[The relationship between selenium and gastrointestinal inflammatory diseases]. / A szelén és az emésztorendszer gyulladásos betegségeinek kapcsolata.

The cell-membrane toxicity of reactive oxygen and nitrogen species (RONS) plays an increasing role in the pathomechanism of gastrointestinal tract diseases. Trace elements are important parts of antioxidant protecting system, especially the selenium (Se), which, in the form of glutathione peroxidase contributes to the immunity of the gut (GALT). Due to the absorptional disorders and consequent malnutrition observed in the course of inflammatory bowel diseases (IBD) an important role is associated with nutritional therapy, including energy-, protein- and trace element-support. Human studies show, that IBD is mostly accompanied by lower serum Se concentrations, reduced antoxidant and increased proinflammatory activity. Adequate Se-replacement may reduce the severity of organ failure and infections, but not mortality. However, it is encouraging that in animal studies obvious preventive effect of Se has been found on IBD and chronic inflammation induced colon cancer .

VATS therapy of chylothorax caused by leiomyomatosis complicated with tuberous sclerosis complex.

Lymphangioleiomyomatosis with tuberous sclerosis complex is a rare disease. One of the most frequent complications of lymphangioleiomyomatosis is pleural effusion (chylothorax) wich can be treated with the use of VATS. Authors report a case of pulmonary lymphangioleiomyomatosis in a 56-year-old female patient with tuberous sclerosis complex with an 8-week history of recurrent chylothorax, dyspnea and debilitating weakness. By CT scan a flat tissue proliferation was seen in the site of the thoracic duct and it was supposed to be the reason for the pleural effusion. A VATS resection of this laesion and ligation of the thoracic duct was performed successfully. Chylothorax is often associated with pulmonary lymphangioleiomyomatosis. Lymphangioleiomyomatosis combined with tuberous sclerosis complex is extremely rare. In case of chylothorax VATS treatment is successful and may be the first choice.

Hepatobiliary response in postoperative lipid therapy in gastrointestinal surgery.

BACKGROUND/AIMS: Intravenous lipid emulsions may contribute to the development of total parenteral nutrition (TPN)--induced hepatobiliary complications. METHODS: In a prospective, randomised setting the authors compared the short-term hepatic effects of medium-chain triglycerides/short-chain triglycerides (MCT/LCT) physical mixture with a four-component intravenous (i.v.) lipid emulsion (LCT, MCT, Olive-oil and Fish-oil) in patients undergoing elective gastrointestial surgery during the early postoperative period. RESULTS: The authors demonstrated that total and conjugated bilirubin, alkaline phosphatase, alanine aminotransferase, aspartate amino transferase and cholinesterase did not change significantly during the 5-days observation period. In contrast to this, gamma-glutamyl transferase (GGT) activity increased by 2,4 times during 5-days therapy with the lipid emulsions mentioned above (SMOF lipid: 21,9 to 52,9 U/L, Lipofundin: from 32,5 to 79,6 U/L). CONCLUSION: during a 4-days administration hepatic effect of the intravenous lipid emulsions did not differ significantly. The changes in enzyme levels confirm the cholestatic type of hepatobiliary deviations without clinical impact on short-term TPN therapy.

Use of three lumen catheter facilitates bowel movement after pancreato-duodenectomy.

BACKGROUND/AIMS: The advantages of jejunal nutrition in postoperative bowel paralysis following pancreato-duodenectomy were analyzed. METHODOLOGY: Patients resected for pancreatic cancer received 25 kcal/kg/day and were followed up for 10 days postoperatively. Nasojejunal tube ensured enteral feeding in 16 patients (Gr. I), 6 patients (Gr. II) were nourished parenterally. Laboratory parameters, outcome were compared. Bowel movements were registered. Patients of Gr.1 received 25 kcal/kg parenterally. Jejunal nutriment (1.5 cal/mL) followed gradually up to 1500mL. Parenteral nutriment decreased reflecting enteral intake. Patients of Gr. II were nourished parenterally only for 8 days. Laboratory data were measured preoperatively, on the 1st, 4th, 10th days. RESULTS: The first stool appeared on the 4th day in Gr. I In Gr. II the bowel movement was delayed by 8 days. Laboratory data from the 1st, and 10th days were compared. In Gr. I serum total protein increased from 48.06 to 58.7g/L (p<0.001), serum albumin from 27.5 to 32.2g/L (p<0.02), CRP decreased from 117.8 to 74.1mg/L (p<0.035). No changes were significant in Gr. II. Length of hospitalization, weight loss did not differ between the 2 groups. CONCLUSIONS: Immediately postoperative use of a three-luminal tube ensured early enteral nutrition, improved serum total protein, albumin values and facilitated bowel movements.

[Anaesthesia of the myasthenic patients during thymectomy]. / Myastheniás betegek altatása thymectomia során.

Myasthenia is a rare autoimmune disease characterized by fluctuating muscle weakness and fatigability due to a reduction in available acetylcholine receptors at the neuromuscular junction. Data of 186 patients suffering from myasthenia were collected retrospectively. All patients underwent thymectomy over a 23 years period from 1981 to 2006 without surgical mortality. Postoperative ventilation was required for more than 24 hours in seven patients and one patient needed postoperative ventilatory support more than seven days. Thymectomy for myasthenia was performed using promethazine and atropine in general anaesthesia. Introduction could be facilitated with propofol, etomidate or thiopental and sevoflurane, avoiding use of any muscle relaxants. Non-depolarizing muscle relaxants were not used during the procedures. Adequate surgical conditions were provided by short-acting inhaled anaesthetics (sevoflurane) and small doses of opiates. 95% of the narcotized patients were immediately extubated after the procedure in the operating room. Length of stay in intensive care unit could have been reduced without any postoperative ventilatory support. Nonsteroid analgesics and nalbuphine were used for pain relief. Anaesthesia of thymectomy is based on volatile gases. Airway complications can be prevented with use of small amounts of anticholinergic drugs, perhaps steroids.

[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.

[Use of FREKA TRELUMINA tube after pancreatoduodenectomy]. / FREKA TRELUMINA szonda alkalmazása pancreatoduodenectomiát követoen.

UNLABELLED: Patients operated on for pancreas head cancer were investigated postoperatively. Fifteen patients (Group I) were treated with FREKA TRELUMINA tube (they benefited of safe gastric emptying and jejunal feeding), 5 patients (Group II) did not receive this treatment. Laboratory results were measured preoperatively, on the first, 4th and 10th days. Bowel movements were monitored. All patients were received Total Parenteral Nutrition--25 kcal/kg/day. Group I received on the first postoperative day 500 ml tea, from the second day we gradually increased the oral intake to a maximum of 1500 mls. Patients in Group II were fed only parenterally. RESULTS: In Group I the first bowel sounds could be heard on the 3rd postoperative day, the first stool was detected on the 3rd-4th. Laboratory results of the first postoperative day were compared to results of the 10th day. Serum protein changed from 47.7 to 59 g/l (p < 0.001), albumin rose from 26.9 to 32.5 g/l (p < 0.012), C-reactive protein reduced from 119.7 to 66.05 mg/l (p < 0.014). Changes in retinol-binding protein, prealbumin and immunoglobulin were not significant. In Group II were no significant laboratory changes. First bowel movements were detected on the 8th day. Clinical stay was no longer than in Group I. Though FREKA TRELUMINA delays natural gastric emptying, it enables early enteral nutrition, patients feel better with increased peristalsis, and the use of the tube is cost-effective.

[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.

CT-guided percutaneous peripancreatic drainage: a possible therapy in acute necrotizing pancreatitis.

BACKGROUND/AIMS: To examine the effectiveness of therapeutic percutaneous drainage of peripancreatic fluid in the treatment of acute necrotizing pancreatitis. METHODOLOGY: Twenty-eight patients treated for serious acute necrotizing pancreatitis (19 male, 9 female; average age 47.3 years) took part in the study. The cause of acute necrotizing pancreatitis was alcohol abuse in 20 of the cases, gallstone disease in 7 cases, endoscopic retrograde cholangiopancreatography in 2 cases, trauma in one case, and 4 of the cases had unknown cause. In all cases preventative antibiotics were given as part of intensive therapy, early nasojejunal nutrition was used, and we endeavored to avoid surgery or to delay it depending on the case. The acute peripancreatic fluid was drained percutaneously. In total, percutaneous drainage was used in 12 patients. RESULTS: Of the 28 patients, only 3 patients recovered solely with conservative therapy, without drainage. Three patients recovered using only percutaneous drainage without surgery. In 9 patients surgery was necessary after percutaneous drainage was performed. In the remaining 13 patients, only surgical treatment was used, without percutaneous drainage. In total 20 reoperations were done in 10 patients. Of the 12 patients treated with percutaneous drainage, one patient died. The total mortality was 14.3%. CONCLUSIONS: In certain cases the percutaneous drainage of the acute peripancreatic fluid that collects in acute necrotizing pancreatitis is sufficient for the total recovery of acute necrotizing pancreatitis, in other cases can be used to postpone surgery.

[Surgical aspects in the treatment of myasthenia gravis]. / A myasthenia gravis gyógykezelésének sebészeti vonatkozásai.

We treated 81 patients suffering from myasthenia with thymectomy in a 10-year period (1991-2000). We think, that thymectomy must be carried out in the treatment of myasthenia gravis, unless contraindications are present. The operation is not urgent and in the preoperative period patients must reach optimal condition with the help of standard medical treatment. The result of the operation is influenced by the length of time between the beginning of the complaints and the operation. The best results can be expected when the operation is performed in less than 2 years time, however an operation performed later may also be successful. We operated on 63% (n = 51) of the patients between 4-12 months, on 18% (n = 15) between 13-24 months and on 18.6% (n = 15) more than 25 months after the beginning of the complaints. Complete thymectomy was performed in all patients through median sternotomy. We had no operative mortality. Our postoperative results were evaluated with Jaretzki classification: 75% of our patients are in remission and asymptomatic (n = 61).

[Surgical treatment for primary and secondary tumors of the liver]. / A primer és szekunder májdaganatok sebészi kezelése.

We performed liver resection for focal liver disease in 266 patients between January 1, 1992 and December 31, 2001 at the University of Debrecen Medical and Health Science Center, Medical School of Medicine, 2nd Department of Surgery in Debrecen, Hungary. The indication was primary liver cancer in 35 cases, liver metastasis in 97 cases. The primary tumour and its liver metastases were removed synchronously in 28 patients (29.9%). Comparing the results of different operating methods we found the need of transfusion significantly less in "anterior" liver resections. Regarding operating time, complications and survival time there were no significant differences between the different operations. One patient died in the perioperative period because of cardiac failure and one because of DIC (1.5%). There were 4 complications which needed reoperation in the early postoperative period. Eighty of the patients were treated with systemic adjuvant chemotherapy (Mayo protocol), with added chemoembolisation in another 26 patients. This has not increased life expectancy significantly. Thirty-two patients are still alive, their average survival time is 21.2 (5 to 59) months. The average survival time of the 78 patients' who died is 16.5 (3 to 58) months. Twenty-two patients were lost out of our follow-up.

[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.

[Jejunal feeding in necrotizing pancreatitis or after esophagectomy]. / Jejunalis táplálás nekrotizáló pancreatitisben, illetve nyelócsó reszekciót követóen.

Has early jejunal glutamine-rich diet any advantage in the treatment of patients suffering from acute pancreatitis and after oesophagectomy? Eleven patients suffering from necrotizing pancreatitis and 23 patients operated on radically for esophageal cancer were fed intra jejunally with glutamine-rich Stresson Multi Fibre diet. Eight patients with necrotising pancreatitis and 13 oesophagectomy patients were fed with glutamine-poor Nutrition Multi Fibre. Nutritional status, serum proteins, acute phase proteins, immune-globulins, complement components (C3, C4), the ratio of subsets of peripheral lymphocytes were analysed on the 1st, 2nd, 4th and 10th days. Serum protein parameters were measured by laser nephelometry. CD cell surface antigen expression was measured with flow cytofluorometry, activity of phagocytes with whole blood chemiluminescences. Laboratory parameters showed an improvement during the 10-day-treatment in both diet types, but significant improvement could be measured only in patients with necrotizing pancreatitis and fed with Stresson Multi Fibre: IgG (p < 0.05), serum protein (p < 0.02), prealbumin (p < 0.05), retinol binding protein (p < 0.03). The different diets did not cause difference in the laboratory results of the oesophagectomy patients. Early immune-enhancing diet improved serum proteins, acute phase proteins and immunoglobulins significantly in necrotizing pancreatitis. The length of hospital stay also decreased.