[Treatment of duodenal ulcer and its complications in the era of Helicobacter pylori. When and how long is the gastroenterologic-internal medicine therapy indicated and when is the surgical treatment necessary?]. / A nyombélfekély és szövódményeinek kezelése a Helicobacter pylori korszakában. Mikor és meddig indokolt a betegség gasztroenterológus-belgyógyászati kezelése, és mikor válik indokolttá a sebészi megoldás?

With the widespread use of modern H2-receptor antagonists, the proton pump inhibitors and Helicobacter pylori eradication therapy the number of antiulcer operations decreased spectacularly. The treatment of uncomplicated ulcus duodeni got nearly exclusively into internists' hands. Becoming enthusiastic over the excellent results of conservative therapy there are unjustified attempts to avoid the operation in the complications of ulcus duodeni, particularly in bleeding, but also often in perforation and stenosis. With the use of operation-substitute procedures the patients often get in a more unfavourable situation than an operation would offer performed in time and in acceptable conditions. The authors on the basis of their surgical experiences summarize in what cases the deliberation of surgical indication or the performance of an operation is needed in the era of Helicobacter pylori.

AZFc deletion detected in a newborn with prenatally diagnosed Yq deletion.

A case of prenatally diagnosed Yq deletion is described. Fluorescence in situ hybridisation (FISH) was used to identify the abnormal chromosome and to exclude mosaicism. Based on the cytogenetic result and the ultrasound investigation the pregnancy was continued. A newborn with normal male genitalia was delivered. Microdeletion analysis of the Yq showed the absence of the AZFc region. This type of deletion has been described as being associated with azoospermia or oligozoospermia with a progressive decrease of sperm number over time. Long-term andrological follow-up of the newborn will be necessary with eventual cryoconservation of sperm at early adulthood. The present report proposes that AZF analysis combined with FISH has an important role in accurate genetic counselling in sex chromosome anomalies.

Fluorescence in situ hybridization of chorionic interphase cells for prenatal screening of Down syndrome.

OBJECTIVE: Our purpose was to determine the usefulness and reliability of fluorescence in situ hybridization on interphase chorionic villi cells in the prenatal diagnosis of Down syndrome. METHODS: A total of 336 samples of chorionic villi were analysed by direct chromosome preparation and FISH with a DNA probe specific to chromosome 21. The samples were obtained as part of the routine obstetric investigation and management. RESULTS: The sampling and direct karyotyping was successful in all cases. At least 50 cells were valuable by FISH in 331 of 336 samples. Both methods showed Down syndrome in 12 cases. The follow-up investigations showed that there was no false-negative or false-positive result following these procedures. CONCLUSION: Based on these results and the fact that it is possible to analyse by interphase FISH at least ten times more cells than by conventional cytogenetic methods, and these cells originate from different tissues of chorionic villi, it is concluded that FISH increases the reliability of the diagnosis. Nevertheless, more data are needed for correct statistical analysis. Since this method is cheaper and gives diagnosis earlier than cell culture, the combination of direct chromosome preparation and FISH on chorionic villi is offered for prenatal Down syndrome screening.

Intraabdominal abscess managed successfully via the laparoscopic approach.

A rare complication of laparoscopic fundoplication-an intraabdominal abscess located between the fundus and the caudate lobe of the liver-is described. A 41-year-old man had undergone a laparoscopic Nissen-Rossetti fundoplication for longstanding gastroesophageal reflux disease. On the 5th postoperative day, the patient's general condition became worse, and he developed intermittent-remittent fever (40 degrees C), an elevated white blood cell count (WBC), and an accelerated sedimentation rate. Evidence of leakage was excluded by Gastrografin swallow. The diagnosis was finally revealed by means of ultrasound and computed tomography (CT) scan, which showed an intraabdominal fluid collection with an air cap of ~10 cm in diameter situated between the diaphragmatic crura, the caudate lobe of the liver, and the gastric fundus. The location did not allow semi-invasive management of the abscess, such as ultrasound or CT-guided puncture and drainage. On the 8th postoperative day, a laparoscopic exploration was performed utilizing the previous port sites. The adhesions were easily dissected, and evacuation of ~300 ml of white, dense fluid, and lavage and drainage were performed without intraabdominal dissemination of pus. The patient was discharged on the 12th postoperative day free of symptoms. Microbiological examination of the pus showed the presence of Peptostreptococcus. The patient remained symptom free. At 8 weeks postoperatively, barium swallow, endoscopy, 24-h pH monitoring, and stationary manometry of the esophagus yielded normal results. Because there was no direct evidence of leakage at the fundus, the development of the abscess was concluded to be due to the use of deep transmucosal stitches rather than seromuscular ones to create the wrap. The nonabsorbable multifilament suture material passing through the entire gastric wall could have facilitated bacterial contamination of the operative field.

Laparoscopic cholecystectomy in acute cholecystitis.

The authors retrospective analyze the role of golden standard laparoscopic cholecystectomy for the treatment of acute cholecystitis. They make a comparison between the results of 50 early cholecystectomy and 44 "a froid" cholecystectomy (operation was postponed until 6 weeks after acute cholecystitis had healed). From January 1997 to December 1998 536 laparoscopic cholecystectomies were performed. In 491 cases (91.6%) laparoscopic, and in 45 cases (8.4%) traditional (opening) method was indicated. Converted cholecystectomies were in 36 cases (7.3%). Agreeing to the literature they can determine the optimal timing of the operation in 72 hours from the onset of acute cholecystitis [2, 4]. In this group (first group) there were 50 cases, with 14 conversions (28%). In the second group (postponed, so called "a froid" phase) there were 44 patients. From this group was the intraoperative diagnosis serious acute-subacute cholecystitis in 24 cases (54.54%) causing complicated laparoscopic cholecystectomy and resulting in 11 conversions (11/44: 25%). The causes of the higher rate of conversion were the grave inflammation and slow dissection of central formation. There were no serious complication and mortality in both groups. It was diagnosed bile leak (two cases) which ceased spontaneously, one haematoma in abdominal layers, and one trocar's hernia. The authors have recommended the laparoscopic cholecystectomy for early diagnose acute cholecystitis in order to prevent the complications and reduce the sick-leave. Supporting their viewpoint the most important clinical end economical facts are: the recurrence of inflammation forced urgent surgery and caused more complication in the course of "a froid" phase there were scrutable anatomical situation the patients recovered in a shorter time.

The laparoscopic technique for bilateral inguinal hernias.

From March 1994 to March 1999 359 laparoscopic hernioplasties have been performed on 295 patients. In 349 cases (97.2%) TAPP (transabdominal preperitoneal), in 10 cases (2.8%) TEP (total extraperitoneal) method was used for the treatment. In 64 cases (21.7%) bilateral hernias were operated using TAPP-method only. There were 15 hidden hernias and 14 recurrences on the contralateral side in this group. The hernial ring was covered with two smaller meshes or one bigger. There were no intraoperative complications. In 21 cases (32.8%) subcutaneous emphysema and in 3 cases (4.6%) sero-haematoma was developed. The emphysemas were solved spontaneously in 2-3 hours after the surgery. One haematoma was needed punction. The patients were discharged from the hospital on the second or third postoperative day. The authors found that the bilateral laparoscopic hernioplasty much more favourable for the patients.

Synchronically performed laparoscopic cholecystectomy and hernioplasty.

Cholecystectomies and hernioplasties are the two most frequently performed surgical interventions. The laparoscopic technique can be offered for the simultaneous treatment with both operating indications. The synchronical operation can give all the advantages of the minimally invasive technique. Authors had performed laparoscopic cholecystectomy with laparoscopic hernioplasty in five cases. Two inguinal and three postoperative hernias were reconstructed. The cholecystectomy was performed with a "three punction method", and the hernioplasty by using the same approach, completed by inserting a fourth assisting trocar as required. The hernial ring was covered with an intraperitoneally placed mesh, which was fixed by staplers (the so-called "IPOM-method": intraperitoneal on-lay mesh). There was no intra-, nor postoperative complication. The hernioplasty combined with laparoscopic cholecystectomy did not have effect on postoperative pain and nursing time. The return to the normal physical activity was short, similar to laparoscopic hernioplasty (in 1-2 weeks). Authors conclude that the simultaneous, synchronous laparoscopic cholecystectomy and hernioplasty is recommended and should be the method of choice because it is more advantageous for patients.

Investigation of effect of lesser curvature seromyotomy of the stomach in animal experiments.

The effectiveness of seromyotomy of the lesser curvature of the stomach--the simplified version of proximal selective vagotomy--was investigated in eleven dogs. Decreased acid secretion was proved with congo red test and pH measuring by glass electrode. No significant damage to the motor function of the stomach was found with scintigraphy. Histological examinations revealed neurofibre degeneration peripherally to the seromyotomy line after peripheral vagotomy and vacuolar degeneration in the ganglion cells and amputation neuromas in the seromyotomy line.

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.

Transabdominal preperitoneal herniorraphy: technique and results.

As enthusiasm for laparoscopic surgery has grown, laparoscopic approaches to the groin hernia have evolved. The most widely accepted laparoscopic repair employs the placement of a large sheet of mesh in a preperitoneal position to cover potential hernia spaces. Between March 1994 and February 1997 160 inguinal and 3 femoral hernia were operated of an transabdominal preperitoneal (TAPP) polipropylen mesh. 131 patients were operated (128 males and 3 females, ranging in age from 19 to 82 years), 31 (23%) of them had bilateral hernias. Recurrent hernia was the indication in 52 (32%) cases. Average operating time for unilateral repair was 80 minutes and for bilateral repairs was 108 minutes. Postoperative complications included 7 (4.3%) cases of transient neuralgias, 20 (12%) cord/scrotal transient seromas-hematomas and 2 (1.2%) hydrocele. The 5 (3.1%) early recurrences were considered to be caused by technical inexperience and/or too small prosthetic patch. The laparoscopic hernioplasty has definitive advantage: minimal postoperative pain, short hospital stay (average postoperative time of hospitalization 3.1 days) and early restoration of full physical activity (in 1 to 2 weeks). The method should be considered as a potential "best option" in patients with recurrences and bilateral inguinofemoral hernias.

The blood supporting of nipple-areolar (NAC) complex performing for mammaplasties.

In case of mammaplasties the blood support of the nipple-areolar complex is one of the most important. The authors give a comprehensive clinical summary of the operating technics which are suitable to correct mastoptosis and breast hypertrophy (or macromastia). After mentioning the anatomy, blood and nerve supply of breast, following the classifying of mastoptosis and breast hypertrophy. Summarizing of the historical development of operating methods, which resulting in modern solutions, and adding Hungarian-related data. The widely used mastopexies and reduction mammaplasties will be analyzed, with demonstration of transposition of NAC using different kind of dermo-glandular flaps, e.g.: Skoog-, Pitanguy-, McKissock-, Strömbeck-, Robbins-, Regnault- and other's method. After discussing the possible postoperative complications, authors underline the necessity of detailed analysis and exact planning in varied clinical cases for achieving wanted functional and aesthetic result. Attaching importance to have more perfect operating techniques.

The cryovaricectomy (demonstration of a new method).

The operating technique of the primary varicosity has changed recently. The subcutaneous methods have been used nowdays. We give account of making 416 cases by cryovaricectomy, which is a quite new method. Using this technic we can remove the dilated venous branches during a 3-4 millimeters wide incision of skin and preserve the sufficient main vein. Summarizing of our advantageous experience: the cryovaricectomy is suitable for principles of minimally invasive surgery, and the operating time is much more briefer, the aesthetic results are best, the attendance far shorter and the postoperative complaints of patients much more fewer.

[New possibility in inguino-femoral hernia repair: laparoscopic herniaplasty]. / Uj lehetóség az inguino-femoralis sérvek rekonstrukciójában: a laparoscopos hernioplastica.

The development of minimally invasive surgery brought up the challenge: to repair the frequent inguino-femoral hernias laparoscopically. The authors performed 65 laparoscopic hernioplasties in one year: "transabdominal preperitoneal" technique was used in 61 cases und "intraperitoneal onlay mesh" in 4 cases. Fifty-three patients were operated on, 12 of them had bilateral hernias. Recurrent hernia was the indication in 22 patients (34%). The average operating time was 102 and 144 minutes in the unilateral and the bilateral cases, respectively. There was no wound infection, or general complication. Spontaneously dissolving seroma/hematoma of the spermatic cord was noticed and detected by ultrasound in 5 patients (7.7%). The neuralgia caused by the irritation of the nerves of the region in 4 patients (6.1%) disappeared without sequels after treatment with vitamins B. The 2 early recurrences (3.2%), considered to be caused by technical inexperience, these patients were treated successfully with the "intraperitoneal onlay mesh" technique. In the authors' opinion there are definite advantages of laparoscopic hernioplasty, namely the minimal postoperative pain, early mobilization, shorter hospital stay and early restoration of full physical activity (in 1-2 weeks) as well as the known disadvantages of this technique (narcosis, longer operative time, intraperitoneal procedure, higher costs).

[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.

Long-term clinical results of highly selective vagotomy performed between 1980 and 1990.

A retrospective analysis was conducted of 778 patients who underwent highly selective vagotomy between 1980 and 1990. Surgery was performed for duodenal ulcers without any complications in 485 (62.3%) patients; for duodenal ulcers with complications such as stenosis, bleeding, or perforation in 270 (34.7%); for combined duodenal and ventricular ulcers in 12 (1.5%), and for ventricular ulcers alone in 11 (1.4%). Pyloroplasty was additionally performed in the presence of complications only. The incidence of intraoperative complications proved to be as high as 1.4%, occurring in 11 patients, while postoperative complications developed in 247 patients (31.7%). Although the overall mortality was 0.6% (5 patients), the mortality rate of those patients who underwent surgery for uncomplicated ulcer disease was 0.2% only (2 patients). The patients comprised 554 men (71.2%) and 224 women (28.8%) with an average age of 41.4 +/- 0.7 years. The average duration of duodenal ulcer disease was 9.5 years, and 643 (83.2%) of the patients were able to be regularly followed up for between 3 and 13 years. Recurrence developed in 62 patients (9.6%): in the duodenum in 57 patients (91.9%), and in the stomach in 5 (8.1%). The rate of recurrence according to sex was 9.4% in men and 10.3% in women, being 42 and 20 patients, respectively. The average duration until recurrence appeared was 27.06 +/- 3.44 months. A reoperation proved necessary in 28 of these 62 patients (45.1%). The clinical results were evaluated by means of a modified Visick classification, according to which 81.8% of the patients belonged to groups 1 or 2, 7.9% to group 3, and 10.3% to group 4.

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.

A new method to repair inguino-femoral hernias: laparoscopic hernioplasty.

The development of minimally invasive surgery has accepted the challenge by having tried to repair inguino-femoral hernias laparoscopically. The authors performed 65 laparoscopic hernioplasties in one year. "Transabdominal preperitoneal" technique was applied in 61 cases and "intraperitoneal onlay mesh" in 4 cases. Fifty-three patients were operated, 12 of them had bilateral hernias. Recurrent hernia was the indication in 22 patients (34%). The average operating time was 102 and 144 minutes in the unilateral and the bilateral cases, respectively. There was neither wound infection, nor general complication. Spontaneously dissolving seroma/haematoma of the spermatic cord was noticed (detected by ultrasound) in 5 patients (7.7%). The neuralgia caused by the irritation of the nerves of the region in 4 patients (6.1%) disappeared without sequels after treatment with vitamins B. The 2 early recurrences (3.2%) were considered to be caused by technical unexperience; the affected patients were treated successfully with the "intraperitoneal onlay mesh" technique. It is emphasized that laparoscopic hernioplasty has definite advantages, namely minimal postoperative pain, early mobilization, short hospital stay and early restoration of full physical activity (in 1 to 2 weeks). On the other hand, general anaesthesia and intraperitoneal invasion are required and the operation consumes much time and cost.

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.