A meta-analysis of outcomes after routine aspiration of the gallbladder during cholecystectomy.

We conducted a meta-analysis of published literature comparing outcomes after aspirating (ASP) the gallbladder versus nonaspiration (NASP). Electronic databases were searched from January 1985 to November 2009. A meta-analysis was performed to obtain a summative outcome. Two randomized, controlled trials involving 360 patients were analyzed. A total of 180 patients were in the ASP group, and 180 were in the NASP group. There was no significant increase in operative time in the ASP group compared with the NASP group [random-effects model: standardized mean difference, -0.72; 95% confidence interval (CI), -2.16, 0.71; z = 0.99; df = 1; P = 0.32], but there was significant heterogeneity among trials (Q = 42.4; P < 0.001; I2 = 98%). Patients undergoing ASP were less likely to have a gallbladder perforation [random-effects model: risk ratio (RR), 0.42; 95% CI, 0.19, 0.96; z = 2.05; df = 1; P < 0.05], but no difference was found regarding the loss of gallstones (random-effects model: RR, 1.33; 95% CI, 0.30, 5.85; z = 0.38; df = 1; P = 0.70). No difference was seen for liver bed bleeding (P = 0.43) or overall 30-day infection rates (P = 0.66). After aspiration, gallbladder perforation rates may be lower. This does not appear to translate into decreased loss of gallstones or infection rates. There was no significant difference between techniques in blood loss from the liver bed. Further randomized, controlled trials and follow-up studies are required to confirm these results and to establish long-term sequelae.

[Surgery without boundaries]. / Határtalan sebészet.

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

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.

Why laparoscopic cholecystectomy today?

Traditional open cholecystectomy became the "gold standard" of surgical treatment for symptomatic gallstone disease during the last century. In spite of its good results, clinicians have been trying to establish effective nonsurgical methods of eliminating gallstones. Although oral, percutaneous, or retrograde litholysis can be used effectively for cholesterol stones, these represent only 10% of all gallstones. Moreover, intracorporeal lithotripsy is an invasive method, and while extracorporeal shock wave lithotripsy is a promising procedure, even after careful selection, only 70%-80% of the patients become stone-free within 1 year. In fact, none of the methods which leave the gallbladder intact are free of complications, and they are followed by 50% stone recurrence within 5 years. Since 1987, laparoscopic cholecystectomy has become the procedure of choice as it is safe and only minimally invasive. We believe that the laparoscopic technique is a promising way to the surgery of the future.

[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.

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.

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

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

[Postgraduate educational possibilities for young surgeons in the United Kingdom]. / Fiatal sebészek továbbképzési lehetöségei az Egyesült Királyságban.

The authors describe the surgical training opportunities provided by the ODTS since 1986. These posts offer excellent postgraduate training. Hungarians may apply for ODTS posts after they have passed the Hungarian General Surgical examination, but preferably before the age of 35. The applications should be supported by Home Sponsors. The applicants must pass a high standard English Language examination.

Late vascular complication after blunt trauma.

The left clavicle of a 52-year-old patient was fractured at a road traffic accident in 1991. Three months after uneventful recovery axillary vein thrombosis developed on the side of the trauma, which was treated conservatively. One year after the trauma embolization of the left hand developed. The cause was an intimal tear with application thrombus, which were successfully excised. The case proves the importance of awareness of late vascular complications after blunt traumas.

The role of Ca2+ level in liver transplantation.

During orthotopic liver transplantation Ca2+ assessment was made in the recirculation phase and the ultrastructural changes in the liver were studied. It was established that the Ca2+ level decreased progressively. The Ca2+ level in the hepatic vein was lower than the arterial value. The EM studies performed in the recirculation phase did not reveal any cellular damage, only the swelling of the mitochondria was striking. Based on the results, the question was raised whether Ca2+ can have a prognostic role in assessing the viability of the liver.

Surface pH and morphological changes of the liver in the recirculation phase of experimental liver transplantation.

Measurement of the surface pH of the liver in the recirculation phase of liver transplantation is an indicator of tissue perfusion. In the recirculation phase there is a close correlation between arterial blood and the surface pH of the liver. The surface pH of the liver and EM study together can be of prognostic importance in establishing the viability of the transplanted liver.

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

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

[Initial experiences with the use of the surgical CO2 laser scalpel]. / Erste Erfahrungen mit der Anwendung des chirurgischen CO2-Lasermessers.

Reported in this paper is the surgical applicability, as established from 35 operations, of the Type TLS 61 laser scalpel of Tungsram Rt, 60 Watt in output. Useful experience has been recorded from surgical approaches to thorax cavity as well as from general, gastro-enterological, vascular, and dermatological surgery. Minimised bleeding and sterile incisions are benefits of laser operations. The above model has proved to be applicable to skin, muscles, lung, stomach, intestines, bones, and other tissues. Wound healing was absolutely okay. After-bleeding or other complications did not occur.

Changes in pH and acid-base equilibrium during experimental liver transplantation by active and passive veno-venous bypass.

The effect of experimental liver transplantation on pH and the acid-base equilibrium by active and passive veno-venous bypass was examined. It is concluded that the use of active veno-venous bypass may considerably decrease but not completely prevent the development of metabolic acidosis by elimination of the phase.

Changes in bile and lymph composition following portacaval anastomosis (PCA) in rat.

The effect of PCA on bile and lymph composition in rats was studied. It was established that secretion of bile acid decreased significantly and this resulted in reduced bile flow. In studying lymph flow and protein content, the most important observation was a decrease in the protein concentration of hepatic lymph. It can be supported that hepatic blood flow decreased due to PCA is responsible for all these changes.

'Cuffed' portacaval anastomosis in rat.

Preparation of portacaval anastomosis (PCA) in patients suffering from portal hypertension has been an accepted procedure for reducing portal pressure. Recently, fashioning of mesocaval anastomosis has got preference. In the era of portacaval anastomoses numerous experimental works were concerned with the technique of performing them. During these experiments it was revealed that PCA produces considerable changes both in the metabolism and the circulation of the liver. Fischer et al. state that, following PCA, the weight of the liver decreased, on an average by 55%, as compared to the controls. Ossenberg et al. observed that after PCA liver perfusion was reduced by about 55-65%. Rubin et al. demonstrated that the hepatic cytochrome P 450 content was significantly decreased and the function of the microsomal drug metabolizing enzymes markedly altered subsequent to PCA. All these data indicated that, as a results of the bypassing of portal inflow from the liver, PCA significantly influences liver function and the intervention in experimental animals, i.e. rats, can be used as a model for chronic hepatic insufficiency.