Search

Background/aims: To prospectively evaluate our palliative management of unresectable cholangiocarcinoma (CC) treated with tailored multimodal oncological therapy., Methods: Between January 2005 and January 2010, 50 consecutive patients with unresectable CC and jaundice were palliated with percutaneous drainage. Forty-three patients underwent metallic-stent implantation followed by brachytherapy. Patients were divided into two arms: the intra-arterial chemotherapy arm (IA arm, n=17) consisted of patients treated with locoregional treatment (IA admission of Cisplatin and 5-fluorouracil, or chemoembolization with Lipiodol) and/or systemic chemotherapy, while the systemic chemotherapy arm (IV arm, n=23) included all the other patients, who were treated only with systemic chemotherapy., Results: In total, 78 metal self-expandable stents were placed. Hilar involvement with mass-forming and periductal infiltrating types of CC (84%) was predominant. The average number of percutaneous interventional procedures was 11.61 per patient (range, 4-35). The median overall survival from diagnosis of disease for all patients was 13.5 months (range, 11.0-18.8 months). The median overall survival times were 25.2 months (range, 15.2-31.3 months) and 11.5 months (range, 8.5-12.6 months) in the IA and IV arms, respectively (p<0.05). The 1-, 2-, and 3-year survival rates in the IA and IV arms were 88.2%, 52.9%, and 10.1% and 43.5%, 25.4, and 0%, respectively. There were no major complications (WHO III/IV) due to interventional procedures., Conclusions: We could reach acceptable prognosis in patients with unresectable CC using complex tailored oncological therapy. However, the main limitations of prolonging survival are performance status, patient compliance and the maintaining of biliary tract patency.

Background: Neoadjuvant chemotherapy for potentially resectable metastatic colorectal cancer (MCC) is becoming a more common treatment algorithm. The aim of the present study was to evaluate the efficacy of precision hepatic arterial Irinotecan therapy in unresectable MCC., Methods: An open-label, multi-centre, multi-national single arm study of MCC patients, who received hepatic arterial irinotecan. Primary endpoints were safety, tolerance and metastatic tumour resection., Results: Fifty-five patients with metastatic colorectal to the liver underwent a total of 90 hepatic arterial irinotecan treatments. The extent of liver involvement was < 25% in 75% of the patients (n= 41), between 26 and 50% in 15% of the patients (n= 11) and >50% in 10% of the patients (n= 24). The median number of hepatic lesions was four (range 1-20), with a median total size of all target lesions of 9 cm (range 5.5-28 cm) with 50% of patients having bilobar tumour distribution. The median number of irinotecan treatments was two (range 1-5). The median treatment dose was 100 mg (range 100-200) with a median total hepatic treatment of 200 mg (range 200-650). The majority of treatments (86%) were performed as lobar infusion treatments, and 30% of patients were treated with concurrent simultaneous chemotherapy. Eleven (20%) patients demonstrated significant response and downstage of their disease or demonstrated stable disease without extra-hepatic disease progression allowing resection, ablation or resection and ablation. There were no post-operative deaths. Post-operative complications morbidity occurred in 18% of patients, with none of them hepatic related. Non-tumorous liver resected demonstrated no evidence of steatohepatitis from the irinotecan arterial infusion., Conclusions: Hepatic arterial infusion irinotecan drug-eluting beads is safe and effective in pre-surgical therapy and helpful in evaluating the biology of metastatic colorectal cancer to the liver prior to planned hepatic resection.

Crohn's disease is an inflammatory bowel disease (IBD) characterized by a relapsing clinical pattern that typically affects people during their adult and economically productive lives. Affected patients require clinical follow-up because of the periodic flare-up of the disease and of the risk of long-term complications. Extensive diagnostic procedures, medical and surgical treatments are often needed over a lifetime. The challenge posed by the management of IBD is better faced by a multidisciplinary team that includes health care providers with complementary diagnostic or therapeutic skills. The team is expected to provide the best practice to manage IBD by defining a realistic "diagnostic and therapeutic pathway" for the patients to follow based on the locally available professional, structural and technological resources. For such a "pathway" the correct questions and answers are essential. Sometimes it is not easy to make sense out of these questions. To ask a right question is not simple. Of course, different surgeons and gastroenterologists ask different questions. If radiologists want to choose the right imaging method, they must know these questions. There exist a simple equation: good question=correct imaging method=right answer.

Unlabelled: The authors refer about their first experience with radiofrequency ablation of locally advanced pancreatic tumors. They put forward the prospective study of five patients (four with ductal adenocarcinoma of the head and one with malignant neuroendocrine tumor of pancreatic body), who either because of local advanced disease or performance status, were not able to undergo radical curative surgery. All patients underwent peroperative radiofrequency ablation of pancreatic tumors. In the case of pancreatic head localization, posterior retrocolic gastro-enterostomy and hepatico-jejunostomy to Y Roux jejunal loop were performed. There was no perioperative mortality. In one case duodenal leak apeared in the fourth postoperative day. This was healed conservatively by drainage. At one patient the subfascial absces developed. This was solved by drainage reoperation at the fourteenth postoperative day. After consolidation, all patients were released to home care., Conclusion: According to our early experience, radiofrequency ablation of inoperable pancreatic tumors is relatively save cytoreductive procedure.

Unlabelled: Amyloidosis is a rare disease characterized by forming pathological protein deposits - amyloid - in many organs and tissues. This decreases their functionality. The aim of this small study was to determine, whether the radiological picture of the small intestine involvement in amyloidosis is in some sense specific as sometimes described in literature giving rise to high suspicion for the disease in symptomatic patients., Material and Methods: The prospective study comprising seven patients hospitalized in surgical department is presented together with a survey on the disease, its appearance in radiological imaging. All patients underwent abdominal ultrasound (ATL 5000 HDI, 7-12MHz linear probe, no contrast enhancement, supine position), abdominal CT (Somatom Plus, Siemens, single detector, conventional abdominal CT protocol) and enteroclysis (Micropaque suspension 300ml, application rate of 75ml/min, dilution with HP-7000 being 1:1 and HP-7000 solution 2000ml, application rate of 120ml/min.)., Results: The amyloid deposits in the small intestine could be visualized in five of seven patients with the disease. Enteroclysis revealed a diffuse slowed down intestinal motility with an obstruction-like picture in all of our seven patients. The intestinal secretion was normal, plicae were getting polyp-like shape in five of them forming so called "thumb printing" picture. CT showed thickening of the intestinal wall due to deposits with poor blood supply and contrast retention in five of seven patients. Ultrasound visualized thickened, hypoechoic nodular plicae and slowed down motility in these five patients. The most striking finding was the pathological deposits in the intestinal wall were highly hypo-vascular. However, this picture is very similar to that of ischemic enteritis. All seven patients had proven amyloid deposits from bioptic specimens., Conclusion: The diagnosis of amyloidosis must be supported by bioptic examination as it has no pathognomic radiological picture. Nevertheless, it allows usually to rise a high suspicion for this and sometimes even guess the type of the pathological protein involved. This can start a search for the primary reason of possible amyloidosis and thus perhaps spear the patients quality of life.

Purpose: The aim of our study was to compare the accuracy of computed tomography and endoscopic ultrasound (EUS) in pre-operative staging of pancreatic cancer., Methods: Comparative retrospective study of 86 patients with pancreatic cancer. CT was done in 55 patients, 41 patients were examined by EUS. Each patient underwent surgery and had proven pancreatic cancer by histology. CT and EUS results were correlated to per-operative and histological findings. The main attention was paid to the description of peri-pancreatic lymphadenopathy, para-aortic lymphadenopathy, peri-coeliac lymphadenopathy and tumor relationship to superior mesenteric vein, superior mesenteric artery, portal vein, inferior caval vein and common hepatic artery. A description rate was defined as number of pre-operative findings where the structures and relationships mentioned above were described., Results: The description rates of peri-pancreatic lymph nodes were 11 (20%) at CT and 36 (88.0%) at EUS. Para-aortic lymphadenopathy was described in 9 (16.0%) cases at CT and none at EUS. Peri-coeliac lymphadenopathy was mentioned only one time (2.0%) at CT contrary to 12 (29.0%) at EUS. Relationship of the tumor to the mesenteric vessels was well depicted in nine (16.0%) at CT versus nine (22.0%) at EUS. Portal vein relationship was well described in two (4.0%) at CT and seven (17%) cases at EUS. This description rate in vena cava inferior was one (2%) at CT and three (7.0%) at EUS, in hepatic artery it was one (2%) at CT and six (15%) at EUS. In the group of CT, resectability or non-resectability were well predicted in 33 (60%) patients and wrong predicted in 22 (40%) patients. In the group of EUS, resectability or non-resectability were well predicted in 34 (83%) patients and wrong predicted in 7 (17%) patients., Conclusion: According to our study, EUS is more accurate in prediction of local PC resectability than CT.

Purpose: To evaluate the effect of radiation therapy including intraluminal brachytherapy with iridium-192 on survival of patients with malignant biliary strictures (cholangiocarcinoma, histologically improved) treated with metallic stent in a prospective randomised study., Method and Materials: In the prospective randomised study, 21 patients with cholangiocarcinoma were treated with implantation of percutaneous stents followed with intraluminal Ir-192 brachytherapy (mean dose 30 Gy) and external radiotherapy (mean dose 50 Gy) and 21 patients were treated only with stents insertion. We did not find any statistically significant differences in age and tumor localization between these two groups of patients., Results: All the patients died. In the group of patients treated with brachytherapy and with stent implantation, the mean survival time was 387.9 days. In the group of patients treated only with stent insertion the mean survival was 298 days. In effort to eliminate possible effect of external radiotherapy we treated the control group of eight patients with cholangiocarcinoma by stent insertion and brachytherapy only., Conclusion: Our results show that combined radiation therapy could extend the survival in the patients with cholangiocarcinoma obstruction.

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

Unlabelled: Primary, secondary, benign or malignant tumorous diseases of the small intestine are rare. They are very often diagnosed by accident or as a cause of acute abdomen. This work should answer the question, whether there is a method of making the diagnosis earlier when the disease is limited and easy to cure., Methodology: A retrospective study comprising 96 patients having undergone surgery for a small intestine tumor in our hospital from 1996 to 2005 is presented. An analysis of first symptoms, diagnostic methods and number of patients admitted during the years was made. In the year 1998 we changed our philosophy in trying to directly detect the small intestine pathology and not making the diagnosis by the exclusion only. Intestinal ultrasound was performed on the Ultramark 3000 HDI device with autofocussable convex 5 MHz and linear 7.5 MHz probes or nowadays ATL 5000 HDI, 7-12 MHz linear probe. No contrast enhancement was used. Abdominal CT engaged Somatom Plus appliance by Siemens, single detector with our conventional abdominal CT protocol. Enteroclysis was done with Micropaque suspension diluted 1:1 with HP-7000 300 ml with its application rate of 75 ml/min followed by HP-7000 solution 2000 ml, application rate of 120 ml/min., Results: We treated surgically 96 patients with the small intestine tumor. A shift in the diagnostic algorithm was noticed in the bowel ultrasound now taking the lead. An enlarged portion of patients diagnosed by means of capsule endoscopy was also seen. An increase of surgically treated patients after 1998 was recorded and the majority of them could be offered an elective laparoscopic surgery in contrast to before 1998 when the majority of them had undergone surgery for an acute abdomen., Conclusion: The small bowel ultrasound can be recommended as the first choice method. All patients with even very moderate abdominal symptoms ought to be examined for the small intestine pathology. As a result one can get higher rate of elective surgery, if possible laparoscopic and higher number of R0 resections accompanied by longer survival.

Anticoagulation therapy may be complicated by spontaneous onset of an intramural hematoma of the duodenum and small intestine. Other causes were published only as case reviews. Radiological literature describes typical findings, which are fundamental for the diagnostics. However, only a fraction of patients present with them. This article describes a case of a female patient, treated for stomach pains. Based on her history, laboratory findings, ultrasound and CT findings, the condition was mistaken for acute pancreatitis and the pancreatic body necrosis with pseudocysts, drained under the CT control. The correct diagnosis was established a year later. Surgical revision indicated for a cystoid relaps and difficulties with intestinal passage revealed an old intramural hematoma within the duodenojejunal junction wall, the hematoma was evacuated and gastroenteroanastomosis performed.

The authors present a rare case of the fish bone migration from the upper GIT into the liver parenchyma. Furthermore, a possibility of the diagnostics and management of its rare complication- an inflammatory pseudotumor of the liver is presented. Based on the literature data, other possible complications of foreign objects in the liver parenchyma are listed, including their diagnostic and treatment options.

Recently, with improvements in surgical techniques there has been a substantial reduction in the incidence of biliary complications of hepatobiliary surgery. Nevertheless, bile duct injuries and other post-cholecystectomy complications are a serious problem and a major cause of morbidity and mortality. Early complications may include bile duct injury caused by mistakenly placed clips, erroneous cutting of bile ducts based on misinterpretation of biliary anatomy, periductal bile leakage that causes edema, fibrosis and secondary stricturing, and ischemia due to injury to the right hepatic artery. Bile duct strictures are the most common of the late complications and can develop a few months or many years after surgery. Early detection and accurate diagnosis have a fundamental importance for the successful treatment of these complications. Therefore, early and meaningful application of the imaging methods immediately after detection of the first symptoms is essential. Peroperative ultrasound and direct iodine contrast application into the biliary tree (operative cholangiography) are highly important for immediate visualization of the complications during surgery. Ultrasound can be used to aid in identification of ductal structures and the cholangiogram should be obtained to document the anatomy. Plain abdominal film could be made in the patients in poor clinical conditions after biliary surgery. Oral cholecystography has largely been replaced by ultrasonography (US) for evaluation of cholelithiasis and complications like post-cholecystectomy fluid collections. The same methodology replaced the conventional intravenous cholangiography. Nowadays computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiography (MRCP) and ultrasound (US) have essential roles as primary imaging modalities after biliary tree and gallbladder surgery in the evaluation of associated complications and residual biliary stones. We review the role of the imaging in complications after biliary tree and gallbladder surgery.

The article overviews vascular and percutaneous interventional methods used in the locoregional chemotherapy of liver tumors. It is based on experience from the treatment of 248 patients on the Radiodiagnostic clinic of the Teaching hospital in Brno (Bohunice department). Chemoembolization includes precisely aimed administration of cytostatics and a total ischaemization of the malignant tissue. Another method of locoregional chemotherapy is the administration of high doses of cytostatics into the afferent artery. Positive effect can be achieved only when the cytostatic perfuses all liver segments. Preoperative embolization of the portal vein represents an effective preliminary treatment of patients before the liver ablation. Percutaneous thermal ablation and the use of percutaneous ethanol injections are limited by the costs of treatment, by the number, size and location of tumors. Percutaneous ethanol injections are indicated in the treatment of hepatocellular carcinoma in the cirrhotic tissue. Percutaneous thermal ablation can effectively destroy foci in the liver up to the size of 5 cm without impairment of the surrounding tissue. Locoregional and percutaneous therapy of malignant liver processes represent alternative methods and individual approaches should be combined. Indication has to be carefully thought about by an interdisciplinary committee. It is necessary to realise that the aim is not to perform "technically precise operation" gut the lengths and quality of the patient's life.

Experience with treatment of more than 800 patients with malignant stenosis of the biliary tract is reviewed. The significance of complex treatment using simple internal or external drainage, stent introduction, brachytherapy, percutaneous actinotherapy and locoregional chemotherapy is presented. Advantages of individual percutaneous methods are compared and indications for using metallic stent in patients with malignant stenosis of the biliary tract are evaluated. Significance and indications for the percutaneous treatment is discussed and its advantages are compared with the endoscopic approach.

Locoregional chemotherapy is one of the possible ways of treatment of inoperable metastatic affection of the liver by colorectal carcinoma. The advantage of regional administration of the cytostatic is the possibility to achieve a higher local concentration of the cytostatic associated with a higher percentage of therapeutic responses. In our department we preferred combined locoregional intraarterial chemotherapy (5-fluorouracil/Mitmycin C/Doxorubicin) combined with systemic intravenous chemotherapy (5-fluorouracil/leukovirin). Locoregional cghemotherapy was administered in the majority as chemotherapy of series 2 or 3 with a very good tolerance. In 2/19 patients we observed marked diminution of liver metastases and subsequent operability and with a duration of complete response for 13 and 18 months. In 7/19 patients a partial therapeutic response was achieved. The total therapeutic response (complete and partial) was 47%. Locoregional chemotherapy attains a higher therapeutic response as compared with systemic chemotherapy and is associated with an acceptable toxicity.

Although intervention radiology has affected all spheres of oncology, in particular in diagnostics and therapy of malignant liver processes, its importance is fundamental. The authors summarize their long-term experience with invasive diagnosis of focal processes in the liver and with a minimally invasive therapy in more than 250 patients with malignant focal processes in the liver. Intervention radiology extends common diagnostic methods by the possibility of aimed administration of contrast substance before examination (CT after administration of Lipiodol) or during examination (CT angiography). Biopsy from a focus only 10 mm in size or less under CT control, ultrasound or MR lead rapidly to histological assessment of the nature of the process. In preoperative staging in particular in patients with colorectal carcinoma and secondaries in the liver peroperative ultrasound and CT arterial portography is of great importance. These methods are highly sensitive (CTAP) and also specific (peroperative ultrasound). Angiography combined with therapeutic procedures, similarly as percutaneous thermoablation methods have become an integral part of intervention radiology. An advantage of this approach to treatment of malignant focal hepatic processes is short hospitalization, the procedure is done under local anaesthesia and treatment can be repeated. However careful indication of the procedure is essential, best by an indication commission (surgeon, oncologist, gastroenterologist, radiologist).

The set consisting of 3 patients with esophageal achalasia diagnosed by manometry, pseudoachalasia excluded by esophagoscopy and endosonography, was treated with combined conservative procedure. Botulinum toxin 250u (Dysport) was applied to the area of lower esophageal sphincter and after 7 days balloon dilatation was carried out. Treatment efficacy was evaluated by the data obtained about the subjective condition, manometrically and endoscopically. The spine condition was evaluated in all patients before treatment and functional blockades were released by manual medicine and even by acupuncture. We succeeded in restoring propulsive peristalsis of the esophagus in all of them. It is objectively proven in the longest duration of 44 months in the case of a patient treated with a balloon dilatation.

Objective: To demonstrate in a group of 26 patients with benign stenosis of the trachea the possibility to use a Palmaz stent as the method of choice., Material and Methods: The authors introduced since 1995 to patients with benign stenosis of the trachea 36 stents (1 Wallstent, 2 Z stents and 33 Palmaz stents). The operation was performed under general anaesthesia in an operating theatre under skiascopic and optic control. The stent was inserted along a guide. Before insertion of the stent they dilated the stenosis by means of a balloon dilatation catheter., Results: Respiration improved in all patients within 6 days after introduction of the stent. Within 30 days after insertion of the stent none of the patients died. Two patients (7.7%) died four weeks (Palmaz stent) and 11 months (Wallstent) after insertion of the stent. Restenosis was observed in 9 patients (34.6%) 2-16 weeks after introduction of the stent. In 5 patients restenosis developed repeatedly. At present 19 patients (73%) are free from complaints for 1 month to 4 years after insertion of the stent (average 28 months). 5 patients (19%) had a tracheostomy and insertion of the stent in these patients did not produce so far the anticipated result., Conclusion: The authors assume that the use of Palmaz stent is in patients with benign stenosis of the trachea in indicated cases the method of choice.

Objective: The authors submit for discussion a group of patients where they resolved a relapsing benign stenosis of the biliary pathways by insertion of a metal stent., Material and Methods: Since 1995 the authors introduced a metal stent in 29 patients with benign stenosis of the biliary pathways. In the majority they used a Palmaz stent., Results: The 30-day mortality in the group of patients was 3.4% (1 patient, myocardial infarction). Two patients (6.9%) died 3 and 18 months resp. after insertion of the stent (pneumonia complicated by a pulmonary abscess, hepatorenal failure). Signs of obstruction of the stent (raised levels of bilirubin and liver enzymes) were observed in 5 patients (17%). In 8 cases (27%) migration of the stent occurred. The follow-up period in 26 patients with benign stenosis with a stent is two months--4 years (mean 19 months). Sixteen patients are followed up for more than 12 months., Conclusion: In the treatment, in particular of relapsing benign stenosis of the biliary pathways, specially when located in the area of the anastomosis, insertion of a metal stent is effective alternate treatment.

The contemporary incidence of the tumours of the pancreas is approximately 3.5% in the Czech Republic. Benign tumours represent only about 2% of them. We have found 7 such patients (2.3%) in our population of 303 patients operated for pancreatic tumours. This paper summarizes our experience with the diagnostics and surgical treatment of these patients.

The authors used between October 1993 and January 1997 in 131 patients with inoperable malignant or benign stenosis of the oesophagus an expansible metal stent. In 25 patients the stenosis was in the upper third of the oesophagus, in 44 in the medium part, in 53 in the lower third of the oesophagus and in 9 patients in the area of the anastomosis. All patients suffered at the time when the stent was introduced from marked dysphagia (stage 3-4 according to the international classification). In 45 patients the authors introduced more than one stent. 112 patients suffered from malignant stenosis (67 squamous cell carcinoma, 27 adenocarcinoma, 9 pulmonary or bronchogenic carcinoma, in two instances lymphoma, in two instances leiomyosarcoma and in five patients another type of tumour). Seventeen patients suffered from benign stenosis (8 complications of reflux oesophagitis, 3 stenosis in the anastomosis, in two instances corrosion by acid, 2 cases of epidermolysis bullosa oesophagi and one post-radiation stenosis). In these patients repeatedly before introduction of the stent dilatation of the stenosis by means of a balloon dilatation catheter was attempted. In two instances the etiology of the stenosis was obscure. Complications related to the procedure proper or after insertion of the stent were recorded in 49 patients-dislocation of the stent 23x, occlusion of the stent 17x, development of a fistula 6x, ulceration 16x, haemorrhage 4x, hyperplasia of the mucosa 21x, ileus 2x, inadequate expansion of the stent 8x.

The authors compare the importance of modern imaging methods and simple X-rays of the abdomen for the accurate diagnosis of ileus conditions. They discuss the possibilities of different methods and emphasize the importance of series of simple X-rays of the abdomen in different positions. The objective of the recommended procedures is to examine as well as possible a group of patients with an obstruction in the small or large intestine, to localize the obstruction, assess its etiology and not merely state that on the simple X-ray the horizontal beam reveals levels.

The authors summarise their experience with the treatment of almost 100 patients with malignant or benign stenosis of the biliary pathways by a percutaneously inserted expansible metal stent. They compare the advantages of different percutaneous procedures and evaluate critically indication for the introduction of an expansible metal stent or self-expansible stent in patients with malignant or benign stenosis of the bile ducts.

External pancreatic fistulas are feared complications of pancreatic surgery or to trauma of the pancreas. In our paper we report on 2 patients suffering of external pancreatic fistulas successfully treated by operation. We demonstrate the examinations suitable for preoperative mapping of the fistula, the possibilities of conservative treatment and the strategy of surgical management of the fistulas. During the follow-up time the results of the operation are excellent.

The authors present their experience with preoperative external-internal percutaneous transhepatic drainage of the biliary pathways (PTD) in 143 patients. From this group in the final stage 53 patients were operated. The authors discuss the contemporary position and importance of preoperative PTD and compare the advantages of external-internal PTD and external drainage of the biliary pathways. A rapidly performed and correctly indicated external-internal PTD reduces effectively within several days the patient's bilirubin level, the bile passes into the duodenum, dehydration of the organism does not occur and vitamin K absorption is not impaired. All this has an impact on the success of surgery. Moreover, the external-internal drain modified in a suitable way surgical tactics and ensured effective drainage of the biliary pathways during the early postoperative period. If radical surgery is impossible, it is feasible as a suitable alternative procedure of palliative surgery to insert by the percutaneous route an expansible metal stent or leave the external-internal PTD drain in situ for a prolonged period. The authors discuss the criteria for indication, analyze the main problems of this procedure and submit their results.

In a group of patients with headache the authors found that mental therapy was very effective. It produced a better effect than previous therapeutic procedures. The authors discuss contemporary views of mechanisms of modern pharmacotherapy of headache and draw attention to its hazards, economic pretentiousness and frequently low availability. The authors mention also non-pharmacological methods used nowadays in the therapy of headache and their relationship to the endogenous opioid system. They explain mental therapy as the interaction and energy exchange between the aura of the emitor and percipient of the mental energy. The authors expressed the hypothetical idea on the basis of analgetic action of mental therapy. They recommend to extend research of mental energy in medical disciplines--theoretical and clinical--and to introduce mental therapy into practice on a professional level. Based on their own experience the authors decided to apply it already now where it gives hope of recovery or mitigation of the patients' suffering. They consider it their duty.

Risk factors of atherosclerosis were examined in 63 offspring and 30 siblings of type 2 diabetics and in 22 controls. Clinical complications of atherosclerosis were not found very frequently in direct relatives of diabetic patients. Diabetes was detected in 17% siblings, an impaired glucose tolerance in 11% of the offspring and in 33% siblings. The offspring of diabetics had higher blood sugar values and serum insulin levels on fasting and after stimulation, as compared with controls; as to other metabolic parameters lipids and apolipoproteins, body mass indexes, uricaemia, glycated proteins, C-peptide), the two groups did not differ significantly. In middle age, i.e. in siblings of diabetic patients, the incidence of obesity rose significantly as well as hyperlipoproteinaemia type IV and hypertension, while smoking was less common than in offspring. The glucose tolerance deteriorated further, although the insulin levels did not increase substantially. The mentioned findings indicate the orientation for preventive provisions in families of type 2 diabetics.

Enteroclysis is rightly included to modern diagnostic methods for detecting damage to alimentary canal. It enables to visualize even small morphological changes on the mucous membrane of intestine, to prove fistulas if present and to evaluate functional changes if correctly applied. It significantly contributes to establishing early diagnosis in affections of the intestine and consequent use of adequate therapy. The authors in their communication summarized their experience, obtained in the examination of one hundred patients. They selected a modified procedure of examination according to Herlinger with the use of Prontobarium suspension and methyl cellulose. The application was made with a controlled duodenal probe from the Nicholas Company, introduced by nose. The average duration of one examination was 44 minutes.