INTRODUCTION:A carotid web is a rare but clinically important cause of cryptogenic ischemic stroke. It is an atypical form of fibromuscular dysplasia localized at the carotid bulb. The aim of this paper is to present this less-known cause of ischemic stroke based on a case study. CASE REPORT:In a 55-year-old female patient with acute ischemic strok in the left carotid territory, a carotid web was diagnosed on CT angiography. Other extracranial or intracranial cerebral arteries showed no stenoses or occlusions. The patient was initially treated effectively with intravenous thrombolysis. A follow-up brain MRI revealed a small cortical ischemia and a detailed cardiological evaluation excluded the cardioembolic etiology of the stroke. As part of the secondary stroke prevention, the patient was managed with antiplatelet therapy and underwent an uncomplicated carotid endarterectomy. During a 10-month follow-up period, there was no recurrence of cerebral ischemia. CONCLUSION:Carotid endarterectomy represents a safe and effective method for treating symptomatic carotid web.

Background and Importance According to the global recommendations for COVID-19 therapy, adult patients at risk of severe disease (including patients after organ transplantation) should be treated with antivirals: preferably nirmatrelvir/ritonavir (Paxlovid) or remdesivir (Veklury). Alternative choice is unlicensed use of molnupiravir (Lagevrio). Aim and Objectives Our study focused on evaluating the effectiveness and safety of molnupiravir in patients with COVID-19 after successful kidney transplantation (KTx). Material and Methods A cohort of 93 patients (62 males) was retrospectively evaluated, with 89.0% of patients having had a first KTx (the remainder having had a second KTx) and 39.0% with diabetes mellitus. The mean age of the patients at the time of molnupiravir therapy was 56 years (SD 12.9) and they received molnupiravir with mean of 2.24 days (SD 1.67) since confirmation of SARS-2-positivity. Immunosuppressive therapy was adjusted uniformly according to the site protocol and prednisone was increased for a maximum of two to three weeks. The safety of the proposed procedure concerning graft function and risk of rejection was evaluated based on the trend in creatininemia and urinary protein/creatinine index. Nonparametric Wilcoxon test was used. Results The median serum creatinine value in the study population was 127 μmol/l (IQR 52) before COVID-19. Outpatient follow-up was within 1 month after quarantine with median 124 μmol/l post-disease creatinine (IQR 53,2). The difference in median creatinine values before and after molnupiravir therapy was not statistically significant (p = 0.8175). COVID-19 related hospitalisation occurred in 5.4% patients, one patient in the cohort died due to COVID-19 disease. Short-term discontinuation or modification of immunosuppression did not induce any rejection episode. Conclusion and Relevance Our experience demonstrates that early initiation of molnupiravir may be an effective and safe therapy for COVID-19 disease in patients after kidney transplantation (where it is authorised in the Czech Republic until the end of 2023). Moreover, compared to Paxlovid, its use is not limited by drug-drug interactions and thus can be administered with calcineurin inhibitors. References and/or Acknowledgements Supported by projects of the Ministry of Health of the Czech Republic – RVO; FNHK, 00179906 and the COOPERATIO programme, INDI scientific area and SVV 260 665. Conflict of Interest No conflict of interest.

INTRODUCTION:Autosomal dominant polycystic kidney disease (ADPKD) is a genetic disease that leads to chronic renal failure in about half of patients. It is a multisystemic disease with a predominance of kidney involvement, which significantly worsens the patient's health. Controversial issues include the indication and the timing and technique of nephrectomy of native polycystic kidneys.METHODS:A retrospective observational study focused on the surgical aspects of patients with ADPKD who underwent native nephrectomy at our institution. The group included patients operated on in the period 1/1/2000-31/12/2020. A total of 115 patients with ADPKD were enrolled (14.7% of all transplant recipients). We evaluated the basic demographic data, type of surgery, indications and complications in this group.RESULTS:Native nephrectomy was performed in 68 out of a total of 115 (59%) patients. Unilateral nephrectomy was done in 22 (32%) patients and bilateral in 46 (68%). The most common indications were infections (42 patients, 36%), pain (31 patients, 27%), hematuria (14 patients, 12%), gastrointestinal reasons (1 patient, 1%), respiratory reasons (1 patient, 1%), obtaining a site for transplantation (17 patients, 15%) and suspected tumor (5 patients, 4%).CONCLUSION:Native nephrectomy is recommended in symptomatic kidneys, or in asymptomatic kidneys when it is necessary to obtain a place for kidney transplantation, and in kidneys where a tumor is suspected.

INTRODUCTION Left paraduodenal hernia is an internal herniation that develops due to anomalous fetal development. If incarcerated, it becomes an unusual cause of acute abdomen. CASE REPORT This case report presents an uncommon case of a 39-year-old man with acute abdominal pain with vomiting. The patients medical history included recurrent subileous events and Crohn´s disease in long-term remission. CT scan of abdominal cavity indicated a possible mechanical obstruction of small bowel loops in the upper left abdominal quadrant. Incarcerated left paraduodenal herniation was identified during surgery. Repositioned small bowel loops did not require resection and the entrance of Landzert´s fossa was sutured. CONCLUSION Left paraduodenal hernia is the most common congenital internal herniation. Although rare, it should be considered in the differential diagnosis of acute abdomen.

INTRODUCTION:Acute symptomatic occlusion of the internal carotid artery (ICA) is associated with unfavorable prognosis. However, no clear definition of its optimal treatment exists. The aim of this study was to evaluate the efficacy and risks of urgent carotid endarterectomy (CEA) in patients with ischemic stroke due to acute extracranial ICA occlusion.METHODS:A retrospective analysis was performed of all consecutive patients undergoing urgent CEA for acute extracranial ICA occlusion during the period from July 2014 to June 2021. The primary outcome was functional independence at three months defined as modified Rankin Scale (mRS) score 2. Secondary outcomes included the severity of the neurological deficit at the time of discharge and its comparison with the preoperative condition as assessed using the National Institutes of Health Stroke Scale (NIHSS), the incidence of symptomatic intracerebral hemorrhage (ICH), and 30-day periprocedural mortality.RESULTS:During the study period, a total of 42 urgent CEAs were performed for acute extracranial ICA occlusions. The median preoperative NIHSS score was 7 (interquartile range [IQR] 5-13). The median time interval between the onset of symptoms and surgery was 290 minutes (IQR 235-340). Technical success rate of urgent CEA was 97.6% (41 patients). The median NIHSS at the time of hospital discharge was 2 (IQR 3-7; p.

INTRODUCTION:Visceral artery aneurysms are rare vascular pathologies. They are usually incidental findings during the examination for other reasons. The most common clinical symptoms are nonspecific abdominal pain and bleeding caused by their rupture, with a severe clinical presentation. Aneurysms of pancreaticoduodenal arcade are more common in patients with well-developed collateral circulation due to the coeliac trunk stenosis or occlusion.CASE REPORT:In this case report the authors present a rare case of a patient with incidental finding of pancreaticoduodenal arcade aneurysm in the setting of severe stenosis of coeliac trunk origin caused by medial arcuate ligament compression. The diameter of the aneurysm was 40 mm and endovascular treatment was not possible because of unfavorable anatomical setting. The patient was successfully treated with resection of the aneurysm and the division of medial arcuate ligament during one surgery.CONCLUSION:There is no correlation between the diameter and the risk of rupture of the pancreaticoduodenal arcade aneurysm. Because of high morbidity and mortality of their rupture, most authors recommend active treatment of these aneurysms. The necessity to treat truncus coeliacus stenosis or occlusion remains a controversial issue.

Uvod: Aneuryzmata visceralnich tepen patři mezi raritně se vyskytujici cevni patologie. Obvykle bývaji nahodným nalezem při zobrazovacich vysetřenich. Nejcastějsim klinickým projevem jsou nespecificke bolesti břicha a krvaceni při jejich ruptuře se zavažným klinickým stavem. Aneuryzmata tepen pankreatikoduodenalni arkady se vyskytuji zejmena u pacientů se stenozou nebo uzavěrem truncus coeliacus a kompenzacně rozvinutou kolateralni cirkulaci.Kazuistika: V kazuistice autoři prezentuji připad pacientky s nahodně zjistěným aneuryzmatem pankreatikoduodenalni arkady, při významne stenoze v odstupu truncus coeliacus, způsobene utlakem ligamentum arcuatum mediale. Průměr výdutě byl 40 mm a endovaskularni terapie nebyla vzhledem k nepřiznivým anatomickým poměrům možna. Pacientka byla uspěsně lecena v jedne době kombinovaným chirurgickým výkonem s resekci aneuryzmatu a soucasně uvolněnim ligamentum arcuatum mediale.Zavěr: U aneuryzmat pankreatikoduodenalni arkady neni korelace mezi průměrem výdutě a rizikem ruptury. Jejich ruptury maji relativně vysokou morbiditu a mortalitu, a proto větsina autorů doporucuje aktivni přistup bez ohledu na velikost výdutě. Nutnost řeseni stenozy nebo okluze truncus coeliacus je diskutabilni.

Aim: To assess the procedural risk of carotid endarterectomy (CEA) in relation to its timing after ischemic stroke and to define the reasons that delay surgery beyond the recommended time interval. Materials and methods: A retrospective analysis was performed using prospectively collected data from all consecutive patients with symptomatic internal carotid artery stenosis who underwent CEA during the period from January 2013 to August 2019. The patients were divided into four groups according to the timing of CEA: group 1 - CEA within 2 days; group 2 - CEA between 3-7 days; group 3 - CEA between 8-14 days; and group 4 - CEA between 15-180 days. The primary outcome measure was the combined perioperative rate of any stroke or death within 30 days. Results: A total of 246 patients were included in the study. The median time interval between stroke and CEA was 8 days. A total of 191 patients (77.6%) underwent CEA within the recommended 14-day period from ischemic stroke, whereas 55 patients (22.4%) underwent CEA more than 14 days after stroke. Medical reasons were the cause of CEA delay in only 18 out of these 55 patients. For the entire cohort, the overall 30-day rate of any stroke or death was 3.7% (9 patients out of 246). The procedural risk was 5.9% (3 patients out of 51) in group 1, 1.5% (1 patient of 68) in group 2, 5.6% (4 patients out of 72) in group 3, and 1.8% (1 patient out of 55) in group 4 (P = 0.477). Conclusion: In this study, the time interval between the stroke and CEA was not associated with significant increase of procedural risk of any stroke or death.

INTRODUCTION:Symptomatic lymphocele could impair the function of a graft kidney. The aim of our research was to conduct a five-year follow-up after symptomatic lymphocele therapy.METHODS:Overall 50 patients undergoing the therapy of symptomatic lymphocele were enrolled in the study cohort. Demographic data, renal failure causes, indication of therapy and lymphocele management were retrospectively evaluated. Laboratory tests were done to evaluate serum creatinine, total plasma protein and albumin levels. Survival rates of the patients and of the grafts were analysed using Kaplan-Meier curves.RESULTS:The mean age of the 50 patients (44% females, 56% males) was 51.5±11.8 years, and the time between kidney transplantation and symptomatic lymphocele diagnosis was 12.8±21.5 months. Average lymphocele diameter was 71±35 mm. Causes of the native kidney failure were: glomerulonephritis (34%), tubulointerstitial nephritis (30%), polycystosis (24%), diabetic nephropathy (10%) and nephrosclerosis (2%). The therapy indications were: serum creatinine elevation (44%), graft hydronephrosis (38%), serum creatinine elevation associated with hydronephrosis (8%), infection associated with hydronephrosis (6%) and infection (4%). The lymphocele was managed by: open surgical intraperitoneal drainage (40%), percutaneous aspiration (26%), percutaneous long-term drainage (18%) and laparoscopic intraperitoneal drainage (16%). Mean serum creatinine levels at the time of the therapy and 60 months later were 231 µmol/L and 172 µmol/L, respectively; total plasma protein levels were 59 g/L and 69 g/L, respectively; albumin plasma levels were 36 g/L and 43 g/L, respectively. The five-year patient survival rate was 86% and the graft survival rate was 66%.CONCLUSION:Adequate management of symptomatic lymphocele stabilizes the graft function. If the post-transplant lymphocele is indicated for therapy, the therapy should be applied as soon as possible to prevent fibrous changes in the surrounding tissues. No patient death or graft loss had any direct relationship with lymphocele management.

Uvod: Symptomaticka lymfokela může významným způsobem negativně ovlivňovat funkci transplantovane ledviny. Cilem nasi prace bylo pětilete sledovani nemocných, kteři podstoupili lecbu.Metody: Do souboru bylo zařazeno 50 nemocných, kteři byli leceni pro symptomatickou lymfokelu. Retrospektivně jsme hodnotili demograficka data, přicinu renalniho selhani, indikaci k lecbě, provedenou terapii. Laboratorně byly hodnoceny hladiny kreatininu, celkove bilkoviny a albuminu. Celkove přežiti pacientů a stěpů bylo hodnoceno Kaplan-Meierovými křivkami.Výsledky: Průměrný věk 50 nemocných (44% žen, 56% mužů) byl 51,5±11,8 roku, doba mezi transplantaci a diagnozou lymfokely byla 12,8±21,5 měsiců. Průměrna velikost lymfokely byla 71±35mm. Přicina renalniho selhani vlastnich ledvin byla: glomerulonefritida (34 %), tubulointersticialni nefritida (30 %), polycystoza (24 %), diabeticka nefropatie (10 %) a nefroskleroza (2 %). Indikace k lecbě byla: elevace seroveho kreatininu (44 %), hydronefroza stěpu (38 %), hydronefroza stěpu s elevaci kreatininu (8%), hydronefroza s infekci (6 %) a infekce (4 %). Lecba byla provedena: otevřenou drenaži do peritonea (40 %), jednorazovou aspiraci (26 %), zevni drenaži (18 %) a laparoskopickou drenaži do peritonea (16 %). Průměrna hladina kreatininu v době lecby, resp. v 60. měsici byla, 231μmol/l, resp. 172 μmol/l, plasmaticka hladina celkove bilkoviny byla 59g/l, resp. 69g/l, plasmaticka hladina albuminu 36g/l, resp. 43g/l. Pětilete přeživani nemocných bylo 86% a přeživani stěpů 66%.Zavěr: Adekvatni lecba symptomaticke lymfokely vede ke stabilizaci funkce stěpu. Pokud je lymfokela indikovana k lecbě, je třeba ji provest co nejdřive, aby se předeslo vzniku fibroznich změn. Žadne umrti ani ztrata stěpu neměly přimou souvislost s lecbou lymfokely

INTRODUCTION:Cerebrovascular events are among the most common causes of invalidity or death. The aim of treatment in acute cerebral ischemia is to restore the blood flow before irreversible necrosis of brain tissue and persistent neurologic deficit occur. Pharmacological, endovascular and surgical methods are employed in the treatment of these patients.CASE REPORT:The authors present a case report of a 56-year-old woman with acute cerebral ischemia caused by tandem occlusion of the left common carotid artery and the M1 segment of middle cerebral artery. In the initial phase the patient was treated by intravenous thrombolysis with minimal success. Common carotid artery was occluded and mechanical extraction of embolus was successfully performed through direct carotid bifurcation puncture. Almost complete regression of neurologic deficit occurred after the endovascular recanalization. Occluded common carotid stump and bifurcation was considered as a source of embolization and therefore, to prevent further cerebrovascular event, a subclavian-carotid bypass was performed on the 15th day after the stroke.CONCLUSION:In the reported patient with symptomatic tandem occlusion of common carotid artery and the M1 part of middle cerebral artery, recanalization of cerebral artery was attained by the combination of pharmacological and endovascular method. Consequent subclavian-to-carotid bypass was performed in tertiary prevention of further cerebrovascular event.

Uvod: Cevni mozkova přihoda patři mezi nejcastějsi přiciny invalidity nebo umrti pacientů. Cilem lecby u akutni mozkove ischemie je zprůchodněni uzavřene tepny dřive, než dojde k ireverzibilni nekroze mozkove tkaně a rozvoji trvaleho neurologickeho deficitu. V lecbě takto postižených se uplatňuji jak farmakologicke postupy, tak endovaskularni ci chirurgicke výkony.Kazuistika: Autoři prezentuji připad 56lete pacientky s akutni cerebralni ischemii při tandemovem uzavěru leve spolecne karotidy a M1 useku arteria cerebri media. Nemocna byla v inicialni fazi lecena intravenozni trombolýzou, avsak s minimalnim zlepsenim neurologickeho nalezu. Vzhledem k okluzi spolecne karotidy byla mechanicka extrakce embolu z M1 useku arteria cerebri media provedena přistupem z přime punkce bifurkace karotidy. Po endovaskularni rekanalizaci arteria cerebri media doslo prakticky ke kompletni regresi neurologickeho deficitu. Jako zdroj arterio-arterialni embolizace do M1 useku arteria cerebri media byla předpokladana oblast pahýlu uzavřene spolecne karotidy a jeji bifurkace. Patnactý den po cevni mozkove přihodě byl pacientce s cilem prevence dalsiho iktu uspěsně proveden subklavio-karotický bypass.Zavěr: U pacientky se symptomatickou tandemovou okluzi M1 useku arteria cerebri media a arteria carotis communis byla kombinaci farmakologicke a endovaskularni lecby docilena rekanalizace mozkove tepny a byl dosažen dobrý funkcni výsledek. Nasledný subklavio-karotický bypass byl proveden v ramci terciarni prevence ischemicke cevni mozkove přihody.

Retrospective evaluation of 12-year experience with endovascular management of acute mesenteric ischemia (AMI) due to embolic occlusion of the superior mesenteric artery (SMA).

Aim: Carotid artery angioplasty is a preventive measure to decrease a risk of cerebral ischemia due to stenosis of the internal carotid artery bifurcation. To achieve this purpose, it is crucial that the procedure has a minimal risk of complications and its effect is long-lasting. The purpose of our study was to verify safety of carotid angioplasty and its long-term effect in clinical practice. Material and method:The study included 450 patients with 442 carotid artery stents and 8 plain carotid angioplasties since 1997. Complications occurring during the first three days after the procedure (periprocedural complications) and during long-term clinical and ultrasonographical follow-up (median 33 months) were recorded. Results: The risk associated with carotid angioplasty was low: in hospital mortality due to intracerebral hemorrhage was 0.5%, minor stroke occurred in 1.0%, transient ischemic attack in 2.4%. > 70% restenosis was found in 3.6% of the 76% of all patients who had long-term follow-up. Asymptomatic restenoses were 81%. Conclusions: Our results confirmed that carotid angioplasty is a safe method with beneficial long-term effect if it is done for appropriate indication and performed by a skilled intervention radiologist.

UNLABELLED:Free-floating thrombus in the internal carotid artery is a rare clinical finding. Only case reports and small cohorts of patients are described in the literature. The authors present a case report of a patient with ischemic stroke due to arterio-arterial embolisation from ulcerated internal carotid artery stenosis with a free-floating thrombus. Initially, the patient was treated with anticoagulants, resulting in total dissolution of the free-floating thrombus based on ultrasound documentation, without any further symptomatic embolisation. Endarterectomy was performed in the second step for the critical stenosis of the internal carotid artery. After this combined treatment, the patient showed no neurological deficit. Currently, the opinion on optimal therapy of the free-floating thrombus in the internal carotid artery still remains unclear.KEY WORDS:free-floating thrombus - anticoagulation internal carotid artery.

Cil: Praskle břisni a panevni výdutě patři mezi nejzavažnějsi život ohrožujici situace s vysokou mortalitou mezi 40–80 %. Retrospektivně jsme analyzovali výsledky endovaskularni lecby u těchto urgentnich stavů. Material/metodika: V obdobi unora 2009 až listopadu 2014 jsme endovaskularně lecili 12 pacientů (12 mužů, průměrný věk 75,2 let) s prasklou aortoilickou nebo panevni výduti. Vsichni pacienti vzhledem k ostatnim komorbiditam byli rizikovi ke standardni operacni lecbě. Jednalo se 7 × o rupturu degenerativni aortoilicke výdutě (rAAA), 3 × rupturu výdutě vnitřni ilicke tepny (AII), 2 × rupturu výdutě spolecne ilicke tepny (AIC). Celkem jsme použili u 7 nemocných bifurkacni stentgraft, u 4 nemocných tubularni stentgraft a jeden pacient byl lecen pouze embolizaci AII (okluder a akrylatove lepidlo). Výsledky: Průměrna doba od přijeti do ukonceni endovaskularni lecby byla 73 minut (rozmezi 45–180 minut). Dvakrat se po lecbě rozvinul břisni kompartment syndrom, který si vyžadal chirurgicke řeseni s drenaži retroperitonealniho hematomu. Třicetidenni letalita v nasem souboru byla 0 %, jednorocni letalita 16,7 % (2/12) a celkova letalita souboru pak 25 % (3/12). V průběhu sledovaneho obdobi se nevyskytly žadne komplikace ci umrti souvisejici s výkonem ci zakladnim onemocněnim (median sledovani 15 měsiců, rozsah 4–48). Zavěr: Akutni endovaskularni lecba prasklých aortoiliackých a panevnich výduti je v nasem centru organizacně proveditelna a dosahuje slibných výsledků. Podle specifickeho protokolu stratifikuje nemocne k endovaskularni ci operacni lecbě. Při dodrženi zakladnich předpokladů planujeme pokracovat v endovaskularni lecbě prasklých aortoilických a panevnich výduti.

INTRODUCTION:Current medical knowledge has provided us with a wide range of possibilities of treating chronic wounds. Over the recent decades, in particular, significant progress has been made in this field. The authors present an overview of current knowledge of chronic wound healing, pointing out the surgeons role in the process of chronic wound management. Using surgical therapy, we are able to heal a chronic wound in a shorter period of time, particularly if the treatment is accelerated by the application of platelet-rich plasma (PRP) as a source of growth factors.METHODS:The pilot randomized prospective study included four patients with chronic wounds of the lower leg after previous failure of conservative therapy who were indicated for skin transplantation. Following previous vacuum-assisted closure therapy, the patients undergoing skin transplantation were prospectively randomized into two groups. Autologous PRP was used in one of the groups and standard skin transplantation without PRP was performed in the other one.RESULTS:In the PRP group, 99% of the wound areas were healed on the 15th day after the operation. In the other group, 90% of the areas were healed on the 15th day following the operation. In the PRP group, complete healing of the defect occurred in both patients at 15 and 20 days post-surgery. In the second group, one patient completely healed within 28 days; the other one was not fully healed even at 3 months post-surgery.CONCLUSIONS:Most patient groups at great risk may benefit from the method using PRP, as well as patients with chronic wounds who have failed conventional methods available for both general and local therapy. This fact has been confirmed by the authors initial experience presented.Key words: platelet-rich plasma (PRP) - platelets wound healing chronic wound.

OBJECTIVEAn experience with laparoscopic sleeve gastrectomy using the natural orifice specimen extraction (NOSE) technique.BACKGROUNDBariatric surgery is nowadays the only long term effective obesity treatment method.METHODSTwenty one consecutive patients underwent laparoscopic sleeve gastrectomy with the use of natural orifice specimen extraction (NOSE) in the Surgical Clinic of Faculty Hospital Ostrava between May 2012 and August 2012. Inclusion criteria were the body mass index (BMI) higher than 35 kg/m2 or higher than 32 kg/m2 accompanied with relevant comorbidities.RESULTSAmong 21 patients in this series, there were three men (14.3%) and 18 women (85.7%). Their mean age was 40.9±10.2 years. Their mean preoperative BMI was 40.4±4.6 kg/m2. No patient had previous bariatric surgery, one patient had laparoscopic fundoplication. All operations were completed laparoscopically with no conversions to an open procedure. In two cases, laparoscopic cholecystectomy was performed and the gallbladder was extracted along with the gastric specimen by transgastric approach.CONCLUSIONLaparoscopic sleeve gastrectomy is a safe and effective bariatric procedure with low morbidity and mortality. Based on our initial experiences it could be an indication for NOSE with transgastric approach. Obese patients would benefit from this approach due to the elimination of wound complications (Tab. 2, Fig. 3, Ref. 22).