Rozhledy v Chirurgii最新文献

Acute abdomen represents a large complex of acute situations in general surgery. There could be inflammatory (such as acute appendicitis, acute cholecystitis etc.), non-inflammatory (ileus), hemorrhage or traumatic situations (perforation of the gastrointestinal tract etc.). Our work presents two case reports of two not significantly ill female patients with an uncommon inflammatory process of the caecum. Acute typhlitis is an archaism for most of surgeons. It used to be a synonym for acute appendicitis; however, the modern literature defines this diagnose as a different disease - neutropenic enterocolitis. It is a rare but serious disease causing a right lower quadrant pain, often mimics acute appendicitis. Usually, it occurs in immunocompromised patients (patients after an immunosuppressive therapy, neutropenic patients, people with hematologic malignancies, AIDS positive patients, etc.); however, a few case reports of entirely healthy patients have been published. Nevertheless, there is however a limited number of these cases.

Introduction: Cholecystectomy is one of the most common operations in surgical departments. Complications after gallbladder removal are mainly bleeding, infection including abscess in the gallbladder bed or in the abdominal wall, wound dehiscence, acute pancreatitis or injury of the bile ducts. In the further course, hernias in the scar may appear after both laparoscopic and open cholecystectomy, strictures of the bile ducts and symptoms of the so-called postcholecystectomy syndrome. The presence of residual gallstones is rare, statistically reported in 0.08-0.3%.

Case report: The goal of our message is to present the case of a patient taken into our care 7 years after laparoscopic cholecystectomy indicated for cholecystitis with wedged lithiasis in the gallbladder neck, proven by ultrasound. In our department, the -patient was treated for a re-current fistula in the scar of the right subcostal area. Definitive -healing from the initial manifestation of the fistula occurred despite repeated revisions after the precise localization and removal of the retained gallstone.

Conclusion: Thanks to the use of an extensive spectrum of diagnostic methods and at the same time thinking about the rare causes of a recurrent purulent collection with a fistula, we purposefully searched for an infectious source. Only perioperative radiography with injection of contrast material identified the presence of a retained gallstone. It was possible to extirpate it from the space between the intercostal muscles and the peritoneum, thereby relieving the patient of her problems.

We present a case report of a 26-year-old patient with an incidental finding of intra-abdominal fibromatosis (desmoid) in the small pelvis who presented to the urology outpatient clinic for erectile dysfunction. Ultrasound examination revealed hydronephrosis of the right kidney with parenchymal reduction, and a bulky tumor was detected in the small pelvis, which was compressing the right-sided ureter. The patient was followed up with a CT scan which confirmed a solid tumour in the small pelvis of unclear origin, the nature of the tumour and the treatment were discussed by the multidisciplinary team and a decision was made to resect the tumour. Pathologist confirmed sporadic variant of desmoid. Desmoid tumors are characterized by both locally aggressive carcinomas mimicking growth and frequent recurrences after resection, which may require subsequent oncological treatment. For these reasons, patients with desmoids should be fol-lowed up by an oncologist, ideally at centers experienced in treating this rare disease.

Multiple primary malignancy is defined as the occurrence of two or more primary malignancies in one patient. Although this is a rare situation, its occurrence has been increasing over the last decade. Patients with an oncological disease have up to a 20% higher risk of a new primary oncological disease compared to the general population. Depending on the time interval between the diagnosis of individual malignancies, we divide multiple cancer cases into synchronous and metachronous. The diagnosis of four synchronous malignancies is extremely rare. In our case report, we present a patient with caecal adenocarcinoma, hepatic flexure adenocarcinoma, clear cell carcinoma of the right kidney and pheochromocytoma of the right adrenal gland occurring synchronously.

Diverticulitis of the colon, i.e. inflammation of one or more diverticula, is the most common manifestation of diverticulosis, which affects more than 60% of people over the age of 70 in developed countries. Acute diverticulitis includes a range of degrees of inflammatory involvement, from mild diverticulitis to stercoral erythematosis. The diagnosis of diverticulitis of the colon has changed, especially in the last 30 -years. Imaging using ultrasound and computed tomography allows the assessment of the severity and extent of inflammation without surgery expressed by classification and facilitates the decision on the choice of treatment. Treatment has also changed. Uncomplicated diverticulitis can now be treated without antibiotics and without hospitalization, abscesses can be evacuated by percutaneous guided drainage. The basis of the surgical treatment of peritonitis of diverticular origin remains the arrest of contamination and sanitation of the abdominal cavity.  Mere diversion is insufficient. An effective solution is resection of the inflamed or perforated segment of the intestine, a new option is laparoscopic lavage. The best results are -achieved by intestinal resection with primary anastomosis; which should be established only if certain conditions can be met. Exclusion of the anastomosis reduces the demands of the operation, but generally leads to worse results. Despite the recommendations -based on EBM, opinions on the choice of operation are still not clear today. The text presents the development of diverticulitis treatment, arguments in favor of or against resection with anastomosis, resection with exclusion of the anastomosis and laparoscopic lavage. The conditions of the procedures, especially the safe establishment of the anastomosis, and current recommendations are presented.

Introduction: Coral reef aorta (CRA) is a rare clinical entity characterised by hard, protruding calcifications in the juxta and supra-renal aorta, which cause haemodynamically significant stenosis of the aorta and its branches. We are presenting a case report of a 65-year-old female patient with bilateral 30-meter claudication on both lower extremities and a haemodynamically significant stenosis of the left renal artery.

Case report: The patient underwent computed tomography angiography (CTAG) of the abdominal aorta and lower extremities. CTAG revealed severe abdominal aortic wall calcification with circular atherosclerotic calcification in the area of the renal arteries branch off, causing haemodynamically significant stenosis of the aorta and the left renal artery. The patient was scheduled for an elective open surgery. The left retroperitoneal approach dissects the abdominal aorta, including both renal arteries. -Cross-clamps were placed on both renal arteries, the subrenal aorta and the suprarenal aorta, just below the superior mesenteric artery. Circular aortic calcifications protruded through the aortotomy, and aortal endarterectomy was performed. The calcific plaques extend-ing to the left renal artery were dissected similarly. Identically, an endarterectomy of both common iliac arteries orifice was performed.

Result: The patient was discharged on the 8th postoperative day with excellent renal parameters, normal left kidney perfusion, and without limiting claudications on both lower extremities. Currently, we have a 12-month follow-up with the patient.

Conclusion: CRA is a rare clinical entity. The optimal treatment has yet to be established. Up-to-date, the gold standard treatment for CRA is surgical endarterectomy.

Introduction: Gastric bypass has not gained as much popularity in the Czech Republic as technically simpler restrictive bariatric procedures, frequently with a fading long-term effect. The aim of the presentation is to point out the long-term results after two types of gastric bypasses.

Method: Retrospective analysis of prospectively collected data in an initial set of patients after laparoscopic RYGB (Roux Y gastric bypass) and OAGB/MGB (one anastomosis/mini gastric bypass) performed at Breclav Hospital in 2010-2013. Evaluation based on the BAROS system, according to weight development, comorbidities, psychological aspects, complications and reoperations.

Results: Data available for evaluation are from 32 patients out of a total of 60; the follow-up rate is 53%. The patients are lighter by 34 kg on average (0-64 kg); TBWL (total basic weight loss): 25.7%. The majority of operated diabetics are free of signs of diabetes, and all others have a reduced need for antidiabetic medication. Hypertension, sleep apnea and psychological assessment of life in 6 domains improved. Eight of the 32 followed patients underwent reoperation during 10 years; only 2 of these procedures were acute for complications (anastomotic ulceration), both in smokers; further elective reoperations included 2 conversions of OAGB/MGB to RYGB due to reflux, 2 corrective surgeries, and 2 procedures for a suspected internal hernia. There was no conversion from laparoscopic to open surgery, no peritonitis associated with a leak, and no mortality within 30 days. The BAROS score (5.56) indicates a "very good result" of the gastric bypasses after 10 years.

Conclusion: Gastric bypasses are safe and provide a high and lasting metabolic effect that meets the general expectations of an invasive intervention that can fundamentally improve the quality of treatment for otherwise incurable chronic diseases related to adiposity (so-called ABCD), especially type 2 diabetes.

Introduction: Thanks to mammographic screening and the improvement of breast cancer diagnostics, the detection of precancers is also increasing. They are defined as morphological changes of the mammary gland which are more likely to cause cancer. The evaluated precancers are atypical ductal hyperplasia (ADH), lobular carcinoma in situ (LCIS) and radial scar.

Methodology: In the period 1. 1. 2018-31. 12. 2022, we performed 1,302 planned operations for breast disease at the Surgical Clinic of Teaching Hospital Plzeň, of which 30 (2%) were precancer operations. ADH was confirmed 11×, LCIS 8×, and a radical scar 11×. The average age of the patients in all three groups was 56 years (27-85). Precancer was diagnosed 8× only by sonography, 3× by mammography and 19× by a combination of both methods. Subsequently, a puncture biopsy was always completed. We performed 28 tumor excisions with intraoperative biopsy and 2 mastectomies.

Results: In the case of ADH from puncture biopsy, ADH was confirmed intraoperatively 8×, DCIS was diagnosed 2×, and mucinous carcinoma 1×. In LCIS, no tumor was found by intraoperative biopsy 4×, LCIS was confirmed 1×, lobular invasive carcinoma was diagnosed 1×, mastectomy was performed 2× without intraoperative biopsy. In the radial scar, ADH was diagnosed 3×, sclerosing adenosis 6×, DCIS 1×, invasive carcinoma 1×. After the final histological processing of the samples, there was an increase in diagnosed carcinomas. In ADH, DCIS was confirmed 3×, DIC 2×, and mucinous carcinoma 1×. In LCIS, LIC was diagnosed 3×. In the radial scar, DCIS was confirmed 1×, and invasive carcinoma remain 1×. Thus, carcinoma was diagnosed in 11 patients (37%) thanks to the surgical solution. No patient underwent axillary node surgery. All 11 patients subsequently underwent oncological treatment, always a combination of radiotherapy and hormone therapy. All patients are alive, 10 patients are in complete remission of the disease, one with DCIS experienced a local recurrence after 4 years.

Conclusion: Surgical treatment of precancers of the breast makes sense, DCIS or even invasive cancer is often hidden in addition to precancer. Thanks to the surgical solution, the cancer was detected in time.

This paper provides a brief overview of current information and recommendations for surgical treatment of breast cancer in pregnancy, including three currently controversial areas - indications for breast-conserving surgery in the 1st trimester of pregnancy, indications for sentinel lymph node biopsy and its technique, and fetal monitoring during surgery.

Introduction: Lymphangiomas belong to the group of benign vascular tumors that originate in the lymphatic tissue. Up to 90% of cases manifest in children before the second year of life. In adults, their presence is very rare. In most cases, they are located in the head, neck and axilla. Intra-abdominal lymphangiomas are very rare and represent less than 1% of all cases.

Case report: The authors present the case of a 64-year-old female patient diagnosed with an intra-abdominal cystic lesion following a routine examination. A CT scan of the abdomen confirmed a cystic lesion located in the lesser omentum between the left lobe of the liver and the lesser curvature of the stomach. The patient was scheduled for laparoscopic exstirpation of the lesion. Histological examination confirmed the clinical diagnosis of cystic lymphangioma of the lesser omentum.

Conclusion: The etiopathogenesis of lymphangiomas remains unclear. Despite the fact that they are benign tumors, lymphangiomas tend to have an infiltrative pattern of growth, invading surrounding structures. The majority of cases are asymptomatic and the diagnosis is incidental. The gold standard in treatment remains complete surgical extirpation with microscopically negative margins.