Evaluation of perioperative cholangiography in one thousand laparoscopic cholecystectomies.

We analyzed a teaching institution's experience with intra-operative cholangiography (IOCG) and endoscopic retrograde cholangiopancreatography (ERCP) and established an algorithm for their timing and use. The records of all patients undergoing LC during a five year period were reviewed. Patients with a history of jaundice or pancreatitis, abnormal bilirubin, alkaline phosphatase, serum glutamic-oxaloacetic transaminase, or radiographic evidence suggestive of choledocholithiasis were considered "at risk" for common bile duct stones (CBDS). The remaining patients were considered to be at low "risk." LC was attempted on 1002 patients during the study period and successfully completed on 941 (94% of the time). The major complication rate was 3.1% and the common bile duct injury rate 0.1%. Eighty eight (9.5%) patients underwent ERCP, 67 in the preoperative period and 19 in the postoperative period. IOCG was attempted in 272 (24%) patients and completed in 234 for a success rate of 86%. Intraoperative cholangiography (IOCG) and preoperative endoscopic retrograde cholangiopancreatography (ERCP) were equivalent in the detection of CBDSs Twelve of the 21 patients (57%) with IOCG positive for stones underwent successful laparoscopic clearance of the common duct, and did not require postop. ERCP. No patients were converted to an open procedure for common bile duct exploration. Because postoperative ERCP was 100% successful in clearing the common duct, reoperation for retained common bile duct stones was not necessary. IOCG is an alternative procedure to ERCP for patients at risk with biochemical, radiological, or clinical evidence of choledocholithiasis. The incidence of CBDS in low-risk patients is 1.7%, a risk that does not warrant routine cholangiography. Preoperative ERCP is recommended in cases of cholangitis unresponsive to antibiotics, suspicion of carcinoma, and biliary pancreatitis unresponsive to supportive care. Although IOCG leads to a similar percentage of nontherapeutic studies as preoperative ERCP, it often allows for one procedure therapy.

Effects of interleukin-11 and epidermal growth factor on residual small intestine after experimental massive small bowel resection.

Interleukin 11 (IL-11) is a multifunctional cytokine derived from bone marrow, which has a trophic effect on small bowel epithelium. This study compares the effects of IL-11 with epidermal growth factor (EGF), a growth factor known to enhance small bowel adaptation. Forty Sprague-Dawley rats (90-100g) underwent an 85% mid-small bowel resection with primary anastomosis on day 0. Rats were divided into four treatment groups: controls (group I) received bovine serum albumin (BSA), group II received IL-11, 125 microg/kg subcutaneously (SC) twice daily, group III received EGF, 0,10 microg/g SC bid, and group IV received EGF and IL-11 in the above doses. Half of the animals (five per group) were killed on day 4 of therapy, and the rest on day 8. Animals were evaluated for weight, mucosal length, and bowel wall muscle thickness on days 4 and 8, and expression of proliferating cell nuclear antigen (PCNA) in intestinal crypt and smooth muscle cells on day 8. Body weight was similar at day 4 and 8. Mucosal thickness in groups 11 (IL-11) and IV (IL-11 and EGF) was significantly increased at day 4 and 8 compared with controls (group I) and EGF (group III, P<.001). Muscle thickness was significantly increased in the EGF and combined group IV compared with the BSA controls and IL-11 groups (P < .001). Thirty-two percent of the mucosal crypt cells in group I stained positive for PCNA, whereas 51%, 53%, and 60% stained positive in groups II (IL-11), III (EGF), and IV (IL-11 and EGF), respectively. In groups I and II, 2% and 1.7% of the myocytes stained positive for PCNA, whereas 11.2% and 5.2% in group III and IV. These data suggest that IL-11 has a trophic effect on small intestinal enterocytes, causing cell proliferation and increased mucosal thickness. EGF has a more generalized effect causing proliferation of both enterocytes and myocytes. IL-11, with or without EGF may be a useful adjunct in treatment of short bowel syndrome.

Gastrointestinal stromal tumors (GIST).

BACKGROUND/AIMS: Gastrointestinal stromal tumors (GIST) are the most frequent non-epithelial tumors of the alimentary tract. The interstitial cells of Cajal or more primitive progenitor mesenchymal cells are suggested as their cells of origin. GIST's occur throughout the gastrointestinal tract but are generally located in the stomach and the intestine. About 70% of GIST's are immunohistochemically positive for CD34 and more than 90% for c-kit protein (CD117). About two thirds of GIST's are malignant. The tumor size, mitotic rate, cellularity and nuclear pleomorphism are the most important parameters characterizing the biological behavior of tumors. The diagnostic procedures are similar to those of other gastrointestinal neoplasms but only a half of the patients will have correct preoperative histological diagnosis. GIST's can be cured only by surgery. The procedure of choice, if possible, is resection without extended lymphadenectomy. Radiation and chemotherapy are generally ineffective. METHODOLOGY: 22 patients were operated on for GISTs in our department between 1996 and 2003. RESULTS: All but one proved to be benign. The patients were all asymptomatic after the operation except the malignant case. In his case an irresectable local recurrence developed later. CONCLUSIONS: GIST is a rare neoplasm of the GI tract. The only possibility for treatment of GISTs is surgical removal.

[The treatment of gastric tumours in our practice: a five year survey]. / Ein 5-Jahres-Uberblick über unsere Behandlung des Magenkarzinoms.

Between the 1st of January, 1998 and the 31st of December, 2002 we treated 111 patients for gastric cancer in the 2nd Department of Surgery, Semmelweis University, Budapest, Hungary. The majority of patients belonged to the advanced stages of the disease. In 65% of the cases a partial or total gastrectomy was performed. We combined the operation with D2 lymph node dissection if a R0 resection was possible, in the other cases with D1 lymphadenectomy. Postoperative morbidity rate ranged to 15%, the mortality 5.4%. 74 patients could be followed, 41 are dead and 33 still alive. According to the follow up examination the median survival time is 20.4 months at the moment. We observed a significantly shorter survival time, if vascular or lymphoid vessel invasion was present in the histologic specimen. The study has not been finished and the follow up will be continued.

[Sibutramin in obesity treatment (multicenter, open, prospective 12-month-long study)]. / Sibutramín v liecbe obezity (multicentrická, otvorená, prospektívna 12-mesacná stúdia).

Obesity presents a significant medical and socio-economic problem due its prevalence exceeding 20% of adult population. Body weight reduction significantly decreases both morbidity from numerous complications and total mortality. Nonpharmacological measures are the first step in weight reduction, however an effective pharmacotherapy is also needed in some of the patients. In a 12-month-long study 50 obese female patients were treated with Sibutramin doses of 10 mg or 15 mg. Sibutramin is a drug with a dual effect: it reduces intake of energy by simultaneous bringing on a sense of satiety and inhibiting reduction of the energy release which usually accompanies low energy diets. Medication accompanied with a diet therapy and physical activity led to a reduction of body weight by 14.9 kg and an important weight loss by 5% have reached nearly 95% of patients. The treatment was well tolerated and no significant side effects have been indicated.

[Breast reconstructions using thoracodorsal flaps according to Holmstrom--a fourteen-year experience]. / Rekonstrukce prsu torakodorzálním lalokem podle Holmströma--ctrnáctileté zkusenosti.

Breast reconstructions after completed mastectomies using fascio-cutaneous flaps in combination with silicone prostheses implantations, are considered routine breast reconstruction procedures. The authors present their fourteen-year experience with the breast reconstructions using the thoracodorsal flaps with the silicone prostheses.

[Bone changes in patients after partial gastric resection]. / Kostné zmeny u pacientov po parciálnej resekcii zalúdka.

Metabolic diseases of the bones may be a serious complication of gastrectomy. The pathogenesis of osseous changes is multifactorial. The most important causes include a reduced intake of dairy products, their fastened passage through the stomach and reduced calcium and vitamin D absorption. The objective of the work was to assess bone changes in patients after partial gastrectomy. From a total number of 261 patients with a minimal 10-year history of gastrectomy, in the investigation 31 patients were included (18 men and 13 women) who met the required criteria. The results were compared with a control group of 18 men and 13 women of equal age. The authors compared also groups of patients with the condition after surgery type Billroth I (8 patients) and Billroth II (23 patients). In all investigated subjects the authors examined the bone density in the area of the lumbar spine and neck of the femur and parameters of osteoresorption and osteoformation. The authors found a significant reduction of bone density in the area of the spine and neck of the femur (p < 0.001) and a significantly higher level of total alkaline phosphatase and intact parathormone in serum and N-terminal telopeptide collagen type I in urine (p < 0.001), as compared with the control group. The other parameters did not differ in the investigated groups. The authors did not find a statistically significant difference in the investigated parameters between patients after resection Billroth I and Billroth II. The results confirm the need of early diagnosis and treatment of bone changes in patients after partial gastrectomy.

[Infiltration of subcutaneous tissue for prevention of blood loss in extensive plastic surgery operations--10 years' experience]. / Infiltrace podkozní tkáne jako prevence krevních ztrát u rozsáhlých výkonu v plastické chirurgii--desetileté zkusenosti.

The authors emphasize the importance of extensive preoperative infiltration of subcutaneous tissue in some selected plastic operations as prevention of major blood losses and reduction of the number of blood transfusions during operation and the postoperative period.

Carcinoid tumors--somatostatine in the diagnosis and therapy.

BACKGROUND: Carcinoid tumors have a neuroendocrine origin and endocrine activity is typical for them. OBJECTIVES: The main objective of the present study was to determine differences in the levels of an endogenous somatostatin, a neuron specific enolase in serum and excretion of 5-HIAA in the urine in patients with carcinoid tumors and also to determine the changes of these parameters during the treatment with long acting somatostatin analogue--lanreotide. SUBJECTS AND METHODS: 30 pts with carcinoid tumors (20 pts with metastatic disease, 10 pts after resection of the primary tumor without known metastases at the time of the investigation) and 12 healthy probands were included in the study. Circadian rhythm of endogenous somatostatin in all groups was performed. Levels of neuron specific enolase in the serum and the excretion of 5-HIAA in the urine in pts with carcinoid tumors were done. The estimation of these parameters were repeated in the group of pts with advanced metastatic disease during the treatment with the lanreotide. RESULTS: We confirmed the existence of the circadian rhythm of endogenous somatostatin in all groups. Chronogram of somatostatin in pts without known metastases shows the same characteristics as the chronogram of healthy volunteers. The chronogram of pts with metastatic carcinoid disease shows a statistically significant differences in comparison with healthy volunteers--higher mesor and later acrophase of 24-hour rhythm (p < 0.05). During the therapy with lanreotide lower mesor was observed (p < 0.05). The amount of the 5-hydroxyindolacetate acid in urine in pts with metastatic carcinoid was statistically significant higher than in the pts without metastases (p < 0.001). During therapy with the lanreotide the decrease in the 5-HIAA in the urine (p < 0.05) was observed. Neuron specific enolase in the serum was higher in group with the metastatic disease (p < 0.001). CONCLUSION: Abnormalities in the somatostatin secretion and the concentration of the neuron specific enolase in serum are useful markers for the differential diagnosis and might distinguish the carcinoid patients with and without metastases. Urine excretion of 5-HIAA is a good marker of endocrine activity of the carcinoid tumor. (Fig. 4, Tab. 3, Ref. 22.)

[Diurnal rhythm of endogenous somatostatin in patients with carcinoid]. / Diurnálny rytmus endogénneho somatostatínu u pacientov s karcinoidom.

AIM OF THE STUDY: Was to investigate the differences of the circadian rhythm of the endogenous somatostatin in patients with carcinoid and in healthy probands. METHODS: The group of 30 patients (16 men/14 women) was divided onto two groups. The group M of 20 (12/8) pts with metastatic disease and group B of 10 pts without known metastases at the time of investigation. The control group A included by 12 healthy probands (7/5). Plasma levels of somatostatin were determined by radioimmunoassay. Fisher periodogram and Halberg's cosinor were used for statistical evaluation. RESULTS: We confirmed the 24-hour circadian rhythm of somatostatin in group A, B and M. Patients of the M group when compared with A and B groups had higher mesor and the later 24-hour acrophase (p < 0.05) and 12-hour acrophase (p < 0.05). Treatment with lanreotide led to the significant decrease of the somatostatin mesor (p < 0.05).

[Giant cell angiofibroma of the lower eyelids]. / Giant cell angiofibrom dolních vícek.

The authors present a rare case of giant cell angiofibroma (GCAF) of the lower eyelids and the possibility of its surgical treatment. They emphasize the basic morphological indicators for assessment of GCAF and its difference from similar entities.

[Flesh-eating bacteria infection of an immunocompromised patient]. / Húsevó baktérium fertózés immunszupprimált betegnél.

After years of steadily declining morbidity and mortality due to group A streptococcal infections, a resurgence of severe, invasive disease has been ongoing since 1980, leading to the recognition of streptococcal shock syndrome (STSS), necrotizing fasciitis, the most severe form of invasive infection. The patients suffer from rapid local deep soft tissue destruction, severe septic shock and multi organ failure. The increased incidence of these infections has been accompanied by remarkable vigor in virulence and severity of the disease. The reason for this impressive change in the epidemiology and clinical manifestation of group A streptococcal infections remains unknown. The possible etiological factor is changing in virulence factor or the lack of protective immunity of the population (immunocompromise) against the invasive strains. We describe a severe necrotizing fasciitis of a 41-year-old previously immunocompromised woman. The patient developed severe septic shock, multi organ failure and perineal and lower abdominal skin, fat and fascia necrosis due to mixed GAS (aerob, anaerob) infection of the perineum and the Bartholini glands. After an aggressive surgical debridement, antibiotic and supportive therapy the generalised and local infection was treated.

Plasma gastrin levels in alcoholic and idiopathic chronic pancreatitis patients free from Helicobacter pylori infection.

BACKGROUND: Previous studies on gastrin levels in chronic pancreatitis (CP) patients have given conflicting results. These studies did not take into consideration the influence of Helicobacter pylori (H. pylori) infection on gastrin release. Also, there is no previous study that compared alcoholic CP patients to patients with idiopathic pancreatitis. Our aim was to measure basal and postprandial plasma gastrin levels in all CP patients, including subgroups of alcoholic, idiopathic, severe and mild CP patients, and compare them with healthy subjects after the eradication of H. pylori infection. PATIENTS AND METHODS: Basal and postprandial gastrin levels were measured in 30 patients with CP (10 patients with alcoholic and 20 patients with idiopathic CP) and in 25 healthy subjects. RESULTS: A significant increase in basal gastrin levels was found only in a subgroup of alcoholic CP (P<0.05) in comparison to healthy subjects. A significant increase in postprandial plasma gastrin levels (P<0.01) was found in all chronic pancreatitis compared to healthy subjects. CONCLUSION: In the absence of H. pylori infection, plasma gastrin levels were significantly higher in chronic pancreatitis patients than in healthy subjects. Chronic alcoholism, however, does not appear to be the only factor responsible for the increased plasma gastrin levels in these patients.

[Gastrointestinal stromal tumors in our practice]. / Gasztrointesztinális stromális tumorok (GIST) elófordulása klinikánk anyagában.

The classification of tumours originating from the wall of gastrointestinal organs changed dramatically since of electronmicroscopy and immunohystochemistry were introduced. Previously these tumours were classified as leiomyomas, leiomyosarcomas or schwannomas. With the new methods these disorders can be described in more details and unified, and so the change to provide correct prognosis improved. Still, there are some unanswered questions remaining for the pathologists. In our material in the past 5 year we treated 9 patients because of GIST. Most of them were found in the stomach (6), one developed in the oesophagus, one in the small bowel and another one in the rectum. With describe our patients and look at the related articles literature about this important diseases. Though the incidence is under 1% of patients operated on because of gastrointestinal diseases, we would like to share our experiences in treatment.

Plasma cholecystokinin and somatostatin levels in chronic pancreatitis patients.

BACKGROUND/AIMS: The existence of a negative-feedback mechanism between pancreatic enzyme secretion and intraduodenal proteases and the role of cholecystokinin in its mediation in humans is debatable. The presence of such a feedback mechanism in chronic pancreatitis patients with exocrine enzyme deficiency possibly leads to an increase in cholecystokinin plasma levels. Somatostatin has been used in many studies in the therapy of pain in chronic pancreatitis and plays a role in the regulation of cholecystokinin levels, however data on its plasma levels are still lacking. METHODOLOGY: Basal and the postprandial cholecystokinin and somatostatin levels in 30 patients with chronic pancreatitis (11 with severe chronic pancreatitis and 19 with mild chronic pancreatitis) were measured 14 days after discontinuation of enzymatic substitution therapy and then were compared with the levels taken from 25 healthy subjects. RESULTS: The cholecystokinin postprandial plasma levels were significantly higher in patients with chronic pancreatitis when compared with those of healthy individuals (P < 0.01). Basal, somatostatin, cholecystokinin and postprandial somatostatin levels were not significantly higher than those in healthy subjects. There was no correlation between basal and postprandial levels of cholecystokinin and somatostatin in our study. CONCLUSIONS: The cholecystokinin postprandial plasma levels were significantly higher in all patients with chronic pancreatitis when compared with healthy individuals, which suggests the role of cholecystokinin in the feedback control of pancreatic secretion.

Isolated massive pleural effusion caused by pancreatico-pleural fistula.

BACKGROUND: Massive pleural effusions are uncommon but well-documented complications of chronic pancreatitis, usually caused by the development of a pancreaticopleural fistula. The mechanism of the fistula formation is thought to be rupture of the pancreatic duct or pseudocyst. MATERIAL AND METHODS: In the past 7 years we have treated 5 patients with massive pleural effusion of pancreatic origin in the Surgical Department of Semmelweis University Medical School. 4 patients were males; the average age was 52 years (range: 46-59 years). RESULTS: All 5 patients had a history of alcohol abuse and were admitted to the pulmonary department because of respiratory distress. Other symptoms such as abdominal pain, chest pain, or weight loss were not always present. The diagnosis was confirmed by a markedly elevated amylase level in the aspirated pleural fluid. Abdominal ultrasound, CT scan, and ERCP examinations were carried out in order to determine the cause of the pancreaticopleural fistula. Conservative (nonsurgical) treatment was effective within 3 weeks in only one case. The other 4 patients required surgical management. In 3 cases distal pancreatic resection with splenectomy and cholecystectomy was done. In one case cystojejunostomy was performed. All 5 patients have been cured with complete resolution of their pleural effusions. CONCLUSIONS: Patients with large pleural effusions may have underlying pancreatitis with a pancreaticopleural fistula. It is important to establish this diagnosis because treatment may require operative interventions.

[Effect of pancreatic substitutes on fecal and serum elastase and on pain in patients with chronic pancreatitis]. / Vplyu pankreatickej substitúcie na fekálnu a sérovú elastázu a na bolest' u pacientov s chronickou pankreatitídou.

Views on the existence of a negative feedback between pancreatic secretion and intraduodenal of proteases in humans are controversial. The objective of the study was to find out whether enzyme substitution will have an impact on pancreatic enzyme secretion and pain in chronic pancreatitis. The preparation Panzytrate 2500 (2 x 3 capsules/day containing 1250 units of proteases per capsule) was administered for a 4-week period. In 18 patients with chronic pancreatitis (7 with the severe and 11 with the medium severe and mild form of pancreatitis) the faecal and serum pancreatic elastase was assessed one day before and one day after enzyme substitution therapy. A significant reduction of the faecal elastase concentration (p = 0.03) and serum elastase (p = 0.00375) was recorded in patients with mild and medium severe CP. The values of faecal and serum pancreatic elastase 1 were insignificantly reduced also in patients with severe chronic pancreatitis. Pain relief was statistically significant already after two weeks' administration of enzyme substitution therapy (p = 0.0233) and after four weeks' treatment (p = 0.00766). The results support the importance of the negative feedback on regulation of pancreatic secretion and the positive effect of substitution therapy on pain in chronic pancreatitis.

[Effect of alendronate therapy on bone turnover--results of a multicenter study]. / Vplyv liecby alendronátom na kostný obrat--výsledky multicentrickej stúdie.

Sodium alendronate is a bisphosphonate of the IInd generation with a strong antiresorptive effect. Its favourable effect on reduction of the incidence of vertebral and non-vertebral fractures was repeatedly confirmed. The objective of the multicentre study was to evaluate the effect of administration of 10 mg of sodium alendronate combined with 1000 mg of elemental calcium administered in the course of three months on the N-terminal telopeptide(NTx) a sensitive marker of bone resorption. The group comprised 275 postmenopausal women with densitometrically confirmed osteoporosis. After three months treatment a 53% decline of NTx values occurred as compared with baseline values. This finding confirms the favourable effect of sodium alendronate on bone remodelling. A decline of the concentration of bone markers is one of the good predictors of the effectiveness of treatment focused on reduction of atraumatic osteoporotic fractures.

[Acute gastrointestinal bleeding caused by a rare, benign tumor of the duodenum (gangliocytic paraganglioma)]. / A duodenum heveny vérzést okozó, ritka, benignus daganata (gangliocytic paraganglioma duodeni).

Diagnosis and treatment of massive gastrointestinal bleeding is sometimes very difficult problem in a surgical unit. Authors present a case of a 40 years old female with an atypical source of upper gastrointestinal bleeding. The origin of the bleeding was detected only by intraoperative enteroscopy. The source of the bleeding was a very rare benign tumour of the duodenum (Gangliocytic paraganglioma) which involved the papilla of Vater. During the operation resection of the pedunculated tumour was carried out, with choledochal--and Wirsungoplastyc, associated with external drainage of these ducts. According to the literature in preoperative diagnosis of this rare tumour endoscopy, angiography, and EUS are very useful. In case of malignancy, metastases radical operation-pancreatoduodenectomy--is indicated.

[Splenic rupture: a rare complication of colonoscopy]. / Kolonoszkópia ritka szövódménye: a lépruptura.

Splenic rupture due to colonoscopy is very rare. Only a few cases have been reported previously in the English literature. Authors present their own case and they call attention to the mechanism of this complication. They conclude consequences from the literature.