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Prague, Czech Republic

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.

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.

Heterotopic pancreas (HP) is defraed as abnormally localized pancreatic tissue without any anatomical and vascular connection with pancreas. Incidence of HP is 0.2-0.5% of patients underwent upper medial laparotomy. The most common symptoms of HP are abdominal discomfort and pain, upper gastrointestinal bleeding and intermittent bowel obstruction. Gastroscopy is the most commonly used first diagnostic procedure. Ultrasound evaluation, computer tomography and namely endoscopic ultrasound evaluation are useful imaging procedures of HP. Casuistic report of patient with upper gastrointestinal bleeding is presented. Imaging procedures have recorded stomach tumor 3cm in diameter in back wall of stomach. Billroth II resection of stomach was performed. Histological evaluation of removed part of stomach recorded heterotopic pancreas type 1 of Heinrich classification. HP diagnosis before surgery is difficult because of submucous localization of lesion. Fine needle biopsy during gastroscopy is one of diagnostic possibilities without surgery. Endoscopic excision of lesion is possible if histological evaluation by fine needle biopsy is successful and anatomical localization is appropriate. The most of patients need surgical excision of HP. Peroperative histological evaluation allows a minimalization of excision area. Opinions of asymptomatic HP treatment are ambiguous. The most of published papers recommend excision of asymptomatic HP also, because of risk of next complications.

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.

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.

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