INTRODUCTION:The incidence of acute pancreatitis has been increasing over the past twenty years and there is still no causal treatment available. Although cases of severe acute pancreatitis account for only about a fifth of all cases of acute pancreatitis, high morbidity and lethality call for an optimization and unification of treatment procedures.METHODS:We operated on 27 patients suffering from severe acute pancreatitis in the past five years. We compared selected parameters such as gender, age, body mass index, aetiology, presence of type 2 diabetes, BISAP score, previous minimally invasive treatment and presence of the intraabdominal compartment syndrome.RESULTS:The average age of men and women was similar in our group. Most patients were overweight or obese. Alcoholic aetiology was more common in men while biliary aetiology prevailed in women. The mortality rate was 26% in our group. The intra-abdominal compartment syndrome followed by emergency decompression surgery was present in one fourth of the patients. A minimally invasive approach was used in approximately in one half of the patients, and surgical treatment was used only in cases where the minimally invasive approach failed.CONCLUSION:After each surgical revision, clinical deterioration of the patient´s condition occurs during the first two to three days in response to operative stress. Therefore, the current trend in the treatment of acute pancreatitis is to proceed as conservatively as possible, or using the minimally invasive approach, and surgical treatment should be reserved only for conditions that cannot be managed otherwise. If surgical treatment is used, it is advisable to perform cholecystectomy, whatever the aetiology of the pancreatitis.

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Chronic pancreatitis accompanies the humankind for a long time. Its treatment has evolved from the “trial-error” method to the current pursuit of “evidence-based medicine”. With the development of medical knowledge and progress in technology, the surgical operation gradually changed. Current practices are another step in the pyramid, the foundations of which were built by our courageous predecessors.

Chronic pancreatitis accompanies the humankind for a long time. Its treatment has evolved from the “trial-error” method to the current pursuit of “evidence-based medicine”. With the development of medical knowledge and progress in technology, the surgical operation gradually changed. Current practices are another step in the pyramid, the foundations of which were built by our courageous predecessors.

Background: This dual-center, randomized controlled trial aimed to compare 2 types of intra-abdominal drains after pancreatic resection and their effect on the development of pancreatic fistulae and postoperative complications. Methods: Patients undergoing pancreatic resection were randomized to receive either a closed-suction drain or a closed, passive gravity drain. The primary endpoint was the rate of postoperative pancreatic fistula. A secondary endpoint was postoperative morbidity during follow-up of 3 months. The planned sample size was 223 patients. Results: A total of 294 patients were assessed for eligibility, 223 of whom were randomly allocated. One patient was lost during follow-up, and 111 patients in each group were analyzed. The rate of postoperative pancreatic fistula (closed-suction 43.2%, passive 36.9%, P = .47) and overall morbidity (closed-suction 51.4%, passive 40.5%, P = .43) were not different between the groups. We did not find any differences between the groups in reoperation rate (P=.45), readmission rate (P = .27), hospital stay (P = .68), or postoperative hemorrhage (P = .11). We found a significantly lesser amount of drain fluid in the passive gravity drains between the second and fifth postoperative days and also on the day of drain removal compared with closed-suction drains. Conclusion: The type of drain (passive versus closed suction) had no influence on the rate of postoperative pancreatic fistulae. The closed-suction drains did not increase the rate of postoperative complications. We found that the passive gravity drains are more at risk for obstruction, whereas the closed-suction drains kept their patency for greater duration. (C) 2018 Elsevier Inc. All rights reserved.

PURPOSE:Patients who develop complications consume a disproportionately large share of available resources in surgery; therefore the attention of healthcare funders focuses on the economic impact of complications. The main objective of this work was to assess the clinical and economic impact of postoperative complications in pancreatic surgery, and furthermore to assess risk factors for increased costs.METHODS:In all, 161 consecutive patients underwent pancreatic resection. The costs of the treatment were determined and analyzed.RESULTS:The overall morbidity rate was 53.4%, and the in-hospital mortality rate was 3.7%. The median of costs for all patients without complication was 3,963 Euro, whereas the median of costs for patients with at least one complication was significantly increased at 10,670 Euro (P < 0.001). In multivariate analysis American Society of Anesthesiologists ≥ 3 (P = 0.006), multivisceral resection (P < 0.001) and any complication (P < 0.001) were independently associated with increased costs.CONCLUSION:Postoperative complications are associated with an increase in mortality, length of hospital stay, and hospital costs. The treatment costs increase with the severity of the postoperative complications. Those factors that are known to increase the treatment costs in pancreatic resection should be considered when planning patients for surgery.

Introduction: Although the beginnings of laparoscopic liver resection is dated into the first half of the 90s of last century, even after almost 20 years is not a standard method of treatment of malignant liver tumors. Recently, oncological aspects of laparoscopic procedures are still debated and quality prospective randomized studies are missing. Objective: To evaluate the oncological results of laparoscopic and open liver resection for metastatic colorectal cancer in patients operated on at the Department of Surgery, University Hospital Hradec Králové. Methods: We prospectively analyzed a group of patients operated for liver metastases of colorectal cancer in the time period January 2008 to January 2014 with a focus on basic indicators of cancer treatment – radicality (percentage of R0 resection), overall survival (OS) and disease-free survival (DFI). Results: During the follow up period, 142 patients were operated. Laparoscopy was performed in 28 (20%) patients. 6 of 28 (21%) required a conversion to open procedure. Both groups had comparable percentage of achieving R0 resection (81 vs. 85%). 3-year overall survival was comparable in both groups (65 vs. 69%) was comparable and even 3-year disease-free survival (58 vs. 59%). Conclusion: In this group of patients own evaluation and analysis of the published literature, it appears that at the selected group of patients with colorectal cancer liver metastases achieved comparable results in a group of patients resected by open approach.

BACKGROUND:The morbidity of pancreatic resection remains high, with pancreatic fistula being the most common cause. The important question is whether any postoperative treatment adjustment may prevent the development of clinically significant postoperative pancreatic fistulae. Recent studies have shown that intraabdominal drains and manipulation using them are of great importance. Although authors of a few retrospective reports have described good results of pancreatic resection without the use of intraabdominal drains, a recent prospective randomized trial showed that routine elimination of drains in pancreaticoduodenectomy is associated with poor outcome. An important issue arises as to which type of drain is most suitable for pancreatic resection. Two types of surgical drains exist: open drains and closed drains. Open drains are considered obsolete nowadays because of frequent retrograde infection. Closed drains include two types: passive gravity drains and closed-suction drains. Closed-suction drains are more effective, as they remove fluid from the abdominal cavity under light pressure. However, some surgeons believe that closed-suction drains represent a potential hazard to patients and that negative pressure might increase the risk of pancreatic fistulae. Nobody has yet specifically dealt with the question of which kind of drainage is most appropriate in pancreatic surgery.METHODS/DESIGN:The aim of the DRAins in PAncreatic surgery (DRAPA) trial is to compare the closed-suction drain versus the closed passive gravity drain in pancreatic resection. DRAPA is a dual-centre, prospective, randomized controlled trial. The primary endpoint is the rate of postoperative pancreatic fistula; the secondary endpoint is postoperative morbidity with follow-up of 3 months.DISCUSSION:No study to date has compared different types of drains in pancreatic surgery. This study is designed to answer the question whether any particular type of drain might lower the rate of postoperative pancreatic fistula or other complications.TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT01988519. Registered 13 November 2013.

AIM: To study all the aspects of drain management in pancreatic surgery.METHODS: We conducted a systematic review according to the PRISMA guidelines. We searched the Cochrane Central Registry of Controlled Trials, EMBASE, Web of Science, and PubMed (MEDLINE) for relevant articles on drain management in pancreatic surgery. The reference lists of relevant studies were screened to retrieve any further studies. We included all articles that reported clinical studies on human subjects with elective pancreatic resection and that compared various strategies of intra-abdominal drain management, such as drain vs no drain, selective drain use, early vs late drain extraction, and the use of different types of drains.RESULTS: A total of 19 studies concerned with drain management in pancreatic surgery involving 4194 patients were selected for this systematic review. We included studies analyzing the outcomes of pancreatic resection with and without intra-abdominal drains, studies comparing early vs late drain removal and studies analyzing different types of drains. The majority of the studies reporting equal or superior results for pancreatic resection without drains were retrospective and observational with significant selection bias. One recent randomized trial reported higher postoperative morbidity and mortality with routine omission of intra-abdominal drains. With respect to the timing of drain removal, all of the included studies reported superior results with early drain removal. Regarding the various types of drains, there is insufficient evidence to determine which type of drain is more suitable following pancreatic resection.CONCLUSION: The prophylactic use of drains remains controversial. When drains are used, early removal is recommended. Further trials comparing types of drains are ongoing.

Pancreatic fistula is a significant complication following pancreatic resection. Several methods aimed at lowering the postoperative pancreatic fistula rate were studied in the past. These methods mainly include pharmacological prophylaxis and technical modifications of pancreatic remnant management. Another method which can influence postoperative pancreatic fistula rate is the use of and the manipulation with intra-abdominal drains following pancreatic resection. Recent studies have shown that the use of the drains, the type of drain and manipulation with the drains can influence the outcomes. The aim of this review is to summarize current knowledge about the use of drains in pancreatic surgery. There are three questions to ask when studying the use of drains in pancreatic surgery: 1) Whether to use the drains at all 2) When to remove the drains? 3) Which type of the drain is more appropriate? Ad 1) Despite the growing number of studies showing comparable or even better results in patients without intra-abdominal drains following pancreatic resection, the latest randomized study proved that avoiding the use of drains is associated with more clinically significant postoperative complications and higher postoperative mortality. It is also important to consider the risk factors of pancreatic fistula development, especially pancreatic texture and the main pancreatic duct diameter. Currently, pancreatic resection without intra-abdominal drains cannot be routinely recommended. Ad 2) Two studies addressed the question when to remove the drains after pancreatic resection, and both studies clearly showed that early removal brings better results. Ad 3) No study has specifically addressed the question whether the type of drain can influence the rate of postoperative pancreatic fistula and of other complications. Gravity drains and closed-suction drains are most commonly used nowadays. The closed-suction drains are more effective due to the active suction. On the other hand, active suction can cause leak of the amylase-rich fluid through the pancreatic anastomosis or suture line and thus promote the development of pancreatic fistula or even worsen its clinical significance. There are no data in the literature so far regarding the type of drain. Therefore, we have commenced a randomized control trial which aims to compare closed-suction drains and closed gravity drains.

Background : Solid pseudopapillary tumour (SPT) of the pancreas is a relatively rare entity which most commonly occurs in young women. In this paper we report our clinical experience together with the current knowledge on the diagnostics, treatment and prognosis of this rare tumour.Methods : We reviewed hospital records of patients diagnosed with a solid pseudopapillary tumour of the pancreas between January 2002 and December 2011 at the Department of Surgery, University Hospital Hradec Kralove, Czech Republic. Clinical, operative, pathological data were obtained on all the patients.Results : Over the 10-year period of the study we performed 181 planned pancreatic resections in our department. Overall, the 30-day postoperative mortality rate in this series of patients was 2.2%. SPT was diagnosed in 4 cases. All the patients were women and the average age was 34 years. Preoperative endosonography with biopsy sample was performed in all the patients and the diagnosis of SPT was known in all the patients before the surgical procedure.Conclusions : The current knowledge of SPT is based only on case reports and small series. It typically occurs in young women and therefore the presence of a large pancreatic mass in a young woman may suggest a diagnosis of SPT. SPT has a low malignant potential and the prognosis is excellent following complete surgical resection in the majority of the cases.

Despite recent improvements in surgical technique, the morbidity of distal pancreatectomy remains high, with pancreatic fistula being the most significant postoperative complication. A systematic review of randomized controlled trials (RCTs) dealing with surgical techniques in distal pancreatectomy was carried out to summarize up-to-date knowledge on this topic. The Cochrane Central Registry of Controlled Trials, Embase, Web of Science, and Pubmed were searched for relevant articles published from 1990 to December 2013. Ten RCTs were identified and included in the systematic review, with a total of 1286 patients being randomized (samples ranging from 41 to 450). The reviewers were in agreement for application of the eligibility criteria for study selection. It was not possible to carry out meta-analysis of these studies because of the heterogeneity of surgical techniques and approaches, such as varying methods of pancreas transection, reinforcement of the stump with seromuscular patch or pancreaticoenteric anastomosis, sealing with fibrin sealants and pancreatic stent placement. Management of the pancreatic remnant after distal pancreatectomy is still a matter of debate. The results of this systematic review are possibly biased by methodological problems in some of the included studies. New well designed and carefully conducted RCTs must be performed to establish the optimal strategy for pancreatic remnant management after distal pancreatectomy.

BACKGROUND: Postoperative pancreatic fistula is the main cause of morbidity after pancreatic resection. This study aimed to quantify the clinical and economic consequences of pancreatic fistula in a medium-volume pancreatic surgery center.METHODS: Hospital records from patients who had undergone elective pancreatic resection in our department were identified. Pancreatic fistula was defined according to the International Study Group on Pancreatic Fistula (ISGPF). The consequences of pancreatic fistula were determined by treatment cost, hospital stay, and out-patient follow-up until the pancreatic fistula was completely healed. All costs of the treatment are calculated in Euros. The cost increase index was calculated for pancreatic fistula of grades A, B, and C as multiples of the total cost for the no fistula group.RESULTS: In 54 months, 102 patients underwent elective pancreatic resections. Forty patients (39.2%) developed pancreatic fistula, and 54 patients (52.9%) had one or more complications. The median length of hospital stay for the no fistula, grades A, B, and C fistula groups was 12.5, 14, 20, and 59 days, respectively. The hospital stay of patients with fistula of grades B and C was significantly longer than that of patients with no fistula (P<0.001). The median total cost of the treatment was 4952, 4679, 8239, and 30 820 Euros in the no fistula, grades A, B, and C fistula groups, respectively.CONCLUSIONS: The grading recommended by the ISGPF is useful for comparing the clinical severity of fistula and for analyzing the clinical and economic consequences of pancreatic fistula. Pancreatic fistula prolongs the hospital stay and increases the cost of treatment in proportion to the severity of the fistula.

BACKGROUND: Castleman disease is an uncommon lympho-proliferative disorder most frequently occurring in the mediastinum. Abdominal forms are less frequent, with pancreatic localization of the disease in particular being extremely rare. Only seventeen cases have been described in the world literature.METHOD: This report describes an interesting and unusual case of pancreatic Castleman disease treated with laparoscopic resection.RESULTS: A 48-year-old woman presented with epigastric pain. CT scan showed a well-encapsulated mass on the ventral border of the pancreas. Endosonography with fine needle aspiration biopsy was performed. Biopsy showed lymphoid elements and structures of a normal lymph node. The patient was treated with laparoscopic distal pancreatectomy. The pancreas was transected with a Ligasure device and the pancreatic stump was secured with a manual suture. One year after surgery the patient was complaint-free and showed no signs of recurrence of the disease.CONCLUSIONS: Laparoscopic distal pancreatectomy is a feasible and safe method for the treatment of lesions in the body and tail of the pancreas. Transection of the pancreas with a Ligasure device offers the advantages of low bleeding and low risk of pancreatic fistula.

Pancreatic fistula is a common complication after pancreatic resections. Its incidence oscillates between 10 and 30%. The differences in the incidence cited in the studies are due to the various fistula definitions. According to ISGPF, pancreatic fistula is an output -via an operatively placed drain (or a subsequently placed percutaneous drain) - of any measurable volume of drain fluid on or after postoperative day 3, with an amylase content higher than 3 times the upper normal serum value. The fistula is then classified according to the clinical impact in grades A, B, and C. There are known three risk factor categories for the development of pancreatic fistula: the risk related to the pancreatic disease, to the patient, and to the surgical procedure. Most of the risk factors for the development of pancreatic fistula cannot be influenced either prior to or during the surgery. There are two basic options for the prevention of pancreatic fistula: pharmacological intervention (administration of somatostatin and its analogues) and technical modifications of the pancreatic remnant treatment. However, the routine administration of somatostatin and its analogues is not advisable in all pancreatic surgical procedures. In high risk cases the selective administration is preferred. The second option is modification of pancreatic remnant treatment. Most of the studies dealing with various modifications of the pancreatic remnant treatment were retrospective with lower level of evidence. There were only a few properly designed randomized trials, and most of them did not prove benefit of one method over another. It has been shown that the results depend on the experience of a given surgical department, and above all on the experience of an individual surgeon who performs the pancreatic resection. The therapy of pancreatic fistula is based on the clinical severity. Conservative approach is warranted in most patients. In cases when reoperation is required, there are two basic strategies: surgical drainage of the collections, and completion of total pancreatectomy. Total pancreatectomy was preferred in the past, however, this procedure is technically very demanding with mortality up to 80 per cent. Nowadays, most of the authors prefer surgical drainage; this procedure is technically less demanding, has lower mortality, the endocrine function of pancreas is protected, and the patients usually need no further interventions.

BACKGROUNDS:Pancreatic cancer is an aggressive malignant disease with increasing incidence. Radical resection, the only potentially curative method, is possible in only 20-30% of patients. The main symptoms of advanced non-resectable pancreatic head tumors include obstructive jaundice, caused by stenosis of distal common bile duct, duodenal obstruction and pain, especially in the epigastric region and back. The aim of palliative treatment is to relieve these complaints. This paper evaluates our own palliative surgical treatment results in patients with pancreatic head and periampullary region cancer.PATIENTS AND METHODS:This study included all patients with pancreatic head and periampullary region cancer who underwent surgery at the Department of Surgery, University Hospital in Hradec Kralove from 1st January 2006 to 31st December 2010. The aim of the surgery in all patients was to resect the tumor. Palliative surgical procedure was performed in patients witn an inoperable tumor. We performed gastro-entero anastomosis in all the patients. When perioperative situation allowed, hepatico-jejuno anastomosis was performed in patients with obstructive jaundice. Surgical splanchnicectomy was performed in patients with back pain.RESULTS:Over five years, we performed a surgery in 94 patients for malignant disease of pancreas and periampullary region. Radical resection was performed in 45 patients. Palliative bypass procedure was performed in 42 patients. Exploration only was performed in 7 patients. Postoperative complications after palliative bypass procedures were noted in 15 patients (30.6%), the majority of these complications were minor.CONCLUSION:The advantage of surgical hepatico-jejuno anastomosis over endoscopically placed stent is particulary in superior long-term patency. Therefore, it is advisable to perform these procedures in patients with longer expected survival. Morbidity associated with palliative surgical procedures was relatively low and there was no mortality.

BACKGROUND: The prophylactic use of somatostatin and its analogs has been suggested to lower the rate of pancreatic fistula. The aim of this review is to discuss the results of published randomized trials and meta-analyses studying the effect of somatostatin and its analogs. METHODS: We performed a Medline search for prospective randomized trials, systematic reviews and meta-analyses with regard to the prophylactic use of somatostatin and its analogs. RESULTS: Eleven randomized trials and six meta-analyses were identified. The randomized trials differ in terms of study designs, diagnosis, operative procedures, drug dosage, time of administration, and the pancreatic fistula definition; therefore, it is advisable to carefully interpret the results of the individual randomized trials. CONCLUSIONS: The routine administration of somatostatin and its analogs in elective pancreatic surgery cannot be recommended. However, selective administration is advisable in cases which carry significantly higher risk of developing pancreatic fistula.

INTRODUCTION:The aim of this report is to present results of prospective multicentric study on quality of life (QoL) in advanced ductal pancreatic adenocarcinoma patients.MATERIAL AND METHOD:In 426 patients with advanced ductal pancreatic adenocarcinoma, the following parameters were studied: type of treatment, complication rates, 1, 2 and 3-year survival rates. QoL was assessed in 151 patients, using a generic SF-36 questionnaire prior the therapy and then 3 months after the treatment. Arithmetic mean and standard deviation (SD) were used for the QoL pool analysis. The results were evaluated using SF-36 software, t-test for independent samples, ANOVA, paired t-test and SPSS 19.0.1 (IBM Corporation, 2010). The p value < 0.05 was considered as statistically significant.RESULTS:There was a significant difference in the median, 1,2 and 3-year survival rates in the patients with stage III pancreatic cancer who underwent radical resection (RR) compared to the paliative therapy patients (p < 0.001). The highest initial overal QoL value was observed in 39 stage III patients who underwent RR (60.5 +/- 1.84) and no significant decrease in this value was recorded over a 3-month postoperative period (difference--5.1 +/- 16.6, p = 0.064). Paliative therapy resulted in significant reduction in the overall QoL value (p = 0.020). In the paliative therapy group of patients, BDA resulted in significant reduction in the overall QoL value 3 months after the procedure (p = 0.017 vs. ns.). In the group of stage IV patients, nonsignificant increase in the overall QoL value was recorded in 8 patients 3 months after BDA (46.4 +/- 17.0 vs. 51.1 +/- 9.5 p = 0.525). Nonsignificant increase in the overal QoL values was also observed in 18 patients after stent introduction (30.6 +/- 8.3 vs. 31.5 +/- 8.5 p = 0.783). Nonsignificant deterioration in QoL was recorded in patients undergoing exploration, whose initial QoL values corresponded with those in RR patients, while 3 months after the explorative surgery their QoL values were similar to those recorded in the stent group patients (62.0 +/- 16.1 vs. 41.7 +/- 23.6 s rozdílem -20.3 +/- 16.2 p < 0.001).CONCLUSION:Based on the results of the multicentric prospective study in patients with locally advanced stage III and IV ductal pancreatic adenocarcinoma, the following conclusions can be presented: (1) median and 1, 2 and 3-year survival rates in stage III patients were significantly higher in the RR group compared to the paliative therapy patients, (2) initial QoL in stage III patients was significantly the highest in patients who underwent RR. Significant decrease in QoL was recorded in BDA patients. Paliative stent introduction resulted in nonsignificant improvement in the QoL 3 months after the procedure, while the initial QoL values were the lowest in this group, (3) QoL assessment in stage IV patients showed statistically nonsignificant improvement after BDA or stent procedures, the most significant deterioration was observed in the exploration group, (4) no complication which would result in prolongation of the respective hospitalization times was recorded in 67%, (5) early postoperative complications did not result in significant QoL deterioration 3 months after the procedure, (6) absence of chemotherapy results in significant decrease in QoL.