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ABSTRACT: INTRODUCTION: Somatostatinoma is a rare, slowly growing tumor with malignity potential, most commonly located in the pancreas or duodenum. By the time its diagnosis is established, it is usually large and liver metastases are present. Increased concentrations of somatostatin, produced by pancreatic D cells or by intestinal mucosa, inihibit secretion of a number of GIT hormones, endocrine and exocrine pancreatic secretion. The clinical findings include symptoms of diabetes, dyspepsia, diarrhoea, steatorhoea, abdominal pain, hypochlorhydria, anemia. Sometimes, the finding is accidental. A CASE REVIEW: The authors present a case of somatostatinoma, detected accidentaly in a 72-year-old male. The tumor originated from the pancreatic head, partially spreading invasively into surrounding organs (duodenum), invading blood vessels and metastazing into peripancreatic lymphonodes. The tumor was asymptomatic and was detected as an accidental finding on ultrasound and CT abdominal examinations for the patient's urological disorder (vesicolithiasis). Pylorus saving hemipancreatoduodenectomy was performed and, on microscopic and subsequent immunohistochemical examination of the resecate, a well- differentiated endocrine, somatostatin- producing pancreatic carcinoma was verified.
Rozhledy v chirurgii: měsíčník Československé chirurgické společnosti 01/2008; 86(12):643-7.
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ABSTRACT: On the basis of retrospective five years analysis the authors process the problematic of idiopatic bowel disease--Morbus Crohn and ulcerative colitis. They pay main attention to surgical issue--types of operations, differences between acute and elective surgery, perioperative problems and results.
Rozhledy v chirurgii: měsíčník Československé chirurgické společnosti 06/2006; 85(5):244-8.
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ABSTRACT: Exenteration pelvic procedures are surgical options for treatment of locally advanced pelvic tumors. Due to the procedure's success rates, it has become a standard therapeutic procedure, when indicated. From the medical point of view, the following factors characterize the level of seriousness of these procedures: the fact that the procedure is extensive, its complicated reconstruction phase and high postoperative morbidity rates. From the patient's point of view, it is characterized by a principal change in the quality of life. In this case review the authors present their experience with a multidisciplinary approach to these procedures.
Rozhledy v chirurgii: měsíčník Československé chirurgické společnosti 09/2005; 84(8):403-9.
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ABSTRACT: Review of reconstruction procedures following pelvic exenterations.
Review article.
Department of Obstetrics and Gynecology, Department of Urology, 1st Department of Surgery, Faculty Teaching Hospital and 1st Medical Faculty of the Charles University, Prague.
Review and critical assessment of published data.
Reconstruction procedures are important part of pelvic exenterations. The procedures are crucial for following quality of life. Currently the most frequently used techniques for isolated pelvic floor support are omental flaps (carpets), for combined reconstruction of pelvic floor and vagina TRAM (transverse rectus abdominis musculocutaneus flap). Reconstructions prolong operation time; however they are accompanied with low morbidity and some techniques decrease total morbidity of exenterative procedure. Total and posterior exenterations require sigmoideostomy in vast majority of cases. Low rectal anastomosis might be used in cases of supralevator procedures. They cause high morbidity especially in patients following radiotherapy. In these patients temporary diverting colostomy is being recommended. A bowel segment is usually used for urinary diversion following total or anterior exenteration. Golden standard remain the incontinent ureteroenterostomies using ileum or colon transversum. Currently continent diversions are considered more often due to encouraging results and good quality of life. Heterotopic diversions, with continent conduit and cutaneous stoma, are frequently used. Risk of serious complications, especially fistulas and stoma stenosis, after all types of diversions is possible to reduce by using appropriate bowel segment not handicapped by previous radiotherapy.
Ceska gynekologie / Ceska lekarska spolecnost J. Ev. Purkyne 06/2005; 70(3):205-10.
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ABSTRACT: INTRODUCTION: Endoscopic invasive procedures in 70th and 80th years leaded to decrease reoperations on biliary tree. Iatrogenic injury of the biliary tract have increased in incidence in the first decade with the introduction of laparoscopic cholecystectomy. Athough a number of factors have been identified with a high risk of injury ( and number of technical steps have been emphasized to avoid these injury, the incidence of the bile duct injury has reached at least double the rate observed with open cholecystectomy. Cholecystectomy is most frequently performed abdominal operation and the most serious complication associated with this procedure is accidental injury to the common bile duct (0.3-0.4%). This preventable technical error has tradicionally been thought to occur in one or more of three situations: 1. When the operator attempts to clip or ligate a bleeding cystic artery and also clips the common hepatic duct (Fig. 3a). 2. When too much traction has been exerted on the gallbladder so that the common bile duct has tented up into an albow, which was either tied off with ligature or clipped (Fig. 3b). 3. When anatomic anomalies were not recognized and the wrong structure is divided, for example, when the cystic duct winds anterior to the common bile duct and enters on the left side, or when the cystic duct joins the right hepatic duct rather than the junction of the common hepatic and the common bile ducts (Fig. 1, 2, 3cd). In anatomical incertain cases is discussed about cholangiography and cholecystocholangiography during laparoscopy cholecystectomy. Most patients sustained a bile duct injury are recognized in the weeks folloving laparoscopic cholecystectomy. Careful preoperative preparation should include control of sepsis by draining any bile collections or fistulas and komplete cholangiography. Long-term results are best achieved in specialized hepatobiliary centres performing biliary reconstruction with a Roux-Y hepaticojejunostomy. Success rates over 90% have been reported from several centres to date with intermediate follow-up. Papila injury increased with introduction of a invasive endoscopy. Risk of deadly retroperitoneal inflamation is very high. Injury require same surgery procedure as duodenum injury. OWN EXPERIENCES: In an article a review of experiences of the 1st surgery department of General hospital in Prague since 1971 in 1 017 reoperations on biliary tree was carried out. There was in 311 patients 164 hepatohepatostomies and 147 hepaticojejunostomies used (Tab. 1). By laparoscopic injuries were high hilar injuries (Bismuth IV) in last decade and hepaticojejunostomy was done in all cases. Died 6%, long term results are acceptable by injured patients with hepaticohepaticostomies in 70%, by hepaticojejunostomies in 90%. Reoperated were 10% patients (Tab. 1). Remnant patients were dilated endoscopicaly. Postoperatively morbidity was high, above 26%. In years 1995-2003 were 8 patients with papila injury and inflamation in retroperitoneum operated as a injured duodenum (Tab. 2). CONCLUSIONS: Better experiences with treatment of injured biliary tree and papila are in centres interested in hepatobilliary surgery which knowledge anatomy of hilus of liver and can make wide hepaticojejunostomy. Transfer of drained injured patient to centre is possible.
Rozhledy v chirurgii: měsíčník Československé chirurgické společnosti 05/2005; 84(4):176-81.
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ABSTRACT: INTRODUCTION: Introduction of endoscopic invasive procedures in the 70th and 80th years leaded to decrease reoperations on biliary tree. latrogenic injury of the biliary tract have increased in incidence in the first decade with the introduction of laparoscopic cholecystectomy. Athough a number of factors have been identified with a high risk of injury (and number of technical steps have been emphasized to avoid these injury, the incidence of the bile duct injury has reached at least double the rate observed with open cholecystectomy. Most patients that sustained a bile duct injury are recognized in the weeks following laparoscopic cholecystectomy. Careful preoperative preparation should include control of sepsis by draining any bile collections or fistulas and complete cholangiography. Long-term results are best achieved in specialized hepatobiliary centers performing biliary reconstruction with a Roux-Y hepaticojejunostomy. Success rates over 90% have been reported from several centres to date with intermediate follow-up. Introduction of an invasive endoscopy. Very dangerous is injury after endoscopic papilotomy. OWN EXPERIENCES: In an article of a review of experiences of the Ist Department of Surgery of General hospital in Prague since 1971 in 1 017 reoperations on biliary tree has been carried out. There were in 311 patients 164 hepato-hepatostomies and 147 hepaticojejunostomies used (Tab. 1). By laparoscopic injuries in the last decade were hilary injuries (Bismuth IV) and hepaticojejunostomy was done in all cases. Died 6%, long-term results are acceptable by injured patients with hepatico-hepaticostomies in 70%, by hepaticojejunostomies in 90%. Reoperated were 10% patients. Remnant patients were dilated endoscopically. Postoperatively morbidity was high, above 26%. In years 1995-2003 were 8 patients with papila injury and inflammation in retroperitoneum operated as a injured duodenum (Tab. 2). CONCLUSIONS: Better experiences with treatment of injured biliary tree and papila are in centres interested in hepatobiliary surgery which know anatomy of hilus of the liver and can see wide hepaticojejunostomy. Transfer of drained injured patient to centre is possible.
Rozhledy v chirurgii: měsíčník Československé chirurgické společnosti 05/2005; 84(4):182-90.
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ABSTRACT: Authors present the case (from the year 2003) of a 38 years old patient, female with large tumor in the abdominal cavity. Preoperative differential diagnostic examination showed either tumor of pancreas or left liver lobe. The surgery confirmed large tumor body of the pancreas. Histological and immunohistochemical examination determined gastrointestinal stromal tumor (GIST) of the pancreas from autonomous nerves with malignant character. Tumor was radically removed. In the postoperative period regular follow up was done at the department of oncology, abdominal ultrasound every 3 months, CT scan every 6 month. 2.5 years after operation the patient has no problems, CT scan is without signs of recurrent diseases. The analysis of GIST was performed in agreement with contemporary knowledge. According to the references, our case report GIST of pancreas is the first of this kind (till 2003).
Prague medical report 02/2005; 106(2):201-8.
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ABSTRACT: Hemipancreatoduodenectomy has remained afflicted with high postoperative morbidity rates. Preoperative icterus is considered a significant risk factor. Therefore, a preoperative biliary drainage has been considered a standard preoperative procedure. This study aims to assess the preoperative drainage of the biliary tract significance with respect to the postoperative complications rates.
This retrospective study includes 304 patients after completed hemipancreatoduodenectomies, who were operated in the 1st Surgical Clinic of the 1st Medical Faculty of the Charles University and the General Faculty Hospital in Prague between January 1990 and December 2002. In this trial group, 144 patients had underwent preoperative drainage of the biliary ducts and 160 patients underwent surgical procedures without the preoperative drainage.
In the trial group, no significant difference in the gender rates, the history of the risk factors, the surgical procedure duration, the perioperative blood loss and the disease stage was detected. The patient trial group with the preoperative drainage of the biliary ducts completed was statistically significantly older (p = 0.05), had higher serum bilirubin levels recorded (118, respectively 81, p = 0.01), had more complications recorded postoperatively (42.4%, respectively 25%; p = 0.05), and more infectious complications (29%, respectively 13%; p = 0.05) when compared with the trial group without the preoperative drainage completed. Upon comparison of the both groups, we have not detected any statistically significant differences regarding the time interval between the diagnosis and the surgical procedure, the hospitalization duration or the mortality rates.
The operated who had had the internal drainage of the biliary ducts conduted preoperatively, suffered from more complications in total as well as from more infectious complications, compared with the patients without the drainage. On the other hand, the patients who had had the preoperative drainage completed were older and had had higher preoperative bilirubin levels. With respect to the above results we strongly advise the patients with the pancreatic head carcinoma to early consult a hepatobiliary surgeon. As far as the examination algorithm is concerned, we strongly recommend using not only the spiral CT, but also non-invasive methods of examination (the MRI and the MRI cholangiography).
Rozhledy v chirurgii: měsíčník Československé chirurgické společnosti 01/2005; 83(12):624-8.
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ABSTRACT: Discussion of experiences with pelvic exenterations.
Case-report.
Department of Obstetrics and Gynecology, Department of Urology, Department of Surgery, Department of Pathology, Department of Clinical Oncology, General Teaching Hospital and Ist Medical Faculty of the Charles University, Prague, Czech Republic.
Presentation of 4 cases of pelvic exenterations. Discussion with published data.
Altogether four cases of pelvic exenterations are presented, one case of supralevator total exenteration for recurrent cervical cancer, one case of infralevator total exenteration for recurrent vaginal cancer, one case of supralevator anterior exenteration in the treatment of locally advanced cancer of urinary bladder, and one case of supralevator posterior exenteration for recurrent vaginal cancer.
Ceska gynekologie / Ceska lekarska spolecnost J. Ev. Purkyne 12/2004; 69(6):483-8.
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ABSTRACT: The colorectal carcinoma incidence increases with age. The radical resection procedure significantly extends the survival period, when compared with other therapeutic approaches. The tissue damage may exceed the organ reserve capacity in cases of the elderly patients and may result in higher postoperative morbidity and mortality rates. The aim of this study was to compare the results and the surgical risks of the large intestine carcinoma resection procedure in elderly patients, compared to younger patients with the same diagnosis. THE PATIENT GROUP AND METHODOLOGY: The retrospective study summons up the clinical results of 3778 patients from all over the Czech Republic, who underwent primeoperations for the following diagnoses: C18--a malignant neoplasm of the large intestine, and C19--a malignant neoplasm of the rectosigmoideal junction, in 2001. The results are compared with our own patient group in the same time-period. The results were assessed according to the following age-group criteria: 21-59 yrs., 60-69 yrs. and over 70 yrs. of age. We assessed the following factors: age, diagnosis, incidence of early postoperative complications and duration of patients hospitalization. RESULTS: The patients in the 21-59 year-group and in the group over 70 years of age, had significantly different rates of early postoperative complications (12.3% vs 17.6%, p < 0.001). The rate of complications was twice as high in urgent procedures compared to planned procedures in all age groups (p < 0.001). The average hospitalization lasted 14.8 +/- 10.9 days. We discovered statistically significant differences in the duration of hospitalization among all three age groups respectively (p < 0.01). CONCLUSION: Based on our results, we believe the age itself not be an indication-limiting factor for the radical resection procedure for the large intestine carcinoma. The elderly patients benefit from its oncological radicality with acceptable rates of the postoperative complications risks. We believe even extensive surgical procedures to be feasible in cases of appropriately indicated elderly patients, and their surgical risks to be acceptable considering the expected benefits for the respective patient.
Rozhledy v chirurgii: měsíčník Československé chirurgické společnosti 08/2004; 83(7):320-4.
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M Pesková
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ABSTRACT: Previous half of the century has influenced surgery not only by enormous progress of the knowledge in medicine, but namely in the last decade, by the introduction of mini-invasive operation techniques. Because of the highly effective conservation treatment, the spectrum of operations has been changed as well as the tactics and techniques of individual surgical procedures. Perspectives of surgery are in further specialization, introduction of one-day operations, and in the continuous development of mini-invasive operation techniques. The share of robots in the clinical praxis and in the training of surgeons is still difficult to forecast.
Casopís lékar̆ů c̆eských 02/2003; 142(12):707-9.
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ABSTRACT: Diffuse necrotizing soft-tissue infections are severe due to their rapid progression; there is a vital need for settling proper early diagnosis. The task of the clinician is mainly in distinguishing localized infection from the diffuse process.
In our case report we demonstrate a 32 yr old man with a curious development of severe necrotizing infection of submucosis with gas production as a conclusion of perforation of Schloffer's tumour, which developed after appendectomy carried 20 years ago.
In case of diffuse necrotizing soft-tissue infections only immediate surgical revision can confirm initial stages of severe forms of infection.
Sbornik lekarsky 01/2003; 104(2):139-43.
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ABSTRACT: A total of 1511 patients were operated on at the 1st Department of Surgery Charles University in Prague during 1996 through 2000. Of this number, 81.3% underwent surgery for primary and 18.7% for recurrent inguinal hernia. Among the patients with recurrences, 81% had the first, 15% patients the second, and 4% at least the third episode of recurrent hernia. A total of 604 patients were operated on during 1999-2000, when a plug system (Bard Mesh Perfix Plug) was introduced into surgery protocols. Of this number, 113 patients had a recurrent hernia with an identical ratio of recurrences. The following plastic surgery interventions were carried out during the latter period: McVay-Lotheissen (54.2%), TAPP (26.5%), PHS (13.2%), Plug (3.3%), and Lichtenstein (2.6%). The following interventions were used when operating recurrences: McVay-Lotheissen (20.3%), TAPP (31%), PHS (21.2%), Plug (16.8%), and Lichtenstein (9.7%). During the 1-24-month follow-up period, recurrences occurred 1x after the TAPP procedure, 1x after McVay-Lotheissen, and 1x after the Lichtenstein procedure (95% and 88% patients who underwent plug and Lichtenstein procedures, respectively, were included in the follow-up). Comparison of plug vs. TAPP in patients with recurrent hernia (Plug/TAPP): mean age of patients: 62/45 years, length of operation: 66/48 minutes, overall post-operative morbidity: 9.4%/3.6%, hospitalization: 4.3/1.8 days, return to the working process 28 days (range 9-38 days) vs. 7.2 days (range 2-15 days). Both procedures can be considered safe and reliable interventions for treatment of recurrent inguinal hernia. They meet the requirements for elastic strength (more the plug procedure), closure, and bridging of defects even in several layers. The plug system can be implanted under local anaesthesia, it is capable of bridging large defects in a firm and elastic manner, and appears to be a very suitable solution for large defects in patients with advanced biological age. In these indications, the plug system brings many benefits but also the risk of more open access and greater "quantity" of materials. TAPP appears to be more suitable in younger patients with recurrences and large defects. We evaluate favourably in particular, all aspects of the postoperative period. An experienced team of surgeons is needed to achieve good results in both procedures.
Rozhledy v chirurgii: měsíčník Československé chirurgické společnosti 04/2002; 81(3):133-7.
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ABSTRACT: The authors reflect on the etiology of torsions of intraabdominal organs and the testes. They mention anamnestic data, which may lead to suspicion of possible organ torsion. They analyze the clinical picture of a patient who suffered such an attack. The authors submit a list of diagnostic possibilities using modern imaging methods: sonography, computed tomography, angiography, scintigraphy and magnetic resonance. They discuss laparoscopy as a diagnostic and therapeutic method.
Rozhledy v chirurgii: měsíčník Československé chirurgické společnosti 02/2002; 81(1):10-3.
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ABSTRACT: Torsions are rare acute abdominal conditions and are mistaken for other more frequent diseases. The present work draws attention to the most frequent diagnostic errors. The authors present three cases of torsions of intraabdominal organs and two cases of testicular torsion. All patients attended their doctor because of abdominal pain. In four of five cases the patients were first treated for an erroneous diagnosis of acute abdomen. In the first case the torsion of the omentum was mistaken for diverticulitis of the sigmoid, later for an intraperitoneal lipoma, in he second case for cholecystitis, in the third case a patient with torsion of a myoma was indicated for surgery on account of acute appendicitis. In the fourth case incomplete torsion of the testis was mistaken for irritation of the appendix. In the fifth case where abdominal symptomatology dominated the correct diagnosis of testicular torsion was made and atypically spontaneous detorsion of the testis occurred.
Rozhledy v chirurgii: měsíčník Československé chirurgické společnosti 02/2002; 81(1):14-7.
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ABSTRACT: The authors demonstrate analgetic effect on a group of 32 patients operated for pancreatic cancer pain after videothoracoscopic splanchnikectomy. The authors define adequate criteria for selection of splanchnikectomy.
Sbornik lekarsky 02/2002; 103(2):227-32.
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ABSTRACT: Barrett's esophagus (BE) the serious complication of gastroesophageal reflux disease (GERD) is discussed. BE has been defined as the complete intestinal metaplasia of distal esophagus. The most serious complication of BE is esophageal adenocarcinoma. We present our results with the group of patients with GERD from the years 1998-2000. We prospectively followed 67 patients with GERD (group A) and 8 patients with GERD/BE (group B). All patients underwent laparoscopic fundoplication. The average length of the Barrett's segment was 4.3 cm. Average time of the surgery was 75 min. Nissen fundoplication was used in seven cases in group B, in one case we used Rossetti laparoscopic fundoplication. The postoperative endoscopic controls were performed at two months after surgery and then every one-year. RESULTS: In one case we observed the complete reepithelization with the mixed spinocelullar and columnar components. We didn't observe any one case of histological deterioration. There was on any difference between two groups regarding the subjective complains. Six patients form group B reported complete disappearing of pyrosis. Two patients reported significant improvement, with very rare pyrosis or dysphagia. Our experience (together with the literature) proved the surgical antireflux therapy is very safe, very effective and with very long lasting effect. The effectivity of surgical therapy is increased by the laparoscopy. Described laparoscopic approaches can lead to the reepithelization of Barrett's metaplasia or, at least, they can diminish the symptoms without any long-term medication. Surveillance endoscopy and biopsy are strictly recommended in all patients with BE and also in the patients with BE after antireflux surgery. The intervals depend on the grade of dysplasia in metaplastic epithelium.
Sbornik lekarsky 02/2002; 103(2):181-7.
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ABSTRACT: The common basis of systemic inflammatory response to surgical trauma is the activation of cytokine cascade, accompanied by the release of soluble cytokine receptors. The main cytokine axis stimulates the release of acute phase proteins (APP) form liver, modulates metabolic pathways and hormonal responses. The aim of this study was to assess characteristic changes in levels of pro- and anti-inflammatory cytokines in early post-op stages after a major intraabdominal surgery and to compare the results with dynamic changes in APP levels. The results will form a basis of evaluation of diagnostic value of certain cytokines and APP in post-operative complications.
Subjects fell into three categories: 1--patients after colonic resection for colorectal carcinoma I. and II. grade (N = 20), 2--patients after hemipancreatoduodenectomia (N = 17) and 3--control group of 18 healthy subjects. The levels of following parameters were measured between from one day before to three days after surgery: tumour necrosis factor-alpha, interleukin (IL)-1 beta, IL-1ra, IL-2, IL-6, IL-8, IL-10, soluble IL-2 receptors, C reactive protein (CRP) and alpha1-antitrypsin (AAT).
Measured parameters exhibited different dynamic changes in reaction to surgical trauma, according to their roles in immune reaction. Main pro-inflammatory cytokines culminated within 24 hours from the onset of surgery, marked elevations were noted in IL-1ra and the soluble IL-2 receptor. Both measured APP were rising until he 72nd hour post surgery, and their rise was markedly delayed compared to cytokines. The extent of immune reaction as measured by the amplitude of changes in both types of surgery was similar in most measured parameters, apart from marked difference in IL-2R. We also noted significant correlation of plasma levels of IL-6 and IL-1ra.
Surgical trauma as any other significant painful stimulus activates the pro-inflammatory cytokine axis with secondary response of APP. The release or pro-inflammatory cytokines, i.e. TNF-alpha, IL-1, IL-6 and IL-8 is synchronized with the release of antagonistic mediators (i.e. IL-1ra, IL-10, IL-2 and IL-6 soluble receptors), who precede the acceleration of APP production and thus modulate its extent. The evaluation of relationships between pro- and anti-inflammatory factors with regard to prognosis is confounded by unclear interpretation of their changes. The maximum effect of cytokines takes place at local autocrine and paracrine level and systemic levels do not reflect this. This is how we explain minimal changes in plasma levels of IL-1 beta and IL-2, despite their key role as initiators of cytokine cascade. In order to increase their diagnostic value the use a series of measurements is advocated in combination with other clinical and laboratory parameters of inflammation, such as the levels of acute phase proteins.
Sbornik lekarsky 02/2002; 103(2):273-82.
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ABSTRACT: We had operated 72 patients for hepatic metastatic malignancies from 1991 to 2000. In 66 cases were colorectal metastases. Extend of operations were from no anatomical resections, segmentectomies to hemihepatectomies. Operating lethality was 5.5% and long time survival only 10%. In the same period we took arterial port for 22 patients for regional chemotherapy. Response rate was 20% patients. The first experience with radiofrequency ablation (we had 12 ablation procedure) show, that minimal invasive treatment (RFA) is good procedure for high-risk patients. If the patient is able to hepatic resection it will be still standard for treatment.
Sbornik lekarsky 02/2002; 103(2):167-71.
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ABSTRACT: Conventional surgical techniques play an important role in rectal cancer. Dehiscence of the anastomosis after low anterior resection of the rectum is a serious complication. The incidence of dehiscences can be reduced when known principles of preoperative care are respected but in particular by correct surgical technique. In 92 patients operated for rectal cancer at First Surgical Clinic of Charles University we had six patients (6.5%) with dehiscences of anastomosis. The serious character of this surgical complication can be reduced by a primary derivative stomy. Authors recommend implementing a preventive ileostomy in low resection of the rectum in high-risk patients.
Sbornik lekarsky 02/2002; 103(2):189-92.
