[Role of the monocye-lymphocye system and of endogenous mediators in the severity of acute pancreatitis and in development of its septic complications]. / A monocita/limfocita rendszer és az endogén mediátorok szerepe az akut pancreatitis súlyosságának és szeptikus szövódményeinek kialakulásában.

The activity of monocyte/lymphocyte system and the splanchnic circulation was investigated in acute pancreatitis. The splanchnic blood flow was characterised indirectly by gastric intramucosal pH changes, which strongly correlated with APACHE-II score, and predicted the bad prognosis. The high CD14/HLA-DR and CD14/CD16 coexpression, the low TNF-alpha production proved to be unfavourable prognostic factor in the early phase of the disease. The expression of IL-2, IL-10 and moderately of IL-4 was elevated, but the expression of INF gamma did not show significant alteration. The thrombocyte aggregation decreased in the early phase. There are bad prognostic signs if its level remains constantly low and ATP-release increases. The activity and index of phagocytosis were higher in comparison with controls, but these parameters were not increasable with higher cell concentration. The ROI production increased, and the increase in the fMLP and o'zymosan indicated LDCL seems to be unfavourable prognostic sign, which well correlated with the APACHE-II score.

[Surgery without boundaries]. / Határtalan sebészet.

Surgery at the turn of the century and at the millennium is characterised by an extremely rapid development. There are no boundaries anymore among the different branches of medicine, in different anatomical regions of the human body, between the living human and the artificial tissues, between the reality and the virtual reality. Nanotechnology and robotics offer new possibilities for minimally invasive procedures. By the introduction of telepresence surgery there are no more surgical limits among countries and continents, between Earth and Space as well. A new chapter in history of medicine is the Cyber Surgery. The future has already arrived. Even in this new world we have to follow the ethical requirements summarised in the Hyppocrates Oath.

The first histological demonstration of pancreatic oxidative stress in human acute pancreatitis.

Necrotizing acute pancreatitis is associated with an inflammatory explosion involving numerous pro-inflammatory mediator cascades and oxidative stress. Acinar oxygen free radical production aggravates pancreatic tissue damage, and promotes cellular adhesion molecule upregulation resulting in leukocyte adherence and activation. The cerium capture oxygen free radical histochemistry combined with reflectance confocal laser scanning microscopy allows the "in situ" histological demonstration of oxygen free radical formation in live tissues. Here we present a case report, where oxidative stress is demonstrated on a histological level for the first time in human acute pancreatitis. A 44-year-old male patient suffering from acute exacerbation of his chronic pancreatitis developed a pancreato-pleural fistula with amylase-rich left pleural exudate causing respiratory compromise. Subsequent to an urgent thoracic decompression a distal pancreatectomy and splenectomy was performed with the closure of abdomino-thoracic fistula. The postoperative course was uneventful, except for a transient pancreatico-cutaneous fistula, which healed after conservative treatment. To carry out cerium capture oxygen free radical histochemistry the resected pancreas specimen was readily perfused with cerium-chloride solution through the arteries on the resection surface. Frozen sections were cut, E-, P-selectin, ICAM and VCAM were labeled by immunofluorescence. The tumor-free margin of an identically treated pancreas carcinoma specimen served as a control. Intrapancreatic oxidative stress and cellular adhesion molecule expression were detected by confocal laser scanning microscopy. Numerous pancreatic acini and neighboring capillaries showed oxygen free radical-derived cerium-perhy-droxide depositions corresponding to strong local oxidative stress. Acinar cytoplasmic reflectance signals suggested xanthine-oxidase as a source of oxygen free radicals. These areas presented considerably increased endothelial P-selectin expression with adherent, oxygen free radical-producing polymorphonuclear leukocytes displaying pericellular cerium-reflectance. Modest ICAM upregulation was noted, E-selectin and VCAM expression was negligible. The control pancreas specimen showed minimal oxidative stress with weak, focal P-selectin expression. The development of deleterious pancreatic oxidative stress was based on indirect evidence in human acute pancreatitis. To the best of our knowledge this is the first report demonstrating persistent intrapancreatic oxidative stress histologically in human acute pancreatitis. We have noted P-selectin overexpression with a preponderance in the areas of acinar oxidative stress.

[Calculated gastric intramucosal pH changes in the early phase of acute pancreatitis]. / Számított intramucosalis pH-változások a gyomorban az akut pancreatitis kezdeti szakaszában.

Based on the literature dysfunction of splanchnic circulation may be assumeol in the development of severe acute pancreatitis. Abnormal gut functions investigated by routinely used clinical examination is not available. Gastric tonometry indirectly gives information about gut function. Authors followed prospectively 12 patients who suffered from acute pancreatitis. Four patients recovered without complications, 4 patients had different complications and 4 patients died. Gastric intramucosal pH (pHi) was measured by TRIP NGS catheter and Tonocap monitor. Measurements were started at the time of hospitalisation and repeated every six hours on the first 3 days. Intramucosal acidosis (pHi < 7.3) could be measured independently from aetiology. Gastric pHi showed strong correlation with Acute Physiology and Chronic Health Evaluation II. (APACHE II) score (p = 0.02). APACHE II scores were significantly higher in-group pHi < 7.2 (13.9 +/- 1.7) compared to group pHi > 7.2 (7.33 +/- 1.06) (p = 0.002). 24-hour changes in APACHE II scores were significantly greater in the cases of pHi < 7.2 (3.3 +/- 1.47) versus pHi > 7.2 (-0.6 +/- 0.97) (p = 0.03). Changes of pHi in the early phase of acute pancreatitis indicate that splanchnic circulation is already involved and the pHi may have a prognostic value.

Biliary tract complications in laparoscopic cholecystectomy. A multicenter study of 148 biliary tract injuries in 26,440 operations.

BACKGROUND: The higher risk of biliary tract injury is considered the most significant disadvantage of laparoscopic cholecystectomy. METHODS: A national multicenter retrospective study was performed to determine the frequency, etiology, and treatment of biliary tract injuries between January 1, 1991, and December 31, 1994. Follow-up was by questionnaire. RESULTS: Some 148 biliary tract complications were observed during 26,440 laparoscopic cholecystectomies. There was no significant correlation found between the number of LCs performed in one institute and the incidence of biliary tract injuries and postoperative bile leakage, but in the 2nd year of practice, the incidence of both complications decreased. In institutes with more conversions, more cases of bile leakage were also observed. A significant positive relationship was found between biliary tract injuries and postoperative bile leaks. There was no significant relationship between usage of intravenous and intraoperative cholangiography and ERCP. In univariant analysis of the type of injury, the primary treatment modality did not affect the outcome of injury or entail the necessity of reoperation. Obscure anatomy leads to significantly more main bile duct injuries. According to multivariant analysis, the outcome is significantly influenced unfavorably by the necessity of repeated interventions and advanced age. CONCLUSIONS: The definitely higher risk of bile duct injury mentioned in early studies was not confirmed.

Complications of laparoscopic cholecystectomy in Hungary: a multicentre study of 13,833 patients.

OBJECTIVE: To report our countrywide experience of laparoscopic cholecystectomy with particular reference to complications. DESIGN: National multicentre retrospective study. SETTING: 71 university departments and public hospitals in Hungary. SUBJECTS AND INTERVENTIONS: 13,833 patients operated on between 1 January 1990 and 31 December 1993. Follow up by questionnaire. RESULTS: 732 patients (5.3%) required conversion to open cholecystectomy, urgently because of intraoperative complications in 204 (1.5%), electively for acute or chronic inflammation or obscure anatomy in 441 (3.2%), for unexpected findings in 72 (0.5%) and for technical problems in 15 (0.1%). There were postoperative complications in 598 (4.3%) but reoperation was indicated in only 154 patients (1.1%). There were bile duct injury in 81 (0.6%) and 199 bleeds (1.4%) which required conversion in 102 patients (0.7%) and reoperation in 38 (0.3%). 36 of the 181 postoperative recognized bile leaks required reoperation (20%). 19 patients died (0.1%). CONCLUSIONS: The morbidity and the mortality of laparoscopic cholecystectomy are better than after the open operation. The 2-6 times higher risk of bile duct injury mentioned in early studies was not confirmed.

[Laparoscopic cholecystectomy causing injury to biliary tracts. Analysis of the results of 26,440 operations in Hungary]. / A laparoscopos cholecystectomia s az epeútsérülések. 26.440 hazai mütét tapasztalatainak elemzése.

The authors analyse the etiology, diagnosis, treatment and outcome of 148 biliary tract injuries in connection with 26,440 laparoscopic cholecystectomies performed in 89 domestic institutes between January 1st, 1991, and December 31st, 1994. There was no significant correlation between the amount of laparoscopic cholecystectomies performed in one institute and the incidence of biliary tract injuries and postoperative bile leakage (wide range of figures were found in different institutes), but in the second year of practice, the incidence of both complication decreased (there was statistically significant difference between the regression co-efficients). There was no significant correlation between the laparoscopic cholecystectomies performed and the rate of conversion, but the co-efficient of the regression curve showing the correlation of the absolute number of laparoscopic cholecystectomies and conversions significantly decreased in the second year of practice. In institutes having significantly more conversions, more cases of bile leakage was found also. There is a significantly positive relationship between biliary tract injuries and postoperative bile leakage; the more lesions are found in an institute, the more cases of bile leakage they have. There was no significant relationship between the incidence biliary tract injuries and postoperative bile leakage and the usage of intraoperative cholangiography, preoperative intravenous cholangiography and/or ERCP. The partial and complete injuries of main bile ducts were detected intraoperatively significantly more often while most of the lesions of the area of cystic duct were detected postoperatively. There was no significant difference between the types of the only postoperative recognized injuries and the time of establishing the diagnosis. Simple suture was performed in 69.2% of the partial injuries (with or without T-tube or other drainage), while 63.3% of the complete transsections were treated with biliodigestive anastomosis. In univariant analysis the type of injury, the primary treatment modality did not affect on the outcome (the ratio of cured and expired), but significantly more patients continue to have complaints following biliodigestive anastomosis than following the treatment of lesions around the cystic duct. The older the patient is, the worse the prognosis is. The primary treatment modality (biliodigestive anastomosis or biliary tract reconstruction with or without drain) did not significantly altered the necessity of reoperation. Thermic injury caused significantly more partial than complete lesion. Disturbance in identification of the anatomic structures leads significantly more partial or complete main bile duct injuries than lesion in region of the cystic duct and causes more complete transsections than partial lesions. According to multivariant analysis the outcome is significantly influenced in an adverse way by the necessity of repeated interventions and higher age.

[Bile duct injuries in laparoscopic cholecystectomy. A computerized analysis of 148 lesions in 24,440 operations in 89 Hungarian institutes (publication by the Hungarian Society of Surgery)]. / Gallenweg-Verletzungen bei laparoskopischer Cholecystektomie. Eine Computer-Analyse von 148 Läsionen bei 26,440 Operationen in 89 ungarischen Instituten (Publikation der Ungarischen Gesellschaft für Chirurgie).

The authors analyse the etiology, diagnosis, symptoms, treatment and outcome of 148 biliary tract injuries in connection with 26,440 laparoscopic cholecystectomies performed in Hungary. In univariant analysis, the type of injury, the primary treatment modality did not affect the outcome of injury or the necessity of reoperation; in multivariant analysis, the outcome is significantly influenced adversely by the necessity of repeated interventions and higher age. Disturbances in the identification of anatomic structures lead significantly to more main bile duct injuries than lesions in the region of the cystic duct and cause more complete trans-sections than partial lesions.

Unexpected gallbladder cancer and laparoscopic surgery.

Case histories of three patients who underwent laparoscopic cholecystectomy for unexpected gallbladder cancer are reviewed. Port-site recurrence was observed in two of them. In one patient whose abdominal wall recurrent tumor was excised, a new recurrence developed, but after the reexcision she is symptom-free 10 months after the last procedure. The surgeon has to be aware of the fact that the survival rate can be doubled in stage pT2 if cholecystectomy is followed by extended radical operation. Only gallbladder cancer in stage pT1 does not need further procedure, except for excision of port sites. In case of uncertain diagnosis preoperative frozen section is recommended. Port-site recurrence does not mean an incurable stage of the disease or a sign of diffuse metastases. Even after reexcision of abdominal wall metastasis patients might be free from other detectable recurrences.

[Laparoscopic cholecystectomy and cancer of the gallbladder]. / Laparoszkópos cholecystectomia és az epehólyagrák.

Performing a series of 960 laparoscopic cholecystectomies we have removed 3 unsuspected gallbladder cancers. In one case we have observed the development of trocar site abdominal wall metastasis twice. After resection and reresection of the metastases the patient is symptom-free in the 14th month. During laparoscopic cholecystectomy if there is a suspicion of gallbladder cancer we have to manipulate with special care to avoid rupture of the gallbladder. In doubtful cases frozen section is mandatory. If the malignant process extends over the serosal layer--conversion and radical-extended operation is recommended.

[The role of sonography in laparoscopic cholecystectomy]. / A sonographia szerepe a laparoscopos cholecystectomiában.

Between January 1991. and December 1993. in the 3rd Surgical Department of Semmelweis Medical University 735 laparoscopic cholecystectomies were performed. Intraoperative and postoperative complications occurred in 2.7% and 3% respectively. Conversion to open procedure was necessary in 8.4%, reintervention was indicated in 2.3%. The total occurrence of common bile duct stones was noticed in 1.6%. The incidence of bile duct injury 0.54%. The role of sonography in laparoscopic cholecystectomy is multiple: patient-selection, diagnosis of complications, ultrasound guided interventions in cases of complications, follow up of patients. The authors compared in 419 cases the preoperative sonography with the intraoperative finding. The risk of intra- and postoperative complications was significantly higher if the stone was impacted into the cystic region, if the gallbladder was enlarged, especially with wall-thickening and signs of acute inflammation. The fibrosis and scarring of gallbladder represent an increased risk as well. The accuracy in estimation of common bile duct dilatation is very high, but in the judgement of bile duct stones there was a high false positive rate. In spite of this, the echography is very well applicable for patient-selection. In the patient group selected with positive sonographical finding for open cholecystectomy, the prevalence of common bile duct stones was 25%, compared with 1.6% in laparoscopic group. In cases of postoperative complications the diagnostic sonography may be followed with ultrasound-guided puncture and/or drainage.

The role of invasive sonography in the differential diagnosis and treatment of intraabdominal fluid collections.

Sixty-nine ultrasound-guided interventions (23 punctures and 46 drainages) were performed on 51 patients with the suspicion of intraabdominal abscess or another type of fluid collection in a prospective-controlled study. Of the procedures, 58.8% were carried out following surgery, while in 41.2% the indication were not related to prior surgical intervention. Repeated procedures were done in 10 patients. In the group of punctures the procedure was therapeutic in 3 cases and diagnostic in 16 patients. The drainage was technically successful in 92.7%. The drain was displaced or blocked in 27% (n = 10), but reinterventions were necessary in only 5 cases for this reason. The total number of redrainages was 18.9%. The percutaneous (pc) drainage was insufficient in 8 patients (21.6%), all these patients were operated on. 62.2% of the patients recovered after pc drainage, 13.5% following redrainage (total 75.5%). In 8.1% of the cases after pc drainage and in 5.4% after pc redrainage open surgery became necessary. There was only one complication due to the procedure. Seven patients (14.3%) died of the disease which indicated the procedure. There were no fatal outcomes on the account of the intervention. Ultrasound-guided puncture is a suitable method to indicate or contraindicate open surgery in the case of intraabdominal fluid collection. The diagnostic puncture may be followed by sonographically guided drainage or in selected cases by therapeutic puncture, but if the pc drainage is insufficient, open surgery should be performed in time.

Surgical relations of Crohn's disease and the frequency of recurrence.

There is no disease that would have as many and variable complications as Crohn's disease. One of the most common complications is bowel obstruction which can be caused by the angulation of the bowel or by inflammation, or by formation of granulation tissue (32.3%). Very common is the formation of fistulae amongst the bowels involved and other abdominal organs, and also entero-cutaneous fistulae occur frequently (11.3-14.4%). The frequency of complications is increasing with the duration of the illness. If they are life-threatening, only surgical treatment can help. Surgical treatment is also indicated when conservative treatment fails. The most commonly used surgical interventions are bowel resection and, recently, the plasty of stenotic areas. The operative mortality (3.7%) is influenced by the length of the disease and by the numbers of complications. Recurrence is very common in Crohn's disease (30.1-34.9%). The mortality rate of the second operation is 17.5%. The prognosis is usually poor because recurrence can occur years after the primary operation. In Hungary, the frequency of surgically treated patients with Crohn's disease is low, they count for 0.06% of all general surgical operations.

[Technics and results of pancreas transplantation]. / A pancreas transzplantáció technikája és eredményei.

Long-term normoglycaemia cannot be achieved in patients with insulin dependent diabetes mellitus neither with conventional nor with intensified insulin therapy. The only ideal method to obtain this seems the islet cell or pancreas transplantation. The number of pancreas transplantation approaches 5000 all over the world. The first simultaneous pancreas-kidney transplantation in Germany was performed in 1979 by the Munich group. Till 1991 in Grosshadern 141 pancreas transplantations have been performed. At the beginning duct occlusion (n = 106) later bladder drainage (n = 35) were used as a standard procedure. The authors discuss in detail the indications and contraindications, the types of pancreas transplantation, the different diversions of exocrine secretion. They analyse the effect of pancreas transplantation upon diabetic metabolism, retinopathy, neuropathy, nephropathy and quality of life, based on own experiences and literary data. At present the indication for pancreas transplantation is the stadium of late complications in IDDM. Because of the definitive lesions its beneficial effect is limited. After successful transplantation the peripheral (and autonomic?) neuropathy improves, the retinopathy seems to remain stabile, and the pancreas protects the transplanted kidney against recurrent diabetic nephropathy. Most patients will become insulin independent with tight metabolic control, but the complications of immunosuppressive therapy must be taken into consideration. The working ability and the quality of life seem to improve considerably.

[Pancreas transplantation]. / Pankreastransplantation.

The results of pancreatic transplantation improved markedly during the last years. Transplantation of the pancreas together with the kidney is the most common treatment of Type I-diabetic patients. At present different surgical techniques are used for the handling of the exocrine secretion of the gland. However, each technique has its own advantages and disadvantages. A successful pancreatic transplantation provides a normal glucose metabolism in the majority of the patients. This leads to an improvement of the peripheral and autonomic neuropathy. Clinical observations suggest a beneficial effect on diabetic retinopathy and peripheral microcirculation. More long-term-results are mandatory to assess the preventive effect of pancreatic transplantation on the development of late diabetic complications. Timing of pancreatic transplantation has a major influence on the course of secondary complications. There is no need for further dietary restrictions or exogenous insulin replacement, so that a better quality of life can be achieved.

[Experience with the management of pyogenic liver abscesses by percutaneous transhepatic puncture and drainage]. / Tapasztalataink a pyogen májtályogok kezelésében percutan transhepaticus punctióval és drénezéssel.

The authors treated forty-two patients with liver abscesses guided by computer tomography or ultrasound percutaneous transhepatic puncture or drainage from January 1 1983, to 1989 December 31. Closed aspiration or drainage was done in 42 patients altogether 56 times. Three patients died (3/42 = 7.2%), postdrainage complications happened in 9 cases (9/42 = 21.4). Operative intervention was necessary in 11 patient after the percutaneous procedure (11/42 = 26.2%). The authors wrote about the technics particularly of the percutaneous puncture or drainage. The authors are considering the method as an effective treatment for pyogenic liver abscesses if the personal and technical circumstances are given.

[The role of real-time sonography in the differential diagnosis of acute appendicitis and in the detection of post-appendectomy complications]. / A real-time sonographia szerepe az acut appendicitis differenciáldiagnosztikájában és a postappendectomiás szövödmények felismerésében.

110 urgent sonography were performed on 101 patients with suspected acute appendicitis and on subsequent 26 patients 33 echography with suspected postappendectomy abscess. Although according to a few publications in connection with acute appendicitis there are characteristic sonographic signs, the authors didn't find any typical structures at patients having non-complicated appendicitis. But at perforated appendicitis and periappendicular abscesses the fluid collection was frequently very well visualizable and the periappendicular infiltration was detectable as well. The differentation between infiltration and abscess is difficult, often unsuccessfull. The authors confirm the high sensitivity of sonography in the detection of postappendectomy intraabdominal abscesses, similarly to other abscesses of unrelated origin. They emphasize the differentialdiagnostic aid of sonography, if the clinical symptoms are atypical or the signs of acute appendicitis are imitated by other disease.