[The frequency of bacteria in human gallstones]. / Epekövekben levo baktériumok elofordulásának gyakorisága.

INTRODUCTION: Complications caused by lost gallstones within the abdominal cavity are well known. Abscesses, perforation of the gastro-intestinal tract were all described in the literature, but gallstones were found in hernial sac, or even in sputum after it penetrated through the diaphragm into the respiratory tract. These complications can develop between several weeks to several years postoperatively. Most complications can be treated surgically only. MATERIALS AND METHODS: Fifty gallstones and bile samples were collected from 50 patients who underwent cholecystectomy (36 female / 14 male, avarge age: 60.8 ± 6.8 years). All samples were sent for microbiological examination. RESULTS: bacterial colonization of the gallstone and the bile were found in 16 cases. Four of them showed acute inflammation in the gallbladder while pathological signs of chronic inflammation in the gallbladder wall were detected in eight cases. Empyema was found in four cases. Bacteria from enteral origin (Esherichia coli, Enterococcus faecalis, Enterobacter cloacae) was detected in 13 cases, while non-enteral (Klebsiella penumoniae, Streptococcus alfa-haemoliticus) colony were detected in three cases. Positive bacterial cultures were identified in twelve female and fourmale patients. CONCLUSIONS: Different types of bacteria can be found in the gallstones, which may cause various complications.

[Robotic surgery]. / Robotsebészet.

Due to the fast spread of laparoscopic cholecystectomy, surgical procedures have been changed essentially. The new techniques applied for both abdominal and thoracic procedures provided the possibility for minimally invasive access with all its advantages. Robots - originally developed for industrial applications - were retrofitted for laparoscopic procedures. The currently prevailing robot-assisted surgery is ergonomically more advantageous for the surgeon, as well as for the patient through the more precise preparative activity thanks to the regained 3D vision. The gradual decrease of costs of robotic surgical systems and development of new generations of minimally invasive devices may lead to substantial changes in routine surgical procedures.

[New possibilities in practical education of surgery]. / Új lehetoségek a sebészet gyakorlati oktatásában.

The fast spread of laparoscopic surgery in the surgical community also required introduction of new methods of surgical education of these techniques. Training boxes applied for this reason meant a considerable help. The technique of the virtual reality introduced simulation, which is a new possibility in education. For the first time in the history of surgery we can measure medical students' or residents' dexterity and one can get acquainted with a surgical procedure in the form of "serious games". By application of the up-to-date imaging methods we can plan the movements of the surgeon's hand even before the planned operation, practice and repeating can contribute to the safety of the real procedure. Open surgical procedures can be practiced on plastic phantoms mimicking human anatomy and the use of interactive touch devices and e-learning can also contribute to practical education of surgery.

[Examination of cytoprotective and anti-inflammatory effect of PACAP-38 on small bowel autotransplantation]. / A PACAP-38 citoprotektív és antiinflammatórikus hatásának vizsgálata vékonybél-autotranszplantációs modellben.

INTRODUCTION: The small intestine is one of the most sensitive organs to ischemia-reperfusion injury during transplantation. Cytoprotective effect of pituitary adenylate cyclase-activating polypeptide (PACAP) is well known. The aim of our study was to measure changes of PACAP-38-like immunoreactivities and cytokine levels in intestinal grafts stored PACAP-38 containing preservation solution. MATERIAL AND METHODS: Small-bowel autotransplantation was performed on male Wistar rats (n = 56). Grafts were stored in University of Wisconsin (UW) solution at 4 °C for 1 (GI), 3 (GII), and 6 hours (GIII); and in PACAP-38 containing UW solution for 1 (GIV), 3 (GV), and 6 hours (GVI). Reperfusion lasted 3 hours in each group. Intestinal PACAP-38 immunoreactivities were measured by radioimmunoassay. To measure cytokine from tissue homogenates we used rat cytokine array and Luminex Multiplex Immunoassay. RESULTS: Levels of PACAP-38-like and PACAP-27-like immunoreactivities decreased by preservation time compared to control. This decrease was significant following 6 hours cold storage (p < 0.05). Values remained significantly higher in grafts stored in PACAP-38 containing UW. Expressions of sICAM-1, L-selectin, tissue inhibitor of metalloproteinase-1 were increased in GIII and were decreased in GVI. CONCLUSION: PACAP-38 increased tissue levels of PACAP-38 and PACAP-27, and decreased cytokine expression. This indicates that PACAP-38 has anti-inflammatory and cytoprotective effects in intestinal autotransplantation model.

[The mechanism of adhesion formation and the possibilities of modeling -- a preliminary study]. / Az adhaesioképzodés mechanizmusa és modellezésének lehetoségei -- Elokísérleti modellek.

A huge number of factors play a significant role in the process of adhesion formation, like bleeding, the presence of foreign bodies, tissue injury, tissue destruction, ischemia and hypoxia. Adhesions are present in 95% of the cases following abdominal surgery. As a result of adhesions a large number of postoperative complications can occur, such as abdominal pain, bowel motility disturbances and infertility. Hence, it is important to know the precise mechanism of adhesion formation process and establish a suitable animal model to investigate the underlying mechanisms. Molecules which play a part in the process of adhesion formation were collected from the international literature. Male Wistar rats were used to create the adhesion model. Bleeding, implantation of foreign bodies, creation of ischemic areas and tissue destructions were carried out. Within this experiment the tiny bleeding and ischemic areas did not result in adhesion formation. The adhesion formation due to foreign body implantation depends on the type of the materials. Due to the inhibitory mechanism of adhesion formation there was no adhesion detectable due to tiny peritoneal destruction. The most reliable model was the one when gross tissue destruction of the abdominal wall was applied and the resulting bleeding initiated the adhesion formation process. It is also extremely important to know the key participants in the complex process of adhesion formation. This reliable model can help to work out the proper method of prevention.

[Trocar site herniation (TSH) following laparoscopic cholecystectomy: incidence, pathogenesis, and prevention -- animal study]. / A trokárok helyén kialakult hasfali sérvekrol (Trocar Site Hernia) laparoscopos cholecystectomia után: incidencia és megelozés -- állatkísérletes tanulmány.

INTRODUCTION: In 1968 R. E. Fear first reported a trocar site hernia (TSH) in his large series on laparoscopy. Currently, the incidence of TSH is estimated to be 0.65-2.80%. Ports ≥10-mm are usually closed, but ports of the 5-mm trocars are always left open, which may lead to herniation. MATERIAL AND METHODS: Authors guided teaching courses for hands-on animal laparoscopic cholecystectomy (LC) operations, where trainees performed LC-s on 60 animals. Two and four weeks following the operations the animals underwent second look laparoscopy to detect adhesion formation. RESULTS: Trocar site herniation was observed, and in 20% of the animals herniation was found. 70% of the hernias were situated in the 5-mm ports and 30% in the 10-mm ports. CONCLUSION: Port sites should be closed to prevent the formation of TSH. Attention should be payed on the closure of 5-mm trocar sites as well.

[The treatment of Aspergillus empyema using open thoraco-myoplasty with the preservation of lung function -- case report]. / Aspergillus empyema kezelése nyitott thoracostomiával és izomplasztikával, a tüdo funkciójának megorzésével -- esetismertetés.

CASE REPORT: Invasive aspergillosis is a life threatening complication in immune-compromised patients causing lung tissue destruction. Aspergillus empyema requires aggressive multimodality treatment. MATERIAL AND METHOD: We present a case of Aspergillus empyema treated by thoracic and plastic surgery preserving the lung function in an 18 year-old male patient suffering dermatomyositis and treated with steroids for a long time. After open window thoracostomy (OWT) we used pedicled musculus latissimus dorsi (MLD) flap and mobilised the anterior serratus muscle to close the pleural cavity. CONCLUSION: The intrathoracic use of muscle flaps after OWT in case of chronic Aspergillus empyema can preserve the underlying lung tissue. Cooperation of thoracic and plastic surgeons - as in the cases presented - provides an excellent opportunity to treat successfully of otherwise hopeless patients.

Deletion of prolyl carboxypeptidase attenuates the metabolic effects of diet-induced obesity.

α-Melanocyte-stimulating hormone (α-MSH) is a critical regulator of energy metabolism. Prolyl carboxypeptidase (PRCP) is an enzyme responsible for its degradation and inactivation. PRCP-null mice (PRCP(gt/gt)) showed elevated levels of brain α-MSH, reduced food intake, and a leaner phenotype compared with wild-type controls. In addition, they were protected against diet-induced obesity. Here, we show that PRCP(gt/gt) animals have improved metabolic parameters compared with wild-type controls under a standard chow diet (SD) as well as on a high-fat diet (HFD). Similarly to when they are exposed to SD, PRCP(gt/gt) mice exposed to HFD for 13 wk showed a leaner phenotype due to decreased fat mass, increased energy expenditure, and locomotor activity. They also showed improved insulin sensitivity and glucose tolerance compared with WT controls and a significant reduction in fasting glucose levels. These improvements occured before changes in body weight and composition were evident, suggesting that the beneficial effect of PRCP ablation is independent of the adiposity levels. In support of a reduced gluconeogenesis, liver PEPCK and G-6-Pase mRNA levels were reduced significantly in PRCP(gt/gt) compared with WT mice. A significant decrease in liver weight and hepatic triglycerides were also observed in PRCP(gt/gt) compared with WT mice. Altogether, our data suggest that PRCP is an important regulator of energy and glucose homeostasis since its deletion significantly improves metabolic parameters in mice exposed to both SD and HFD.

Paradoxical alteration of indocyanine green concentration in bile and the visibility of the intra-operative fluorescence cholangiography in pigs.

Background: A significant difference exists between the reported optimal timing of indocyanine green (ICG) injection during fluorescence cholangiography and ICG dissipation time from the serum. There are no reports on alterations in ICG concentration in biliary fluid over time. Herein, we measured the concentration of ICG and the fluorescence intensity ratio between the common bile duct (CBD) and liver, which was recognized as a parameter of the visibility of the CBD. Materials and methods: ICG (0.05 mg/kg) was injected intravenously into female pigs (n = 7). Afterwards, the fluorescence of the CBD and liver was detected at 30 min, 2 h, and 4 h. Biliary fluid was collected from cannulated CBD tubes. The fluorescence intensity was measured using captured images and calculated using the ImageJ image-processing program. ICG concentration was measured using spectrophotometry and compared using an analysis of variance test. Results: Biliary ICG concentrations at 30 min, 2 h, and 4 h were 92.07 ± 27.72 µg/mL, 37.14 ± 9.76 µg/mL (p < 0.05 vs. 30 min), and 13.91 ± 5.71 µg/mL (p < 0.05 vs. 30 min), respectively; p < 0.01. The CBD/liver fluorescence intensity ratios at 30 min, 2 h, and 4 h were 1.25 ± 0.72, 2.39 ± 1.28 (p < 0.05 vs. 30 min and 4 h), and 3.38 ± 1.73 (p < 0.05 vs. 30 min and 2 h), respectively. Conclusions: The ICG biliary concentration was highest at 30 min, whereas the CBD/liver fluorescence intensity ratio was highest at 4 h. Decreasing the fluorescence intensity of the liver may be an important approach for improving the visualization of the CBD during fluorescence cholangiography. Institutional protocol number: PE/EA/491-5/2020.

#Erasmus+ ­ or surgical research, development and innovation at the Department of Surgical Research and Techniques at Semmelweis University / #Erasmus+ - avagy sebészeti kutatás-fejlesztés és innováció a Semmelweis Egyetem Kísérletes és Sebészeti Mutéttani Tanszékén

The European Union is earmarking more and more resources each cycle to support research, development and innovation, and the projects set up by the working groups are helping to develop innovative solutions to reflecting societal issues of today. Since 2014, the Department of Surgical Research and Techniques of the Cardiovascular Center at Semmelweis University has been participating in international consortia supported by the Erasmus+ programme, which aim to modernise the teaching methodology of surgical training and to integrate IT technology into the training of surgical residents at pan-European level. This paper briefly summarises the international projects in which the Department has been involved over the last 7 years.

Early and late effects of absorbable poly(vinyl alcohol) hernia mesh to tissue reconstruction.

Hernia is a defect of the abdominal wall. Treatment is principally surgical mesh implantation. Non-degradable surgical meshes produce numerous complications and side-effects such as inflammatory response, mesh migration and chronic pain. In contrast, the biodegradable, poly (vinyl alcohol) (PVA) based polymers have excellent chemical, mechanical and biological properties and after their degradation no chronic pain can be expected. The toxicology of PVA solution and fibers was investigated with Human dermal fibroblast- Adult cell line. Implantation tests were observed on long-term contact (rat) and large animal (swine) models. To measure the adhesion formation, Diamond and Vandendael score were used. Macroscopical and histological responses were graded from the samples. In vitro examination showed that PVA solution and fibers are biocompatible for the cells. According to the implantation tests, all samples were integrated into the surrounding tissue, and there was no foreign body reaction. The average number of adhesions was found on the non-absorbable suture line. The biocompatibility of the PVA nanofiber mesh was demonstrated. It has a non-adhesive, non-toxic and good quality structure which has the potential to be an alternative solution for the part of the hernia mesh.

Adhesion stabilization in the early postoperative period in a rat model / Az adhézió stabilizálódásának meghatározása a korai posztoperatív idoszakban patkány modellen

Introduction: Adhesion formation is a complex series of events that results from cellular and molecular processes where, in contrast to the normal case, events that support adhesion genesis dominate over adhesion lysis. Tissue injury, haemorrhage, tissue desiccation and inflammatory processes, among others, play a role in its induction. Since the presence of adhesions can be associated with a number of negative complications, the primary aim is to prevent their development. There are several preventive targets for the process, but in many cases therapy is only provided immediately after the procedure. In this study, we present an experimental rat model of adhesion, where the aim is to understand the stabilization period of adhesion. All animals underwent the same surgical procedure, inducing tissue injury, minor haemorrhage and tissue desiccation, differing only in the timing of reoperations and sampling. On postoperative days 1­7, we assessed macroscopically and histopathologically the type of adhesions formed, the adhesive tissue, the stability of the adhesion. We found that stabilization was a process lasting several days, with unstable and moderately stable adhesions predominating by postoperative day 4. Knowing this allows to broaden the therapeutic window, targeting the most appropriate period in the early postoperative period, possibly combining treatments, to make adhesion prevention even more effective.

Peritoneum, the multifunctional membrane / Peritoneum, a multifunkcionális hártya

Introduction: Not only atraumatic surgical technique, precise bleeding control, removal foreign materials from the abdomen, but also avoiding desiccation or mechanical damage of peritoneal surface at abdominal surgery mean today evidence based expectation. Peritoneum with its extensive surface and special histological structure represents an important factor in normal physiological processes, furthermore as "Guard of abdomen" it has an important role to localise inflammatory reactions, useful as dialysing surface and provides also possibility for hyperthermic abdominal chemotherapy in tumour treatment. Largest part of peritoneal sac covers small intestine and colon. To prevent postoperative complications it is necessary to avoid desiccation of intestinal tract at laparoscopic and at open procedures as well ­ consequently "rehyration" is a routine recommendation today. Desiccation of intestinal tract results postoperative adhesions, furthermore damage of serosa will increase permeability of intestine wall and can result perforation. All the surgical recommendations suggest keeping intestine moist, whereas there are only a few real studies in surgical literature to support or to deny this theory. Our study reviews the pathophysiological and surgical respects of this situation and summarizes the results of latest researches of combined functions of peritoneum.

Poly(amino acid) based fibrous membranes with tuneable in vivo biodegradation.

In this work two types of biodegradable polysuccinimide-based, electrospun fibrous membranes are presented. One contains disulfide bonds exhibiting a shorter (3 days) in vivo biodegradation time, while the other one has alkyl crosslinks and a longer biodegradation time (more than 7 days). According to the mechanical measurements, the tensile strength of the membranes is comparable to those of soft the connective tissues and visceral tissues. Furthermore, the suture retention test suggests, that the membranes would withstand surgical handling and in vivo fixation. The in vivo biocompatibility study demonstrates how membranes undergo in vivo hydrolysis and by the 3rd day they become poly(aspartic acid) fibrous membranes, which can be then enzymatically degraded. After one week, the disulfide crosslinked membranes almost completely degrade, while the alkyl-chain crosslinked ones mildly lose their integrity as the surrounding tissue invades them. Histopathology revealed mild acute inflammation, which diminished to a minimal level after seven days.

Proximal conduction abnormality of the facial nerve in Miller Fisher syndrome: a study using transcranial magnetic stimulation.

OBJECTIVE: To investigate facial nerve conduction, including its proximal segment, in Miller Fisher syndrome. METHODS: Three patients underwent facial nerve conduction studies comprising stylomastoid electrical stimulation and transcranial magnetic stimulation at the entrance of the facial canal within the skull and of the cortical representation area. All 3 patients presented with acute bilateral complete ophthalmoplegia, areflexia, mild ataxia and varying other symptoms. One of the patients had bilateral facial palsy; the other two had normal facial innervation. RESULTS: Findings suggestive of demyelination of the proximal segment of the facial nerve were observed in each of the 3 patients with Miller Fisher syndrome. The patient with bilateral facial palsy had absent responses to canalicular stimulation on both sides, while the other two showed increased temporal dispersion and prolonged latency in the proximal nerve segments. CONCLUSIONS: Our findings suggest that the primary pathology of facial nerve lesion in Miller Fisher syndrome is demyelination and that it is localized to the proximal nerve segment. This is in line with the known vulnerability of proximal nerve segments (spinal roots) in other dysimmune demyelinating polyneuropathies. SIGNIFICANCE: Facial nerve conduction study with magnetic stimulation can localize and detect even subclinical facial nerve dysfunction in patients with Miller Fisher syndrome. The technique may contribute to the diagnosis of this disease, where electrophysiologic findings are scanty.

[The role of pneumoperitoneum and the "chimney effect" on the development of port site metastasis. A new experimental animal model using Furka's spleen tissue suspension]. / A pneumoperitoneum és a "kémény effektus" szerepe a port site metastasis kialakulásában. Furka-féle lép suspensióval végzett új állatkísérletes modell.

Following the introduction of laparoscopic cholecystectomy, laparoscopic technology has been applied in many other fields of surgery, including surgery for malignancies, even before prospective, randomised trials were available. Many authors observed development of port site metastases following laparoscopic surgery in malignancies (1-2%). The studies report about the pathomechanism of the development of port site metastasis, some describe the role of pneumoperitoneum. We developed a new model to show the role of pneumoperitoneum and the "chimney effect" on the development of port site metastasis, using a large experimental animal with a suspension of its own spleen tissue. On follow up histology viable spleen tissue was found between the layers of the trocar incisions.

[The importance of hemorheological examinations in experimental limb ischemia-reperfusion injuries]. / A haemorheologiai vizsgálatok jelentosége kísérletes végtagi ischaemiareperfusiós károsodások kapcsán.

Rheological properties of the blood are determined by several factors and if they change it may be diagnostic for many diseases. It is well-known that during ischemia and reperfusion different free-radical liberating pathways are inducted besides the local physical and metabolical changes. These processes may harm red blood cells by increasing their rigidity and impairing their deformability. In ischemia-reperfusion models measurements of erythrocyte deformability is important. Characteristic alterations were observed in both rat and dog hind limb ischemia-reperfusion with vascular clamping on femoral vessels for 1 or 3 hours. Erythrocyte deformability was significantly impaired on the postoperative 1st-3rd days. The acute limb ischemia-reperfusion experimental models seem suitable for further in vivo rheological studies.

Prolyl carboxypeptidase regulates energy expenditure and the thyroid axis.

Hypothalamic α-melanocyte-stimulating hormone (α-MSH) plays a central role in regulating energy uptake and expenditure. Prolyl carboxypeptidase (PRCP), a protease expressed in the hypothalamus, is responsible for the degradation of α-MSH. PRCP null animals (PRCP(gt/gt) mice) display elevated α-MSH in the hypothalamus, lower body weight, and are protected from diet induced obesity. Here, we report that PRCP(gt/gt) mice have a significant decrease in fat mass, although an increase in lean mass was also observed. In agreement with low fat accumulation, reduced leptin levels were found. Consistent with the effect of α-MSH on energy metabolism, PRCP(gt/gt) mice had increased energy expenditure with elevated circulating thyroid hormone levels and brown adipose tissue uncoupling protein 1 mRNA levels compared with control mice when exposed to regular diet. TRH mRNA levels in the PVN were significantly higher in fed PRCP(gt/gt) animals compared with fed wild-type controls. Fasting significantly decreased TRH mRNA levels in both PRCP(gt/gt) and wild-type (WT) mice. However, TRH mRNA levels in fasted PRCP(gt/gt) animals were significantly higher than those of fasted WT mice. Refeeding analysis after fasting showed a reduced food intake in PRCP(gt/gt) compared with WT mice. Finally, TRH mRNA levels in T(3)-treated hypothyroid PRCP(gt/gt) mice showed a non significant reduction compared with those of hypothyroid PRCP(gt/gt) mice, supporting the impairment of the hypothalamo-pituitary-thyroid axis in PRCP(gt/gt) mice. All together, these data confirm that PRCP plays a role in the regulation of energy metabolism.

Cariprazine (RGH-188), a potent D3/D2 dopamine receptor partial agonist, binds to dopamine D3 receptors in vivo and shows antipsychotic-like and procognitive effects in rodents.

We investigated the in vivo effects of orally administered cariprazine (RGH-188; trans-N-{4-[2-[4-(2,3-dichlorophenyl)-piperazin-1-yl]-ethyl]-cyclohexyl}-N',N'-dimethyl-urea), a D(3)/D(2) dopamine receptor partial agonist with ∼10-fold preference for the D(3) receptor. Oral bioavailability of cariprazine at a dose of 1mg/kg in rats was 52% with peak plasma concentrations of 91ng/mL. Cariprazine 10mg/kg had good blood-brain barrier penetration, with a brain/plasma AUC ratio of 7.6:1. In rats, cariprazine showed dose-dependent in vivo displacement of [(3)H](+)-PHNO, a dopamine D(3) receptor-preferring radiotracer, in the D(3) receptor-rich region of cerebellar lobules 9 and 10. Its potent inhibition of apomorphine-induced climbing in mice (ED(50)=0.27mg/kg) was sustained for 8h. Cariprazine blocked amphetamine-induced hyperactivity (ED(50)=0.12mg/kg) and conditioned avoidance response (CAR) (ED(50)=0.84mg/kg) in rats, and inhibited the locomotor-stimulating effects of the noncompetitive NMDA antagonists MK-801 (ED(50)=0.049mg/kg) and phencyclidine (ED(50)=0.09mg/kg) in mice and rats, respectively. It reduced novelty-induced motor activity of mice (ED(50)=0.11mg/kg) and rats (ED(50)=0.18mg/kg) with a maximal effect of 70% in both species. Cariprazine produced no catalepsy in rats at up to 100-fold dose of its CAR inhibitory ED(50) value. Cariprazine 0.02-0.08mg/kg significantly improved the learning performance of scopolamine-treated rats in a water-labyrinth learning paradigm. Though risperidone, olanzapine, and aripiprazole showed antipsychotic-like activity in many of these assays, they were less active against phencyclidine and more cataleptogenic than cariprazine, and had no significant effect in the learning task. The distinct in vivo profile of cariprazine may be due to its higher affinity and in vivo binding to D(3) receptors versus currently marketed typical and atypical antipsychotics.