[Acute acalculous cholecystitis: from common to rare causes]. / Akut acalculosus cholecystitis: a mindennapostól a nagyon ritkáig.

Diagnostic and therapeutic approaches of acute calculous cholecystitis are well defined. Cholecystectomy is among the most frequently performed surgical interventions. In contrast, acute acalculous cholecystitis is a secondary condition; its cause may be difficult to determine and indication for surgical intervention has not been clearly established. The authors summarize the primary causes of acute acalculous cholecystitis and discuss ultrasonographic features which may help the decision to perform cholecystectomy in patients with acalculous cholecystitis.

[Acute cytomegalovirus infection-associated hemophagocytic syndrome in a patient treated with azathioprine]. / Azathioprin adása mellett kialakult haemophagocytosis szindrómával szövodött akut cytomegalovirus-fertozés.

The authors present the case of a 21-year-old woman with ulcerative colitis. Azathioprine treatment was complicated with pancytopenia and septic shock. Acute cytomegalovirus infection related to the immunosuppressive therapy, resulting in hemophagocytosis syndrome and neutropenic fever was diagnosed. Recovery was achieved by the administration of parenteral ganciclovir, broad spectrum antibiotic and complex intensive care.

[Empyema thoracis, hemorrhagic pericarditis and acalculous cholecystitis caused by Eikenella corrodens sepsis]. / Empyemát, haemorrhagiás pericarditist és acalculosus cholecystitist okozó Eikenella corrodens szepszis.

The authors present a case of a 29-year-old woman who was diagnosed with pneumonia in the left side complicated with pleural effusion and hemorrhagic pericarditis one month after she had undergone tonsillectomy. Eikenella corrodens was identified as pathogenic agent when the empyema was removed during thoracotomy. After the patient was given antibiotic treatment she was discharged from the hospital without any symptoms or complaints. However, one month after she had left the hospital she was readmitted to the surgical unit as an emergency because of acute abdominal complaints. On admission acalculous cholecystitis as well as hemorrhagic pericarditis requiring pericardiocentesis were also observed. A rare cause of sepsis, Eikenella corrodens was identified which resulted in a severe disorder including polyserositis. Pericardiocentesis was performed two times and the patient was given targeted antibiotics and non-steroidal anti-inflammatory drugs. She was also treated with antimycotics as she had developed mycosis. After one month the patient recovered and was discharged from the hospital. No further recurrence of symptoms or complaints was observed during follow up.

[Intravenous glutamine and early nasojejunal nutrition in severe acute pancreatitis -- a prospective randomized clinical study]. / Intravénás glutamin és korai nasojejunalis táplálás együttes alkalmazása súlyos acut pancreatitisben -- prospektív randomizált kettos vak kontrollált klinikai vizsgálat.

INTRODUCTION: Severe acute pancreatitis (SAP) is still one of the great challenges in gastro-intestinal surgery. According to recent studies, intravenously administered glutamine with total parenteral nutrition may be beneficial in the prevention of infectious complications and may reduce mortality rate. However, it has not been investigated yet, whether i.v. glutamine is able to achieve the same effect with early enteral nutrition as well. OBJECTIVES: The objective of our prospective randomized double-blind study was to explore the effects of intravenously administered glutamine with early nasojejunal nutrition in severe acute pancreatitis. PATIENTS AND METHODS: Forty-five patients with severe acute pancreatitis (with a Glasgow score at least 3 and/or a CRP level above 150 mg/ml on admission) were randomized into two groups. Group Glutamine (n = 24) was given 0.5 g/kg/die glutamine intravenously, while the control group (n = 21) received normal amino acid solution in the same quantity for 7 days. Nasojejunal nutrition was introduced 48 hours after admission in case of all patients, and their management was the same in every other aspect, too. The primary end-points of the study were the rate of pancreas-specific infectious complications and organ failure, and the secondary end-points were the necessity for radiological and surgical interventions, length of hospital stay and mortality rate. RESULTS: In group Glutamine, infected acute peripancreatic fluid collections (APFC) were detected in 4 patients, 2 patients had post-necrotic pancreatic/peripancreatic fluid collections (PNPFC), 2 patients had infected pseudocysts and 2 patients had walled-off pancreatic necrosis (WOPN). Ten patients were cured by ultrasound assisted puncture or drainage successfully. No surgical intervention was necessary. In the control group, 4 patients had infected APFC, 2 patients had infected PNPFC, infected pseudocysts and infected WOPN were diagnosed in 3 cases. Radiological intervention was effective in 9 cases, but 3 patients needed surgery. Three patients died of multi-organ failure, thus the mortality rate of the control group was 14%, while the mortality rate of the Glutamine group was zero. The mean hospital stay of the Glutamine group was 10.6 days, which is significantly shorter than the mean hospital stay of the control group, which was 15.9 days (p = 0.00104). DISCUSSION: The results of the Glutamine group are better in every end-points, however, statistically significant difference was detected in one parameter only, the length of hospital stay.

[Effect of postoperative complications on late recurrence and distant metastasis in patients previously treated with elective, curative resection of colorectal carcinoma]. / Hogyan befolyásolják a posztoperatív komplikációk a késoi recidívák és a távoli metastasisok kialakulását colorectalis carcinomák elektív, kuratív resectióját követoen?

BACKGROUND: The aim of the present study is to investigate whether severe postoperative complications following elective colorectal surgery increase local recurrence or distant metastasis rate. METHODS: 332 patients underwent elective, curative colorectal carcinoma resection in the period between 01.01.2000 and 31.12.2004. Postoperative complications were classified according to the modified Clavien Scale. Complications occurring up to postoperative day 30 were recorded. All complications were analyzed but the most severe one was considered for each patient and included in further analysis. Patients were followed up until 31.12.2009. Univariate and multivariate statistical analyses were performed. RESULTS: The mean age of patients was 64 years, 187 (56%) were male. 84 patients (25.3%) received preoperative oncological treatment. We included patients only with R0 resections. 182 patients (56.3%) recovered after the surgery without any complications. Mortality rate was 3.3%. Grade 4 complication developed in 5 (1.5%) patients, while Grade 3 in 26 (8%) patients, Grade 2 in 83 (25.8%) patients, and Grade 1 in 25 (7.7%) patients. During the follow up period 75 (23.3%) patients developed local tumor recurrence and/or distant metastasis. Tumor grade (p = 0.008), stage (p = 0.0001) and histological lympho-vascular invasion of the tumor (p = 0.0001) were associated with increased local and distant tumor recurrence rates. Further, Grade 3 postoperative complications were associated with increased tumor recurrence rate (p = 0.0039) and tumor related mortality (p = 0.05%). CONCLUSIONS: application of the modified Clavien Scale is suitable to classify the severity of postoperative complications. Grade 3 complications following elective curative resection of colorectal carcinoma increase local and distant tumor recurrence rates as well as tumor related mortality. Complications developing after colorectal surgery endanger not only the immediate postoperative period, but long term survival is also threatened due to its oncological effect.

Successful treatment of mediastinal pancreatic pseudocyst by pancreatic head resection.

CONTEXT: A mediastinal pseudocyst is an unusual and rare complication of acute and chronic pancreatitis. CASE REPORT: The authors report the case of a 41-year-old male patient with a documented history of chronic pancreatitis who developed a pancreaticomediastinal fistula with mediastinal pseudocyst, which was successfully treated by pancreatic head resection (Frey). CONCLUSION: Though the choice of treatment is still controversial, the main goal of surgical treatment is to ensure the adequate flow of pancreatic juice from the pseudocyst and the pancreas.

[A novel technique for the closure of the pancreatic remnant using jejunal serosa following distal pancreatectomy]. / Pancreas csonk szerotizálása distalis reszekció kapcsán.

Postoperative complication rate after distal pancreatectomy is as high as 10-30% in the published literature. Intraabdominal abscess formation and pancreatic fistula are the most common and clinically relevant complications, and they are thought to depend on surgical technique and skills. Using a novel method, we covered the pancreatic stump with the serosal surface of the first jejunal loop. Our aim was to compare the efficacy of this new technique to the traditional "stapling and handsewn suturing" method in terms of postoperative complication rate. Between 2002 and 2005, 50 patients, who underwent distal pancreatectomy, were randomized prospectively into two groups. In the first group of patients (n=23) the remnant of the pancreas was closed by the novel technique using the serosal surface of the first jejunal loop. In the second group (n=27) the pancreatic stump was closed in the traditional way using a combination of stapler and handsewn suture method. The incidence of postoperative pancreatic fistula and/or intra-abdominal abscess formation were compared using Fischer's test. Pancreatic fistula was defined as a loss of greater than 100 ml fluid drainage beyond postoperative day 5. We found a significantly lower postoperative complication rate using the novel technique compared to the traditional way to cover the pancreatic stump after distal pancreatectomy (8.7% vs. 33% (P = 0.0458). However, there was no significant difference in postoperative hospital stay. We concluded that using the serosal surface of the first jejunal loop is a simple, quick and secure method of closure of the proximal pancreas in terms of surgical practicability. This new technique significantly decreases the rate of postoperative fistula or abscess formation after distal pancreatectomy.

Multiorgan resection (including the pancreas) for metastasis of cutaneous malignant melanoma.

CONTEXT: Several studies have demonstrated improved survival after complete resection of hollow viscus gastrointestinal metastases of malignant melanoma. Patients with metastatic disease of intra-abdominal solid organs might also benefit from complete surgical resection. CASE REPORT: The authors report the case of a 22-year-old female patient with multiorgan abdominal metastases of cutaneous malignant melanoma, including the ovarium, jejunum, stomach and pancreas. All metastases were resected successfully. CONCLUSION: In highly selected patients with melanoma metastatic to intra-abdominal solid organs and hollow viscus gastrointestinal organs, aggressive attempts and complete surgical resection may improve survival.

[Combination of early nasojejunal feeding with modern synbiotic therapy in the treatment of severe acute pancreatitis (prospective, randomized, double-blind study)]. / Jejunális táplálás és korszeru synbiotikum kombinációja súlyos acut pancreatitisben.

BACKGROUND: We showed previously that probiotics containing lactobacilli significantly improve the outcome of acute pancreatitis. "Synbiotic 2000", a new synbiotic composition with high colony forming unit (CFU) comprises four different types of pre- and probiotics. In this prospective, randomized, double-blind study we evaluated the role of "Synbiotic 2000" in the treatment of severe acute pancreatitis. METHODS: Patients with severe acute pancreatitis were randomized into two groups. Nasojejunal feeding was commenced within 24 hours after admission in both groups and continued for at least seven days. The first group of patients received four different lactobacilli preparations with 10(10) CFU, respectively, and prebiotics containing four bioactive fibres (inulin, beta-glucan, resistant starch and pectin) in addition. Patients in the second (control) group received only prebiotics. RESULTS: 62 patients with severe acute pancreatitis completed the study. Altogether 8 patients died. We detected lower incidence of multiorgan failure (MOF), septic complications and mortality in the first group compared to the control, but the differences were statistically not significant. The total incidence of systemic inflammatory response syndrome (SIRS) and MOF were significantly different between the two groups (8 vs. 14; p < 0.05). Furthermore, the number patients recovering with complications were significantly less in the first group receiving modern synbiotic therapy compared to the control (p < 0.05). Finally, we found lower rate of late (over 48 hours) organ failure in the first versus the control group (3.0% vs. 17.2%). CONCLUSION: Our results suggest that early nasojejunal feeding with synbiotic may prevent organ dysfunctions in the late phase of severe acute pancreatitis. In addition, our data also indicate that the infection of pancreatic necrosis may be associated with early phase organ failure.

Value of procalcitonin quick test in the differentiation between sterile and infected forms of acute pancreatitis.

BACKGROUND/AIMS: Authors analyzed the clinical value of procalcitonin quick test (PCT-Q; BRAHMS Diagnostica, GmbH, Berlin) in infected pancreas necrosis verified by guided fine-needle aspiration (FNA). METHODOLOGY: In the prospective, controlled study data of 24 patients were evaluated. PCT-Q was performed in patients with necrosis--verified on computer tomography (CT scan)--and/or sepsis. If PCT-Q test was positive or septic complication (infected necrosis or abscess) developed, CT or ultrasound (US) guided fine-needle aspiration was performed with Gram staining and bacteriology. Positive FNA result was indication for surgery with repeated staining and bacteriology of the surgical specimen. RESULTS: Septic complications developed in 12 patients. Analyzing the results, fine-needle aspiration was more authentic with 92% sensitivity and 100% specificity, while sensitivity of PCT-Q test remained 75% and its specificity 83%. Comparing abscess with infected necrosis significantly higher procalcitonin values were detected in patients with necrosis. CONCLUSIONS: These results show that PCT-Q test is a possible non-invasive method which can be used besides fine-needle aspiration. Elevated levels of procalcitonin (higher than 2ng/mL) clearly suggest infection, while lower values do not exclude the possibility of local sepsis.

[Membranous constriction of the colon caused by non-steroidal anti-inflammatory drugs--case report]. / Nem szteroid gyulladáscsökkentó gyógyszer indukálta membranosus vastagbélszúkület--esetismertetés.

A 79-year-old female patient with rheumatoid arthritis treated with NSAIDs on long-term developed iron-deficiency anaemia and subsequently subacute intestinal obstruction. Barium enema showed multiple diaphragm-like strictures. At colonoscopy the lumen of the ascending colon was divided into compartments by multiple thin circumferential mucosal membranes. Right hemicolectomy was carried out. The histology of the resected specimen confirmed diaphragm disease of the large bowel. Diagnosis is usually difficult, even at laparotomy, due to the poor external presence of the disease. Such lesions are rare (about 10 cases have been reported in the world literature) and are similar to those previously described in the small bowel. With the increasing world-wide use of NSAIDs, clinicians must be aware of this rare gastrointestinal complication, which may require emergency surgical intervention.

Pancreatic transection from blunt abdominal trauma: early versus delayed diagnosis and surgical management.

BACKGROUND AND AIMS: Pancreatic trauma is relatively uncommon, but carries high morbidity and mortality rates, especially when diagnosis is delayed or inappropriate surgery is attempted. PATIENT MATERIAL: The clinical course and surgical management of 14 patients with distal pancreatic transection or severe laceration with or without main pancreatic duct (MPD) injury caused by blunt abdominal trauma were analyzed in a university teaching hospital. The average age of the 14 patients (12 male, 2 female) was 28.9 years (range 5-56). Six patients had isolated pancreatic trauma, and intra-abdominal and extra-abdominal (mean 0.8) injuries associated with pancreatic transection were seen in the other 8 patients. RESULTS: Nine patients were diagnosed and operated on within the first 24 h. Eight of them underwent transection of the gland with MPD injury; distal pancreatectomy with splenectomy was performed in 3 and without splenectomy in 2, distal pancreatogastrostomy in 1, and - due to associated duodenal laceration and/or contusion of the pancreatic head - pylorus-preserving pancreatoduodenectomy in 2. In 1 case (grade II laceration) only external drainage was necessary. All the patients with early, correctly diagnosed parenchymal and ductal injury survived. Only 1 patient required reoperation due to haemorrhage after pancreatoduodenectomy. The other 5 cases were referred elsewhere after initial treatment, and all of them underwent some kind of external drainage. Three had undetected MPD injury, and in the other 2 cases the parenchymal lesions were either underestimated or missed. All of these cases required subsequent resection (1), internal drainage due to fistula (2), or drainage of developed abscess (2). Three of them had severe septic and pulmonary complications; 1 patient with MPD injury was lost to follow-up. CONCLUSION: Patients requiring delayed surgical intervention after an unsuccessful period of observation or a subsequent operation due to undetected MPD injury demonstrated a higher rate of pancreas-specific mortality and morbidity.

[Role of procalcitonin rapid test in the differential diagnosis of uninfected and infected forms of acute pancreatitis]. / Procalcitonin gyorsteszt szerepe az akut necrotizáló pancreatitis steril és inficiált formáinak elkülönítésében.

We analysed the clinical value of the procalcitonin quick test (PCT-Q; BRAHMS Diagnostica, GmbH, Berlin) in infected pancreatic necrosis verified by guided fine-needle aspiration (FNA). In a prospective, controlled study the results of 24 patients were evaluated during 2001. PCT-Q test was performed in patients with necrosis verified on CT scan and/or septic symptoms. If PCT-Q test was positive or septic complication (infected necrosis or abscess) developed CT or US guided fine-needle aspiration was performed with Gram staining and bacterial culture of the sample. Positive FNA result was indication for surgery with repeated staining and bacterial culture of the surgical specimen. Septic complications of pancreatic origin developed in 12 patients. Comparing the results fine-needle aspiration was more authentic with a sensitivity of 92% and a specificity of 100%, while the sensitivity of the PCT-Q test remained 75% and its specificity 83%. Comparing abscess and infected necrosis, significantly higher procalcitonin values were detected in patients with necrosis. These results show that PCT-Q test can be a possible non-invasive method besides fine-needle aspiration. Elevated levels of procalcitonin (higher than 2 ng/ml) clearly suggest infection of the necrosis, while lower values do not exclude the possibility of local septic progression.

[Surgical treatment of giant hemangiomas of the liver]. / Nagyméretú májhaemangiomák sebészi kezelése.

Spontaneous rupture of liver hemangiomas is exceptional, they rarely increase in size. Elective surgery of liver hemangiomas is safe and effective. In our teaching hospital during a 5-year period 9 patients underwent elective surgery for giant liver hemangiomas, one more patient required urgent operation for spontaneous rupture. Indications for elective surgery were: abdominal pain in 5 patients, enlargement in 1 patient, and 3 patients were worried about the risk of rupture or having a tumor left in situ. The average age of our four male and six female patients was 44.5 years (30-58). The median largest dimension of the lesions was 8.5 cm (5.5-14); six of them located in the right, four in the left lobe. Enucleation was performed in most patients (8, mostly of them in the right lobe); anatomical resections were performed only in two cases (left lobectomy). There was no postoperative mortality, the only complication was mild pneumonia in one patient. Elective surgery is indicated only in a small number of patients with hemangiomas, it should be limited to giant, symptomatic tumors or those with a documented tendency to increase in size. The type of resection depends on the site and the size of the lesion. Enucleation can be performed rapidly and safely in most patients and as such it is preferable to anatomical resection.

[Surgical aspects of histologically unproven space-occupying lesions of the pancreas head]. / Szövettanilag tisztázatlan pancreasfeji térfoglaló folyamatok sebészi megoldásának dilemmái.

A suspected, but unproved malignant tumor in the head of the pancreas is a fairly common problem for surgeon. Even intraoperatively, differentiation between chronic pancreatitis and carcinoma is difficult. We try to give guidelines about what can be done with a pancreas head mass intraoperatively without previous cytology or histology. When do we have to achieve definite diagnosis at all costs, and how can we achieve it? Results of 40 intraoperative aspiration cytologies, performed for suspected pancreatic cancer were analysed. All of them were controlled by histology in the resected specimen. Intraoperative biopsy was false negative in 12.5% and the diagnosis was uncertain in 35%. These data show that a benign result by itself never excludes the presence of malignancy. If pathology will alter our decision about resection, all efforts should be made to confirm the diagnosis. On the other hand, in a case of a mass lesion with obstructive symptoms, cytology does not alter the need for surgical decompression, and some kind of resection is a reasonable option, even in case of chronic pancreatitis. Nihilistic approach in the case of pancreatic head mass with suspected but unproved malignancy is not justified. Pancreatoduodenectomy should be performed for all tumors even without histologic confirmation if an experienced team can perform it with low postoperative morbidity and mortality.

Early nasojejunal feeding in acute pancreatitis is associated with a lower complication rate.

OBJECTIVE: We investigated the effect of early jejunal feeding on septic complications and mortality rate in patients with acute pancreatitis in a two-phase, prospective, controlled study. METHODS: In the first, randomized phase of the study, conventional parenteral nutrition was compared with early (within 24-72 h after the onset of symptoms) enteral nutrition. Of 89 patients admitted with acute pancreatitis, 48 patients were randomized into a parenteral group (Rindex 10, Infusamin S, Intralipid 10%; 30 kcal/kg) and 41 patients into an enteral group (jejunal tube feeding; Survimed OPD; 30 kcal/kg). RESULTS: The rate of septic complications (infected pancreatic necrosis, abscess) was lower in the enteral group (P = 0.08, chi(2) test). In the second phase of the study, early jejunal feeding was combined with prophylactic imipenem (Tienam, 500 mg intravenously twice each day) when necrosis of the pancreas was detected by abdominal computed tomography. When the outcomes of 92 patients in the third group were compared with those of patients in the parenteral group, the rate of septic complications decreased significantly (P = 0.03). Multiple organ failure (P = 0.14) and mortality (P = 0.13) tended to decrease. CONCLUSIONS: We believe that the combination of early enteral nutrition and selective, adequate antibiotic prophylaxis may prevent multiple organ failure in patients with acute pancreatitis.