[Early results of various reconstructions of abdominal incisional hernias with Prolene mesh]. / Hasfali hegsérvek Prolene hálóval történó, különbözó rekonstrukcióinak korai eredményei.

Authors report on the early results of 127 operations performed for incisional hernias without selection in the last two years. Prolene mesh (in 8 patients with sublay, in 5 with inlay and in 27 with onlay technique) was implanted into the abdominal wall. They examined the wound healing influenced by the various methods of mesh placement. The time of operation, drainage and postoperative stay was shorter, the volume of liquid drained from the wound was less in reconstructions of incisional hernias without mesh. In the group without mesh (n = 87) 4 patients were lost, and wound complications developed in 8.1%. After mesh implantations (n = 40) wound complications occurred in 12.5% of the patients. In 2 patients the mesh had to be removed, then a new one reimplanted. There was no difference in results of various methods of mesh placements. According to their good experiences obtained in operations for incisional hernias, if indicated, the use of a mesh in recommended to avoid recurrences.

[Surgical treatment of duodenal perforation]. / A nyombélfekély perforációjának sebészeti kezelése.

Duodenal ulcer can be cured successfully by the eradication of Helicobacter pylori (H. p.) and administration of anti-acid secretory drugs, however, from among the complications of duodenal ulcer, perforation with unchanged incidence continues to need an urgent operation. The authors examined the case histories, results of preoperative examinations, data of operations, and postoperative events of 175 patients hospitalized for perforation of duodenal ulcer in the past five years. The average age of the 38 women was more than 20 years greater than that of the 137 men. The time between the appearance of the serious symptoms and the operation exceeds 24 hours in 31 patients. There was serious preoperative general condition (ASA IV. and V.) in 13.7% of the cases. In the last year infection with H. p. was proved with Pylori Screen II (Orion Diagnostica) serological examination in 22 patients. Closure of the perforation was made in open fashion in 155 (average operative time: 54.1 min.), laparoscopically in 7 (average operative time: 117.9 min.) and gastric resection was necessary in 12 patients (average operative time: 154.6 min.). In 20.4% of the survivors a complication was observed. All of the 18 non-survivors (10.3%) were operated on in poor condition and beyond recovery. Seven patients operated on laparoscopically experienced undisturbed recovery, and stayed in the hospital the shortest time (average: 5.4 days). In the authors opinion the preoperative knowledge of H. p. infection influences the method of the operation of choice, and they recommend the laparoscopic access in elected cases.

Video-choledochoscopy in bile duct surgery.

The authors report on common bile duct explorations performed in 92 patients and in one patient laparoscopically. In their practice usually ERCP and EST were attempted first when bile duct stones were suspected. Open choledochotomy was performed when the endoscopic approach was unsuccessful, or a stone was detected during selective intraoperative cholangiography. In 16 cases intraoperative video-choledochoscopy was performed. The thing that increased the average operating time by 47 minutes. In 4 patients in this group residual stones were detected postoperatively, presumably because of the inexperience of the surgeons with the use of the choledochoscope. Postoperative cholangiography raised the suspicion of a residual stone altogether in 8 cases. Postoperative ERCP was negative in 2 instances, EST and stone extraction were successful in 3 patients, but unsuccessful in 3 patients. In these last cases a successful reoperation was made in one, ESWL and dissolution therapy were performed in two patients. The authors advise to learn the technique of laparoscopic removal of the bile duct stones and the application of guide-wire, Dormia basket, Fogarty balloon catheter, and balloon dilatator. According to the data of the literature, the one stage laparoscopic procedure is successful in most of the patients, more comfortable, and cost saving.

Laparoscopic removal of a foreign body from the jejunum.

Swallowed foreign bodies evacuate spontaneously; therefore, their removal is necessary only if a complication is under suspicion or has ensued. A man of 22 years swallowed, with suicidal intentions, the 9-cm-long and 1.5-cm-wide blade of his pocket knife, which, according to repeated x-ray investigations, was impacted partly through the pylorus into the duodenum. Because of the symptoms, perforation could not be excluded, so laparoscopic removal was decided on. The blade meanwhile passed into the jejunum and was localized intraoperatively with a c-arm fluoroscope. After jejunotomy and removal of the blade, the opening of the small bowel was closed with intracorporeal hand-suturing technique. Postoperative recovery was quick and uneventful. On the evidence of the case history presented, the laparoscopic removal of a foreign body from the gastrointestinal tract can be judged a convenient procedure.

Laparoscopic removal of posterior gastric wall polyp trough gastrotomy using hand suturing and mechanical abdominal wall retractor.

Gastrofiberscopy is suitable not only for diagnostics, but for the therapy of benign gastric polyp and early gastric cancer as well. Surgery is necessary if endoluminal ultrasonography cannot exclude the extension of early gastric cancer to the submucosa or if, because of a recurrent or giant polyp, gastrofiberscopic polypectomy is unsuccessful.

[Management of pancreatic necrosis]. / Pancreasnecrosis kezelése.

The authors report on the results of operations successively carried out in the last one and a half years on 10 patients with pancreatic and peripancreatic necrosis. On admission objective prognostic signs were quantified according to Ranson (average: 4.89), and the prognoses of serious disease-processes were correctly determined. On admission on the intensive care unit APACHE II points were calculated (average: 13.9), and the individual risk of hospital mortality (average: 42.2%) was defined. In spite of this high average, only 2 patients were lost (20% actual mortality). This can be attributed to monitoring the patients in the intensive care unit, successful therapy of multiorgan dysfunctions and failures, radical necrectomy, continuous lavage of the lesser sac, epidural sympathicolysis, reoperations performed in time, total parenteral and jejunal nutrition, and antibiotic therapy based on results of serial cultures. The authors point to the possibility of infection originating sometimes from the treatment applied, mostly from repeated operations. For the sake of improvement and international comparison of the results they suggest the application of Ranson- and APACHE II scores in medical, surgical and intensive care units, where the treatment of patients with acute pancreatitis takes place. The subsequent complete restitution of the saved patients justifies the long-lasting and expensive treatment.

[Management of cholelithiasis associated with acute edematous pancreatitis]. / Az akut ödémás pancreatitisszel társuló epeköbetegség kezelése.

The authors operated on fifty-four patients for gallstone disease associated with acute edematous pancreatitis in the years 1988-1993. The patients were operated on in the first admission, after the symptoms of pancreatitis had run their course and after normalization of amylase-concentration. Preoperative EST was successful in 7%. Depending on the results of routine intraoperative cholangiomanometry choledochotomy was carried out in 11% of the cases. There were no surgical technical difficulties in operations performed in the same admission. At the onset of pancreatitis the authors consider it right to apply one of the objective prognostic scoring systems suitable to predict the severity and prognosis of pancreatitis. Then, depending on its result and the risks of the planned intervention, ERCP-EST is proposed, leaving the gallbladder "in situ" and, either traditional, or laparoscopic cholecystectomy is also permissible.

[Surgical treatment of gallbladder diseases in patients over 70 years of age]. / A 70 éven felüliek epebetegségének sebészeti kezelése.

The authors give a retrospective analysis of the results of 162 biliary operations performed in a five-year period on patients over 70 years of age. The mortality rate of 87 elective operations was 3.45%, of 75 acute operations 6.17%. During the same period 321 ERCPs and 120 ESTs were carried out in patients over 70, out of whom 2 were operated on and lost (mortality: 1.67%) because of bleeding after EST. The total mortality rate was 7.41% (n = 12). The circumstances of negative and positive choledochotomies were analysed together with the relationship between the operating time and the course of the disease. Out of the negative choledochotomised patients (n = 10) 3, out of the positive ones (n = 40) 5 patients died. For each patient over 70, to shorten the operative time and to prevent perioperative complications, the authors recommend the consideration of ERCP prior to biliary operation, and in certain cases, instead of elective biliary surgery, for bile duct stone, EST and stone extraction is advisable, leaving the calculous gallbladder "in situ". Further investigations are necessary, in the authors opinion, to decide whether prior to emergency operation on patients over 70 urgent ERCP and, when bile duct stone is diagnosed, EST with stone extraction is justified, too.

Late results of thyroid surgery for hyperthyroidism performed in childhood.

The authors report on the complex follow-up of 60 patients operated on for hyperthyroidism in childhood, on average 13.7 years after surgery. In 16.7% of the patients manifest hypothyroidism, in 45% subclinical hypothyroidism was found; 30% of the patients were euthyroid, and manifest hyperthyroidism recurred in 8.3%. Autonomous adenomas were enucleated in two children and three young adults. Severe disorders in thyroid function developed especially after the surgery of diffuse toxic goiters accompanied by ophthalmopathy. The disorders of humoral and cellular immunity were detected most frequently in recurrent manifest hyperthyroidism. There was no case where ophthalmopathy progressed after the operation. In the offspring of the operated patients the incidence of hyperthyroidism was not increased in childhood. The authors call attention to the importance of postoperative follow-up and hormone treatment.

Late prognosis of childhood and juvenile thyroid carcinomas.

The authors report on the biological properties and late prognosis of 16 children and juvenile patients operated on during the past 24 years for thyroid tumour who underwent regular followup. The clinical and morphological characteristics of the carcinomas are described, together with the late immune response of the patients undergoing complex treatment. The study is also concerned with the characteristics of the DNA content of the tumorous cell nuclei, the pregnancy success rate of the operated patients and the thyroid function of the children born.

[Cellular immunologic studies in pediatric and juvenile thyroid cancer]. / Zellularimmunologische Untersuchungen beim kindlichen und juvenilen Schilddrüsenkrebs.

Reported in this paper are findings recorded from nine thyroid cancer patients in childhood and adolescence. T-cell sub-populations were determined by means of the rosette method and by reference to monoclonal antibodies. The investigations were concerned also with detectability of tumour antigens and with cytotoxicity. The immune activity exhibited by young patients was better than that recordable from adults. These findings are likely to suggest relative benignity of thyroid cancer, when surgically treated in childhood and adolescence.

The validity of some morphologic methods in the diagnosis of thyroid malignancy.

The diagnostic accuracy of intraoperative frozen section and imprint cytology in thyroid conditions was analyzed along with that of cytofluorimetric nuclear DNA determination. Of 149 frozen sections in a four-year period, 90% gave a correct diagnosis, while four results were false-positive and one was false-negative. The intraoperative accuracy of imprint cytology was 95% in 309 examinations, with 12 false-positive and four false-negative results. The misjudgements with both morphologic methods derived mainly from decisions on benignancy or malignancy of follicular tumor types. Neither atypical adenoma nor encapsulated follicular carcinoma can be conclusively distinguished with these methods. Their routine application nevertheless is of great help to the surgeon, in that they can considerably reduce the need for second (radical) operations and thus the risk of complications. Nuclear DNA determination was unhelpful in the intraoperative situation.

[Preclinical and manifest hypothyroidism following thyroid gland operation]. / Präklinische und manifeste Hypothyreose nach Schilddrüsenoperationen.

62 patients who were strumectomized on account of carcinoma of the thyroid gland, hyperthyroidism and thyroiditis underwent an after-examination on an average 6 years after operation. In preclinical hypothyroidism which cannot be differed from euthyroidism on the basis of the thyroid hormone concentrations, or only by means of the TRH-tolerance test, an increased TSH-response after TRH-tolerance and a T3-preference in comparison to T4 were observed. In manifest hypothyroidism the compensatory mechanisms exhausted and despite the increased TSH-concentration in the serum the ability for TRH-stimulation and the concentrations of the thyroid hormone are reduced. In preclinical and manifest hypothyroidism are recommended ca. 160-170 micrograms thyroxin per day for the substitution therapy after operation of benign diseases of the thyroid gland and after operations of the thyroid tumour the suppression therapy with ca. 220 micrograms thyroxin per day.

Simultaneous occurrence of Graves' disease with endocrine ophthalmopathy. Thyroiditis and thyroid carcinoma.

The simultaneous occurrence of Graves' disease with ophthalmopathy lymphocytic and subacute de Quervains' thyroiditis has been observed in two male patients suffering from follicular-type thyroid carcinoma. In one of them Sjögren syndrome and a mild form of diabetes were also diagnosed. It is assumed, on the basis of indirect evidence, that the humoral and cellular lesions determined by genetic factors and influenced by prolonged thyrostatic and steroid treatment are jointly responsible for tumour genesis.

[Thyroid neoplasms and pregnancy]. / Schilddrüsencarcinom und Schwangerschaft.

Pregnancies and deliveries of ten patients are reported who underwent a complex treatment (surgery, 131J, thyroid hormone) for highly differentiated follicular and papillary thyroid carcinomas. Out of ten cases, in 3 cases two were pregnant and in two cases two delivered. Besides papillary and papillofollicular carcinomas, surgery revealed that six patients had regional lymph node metastases of N1 or N2. On the evidence of the deliveries, follow-up examinations after the operation, and complementary treatment of these two types of tumor, pregnancy is not contraindicated, since a progression of the primary disease, neonatal hypothyroidism, and factitious hyperthyroidism have not been found.