[Obstructed defecation syndrome - review article]. / ODS Obstrukcní defekacní syndrom - souhrnné sdelení.

INTRODUCTION: Obstructed defecation syndrome (ODS) is one of the main causes of primary constipation. It is caused by anatomical disorders in the pelvic floor region (rectocoele, en-terocoele, rectal intussusception, rectal prolapse), but it always occurs in combination with a functional defect of defecation. This review provides a comprehensive view of the diagnosis and treatment of the syndrome. METHOD: Treatment may be conservative or surgical. Conservative treatment involves a complex of approaches to the practice of defecation, regime and dietary measures together with pelvic floor rehabilitation and psychological support. The symptoms of ODS persist in some patients despite conservative treatment and this is why these patients are eligible for surgery. Surgical approaches can be divided into transvaginal, transabdominal and transanal. Transanal procedures, associated with good short-term results and low complication rates, are used most frequently. Long-term results are still under discussion. CONCLUSIONS: Since ODS is caused by the combination of functional and anatomical disorders, treatment has to be targeted at a wide range of causes. Therefore, only a multidisciplinary approach as well as a combination of conservative treatment and strictly and correctly indicated surgical procedures can lead to good long-term results.Key words: ODS - rectocoele - intussusception - STARR.

[Current status regarding surgical treatment of pancreatic cancer in the Czech Republic]. / Aktuální stav chirurgické lécby karcinomu pankreatu v Ceské republice.

INTRODUCTION: The aim is to map the current situation in the surgical treatment of pancreatic cancer in the Czech Republic. This information has been obtained from surgical treatment providers using a simple questionnaire and by identifying the so called high volume centres. The information has been collected in the interest of organizing and planning research projects in the field of pancreatic cancer treatment. METHOD: We addressed centres known to provide surgical treatment of pancreatic cancer. A simple questionnaire formulated one question about the total number of pancreatic resections, also separately for the diagnoses PDAC - C25, in the last two years (2014 and 2015). Other questions focused on the use of diagnostic methods, neoadjuvant therapy, preoperative assessment of risks, the possibility of rapid intraoperative histopathology examination, Leeds protocol, monitoring of morbidity and mortality including long-term results, and the method of postoperative follow-up and treatment. ÚZIS (Institute of Health Information and Statistics of the Czech Republic) was addressed with a request to analyze the frequency of reported total numbers for DPE, LPE, TPE and to do the same with respect to diagnosis C 25 for the last two years, available for the entire Czech Republic (2013, 2014). RESULTS: Altogether 19 institutions were identified by the preceding audit, which reported more than 10 pancreatic resections annually; these institutions were addressed with the questionnaire. Sixteen institutions responded to the questions, 13 of them completely. CONCLUSION: The majority of potentially radical surgeries for PDAC in the Czech Republic are carried out at 6 institutions. All of the institutions that participated in the survey collect data about morbidity and mortality and monitor their results. KEY WORDS: pancreas cancer outcomes surgery.

[Different impact of the laparoscopic and laparotomic approach on the immune response induced by surgical procedure]. / Rozdílný dopad laparoskopické ho a laparotomického prístupu na imunitní odpoved' navozenou chirurgickým zákrokem.

INTRODUCTION: The laparoscopic approach has been adopted to treat gastrointestinal tract malignities over the last decade. This approach has become a routine method. The laparoscopic approach has been proven to provide better short-term results. Its long-term results are similar. There has also been research into the affection of the local and systemic immune reaction following surgical procedures. Available findings reveal demonstrably diminished negative impacts on the systemic immune response after laparoscopic procedures. The research papers dealing with local immunity are only experimental and their results are heterogeneous. AIM: To give a literature review of the influence of a surgical procedure on the systemic and local immune response and to focus more closely on the comparison the immune response after laparoscopic and laparotomic approaches. REVIEW: Authors provide a summary of current knowledge and studies which deal with the affection of the immune system by surgical procedures. The summary is dividend into parts discussing systemic and local immune responses. The role of macrophages is elaborated on in detail depending on the type of surgical approach. The results and the above-mentioned of experimental studies and their possible impact on clinical practice are subjected to critical analysis. CONCLUSION: A great majority of studies support the hypothesis that the laparoscopic approach leads to less systemic immunosuppression and thus to the lower risk of the malignant spread of disease. Comparison of the impacts of laparoscopy and of open procedures on the local immune response has not been resolved yet.

[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.

[Perilunar dislocation of the corpus in a patient with aplasia of the scaphoid]. / Perilunátní luxace karpu u pacienta s aplazií skafoidea.

Congenital aplasia of the scaphoid is a rare abnormality arising when the distal row of carpal bones is dislocated radially and proximally, the capitate replaces the scaphoid, and the lunate is triangular instead of quadrilateral in shape. The scaphoid bone which makes a functional bridge between the proximal and the distal row is a stabilising element under normal anatomical conditions. If it is absent, the carpus structure is disturbed and its radial part is prone to perilunar dislocation, because stability is provided only by the ligaments. However, a perilunar dislocation associated with aplasia of the scaphoid has not been described in the literature yet. In the case reported here, after arthroscopic examination ascertaining that the capsular ligaments are not interposed between the joints, the dislocation was managed by closed reduction and Kirschner wire transfixation for 8 weeks, and the wrist was immobilised with a below-elbow plaster splint for the same period. A 22-month follow-up did not show any signs of wrist instability or restriction in hand function.

[Gastrointestinal stromal and other mesenchymal gastric tumors--laparoscopic management?]. / Gastrointestinální stromální a jiné mezenchymilni tumory zaludku--laparoskopické resení?

INTRODUCTION: This study was aimed to evaluate a set of gastrointestinal stromal tumors (GIST) of the stomach managed with a laparoscopic technique (GIST). MATERIALS AND METHODS: The study covers a period from January 1,2007 until December 31, 2009 during which 12 patients underwent the laparoscopic removal of stomach tumors in the Regional Hospital in Pardubice. In all cases tumors were removed completely in a laparoscopic way, including the healthy border of the stomach tissue. The defect created in the stomach wall was sutured laparoscopically as well. On completion the sufficiency of the sutures was reviewed gastroscopically. RESULTS: No death was observed in our study. Two patients suffered from wound infection (secondary healing), one of them requiring repeat surgery owing to the excessive narrowing of the distal part of the stomach. The dehiscence of the laparoscopic suture or other intraabdominal complications was not observed. 3 patients underwent chemotherapy by Imitinib. During surveillance all patients were free of signs of tumor progression or local recurrence. DISCUSSION: Gastric GISTs are very rare tumors but their incidence is increasing. At this time the consensus about the necessity of preoperative unambiguous differentiation between malignant or less malignant variants is not available. The strict differentiation is very difficult and the determination to choose a more radical surgical approach for more malignant variants is not clear-cut. CONCLUSION: In case of gastric GIST the local removal of a tumor with the healthy border of the stomach tissue may be chosen as an adequate approach. Our results support this local surgical approach.

[Chronic lunotriquetral instability of the wrist. Presentation of our method of treatment]. / Chronické lunotriquetrální nestability zápestí--vlastní metoda osetrení

PURPOSE OF THE STUDY: One of the causes of pain on the ulnar side of the wrist is post-traumatic lunotriquetral (LTq) instability, which is difficult to detect on radiographs. For diagnosis, arthroscopic examination is most reliable. The methods for treatment of LTq instability include mere immobilization, ligament reconstructions and LTq joint stabilization with Kirschner's wires in acute conditions, and stabilization of the LTq joint by tenodesis or arthrodesis. In this study our method of treating chronic isolated injury to the lunotriquetral ligament is described. MATERIAL: The group comprised 43 wrists with isolated lunotriquetral ligament injuries diagnosed by arthroscopy. In 19 patients with persisting complaints, stabilization was performed using our original method. At 4 months after surgery, the results were evaluated by the method of Green and O'Brien. METHODS: Access to the LTq joint was gained through the fifth extensor compartment. At about 3 cm proximal to the ulnar head, one third of the extensor capri ulnaris (ECU) tendon was detached, without doing damage to the tendinous sheath on the ulnar head, and stretched distally up to the triquetrum-hamate joint level. Using a 3.2-mm drill, a tunnel was made on the dorsal side of the triquetrum, starting at the distal third of the ulnar side of the triquetrum and opening at the attachment site of the dorsal LTq ligament. In the middle part of the dorsal side of the lunate, a groove 4 mm deep and 6 mm long was made with a cutter and a two-suture Mitek anchor was inserted in its radial side. The graft was passed through the tunnel in the triquetrum, tightened up and inserted in the groove on the lunate, and sutured to the anchor. The rest of the tendon was reinserted to the ECU tendon. After suturing the dorsal structures and skin, a high plaster cast reaching up above the elbow was applied for 4 weeks, followed by application of a short plaster splint for another 2 weeks. RESULTS: Using the method of Green and O'Brien, we assessed pain, function (return to full activity), range of motion and grip strength. An excellent result was recorded in 48%, good in 42% and satisfactory in 10% of the patients; there were no poor results. DISCUSSION: Our method gives better results than the published methods of tenodesis, because it secures stability of both the triquetrum and lunate bones. Also, these methods restrict motion to a lesser degree than LTq joint arthrodesis. CONCLUSIONS: LTq instability of the wrist is a limiting condition for the patient's daily activities. It appears when, for gripping, the hand is positioned in dorsal flexion and ulnar duction. The diagnosis and therapy are complicated and only arthroscopy is reliable for LTq instability detection. The method described here provides an option for treating this disorder with good outcome and, in case of failure, does not interfere with a subsequent LTq joint arthrodesis.

[Haemothorax after blunt thoracic trauma]. / Hemotorax pri tupém poranení hrudníku.

BACKGROUND: Haemothorax is frequent consequence of blunt and penetrating thoracic trauma and is usually associated with pneumothorax. The occurence of haemothorax in blunt thoracic trauma patients is estimated between 25-75%. The reason of bleeding is impairment of intercostal arteries or lung parenchyma after trauma of the ribs. Uncontrolled bleeding is the main cause of the death. The article is focused on the treatment of this injury. MATERIAL AND METHODS: There were enrolled 238 patients with thoracic trauma, who were admitted into our department, into the study. The average age of the patients was 42.5 years. The ISS > or = 16 were in 101 patients. Forty two patients were artefitially ventilated. Conservative treatment prevails, almost in 65%. Special care was indicated in patients with haemothorax (fluidotoraxem). RESULTS: Clinically and based on other screening methods the presence of the fluid in thoracic cavity was in 131 patients. Surgical treatment (punction, drainage, videothoracoscopy and thoracotomy) was necessary in 47 (35.0%). Thoracotomy for the bleeding was indicated in seven cases (5.3 %). CONCLUSION: In diagnostics and in treatment of the bleeding in thoracic trauma patients the most important factor is clinical status of the patient. Indication for thoracotomy must be unambigous. Massive haemotorax leads to restrictive ventilation disorder with decreased preload and can be activator of the haemocolaguation disorders. This fact decreases chance for the survival of the patient.

[Traumatic perforation of the duodenum--a case review]. / Traumatická perforace duodena--kazuistika.

A blunt duodenal injuries are rare in spite of high-energetic injuries are common in this time. The diagnostic is very difficult not only for the reason of the little experience with this type of the injury but in term of the duodenal anatomic localization too. On the other side just late injury Identification of the retroperitoneal part of the duodenum leads to rapid development of the fatal retroperitoneal phlegmon. The development of the clinical symptoms and results of the paraclinical equipment examinations during blunt injury of the upper abdominal part with consequent perforation of the posterior retroperitoneal segment of the duodenum is well-documented by means of the mentioned case. The development of the retroperitonal phlegmon was not noticed despite of the slight diagnostic delayed and defect in the duodenal wall was treated by suture of the perforation aperture. The early detection of the duodenal injury is necessary premise for the good choice of the adequate surgical treatment.

[Haemobilia, the rare case of bleeding into GIT]. / Hemobilie, vzácná prícina krvácení do GIT.

AIM OF THE WORK: Bleeding into GIT is still serious problem with not low lethality. Especially, acute bleeding needs fast diagnostics and treatment. The aim of our work is to present the rare case of bleeding into GIT--haemobilia. GROUP OF THE PATIENTS: There is presented casuistics of the patient who was successfully treated on our department for bleeding from erosion of cystic artery as a consequence of acute cholecystitis. CONCLUSION: Nowadays there is dominantly preferred endoscopic approach in diagnostics and treatment of the bleeding into GIT. But surgical approach is in some cases the only one method in treatment of these complications.

[Crossectomy doesn't improve outcome of endovenous laser ablation of varicose veins]. / Krossektomie nezlepsuje výsledky endovenózní laserové lécby varixu.

AIMS: Crossectomy (extended saphenofemoral or saphenopopliteal junction ligation) and stripping of refluxing saphenous trunk represent the basis of the traditional surgical therapy of varicose veins. Endovascular techniques of saphenous ablation are the mini-invasive alternatives of the radical surgical treatment. The objective of this study is the comparison of the endovenous laser ablation with and without crossectomy through open groin access. MATERIAL AND METHODS: Retroprospective study compares the results of the group of patients treated with simple endovenous laser ablation (HVL - 329 limbs) and HVL completed with crossectomy (35 limbs). Both groups were comparable in terms of basic demographic and preoperative clinical data (p > 0.05). In both cohorts, subgroups with identical laser parameters were selected (p > 0.05). All procedures were performed according the same standard protocol, EVL patients received LMWH in the postoperative period. The results were evaluated by the comparison of CEAP clinical class pre and postoperatively, the percentage of recanalizations and also using the Kaplan-Meier life-table method. RESULTS: No thrombosis, nor pulmonary embolism were diagnosed in the post-operative period. During the follow-up (98% treated limbs), venous occlusion was observed in 88% of them (91.05 % in the endovenous group and 65.71% in the combined group). These differences are not statistically significant (p = 0.24). Same results were found using the Kaplan-Meier method (p = 0.086). Treatment significantly reduced CEAP clinical class in both groups but the results are better (C = 0.41 vs. 0.8) in the endovenous group (p = 0.004). CONCLUSIONS: Endovenous ablation of the refluxing saphenous vein represents good alternative of crossectomy and stripping. Combination of both procedures is not effective and, on the contrary, can cause short and long-term complications.

[Disorder of vertebral metastasis]. / Metastatické onemocnení pátere.

The aim of this article is putting near problems of treatment vertebral metastasis to professional public. Because of improving of imagine methods the diagnosis of this disorder is early making and that is way patient benefit of early initiation of adequate therapy. Authors of this paper rate literary studies concerning of therapeutic methods for treatment of vertebral metastasis and comper to their group of patients.

[New aspects in enteral nutrition in critical patients at the surgical intensive care unit]. / Nové aspekty v enterální nutricní podpore kriticky nemocných na chirurgické JIP.

INTRODUCTION: Nutritional support in critically ill patients has an impact on both prevention and treatment. Development of complications and organ failure can be prevented, good status of gut mucosa kept and positive nitrogen balance induced. Inflammatory response can be modulated. NUTRITIONAL SCREENING: Patients undergoing major surgery should be actively screened for the nutritional risk level according to described parameters since it is considered to be very important for the postoperative period. Enteral nutrition (EN) versus parenteral nutrition (PN): Current study findings do not show any difference in mortality of critically ill patients with regard to the administration route. Inflammatory complications rate is significantly lower in EN patients. ESPEN Guidelines on Enteral Nutrition: The most recent recommendations for surgery patients are based on the evidence. CONCLUSION: There is a need for an active nutritional screening to find patients in the risk. Other important points are the following: a progressive approach to early enteral nutrition combined with PN, multiprofessional cooperation and protocol implementation.

[Comparison of coated and bare metallic stents in inoperable carcinomas of the oesophagus and cardia]. / Srovnání potazených a nepotazených kovových stentu inoperabilních karcinomu jícnu a kardie.

INTRODUCTION AND AIM: The authors discuss paliative treatment using coated and bare metallic stents in a prospective randomized study for inoperable oesophageal carcinomas. The aim of this study is to assess the following parameters in both treatment groups: duration of the stents functionality, survival rates, complications rates and histological findings. METHODS: From 1999 to 2003, the total of 60 patients with oesophageal and cardial carcinomas were randomized. They had either bare (N-31 subjects) or coated (P-29 subjects) stents introduced. The patients were followed-up at one-month intervals. RESULTS: No statistical differences between the groups were found when the above parameters were assessed. DISCUSSION: The complications rate depended on the patients survival period in both stent types. Survival rates depended on the disease stage of the local tumorous process and on the individual patient's condition prior to the treatment. CONCLUSION: The study showed that the metallic selfexpandible stents treatment method may become a widely used paliative procedure in patients with malignant dysphagia, however, it has not proved any differences in complication rates depending on the stent coating.

[Blunt thoracic injury and the oxidation stress]. / Tupé poranení hrudníku a oxidacní stres.

INTRODUCTION: Each injury is accompanied with the oxidation stress with an increase in the level of free oxygen radicals accompanied with a simultaneous decrease in the body's antioxidation capacity. The objective of the study: The objective of this study is to verify connection between the severity of an injury and the intensity of oxidation stress. METHODS: 126 patients with blunt chest injuries were evaluated during 33 months. The patients were divided into four groups, depending on the extent of trauma severity assessed by means of ISS (Injury Severity Score). Randomly selected patients in each group were administered--in addition to standard therapy--indomethacin in usual doses. Level of free oxygen radicals and the body's antioxidation capacity were observed. All tests were carried out at a significance level alpha of 0.05. RESULTS: Practically all patients, regardless of their respective subgroups, experienced an increase in the level of free oxygen radicals accompanied with a simultaneous decrease in the body's antioxidation capacity. CONCLUSION: The identified results display a connection between the severity of an injury and the intensity of oxidation stress.

[SIRS and serious blunt thoracic injuries]. / SIRS u závazných tupých poranení hrudníku.

INTRODUCTION: Serious blunt injuries are accompanied with the worsening of the mechanics of ventilation due to the chest and lung injuries alone as well as with a systemic inflammatory response (SIRS) that always affects the lungs. The development of an injury-induced respiratory failure is multifactorial and timely pharmacological intervention is likely to contribute to the treatment algorithm, thus improving prognosis in some patients with a serious chest trauma. THE OBJECTIVE OF THE STUDY: The objective of this study is to verify the efficacy of the pharmacological blockade of the systemic inflammatory response of the body (SIRS) in serious blunt chest injuries. The study also intends to identify whether the administration of indomethacin could reduce SIRS score and prevent multiorgan dysfunction and multiorgan failure. METHODS: 126 patients with blunt chest injuries were evaluated during 33 months. The patients were divided into four groups, depending on the extent of trauma severity assessed by means of ISS (Injury Severity Score). Randomly selected patients in each group were administered--in addition to standard therapy--indomethacin in usual doses. All tests were carried out at a significance level alpha of 0.05. RESULTS: The onset of SIRS in the subgroup with indomethacin was statistically significantly postponed in groups I. and II. Groups ISS I to III showed a statistically markedly shorter time of SIRS duration in the subgroup with indomethacin. The first increase in inflammatory markers (acute phase proteins) was statistically significantly postponed in the group ISS I without the administration of indomethacin. Groups ISS II through IV did not show a statistically significant differences in the first onsets of inflammatory markers. The evaluation of all four groups did not detect any statistically significant differences in the duration of the inflammatory markers increase in the subgroup with indomethacin and in a control group. There was no statistical significance in the average time of ventilation support. An average hospitalization time was shorter in the subgroup ISS II with indomethacin. There was found statistically significant difference. Of the patients included in our file seven died during the monitored period. Lethality is thus 5.6%. A multiorgan failure was the cause of death in two patients in the non-indomethacin subgroup and in one patient in the indomethacin subgroup. CONCLUSION: We proved that the factors that can be affected by the blockade of cyclooxygenase display statistically significant changes in subgroups with the administration of indomethacin. No changes were recorded with regard to acute phase proteins whose synthesis is not mediated by prostaglandins. The administration of indomethacin positively affects the development of SIRS, reduces and diminishes its effects as well as impact on the impaired body.

[Endoscopic solution of iatrogenic lesion of oesophagus]. / Endoskopické resení iatrogenního poskození jícnu.

The case report dissertates upon successful treatment of iatrogenic perforation of distal oesophagus with subcutaneous emphysema, pneumoperitoneum and pneumomediastinum. The endoclips and classic conservative treatment were used in therapy. The patient was treated 3 hours after the injury, no early or late complications related to perforation were noted.

Mother-daughter interaction and adherence to diabetes regimens.

This study explores the relationship of mother-daughter interaction to adherence to treatment plans among diabetic adolescents. Fifty mother-daughter dyads discussed conflict issues and feelings, problems, and concerns related to diabetes. Discussions were analyzed using the Hill Interaction Matrix and modified Beavers-Timberlawn Family Evaluation Scales. Interview questionnaires provided information on adherence, feelings, problems and concerns, parental supervision, adjustment, and family life. The less adherent the adolescent, the more emotionally charged the interaction, the more directly confrontive mother and daughter were, and the less efficient they were at negotiating issues. The adolescent's statements about herself confirmed observations that poor adherers, more than good adherers, had difficulty discussing feelings, problems, and concerns with their mothers (r = -0.51, P less than or equal to 0.001). Poor adherers reported believing less strongly that adherence would delay/avoid complications (r = 0.51, P less than or equal to 0.001), became more anxious about seeing a disabled diabetic person (r = -0.29, P less than or equal to 0.29), and worried more about future health (r = -0.27, P = NS). No relationships were found between adherence and adolescent-physician rapport. Many adolescents were not engaging in good self-care behaviors, were quite concerned about future health, perceived mothers to be very concerned, hesitated telling peers about their illness, and did not share deeper illness-related concerns with their closest nondiabetic friends.

DNA topoisomerase II-alpha in pulmonary carcinoid tumors.

Fifty-four pulmonary carcinoid tumors of surgically treated patients were diagnosed according to modified Arrigoni histological criteria (WHO 1999). Forty-seven typical (TC) and seven atypical carcinoids (AC) formed the basic groups. Four subgroups were selected from the TCs and consisted of cases with higher tumor size (T2) or those associated with nodal involvement (N1), tumor satellites, and tumorlets. Subgroup tumors were regarded as affections with possible increased proliferation potential. The proliferate activity was examined immunohistochemically by topoisomerase II-alpha (clone SWT3D1) on paraffin material and calculated by the number of positive nuclei per 10 HPF. The topoisomerase expression was found to be statistically different in both principal groups made up of typical and atypical carcinoids with a mean value of 49 and 135 positive nuclei per 10 high power field in TC and AC, respectively. The remaining subgroups of the TCs associated with examined characteristics (larger tumor diameter, metastases, satellites, tumorlets) were not found to be statistically different. The topoisomerase II-alpha is a marker giving valuable information about the diagnosis of pulmonary typical and atypical carcinoids.