INTRODUCTION: Over the last decades outcomes for rectal cancer surgery have improved, with increasing survival rates. Nevertheless, functional disorders are still frequent. AIM: To evaluate sexual and urinary outcomes of miniinvasive total mesorectal excision (TME). MATERIAL AND METHODS: Between March 2016 and June 2018 patients with rectal cancer who underwent miniinvasive TME with a sphincter-saving procedure were enrolled. The questionnaires were completed before therapy, and 6, 12, and 24 months after stoma closure. We used the Female Sexual Function Index (FSFI), the International Prostate Symptom Score (IPSS) and the International Index of Erectile Function questionnaire (IIEF). RESULTS: Ninety-eight patients completed the questionnaires. Only patients who underwent laparoscopic (39) or robotic TME (27) were enrolled. The characteristics and surgical outcomes did not differ significantly between these groups. The IPSS between the groups was comparable before and after the operation with no significant difference, increased at 6 months and then decreased consecutively. In comparison with baseline, IPSS was significantly lower in the laparoscopic and robotic groups at 6 months and was comparable to baseline at 24 months in both groups. Oppositely, the IIEF was significantly lower at 6 months after ileostomy closure in the robotic group (p < 0.05), but not in the laparoscopic group (p = 0.59) and both returned to baseline at 24 months. FSFI was significantly lower in the laparoscopic group (p = 0.017) 6 months after surgery and returned to baseline at 24 months in both groups. CONCLUSIONS: Laparoscopic and robotic TME showed similar functional results 2 years after stoma resection.
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Introduction: The authors report long-term outcomes in patients who received neoadjuvant chemoradiotherapy and consequently underwent hybrid oesophagectomy for oesophageal cancer (OC). Aim: To evaluate long-term outcomes in patients suffering from OC, who underwent hybrid oesophagectomy. Material and methods: Our cohort consisted of patients suffering from OC, who received neoadjuvant chemoradiotherapy. Hybrid esophagectomy was performed 8-10 weeks after oncological treatment. Results: Ninety-four patients underwent surgery for OC from 2011 to 2015. Histology revealed adenocarcinoma in 60.6%, squamous cell carcinoma (SCC) in 36.2%, and other type of cancer in 3.2%. Seventy-three (77.7%) patients with advanced stage (T3-4, N0-2, M0) were indicated to receive neoadjuvant chemoradiotherapy (nCRT). Trans-hiatal hybrid oesophagectomy was performed in 83 (88.3%) patients. Transthoracic hybrid oesophagectomy was performed in 11 (11.7%) patients. Histology of the resected specimens of 18 (24.7%) patients did not reveal OC, i.e. pathological complete response (pCR). In our cohort, we proved an association between occurrence of pCR and age as well as disease-free survival (DFS). The patients who presented with pCR were significantly younger - below 60 years of age (p = 0.017). They also showed significantly higher mean DFS (p = 0.004). Conclusions: Combined oesophagectomy with neoadjuvant chemoradiotherapy results in a better long-term outcome in patients suffering from oesophageal cancer. In our set of patients who underwent hybrid esophagectomy, satisfactory short-term and especially long-term results of surgical treatment for oesophageal cancer were observed.
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Introduction: Sarcopaenia seems to be predictive factor for postoperative morbidity and mortality after colorectal resection for cancer. Nevertheless, an ideal sarcopaenic indicator is still to be identified. Aim: To evaluate computed tomography (CT) measured total abdominal muscle area (TAMA), total psoas muscle area (TPA), and psoas density (PD) - previously described sarcopaenia indicators - as possible risk factors for postoperative complications in patients after curative colon and rectal resections for colorectal cancer. Material and methods: Consecutive patients after elective curative colon or rectal resection for cancer at a single institution were divided into cohorts with uncomplicated postoperative course or complications Clavien-Dindo grade I-II (Cl-Di 0-II) and complications Clavien-Dindo grade III-V (Cl-Di III-V). Cohorts were statistically tested for significant differences in TAMA, TPA, and PD calculated from preoperative staging CT scans at the level of the third lumbar vertebra. Results: Data of 112 patients were analysed from a prospectively run database; 65 underwent colon and 47 rectal resections. PD was significantly higher in the Cl-Di 0-II cohort compared to the Cl-Di III-V for both colon (42.67 ±6.52 vs. 40.11 ±7.57 HU, p = 0.002) and rectal resections (44.08 ±5.86 vs. 43.03 ±5.70HU, p = 0.016). TAMA and TPA failed to show significant differences. Conclusions: Psoas density is significantly decreased in patients with Clavien-Dindo grade III-V complications after curative resection for colon and rectal cancer. Due to the simplicity and affordability of its assessment from preoperative staging CT scan, it might be considered an optimal sarcopaenic indicator to be utilised in everyday practice.
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Introduction: Sinus pilonidalis (SP) is an acquired inflammatory disease, which is relatively common in the paediatric population. Surgery is indicated in symptomatic patients. In 2017, minimally invasive pilonidal sinus treatment (EPSiT) was adapted to the paediatric population. Aim: To evaluate the first experience with minimally invasive endoscopic treatment of SP (PEPSiT) in children and adolescents in the Czech Republic. Material and methods: A retrospective review of all consecutive paediatric patients who underwent PEPSiT from November 2018 to February 2020. The monitored parameters were demographics, perioperative course of the disease, surgery, length of hospitalisation, postoperative complications, healing, disease recurrence, and follow-up. Results: Seventeen patients were enrolled in the study. The median age at surgery was 17.1 years (range: 12.5-18). The subjects comprised 76% males, and the median body mass index was 25.6 kg/m2 (range: 17-30.3 kg/m2). Thirteen patients underwent previous surgical treatment (76%) under local anaesthesia. The median duration of PEPSiT was 50 min (range: 30-85 min). The subjective evaluation of pain by patients on the VAS scale was 0 on the day of discharge. There were no postoperative complications up to the 30th postoperative day. Two disease recurrences were successfully managed by re-PEPSiT. By the end of follow-up, 14/15 patients had healed. Two patients are still within 3 months of surgery, which is too soon to definitively evaluate possible recurrence of the disease. Conclusions: These preliminary results show that PEPSiT is a highly promising method. It is safe and well-tolerated by patients (short hospital stay, quick return to normal life, low pain and analgesic consumption). Two recurrences of disease were treated by re-PEPSiT.
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Introduction: A proactive approach is recommended in colorectal anastomosis leak treatment, and early diagnosis is very important. Early postoperative endoscopy would allow rapid diagnosis of anastomotic pathologies and consequent prompt intervention according to anastomotic disruption morphology. Aim: To evaluate the effectiveness of close endoscopic follow-up of all patients (including asymptomatic ones) in improving diagnosis of acute leak (AL) and reducing its complications. Material and methods: This study included 124 patients who had undergone rectum resection for rectal cancer with stapled anastomosis. Endoscopy was performed between the 7th and 10th postoperative day and 1 month postoperatively. For defect morphology assessment, a classification system was created based on four levels of severity. Photographic findings were evaluated by an independent, experienced gastroenterologist. Results: Postoperative endoscopy revealed 28 (22.6%) patients with acute leakage. Initial endoscopy confirmed AL in 18 patients. Six (31.6%) patients were asymptomatic and 13 (68.4%) were symptomatic. The second endoscopy revealed another 9 (32.1%) leaks (4 (44.5%) asymptomatic and 5 (55.5%) symptomatic). Sixteen (57.1%) patients had grade A leakages, 7 (25.0%) had grade B leakages, and 5 (17.9%) had grade C leakages. Furthermore, 22 of 27 (81%) defects were located posterior and posterior-laterally. Fifteen (55.5%) defects were smaller than 1/3 the circumference, 7 (25.9%) affected 1/3-1/2 of the circumference, and 5 (18.5%) affected more than 1/2 of the circumference. Conclusions: Incorporation of early endoscopy in postoperative management allows rapid diagnosis of AL and allows faster intervention, even in leaks that are clinically silent.
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Introduction: Bariatric surgery has a significant impact on dietary intake, weight loss, patient's metabolism and also on defaecation stereotypes. Aim: To investigate changes in bowel habits of morbidly obese patients after laparoscopic sleeve gastrectomy (LSG). Material and methods: This was a prospective clinical cohort study conducted to assess changes in bowel habits after LSG in a single institution. Results: In total, 124 patients were enrolled in the study (age 47.1 ±11.2 years, body mass index (BMI) 44.3 ±6.8 kg/m2). The mean weight loss 6 months after LSG was 29.1 ±11.1 kg; percentage excess weight loss was 56.2 ±20.4%. Before surgery, 35.5% of patients had constipation and 6.5% of patients had faecal incontinence (FI). No correlation was found between rising level of BMI and constipation or incontinence prevalence/severity. Data analysis has not confirmed increased prevalence/severity of postoperative constipation or incontinence 6 months after LSG. Out of the group of patients with preoperative constipation, clinically relevant improvement was noted in 45.5% of patients after the surgery. Among patients without constipation before surgery, impairment was noted in 21.2% of patients. Out of the group of patients with preoperative incontinence, improvement was found in 37.5% of patients; none of these patients reported clinically relevant impairment of incontinence symptoms. Conclusions: The present study has not revealed increased prevalence/severity of postoperative constipation or anal incontinence 6 months after LSG. Our findings suggest that weight loss in patients after LSG might be associated with an improvement of constipation symptoms of individual patients.
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Introduction: Anastomotic leak is a very serious complication in colorectal surgery. Tissue perfusion of the anastomosis plays an integral role in its multifactorial etiology. Fluorescence angiography using indocyanine green allows visualization of perfusion in real time. Aim: To evaluate the effectiveness of intraoperative fluorescence angiography as a tool to decrease the incidence of anastomotic leak after laparoscopic or robotic low resection of the rectum for cancer. Material and methods: Intraoperative fluorescence angiography was performed sequentially in 50 patients during low rectal resection for cancer with total mesorectal excision, primary anastomosis and protective ileostomy using laparoscopic or robotic technique. The results were compared to a historical control group of 50 patients with the same procedure without the use of fluorescence angiography. Results: The patient sets were comparable in basic demographic and clinical parameters. Intraoperative visualization of perfusion by fluorescence angiography was achieved in all patients without unwanted side-effects. In 6 (12%) patients, the resection line was adjusted based on the fluorescence angiography. The incidence of anastomotic leak was insignificantly lower in the group with fluorescence angiography (18% vs. 10%), which led to significantly shorter hospital stay. Other postoperative complications were comparable between the two groups. Conclusions: Fluorescence angiography using indocyanine green is a safe and effective method with the potential of reducing anastomotic leak during minimally invasive low resection of the rectum for cancer.
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Introduction: Bariatric procedures lead to changes in body composition. Desired fat loss may be accompanied by decrease of muscle mass, thus raising the risk of sarcopenia. Aim: To detect the risk of sarcopenia in patients 24 months after different bariatric/metabolic (B/M) procedures by DEXA. Material and methods: Consecutive patients scheduled for a B/M procedure underwent DEXA scan and anthropometric assessment before and 24 months after surgery in a prospective manner. Obtained data were tested for significant differences (p < 0.05) to detect body composition changes and occurrence of sarcopenia. The International Physical Activity Questionnaire (IPAQ) was answered at 24 months to assess physical activity. Results: Nineteen patients were enrolled, with no drop-off at follow-up. Body mass index dropped from 42.4 ±6.3 to 30.3 ±4.9 kg/m2, with excess weight loss of 72 ±25% and substantial improvement of all relevant anthropometric measurements (p < 0.001). Significant changes in DEXA parameters were observed: fat mass index (19.5 ±4.7 vs. 12.1 ±3.7 kg/m2), estimated visceral adipose area (235.8 ±70.0 vs. 126.5 ±50.4 cm2), lean mass index (22.1 ±2.4 vs. 18.1 ±2.3 kg/m2), appendage lean mass index (9.7 ±1.3 vs. 7.7 ±1.1 kg/m2), bone mineral content (1.22 ±0.1 vs. 1.12 ±0.1 kg), Z score (2.32 vs. 0.96) and T score (0.58 vs. -0.58). A low level of physical activity was recorded at 24 months. Conclusions: B/M procedures lead to significant changes in body composition at 24 months after surgery. DEXA detects these changes effectively. Desired fat loss is associated with significant reduction of skeletal muscle and bone mineral mass. As such, patients after B/M surgery are at risk of sarcopenia. A low level of physical activity may also play a negative role.
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Introduction: Respiratory complications (RC) including respiratory failure and adult respiratory distress syndrome (ARDS) affect the outcomes of esophagectomy substantially. In order to decrease their incidence, identification of important features of RC is necessary. Aim: To evaluate the incidence and risk factors of postoperative RC following hybrid esophagectomy. Material and methods: The retrospective analysis of consecutive hybrid esophagectomies for malignancies (transhiatal laparoscopic or thoracoscopic resection and limited open reconstruction phase) assessed the incidence and outcomes of RC in relation to the patients' age, ASA score, neoadjuvant therapy, type of surgical procedure, TNM stage, the incidence of anastomotic leak and Clavien-Dindo classification. Results: Transhiatal laparoscopic (176, 81.9%) or thoracoscopic hybrid esophagectomy (39, 18.1%, conversion in 7 patients) was completed in 215 patients, 187 (87%) men and 28 (13%) women. Respiratory complications developed in 86 (40%) and severe respiratory failure or ARDS occurred in 29 (13.5%) patients. The overall in-hospital mortality was 7.4%, 30-day mortality 5.6% (RC 9, myocardial infarction 1, conduit necrosis 1), and 90-day mortality a further 1.8% (multiple organ failure, ARDS). The incidence of RC correlates significantly with ASA score II and III (p = 0.0002) and Clavien-Dindo grade 4 and 5 in severe RC (p < 0.0001). Furthermore, hospital stay (p < 0.0001) and mortality (p < 0.0001) were significantly increased in RC. Conclusions: The results show a higher occurrence of RC in polymorbid patients and patients with severe complications according to the Clavien-Dindo classification. Adequate risk management including surgical technique and perioperative prophylaxis and therapy of RC should be studied and standardized.
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Introduction: The preferred treatment for acute cholecystitis is cholecystectomy, but for patients with precluded general anesthesia due to critical illness or multiple medical comorbidities it is not suitable. Cholecystostomy could be a minimally invasive therapeutic alternative. Aim: To retrospectively evaluate the indications, technical features, efficacy, complications, patients' development and relationships among monitored parameters of percutaneous computed tomography (CT)-guided cholecystostomies in cases of acute cholecystitis and find the role of this procedure in appropriate treatment selection. Material and methods: Over the course of 10 years, 75 percutaneous cholecystostomy procedures in 69 patients were performed in cases with diagnosed acute cholecystitis, precluded general anesthesia and contraindicated cholecystectomy by an experienced surgeon and anesthesiologist. These interventions were done using only local anesthesia. The patients were men in 39 cases and women in 33 cases, aged 33 to 91 years. Results: Technical success was achieved in all cases. The indications were sepsis in 34 (45.3%) cases, bridging acute gallbladder inflammatory status in 15 (20%) interventions, serious medical comorbidities in 8 (10.7%) cases, disseminated malignancy and cardiac failure in 6 cases each (both 8%) and neurological affections in 5 (6.5%) cases. Cholecystostomy was frequently the final solution in acalculous cholecystitis (79.3%). The 30-day mortality rate was determined at 10.7% and the overall complication rate was 21.3%, but all of these complications were managed conservatively or using minimally invasive treatment. Conclusions: Percutaneous CT-guided cholecystostomy is reserved for patients with a serious medical status for various reasons that preclude surgical treatment and general anesthesia. Simultaneously, technical success and efficacy are high and the complication rate is acceptable.
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