Histological and Mechanical Assessment of Decellularized Porcine Biografts, and Its Biological Evaluation following Aortic Implantation during Mid-Term Follow-Up.

AIMS: Prosthetic graft infection frequently requires graft replacement. Among other options, a biological graft could serve as an alternative choice. Decellularization reduces tissue immunogenicity. Our aim was to determine an efficient decellularization method and to evaluate the decellularized porcine biografts' adaptability. METHODS: Four different protocols were implemented to decellularize porcine aortic segments (n = 4). Cell removal effectiveness and matrix structure preservation were histologically examined. Mechanical tests were performed. Decellularized porcine grafts were interpositioned in a porcine aorta. After a 6-month period, implanted samples were removed and evaluated using light and electron microscopy. RESULTS: Histological results showed complete removal of cells and preserved connective tissue fiber structure following decellularization, using sodium dodecyl sulfate and sodium azide. Pressure tests demonstrated similar compliance to fresh vessels. In 9 out of 10 cases, pigs survived the follow-up period. Graft rejection, intimal hyperplasia, reocclusion and/or aneurysm formation were not observed. Presence of host cells and neoendothelialization were microscopically confirmed. CONCLUSIONS: This decellularization protocol enables a cost-effective preparation of biological grafts featuring reduced immunogenicity. The implanted grafts did not degenerate during the 6-month follow-up period, the lack of graft rejection suggests acceptable immunological tolerance, while recipient cells migrate into, proliferate and differentiate, thus creating the possibility for further use as an optional vascular graft.

[Stereotactic radiosurgery of abdominal cancer metastases. Report on the first successful extracranial radiosurgical intervention in Hungary]. / Hasüregi daganatáttétek stereotaxiás sugárkezelése egy ülésben. Beszámoló az elso hazai, koponyán kívüli sugársebészeti beavatkozásról.

Due to the development and increasing effectiveness of novel cancer therapies, the role of local treatments in metastatic diseases have been increasing in the last decades. The aim of the authors was to present the first successful extracranial stereotactic radiosurgical intervention in Hungary. A 58-year-old male patient with gastric adenocarcinoma underwent surgery and adjuvant chemotherapy. Later, surgical removal of suprarenal gland metastases and first line chemotherapy were carried out. Four years after the first surgery a follow up computed tomographic scan revealed bifocal peritoneal metastases caudally from the edge of the liver and the left kidney with diameters of 2 cm in size. Definitive stereotactic body radiosurgery of 12 Gy single dose was performed using cone beam computed tomography image guidance and intensity modulated arc therapy with two pairs of arcs. The total duration of the procedure was only 25 min and early or late side effects were not observed. Follow up computed tomography scans performed 3 and 7 months after the intervention showed complete regression of the metastases. The authors conclude that stereotactic body radiosurgery can be a safe and effective alternative of metastasis surgery in case of slow growing oligo-metastases.

[Endovascular treatment of subclavian artery pseudoaneurysm as a delayed complication after surgery for aorto-bifemoral graft infection]. / Aortobifemoralis graft gennyedés megoldásának kései szövodményeként jelentkezo subclavia álaneurysma endovascularis kezelése.

CASE REPORT: In this article we present a relatively rare vascular surgical complication and an uncommon treatment of it. In this case we used an aorto-bifemoral bypass on a patient with Leriche syndrome. The implanted Y-graft got infected and we were forced to remove it. Having inserted the abdominal aortic graft, an axillobifemoral bypass was also applied to secure the circulation of the lower limbs. However, the graft occluded later on, and 37 months after the inital surgery a rather large pseudoaneurysm developed at the origin of the graft in the right subclavian artery. Another surgical intervention was indicated to prevent embolisation, rupture and compression. Instead of the conventional surgical method (resection, interposition) we did an endovascular procedure. We removed the false aneurysm by inserting a covered stent, using catheter technique, into the right brachial artery and therefore prevented the previously mentioned complications. DISCUSSION: This minimal invasive method is very useful for high risk patients to prevent the injury of neighbouring anatomical structures in the region as well as minimize blood loss and potential complications of long term anaesthesia when open surgery is done.

Nationwide effectiveness of five SARS-CoV-2 vaccines in Hungary-the HUN-VE study.

OBJECTIVES: The Hungarian vaccination campaign was conducted with five different vaccines during the third wave of the coronavirus disease 2019 (COVID-19) pandemic in 2021. This observational study (HUN-VE: Hungarian Vaccine Effectiveness) estimated vaccine effectiveness against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and COVID-19-related mortality in 3.7 million vaccinated individuals. METHODS: Incidence rates of SARS-CoV-2 infection and COVID-19-related mortality were calculated using data from the National Public Health Centre surveillance database. Estimated vaccine effectiveness was calculated as 1 - incidence rate ratio ≥7 days after the second dose for each available vaccine versus an unvaccinated control group using mixed-effect negative binomial regression controlling for age, sex and calendar day. RESULTS: Between 22 January 2021 and 10 June 2021, 3 740 066 Hungarian individuals received two doses of the BNT162b2 (Pfizer-BioNTech), HB02 (Sinopharm), Gam-COVID-Vac (Sputnik-V), AZD1222 (AstraZeneca), or mRNA-1273 (Moderna) vaccines. Incidence rates of SARS-CoV-2 infection and COVID-19-related death were 1.73-9.3/100 000 person-days and 0.04-0.65/100 000 person-days in the fully vaccinated population, respectively. Estimated adjusted effectiveness varied between 68.7% (95% CI 67.2%-70.1%) and 88.7% (95% CI 86.6%-90.4%) against SARS-CoV-2 infection, and between 87.8% (95% CI 86.1%-89.4%) and 97.5% (95% CI 95.6%-98.6%) against COVID-19-related death, with 100% effectiveness in individuals aged 16-44 years for all vaccines. CONCLUSIONS: Our observational study demonstrated the high or very high effectiveness of five different vaccines in the prevention SARS-CoV-2 infection and COVID-19-related death.

[Effects of performance-volume limit on the institutional financing of the Clinical Centre of the University of Pécs, Hungary]. / A teljesítményvolumen-korlát hatása a Pécsi Tudományegyetem Klinikai Központ intézményi finanszírozására.

UNLABELLED: The aim of our study is to demonstrate the effects of performance-volume limit (PVL) on the institutional financing of the Clinical Centre of the University of Pécs (CC UP). DATA AND METHODS: The data involved in the analysis are based on the reports towards the National Health Insurance Fund Administration (NHIFA), concerning the active inpatient care by specialist in the period between 2004 and 2008. We determined the real NHIFA reimbursement per weighted case number and the financial loss caused by the PVL. We analyzed the proportion of local health care obligation and urgency cases in comparison of various clinics. RESULTS: The reimbursement per weighted case number of CC UP has been less than the pre-announced NHIFA amounts after the installation of PVL. During the examined 5 years, i.e. 2004-2008, the loss in case of CC UP has been up to 3.256 million HUF due to the PVL. Concerning the whole of CC UP it means that 25.3 % of the treated cases and 24.5 % of the executed weighted case number has been out of local health care obligation. Studying the ratio of urgency cases inside the total volume of medical attendance, it is represented that 31.5 % of the cases and 36.1 % of the weighted case numbers came from the treatment of urgency cases. CONCLUSION: The introduction of performance-volume limit considerably reduced the health insurance financing of CC UP between 2004 and 2008.

[Current methods of treatment and prevention of pathologic scars]. / A kóros hegek kezelésének és megelozésének lehetoségei napjainkban.

The aetiology of pathologic scarring is unknown today regarding the keloids. The authors have analyzed the literature and own experience retrospectively according to the evidence based treatments and prevention of the hypertrophic and keloid scars. The corticosteroids have been used intralesionally since the beginning of the 1960-ies. It was followed by the pressure garment therapy in order to treat the widespread burns scars in the early 1970-ies. The silicone gel sheeting is being used since the 1980-ies. The basic treatment of keloids changed, radiotherapy was combined with the above mentioned methods because of its high recurrence rate. Newer methods, cryosurgery as well as lasers were used to treat keloids. The number of effective topical agents was increased. The researchers have been looking for other, intralesionally usable medicine and genetic causes for more than ten years. The clinicians have had the standard protocols of the adjunct and alternative methods too. After having the standard and internationally accepted scar assessment system (Vancouver-scar scale and score), the controlled, randomized trials were practicable. The prospective evaluation of the efficacy of different protocols with adequate follow-up became performable. The comparison of different methods is difficult because of the lack of its standard outcome.

[A comparative clinical study of the treatment of hypertrophic scars with either intralaesional steroid or silicone gel sheeting]. / A hypertrophiás hegek intralaesionalis szteroid és polisziloxán-tapaszos kezelésének összehasonlító klinikai vizsgálata.

The linear (or "surgical") hypertrophic scar is the most common type of pathologic scarring. There has been a steady increase in the number of patients with hypertrophic scars over the years due to the rising number of operative interventions altogether. However, the therapeutic protocols are not homogeneous and they show significant variations. 200 cases with hypertrophic scars were treated by the authors from April 2001 to March 2004. 24 patients were selected in the study from these cases; and two randomized groups were formed. Each group included 12-12 patients, who were treated with either intralaesional steroid or silicone gel sheeting. The therapeutic protocols were defined by the authors. The aim of this study was to compare and determine the roles of these two commonly used treatment options of hypertrophic scars. The authors present patient demographics; and analyze the results and outcome of the study. Both methods were efficient significantly, however intralaesional steroid therapy had a more rapid effect and it lasted longer than silicone gel sheeting. These results confirmed the role of these two treatment modalities in the protocols. The authors concluded that silicone gel sheeting is the first line, while intralaesional steroid is the second line treatment for primary linear hypertrophic scars. Based on the authors' experience, in recurrent linear hypertrophic scars, intralaesional steroid therapy is recommended in first line, because silicone gel sheeting was largely ineffective. Prospective randomized clinical trials should be needed to further clarify their role in the treatment protocols.

[Pathology and diagnostic opportunities of lower limb compartment syndrome]. / Az alsó végtagi compartment-syndroma kórtana és diagnosztikai lehetoségei.

BACKGROUND: The indication for the surgical treatment of lower limb compartment syndrome mostly depends on the clinical signs, which can be uncertain and often delayed, resulting in a late and insufficient intervention. AIM: In this study, the progression of compartment syndrome was monitored with the measurement of intracompartmental pressure and tissue oxygen saturation. MATERIALS AND METHODS: 16 patients (12 male and 4 female; mean age: 62,7 years) underwent acute lower limb revascularization surgery due to critical (more than 4 hour) limb ischaemia. The indications were the following: 5 iliac artery embolisms and 11 femoral artery occlusions. After revascularization, significant lower limb oedema and swelling were detected. To monitor the elevated intracompartmental pressure (ICP), KODIAG pressure meter was used. Tissue oxygen saturation (StO2) was measured with near-infrared-spectroscopy. RESULTS: In 12 cases the IPC exceeded the critical 40 mmHg. In these patients, StO2 was 50-53%, in spite of the successful re-canalisation. An urgent, semi-open fasciotomy was performed in these cases. In four patients, the clinical picture suggested compartment syndrome. However, the measured parameters did not indicate surgical intervention (ICP: 25-35 mmHg, StO2: normal). SUMMARY: In addition to the empirical guidelines, we describe an evidence based surgical intervention strategy for lower limb compartment syndrome. Our results and advised parameter intervals help the clinicians to decide between conservative and operative treatment of the disease.

[Oxidative stress and leukocyte activation after lower limb revascularization surgery]. / Alsóvégtagi revaszkularizációs mutéteket követo oxidatív stressz vizsgálata.

The authors aimed to study of oxidative stress and thrombocyte function in the perioperative interval following the revascularization surgery of lower limb. The prospective randomised study involved 10 patients whose surgical interventions were indicated by lower limb embolism, thrombosis or abdominal aorta aneurysm, and 10 healthy volunteers were also involved in the study. Peripheral blood samples were collected before, and after the surgery (2, 24 hours and one week). The maximal free radical production and lag time of the free radical production of activated leukocytes were measured, and leukocyte adhesion molecules (CD11a and CD18) signing leucocyte activation were determined as well. Endogenous antioxidant defence status, reduced glutathione (GSH), total thiol-groups (-SH), SOD activity and thrombocyte function were investigated in platelet rich plasma and in whole blood. White blood cell count and free radical production was significantly higher in patients group before surgery than in healthy group (in case of the free radical production the difference proved to be 10 times (p < 0.01)) and elevated continuously during the observation time. The CD11a and CD18 expression of the granulocytes significantly decreased right after the revascularization, but with a gradual elevation, until the 7th day they exceed the ischaemic value. GSH concentration decreased significantly 2 and 24 hours after surgery and total thiol groups (-SH) followed the same kinetics. SOD activity was significantly lower in patients group haemolysates before surgery when it was measured in healthy groups (p < 0.01) and decreased further significantly 24 hours after the surgery (p < 0.01 vs. before surgery). Suppressed thrombocyte aggregation was detected in platelet rich plasma and in whole blood during the observation excepted the one week samples, where a highly significant elevation in ADP and collagen induced aggregation were observed. Our results show a great alteration in the antioxidant-prooxidant balance and the insufficiency of platelet aggregation's inhibition after peripheral vessel closure and revascularization intervention. We suggest the monitoring of the antioxidant status and thrombocyte function of patients going to underwent surgical intervention and if it necessary the therapeutic help.

[Evaluation of calf muscle pump function after subfascial endoscopic perforator dissection]. / Lábszgári izompumpa-funkció vizsgálata endoszkópos perforans dissectio után.

INTRODUCTION: Perforating vein incompetence can be demonstrated in many cases of chronic venous insufficiency. Subfascial endoscopic perforating vein surgery has become an accepted method in the treatment of perforator insufficiency over the past decade. However, what the hemodynamic consequences of perforating vein interruption are, is not clear. OBJECTIVE: To analyse the results of endoscopic perforating vein surgery performed in the authors' department over the past four years. To compare the outcome of the operation in patients with deep venous reflux with those who only had superficial and perforating vein reflux. To analyze the changes in calf muscle pump function with photoplethysmography carried out before and after the operation. METHODS: Subfascial endoscopic perforator dissection was performed on 53 patients who suffered from severe chronic venous insufficiency mainly with active ulcer. With the follow-up of 51 patients, a prospective clinical trial was carried out which consisted of physical examination and Doppler ultrasound, six weeks after the operation and every three months thereafter. The data were analyzed with standard statistical methods. RESULTS: Clinical symptoms improved and proved to be durable in 33 (64%) of 51 patients during the follow-up. The healing rate of 40 patients with venous ulcer was 82% after the operation. 62% of the patients were ulcer-free on a long term. While of the 33 patients with deep venous reflux 17 (52%) showed durable improvement, of the 18 patient who had only superficial and perforating vein insufficiency only 2 patients did not experience improvement. Average venous refilling time of the 33 patients who underwent photoplethysmography increased from 12.5 sec to 14.6 sec after endoscopic perforating vein surgery although significant improvement was demonstrated only on patients who had only superficial venous reflux together with perforating vein insufficiency. CONCLUSIONS: Subfascial endoscopic perforating vein surgery proved to be a successful alternative in the authors' clinical trial in treating patients with severe chronic venous insufficiency. Mid-term evaluation showed excellent results with patients without deep venous reflux and acceptably good outcome with patients with deep venous insufficiency. Improvement of clinical symptoms after endoscopic perforator dissection was followed by significant improvement of calf muscle pump function only on patients without deep venous reflux.

[Stent graft implantation for aneurysm of thoracic aorta with involvement of the origin of left subclavian and carotid arteries]. / Bal arteria subclavia és carotis szájadékot involváló aneurysma megoldása stentgrafttal.

Development in endovascular surgery made it possible to treat thoracic and abdominal aortic aneurysm by using catheter techniques. In 1990, Parodi performed the first unilateral stentgraft implantation after which a rapid progress commenced in this field. Since middle nineties, bifurcated stentgrafts have been brought into general use. In Hungary, stentgraft implantations have been performed in certain centers since 1999. The authors demonstrate a case operated on at the Department of Vascular Surgery, University of Pécs for aneurysm of thoracic aorta with involvement of the origin of left subclavian and carotid arteries. In order to maintain the flow in left carotid artery, right to left carotico-carotid interposition was shaped, then stentgraft implantation was carried out for the thoracic aneurysm. Preoperative investigations, surgical technique and postoperative follow up are discussed in this case report.

[Experiences with endoscopic thoracic sympathectomy]. / Tapasztalataink endoszkóposan végzett thoracalis sympathectomiával.

PATIENTS AND METHOD: Thoracic sympathectomy using thoracoscopy was performed in 38 cases on 35 patients from January 01. 1996, till December 31. 2000. In 3 cases bilateral sympathectomy was carried out. The youngest patient was 18, the oldest was 76 years old, the average age was 42 years. The indications for surgery were Raynaud syndrome, causalgia, post-traumatic sympathetic dystrophy, thoracic outlet syndrome combined with vasospastic syndrome, Buerger syndrome, obliteration of digital arteries, embolism and hyperhidrosis. This method was chosen if conservative therapy was unsuccessful. Laparoscopic instruments are particularly suitable for minimal invasive interventions. RESULTS: Authors describe their operative technique whereby the postoperative pain and also the duration of hospitalisation can be reduced, and the cosmetic result can be improved. In two cases conversion was the only choice due to pleural adhesions. Pneumothorax occurred in two cases, haemothorax in one case and transient intercostal neuralgy was seen in 3 cases. In four cases sympathetic activity returned during the follow up. Ceasing the sympathetic innervation dilates the arterioles of the skin, and the temperature of the skin increases. During follow-up the complaints of the patients improved significantly, the progression became slower and clear improvement was found with instrumental investigations. CONCLUSION: This method can be recommended to every institute where the conditions for traditional laparoscopic surgery are given and staff is experienced in thoracotomy.

[Alternative options for examination of the patency of peritoneo-venous shunts]. / A peritoneo-venosus shuntök vezetoképességének vizsgálati lehetoségei.

For the treatment of refractory ascites we use the saphenoperitoneal shunt described by Pang in 1992 approximately 2 years. This procedure eliminates the most frequent complications of the former synthetic shunts: occlusion of the collector branches and infections as well. In addition, the use of autologous vein is cost-saving. The first Hungarian publications (K. Vincze and Z. Nagy et al.) reported good results, which are confirmed also by us, after we performed 21 operations. The publications until now usually describe the technique. This intervention is now a widely accepted one. On the other hand, just a small number of papers describe the options for the examination of patency and the follow-ups. We report about the algorithm used in our department after surgery to evaluate graft patency and surgical efficacy. A method to determine the volume of ascites developed by ourselves is described. We feel that the successful application of saphenoperitoneal shunts depends on very close follow-up. Considering that no objective method to check the patency does exist, we are sure that decisions about further operations can only be made if simultaneous diverse follow-up methods are available.