Parathyroid surgical failures with misleading falls of intraoperative parathyroid hormone levels.

According to earlier reports, a decrease below 50% of baseline of intraoperative PTH levels measured 5 min after resection of the parathyroid adenoma predicts a cure of hyperparathyroidism. To reveal previously unrecognized pitfalls of intraoperative PTH measurements, we reviewed surgical failures in our series of parathyroidectomies combined with intraoperative PTH sampling. PTH measurements were performed in 251 patients with primary hyperparathyroidism (PHPT) between November 1999 and December 2002. PHPT due to parathyroid hyperplasia were found in 8 cases, double parathyroid adenomas in 6 cases, parathyroid carcinoma in 1 case and single parathyroid adenomas in 236 cases, all confirmed by histological examination. Of the 236 cases of single adenomas, initial surgery failed to cure PHPT in 4 patients. In 3 patients a false-positive decrease of intraoperative PTH (from 269 to 40 pg/ml, from 211 to 27 pg/ml, and from 140 to 59 pg/ml) was observed, whereas in the fourth patient a true-negative decrease of intraoperative PTH (from 758 to 401 pg/ml) was mistakenly interpreted as indication for a cure of PHPT. In each of the 4 patients in whom initial surgery failed the intervention included thyroid surgery and reoperative parathyroid surgery resulted in a permanent cure of PHPT. These observations support the possibility that thyroid surgery may compromise the blood supply of parathyroid adenomas resulting in a misleading drop of intraoperative PTH levels. Therefore, a careful evaluation of intraoperative PTH levels and, perhaps, other intraoperative aids such as histological evaluation of frozen sections are recommended when parathyroid surgery is combined with simultaneous thyroid intervention.

[New intraoperative diagnostic methods in parathyroid surgery: intraoperative measurement of parathyroid hormone]. / Mútét alatti új diagnosztikus módszerek a mellékpajzsmirigy-sebészetben: intraoperatív parathormonszint-ellenórzés.

In thirty-seven patients undergoing parathyroidectomy from November 1999 to July 2000 with diagnosis of primary hyperparathyroidism the intraoperative intact parathyroid hormone level were studied. Preoperative samples of blood were taken from a peripheral vein before the beginning the operation. The second sample was taken 5 minutes after removal of parathyroid adenoma. The plasma intact parathyroid hormone concentration was measured by quick IRMA method. The preoperative high PTH levels reduced after excision of adenoma to the mean 18%. 33 patients had normal PTH levels after 5 minutes of removing. The total measuring time of quick PTH assay was about 30 minutes. The QPTH assay was a quantitative adjunct for the surgeon to ensure a successful parathyroidectomy. When the intraoperative QPTH level is not reduced to 50%, then the exploration should be continued and the probability of reoperation is decreased. They propose the application of the routine intraoperative measurement of QPTH level in all parathyroidectomy.

[Procalcitonin rapid test in surgical patients treated in the intensive care unit]. / Procalcitonin gyorsteszt alkalmazása sebészeti intenzív osztályon kezelt betegeknél.

Procalcitonin test (PCT) has been proposed to check severity of generalized infections or sepsis. The authors measured the PCT values with PCT-Q quick test (BRAHMS DIAGNOSTICA GmbH, Berlin) at 14 surgical patients treated in their intensive care unit (7 sepsis, 4 peritonitis, 2 localized pancreatic abscess, 1 postoperative fever). At 3 septic patients (2 pancreatitis, 1 intestinal necrosis) they measured the PCT levels repeatedly during treatment. In 2 patients with localized pancreatic abscess and in 1 patient with postoperative fever without evidence of infection the PCT levels were low (< 0.5 ng/ml). At 4 patients with peritonitis following gastric or colon perforation the PCT levels were highly elevated (> 10 ng/ml). At 7 patients with severe sepsis the PCT values were high (> 2 ng/ml), except for 1 patient with intestinal necrosis. At this patient the PCT levels were repeatedly low. In 2 septic patients with pancreatitis elevated PCT levels indicated the need for surgery. In most patients PCT was a good indicator of generalized infections. PCT levels measured repeatedly in sepsis were lower than in patients with peritonitis.

General anaesthesia for laparascopic adrenalectomy.

Surgical treatment of adrenal disorders is increasingly performed under laparascopic approach. Both pneumoperitoneum and adrenal tumour manipulation may induce haemodynamic variations. The aim of this study was to compare the inhalational and intravenous anaesthetic management for laparascopic adrenalectomy. Between 1977 and 1999 there were performed 28 laparascopic adrenalectomies. At patients with functioning adenoma and hypertension the anaesthesia was maintained with isoflurane in 8 cases and sevoflurane in 6 cases, et 14 patients with non-functioning adrenal masses with propofol and fentanyl (TIVA). In addition to the circulatory and respiratory monitoring there were made serial laboratory determinations (acid-base state, serum potassium, blood glucose) during the operation. On the basis of measured parameters isoflurane and sevoflurane anaesthesia proved to be favourable in case of functioning adrenal adenoma and TIVA with propofol and fentanyl in case of non-functioning adenoma.

Sedation for ambulatory endoscopy.

Diagnostic and therapeutic fiberoscopy of gastrointestinal tract is often performed ambulatory and sedation is sometimes also required. Indication for sedation can be the intervention itself or the patient's psychological state. Aim of the study was to compare the effects of midazolam and combination of midazolam and fentanyl during endoscopy. Twenty eight cases were investigated: oesophagogastroduodenoscopy (n = 14) and colonoscopy (n = 14). Anaesthetics were midazolam (M) in 16 cases, midazolam-fentanyl (MF) in 12 cases. Non-invasive mean arterial pressure, pulse rate, acid-base balance and blood gases (by Astrup method) were recorded before endoscopy, at the 5th and 10th minutes of endoscopy, 15 minutes after intervention and also before emission. Pulse rate changed between 78-92/min. Mean arterial pressure appeared between 84-90 mm Hg. In MF group both were lower but there was not significant difference between the groups. The values were in normal range, there were not metabolic acidosis which needed correction. Onset of sedative effect was 2.8 min. in M group, 2.3 min. in MF group. The ability for adequate reaction returned within 11 min. in M group, within 14 min. in MF group. Fentanyl prolongs sedative effect of midazolam and offers sufficient pain relief. After 3 hours, patients could be emitted from the hospital.

Laparoscopic adrenalectomy. New experiences.

Authors have performed 23 laparoscopic adrenalectomies between 03.04.1997 and 02.04.1999. They have removed 16 cortical adenomas, 2 nodular hyperplasias, 2 cysts, 1 carcinoma, 1 pheochromocytoma and 1 myolipoma. The operation time was 90-260 minutes that gradually has been decreased by using "Ultracision" ultrasonic shear. They have made simultaneously two cholecystectomies and one liver wedge biopsy. During removing pheochromocytoma they have not detected extremely high blood pressure data. They had one intraoperative complication, the perforation of the diaphragm which required a temporary thoracic suction drainage. All operations were completed laparoscopically. Patients have been released on the 2nd-3rd postoperative day. Their experiences confirm the literary data that the laparoscopic approach to adrenalectomy is the method of choice today.

[Anesthesia ambulatory one-day surgery]. / Erzéstelenítés egynapos, ambuláns sebészeti beavatkozások során.

The spreading of the cost-benefit attitude is a considerable help in the progress of the one day surgery. The patient selection, the preoperative patient preparations and the preoperative examination has done in the anaestesiologic ambulance. Aims of ambulatory anaesthesia are to achieve sedation, hypnosis, analgesia, amnesia and muscle relaxation during the operation, to preserve preoperative mental and physiologic state, analgesia and to make early postoperative nourishing possible. Besides personnel and equipment of anaesthesia and reanimation, monitoring of circulation, respiration and neuromuscular transmission is needed. Anaesthetic methods: local, regional and general anaesthesia or sedation. Ways of general anaesthesia are intravenous, inhalation or combined. Intravenous anaesthetic drugs (barbiturates, ketamine, etomidate, midazolam, propofol and eltanolon) can be used in monotherapy or in combination with each other or opioids (morphine, alfentanil, fentanyl, sufentanil, remifentanil). Among inhalatic agents N2O isoflurane, desflurane, sevoflurane are advisable. Recommended non depolarising muscle relaxants are the short-acting atracurium, mivacurium, vecuronium and rocuronium. Methods for loco-regional anaesthesia are infiltration, peripheral nerve blockade, epidural and intradural anaesthesia which can be used with additional vigil sedation. Blockades with local analgetics, intraoperative opioids, non-steroid anti-inflammatory drugs, sedatives, pre-emptiv analgesia and patient controlled analgesia can be used for postoperative pain relief. Besides the patient and intervention type selection the adequate perioperative anaesthesiologic work and the prudent specifications of leaving conditions is the most important terms of the safety of one-day surgery and anaesthesia.

[Laparoscopic adrenalectomy]. / Laparoszkópos adrenalectomia.

The authors performed three left and one right sided laparoscopic adrenalectomies between 3rd April and 8th August 1997. The indication of surgery was hormonally active cortical adenoma of about 2 cm size in three cases, a 6 cm large hormonally inactive tumour in one case respectively. For the operation on the left side three, on the right side four trocars with 11 mm diameter was used. The duration of the operations was between 115 and 220 min. The patients left one the second or third postoperative day, no complication was observed. The authors' opinion based on both literature data and their own experience is that laparoscopic approach to adrenalectomies is the method of choice today.

Anaesthesiological indications and contraindications of minimally invasive surgery.

Spreading of laparoscopic techniques caused changes in anaesthesiological contraindications. In the first period laparoscopy was contraindicated in ischemic heart disease (IHD). Early mobilisation and short postoperative period are positive goals, IHD was taken out of contraindications. Present study compares changes in circulatory, blood gas and acid-base balance values during laparoscopic cholecystectomy (LC) in groups of patients ASA I-II. and ASA III. with IHD. There were 30 patients in group ASA I-II, 30 patients with IHD in category of ASA III. investigated during LC. Fifteen patients of both groups went under Propofol-Fentanyl (TIVA) anaesthesia, others were on Propofol-Fentanyl-N2O (IVA) protocol. All of them got also Atracurium. Pulse rate, mean arterial pressure, O2 saturation and end tidal CO2, blood gases and acid-base state were recorded before induction, after CO2 insufflation, after desufflation, 1 and 3 hours postoperatively. After CO2 insufflation there was a moderate tachycardia in both ASA III. groups (74/min-->88/min). In all groups pCO2 increased (40-->48 mmHg) but normalised till the 3rd postoperative hours (42 mmHg). Ventricular extrasystoles appeared in 3 ASA III. patients in IVA group. Three high risk patients had serious metabolic acidosis postoperatively. Present time the ischaemic heart disease does not contraindicates laparoscopic interventions. TIVA with Propofol is better choice because of its favourable effects on circulation and acid-base balance. Using N2O caused higher grade of intestinal distension. The cardio-respiratory, blood gas parameters and acid-base balance have to be monitorised in perioperative period of laparoscopic surgery.

[The effect of blood transfusion on the late results of the surgical treatment of rectal cancer]. / A transzfúzió befolyása a végbélrák sebészi kezelésének késói eredményeire.

UNLABELLED: Prospectively recorded data of 149 patients undergoing curative resection for rectal cancer between 1985-1992 were evaluated. Survival rate and tumor recurrence were studied in transfused and non-transfused groups of patients. There wasn't statistically significant difference found between the two groups concerning the 5 year survival rate (53 and 59%). Whole blood had more deleterious effect on survival than packed red cells (48 versus 61%), but the difference didn't reach the statistical significance level. The 5 year survival rate of patients without transfusion was significantly higher (p < 0.05) than those received > 800 ml of blood (59 v.s. 33%). The tumor recurrence wasn't associated with transfusion. Neither the quality, nor the amount of blood seems to influence on the recurrence rate significantly. In the group of patients with > 800 ml of transfusion the lower preoperative hematocrit, the higher rate of abdominoperineal resection of the rectum and the longer duration of surgery than those of patients nontransfused reflect the unfavorable tumor stage and the difficulties in removing the tumor. Authors believe these circumstances necessitating the transfusion may be responsible for worse outcome of rectal cancer but the immunosuppressive effect of the blood can't be excluded. CONCLUSIONS: stricter indication than earlier is necessary for administration of blood transfusion to patients with rectal cancer to decrease the risk of transfusion-transmitted infections and to avoid the possible immunosuppressive effect of the blood. Packed red cells is preferable. Decreasing volume of perioperative homologous transfusion by improving surgical technique and clinical application of autologous transfusion should be considered.

The results of 1009 kidney transplantations performed in Hungary.

Kidney transplantation is a widely used method throughout the world for the treatment of end-stage renal disease. Following the pioneering work of Szeged Medical University Hospital and Miskolc District General Hospital, the first successful kidney transplantation in Hungary was performed at the Department of Transplantation and Surgery at Semmelweis Medical University on November 16, 1973. This patient is still alive with a functioning kidney graft after 21 years. We report herein our review of the global results of Hungarian kidney transplantation. Hungary is a medium-developed country with a population of over 10 million where the gross national product is about 4000 U.S. dollars per person per year. In Hungary there are 49 dialysis centers, 4 immunological laboratories, and 4 transplantation centers.

Respiration paralysing and circulatory effects of a new non-depolarizing relaxant, pipecurium bromide, in anaesthetized dogs.

The effect of a new sterane-structure, non-depolarizing muscle relaxant 2 beta,16 beta-bis(4'-dimethyl-1'-piperazino)-3 alpha,17 beta-diacetoxy-5 alpha-androstane dibromide (pipecurium bromide, RGH-1106, Arduan) was studied in 42 mongrel dogs under general anaesthesia (ether, halothane, methoxyflurane, thiobutobarbital, hydroxydione and dehydrobenzperidol-fentanyl (NLA II). Onset and duration of action and the presence of circulatory side effects were examined. It was found that the mean onset of respiration paralysing action was 156.1 s and apnea lasted for 38 min. In the thiobutobarbital group apnea lasted for 74 min. Arterial systolic blood pressure and central venous pressure did not change, but the heart rate was mildly decreased by pipecurium bromide. ECG intervals (PQ, QT and TP) did not change considerably, and the variations ran parallel with the prolongation of RR intervals due to the decrease of heart rate. Pipercurium bromide is a non-depolarizing muscle relaxant of medium duration, without any significant circulatory effects. Its duration of action was prolonged in the presence of thiobutobarbital, indicating a drug interaction between the two preparations.

First clinical experience with a new neuromuscular blocker pipecurium bromide.

The clinical trial of the new non-depolarizing muscle relaxant 2 beta,16 beta-bis-(4'-dimethyl-1'-piperazino)-3 alpha,17 beta diacetoxy-5 alpha-androstane dibromide (pipecurium bromide, RGH-1106, Arduan) was performed on 80 patients who had to undergo medium and major size intraabdominal operation on the basis of chronic surgical indication. Four types of general anaesthetic methods were applied, neuroleptanalgesia, halothane, halothane-fentanyl combination and hydroxydione. The clinical applicability of pipecurium bromide was tried to establish the dose needed for complete muscle relaxation initially and repeatedly and the effect of antagonist drugs on the muscle relaxation. We investigated the duration of the first and repeated dose of the relaxant. Heart rate and arterial blood pressure were measured, mean arterial pressure and pulse pressure were calculated. In 10 patients of the halothane group the behaviour of some haemodynamic parameters was investigated. The changes of acid base parameters, blood gases, serum electrolytes and blood sugar were also observed. The administered doses were initially 3.88 mg/h, repeated doses 2.32 mg/h, this means 0.052 mg/kg body weight initially and 0.026 mg/kg body weight repeatedly The duration of effect after the first dose was 53 min, after the repeated doses 45 min. There were no direct effects on heart rate and arterial blood pressure. It did not affect myocardial contractility or work function, there was no remarkable changes in cardiac output. There were no direct metabolic changes due to pipecurium bromide. The relaxant has no histamine releasing effect. At the end of the anaesthesia the effect can be antagonized with neostigmine. During our observations there were no side effects or allergic reactions caused by pipecurium bromide.

Herpes zoster and acute rejection crisis of renal homograft.

The case of a patient developing acute rejection crisis 8 months after transplantation in the prodromal stage of a herpes zoster infection is reported. The joint therapeutic measures resulted in suppression of rejection and control of the infection. Complications did not occur. The case suggests a definite association between the viral infection and acute homograft rejection. The case report is followed by a critical review of the pertinent literature.

[Changes in the Na+, K+, and Ca++ concentrations in the urine in the course of surgical interventions]. / Anderungen der Na+-, K+- und Ca++- Konzentration im Harn im Laufe von chirurgischen Eingriffen.

The tests were carried out on 27 surgical patients. Diuresis and the Na, K and Ca concentrations in the urine were measured before, during and after operation. Due to operational stress and to the drugs used for general anaesthesia diuresis decreases progressively during operation and compared to the conscious state the amount of cations excreted during operations is significantly lower. Decrease of the serum potassium and calcium levels is not explained with the quantity of ions excreted with the urine.

[Changes in kidney function in abdominoperineal rectum excision under halothane anesthesia]. / Anderungen der Nierenfunktion bei abdominoperinealer Rektumexstirpation in Halothan-Narkose.

In 17 cases of abdomino-perineal rectum extirpation performed under combined intratracheal halothane anaesthesia, the volume of urine and the osmolality of serum and urine were determined. Though urinary volume decreased significantly, its osmolality did not rise. According to the operational stress this type of operation can be divided into an: 1) intra-abdominal and a 2) perineal phase. In the secretory and concentrating capacity of the kidney, again two phases can be distinguished. Owing to the great operational stress patients with deficient renal function often develop renal failure. It is stressed that such patients close observation, careful hydration prior to operation and the administration of diuretics are of particular importance.