The value of "diaphragmatic relaxing incision" for the durability of the crural repair in patients with paraesophageal hernia: a double blind randomized clinical trial.

Background: Surgical repair of paraesophageal hernias (PEHs) is burdened with high recurrence rates, and hitherto various techniques explored to enforce the traditional crural repair have not been successful. The hiatal reconstruction in PEH is exposed to significant tension, which may be minimized by adding a diaphragmatic relaxing incision to enhance the durability of the crural repair. Patients and methods: All individuals undergoing elective laparoscopic repair of a large PEH, irrespective of age, were considered eligible. PEHs were classified into types II-IV. The preoperative work-up program included multidetector computed tomography and symptom assessment questionnaires, which will be repeated during the postoperative follow-up. Patients were randomly divided into a control group with crural repair alone and an intervention group with the addition of a left-sided diaphragmatic relaxing incision at the edge of the upper pole of the spleen. The diaphragmatic defect was then covered by a synthetic mesh. Results: The primary endpoint of this trial was the rate of anatomical PEH recurrence at 1 year. Secondary endpoints included symptomatic gastroesophageal reflux disease, dysphagia, odynophagia, gas bloat, regurgitation, chest pain, abdominal pain, nausea, vomiting, postprandial pain, cardiovascular and pulmonary symptoms, and patient satisfaction in the immediate postoperative course (3 months) and at 1 year. Postoperative complications, morbidity, and disease burden were recorded for each patient. This was a double-blind study, meaning that the operation report was filed in a locked archive to keep the patient, staff, and clinical assessors blinded to the study group allocation. Blinding must not be broken during the follow-up unless required by any emergencies in the clinical management of the patient. Likewise, the patients must not be informed about the details of the operation. Trial Registration: ClinicalTrials.gov, identification number NCT04179578.

Surgical treatment of obesity in DM1--a case report and a review of the literature.

In patients with myotonic dystrophy type 1 overweight and obesity are frequent. When present this has further negative effects on the patients' pulmonary and muscle function as well as social participation. Anesthesia in myotonic dystrophy type 1 patients is associated with increased risks, especially in those who are obese. We describe the outcome of the first patient reported who has undergone gastric bypass surgery. The operation went without complications. Within two years after surgery she has lost 56.5 kg corresponding to 44% of her preoperative body weight (128.5 kg). She has lost muscle mass and muscle strength, but has gained somewhat in functional tests including pulmonary function and has no longer any need for nocturnal ventilation. Surgical treatment of obesity may be feasible in selected myotonic dystrophy type 1 patients but further studies are needed to determine appropriate criteria for surgery including body mass index limits and how pre- and post-operative follow-up should best be made.

The effects of intraganglionic injection of calcium/calmodulin-dependent protein kinase II inhibitors on pain-related behavior in diabetic neuropathy.

Calcium/calmodulin-dependent protein kinase II (CaMKII) has been implicated in the transmission of nociceptive input in diabetic neuropathy. The aim of this study was to test whether intraganglionic (i.g.) injection of CaMKII inhibitors may alleviate pain-related behavior in diabetic rats. Diabetes was induced in Sprague-Dawley rats using 55 mg/kg streptozotocin intraperitoneally. Two weeks after diabetes induction, CaMKII inhibitors myristoil-AIP and KN93 were injected directly into the right L5 dorsal root ganglion (DRG). Behavioral testing with mechanical and thermal stimuli was performed before induction of diabetes, the day preceding the injection, as well as 2 and 24h after the i.g. injection. The expression of total CaMKII and its alpha isoform in DRG neurons was analyzed using immunohistochemistry. CaMKII inhibitors attenuated pain-related behavior in a modality-specific fashion. Attenuation of nociceptive behavior was accompanied with a corresponding decrease of CaMKII alpha expression in DRG neurons on the side of injection. A significant decrease of CaMKII alpha expression was seen in small- and medium-sized neurons. In conclusion, our study provides evidence that CaMKII inhibitors are potential pharmacological agents that should be further explored for treatment of diabetic neuropathy symptoms.

Attenuation of pain-related behaviour evoked by carrageenan injection through blockade of neuropeptide Y Y1 and Y2 receptors.

BACKGROUND: It is well known that neuropeptide Y (NPY) participates in the modulation of chronic pain, but its exact role has not yet been fully explained. In this study, we explored whether targeted delivery of NPY and its antagonists into dorsal root ganglion (DRG) modulates pain-related behaviour in rats with experimentally induced inflammatory nociception. METHODS: Inflammatory nociception was induced by intraplantar carrageenan injection. Immediately after carrageenan injection, NPY or its antagonists were injected directly into DRG. Behavioural testing was performed on the day preceding the carrageenan injection and four times (5 h after, on the first, fifth and eighth days) following the injection. Immunohistochemical analysis was performed 8 days following the surgery. RESULTS: Our results showed that NPY, applied directly to DRG, induced cold allodynia in carrageenan inflammatory pain model. NPY in carrageenan-injected rats did not additionally exacerbate activation of satellite cells in DRG and astrocytes in dorsal horn caused by intraplantar carrageenan injection. However, application of NPY Y1 and Y2 antagonists directly into DRG reversed carrageenan proalgesic effects and reduced gliosis in DRG and dorsal horn. CONCLUSION: These findings indicate an important link between pain-related behaviour and neuroimmune actions of NPY Y1 and Y2 receptors.

Disconnection of chamber and catheter as a complication of central venous catheter type port-a-cath.

The use of a central vein catheter (CVC) type port-a-cath (VPS), apart from the comfort it provides to the patient undergoing chemotherapy, also carries certain complications. In this study, our patient was subjected to chemotherapy after a radical breast cancer operation and was given a CVC type VPS. After further care, a rare complication was verified--disconnection of the chamber and catheter, which one was visually identified in the right heart chamber. As the patient was vitally endangered, she was immediately hospitalized and the catheter was removed by catheterization of the right femoral vein, with scopic imaging. Early diagnosis and localization of the problem prevented more severe complications and mortality.

Evaluation of the response to treatment in patients with idiopathic achalasia by the timed barium esophagogram: results from a randomized clinical trial.

To choose which treatment would be most effective for the individual patient with newly diagnosed achalasia is difficult for the tending physician. A diagnostic tool that would allow prediction of the symptomatic and functional response after treatment for achalasia is therefore needed. The timed barium esophagogram (TBE) is a method that allows objective assessment of esophageal emptying, but the value of TBE in the clinical management of achalasia remains to be clarified. The aim of this study was first, to assess the ability of TBE to predict symptoms and treatment failure during post-treatment follow-up. Second, to determine whether esophageal emptying as assessed by TBE differs after treatment with pneumatic dilatation or laparoscopic myotomy. Fifty-one patients with newly diagnosed achalasia were prospectively randomized to pneumatic dilatation (n = 26) or laparoscopic myotomy (n = 25). Evaluation with TBE was performed before (n = 46) and after treatment (n = 43). The median interval between treatment and post-treatment TBE was 6 months, and the median follow-up time after the post-treatment TBE was 18 months. Following therapeutic intervention, TBE parameters did not differ significantly between treatment groups. However, significant correlations were found between the height of the barium column at 1 min and the symptom scores at the end of follow up for 'dysphagia for liquids' (P < 0.05, rho = 0.47), 'chest pain' (P < 0.05, rho = 0.42), and the 'Watson dysphagia score' (P < 0.05, rho = 0.46). Patients with less than 50% improvement in this TBE-parameter (height at 1 min) post-treatment had a 40% risk of treatment failure during follow-up. In summary, pneumatic balloon dilatation and laparoscopic myotomy similarly affected esophageal function as assessed by TBE-emptying. Lack of improvement in barium-column height post-treatment was associated with an increased risk of treatment failure which should motivate close surveillance in order to detect symptomatic recurrence at an early stage.

Health economic evaluation of therapeutic strategies in patients with idiopathic achalasia: results of a randomized trial comparing pneumatic dilatation with laparoscopic cardiomyotomy.

BACKGROUND: We have prospectively collected information concerning the costs incurred during the management of patients allocated to either forceful dilatation or to an immediate laparoscopic operation because of newly diagnosed achalasia. METHODS: Fifty-one patients with newly diagnosed achalasia were randomized to either pneumatic dilatation to a diameter of 30-40 mm or to a laparoscopic myotomy to which was added a posterior partial fundoplication. Follow-ups were scheduled at 1, 3, 6, and 12 months after inclusion. At each follow-up visit a study nurse interviewed the patients regarding symptoms and their quality of life (QoL) and a health economic questionnaire was completed. In the latter questionnaire, patients were asked to report the presence and character of contacts with the healthcare system since the last visit. RESULTS: In the dilatation group six patients (23%), including the patient who was operated on because of perforation, were classified as failures during the first 12 months of follow-up compared to one (4%) in the myotomy group (p = 0.047). Five of those classified as failures in the dilatation group subsequently had a surgical myotomy and the sixth patient was treated with repeated dilatations. The patient classified as failure in the myotomy group was treated with endoscopic dilatation. The initial treatment cost and the total costs were significantly higher for laparoscopic myotomy compared to a pneumatic dilatation-based strategy (p = 0.0002 and p = 0.0019, respectively). When the total costs were subdivided into the different resources used, we found that the single largest cost item for pneumatic dilatation was that for hospital stay and that for laparoscopic myotomy was the actual operative treatment (operating room time). The cost-effectiveness analysis, relating to the actual treatment failures, revealed that the cost to avoid one treatment failure (incremental cost-effectiveness ratio) amounted to 9239 euros. CONCLUSION: The current prospective, controlled clinical trial shows that despite a higher level of clinical efficacy of laparoscopic myotomy to prevent treatment failure in newly diagnosed achalasia, the cost effectiveness of pneumatic dilatation is superior, at least when a reasonable time horizon is applied.

Pneumatic dilatation or laparoscopic cardiomyotomy in the management of newly diagnosed idiopathic achalasia. Results of a randomized controlled trial.

BACKGROUND: The most effective therapeutic strategy in newly diagnosed achalasia is yet to be established. Therefore we designed a study in which pneumatic dilatation was compared to laparoscopic cardiomyotomy to which was added a partial posterior fundoplication. PATIENTS AND RESULTS: A series of 51 patients (24 males, mean age 44 years) were randomly allocated to the therapeutic modalities (dilatation = 26, surgery = 25). All patients were followed for at least 12 months, and during that period the pneumatic dilatations strategy had significantly more treatment failures (P = 0.04). Only minor differences emerged between the study groups when symptoms, dysphagia scorings, and quality-of-life assessments were evaluated 12 months after initiation of therapy. CONCLUSIONS: Laparoscopic myotomy was found to be superior to an endoscopic balloon dilatation strategy in the treatment of achalasia when studied during the first 12 months after treatment.

MRI combined with MR cholangiopancreatography versus helical CT in the evaluation of patients with suspected periampullary tumors: a prospective comparative study.

PURPOSE: To establish the diagnostic accuracy of MRI including MR cholangiopancreatography (MRCP) compared with helical CT in the differentiation of malignant and benign lesions in the periampullary region. MATERIAL AND METHODS: Fifty-one patients (27 M, 24 F, mean age 66 years, range 39-86 years) with obstructive jaundice and sonographic evidence of intra- and extrahepatic bile duct dilatation (n=31) or suspicion of periampullary tumor, based on previously performed ultrasound and/or CT examination (n=20), were studied. MRI with MRCP and helical CT were reviewed blindly under standardized conditions. Lesion status (differentiation of malignant versus benign) was rated on a 5-point diagnostic confidence scale. Reference standards for comparison were findings at surgery or laparoscopy and/ or the clinical outcome. The predictive value of imaging findings was determined with multivariate logistic regression analysis. RESULTS: The areas under the receiver operating characteristic curve were 0.96 for MRI with MRCP and 0.81 for CT (P <0.05). Multivariate analysis of eight imaging variables at MRI indicated that a stricture with malignant characteristics at MRCP was the best predictor of malignancy. CONCLUSION: MRI with MRCP was significantly more accurate than CT in differentiating between malignant and benign lesions in patients with suspected periampullary tumors, mainly due to the information obtained on the MRCP images of the biliary and pancreatic duct anatomy.

Timed barium esophagogram: A simple physiologic assessment for achalasia.

OBJECTIVE: Success of achalasia therapy is difficult to determine because repeated physiologic study is impractical and symptoms are subjective. Timed barium esophagography directly measures esophageal emptying and is simple to perform. This study (1) evaluates the assessment of myotomy by timed barium esophagography and (2) compares it with premyotomy and postmyotomy symptoms. METHODS: Fifty patients ingested 250 mL low-density barium and had upright films at 1, 2, and 5 minutes premyotomy. Forty-five underwent repeat timed barium esophagography 8 weeks (median) postmyotomy. Premyotomy and postmyotomy height and width of the barium column were compared and related to symptoms. RESULTS: At 1, 2, and 5 minutes premyotomy, median barium column height was 19, 17, and 15 cm, and width was 5.2, 4.8, and 4.5 cm, respectively. Surgery reduced these to 7.0, 5.0, and 1.0 cm and to 3.5, 3.0, and 1.0 cm, respectively (P <.001). Postmyotomy complete esophageal emptying was seen in 29%, 36%, and 49% at 1, 2, and 5 minutes. Postmyotomy height was unrelated (r approximately 0.2) to premyotomy height but was directly related to premyotomy width (r = 0.3-0.5; P <.05); postmyotomy width was directly related to premyotomy width (r approximately 0.6; P <.001). Premyotomy dysphagia was more severe when little change in width occurred from 1 to 5 minutes (r = 0.26, P =.07). Premyotomy regurgitation was more severe the higher the barium column (r approximately 0.4, P <.007). Surgery relieved symptoms in the majority of patients (grade 2-5 dysphagia from 72% to 4%, grade 2-5 regurgitation from 79% to 4%). Postmyotomy symptoms were unrelated to the timed barium esophagogram. CONCLUSIONS: (1) The timed barium esophagogram gives objective confirmation of successful myotomy. (2) Symptoms are unreliable in assessing esophageal emptying.

Analyses of bronchial bulky DNA adduct levels and CYP2C9, GSTP1 and NQO1 genotypes in a Hungarian study population with pulmonary diseases.

Carcinogen-DNA adducts may represent an intermediate end-point in the carcinogenic cascade and may reflect exposure to chemical carcinogens, as well as susceptibility and, ultimately, cancer risk. Interindividual variability in activity of enzymes involved in the metabolism of polycyclic aromatic hydrocarbons to mutagenic diol epoxides may predict adduct levels and, indirectly, lung cancer risk. Using 32P-postlabeling methods, the levels of bulky DNA adducts were determined in macroscopically normal bronchial tissues obtained from resected lobes of 143 Hungarian patients with lung malignancy and other pulmonary conditions. DNA from normal tissue was also evaluated for polymorphisms in cytochrome P450 2C9 (CYP2C9) at two sites, codons 144 (Arg/Cys) and 359 (Ile/Leu), for glutathione S-transferase P1 (GSTP1) at codon 105 and for NAD(P)H:quinone oxidoreductase (NQO1) at codon 187 (Pro/Ser). Using the Mann-Whitney U-test and analysis of variance, levels of adducts were evaluated in relation to variant genotypes, separately for smokers and non-smokers. As previously reported, bulky DNA adduct levels in smokers (n = 104) were estimated to be 54% higher than in non-smokers (n = 39) (8.6 +/- 4.2 versus 5.6 +/- 3.3 per 10(8) nucleotides, respectively, P < 0.01). Adduct levels were 16-29% higher in individuals with the homozygous Ile359/Ile359 CYP2C9 allele than in those heterozygous for the variant allele (Ile359/Leu359) [8.8 +/- 4.3 (n = 84) versus 7.6 +/- 3.5 (n = 20) for smokers and 5.8 +/- 3.5 (n = 32) versus 4.5 +/- 1.3 (n = 7) for non-smokers], although differences were not statistically significant. There were no clear differences in adduct levels in relation to genotypes of NQO1 or GSTP1. Although numbers of patients in this study are large in relation to many studies of carcinogen-DNA adducts, it is still possible that significant differences were not noted for polymorphisms in xenobiotic metabolizing enzymes due to relatively small numbers in stratified data.

Smoking-associated bulky DNA adducts in bronchial tissue related to CYP1A1 MspI and GSTM1 genotypes in lung patients.

Relationships between smoking status and levels of bulky DNA adducts were investigated in bronchial tissue of lung patients in relation to their GSTM1 and CYP1A1 MspI genotypes. A total of 150 Hungarian patients undergoing pulmonary surgery were included in the study, 124 with lung malignancies and 26 with non-malignant lung conditions. There were significant relationships between smoking status and bulky DNA adduct levels, as determined by 32P-post-labelling analysis, in macroscopically normal bronchial tissues. There was a highly significant difference in the adduct levels of a combined group consisting of current smokers and short-term ex-smokers (< or = 1 year abstinence) compared with life-time non-smokers and long-term ex-smokers (> 1 year abstinence) (P = 0.0001). The apparent half-life was estimated to be 1.7 years for bulky DNA adducts in the bronchial tissue from ex-smokers. There were no statistically significant correlations between (i) daily cigarette dose and DNA adduct levels in current smokers, (ii) DNA adduct level and histological type of lung cancer, or (iii) GSTM1 and CYP1A1 MspI genotypes and DNA adduct levels after adjustment for either smoking status or malignancy. By multiple logistic regression analysis, smoking and GSTM1 null genotype were found to be risk factors for squamous cell carcinoma. However, bulky DNA adduct levels in bronchial tissue did not appear to be a statistically-significant risk factor for the major histological types of lung cancer.

Transdiaphragmatic cyst-jejunostomy with Roux-en-Y loop for an exclusively mediastinal pancreatic pseudocyst.

In a patient presenting with a roentgenographic retrocardiac density, left pleural effusion and distal oesophageal displacement, echocardiography confirmed presence of a pseudocyst in the posterior mediastinum. Pancreatic origin was suspected. Left thoracolaparotomy revealed the large (900 ml), exclusively mediastinal pseudocyst, surrounding the aorta and adherent to the diaphragm, with high amylase content. Decompression was achieved with a retrocolic and gastric Roux-en-Y loop by transdiaphragmatic cystojejunostomy.

[Nutrition and physical activity of obese and properly nourished children]. / Ishrana i fizicka aktivnost gojazne i normalno uhranjene dece.

The aim of the study which included 2297 children (aged 5-18), was to determine the role of nutrition and physical activity in the occurrence of obesity in this population. Nutritional status of children was estimated by body mass index. In order to examine nutrition we used a quantitative questionnaire, and physical activity was examined by a specially designed questionnaire (made according to the WHO recommendations). The obtained results showed that abundant nutrition and insufficient physical activity played a significant role in the occurrence of child obesity.

Smoking-related increase in O6-alkylguanine-DNA alkyltransferase activity in human lung tissue.

O6-Alkylguanine-DNA alkyltransferase (AGAT) activity was determined in macroscopically normal peripheral lung tissues from 122 patients undergoing lung surgery. AGAT activity of smokers was 1.4-fold higher than that of lifetime non-smokers (P = 0.030). Less than one year of abstinence from smoking did not cause a significant decrease in AGAT activity in former smokers, however, longer abstinence resulted in a decrease in AGAT activity to the level detected in lifetime non-smokers. There was no significant difference between levels of AGAT activity in lung cancer and noncancer patients. The results demonstrate that the level of AGAT activity in human peripheral lung tissue is influenced by smoking habits but does not have a diagnostic correlation to lung cancer.

[Minimally invasive thoracic surgical procedures. Experience with standard video-thoracoscopic and mini-thoracotomy methods]. / Minimálisan invazív mellkasi mütétek. Tapasztalataink a standard video-thoracoscopos és mini-thoracotomiás módszerrel.

Experiences based on 75 minimal invasive intrathoracic procedures performed during a one and half--year--period are reported. The standard video thoracoscopic and mini-thoracotomy methods are compared. The possible indications are discussed, and the authors' opinion about the role of these methods in pulmonary resections is presented. They call attention to the consideration of the limits and possibilities of this new technique.

[Possibilities and limitations of minimally invasive methods in thoracic surgery]. / A "minimal invasive" mütéti irányzat lehetöségei és korlátai a mellkassebészetben.

First experiences with minimal invasive thoracic surgery are presented. Between November 1991 and September 1992 37 intrathoracic operations--3 lobectomies among them--have been performed by their modified method. A special surgical thoracoscope was inserted through a 6-7 cm-s incision into the thorax. This instrument provides a direct view with excellent distal illumination and it also can be applied by video-thoracoscopic system. It is emphasized that their method needs further development. It's practical value and result depend on the appropriate consideration of possibilities and limits, and on careful selection of the patients.

Beta 2-microglobulin elimination in end-stage renal disease patients on renal replacement therapy.

beta 2-microglobulin (beta 2M) is a small molecular mass protein associated with dialysis amyloidosis. We have studied beta 2M elimination in end-stage renal disease (ESRD) patients treated by peritoneal dialysis. In 12 patients on continuous ambulatory peritoneal dialysis (CAPD) and 7 patients on intermittent peritoneal dialysis (IPD) 30.4 +/- 4.2 mg/day and 21.3 +/- 1.8 mg/12 hour of beta 2M, respectively, were removed by dialysis fluid. Approximately the same amount of beta 2M was removed by each of four 2-L exchanges in CAPD; however, the most efficient removal of beta 2M was in the first IPD exchange. Serum beta 2M levels in these patients were 25.7 +/- 4.4 and 31.4 +/- 5.2 mg/L, respectively. In 24 patients on hemodialysis using cuprophan membrane the serum level of beta 2M was 55.1 +/- 4.1 mg/L. After a 3-month dialysis on polyacrylonitrile (PAN) membrane, the serum beta 2M level decreased to 45.0 +/- 2.3 mg/L. A substantial amount of beta 2M was removed by urine, 14.6 +/- 2.3 mg/L, and saliva, 2.3 +/- 0.4 mg/L. This study has shown markedly increased beta 2M levels in patients on conventional hemodialysis treatment, predisposing to beta 2M-related amyloidosis. A significant amount of beta 2M was removed during both CAPD and IPD treatment.

Determination of smoking-related DNA adducts in lung-cancer and non-cancer patients.

Aromatic DNA adduct levels were determined in macroscopically normal bronchial tissues from 98 patients undergoing pulmonary surgery. The mean DNA adduct level for the 45 current smokers was significantly higher than that of the 16 life-time non-smokers. There was a weak association between adduct levels and daily cigarette consumption above 10 cigarettes per day. DNA adduct levels in the 37 former smokers suggested an exponential form of adduct elimination with a rapid initial and a slower later phase after cessation of smoking. There was no quantitative association between bronchial DNA adduct levels and lung cancer.

[Surgical management of mediastinal tumors based on experience with 1000 cases]. / Ezer gátori daganat sebészi kezelésével szerzett tapasztalataink.

One thousand operated mediastinal tumours are analysed. Their characteristic features are discussed and some uncommon manifestations are presented. It is emphasized that in most cases (80-90%) the traditional simple X-ray methods can give a sufficient information for the diagnosis. On the other hand, vascular lesions, cervicomediastinal goiters, dumbbell neurinomas, lymphatic diseases and esophageal lesions should be detected carefully by especial diagnostic methods before surgery because of the different operative tactics and consequences. The diagnosis of the mediastinal neoplasm indicates surgery due to their compressive behaviour.