea behind reverse strategies is to give preference to liver resection over colorectal resection (prognosis of patients with stage IV colorectal cancer is determined mainly by the curability of liver metastases). According to available literature, reverse strategies are suitable mainly for patients with asymptomatic primary tumor. Treatment strategy for each patient should be individualized depending on the patients performance status, comorbidities, and tumor stage. In this paper, the authors offer an up-to-date review of treatment strategies for patients with colorectal carcinoma and synchronous liver metastases focusing on available data of evidence-based medicine. Key words: liver first - primary first - colorectal carcinoma - liver metastases - reverse strategies.

[Radiotherapy in the treatment of rectal cancer is it time to move on?] / Radioterapie v lécbe karcinomu rekta - cas na zmenu?

Multidisciplinary treatment approach in accordance with current guidelines represents a gold standard of care for patients with rectal cancer. Radical surgical resection is a fundamental and the only curative treatment modality. Patients with locally advanced rectal cancer (cT3-4N0M0 or anyTN1-2M0) are indicated for neoadjuvant radiotherapy or radiochemotherapy. However, there are many controversies regarding neoadjuvant radiotherapy indications in the available literature. Evidence-based medicine data suggest that neoadjuvant radiotherapy is associated with improved local control of the disease, but has no impact on patients survival. Moreover, neoadjuvant radiotherapy is associated with less favorable perioperative outcomes and significantly deteriorates anorectal function of patients after sphincter-preserving rectal resections.Key words: rectal cancer - radiotherapy - postoperative morbidity - survival - functional outcome.

[The risks of retroperitoneoscopic adrenalectomy]. / Rizika retroperitoneoskopické adrenalektomie.

INTRODUCTION: Minimally invasive adrenalectomy has become the gold standard for surgery of the suprarenal gland. Retroperitoneoscopic adrenalectomy with dorsal approach is preferred. The aim of our case report is to discuss potential complications that may arise from retroperitoneoscopic adrenalectomy, specifically an intra-operative injury of the inferior vena cava. CASE REPORT: A 47-year-old male patient was admitted to undergo elective adrenalectomy on the right side. The reason for the surgery was a hormonally active adenoma with clinical signs of Conns syndrome. Biochemistry revealed the typical signs of hyperaldosteronism. A one-year history of unsuccessful treatment for hypertension was known. Ultrasound examination showed an enlarged suprarenal gland on the right side with the diameter of 5.2 cm. A CT scan confirmed the results of the ultrasound examination. Retroperitoneoscopic adrenalectomy was performed. The inferior vena cava was intraoperatively injured. The high pressure in the retroperitoneal space prevented bleeding. The injury to the vena cava was treated using a continuous stitch without the necessity of conversion to open surgery. The patient was discharged on the third postoperative day without any other complications. CONCLUSIONS: Retroperitoneoscopic approach is regarded by many authors as the new gold standard for adrenalectomy. However, very serious complications such as an injury of the inferior vena cava may occur. It is possible to treat this injury using retroperitoneoscopy. The risk of air embolization due to elevated pressure in the retroperitoneum (20 mm Hg) and open lumen of the IVC needs to be taken seriously.Key words: adrenalectomy - retroperitoneoscopy - complication.

[Minimally invasive liver resections]. / Miniinvazivní resekce jater.

INTRODUCTION: Laparoscopic surgery is a standard and preferred modality of surgical treatment. Progress in laparoscopic procedures and the development of dedicated technology have made it possible to approach laparoscopic liver resections in selected patients. Initially operations were performed for benign and peripheral lesions, but nowadays more than 50% of total laparoscopic surgery is due to malignancy. METHOD: We conducted a literature search using Pubmed; by entering the keywords "Laparoscopic Liver Resection" we obtained a set of publications focused on this issue. We limited the selection to the period from 1991 to the present. Additionally, the selection was limited to reviews, prospective randomized trials or cohort studies. Also, we selected publications in the English and Czech languages. RESULTS: On the basis of the search, we identified 2345 publications, of which the abovementioned criteria were satisfied by 319 papers. Of these, 312 publications were in English and 7 in the Czech language. 59% of the searched publications were published in the last 5 years, which gives evidence of progression of the laparoscopic liver resection method. CONCLUSIONS: Laparoscopic liver resections are considered as safe for both benign and malignant lesions with comparable oncological outcomes compared to open resections. They also provide better short-term results such as a shorter hospital stay, lower overall costs, lower postoperative pain, reduced blood loss, earlier intestinal recovery, generally shorter convalescence of the patient, better cosmetic results and a lower rate of complications.Key words: laparoscopic liver resections - hand-assisted laparoscopy.

[Laparoscopic diverting ileostomy in rectal cancer surgery]. / Laparoskopická protektivní ileostomie v chirurgii karcinomu rekta.

INTRODUCTION: Low anterior resection (LAR) with total mesorectal excision (TME) represents the gold standard for patients with low rectal carcinoma. Protective ileostomy (PI) is commonly performed during LAR in an effort to protect low rectal anastomosis. The aim of this study is to analyse outcomes in our own patient population, focusing on morbidity associated with PI. METHOD: A retrospective clinical study of patients operated on between 2013 and 2015 was conducted in University Hospital Ostrava. All patients after LAR with PI due to low rectal cancer were included. The study design did not require randomisation. RESULTS: A total of 52 patients who underwent LAR with PI were included. Mean tumour height was 9.1±2.3 cm. 15.4% of the patients were classified as ASA I, 53.8% were classified as ASA II and 32.7% of the patients as ASA III. 30-day postoperative morbidity was 38.5%, and complications associated with PI (within 30 days after LAR) occurred in 7 (13.5%) patients. Three of these patients underwent urgent surgical revision due to small bowel obstruction (PI semirotation around its longitudinal axis in two patients and volvulus of the small bowel around PI in one patient). Mean time interval between PI creation and reversal was 252 days. During this period, complications associated with PI were detected in 25 (48.1%) patients; seven patients had more than one complication. Minor complications (such as peristomal dermatitis, stoma herniation or bleeding, wound infection after stoma reversal) were observed in 17 (32.7%) patients. Major complications (small bowel obstruction at the site of PI, dehydration due to high stoma output, intraabdominal abscess after stoma reversal) occurred in 8 (15.4%) patients. CONCLUSIONS: PI offers protection to low colorectal or coloanal anastomosis in rectal cancer surgery. However, this benefit is counterbalanced by a high risk of various complications which may occur during the whole period when PI is present. The decision for diversion should therefore be made only after careful consideration.Key words: rectal cancer - low anterior resection - laparoscopy - protective ileostomy - stoma complications.

[Complete minimally invasive Ivor-Lewis esophageal resection]. / Kompletní miniinvazivní Ivor-Lewisova resekce jícnu.

INTRODUCTION: Minimally invasive esophagectomy is becoming a standard procedure in the treatment of esophageal cancer. We would like to present our experience with Ivor Lewis esophagectomy completed by minimally invasive technique. METHODS: The primary aim of the study was to analyse potential technical difficulties and intraoperative complications of thoracolaparoscopic Ivor Lewis esophagectomy with intrathoracic anastomosis. A secondary aim of the study was to evaluate postoperative complications according to the Clavien-Dindo classification. The inclusion criterion for the study was a history of thoracolaparoscopic esophagectomy. Multidisciplinary approach was employed in the diagnosis, surgery indications and perioperative care of all patients. RESULTS: Between January 2011 and January 2016, 19 patients underwent completely minimally invasive esophagectomy with intrathoracic anastomosis. There were 13 men and 6 women. Adenocarcinoma was confirmed by histopathological examination in all the patients. The cumulative postoperative morbidity was 68.4%. According to the Clavien-Dindo classification, we recorded grade I complications in 10.5% of the patients, grade II in 15.8%, grade III in 36.8% and grade IV in 5.3% of the patients. Anastomotic leak was the most serious complication; it was initially managed by negative pressure (vacuum) therapy followed by stent implantation. Postoperative mortality was 0%. Mean hospital stay was 12 days and mean stay at intensive care unit was 3.6 days. CONCLUSIONS: The basic oncosurgical principles of radicality need to be respected during minimally invasive procedures. However, functionality, safety, and cost effectiveness have to be preserved as well. In this paper, we present thoracolaparoscopic Ivor Lewis esophagectomy as one of feasible and accessible options of intrathoracic anastomosis. It seems to be safe with respect to technical obstacles, short-term and long-term complications.Key words: esophagectomy - intrathoracic - anastomosis - laparoscopy - thoracoscopy.

[Primary malignant small bowel tumors]. / Primární zhoubné nádory tenkého streva.

INTRODUCTION: Small bowel presents 75% of the gut length and 90% of the gut surface. However, primary malignant tumors of the small bowel represent only 1-3% of all malignant gastrointestinal tumors. The aim of the present paper is to offer a current review of primary malignant small bowel tumors - their epidemiology, localization, symptoms, diagnostic and treatment options. METHODS: The authors have performed a comprehensive review of databases Medline, Scopus and Google Scholar focusing on studies regarding small bowel cancer. RESULTS: The most frequent small bowel tumors are adenocarcinoma (30-40%), neuroendocrine tumors (35-44%), lymphomas (10-20%) and gastrointestinal stromal tumors (12-18%). Symptomatology is non-specific and varies widely, which is why small bowel cancer is usually diagnosed in a locally advanced stage of the disease. Diagnosis is determined through standard methods (gastroscopy, colonoscopy, CT) and complementary special diagnostic modalities (capsule enteroscopy, enteroscopy, octreotide scan, etc.). Diagnostic process with a negative outcome frequently leads to diagnostic laparoscopy/laparotomy.The treatment of small bowel cancer in patients operated in acute settings is done according to acute abdomen management guidelines. Elective surgery of small bowel cancer differs with respect to the tumor type. Adenocarcinomas and neuroendocrine tumors should be treated with surgical R0 resection with radical lymphadenectomy (and multivisceral resection if necessary). Patients with GIST should undergo en bloc resection with 2-3cm safety resection margins (lymphadenectomy is not necessary). Palliative resection of neuroendocrine tumors can be associated with a significant clinical effect. On the other hand, palliative resection of adenocarcinomas of GIST is not advocated. CONCLUSION: Small bowel cancer is an infrequent condition. Symptoms are non-specific; patients are often diagnosed in an advanced stage of the disease. Achieving R0 surgical resection is usually difficult due to locally advanced stage of the disease. Besides the tumor type, patients prognosis is influenced by very late diagnosis of the tumor. KEY WORDS: primary tumor - small intestine - diagnostics - treatment options - surgical resection.

[Laparoscopic resection rectopexy in the treatment of obstructive defecation syndrome]. / Laparoskopická resekcní rektopexe v lécbe obstrukcního defekacního syndromu.

INTRODUCTION: Obstructive defecation syndrome (ODS) presents a common medical problem, which can be caused by various pelvic disorders; multiple disorders are frequently diagnosed. At the present, a high number of corrective techniques are available via various surgical approaches. Laparoscopic resection rectopexy is a minimally invasive technique, which comprises redundant sigmoidal resection with rectal mobilisation and fixation. METHODS: The aim of this paper was to evaluate the safety and effectiveness of laparoscopic resection rectopexy in the treatment of patients with ODS. The evaluation was performed via our own patients data analysis and via literature search focused on laparoscopic resection rectopexy. RESULTS: In total, 12 patients with ODS undergoing laparoscopic resection rectopexy in University Hospital Ostrava during the study period (2012-2015) were included in the study. In our study group, mean age was 64.5 years and mean BMI was 21.9; the group included 11 women (91.6%). ODS was caused by multiple pelvic disorders in all patients. Dolichosigmoideum and rectal prolapse (internal or external) were diagnosed in all included patients. On top of that, rectocoele and enterocoele were diagnosed in several patients. Laparoscopic resection rectopexy was performed without intraoperative complications; mean operative time was 144 minutes. Mean postoperative length of hospital stay was 7 days. Postoperative 30-day morbidity was 16.6%. All postoperative complications were classified as grade II according to Clavien-Dindo classification. Mean preoperative Wexner score was 23.6 points; mean score 6 months after the surgery was 11.3 points. Significant improvement in ODS symptoms was noted in 58.3% of patients, and a slight improvement in 16.6% of patients; resection rectopexy provided no clinical effect in 25% of patients. CONCLUSION: It is fundamental to carefully select those patients with ODS who could possibly profit from the surgery. Our results, in accordance with published data, suggest that laparoscopic resection rectopexy is a valuable surgical technique in the treatment of patients with ODS caused by multiple pelvic disorders. KEY WORDS: obstructive defecation syndrome - constipation - resection rectopexy - operative techniques - pelvic floor disorders.

[Current standards of care in the management of patients with abdominal sepsis]. / Soucasné standardy v péci o pacienty s brisní sepsí.

INTRODUCTION: Abdominal sepsis patient management is an issue of high current importance, and the amount of knowledge keeps increasing and changing the approach to critically ill patients with abdominal sepsis. METHODS: Literature search (in MEDLINE, PubMed and Google Scholar databases) was done, focused on identification of relevant studies. The aim of this paper is to provide a review of current trends in diagnosing and predicting the prognosis of, and recommended treatment standards for patients with abdominal sepsis. RESULTS: Abdominal sepsis is defined as the Systemic Inflammatory Response Syndrome (SIRS) with an abdominal infection requiring a surgical intervention to control the source; or SIRS with an infection within 14 days after any major surgery. Although many different monitoring and scoring systems exist, daily careful clinical examination is the most reliable diagnostic tool in identification of septic patients. Whenever abdominal sepsis is suspected, the gold standard comprises immediate administration of broad-spectrum antibiotics, transferring the patient to the intensive care unit, with surgical intervention and supportive intensive care based on current guidelines of the Surviving Sepsis Campaign. Source control surgery is the principal therapeutic modality for patients with abdominal sepsis. The most relevant negative prognostic factors include clinical signs of septic shock and the necessity of high doses of catecholamines. CONCLUSION: Early identification of septic patients and prompt implementation of a complex, evidence-based interdisciplinary approach are the principal conditions for improving healthcare outcomes of care provided to patients with abdominal sepsis.

[Hepatic pseudolesions adjacent to the falciform ligament]. / Hepatální pseudoléze v blízkosti falciformního ligamenta.

INTRODUCTION: Accurate detection of hepatic pseudolesions using multi-detector CT and MRI examinations is crucial for the differentiation of benign alterations from primary and secondary malignant lesions in hepatic parenchyma. METHOD: The authors conducted a systematic literature review in PubMed. "Liver" and "pseudolesion" were used as keywords in English and Czech, and papers/articles published from 2000 to 2014 were retrieved. RESULTS: The authors presented a literature review. In addition, the authors performed a retrospective evaluation of a group of patients treated for liver disease at University Hospital Ostrava where this anomaly was encountered in 7 cases.In 3 of the patients, diagnostic laparoscopy was done, with visual examination of the lesion accompanied by intraoperative ultrasound exam (IOUS) and partial excision, to establish the diagnosis. Subsequent histological assessment of the specimens confirmed the diagnosis of a steatotic lesion in each of these 3 patients. Additional 2 of the 7 patients underwent liver surgery for concurrent metastatic lesions of colorectal cancer and an open-access revision of the suspected lesions was performed. Visual inspection and intraoperative ultrasound (IOUS) was followed by excisional biopsy. The histology revealed macro- and micro-vesicular steatosis and excluded malignant changes. The last 2 patients still continue to be followed-up regularly on a 6-month routine check-up basis at our hepatology unit. CONCLUSION: The authors presented their own experience gained through inter-disciplinary cooperation at Multidisciplinary conferences. A literature overview of this unusual subject is also included. Particularly in oncologic patients, correct interpretation of these pseudolesions may help to avoid unnecessary biopsies, further imaging examinations and diagnostic laparoscopies and/or explorative laparotomies.

[A new strategy in the surgical treatment of multiple liver tumors - ALPPS]. / Nová strategie chirurgické lécby mnohocetného nádorového postizení jater - ALPPS.

INTRODUCTION: This systematic review was performed to introduce the two-staged hepatectomy procedure (Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy - ALPPS) and present its current results. MATERIAL AND METHODS: We conducted a systematic literature search using the PubMed database with key words "ALPPS" or "staged liver resection". The inclusion criteria were randomized trials or cohort studies. Case reports were excluded. The primary end-point was the assessment of liver tissue hypertrophy after the ALPPS procedure. Morbidity and mortality evaluation were the secondary end-point. RESULTS: After an electronic data search of PubMed with the selected key words, six cohort studies evaluating 96 patients met the inclusion criteria. There was no prospective randomised trial. Based on the results of the individual studies, liver hypertrophy ranged from 74 to 87%. Morbidity and mortality ranged from 53 to 71% and 0 to 13% respectively. CONCLUSIONS: Despite the higher morbidity and mortality the ALPPS procedure could be a promising technique for a selected group of patients with multiple liver tumors. However long term results are not yet available.

[Surgical rectocele repair - many techniques, few unambiguous conclusions]. / Chirurgická lécba rektokély - mnoho technik, málo jednoznacných záveru

INTRODUCTION: Surgical treatment of rectocele represents a controversial issue on the boundary between medical specialisations with many different corrective surgical techniques. Is it possible, based on the available knowledge, to determine an optimal operative technique for rectocele repair? METHODS: Complex literature search focusing on the identification of rectocele surgical repair studies in the MEDLINE, PubMed and Google Scholar databases. The aim of this paper is to offer a comprehensive review of the contemporary situation as regards rectocele surgical repair. RESULTS: There are four main possible approaches for rectocele repair - transvaginal, transanal, transperineal and transabdominal. Posterior colporrhaphy with levatoroplasty is the traditional transvaginal technique, performed at most gynaecological departments in various modifications. Defect-specific rectocele repair and mesh repair represent newer transvaginal techniques which offer better postoperative functional results, although with the risk of possible serious complications. Traditional transanal rectocele repair (vertical and horizontal plication of the rectovaginal septum) is currently performed only rarely due to its worse results in comparison with the transvaginal approach. Rectal resection using endostaplers (STARR and TRANSTAR techniques) is a modern transanal technique. Stapled rectocele repair leads to the correction of anorectal anatomical conditions and to the improvement of obstructive defecation symptoms with acceptable morbidity. Transperineal approach is usually used in patients with rectocele and anal incontinence due to a proven sphincter defect. Transabdominal laparoscopic approach is based on vaginorectopexy by means of mesh implantation, and it is indicated especially in patients with rectocele and enterocele. CONCLUSION: Based on the results of published studies, it is not possible to determine clear guidelines for rectocele surgical repair. Posterior colporrhaphy and stapled transanal repair are the most common techniques in practice. Prospective randomized studies focusing on the comparison between transvaginal and stapled transanal approach for rectocele repair are needed.

3D high resolution anorectal manometry in functional anorectal evaluation.

INTRODUCTION: Anorectal manometry is a diagnostic tool designed for the evaluation of functional parameters and assessment of anorectal activity coordination. In the last decade, the development of 3D high-resolution (HR) manometry and its expansion in experimental and clinical settings has been evident. Literature search (in the MEDLINE and PubMed databases) focusing on studies about 3-dimensional HR manometry was performed. The aim of this paper is to offer an overview of the current state of the art of manometry while concentrating on indications, protocol of the procedure and applicability of this examination in clinical practice. RESULTS: Development of solid catheters with miniaturized semiconductor sensors has enabled very precise measurement (high resolution) and creation of anorectal 3D pressure models. In comparison with water-perfused manometry systems, this method offers more accurate and more detailed data that can be employed in functional disorders assessment. The indications for anorectal manomery are symptoms of faecal incontinence and functional constipation. This modality can also be used in biofeedback therapy, in functional anorectal pain and when assessing patients undergoing continent rectal resection. The HR manometry protocol should comprise the measurement of anorectal resting pressures, the squeeze manoeuvre, the bear down manoeuvre, the cough reflex test, the rectoanal inhibitory reflex examination, rectal sensitivity testing and rectal compliance measurement. Processed data are fundamental in determining an individually tailored treatment plan for patients suffering from anorectal functional disorders. CONCLUSION: Anorectal 3D HR manometry presents a valuable diagnostic modality offering a new dimension in anorectal function understanding and can reveal new pathophysiologic mechanisms of anorectal functional disorders.