Stromal Derived Factor-1 Gene Polymorphism in Pediatric Immune Thrombocytopenia.

Immune thrombocytopenia (ITP) is a multifactorial disease in which both environmental and genetic factors have been implicated. The study aimed to investigate a possible association of single nucleotide polymorphisms (SNPs rs266085 and rs2839693) in the stromal derived factor-1 (SDF-1) gene and its association to ITP and effect on ITP severity and response to treatment. Genomic DNA was extracted from peripheral blood and polymorphism in SDF-1 gene rs266085 and rs2839693 was analyzed using PCR-restriction fragment length polymorphism technique in DNA extracted from 60 children with ITP together with 90 healthy controls. On analysis of SDF-1 rs266085 polymorphism, there was a high frequency of CC genotype in cases than controls and that difference was significant at codominant, overdominant, and dominant models (P<0.05). Furthermore, carriers of the CC genotype were more susceptible to severe ITP at onset, steroid dependency, and chronicity than carriers of other genotypes (P<0.05). Otherwise, no significant differences between ITP patients and controls as regard SDF-1 rs2839693 genotypes and alleles, and we did not find a relation between this polymorphism and ITP severity, steroid dependency, or duration. SDF-1 gene rs266085 SNP C allele is associated with susceptibility to develop ITP as well as increases the risk for severe ITP at onset, chronic ITP and steroid dependency.

Adhesion formation with open versus laparoscopic cholecystectomy: an immunologic and histologic study.

BACKGROUND: This randomized study aimed to compare the reaction of the immune system to the process of postoperative adhesion formation after open and laparoscopic cholecystectomy. METHODS: In this study, 20 mongrel dogs were used: 10 each in the laparoscopic and open cholecystectomy groups. Blood and peritoneal lavage samples were taken up to postoperative day 14, followed by second-look laparoscopy and reoperation to detect the rate of adhesion formation. Also, specimens were obtained from the liver bed for histology. RESULTS: In the open cholecystectomy group, the white blood cell count was higher in blood samples and lower in lavage specimens. Adhesion formation was extensive, and the histologic immune reaction was more intensive in the open cholecystectomy group. CONCLUSION: This randomized study proved that laparoscopic cholecystectomy was associated with less immune suppression, less inflammatory reaction, and therefore less adhesion formation than open cholecystectomy.

Esophageal intramural metastasis from adenocarcinoma of the gastroesophageal junction.

Among a total of 143 patients examined for diagnosis of adenocarcinoma of the cardia, intramural esophageal metastases were verified in six patients (4.19 %). In each case the diagnosis was confirmed by histological examination. The histological structure of the primary tumors and metastases was the same. Metastases were detected by endoscopic ultrasound examination in three cases. All the cardia tumors proved to be well advanced. As well as endoscopic identification of the primary tumor, thorough examination of the proximal part of the esophagus is of great importance.

[What kind of surgical radicality is justified in the treatment of esophageal and cardial carcinoma?]. / Wie radikal soll das Osophagus- bzw. Kardiakarzinom operiert werden?

In the period from January 1, 1973 to November 30, 1994, a total number of 1 856 patients had been admitted to our Department of Surgery because of cancer of the esophagus and esophago-gastric junction. We divided our activities into two study periods. In the first study period from 1973 to 1984 only so called "conventional operations" were performed. Since 1985 new oncological aspects were introduced into our operative tactics:1. the subtotal esophagectomy combined with the two-field lymphadenectomy,2. the total gastrectomy with extended lymph node dissection. The analysis of our results with respect to the survival parameters (TNM staging, histological type, grade of differentiation, gross pathology) showed that the best chances were obtained by curative resection and lymphadenectomy in tumours of low-grade biologic malignancy. In esophageal cancers the former 6 % 5-year cumulative survival rate increased to 26 %, and in cardia tumours from 9 to 27 %, because of enhancement of radicality and extension of lymphadenectomy.

[Siewert-Stein classification of adenocarcinoma of the esophagogastric junction]. / Az oesophagogastricus junctio adenocarcinomáinak Siewert-Stein klasszifikációjáról.

Nowadays the terminology used for the definition of adenocarcinomas at the oesophagogastric junction is "cardiac carcinoma", which can be easily misunderstood. This definition of adenocarcinomas of the oesophagogastric junction does not allow correct comparison of diagnosis (endoscopic, radiological and pathologic), epidemiology and surgical therapy in national and international aspects, because different tumours can develope in the same area, and all called cardia tumors. Siewert and Stein recommended a classification to solve this problem. The classification of the tumours is morphological/topographical. Type I is adenocarcinoma of the distal part of the oesophagus. Type II is adenocarcinoma of the real cardia and type III is subcardial gastric adenocarcinoma. At classification, we always consider results of endoscopy (ortograde and retroflexed view of the oesophago-gastric junction), the x-rays of the oesophagus and stomach, findings at the operation and pathohistologic results. Between 1/1/1974 and 31/12/2000, a total number of 50,878 upper panendoscopic examinations were performed at the Endoscopic Laboratory of the Surgical Department. Adenocarcinoma of the cardia was diagnosed in 488 patients. According to the Siewert-Stein classification, type I tumour was found in 123 (25.2%), type II in 240 (49.18%), and type III was present in 125 (25.61%) patients. The importance of this classification is it enables unified pre-operative assessment and it can also help to decide the type of the surgical intervention. In our patients with type I cancer--depending of the size of the tumour--distal 2/3 oesophagectomy with the resection of the proximal lesser curve of the stomach or total gastrectomy were performed. In the first group oesophago-jejuno-gastrostomy, in case of total gastrectomy Roux-en-Y loop anastomosis was created. In patients with types II and III cancers total gastrectomy was performed. In every patient lymphadenectomy was performed. We suggest the use of this new classification in clinical, gastroenterology--with special regard to the endoscopy--and pathology.

The influence of intraoperative complications on adhesion formation during laparoscopic and conventional cholecystectomy in an animal model.

BACKGROUND: The aim of this study was to evaluate the extent of postoperative adhesion formation after laparoscopic and open cholecystectomy. MATERIALS AND METHODS: Qualified surgeons performed 60 experimental laparoscopic cholecystectomies (LC) in dogs with the aim to acquire the laparoscopic technique. To assess the relation between the complications during the operation (bleeding, laceration of the liver bed, or gallbladder perforation) and the formation of adhesions, surviving animals were divided into four groups according to the type of complication occurred. Assessment of the results was made by second-look laparoscopy 4 weeks after LC using the adhesion index (AI; score range, 0-4). The animals then were killed so the extent of adhesion formation could be measured. As a control, open cholecystectomy was performed in 15 dogs without intraoperative complications. The Mann-Whitney rank-sum test and Dunn's method were used for statistical analysis. RESULTS: No adhesion formation or intraoperative complications were registered in the laparoscopic group I. In all the cases wherein bleeding or laceration of the liver bed occurred and was managed with electrocoagulation, adhesions formed. Adhesion formation in these groups was significantly higher than in "ideal LC" or cases of gallbladder perforation alone (p < 0.01). All the animals in the control group developed significantly more adhesions than those in the experimental group (p < 0.05). CONCLUSIONS: It seems that LC has a lower rate of adhesion formation than the conventional open technique. Complications such as bleeding or laceration of the liver bed during LC can enhance adhesion formation. No adhesion formation can be mentioned in relation to gallbladder perforation during LC.

[Laparoscopic adrenalectomy with transperitoneal approach]. / Laparoszkópos adrenalektómia transzperitonealis módszerrel.

UNLABELLED: The feasibility, safety, and results of 52 laparoscopic transperitoneal adrenalectomies were evaluated. METHODS: A total of 52 patients were included in the study based on thorough endocrinological and imaging assessment. 15 patients with Conn syndrome, 3 with Cushing syndrome, 15 with nonfunctioning adenoma, 14 with pheochromocytoma, 2 with adrenocortical cyst, 2 with adrenocortical lipoma and 1 with metastasis were considered eligible for adrenalectomy. Lesion size ranged from 1 to 12 cm (mean 4.53 cm). Concurrent surgical procedures were performed in 6 patients (11%). RESULTS: There was one conversion (during a left adrenalectomy), because of our learning curve. After we changed the technique, there was no more conversion. There were two (3.8%) postoperative complications: postoperative pancreatitis, one of the patients required re-operation (lavage and drainage). There was one wound infection. We had no postoperative mortality. Mean postoperative hospital stay was 6 days (range, 2-27 days). CONCLUSION: Patients with secreting and non-secreting adrenal lesions can be treated safely and effectively by laparoscopic adrenalectomy.

[Laparoscopic colon surgery]. / Laparoszkópos vastagbélsebészet.

We review our experience in laparoscopic colorectal surgery, with indications, technical aspects and results. Between 1992 and 31/12/2000, we performed 113 laparoscopic or laparoscopically assisted colorectal operations. Of 79 malignant cases, 37 operations were oncologically radical and therapeutic, 42 were palliative. During the immediate postoperative period two deaths occurred (2.8%), the causes of death were not related to surgery. Port site metastasis developed in one patient (1.4%). Postoperative complications developed in 18 patients (14.5%). Only one patient required conversion to laparotomy. We emphasize the importance of hand assisted laparoscopic surgery (HALS) in laparoscopic colorectal surgery, because it can increase the number of laparoscopic colorectal operations. Based on our results and experience, we recommend the routine use of laparoscopic technique in colorectal surgery.

[Effect of pentoxifylline on the healing of experimental anastomosis of the left colon in rats]. / A pentoxifyllinum hatása a kísérletes bal colonfél anasztomózis gyógyulására.

The healing of colonic anastomoses is determined by several factors such as microcirculation, the strength of the inflammatory response, and the time required for regeneration. We investigated the effects of pentoxifylline--a drug which improves microcirculation and modulates leukocyte functions--on the healing of experimental anastomosis on the left colon of rats. As a result of drug treatment (0.25 mg/100 g, i.p.) in Group I anastomosis bursting pressure (ABP) was by 56 +/- 17% higher at day 2 than in controls with no pentoxifylline treatment. On the 5th postoperative day in Group I, ABP reached 80 +/- 8% the value for the intact colon (218 +/- 21 mmHg), whereas respective value in the control (untreated) group was only 47 +/- 7%. In Group II (pentoxifylline: 2 mg/100 g, i.p.) ABP was by 55 +/- 10% and by 73 +/- 8% higher than control values at postoperative days 1 and 2, respectively. At day 2, in Group I colonic blood flow measured at the anastomosis line by 86Rb uptake technique was significantly higher than in the untreated controls (0.18 +/- 0.01 ml/min vs. 0.14 +/- 0.01 ml/min, (p < 0.02). Blood flow measured in colon tissue above and below the anastomosis changed differently. Pentoxifylline treatment also suppressed the peritoneal inflammatory response assessed with peritoneal reaction index (2.0 +/- 0.3 vs. 1.1 +/- 0.2, p < 0.01). The results of the present study show that pentoxifylline treatment shortens the time needed for the healing of colonic anastomosis. These observations suggest that pentoxifylline medication can prevent failure of colonic anastomoses.

[How do intraoperative complications effect adhesion formation after laparoscopic cholecystectomy: a comparative animal study]. / Az intraoperatív szövódmények hatása a posztoperatív hasúri adhesiók kialakulására laparoszkópos cholecystectomiát követóen: összehasonlító állatkísérlet.

BACKGROUND: The aim of this study was to evaluate the extent of postoperative formation of adhesions following laparoscopic and open cholecystectomy. MATERIAL AND METHODS: 60 experimental laparoscopic cholecystectomies (LC) were performed in dogs by qualified surgeons to learn laparoscopic technique. To assess the relationship between complications occurred during the operation (bleeding, laceration of the liver bed or gallbladder perforation) and the formation of adhesions surviving animals were divided into 4 groups according to the type of complication. We assessed the results during second-look laparoscopy 4 weeks following LC using the adhesion index (AI: 0-4 score). Animals were then sacrificed to measure the extent of adhesions. As a control group open cholecystectomy was performed in 15 dogs without intraoperative complications. Mann-Whitney Rank Sum test and Dunn's Method were used for statistical analysis. RESULTS: No adhesions were observed in the laparoscopic group without intraoperative complications. In all dogs with bleeding or laceration of the liver bed maintained by electrocoagulation, adhesions developed. Formation of adhesion in these groups was significantly higher than in "ideal LC" or in case of gallbladder perforation (P < 0.01). All animals in the control group developed significantly more adhesions compared to the experimental group (p < 0.05). CONCLUSION: LC produces less adhesion compared to conventional open technique. Complications such as bleeding or laceration of the liver bed during LC can increase the formation of adhesions. No formation of adhesions can be related to gallbladder perforation during LC.

Percutaneous video choledochoscopic treatment of retained biliary stones via dilated T-tube tract.

BACKGROUND: Retained biliary stones is a common clinical problem in patients after surgery for complicated gallstone disease. When postoperative endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy are unsuccessful, several percutaneous procedures for stone removal can be applied as alternatives to relaparotomy. These procedures are performed either under fluoroscopic control or with the use of choledochoscopy, but it is also possible to combine these methods. METHODS: Since 1994, we have used the percutaneous video choledochoscopic technique for the removal of difficult retained biliary stones via dilated T-tube tract in 17 patients, applying the technique of percutaneous stone extraction used in urology. While waiting for the T-tube tract to mature and after the removal of the T-tube, the dilatation of its tract was 26-30 Fr. Stone removal was carried out using a flexible video choledochoscope and a rigid renoscope under fluoroscopic control, with the aid of Dormia baskets, rigid forceps, and high-pressure irrigation. RESULTS: We performed 23 operative procedures, and the clearance of the biliary ducts was successful in all cases. There were no major complications or deaths. CONCLUSION: Percutaneous video choledochoscopic-assisted removal of large retained biliary stones via the T-tube tract is a highly effective and safe procedure. Its advantages over other procedures include the ability to visualize the stones and noncalculous filling defects; it also guarantees that the stones can be removed under visual video endoscopic control. It has no problems related to tract or stone size.

[Esophageal implantation metastasis from adenocarcinoma of the cardia]. / Kardia adenokarcinóma implantációs metasztázisa a nyelócsóben.

A 74 years old male patient was admitted to our department suffering from dysphagia for five months. Gastric Barium studies showed a cardia tumour with polypoid lesions in the wall of the esophagus, and gastro-esophageal reflux disease was also diagnosed. Endoscopy verified a cardia tumour with esophageal metastasis, and biopsy was obtained from the two lesions. Histology showed that both tumours were adenocarcinomas. Endoscopic ultrasonography classified the cardia tumour as grade T2. As observed during endoscopy, the wall of the esophagus at the level of the polypoid lesion was hypo-echogenic and thick which was result of thickened mucosa. Total gastrectomy and oesophagectomy was performed. Pathology showed that the cardia tumour was pT2N2 and type Siewert-Stein II. The esophageal polypoid lesion was also proved an adenocarcinoma, which was localized only to the mucosa. No tumour cells were found in the blood- or in lymph vessels between the tumour and the esophageal adenocarcinoma. We think that the polypoid adenocarcinoma in the esophagus is an esophageal metastasis implantation from the cardia adenocarcinoma. It is based on the exclusion of other possible tumour dissemination routes. Probably the gastro-esophageal reflux is responsible for the implantation of tumour cells.

Use of different absorbable sutures for continuous single-layer anastomosis in the gastrointestinal tract. A prospective, randomized study.

BACKGROUND AND AIMS: A prospective, randomized study was designed to test the safety of the single-layer continuous anastomosis technique in gastrointestinal surgery. Results from the use of two different sutures were compared in relation to postoperative complications. MATERIAL AND METHODS: The safety of a single-layer continuous technique using two different types of absorbable suture was studied in 247 anastomoses performed on 183 patients between 1996 and 1997. There were 26 gastric, 117 small-bowel, 32 colonic, 29 pancreatic and 43 biliary anastomoses in the study. In 134 cases, Poliglecaprone 25 (Monocryl, Johnson & Johnson) was used, and in 113 cases Glycomer 631 (Biosyn, USSC). All procedures were carried out by the same surgeon. RESULTS: Anastomosis-related complications were detected in 7 patients (2.8%). Anastomotic failures including minor leakage occurred in 5 cases (2.0%). Reoperation was required in only 1 patient (0.4%), and there were no deaths. No difference was found in the dehiscence rate between the two types of absorbable material (1.5% with Monocryl and 2.6% with Biosyn; p = 0.5). CONCLUSION: Compared with other techniques used for gastrointestinal anastomosis, this technique is safe and easy to apply using either suture material.

Laparoscopic unroofing of retroperitoneal lymphoceles after bilateral retroperitoneal lymphadenectomy for testicular cancer.

BACKGROUND: Symptomatic lymphoceles after retroperitoneal lymphadenectomy for testicular cancer are a rare complication that can be managed by either a computed tomography (CT)-guided subcutaneous aspiration or surgery. One surgical method of choice is laparoscopic unroofing. METHODS: One case of two retroperitoneal lymphoceles managed by laparoscopy is presented. After successful creation of pneumoperitoneum, first trocar insertion, and lysis of adhesions, the two lymphoceles were unroofed, and specimens from the wall and fluid were taken. RESULTS: Laparoscopic surgery was uneventful, and the patient returned to activity and work within 14 days after the operation. No pathologic signs of malignancy were discovered during biopsy and cytology investigations. At the 1-month follow-up assessment, CT scan demonstrated the regression, and 1 year later the total absence of the lymphoceles. CONCLUSIONS: After retroperitoneal lymphadenectomy for testicular cancer, clinical suspicion should remain high to detect and properly treat symptomatic lymphoceles. Large retroperitoneal lymphoceles can be treated effectively by unroofing under the safe direct vision of the laparoscope.

Laparoscopic wedge resection of the gastric wall for gastric benign tumour. The collaboration of the laparoscopic surgeon and the endoscopist.

INTRODUCTION: By the introduction of the laparoscopy for the management of gastric pathology many techniques are applied by now. In these techniques the collaboration of the endoscopist and the laparoscopic surgeon is mandatory. AIMS OF THE STUDY: To emphasise the necessity of the collaboration of the endoscopist and the laparoscopic surgeon for the management of the gastric pathology using the double lifting and wedge resection technique. METHOD: A case of a female with 2 x 2.5 cm submucosal tumour is presented. The tumour was located in the antrum. After the onset of the general anaesthesia the gastroscope was introduced to locate the position of the tumour, the free edges of the tumour were elevated by a double lifting method and the tumour was resected by a laparoscopic linear stapler. The process of the proper resection was all through observed and directed by the view of the gastroscope. CONCLUSION: Correct wedge resection of the gastric wall can be safely performed, if the correct gastroscopic control is present. The collaboration of the endoscopist and the laparoscopic surgeon seems to be mandatory, thus avoiding the hazards arising from the use of tattooing.

The judgement of adhesion formation following laparoscopic and conventional cholecystectomy in an animal model.

INTRODUCTION: The development of postoperative adhesions remains an almost inevitable consequence of visceral and gynaecologic surgery, appearing in 50-95% of all patients. Although decreased adhesion formation is one of the accepted advantages of laparoscopic surgery, only a small number of prospective studies have been done to support this claim. AIMS OF THE STUDY: To evaluate the extent of postoperative adhesion formation after laparoscopic and open cholecystectomy. MATERIAL AND METHOD: 60 experimental laparoscopic cholecystectomies (LC) were performed by qualified surgeons in dogs with the aim to acquire the laparoscopic technique. To assess the relation between the complications during the operation (bleeding, injury to the liver substance or gallbladder perforation) and the formation of adhesions, the surviving animals were divided into 4 groups according to the complications occurred. The assessment of the results was made by second--look laparoscopy 4 weeks following LC using the adhesion index. As a control group open cholecystectomy was then performed in 5 dogs without intraoperative complications. RESULTS: No adhesion formation was observed in the groups where no intraoperative complications occurred. In all the cases where bleeding or injury to the liver bed occurred adhesion formation occurred. No adhesion formation was observed in case of gallbladder perforation. In all the animals of the control group adhesion formation was observed. CONCLUSION: It seems that LC has a reduced rate of adhesion formation when compared with the open technique. Complications such as bleeding or injury to the liver substance during LC can enhance adhesion formation. No adhesion formation can be mentioned in relation with gallbladder perforation when the laparoscopic technique is applied.

The history and the future of teaching and training of laparoscopic surgery in Hungary.

INTRODUCTION: Laparoscopic biliary surgery was introduced in Hungary at the end of the 1990. A variety of experimental training and teaching courses had been performed in basic techniques and the human field, which was followed by laparoscopic biliary surgery and various advanced fields. AIMS OF THE STUDY: To review the history of teaching and training of laparoscopic surgery in Hungary in both the experimental and the human field, and to draw the consequences of this experience. MATERIAL AND METHODS: In a period of 6 years 704 qualified surgeons received a full hands--on hands experimental training in laparoscopic biliary surgery, laparoscopic advanced surgery, laparoscopic gynaecologic and laparoscopic urology surgery. DISCUSSION: The courses performed in the first and the second phase were of theoretical and practical components. The theoretical knowledge was based with emphasise to the new instruments and equipment, the indications, the new surgical technique. The practical knowledge gave every participant the full time to acquire this new type of surgery. At the end of the courses the successful participants received certificates to shift for training to the human field. Each institution needs to wrestle with issues concerning credentialling in advanced laparoscopic surgery. Like many technical skills, proficiency is maintained through repetition. A philosophy must be developed to determine whether each surgeon will perform this highly specialised type of surgery or whether it will be considered a general skill.

Late epigastric incisional hernias following laparoscopic cholecystectomy.

By the introduction of laparoscopic cholecystectomy a new "gold standard" procedure became a routinely performed operation in the field of biliary tract surgery. Thus, the incision related early and late complications are thought to diminish, especially the formation of incisional hernias. Five patients had been referred to our department suffering from chronic incisional hernias following laparoscopic cholecystectomy. All of the hernias were located to the site of the epigastric trocar. The contents of the hernias proved to be omentum. The documentation's of the laparoscopic cholecystectomies revealed the extraction of thick walled gallbladders that contain large stones, and the wounds through which the extraction was performed had not been closed. Taking into consideration the fact of the "Chimney Effect" caused by the desufflation of the pneumoperitoneum at the end of the laparoscopic operation, bowel or omentum can easily escape through the relatively large wound formed during the extraction of the gallbladder, resulting in the formation of incisional hernias. This can be avoided by the complete desufflation and the prompt closure of the wound.

Details of teaching, learning and training in laparoscopic surgery.

The authors discuss the specific details of teaching, learning and training in laparoscopy in 6 main sections, on the basis of their experience gained through basic and advanced courses held for approximately 480 participants at the courses organised at the Department of Experimental Surgery of the University Medical School of Debrecen, between 1989 and 1996. The 6 section cover the following: 1. Why these courses are needed? 2. Who should participate in them? 3. When courses should be held (continuously for beginners, at an appointed time for advanced participants, and chances for training should be provided at any time, according to demand) 4. What should be taught? 5. Where teaching and training should take place (surgical learning/training centres) and 6. What methods of teaching should be used.