Changes in the operating time of laparoscopic cholecystectomy of the surgeons and novices between 1994-2012.

BACKGROUND: The technique of laparoscopic cholecystectomy(LC) has not changed over the past recent years; therefore the possibility is open to study its learning curve. METHODS: Retrospectively, every third year's LCs were analysed between 1994 and 2012. The learning curves of surgeons and novices were defined in the department. The surgeons have scored the laparoscopic technique of their colleagues on a scale of 1 to 10 and operation time (OT) was examined in light of the assistant's technique. RESULTS: 2,216 LCs were performed in the examined period.The average OT of the department was 78.3 minutes in 1994,which had decreased to 45.4 minutes (42.0%) by 2003. The improvement rates of surgeons and novices were 36.7% and respectively 9.9%, and the variance between the minimum and maximum OT changed in parallel. The OT in the initial 3 years of learning had become 13% shorter by 2006 and the first section of the learning curve has also become steeper. In case of surgeons whose technical points were low and OT was short, the assistants average technical score was significantly higher than in case of surgeons whose technical score was high and the OT was short. CONCLUSION: The OT alone is not an objective factor in the definition of the surgical technique.

Experimental models of hemorrhagic shock: a review.

Massive blood loss leading to hypovolemic shock is still a life-threatening situation. Recently, a great number of investigations have been conducted in order to understand the pathophysiological and immunological changes taking place during shock and to develop treatment strategies. These preclinical trials are based on animal studies. Although a wide spectrum of species and experimental models are available to researchers, it is rather difficult to create an ideal animal model to study hemorrhagic shock. A major challenge for investigators is the generation of a system which is simple, easily reproducible and standardized, while being an accurate replica of the clinical situation. The goal of this review is to summarize the current experimental models of hemorrhagic shock, highlighting their advantages and disadvantages to help researchers find the most appropriate model for their own experiments on hypovolemic shock.

Efficacy and Safety of FOLFIRINOX in Locally Advanced Pancreatic Cancer. A Single Center Experience.

The management of locally advanced pancreatic cancer (LAPC) is a major challenge. Although new drugs are available for the treatment of metastatic disease, the optimal treatment of non-metastatic cases remains controversial. The role of neoadjuvant therapy is still a question of debate in this setting. The aim of the study was to prospectively collect and analyse data on efficacy and safety of a modified FOLFIRINOX regimen in LAPC patients treated in a single institution. Another major objective was to assess the capability of FOLFIRINOX to render primary non-resectable cancer to resectable. No bolus fluorouracil was given and a 20% dose reduction of oxaliplatin and irinotecan was applied. Primary G-CSF prophylaxis was applied to prevent febrile neutropenia. Thirty-two patients (mean age 60.2 years, range: 40-77 years) have been enrolled into the study. All patients had ECOG performance status of 0 or 1. Best response to therapy was stable disease (SD) or partial regression (PR) in 18 (56.2%) and 6 (18.8%) cases. Two patients (6.3%) underwent surgical resection (100% R0). The most frequent grade 3/4 adverse events were nausea (18.8%), fatigue (12.5%) and diarrhea (12.5%). The incidence of severe neutropenia was 28.1%, with only one documented case of febrile neutropenia. The probability of disease progression was 25% and 50% after 75 and 160 days with 88.4% of possibility of disease progression after 500 days. OS probability was 92.1, 71.5% and 49.5% at 180-, 365 and 540 days. Our data does not support the capability of FOLFIRINOX to render primary non-resectable cancer to resectable. However, due to the high disease control rate observed, FOLFRINOX might be recommended as first line option for the palliative treatment of LAPC. Despite reduced chemotherapy doses significant toxicity has been seen.

Comparison of immunophenotypes of primary breast carcinomas and multiple corresponding distant metastases: an autopsy study of 25 patients.

Phenotypical change in metastatic breast carcinoma has widely been accepted as an inherent biological feature rather than technical fault. We analyzed the immunohistochemical phenotype and histopathological features of 25 primary breast carcinomas and 90 corresponding distant metastases in 23 organs retrospectively. Histological slides were reviewed for prognostic and predictive factors. Overall, metastases were more similar to each other and often differed from the primary tumor. We created a 3-step grouping system based on the localization of metastases. Regions: tumors metastasizing to the abdominal region were likely to lose ER (p = 0.002); we detected loss of PR in metastases to the thorax (p = 0.039) and abdomen (p < 0.001). Organ systems: loss of ER and PR was observed in metastases to the gastrointestinal system (p = 0.026 and p = 0.001, respectively), in the respiratory system only the loss of PR was significant (p = 0.05). Individual organs: the primaries were likely to lose the hormone receptors in liver metastases (ER p = 0.026; PR p = 0.004). In lung metastases only loss of PR was apparent (p = 0.049). We did not observe significant change in HER2 status, regarding Ki67 change occurred only in bone metastases compared to the primary (p = 0.048). 7/25 patients' distant metastases had heterogeneous immunoprofiles. The later the metastasis was discovered the more likely it had a differing IHC profile compared to the primary tumor, patients who had longer OS had a higher chance to develop a discordant metastasis. Immunoprofile of metastases may differ from primary breast cancer and from each other, probably resulting in different response to therapy.

ESPEN Guidelines on Enteral Nutrition: Surgery including organ transplantation.

Enhanced recovery of patients after surgery ("ERAS") has become an important focus of perioperative management. From a metabolic and nutritional point of view, the key aspects of perioperative care include: Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and if necessary tube feeding (TF) offers the possibility of increasing or ensuring nutrient intake in cases where food intake is inadequate. These guidelines are intended to give evidence-based recommendations for the use of ONS and TF in surgical patients. They were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1980. The guideline was discussed and accepted in a consensus conference. EN is indicated even in patients without obvious undernutrition, if it is anticipated that the patient will be unable to eat for more than 7 days perioperatively. It is also indicated in patients who cannot maintain oral intake above 60% of recommended intake for more than 10 days. In these situations nutritional support should be initiated without delay. Delay of surgery for preoperative EN is recommended for patients at severe nutritional risk, defined by the presence of at least one of the following criteria: weight loss >10-15% within 6 months, BMI<18.5 kg/m(2), Subjective Global Assessment Grade C, serum albumin <30 g/l (with no evidence of hepatic or renal dysfunction). Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.

Effect of enteral nutrition on exocrine pancreatic function.

Twelve patients with chronic pancreatitis underwent a pancreatoduodenectomy in which the pylorus was preserved. The effects of parenteral and enteral nutrition on pancreatic secretion were compared. Postoperative nutrition was administered by needle-catheter jejunostomy in seven patients and by total parenteral nutrition in five patients. Pancreatic juice, drained directly from the pancreatic duct, was collected in 4-hour fractions. Volume, bicarbonate, protein, amylase, and chymotrypsin were measured. In the first two postoperative days, there was a slow increase in all measured indices. On the third postoperative day, an abrupt rise occurred, after which pancreatic secretion stabilized. No differences in exocrine pancreatic secretion were observed between the enteral and parenteral methods of feeding.

Gastrocystoplasty, a wrong choice in an adult case.

A 28-year-old woman presented a huge vesico-vagino-rectal fistula after radiotherapy because of a gynecological tumour. Reconstruction consisted of a colostomy, closure of the rectal hole with a pedicled perineal skin graft, a bivalve opening of the bladder and, with the two valves coverage of the vaginal suture line, and augmentation gastrocystoplasty. The fistulas healed but the patient suffered from an intolerable burning sensation, that is why the stomach wall was removed and uretero-ileo-cutaneostomy was created. The colostomy was closed, and the patient now has a well functioning urine stoma.

[Micromorphology of torsional bone fractures]. / Udaje k mikromorfológii torzných zlomenín kostí.

Characteristic microlesions can be found along the torsion fractures of long bones related to special anatomy of compact tissue: Torsion severs singular lamellae of broken osteons along the longitudinal fracture lines. Exposed bone bridges are partially broken and haversian canaliculi longitudinally opened among severed lamellae. Torsion mechanism of the bone injury can be estimated and reconstructed by SEM with sufficient certainty. An expert can be more conclusive about the body fall or flight in the moment of injury or collision. Evidence of rotation movement can be helpful in explaining secondary injuries. A more perfect medical opinion can help to more satisfactory elucidation and evaluation of accident conditions by the court.

[Excision of a splenic cyst using a surgical stapler in partial splenectomy]. / Lépcysta eltávolítása kapocsvarrógéppel végzett részleges léprezekcióval.

The authors extirpated the splenic cyst of a young girl with the use of stapler in such a way that the distal part of the spleen was preserved. During this case the types of splenic preservative operations and the question of fulminant sepsis found in the patients went under splenectomy were surveyed. According to us the advantage of using stapler in partial splenectomy than the others is that firstly it is technically simple, less time consuming, and the haemostasis is safe. This is thought to be a valuable additional procedure to the ultimately known and the procedures which are used.

[The effect of two different methods of jejunal feeding on pancreatic function]. / A jejunalis mesterséges táplálás két módjának hatása a hasnyálmirigy müködésére.

Pancreatic juice was continuously diverted from the Wirsungial duct by nasopancreatic drainage of the remnant of the gland after pylorus preserving partial pancreato-duodenectomy in 14 patients. On the 7th postoperative day with stabilized pancreatic secretion the juice was collected in 10 min fractions, while interdigestive secretory phases of the parenchyma were established by volume changes. At the beginning of a phase 100 ml slightly hyperosmolar (400 mosmol/L) oligopeptide diet with 90 kcal was given as a bolus injection for 7 patients or 60 min infusion into the second jejunal loop by fine needle catheter jejunostomy for 7 patients also. Pancreatic water, bicarbonate, protein, chymotrypsin, amylase levels peak, and integrated secretory responses were measured. It was observed, that infusion of the diet did not disturb cycling interdigestive phases and did not increase peak and integrated outputs. Bolus administration interrupted interdigestive phases and stimulated pancreatic water, bicarbonate, protein, chymotrypsin and amylase outputs nonparallelly. On the basis of their data authors concluded, that pancreatic secretion seems to be well preserved without duodenalregulatory mechanisms; and continuous jejunal infusion feeding seems to be useful in pancreatic disease and in other postoperative states when pancreas has to be put into rest.

[The effect of early postoperative jejunal feeding on the exocrine function of the pancreas]. / A korai postoperativ jejunalis mesterséges táplálás hatása a hasnyálmirigy exocrin müködésére.

Subsequent to pancreatoduodenectomia with pylorus retention on 12 patients suffering from chronic pancreatitis we analysed the effect of artificial nutrition on pancreas-secretion by examining the pancreatic juice extracted directly from the Wirsung duct. We used post-operative nutrition administered by fine-needle catheter jejunostomy in 7 patients and 5 patients received postoperative support by total parenteral nutrition as a control-group. We analysed the pancreatic juice collected in four hour fractions for volume, direct protein, amylase, chymotrypsin, bicarbonate. It has been found that on the first two days after the operation we can see a slow increase in the measured values and on the third postoperative day after an abrupt rise the pancreas secretion became steady. Between the two methods of artificial nutrition applied it was impossible to prove an observable difference concerning their effect on the pancreas. According to our observations the two methods are equivalent in the postoperative therapy of patients operated on because of chronic pancreatitis.

[Difficulties of artificial nutrition in short bowel syndrome]. / A mesterséges táplálkozás nehézségei rövidbél-szindrómában.

The authors expound the case of a 47 years old woman who was operated on 25 months ago for bowels necrosis caused from occlusion of arteria mesenterica superior. The operation was composed of a partial jejunale resection, total ileum resection and a right side hemicolectomy, the residual part of the intestine (jejunum) is 70-80 cm. Eleven months after the operation her status has got worse with 10-12 watery faeceses, abdominal pain and body weight losing (15 kg in 2 months). In the beginning a complete central parenteral and enteral nutrition was necessary. The authors expound the complications connected with the nutrition and the successful rehabilitation of the patient as well. They built her nutrition gradually completed with oral given nutriment. The nutritional status of the patient now is adequate and she is able to do the housekeeping.

[Percutaneous endoscopic gastrostomy: experience of three years]. / Percutan endoscopos gastrostomia: 3 év tapasztalatai.

UNLABELLED: Patients who are not able to eat do need tube feeding. The most preferred way of artificial enteral nutritional support is feeding via percutaneous endoscopic gastrostomy (PEG) tubes. Head and neck cancer patients do represent a special group of patients needing a PEG. On the one hand at the time of admission to the hospital they are mainly undernourished. On the other hand the failure rate of placing a PEG is the highest among them. Furthermore in the perioperative period nasogastric tubes do cause a lot of complications in these settings. 188 PEG placements were carried out from July 1995 till November 1998. INDICATIONS: head and neck cancer (n = 171), neurologic disorders (n = 17). PEG tubes were placed 76 times during intratracheal narcosis and 112 times following local anaesthesia. 39 times there was a prior abdominal surgery in our patients medical history. The pull-through, the push-wire and the introducer techniques were used. Beside the usual oro-gastric way of endoscopying (n = 163), 25 times the following alternative ways of entering the upper gastrointestinal tract were used: transnasal route (n = 4), through a Kleinsasser type direct laryngoscope (n = 7) and via the opened pharynx (n = 14). No immediate or late onset procedure related complications occurred. During a follow-up of 22,480 tubedays 26 minor (dermatitis n = 24, ulcer n = 2) and 8 major (abscess n = 4, perforation/peritonitis n = 3, stomach and bowel wall necrosis n = 1) complications occurred. The success rate of placing a PEG was 98.9%. In head and neck cancer patients placing a PEG is suggested when there is a need for at least a 7 days time tube-feeding. Using the described alternative ways, a PEG tube can be placed almost always. Because of the uncertain outcome, nutritional support via PEG tubes is suggested also in cachectic patients and in vegetative state as well.

[Rare indication for surgery: liver metastasis of planocellular laryngeal cancer]. / Ritka mútéti javallat: planocellularis gégerák májáttéte.

This is a report of a successfully operated case of a solid liver metastasis developed following radical total laryngeal extirpation. The biological characteristic of the laryngeal cancer is also discussed from the surgical point of view. We underline the importance of a detailed, regular control of patients with malignancies and encourage of active surgical treatment of solid metachronous liver metastases.

[Successfully operated infraperitoneal hemangiopericytoma infiltrating the left ureter]. / Infraperitoneális elhelyezkedésú, urétert infiltráló haemangiopericytoma sikerrel operált esete.

Hemangiopericytoma is a very rare tumour originating from the lining cells of small vessels. Despite benign histology it is clinical presentation similar to malignancy. There are only less than hundred cases reported sporadically in the literature. Authors report a case and successful radical removal of an infraperitoneal hemangiopericytoma infiltrating the left ureter. The literature of this strange, rare pathology is also analysed in the article.

[20-years experience with tooth reimplantation]. / 20 év replantációs tapasztalatai.

Tooth reimplantation experiences through 20 years are reported on. On basis of his results the tooth maintaining method is suggested to be employed by practicing dentists.

[The focus of dental infection]. / Adatok a fogászati góc kérdéséhez.

The authors taking into consideration the ways of therapy divide dental centers into two groups: 1. The active center, the patient has a center-originated or an illness possibly dependent of a center. The treatment is the elimination of the center, medical preparation, in close cooperation with the physicians curing the second illness. 2. The passive center. The patient has no other illness in connection with the center. From the therapeutical point of view the center must be treated as separate disease.

[Dental status of young recruits--in the light of the past 15 years]. / Bevonuló fiatalok fogazati állapota--15 év tükrében.

The tendency of the caries frequency and the caries intensity was intended to be described in our report. Our results were, essentially, concordant in the Hungarian professional literature while they significantly differed from the data published in western professional literature, especially as regards its course-formation. Our results (also) signal that much yet remains to be done by both the civil and the dental care and prevention network of our country.