Introduction: Biliary complications (BC) after liver transplantation (LTx) are serious problems with an incidence rate of 6-35%. There are two types of BC, early and late. Early BC is observed for 30 days post LTx or during the entire... more
Introduction: Biliary complications (BC) after liver transplantation (LTx) are serious problems with an incidence rate of 6-35%. There are two types of BC, early and late. Early BC is observed for 30 days post LTx or during the entire period of the patient's first hospital stay after LTx. The main causes of early BC are ischemia of the biliary tree (the bile duct of the transplanted liver is supplied only from the right hepatic artery descendingly; the supply from the gastroduodenal artery is lacking) as well as implementation of the biliary anastomosis surgical technique. Treatment of BC is administered by a surgeon, a gastroenterologist and a radiologist. Aim: To evaluate early biliary complications after LTx Patients and methods: We reviewed patients with early BC after LTx from 4/2004 - 12/2009. We defined early BC as a complication that is present during the first 30 days post LTx or during the entire period of the patient's first hospital stay after LTx. Results: We performed 384 LTx during the above-mentioned period. We carried out reconstruction of the biliary tree in the form of a choledochocholedochostomy (CDD) in 312 cases and in the form of a choledochojejunostomy (CDJ) in 72 cases. Sixty-eight patients had early BC (17.7%), 25 patients experienced biliary leak (6.5%), 40 patients had anastomotic stenosis (10.4%) and 3 patients (0.8%) experienced both complications (biliary leak and stenosis). Most complications were eliminated by ERCP with a papilosfincterotomy, a balloon dilatation of stenosis, and a biliary stent implant with repeated stent replacements (45 cases in total- all patients with biliary stenosis). Twenty-two patients were reoperated on (16x CDJ, 3x re-CDD, 2x suture of aberrant bile duct, 1x suture common bile duct) and 1 patient was treated by percutaneous transhepatic bilary drainage (PTD). The mortality rate was zero. Conclusion: BC after LTx continue to pose a serious surgical problem. The treatment of choice when dealing with BC is ERCP, which has more than a 70% success rate. If ERCP or PTD are not successful, or when biliary peritonitis is present, we perform a reanastomosis of the bile duct. The combined effort of the surgeon, gastroenterologist and radiologist is the most important factor for successful treatment. The incidence of BC after LTx at IKEM is similar to that of treatment centers all over the world.
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Radiofrequency ablation (RFA) is a mini-invasive loco-regional ablation technique that is increasingly being used as a palliative treatment for pancreatic cancer and cholangiocarcinoma. Ablation-triggered immune system stimulation has... more
Radiofrequency ablation (RFA) is a mini-invasive loco-regional ablation technique that is increasingly being used as a palliative treatment for pancreatic cancer and cholangiocarcinoma. Ablation-triggered immune system stimulation has been proposed as a mechanism behind the systemic effects of RFA. The aim of our study was to investigate the immune response to endoluminal biliary RFA. Peripheral blood samples were collected from patients with pancreatic cancer and cholangiocarcinoma randomised to receive endoluminal biliary radiofrequency ablation + stent (19 patients) or stent only (21 patients). We observed an early increase in IL-6 levels and a delayed increase in CXCL1, CXCL5, and CXCL11 levels as well as an increase in CD8+ and NK cells. However, these changes were not specific to RFA treatment. Explicitly in response to RFA, we observed a delayed increase in serum CXCL1 levels and an early decrease in the number of anti-inflammatory CD206+ blood monocytes. Our study provides t...
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Probe-based confocal laser endomicroscopy (pCLE) enables real-time histopathological assessment during endoscopic procedures to evaluate epithelial and subepithelial structures with a 1000x magnification. It may be used in various... more
Probe-based confocal laser endomicroscopy (pCLE) enables real-time histopathological assessment during endoscopic procedures to evaluate epithelial and subepithelial structures with a 1000x magnification. It may be used in various localizations not only in the digestive tract, but its role in clinical practice is still a matter of discussion. The main advantages of pCLE compared to standard biopsies may be: 1) real-time diagnosis; 2) which may be done by the endoscopist; and 3) a larger evaluated area compared to standard biopsies. In theory, pCLE has the potential to eliminate the need for biopsy. However, pCLE cannot replace standard biopsies at this time, among others, standard forceps biopsies are presently more cost-effective. pCLE may be used to enhance the diagnostic arsenal and improve mucosal visualization and evaluation in patients with Barrett's esophagus (BE), with visible esophageal lesions and in patients undergoing surveillance endoscopy after endoscopic treatment of BE related neoplasia. pCLE requires sufficient training and use of validated classifications systems. At present, the majority of endoscopic centers do not use pCLE routinely and no guidelines recommend its routine use for patients with different esophageal diseases, although pCLE is (in selected indications) reimbursed in some countries. This article describes the principle and performance of pCLE and reviews its use in patients with BE and early esophageal neoplasia.
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UNLABELLED Prothrombotic states related to idiopathic bowel disease (IBD) are typically caused by abnormalities of hemostasis associated with inflammatory processes. The risk of thromboembolic complications in patients with IBD is... more
UNLABELLED Prothrombotic states related to idiopathic bowel disease (IBD) are typically caused by abnormalities of hemostasis associated with inflammatory processes. The risk of thromboembolic complications in patients with IBD is approximately three times as high as in the general population. A critical role is played by the acquired risk factors including medication, while the proportion of inherited thrombophilia in patients with IBD is the same as in the general population. Many abnormalities can be identified through laboratory testing at the level of coagulation factors, fibrinolysis, thrombocytes and endothelium. Although there are no systematic guidelines for the prevention of thromboembolism in patients with IBD available, valid reasons for prophylactic administration of low-molecular-weight heparin are immobilization, hospitalization for IBD activity and surgery. The treatment of thromboembolism which complicates the course of IBD does not differ from its treatment among t...
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Esophagectomy is a standard of care for patients with "high-risk" early esophageal cancer (HRC) despite a growing evidence that endoscopic treatment may be a safe alternative. Our aims were 1. to prospectively evaluate the... more
Esophagectomy is a standard of care for patients with "high-risk" early esophageal cancer (HRC) despite a growing evidence that endoscopic treatment may be a safe alternative. Our aims were 1. to prospectively evaluate the long-term results of endoscopic and surgical treatments in consecutive patients with HRC and 2. to determine the risk of lymph node (LN) metastases and micrometastases in patients with HRC. Methods HRC was defined as any cancer with submucosal (sm) invasion or mucosal cancer with at least one of the following: poor differentiation, invasion to blood or lymphatic vessels and high tumor cell dissociation (TCD3). All patients (n = 69) underwent endoscopic resection (ER or ESD) and after the histopathological diagnosis of HRC, patients without contraindications were referred to surgery (n = 30). The remaining patients (n = 39) continued in endoscopic treatment, if necessary. All resected LNs were stained for hematoxylin–eosin to evaluate metastases and imm...
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Research Interests: Pathology, Surgery, Treatment, Medicine, Humans, and 9 moreMutation, Male, Skin, Clinical Sciences, European, Adult, PTEN, Intestinal Polyposis, and papillomatosis
Introduction: Barrett?s esophagus (BE) is a well established precursor of esophageal adenocarcinoma. Both, surveillance and therapeutic strategies have been proposed over the years. Recent development of endoscopic radiofrequency ablation... more
Introduction: Barrett?s esophagus (BE) is a well established precursor of esophageal adenocarcinoma. Both, surveillance and therapeutic strategies have been proposed over the years. Recent development of endoscopic radiofrequency ablation (RFA) brought new perspectives in the treatment of BE, with excellent initial results. Methods: The study of 40 pts with macroscopically visible BE on endoscopy and biopsy proven goblet cells presence, was conducted from January 2010 until March 2012. In all pts a complete symptomatic, endoscopic and manometric evaluation was performed. Initially RFA HALO 90 and 360 were performed in 28 and 12pts respectively. Repeated treatments were conducted in 7 pts. The overall number was 50, while the mean number of RFA procedures per patient was 1.25. Results: The mean circumferential length and maximal extent of BE were 1.61 and 3.29 cm respectively. We did not encounter esophageal perforation or hemorrhage during the procedure. Complications were transient...
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Liver stiffness is a reliable non-invasive predictor of Hepatic Venous Pressure Gradient (HVPG) above 10 mm Hg. However, it failed to predict higher thresholds of HVPG. Our aim was to investigate whether liver stiffness and selected... more
Liver stiffness is a reliable non-invasive predictor of Hepatic Venous Pressure Gradient (HVPG) above 10 mm Hg. However, it failed to predict higher thresholds of HVPG. Our aim was to investigate whether liver stiffness and selected previously published non-invasive blood biomarkers could predict higher HVPG thresholds in liver transplant candidates without ongoing alcohol use. One hundred and nine liver transplant candidates with liver cirrhosis of various aetiologies underwent direct HVPG measurement, liver stiffness measurement by 2D shear-wave elastography (Aixplorer Multiwave, Supersonic Imagine, France) and assessment of blood HVPG biomarkers (osteopontin, VCAM-1, IL-6, TNF-α, IL-1ra/IL-1F3 and ELF score). The correlation between liver stiffness and HVPG was linear up to 30 mm Hg of HVPG (r = 0.765, p < 0.0001). The regression lines had similar slopes for HVPG values below and above 16 mm Hg (p > 0.05) and the correlation in patients with HVPG <16 mm Hg (r = 0.456, p ...
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Heterozygotes for Z or S alleles of alpha-1-antrypsin (AAT) have low serum AAT levels. Our aim was to compare the risk of hepatocellular carcinoma (HCC) in patients with liver cirrhosis carrying the SERPINA1 MM, MZ and MS genotypes. The... more
Heterozygotes for Z or S alleles of alpha-1-antrypsin (AAT) have low serum AAT levels. Our aim was to compare the risk of hepatocellular carcinoma (HCC) in patients with liver cirrhosis carrying the SERPINA1 MM, MZ and MS genotypes. The study groups consisted of 1119 patients with liver cirrhosis of various aetiologies, and 3240 healthy individuals served as population controls. The MZ genotype was significantly more frequent in the study group (55/1119 vs. 87/3240, p < 0.0001). The MS genotype frequency was comparable in controls (32/119 vs. 101/3240, p = 0.84). MZ and MS heterozygotes had lower serum AAT level than MM homozygotes (medians: 0.90 g/L; 1.40 g/L and 1.67 g/L; p < 0.001 for both). There were significantly fewer patients with HCC in the cirrhosis group among MZ and MS heterozygotes than in MM homozygotes (5/55 and 1/32 respectively, vs. 243/1022, p < 0.01 for both). The risk of HCC was lower in MZ and MS heterozygotes than in MM homozygotes (OR 0.3202; 95% CI 0...
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Background & Aims: Radiofrequency ablation (RFA) with/without endoscopic resection (ER) is the standard endoscopic treatment modality for Barrett‘s esophagus (BE) related neoplasia (BORN). The main aim of this study was to assess the... more
Background & Aims: Radiofrequency ablation (RFA) with/without endoscopic resection (ER) is the standard endoscopic treatment modality for Barrett‘s esophagus (BE) related neoplasia (BORN). The main aim of this study was to assess the long-term outcomes of RFA in patients with BORN. Methods: We retrospectively analyzed the prospectively collected data from the Czech national database. Main outcomes were: complete remission of neoplasia (CR-N), complete remission of intestinal metaplasia (CR-IM), recurrence of both neoplasia and IM, and safety. Results: From a total of 170 patients with BORN treated with RFA, 136 patients were analyzed. They were followed up for a median of 27.5 months. Fifty-six patients (41%) had low-grade intraepithelial neoplasia (LGIN), 46 (34%) had high-grade intraepithelial neoplasia (HGIN) and 34 (25%) had early adenocarcinoma (EAC). RFA was combined with previous ER in 65 patients (48%). CR-IM and CR-N were achieved in 77.9% (95% CI 70.0-84.6%) and 98.5% (95%...
The duodenum has recently emerged as a key regulator in glucose metabolism via modulation of a complex network of neural and hormonal signals in response to ingested food. DiaGone™ is an endoscopic device which utilizes precisely... more
The duodenum has recently emerged as a key regulator in glucose metabolism via modulation of a complex network of neural and hormonal signals in response to ingested food. DiaGone™ is an endoscopic device which utilizes precisely controlled laser technology to target the duodenal submucosal neural plexi with the aim of improving glucose control by modulating the gastrointestinal neurohumoral axis. Nine subjects (5 males) with obesity (BMI 34.0 ± 4.6 kg/m2) and type 2 diabetes mellitus (T2DM) insufficiently controlled on metformin were included in this first-in-human trial in order to assess the efficacy and safety of DiaGone™. Subjects were instructed to continue with regular diet 24h after the procedure and metformin dose was not changed during the study period. Biochemical and anthropometric parameters were assessed at baseline and 3 and 6 months after the procedure and continuous glucose monitoring (CGM) and a standard liquid meal test were performed at baseline and 3 months after the procedure. DiaGone™ significantly decreased HbA1C from 78.3 ± 13.3 mmol/mol at baseline to 64.9 ± 6.4 mmol/mol and 64.8 ± 7.1 mmol/mol at 3 and 6 months, respectively (p In conclusion, these pilot results suggest that endoscopic duodenal submucosal laser ablation using the DiaGone™ device is associated with improvements in both baseline and postprandial glycemia as well as HbA1C with no significant changes in insulin levels or body weight while having a favorable safety and tolerability profile. Disclosure M. Mraz: None. I. Marcovitch: Employee; Self; Digma Medical. I. Lankova: None. H. Kratochvilova: None. A. Cinkajzlova: None. M. Benes: None. J. Korner: Board Member; Self; Digma Medical. Stock/Shareholder; Self; Digma Medical. Z. Vlasakova: None. J. Spicak: None. T. Pelikanova: None. M. Haluzik: None. Funding MH CZ - DRO; Institute for Clinical and Experimental Medicine (IN00023001); RVO (VFN64165)
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Background POEM has gained trust by proved safety and short-term efficacy and at present, it is considered as a standard and safe method for treatment of achalasia. The aim of this prospective single-center case series was to assess the... more
Background POEM has gained trust by proved safety and short-term efficacy and at present, it is considered as a standard and safe method for treatment of achalasia. The aim of this prospective single-center case series was to assess the long-term efficacy of POEM with emphasis on post-POEM reflux and to summarize adverse events. Methods Since 2012 until 10/2017, a total of 223 achalatic patients underwent 233 POEMs. Follow-up visits at 3, 12, 24 and 36M were completed in 194, 144, 80 and 44 patients. Upper GI endoscopy, HRM and 24-hour pH metry were performed 3M after POEM; endoscopy was then repeated between 24–36M. Main outcomes were treatment success (Eckardt score <3), recurrence rate, post-POEM reflux and adverse events. Results At 3, 12, 24 and 36 months, treatment success was achieved in 97% (CI 95%; 95–100), 99% (97–100), 94% (88–100) and 93% (86–100) of patients. A total of 15 patients experienced treatment failure (n = 5) or recurrence (n = 10). The recurrences occurred...
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Background Gastroparesis is a chronic, debilitating motility disorder. Effective treatment is challenging especially in patients with severe symptoms. G-POEM is an emerging modality for refractory gastroparesis with promising preliminary... more
Background Gastroparesis is a chronic, debilitating motility disorder. Effective treatment is challenging especially in patients with severe symptoms. G-POEM is an emerging modality for refractory gastroparesis with promising preliminary results. The aim of this prospective case series was to assess the first single-center experience with G-POEM. Main outcomes were: the clinical efficacy defined by an improvement of GCSI ≥ 40% from baseline; gastric emptying study (GES) and safety. Methods Since Nov 2015, a total of 8 patients have undergone G-POEM. The etiology of gastroparesis was post-operative in 5, diabetic in 2 and idiopathic in 1 patient. One patient underwent G-POEM for gastroparesis following a multivisceral transplantation; one underwent G-POEM and POEM as a single procedure for coexisting refractory idiopathic gastroparesis and achalasia. All patients had abnormal GES. F-u visit at 3, 6, 12 and 24M were completed in 7/8 (87.5%), 7/8 (87.5%), 5/8 (62.5%) and 1/8 (12.5%) of...
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Peroral endoscopic myotomy (POEM) is an evolving therapeutic modality for achalasia. According to the original Inoue's technique, a submucosal lavage with gentamicin has been practiced due to the fear of infection. This... more
Peroral endoscopic myotomy (POEM) is an evolving therapeutic modality for achalasia. According to the original Inoue's technique, a submucosal lavage with gentamicin has been practiced due to the fear of infection. This single-tertiary center study was intended to assess the clinical significance of the topical antibiotic lavage during POEM. A retrospective analysis of prospectively collected data was conducted. The outcomes of patients who received the gentamicin lavage (group A) during POEM were compared to those who did not (group B). The main outcome variables were infectious adverse events, post-POEM fever, and markers of systemic inflammatory response. One day before and after POEM, all patients received systemic antibiotic prophylaxis with ceftriaxone. Of 124 consecutive patients having undergone POEM, 60 patients received a lavage with 80 mg of gentamicin into the submucosal tunnel before starting the myotomy, while 64 patients did not. The overall treatment success at 3...
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Aims. The aim of our study was to determine the physiologic impact of NOTES and to compare the transgastric and transcolonic approaches. Methods. Thirty pigs were randomized to transgastric, transcolonic, or laparoscopic peritoneoscopy.... more
Aims. The aim of our study was to determine the physiologic impact of NOTES and to compare the transgastric and transcolonic approaches. Methods. Thirty pigs were randomized to transgastric, transcolonic, or laparoscopic peritoneoscopy. Blood was drawn and analyzed for C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), interleukin- (IL-) 1β, IL-6, WBCs, and platelets. Results. Endoscopic closure with an OTSC was successful in all 20 animals. The postoperative course was uneventful in all animals. CRP values rose on day 1 in all animals and slowly declined to baseline levels on day 14 with no differences between the groups (P > 0.05, NS). The levels of TNF-α were significantly increased in the transcolonic group (P < 0.01); however this difference was already present prior to the procedure and remained unchanged. No differences were observed in IL1-β and IL-6 values. There was a temporary rise of WBC on day 1 and of platelets on day 7 in all groups (P > 0.05, NS). Co...
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Patients with advanced liver fibrosis owing to chronic hepatitis C virus genotype 1 represent a difficult-to-treat group even if a protease inhibitor is added to pegylated interferon alpha and ribavirin. Therefore, only patients with a... more
Patients with advanced liver fibrosis owing to chronic hepatitis C virus genotype 1 represent a difficult-to-treat group even if a protease inhibitor is added to pegylated interferon alpha and ribavirin. Therefore, only patients with a high chance of cure should be treated with interferon-based treatment. Expression of IFNG, IFNLR1, and interferon-sensitive genes CXCL9, IFI16, IFI27, ISG15, and USP18 in peripheral blood mononuclear cells was assessed before and during the initial 12 weeks of treatment. The studied group consisted of 26 treatment-experienced patients of average age of 50 years with advanced liver fibrosis compared to seven healthy volunteers. Fourteen patients were treated with pegylated interferon alpha 2b, ribavirin, and boceprevir and 12 patients with telaprevir. The overall sustained virological response (SVR) rate was 69% (18/26). A significant difference in the initial expression (median, interquartile range [IQR]) of CXCL9 2.9×, IQR: 1.7-12.4 vs 1.2×, IQR: 0.5...
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Idiopatický střevni zanět doprovazejici primarni sklerozujici cholangitidu (PSC – IBD) lze pro jeho cetna specifika chapat jako samostatný fenotyp IBD. Nejvyssi prevalenci nachazime v zemich severni Evropy a Ameriky, kde je i největsi... more
Idiopatický střevni zanět doprovazejici primarni sklerozujici cholangitidu (PSC – IBD) lze pro jeho cetna specifika chapat jako samostatný fenotyp IBD. Nejvyssi prevalenci nachazime v zemich severni Evropy a Ameriky, kde je i největsi prevalence PSC. IBD i PSC jsou multifaktorialně podminěna onemocněni, na jejichž rozvoji maji zasadni podil geneticke predispozice. Patogeneticka souvislost mezi oběma chorobami je takřka nezpochybnitelna, nicmeně přesný kauzalni vztah zůstava neobjasněn. Důležitou roli zde pravděpodobně sehravaji sekundarni žlucove kyseliny, střevni mikroflora, porucha střevni bariery a regulacni T-lymfocyty. Přes vsechny popsane vazby býva vznik obou onemocněni metachronni - PSC se může projevit mnoho let po totalni proktokolektomii a naopak kolitida vznika v až 30 % připadů de – novo po transplantaci jater. U větsiny pacientů vsak vznik IBD předchazi rozvoji PSC. PSC - IBD se zpravidla manifestuje jako relativně mirna pankolitida s predominantnim postiženim pravostranneho kolon. Typickými znaky jsou soucasne postiženi terminalniho ilea („back – wash“ ileitida) a usetřeni rekta („rectal sparing“). Z histologickeho hlediska býva v drtive větsině připadů popsan jako ulcerozni kolitida (79 - 91,2 %), jen výjimecně pak jako Crohnova nemoc (6,3 – 7 %). Vzhledem k mirnemu průběhu kolitidy je nejcastěji použivanou lecbou monoterapie aminosalicylaty. U thiopurinů je třeba mit na paměti zvýsený výskyt nežadoucich, zejmena hepatotoxických, ucinků. Stran použiti biologicke lecby u teto skupiny nemocných zatim neexistuji dostatecna data. Metodou volby v chirurgicke lecbě je proktokolektomie se zhotovenim ileo-pouch-analni anastomozy (IPAA). U pacientů s PSC byla popsana vyssi frekvence pouchitidy (63 – 75 %), a to jak akutni, tak chronicke. Pro zvýsene riziko vzniku kolorektalniho karcinomu (KRK) u teto skupiny pacientů je doporuceno provadět totalni koloskopicke vysetřeni v rocnim intervalu. Již jedine ložisko nepolypoidni leze s low – grade dysplazii, verifikovane 2 patology, by mělo vest k uvaze o profylakticke kolektomii vzhledem k vysokemu riziku progrese do KRK (až 50 % do 5 let). Z hlediska chemoprevence KRK u pacientů s PSC – IBD ma dobre výsledky podavani kyseliny ursodeoxycholove v nizkých davkach (8 – 15mg/kg/den).