Pancreatic head mass: what can be done? Diagnosis: computed tomography scan.

The diagnosis of different pancreatic diseases has recently become a recurrent problem. In cases with pancreatic head mass the main question is the differentiation between malignant and benign lesions. When a neoplasm is suspected, the main task is to judge operability. The usefulness of computed tomography imaging in the evaluation of pancreatic carcinoma has been well established. In this article the authors discuss the possibilities of computed tomography (CT) in diagnostic work-up.

Pancreatic head mass: how can we treat it? Tumor: surgical treatment.

Pancreatic carcinoma is a devastating disease. Untreated 5-year survival is 0%. The only possibility of being cured is given by surgical removal of the tumor. Pancreatoduodenectomy previously involved high morbidity and mortality rates until it was postulated that palliation gave better results. Today, morbidity and mortality rates have been decreased to an acceptable level, mortality rates in specialized centers being under 5%. Prognostic factors determining survival were found to be the size of the tumor, grade, lymph node involvement and stage. In order to be able to compare results of the different centers, standardization of the surgical technique is mandatory. It is unanimously accepted that in order to improve survival in pancreatic carcinoma, the radicality of the surgical procedure should be increased to include lymphadenectomy. Postoperative adjuvant therapy could also be a determinant factor. Prospective randomized clinical trials will give an answer to these still unanswered questions.

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.

The laparoscopic treatment of non-parasitic liver cysts. Five years experience.

The incidence of cystic liver lesions seems to be more frequent as previously suggested. The treatment of symptomatic non-parasitic cysts is controversial. Ultrasonography (US) or computer tomography (CT) guided drainage and/or sclerotization versus surgical fenestration or partial resection, even liver resection has been advocated. Recently with the development of laparoscopic surgery this minimal invasive approach was also applied in the surgical treatment of single or multiple cystic lesions. Between 1994 and April 1999 21 patients with non-parasitic cysts were treated by laparoscopic fenestration or partial resection at the 1st Department of Surgery, Semmelweis University of Medicine. In 13 cases the symptomatic cyst presented the indication for surgery, while in the others cholelithiasis and GERD was the primary cause of intervention in 7 and 1 patient respectively. There were 16 woman and 5 men with a mean age of 42.3 years (17-78). The cyst was solitary in 17 cases and multiple 3-6-number in four patients. The size varied between 1.5-25 cm (average 7.2 cm). Patients were selected for the laparoscopic approach according to the US and/or CT appearance and superficial localization of the cyst. Wide unroofing or partial resection of the cyst wall till the margin of normal liver tissue was performed in all cases. The cystic cavity was drained. All operations were completed laparoscopically. Intraoperative complication did not occur. Bleeding from the resected margin could be well controlled by electrocautery or clipping. Patients left the ward after the drains were removed on postoperative day 2-4 depending upon the amount of serious discharge. No complication was observed postoperatively. During the average of 12.5 months (1 to 54 months) follow-up of 19 patients no recurrence was observed. Two patients required reoperation. In one 17 year old male patient cystadenocarcinoma was verified by histology, upon reoperation the lesion was found unresectable. In another case left hemi-hepatectomy was performed because of cyst recurrence caused by cholangiocell adenoma. In selected cases of superficially located symptomatic, non-parasitic cysts the laparoscopic fenestration might be the first choice of treatment. The method is safe and effective in the hands of surgeons experienced in both laparoscopic and liver surgery. Careful exploration of the cystic cavity and histological examination of the resected cyst wall is mandatory to avoid diagnostic mishaps.

[Ultrasound-guided fine-needle aspiration biopsy of focal liver lesions]. / Gócos májelváltozások ultrahangvezérelt vékonytü aspirációs citológiája.

The ultrasound guided percutaneous fine needle biopsy (US-FNAB) of focal lesions in the liver is indispensable in many clinical situations. During the last 12 years, 657 US-FNAB were performed on patients with suspected neoplastic involvement of the liver with 22-gauge Chiba needles at our department. US-FNAB was performed mostly with the "free hand" technique. Sufficient material for cytologic analysis was obtained in 84% of the cases. The biopsies confirmed malignancy in 39.3%, including 9% primary hepatocellular carcinoma, 8% of the cases were suspect for malignancy, and in 36.7% were diagnosed benign lesion. 233 cases were confirmed histologically and with other follow up methods. The sensitivity rate was 91%, and specificity was 100%. There was no false positive diagnosis and no noteworthy complications were observed. US-FNAB is a highly reliable, safe, inexpensive and easy diagnostic procedure. On the basis of our experience, we recommend US-FNAB as a routine, first level procedure for the diagnosis of focal liver diseases.

[Gastroenterologic endoscopic ultrasonic examinations using a convex transducer]. / Gastroenterologiai endoscopos ultrahangvizsgálatok convex transducerrel.

Interest in endoscopic ultrasonography (EUS) has increased during the past fifteen years. Since few years new instrument have been produced, which was equipped with a small curved array transducer mounted in a front of the optic lens. The instrument, which is connected to a Hitachi ultrasonic scanner allows for duplex examination, colour flow imaging, and spectral analysis for measurement of flow velocity. Comparing to the recent unit with mechanical sector transducer, this instrument was equipped with a working channel, which allows to perform biopsies and define the TNM stages. The paper is discussed the evaluation of 55 patient data. This method developing worldwide quickly. By this new EUS technology there is a growing opportunity to substitute other either costly or more invasive methods, and using the TNM classification there is also possible to define whether the patient is suitable for curative surgical intervention or not.

Multimodality treatment of pancreatic pseudoaneurisms.

Vascular lesions of pancreatitis manifest in the form of haemorrhage into the pseudocyst (PC), the development of pseudoaneurisms (PA) or splenic lesions. Between 1987 and 1996 31 patients were found to develop vascular lesions either in the form of haemorrhage into a PC (12) or PA (19). Diagnosis of pancreatic PA was established preoperatively in 8 cases only. Gastrointestinal (GI) bleeding manifested in 12 patients, but only in 6 of them was the pancreatic origin of the bleeding considered. All patients were operated. For the management of the lesions resection of the pancreas (11 cases) or ligation of the bleeding vessel with external or internal drainage of the PC was performed (12 cases). Simple external drainage of a haemorrhaged PC in 3, and cystoduodenostomy or cystogastrostomy was performed in 5 cases respectively. Intraoperatively moderate bleeding gave some concern (7 cases), while post operatively pancreatic fistula developed in 9 patients drained externally. All stopped spontaneously. In two cases severe GI bleeding occurred post operatively. In both cases embolization of the bleeding vessels was performed successfully. No operative mortality occurred. The mean follow-up time was 40.6 months (5-106). Five patients died of unrelated causes, 3 patients underwent subsequent pancreatic operation, and 74.2% of the patients are doing well. Development of pancreatic PA was associated with a longer observation or conservative treatment period. Angiography should be considered whenever severe upper GI bleeding occurs in patients with known pancreatic disease and the source of bleeding is obscure. In selected cases selective embolization of the bleeding site may provide definitive treatment.

Laparoscopic distal resection of the pancreas with the preservation of the spleen.

UNLABELLED: Management of the pancreatic diseases is still a challenge to the laparoscopic technique. Some experience has been gained in the laparoscopic exploration of the pancreas and staging in cancer. Anatomically the accessibility of the distal pancreas provides the laparoscopic approach technically feasible. PATIENT AND METHOD: A case of insuloma in the tail of the pancreas is presented, where distal pancreatic resection was performed laparoscopically with the preservation of the spleen. In a 55 years old female patient with typical clinical symptoms of hyperinsulinism CT identified a 3 cm large solid tumor in the tail of the pancreas. Complete mobilization of the distal pancreas was enhanced by the use of an ultrasonic dissector (UltraCision). The pancreas is detached from the splenic hilum after dividing the spleen vessels. The pancreas is transected proximally by laparoscopic linear stapler. Preservation of the short gastric vessels provides the necessary blood supply of the spleen following division of the splenic artery and vein. Thus removal of the spleen is not a necessary step in this procedure. The operation was carried out within 4.5 hours. Postoperative course was uneventful, the patient left the hospital on the 5th postoperative day. Advantages of the procedure were the earlier mobilization and shorter recovery time, less postoperative pain. The procedure can be safely performed with a good experience in both pancreatic and laparoscopic surgery.

[The value of ultrasonic diagnosis in acute appendicitis]. / Az akut appendicitis ultrahangos diagnózisának értékelése.

The diagnostic accuracy and practical value of graded compression ultrasound was evaluated in 298 patients admitted for ultrasound examination because of having suspected appendicitis by surgeons. The result of the ultrasound was considered to be positive, if the inflamed appendix, larger, than 6.5 mm in outer diameter or an abscess was depicted. Of the 99 pathologically proven cases of acute appendicitis ultrasound was positive in 94, that is the sensitivity was 94.9%. The diagnostic accuracy and specificity were 96.3% and 97.9%. The predictive value of a positive test was 95.9%, and was 97.5% of a negative one. In the group of patients under 18 years (140 patients) sensitivity, specificity and diagnostic accuracy were 93.3%, 96.3% and 95% respectively. The use of ultrasound helped many patients to earlier operation and reduced considerably the negative laparotomy rate. The routine use of ultrasound in the diagnosis of appendicitis especially if the clinical presentation is equivocal, complements usefully the clinical signs and increases diagnostic accuracy.

[Excision of a splenic cyst using a surgical stapler in partial splenectomy]. / Lépcysta eltávolítása kapocsvarrógéppel végzett részleges léprezekcióval.

The authors extirpated the splenic cyst of a young girl with the use of stapler in such a way that the distal part of the spleen was preserved. During this case the types of splenic preservative operations and the question of fulminant sepsis found in the patients went under splenectomy were surveyed. According to us the advantage of using stapler in partial splenectomy than the others is that firstly it is technically simple, less time consuming, and the haemostasis is safe. This is thought to be a valuable additional procedure to the ultimately known and the procedures which are used.

[The role of intraoperative ultrasonic studies in abdominal surgery]. / Az intraoperatív ultrahangvizsgálatok szerepe a hasi sebészetben.

Intraoperative echography is a new field of application of the ultrasound diagnostics. With a special intraoperative examination head the parenchymal abdominal organs may be examined directly in the course of the operation. The intraoperative echo-examination of the tumors and cysts of the liver and pancreas as well as of nephroliths and gallstones is routinely applied in several institutions abroad. The authors report on their initial experiences with intraoperative ultrasonography of different abdominal organs.