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ntroduction: Postoperative pancreatic fistula (POPF) is one of the most serious complications in pancreatobiliary surgery. The management of clinically relevant grade B and C fistulas requires interventional management or reoperation. POPF is accompanied with high mortality rate. Prevention of fistula formation is a possible solution of the problem. Methods: A retrospective observational study of patients with pathology of pancreatic body or tail, who underwent laparoscopic distal pancreatectomy or splenopancreatectomy (LDP) a tour instution between 2016 and 2021. From 2020, a set of perioperative precautions to reduce POPF has been standardised. Primary objective was to determine the total number of POPFs, the number of POPF-associated bleeds, and POPF-associated mortality in the 2016–2021 cohort. Secondary objective was to compare the outcomes of the group of patients with standardised preventive measures operated on in 2020–2021 with the group of patients without standardised measures operated on in 2016–2019. Results: In 2016–2021, we performed a total of 67 laparoscopic distal pancreatectomies. Of these, 10 patients (14.9%) had clinically relevant POPF (CR-POPF) grade B or C and we observed biochemical leakage in 22 cases (32.8%). There was no POPF associated bleeding or POPF associated mortality. In the 2020–2021 group of 20 patients treated with the standardised precautions, we observed no CR-POPF, and biochemical leakage occurred in 7 patients (35%). In contrast, in the group of patients without any standardisation of treatment (47 patients), operated on in 2016–2019, CR-POPF occurred in 10 patients (21.3%) and biochemical leakage in 15 patients (31.9%). Conclusion: The results of our entire cohort of patients confirm high numbers of POPFs after LDP. The results of the subgroup of patients with standardised perioperative procedures aimed at reducing POPFs showed a significant reduction in CR-POPFs, suggesting good rates of efficacy of the preventive measures introduced. Keywords: surgery – Pancreas – postoperative complications – pancreatic fistula – distal pancreatectomy

SARS-CoV-2 is an etiological factor in several diseases that the WHO designated covid-19. Covid-19 infection may affect the digestive tract, including the pancreas. The main/most common symptoms of covid-19 include fever (71.6%), cough (68.9%) subjective feeling of shortness of breath (71.2%). The gastrointestinal symptoms include abdominal pain, nausea and vomiting and/or diarrhea. The relationship of covid-19 and pancreas affection is not clearly described. A common finding is hyperlipasemia, eventually hyperamylasemia. Both conditions are usually associated with either no or minimal histomorphological changes, i.e. changes referred to as edematous glandular infiltration. Rarely, a necrotic form was reported. Nevertheless, the mortality of patients with acute pancreatitis who were covid-19 positive was higher than in covid-19 negative individuals. The available data indicate there is a link between covid-19 infection and the pancreas presenting as an acute disorder of the gland. SARS-CoV-2 impairment of both exocrine and endocrine function of the pancreas is multifactorial. It is debatable whether the involvement of the gland is directly related to the presence of the virus or whether it is an epiphenomenon. Angiotensin-converting enzyme 2 (ACE-2) receptors, inflammatory changes (especially in pancreatic beta cells), together with high IL-18 levels, virus-induced lipotoxicity and immunological dysregulation play an important role in the induction of pancreatic damage. During the covid-19 pandemic, pancreatopathies represent a very lively topic and are being studied intensively. Keywords SARS-CoV-2, COVID-19, chronic pancreatitis, pancreas, endoscopy

Crohn’s disease and ulcerative colitis are both chronic inflammatory bowel diseases (IBD). This article summarizes current best practice in treating pregnant patients with IBD, ranging from conservative therapy to endoscopy and imaging methods, including a description of surgical therapy indications. Female patients with IBD should ideally plan their pregnancies for when their disease is in remission. Patients in remission may also have complications during pregnancy, however the risk of complications is lower than in patients with active disease. Any chronic medications they were on before becoming pregnant (with the exception of teratogenic methotrexate) should remain unchanged. According to the current literature, pregnancy does not itself complicate the course of IBD. In cases of a severe relapse or an occurrence of complications in these patients, careful multidisciplinary cooperation is required, especially between the gastroenterologist, surgeon, radiologist, and gynaecologist. Surgical treatment is required only in cases of acute complications of IBD (such as acute severe colitis resistant to medical therapy, perianal abscess, and complications of IBD in the sense of such acute abdomen events as perforations, ileus due to a stenosis, or massive haemorrhage).

Pneumoperitoneum is a condition that refers to the presence of free air (gas) in the abdominal cavity. Differential diagnosis of the causes of pneumoperitoneum varies widely and represents varying degrees of severity. In the patients who have not recently underwent laparotomy or laparoscopy, the finding of pneumoperitoneum is usually a sign of gastrointestinal perforation that requires immediate surgical approach due to the risk of peritonitis with subsequent life-threatening sepsis. However, not all causes of pneumoperitoneum require surgery. In our case report, we present a rare case of clinically asymptomatic pneumoperitoneum that developed in a 66-year-old patient after CT colonography. In this diagnostic method, we inflate colon with carbon dioxide (CO2 ); therefore this kind of pneumoperitoneum can de facto be called capnoperitoneum. In this patient, free air (gas) in the abdominal cavity manifested itself in the so-called benign pneumoperitoneum, which is defined as asymptomatic free air in the abdominal cavity and pneumoperitoneum without peritonitis. Despite the fact that CT colonography is considered a method with a very low incidence of complications, it is necessary to take into account the presence of risk factors in its indication and to contraindicate to avoid the number of postoperative complications. The fundamental message of our case report is that extensive pneumoperitoneum after proven CT colonography can be asymptomatic and can be treated conservatively (if clinical and laboratory results are favorable).

Prezentujeme kazuistiku pacienta se somatickou retardaci a abnormalnim vzhledem vlasů, který trpěl opakovanými epizodami vodnateho hlenoviteho průjmu, postihem jaternich funkci a neprospivanim. U pacienta byly pozorovany těžke průběhy infekci vcetně hepatitidy neznameho původu komplikovane selhanim jater ve 4 měsicich, bronchopneumonie ve 4 letech a septickeho soku ve věku 8 let. Ezofagogastroduodenoskopie a koloskopie byly provedeny ve 4 letech, k vylouceni zanětliveho onemocněni střev (IBD). Histologicky vsak byly patrne pouze znamky nespecificke kolitidy. Imunologicke vysetřeni odhalilo snižený pocet naivnich CD4+ lymfocytů a sniženou T-lymfoproliferativni odpověď na mitogeny. K vysetřeni vzorku DNA pacienta bylo použito masivni paralelni sekvenovani (nazývane take sekvenovani nove generace, next generation sequencing – NGS) zaměřene na panel genů souvisejicich s primarnimi imunodeficiencemi. NGS analýza odhalila dvě heterozygotni varianty v genu TTC37. Nonsense varianta p.Arg1201* a missense varianta p.Leu1505Ser v exonu 34, resp. 42, byly vyhodnoceny jako patogenni na zakladě predikce in silico a jejich vzacneho výskytu v obecne populaci. Vzhledem k tomu, že obě mutace již byly popsany u pacientů s trichohepatoenterickým syndromem (THES) a klinicke znamky u naseho pacienta byly v souladu s touto diagnozou, považujeme nase zjistěni za přicinne. THES je v dětstvi casto život ohrožujicim onemocněnim, zejmena u pacientů, u kterých se rozvine onemocněni jater nebo trpi zavažným průběhem infekcnich onemocněni. THES může mit podobný klinický obraz jako zanětlive onemocněni střev s velmi casným zacatkem (very early-onset inflammatory bowel disease – VEO-IBD) a je casto do teto skupiny přiřazovan. IBD jsou obecně považovana za polygenni onemocněni, nicmeně u některých děti s VEO-IBD je znamo, že jejich onemocněni ma monogenni etiologii, tak jako je tomu u THES. Cilený NGS je ucinným nastrojem pro jednoznacne stanoveni diagnozy u pacientů s VEO-IBD.

Background: Eosinophilic esophagitis (EoE) is a chronic, progressive inflammatory disease of the esophagus characterized by local eosinophilic infiltration accompanied by symptoms of esophageal dysfunction. The aim of this study was to characterize features of EoE dia gnosed regionally and to describe local strategies for its treatment. Methods: The observational survey retrospectively analyzed a data set of child patients with histologically proven EoE from five pediatric endoscopy centers. This analysis focused on describing their general situation (age, gender, symptoms) and also aimed to investigate any possible linkage between age and symptoms or length of dia gnosis period. Demographic features; clinical symptoms; laboratory, endoscopic, and histopathological findings; and chosen treatment of patients were recorded and analyzed. Results: From January 2010 to September 2020, 33 new cases of EoE were reported. Strong association of EoE with male sex is consistent with the results from formerly published studies (81.8%). The median age of symptom onset was 7 years, while the median age for dia gnosis was almost 13 years. The most common symptoms were reflux symptoms in general (39.4%), followed by vomiting (36.4%), and dysphagia (33.3%). Examination for sensitization to food allergens was performed on 23 (69.7%) patients with dia gnosed EoE. Out of these, 17 (51.5% of all cases) were found to be sensitive to some allergens. Most of this subgroup (and 48.5% of all cases) were examined by specific IgE testing, and just 2 (6.1% of all cases) patients were tested only by skin prick tests. Another allergic comorbidity was present in 75.8% of patients, and the most common of these were bronchial asthma and allergic rhinoconjunctivitis (45.5% and 42.2%, respectively). More than two-thirds of patients (69.7%) had abnormal macroscopic findings during dia gnostic endoscopy, and the most common were longitudinal furrows and white exudates. The most common initial modality of treatment was to use proton-pump inhibitors (PPI; 93.9%), followed by food elimination (75.8%) and then by corticosteroid administration (63.6%). The vast majority of patients treated with corticosteroids received a topical preparation (90.9%). Conclusion: This is the first retrospective study on pediatric patients with EoE in the Czech Republic. We found similar features of EoE as reported in formerly published works elsewhere. Collecting long-term prospective observational data in a national EoE register of patients in the Czech Republic would significantly improve our knowledge of this disease.

An acute abdomen is an urgent condition requiring rapid diagnosis and treatment. Nowadays, with the new developments and progression in ultrasonography (US) and computed tomography (CT), these methods have become a far better alternative to plain abdominal radiography. US is now an available and proven method used to provide a “final” diagnosis in various conditions. The frequency for CT examination for the diagnosis of acute abdomen has increased. A disadvantage of using CT examination includes high doses of radiation for the patient. Fortunately, this disadvantage is outweighed by the multitude of advantages. The advantages include high sensitivity and specificity in the detection of causes in urgent conditions. The CT protocol of examination is primarily lead by the radiologist.

Uvod: Krvaceni do horniho gastrointestinalniho traktu (GIT) patři mezi život ohrožujici stavy, ktere vyžaduji aktivni přistup a dynamický management akutni pece. Gastroskopie představuje zasadni diagnostický a terapeutický krok. Bohužel mnoho mensich nemocnic nema možnost provest gastroskopii mimo pracovni dobu. Glasgow-Blatchford skore (GBS) představuje nastroj umožňujici odhad vývoje stavu pacienta s krvacenim do horniho GIT. Evropska guidelines doporucuji ambulantni řeseni pacientů s GBS rovno 0 nebo 1. Cilem nasi studie bylo posoudit použitelnost GBS na ceske populaci a zhodnotit bezpecnost vyssi hranice GBS pro řeseni pacientů v ambulantnim režimu. Metody: Retrospektivni sběr dat pacientů, kteři byli hospitalizovani a endoskopovani v Nemocnici Boskovice pro symptomy krvaceni z horniho GIT od řijna 2018 do prosince 2019. Výsledky: Data hodnotici celkový průběh onemocněni naznacuji, že optimalni GBS pro stanoveni pacienta s nizkým rizikem je 3, ale s přihlednutim k endoskopickým nalezům lze za bezpecne pro ambulantni lecbu považovat GBS 2. GBS 10 pak předpovida zavažný celkový průběh nemoci a zavažne endoskopicke nalezy. Zavěr: Dle nasich dat lze zvýsit hodnotu GBS na 2 pro ambulantni řeseni pacientů, což by mohlo snižit delku hospitalizace a tlak na urgentni endoskopie. Tyto zavěry je nutne ověřit dalsim výzkumem – idealně multicentrickou prospektivni studii s velkým množstvim analyzovaných pacientů.

Herpeticka ezofagitida je onemocněni dia­gnostikovane zejmena u imunokompromitovaných pacientů. U imunokompetentnich jedinců se jedna o vzacne onemocněni, na ktere je ale třeba pomýslet při akutně vznikle triadě potiži – odynofagie, bolesti na hrudi a horecka nejasneho původu. Nejcastějsim původcem je herpes simplex virus typu 1 (HSV1). Ve větsině připadů vznika onemocněni reaktivaci latentni infekce HSV1, vzacněji při primoinfekci. Zakladem dia­gnostiky je endoskopicke vysetřeni jicnu s provedenim bio­psie a přimým průkazem přitomnosti viru v bio­ptickem vzorku. U imunokompromitovaných pacientů je vždy indikovana lecba acyklovirem, který je v teto indikaci virostatikem prvni volby. U imunokompetentnich pacientů se jedna o tzv. self-limiting onemocněni, kdy v naproste větsině připadů postacuje symptomaticka lecba. Kazuistika popisuje imunokompetentniho pacienta s nahle vzniklou typickou triadou potiži způsobených herpetickou ezofagitidou. Dia­gnoza byla potvrzena průkazem přitomnosti virove DNA metodou PCR ze vzorku odebraneho při endoskopickem vysetřeni. Vzhledem k těžsimu průběhu onemocněni byl pacient přelecen acyklovirem a doslo k rychle upravě celkoveho stavu i lokalniho endoskopickeho nalezu. Herpeticka ezofagitida je onemocněni dia­gnostikovane zejmena u imunokompromitovaných pacientů. U imunokompetentnich jedinců se jedna o vzacne onemocněni, na ktere je ale třeba pomýslet při akutně vznikle triadě potiži – odynofagie, bolesti na hrudi a horecka nejasneho původu. Nejcastějsim původcem je herpes simplex virus typu 1 (HSV1). Ve větsině připadů vznika onemocněni reaktivaci latentni infekce HSV1, vzacněji při primoinfekci. Zakladem dia­gnostiky je endoskopicke vysetřeni jicnu s provedenim bio­psie a přimým průkazem přitomnosti viru v bio­ptickem vzorku. U imunokompromitovaných pacientů je vždy indikovana lecba acyklovirem, který je v teto indikaci virostatikem prvni volby. U imunokompetentnich pacientů se jedna o tzv. self-limiting onemocněni, kdy v naproste větsině připadů postacuje symptomaticka lecba. Kazuistika popisuje imunokompetentniho pacienta s nahle vzniklou typickou triadou potiži způsobených herpetickou ezofagitidou. Dia­gnoza byla potvrzena průkazem přitomnosti virove DNA metodou PCR ze vzorku odebraneho při endoskopickem vysetřeni. Vzhledem k těžsimu průběhu onemocněni byl pacient přelecen acyklovirem a doslo k rychle upravě celkoveho stavu i lokalniho endoskopickeho nalezu.

Cystic fibrosis (CF) is a genetic disease affecting many organs including the gastrointestinal tract. While the pulmonary damage is the most life threatening, the pancreas is one of the first and most affected organs by CF. Mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene results in a reduced volume of pancreatic juice and hyperconcentration of macromolecules leading to precipitation in the duct lumina, causing obstruction and damage. The clinical presentation of individual cases depends on a combination of different CFTR mutations, potential presence of modifier genes mutations, and environmental factors. The CFTR mutations are historically divided into 5 classes - severe mutations (classes I-III) and mild mutations (classes IV-V). The CFTR functional status depends on the combined effects of both CFTR allels and the severity of the phenotype depends on the milder mutation. The majority of CF patients exhibit exocrine pancreatic insufficiency in early childhood because functional acinar tissue has been lost in utero or soon after birth. These patients rarely suffer from pancreatic complications such as recurrent acute pancreatitis and/or chronic pancreatitis which, on contrary, can occur in the minority of patients who possess residual pancreatic exocrine function. CFTR mutations are found more frequently in idiopathic and alcoholic chronic pancreatitis but the data is conflicting. A combination with SPINK-1 mutations can be found in idiopathic chronic pancreatitis group, as well as presence of environmental factors. Malnutrition is directly related to worse prognosis of CF patients and delivery of active digestive enzymes is a cornerstone of the treatment with acid supression and vitamins supplementation playing an important additional role.

Echinococcosis is a rare parasitic infection in Central Europe. The most commonly affected organ is liver. There are two types, cystic and alveolar echinococcosis with different type of treatment management. A radical liver resection remains the method of choice in the management of alveolar echinococcosis. We report a case of a 40-year-old woman with an echinococcal alveolar liver lesion successfully treated with a laparoscopic resection of the 5th liver segment. Laparoscopic technique, with all its benefits over the open surgery, provides a save and efficient treatment of selected types of echinococcal cysts located in the liver. It is a mini-invasive surgical approach which enables lower postoperative discomfort, quicker recovery and better cosmetic outcome.

Liver cirrhosis is a chronic liver disease in which the liver tissue and the vascular beds are remodeled leading to impaired hepatic function. Portal hypertension and subsequent esophageal varices are a frequent complication of liver cirrhosis and are a cause of mortality in patients with liver cirrhosis. Pregnancy in women with liver cirrhosis is uncommon, the incidence being about 1 in 5 950 pregnancies. Hepatocellular damage and the associated alteration in the metabolism of the sex hormones is thought to be responsible and leads to anovulation. In spite of all these factors, women with cirrhosis can and do become pregnant. Pregnancy is successful in most of the patients with chronic liver disease, but maternal and fetal complication rates are still high for decompensated liver cirrhosis. Portal hypertension associated with pregnancy is a high-risk situation as both pregnancy and portal hypertension share some of the hemodynamic changes. Risks of variceal bleeding and hepatic decompensation increases many fold during pregnancy. Despite the possible complications mentioned above, the maternal-fetal morbidity and mortality rates have been decreased by the current developments in hepatology, prevention of bleeding from varices with drugs and/or endoscopic variceal ligation, improvement in liver transplantation, and an increased experience in these issues. We present a case of a 31-year-old female patient with liver cirrhosis who successfully managed pregnancy and birth without complications after the insertion of transjugular intrahepatic portosystemic shunt (TIPS). Unfortunately, 2 years after delivery, the patient developed lymphoblastic lymphoma and, despite intensive therapy for this disease, the patient died at the age of 40. We did not find any link between liver cirrhosis and lymphoblastic lymphoma.

Crohn’s disease (CD) and Familial adenomatous polyposis (FAP) are two different diseases which both affect gastrointestinal tract. FAP is an autosomal dominant inherited disease, however the etiology of CD is still unknown but is supposed to be multifactorial (genetics, environment, immune state, microbiom). The therapy of these two diseases differs as well. The ultimate solution for FAP is surgery (colectomy or proctocolectomy). On the other hand, the therapy of CD can be either conservative or surgical. Generally, in cases of bowel resections the alternatives of gastrointestinal tract restoration have to be considered in advance. Furthermore, this decision is even more demanding in patients diagnosed with both diseases (CD and FAP). We present a case of a young female with FAP who was recently diagnosed with active CD in the ileocaecal region. Due to large multiple colon polyps and stenotic terminal ileum she was indicated for surgery (colectomy with terminal ileostomy and terminal ileum resection). Subsequently, the ileorectal anastomosis was constructed in this case. In further text, we also discuss other types of possible bowel restoration solutions (ileal pouch-anal anastomosis and abdominoperineal resection with terminal ileostomy) in such a patient.

Ampularni adenokarcinom (AA) je relativně vzacne onemocněni, tvořici meně něž 1 % vsech nadorů gastrointestinalniho traktu, ackoli je to druha nejcastějsi malignita periampularni oblasti (po karcinomu pankreatu). Mezi možnosti lecby ampularnich neoplazii patři endoskopicka resekce, transduodenalni chirurgicka ampulektomie nebo hemipankreatoduodenektomie. V době diagnozy onemocněni je u AA vyssi pravděpodobnost kurabilni chirurgicke resekce než u karcinomu pankreatu (80 vs. 20 %) a rovněž 5lete přeživani je významně delsi. Laparoskopicke resekcni výkony se staly standardem v kolorektalni chirurgii s prokazanými výhodami v casnem pooperacnim průběhu. V tomto clanku prezentujeme kazuistiku 68lete pacientky s AA, u ktere byla provedena laparoskopicka hemipankreatoduodenektomie (LPD). Pojednavame o výhodach a nevýhodach LPD s hepankreatoduodenektomii provaděnou z otevřeneho přistupu, rozebrany jsou lecebne možnosti teto diagnozy (vc. endoskopicke) a přinasime přehled soucastne literatury.

Hiatove hernie jsou casto spojovany s lecbou refluxni choroby jicnu. V tomto připadě je u nich zvažovano buď pokracovani zavedene lecby pomoci inhibitorů protonových pump, anebo provedeni antirefluxni operace. U malých hiatových kýl je cetnost výskytu komplikacinizka. S narůstajici velikosti hiatove hernie se ale zvysuje riziko výskytu akutnich komplikaci, ktere mohou pacienta ohrozit na životě. Důležitou soucasti lecby komplikaci hiatových hernii je prevence. Elektivni operacni řeseni hiatových kýl ma velmi dobre funkcni výsledky s nizkým rizikem pooperacnich komplikaci. Proto by měly být planovaně operovany předevsim kýly paraezofagealni nebo objemne smisene hiatove hernie. Nejzavažnějsimi akutnimi komplikacemi jsou volvulus žaludku a rozvoj zavažneho krvaceni. Volvulus žaludku je život ohrožujici stav, který vyžaduje rychlou diagnostiku a lecbu. Symptomy volvulu žaludku nemusi být typicky vyjadřene, což ztěžuje diagnostiku onemocněni. Zakladni soucasti chirurgicke lecby akutnich komplikaci u hiatových hernii je repozice žaludku do dutiny břisni a jeho pexe ke stěně břisni. Při akutni operaci objemne hiatove hernie je významně vyssi riziko nutnosti laparotomie než při operaci elektivni, ktere se větsinou daři dokoncit laparoskopicky. Narůsta riziko peroperacniho poraněni jicnu, sleziny, ale take nechirurgických pooperacnich komplikaci, jako jsou pneumonie, delirium a arytmie. U vybraných pacientů s volvulem žaludku bez jeho perforace může být uspěsne i řeseni endoskopicke. Akutni operacni řeseni si může vyžadat i masivni krvaceni ze žaludku při objemne hiatove hernii, u ktereho je uspěsnost endoskopicke lecby a konzervativniho postupu nizka.

Purpose: The diagnosis of pancreatic ductal adenocarcinoma (PDAC) in treatable early stages continues to be challenging. Autoimmune pancreatitis (AIP) can, similarly to PDAC, present as a focal mass and, therefore, an accurate differential diagnosis is of crucial importance. Raised serum immunoglobulin G4 (IgG4) levels, over the twice the normal value, are considered to be one of the significant diagnostic features of type 1 AIP. However, IgG4 can also be increased in patients with PDAC, but levels usually do not exceed twice the normal value. Materials and methods: In the years 2012 - 2018, IgG4 serum levels were examined in 117 patients with histologically confirmed PDAC. Histological resection specimens or bioptic specimens were taken from the pancreatic lesions of patients with both PDAC and an elevated IgG4 level (above 135mg/dL). These were then tested for the presence of IgG4 and plasmocytes in the pancreatic tissue, and changes characteristic for type 1 AIP were also searched for. Results: In 14/117 PDAC patients (11.9 %) the plasmatic IgG4 levels were higher than 135 mg/dL. In 2 patients (1.7 %) the serum IgG4 levels were more than double the normal value, and thus suggestive of AIP according to the guidelines. Of these two patients - one of them met the histological criteria for diagnosis of AIP in the simultaneous presence of PDAC. Conclusions: Differentiating AIP from PDAC can be sometimes problematic since these diseases can both present as focal pancreatic mass/ lesions. IgG4 has been considered useful for AIP diagnosis, however, IgG4 levels can be slightly elevated, as is the case with PDAC. IgG4 levels of over the twice of the upper limit are rare among PDAC patients (1.7% in our study group). However, cases of simultaneous presentation of PDAC and AIP have been documented and should not be neglected. Therefore, targeted biopsy of the pancreas is the method of choice in cases suspected of being a focal form of AIP, and we recommend it over other modalities, such as e.g. response to steroid therapy.