Rozhledy v Chirurgii最新文献

Introduction: The genitourinary tract and retroperitoneal hemorrhage belong to severe and sometimes life-threatening urological emergencies. Interventional radiology methods can significantly reduce morbidity and mortality in patients who fail conservative treatment and are unfit for surgery.

Materials: We performed a retrospective analysis of patients indicated for angiography and vasographic intervention due to urological pathology in 2015-2020. The study focused on the etiology, technical, clinical success, and possible complications related to angioembolization.

Results: In 5 years, we recorded 51 patients who underwent angiography to localize arterial bleeding or diagnose arteriovenous malformation. In 46 patients (90%), the interventional radiologist subsequently embolized active bleeding or selectively obliterated the main branches of the artery. Angiography did not show extravasation in five patients. Therefore, embolization was not performed. The radiologist assessed the technical success of embolization as 100% in all cases. Two patients experienced a recurrence of bleeding between 24 and 72 hours after the procedure, and the vasography had to be repeated. The predominant finding was hematuria in more than 75% of cases, followed by retroperitoneal hematoma, including perirenal hematoma. Twenty-four embolizations were performed in the renal artery basin; internal pelvic arteries were embolized or obliterated in 21 cases. In one case, a urologist indicated vasography of the left bulbar artery of the penis due to high-pressure priapism.

Conclusion: Vasographic embolization remains an important treatment option in case of hemodynamically significant hemorrhage. Our data support the importance of angioembolization in cases of severe bleeding in the urinary tract with good patient tolerability.

Introduction and aims: The training of young surgeons in the Czech Republic includes the completion of mini-invasive, laparoscopic simulation courses on a voluntary basis. The aim of this study is to show how simulation is used now to train surgeons and to look back at 10 years of running a simulation, laparoscopic, mini-invasive course from the graduates' points of view using box and virtual reality simulators.

Type of study: Observational, survey.

Methods: Data were collected from 26 courses (2014-2024) by an anonymous question-naire. The questionnaires were completed by all graduates (100%). Their evaluation was done by the descriptive statistics method. Questions were asked about expecta-tions and fulfilment of the expectations from the course with its possible recommendation and financial cost.

Results: A total of 96 doctors, 55 men and 41 women, participated in the courses. The questionnaires were completed by all participants. In 89 cases (92.7%), the candi-dates wanted to learn the correct technique, tips, and tricks in laparoscopic surgery; in 42 cases (43.8%), they expected an increase in the operative time; and in 37 cases (38.5%), a deepening of anatomical and theoretical knowledge was mentioned. The course completely fulfilled the expectations in 92% of the cases, in 6.0% of the cases, it fulfilled them with minor reservations and in 2.0% it fulfilled them partially. Ninety seven percent of participants would recommend the course as compulsory; 3% would leave its recommendation to the discretion of the graduate. Twenty-eight participants (29.2%) fully paid for the course; 5 (5.2%) participants partially paid; and 63 (65.6%) participants received payment from their employer.

Conclusion: The participants recommended the simulation course for compulsory inclusion in the surgical education curriculum, and about one-third of them also expressed willingness to pay for the optional education. Although simulators and simulations in surgery represent an important training potential, the subsequent role of mentor in the form of certified, experienced colleague(s) cannot be replaced by them.

Introduction and aim: For a correct assessment of anorectal dysfunction, adequate physical and imaging examinations are required. The aim of our study was to evaluate the use of MRI defecography in patients with anorectal dysfunction. Its comparison with anorectal manometry, standard clinical examination, and patients' subjective perceptions.

Type of study: An observational, retrospective analysis.

Methods: Forty patients with symptoms of anorectal dysfunction referred to a colorectal clinic between 9/2022 and 5/2023 participated in the study. All underwent proctological examination, anorectal manometry and MRI defecography. The results of the study were statistically processed with Statistica 12.0 software.

Results: The average age of the patients was 55 years. Primary complaints were obstipation in 60% of patients, fecal incontinence in 33%, 1 patient had proctalgia and 2 patients presented for rectal prolapse. On clinical examination, 20% of patients had rectoanal intussusception and 15% had complete rectal prolapse. A total of 36% of patients reported concomitant urinary incontinence. Pelvic floor drop in the anterior compartment was also demonstrated in patients who had physiological internal sphincter function according to anorectal manometry, however, due to the small sample size, only a trend was observed and statistical significance of these differences was not -reached (P = 0.109). Patients without evidence of obstructive defecation syndrome on anorectal manometry had complete rectal emptying on MRI defecography (P = 0.0598).

Conclusion: Dynamic MRI defecography can identify anatomical and functional abnormalities of the pelvic floor. The main use of the method is in the detection of multi-compartment pathology. Multidisciplinary collaboration is required to interpret the results and establish an accurate diagnosis.

Ruptures of the distal tendon of the biceps brachii muscle usually require surgical treat-ment to restore strong elbow flexion and forearm supination. However, the surgical procedure carries a risk of injury to neurovascular structures adjacent to the insertional tendon, and its success relies on respecting the original anatomical relations during reconstruction of the tendon. The aim of this article is to present a compendious review of relevant anatomy and practical notes which may enhance the optimal functional outcomes. Structured discussion on morphological aspects of the insertional tendon and its topography in relation to osseous and soft-tissue structures is presented. Moreover, attention is paid to technical aspects of implantation of fixation devices, so that physiological and anatomical reconstruction can be assured. This paper contains numerous schematic drawings to demonstrate the surgically relevant anatomy.

The technique of total mesorectal excision (TME) has become a widely accepted component of rectal cancer resection since its introduction in the 1980s. The quality of TME remains the only way for a surgeon to influence the oncological outcomes of surgical treatment for rectal cancer. A thorough understanding of the surgical anatomy of the pelvis, particularly the pelvic fasciae, vascular supply, and lymphatic drainage of the rectum, is essential for the proper technique of TME. Functional outcomes of rectal resections also depend on meticulous dissection and respect for the anatomy of the pelvic autonomic nerve plexuses. In this article, the authors define the key anatomical structures and terms, including lesser-known eponyms commonly used in rectal surgery. Finally, they describe the TME procedure based on the surgical anatomy of the pelvis, emphasizing the importance of respecting the developmental tissue planes and anatomical structures involved.

Introduction: Pancreaticopleural fistula (PPF) represents a rare complication of chronic pancreatitis. The treatment is complex including pleural drainage, decompression of main pancreatic duct by endoscopic retrograde cholangiopancreatography, pancreas rest with parenteral or enteral nutrition via naso-jejunal feeding tube and somato-statin analogues application. Surgery is indicated when the conservative or endoscopic treat-ment is not successful. In selected cases, total pancreatectomy may be consid-ered. -After these procedures, unstable diabetes mellitus may be a problem. In this case report, the authors present an alternative way to resolve pancreatico-pleural fistula in patients with a history of pancreatic resection.

Case report: A 49-year-old man underwent pancreatoduodenectomy with pancreato-gastrostomy for chronic pancreatitis in 2018. Two years after the procedure, he had severe dyspnea, with X-ray showing left-sided fluidothorax. Pleuracentesis confirmed high amylase activity in pleural effusion. A CT scan was performed and a diag-nosis of pancreaticopleural fistula was made. Due to the failure of conservative treatment, the residual pancreas was resected. The islets of Langerhans from the resected pancreatic tissue were isolated and transplanted back into the patient's liver via the portal vein. The postoperative course was uneventful. Two year after the procedure, the patient was asymptomatic without pleural effusion recurrence and no need of insulin replacement therapy.

Conclusion: Total pancreatectomy with islet autotransplantation may be an appropri-ate method of treatment for recurrent pancreaticopleural fistula in situations where less radical procedures are not possible.

Background: The inflammatory myofibroblastic tumour (IMT) of the stomach is an extremely rare tumor. The authors present the case report of a patient with primary gastric IMT.

Case presentation: A 24-year-old man presented with a 50-mm tumorous mass on the anterior wall of the middle third of the stomach, detected by -upper gastrointestinal endoscopy and suspected to be a gastrointestinal stromal tumour. Endoscopic ultrasonography-guided fine needle aspiration was performed and an inflammatory myofibroblastic tumour of the stomach was confirmed. A laparoscopic wedge resection was performed.

Discussion: A primary gastric inflammatory myofibroblastic tumour is a very rare mesenchymal neoplasm of uncertain malignant potential. Upper gastrointestinal endoscopy, endoscopic ultrasonography followed by fine needle aspiration, seems to be a method of choice in the preoperative diagnostic method for submucosal tumors of the stomach. The types of surgical procedures used in the treatment of primary gastric IMTs depend on the localization of the tumor and its size as well as on the general condition of patients. The recurrence rate after resection is about 15-35%, with distant metastases occurring in less than 5% of patients. In the event of a recurrence, re-excision is generally recommended, when possible. Modern biological treatment with significant effects includes the use of ALK inhibitors and other targeted therapy guided by molecular predictors.

Conclusions: When submucosal tumour of the stomach is identified, the possibility of gastric IMT should be considered.

Acute conditions in proctology refer to anorectal disorders presenting with symptoms such as acute anal pain and bleeding that may require immediate treatment. This pub-lication discusses the diagnosis and management of common anorectal emergencies such as hemorrhoidal crisis, bleeding anorectal varices, anal fissure, anorectal abscess, strangulated rectal prolapse, Fournier gangrene and retained anorectal foreign bodies. Although many acute complications occurring in emergency cases are not life-threat-ening and can be successfully treated in an outpatient setting, accurate diagnosis and proper treatment can prevent serious complications such as sepsis or permanent func-tional impairment. A detailed medical history and careful physical examination, including digital rectal examination and anoscopy, are essential for a correct diagnosis and treatment plan. In some cases, some imaging tests such as computed tomography and ultrasonography are required. When in doubt, treating physicians should not hesitate to consult a specialist for diagnosis, proper treatment and appropriate follow-up, e.g. colorectal surgeon.

Introduction: Laparoscopic cholecystectomy is currently the gold standard of treatment for cholecystolithiasis. The authors present a rare postoperative complication that -caused the development of septic shock with multiorgan failure and necessitated a number of other operations.

Case report: A 57-year-old woman underwent elective uncomplicated laparoscopic cholecystectomy for symptomatic cholecystolithiasis. The postoperative period was complicated by the development of septic shock with extensive abdominal wall gangrene. The finding necessitated surgical management and complex resuscitative care.

Discussion: Knowledge and skills in intensive and resuscitation care are nowadays among the basic minimum that an erudite surgeon working in hospital surgery must possess. One cannot rely solely on the intensive care provided by anaesthetists. Intensivists recruited from a specific specialty (surgery, internal medicine, pediatrics) may have a better insight into the problem due to their knowledge of the complexity of the disease and are complemented by anesthesiologists.

Conclusion: Initial treatment of septic shock must be early and aggressive, after stabilization of the condition it is necessary to sanitize the source of infection, if possible. Intensive care is an mandatory and necessary part of adequate treatment of septic patients.

Introduction: Principles of complete mesocolic excision with central vascular ligation were first published by Hohenberger with promising oncological results of right-sided colon carcinoma. Nowadays preserving of mesocolon is a gold standard; however, -there is a lack of definitive answer about the extent of lymphadenectomy. Our modified D3 lymphadenectomy can reach higher count of lymph nodes retrieval, and therefore can lead to upstaging in the patient. Nevertheless, more complex procedure can lead to various perioperative complications.

Methods: A total of 28 patients were operated by robotic assisted approach with modified D3 lymphadenectomy in the period 1/2023-12/2024 for carcinoma of the cecum and ascending colon. As a control group, 59 patients were enrolled from the period 1/2020-12/2022 operated by an open approach with standard D2 lymphadenectomy. In each input parameter, both groups were comparable.

Results: An operating time was significantly longer in robotic assisted group (P < 0.001). Blood losses were comparable for both groups. Postoperative hospital stay was lower in robotic assisted group and reached a significant threshold (P = 0.011). The re-trieved lymph node count was significantly higher in the group of modified D3 lymphadenectomy (P = 0.002). There were no surgical site infections in the miniivasive group, while in the open group they reached 17%. The occurrence of paralytic ileus was lower in the robotic assisted group (10 vs. 27.1%; P = 0.146).

Conclusion: The results of this pilot study indicate that complete robotic assisted mesocolic excision with modified D3 lymphadenectomy at right-sided colorectal carcinoma is a safe method, and does not increase the risk of peroperative vascular injuries and postoperative complications, such as paralytic ileus or surgical site infection, which leads to a shorter hospital stay.