Changes in microcirculation of small intestine end-to-end anastomoses in an experimental model.

INTRODUCTION: Sufficient perfusion is essential for a safe intestinal anastomosis. Impaired microcirculation may lead to increased bacterial translocation and anastomosis insufficiency. Thus, it is important to estimate well the optimal distance of the anastomosis line from the last mesenterial vessel. However, it is still empiric. In this experiment the aim was to investigate the intestinal microcirculation at various distances from the anastomosis in a pig model. MATERIALS AND METHODS: On 8 anesthetized pigs paramedian laparotomy and end-to-end jejuno-jejunostomy were performed. Using Cytocam-IDF camera, microcirculatory recordings were taken before surgery at the planned suture line, and 1 to 3 mesenterial vessel mural trunk distance from it, and at the same sites 15 and 120 min after anastomosis completion. After the microcirculation monitoring, anastomosed and intact bowel segments were removed to test tensile strength. RESULTS: The proportion and the density of the perfused vessels decreased significantly after anastomosis completion. The perfusion rate increased gradually distal from the anastomosis, and after 120 min these values seemed to be normalized. Anastomosed bowels had significantly lower maximal tensile strength and higher slope of tensile strength curves than intact controls. CONCLUSION: Alterations in microcirculation and tensile strength were observed. After completing the anastomosis, the improvement in perfusion increased gradually away from the wound edge. The IDF device was useful to monitor intestinal microcirculation providing data to estimate better the optimal distance of the anastomosis from the last order mesenteric vessel.

A Custom-Tailored Multichannel Pressure Monitoring System Designed for Experimental Surgical Model of Abdominal Compartment Syndrome.

In experimental medicine, a wide variety of sensory measurements are used. One of these is real-time precision pressure measurement. For comparative studies of the complex pathophysiology and surgical management of abdominal compartment syndrome, a multichannel pressure measurement system is essential. An important aspect is that this multichannel pressure measurement system should be able to monitor the pressure conditions in different tissue layers, and compartments, under different settings. We created a 12-channel positive-negative sensor system for simultaneous detection of pressure conditions in the abdominal cavity, the intestines, and the circulatory system. The same pressure sensor was used with different measurement ranges. In this paper, we describe the device and major experiences, advantages, and disadvantages. The sensory systems are capable of real-time, variable frequency sampling and data collection. It is also important to note that the pressure measurement system should be able to measure pressure with high sensitivity, independently of the filling medium (gas, liquid). The multichannel pressure measurement system we developed was well suited for abdominal compartment syndrome experiments and provided data for optimizing the method of negative pressure wound management. The system is also suitable for direct blood pressure measurement, making it appropriate for use in additional experimental surgical models.

Pressure Distribution during Negative Pressure Wound Therapy of Experimental Abdominal Compartment Syndrome in a Porcine Model.

(1) Introduction: Negative pressure wound therapy (NPWT) is a frequently applied open abdomen (OA) treatment. There are only a few experimental data supporting this method and describing the optimal settings and pressure distribution in the abdominal cavity during this procedure. The aim of our study was to evaluate pressure values at different points in the abdominal cavity during NPWT in experimental abdominal compartment syndrome (ACS) animal model; (2) Methods: In this study (permission Nr. 13/2014/UDCAW), 27 Hungahib pigs (15.4-20.2 kg) were operated on. ACS was generated by implanting a plastic bag in the abdomen through mini-laparotomy and filled with 2100-3300 mL saline solution (37 °C) to an intraabdominal pressure (IAP) of 30 mmHg. After 3 h, NPWT (Vivano Med® Abdominal Kit, Paul Hartmann AG, Germany) or a Bogota bag was applied. The NPWT group was divided into -50, -100 and -150 mmHg suction groups. Pressure distribution to the abdominal cavity was monitored at 6 different points of the abdomen via a multichannel pressure monitoring system; (3) Results: The absolute pressure levels were significantly higher above than below the protective layer. The values of the pressure were similar in the midline and laterally. Amongst the bowels, the pressure values changed periodically between 0 and -12 mmHg which might be caused by peristaltic movements; (4) Conclusions: The porcine model of the present study seems to be well applicable for investigating ACS and NPWT. It was possible to provide valuable information for clinicians. The pressure was well distributed by the protective layer to the lateral parts of the abdomen and this phenomenon did not change considerably during the therapy.

[The treatment of walled-off pancreatic necrosis. Review]. / A demarkált pancreasnecrosis kezelése. Irodalmi áttekintés.

Walled-off pancreatic necrosis is a late complication of severe acute pancreatitis that generally needs some interventions. The aim of this review is to analyse the indications, technical aspects and limits of these therapeutic options. The development of the walled-off pancreatic necrosis needs 4-6 weeks from the onset of the disease. The necrosectomy is recommended after this time. Endoscopic necrosectomy offers good results if the necrosis is in retrogastric or retroduodenal localisations. Open necrosectomy can be performed through the gastrocolic ligament or the mesocolon. It is suggested to complete necrosectomy with open or closed omental bursa drainage or packing. The transgastric necrosectomy does not need external drainage. Surgical procedures can be performed with laparoscopy either. In localized necrosis other minimal invasive approaches can be used. CONCLUSIONS: In addition to the transluminal endoscopic or minimal invasive necrosectomies different types of surgical procedures has an important role in the treatment of walled-off pancreatic necrosis. Orv. Hetil., 2016, 157(47), 1866-1870.

Primary angiosarcoma of the pancreas mimicking severe acute pancreatitis--case report.

Primary angiosarcoma of the pancreas is an extremely rare neoplasm that often mimicks severe acute pancreatitis. A 58-year-old man was admitted with clinical and laboratory signs of severe acute pancreatitis. Contrast enhanced CT scan demonstrated haemorrhagic necrotizing inflammation of the pancreas involving the pancreatic tail, splenic hilum and small bowels with multiple peripancreatic and free abdominal fluid collection. Percutaneous drainage was performed. After 13 days, laparotomy was indicated because of persistent intra-abdominal bleeding, fever and a palpable, rapidly growing mass in the left upper quadrant of the abdomen. During the operation a necrotic, haemorrhagic mass was found in the pancreatic tail; a frozen section showed malignancy, although the tumour was unresectable. Despite all conservative and surgical therapeutic attempts, the patient died within four weeks after diagnosis. Final histology justified primary angiosarcoma of the pancreas. If a patient with signs of severe acute pancreatitis has fever without elevated PCT, the presence of a malignant tumour of the pancreas should be considered.

Genetic analysis of the bicarbonate secreting anion exchanger SLC26A6 in chronic pancreatitis.

BACKGROUND: Pancreatic ductal HCO3(-) secretion is critically dependent on the cystic fibrosis transmembrane conductance regulator chloride channel (CFTR) and the solute-linked carrier 26 member 6 anion transporter (SLC26A6). Deterioration of HCO3(-) secretion is observed in chronic pancreatitis (CP), and CFTR mutations increase CP risk. Therefore, SLC26A6 is a reasonable candidate for a CP susceptibility gene, which has not been investigated in CP patients so far. METHODS: As a first screening cohort, 106 subjects with CP and 99 control subjects with no pancreatic disease were recruited from the Hungarian National Pancreas Registry. In 60 non-alcoholic CP cases the entire SLC26A6 coding region was sequenced. In the Hungarian cohort variants c.616G > A (p.V206M) and c.1191C > A (p.P397=) were further genotyped by restriction fragment length polymorphism analysis. In a German replication cohort all exons were sequenced in 40 non-alcoholic CP cases and variant c.616G > A (p.V206M) was further analyzed by sequencing in 321 CP cases and 171 controls. RESULTS: Sequencing of the entire coding region revealed four common variants: intronic variants c.23 + 78_110del, c.183-4C > A, c.1134 + 32C > A, and missense variant c.616G > A (p.V206M) which were found in linkage disequilibrium indicating a conserved haplotype. The distribution of the haplotype did not show a significant difference between patients and controls in the two cohorts. A synonymous variant c.1191C > A (p.P397=) and two intronic variants c.1248 + 9_20del and c.-10C > T were detected in single cases. CONCLUSION: Our data show that SLC26A6 variants do not alter the risk for the development of CP.

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.

[Data on liver enzyme and histological changes caused by intermittent clampings of the hepatoduodenal ligament in an experimental model]. / Adatok a ligamentum hepatoduodenale idoleges leszorítása által kiváltott májenzim- és szövettani változások vizsgálatához kísérletes modellen.

Intermittent compression of the structures of the hepatoduodenal ligament, is often performed during liver surgery. As a result, changes in hepatic blood supply and consequent reperfusion induced tissue damages will develop. Ischemia-reperfusion injury, which occur in local and distant regions, influence outcome of hepatic surgery, and it is in close correlation with the duration of hypoxia during the intervention. In animal model the effect of Baron/Pringle manoeuvre was investigated in terms of changes in liver function tests and histology. The study was carried out on 12 Beagle dogs, clamping of the hepatoduodenal ligament for 3×15 minutes then half an hour reperfusion was performed followed by blood and tissue sampling. Significant histological changes were observed both in the liver as well as the small intestine. In terms of liver function changes, GPT elevation occurred the earliest, GOT and LDH were also increased at the end of the 30 minutes reperfusion. In this animal model, the third 15 minutes compression turned out to be too long. Elevation in GPT levels was the most sensitive marker.

[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.

[Abdominal compartment syndrome in severe acute pancreatitis -- literature review]. / Abdominalis compartment-syndroma súlyos acut pancreatitisben -- irodalmi áttekintés.

The incidence of intraabdominal hypertension or abdominal compartment syndrome, as the more severe form is called, is relatively high in patients with severe acute pancreatitis, and therefore more attention is needed to the topic. If conservative treatment fails, immediate surgical decompression is indicated. The most commonly used operation is a full thickness median laparotomy, but a transversal laparotomy may also be effective. Although subcutaneous linea alba, or bilateral anterior rectus fasciotomy is safe and effective, decompressive laparotomy is indicated in failure of these methods. The open abdomen therapy is not advised due to high morbidity. Primary closure of the abdomen is preferable.

Hemorheological and Microcirculatory Relations of Acute Pancreatitis.

Acute pancreatitis still means a serious challenge in clinical practice. Its pathomechanism is complex and has yet to be fully elucidated. Rheological properties of blood play an important role in tissue perfusion and show non-specific changes in acute pancreatitis. An increase in blood and plasma viscosity, impairment of red blood cell deformability, and enhanced red blood cell aggregation caused by metabolic, inflammatory, free radical-related changes and mechanical stress contribute to the deterioration of the blood flow in the large vessels and also in the microcirculation. Revealing the significance of these changes in acute pancreatitis may better explain the pathogenesis and optimize the therapy. In this review, we give an overview of the role of impaired microcirculation by changes in hemorheological properties in acute pancreatitis.

[Successful treatment of retrohepatic inferior vena cava injury: report of two cases]. / Retrohepaticus vena cava sérülés két sikeresen operált esete.

UNLABELLED: Authors present two cases of successfully operated patients with retrohepatic inferior vena cava (IVC) injury. In the first case a 79 year old female patient suffered from multiple stab wounds in the area of the 4th segment of the right lung as well as in the retrohepatic region in close proximity to the IVC. At the time of the first surgery the IVC injury was not identified. During a second operation, however, the IVC was isolated from the liver using an anterior dissection of the parenchyma with finger-fracture technique and the injury was oversawn finally. Successful haemostasis of the liver was achieved by packing of the perihepatic space, which was removed three days later. In the second case a 25 year-old male patient had suffered blunt abdominal trauma. He underwent laparotomy and packing on the site of the hepatic injury, which had to be repeated seven more times. Later on, another urgent laparotomy was carried out for recurring intraabdominal bleeding and bile leakage, and cholecystectomy was performed due to gallbladder perforation. Another two days later a further emergency laparotomy was indicated for ongoing intraabdominal bleeding, when the bleeding source - an injury (3 mm in diameter) of the retrohepatic IVC - was oversawn. After relatively long postoperative stay both patients were fully recovered and discharged from hospital. CONCLUSIONS: penetrating injuries of the IVC are associated with high mortality rate of approximately 78%. Proper management of these injuries requires experience in both vascular and liver surgery. Retrohepatic IVC injury needs to be considered in the differential diagnosis of ongoing bleeding in penetrating or blunt liver trauma. Packing of the liver is a reliable haemostatic method if bleeding persists due to division of the liver parenchyma.

[Surgical treatment of acute pancreatitis today]. / A mutéti kezelés aktuális kérdései akut pancreatitisben.

UNLABELLED: In case of mild acute pancreatitis the treatment is basically conservative, but in severe cases surgical treatment has an important role. METHODS: authors analyze the indications for operation, the timing and the technical questions of it on the basis of the literature published in the previous ten years. RESULTS AND CONCLUSIONS: sterile pancreas necrosis is rarely but septic necrosis is an indication for surgery if the conservative treatment is unsuccessful. Therapy resistant multiple organ failure, abdominal compartment syndrome and other surgical complications such as bleeding, perforation need surgery treatment. In biliary pancreatitis associated with cholestasis urgent endoscopic sphincterotomy and later cholecystectomy is suggested. In case of pancreas necrosis the ideal time of operation is 21 days after the beginning of the disease because the rate of complications and mortality is high in early operations. Careful necrosectomy is important which has to be extended to the retrocolic and retroduodenal areas as well. Open abdominal surgery has more complications so it is suggested only in selected cases. Operation should be amended with postoperative bursa omental lavage.

[Analysis of clinical course of severe acute biliary and non biliary pancreatitis: a comparative study]. / Biliaris és nem biliaris eredetu súlyos akut pancreatitises betegek kórlefolyásának összehasonlító elemzése.

UNLABELLED: The acute pancreatitis is a relative common disease with incidence of 5-80 per 100000 people of the population. The number of new cases has steadily increased in recent years. The two main etiological factors are alcohol and cholelithiasis. The incidence of alcoholic pancreatitis is higher in male, and the incidence of gallstone pancreatitis is higher in female. AIM: To summarize the difference between the clinical course of biliary and not biliary type of severe acute pancreatitis by analyzing the data of these patients. METHODS: 139 patients treated with severe acute pancreatitis were divided in two groups: biliary (A group) and non biliary (B group) of origin. The two groups were compared on the basis of sex and age, mortality, morbidity, number of surgery and hospital stay. chi 2 probe was used for the statistical analysis. RESULTS: The complications in biliary group were more serious. The average mortality rate was 15.1%, 17.8% in group A and 13.8% in group B. The mortality rate of female patients in group A was significantly higher. CONCLUSION: Female patients suffering from severe biliary acute pancreatitis have higher morbidity and mortality rate. Therefore an elective cholecystectomy is suggested in old female patients with serious co-morbidity and gallstones, before any complications.

[Distal pancreas resection for metastasis of clear cell renal cancer]. / Distalis pancreasresectio világos sejtes veserák metastasisa miatt.

BACKGROUND: Distant spread from renal cell carcinoma is commonly found in the liver and lung. Metastatic involvement of any other gastro-intestinal organ (duodenum, other kidney, adrenal gland) is unexpected. However, clear cell renal carcinoma is known to cause pancreatic metastasis. METHODS: The authors present the case of a successfully operated 82- year-old man, who was operated for a metastatic tumor in his pancreas. 8 years prior to his current hospitalization, a left sided nephrectomy was performed for renal cell carcinoma. The CT scan revealed a tumor localised in the tail of the pancreas. Distal pancreas resection was performed with splenectomy. Histology revealed clear cell renal carcinoma metastasis. CONCLUSIONS: pancreatic tumors are mostly primaries. Renal cell carcinoma generally gives hepatic and pulmonary metastases. However, clear cell renal carcinoma is known to give pancreatic metastasis, too.

[The treatment of spontaneous pneumothorax--focusing on the use of videothoracoscopy]. / A spontán pneumothorax kezelése különös tekintettel a videothoracoscopiára.

AIMS: Videothoracoscopy plays a leading role in the management of spontaneous pneumothorax. This study evaluates various treatment strategies based on early results. PATIENTS AND METHODS: In a five-year period 243 (184 male, 59 female, mean age: 37.1 years) patients were treated with spontaneous pneumothorax in 302 cases. In case of partial ptx observation was used in 24 (8%) and aspiration in 6 (2%) patients. Chest drain was inserted in 241 (67.6%) cases. Indications for surgery were recurrence of disease, previous contralateral pneumothorax and failure of drainage. Videothoracoscopy was indicated in 71 (23.5%), Jakoscopy in 5 (1.7%), thoracotomy in 13 (4.3%) cases. The operation was completed with partial pleurectomy in 25, talcum or mechanical pleurodesis in 32 and 3 cases, respectively. RESULTS: Conservative treatment was successful in 24 (80%) of the 30 conservatively treated cases, while chest drainage succeeded in 204 (84.7%) of the 241 cases. Conversion was needed in 8 (11.3%) cases of the 71 VATS. The remaining 63 patients recovered. Thoracotomy and Jakoscopy were successful in all cases. The postoperative complication rate was 6.3% after VATS, and 7.7% after thoracotomy. Reoperation was performed because bleeding in one case after VATS and thoracotomy. In one case empyema, and in another patient pneumonia developed after VATS. Postoperative bleeding occurred in one case after thoracotomy. The mean hospitalization was 8.5 days after drainage, 9.1 days after VATS and 11.3 days after thoracotomy. The postoperative mortality rate was 1.3% (4 patients). CONCLUSIONS: In case of spontaneous pneumothorax the first choice of therapy is chest tube drainage. VATS is indicated in case of recurrence, failure of drainage and previous contralateral pneumothorax.

Hydatid disease of pancreas: A case report.

Primary pancreatic hydatid disease is extremely rare. Diagnosis of the disease is difficult because hydatid cysts can be confused with a pseudocyst or neoplastic cystic diseases. Authors report a case of a surgically treated hydatid disease of the uncinate process of pancreas. In a 34-year-old patient with minor symptoms, a cystic disease of the pancreas was accidentally identified. CT scan revealed a multivesicular cystic mass with a maximum of 13-cm diameter and with a calcificated wall. During laparotomy, the uncinate process of pancreas was resecated and the cystic lesion was enucleated. Patient was recovered without complications and recurrence of the disease. There must be a suspicion of hydatid disease when cysts are identified in good conditioned, asymptomatic patients, or in case of wall calcification or multivesicular cysts revealed by radiological images. Surgical procedures are recommended in uncertain diagnoses too, because differentiation preoperatively between cystic pancreatic lesions is often impossible.

[Open transgastric necrosectomy for extended walled-off pancreas necrosis]. / Kiterjedt, demarkált pancreas necrosis sebészi kezelése transgastricus necrectomiával.

AIMS: In severe acute pancreatitis the timing of necrosectomy is ideally should be postponed 4-6 weeks after the onset of the disease when the walled-of pancreatic necrosis (WOPN) has developed. The authors present their experience with open transgastric necrosectomy for extended WOPN. PATIENTS AND METHODS: The authors performed 17 (12 male, 5 female with a mean age of 61.6 ± 15.1 years) open transgastric necrosectomies for extended WOPN in a period of 1, January 2012 and 31, December 2017. Before the operations conservative and semiconservative therapy was used for an average of 74.6 ± 83.1 days. The mean size of the WOPNs was 13.8 ± 5.2 cm with localisation of the retrocolic and retroduodenal regions. All necroses were septic. RESULTS: Complications related to the operation were not observed. The mean time of hospitalization after the surgery was 11.6 ± 12.8 days. The mortality rate was 5.9%. Late operation or other interventions for pseudocyst or pancreas fistula formation was not performed. Two patients needed endoscopic dilatation with lavage in the early postoperative period because of fever. New diabetes mellitus was not observed but worsening of previously existed diabetes developed in 6.3% of the cases. CONCLUSIONS: The open transgastric necrosectomy is safe and effective for extended WOPN. The advantage of this type of necrosectomy is the prevention of pancreatic pseudocyst and fistula formation.

Endoscopic sphincterotoMy for delayIng choLecystectomy in mild acute biliarY pancreatitis (EMILY study): protocol of a multicentre randomised clinical trial.

INTRODUCTION: According to the literature, early cholecystectomy is necessary to avoid complications related to gallstones after an initial episode of acute biliary pancreatitis (ABP). A randomised, controlled multicentre trial (the PONCHO trial) revealed that in the case of gallstone-induced pancreatitis, early cholecystectomy was safe in patients with mild gallstone pancreatitis and reduced the risk of recurrent gallstone-related complications, as compared with interval cholecystectomy. We hypothesise that carrying out a sphincterotomy (ES) allows us to delay cholecystectomy, thus making it logistically easier to perform and potentially increasing the efficacy and safety of the procedure. METHODS/DESIGN: EMILY is a prospective, randomised, controlled multicentre trial. All patients with mild ABP, who underwent ES during the index admission or in the medical history will be informed to take part in EMILY study. The patients will be randomised into two groups: (1) early cholecystectomy (within 6 days after discharge) and (2) patients with delayed (interval) cholecystectomy (between 45 and 60 days after discharge). During a 12-month period, 93 patients will be enrolled from participating clinics. The primary endpoint is a composite endpoint of mortality and recurrent acute biliary events (that is, recurrent ABP, acute cholecystitis, uncomplicated biliary colic and cholangitis). The secondary endpoints are organ failure, biliary leakage, technical difficulty of the cholecystectomy, surgical and other complications. ETHICS AND DISSEMINATION: The trial has been registered internationally ISRCTN 10667869, and approved by the relevant organisation, the Scientific and Research Ethics Committee of the Hungarian Medical Research Council (EKU/2018/12176-5). TRIAL REGISTRATION NUMBER: ISCRTN 10667869; Pre-results.