A retrospective study comparing minimally invasive versus open surgical resection of small intestinal neuroendocrine neoplasms at a tertiary referral center.

INTRODUCTION: Neuroendocrine neoplasms (SI-NEN) are the commonest malignancies of the small intestine. Traditionally, surgical treatment for SI-NEN has been open surgery. PURPOSE: The purpose of this study was to compare minimally invasive surgery (MIS) with the traditional open surgery approach for treating SI-NEN in a Swedish population. METHODS: Patients with histopathological confirmed SI-NEN who underwent open surgery or MIS resection within 2009-2021 were extracted from the hospital's medical records. RESULTS: 65 patients were included in this study, with 35 (54 %) undergoing MIS and 30 (46 %) undergoing open surgery. We found no statistically significant difference (p = 0.173) in the frequency of R0 resections (MIS group n = 34 (97 %), open surgery group n = 26 (87 %)). Nor was there a significant difference (p = 0.101) when comparing the median number of resected lymph nodes (MIS group n = 13.5, open surgery group n = 10). A post-operative paralytic ileus was more often reported (p = 0.052) in the MIS group (n = 9, 26 %) compared to the open surgery group (n = 2, 7 %). In light of this, the days of hospital stay did not differ significantly (MIS group median = 6, IQR (5-8), open surgery group median = 6, IQR (5-9)). The Kaplan-Meier analysis did not reveal differences concerning cancer-related deaths (p = 0.109). CONCLUSION: The results from this study support that a MIS approach for the treatment of SI-NEN may not be inferior to open surgery. The higher number of resected lymph nodes and R0 resections may even speak in favor for a MIS approach. More studies with a longer time of observation are needed to further support this conclusion.

Hemorheological and Microcirculatory Relations of Acute Pancreatitis.

Acute pancreatitis still means a serious challenge in clinical practice. Its pathomechanism is complex and has yet to be fully elucidated. Rheological properties of blood play an important role in tissue perfusion and show non-specific changes in acute pancreatitis. An increase in blood and plasma viscosity, impairment of red blood cell deformability, and enhanced red blood cell aggregation caused by metabolic, inflammatory, free radical-related changes and mechanical stress contribute to the deterioration of the blood flow in the large vessels and also in the microcirculation. Revealing the significance of these changes in acute pancreatitis may better explain the pathogenesis and optimize the therapy. In this review, we give an overview of the role of impaired microcirculation by changes in hemorheological properties in acute pancreatitis.

Effects of various drugs (flunixin, pentoxifylline, enoxaparin) modulating micro-rheological changes in cerulein-induced acute pancreatitis in the rat.

Previously we have investigated the cerulein-induced acute pancreatitis and provided data on its micro-rheological impact in the rat. We hypothesized that non-steroid anti-inflammatory agent flunixin, the xanthine-derivate pentoxifylline and the low molecular weight heparin enoxaparin may have various beneficial effects improving microcirculatory and rheological parameters. In female rats, under general anesthesia, 10 µg/kg cerulein s.c. was administered and 2 hours afterwards microcirculation was tested by laser Doppler flowmetry on the tongue and after performing laparotomy on the small intestine, liver and pancreas prior to terminal blood sampling. From blood samples hematological parameters, blood pH, lactate concentration, erythrocyte deformability, osmoscan parameters and erythrocyte aggregation were tested. Compared to normal control in acute pancreatitis group we found severe deterioration in tissue microcirculation together with impaired erythrocyte deformability and enhanced aggregation, accompanied by acidic pH and increasing lactate concentration. Improvement was found when using flunixin (s.c.), pentoxifylline (i.p.) or enoxaparin (s.c.). These drugs could partly improve the blood flux on the surface of the investigated organs, and the flunixin had the most expressed improving effects on micro-rheological parameters. Surprisingly, the improving effect of pentoxifylline on micro-rheological parameters was not obvious (red blood cell deformability did not improved better than in the other treated groups), however, microcirculatory parameters improved.

[Comparison of wound infection rates after colon and rectal surgeries using triclosan-coated or bare sutures -- a multi-center, randomized clinical study]. / Sebfertozések gyakoriságának összehasonlítása colon- és rectummutétek után triclosan bevonatú varróanyag (PDS plus®) és azonos alapanyagú nem bevont varróanyag (PDS II®) felhasználása esetén - multicentrikus, randomizált, klinikai tanulmány.

BACKGROUND: Surgical Site Infection (SSI) is the third most frequent nosocomial infection, and accounts for 14-16% of all infections. While the treatment of SSI can be very costly, previous results indicated that triclosan may reduce SSI rate. Therefore, we carried out a prospective randomised trial to further evaluate the effect of triclosan after elective colorectal surgery. METHODS: Seven surgical units in Hungary were involved in a prospective, randomised, multicentric clinical trial to compare triclosan coated (PDS plus®) and uncoated (PDS II®) sutures for abdominal wall closure in elective colorectal surgery. Pre- and perioperative variables were recorded in an online database. The primary aims of the study were to determine the incidence of SSI and the pathogens associated with it, as well as evaluation of additional cost of treatment. RESULTS: 485 patients were randomised. SSI occurred in 47 cases (12.5%), of those 23 (12.23%) from the triclosan group (n = 188) and 24 (12.18%) from the uncoated group (n = 197, p = 0.982). In 13 (27.66%) cases late appearance of SSI was detected, of those 4 patients with triclosan coated suture (8.51%) and 9 patients with uncoated suture (19.15%, p = 0.041). There was no difference between the type of incisions or elective colon and rectal resections in terms of incidence of SSI. CONCLUSION: Beneficial effect of triclosan against Gram positive bacteria could not be confirmed in our study due to the relatively low number of patients with SSI. Furthermore, triclosan did not influence the incidence of SSI due to Gram negative bacteria. SSI rate decreased by 50% compared to our previous study, however, it was regardless of the use of coated or uncoated PDS loop. Finally, operative factors were more important than patient's risk factors in terms of incidence of SSI. In case SSI developed, delayed discharge from hospital as well as special wound care significantly increased overall cost of treatment.

Micro-rheological changes during experimental acute pancreatitis in the rat.

Although microcirculatory disturbances play pivotal role in the pathomechanism of acute pancreatitis (AP), very few papers can be found which had been tested any of hemorheological parameters. The aim of our study was to analyze the hemorheological changes in cerulein-induced experimental acute pancreatitis in rat in two doses (5 and 10 µg/kg, s.c.). Male and female rats were subjected to Control group, or AP with 5 or 10 µg/kg cerulein groups. Blood samplings (lateral caudal vein) were completed before cerulein administration, and 1, 2 and 24 hours later. Hematological parameters, amylase activity, erythrocyte deformability (ektacytometry) and aggregation (light-transmission method) were tested. The presence of AP could be confirmed by amylase testing and histological examination. The earliest impairment of the red blood cell deformability could be observed 1 hour after cerulein administration in 10 µg/kg dosage. Female animals had the worst rheological results with high mortality. In conclusion, subcutaneously administrated cerulein in dosage of 5 and 10 µg/kg resulted in AP in rats, with significant changes in red blood cell deformability and alterations in erythrocyte aggregation. This model seems to be suitable for further comparative studies.

[Surgical treatment of acute pancreatitis today]. / A mutéti kezelés aktuális kérdései akut pancreatitisben.

UNLABELLED: In case of mild acute pancreatitis the treatment is basically conservative, but in severe cases surgical treatment has an important role. METHODS: authors analyze the indications for operation, the timing and the technical questions of it on the basis of the literature published in the previous ten years. RESULTS AND CONCLUSIONS: sterile pancreas necrosis is rarely but septic necrosis is an indication for surgery if the conservative treatment is unsuccessful. Therapy resistant multiple organ failure, abdominal compartment syndrome and other surgical complications such as bleeding, perforation need surgery treatment. In biliary pancreatitis associated with cholestasis urgent endoscopic sphincterotomy and later cholecystectomy is suggested. In case of pancreas necrosis the ideal time of operation is 21 days after the beginning of the disease because the rate of complications and mortality is high in early operations. Careful necrosectomy is important which has to be extended to the retrocolic and retroduodenal areas as well. Open abdominal surgery has more complications so it is suggested only in selected cases. Operation should be amended with postoperative bursa omental lavage.

[Analysis of clinical course of severe acute biliary and non biliary pancreatitis: a comparative study]. / Biliaris és nem biliaris eredetu súlyos akut pancreatitises betegek kórlefolyásának összehasonlító elemzése.

UNLABELLED: The acute pancreatitis is a relative common disease with incidence of 5-80 per 100000 people of the population. The number of new cases has steadily increased in recent years. The two main etiological factors are alcohol and cholelithiasis. The incidence of alcoholic pancreatitis is higher in male, and the incidence of gallstone pancreatitis is higher in female. AIM: To summarize the difference between the clinical course of biliary and not biliary type of severe acute pancreatitis by analyzing the data of these patients. METHODS: 139 patients treated with severe acute pancreatitis were divided in two groups: biliary (A group) and non biliary (B group) of origin. The two groups were compared on the basis of sex and age, mortality, morbidity, number of surgery and hospital stay. chi 2 probe was used for the statistical analysis. RESULTS: The complications in biliary group were more serious. The average mortality rate was 15.1%, 17.8% in group A and 13.8% in group B. The mortality rate of female patients in group A was significantly higher. CONCLUSION: Female patients suffering from severe biliary acute pancreatitis have higher morbidity and mortality rate. Therefore an elective cholecystectomy is suggested in old female patients with serious co-morbidity and gallstones, before any complications.

Therapeutic tactics in the treatment of acute necrotizing pancreatitis.

BACKGROUND/AIMS: The authors analyze the possibilities for the delay of surgery with special consideration regarding percutaneous peripancreatic drainage in the treatment of acute necrotizing pancreatitis. METHODOLOGY: In addition to intensive care therapy, 61 patients were also given antibiotic prophylaxis, and early nasojejunal enteral feeding was commenced. In a total of 22 cases where peripancreatic fluid was found, percutaneous drainage was performed. Septic necrosis, sepsis, multi-organ failure not resolving with conservative treatment, gastrointestinal perforation, and bleeding were the indications for operation. Only 9 patients underwent surgery within one week and in 40 patients delayed (more than 7 days) necrectomy was performed. Following surgery, closed omental bursa rinsing was performed. RESULTS: Five patients were cured with only conservative therapy and 7 others were cured under the influence of percutaneous drainage. In 15 patients it was possible to delay surgery using percutaneous drainage with combination of conservative treatment. A total of 39 reoperations occurred due to septic focus, bleeding, colonic necrosis and gastric perforation. The average days of nursing care was 43.3 (3-120). Mortality was 16.4% (10/61 patients). CONCLUSIONS: The number of early operations can be reduced with the use of antibiotic prophylaxis, nasojejunal feeding and percutaneous drainage.

[Anterior approach for liver resection in the cases of the treatment of large liver tumors]. / Anterior májreszekció, mint a nagyméretu májtumorok ellátácsára alkalmas mutéti módszer.

The authors compare the results of the patients who underwent right hemihepatectomy through anterior approach with those by conventional hemihepatectomy. In 119 patients hemihepatectomy was done, 52 of them were anterior approaches. We used this technique when the tumor was large, or it seemed to be fragile and its mobilisation could be dangerous or infiltrated the diaphragm or the the hepatic vein's preparation was difficult or impossible. We started the operation with dissecting parenchyma from the anterior surface toward hilus without preparation and ligation of the affected vessels and bile duct. No patient died following anterior technique. Death and reoperation occurred in two cases following conventional hemihepatectomy. The operation time and the average nursing days was not significantly different. The blood transfusion was significantly less during anterior approach. However, between the two groups, in those cases when the operations were performed because of liver malignancies, there were no differences regarding to survival rate after 62 months follow up in contrast with the literature. The anterior technique used and modified by authors can be performed safely. The blood consumption is significantly less in the cases of anterior technique. There was no significant difference between the groups regarding to the operation-time and the average nursing days. The median survival rate was similar in both groups. Our team suggest this method of the anterior approach for liver resection in the above mentioned cases.

[Non septic, surgical complications and their treatment of acute necrotizing pancreatitis in 131 cases]. / Akut nekrotizáló pancreatitist kíséro sebészi kezelést igénylo, nem szeptikus szövodmények és azok kezelése 131 eset kapcsán.

The authors analyse non septic, surgical complications and their treatment in 131 patients with acute necrotizing pancreatitis. Bleeding occurred in 13 patients 16 times. There were 3 cases with large intestine perforation, small intestine perforation twice in one patient and hydrothorax in 12 patients. The patients APACHE-II score was in the range of 15, 5, which was quite high. They experienced complications such as bleeding and bowel perforations mostly in those who underwent several reoperations. For the bleeding from acute duodenal ulcer conservative and surgical therapy (suturing) was executed. In the cases of intraabdominal bleeding they used several options such as, ligature, collagen mesh, Surgicell net and tamponation. Large intestine perforations were surgically treated with Hartmann's procedure or loop colostomy. The small intestine perforation was simply sutured. From the 12 patients with hydrothorax 8 underwent thoracic drainage. We lost 7 patients with bleeding, 3 with bowel perforations and 2 with hydrothorax. The authors believe that complications during therapy of acute necrotizing pancreatitis are high risk factor, but their treatment is not hopeless.

[Laparoscopic resection of intraoperatively diagnosed parasitic cyst of the liver with the use of harmonic scalpel]. / Intraoperatíven diagnosztizált parazitás májciszta laparoszkópos reszekciója Harmonic Scalpel segítségével.

Echinococcus granulosus is one of the most important parasitic infections in the Mediterranean countries, it presents in the form of cystic lesions of the liver. During their development the cysts may cause various symptoms due to compression. Rupture of the cysts may lead to anaphylactoid reactions and/or to acute abdomen. We operated on a patient with symptoms of cholelithiasis and cholecystitis; she underwent laparoscopic cholecystectomy, during which a cystic tumour in the liver was accidentally detected. Successful laparoscopic pericystectomy was performed with Harmonic Scalpel. We are sure that laparoscopic resection of hydatid cysts is a safe option for a number of patients in the treatment of parasitic cysts of the liver.

Quality of life following acute necrotizing pancreatitis.

BACKGROUND/AIMS: The authors examine the quality of life of patients treated for acute necrotizing pancreatitis an average of 37.8 months following their illness. METHODOLOGY: The questionnaire used in the examinations was a version of the Short Form-36 (SF-36) which was adapted to a Hungarian environment and included additional questions regarding the patient's illness. During the treatment of the pancreatic necrosis, prophylactic antibiotic treatment, early nasojejunal feeding, percutaneous peripancreatic drainage, and late surgical necrectomy was used. Postoperatively the lavage of the closed omental bursa was performed. RESULTS: It was determined that 77.3% of patients considered their quality of life to be good or fair. Quality of life was considered worse in older patients, patients with complaints of abdominal distension and bowel problems, patients who had lost significant amounts of weight since their illness, patients with poor appetite, and patients who were female. CONCLUSIONS: The long-term result, and the quality of life after acute necrotizing pancreatitis is good.

[Therapeutic strategy in acute necrotizing pancreatitis]. / Kezelési stratégia akut nekrotizáló pancreatitisben.

We describe our therapeutic principles in connection with the treatment of 43 patients (30 male and 13 female) with acute necrotizing pancreatitis. The etiology of the disease was alcohol in 72.1%, gallstones in 23.3%, trauma, hyperlipidemia, ERCP and unknown in 4.7%. In all patients, the necrosis was proved by CT and histological examination. The patients were treated in intensive care unit. It involved prophylactic antibiotics (Imipenem) and early nasojejunal feeding. In each case, we endeavoured to delay surgery, which was a wide necrosectomy extending to the retroperitoneum. In 13 patients (30.2%) CT-guided percutaneous drainage was performed because of extensive peripancreatic fluid. Ten such patients were operated on at a later time. In 81.4% (35 patients) an average of 1.8 operations were performed. The first indications were acute abdomen, septic necrosis and multi-organ failure (MOF) unreactive to conservative therapy. Five patients (11.6%) were cured with conservative treatment and 3 patients (7%) were cured by treatment which included percutaneous drainage. Twenty-seven reoperations were performed in 12 patients because of sepsis, suspected peritonitis, abscess, bleeding and gastro-intestinal perforation. The average hospital stay was 44.5 days (3-120 days) long, and mortality was 16.2%. In our opinion in addition to intensive therapy, prophylactic antibiotics, early nasojejunal feeding and late, delayed surgery are important in the treatment of acute necrotizing pancreatitis. Percutaneous peripancreatic drainage is a useful way to delay operation. These therapeutic possibilities improve the survival rate of patients with pancreatic necrosis.