{"id":669,"date":"2013-03-14T09:39:51","date_gmt":"2013-03-14T09:39:51","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=669"},"modified":"2013-06-12T08:24:32","modified_gmt":"2013-06-12T08:24:32","slug":"13-2","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=669","title":{"rendered":"13 N\u00e1dory j\u00edcnu"},"content":{"rendered":"<h3>13.1 Benign\u00ed n\u00e1dory<\/h3>\n<p style=\"text-align: justify;\"><em>V\u00fdskyt a p\u0159\u00edznaky:<\/em> <span class=\"p\">nezhoubn\u00e9 n\u00e1dory j\u00edcnu jsou vz\u00e1cn\u00e9. Jejich klasifikace a mo\u017en\u00e9 druhy jsou uvedeny v tab. 1. Asi 75 % benign\u00edch n\u00e1dor\u016f jsou leiomyomy, ostatn\u00ed pat\u0159\u00ed k rarit\u00e1m [1].<\/span><\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"border: 1px solid #ffffff; text-align: center;\" align=\"center\" valign=\"top\"><span style=\"color: #ffffff;\">Tab. 1<\/span><br \/>\n<span style=\"color: #ffffff;\">Benign\u00ed n\u00e1dory j\u00edcnu a stavy napodobuj\u00edc\u00ed n\u00e1dor<\/span><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff; text-align: left;\" align=\"left\" valign=\"top\">\n<ul>\n<li><strong><span style=\"line-height: 19px;\">Epiteli\u00e1ln\u00ed<\/span><\/strong>\n<ul>\n<li><span style=\"line-height: 19px;\">adenom<\/span><\/li>\n<li><span style=\"line-height: 19px;\">skvam\u00f3zn\u00ed papilom<\/span><\/li>\n<li><span style=\"line-height: 19px;\">hyperplastick\u00fd polyp<\/span><\/li>\n<li><span style=\"line-height: 19px;\">reten\u010dn\u00ed cysta<\/span><\/li>\n<li><span style=\"line-height: 19px;\">akant\u00f3za maligna (acanthosis nigricans)<\/span><\/li>\n<li><span style=\"line-height: 19px;\">lymfoepiteli\u00e1ln\u00ed cysta<\/span><\/li>\n<li><span style=\"line-height: 19px;\">cysta j\u00edcnu<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"left\" valign=\"top\">\n<ul>\n<li><strong><span style=\"line-height: 19px;\">Neepiteli\u00e1ln\u00ed<\/span><\/strong>\n<ul>\n<li><span style=\"line-height: 19px;\">leiomyom<\/span><\/li>\n<li><span style=\"line-height: 19px;\">lipom<\/span><\/li>\n<li><span style=\"line-height: 19px;\">hemangiom<\/span><\/li>\n<li><span style=\"line-height: 19px;\">lymfangiom<\/span><\/li>\n<li><span style=\"line-height: 19px;\">rhabdomyom<\/span><\/li>\n<li><span style=\"line-height: 19px;\">osteochondrom<\/span><\/li>\n<li><span style=\"line-height: 19px;\">neurogenn\u00ed n\u00e1dor<\/span><\/li>\n<li><span style=\"line-height: 19px;\">xanthom<\/span><\/li>\n<li><span style=\"line-height: 19px;\">z\u00e1n\u011btliv\u00fd fibroidn\u00ed polyp<\/span><\/li>\n<li><span style=\"line-height: 19px;\">fibrovaskul\u00e1rn\u00ed polyp<\/span><\/li>\n<li><span style=\"line-height: 19px;\">pyogenn\u00ed granulom<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\"><span style=\"color: #ffffff;\">.<\/span><\/p>\n<div style=\"width: 260px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_462.png\"><img loading=\"lazy\" decoding=\"async\" class=\" \" title=\"Obr. 1 \u2013 Torakoskopick\u00e1 enukleace leiomyomu j\u00edcnu\" alt=\"Obr. 1 \u2013 Torakoskopick\u00e1 enukleace leiomyomu j\u00edcnu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_462.png\" width=\"250\" height=\"187\" \/><\/a><p class=\"wp-caption-text\">Obr. 1<br \/>Torakoskopick\u00e1 enukleace leiomyomu j\u00edcnu<\/p><\/div>\n<p style=\"text-align: justify;\">Tyto n\u00e1dory jsou v\u011bt\u0161inou jen n\u00e1hodn\u00fdm n\u00e1lezem a ned\u011blaj\u00ed obt\u00ed\u017ee. Pouze p\u0159i v\u011bt\u0161\u00edch rozm\u011brech mohou tlakem p\u016fsobit dysfagii. Intralumin\u00e1ln\u00ed slizni\u010dn\u00ed n\u00e1dory mohou b\u00fdt p\u0159\u00ed\u010dinou krv\u00e1cen\u00ed.<\/p>\n<p style=\"text-align: justify;\"><em>Diagn\u00f3za:\u00a0<\/em>stanov\u00edme ji na z\u00e1klad\u011b rentgenov\u00e9ho a endoskopick\u00e9ho vy\u0161et\u0159en\u00ed. Indikac\u00ed k operaci jsou obt\u00ed\u017ee nemocn\u00e9ho nebo nemo\u017enost jednozna\u010dn\u011b vylou\u010dit malign\u00ed onemocn\u011bn\u00ed. U intramur\u00e1ln\u00edch n\u00e1dor\u016f, jako je leiomyom, se nedoporu\u010duje\u00a0endoskopick\u00fd odb\u011br biopsie, proto\u017ee se t\u00edm vytvo\u0159\u00ed jizevnat\u00e9 zm\u011bny mezi sliznic\u00ed a n\u00e1dorem, co\u017e pak zt\u011b\u017euje bezprobl\u00e9movou enukleaci n\u00e1doru p\u0159i torakoskopick\u00e9m p\u0159\u00edstupu.<\/p>\n<div id=\"attachment_3320\" style=\"width: 50px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=3357\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3320\" class=\" wp-image-3320 \" title=\"VIDEO 4\" alt=\"VIDEO 4\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/06\/video.jpg\" width=\"40\" height=\"40\" srcset=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/06\/video-150x150.jpg 150w, https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/06\/video-120x120.jpg 120w\" sizes=\"auto, (max-width: 40px) 100vw, 40px\" \/><\/a><p id=\"caption-attachment-3320\" class=\"wp-caption-text\">VIDEO 4<\/p><\/div>\n<p style=\"text-align: justify;\"><em>Terapie:<\/em> <span class=\"p\">intralumin\u00e1ln\u00ed tumory lze zpravidla odstranit endoskopicky. U intramur\u00e1ln\u00edch n\u00e1dor\u016f je v\u011bt\u0161inou mo\u017en\u00e1 enukleace bez naru\u0161en\u00ed sliznice. M\u00e9n\u011b \u010dasto je nutn\u00e1 kl\u00ednovit\u00e1 resekce st\u011bny j\u00edcnu s otev\u0159en\u00edm sliznice. Tyto v\u00fdkony se prov\u00e1d\u011bly z torakotomie a v dne\u0161n\u00ed dob\u011b p\u0159ev\u00e1\u017en\u011b torakoskopicky, co\u017e je pro nemocn\u00e9ho m\u00e9n\u011b zat\u011b\u017euj\u00edc\u00ed. Obr\u00e1zek 1 ukazuje torakoskoskopickou enukleaci leiomyomu j\u00edcnu a tot\u00e9\u017e je zn\u00e1zorn\u011bno <a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=3357\" target=\"_blank\">na videu dostupn\u00e9m v elektronick\u00e9 verzi \u2013 viz tir\u00e1\u017e knihy<\/a>.<\/span><\/p>\n<h3 class=\"s18\">13.2 Malign\u00ed n\u00e1dory<\/h3>\n<h4 class=\"s15\">13.2.1 Klasifikace<\/h4>\n<p style=\"text-align: justify;\">Malign\u00ed n\u00e1dory j\u00edcnu lze d\u011blit z n\u011bkolika hledisek. Histologicky jsou nej\u010dast\u011bj\u0161\u00ed spinocelul\u00e1rn\u00ed karcinom a adenokarcinom, vyskytuj\u00edc\u00ed se p\u0159edev\u0161\u00edm v termin\u00e1ln\u00edm j\u00edcnu a oblasti gastroezofage\u00e1ln\u00edho p\u0159echodu. Zat\u00edmco d\u0159\u00edve ve statistik\u00e1ch p\u0159eva\u017eoval spinocelul\u00e1rn\u00ed karcinom v 80\u201395 %, v posledn\u00edch desetilet\u00edch se tato situace m\u011bn\u00ed, p\u0159ib\u00fdv\u00e1 adenokarcinomu, a jejich pom\u011br se prakticky vyrovn\u00e1v\u00e1. V j\u00edcnu se m\u016f\u017ee vz\u00e1cn\u011b vyskytovat \u0159ada dal\u0161\u00edch histologick\u00fdch typ\u016f n\u00e1dor\u016f, vesm\u011bs jde v\u0161ak o velmi vz\u00e1cn\u00e9 n\u00e1lezy (tab. 2).<\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\"><span style=\"color: #ffffff;\">Tab. 2<\/span><br \/>\n<span style=\"color: #ffffff;\">N\u011bkter\u00e9 vz\u00e1cn\u00e9 malign\u00ed n\u00e1dory j\u00edcnu<\/span><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"left\" valign=\"top\">\n<ul>\n<li><strong><span style=\"line-height: 19px;\">Neepiteli\u00e1ln\u00ed<\/span><\/strong>\n<ul>\n<li><span style=\"line-height: 19px;\">leiomyosarkom<\/span><\/li>\n<li><span style=\"line-height: 19px;\">liposarkom<\/span><\/li>\n<li><span style=\"line-height: 19px;\">angiogenn\u00ed sarkom<\/span><\/li>\n<li><span style=\"line-height: 19px;\">fibrosarkom<\/span><\/li>\n<li><span style=\"line-height: 19px;\">rhabdomyosarkom<\/span><\/li>\n<li><span style=\"line-height: 19px;\">gastrointestin\u00e1ln\u00ed strom\u00e1ln\u00ed tumor (GIST)<\/span><\/li>\n<li><span style=\"line-height: 19px;\">extramedul\u00e1rn\u00ed plasmocytom<\/span><\/li>\n<li><span style=\"line-height: 19px;\">Kaposiho sarkom<\/span><\/li>\n<\/ul>\n<\/li>\n<li><strong><span style=\"line-height: 19px;\">Karcinosarkom<\/span><\/strong><\/li>\n<li><strong><span style=\"line-height: 19px;\">Malign\u00ed melanom<\/span><\/strong><\/li>\n<li><strong><span style=\"line-height: 19px;\">Metastatick\u00e9 n\u00e1dory (karcinom prsu, plic)<\/span><\/strong><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">V \u010dasn\u00fdch stadi\u00edch roste karcinom j\u00edcnu polyploidn\u011b, pozd\u011bji cirkul\u00e1rn\u011b zu\u017euje j\u00edcen a dal\u0161\u00edm charakteristick\u00fdm znakem je \u010dast\u00e1 pod\u00e9ln\u00e1 submuk\u00f3zn\u00ed tumor\u00f3zn\u00ed infiltrace j\u00edcnu. \u010cast\u00e9 je i pror\u016fst\u00e1n\u00ed do okol\u00ed a metast\u00e1zov\u00e1n\u00ed do region\u00e1ln\u00edch paraezofage\u00e1ln\u00edch a infradiafragmatick\u00fdch uzlin. Vzd\u00e1len\u00e9 metast\u00e1zov\u00e1n\u00ed je nej\u010dast\u011bj\u0161\u00ed do jater, plic, kost\u00ed a mozku.<\/p>\n<p style=\"text-align: justify;\">Z hlediska l\u00e9\u010debn\u00e9 taktiky je d\u016fle\u017eit\u00e1 topograficko-anatomick\u00e1 klasifikace lokalizace n\u00e1doru. Um\u00edst\u011bn\u00ed n\u00e1doru na j\u00edcnu se definuje vzd\u00e1lenost\u00ed od \u0159ez\u00e1k\u016f k horn\u00edmu okraji n\u00e1doru p\u0159i endoskopick\u00e9m vy\u0161et\u0159en\u00ed. Rozli\u0161ujeme j\u00edcen kr\u010dn\u00ed od hypofaryngu po horn\u00ed hrudn\u00ed aperturu, hrudn\u00ed j\u00edcen se d\u011bl\u00ed na horn\u00ed t\u0159etinu do \u00farovn\u011b v. azygos, st\u0159edn\u00ed t\u0159etinu do \u00farovn\u011b doln\u00ed plicn\u00ed v\u00e9ny a doln\u00ed t\u0159etinu do vstupu j\u00edcnu do dutiny b\u0159i\u0161n\u00ed v \u00farovni hi\u00e1tu a zbylou \u010d\u00e1st\u00ed ezofagu do ezofagogastrick\u00e9 junkce je abdomin\u00e1ln\u00ed j\u00edcen (obr. 2). R\u016fzn\u011b ud\u00e1van\u00e9 \u00fadaje ve v\u00fdskytu n\u00e1dor\u016f v doln\u00ed t\u0159etin\u011b j\u00edcnu vypl\u00fdvaj\u00ed z toho, kter\u00e9 n\u00e1dory gastroezofage\u00e1ln\u00edho p\u0159echodu za\u0159ad\u00edme k n\u00e1dor\u016fm j\u00edcnu a kardie.<\/p>\n<p style=\"text-align: justify;\">\u010casto je v r\u00e1mci diagnostick\u00e9 klasifikace obt\u00ed\u017en\u00e9 odli\u0161it adenokarcinom dist\u00e1ln\u00edho j\u00edcnu od karcinomu kardie. Za adenokarcinom j\u00edcnu se obvykle pova\u017euje ten tumor, kdy se v\u00edce ne\u017e 80 % n\u00e1doru nach\u00e1z\u00ed v tubul\u00e1rn\u00edm j\u00edcnu. V\u011bt\u0161ina adenokarcinom\u016f j\u00edcnu se vyv\u00edj\u00ed na podklad\u011b Barrettova j\u00edcnu. Dal\u0161\u00edm krit\u00e9riem p\u0159esn\u00e9 klasifikace adenokarcinomu gastroezofage\u00e1ln\u00edho p\u0159echodu je ur\u010den\u00ed centra tumoru, a tedy p\u0159edpokl\u00e1dan\u00e9ho po\u010d\u00e1tku zhoubn\u00e9ho bujen\u00ed. V praxi je \u010dasto p\u0159esn\u00e1 klasifikace n\u00e1doru gastroezofage\u00e1ln\u00edho spojen\u00ed obt\u00ed\u017en\u00e1 [2] (obr. 3).<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_467.png\"><img decoding=\"async\" class=\"  \" title=\"Obr. 2 \u2013 Rozd\u011blen\u00ed j\u00edcnu na oblasti\" alt=\"Obr. 2 \u2013 Rozd\u011blen\u00ed j\u00edcnu na oblasti\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_467.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 2 \u2013 Rozd\u011blen\u00ed j\u00edcnu na oblasti<br \/>kr\u010dn\u00ed (I)<br \/>hrudn\u00ed (II)<br \/> \u2022 a \u2013 horn\u00ed t\u0159etina<br \/> \u2022 b \u2013 st\u0159edn\u00ed<br \/> \u2022 c \u2013 doln\u00ed<br \/>b\u0159i\u0161n\u00ed (III)<br \/>Hy \u2013 hypofarynx<br \/>s \u2013 horn\u00ed okraj sterna<br \/>B \u2013 trache\u00e1ln\u00ed bifurkace<br \/>D \u2013 br\u00e1nice (diafragma)<br \/>H \u2013 j\u00edcnov\u00fd hi\u00e1tus<br \/>EGJ \u2013 ezofagogastrick\u00e1 junkce<br \/>\u017d \u2013 \u017ealudek<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_468.png\"><img decoding=\"async\" class=\" \" title=\"Obr. 3 \u2013 Klasifikace karcinomu v oblasti gastoezofage\u00e1ln\u00edho p\u0159echodu dle Siewerta\" alt=\"Obr. 3 \u2013 Klasifikace karcinomu v oblasti gastoezofage\u00e1ln\u00edho p\u0159echodu dle Siewerta\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_468.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 3<br \/>Klasifikace karcinomu v oblasti gastoezofage\u00e1ln\u00edho p\u0159echodu dle Siewerta<br \/>\u2022 I \u2013 karcinom v Barrettov\u011b (dist\u00e1ln\u00edm) j\u00edcnu<br \/>\u2022 II \u2013 karcinom kardie<br \/>\u2022 III \u2013 subkardi\u00e1ln\u00ed (fund\u00e1ln\u00ed) karcinom<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\"><span style=\"color: #ffffff;\">.<\/span><\/p>\n<h4>13.2.2 Etiologie a v\u00fdskyt<\/h4>\n<p style=\"text-align: justify;\">Z hlediska epidemiologie, etiopatogeneze a lokalizace n\u00e1dor\u016f ezofagu je d\u016fle\u017eit\u00e9 rozli\u0161ovat mezi spinocelul\u00e1rn\u00edm karcinomem a adenokarcinomem j\u00edcnu. Ofici\u00e1ln\u00ed statistick\u00e1 data v\u0161ak zpravidla uv\u00e1d\u011bj\u00ed celkov\u00fd v\u00fdskyt a mortalitu karcinomu j\u00edcnu a jen z\u0159\u00eddka se p\u0159esn\u011b rozli\u0161uj\u00ed histologick\u00e9 subtypy. Nejv\u011bt\u0161\u00ed v\u00fdskyt je uv\u00e1d\u011bn ve St\u0159edn\u00ed Asii a Ji\u017en\u00ed Americe a u Ameri\u010dan\u016f africk\u00e9ho p\u016fvodu. Mimo\u0159\u00e1dn\u011b vysok\u00e1 incidence je v ur\u010dit\u00fdch oblastech \u010c\u00edny, v Japonsku, Indii a Braz\u00edlii. Z evropsk\u00fdch zem\u00ed pak ve Velk\u00e9 Brit\u00e1nii, Irsku a Holandsku (obr. 4a,b,c,d).<\/p>\n<p style=\"text-align: justify;\">V\u00fdskyt spinocelul\u00e1rn\u00edho karcinomu v posledn\u00edch desetilet\u00edch stagnuje, zat\u00edmco je z\u0159eteln\u00fd n\u00e1r\u016fst v\u00fdskytu adenokarcinomu, zejm\u00e9na u b\u011blo\u0161sk\u00e9 populace ve vysp\u011bl\u00fdch z\u00e1padn\u00edch zem\u00edch Evropy a v Americe. Z\u0159eteln\u00e1 je i souvislost s v\u00fdskytem Barrettova j\u00edcnu [3, 4, 5]. V ofici\u00e1ln\u00edch sv\u011btov\u00fdch i na\u0161ich statistik\u00e1ch o karcinomu j\u00edcnu se v\u0161ak v\u011bt\u0161inou spinocelul\u00e1rn\u00ed karcinom a adenokarcinom nerozli\u0161uje.<\/p>\n<p style=\"text-align: justify;\">Z \u0159ady epidemiologick\u00fdch studi\u00ed bylo prok\u00e1z\u00e1no, \u017ee kou\u0159en\u00ed a po\u017e\u00edv\u00e1n\u00ed alkoholu m\u00e1 i v na\u0161ich podm\u00ednk\u00e1ch v\u00fdznamn\u00fd vliv na vznik karcinomu j\u00edcnu [6, 7].<\/p>\n<p style=\"text-align: justify;\">V\u00fdznamn\u00fdm rizikov\u00fdm faktorem pro vznik adenokarcinomu doln\u00edho j\u00edcnu je gastroezofage\u00e1ln\u00ed reflux s n\u00e1sledn\u00fdm Barrettov\u00fdm j\u00edcnem. Za rizikov\u00fd faktor adenokarcinomu je pova\u017eov\u00e1na i obezita [5, 8].<\/p>\n<p style=\"text-align: justify;\">K dal\u0161\u00edm stav\u016fm se zv\u00fd\u0161en\u00fdm rizikem vzniku karcinomu j\u00edcnu pat\u0159\u00ed achal\u00e1zie, striktury po polept\u00e1n\u00ed j\u00edcnu, infekce Helicobacter pylori a papilomat\u00f3zn\u00edm virem stejn\u011b jako p\u0159\u00edslu\u0161nost k ni\u017e\u0161\u00edm socioekonomick\u00fdm vrstv\u00e1m [9, 10, 11].<br \/>\nTypickou lokalizac\u00ed pro spinocelul\u00e1rn\u00ed karcinom je hrudn\u00ed j\u00edcen, zat\u00edmco adenokarcinom se a\u017e na v\u00fdjimky vyskytuje v doln\u00ed t\u0159etin\u011b j\u00edcnu, zpravidla v souvislosti s Barrettov\u00fdm j\u00edcnem.<\/p>\n<p style=\"text-align: justify;\">\u00dadaje o l\u00e9\u010den\u00ed nemocn\u00fdch se solidn\u00edmi n\u00e1dory v \u010cesk\u00e9 republice jsou shroma\u017e\u010fov\u00e1ny v N\u00e1rodn\u00edm onkologick\u00e9m registru (NOR). Data jsou ulo\u017eena v elektronick\u00e9 podob\u011b a pomoc\u00ed origin\u00e1ln\u00edho softwaru, nazvan\u00e9ho Syst\u00e9m pro vizualizaci onkologick\u00fdch dat (SVOD), je mo\u017en\u00e9 p\u0159ehledn\u00e9 grafick\u00e9 zpracov\u00e1n\u00ed r\u016fzn\u00fdch kombinac\u00ed ulo\u017een\u00fdch parametr\u016f \u2013 N\u00e1rodn\u00ed onkologick\u00fd registr (NOR) \u010cesk\u00e9 republiky, Syst\u00e9m pro vizualizaci onkologick\u00fdch dat SVOD (www.cba.muni.cz\/svod). \u0158ada d\u016fle\u017eit\u00fdch \u00fadaj\u016f z t\u00e9to rozs\u00e1hl\u00e9 datab\u00e1ze je p\u0159ehledn\u011b zpracov\u00e1na i v ned\u00e1vno vydan\u00e9 monografii Czech cancer care in numbers 2008\u20132009 [12]. N\u00e1sleduj\u00edc\u00ed statistick\u00e1 anal\u00fdza \u00fadaj\u016f o zhoubn\u00fdch n\u00e1dorech j\u00edcnu v \u010cesk\u00e9 republice byla provedena z t\u00e9to datab\u00e1ze NOR [13].<\/p>\n<p style=\"text-align: justify;\">Zhoubn\u00e9 n\u00e1dor y (ZN) j\u00edcnu p\u0159edstavuj\u00ed v \u010cesk\u00e9 republice (\u010cR) jen n\u011bco m\u00e9n\u011b ne\u017e 1 % ze v\u0161ech solidn\u00edch malign\u00edch n\u00e1dor\u016f a s incidenc\u00ed 4,9 onemocn\u011bn\u00ed na 100 000 obyvatel pat\u0159\u00edme mezi zem\u011b se st\u0159edn\u00edm v\u00fdskytem tohoto onemocn\u011bn\u00ed. Zat\u00edmco u mu\u017e\u016f je incidence 8,4 na 100 000 obyvatel, u \u017een je podstatn\u011b ni\u017e\u0161\u00ed, jen 1,7 (obr. 5, 6).<\/p>\n<p style=\"text-align: justify;\">V\u00fdvoj incidence a mortalitu zhoubn\u00fdch n\u00e1dor\u016f j\u00edcnu v posledn\u00edch t\u0159iceti letech ukazuj\u00ed obr\u00e1zky 7 a 8. Rozd\u00edln\u00e1 je i incidence v jednotliv\u00fdch regionech \u010cesk\u00e9 republiky. Nakolik se na t\u011bchto rozd\u00edlech pod\u00edlej\u00ed obecn\u011b zn\u00e1m\u00e9 rizikov\u00e9 faktory, jako je konzumace alkoholu, kou\u0159en\u00ed a socioekonomick\u00e1 \u00farove\u0148 regionu, lze jen spekulovat (obr. 9a,b). I kdy\u017e frekvence v\u00fdskytu karcinomu j\u00edcnu je v \u010cesk\u00e9 republice ve srovn\u00e1n\u00ed s ostatn\u00edmi solidn\u00edmi n\u00e1dory mal\u00e1, m\u00e1 prevalence ZN j\u00edcnu v pr\u016fb\u011bhu let vzestupnou tendenci (obr. 10) a v absolutn\u00edch \u010d\u00edslech se nejedn\u00e1 o nijak zanedbateln\u00fd po\u010det nemocn\u00fdch, kte\u0159\u00ed s touto diagn\u00f3zou vy\u017eaduj\u00ed na\u0161i pozornost. Celkovou epidemiologickou situaci zhoubn\u00fdch n\u00e1dor\u016f j\u00edcnu v roce 2008 shrnuje tab. 3.<\/p>\n<table class=\"CSSTableGenerator\" style=\"border-collapse: collapse; width: 100%;\" border=\"0\" cellspacing=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\" colspan=\"4\"><span style=\"color: #ffffff;\">Tab. 3 \u2013 Celkov\u00e1 epidemiologick\u00e1 situace ZN j\u00edcnu (C15) v \u010cR v roce 2008<\/span><br \/>\n<span style=\"color: #ffffff;\"> ZN j\u00edcnu (C15)<\/span><\/td>\n<\/tr>\n<tr>\n<td><\/td>\n<td style=\"text-align: center;\" width=\"20%\">Mu\u017ei<\/td>\n<td style=\"text-align: center;\" width=\"20%\">\u017deny<\/td>\n<td style=\"text-align: center;\" width=\"20%\">Celkem<\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\"><strong>Incidence<\/strong> <i>(rok 2008)<\/i><\/td>\n<\/tr>\n<tr>\n<td>Absolutn\u00ed po\u010det<\/td>\n<td style=\"text-align: center;\">468<\/td>\n<td style=\"text-align: center;\">93<\/td>\n<td style=\"text-align: center;\">561<\/td>\n<\/tr>\n<tr>\n<td>Po\u010det na 100 000 osob<\/td>\n<td style=\"text-align: center;\">9,1<\/td>\n<td style=\"text-align: center;\">1,7<\/td>\n<td style=\"text-align: center;\">5,4<\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\"><strong>Mortalita<\/strong> <i>(rok 2008)<\/i><\/td>\n<\/tr>\n<tr>\n<td>Absolutn\u00ed po\u010det<\/td>\n<td style=\"text-align: center;\">368<\/td>\n<td style=\"text-align: center;\">84<\/td>\n<td style=\"text-align: center;\">452<\/td>\n<\/tr>\n<tr>\n<td>Po\u010det na 100 000 osob<\/td>\n<td style=\"text-align: center;\">7,2<\/td>\n<td style=\"text-align: center;\">1,6<\/td>\n<td style=\"text-align: center;\">4,3<\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\"><strong>Prevalence<\/strong> <i>(rok 2008)<\/i><\/td>\n<\/tr>\n<tr>\n<td>Absolutn\u00ed po\u010det<\/td>\n<td style=\"text-align: center;\">657<\/td>\n<td style=\"text-align: center;\">134<\/td>\n<td style=\"text-align: center;\">791<\/td>\n<\/tr>\n<tr>\n<td>Po\u010det na 100 000 osob<\/td>\n<td style=\"text-align: center;\">12,8<\/td>\n<td style=\"text-align: center;\">2,5<\/td>\n<td style=\"text-align: center;\">7,6<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\"><span style=\"color: #ffffff;\">.<\/span><\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_473.png\"><img loading=\"lazy\" decoding=\"async\" class=\" \" title=\"Obr. 4a \u2013 Incidence ZN j\u00edcnu (C15) v mezin\u00e1rodn\u00edm srovn\u00e1n\u00ed\" alt=\"Obr. 4a \u2013 Incidence ZN j\u00edcnu (C15) v mezin\u00e1rodn\u00edm srovn\u00e1n\u00ed\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_473.png\" width=\"200\" height=\"292\" \/><\/a><p class=\"wp-caption-text\">Obr. 4a<br \/>Incidence ZN j\u00edcnu (C15) v mezin\u00e1rodn\u00edm srovn\u00e1n\u00ed<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_474.png\"><img decoding=\"async\" title=\"Obr. 4b \u2013 Incidence ZN j\u00edcnu (C15) v mezin\u00e1rodn\u00edm srovn\u00e1n\u00ed\" alt=\"Obr. 4b \u2013 Incidence ZN j\u00edcnu (C15) v mezin\u00e1rodn\u00edm srovn\u00e1n\u00ed\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_474.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 4b<br \/>Incidence ZN j\u00edcnu (C15) v mezin\u00e1rodn\u00edm srovn\u00e1n\u00ed<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_475.png\"><img decoding=\"async\" title=\"Obr. 4c \u2013 Mortalita ZN j\u00edcnu (C15) v mezin\u00e1rodn\u00edm srovn\u00e1n\u00ed\" alt=\"Obr. 4c \u2013 Mortalita ZN j\u00edcnu (C15) v mezin\u00e1rodn\u00edm srovn\u00e1n\u00ed\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_475.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 4c<br \/>Mortalita ZN j\u00edcnu (C15) v mezin\u00e1rodn\u00edm srovn\u00e1n\u00ed<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_476.png\"><img decoding=\"async\" title=\"Obr. 4d \u2013 Mortalita ZN j\u00edcnu (C15) v mezin\u00e1rodn\u00edm srovn\u00e1n\u00ed\" alt=\"Obr. 4d \u2013 Mortalita ZN j\u00edcnu (C15) v mezin\u00e1rodn\u00edm srovn\u00e1n\u00ed\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_476.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 4d<br \/>Mortalita ZN j\u00edcnu (C15) v mezin\u00e1rodn\u00edm srovn\u00e1n\u00ed<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_478.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 5 \u2013 Incidence zhoubn\u00fdch novotvar\u016f (ZN) v \u010cR v obdob\u00ed 2004\u20132008\" alt=\"Obr. 5 \u2013 Incidence zhoubn\u00fdch novotvar\u016f (ZN) v \u010cR v obdob\u00ed 2004\u20132008\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_478.png\" width=\"200\" height=\"135\" \/><\/a><p class=\"wp-caption-text\">Obr. 5<br \/>Incidence zhoubn\u00fdch novotvar\u016f (ZN) v \u010cR v obdob\u00ed 2004\u20132008<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_479.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 6 \u2013 Incidence zhoubn\u00fdch novotvar\u016f (ZN) v \u010cR v obdob\u00ed 2004\u20132008 u mu\u017e\u016f a \u017een\" alt=\"Obr. 6 \u2013 Incidence zhoubn\u00fdch novotvar\u016f (ZN) v \u010cR v obdob\u00ed 2004\u20132008 u mu\u017e\u016f a \u017een\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_479.png\" width=\"200\" height=\"133\" \/><\/a><p class=\"wp-caption-text\">Obr. 6<br \/>Incidence zhoubn\u00fdch novotvar\u016f (ZN) v \u010cR v obdob\u00ed 2004\u20132008 u mu\u017e\u016f a \u017een<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_481.png\"><img decoding=\"async\" title=\"Obr. 7a \u2013 V\u00fdvoj incidence ZN j\u00edcnu (C15) v letech 1977\u20132007\" alt=\"Obr. 7a \u2013 V\u00fdvoj incidence ZN j\u00edcnu (C15) v letech 1977\u20132007\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_481.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 7a<br \/>V\u00fdvoj incidence ZN j\u00edcnu (C15) v letech 1977\u20132007<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_482.png\"><img decoding=\"async\" title=\"Obr. 7b \u2013 V\u00fdvoj mortality ZN j\u00edcnu (C15) v letech 1977\u20132007\" alt=\"Obr. 7b \u2013 V\u00fdvoj mortality ZN j\u00edcnu (C15) v letech 1977\u20132007\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_482.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 7b<br \/>V\u00fdvoj mortality ZN j\u00edcnu (C15) v letech 1977\u20132007<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_483.png\"><img decoding=\"async\" title=\"Obr. 8 \u2013 V\u00fdvoj incidence a mortality ZN j\u00edcnu (C15) v letech 1977\u20132007, incidence v\u011bkov\u011b standardizov\u00e1na na v\u011bkovou strukturu obyvatel \u010cR v roce 2008\" alt=\"Obr. 8 \u2013 V\u00fdvoj incidence a mortality ZN j\u00edcnu (C15) v letech 1977\u20132007, incidence v\u011bkov\u011b standardizov\u00e1na na v\u011bkovou strukturu obyvatel \u010cR v roce 2008\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_483.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 8<br \/>V\u00fdvoj incidence a mortality ZN j\u00edcnu (C15) v letech 1977\u20132007, incidence v\u011bkov\u011b standardizov\u00e1na na v\u011bkovou strukturu obyvatel \u010cR v roce 2008<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"border-color: #ffffff; border-width: 0px; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_485.png\"><img decoding=\"async\" title=\"Obr. 9a \u2013 Hrub\u00e1 incidence ZN j\u00edcnu (C15) v kraj\u00edch \u010cR v obdob\u00ed 2004\u20132008\" alt=\"Obr. 9a \u2013 Hrub\u00e1 incidence ZN j\u00edcnu (C15) v kraj\u00edch \u010cR v obdob\u00ed 2004\u20132008\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_485.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 9a<br \/>Hrub\u00e1 incidence ZN j\u00edcnu (C15) v kraj\u00edch \u010cR v obdob\u00ed 2004\u20132008<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_486.png\"><img loading=\"lazy\" decoding=\"async\" class=\" \" title=\"Obr. 9b \u2013 V\u011bkov\u011b standardizovan\u00e1 incidence ZN j\u00edcnu (C15) v kraj\u00edch \u010cR v obdob\u00ed 2004\u20132008\" alt=\"Obr. 9b \u2013 V\u011bkov\u011b standardizovan\u00e1 incidence ZN j\u00edcnu (C15) v kraj\u00edch \u010cR v obdob\u00ed 2004\u20132008\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_486.png\" width=\"200\" height=\"285\" \/><\/a><p class=\"wp-caption-text\">Obr. 9b<br \/>V\u011bkov\u011b standardizovan\u00e1 incidence ZN j\u00edcnu (C15) v kraj\u00edch \u010cR v obdob\u00ed 2004\u20132008<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_487.png\"><img decoding=\"async\" title=\"Obr. 10 \u2013 V\u00fdvoj prevalence ZN j\u00edcnu v \u010cesk\u00e9 republice v posledn\u00edch dvou desetilet\u00edch\" alt=\"Obr. 10 \u2013 V\u00fdvoj prevalence ZN j\u00edcnu v \u010cesk\u00e9 republice v posledn\u00edch dvou desetilet\u00edch\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_487.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 10<br \/>V\u00fdvoj prevalence ZN j\u00edcnu v \u010cesk\u00e9 republice v posledn\u00edch dvou desetilet\u00edch<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6 class=\"s19\">Rozd\u00edly mezi spinocelul\u00e1rn\u00edm karcinomem a adenokarcinomem j\u00edcnu<\/h6>\n<p style=\"text-align: justify;\">V etiologii koreluje v\u00fdskyt adenokarcinomu s kou\u0159en\u00edm m\u00e9n\u011b v\u00fdrazn\u011b ne\u017e u spinocelul\u00e1rn\u00edho karcinomu, zato je u n\u011bj v\u00fdrazn\u00e1 souvislost s v\u00fdskytem refluxn\u00edch obt\u00ed\u017e\u00ed a Barretov\u00fdm j\u00edcnem. To se odr\u00e1\u017e\u00ed i v anamn\u00e9ze a klinick\u00e9 symptomatologii, kdy u spinocelul\u00e1rn\u00edho karcinomu dominuje dysfagie a \u00fabytek hmotnosti, u adenokarcinomu se \u010dast\u011bji jedn\u00e1 o mlad\u0161\u00ed jedince s refluxn\u00edmi obt\u00ed\u017eemi a m\u00e9n\u011b \u010dast\u011bj\u0161\u00ed je konzumace nikotinu a alkoholu. Pokud se t\u00fdk\u00e1 metast\u00e1zov\u00e1n\u00ed a progn\u00f3zy, nebyly v retrospektivn\u00edch studi\u00edch shled\u00e1ny \u017e\u00e1dn\u00e9 signifikantn\u00ed rozd\u00edly. Je samoz\u0159ejm\u00e9, \u017ee se li\u0161\u00ed frekvence metast\u00e1zov\u00e1n\u00ed do uzlin jednotliv\u00fdch kompartment\u016f podle jeho lokalizace na oblast kr\u010dn\u00edho, hrudn\u00edho a abdomin\u00e1ln\u00edho j\u00edcnu. N\u00e1dory doln\u00edho j\u00edcnu metast\u00e1zuj\u00ed p\u0159ev\u00e1\u017en\u011b do mediastina a abdomin\u00e1ln\u011b, n\u00e1dory horn\u00ed \u010d\u00e1sti j\u00edcnu do mediastina a do kr\u010dn\u00edch uzlin a n\u00e1dory ve st\u0159edn\u00ed t\u0159etin\u011b do v\u0161ech t\u011bchto oblast\u00ed.<\/p>\n<h4 class=\"s15\">13.2.3 Molekul\u00e1rn\u011b biologick\u00e1 charakteristika<\/h4>\n<p class=\"s15\" style=\"text-align: justify;\">V\u00fdzkum v oblasti molekul\u00e1rn\u00ed biologie popisuje \u010detn\u00e9 molekul\u00e1rn\u011b biologick\u00e9 markery v n\u00e1dorov\u00e9 tk\u00e1ni tumoru j\u00edcnu. Pat\u0159\u00ed mezi n\u011b nap\u0159. r\u016fstov\u00e9 faktory a receptory<\/p>\n<ul>\n<li style=\"text-align: justify;\">EGFR (epidermal growth factor receptor), VEGF (vascular endothelial growth factor), supresorov\u00e9 geny \u2013 P53 gen, onkogeny \u2013 cyklin D1, prolifera\u010dn\u00ed markery<\/li>\n<li style=\"text-align: justify;\">PCNA (proliferating cell nuclear antigen), heat \u2013 shock proteiny \u2013 HSP 70 a 27 a cel\u00e1 \u0159ada dal\u0161\u00edch faktor\u016f. Byl zkoum\u00e1n zejm\u00e9na jejich v\u00fdznam jako nez\u00e1visl\u00fdch prognostick\u00fdch faktor\u016f. N\u00e1zory na jejich v\u00fdznam se v\u0161ak p\u0159es rozs\u00e1hl\u00fd v\u00fdzkum zat\u00edm r\u016fzn\u00ed a celkov\u011b neposkytuj\u00ed spolehlivou prognostickou odpov\u011b\u010f ve srovn\u00e1n\u00ed s klasicky ov\u011b\u0159en\u00fdmi prognostick\u00fdmi faktory, jako je radikalita operace (R0), hloubka n\u00e1dorov\u00e9 infiltrace \u010di posti\u017een\u00ed lymfatick\u00fdch uzlin.<\/li>\n<\/ul>\n<h4 class=\"s15\">13.2.4 Klinick\u00fd obraz, diagnostika a screening<\/h4>\n<p style=\"text-align: justify;\">Nej\u010dast\u011bj\u0161\u00edmi klinick\u00fdmi p\u0159\u00edznaky karcinomu j\u00edcnu jsou dysfagie, \u00fabytek t\u011blesn\u00e9 hmotnosti a retrostern\u00e1ln\u00ed bolest. Dysfagie je bohu\u017eel p\u0159\u00edznakem pozdn\u00edm, kdy jsou ji\u017e tumorem infiltrov\u00e1ny nejm\u00e9n\u011b dv\u011b t\u0159etiny obvodu j\u00edcnu. \u010casn\u00e9 klinick\u00e9 p\u0159\u00edznaky, kter\u00e9 by byly specifick\u00e9 pro malign\u00ed n\u00e1dor j\u00edcnu, bohu\u017eel nejsou. Epidemiologick\u00e9 studie o karcinomu j\u00edcnu ukazuj\u00ed, \u017ee vy\u0161\u0161\u00ed v\u00fdskyt je u mu\u017e\u016f ne\u017e u \u017een. Pr\u016fm\u011brn\u00fd v\u011bk p\u0159i stanoven\u00ed diagn\u00f3zy je u mu\u017e\u016f 62 a u \u017een 68 let (obr. 11a,b).<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_490.png\"><img decoding=\"async\" title=\"Obr. 11a \u2013 V\u011bk pacient\u016f se ZN j\u00edcnu (C15) v obdob\u00ed 2004\u20132008, v\u011bkov\u00e1 struktura\" alt=\"Obr. 11a \u2013 V\u011bk pacient\u016f se ZN j\u00edcnu (C15) v obdob\u00ed 2004\u20132008, v\u011bkov\u00e1 struktura\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_490.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 11a<br \/>V\u011bk pacient\u016f se ZN j\u00edcnu (C15) v obdob\u00ed 2004\u20132008, v\u011bkov\u00e1 struktura<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_491.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 13px; line-height: 19px; text-align: justify;\" title=\"Obr. 11b \u2013 V\u011bk pacient\u016f se ZN j\u00edcnu (C15) v obdob\u00ed 2004\u20132008, v\u011bkov\u011b specifick\u00e1 incidence\" alt=\"Obr. 11b \u2013 V\u011bk pacient\u016f se ZN j\u00edcnu (C15) v obdob\u00ed 2004\u20132008, v\u011bkov\u011b specifick\u00e1 incidence\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_491.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 11b<br \/>V\u011bk pacient\u016f se ZN j\u00edcnu (C15) v obdob\u00ed 2004\u20132008, v\u011bkov\u011b specifick\u00e1 incidence<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6 style=\"text-align: justify;\">Diagnostika<\/h6>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 280px;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"right\">\n<tbody>\n<tr>\n<td style=\"width: 33%; border-color: #ffffff; background-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div id=\"attachment_3320\" style=\"width: 50px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=3363\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3320\" class=\" wp-image-3320\" title=\"VIDEO 5\" alt=\"VIDEO 5\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/06\/video.jpg\" width=\"40\" height=\"40\" srcset=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/06\/video-150x150.jpg 150w, https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/06\/video-120x120.jpg 120w\" sizes=\"auto, (max-width: 40px) 100vw, 40px\" \/><\/a><p id=\"caption-attachment-3320\" class=\"wp-caption-text\">VIDEO 5<\/p><\/div><\/td>\n<td style=\"width: 33%; border-color: #ffffff; background-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div id=\"attachment_3320\" style=\"width: 50px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=3368\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3320\" class=\" wp-image-3320  \" title=\"VIDEO 6\" alt=\"VIDEO 6\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/06\/video.jpg\" width=\"40\" height=\"40\" srcset=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/06\/video-150x150.jpg 150w, https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/06\/video-120x120.jpg 120w\" sizes=\"auto, (max-width: 40px) 100vw, 40px\" \/><\/a><p id=\"caption-attachment-3320\" class=\"wp-caption-text\">VIDEO 6<\/p><\/div><\/td>\n<td style=\"width: 33%; border-color: #ffffff; background-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div id=\"attachment_3320\" style=\"width: 50px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=3373\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3320\" class=\" wp-image-3320 \" title=\"VIDEO 7\" alt=\"VIDEO 7\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/06\/video.jpg\" width=\"40\" height=\"40\" srcset=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/06\/video-150x150.jpg 150w, https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/06\/video-120x120.jpg 120w\" sizes=\"auto, (max-width: 40px) 100vw, 40px\" \/><\/a><p id=\"caption-attachment-3320\" class=\"wp-caption-text\">VIDEO 7<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">Ke klasick\u00e9 diagnostice n\u00e1dor\u016f j\u00edcnu dlouhodob\u011b vedle anamn\u00e9zy a klinick\u00e9ho vy\u0161et\u0159en\u00ed pat\u0159ila kontrastn\u00ed pas\u00e1\u017e j\u00edcnem a \u017ealudkem (obr. 12a,b; <a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=3363\" target=\"_blank\">videoz\u00e1znam\u00a0rtg pas\u00e1\u017ee u karcinomu st\u0159edn\u00edho j\u00edcnu<\/a>, <a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=3368\" target=\"_blank\">rtg pas\u00e1\u017ee u karcinomu doln\u00edho j\u00edcnu<\/a> a <a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=3373\" target=\"_blank\">rtg pas\u00e1\u017ee \u017ealude\u010dn\u00edm tubusem po n\u00e1hrad\u011b j\u00edcnu<\/a> jsou dostupn\u00e9 v elektronick\u00e9 verzi \u2013 viz tir\u00e1\u017e knihy), jej\u00ed\u017e v\u00fdznam dnes ustupuje do pozad\u00ed. V diagnostice zhoubn\u00fdch n\u00e1dor\u016f j\u00edcnu m\u00e1 dnes rozhoduj\u00edc\u00ed v\u00fdznam endoskopie s biopsi\u00ed (obr. 12c). Ur\u010d\u00ed lokalizaci n\u00e1doru a histologick\u00e9 vy\u0161et\u0159en\u00ed pak p\u0159esn\u00fd typ n\u00e1doru, stupe\u0148 malignity (grading) a u \u010dasn\u00fdch n\u00e1dor\u016f i stupe\u0148 infiltrace st\u011bny. Ke zp\u0159esn\u011bn\u00ed stadia onemocn\u011bn\u00ed je pak k dispozici cel\u00e1 \u0161k\u00e1la zobrazovac\u00edch metod.<\/p>\n<p>&nbsp;<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_492.png\"><img decoding=\"async\" title=\"Obr.12a \u2013 Karcinom st\u0159edn\u00edho j\u00edcnu, rtg pas\u00e1\u017e j\u00edcnem v \u0161ikm\u00e9 projekci\" alt=\"Obr.12a \u2013 Karcinom st\u0159edn\u00edho j\u00edcnu, rtg pas\u00e1\u017e j\u00edcnem v \u0161ikm\u00e9 projekci\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_492.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr.12a<br \/>Karcinom st\u0159edn\u00edho j\u00edcnu, rtg pas\u00e1\u017e j\u00edcnem v \u0161ikm\u00e9 projekci<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_493.png\"><img decoding=\"async\" title=\"Obr. 12b \u2013 Karcinom doln\u00ed t\u0159etiny j\u00edcnu, rtg pas\u00e1\u017e j\u00edcnem v \u0161ikm\u00e9 projekci\" alt=\"Obr. 12b \u2013 Karcinom doln\u00ed t\u0159etiny j\u00edcnu, rtg pas\u00e1\u017e j\u00edcnem v \u0161ikm\u00e9 projekci\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_493.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 12b<br \/>Karcinom doln\u00ed t\u0159etiny j\u00edcnu, rtg pas\u00e1\u017e j\u00edcnem v \u0161ikm\u00e9 projekci<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">Dal\u0161\u00edm nezbytn\u00fdm vy\u0161et\u0159en\u00edm je ze zobrazovac\u00edch metod v\u00fdpo\u010detn\u00ed tomografie hrudn\u00edku a b\u0159icha (spir\u00e1ln\u00ed CT) (obr. 13a,b,c) a endosonografie [14, 15] (obr. 14). V jednotliv\u00fdch p\u0159\u00edpadech jsou tato vy\u0161et\u0159en\u00ed dopln\u011bna ORL vy\u0161et\u0159en\u00edm, bronchoskopi\u00ed, perkut\u00e1n\u00ed sonografi\u00ed a p\u0159\u00edpadn\u011b diagnostickou laparoskopi\u00ed. C\u00edlem diagnostick\u00e9ho postupu je stanovit p\u0159esn\u00e9 stadium onemocn\u011bn\u00ed, co\u017e m\u00e1 v\u00fdznam pro stanoven\u00ed progn\u00f3zy a spr\u00e1vnou strategii l\u00e9\u010dby.<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"border: 1px solid #ffffff; width: 50%;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_495.png\"><img decoding=\"async\" title=\"Obr. 12c \u2013 Endoskopick\u00fd obraz karcinomu j\u00edcnu\" alt=\"Obr. 12c \u2013 Endoskopick\u00fd obraz karcinomu j\u00edcnu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_495.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 12c<br \/>Endoskopick\u00fd obraz karcinomu j\u00edcnu<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_496.png\"><img decoding=\"async\" title=\"Obr. 13a \u2013 CT obraz karcinomu j\u00edcnu v axi\u00e1ln\u00ed projekci, uvedeny rozm\u011bry n\u00e1dor\u016f v p\u0159\u00ed\u010dn\u00e9m \u0159ezu\" alt=\"Obr. 13a \u2013 CT obraz karcinomu j\u00edcnu v axi\u00e1ln\u00ed projekci, uvedeny rozm\u011bry n\u00e1dor\u016f v p\u0159\u00ed\u010dn\u00e9m \u0159ezu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_496.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 13a<br \/>CT obraz karcinomu j\u00edcnu v axi\u00e1ln\u00ed projekci, uvedeny rozm\u011bry n\u00e1dor\u016f v p\u0159\u00ed\u010dn\u00e9m \u0159ezu<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff; width: 50%;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_498.png\"><img decoding=\"async\" title=\"Obr. 13b \u2013 CT obraz, sagit\u00e1ln\u00ed rekonstrukce, d\u00e9lka n\u00e1doru 66,9 mm\" alt=\"Obr. 13b \u2013 CT obraz, sagit\u00e1ln\u00ed rekonstrukce, d\u00e9lka n\u00e1doru 66,9 mm\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_498.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 13b<br \/>CT obraz, sagit\u00e1ln\u00ed rekonstrukce, d\u00e9lka n\u00e1doru 66,9 mm<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_500.png\"><img loading=\"lazy\" decoding=\"async\" class=\" \" title=\"Obr. 13c \u2013 CT obraz, koron\u00e1rn\u00ed rekonstrukce (front\u00e1ln\u00ed \u0159ez), d\u00e9lka tumoru 65,8 mm\" alt=\"Obr. 13c \u2013 CT obraz, koron\u00e1rn\u00ed rekonstrukce (front\u00e1ln\u00ed \u0159ez), d\u00e9lka tumoru 65,8 mm\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_500.png\" width=\"200\" height=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 13c<br \/>CT obraz, koron\u00e1rn\u00ed rekonstrukce (front\u00e1ln\u00ed \u0159ez), d\u00e9lka tumoru 65,8 mm<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff; width: 50%;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_499.png\"><img decoding=\"async\" title=\"Obr. 14a \u2013 Endosonografick\u00fd obraz karcinomu j\u00edcnu (T1) (obr. 14 poskytl MUDr. I. Tozzi z II. intern\u00ed kliniky FN Olomouc)\" alt=\"Obr. 14a \u2013 Endosonografick\u00fd obraz karcinomu j\u00edcnu (T1) (obr. 14 poskytl MUDr. I. Tozzi z II. intern\u00ed kliniky FN Olomouc)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_499.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 14a<br \/>Endosonografick\u00fd obraz karcinomu j\u00edcnu (T1) (obr. 14 poskytl MUDr. I. Tozzi z II. intern\u00ed kliniky FN Olomouc)<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_501.png\"><img decoding=\"async\" title=\"Obr. 14b \u2013 Endosonografick\u00fd obraz karcinomu j\u00edcnu (T4)\" alt=\"Obr. 14b \u2013 Endosonografick\u00fd obraz karcinomu j\u00edcnu (T4)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_501.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 14b<br \/>Endosonografick\u00fd obraz karcinomu j\u00edcnu (T4)<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">V\u0161echna u\u017e\u00edvan\u00e1 klasifika\u010dn\u00ed sch\u00e9mata \u2013 Union Internationale Contre le Cancer (UICC), American Joint Commitee on Cancer (AJCC) TMN classification a Japanese Classification of Esophageal Cancer \u2013 se zakl\u00e1daj\u00ed na stanoven\u00ed hloubky n\u00e1dorov\u00e9 infiltrace ve st\u011bn\u011b j\u00edcnu, posti\u017een\u00ed uzlin a p\u0159\u00edtomnosti vzd\u00e1len\u00fdch metast\u00e1z. U n\u00e1s je u\u017e\u00edvan\u00e1 TMN klasifikace a za\u0159azen\u00ed n\u00e1dor\u016f do jednotliv\u00fdch klinick\u00fdch stadi\u00ed I\u2013IV. V sou\u010dasnosti je k dispozici 7. vyd\u00e1n\u00ed klasifikace n\u00e1dor\u016f AJCC z roku 2010 [16] (tab. 4 a 5).<\/p>\n<table class=\"CSSTableGenerator\" style=\"border-collapse: collapse; width: 100%;\" border=\"0\" cellspacing=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\"><span style=\"color: #ffffff;\">Tab. 4<\/span><br \/>\n<span style=\"color: #ffffff;\">TNM klasifikace n\u00e1dor\u016f j\u00edcnu<\/span><\/td>\n<\/tr>\n<tr>\n<td><strong>T \u2013 Prim\u00e1rn\u00ed n\u00e1dor<br \/>\n<\/strong><span style=\"line-height: 19px;\">TX \u2013 prim\u00e1rn\u00ed n\u00e1dor nelze hodnotit<\/span><br \/>\n<span style=\"line-height: 19px;\">T0 \u2013 bez zn\u00e1mek prim\u00e1rn\u00edho n\u00e1doru<\/span><br \/>\n<span style=\"line-height: 19px;\">Tis \u2013 karcinom <\/span><i style=\"line-height: 19px;\">in situ<\/i><br \/>\nT1 \u2013 n\u00e1dor postihuje lamina propria mucosae (T1a) nebo submuk\u00f3zu (T1b)<br \/>\n<span style=\"line-height: 19px;\">T2 \u2013 n\u00e1dor postihuje muscularis propria<\/span><br \/>\n<span style=\"line-height: 19px;\">T3 \u2013 n\u00e1dor postihuje adventicii<\/span><br \/>\n<span style=\"line-height: 19px;\">T4 \u2013 n\u00e1dor postihuje pleuru, perikard a br\u00e1nici (T4a) nebo aortu, obratle a tra<\/span><span style=\"line-height: 19px;\">cheu (T4b)<\/span><\/td>\n<\/tr>\n<tr>\n<td><strong>Region\u00e1ln\u00ed lymfatick\u00e9 uzliny<br \/>\n<\/strong>NX \u2013 region\u00e1ln\u00ed lymfatick\u00e9 uzliny nelze hodnotit<br \/>\n<span style=\"line-height: 19px;\">N0 \u2013 v region\u00e1ln\u00edch lymfatick\u00fdch uzlin\u00e1ch nejsou metast\u00e1zy<\/span><br \/>\n<span style=\"line-height: 19px;\">N1 \u2013 metast\u00e1zy v 1\u20132 region\u00e1ln\u00edch lymfatick\u00fdch uzlin\u00e1ch<\/span><br \/>\n<span style=\"line-height: 19px;\">N2 \u2013 metast\u00e1zy v 3\u20136 region\u00e1ln\u00edch uzlin\u00e1ch<\/span><br \/>\n<span style=\"line-height: 19px;\">N3 \u2013 metast\u00e1zy v 7 a v\u00edce region\u00e1ln\u00edch uzlin\u00e1ch<\/span><\/td>\n<\/tr>\n<tr>\n<td><strong>Vzd\u00e1len\u00e9 metast\u00e1zy<br \/>\n<\/strong>MX \u2013 vzd\u00e1len\u00e9 metast\u00e1zy nelze hodnotit<br \/>\n<span style=\"line-height: 19px;\">M0 \u2013 nejsou vzd\u00e1len\u00e9 metast\u00e1zy<\/span><br \/>\n<span style=\"line-height: 19px;\">M1 \u2013 vzd\u00e1len\u00e9 metast\u00e1zy<\/span><br \/>\n<em style=\"line-height: 19px;\">Pro n\u00e1dory doln\u00edho hrudn\u00edho j\u00edcnu plat\u00ed:\u00a0<\/em><br \/>\n<span style=\"line-height: 19px;\">M1a \u2013 metast\u00e1za(y) v celiak\u00e1ln\u00edch lymfatick\u00fdch uzlin\u00e1ch<\/span><br \/>\n<span style=\"line-height: 19px;\">M1b \u2013 jin\u00e9 vzd\u00e1len\u00e9 metast\u00e1zy<\/span><br \/>\n<em style=\"line-height: 19px;\">Pro n\u00e1dory horn\u00edho hrudn\u00edho j\u00edcnu plat\u00ed:\u00a0<\/em><br \/>\n<span style=\"line-height: 19px;\">M1a \u2013 metast\u00e1za(y) v kr\u010dn\u00edch lymfatick\u00fdch uzlin\u00e1ch<\/span><br \/>\n<span style=\"line-height: 19px;\">M1b \u2013 jin\u00e9 vzd\u00e1len\u00e9 metast\u00e1zy<\/span><br \/>\n<em style=\"line-height: 19px;\">Pro n\u00e1dory st\u0159edn\u00edho horn\u00edho j\u00edcnu plat\u00ed:\u00a0<\/em><br \/>\n<span style=\"line-height: 19px;\">M1a \u2013 nepou\u017eiteln\u00e1<\/span><br \/>\n<span style=\"line-height: 19px;\">M1b \u2013 metast\u00e1zy v m\u00edzn\u00edch uzlin\u00e1ch jin\u00fdch ne\u017e region\u00e1ln\u00edch nebo jin\u00e9 vzd\u00e1len\u00e9\u00a0<\/span><span style=\"line-height: 19px;\">metast\u00e1zy<\/span><\/td>\n<\/tr>\n<tr>\n<td><strong>Region\u00e1ln\u00ed lymfatick\u00e9 uzliny<br \/>\n<\/strong><\/p>\n<ul>\n<li><span style=\"color: #231f20;\">kr\u010dn\u00ed j\u00edcen: kr\u010dn\u00ed uzliny, v\u010detn\u011b supraklavikul\u00e1rn\u00edch<\/span><\/li>\n<li><span style=\"color: #231f20;\">hrudn\u00ed j\u00edcen: mediastin\u00e1ln\u00ed a perigastrick\u00e9 lymfatick\u00e9 uzliny (ne celiak\u00e1ln\u00ed<\/span><br \/>\nlymfatick\u00e9 uzliny)<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\"><span style=\"color: #ffffff;\">.<\/span><\/p>\n<p style=\"text-align: justify;\">V diagnostick\u00e9m algoritmu karcinomu j\u00edcnu je dnes tedy z\u00e1kladem endoskopie s biopsi\u00ed. Pro p\u0159edopera\u010dn\u00ed staging m\u00e1 rozhoduj\u00edc\u00ed v\u00fdznam CT vy\u0161et\u0159en\u00ed a endosonografie. Umo\u017e\u0148uj\u00ed posoudit velikost a lokalizaci tumoru, jeho \u0161\u00ed\u0159en\u00ed do okol\u00ed,\u00a0posti\u017een\u00ed mediastin\u00e1ln\u00edch a b\u0159i\u0161n\u00edch uzlin a p\u0159\u00edtomnost vzd\u00e1len\u00fdch metast\u00e1z. Lokoregion\u00e1ln\u00edmu stagingu slou\u017e\u00ed jak CT, tak endoskopick\u00e1 sonografie. Jej\u00ed dostupnost u n\u00e1s je zpravidla ve srovn\u00e1n\u00ed s CT men\u0161\u00ed, ale kombinace obou vy\u0161et\u0159en\u00ed je \u017e\u00e1douc\u00ed zejm\u00e9na v p\u0159\u00edpadech sporn\u00e9ho n\u00e1lezu lokoregion\u00e1ln\u00edho \u0161\u00ed\u0159en\u00ed dle CT vy\u0161et\u0159en\u00ed. Konven\u010dn\u00ed radiologick\u00e9 vy\u0161et\u0159en\u00ed hraje ji\u017e jen sekund\u00e1rn\u00ed roli. Perkut\u00e1nn\u00ed ultrasonografie m\u00e1 v\u00fdznam jen p\u0159i posouzen\u00ed kr\u010dn\u00edch uzlin u karcinomu v t\u00e9to lokalizaci.<\/p>\n<table class=\"CSSTableGenerator\" style=\"border-collapse: collapse; width: 100%;\" border=\"0\" cellspacing=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\" colspan=\"6\"><span style=\"color: #ffffff;\">Tab. 5<\/span><br \/>\n<span style=\"line-height: 19px; color: #ffffff;\">Klasifikace karcinomu j\u00edcnu podle 7. vyd\u00e1n\u00ed AJCC 2010<\/span><\/td>\n<\/tr>\n<tr>\n<td width=\"16%\"><strong>Stadium<\/strong><\/td>\n<td style=\"text-align: center;\" width=\"16%\"><strong>T<\/strong><\/td>\n<td style=\"text-align: center;\" width=\"16%\"><strong>N<\/strong><\/td>\n<td style=\"text-align: center;\" width=\"16%\"><strong>M<\/strong><\/td>\n<td style=\"text-align: center;\" width=\"16%\"><strong>Grading<\/strong><\/td>\n<td style=\"text-align: center;\"><strong>Lokalizace na j\u00edcnu<\/strong><\/td>\n<\/tr>\n<tr>\n<td><strong>0<\/strong><\/td>\n<td style=\"text-align: center;\">Tis<\/td>\n<td style=\"text-align: center;\">0<\/td>\n<td style=\"text-align: center;\">0<\/td>\n<td style=\"text-align: center;\">1<\/td>\n<td style=\"text-align: center;\">v\u0161echny<\/td>\n<\/tr>\n<tr>\n<td><strong>IA<\/strong><br \/>\n<strong>IB<\/strong><\/td>\n<td style=\"text-align: center;\">1<br \/>\n2<\/td>\n<td style=\"text-align: center;\">0<br \/>\n0<\/td>\n<td style=\"text-align: center;\">0<br \/>\n0<\/td>\n<td style=\"text-align: center;\">1<br \/>\n2\u20133<\/td>\n<td style=\"text-align: center;\">v\u0161echny<br \/>\nv\u0161echny<\/td>\n<\/tr>\n<tr>\n<td><strong>IIA<\/strong><br \/>\n<strong>IIB<\/strong><\/td>\n<td style=\"text-align: center;\">3<br \/>\n1\u20132<\/td>\n<td style=\"text-align: center;\">0<br \/>\n1<\/td>\n<td style=\"text-align: center;\">0<br \/>\n0<\/td>\n<td style=\"text-align: center;\">1 v\u0161echny<\/td>\n<td style=\"text-align: center;\">horn\u00ed, st\u0159edn\u00ed v\u0161echny<\/td>\n<\/tr>\n<tr>\n<td align=\"left\" valign=\"top\"><strong>IIIA<\/strong><br \/>\n<span style=\"color: #ffffff;\"><strong>.<\/strong><\/span><br \/>\n<span style=\"color: #ffffff;\"><strong>.<\/strong><\/span><br \/>\n<strong> IIIB<\/strong><br \/>\n<strong>IIIC<\/strong><\/td>\n<td style=\"text-align: center;\">4a*<br \/>\n3<br \/>\n1,2<br \/>\n3<br \/>\n4a*<br \/>\n4b*<br \/>\nv\u0161echna<\/td>\n<td style=\"text-align: center;\">0<br \/>\n1<br \/>\n2<br \/>\n2<br \/>\n1\u20132<br \/>\nv\u0161echna<br \/>\nN3<\/td>\n<td style=\"text-align: center;\">0<br \/>\n0<br \/>\n0<br \/>\n0<br \/>\n0<br \/>\n0<br \/>\n0<\/td>\n<td style=\"text-align: center;\">v\u0161echny<br \/>\nv\u0161echny<br \/>\nv\u0161echny<br \/>\nv\u0161echny<br \/>\nv\u0161echny<br \/>\nv\u0161echny<br \/>\nv\u0161echny<\/td>\n<td style=\"text-align: center;\">v\u0161echny<br \/>\nv\u0161echny<br \/>\nv\u0161echny<br \/>\nv\u0161echny<br \/>\nv\u0161echny<br \/>\nv\u0161echny<br \/>\nv\u0161echny<\/td>\n<\/tr>\n<tr>\n<td><strong>IV<\/strong><\/td>\n<td style=\"text-align: center;\">v\u0161echna<\/td>\n<td style=\"text-align: center;\">v\u0161echna<\/td>\n<td style=\"text-align: center;\">1<\/td>\n<td style=\"text-align: center;\">v\u0161echny<\/td>\n<td style=\"text-align: center;\">v\u0161echny<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\"><span style=\"color: #ffffff;\">.<\/span><\/p>\n<p class=\"s50\"><em>Tis \u2013 high grade dysplasia<\/em><br \/>\n<em>* Vysv\u011btlen\u00ed str. 283 (stadium T4)<\/em><\/p>\n<p style=\"text-align: justify;\"><em><\/em>Pro staging karcinomu j\u00edcnu je dnes na n\u011bkter\u00fdch pracovi\u0161t\u00edch pou\u017e\u00edv\u00e1na i magnetick\u00e1 rezonance (MRI). V sou\u010dasnosti v\u0161ak nep\u0159in\u00e1\u0161\u00ed vyu\u017eit\u00ed t\u00e9to metody p\u0159\u00ednos proti konven\u010dn\u00edmu zobrazen\u00ed CT a nen\u00ed standardn\u011b za\u0159azov\u00e1na do diagnostick\u00e9ho sch\u00e9matu [17, 18].<\/p>\n<p style=\"text-align: justify;\">Naproti tomu roste v\u00fdznam vyu\u017eit\u00ed pozitronov\u00e9 emisn\u00ed tomografie (PET), zpravidla v kombinaci s CT (PET\/CT) v p\u0159edopera\u010dn\u00ed diagnostice karcinomu j\u00edcnu (obr. 15). V p\u0159edopera\u010dn\u00edm stagingu je p\u0159ednost\u00ed t\u00e9to metody detekce generalizace, posouzen\u00ed efektu neadjuvantn\u00ed l\u00e9\u010dby a nezastupiteln\u00fd v\u00fdznam m\u00e1 PET\/CT p\u0159i diagnostice recidivy a generalizace karcinomu j\u00edcnu v poopera\u010dn\u00edm sledov\u00e1n\u00ed. Byla provedena cel\u00e1 \u0159ada srovn\u00e1vac\u00edch studi\u00ed s dal\u0161\u00edmi zobrazovac\u00edmi metodami,\u00a0zejm\u00e9na CT a endoskopickou sonografi\u00ed, ani\u017e bylo dosa\u017eeno jednozna\u010dn\u00e9 shody o v\u00fdhodnosti a spolehlivosti t\u00e9 \u010di on\u00e9 metody. V\u011bt\u0161inou je doporu\u010dov\u00e1na kombinace v\u00edce zobrazovac\u00edch vy\u0161et\u0159en\u00ed k dosa\u017een\u00ed co nejp\u0159esn\u011bj\u0161\u00edho diagnostick\u00e9ho z\u00e1v\u011bru [19, 20]. P\u0159ev\u00e1\u017en\u00e1 \u010d\u00e1st ZN j\u00edcnu je u n\u00e1s odhalena a\u017e v pokro\u010dil\u00e9m stadiu, kdy\u017e se onemocn\u011bn\u00ed projev\u00ed poruchou polyk\u00e1n\u00ed a \u010dasto jde ji\u017e o generalizaci (obr. 15c,d, obr. 16a,b).<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_506.png\"><img decoding=\"async\" title=\"Obr. 15a \u2013 PET\/CT obraz karcinomu j\u00edcnu; n\u00e1dor ve st\u0159edn\u00ed \u010d\u00e1sti j\u00edcnu bez generalizace\" alt=\"Obr. 15a \u2013 PET\/CT obraz karcinomu j\u00edcnu; n\u00e1dor ve st\u0159edn\u00ed \u010d\u00e1sti j\u00edcnu bez generalizace\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_506.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 15a<br \/>PET\/CT obraz karcinomu j\u00edcnu; n\u00e1dor ve st\u0159edn\u00ed \u010d\u00e1sti j\u00edcnu bez generalizace<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_508.png\"><img decoding=\"async\" title=\"Obr. 15b \u2013 CT obraz karcinomu st\u0159edn\u00edho j\u00edcnu u n\u00e1doru zobrazen\u00e9ho na PET na obr. 15a\" alt=\"Obr. 15b \u2013 CT obraz karcinomu st\u0159edn\u00edho j\u00edcnu u n\u00e1doru zobrazen\u00e9ho na PET na obr. 15a\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_508.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 15b<br \/>CT obraz karcinomu st\u0159edn\u00edho j\u00edcnu u n\u00e1doru zobrazen\u00e9ho na PET na obr. 15a<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_507.png\"><img decoding=\"async\" title=\"Obr. 15c \u2013 PET\/CT obraz karcinomu j\u00edcnu s rozs\u00e1hlou generalizac\u00ed n\u00e1doru\" alt=\"Obr. 15c \u2013 PET\/CT obraz karcinomu j\u00edcnu s rozs\u00e1hlou generalizac\u00ed n\u00e1doru\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_507.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 15c<br \/>PET\/CT obraz karcinomu j\u00edcnu s rozs\u00e1hlou generalizac\u00ed n\u00e1doru<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_509.png\"><img decoding=\"async\" title=\"Obr. 15d \u2013 PET\/CT obraz karcinomu j\u00edcnu s rozs\u00e1hlou generalizac\u00ed n\u00e1doru v transverz\u00e1ln\u00edm \u0159ezu\" alt=\"Obr. 15d \u2013 PET\/CT obraz karcinomu j\u00edcnu s rozs\u00e1hlou generalizac\u00ed n\u00e1doru v transverz\u00e1ln\u00edm \u0159ezu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_509.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 15d<br \/>PET\/CT obraz karcinomu j\u00edcnu s rozs\u00e1hlou generalizac\u00ed n\u00e1doru v transverz\u00e1ln\u00edm \u0159ezu<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_511.png\"><img decoding=\"async\" title=\"Obr. 16a \u2013 St adium onemocn\u011bn\u00ed p\u0159i stanoven\u00ed diagn\u00f3zy u ZN j\u00edcnu (C15) v \u010cR, v\u00fdvoj incidence stadi\u00ed v letech 1982\u20132008\" alt=\"Obr. 16a \u2013 St adium onemocn\u011bn\u00ed p\u0159i stanoven\u00ed diagn\u00f3zy u ZN j\u00edcnu (C15) v \u010cR, v\u00fdvoj incidence stadi\u00ed v letech 1982\u20132008\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_511.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 16a<br \/>St adium onemocn\u011bn\u00ed p\u0159i stanoven\u00ed diagn\u00f3zy u ZN j\u00edcnu (C15) v \u010cR, v\u00fdvoj incidence stadi\u00ed v letech 1982\u20132008<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_512.png\"><img loading=\"lazy\" decoding=\"async\" class=\"  \" title=\"Obr. 16b \u2013 V\u00fdvoj zastoupen\u00ed stadi\u00ed v letech 1982\u20132008\" alt=\"Obr. 16b \u2013 V\u00fdvoj zastoupen\u00ed stadi\u00ed v letech 1982\u20132008\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_512.png\" width=\"200\" height=\"197\" \/><\/a><p class=\"wp-caption-text\">Obr. 16b<br \/>V\u00fdvoj zastoupen\u00ed stadi\u00ed v letech 1982\u20132008<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6>\u00a0Historick\u00fd pohled<\/h6>\n<div style=\"width: 490px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 17 \u2013 Osov\u00e1 \u00fachylka j\u00edcnu p\u0159i klasick\u00e9 rtg pas\u00e1\u017ei ezofagem: A \u2013 dosud nepokro\u010dil\u00fd n\u00e1dor, B, C, D \u2013 r\u016fzn\u00e9 typy osov\u00e9 \u00fachylky sv\u011bd\u010d\u00edc\u00ed pro pokro\u010dilost n\u00e1doru, E \u2013 odd\u00e1len\u00ed lumina j\u00edcnu od p\u00e1te\u0159e sv\u011bd\u010d\u00ed rovn\u011b\u017e pro pokro\u010dil\u00fd n\u00e1dor\" alt=\"Obr. 17 \u2013 Osov\u00e1 \u00fachylka j\u00edcnu p\u0159i klasick\u00e9 rtg pas\u00e1\u017ei ezofagem: A \u2013 dosud nepokro\u010dil\u00fd n\u00e1dor, B, C, D \u2013 r\u016fzn\u00e9 typy osov\u00e9 \u00fachylky sv\u011bd\u010d\u00edc\u00ed pro pokro\u010dilost n\u00e1doru, E \u2013 odd\u00e1len\u00ed lumina j\u00edcnu od p\u00e1te\u0159e sv\u011bd\u010d\u00ed rovn\u011b\u017e pro pokro\u010dil\u00fd n\u00e1dor\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_514.png\" width=\"480\" height=\"163\" \/><p class=\"wp-caption-text\">Obr. 17<br \/>Osov\u00e1 \u00fachylka j\u00edcnu p\u0159i klasick\u00e9 rtg pas\u00e1\u017ei ezofagem:<br \/>A \u2013 dosud nepokro\u010dil\u00fd n\u00e1dor,<br \/>B, C, D \u2013 r\u016fzn\u00e9 typy osov\u00e9 \u00fachylky sv\u011bd\u010d\u00edc\u00ed pro pokro\u010dilost n\u00e1doru,<br \/>E \u2013 odd\u00e1len\u00ed lumina j\u00edcnu od p\u00e1te\u0159e sv\u011bd\u010d\u00ed rovn\u011b\u017e pro pokro\u010dil\u00fd n\u00e1dor<\/p><\/div>\n<p style=\"text-align: justify;\">A\u017e do 60. let minul\u00e9ho stolet\u00ed bylo konven\u010dn\u00ed rentgenov\u00e9 vy\u0161et\u0159en\u00ed pas\u00e1\u017ee j\u00edcnem jedinou mo\u017enost\u00ed, jak stanovit rozsah a d\u00e9lku z\u00fa\u017een\u00ed a pokro\u010dilost n\u00e1doru (obr. 17).<\/p>\n<p style=\"text-align: justify;\">Vztahy n\u00e1doru k okol\u00ed, \u00fatlak \u010di pror\u016fst\u00e1n\u00ed a posti\u017een\u00ed region\u00e1ln\u00edch uzlin bylo mo\u017eno posuzovat jen nep\u0159\u00edmo, vod\u00edtkem bylo zobrazen\u00ed osy j\u00edcnu p\u0159i kontrastn\u00ed pas\u00e1\u017ei ezofagem. V 60. letech minul\u00e9ho stolet\u00ed byla rozpracov\u00e1na v t\u00e9 dob\u011b modern\u00ed metoda pneumomediastina, kter\u00e1 umo\u017e\u0148ovala daleko p\u0159esn\u011bj\u0161\u00ed stanoven\u00ed stadia onemocn\u011bn\u00ed, ne\u017e tomu bylo u pouh\u00e9 kontrastn\u00ed pas\u00e1\u017ee j\u00edcnem. Publikace olomouck\u00fdch pracovn\u00edk\u016f na toto t\u00e9ma (Holub, \u0160ime\u010dek 1968) vyvolala zna\u010dn\u00fd mezin\u00e1rodn\u00ed ohlas. Vpichem v jugulu sm\u011brem pod sternum byl do mediastina aplikov\u00e1n plyn a na zhotoven\u00e9m rentgenov\u00e9ho sn\u00edmku bylo mo\u017eno posuzovat zevn\u00ed obrysy j\u00edcnu a pak velikost n\u00e1doru j\u00edcnu a jeho vztah k okol\u00ed [21]. Toto vy\u0161et\u0159en\u00ed bylo pozd\u011bji zcela nahrazeno daleko dokonalej\u0161\u00ed v\u00fdpo\u010detn\u00ed tomografi\u00ed (CT). Po zaveden\u00ed CT vy\u0161et\u0159en\u00ed pat\u0159ili olomou\u010dt\u00ed chirurgov\u00e9 op\u011bt k pr\u016fkopn\u00edk\u016fm vyu\u017eit\u00ed t\u00e9to metody u karcinomu j\u00edcnu a prvn\u00ed zku\u0161enosti publikovali v roce 1989 [22], stejn\u011b tomu bylo u endoskopick\u00e9 sonografie [23]. V posledn\u00edch letech pak ke zdokonalen\u00ed diagnostiky p\u0159isp\u00edv\u00e1 zaveden\u00ed PET\/CT vy\u0161et\u0159en\u00ed, jeho\u017e v\u00fdznam u karcinomu j\u00edcnu vyhodnocuje sou\u010dasn\u00e1 generace olomouck\u00fdch j\u00edcnov\u00fdch chirurg\u016f, navazuje tak na tradice a reflektuje mo\u017enosti nov\u00fdch zobrazovac\u00edch metod [24].<\/p>\n<p style=\"text-align: justify;\">Lze shrnout, \u017ee v sou\u010dasnosti je k dispozici velk\u00fd po\u010det zobrazovac\u00edch metod k posouzen\u00ed stadia karcinomu j\u00edcnu. Obecn\u011b je doporu\u010dov\u00e1n multimod\u00e1ln\u00ed p\u0159\u00edstup s vyu\u017eit\u00edm CT, endoskopick\u00e9 ultrasonografie a PET\/CT vy\u0161et\u0159en\u00ed, co\u017e vede k maxim\u00e1ln\u00edmu zp\u0159esn\u011bn\u00ed stagingu. Naproti tomu konven\u010dn\u00ed radiologie, perkut\u00e1nn\u00ed ultrasonografie (s v\u00fdjimkou karcinomu kr\u010dn\u00edho j\u00edcnu) a MRI nejsou v sou\u010dasnosti rutinn\u011b za\u0159azov\u00e1ny do diagnostick\u00e9ho sch\u00e9matu.<\/p>\n<h6 class=\"s32\">\u010casn\u00e1 diagnostika a screening<\/h6>\n<p style=\"text-align: justify;\">\u010casn\u00e1 diagnostika je mo\u017en\u00e1 jen endoskopicky. P\u0159\u00edzniv\u00fdch l\u00e9\u010debn\u00fdch v\u00fdsledk\u016f lze dos\u00e1hnout jen u ni\u017e\u0161\u00edch stadi\u00ed onemocn\u011bn\u00ed, a na m\u00edst\u011b je proto snaha o aktivn\u00ed vyhled\u00e1v\u00e1n\u00ed t\u011bchto nemocn\u00fdch v rizikov\u00fdch skupin\u00e1ch v r\u00e1mci preventivn\u00edch program\u016f. Teoreticky by to znamenalo pravideln\u00e9 preventivn\u00ed vy\u0161et\u0159ov\u00e1n\u00ed rizikov\u00fdch skupin (nap\u0159. mu\u017e\u016f, ku\u0159\u00e1k\u016f, alkoholik\u016f nad 50 let), co\u017e se v praxi zat\u00edm nepoda\u0159ilo uskute\u010dnit.<\/p>\n<p style=\"text-align: justify;\">Pouze v centr\u00e1ln\u00edch oblastech \u010c\u00edny s vysokou incidenc\u00ed spinocelul\u00e1rn\u00edho karcinomu j\u00edcnu byl tamn\u00ed vl\u00e1dou organizov\u00e1n screeningov\u00fd program u\u017e\u00edvaj\u00edc\u00ed cytologick\u00fd odb\u011br z j\u00edcnu balonkov\u00fdm kat\u00e9trem. Program byl \u00fasp\u011b\u0161n\u00fd v odhalen\u00ed \u010dasn\u00fdch asymptomatick\u00fdch stadi\u00ed tumoru. Nebyl v\u0161ak prok\u00e1z\u00e1n vliv screeningov\u00e9ho programu na sn\u00ed\u017een\u00ed mortality [25].<\/p>\n<p style=\"text-align: justify;\">V USA ani v z\u00e1padn\u00ed Evrop\u011b nen\u00ed zat\u00edm screening pro spinocelul\u00e1rn\u00ed karcinom j\u00edcnu doporu\u010dov\u00e1n. Naproti tomu u Barrettova j\u00edcnu, kde je prok\u00e1zan\u00e9 zv\u00fd\u0161en\u00e9 riziko vzniku karcinomu, je nam\u00edst\u011b pravideln\u00e9 endoskopick\u00e9 sledov\u00e1n\u00ed s odb\u011brem biopsi\u00ed. Po\u010d\u00e1te\u010dn\u00ed stadium karcinomu j\u00edcnu nem\u00e1 \u017e\u00e1dn\u00e9 specifick\u00e9 p\u0159\u00edznaky a diagn\u00f3za \u010dasn\u00e9ho tumoru m\u016f\u017ee b\u00fdt stanovena pouze v r\u00e1mci pravideln\u00e9ho programu endoskopick\u00e9ho sledov\u00e1n\u00ed nebo jako n\u00e1hodn\u00fd n\u00e1lez. Program endoskopick\u00e9ho sledov\u00e1n\u00ed je u t\u00e9to rizikov\u00e9 skupiny nutn\u00fd [26]. Pravideln\u00e9 sledov\u00e1n\u00ed t\u011bchto nemocn\u00fdch vedlo k podstatn\u00e9mu zv\u00fd\u0161en\u00ed pod\u00edlu operovan\u00fdch pro \u010dasn\u00fd adenokarcinom v sestav\u011b chirurgick\u00e9 kliniky v Mnichov\u011b v pr\u016fb\u011bhu let 1982 a\u017e 2003 z 13,2 % na 49,2 % ze v\u0161ech operovan\u00fdch pro karcinom j\u00edcnu [27]. Zv\u00fd\u0161en\u00e9 riziko v\u00fdskytu karcinomu j\u00edcnu a vhodnost endoskopick\u00e9ho sledov\u00e1n\u00ed se uv\u00e1d\u00ed i u nemocn\u00fdch po del\u0161\u00ed dob\u011b (10\u201320 let) od polept\u00e1n\u00ed j\u00edcnu a s pokro\u010dilou ezofagokardi\u00e1ln\u00ed achal\u00e1zi\u00ed.<\/p>\n<h4 class=\"s15\">13.2.5 Stanoven\u00ed l\u00e9\u010debn\u00e9ho pl\u00e1nu a progn\u00f3za<\/h4>\n<p style=\"text-align: justify;\">Na z\u00e1klad\u011b p\u0159edopera\u010dn\u00edho vy\u0161et\u0159en\u00ed lze asi s 80\u201390% spolehlivost\u00ed stanovit rozsah n\u00e1doru a stadium onemocn\u011bn\u00ed, optim\u00e1ln\u00ed l\u00e9\u010debn\u00fd postup a progn\u00f3zu onemocn\u011bn\u00ed. P\u0159ihl\u00e9dnout je nutno i k celkov\u00e9mu stavu nemocn\u00e9ho, v\u011bku a dal\u0161\u00edm doprovodn\u00fdm onemocn\u011bn\u00edm. Potom je nutn\u00e9 stanovit l\u00e9\u010debn\u00fd pl\u00e1n. Rozhodujeme se mezi radik\u00e1ln\u00ed operac\u00ed, paliativn\u00edmi v\u00fdkony a radioa chemoterapi\u00ed. Chirurgickou l\u00e9\u010dbu je nutno za\u010dlenit do multimod\u00e1ln\u00edho l\u00e9\u010debn\u00e9ho postupu. Z tabulky 6 je patrn\u00e9, \u017ee multimod\u00e1ln\u00ed l\u00e9\u010dba byla v \u010cR u karcinomu j\u00edcnu v uplynul\u00fdch letech provedena u necel\u00fdch 20 % l\u00e9\u010den\u00fdch pacient\u016f [28].<\/p>\n<p style=\"text-align: justify;\">N\u00e1dory um\u00edst\u011bn\u00e9 or\u00e1ln\u011b od bifurkace trachey maj\u00ed obecn\u011b hor\u0161\u00ed progn\u00f3zu vzhledem k jejich \u010dast\u00e9mu pror\u016fst\u00e1n\u00ed do okoln\u00edch struktur. Pom\u011brn\u011b nejlep\u0161\u00ed progn\u00f3zu m\u00e1 diferencovan\u00fd spinocelul\u00e1rn\u00ed karcinom. Nejd\u016fle\u017eit\u011bj\u0161\u00edm prognostick\u00fdm faktorem je pokro\u010dilost onemocn\u011bn\u00ed. Z nemocn\u00fdch, u kter\u00fdch byl zji\u0161t\u011bn n\u00e1dor j\u00edcnu, lze operovat jen men\u0161\u00ed \u010d\u00e1st. Jak vypl\u00fdv\u00e1 z \u00fadaj\u016f v tab. 7, z celkov\u00e9ho po\u010dtu diagnostikovan\u00fdch n\u00e1dor\u016f j\u00edcnu byla mo\u017en\u00e1 operace jen asi ve 40 % a radik\u00e1ln\u011b bylo operov\u00e1no jen necel\u00fdch 20 %.<\/p>\n<table class=\"CSSTableGenerator\" style=\"border-collapse: collapse; width: 100%;\" border=\"0\" cellspacing=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\" colspan=\"5\"><span style=\"color: #ffffff;\">Tab. 6<\/span><br \/>\n<span style=\"color: #ffffff;\">Prim\u00e1rn\u00ed opera\u010dn\u00ed l\u00e9\u010dba v kombinaci s dal\u0161\u00edmi l\u00e9\u010debn\u00fdmi modalitami u nov\u011b diagnostikovan\u00fdch zhoubn\u00fdch novotvar\u016f v \u010cR za rok, pr\u016fm\u011br z obdob\u00ed 2001\u20132005 <span class=\"s25\">[28]<\/span><\/span><\/td>\n<\/tr>\n<tr>\n<td><\/td>\n<td style=\"text-align: left; width: 15%;\" valign=\"top\"><strong>Po\u010det pacient\u016f ro\u010dn\u011b celkem<\/strong><\/td>\n<td style=\"width: 15%;\" valign=\"top\"><strong>V\u0161ichni operovan\u00ed<\/strong><\/td>\n<td style=\"width: 15%;\" valign=\"top\"><strong>Pouze operace<\/strong><\/td>\n<td style=\"width: 15%;\" valign=\"top\"><strong>Operace<\/strong><br \/>\n<strong> v kombinaci<\/strong><br \/>\n<strong> s jinou l\u00e9\u010dbou<\/strong><\/td>\n<\/tr>\n<tr>\n<td>dutina \u00fastn\u00ed a hltan (C00\u2013C14)<\/td>\n<td>1 177<\/td>\n<td>75,7 %<\/td>\n<td>24,5 %<\/td>\n<td>51,2 %<\/td>\n<\/tr>\n<tr>\n<td>j\u00edcen (C15)<\/td>\n<td>454<\/td>\n<td>39,9 %<\/td>\n<td>20,3 %<\/td>\n<td>19,6 %<\/td>\n<\/tr>\n<tr>\n<td>\u017ealudek (C16)<\/td>\n<td>1 726<\/td>\n<td>59,8 %<\/td>\n<td>42,9 %<\/td>\n<td>16,9 %<\/td>\n<\/tr>\n<tr>\n<td>tlust\u00e9 st\u0159evo a kone\u010dn\u00edk (C18\u2013 C21)<\/td>\n<td>8 020<\/td>\n<td>82,3 %<\/td>\n<td>44,2 %<\/td>\n<td>38,1 %<\/td>\n<\/tr>\n<tr>\n<td>j\u00e1tra a intrahepat\u00e1ln\u00ed \u017elu\u010dov\u00e9 cesty (C22)<\/td>\n<td>809<\/td>\n<td>13,4 %<\/td>\n<td>9,3 %<\/td>\n<td>4,1 %<\/td>\n<\/tr>\n<tr>\n<td>\u017elu\u010dn\u00edk a \u017elu\u010dov\u00e9 cesty (C23, C24)<\/td>\n<td>1 009<\/td>\n<td>45,1 %<\/td>\n<td>34,9 %<\/td>\n<td>10,2 %<\/td>\n<\/tr>\n<tr>\n<td>slinivka b\u0159i\u0161n\u00ed (C25)<\/td>\n<td>1 704<\/td>\n<td>31,8 %<\/td>\n<td>20,1 %<\/td>\n<td>11,7 %<\/td>\n<\/tr>\n<tr>\n<td>hrtan (C32)<\/td>\n<td>535<\/td>\n<td>79,7 %<\/td>\n<td>27,0 %<\/td>\n<td>52,7 %<\/td>\n<\/tr>\n<tr>\n<td>pr\u016fdu\u0161nice, pr\u016fdu\u0161ky a pl\u00edce (C33, C34)<\/td>\n<td>6 146<\/td>\n<td>15,6 %<\/td>\n<td>8,6 %<\/td>\n<td>7,0 %<\/td>\n<\/tr>\n<tr>\n<td>melanom k\u016f\u017ee (C43)<\/td>\n<td>1 653<\/td>\n<td>97,6 %<\/td>\n<td>85,9 %<\/td>\n<td>11,7 %<\/td>\n<\/tr>\n<tr>\n<td>jin\u00fd ko\u017en\u00ed n\u00e1dor (C44)<\/td>\n<td>14 659<\/td>\n<td>98,2 %<\/td>\n<td>96,3 %<\/td>\n<td>1,9 %<\/td>\n<\/tr>\n<tr>\n<td>pojivov\u00e9 a m\u011bkk\u00e9 tk\u00e1n\u011b (C47, C49)<\/td>\n<td>261<\/td>\n<td>86,6 %<\/td>\n<td>46,9 %<\/td>\n<td>39,7 %<\/td>\n<\/tr>\n<tr>\n<td>prs \u2013 \u017eeny (C50)<\/td>\n<td>5 600<\/td>\n<td>84,4 %<\/td>\n<td>10,5 %<\/td>\n<td>73,9 %<\/td>\n<\/tr>\n<tr>\n<td>hrdlo d\u011blo\u017en\u00ed \u2013 cervicis uteri (C53)<\/td>\n<td>1 038<\/td>\n<td>74,6 %<\/td>\n<td>35,9 %<\/td>\n<td>38,8 %<\/td>\n<\/tr>\n<tr>\n<td>d\u011bloha (C54, C55)<\/td>\n<td>1 746<\/td>\n<td>89,9 %<\/td>\n<td>39,9 %<\/td>\n<td>50,0 %<\/td>\n<\/tr>\n<tr>\n<td>vaje\u010dn\u00edk (C56)<\/td>\n<td>1 235<\/td>\n<td>81,7 %<\/td>\n<td>22,5 %<\/td>\n<td>59,2 %<\/td>\n<\/tr>\n<tr>\n<td>p\u0159edstojn\u00e1 \u017el\u00e1za \u2013 prostata (C61)<\/td>\n<td>3 955<\/td>\n<td>56,9 %<\/td>\n<td>28,6 %<\/td>\n<td>28,4 %<\/td>\n<\/tr>\n<tr>\n<td>varle (C62)<\/td>\n<td>415<\/td>\n<td>97,6 %<\/td>\n<td>18,0 %<\/td>\n<td>79,6 %<\/td>\n<\/tr>\n<tr>\n<td>ledvina (C64)<\/td>\n<td>2 613<\/td>\n<td>70,8 %<\/td>\n<td>62,7 %<\/td>\n<td>8,2 %<\/td>\n<\/tr>\n<tr>\n<td>mo\u010dov\u00fd m\u011bch\u00fd\u0159 (C67)<\/td>\n<td>2 263<\/td>\n<td>91,0 %<\/td>\n<td>75,4 %<\/td>\n<td>15,6 %<\/td>\n<\/tr>\n<tr>\n<td>mozek a m\u00edcha (C70\u2013C72)<\/td>\n<td>780<\/td>\n<td>64,8 %<\/td>\n<td>24,8 %<\/td>\n<td>39,9 %<\/td>\n<\/tr>\n<tr>\n<td>\u0161t\u00edtn\u00e1 \u017el\u00e1za (C73)<\/td>\n<td>646<\/td>\n<td>90,8 %<\/td>\n<td>37,6 %<\/td>\n<td>53,3 %<\/td>\n<\/tr>\n<tr>\n<td>ostatn\u00ed zhoubn\u00e9 n\u00e1dory<\/td>\n<td>2 729<\/td>\n<td>49,1 %<\/td>\n<td>29,7 %<\/td>\n<td>19,4 %<\/td>\n<\/tr>\n<tr>\n<td>Celkem<\/td>\n<td>61 173<\/td>\n<td>72,8 %<\/td>\n<td>48,2 %<\/td>\n<td>24,5 %<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\"><span style=\"color: #ffffff;\">.<\/span><\/p>\n<p>&nbsp;<\/p>\n<table class=\"CSSTableGenerator\" style=\"border-collapse: collapse; width: 100%;\" border=\"0\" cellspacing=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\" colspan=\"5\"><span style=\"color: #ffffff;\">Tab. 7<\/span><br \/>\n<span style=\"color: #ffffff;\"> Prim\u00e1rn\u00ed opera\u010dn\u00ed l\u00e9\u010dba u nov\u011b diagnostikovan\u00fdch zhoubn\u00fdch novotvar\u016f v \u010cR za rok, pr\u016fm\u011br z obdob\u00ed 2001\u20132005 <span class=\"s25\">[28]<\/span><\/span><\/td>\n<\/tr>\n<tr>\n<td><\/td>\n<td style=\"width: 15%;\" valign=\"top\"><strong>Po\u010det pacient\u016f ro\u010dn\u011b celkem<\/strong><\/td>\n<td width=\"15%\"><strong>V\u0161ichni prim\u00e1rn\u011b operovan\u00ed pacienti ro\u010dn\u011b<\/strong><\/td>\n<td style=\"width: 15%;\" valign=\"top\"><strong>Radik\u00e1ln\u00ed operace* ro\u010dn\u011b<\/strong><\/td>\n<td style=\"width: 15%;\" valign=\"top\"><strong>Jin\u00e9 operace ro\u010dn\u011b<\/strong><\/td>\n<\/tr>\n<tr>\n<td>dutina \u00fastn\u00ed a hltan (C00\u2013C14)<\/td>\n<td>1 177<\/td>\n<td>891 (75,7 %)<\/td>\n<td>601 (51,1 %)<\/td>\n<td>290 (24,6 %)<\/td>\n<\/tr>\n<tr>\n<td>j\u00edcen (C15)<\/td>\n<td>454<\/td>\n<td>181 (39,9 %)<\/td>\n<td>89 (19,6 %)<\/td>\n<td>92 (20,3 %)<\/td>\n<\/tr>\n<tr>\n<td>\u017ealudek (C16)<\/td>\n<td>1 726<\/td>\n<td>1 032 (59,8 %)<\/td>\n<td>686 (39,7 %)<\/td>\n<td>346 (20,0 %)<\/td>\n<\/tr>\n<tr>\n<td>tlust\u00e9 st\u0159evo a kone\u010dn\u00edk (C18\u2013C21)<\/td>\n<td>8 020<\/td>\n<td>6 602 (82,3 %)<\/td>\n<td>5 574 (69,5 %)<\/td>\n<td>1 028 (12,8 %)<\/td>\n<\/tr>\n<tr>\n<td>j\u00e1tra a intrahepat\u00e1ln\u00ed \u017elu\u010dov\u00e9 cesty (C22)<\/td>\n<td>809<\/td>\n<td>108 (13,3 %)<\/td>\n<td>29 (3,6 %)<\/td>\n<td>79 (9,8 %)<\/td>\n<\/tr>\n<tr>\n<td>\u017elu\u010dn\u00edk a \u017elu\u010dov\u00e9 cesty (C23, C24)<\/td>\n<td>1 009<\/td>\n<td>455 (45,1 %)<\/td>\n<td>255 (25,3 %)<\/td>\n<td>200 (19,8 %)<\/td>\n<\/tr>\n<tr>\n<td>slinivka b\u0159i\u0161n\u00ed (C25)<\/td>\n<td>1 704<\/td>\n<td>542 (31,8 %)<\/td>\n<td>135 (7,9 %)<\/td>\n<td>407 (23,9 %)<\/td>\n<\/tr>\n<tr>\n<td>hrtan (C32)<\/td>\n<td>535<\/td>\n<td>426 (79,6 %)<\/td>\n<td>282 (52,7 %)<\/td>\n<td>144 (26,9 %)<\/td>\n<\/tr>\n<tr>\n<td>pr\u016fdu\u0161nice, pr\u016fdu\u0161ky a pl\u00edce (C33, C34)<\/td>\n<td>6 146<\/td>\n<td>960 (15,6 %)<\/td>\n<td>689 (11,2 %)<\/td>\n<td>271 (4,4 %)<\/td>\n<\/tr>\n<tr>\n<td>melanom k\u016f\u017ee (C43)<\/td>\n<td>1 653<\/td>\n<td>1 613 (97,6 %)<\/td>\n<td>1 567 (94,8 %)<\/td>\n<td>46 (2,8 %)<\/td>\n<\/tr>\n<tr>\n<td>jin\u00fd ko\u017en\u00ed n\u00e1dor (C44)<\/td>\n<td>14 659<\/td>\n<td>14 395 (98,2 %)<\/td>\n<td>14 176 (96,7 %)<\/td>\n<td>219 (1,5 %)<\/td>\n<\/tr>\n<tr>\n<td>pojivov\u00e9 a m\u011bkk\u00e9 tk\u00e1n\u011b (C47, C49)<\/td>\n<td>261<\/td>\n<td>226 (86,6 %)<\/td>\n<td>194 (74,3 %)<\/td>\n<td>32 (12,3 %)<\/td>\n<\/tr>\n<tr>\n<td>prs \u2013 \u017eeny (C50)<\/td>\n<td>5 600<\/td>\n<td>4 728 (84,4 %)<\/td>\n<td>4 203 (75,1 %)<\/td>\n<td>525 (9,4 %)<\/td>\n<\/tr>\n<tr>\n<td>hrdlo d\u011blo\u017en\u00ed \u2013 cervicis uteri (C53)<\/td>\n<td>1 038<\/td>\n<td>775 (74,7 %)<\/td>\n<td>573 (55,2 %)<\/td>\n<td>202 (19,5 %)<\/td>\n<\/tr>\n<tr>\n<td>d\u011bloha (C54, C55)<\/td>\n<td>1 746<\/td>\n<td>1 570 (89,9 %)<\/td>\n<td>1 439 (82,4 %)<\/td>\n<td>131 (7,5 %)<\/td>\n<\/tr>\n<tr>\n<td>vaje\u010dn\u00edk (C56)<\/td>\n<td>1 235<\/td>\n<td>1 009 (81,7 %)<\/td>\n<td>741 (60,0 %)<\/td>\n<td>268 (21,7 %)<\/td>\n<\/tr>\n<tr>\n<td>p\u0159edstojn\u00e1 \u017el\u00e1za \u2013 prostata (C61)<\/td>\n<td>3 955<\/td>\n<td>2 252 (56,9 %)<\/td>\n<td>1 098 (27,8 %)<\/td>\n<td>1 154 (29,2 %)<\/td>\n<\/tr>\n<tr>\n<td>varle (C62)<\/td>\n<td>415<\/td>\n<td>405 (97,6 %)<\/td>\n<td>393 (94,7 %)<\/td>\n<td>12 (2,9 %)<\/td>\n<\/tr>\n<tr>\n<td>ledvina (C64)<\/td>\n<td>2 613<\/td>\n<td>1 850 (70,8 %)<\/td>\n<td>1 770 (67,7 %)<\/td>\n<td>80 (3,1 %)<\/td>\n<\/tr>\n<tr>\n<td>mo\u010dov\u00fd m\u011bch\u00fd\u0159 (C67)<\/td>\n<td>2 263<\/td>\n<td>2 059 (91,0 %)<\/td>\n<td>1 602 (70,8 %)<\/td>\n<td>457 (20,2 %)<\/td>\n<\/tr>\n<tr>\n<td>mozek a m\u00edcha (C70\u2013C72)<\/td>\n<td>780<\/td>\n<td>505 (64,7 %)<\/td>\n<td>375 (48,1 %)<\/td>\n<td>130 (16,7 %)<\/td>\n<\/tr>\n<tr>\n<td>\u0161t\u00edtn\u00e1 \u017el\u00e1za (C73)<\/td>\n<td>646<\/td>\n<td>587 (90,9 %)<\/td>\n<td>571 (88,4 %)<\/td>\n<td>16 (2,5 %)<\/td>\n<\/tr>\n<tr>\n<td>ostatn\u00ed zhoubn\u00e9 n\u00e1dory<\/td>\n<td>2 729<\/td>\n<td>1 339 (49,1 %)<\/td>\n<td>839 (30,7 %)<\/td>\n<td>500 (18,3 %)<\/td>\n<\/tr>\n<tr>\n<td>Celkem<\/td>\n<td>61 173<\/td>\n<td>44 510 (72,8 %)<\/td>\n<td>37 882 (61,9 %)<\/td>\n<td>6 628 (10,8 %)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\"><span style=\"color: #ffffff;\">.<\/span><\/p>\n<h4 class=\"s15\">13.2.6 L\u00e9\u010dba karcinomu j\u00edcnu<\/h4>\n<p style=\"text-align: justify;\">L\u00e9\u010debn\u00e1 strategie karcinomu j\u00edcnu vych\u00e1z\u00ed ze snahy o proveden\u00ed R0 resekce, co\u017e je z\u00e1kladn\u00ed p\u0159edpoklad dosa\u017een\u00ed dlouhodob\u011bj\u0161\u00edho \u010di trval\u00e9ho l\u00e9\u010debn\u00e9ho efektu. Z\u00e1kladn\u00edmi body p\u0159i posuzov\u00e1n\u00ed indikace k l\u00e9\u010db\u011b je lokalizace prim\u00e1rn\u00edho tumoru, hloubka invaze n\u00e1doru a posti\u017een\u00ed uzlin. Pro na\u0161e rozhodov\u00e1n\u00ed m\u00e1 tak\u00e9 z\u00e1sadn\u00ed v\u00fdznam celkov\u00fd stav nemocn\u00e9ho, kter\u00fd m\u016f\u017ee limitovat jak chirurgickou tak multimod\u00e1ln\u00ed l\u00e9\u010dbu.<\/p>\n<p style=\"text-align: justify;\">Dal\u0161\u00edmi l\u00e9\u010debn\u00fdmi mo\u017enostmi jsou chemoterapie a radioterapie. Spinocelul\u00e1rn\u00ed karcinom je chemoa radiosensitivn\u011bj\u0161\u00ed ne\u017e adenokarcinom, ale v dlouhodob\u011bj\u0161\u00edm sledov\u00e1n\u00ed nejsou mezi ob\u011bma histologick\u00fdmi typy v\u00fdrazn\u011bj\u0161\u00ed rozd\u00edly v l\u00e9\u010debn\u00fdch v\u00fdsledc\u00edch. Ke standardn\u011b pod\u00e1van\u00fdm cytostatik\u016fm pat\u0159\u00ed 5-fluorouracil a cisplatina. Oz\u00e1\u0159en\u00ed se prov\u00e1d\u00ed megavolt\u00e1\u017en\u00edmi zdroji frakcionovan\u011b do celkov\u00e9 d\u00e1vky 50\u201360 Gy. P\u0159ed samostatnou chemoa radioterapi\u00ed se dnes d\u00e1v\u00e1 p\u0159ednost kombinaci lok\u00e1ln\u00edho a syst\u00e9mov\u00e9ho p\u0159\u00edstupu a chemoterapie se pod\u00e1v\u00e1 sou\u010dasn\u011b se z\u00e1\u0159en\u00edm. Tento modern\u00ed p\u0159\u00edstup se ozna\u010duje jako konkomitantn\u00ed chemoradioterapie. Roz\u0161\u00ed\u0159en\u00ed t\u00e9to metody umo\u017enilo zaveden\u00ed m\u00e9n\u011b toxick\u00fdch cytostatik, kter\u00e9 nav\u00edc zvy\u0161uj\u00ed sensitivitu na oz\u00e1\u0159en\u00ed. P\u0159esto je st\u00e1le nutno po\u010d\u00edtat s mo\u017enost\u00ed vedlej\u0161\u00edch toxick\u00fdch \u00fa\u010dink\u016f, ke kter\u00fdm pat\u0159\u00ed zvracen\u00ed, pr\u016fjmy, vznik enteritidy apod. Neoadjuvantn\u00ed chemoradioterapie rovn\u011b\u017e negativn\u011b ovliv\u0148uje opera\u010dn\u00ed morbiditu a mortalitu. V l\u00e9\u010debn\u00e9 strategii u spinocelul\u00e1rn\u00edho karcinomu v horn\u00ed a st\u0159edn\u00ed t\u0159etin\u011b j\u00edcnu je konkomitantn\u00ed chemoradioterapie pova\u017eov\u00e1na n\u011bkter\u00fdmi onkology za alternativu ezofagektomie se srovnateln\u00fdmi v\u00fdsledky l\u00e9\u010dby [29].<\/p>\n<p style=\"text-align: justify;\">Neoperativn\u00ed l\u00e9\u010den\u00ed se vol\u00ed zejm\u00e9na u spinocelul\u00e1rn\u00edho karcinomu kr\u010dn\u00edho j\u00edcnu. N\u00e1dor v t\u00e9to lokalizaci je pom\u011brn\u011b vz\u00e1cn\u00fd a vyskytuje se jen asi v 5\u201315 % v\u0161ech zhoubn\u00fdch n\u00e1dor\u016f j\u00edcnu. Progn\u00f3za je \u0161patn\u00e1 pro obvykle vysokou lok\u00e1ln\u00ed agresivitu n\u00e1doru, pozdn\u00ed stanoven\u00ed diagn\u00f3zy a dosud nejednotn\u00fd n\u00e1zor na optim\u00e1ln\u00ed l\u00e9\u010dbu. Publikovan\u00e9 studie zahrnuj\u00ed mal\u00fd po\u010det r\u016fznorod\u00fdch pacient\u016f. \u010casto se pojedn\u00e1v\u00e1 spole\u010dn\u011b o hypofaryng\u00e1ln\u00edm karcinomu, jeho\u017e progn\u00f3za je v\u00fdznamn\u011b lep\u0161\u00ed ne\u017e u karcinomu kr\u010dn\u00edho j\u00edcnu [30, 31]. Z chirurgick\u00e9ho hlediska u operabiln\u00edch stav\u016f p\u0159ich\u00e1z\u00ed v \u00favahu tot\u00e1ln\u00ed nebo kr\u010dn\u00ed ezofagektomie, ale i pharyngo-laryngo-ezofagektomie a rekonstrukce \u017ealude\u010dn\u00edm tubusem \u010di voln\u011b p\u0159enesenou jejun\u00e1ln\u00ed kli\u010dkou. Tyto technicky n\u00e1ro\u010dn\u00e9 v\u00fdkony vy\u017eaduj\u00ed i speci\u00e1ln\u00ed kombinovan\u00fd p\u0159\u00edstup sest\u00e1vaj\u00edc\u00ed obvykle s vysok\u00e9 torakotomie ve t\u0159et\u00edm mezi\u017eeb\u0159\u00ed, laparotomie a \u0161irok\u00e9ho kol\u00e1rn\u00edho \u0159ezu na krku. Morbidita po t\u011bchto n\u00e1ro\u010dn\u00fdch v\u00fdkonech je uv\u00e1d\u011bna v rozmez\u00ed 30\u201370 % a mortalita do 10 % [32, 33, 34].<\/p>\n<p style=\"text-align: justify;\">P\u0159edopera\u010dn\u00ed aktinoterapie (neoadjuvantn\u00ed) m\u00e1 za c\u00edl p\u0159edev\u0161\u00edm zlep\u0161en\u00ed operability spinocelul\u00e1rn\u00edho karcinomu (obvykle kr\u00e1tkodob\u00e9 oz\u00e1\u0159en\u00ed b\u011bhem 1\u20132 t\u00fddn\u016f do d\u00e1vky 15 a\u017e 30 Gy). Opera\u010dn\u00ed v\u00fdkon pak n\u00e1sleduje po 4\u20136 t\u00fddnech. Poopera\u010dn\u00ed aktinoterapie (adjuvantn\u00ed) m\u00e1 za c\u00edl likvidaci rezidu\u00e1ln\u00edch n\u00e1dorov\u00fdch bun\u011bk, p\u0159edev\u0161\u00edm u resekc\u00ed R1 a u posti\u017een\u00ed uzlin. U inoperabiln\u00edch n\u00e1dor\u016f vede aktinoterapie ke zmen\u0161en\u00ed tumor\u00f3zn\u00ed masy a zlep\u0161en\u00ed dysfagie. Pln\u00e1 terapeutick\u00e1 d\u00e1vka (40\u201360 Gy) se obvykle aplikuje b\u011bhem 4\u20136 t\u00fddn\u016f. Metoda intralumin\u00e1ln\u00edho oz\u00e1\u0159en\u00ed \u2013 afterloading \u2013 je vhodn\u00e1 zvl\u00e1\u0161t\u011b pro exofyticky, do lumen rostouc\u00ed n\u00e1dory. V\u00fdhodou je p\u0159\u00edm\u00e1 lok\u00e1ln\u00ed aplikace vysok\u00e9 d\u00e1vky z\u00e1\u0159en\u00ed bez \u0161kodliv\u00e9ho p\u016fsoben\u00ed na okoln\u00ed zdrav\u00e9 tk\u00e1n\u011b (3\u20136 aplikac\u00ed 7 Gy ze vzd\u00e1lenosti 1 cm). Mnoh\u00e9 nad\u011bje vkl\u00e1dan\u00e9 do chemoterapie, kter\u00e1 se dnes u\u017e\u00edv\u00e1 v\u011bt\u0161inou v kombinaci s dal\u0161\u00edmi l\u00e9\u010debn\u00fdmi postupy, nep\u0159inesly zat\u00edm prokazateln\u00e9 v\u00fdsledky. O neoadjuvantn\u00edm \u010di adjuvantn\u00edm l\u00e9\u010debn\u00e9m re\u017eimu v kombinaci s chirurgickou l\u00e9\u010dbou je pojedn\u00e1no d\u00e1le.<\/p>\n<h6 class=\"s32\">\u010casn\u00fd (povrchn\u00ed) karcinom j\u00edcnu (T1)<\/h6>\n<div style=\"width: 491px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_522.png\"><img loading=\"lazy\" decoding=\"async\" class=\" \" title=\"Obr. 18 \u2013 Hloubka n\u00e1dorov\u00e9 invaze a jej\u00ed ozna\u010den\u00ed podle japonsk\u00e9 klasifikace pro spinocelul\u00e1rn\u00ed karcinom j\u00edcnu. \u010casn\u00fd n\u00e1dor j\u00edcnu p\u0159edstavuj\u00ed stadia M1\u20133, kdy infiltrace nezasahuje do submuk\u00f3zy, ale stadium M3 m\u00e1 ji\u017e riziko lymfatick\u00e9ho metast\u00e1zov\u00e1n\u00ed\" alt=\"Obr. 18 \u2013 Hloubka n\u00e1dorov\u00e9 invaze a jej\u00ed ozna\u010den\u00ed podle japonsk\u00e9 klasifikace pro spinocelul\u00e1rn\u00ed karcinom j\u00edcnu. \u010casn\u00fd n\u00e1dor j\u00edcnu p\u0159edstavuj\u00ed stadia M1\u20133, kdy infiltrace nezasahuje do submuk\u00f3zy, ale stadium M3 m\u00e1 ji\u017e riziko lymfatick\u00e9ho metast\u00e1zov\u00e1n\u00ed\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_522.png\" width=\"481\" height=\"184\" \/><\/a><p class=\"wp-caption-text\">Obr. 18 \u2013 Hloubka n\u00e1dorov\u00e9 invaze a jej\u00ed ozna\u010den\u00ed podle japonsk\u00e9 klasifikace pro spinocelul\u00e1rn\u00ed karcinom j\u00edcnu. \u010casn\u00fd n\u00e1dor j\u00edcnu p\u0159edstavuj\u00ed stadia M1\u20133, kdy infiltrace nezasahuje do submuk\u00f3zy, ale stadium M3 m\u00e1 ji\u017e riziko lymfatick\u00e9ho metast\u00e1zov\u00e1n\u00ed<\/p><\/div>\n<p style=\"text-align: justify;\">Je definov\u00e1n jako n\u00e1dor nepror\u016fstaj\u00edc\u00ed do submuk\u00f3zy. Hloubku invaze \u010dasn\u00e9ho n\u00e1doru podle japonsk\u00e9 klasifikace n\u00e1dor\u016f j\u00edcnu [35] ukazuje obr. 18.<\/p>\n<p style=\"text-align: justify;\">Frekvence \u010dasn\u00e9ho karcinomu je v Japonsku ud\u00e1v\u00e1na mezi 15 a 30 % [35\u201337]. V z\u00e1padn\u00edch zem\u00edch je tato incidence mnohem ni\u017e\u0161\u00ed, proto\u017ee na rozd\u00edl od Japonska zde neexistuje \u017e\u00e1dn\u00fd screeningov\u00fd program pro tumory v horn\u00ed \u010d\u00e1sti za\u017e\u00edvac\u00edho traktu \u2013 foregut carcinoma [36]. Pro l\u00e9\u010debnou strategii t\u011bchto n\u00e1dor\u016f je d\u016fle\u017eit\u00e1 ot\u00e1zka mo\u017en\u00e9ho lymfatick\u00e9ho metast\u00e1zov\u00e1n\u00ed. Zat\u00edmco tumory klasifikace T1M1\u2013M2 (viz obr. 18) nedosahuj\u00ed do oblasti lymfatick\u00fdch c\u00e9v a nen\u00ed u nich riziko metast\u00e1zov\u00e1n\u00ed do lymfatick\u00fdch uzlin, tumory stadia T1M3 ji\u017e maj\u00ed lymfatickou dren\u00e1\u017e a frekvence metast\u00e1zov\u00e1n\u00ed do lymfatick\u00fdch uzlin je ud\u00e1v\u00e1na a\u017e v 16 % [38, 39]. N\u00e1dory s v\u011bt\u0161\u00ed hloubkou pror\u016fst\u00e1n\u00ed T1SM2\u20133 maj\u00ed riziko lymfatick\u00e9ho metast\u00e1zov\u00e1n\u00ed p\u0159esahuj\u00edc\u00ed 70 % [36, 38\u201340]. Z t\u011bchto zji\u0161t\u011bn\u00ed vypl\u00fdv\u00e1 z\u00e1v\u011br, \u017ee endoskopick\u00e1 resekce n\u00e1doru (endoskopick\u00e1 mukosektomie) je opr\u00e1vn\u011bn\u00e1 jen u stadia T1M1\u2013M2 japonsk\u00e9 klasifikace, kde nen\u00ed riziko lymfatick\u00e9ho metast\u00e1zov\u00e1n\u00ed. S endoskopickou mukosektomi\u00ed, tj. odstran\u011bn\u00ed n\u00e1doru s okoln\u00ed zdravou sliznic\u00ed a submuk\u00f3zou, byly velmi dobr\u00e9 dlouhodob\u00e9 v\u00fdsledky z\u00edsk\u00e1ny zejm\u00e9na v Japonsku. U n\u00e1s, kde diagnostika t\u011bchto ran\u00fdch stadi\u00ed je zat\u00edm bohu\u017eel v\u00fdjimkou, dostate\u010dn\u00e9 zku\u0161enosti chyb\u011bj\u00ed. U vy\u0161\u0161\u00edch stadi\u00ed japonsk\u00e9 klasifikace (T1M3 a hlub\u0161\u00ed pror\u016fst\u00e1n\u00ed) je pak indikov\u00e1na chirurgick\u00e1 resekce j\u00edcnu s lymfadenektomi\u00ed jako standardn\u00ed postup. Neoadjuvantn\u00ed l\u00e9\u010dba \u010dasn\u00e9ho karcinomu j\u00edcnu je st\u00e1le p\u0159edm\u011btem diskuze a v n\u011bkter\u00fdch centrech je pou\u017e\u00edv\u00e1na, i kdy\u017e jej\u00ed jednozna\u010dn\u00fd p\u0159\u00ednos nen\u00ed dosud na z\u00e1klad\u011b krit\u00e9ri\u00ed evidence based medicine prok\u00e1z\u00e1n.<\/p>\n<h6 class=\"s32\">Pokro\u010dil\u00fd karcinom<\/h6>\n<p style=\"text-align: justify;\"><strong>Stadium T2\u2013T3<br \/>\n<\/strong>L\u00e9\u010dba pokro\u010dil\u00e9ho karcinomu j\u00edcnu spo\u010d\u00edv\u00e1 bu\u010f v samostatn\u00e9m chirurgick\u00e9m l\u00e9\u010den\u00ed, nebo ve spojen\u00ed s multimod\u00e1ln\u00ed l\u00e9\u010dbou. Ta m\u00e1 dv\u011b varianty: neoadjuvantn\u00ed terapii p\u0159edch\u00e1zej\u00edc\u00ed chirurgickou resekci \u010di l\u00e9\u010dbu adjuvantn\u00ed po proveden\u00e9 operaci. O neadjuvantn\u00ed a adjuvantn\u00ed l\u00e9\u010db\u011b je bl\u00ed\u017ee pojedn\u00e1no d\u00e1le.<\/p>\n<p style=\"text-align: justify;\"><strong>Stadium T4<br \/>\n<\/strong>U v\u011bt\u0161iny nemocn\u00fdch v tomto stadiu je indikov\u00e1na definitivn\u00ed radiochemoterapie pro nemo\u017enost proveden\u00ed resekce pro lok\u00e1ln\u00ed inoperabilitu \u010di vzhledem k celkov\u00e9mu stavu nemocn\u00e9ho. Indikace k chirurgick\u00e9 terapii v tomto stadiu je z\u00e1visl\u00e1 na mo\u017enosti proveden\u00ed R0 resekce. Ve stadiu T4a p\u0159i pror\u016fst\u00e1n\u00ed tumoru do pleury, perikardu nebo br\u00e1nice je mo\u017en\u00e9 prov\u00e9st radik\u00e1ln\u00ed resekci nebo se pokusit o zlep\u0161en\u00ed operability (downstaging) neoadjuvantn\u00ed chemoradioterapi\u00ed. P\u0159i invazi n\u00e1doru do vit\u00e1ln\u00edch struktur (T4b), jako jsou velk\u00e9 c\u00e9vy, trachea a podobn\u011b, je obvykle indikov\u00e1na definitivn\u00ed chemoradioterapie, po jej\u00edm\u017e ukon\u010den\u00ed a kontrole \u00fastupu n\u00e1lezu pomoc\u00ed vy\u0161et\u0159en\u00ed v\u00fdpo\u010detn\u00ed tomografi\u00ed (CT) je n\u011bkdy mo\u017eno je\u0161t\u011b p\u0159i dobr\u00e9m stavu pacienta p\u0159istoupit k operaci, ozna\u010dovan\u00e9 v odborn\u00e9 literatu\u0159e jako salvage surgery [41, 42]. Nakolik je tento postup pro nemocn\u00e9ho p\u0159\u00ednosem, nen\u00ed zat\u00edm ov\u011b\u0159eno.<\/p>\n<h6 class=\"s20\">Neoadjuvantn\u00ed chemoradioterapie<\/h6>\n<p style=\"text-align: justify;\">P\u0159\u00ednos a rizika neadjuvantn\u00ed chemoradioterapie byly v posledn\u00edch desetilet\u00edch p\u0159edm\u011bty velk\u00e9 \u0159ady retrospektivn\u00edch i randomizovan\u00fdch klinick\u00fdch studi\u00ed. Tak nap\u0159\u00edklad recentn\u00ed metaanal\u00fdza z roku 2009 [43] hodnot\u00ed 1308 nemocn\u00fdch z 11 randomizovan\u00fdch klinick\u00fdch studi\u00ed z let 1980\u20132008. Posledn\u00ed souborn\u00e1 pr\u00e1ce italsk\u00fdch autor\u016f z roku 2012 [44] analyzuje v\u00fdsledky dal\u0161\u00edch n\u011bkolika des\u00edtek studi\u00ed o neoadjuvanci karcinomu j\u00edcnu. Z hodnocen\u00ed tohoto velk\u00e9ho souboru prac\u00ed vypl\u00fdv\u00e1, \u017ee p\u0159es ve\u0161ker\u00e9 vynalo\u017een\u00e9 \u00fasil\u00ed je ot\u00e1zka neoadjuvance a optim\u00e1ln\u00ed strategie l\u00e9\u010dby karcinomu j\u00edcnu st\u00e1le kontroverzn\u00edm probl\u00e9mem bez jednozna\u010dn\u00e9ho z\u00e1v\u011bru. Neoadjuvantn\u00ed chemoradioterapie je akceptov\u00e1na p\u0159edev\u0161\u00edm pod tlakem onkolog\u016f ve st\u00e1le v\u011bt\u0161\u00edm m\u011b\u0159\u00edtku. Jej\u00ed aplikace zlep\u0161uje po\u010det mo\u017en\u00fdch R0 resekc\u00ed, a je tedy cestou ke zlep\u0161en\u00ed v\u00fdsledku l\u00e9\u010dby. Jak v\u0161ak ukazuje ned\u00e1vn\u00e1 pr\u00e1ce [45], celkov\u00e9 p\u0159e\u017e\u00edv\u00e1n\u00ed po t\u00e9to neoadjuvanci po 2 letech bylo pouze 13 %. Tento pom\u011brn\u011b mal\u00fd p\u0159\u00ednos je nutno pe\u010dliv\u011b korelovat s mo\u017en\u00fdmi vedlej\u0161\u00edmi a toxick\u00fdmi \u00fa\u010dinky t\u00e9to l\u00e9\u010dby a s jej\u00ed finan\u010dn\u00ed n\u00e1ro\u010dnost\u00ed. Tak\u0159ka ka\u017ed\u00e1 z t\u011bchto studi\u00ed kon\u010d\u00ed v\u00fdzvou, \u017ee je t\u0159eba dal\u0161\u00edch dob\u0159e pl\u00e1novan\u00fdch a statisticky vyhodnocen\u00fdch randomizovan\u00fdch klinick\u00fdch studi\u00ed, aby mohlo b\u00fdt l\u00e9pe posouzeno, nakolik je tento postup p\u0159\u00ednosem. Tato situace je st\u00e1le znovu se opakuj\u00edc\u00edm probl\u00e9mem v pr\u016fb\u011bhu posledn\u00edch nejm\u00e9n\u011b \u010dty\u0159 dek\u00e1d. Nen\u00ed proto divu, \u017ee \u0159ada chirurg\u016f zab\u00fdvaj\u00edc\u00edch se dlouhodob\u011b touto problematikou neoadjuvantn\u00ed l\u00e9\u010dbu u prim\u00e1rn\u011b R0 resekovateln\u00e9ho karcinomu j\u00edcnu neindikuje a vyu\u017e\u00edv\u00e1 ji pouze u pokro\u010dilej\u0161\u00edch n\u00e1dor\u016f k zlep\u0161en\u00ed operability (downstaging).<\/p>\n<h6 class=\"s32\">Adjuvantn\u00ed terapie<\/h6>\n<p style=\"text-align: justify;\">Obdobn\u011b jako u neadjuvantn\u00ed l\u00e9\u010dby nen\u00ed v\u00fdznam poopera\u010dn\u00ed (adjuvantn\u00ed) radioterapie a\/nebo chemoterapie jednozna\u010dn\u00fd. Po R0 resekci u spinocelul\u00e1rn\u00edho karcinomu pravd\u011bpodobn\u011b sni\u017euje podle n\u011bkter\u00fdch studi\u00ed lokoregion\u00e1ln\u00ed recidivu, ale nezlep\u0161uje dobu p\u0159e\u017eit\u00ed. Po ezofagektomii lze p\u0159edpokl\u00e1dat p\u0159\u00ednos chemoradioterapie u R1 resekc\u00ed a pozitivit\u011b resek\u010dn\u00edch okraj\u016f a u adenokarcinom\u016f s pozitivn\u00edmi lymfatick\u00fdmi uzlinami. Je mo\u017en\u00e9 se takto sna\u017eit ovlivnit lokoregion\u00e1ln\u00ed progresi [29].<\/p>\n<h6 class=\"s32\">Doporu\u010den\u00ed \u010cesk\u00e9 onkologick\u00e9 spole\u010dnosti<\/h6>\n<p style=\"text-align: justify;\">Jedin\u00e9 ofici\u00e1ln\u00ed doporu\u010den\u00ed v \u010cesk\u00e9 republice, kter\u00e9 se t\u00fdk\u00e1 l\u00e9\u010dby zhoubn\u00fdch n\u00e1dor\u016f j\u00edcnu, vyd\u00e1v\u00e1 ka\u017edoro\u010dn\u011b ji\u017e 15 let \u010cesk\u00e1 onkologick\u00e1 spole\u010dnost v tzv. Modr\u00e9 knize \u010cesk\u00e9 onkologick\u00e9 spole\u010dnosti [46]. Tato publikace obsahuje doporu\u010den\u00e9 farmakoterapeutick\u00e9 postupy v klinick\u00e9 onkologii u solidn\u00edch zhoubn\u00fdch n\u00e1dor\u016f. V kapitole Zhoubn\u00fd novotvar j\u00edcnu, na ejim\u017e sestavov\u00e1n\u00ed se nepod\u00edlej\u00ed onkochirurgov\u00e9, je uvedeno:<\/p>\n<p style=\"text-align: justify;\">\u201e<i>Lokoregion\u00e1ln\u00ed onemocn\u011bn\u00ed (stadia I\u2013III)<\/i><\/p>\n<p style=\"text-align: justify;\">Prim\u00e1rn\u00ed l\u00e9\u010debn\u00e9 mo\u017enosti lok\u00e1ln\u011b pokro\u010dil\u00e9ho resekabiln\u00edho onemocn\u011bn\u00ed (T2 nebo vy\u0161\u0161\u00ed, jak\u00e9hokoliv N) jsou: p\u0159edopera\u010dn\u00ed chemoradioterapie, definitivn\u00ed chemoradioterapie (zejm\u00e9na v p\u0159\u00edpad\u011b kr\u010dn\u00ed lokalizace), p\u0159edopera\u010dn\u00ed chemoterapie nebo ezofagektomie. Preferovanou l\u00e9\u010debnou metodou lok\u00e1ln\u011b pokro\u010dil\u00fdch resekabiln\u00edch adenokarcinom\u016f dist\u00e1ln\u00edho j\u00edcnu a gastroezofage\u00e1ln\u00ed junkce je p\u0159edopera\u010dn\u00ed chemoradioterapie.<\/p>\n<p style=\"text-align: justify;\">Kurativn\u00ed chemoradioterapie je akceptovateln\u00e1 l\u00e9\u010dba spinocelul\u00e1rn\u00edch karcinom\u016f; jedinou kurativn\u00ed l\u00e9\u010dbou adenokarcinom\u016f je radik\u00e1ln\u00ed resekce. Re\u017eimy zalo\u017een\u00e9 na 5-FU nebo taxanech jsou vhodn\u00e9 do konkomitance s radioterapi\u00ed neoadjuvantn\u00ed, definitivn\u00ed, a tak\u00e9 v p\u0159\u00edpad\u011b neresekabiln\u00edho lok\u00e1ln\u011b pokro\u010dil\u00e9ho onemocn\u011bn\u00ed nebo u pacient\u016f nevhodn\u00fdch pro chirurgick\u00e9 \u0159e\u0161en\u00ed z d\u016fvod\u016f komorbidit.<\/p>\n<p style=\"text-align: justify;\">V\u00fdb\u011br chemoterapeutick\u00e9ho re\u017eimu z\u00e1vis\u00ed na celkov\u00e9m stavu pacienta (performance status), komorbidit\u00e1ch, toxick\u00e9m profilu l\u00e9\u010dby a HER2-neu expresi (pouze u pokro\u010dil\u00fdch a metastatick\u00fdch adenokarcinom\u016f EGJ). Poopera\u010dn\u00ed l\u00e9\u010dba z\u00e1vis\u00ed na histologick\u00e9m typu n\u00e1doru, resek\u010dn\u00edm okraji, pozitivit\u011b lymfatick\u00fdch uzlin.<\/p>\n<p class=\"s14\"><em>T1N0M0<\/em><\/p>\n<p style=\"text-align: justify;\">Radik\u00e1ln\u00ed chirurgick\u00fd v\u00fdkon bez poopera\u010dn\u00ed l\u00e9\u010dby. Chemoradioterapie je preferov\u00e1na v p\u0159\u00edpad\u011b kr\u010dn\u00ed lokalizace karcinomu j\u00edcnu, kter\u00fd je technicky neoperabiln\u00ed.<\/p>\n<p class=\"s14\"><em>T2 a vy\u0161\u0161\u00ed N jak\u00e9koli M0<\/em><\/p>\n<ol>\n<li style=\"text-align: justify;\">Radik\u00e1ln\u00ed chirurgick\u00fd v\u00fdkon. Bez poopera\u010dn\u00ed l\u00e9\u010dby u dla\u017edicobun\u011b\u010dn\u00e9ho karcinomu. Chemoradioterapie na b\u00e1zi 5-FU po ezofagektomii v p\u0159\u00edpad\u011b R1 nebo R2 resekce (alternativou p\u0159i makroskopick\u00e9m rezidu\u00e1ln\u00edm onemocn\u011bn\u00ed je paliativn\u00ed chemoterapie). V p\u0159\u00edpad\u011b adenokarcinomu dist\u00e1ln\u00edho j\u00edcnu a gastroezofage\u00e1ln\u00ed junkce se doporu\u010duje adjuvantn\u00ed chemoradioterapie u high risk T2N0, T3N0 (G3, lymfovaskul\u00e1rn\u00ed invaze, neurovaskul\u00e1rn\u00ed invaze, mlad\u00fd v\u011bk), jak\u00e9koli N pozitivn\u00ed adenokarcinomy nebo periopera\u010dn\u00ed chemoterapie ECF (3 cykly p\u0159ed operac\u00ed, 3 cykly po operaci).<\/li>\n<li style=\"text-align: justify;\">Definitivn\u00ed chemoradioterapie je preferov\u00e1na v p\u0159\u00edpad\u011b kr\u010dn\u00ed lokalizace karcinomu j\u00edcnu, kter\u00fd je technicky neoperabiln\u00ed. Je zalo\u017eena na b\u00e1zi fluoropyrimidinu a cisplatiny. V\u00fdsledky studie f. III PRODIGE 5\/ACCORD 17 prok\u00e1zaly re\u017eim s oxaliplatinou jako stejn\u011b afektivn\u00ed.<\/li>\n<li style=\"text-align: justify;\">Ve vybran\u00fdch p\u0159\u00edpadech operaci p\u0159edch\u00e1z\u00ed neoadjuvantn\u00ed chemoradioterapie zalo\u017een\u00e1 na cisplatin\u011b a 5FU.<\/li>\n<\/ol>\n<p class=\"s14\"><em>Stadium IV<\/em><\/p>\n<p style=\"text-align: justify;\">Indikov\u00e1na je paliativn\u00ed chemoterapie zalo\u017een\u00e1 na cisplatin\u011b a fluropyrimidinu. L\u00e9\u010dba dal\u0161\u00edch lini\u00ed, individualizovan\u00e9 paliativn\u00ed chemoterapie je zalo\u017een\u00e1 na cisplatin\u011b a 5-FU; cytostatika s prok\u00e1zanou aktivitou, p\u0159ev\u00e1\u017en\u011b studiemi f.II: docetaxel, paklitaxel, irinoketan, oxyliplatina.\u201c<\/p>\n<p class=\"s32\" style=\"text-align: justify;\">Doporu\u010den\u00ed uv\u00e1d\u011bn\u00e1 v Modr\u00e9 knize jsou neoby\u010dejn\u011b d\u016fle\u017eit\u00e1 a u\u017eite\u010dn\u00e1 pro orientaci v t\u00e9to slo\u017eit\u00e9 problematice. Je t\u0159eba si v\u0161ak uv\u011bdomit, \u017ee uv\u00e1d\u011bn\u00e1 doporu\u010den\u00ed pro l\u00e9\u010dbu lok\u00e1ln\u011b pokro\u010dil\u00e9ho resekabiln\u00edho karcinomu j\u00edcnu (stadium T2 a vy\u0161\u0161\u00ed a jak\u00e9koliv N) jsou pouze l\u00e9\u010debn\u00e9 mo\u017enosti. P\u0159\u00ednos doporu\u010dovan\u00e9 neoadjuvantn\u00ed l\u00e9\u010dby pro nemocn\u00e9ho nen\u00ed podle publikac\u00ed s vy\u0161\u0161\u00edm stupn\u011bm s\u00edly doporu\u010den\u00ed dle EBM, uveden\u00e9 v p\u0159edchoz\u00edch subkapitol\u00e1ch, v\u017edy jednozna\u010dn\u00fd. Je proto nutn\u00e9 u ka\u017ed\u00e9ho pacienta stanovovat l\u00e9\u010debn\u00fd plan v interdisciplin\u00e1rn\u00edm t\u00fdmu, individu\u00e1ln\u011b s p\u0159ihl\u00e9dnut\u00edm k re\u00e1ln\u011b p\u0159edpokl\u00e1dan\u00e9mu profitu r\u016fzn\u00fdch l\u00e9\u010debn\u00fdch modalit pro jeho dal\u0161\u00ed osud.<\/p>\n<h6 class=\"s32\">Taktika a technika chirurgick\u00e9 l\u00e9\u010dby<\/h6>\n<p class=\"s14\"><em>Radik\u00e1ln\u00ed chirurgick\u00e1 terapie<\/em><\/p>\n<p style=\"text-align: justify;\">U ran\u00fdch stadi\u00ed karcinomu j\u00edcnu (TisT1) m\u016f\u017ee b\u00fdt dostate\u010dn\u00fdm v\u00fdkonem pouh\u00e1 resekce sliznice \u2013 endoskopick\u00e1 ukosektomie, jak je o tom pojedn\u00e1no v \u010d\u00e1sti o \u010dasn\u00e9m karcinomu j\u00edcnu.<\/p>\n<p style=\"text-align: justify;\">V oblasti gastroezofage\u00e1ln\u00edho p\u0159echodu se klasick\u00e9 resek\u010dn\u00ed postupy li\u0161\u00ed podle lokalizace n\u00e1doru. U adenokarcinomu gastroezofage\u00e1ln\u00edho p\u0159echodu typu II a III (viz obr. 2), kter\u00e9 se klasifika\u010dn\u011b za\u0159azuj\u00ed ke karcinomu \u017ealudku a kardie, je radik\u00e1ln\u00edm \u0159e\u0161en\u00edm tot\u00e1ln\u00ed gastrektomie s resekc\u00ed termin\u00e1ln\u00edho j\u00edcnu a rekonstrukce pas\u00e1\u017ee n\u011bkterou z variant Rouxovy kli\u010dky. Opera\u010dn\u00edm p\u0159\u00edstupem je laparotomie (horn\u00ed st\u0159edn\u00ed laparotomie \u010di p\u0159\u00ed\u010dn\u00e1 v nadb\u0159i\u0161ku), kdysi \u010dasto u\u017e\u00edvan\u00e1 levostrann\u00e1 torakofrenolaparotomie se dnes ji\u017e pro svou p\u0159\u00edli\u0161nou extenzitu jev\u00ed jako zbyte\u010dn\u011b zat\u011b\u017euj\u00edc\u00ed. Z obdobn\u00e9ho p\u0159\u00edstupu nebo z levostrann\u00e9 torakotomie a frenotomie lze prov\u00e9st m\u00e9n\u011b radik\u00e1ln\u00ed resekci kardie (horn\u00ed pol\u00e1rn\u00ed resekci \u017ealudku) s resekc\u00ed termin\u00e1ln\u00edho j\u00edcnu a zalo\u017eit ezofagogastroanastom\u00f3zu end-to-side. U adenokarcinomu z Barrettova j\u00edcnu (adenokarcinom gastroezofage\u00e1ln\u00edho p\u0159echodu typ I) je pro nebezpe\u010d\u00ed submuk\u00f3zn\u00edho \u0161\u00ed\u0159en\u00ed n\u00e1doru or\u00e1ln\u00edm sm\u011brem, stejn\u011b jako u ostatn\u00edch n\u00e1dor\u016f na nitrohrudn\u00edm j\u00edcnu, indikov\u00e1na subtot\u00e1ln\u00ed ezofagektomie.<\/p>\n<p style=\"text-align: justify;\">Term\u00ednem <i>ezofagektomie <\/i>rozum\u00edme zpravidla vlastn\u011b subtot\u00e1ln\u00ed resekci j\u00edcnu (subtot\u00e1ln\u00ed ezofagektomie), kdy ponech\u00e1v\u00e1me r\u016fzn\u011b dlouhou \u010d\u00e1st kr\u010dn\u00edho j\u00edcnu, p\u0159\u00edpadn\u011b p\u0159echod kr\u010dn\u00edho j\u00edcnu v hrudn\u00ed ve vrcholu pleur\u00e1ln\u00ed dutiny. Tot\u00e1ln\u00ed ezofagektomie je nutn\u00e1 jen v p\u0159\u00edpad\u011b karcinomu kr\u010dn\u00edho j\u00edcnu. Zde m\u016f\u017ee b\u00fdt alternativou segment\u00e1ln\u00ed resekce kr\u010dn\u00edho j\u00edcnu s rekonstrukc\u00ed pas\u00e1\u017ee vlo\u017een\u00edm voln\u011b transplantovan\u00e9 jejun\u00e1ln\u00ed kli\u010dky.<\/p>\n<p style=\"text-align: justify;\">Z hlediska chirurgick\u00e9 taktiky a techniky je mo\u017en\u00e9 ezofagektomii prov\u00e1d\u011bt r\u016fzn\u00fdm zp\u016fsobem, s u\u017eit\u00edm r\u016fzn\u00fdch alternativn\u00edch postup\u016f:<\/p>\n<p class=\"s14\"><em>Volba p\u0159\u00edstupu<\/em><\/p>\n<p class=\"s14\" style=\"text-align: justify;\">Na prvn\u00edm m\u00edst\u011b je zvolen\u00ed p\u0159\u00edstupu k j\u00edcnu. <i>Transtorak\u00e1ln\u00ed p\u0159\u00edstup <\/i>z pravostrann\u00e9 torakotomie umo\u017e\u0148uje dokonalou ymfadenektomii, je v\u0161ak spojov\u00e1n s v\u011bt\u0161\u00edm po\u010dtem plicn\u00edch komplikac\u00ed. P\u0159i <i>transhiat\u00e1ln\u00ed <\/i>(transmediastin\u00e1ln\u00ed) ezofagektomii<br \/>\nbez torakotomie navr\u017een\u00e9 Orringerem [47, 48] je j\u00edcen uvoln\u011bn \u201enaslepo\u201c bez kontroly zrakem, rukou p\u0159es roz\u0161\u00ed\u0159en\u00fd hiatus z b\u0159icha. Podle mezin\u00e1rodn\u00edho p\u0159ehledu zpracovan\u00e9ho v roce 2009 d\u00e1v\u00e1 52 % chirurg\u016f p\u0159ednost hrudn\u00edmu p\u0159\u00edstupu a 26 %<br \/>\ntranshiat\u00e1ln\u00edmu [49]. O specifick\u00e9m p\u0159\u00edstupu k tumor\u016fm kr\u010dn\u00edho j\u00edcnu je pojedn\u00e1no ji\u017e na po\u010d\u00e1tku t\u00e9to kapitoly. Dal\u0161\u00ed mo\u017enosti, jak zmen\u0161it opera\u010dn\u00ed z\u00e1t\u011b\u017e, p\u0159in\u00e1\u0161\u00ed miniinvazivn\u00ed chirurgie, jak je o tom pojedn\u00e1no d\u00e1le.<\/p>\n<p class=\"s14\"><em>J\u00edcnov\u00e1 anastom\u00f3za<\/em><\/p>\n<p style=\"text-align: justify;\">Dal\u0161\u00ed diskutovanou ot\u00e1zkou je, zda je v\u00fdhodn\u011bj\u0161\u00ed anastom\u00f3za na krku \u010di v hrudn\u00edku. Obecn\u011b tradovanou p\u0159ednost\u00ed kr\u010dn\u00ed anastom\u00f3zy je, \u017ee v p\u0159\u00edpad\u011b dehiscence se obvykle zhoj\u00ed bez v\u011bt\u0161\u00edch probl\u00e9m\u016f pouhou dren\u00e1\u017e\u00ed, zat\u00edmco dehiscence nitrohrudn\u00ed anastom\u00f3zy je i dnes \u017eivot ohro\u017euj\u00edc\u00ed komplikac\u00ed. Metaanal\u00fdza publikovan\u00e1 v roce 2011, hodnot\u00edc\u00ed dosavadn\u00ed publikace, v\u010detn\u011b \u010dty\u0159 randomizovan\u00fdch studi\u00ed, uv\u00e1d\u00ed, \u017ee kr\u010dn\u00ed anastom\u00f3za je spojena s \u010dast\u011bj\u0161\u00edm v\u00fdskytem dehiscence a \u010dast\u011bj\u0161\u00ed par\u00e9zou vratn\u00e9ho nervu, zat\u00edmco u obou typ\u016f anastom\u00f3zy nen\u00ed rozd\u00edl v mortalit\u011b, plicn\u00edch komplikac\u00edch a vzniku fibr\u00f3zn\u00ed striktury v m\u00edst\u011b spojky. Z\u00e1v\u011brem t\u00e9to studie je, \u017ee v sou\u010dasnosti \u017e\u00e1dn\u00e1 z obou spojek nen\u00ed signifikantn\u011b v\u00fdhodn\u011bj\u0161\u00ed proti druh\u00e9 [50]. Vedle um\u00edst\u011bn\u00ed spojky je d\u016fle\u017eit\u00fd zp\u016fsob zalo\u017een\u00ed a \u0161it\u00ed anastom\u00f3zy. Podle mezin\u00e1rodn\u00edho p\u0159ehledu z roku 2009 ve specializovan\u00fdch centrech zakl\u00e1d\u00e1 kr\u010dn\u00ed anastom\u00f3zu end-to-side 50 % a hrudn\u00ed anastom\u00f3zu 64 % chirurg\u016f. Kr\u010dn\u00ed anastom\u00f3zu \u0161ij\u00ed chirurgov\u00e9 \u010dast\u011bji ru\u010dn\u011b a hrudn\u00ed \u010dast\u011bji pomoc\u00ed stapleru [49]. \u0160it\u00ed anastom\u00f3z srovn\u00e1vala cel\u00e1 \u0159ada studi\u00ed. Metaanal\u00fdza randomizovan\u00fdch studi\u00ed z roku 2001 shledala obdobn\u00e9 v\u00fdsledky u ru\u010dn\u011b i mechanicky \u0161it\u00fdch anastom\u00f3z, pokud se t\u00fdk\u00e1 v\u00fdskytu dehiscence \u010di striktur [51].<\/p>\n<p class=\"s14\"><em>N\u00e1hrada j\u00edcnu<\/em><\/p>\n<p style=\"text-align: justify;\">Mo\u017enost\u00ed, jak nahradit resekovan\u00fd j\u00edcen, je n\u011bkolik. Nej\u010dast\u011bji se v\u00edce ne\u017e v 90 % u\u017e\u00edv\u00e1 tubulizovan\u00fd \u017ealudek [49]. Resekuje se \u010d\u00e1st \u017ealudku pod\u00e9l mal\u00e9ho zak\u0159iven\u00ed a subkardi\u00e1ln\u011b a \u017ealude\u010dn\u00ed tubus vytvo\u0159en\u00fd pod\u00e9l velk\u00e9ho zak\u0159iven\u00ed m\u00e1 zachovan\u00e9 c\u00e9vn\u00ed z\u00e1soben\u00ed z gastroepiploick\u00fdch c\u00e9v. Nepanuje shoda, zda prov\u00e1d\u011bt jako dopln\u011bk gastroplastiky rutinn\u011b pyloroplastiku \u2013 \u010din\u00ed tak 40 % chirurg\u016f, 38 % t\u00edmto v\u00fdkonem tubulizaci \u017ealudku nedopl\u0148uje nikdy [49]. Auto\u0159i metaanal\u00fdzy z roku 2002 doch\u00e1zej\u00ed<br \/>\nna z\u00e1klad\u011b publikovan\u00fdch zku\u0161enost\u00ed s dren\u00e1\u017en\u00edmi operacemi \u017ealudku p\u0159i ezofagektomii k z\u00e1v\u011bru, \u017ee pyloroplastika redukuje \u010dasnou poruchu pr\u016fchodnosti pyloru, ale m\u00e1 mal\u00fd vliv na jeho pozd\u011bj\u0161\u00ed funkci [52]. Pokud nen\u00ed mo\u017eno k n\u00e1hrad\u011b j\u00edcnu vyu\u017e\u00edt<br \/>\n\u017ealudek, u\u017e\u00edv\u00e1 se v\u011bt\u0161inou k jeho substituci tlust\u00e9 st\u0159evo (koloplastika). Nej\u010dast\u011bji je to v p\u0159\u00edpad\u011b, kdy byl \u017ealudek d\u0159\u00edve resekov\u00e1n pro v\u0159ed nebo n\u00e1dor. Ke koloplastice se u\u017e\u00edv\u00e1 zejm\u00e9na lev\u00e1 \u010d\u00e1st kolon a transversum se zachov\u00e1n\u00edm c\u00e9vn\u00edho z\u00e1soben\u00ed z a. colica sinistra. Jen v\u00fdjime\u010dn\u011b p\u0159ich\u00e1z\u00ed v \u00favahu k n\u00e1hrad\u011b j\u00edcnu tenk\u00e1 kli\u010dka.<\/p>\n<p class=\"s14\" style=\"text-align: justify;\">Jejunem v \u00faprav\u011b \u201eY\u201c Rouxovy kli\u010dky je mo\u017eno bez probl\u00e9mu nahradit doln\u00ed t\u0159etinu j\u00edcnu, transpozice a\u017e na krk se nemus\u00ed v\u017edy zda\u0159it. Jejunum je mo\u017en\u00e9 tak\u00e9 u\u017e\u00edt jako voln\u00fd jejun\u00e1ln\u00ed transplant\u00e1t s c\u00e9vn\u00edm napojen\u00edm mikrovaskul\u00e1rn\u00ed technikou p\u0159i resekci kr\u010dn\u00edho j\u00edcnu. Ulo\u017een\u00ed j\u00edcnov\u00e9 n\u00e1hrady je nejv\u00fdhodn\u011bj\u0161\u00ed v zadn\u00edm mediastinu v p\u016fvodn\u00edm l\u016f\u017eku ezofagu. Pokud to nen\u00ed mo\u017en\u00e9, nap\u0159. pro jizevnat\u00e9 zm\u011bny v t\u00e9to oblasti, nej\u010dast\u011bji prov\u00e1d\u00ed-li se n\u00e1hrada a\u017e v druh\u00e9 dob\u011b v odstupu od ezofagektomie, pak se vol\u00ed tup\u011b uvoln\u011bn\u00fd retrostern\u00e1ln\u00ed prostor.<\/p>\n<p class=\"s14\"><em>Lymfadenektomie<\/em><\/p>\n<p style=\"text-align: justify;\">D\u016fle\u017eitou sou\u010d\u00e1st\u00ed chirurgick\u00e9 l\u00e9\u010dby je lymfadenektomie. Je prok\u00e1z\u00e1no, \u017ee metastatick\u00e9 posti\u017een\u00ed uzlin (N+) v\u00fdznamn\u011b zhor\u0161uje progn\u00f3zu onemocn\u011bn\u00ed. Po\u010det posti\u017een\u00fdch uzlin nebo pom\u011br posti\u017een\u00fdch uzlin ku po\u010dtu v\u0161ech odstran\u011bn\u00fdch uzlin koreluje se zhor\u0161uj\u00edc\u00ed se d\u00e9lkou p\u0159e\u017e\u00edv\u00e1n\u00ed. Podle nejnov\u011bj\u0161\u00edho 7. vyd\u00e1n\u00ed TMN klasifikace je u j\u00edcnu stanovena tato N klasifikace N0, N1 (1\u20132 posti\u017een\u00e9 uzliny), N2 (3\u20136), N3 (v\u00edce jak 7). Ke spr\u00e1vn\u00e9mu stanoven\u00ed kategorie N a z toho\u00a0 vypl\u00fdvaj\u00edc\u00edho stanoven\u00ed progn\u00f3zy se pova\u017euje za nutn\u00e9 vy\u0161et\u0159en\u00ed nejm\u00e9n\u011b 16 uzlin [53]. V\u00fdskyt metastatick\u00e9ho posti\u017een\u00ed uzlin koreluje s hloubkou pror\u016fst\u00e1n\u00ed tumoru (T klasifikac\u00ed).<\/p>\n<p style=\"text-align: justify;\">Vyskytuj\u00ed se tak\u00e9 tzv. skip metast\u00e1zy, jak se ozna\u010duje posti\u017een\u00ed vzd\u00e1len\u011bj\u0161\u00edch uzlin bez posti\u017een\u00ed bezprost\u0159edn\u011b region\u00e1ln\u00edch uzlin. Souvis\u00ed to s lymfatick\u00fdm \u0159e\u010di\u0161t\u011bm v submuk\u00f3ze j\u00edcnu. Podle konsenzu\u00e1ln\u00ed konference ISDE (International Society for Diseases of the Esophagus) z roku 1995 byl definov\u00e1n rozsah a typy lymfadenektomie [54]. Lymfadenektomii lze prov\u00e1d\u011bt ve t\u0159ech oblastech (pol\u00edch, kompartmentech):<\/p>\n<ul>\n<li>\u00a0<span style=\"color: #231f20;\">I. kr\u010dn\u00ed<\/span><\/li>\n<li>\u00a0<span style=\"color: #231f20;\">II. hrudn\u00ed<\/span>\n<ul>\n<li><span style=\"color: #231f20;\">standardn\u00ed v doln\u00edm a st\u0159edn\u00edm mediastinu<\/span><\/li>\n<li>r<span style=\"color: #231f20;\">oz\u0161\u00ed\u0159en\u00e1, nav\u00edc horn\u00ed mediastinum na prav\u00e9 stran\u011b<\/span><\/li>\n<li><span style=\"color: #231f20;\">tot\u00e1ln\u00ed, nav\u00edc horn\u00ed mediastinum na obou stran\u00e1ch<\/span><\/li>\n<\/ul>\n<\/li>\n<li>\u00a0<span style=\"color: #231f20;\">III. b\u0159i\u0161n\u00ed<\/span><\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Prov\u00e1d\u00ed se bu\u010f dvou(II. + III.), nebo t\u0159\u00edkompartmentov\u00e1 lymfadektenomie. Od dvoukompartmentov\u00e9 lymfadenektomie je t\u0159eba odli\u0161it tzv. \u201een-block ezofagektomii\u201c.<\/p>\n<p style=\"text-align: justify;\">Tento zp\u016fsob navr\u017een\u00fd Loganem byl znovu zaveden a zpopularizov\u00e1n Skinnerem [55] (viz kapitola 4 \u2013 obr. 5b). C\u00edlem tohoto postupu je minimalizovat vznik lok\u00e1ln\u00ed recidivy. J\u00edcen se p\u0159itom odstra\u0148uje en block spolu s okoln\u00edmi tk\u00e1n\u011bmi. Spolu s j\u00edcnem resekujeme later\u00e1ln\u011b pleuru, ventr\u00e1ln\u011b perikard, tk\u00e1\u0148 mezi j\u00edcnem, aortou a p\u00e1te\u0159\u00ed a v nejradik\u00e1ln\u011bj\u0161\u00ed variant\u011b v\u010detn\u011b duktus toracikus, v. azygos. Tento v\u00fdkon je indikov\u00e1n u tumoru v doln\u00ed a st\u0159edn\u00ed t\u0159etin\u011b j\u00edcnu. V horn\u00ed t\u0159etin\u011b nelze resekovat p\u0159ilehl\u00e9 \u017eivotn\u011b d\u016fle\u017eit\u00e9 org\u00e1ny. Je ot\u00e1zkou, zda je tento v\u00fdkon v sou\u010dasn\u00e9 dob\u011b je\u0161t\u011b opr\u00e1vn\u011bn\u00fd, kdy\u017e m\u00e1me mo\u017enost vyu\u017e\u00edvat chemoradioterapii, kter\u00e1 v kombinaci s ezofagektomi\u00ed a dvoukompartmentovou lymfadenektomi\u00ed podstatn\u011b sni\u017euje riziko lok\u00e1ln\u00ed recidivy.<\/p>\n<p style=\"text-align: justify;\">Roz\u0161\u00ed\u0159enou koncepci t\u0159\u00edkompartmentov\u00e9 lymfadenektomie navrhli a propaguj\u00ed japon\u0161t\u00ed chirurgov\u00e9 ji\u017e od 80. let minul\u00e9ho stolet\u00ed. Tento koncept vych\u00e1z\u00ed ze skute\u010dnosti, \u017ee u kr\u010dn\u00edho j\u00edcnu doch\u00e1z\u00ed \u010dasto k metast\u00e1zov\u00e1n\u00ed do kr\u010dn\u00edch uzlin [56].<\/p>\n<p style=\"text-align: justify;\">Lymfadenektomie v t\u0159et\u00edm kompartmentu p\u0159edstavuje nejen tot\u00e1ln\u00ed odstran\u011bn\u00ed kr\u010dn\u00edch uzlin, ale i \u0159et\u011bzc\u016f uzlin z krku do mediastina pod\u00e9l vratn\u00fdch nerv\u016f. Hlavn\u00edm rizikem tohoto postupu je vysok\u00fd v\u00fdskyt trval\u00e9 par\u00e9zy vratn\u00fdch nerv\u016f dosud bez zcela jasn\u00e9ho pr\u016fkazu p\u0159\u00ednosu pro p\u0159e\u017e\u00edv\u00e1n\u00ed operovan\u00fdch. Pro tumory v doln\u00ed a st\u0159edn\u00ed t\u0159etin\u011b j\u00edcnu je doporu\u010dov\u00e1na dvoukompartmentov\u00e1 lymfadenektomie, t\u0159\u00edkompartmentov\u00e1 lymfadenektomie pak p\u0159ich\u00e1z\u00ed v \u00favahu u tumoru v horn\u00ed \u010d\u00e1sti hrudn\u00edho a v kr\u010dn\u00edm j\u00edcnu, zejm\u00e9na pak p\u0159i pozitivn\u00edm n\u00e1lezu kr\u010dn\u00edch uzlin p\u0159i sonografick\u00e9m vy\u0161et\u0159en\u00ed.<\/p>\n<p class=\"s14\"><em>Opera\u010dn\u00ed postupy<\/em><\/p>\n<p style=\"text-align: justify;\">U\u017e\u00edvan\u00e9 opera\u010dn\u00ed postupy vol\u00ed mezi r\u016fzn\u00fdmi p\u0159\u00edstupov\u00fdmi cestami k j\u00edcnu. Sou\u010d\u00e1st\u00ed je v\u017edy i lymfadenektomie:<\/p>\n<p style=\"text-align: justify;\">Transtorak\u00e1ln\u00ed ezofagektomie <span class=\"p\">s nitrohrudn\u00ed ezofagogastrickou anastom\u00f3zou (Ivor<\/span>-Lewisova ezofagektomie). Tento postup je pom\u011brn\u011b \u010dasto u\u017e\u00edv\u00e1n v z\u00e1padn\u00edch zem\u00edch Evropy a v Americe. V prvn\u00ed abdomin\u00e1ln\u00ed f\u00e1zi je dutina b\u0159i\u0161n\u00ed otev\u0159ena horn\u00ed st\u0159edn\u00ed laparotomi\u00ed, je mobilizov\u00e1n abdomin\u00e1ln\u00ed j\u00edcen a \u017ealudek a vytvo\u0159en z n\u011bho tubus pod\u00e9l velk\u00e9ho zak\u0159iven\u00ed, v\u00fdkon je obvykle dopln\u011bn pyloromyotomi\u00ed. Sou\u010d\u00e1st\u00ed abdomin\u00e1ln\u00ed f\u00e1ze je lymfadenektomie z povod\u00ed a. coeliaca a okol\u00ed b\u0159i\u0161n\u00edho j\u00edcnu. Ve druh\u00e9 f\u00e1zi je z pravostrann\u00e9 posterolater\u00e1ln\u00ed torakotomie izolov\u00e1n j\u00edcen i s tumorem a do dutiny hrudn\u00ed je vta\u017een \u017ealude\u010dn\u00ed tubus. Po resekci j\u00edcnu spolu se subkardi\u00e1ln\u00ed \u010d\u00e1st\u00ed \u017ealudku je zalo\u017eena staplerov\u00e1 anastom\u00f3za v apexu prav\u00e9 pleur\u00e1ln\u00ed dutiny mezi j\u00edcnem a \u017ealude\u010dn\u00edm tubusem. V\u00fdkon je obvykle dopl\u0148ov\u00e1n dvoukompartmentovou roz\u0161\u00ed\u0159enou lymfadenektomi\u00ed a je mo\u017en\u00e9 prov\u00e9st i en bloc resekci.<\/p>\n<p class=\"s14\"><em>T\u0159\u00edf\u00e1zov\u00e1 ezofagektomie<\/em><\/p>\n<p style=\"text-align: justify;\">V prvn\u00ed f\u00e1zi operace se z pravostrann\u00e9 torakotomie provede ezofagektomie a hrudn\u00ed lymfadektomie, ve druh\u00e9, abdomin\u00e1ln\u00ed f\u00e1zi se obdobn\u011b jako p\u0159i p\u0159edchoz\u00edm typu operace p\u0159iprav\u00ed \u017ealude\u010dn\u00ed transpon\u00e1t a provede b\u0159i\u0161n\u00ed lymfadenektomie. Ve t\u0159et\u00ed, kr\u010dn\u00ed f\u00e1zi se po prota\u017een\u00ed \u017ealude\u010dn\u00edho tubusu zalo\u017e\u00ed kr\u010dn\u00ed anastom\u00f3za. Pokud se prov\u00e1d\u00ed sou\u010dasn\u011b kr\u010dn\u00ed lymfadenektomie, u\u017e\u00edv\u00e1 se \u0161irok\u00fd kol\u00e1rn\u00ed \u0159ez, pro zalo\u017een\u00ed anastom\u00f3zy je dostate\u010dn\u00fd \u0159ez pod\u00e9l vnit\u0159n\u00edho okraje k\u00fdva\u010de vlevo.<\/p>\n<p class=\"s14\"><em>Transhiat\u00e1ln\u00ed ezofagektomie (Orringerova ezofagektomie bez torakotomie)<\/em><\/p>\n<p style=\"text-align: justify;\">P\u0159i tomto postupu [47, 48] je z horn\u00ed st\u0159edn\u00ed laparotomie transhiat\u00e1ln\u011b j\u00edcen uvoln\u011bn \u201enaslepo\u201c bez kontroly zrakem, rukou p\u0159es roz\u0161\u00ed\u0159en\u00fd hi\u00e1tus z b\u0159icha a zbytek j\u00edcnu z kr\u010dn\u00ed incize zaveden\u00fdmi prsty ruky. B\u0159i\u0161n\u00ed lymfadenektomie se provede standardn\u00edm zp\u016fsobem. P\u0159\u00edstup je pro pacienta \u0161etrn\u011bj\u0161\u00ed a m\u00e9n\u011b naru\u0161uje plicn\u00ed funkce, neumo\u017e\u0148uje v\u0161ak dokonalou mediastin\u00e1ln\u00ed lymfadenektomii. Tyto v\u00fdhody p\u0159eva\u017euj\u00ed u tumor\u016f v doln\u00ed t\u0159etin\u011b j\u00edcnu [48]. V b\u0159i\u0161e p\u0159ipraven\u00fd tubus se pak prot\u00e1hne do kr\u010dn\u00ed incize, kde se zalo\u017e\u00ed anastom\u00f3za s j\u00edcnem. Postup operace je zn\u00e1zorn\u011bn na obr. 19\u201322 a resek\u00e1t na obr. 23.<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_531.png\"><img loading=\"lazy\" decoding=\"async\" class=\" \" title=\"Obr. 19a \u2013 Mobilizovan\u00fd \u017ealudek\" alt=\"Obr. 19a \u2013 Mobilizovan\u00fd \u017ealudek\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_531.png\" width=\"200\" height=\"151\" \/><\/a><p class=\"wp-caption-text\">Obr. 19a<br \/>Mobilizovan\u00fd \u017ealudek<\/p><\/div><\/td>\n<td style=\"border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_532.png\"><img loading=\"lazy\" decoding=\"async\" class=\" \" title=\"Obr. 19b \u2013 Vytv\u00e1\u0159en\u00ed \u017ealude\u010dn\u00edho tubusu\" alt=\"Obr. 19b \u2013 Vytv\u00e1\u0159en\u00ed \u017ealude\u010dn\u00edho tubusu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_532.png\" width=\"200\" height=\"151\" \/><\/a><p class=\"wp-caption-text\">Obr. 19b<br \/>Vytv\u00e1\u0159en\u00ed \u017ealude\u010dn\u00edho tubusu<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_533.png\"><img decoding=\"async\" title=\"Obr. 19c \u2013 Vytv\u00e1\u0159en\u00ed \u017ealude\u010dn\u00edho tubusu\" alt=\"Obr. 19c \u2013 Vytv\u00e1\u0159en\u00ed \u017ealude\u010dn\u00edho tubusu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_533.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 19c<br \/>Vytv\u00e1\u0159en\u00ed \u017ealude\u010dn\u00edho tubusu<\/p><\/div><\/td>\n<td style=\"border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_534.png\"><img decoding=\"async\" title=\"Obr. 19d \u2013 Vytv\u00e1\u0159en\u00ed \u017ealude\u010dn\u00edho tubus\" alt=\"Obr. 19d \u2013 Vytv\u00e1\u0159en\u00ed \u017ealude\u010dn\u00edho tubus\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_534.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 19d<br \/>Vytv\u00e1\u0159en\u00ed \u017ealude\u010dn\u00edho tubus<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_535.png\"><img decoding=\"async\" title=\"Obr. 19e \u2013 Vytv\u00e1\u0159en\u00ed \u017ealude\u010dn\u00edho tubusu\" alt=\"Obr. 19e \u2013 Vytv\u00e1\u0159en\u00ed \u017ealude\u010dn\u00edho tubusu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_535.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 19e<br \/>Vytv\u00e1\u0159en\u00ed \u017ealude\u010dn\u00edho tubusu<\/p><\/div><\/td>\n<td style=\"border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_536.png\"><img decoding=\"async\" title=\" Obr. 20 \u2013 Vytvo\u0159en\u00fd \u017ealude\u010dn\u00ed tubus s v\u00fd\u017eivou z a. gastroepiploika p\u0159i velk\u00e9m zak\u0159iven\u00ed\" alt=\" Obr. 20 \u2013 Vytvo\u0159en\u00fd \u017ealude\u010dn\u00ed tubus s v\u00fd\u017eivou z a. gastroepiploika p\u0159i velk\u00e9m zak\u0159iven\u00ed\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_536.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 20<br \/>Vytvo\u0159en\u00fd \u017ealude\u010dn\u00ed tubus s v\u00fd\u017eivou z a. gastroepiploika p\u0159i velk\u00e9m zak\u0159iven\u00ed<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_538.png\"><img decoding=\"async\" title=\"Obr. 21 \u2013 Kr\u010dn\u00ed f\u00e1ze operace, do kr\u010dn\u00ed incize je vta\u017een \u017ealude\u010dn\u00ed tubus a uvoln\u011bn\u00fd j\u00edcen s tumorem a subkardi\u00e1ln\u00ed \u010d\u00e1st\u00ed \u017ealudku\" alt=\"Obr. 21 \u2013 Kr\u010dn\u00ed f\u00e1ze operace, do kr\u010dn\u00ed incize je vta\u017een \u017ealude\u010dn\u00ed tubus a uvoln\u011bn\u00fd j\u00edcen s tumorem a subkardi\u00e1ln\u00ed \u010d\u00e1st\u00ed \u017ealudku\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_538.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 21<br \/>Kr\u010dn\u00ed f\u00e1ze operace, do kr\u010dn\u00ed incize je vta\u017een \u017ealude\u010dn\u00ed tubus a uvoln\u011bn\u00fd j\u00edcen s tumorem a subkardi\u00e1ln\u00ed \u010d\u00e1st\u00ed \u017ealudku<\/p><\/div><\/td>\n<td style=\"border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_541.png\"><img decoding=\"async\" title=\"Obr. 22a \u2013 Vytv\u00e1\u0159en\u00ed kr\u010dn\u00ed anastom\u00f3zy mezi j\u00edcnem a \u017ealude\u010dn\u00edm tubusem pomoc\u00ed kruhov\u00e9ho stapleru\" alt=\"Obr. 22a \u2013 Vytv\u00e1\u0159en\u00ed kr\u010dn\u00ed anastom\u00f3zy mezi j\u00edcnem a \u017ealude\u010dn\u00edm tubusem pomoc\u00ed kruhov\u00e9ho stapleru\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_541.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 22a<br \/>Vytv\u00e1\u0159en\u00ed kr\u010dn\u00ed anastom\u00f3zy mezi j\u00edcnem a \u017ealude\u010dn\u00edm tubusem pomoc\u00ed kruhov\u00e9ho stapleru<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_539.png\"><img decoding=\"async\" title=\"Obr. 22b \u2013 Vytv\u00e1\u0159en\u00ed kr\u010dn\u00ed anastom\u00f3zy mezi j\u00edcnem a \u017ealude\u010dn\u00edm tubusem pomoc\u00ed kruhov\u00e9ho stapleru\" alt=\"Obr. 22b \u2013 Vytv\u00e1\u0159en\u00ed kr\u010dn\u00ed anastom\u00f3zy mezi j\u00edcnem a \u017ealude\u010dn\u00edm tubusem pomoc\u00ed kruhov\u00e9ho stapleru\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_539.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 22b<br \/>Vytv\u00e1\u0159en\u00ed kr\u010dn\u00ed anastom\u00f3zy mezi j\u00edcnem a \u017ealude\u010dn\u00edm tubusem pomoc\u00ed kruhov\u00e9ho stapleru<\/p><\/div><\/td>\n<td style=\"border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_542.png\"><img decoding=\"async\" title=\"Obr. 22c \u2013 Vytv\u00e1\u0159en\u00ed kr\u010dn\u00ed anastom\u00f3zy mezi j\u00edcnem a \u017ealude\u010dn\u00edm tubusem pomoc\u00ed kruhov\u00e9ho stapleru\" alt=\"Obr. 22c \u2013 Vytv\u00e1\u0159en\u00ed kr\u010dn\u00ed anastom\u00f3zy mezi j\u00edcnem a \u017ealude\u010dn\u00edm tubusem pomoc\u00ed kruhov\u00e9ho stapleru\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_542.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 22c<br \/>Vytv\u00e1\u0159en\u00ed kr\u010dn\u00ed anastom\u00f3zy mezi j\u00edcnem a \u017ealude\u010dn\u00edm tubusem pomoc\u00ed kruhov\u00e9ho stapleru<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_540.png\"><img decoding=\"async\" title=\"Obr. 22d \u2013 Odstran\u011bn\u00ed p\u0159ebyte\u010dn\u00e9 \u010d\u00e1sti \u017ealude\u010dn\u00edho tubusu\" alt=\"Obr. 22d \u2013 Odstran\u011bn\u00ed p\u0159ebyte\u010dn\u00e9 \u010d\u00e1sti \u017ealude\u010dn\u00edho tubusu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_540.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 22d<br \/>Odstran\u011bn\u00ed p\u0159ebyte\u010dn\u00e9 \u010d\u00e1sti \u017ealude\u010dn\u00edho tubusu<\/p><\/div><\/td>\n<td style=\"border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_543.png\"><img loading=\"lazy\" decoding=\"async\" class=\" \" title=\"Obr. 22e \u2013 Dokon\u010den\u00e1 anastom\u00f3za\" alt=\"Obr. 22e \u2013 Dokon\u010den\u00e1 anastom\u00f3za\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_543.png\" width=\"200\" height=\"151\" \/><\/a><p class=\"wp-caption-text\">Obr. 22e<br \/>Dokon\u010den\u00e1 anastom\u00f3za<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_545.png\"><img decoding=\"async\" title=\"Obr. 23 \u2013 Opera\u010dn\u00ed prepar\u00e1t adenokarcinomu v abdomin\u00e1ln\u00ed \u010d\u00e1sti j\u00edcnu\" alt=\"Obr. 23 \u2013 Opera\u010dn\u00ed prepar\u00e1t adenokarcinomu v abdomin\u00e1ln\u00ed \u010d\u00e1sti j\u00edcnu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_545.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 23<br \/>Opera\u010dn\u00ed prepar\u00e1t adenokarcinomu v abdomin\u00e1ln\u00ed \u010d\u00e1sti j\u00edcnu<\/p><\/div><\/td>\n<td style=\"border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_546.png\"><img decoding=\"async\" title=\"Obr. 23b \u2013 Karcinom st\u0159edn\u00edho j\u00edcnu\" alt=\"Obr. 23b \u2013 Karcinom st\u0159edn\u00edho j\u00edcnu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_546.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 23b<br \/>Karcinom st\u0159edn\u00edho j\u00edcnu<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">Srovn\u00e1n\u00edm dosa\u017een\u00fdch v\u00fdsledk\u016f p\u0159i u\u017eit\u00ed transtorak\u00e1ln\u00ed a transhiat\u00e1ln\u00ed ezofagektomie byla v minulosti v\u011bnov\u00e1na velk\u00e1 pozornost [57]. \u00dazce to souvis\u00ed s hodnocen\u00edm v\u00fdznamu lymfadenektomie pro dlouhodobou progn\u00f3zu a tato ot\u00e1zka nen\u00ed st\u00e1le jednozna\u010dn\u011b zodpov\u011bzena. Nepochybn\u011b je pouze prok\u00e1z\u00e1no, \u017ee zlep\u0161en\u00ed progn\u00f3zy souvis\u00ed s men\u0161\u00edm po\u010dtem metastaticky posti\u017een\u00fdch uzlin. V posledn\u00ed randomizovan\u00e9 studii z roku 2007 [58] srovn\u00e1vaj\u00edc\u00ed tyto dv\u011b metody u adenokarcinomu j\u00edcnu nebyly shled\u00e1ny rozd\u00edly v morbidit\u011b, mortalit\u011b a celkov\u00e9m p\u0159e\u017e\u00edv\u00e1n\u00ed. Byl v\u0161ak sledovateln\u00fd trend k lep\u0161\u00edmu 5let\u00e9mu p\u0159e\u017e\u00edv\u00e1n\u00ed u nemocn\u00fdch s transtorak\u00e1ln\u00ed ezofagektomi\u00ed. Statisticky signifikantn\u00ed se jev\u00ed zlep\u0161en\u00ed p\u0159e\u017e\u00edv\u00e1n\u00ed u pacient\u016f s men\u0161\u00edm posti\u017een\u00edm ne\u017e v 8 uzlin\u00e1ch, kte\u0159\u00ed podstoupili transtorak\u00e1ln\u00ed ezofagektomii. Ke stejn\u00fdm v\u00fdsledk\u016fm dosp\u011bla i jin\u00e1 studie z USA [59]. Tyto v\u00fdsledky sv\u011bd\u010d\u00ed pro dosa\u017een\u00ed lep\u0161\u00edch onkologick\u00fdch v\u00fdsledk\u016f u transtorak\u00e1ln\u00ed ezofagektomie. Transhiat\u00e1ln\u00ed ezofagektomie se svou men\u0161\u00ed z\u00e1t\u011b\u017e\u00ed pro pacienta je nad\u00e1le vhodn\u00e1 pro rizikov\u00e9 nemocn\u00e9, kter\u00fdm zaru\u010duje lep\u0161\u00ed p\u0159e\u017e\u00edv\u00e1n\u00ed ve srovn\u00e1n\u00ed s paliativn\u00ed l\u00e9\u010dbou.<\/p>\n<p class=\"s14\"><em>Miniinvazivn\u00ed ezofagektomie<\/em><\/p>\n<p style=\"text-align: justify;\">Koncem 80. let minul\u00e9ho stolet\u00ed byla Buessem zavedena periviscer\u00e1ln\u00ed endoskopick\u00e1 ezofagektomie. P\u0159i t\u00e9to metod\u011b se z incize na krku zav\u00e1d\u00ed speci\u00e1ln\u00ed mediastinoskop, kter\u00fd umo\u017e\u0148uje bezpe\u010dn\u00e9 miniinvazivn\u00ed uvoln\u011bn\u00ed j\u00edcnu [60]. Z\u0159ejm\u011b i z d\u016fvodu n\u00e1sledn\u00e9ho rozvoje torakoskopick\u00e9 a laparoskopick\u00e9 chirurgie nedoznala tato metoda \u0161ir\u0161\u00edho uplatn\u011bn\u00ed. Prvn\u00ed zpr\u00e1vy o mo\u017enosti proveden\u00ed torakoskopick\u00e9 mobilizace a resekce j\u00edcnu [61, 62] a transhiat\u00e1ln\u00ed laparoskopick\u00e9 mobilizace ezofagu [63] poch\u00e1zej\u00ed ji\u017e z prvn\u00ed poloviny 90. let minul\u00e9ho stolet\u00ed. Tyto nov\u00e9 metody, stejn\u011b jako v jin\u00fdch oblastech chirurgie, sleduj\u00ed zmen\u0161en\u00ed opera\u010dn\u00ed z\u00e1t\u011b\u017ee u t\u011bchto n\u00e1ro\u010dn\u00fdch operac\u00ed. V uplynul\u00fdch dvou desetilet\u00edch byla mnoha t\u00fdmy prok\u00e1z\u00e1na proveditelnost miniinvazivn\u00ed ezofagektomie a provedeno srovn\u00e1n\u00ed s klasickou otev\u0159enou operac\u00ed [64\u201368]. Procento konverz\u00ed je z\u00e1visl\u00e9 na zku\u0161enosti chirurga, miniinvazivn\u00ed v\u00fdkon trv\u00e1 obvykle d\u00e9le, krat\u0161\u00ed je ale hospitalizace, procento respira\u010dn\u00edch komplikac\u00ed je men\u0161\u00ed u miniinvazivn\u00edch operac\u00ed, v ostatn\u00edch parametrech, jako je dehiscence anastom\u00f3zy, onkologick\u00e9 aspekty v\u00fdkonu \u010di poopera\u010dn\u00ed mortalita, nebyly zaznamen\u00e1ny v\u00fdrazn\u011bj\u0161\u00ed rozd\u00edly. Publikovan\u00e9 metaanal\u00fdzy srovn\u00e1vaj\u00edc\u00ed ob\u011b metody [69\u201371] poukazuj\u00ed na mnoho kontroverzn\u00edch probl\u00e9m\u016f v hodnocen\u00ed. Mezi nejd\u016fle\u017eit\u011bj\u0161\u00ed pat\u0159\u00ed skute\u010dnost, \u017ee zat\u00edm nen\u00ed, s v\u00fdjimkou jedn\u00e9 prob\u00edhaj\u00edc\u00ed [72], \u017e\u00e1dn\u00e1 randomizovan\u00e1 klinick\u00e1 studie srovn\u00e1vaj\u00edc\u00ed miniinvazivn\u00ed a otev\u0159enou ezofagektomii. Pacienti indikovan\u00ed k miniinvazivn\u00ed l\u00e9\u010db\u011b maj\u00ed zpravidla m\u00e9n\u011b pokro\u010dil\u00e9 stadium onemocn\u011bn\u00ed a ni\u017e\u0161\u00ed v\u00fdskyt pr\u016fvodn\u00edch onemocn\u011bn\u00ed.<\/p>\n<p style=\"text-align: justify;\">Ezofagektomie m\u00e1 f\u00e1zi prepara\u010dn\u00ed, p\u0159i kter\u00e9 uvol\u0148ujeme j\u00edcen s n\u00e1dorem, a rekonstruk\u010dn\u00ed, kdy vytv\u00e1\u0159\u00edme \u017ealude\u010dn\u00ed tubus, kter\u00fd pak transportujeme do hrudn\u00edku \u010di na krk a prov\u00e1d\u00edme gastroezofage\u00e1ln\u00ed anastom\u00f3zu. Jsou propracov\u00e1ny a pops\u00e1ny r\u016fzn\u00e9 varianty miniinvazivn\u00edch postup\u016f pro ob\u011b f\u00e1ze operace [73, 74]. V\u00fdhody miniinvazivn\u00edho postupu se projev\u00ed p\u0159edev\u0161\u00edm ve f\u00e1zi prepara\u010dn\u00ed, kde\u017eto rekonstruk\u010dn\u00ed f\u00e1zi je v\u00fdhodn\u00e9 prov\u00e9st asistovan\u011b laparoskopicky nebo v\u00fdhradn\u011b otev\u0159en\u011b. Existuj\u00ed tak v podstat\u011b dva mo\u017en\u00e9 postupy:<\/p>\n<p class=\"s14\"><em>Torakoskopick\u00e1 mobilizace j\u00edcnu<\/em><\/p>\n<p style=\"text-align: justify;\">Pacient je intubov\u00e1n speci\u00e1ln\u00ed intuba\u010dn\u00ed kanylou umo\u017e\u0148uj\u00edc\u00ed separ\u00e1tn\u00ed ventilaci jedn\u00e9 pl\u00edce. V prvn\u00ed f\u00e1zi operace je nemocn\u00fd ulo\u017een na lev\u00fd bok obdobn\u011b jako p\u0159i torakotomii a v\u00fdhodn\u00e9 je jeho \u010d\u00e1ste\u010dn\u00e9 nato\u010den\u00ed sm\u011brem na b\u0159icho (semiprona\u010dn\u00ed poloha). Podle zvyklosti operat\u00e9ra se zav\u00e1d\u011bj\u00ed obvykle \u010dty\u0159i porty, z toho t\u0159i p\u0159ibli\u017en\u011b v zadn\u00ed axil\u00e1rn\u00ed \u010d\u00e1\u0159e a jeden pon\u011bkud ventr\u00e1ln\u011bji. Jeden z port\u016f m\u016f\u017ee b\u00fdt nahrazen p\u0159es drobnou incizi zaveden\u00fdm kardi\u00e1ln\u00edm ekarterem, kter\u00fdm asistent odtahuje pl\u00edci.<\/p>\n<div id=\"attachment_3320\" style=\"width: 50px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=3376\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3320\" class=\" wp-image-3320 \" title=\"VIDEO 8\" alt=\"VIDEO 8\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/06\/video.jpg\" width=\"40\" height=\"40\" srcset=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/06\/video-150x150.jpg 150w, https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/06\/video-120x120.jpg 120w\" sizes=\"auto, (max-width: 40px) 100vw, 40px\" \/><\/a><p id=\"caption-attachment-3320\" class=\"wp-caption-text\">VIDEO 8<\/p><\/div>\n<p style=\"text-align: justify;\">N\u00e1mi u\u017e\u00edvan\u00fd zp\u016fsob zaveden\u00ed portu ukazuje obr. 24. Zku\u0161en\u00fd miniinvazivn\u00ed chirurg z tohoto p\u0159\u00edstupu m\u016f\u017ee dokonale uvolnit cel\u00fd j\u00edcen od br\u00e1ni\u010dn\u00edho hi\u00e1tu a\u017e vysoko do apexu pleury. V pr\u016fb\u011bhu preparace se prot\u00edn\u00e1 vena azygos a je mo\u017en\u00e9 prov\u00e9st dokonalou lymfadenektomii. V\u00fdkon je ukon\u010den zaveden\u00edm hrudn\u00edho dr\u00e9nu inciz\u00ed po ventr\u00e1ln\u011b ulo\u017een\u00e9m portu a sm\u011b\u0159uje sm\u011brem do pleur\u00e1ln\u00ed kupoly (obr. 25 a 26, <a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=3376\" target=\"_blank\">video, torakoskopick\u00e1 mobilizace karcinomu hrudn\u00edho j\u00edcnu<\/a>, je dostupn\u00e9 v elektronick\u00e9 verzi knihy \u2013 viz tir\u00e1\u017e knihy).<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_548.png\"><img loading=\"lazy\" decoding=\"async\" class=\" \" title=\"Obr. 24 \u2013 N\u00e1mi u\u017e\u00edvan\u00fd zp\u016fsob zaveden\u00ed portu p\u0159i torakoskopick\u00e9 mobilizaci j\u00edcnu; ventr\u00e1ln\u011b je mo\u017eno alternativn\u011b m\u00edsto portu z mal\u00e9 incize zav\u00e9st ekarter k odsunut\u00ed pl\u00edce\" alt=\"Obr. 24 \u2013 N\u00e1mi u\u017e\u00edvan\u00fd zp\u016fsob zaveden\u00ed portu p\u0159i torakoskopick\u00e9 mobilizaci j\u00edcnu; ventr\u00e1ln\u011b je mo\u017eno alternativn\u011b m\u00edsto portu z mal\u00e9 incize zav\u00e9st ekarter k odsunut\u00ed pl\u00edce\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_548.png\" width=\"200\" height=\"151\" \/><\/a><p class=\"wp-caption-text\">Obr. 24<br \/>N\u00e1mi u\u017e\u00edvan\u00fd zp\u016fsob zaveden\u00ed portu p\u0159i torakoskopick\u00e9 mobilizaci j\u00edcnu; ventr\u00e1ln\u011b je mo\u017eno alternativn\u011b m\u00edsto portu z mal\u00e9 incize zav\u00e9st ekarter k odsunut\u00ed pl\u00edce<\/p><\/div><\/td>\n<td style=\"border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_549.png\"><img loading=\"lazy\" decoding=\"async\" class=\" \" title=\"Obr. 25a \u2013 Pohled do zadn\u00edho mediastina p\u0159ed zah\u00e1jen\u00edm preparace\" alt=\"Obr. 25a \u2013 Pohled do zadn\u00edho mediastina p\u0159ed zah\u00e1jen\u00edm preparace\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_549.png\" width=\"200\" height=\"151\" \/><\/a><p class=\"wp-caption-text\">Obr. 25a<br \/>Pohled do zadn\u00edho mediastina p\u0159ed zah\u00e1jen\u00edm preparace<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_551.png\"><img decoding=\"async\" title=\"Obr. 25b \u2013 \u010c\u00e1ste\u010dn\u011b uvoln\u011bn\u00fd j\u00edcen z mediastina; v lev\u00e9m horn\u00edm rohu je patrn\u00fd ekarter odtla\u010duj\u00edc\u00ed pl\u00edci\" alt=\"Obr. 25b \u2013 \u010c\u00e1ste\u010dn\u011b uvoln\u011bn\u00fd j\u00edcen z mediastina; v lev\u00e9m horn\u00edm rohu je patrn\u00fd ekarter odtla\u010duj\u00edc\u00ed pl\u00edci\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_551.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 25b<br \/>\u010c\u00e1ste\u010dn\u011b uvoln\u011bn\u00fd j\u00edcen z mediastina; v lev\u00e9m horn\u00edm rohu je patrn\u00fd ekarter odtla\u010duj\u00edc\u00ed pl\u00edci<\/p><\/div><\/td>\n<td style=\"border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_552.png\"><img decoding=\"async\" title=\"Obr. 26a \u2013 Vypreparovan\u00fd j\u00edcen, v. azygos a zv\u011bt\u0161en\u00e9 m\u00edzn\u00ed uzliny\" alt=\"Obr. 26a \u2013 Vypreparovan\u00fd j\u00edcen, v. azygos a zv\u011bt\u0161en\u00e9 m\u00edzn\u00ed uzliny\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_552.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 26a<br \/>Vypreparovan\u00fd j\u00edcen, v. azygos a zv\u011bt\u0161en\u00e9 m\u00edzn\u00ed uzliny<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_554.png\"><img decoding=\"async\" title=\"Obr. 26b \u2013 Kompletn\u011b uvoln\u011bn\u00fd j\u00edcen vyzvednut\u00fd z mediastina\" alt=\"Obr. 26b \u2013 Kompletn\u011b uvoln\u011bn\u00fd j\u00edcen vyzvednut\u00fd z mediastina\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_554.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 26b<br \/>Kompletn\u011b uvoln\u011bn\u00fd j\u00edcen vyzvednut\u00fd z mediastina<\/p><\/div><\/td>\n<td style=\"border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_553.png\"><img decoding=\"async\" title=\"Obr. 25c \u2013 Preparace j\u00edcnu od perikardu po otev\u0159en\u00ed mediastin\u00e1ln\u00ed pleury, na j\u00edcnu patrn\u00fd pr\u016fb\u011bh vagu\" alt=\"Obr. 25c \u2013 Preparace j\u00edcnu od perikardu po otev\u0159en\u00ed mediastin\u00e1ln\u00ed pleury, na j\u00edcnu patrn\u00fd pr\u016fb\u011bh vaguObr. 25c \u2013 Preparace j\u00edcnu od perikardu po otev\u0159en\u00ed mediastin\u00e1ln\u00ed pleury, na j\u00edcnu patrn\u00fd pr\u016fb\u011bh vagu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_553.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 25c<br \/>Preparace j\u00edcnu od perikardu po otev\u0159en\u00ed mediastin\u00e1ln\u00ed pleury, na j\u00edcnu patrn\u00fd pr\u016fb\u011bh vagu<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n<p style=\"text-align: justify;\">V druh\u00e9 f\u00e1zi operace je pacient ulo\u017een v poloze na z\u00e1dech a je p\u0159ipraveno jak b\u0159i\u0161n\u00ed, tak i kr\u010dn\u00ed opera\u010dn\u00ed pole. Na krku se vyu\u017e\u00edv\u00e1 obvykle p\u0159\u00edstupu z opera\u010dn\u00edho \u0159ezu na vnit\u0159n\u00ed stran\u011b lev\u00e9ho k\u00fdva\u010de p\u0159i m\u00edrn\u00e9m z\u00e1klonu a vyto\u010den\u00ed hlavy doprava. B\u0159i\u0161n\u00ed f\u00e1ze operace sest\u00e1v\u00e1 z mobilizace \u017ealudku a b\u0159i\u0161n\u00edho j\u00edcnu a vytvo\u0159en\u00ed \u017ealude\u010dn\u00edho tubusu, jak to bylo pops\u00e1no p\u0159i otev\u0159en\u00e9 operaci. Operaci je mo\u017eno prov\u00e1d\u011bt bu\u010f kompletn\u011b, nebo asistovan\u011b laparoskopicky z p\u011btiportov\u00e9ho p\u0159\u00edstupu. V\u011bt\u0161inou v\u0161ak chirurgov\u00e9 p\u0159ipojuj\u00ed alespo\u0148 malou laparotomii, ze kter\u00e9 pak vytv\u00e1\u0159ej\u00ed vlastn\u00ed tubus p\u0159ed p\u0159edn\u00ed st\u011bnou b\u0159i\u0161n\u00ed a tudy tak\u00e9 extrahuj\u00ed cel\u00fd opera\u010dn\u00ed prepar\u00e1t. Dle velikosti prepar\u00e1tu a tumoru je mo\u017eno jej n\u011bkdy extrahovat i p\u0159es kr\u010dn\u00ed incizi. \u0158ada chirurg\u016f prov\u00e1d\u00ed b\u0159i\u0161n\u00ed f\u00e1zi klasicky otev\u0159en\u011b z laparotomie. T\u0159et\u00ed f\u00e1ze operace se prov\u00e1d\u00ed z kr\u010dn\u00edho \u0159ezu otev\u0159en\u011b a prota\u017een\u00fd tubus se anastomozuje se zbytkem kr\u010dn\u00edho j\u00edcnu.<\/p>\n<p class=\"s14\"><em>Laparoskopick\u00e1 mobilizace j\u00edcnu<\/em><\/p>\n<p style=\"text-align: justify;\">P\u0159i t\u00e9to operaci je pacient po celou dobu operace v jedn\u00e9 poloze vle\u017ee na z\u00e1dech. Nejprve se z p\u011btiportov\u00e9ho laparoskopick\u00e9ho p\u0159\u00edstupu provede transhiat\u00e1ln\u00ed uvoln\u011bn\u00ed j\u00edcnu, co\u017e v\u0161ak obvykle nen\u00ed mo\u017en\u00e9 v\u00fd\u0161e ne\u017e do \u00farovn\u011b bifurkace trachey, a proto je tento zp\u016fsob vhodn\u00fd p\u0159ev\u00e1\u017en\u011b pro n\u00e1dory v doln\u00ed t\u0159etin\u011b ezofagu. N\u00e1sleduje vytvo\u0159en\u00ed \u017ealude\u010dn\u00edho tubusu op\u011bt bu\u010f \u010dist\u011b laparoskopicky, nebo \u010dast\u011bji po vysunut\u00ed \u017ealudku z mal\u00e9 laparotomie p\u0159ed p\u0159edn\u00ed st\u011bnu b\u0159i\u0161n\u00ed. Kr\u010dn\u00ed f\u00e1ze operace se pak ji\u017e neli\u0161\u00ed od p\u0159edch\u00e1zej\u00edc\u00edho popisu.<\/p>\n<h6 class=\"s32\">Zhodnocen\u00ed technicko-taktick\u00fdch prvk\u016f v l\u00e9\u010debn\u00e9 strategii<\/h6>\n<p style=\"text-align: justify;\">Resekce a n\u00e1hrada j\u00edcnu je velmi n\u00e1ro\u010dnou operac\u00ed a je t\u0159eba v\u017edy zv\u00e1\u017eit jej\u00ed \u00fanosnost dle celkov\u00e9ho stavu pacienta. V chirurgick\u00e9 onkologii plat\u00ed nepochybn\u011b z\u00e1sada, \u017ee rozhoduj\u00edc\u00ed v\u00fdznam pro dal\u0161\u00ed osud nemocn\u00e9ho m\u00e1 biologie n\u00e1doru. Na druh\u00e9m m\u00edst\u011b je d\u016fle\u017eit\u00fd spr\u00e1vn\u00fd staging onemocn\u011bn\u00ed, jak jsme se o n\u011bm ji\u017e zm\u00ednili. Teprve na t\u0159et\u00edm m\u00edst\u011b m\u00e1 v\u00fdznam volba opera\u010dn\u00ed techniky, kde p\u0159i dokonal\u00e9m technicko-taktick\u00e9m zvl\u00e1dnut\u00ed r\u016fzn\u00fdch alternativn\u00edch metod je dosahov\u00e1no srovnateln\u00fdch v\u00fdsledk\u016f [75, 76]. P\u0159i u\u017eit\u00ed miniinvazivn\u00edch technik je mo\u017eno hlavn\u00ed p\u0159\u00ednos spat\u0159ovat p\u0159edev\u0161\u00edm ve zmen\u0161en\u00ed opera\u010dn\u00ed z\u00e1t\u011b\u017ee, nap\u0159. t\u00edm, \u017ee se vyhneme torakotomii, a m\u00e1me mo\u017enost dokonal\u00e9 vizu\u00e1ln\u00ed kontroly p\u0159i exstirpaci j\u00edcnu a lymfadenektomii ve srovn\u00e1n\u00ed s exstirpac\u00ed j\u00edcnu naslepo. Aby tyto v\u00fdhody nebyly eliminov\u00e1ny ne\u00fam\u011brnou, organizmus zat\u011b\u017euj\u00edc\u00ed d\u00e9lkou operace, je kompromisn\u00edm \u0159e\u0161en\u00edm prov\u00e1d\u011bt miniinvazivn\u011b jen exstirpa\u010dn\u00ed f\u00e1zi operace, a tuto taktiku vol\u00edme i my.<\/p>\n<p class=\"s32\"><em>\u010casn\u00e9 v\u00fdsledky chirurgick\u00e9 l\u00e9\u010dby a komplikace<\/em><\/p>\n<p style=\"text-align: justify;\">P\u0159es zlep\u0161uj\u00edc\u00ed se chirurgickou techniku a periopera\u010dn\u00ed intenzivn\u00ed p\u00e9\u010di je ezofagektomie st\u00e1le spojena s pom\u011brn\u011b vysokou morbiditou a mortalitou. Mortalita v uve\u0159ejn\u011bn\u00fdch studi\u00edch kol\u00eds\u00e1 mezi 2,7\u20139,8 % a celkov\u00e1 morbidita mezi 40\u201360 %.<\/p>\n<p style=\"text-align: justify;\">Nej\u010dast\u011bj\u0161\u00edmi a nejv\u00fdznam\u011bj\u0161\u00edmi komplikacemi jsou respira\u010dn\u00ed komplikace v 18\u201328 % a dehiscence anastom\u00f3zy v 11\u201325 % [77\u201382]. Mezi p\u0159eda periopera\u010dn\u00ed faktory, kter\u00e9 jsou v\u00fdznamn\u011b spojen\u00e9 s vy\u0161\u0161\u00ed morbiditou a mortalitou, pat\u0159\u00ed: vy\u0161\u0161\u00ed v\u011bk, diabetes mellitus, dyspnoe, kou\u0159en\u00ed a po\u017e\u00edv\u00e1n\u00ed alkoholu, nutnost poopera\u010dn\u00edho pod\u00e1v\u00e1n\u00ed transfuz\u00ed a poopera\u010dn\u00ed vznik pneumonie. Naproti tomu neadjuvantn\u00ed chemoradioterapie nevedla ke zv\u00fd\u0161en\u00ed morbidity. Jen v jedn\u00e9 studii [77] nebyla s vy\u0161\u0161\u00edm rizikem komplikac\u00ed spojov\u00e1na torakotomie a rovn\u011b\u017e jedna studie [80]neshledala vliv dehiscence anastom\u00f3zy na vy\u0161\u0161\u00ed frekvenci komplikac\u00ed. Nep\u0159\u00edzniv\u00fd vliv na riziko plicn\u00edch komplikac\u00ed m\u00e1 podle japonsk\u00fdch studi\u00ed i t\u0159\u00edkompartmentov\u00e1 lymfadektomie, kter\u00e1 zvy\u0161uje i riziko poran\u011bn\u00ed vratn\u00fdch nerv\u016f, co\u017e rovn\u011b\u017e v\u00fdznamn\u011b negativn\u011b ovliv\u0148uje plicn\u00ed funkci. Riziko plicn\u00edch komplikac\u00ed je po ezofagektomii vy\u0161\u0161\u00ed ne\u017e po jin\u00fdch velk\u00fdch chirurgick\u00fdch operac\u00edch, v\u010detn\u011b plicn\u00edch resekc\u00ed, a je p\u0159\u00ed\u010dinou v\u00edce ne\u017e poloviny \u00famrt\u00ed po t\u00e9to operaci. Respira\u010dn\u00ed komplikace se projevuj\u00ed r\u016fznou \u0161k\u00e1lou patologick\u00fdch stav\u016f, jako je pleuritida, atelekt\u00e1zy, pneumonie, a mohou se vystup\u0148ovat a\u017e v ARDS (akutn\u00ed respira\u010dn\u00ed distres syndrom). V\u00fdznamnou roli v prevenci t\u011bchto plicn\u00edch komplikac\u00ed m\u00e1 preventivn\u00ed p\u0159edopera\u010dn\u00ed dechov\u00e1 fyzioterapie. Mezi faktory vedouc\u00ed k redukci plicn\u00edch komplikac\u00ed se uv\u00e1d\u00ed: speci\u00e1ln\u00ed protektivn\u00ed ventilace s vyu\u017eit\u00edm PEEP (positive end-expiratory pressure) b\u011bhem separovan\u00e9 ventilace jedn\u00e9 pl\u00edce [83], \u010dasn\u00e1 extubace a mobilizace pacienta, intenzivn\u00ed respira\u010dn\u00ed fyzioterapie a bronchoskopick\u00e1 toaleta, adekv\u00e1tn\u00ed tlumen\u00ed bolesti (epidur\u00e1ln\u00ed kat\u00e9tr) a negativn\u00ed tekutinov\u00e1 bilance. Opera\u010dn\u00ed trauma po ezofagektomii vede v organizmu k vyvol\u00e1n\u00ed z\u00e1n\u011btliv\u00e9 odpov\u011bdi, jej\u00edm\u017e d\u016fsledkem je kumulace tekutin v organizmu [84], obdobnou reakci vyvol\u00e1v\u00e1 poopera\u010dn\u00ed porucha respirace a n\u00e1sledkem je interstici\u00e1ln\u00ed plicn\u00ed ed\u00e9m, kter\u00fd vede ke zv\u00fd\u0161en\u00e9mu riziku vzniku plicn\u00edch a srde\u010dn\u00edch komplikac\u00ed. Restrikce p\u0159\u00edsunu tekutin v pr\u016fb\u011bhu operace a prvn\u00edch poopera\u010dn\u00edch dn\u00ed tak m\u016f\u017ee v\u00fdznamn\u011b p\u0159isp\u011bt ke sn\u00ed\u017een\u00ed rizika poopera\u010dn\u00edch plicn\u00edch a kardi\u00e1ln\u00edch komplikac\u00ed [85].<\/p>\n<p style=\"text-align: justify;\">Pacienti po ezofagektomii byli tradi\u010dn\u011b ponech\u00e1v\u00e1ni na \u0159\u00edzen\u00e9 plicn\u00ed ventilaci p\u0159es noc do n\u00e1sleduj\u00edc\u00edho r\u00e1na, kdy byli extubov\u00e1ni. Mechanick\u00e1 ventilace, zvl\u00e1\u0161t\u011b po separovan\u00e9 ventilaci jedn\u00e9 pl\u00edce, je spojen\u00e1 s barotraumatem, a m\u016f\u017ee tak paradoxn\u011b v\u00e9st ke zv\u00fd\u0161en\u00ed plicn\u00edch komplikac\u00ed. Naopak po \u010dasn\u00e9 extubaci na opera\u010dn\u00edm s\u00e1le je stejn\u00e1 nebo m\u00edrn\u011b men\u0161\u00ed poopera\u010dn\u00ed morbidita a mortalita [86\u201388].<\/p>\n<p style=\"text-align: justify;\">Vznik insuficience j\u00edcnov\u00e9 anastom\u00f3zy m\u00e1 multifaktori\u00e1ln\u00ed p\u016fvod. Mezi obecn\u00e9 p\u0159\u00ed\u010diny ovliv\u0148uj\u00edc\u00ed vznik t\u00e9to komplikace pat\u0159\u00ed celkov\u00fd zdravotn\u00ed stav, porucha kardiorespira\u010dn\u00edch funkc\u00ed, pokro\u010dilost n\u00e1doru a malnutrice. Z lok\u00e1ln\u00edch p\u0159\u00ed\u010din je to \u0161patn\u00e9 c\u00e9vn\u00ed z\u00e1soben\u00ed j\u00edcnu a transpon\u00e1tu, mechanick\u00e9 nap\u011bt\u00ed zalo\u017een\u00e9 spojky, m\u00edstn\u00ed infekce a v neposledn\u00ed \u0159ad\u011b technicky \u0161patn\u011b proveden\u00e1 sutura anastom\u00f3zy. Z uveden\u00fdch d\u016fvod\u016f m\u016f\u017ee kol\u00edsat frekvence t\u00e9to komplikace v jednotliv\u00fdch sestav\u00e1ch ve zna\u010dn\u00e9m rozmez\u00ed. Dehiscence spojky m\u016f\u017ee b\u00fdt asymptomatick\u00e1, je zji\u0161t\u011bna p\u0159i rentgenov\u00e9m vy\u0161et\u0159en\u00ed, nebo m\u016f\u017ee m\u00edt projevy lok\u00e1ln\u00ed infekce a\u017e t\u011b\u017ek\u00e9ho septick\u00e9ho stavu. Diagn\u00f3zu ov\u011b\u0159\u00edme kontrastn\u00ed rentgenovou pas\u00e1\u017e\u00ed vodn\u00fdm kontrastn\u00edm roztokem nebo CT vy\u0161et\u0159en\u00edm. Na \u0159ad\u011b pracovi\u0161\u0165 se rentgenov\u00e1 kontrastn\u00ed pas\u00e1\u017e prov\u00e1d\u00ed rutinn\u011b p\u0159ed zat\u00ed\u017een\u00edm pacienta stravou mezi 4.\u20139. poopera\u010dn\u00edm dnem. Mnoho pacient\u016f s nevelkou, v\u010das diagnostikovanou dehiscenc\u00ed lze l\u00e9\u010dit konzervativn\u011b vy\u0159azen\u00edm peror\u00e1ln\u00edho p\u0159\u00edjmu, parenter\u00e1ln\u00ed v\u00fd\u017eivou \u010di l\u00e9pe enter\u00e1ln\u00ed pomoc\u00ed sondy, dekompres\u00ed transpon\u00e1tu sondou, pod\u00e1n\u00edm antibiotik a lok\u00e1ln\u00ed perkut\u00e1nn\u00ed dren\u00e1\u017e\u00ed oblasti kolem anastom\u00f3zy pod kontrolou sonografu \u010di CT. V posledn\u00edch letech se v l\u00e9\u010db\u011b insuficience anastom\u00f3zy \u00fasp\u011b\u0161n\u011b vyu\u017e\u00edvaj\u00ed samoexpanzibiln\u00ed stenty (viz kap. 14.3 Perforace j\u00edcnu) [89\u201391]. Chirurgick\u00e1 intervence je indikov\u00e1na p\u0159i selh\u00e1n\u00ed konzervativn\u00ed terapie nebo prim\u00e1rn\u011b p\u0159i rozs\u00e1hl\u00e9 dehiscenci, projevech t\u011b\u017ek\u00e9 mediastinitity \u010di peritonitidy spolu se seps\u00ed \u010di p\u0159i nekr\u00f3ze transplant\u00e1tu. Chirurgick\u00e1 revize umo\u017e\u0148uje dokonalej\u0161\u00ed dren\u00e1\u017e, odstran\u011bn\u00ed nekrotick\u00e9ho transplant\u00e1tu; rekonstrukce anastom\u00f3zy v t\u011bchto p\u0159\u00edpadech je mo\u017en\u00e1 jen v\u00fdjime\u010dn\u011b. Sou\u010d\u00e1st\u00ed chirurgick\u00e9ho v\u00fdkonu m\u016f\u017ee b\u00fdt i vyu\u017eit\u00ed samoexpanzibiln\u00edho stentu \u010di zalo\u017een\u00ed kr\u010dn\u00ed ezofagostomie.<\/p>\n<h6 class=\"s32\">Fast-track program po ezofagektomii<\/h6>\n<p style=\"text-align: justify;\">C\u00edlem tohoto programu je urychlen\u00ed rekonvalescence po operaci redukc\u00ed poopera\u010dn\u00edho stresu, a t\u00edm sn\u00ed\u017een\u00ed poopera\u010dn\u00ed morbidity, urychlen\u00ed n\u00e1vratu do stabilizovan\u00e9ho stavu a zkr\u00e1cen\u00ed hospitalizace, a tedy i sn\u00ed\u017een\u00ed n\u00e1klad\u016f. Tento program byl vypracov\u00e1n a je u\u017e\u00edv\u00e1n ji\u017e del\u0161\u00ed dobu v kolorekt\u00e1ln\u00ed chirurgii a je snaha jej aplikovat i na jin\u00e9 oblasti chirurgie [92]. Dle dosud publikovan\u00fdch zku\u0161enost\u00ed zahrnuje zejm\u00e9na n\u00e1sleduj\u00edc\u00ed opat\u0159en\u00ed: P\u0159ed operac\u00ed podrobn\u00e9 pou\u010den\u00ed a dechov\u00e1 cvi\u010den\u00ed. Poopera\u010dn\u00ed program rozpracovan\u00fd na jednotliv\u00e9 dny zahrnuje bezprost\u0159edn\u00ed extubaci, v\u010dasnou rehabilitaci a mobilizaci, udr\u017eov\u00e1n\u00ed negativn\u00ed tekutinov\u00e9 bilance, urychlenou realimentaci, brzk\u00e9 odstran\u011bn\u00ed dr\u00e9n\u016f, sond a kat\u00e9tr\u016f a \u00fa\u010dinnou analgetizaci. Soubor t\u011bchto opat\u0159en\u00ed a jejich algoritmus nen\u00ed dosud obecn\u011b stanoven\u00fd. Z dosavadn\u00edch zku\u0161enost\u00ed v\u0161ak vypl\u00fdv\u00e1, \u017ee aplikace tohoto programu, v\u010detn\u011b zkr\u00e1cen\u00ed pobytu na JIP a celkov\u00e9 d\u00e9lky hospitalizace, p\u0159in\u00e1\u0161\u00ed srovnateln\u00e9 \u010di m\u00edrn\u011b lep\u0161\u00ed v\u00fdsledky v rychlosti zotaven\u00ed a ve v\u00fdskytu poopera\u010dn\u00ed morbidity.<\/p>\n<h6 class=\"s32\">Dlouhodob\u00e9 l\u00e9\u010debn\u00e9 v\u00fdsledky<\/h6>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_558.png\"><img loading=\"lazy\" decoding=\"async\" class=\" \" title=\"Obr. 27 \u2013 P\u011btilet\u00e9 relativn\u00ed p\u0159e\u017eit\u00ed u l\u00e9\u010den\u00fdch on kologick\u00fdch pacient\u016f se solidn\u00edmi n\u00e1dor y v \u010cR v letech 2004\u20132007\" alt=\"Obr. 27 \u2013 P\u011btilet\u00e9 relativn\u00ed p\u0159e\u017eit\u00ed u l\u00e9\u010den\u00fdch on kologick\u00fdch pacient\u016f se solidn\u00edmi n\u00e1dor y v \u010cR v letech 2004\u20132007\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_558.png\" width=\"200\" height=\"161\" \/><\/a><p class=\"wp-caption-text\">Obr. 27<br \/>P\u011btilet\u00e9 relativn\u00ed p\u0159e\u017eit\u00ed u l\u00e9\u010den\u00fdch on kologick\u00fdch pacient\u016f se solidn\u00edmi n\u00e1dor y v \u010cR v letech 2004\u20132007<\/p><\/div><\/td>\n<td style=\"border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_560.png\"><img loading=\"lazy\" decoding=\"async\" class=\"  \" title=\"Obr. 28 \u2013 P\u011btilet\u00e9 relativn\u00ed p\u0159e\u017eit\u00ed u l\u00e9\u010den\u00fdch onkologick\u00fdch pacient\u016f se ZN j\u00edcnu\" alt=\"Obr. 28 \u2013 P\u011btilet\u00e9 relativn\u00ed p\u0159e\u017eit\u00ed u l\u00e9\u010den\u00fdch onkologick\u00fdch pacient\u016f se ZN j\u00edcnu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_560.png\" width=\"200\" height=\"290\" \/><\/a><p class=\"wp-caption-text\">Obr. 28<br \/>P\u011btilet\u00e9 relativn\u00ed p\u0159e\u017eit\u00ed u l\u00e9\u010den\u00fdch onkologick\u00fdch pacient\u016f se ZN j\u00edcnu<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">Skute\u010dnosti, \u017ee u v\u011bt\u0161iny nemocn\u00fdch je n\u00e1dor odhalen a\u017e v pozdn\u00edm stadiu onemocn\u011bn\u00ed, odpov\u00eddaj\u00ed i \u0161patn\u00e9 l\u00e9\u010debn\u00e9 v\u00fdsledky. P\u011btilet\u00e9 p\u0159e\u017e\u00edv\u00e1n\u00ed u l\u00e9\u010den\u00fdch pacient\u016f s karcinomem j\u00edcnu v \u010cesk\u00e9 republice je 15,5 % a hor\u0161\u00ed v\u00fdsledky jsou jen u zhoubn\u00fdch n\u00e1dor\u016f plic, jater a slinivky b\u0159i\u0161n\u00ed (obr. 27).<\/p>\n<p style=\"text-align: justify;\">Dlouhodob\u00e1 progn\u00f3za karcinomu j\u00edcnu je z\u00e1sadn\u011b odvisl\u00e1 od pokro\u010dilosti onemocn\u011bn\u00ed. Vyl\u00e9\u010den\u00ed nebo dlouhodob\u011bj\u0161\u00ed p\u0159e\u017e\u00edv\u00e1n\u00ed lze p\u0159es ve\u0161ker\u00e9 pokroky multimod\u00e1ln\u00ed l\u00e9\u010dby dos\u00e1hnout pouze v po\u010d\u00e1te\u010dn\u00edch stadi\u00edch onemocn\u011bn\u00ed, kde m\u00e1 chirurgick\u00e1 l\u00e9\u010dba rozhoduj\u00edc\u00ed v\u00fdznam. P\u0159e\u017e\u00edv\u00e1n\u00ed nemocn\u00fdch s karcinomem j\u00edcnu podle \u00fadaj\u016f z n\u00e1rodn\u00edho onkologick\u00e9ho registru \u010cesk\u00e9 republiky ukazuje obr. 28. V\u00fdznamn\u011b del\u0161\u00ed je p\u011btilet\u00e9 p\u0159e\u017e\u00edv\u00e1n\u00ed m\u00e9n\u011b pokro\u010dil\u00e9ho n\u00e1doru v 1. a 2. stadiu onemocn\u011bn\u00ed, kde v analyzovan\u00e9m obdob\u00ed 2004\u20132007 bylo 30 % a proti anal\u00fdze periody let 2000\u20132003 do\u0161lo ke zlep\u0161en\u00ed o 10 %.<\/p>\n<p class=\"s32\" style=\"text-align: justify;\">Recidiva n\u00e1dorov\u00e9ho onemocn\u011bn\u00ed m\u016f\u017ee b\u00fdt lokoregion\u00e1ln\u00ed, m\u00e9n\u011b \u010dasto v anastom\u00f3ze, \u010dast\u011bji v l\u016f\u017eku j\u00edcnu a v lokoregion\u00e1ln\u00edch uzlin\u00e1ch. Syst\u00e9mov\u00e1 generalizace nej\u010dasn\u011bji postihuje j\u00e1tra, pl\u00edce, kostn\u00ed d\u0159e\u0148 a mozek. Podle \u00fadaj\u016f ve sv\u011btov\u00e9 literatu\u0159e je recidiva onemocn\u011bn\u00ed po samotn\u00e9 chirurgick\u00e9 l\u00e9\u010db\u011b a po neadjuvantn\u00ed chemoterapii obdobn\u00e1 a pohybuje se kolem 50 % [93, 94]. Posledn\u00ed americk\u00e1 studie publikovan\u00e1 v roce 2010 uv\u00e1d\u00ed sn\u00ed\u017een\u00ed rekurence po neadjuvantn\u00ed terapii na 31,5 % [95].<\/p>\n<h6 class=\"s32\" style=\"text-align: justify;\">Paliativn\u00ed terapie<\/h6>\n<p style=\"text-align: justify;\">Nelze-li n\u00e1dor pro jeho velikost \u010di celkov\u00fd stav nemocn\u00e9ho radik\u00e1ln\u011b odstranit, je na m\u00edst\u011b odstranit nebo alespo\u0148 zlep\u0161it dysfagii. Zalo\u017een\u00ed trval\u00e9 gastrostomie je pro nemocn\u00e9ho v\u00fdkonem mutiluj\u00edc\u00edm, zna\u010dn\u011b zhor\u0161uj\u00edc\u00edm kvalitu jeho \u017eivota. Tato mo\u017enost se proto dnes u\u017e prakticky nevyu\u017e\u00edv\u00e1. V d\u0159\u00edv\u011bj\u0161\u00ed dob\u011b byly u inoperabiln\u00edch stav\u016f zakl\u00e1d\u00e1ny paliativn\u00ed by-passy ze \u017ealudku \u010di st\u0159eva p\u0159i ponech\u00e1n\u00ed inoperabiln\u00edho tumoru in situ. Operace byla obdobou rekonstruk\u010dn\u00ed f\u00e1ze u radik\u00e1ln\u00edch operac\u00ed. Pro nemocn\u00e9ho s inoperabiln\u00edm n\u00e1dorem, v\u011bt\u0161inou ve \u0161patn\u00e9m celkov\u00e9m zdravotn\u00edm stavu, byla tato operace ne\u00fam\u011brn\u011b n\u00e1ro\u010dn\u00e1 a rizikov\u00e1. \u0158adu let byla u\u017e\u00edv\u00e1na intubace stenozuj\u00edc\u00edch tumor\u016f, zvl\u00e1\u0161t\u011b doln\u00edho j\u00edcnu, H\u00e4ringovou endoprot\u00e9zou. Ta byla zav\u00e1d\u011bna z laparotomie a gastrotomie a pozd\u011bji byla vypracov\u00e1na i metoda endoskopick\u00e9ho zaveden\u00ed. V\u00fdkon byl \u010dasto prov\u00e1zen komplikacemi, nej\u010dast\u011bji supurac\u00ed r\u00e1ny a dislokac\u00ed tubusu. Z t\u011bchto d\u016fvod\u016f byla hled\u00e1na nov\u00e1 alternativn\u00ed \u0159e\u0161en\u00ed dysfagie.<\/p>\n<p style=\"text-align: justify;\">Pro nemocn\u00e9 je m\u00e9n\u011b zat\u011b\u017euj\u00edc\u00ed dilatace n\u00e1dorov\u00fdch striktur, kter\u00e1 m\u00e1 v\u0161ak jen omezenou mo\u017enost a kr\u00e1tkodob\u00fd efekt. Pokrokem je laserov\u00e1 rekanalizace j\u00edcnu, vy\u017eaduj\u00edc\u00ed ale obvykle n\u011bkolik sezen\u00ed.<\/p>\n<div id=\"attachment_3320\" style=\"width: 50px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=3378\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3320\" class=\"wp-image-3320 \" title=\"VIDEO 9\" alt=\"VIDEO 9\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/06\/video.jpg\" width=\"40\" height=\"40\" srcset=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/06\/video-150x150.jpg 150w, https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/06\/video-120x120.jpg 120w\" sizes=\"auto, (max-width: 40px) 100vw, 40px\" \/><\/a><p id=\"caption-attachment-3320\" class=\"wp-caption-text\">VIDEO 9<\/p><\/div>\n<p style=\"text-align: justify;\">Zat\u00edm nejdokonalej\u0161\u00edm zp\u016fsobem paliativn\u00edho \u0159e\u0161en\u00ed dysfagie je u\u017eit\u00ed pleten\u00fdch kovov\u00fdch stent\u016f. Zav\u00e1d\u011bj\u00ed se pod rentgenovou \u010di endoskopickou kontrolou, v\u00fdkon nevy\u017eaduje anestezii a lze ho \u010dasto prov\u00e9st i ambulantn\u011b. Stent se na vodi\u010di zavede do striktury a po odstran\u011bn\u00ed obalu se postupn\u011b rozvine, roztla\u010d\u00ed n\u00e1dorovou strikturu a pevn\u011b se do n\u00ed zakl\u00edn\u00ed. Obdukovan\u00e9 stenty (kovov\u00e1 s\u00ed\u0165 je pota\u017eena neprostupnou bl\u00e1nou) lze u\u017e\u00edt i k paliativn\u00edmu uz\u00e1v\u011bru ezofagobronchi\u00e1ln\u00edch p\u00ed\u0161t\u011bl\u00ed (obr. 29 a 30; <a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=3378\" target=\"_blank\">videoz\u00e1znam zav\u00e1d\u011bn\u00ed j\u00edcnov\u00e9ho stentu pod rtg kontrolou u karcinomu st\u0159edn\u00edho j\u00edcnu je dostupn\u00fd v elektronick\u00e9 verzi \u2013 viz tir\u00e1\u017e knihy<\/a>). Zaveden\u00ed stent\u016f je mo\u017en\u00e9 u\u017e\u00edt i jako provizorn\u00ed \u0159e\u0161en\u00ed dysfagie b\u011bhem neoadjuvantn\u00ed terapie p\u0159ed pl\u00e1novanou radik\u00e1ln\u00ed operac\u00ed. Na po\u010d\u00e1tku 90. let minul\u00e9ho stolet\u00ed se na\u0161e pracovi\u0161t\u011b zaslou\u017eilo o zaveden\u00ed a zdokonalen\u00ed t\u00e9to metody v l\u00e9\u010db\u011b karcinomu j\u00edcnu [89, 96\u201398].<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_562.png\"><img decoding=\"async\" title=\"Obr. 29a \u2013 Nitinolov\u00fd neobdukovan\u00fd stent\" alt=\"Obr. 29a \u2013 Nitinolov\u00fd neobdukovan\u00fd stent\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_562.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 29a<br \/>Nitinolov\u00fd neobdukovan\u00fd stent<\/p><\/div><\/td>\n<td style=\"border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_563.png\"><img decoding=\"async\" title=\"Obr. 29b \u2013 Stent obdukovan\u00fd polyuretanem\" alt=\"Obr. 29b \u2013 Stent obdukovan\u00fd polyuretanem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_563.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 29b<br \/>Stent obdukovan\u00fd polyuretanem<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 33%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 110px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_565.png\"><img decoding=\"async\" class=\"  \" title=\"Obr. 30 \u2013 Postup p\u0159i zaveden\u00ed stentu j\u00edcnu p\u0159i \u0159e\u0161en\u00ed dysfagie: Obr. 30a \u2013 Zaveden\u00ed vodi\u010de\" alt=\"Obr. 30 \u2013 Postup p\u0159i zaveden\u00ed stentu j\u00edcnu p\u0159i \u0159e\u0161en\u00ed dysfagie: Obr. 30a \u2013 Zaveden\u00ed vodi\u010de\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_565.png\" width=\"100\" \/><\/a><p class=\"wp-caption-text\">Obr. 30<br \/>Postup p\u0159i zaveden\u00ed stentu j\u00edcnu p\u0159i \u0159e\u0161en\u00ed dysfagie:<br \/>Obr. 30a \u2013 Zaveden\u00ed vodi\u010de<\/p><\/div><\/td>\n<td style=\"width: 33%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 110px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_566.png\"><img decoding=\"async\" class=\" \" title=\"Obr. 30 \u2013 Postup p\u0159i zaveden\u00ed stentu j\u00edcnu p\u0159i \u0159e\u0161en\u00ed dysfagie: Obr. 30b \u2013 Dilatace striktury balonkem\" alt=\"Obr. 30 \u2013 Postup p\u0159i zaveden\u00ed stentu j\u00edcnu p\u0159i \u0159e\u0161en\u00ed dysfagie: Obr. 30b \u2013 Dilatace striktury balonkem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_566.png\" width=\"100\" \/><\/a><p class=\"wp-caption-text\">Obr. 30<br \/>Postup p\u0159i zaveden\u00ed stentu j\u00edcnu p\u0159i \u0159e\u0161en\u00ed dysfagie:<br \/>Obr. 30b \u2013 Dilatace striktury balonkem<\/p><\/div><\/td>\n<td style=\"border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 110px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_567.png\"><img decoding=\"async\" class=\" \" title=\"Obr. 30 \u2013 Postup p\u0159i zaveden\u00ed stentu j\u00edcnu p\u0159i \u0159e\u0161en\u00ed dysfagie: Obr. 30c \u2013 Zaveden\u00ed nerozvinut\u00e9ho stentu\" alt=\"Obr. 30 \u2013 Postup p\u0159i zaveden\u00ed stentu j\u00edcnu p\u0159i \u0159e\u0161en\u00ed dysfagie: Obr. 30c \u2013 Zaveden\u00ed nerozvinut\u00e9ho stentu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_567.png\" width=\"100\" \/><\/a><p class=\"wp-caption-text\">Obr. 30<br \/>Postup p\u0159i zaveden\u00ed stentu j\u00edcnu p\u0159i \u0159e\u0161en\u00ed dysfagie:<br \/>Obr. 30c \u2013 Zaveden\u00ed nerozvinut\u00e9ho stentu<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 33%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 110px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_568.png\"><img decoding=\"async\" class=\" \" title=\"Obr. 30 Postup p\u0159i zaveden\u00ed stentu j\u00edcnu p\u0159i \u0159e\u0161en\u00ed dysfagie: Obr. 30d \u2013 Postupn\u00e9 rozvinut\u00ed stentu pomoc\u00ed balonkov\u00e9 dilatace\" alt=\"Obr. 30 Postup p\u0159i zaveden\u00ed stentu j\u00edcnu p\u0159i \u0159e\u0161en\u00ed dysfagie: Obr. 30d \u2013 Postupn\u00e9 rozvinut\u00ed stentu pomoc\u00ed balonkov\u00e9 dilatace\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_568.png\" width=\"100\" \/><\/a><p class=\"wp-caption-text\">Obr. 30<br \/>Postup p\u0159i zaveden\u00ed stentu j\u00edcnu p\u0159i \u0159e\u0161en\u00ed dysfagie:<br \/>Obr. 30d \u2013 Postupn\u00e9 rozvinut\u00ed stentu pomoc\u00ed balonkov\u00e9 dilatace<\/p><\/div><\/td>\n<td style=\"width: 33%; border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 110px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_569.png\"><img decoding=\"async\" class=\" \" title=\"Obr. 30 Postup p\u0159i zaveden\u00ed stentu j\u00edcnu p\u0159i \u0159e\u0161en\u00ed dysfagie: Obr. 30e \u2013 Postupn\u00e9 rozvinut\u00ed stentu pomoc\u00ed balonkov\u00e9 dilatace\" alt=\"Obr. 30 Postup p\u0159i zaveden\u00ed stentu j\u00edcnu p\u0159i \u0159e\u0161en\u00ed dysfagie: Obr. 30e \u2013 Postupn\u00e9 rozvinut\u00ed stentu pomoc\u00ed balonkov\u00e9 dilatace\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_569.png\" width=\"100\" \/><\/a><p class=\"wp-caption-text\">Obr. 30<br \/>Postup p\u0159i zaveden\u00ed stentu j\u00edcnu p\u0159i \u0159e\u0161en\u00ed dysfagie:<br \/>Obr. 30e \u2013 Postupn\u00e9 rozvinut\u00ed stentu pomoc\u00ed balonkov\u00e9 dilatace<\/p><\/div><\/td>\n<td style=\"border-color: #ffffff; border-style: solid; border-width: 1px;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 110px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_570.png\"><img decoding=\"async\" class=\" \" title=\"Obr. 30 Postup p\u0159i zaveden\u00ed stentu j\u00edcnu p\u0159i \u0159e\u0161en\u00ed dysfagie: Obr. 30f \u2013 Postupn\u00e9 rozvinut\u00ed stentu pomoc\u00ed balonkov\u00e9 dilatace\" alt=\"Obr. 30 Postup p\u0159i zaveden\u00ed stentu j\u00edcnu p\u0159i \u0159e\u0161en\u00ed dysfagie: Obr. 30f \u2013 Postupn\u00e9 rozvinut\u00ed stentu pomoc\u00ed balonkov\u00e9 dilatace\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_570.png\" width=\"100\" \/><\/a><p class=\"wp-caption-text\">Obr. 30<br \/>Postup p\u0159i zaveden\u00ed stentu j\u00edcnu p\u0159i \u0159e\u0161en\u00ed dysfagie:<br \/>Obr. 30f \u2013 Postupn\u00e9 rozvinut\u00ed stentu pomoc\u00ed balonkov\u00e9 dilatace<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><img decoding=\"async\" title=\"Obr. 30g \u2013 Karcinom j\u00edcnu, rtg pas\u00e1\u017e j\u00edcnem bezprost\u0159edn\u011b po zaveden\u00ed stentu\" alt=\"Obr. 30g \u2013 Karcinom j\u00edcnu, rtg pas\u00e1\u017e j\u00edcnem bezprost\u0159edn\u011b po zaveden\u00ed stentu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_572.png\" width=\"200\" \/><p class=\"wp-caption-text\">Obr. 30g<br \/>Karcinom j\u00edcnu, rtg pas\u00e1\u017e j\u00edcnem bezprost\u0159edn\u011b po zaveden\u00ed stentu<\/p><\/div>\n<h6 class=\"s32\">Chirurgick\u00e1 l\u00e9\u010dba karcinomu j\u00edcnu a princip high-volume centers<\/h6>\n<p style=\"text-align: justify;\">Chirurgick\u00e1 l\u00e9\u010dba je vysoce specializovanou \u010dinnost\u00ed hrudn\u00edch chirurg\u016f zam\u011b\u0159en\u00fdch na problematiku j\u00edcnu a spr\u00e1vn\u00e1 je koncentrace nemocn\u00fdch do center ve smyslu principu high-volume centers (HVC \u2013 centra s vysok\u00fdm po\u010dtem operac\u00ed). Cel\u00e1 \u0159ada studi\u00ed potvrzuje, \u017ee p\u0159i vy\u0161\u0161\u00edm po\u010dtu prov\u00e1d\u011bn\u00fdch operac\u00ed se zmen\u0161uje poopera\u010dn\u00ed mortalita a morbidita a zlep\u0161uj\u00ed se v\u00fdsledky l\u00e9\u010dby. Pot\u0159ebn\u00e9 po\u010dty operac\u00ed jsou v odborn\u00e9 literatu\u0159e uv\u00e1d\u011bny ve velk\u00e9m rozmez\u00ed. Americk\u00e1 studie uv\u00e1d\u00ed jako n\u00edzkovolumov\u00e1 centra (LVC \u2013 low-volume centers) pracovi\u0161t\u011b s m\u00e9n\u011b ne\u017e 7 operacemi za rok, kde poopera\u010dn\u00ed mortalita byla v\u00edce ne\u017e 15 %, zat\u00edm co u HVC byla mortalita 7,5 % [99]. \u0160v\u00e9dsk\u00e1 studie uv\u00e1d\u00ed u LVC m\u00e9n\u011b ne\u017e 5 operac\u00ed za rok p\u0159i mortalit\u011b 10,4 %, u center st\u0159edn\u00ed velikosti s 5\u201315 operacemi za rok byla poopera\u010dn\u00ed mortalita 6,3 % a u HVC s v\u00edce ne\u017e 15 operacemi za rok byla mortalita 3,5 % [100]. V holandsk\u00e9 studii je v HVC s pr\u016fm\u011brn\u00fdm po\u010dtem 56 resekc\u00ed\/rok uv\u00e1d\u011bna mortalita 5 % oproti mortalit\u011b 13 % v LVC s m\u00e9n\u011b jak 7 resekcemi\/rok [101]. Na z\u00e1klad\u011b srovn\u00e1n\u00ed v\u00fdsledk\u016f center s r\u016fzn\u00fdm po\u010dtem operac\u00ed doch\u00e1zej\u00ed auto\u0159i metaanal\u00fdzy z roku 2004 k z\u00e1v\u011bru, \u017ee ke zlep\u0161en\u00ed poopera\u010dn\u00ed mortality je nutn\u00e9 prov\u00e9st nejm\u00e9n\u011b 20 ezofagektomi\u00ed za rok [102]. N\u011bkter\u00e9 z t\u011bchto studi\u00ed uv\u00e1d\u011bj\u00ed i p\u0159\u00edzniv\u00fd vliv po\u010dtu operovan\u00fdch na dlouhodob\u00e9 3a 5let\u00e9 p\u0159e\u017e\u00edv\u00e1n\u00ed [32\u201335, 103\u2013105]. Jin\u00ed auto\u0159i v\u0161ak vliv po\u010dtu operovan\u00fdch na dlouhodob\u00e9 p\u0159e\u017e\u00edv\u00e1n\u00ed neprok\u00e1zali [36\u201338, 106\u2013108]. Ukazuje se, \u017ee po\u010det operac\u00ed s\u00e1m o sob\u011b negarantuje vysokou kvalitu chirurgick\u00e9 p\u00e9\u010de. \u00dalohu zde hraje nepochybn\u011b nejen osobn\u00ed zku\u0161enost chirurga, ale ve velk\u00e9 m\u00ed\u0159e zku\u0161enost cel\u00e9ho t\u00fdmu (anesteziolog\u016f, intenzivist\u016f, sester a dal\u0161\u00edho person\u00e1lu), od kter\u00e9ho z\u00e1vis\u00ed proveden\u00ed operace, poopera\u010dn\u00ed p\u00e9\u010de a zvl\u00e1d\u00e1n\u00ed p\u0159\u00edpadn\u00fdch komplikac\u00ed. Definice vysokovolumov\u00fdch center nen\u00ed nikde ve sv\u011bt\u011b jasn\u011b d\u00e1na, a jak vypl\u00fdv\u00e1 z uveden\u00e9ho, nem\u016f\u017ee b\u00fdt jedin\u00fdm krit\u00e9riem jen po\u010det proveden\u00fdch operac\u00ed, ale velkou roli hraje zku\u0161enost cel\u00e9ho t\u00fdmu s o\u0161et\u0159ov\u00e1n\u00edm z\u00e1va\u017en\u00fdch a rizikov\u00fdch stav\u016f. Hlavn\u00edm krit\u00e9riem oprav\u0148uj\u00edc\u00edm prov\u00e1d\u011bn\u00ed ezofagektomi\u00ed by proto m\u011bly b\u00fdt dosa\u017een\u00e9 v\u00fdsledky dan\u00e9ho pracovi\u0161t\u011b ov\u011b\u0159ovan\u00e9 pravideln\u00fdm vyhodnocov\u00e1n\u00edm kvality chirurgick\u00e9 p\u00e9\u010de v dan\u00e9 oblasti.<\/p>\n<h4 class=\"s15\">13.2.7 Karcinom j\u00edcnu v \u010cesk\u00e9 republice \u2013 shrnut\u00ed<\/h4>\n<p style=\"text-align: justify;\">Zhoubn\u00e9 n\u00e1dory j\u00edcnu p\u0159edstavuj\u00ed 0,7 % ze v\u0161ech solidn\u00edch zhoubn\u00fdch n\u00e1dor\u016f v \u010cR (1,1 % u mu\u017e\u016f a 0,2 % u \u017een). V rozmez\u00ed let 1977 a\u017e 2008 vzrostla incidence ze 2 p\u0159\u00edpad\u016f na 5,4 na 100 000 obyvatel a mortalita z 1,9 na 4,1 p\u0159\u00edpad\u016f na 100 000 obyvatel. V absolutn\u00edch \u010d\u00edslech byla v roce 2008 incidence 561 osob (5,4 na 100 000 obyvatel). Mortalita pak byla v absolutn\u00edm po\u010dtu 452 zem\u0159el\u00fdch (4,3 na 100 000 obyvatel) a prevalence (po\u010det \u017eij\u00edc\u00edch s n\u00e1dorem nebo s jeho anamn\u00e9zou) 791 osob (7,6 na 100 000 obyvatel). V mezin\u00e1rodn\u00edm srovn\u00e1n\u00ed je \u010cesk\u00e1 republika v incidenci na 84. m\u00edst\u011b ve sv\u011bt\u011b a 17. m\u00edst\u011b v Evrop\u011b (mortalita 85. m\u00edsto ve sv\u011bt\u011b a 18. m\u00edsto v Evrop\u011b). V \u010cesk\u00e9 republice je nejvy\u0161\u0161\u00ed incidence v kraji Moravskoslezsk\u00e9m a Zl\u00ednsk\u00e9m (6,1 na 100 000), nejni\u017e\u0161\u00ed pak v kraji Plze\u0148sk\u00e9m (4,2) a Vyso\u010dina (4,1). Pr\u016fm\u011brn\u00fd v\u011bk p\u0159i zji\u0161t\u011bn\u00ed diagn\u00f3zy je u mu\u017e\u016f 62 let a u \u017een 68 let, maximum v\u00fdskytu mezi 55 a 69 lety u mu\u017e\u016f a mezi 58 a\u017e 79 lety u \u017een. V dob\u011b stanoven\u00ed diagn\u00f3zy p\u0159eva\u017euj\u00ed vy\u0161\u0161\u00ed stadia onemocn\u011bn\u00ed. V roce 2008 bylo ze zji\u0161t\u011bn\u00fdch onemocn\u011bn\u00ed 28 % v I. a II. stadiu, 60 % bylo ve III. a IV. stadiu a u 12% nebylo stadium ur\u010deno. P\u011btilet\u00e9 p\u0159e\u017e\u00edv\u00e1n\u00ed u l\u00e9\u010den\u00fdch pacient\u016f z anal\u00fdzy obdob\u00ed 2004 a\u017e 2007 bylo celkov\u011b 15,5 %. U I. a II. stadia bylo p\u011btilet\u00e9 p\u0159e\u017e\u00edv\u00e1n\u00ed 30 %, u III. stadia 12 % a IV. stadia 2 %. P\u0159i srovn\u00e1n\u00ed anal\u00fdzy periody 2004 a\u017e 2007 s anal\u00fdzou obdob\u00ed 2000 a\u017e 2003 do\u0161lo u I. a II. stadia ke zlep\u0161en\u00ed o 10 % a u III. stadia o 4 % (viz obr. 3 a\u017e 10, 16, 19, 20). Podle registru hrudn\u00edch v\u00fdkon\u016f Sekce hrudn\u00ed chirurgie z let 2007 a\u017e 2010 se hrudn\u00ed v\u00fdkony prov\u00e1d\u011bj\u00ed v \u010cesk\u00e9 republice na 19 a\u017e 22 pracovi\u0161t\u00edch, resekce j\u00edcnu pak na 13 a\u017e 14 pracovi\u0161t\u00edch, ale jen u 8 a\u017e 9 pracovi\u0161\u0165 je frekvence t\u011bchto v\u00fdkon\u016f 10 a v\u00edce operac\u00ed za rok [109].<\/p>\n<p style=\"text-align: justify;\">V letech 2001\u20132005 bylo ka\u017edoro\u010dn\u011b v \u010cesk\u00e9 republice diagnostikov\u00e1no v pr\u016fm\u011bru 457 nemocn\u00fdch se zhoubn\u00fdm novotvarem j\u00edcnu. Prim\u00e1rn\u00ed opera\u010dn\u00ed l\u00e9\u010dba u nov\u011b diagnostikovan\u00fdch zhoubn\u00fdch novotvar\u016f j\u00edcnu byla provedena jen u 181 nemocn\u00fdch, tedy v necel\u00fdch 40 % zji\u0161t\u011bn\u00fdch n\u00e1dor\u016f, a za radik\u00e1ln\u00ed byl v\u00fdkon pova\u017eov\u00e1n jen u 89 nemocn\u00fdch, tj. v 19,6 % v\u0161ech diagnostikovan\u00fdch p\u0159\u00edpad\u016f. Prim\u00e1rn\u00ed opera\u010dn\u00ed l\u00e9\u010dba byla v 51 % jedin\u00fdm l\u00e9\u010debn\u00fdm postupem a u 49 % operovan\u00fdch byla chirurgick\u00e1 terapie kombinov\u00e1na s dal\u0161\u00edmi l\u00e9\u010debn\u00fdmi modalitami (chemo-, radioterapie) [110].<\/p>\n<p style=\"text-align: justify;\">V uplynul\u00fdch deseti letech bylo v \u010desk\u00e9m p\u00edsemnictv\u00ed publikov\u00e1no jen n\u011bkolik prac\u00ed z men\u0161\u00edho po\u010dtu pracovi\u0161\u0165, kde se prov\u00e1d\u00ed j\u00edcnov\u00e1 chirurgie zam\u011b\u0159en\u00e1 na chirurgickou l\u00e9\u010dbu karcinomu j\u00edcnu [67, 68, 111\u2013115]. Z t\u011bchto zve\u0159ejn\u011bn\u00fdch dat nelze podrobn\u011bji z celost\u00e1tn\u00edho pohledu analyzovat dal\u0161\u00ed \u00fadaje o l\u00e9\u010db\u011b a v\u00fdsledc\u00edch l\u00e9\u010den\u00ed karcinomu j\u00edcnu, ne\u017e jak\u00e9 byly z\u00edsk\u00e1ny z datab\u00e1ze NOR. Bylo by jist\u011b \u017e\u00e1douc\u00ed vytvo\u0159it v budoucnu celost\u00e1tn\u00ed registr t\u011bchto operac\u00ed, z n\u011bho\u017e z\u00edskan\u00e9 a analyzovan\u00e9 \u00fadaje by mohly pomoci zlep\u0161it v\u00fdsledky na tomto poli.<\/p>\n<h4 class=\"s15\">13.2.8 Chirurgie karcinomu j\u00edcnu v zrcadle olomouck\u00e9 j\u00edcnov\u00e9 chirurgie<\/h4>\n<p style=\"text-align: justify;\">Chirurgick\u00e1 l\u00e9\u010dba karcinomu j\u00edcnu m\u00e1 v Olomouci dlouhou tradici. Prvn\u00ed ezofagektomie pro karcinom byla provedena 2. 8. 1946 [116] (viz kap. 4, obr. 3). Problematika l\u00e9\u010dby karcinomu j\u00edcnu byla na I. a II. chirurgick\u00e9 klinice Fakultn\u00ed nemocnice a L\u00e9ka\u0159sk\u00e9 fakulty v Olomouci v letech 1970\u20132006 opakovan\u011b p\u0159edm\u011btem z\u00e1jmu [117\u2013120]. Postupn\u011b byly hodnoceny soubory nemocn\u00fdch. V roce 1976 to bylo 277 operovan\u00fdch z let 1945\u20131975, v roce 1983 pak 61 operovan\u00fdch z let 1976\u20131980 a v roce 1993 sestava dal\u0161\u00edch 54 operovan\u00fdch z let 1986\u20131992. Pro toto obdob\u00ed je charakteristick\u00fd vysok\u00fd pod\u00edl paliativn\u00edch v\u00fdkon\u016f (by-passy, chirurgick\u00e9 zav\u00e1d\u011bn\u00ed j\u00edcnov\u00fdch endoprot\u00e9z) a vysok\u00e1 poopera\u010dn\u00ed \u00famrtnost kol\u00edsaj\u00edc\u00ed mezi 20\u201330 % po radik\u00e1ln\u00edch operac\u00edch.<\/p>\n<p style=\"text-align: justify;\">V posledn\u00edch dvaceti letech se v tomto ohledu situace radik\u00e1ln\u011b zm\u011bnila d\u00edky zlep\u0161en\u00e9 kolem opera\u010dn\u00ed intenzivn\u00ed p\u00e9\u010di a pokrok\u016fm v chirurgick\u00e9 taktice a technice. B\u011b\u017en\u00e9 se stalo u\u017eit\u00ed modern\u00edch stapler\u016f a st\u00e1le \u010dast\u011bji se vyu\u017e\u00edv\u00e1 i mo\u017enost\u00ed miniinvazivn\u00ed chirurgie. Posledn\u00ed z Olomouce publikovan\u00e1 pr\u00e1ce [68] prezentuje sestavu 178 resekc\u00ed j\u00edcnu z let 2000\u20132009. Poopera\u010dn\u00ed mortalita do 30 dn\u016f byla 4,5 % (8 nemocn\u00fdch), nej\u010dast\u011bj\u0161\u00ed byly plicn\u00ed komplikace v 31 %, p\u00ed\u0161t\u011bl v kr\u010dn\u00ed anastom\u00f3ze v 7,3 %, par\u00e9za vratn\u00e9ho nervu v 9 %. U 54,5 % operovan\u00fdch byl vyu\u017eit videoasistovan\u00fd p\u0159\u00edstup k mobilizaci j\u00edcnu, zpravidla laparoskopick\u00fd. V 55 % se jednalo o adenokarcinom. Obdobn\u00fdch v\u00fdsledk\u016f bylo dosa\u017eeno v posledn\u00edch p\u011bti letech na chirurgick\u00e9m odd\u011blen\u00ed nemocnice a Komplexn\u00edho onkologick\u00e9ho centra (KOC) v Nov\u00e9m Ji\u010d\u00edn\u011b, kde byly uplatn\u011bny zku\u0161enosti olomouck\u00e9 j\u00edcnov\u00e9 \u0161koly. Od roku 2007 zde byl zah\u00e1jen pravideln\u00fd program chirurgick\u00e9ho l\u00e9\u010den\u00ed nitrohrudn\u00edch malignit. V KOC Nov\u00fd Ji\u010d\u00edn bylo v tomto obdob\u00ed vy\u0161et\u0159eno celkem 193 nemocn\u00fdch s karcinomem j\u00edcnu, k operaci bylo indikov\u00e1no 38 % nemocn\u00fdch. Celkem bylo do konce roku 2011 provedeno 53 resekc\u00ed a n\u00e1hrad j\u00edcnu (2 pro benign\u00ed strikturu). Poopera\u010dn\u00ed mortalita do 30 dn\u016f byla 3,8 % (2 nemocn\u00ed). Celkov\u00e1 morbidita je 23 %, nej\u010dast\u011bj\u0161\u00ed byly plicn\u00ed a kardi\u00e1ln\u00ed komplikace v 17 % a 6 %, p\u00ed\u0161t\u011bl v kr\u010dn\u00ed anastom\u00f3ze vznikla v 7,5 %, par\u00e9za vratn\u00e9ho nervu v 9 %. Tak\u0159ka u v\u0161ech nemocn\u00fdch byla operace zah\u00e1jena laparoskopickou reviz\u00ed k ov\u011b\u0159en\u00ed operability a u 50 % operovan\u00fdch byl vyu\u017eit videoasistovan\u00fd p\u0159\u00edstup k mobilizaci j\u00edcnu, 19\u00d7 torakoskopick\u00fd, 5\u00d7 laparoskopick\u00fd a 1\u00d7 pomoc\u00ed opera\u010dn\u00edho robotu, 49 % nemocn\u00fdch m\u011blo adenokarcinom [13]. Olomouck\u00e1 pracovi\u0161t\u011b se zaslou\u017eila od po\u010d\u00e1tku devades\u00e1t\u00fdch let minul\u00e9ho stolet\u00ed o zaveden\u00ed miniinvazivn\u00edho \u0159e\u0161en\u00ed polyk\u00e1n\u00ed pomoc\u00ed stent\u016f u nemocn\u00fdch s inoperabiln\u00edmi n\u00e1dory j\u00edcnu v \u010cesk\u00e9 republice, co\u017e p\u0159edt\u00edm bylo \u0159e\u0161eno v\u00fdhradn\u011b gastrostomi\u00ed [96\u201398].<\/p>\n<h3 class=\"s15\">Literatura<\/h3>\n<ol>\n<li style=\"text-align: justify;\">Takubo K. Patology of the Esophagus. An Atlas and Textbook. 2nd ed. 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Klinick\u00e1 onkologie. 1993;2:51\u201355.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>13.1 Benign\u00ed n\u00e1dory V\u00fdskyt a p\u0159\u00edznaky: nezhoubn\u00e9 n\u00e1dory j\u00edcnu jsou vz\u00e1cn\u00e9. Jejich klasifikace a mo\u017en\u00e9 druhy jsou uvedeny v tab. 1. Asi 75 % benign\u00edch n\u00e1dor\u016f jsou leiomyomy, ostatn\u00ed pat\u0159\u00ed k rarit\u00e1m [1]. Tab. 1 Benign\u00ed n\u00e1dory j\u00edcnu a stavy napodobuj\u00edc\u00ed n\u00e1dor Epiteli\u00e1ln\u00ed adenom skvam\u00f3zn\u00ed papilom hyperplastick\u00fd polyp reten\u010dn\u00ed cysta akant\u00f3za maligna (acanthosis nigricans) lymfoepiteli\u00e1ln\u00ed [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":65,"menu_order":65,"comment_status":"closed","ping_status":"open","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-669","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/669","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=669"}],"version-history":[{"count":64,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/669\/revisions"}],"predecessor-version":[{"id":1250,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/669\/revisions\/1250"}],"up":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/65"}],"wp:attachment":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=669"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}