Enteroatmosferická píštěl (enteroatmospheric fistula – EAF) patří mezi nezávažnější a život ohrožující chirurgické komplikace, které výrazně zvyšují náklady na léčbu pacientů. Řadí se do skupiny pooperačních komplikací souhrnně označovaných jako abdominální katastrofy. EAF je specifický typ střevní píštěle, která vzniká otevřením střevního lumen do nezhojeného defektu břišní stěny, vedoucí k permanentní kontaminaci rány znemožňující její hojení. Léčba této komplikace bývá svízelná, dlouhodobá a vyžaduje multidisciplinární přístup ve třech různých fázích. V první fázi je cílem agresivní terapie abdominální sepse a ošetření jejího zdroje. Po stabilizaci pacienta přichází druhá, chronická fáze zaměřující se na péči o defekt a zvrat nutričního stavu z katabolizmu do anabolizmu. Po maturaci adhezí v dutině břišní, zhojení rány v okolí EAF a po adekvátní nutriční přípravě pacient podstupuje fázi rekonstrukční zahrnující obnovení kontinuity zažívacího traktu a rekonstrukci břišní stěny. Ve všech fázích je pacient ohrožen řadou vedlejších komplikací vycházejících z malnutrice a dlouhodobého pobytu na nemocničním lůžku. Nejdůležitější je proto dbát na prevenci vzniku EAF. Cílem této je práce je shrnout současná doporučení pro léčbu EAF a přiblížit některé z moderních postupů řešení EAF.
Enteroatmospheric fistula (EAF) is one of the most severe and life-threatening surgical complications, significantly increasing the cost of patient treatment. It is classified as a postoperative complication, collectively referred to as abdominal catastrophes. EAF is a specific type of intestinal fistula that occurs when the intestinal lumen opens into an unhealed defect in the abdominal wall, leading to continuous wound contamination that complicates healing. Treatment of this complication is challenging, prolonged, and requires a multidisciplinary approach in three distinct phases. In the first phase, the goal is aggressive therapy of abdominal sepsis and management of its source. After stabilizing the patient, the second, chronic phase focuses on care for the defect and reversing the nutritional status from catabolism to anabolism. Following the maturation of adhesions in the abdominal cavity, healing of the wound around the EAF, and adequate nutritional preparation, the patient undergoes the reconstructive phase, which involves restoring the continuity of the digestive tract and reconstructing the abdominal wall. Throughout all phases, the patient is at risk for numerous secondary complications related to malnutrition and prolonged hospitalization. Therefore, preventing the development of EAF is of paramount importance. The aim of this paper is to summarize current recommendations for the treatment of EAF and discuss some of the modern approaches to managing this condition.
Cardiac computed tomography (CT) is vital for safety and efficacy of transcatheter aortic valve implantation (TAVI). We aimed to determine the accuracy of fully automated CT analysis of aortic root anatomy before TAVI by Philips HeartNavigator software. This prospective, academic, single-centre study enrolled 128 consecutive patients with native aortic valve stenosis considered for TAVI. Automated HeartNavigator software was compared to the standard manual CT analysis by experienced operators using FluoroCT software. The sizing of the aortic annulus by perimeter and area significantly differed between both methods: mean perimeter was 76.43 mm vs. 77.52 mm (P < 0.0001) using manual FluoroCT vs. automated HeartNavigator software; mean area was 465 mm2 vs. 476 mm2 (P < 0.0001). Interindividual variability testing revealed mean differences between the two operators were 1.21 mm for the aortic annulus perimeter and 9 mm2 for the aortic annulus area. The hypothetical self-expandable transcatheter prosthesis sizing resulted in 80% agreement in 80% of cases. The time required to perform the automated CT analysis was significantly shorter than the time required for manual analysis (mean 17.8 min vs. 2.1 min, P < 0.0001). Philips HeartNavigator fully automated software for pre-TAVI CT analysis is a promising technology. Differences detected in aortic annulus dimensions are small and similar to the variability of manual CT analysis. Automated prediction of optimal fluoroscopic viewing angles is accurate. Correct transcatheter prosthesis sizing requires clinical oversight.
- Publication type
- Journal Article MeSH
Kontext: Cílem studie bylo zjistit závažnost zánětlivé odpovědi po výkonu PEARS (personalized external aortic root support) s vytvořením personalizovaného externího stentu pro aortální kořen ve srovnání se standardní profylaktickou operací aortálního kořene (standard prophylactic aortic root surgery, SPARS). Materiál a metody: Studie byla monocentrickou, retrospektivní analýzou nemocničních záznamů pacientů, u nichž byla v období 1998-2017 provedena buď PEARS (skupina PEARS), nebo SPARS (skupina SPARS). U všech pacientů se rutinně stanovovaly hodnoty C-reaktivního proteinu (CRP) a počet bílých krvinek (white blood count, WBC) a provádělo se echokardiografické vyšetření. Horečka byla definována jako tělesná teplota ≥ 38 °C. Diagnóza perikarditidy se stanovovala na základě nejméně tří známek z bolesti na hrudi, perikardiálního výpotku, elevace úseku ST, zvýšených hodnot CRP a tělesné teploty. Výsledky: Do skupin PEARS a SPARS bylo zařazeno 13, resp. 14 pacientů s indikací k profylaktické operaci aortálního kořene. Většina pacientů v obou skupinách měla Marfanův syndrom s kauzální mutací v genu pro fibrilin 1 (FBN1) (62 % vs. 79 %). Vstupní charakteristiky pacientů v obou skupinách byly podobné s výjimkou aortálního kořene, který byl ve skupině SPARS statisticky významně větší než ve skupině PEARS (60 ± 12 mm vs. 48 ± 5 mm; p = 0,003). Všechny operace byly úspěšné a proběhly bez větších komplikací. Nejvyšší hodnoty CRP a WBC byly statisticky významně vyšší ve skupině PEARS (264,5 ± 84,4 mg/l vs. 184,6 ± 89,6 mg/l; p = 0,034, resp. 15,2 ± 3,8 109/l vs. 11,9 ± 3,3 109/l; p = 0,029). Časná a recidivující horečka vyžadující opětovnou hospitalizaci se vyskytla častěji ve skupině PEARS (77 % vs. 36 %; p = 0,032, resp. 46 % vs. 7 %; p = 0,020). Časná a recidivující perikarditida vyžadující hospitalizaci byla rovněž častější ve skupině PEARS (31 % vs. 0 %; p = 0,024, resp. 31 % vs. 0 %; p = 0,024). Závěry: Metoda PEARS je velmi slibná chirurgická metoda; pooperační zánětlivá odpověď se však vyskytuje častěji a ve srovnání s metodou SPARS je závažnější. Tyto výsledky je však samozřejmě nutno dále zkoumat a ověřovat.
Background: The study aimed to determine the severity of inflammatory response after the personalized external aortic root support (PEARS) procedure in comparison to after the standard prophylactic aortic root surgery (SPARS). Materials and methods: The study was a single-centre, retrospective, based on hospital record analysis of patients who underwent the PEARS procedure (PEARS group) or SPARS (SPARS group) during 1998-2017. C-reactive protein (CRP), white blood count (WBC), and echocardiography were routinely obtained. Fever was defined as body temperature ≥38 °C. Diagnosis of pericarditis included a minimum of three signs from chest pain, pericardial effusion, ST elevation, elevated CRP, and body temperature. Results: PEARS and SPARS groups consisted of 13 and 14 patients, respectively, scheduled for prophylactic aortic root. A majority of patients in both groups had Marfan syndrome with causal mutation in the fibrillin 1 (FBN1) gene (62% vs 79%). Patient baseline characteristics were similar in the two groups, except aortic root was significantly larger in the SPARS group than in the PEARS group (60±12 mm vs 48±5 mm; p = 0.003). All surgical procedures were successful and without major complications. The peak values of CRP and WBC were significantly higher in the PEARS group (264.5±84.4 mg/L vs 184.6±89.6 mg/L; p = 0.034 and 15.2±3.8 109/L vs 11.9±3.3 109/L; p = 0.029). Early and recurrent fever requiring hospital readmission was significantlymore frequent in the PEARS group (77% vs 36%; p = 0.032 and 46% vs 7%; p = 0.020). Early and recurrent pericarditis requiring hospital readmission was also more frequent in the PEARS group (31% vs 0%; p = 0.024 and 31% vs 0%; p = 0.024)., Conclusions: The PEARS procedure is an extremely promising surgical technique, but the postoperative inflammatory response occurs frequently and more severely in comparison to SPARS. Clearly, these findings warrant further investigation.
- MeSH
- Aortic Aneurysm * surgery MeSH
- C-Reactive Protein analysis MeSH
- Humans MeSH
- Marfan Syndrome surgery MeSH
- Pericarditis surgery MeSH
- Postoperative Complications MeSH
- Prophylactic Surgical Procedures MeSH
- Retrospective Studies MeSH
- Inflammation MeSH
- Check Tag
- Humans MeSH
- Publication type
- Research Support, Non-U.S. Gov't MeSH
Background: Left atrial appendage (LAA) closure (LAAC) is accompanied by a high risk of complications. Due to the complex anatomy of the LAA and the oval-shaped ostium, the proper sizing of the device is often difficult. Purpose: To assess individualized fluoroscopy viewing angles using pre-procedural CT analysis and to compare the results of landing zone measurements obtained from CT, transesophageal echocardiography (TEE), intracardiac echocardiography (ICE), and fluoroscopy. Methods: Patients with indications for LAAC were enrolled. Cardiac CT and TEE were done before the procedure; ICE and fluoroscopy measurements were done peri-procedurally. Multiplanar reconstruction of CT images, using FluoroCT software, was done, and optimal "personalized" viewing angles for fluoroscopy were determined. Moreover, a mean (using multiplanar CT reconstruction, derived from the LAA perimetr) amd maximum (using all four imaging modalitities) landing zone (LZ) of the LAA were masured. Results: Twenty-five patients were analyzed. Despite significant correlation between LZs obtained from different imaging modalities, the values of LZs differed significantly; the mean LZ diameter on CT was 20.60 ± 3.42 mm, the maximum diameters were 21.99 ± 4.03 mm (CT), 18.72 ± 2.44 mm (TEE), 18.20 ± 2.68 mm (ICE), and 17.76 ± 3.24 mm (fluoroscopy). The mean CT diameter matched with the final device selection in 92% patients, while fluoroscopy or TEE maximum diameters in only 72% patients. Optimal viewing angles differed significantly from the fluoroscopy projections usually recommended by the manufacturer in 3 patients. Conclusions: CT provides the best measurement of the LZ and the best prediction of the optimum fluoroscopy projections for the implantation procedure.
- Publication type
- Journal Article MeSH
OBJECTIVES: The aim of this study was to define the optimal fluoroscopic viewing angles of both coronary ostia and important coronary bifurcations by using 3-dimensional multislice computed tomographic data. BACKGROUND: Optimal fluoroscopic projections are crucial for coronary imaging and interventions. Historically, coronary fluoroscopic viewing angles were derived empirically from experienced operators. METHODS: In this analysis, 100 consecutive patients who underwent computed tomographic coronary angiography (CTCA) for suspected coronary artery disease were studied. A CTCA-based method is described to define optimal viewing angles of both coronary ostia and important coronary bifurcations to guide percutaneous coronary interventions. RESULTS: The average optimal viewing angle for ostial left main stenting was left anterior oblique (LAO) 37°, cranial (CRA) 22° (95% confidence interval [CI]: LAO 33° to 40°, CRA 19° to 25°) and for ostial right coronary stenting was LAO 79°, CRA 41° (95% CI: LAO 74° to 84°, CRA 37° to 45°). Estimated mean optimal viewing angles for bifurcation stenting were as follows: left main: LAO 0°, caudal (CAU) 49° (95% CI: right anterior oblique [RAO] 8° to LAO 8°, CAU 43° to 54°); left anterior descending with first diagonal branch: LAO 11°, CRA 71° (95% CI: RAO 6° to LAO 27°, CRA 66° to 77°); left circumflex bifurcation with first marginal branch: LAO 24°, CAU 33° (95% CI: LAO 15° to 33°, CAU 25° to 41°); and posterior descending artery and posterolateral branch: LAO 44°, CRA 34° (95% CI: LAO 35° to 52°, CRA 27° to 41°). CONCLUSIONS: CTCA can suggest optimal fluoroscopic viewing angles of coronary artery ostia and bifurcations. As the frequency of use of diagnostic CTCA increases in the future, it has the potential to provide additional information for planning and guiding percutaneous coronary intervention procedures.
We aimed to determine the incidence, severity, and long-term impact of intravascular haemolysis after self-expanding transcatheter aortic valve implantation (TAVI). We believe this should be evaluated before extending the indications of TAVI to younger low-risk patients. Prospective, academic, single centre study of 94 consecutive patients treated with supra-annular self-expandable TAVI prosthesis between April 2009 and January 2014. Haemolysis at 1-year post-TAVI was defined per the published criteria based on levels of haemoglobin, reticulocyte and schistocyte count, lactate dehydrogenase (LDH), and haptoglobin. All patients had long-term clinical follow-up (6 years). The incidence of haemolysis at 1-year follow-up varied between 9% and 28%, based on different haemolysis definitions. Haemolysis was mild in all cases, no patient had markedly increased LDH levels. The presence of moderate/severe paravalvular aortic regurgitation was associated with haemolysis (7.7% vs. 23.1%, P = 0.044) and aortic valve area post-TAVI did not differ between groups with or without haemolysis (1.01 vs. 0.92 cm2/m2, P = 0.23) (definition including schistocyte count). The presence of haemolysis did not have any impact on patient prognosis after 6 years with log-rank test P = 0.80. Intravascular haemolysis after TAVI with self-expandable prosthesis is present in 9-28% of patients depending on the definition of haemolysis. The presence of haemolysis is associated with moderate/severe paravalvular aortic regurgitation but not with post-TAVI aortic valve area. Haemolysis is mild with no impact on prognosis.
- Publication type
- Journal Article MeSH
OBJECTIVES: To highlight conditions that may cause early-onset degenerative joint disease, and to assess the possible impact of such diseases upon everyday life. MATERIAL: Four adults aged under 50 years from a medieval skeletal collection of Prague (Czechia). METHODS: Visual, osteometric, X-ray, and histological examinations, stable isotope analysis of bone collagen. RESULTS: All four individuals showed multiple symmetrical degenerative changes, affecting the majority of joints of the postcranial skeleton. Associated dysplastic deformities were observed in all individuals, including bilateral hip dysplasia (n = 1), flattening of the femoral condyles (n = 3), and substantial deformation of the elbows (n = 3). The diet of the affected individuals differed from the contemporary population sample. CONCLUSIONS: We propose the diagnosis of a mild form of skeletal dysplasia in these four individuals, with multiple epiphyseal dysplasia or type-II collagenopathy linked to premature osteoarthritis as the most probable causes. SIGNIFICANCE: Combining the skeletal findings with information from the medical literature, this paper defines several characteristic traits which may assist with the diagnosis of skeletal dysplasia in the archaeological record. LIMITATIONS: As no genetic analysis was performed to confirm the possible kinship of the individuals, it is not possible to definitively assess whether the individuals suffered from the same hereditary condition or from different forms of skeletal dysplasia. SUGGESTIONS FOR FURTHER RESEARCH: Further studies on premature osteoarthritis in archaeological skeletal series are needed to correct the underrepresentation of these mild forms of dysplasia in past populations.
- MeSH
- History, Medieval MeSH
- Diet history MeSH
- Adult MeSH
- Cemeteries history MeSH
- Bone and Bones pathology MeSH
- Middle Aged MeSH
- Humans MeSH
- Hip Dislocation pathology MeSH
- Osteoarthritis * history pathology MeSH
- Check Tag
- History, Medieval MeSH
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Historical Article MeSH
- Research Support, Non-U.S. Gov't MeSH
- Geographicals
- Czech Republic MeSH
- MeSH
- Benign Paroxysmal Positional Vertigo therapy MeSH
- Diagnostic Errors psychology MeSH
- Adult MeSH
- Humans MeSH
- Labyrinth Diseases * diagnosis surgery psychology MeSH
- Otologic Surgical Procedures methods MeSH
- Tomography, X-Ray Computed methods MeSH
- Postoperative Complications MeSH
- Semicircular Canals diagnostic imaging surgery MeSH
- Treatment Outcome MeSH
- Check Tag
- Adult MeSH
- Humans MeSH
- Male MeSH
- Publication type
- Case Reports MeSH
BACKGROUND: Little is known about the valve degeneration process after transcutaneous aortic valve implantations (TAVI) that can have an important impact on patients' long-term prognosis. AIM: To evaluate degenerative changes of TAVI using computed tomography (CT) compared to findings in patients that underwent surgical aortic valve replacement (SAVR). Subsequently, to compare the level of immune and inflammatory markers in both groups and test their possible role in the valve degeneration process. METHODS AND RESULTS: 49 patients after TAVI and 29 patients in the control group after SAVR underwent 2 years of follow-up and 8 patients from the TAVI group and 7 patients after SAVR underwent five years of follow-up. CT was performed in all patients and calcifications on prosthesis cusps in both groups were measured using Agatson calcium score. TAVI patients were older compared to patients who underwent SAVR [82 (62;86) vs. 74 (64;84) years, p<0.001], and had more comorbidities - higher EuroScore I [21.0 (5.0;46.0) vs. 6.15 (2.54;11.17), p<0.001]. TAVI patients had more often concomitant coronary artery disease (69.4% vs. 13.8%, p<0.001) and previous history of cardiac surgery (32.7% vs. 0.0%, p<0.001). Slight calcifications (mean Agatson score 50.76) on prosthetic cusps were found in 2 patients 4-5 years after TAVI and in 1 patient 2 years after SAVR (p=NS). Even though significant differences were found in values of tumor necrosis factor-α and E-selectin before, 1 year, and 2 years after implantation, no significant changes in values of inflammatory markers were observed during follow-up period in both groups of patients. Detailed analysis revealed no significant difference between values of inflammatory markers of patients with and without calcifications present on CT. CONCLUSION: Minimal degenerative changes on TAVI prosthesis were observed in mid- and long-term follow-up. Systemic immune response did not differ between patients after TAVI and SAVR.
- MeSH
- Aortic Valve diagnostic imaging surgery MeSH
- Aortic Valve Stenosis surgery MeSH
- Biomarkers blood MeSH
- C-Reactive Protein analysis MeSH
- Heart Valve Prosthesis Implantation methods MeSH
- Cytokines blood MeSH
- E-Selectin blood MeSH
- Middle Aged MeSH
- Humans MeSH
- Multidetector Computed Tomography MeSH
- Follow-Up Studies MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Case-Control Studies MeSH
- Transcatheter Aortic Valve Replacement * MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Comparative Study MeSH
