Petr Kysela

The modern use of radiofrequency energy in surgery, endoscopy and interventional radiology

ZusammenfassungGRUNDLAGEN: Der therapeutische Einsatz der Radiofrequenzenergie (RF) in der Medizin nimmt zu. Diese Arbeit beschreibt 4 neue RF-Instrumente für Chirurgie, Endoskopie und interventioneller Radiologie. METHODIK: Die 4 Instrumente sind: 1) Endoblate zur endoskopischen RF-Therapie beim Rektumkarzinom; 2) Hexablate, ein bipolares RF-Instrument zur Behandlung des Hepatoms; 3) VesCoag, ein bipolarer RF-Katheter zum interventionell-radiologischem Verschluss von Tumorgefäßen der Leber und 4) EndoHPB, ein endoskopischer bipolarer RF-Katheter zur endobiliären Ablation, derzeit im Schweiemodel getestet. ERGEBNISSE: Endoblate, Hexablate and VesCoag zeigten im klinischen Einsatz keine technischen Probleme und unerwünschte Nebenwirkungen. Alle wurden bipolar verwendet bis auf VesCoag, welches nur monopolar Effizienz bei der Gefäßversiegelung zeigte. Bei EndoHPB zeigte sich im Schweinemodell, dass 5–10 Watt für 2 Minuten die ideale Einstellung war. Eine klinische Studie untersucht derzeit den Einsatz bei malignem Verschlussikterus. SCHLUSSFOLGERUNGEN: Die RF-Instrumente stellen eine faszinierende Entwicklung dar, welche vielversprechende therapeutische Methoden in Endoskopie, Chirurgie und interventioneller Radiologie erwarten lassen.SummaryBACKGROUND: The potential applications of radiofrequency (RF) energy in medicine are an expanding field. This paper describes the development and early results of the application of four novel radiofrequency devices in surgery, endoscopy and interventional radiology. METHODS: The four devices that were designed and have been assessed were 1) Endoblate: a bipolar RF catheter for endoscopic use which was assessed in patients with rectal tumors, 2) Hexablate: a bipolar RF ablation/aspiration device which was used to treat liver cancers, 3) VesCoag: a bipolar RF catheter for endovascular ablation which was used by interventional radiologists to seal the blood vessels of tumors within the liver and 4) EndoHPB: an endoscopic bipolar RF catheter for endobiliary ablation which so far has been assessed in a porcine model. RESULTS: In the pilot clinical studies on Endoblate, Hexablate and VesCoag, all the devices could be used in the clinical situation for which they had been designed. There were no technical problems and no serious adverse events associated with their use. All were used in bipolar mode apart from VesCoag, where it was found that a monopolar current was required for effective vessel sealing. For EndoHPB in the porcine model, it was determined that the ideal power setting was 5–10 watts for 2 min. A clinical trial is to be undertaken to determine whether this power setting is applicable for when EndoHPB is used in the management of malignant obstructive jaundice. CONCLUSIONS: It is an exciting time in the development of new RF instruments, and as they become more sophisticated their clinical applications will expand. These early data from the animal and pilot clinical studies are promising and larger studies with longer term follow-up needs to be undertaken to establish their true clinical worth.

Crohn's disease at the small bowel imaging by the ultrasound–enteroclysis

Summary: Crohn’s disease is more likely a systemic disease governed by a shift in the immune response, thus affecting the whole MALT system. Its treatment should be as conservative as possible and surgery is usually taking place after complications like indolent fistulations, stenoses, bleeding, or bowel perforation started. Standard radiological methods to check the extent of the disease are loaded either with certain radiation exposure (enteroclysis, CT) or lack standardization (ultrasound). The aim of this small study was to evaluate the worth of ultrasound-enteroclysis in detecting the extent and complications of the Crohn’s disease in surgically treated patients. Material and methods: Since 1997, when we started with the ultrasound-enteroclysis, 246 surgical performances were involved into our study. Out of them, 181 had conventional abdominal intestinal ultrasound as well as conventional enteroclysis within 1 week. Remaining 65 cases were diagnosed by the ultrasound-enteroclysis. Intestinal ultrasound was performed on the Ultramark 3000 HDI device with autofocussable convex 5 MHz and linear 7.5 MHz probes or nowadays ATL 5000 HDI, 7–12 MHz linear probe. No contrast enhancement was used. Enteroclysis was done with the Micropaque suspension diluted 1:1 with HP-7000 300 ml with its application rate up to 75 ml/min followed by HP-7000 solution 2000 ml, application rate of 120 ml/min. The patients with ultrasound-enteroclysis were applied HP 7000 solution only (2000 ml, rate 100 ml/s) via an enteroclysis catheter. All investigations were video-recorded. Results: Consent with the per-operative finding was reached in 162 from 181 enteroclyses and in 169 of 181 ultrasounds. Ultrasound-enteroclysis was precise in 61 cases from 65. Among these, 60 patients had the recurrence during the treatment proved by clinical and laboratory results. This re-activation was clearly revealed in 38 from 43 cases by enteroclysis, 41 from 43 by US and in 16 from 17 by ultrasound-enteroclysis. From 30 patients that developed acute complication non-responding to the conservative therapy (abscesses, fistulas and intestinal obstructions) there were 18 from 20 accurately diagnosed by enteroclysis, only 12 from 20 by US and 9 from 10 by US-enteroclysis. The differences were either statistically non-significant or there were too small numbers to give sensible statistical results, but low sensitivity of ultrasound in complications (p = 0.05). Conclusion: US-enteroclysis seems to became the standard examination of patients with Crohn’s disease mainly in those with unclear conventional ultrasound. The most important fact is that this examination significantly decreases the radiation load when maintaining high sensitivity. This is very important namely in patients with Crohn’s disease that require life-long observation and repeated examinations. This examination is much more easy to standardize than the conventional US.

Laparoscopically assisted subtotal colectomy for idiopathic pneumatosis cystoides intestinalis

Abstract Pneumatosis cystoides intestinalis (PCI) is a rare entity in which gas filled cysts are found within the intestinal wall. Conservative management and the treatment of underlying illnesses are recommended in most patients and surgery is usually indicated when acute and life-threatening complications such as bowel necrosis, perforation or peritonitis appear. The authors report a case of idiopathic pneumatosis cystoides intestinalis which, after repeated failure of conservative treatment including the oxygen therapy in hyperbaric chamber, was successfully treated by laparoscopic subtotal colectomy. A laparoscopically assisted approach proved to be a good indication in subtotal colectomy in cases of PCI that are non-responsive to standard conservative treatment.

Initial data on a novel endovascular radiofrequency catheter when used for arterial occlusion in liver cancer

ZusammenfassungGRUNDLAGEN: Wir untersuchten die Sicherheit und Wirksamkeit eines neuen endovaskulären Radiofrequenzkatheters (VesCoag) für den Arterienverschluss beim Management von Lebertumoren. METHODIK: Die Patienten hatten einen nicht resektablen primären oder sekundären Lebertumor. Der primäre Endpunkt war, ob VesCoag in das Zielgefäß eingebracht werden konnte, der sekundäre Endpunkt, ob es zu einem Angiographie-geprüften Verschluss des Gefäßes kam. ERGEBNISSE: VesCoag wurde bei 13 Patienten angewendet (4 Metastasen, 7 hepatozelluläre Karzinome, 2 intrahepatale Gallenganskarzinome). In allen Fällen konnte VesCoag ohne Komplikation (Ruptur, Dissektion) in die Zielgefäße eingebracht werden. Die Durchleuchtungszeit betrug 12,86 min, die Sondenaktivierung 240 (20–600) sec. Die abgegebene Energie betrug 2 W–120 W. Die bipolare Radiofrequenz konnte in keinem Fall einen adäquaten Gefäßverschluss erzielen, deshalb wurde der monopolare Modus verwendet. 4mal kam es zu Schmerzen, ein angiographisch nachgewiesener Verschluss wurde in 11 Fällen erzielt. 12 der 13 Patienten erhielten eine weiterführende Therapie (10× Chemoembolization, 1× Chemotherapie, 1× Lipiodol). SCHLUSSFOLGERUNGEN: Diese erste Erfahrung mit VesCoag zeigt, dass die Methode sicher ist und einen gezielten Verschluss von Zielgefäßen erlaubt.SummaryBACKGROUND: To assess the safety and effectiveness of a newly designed endovascular radiofrequency (RF) catheter (VesCoag) when used for arterial occlusion in the management of liver cancer. METHODS: Patients considered for the study had either primary or secondary cancer of the liver, which was not suitable for initial surgical resection. The primary endpoint of the study was whether VesCoag could be manipulated into the target blood vessel and the secondary endpoint was whether on angiography the blood vessel had been sealed. RESULTS: VesCoag was used in 13 patients. The indications for treatment were metastatic disease in 4, hepatocellular carcinoma in 7, and intrahepatic cholangiocarcinoma in 2. In all cases, VesCoag was manipulated into the target vessel for activation. There were no technical problems such as vessel dissection or rupture. The average fluoroscopic time was 12.86 min and the mean duration of probe activation was 240 (range 20–600) seconds. The lowest wattage used was 2 W and the highest 120 W. In no cases was bipolar radiofrequency activation sufficient to produce vessel sealing, so monopolar mode was used throughout. There were four minor complications of pain. The angiographic endpoint of target vessel occlusion was achieved in 11 patients. In 12 out of 13 cases an additional endovascular therapeutic maneuver was performed after VesCoag activation. These additional therapies were chemoembolization n = 10, chemotherapy n = 1, and lipiodol n = 1. CONCLUSIONS: This early assessment of VesCoag shows it to be safe and fulfill its design remit of being able to produce precise occlusion of the targeted vessel.

Small-bowel tumors in the elderly 65+ years: 10 years of experience.

UNLABELLED Primary, secondary, benign or malignant tumorous diseases of the small intestine are rare. They are very often diagnosed by accident or as a cause of acute abdomen. Less serious symptoms can be overseen mainly in older patients. This work represents a prospective evaluation of a diagnostic and therapeutic algorithm in the management of the small-intestine tumor below the ligamentum Treitzi in patients over 65 years of age. RESULTS A population of 96 patients who underwent surgery for a small-intestinal tumor in our hospital from 1996 to 2006 is presented. Thirty-four of these patients were older than 65 years. Ultrasound of the small intestine was sufficient to make the diagnosis in 21 of them. Elective surgery (laparoscopy was highly preferred) could be offered to 31 of these older patients. Perioperative mortality was zero. CONCLUSION The small-bowel ultrasound can be recommended as the first choice method. All complaints regarding the gastrointestinal tract should be verified. Older patients can be safely offered an elective laparoscopic surgery with acceptable morbidity and mortality.

The Use of Biomarkers in Early Diagnostics of Pancreatic Cancer

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal solid malignancies with increasing incidence. The poor prognosis is due to the aggressive nature of the tumor, late detection, and the resistance to chemotherapy and radiotherapy. A radical surgery procedure is the only treatment that has been shown to improve the 5-year survival rate to 20-25%. However, the majority of patients (80-85%) are diagnosed with locally advanced or metastatic disease and just 15-20% patients are diagnosed in an early stage allowing them to undergo the potentially curative surgical resection. The early detection of PDAC without the use of invasive methods is challenging and discovery of a cost-effective biomarker with high specificity and sensitivity could significantly improve the treatment and survival in these patients. In this review, we summarize current and newly examined biomarkers in early PDAC detection.

Vascular Graft Infection - A Single Centre Analysis

Though the frequency of vascular graft infections is very low, its consequences are too serious. The paper aims at the vascular graft infection causes analysis in a single centre. Results achievable by means of several approaches have been discussed and a possible way of lowering the vascular graft infection rate has been tested. Material and methods: A population of 2812 patients having implanted an artificial vascular graft in 2000-2010 were prospectively followed up. Upon the analysis of risk factors, the control group of 653 patients operated on during 2011-2013 were followed up. Results: Number of vascular graft infections was 28 (1,0%). Amputation rate was 19% (5 patients) and the overall mortality 14% (4 patients). Leading signs of the infection were local findings in 88%. All patients with the infection had two or more co-existing independent risk factors picked out by chi-square statistics. It was obesity, repeated interventions and emergency surgery (p<0,001). Gender (men), co-existing infection, diabetes and too long bypass were also significant (p<0,01). There was not MRSA infection at all. After adoption of risk factors reducing approach, there was not proven decreased infection occurrence in patients with implanted artificial grafts. However, during the control period, a higher share of autologous grafts and endovascular methods were used. Thus the overall infection rate was reduced from 0,43 to 0,31%. Conclusion: The graft infection is not a matter of resistant bacteria, but the infection in general. An accumulation of more than two independent risk factors according to local situation should be avoided. As the infection treatment is very demanding with uncertain results, patient’s wish should be taken into account as well. In all primaries, the use of the artificials ought to be minimized and endovascular procedures should be preferred, where appropriate. Emergency surgery should be avoided by in time indication to revascularization.

Tailored antireflux surgery

Background: With increasing age, the functional condition of the lower esophageal sphincter is getting weaker. Recent progress in peri-operative intensive care and the development of laparoscopic technique makes antireflux surgery a safe choice of GERD treatment in the elderly.Aim: This work evaluated the long-term results of tailored antireflux surgery in a group of elderly (more than 60 years old) patients.Results: Five hundred and eighty one patients underwent antireflux surgery in our department from 1999 to 2005. Seventy of them (12,0%) were older than 60 years. Exclusion criteria of surgery were ASA IV classification and high grade esophageal dysmotility. Toupet’s wrap was offered to patients with esophageal dysmotility or esophageal sphincter pressure higher than 15mm Hg (16 cases). The rest were offered Nissen-Rossetti’s complete wrap (54 cases). There was zero mortality and no further significant dysphagia. Pathological gastro-esophageal reflux after the surgery was detected in 6 patients (8,6%), which was a higher proportion than in the group of patients under 60 years.Conclusion: Good results of antireflux surgery with zero mortality and low morbidity can be achieved even in the elderly (more frequent use of incomplete Toupet’s wrap).