Chirurgicka klinika

Prague, Czech Republic

Chirurgicka klinika

Prague, Czech Republic
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Indocyanine green (ICG) is one of the types of fluorescent dyes (fluorophores, fluorochromes). It is a chemical compound containing a reactive group capable of reacting with nucleophilic groups. The principle of fluorescence is the emission of energy in a very short time, caused by the effect of radiation. Each fluorescent substance is characterized by two types of spectra - an excitation and an emission spectrum. ICG has an excitation and emission spectrum in the near infrared region, hence the so-called NIR (near infrared) fluorophores. ICG is the only NIR dye that has been certified by the FDA (U.S. Food and Drug Administration) for use in biomedicine since 1959 (1). Especially in recent years, indocyanine green has received a lot of attention due to its ever-expanding indications for use in clinical medicine. It has been traditionally used in ophthalmology to diagnose diseases of the retina as well as to determine cardiac output and to measure liver function. However, it is also used in surgical oncology to detect sentinel nodes and in neurosurgery, vascular surgery or reconstructive surgery to evaluate microcirculation following free tissue transfer.

Effective diagnostic - therapeutic approach to patients with metastatic colorectal carcinoma leads to more than 50 % 5 year survival. Most effective treatment is curable liver resection with primary indication in 20 % of patients. Other 15-20 % patients reach resection after conversion systemic antitumor therapy. There are special techniques (combined procedures, two stages operations) or portal venous embolisation followed by resection after hypertrophy of liver remnant. Multidisciplinary approach is only the condition for successful treatment on the base of personalized medicine principles in these patients.

Intestinal obstruction caused by an internal hernia is considered to be a rare cause of ileus. The rarest of these is herniation through the falciform ligament. In our article we present the case of a 45-year old female patient operated on for small bowel herniation through a defect in the falciform ligament. The loops were laparoscopically repositioned into the free abdominal cavity and the defect was removed by electrocautery. After the operation the patient was stabilised and discharged into outpatient care. Our article also analyses relevant literature and the diagnostic methods because the abovementioned diagnosis is rare and often established as late as postoperatively. Key words: internal hernia - the falciform ligament - iatrogenous defect in the falciform ligament.

Mergancova J.,Chirurgicka klinika
Rozhledy v chirurgii : měsíčník Československé chirurgické společnosti | Year: 2011

Breast carcinoma in situ is defined as non-invasive form of carcinoma. However, we can see infiltration of sentinel lymph node even in this disease. The aim of this work was to determine indication criteria for detection of sentinel lymph node in breast carcinoma in situ. Summary of current knowledge about examination of sentinel lymph node in breast carcinoma in situ. Comparison of the results with our own results. We summarized the results of 10 trials studying ductal carcinoma in situ (DCIS) and 4 studies with DCIS with microinvasion. Sentinel lymph node infiltration is described in 0 to 7.3%, or 9.3 to 29.4%. In our department during the period of one year, we diagnosed 7 carcinomas in situ, in the final histology examination 5 DCIS, 1 DCIS with microinvasion and I lobular carcinoma in situ (LCIS) with microinvasion. Sentinel lymph node infiltration was diagnosed only in LCIS with microinvasion. The other, non-sentinel axillary lymph nodes, were negative in this patient. The indication criteria for sentinel lymph node examination in breast carcinoma in situ in our department include: greater extent of microcalcifications, indication for total mastectomy for diffuse involvement, microcalcifications with palpable resistance, preoperative diagnosis of carcinoma in situ from core-cut biopsy, carcinoma in situ G3 confirmed in open extirpation. The sentinel lymph node examination in breast carcinoma in situ can change staging of the disease, as well as the treatment modality. In case that the sentinel lymph node is positive, the disease is undoubtedly invasive and the invasive part of the tissue was not seen in the biopsy sample.

Frank M.,Chirurgicka klinika | Mathieu L.,Desgenettes Military Hospital
Acta Chirurgiae Orthopaedicae et Traumatologiae Cechoslovaca | Year: 2013

The extremities continue to be the most frequent sites of wounding during armed conflicts despite the change of combat tactics, soldier armour and battlefield medical support. Due to the advances in prehospital care and timely transport to the hospital, orthopaedic surgeons deal with severe and challenging injuries of the limbs. In contrast to civilian extremity trauma, the most combat-related injuries are open wounds that often have infection-related complications. Data from two recent large armed conflicts (Iraq, Afghanistan) show that extremity injuries are associated with ahigh complication rate, morbidity and healthcare utilization. Asystematic approach that consists of sequential surgical care and good transport capabilities can reduce the complication rate of these injuries. New medical technologies have been implemented in the treatment strategy during the last decade. This article reviews the published scientific data and current opinions on combat-related extremity injuries.

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. 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. 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. 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. 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.

Gunka I.,Chirurgicka Klinika
Rozhledy v chirurgii : měsíčník Československé chirurgické společnosti | Year: 2010

The aim of this study was to evaluate the results of laparoscopically-assisted (LAC) and open (OC) colorectal surgery in elderly patients (a 75 years) and to compare them to a cohort of younger patients (<75 years) undergoing similar surgical procedures. Patients who underwent elective laparoscopically-assisted or open colorectal surgery in the period between January 2001 and December 2009 were included in the analysis. The primary end point was the incidence of short-term postoperative morbidity and mortality, long-term overall and colorectal cancer specific survival which were analyzed in relation to the age and operative technique. During the study period, 557 elective laparoscopic and 404 elective open colorectal operations were performed. 190 patients (20 %) were older than 75 years, 99 of which underwent laparoscopic and 91 open surgery. In geriatric patients, the open approach was associated with increase of postoperative morbidity, statistically nonsignificant (LAC > or = 75 years 30% vs. OC < 75 years 40%, p = 0,151). In the laparoscopic procedures, the morbidity rate did not differ in both age groups (LAC > or = 75 years 30% vs. LAC < 75 years 28%, p = 0,702). Conversely open procedures in elderly patients were associated with a significant increase of postoperative complications compared to younger patients (OC > or = 75 years 40% vs. OC < 75 years 29%, p= 0,033). There was no difference in postoperative mortality rate between laparoscopic and open approach in geriatric patients (LAC > or = 75 years 5% vs. OC > or = 75 years 3%, p=0,548). Mortality rate did not differ in both age groups operated laparoscopically (LAC > or = 75 years 5% vs. LAC < 75 years 3%, p = 0,322) even by open approach (OC > or = 75 years 3% vs. OC <75 years 2%, p = 0,433). Although five year overall survival was significantly lower in the older age group (LAC > or = 75 years 43 +/- 8% vs. LAC < 75 years 58 +/- 4 %, p = 0,049; OC - 75 years 35 +/- 7% vs. OC < 75 years 56 +/- 4%, p = 0,006), five year colorectal cancer specific survival was not different between both age groups (LAC > or = 75 years 76 +/- 9% vs. LAC < 75 years 75 +/- 4%, p = 0,693; OC > or = 75 years 67 +/- 7% vs. OC < 75 years 69 +/- 4%, p = 0,824). In the elderly patients surgical technique did not influenced overall five year survival (LAC > or = 75 years 43 +/- 8% vs. OC > or = 75 years 35 +/- 7%, p = 0,428), even five year colorectal cancer specific survival (LAC . or = 75 years 76 +/- 9% vs. OC a 75 years 69 +/- 7%, p = 0,393). Laparoscopically-assisted colorectal surgery should be particularly considered in geriatric patients, for the reason of lower incidence of postoperative complications. Oncological safety of miniinvasive approach in the treatment of colorectal cancer is valid also for the specific group of elderly patients.

Ryska O.,Chirurgicka klinika
Rozhledy v chirurgii : měsíčník Československé chirurgické společnosti | Year: 2011

Surgical site infections (SSI) are currently one of the most frequent postoperative complications. Emergent surgery is generally subject to a higher risk of SSI. Antibiotic prophylaxis is one of many measures that should be taken to prevent postoperative infection. However, due to possible adverse effects it must be applied only in indicated cases. Many guidelines have been published abroad, but still missing in Czech Republic. Standard use of prophylaxis can be currently followed due to compliance with SCIP (Surgical Care Improvement Project) measurements and reflects the quality of surgical care. The aim of our study was to evaluate the current clinical praxis of prophylactic antibiotic administration in Czech Republic in emergent surgery for diagnosis: acute appendicitis, small bowel obstruction and perforated gastroduodenal ulcer and evaluate the SCIP criteria adherence. The survey was sent to 149 surgical departments. The questionnaire included 7 questions and feedback was considered to be anonymous. The compliance with 3 main SCIP measurements (INF-1, INF-2, INF-3) was evaluated by the patients with acute appendicitis as a indication for emergent surgery. Overall, 85 (57%) completed questionnaires were received back. According to a survey results, antibiotic prophylaxis is always administered in 15% of patients operated for acute appendicitis, 27% operated for small bowel obstruction and 47% of patients with gastroduodenal perforation. No prophylaxis is given in 11 (13%) hospitals for either of the mentioned diagnoses. Antibiotics are mostly (46%) administered at induction of general anesthesia and extended to 24 hours. The SCIP measurements adherence was as follows: INF-1--4.7%; INF-2--86%; INF-3--81% of evaluated departments. All of 3 (all-or-none) criteria were fulfilled only at 3 (3.5%) surgical departments. The clinical praxis of antibiotic prophylaxis in urgent surgical procedures in Czech Republic is highly variable and mostly ignores the current international guidelines (SCIP). There is a need of local specific guideline concerning antibiotic prophylaxis guaranteed by scientific company.

Havel E.,Chirurgicka klinika
Interni Medicina pro Praxi | Year: 2012

Malnutrition before surgery is common and adversely affects the postoperative course. Risk groups are cancer and geriatric patients, patients with inflammatory bowel disease or other chronic catabolic diseases. Nutritional risk assessment is a required component of pre-operative examination. To identify risk patient is nutritionally suitable NRS 2002 ≥ 3 points (Nutritional Risk Score) or SGA (Subject Global Assessment). Nutritional care before surgery involves first improving the nutritional status of the appropriate interventions for malnourished patients with elective surgery, 2. short-term nutritional support for risk people in length from 10 to 12 days before cancer surgery, 3. in the preoperative immunonutrition for all patients undergoing major surgery, regardless of nutritional status and 4. the preoperative drinking isotonic solution with maltodextrin at the time of last meal two hours prior to surgery. Immediate postoperative parenteral nutrition may be risk, according to new findings. The current strategy of the safe operation preffers a pre-operative energy reserves building, which serves for healing following surgery during the transition of insufficient energy intake.

The review article interprets recommendations for treating methicillin-resistant Staphylococcus aureus (MRSA) infections with vancomycin. These stem from a 2009 consensus followed by numerous preclinical and clinical studies carried out until now. They are based on defining the predictors of the bactericidal activity of vancomycin that are different from those in beta-lactam and aminoglycoside antibiotics. The predictors are AUC0-24/MIC > 400 and Cmin. Practice requires recommendations on how to achieve maximum effectiveness and safety of vancomycin administered by intermittent vs. continuous infusion by attaining target concentrations under dynamically changing conditions. Changes in the kinetics and dynamics of the antibiotic due to pathological covariates (SIRS, sepsis) and treatment should be detected as soon as possible by therapeutic monitoring aimed at individual adjustment of dosage.

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