Serum C-reactive protein and white blood cell level as markers of successful percutaneous drainage of acute sterile peripancreatic fluid collection.

BACKGROUND: Percutaneous drainage is not a widely used therapeutic method recently for evacuating peripancreatic sterile fluid collections in patients with severe acute pancreatitis.However, many clinical studies have proved its positive effects. AIM: We tested the changes in serum laboratory parameters:C-reactive protein (CRP), complement factor 3-4 (C 3-4),tumor necrosis factor a (TNF-a), amylase, lipase and white blood cell (WBC) count in patients treated by percutaneous drainage. PATIENTS AND METHODS: 10 patients with severe acute pancreatitis with peripancreatic fluid collection were monitored.Laboratory parameters and the amount of drained fluid were measured on the 1st, 5th and 10th day. Statistical analysis was performed by using Statistica for Windows (Version 7.0)software. P values less than 0.05 were considered statistically significant. RESULTS: We found significant positive correlation between the CRP and WBC serum level and volumes of the drained fluid. We used these parameters as markers of successful percutaneous drainage in case of patients with severe acute pancreatitis complicated with sterile peripancreatic fluid.There was no significant change in the levels of C 3-4,tumor necrosis factor-Î+-, amylase and lipase. CONCLUSIONS: Monitoring of serum CRP and WBC levels maybe recommended for follow up after percutaneous drainage of peripancreatic fluid. ABBREVIATIONS: CRP: C-reactive Protein TNFÎ+-: Tumour Necrosis Factor a, C3-4: Complement 3-4 WBC: White Blood Cell CT: Computed Tomography.

Hemorheological changes caused by intermittent Pringle (Baron) maneuver in beagle canine model.

In liver resection operations the Pringle (Baron) maneuver can be used for temporary ischemia by clamping the hepatoduodenal ligament intermittently. In this beagle canine model we investigated whether hemorheological parameters may alter in systemic, portal and hepatic venous blood and in arterial samples during-after Pringle maneuvers. In Pringle Group unilateral femoral artery and external jugular vein were cannulated. From median laparotomy the hepatoduodenal ligament was exposed. The portal venous system was catheterized via a mesenteric vein and through the inferior caval vein a catheter was led to the hepatic veins. After stabilization, a 15-minute Pringle maneuver was carried out three times with 5-minute interpolated reperfusion periods. In Control Group Pringle maneuvers were not made. Before and after Pringle maneuvers parallel blood samples were taken from the cannulated vessels for determining hematological parameters and erythrocyte aggregation. Following Pringle maneuvers erythrocyte deformability, blood and plasma viscosity were also tested. The results showed that besides systemic hemorheological effects of the intermittent Pringle maneuver local leukocyte count, hematocrit and erythrocyte aggregation index altered mainly in portal venous blood, depending on the repeating number of the maneuvers. Thus, investigations of hemorheological parameters might be useful to determine the optimal duration of the Pringle maneuver.

Surgical treatment of liver metastases from breast cancer.

BACKGROUND/AIMS: The resection of colorectal liver metastases is currently a well accepted and effective treatment. In the past decade liver metastases of breast cancer have been treated more frequently by surgical intervention. METHODOLOGY: The authors retrospectively studied the data of 17 operated patients, and investigated the clinical features of liver metastases, lymph node involvement of primary tumor, the indications of operations, and early and late results of the treatment. RESULTS: The solitary metastasis and demarcated multiple metastases, which seemed (by CT scan) to be operable by Ro resection were among the surgical indications. Different segment resections, 3 laparoscopic resections and one hemihepatectomy were performed. There were no deaths in the perioperative period, though there were two minor postoperative complications in two cases. All patients received chemotherapy. By follow-up, three breast cancer patients died, whose average survival rate was 19.25 months. The other patients' average follow-up time was 15.17 months, without relapse. CONCLUSIONS: In conclusion it appears that in selected cases resection of liver metastases can be safely performed and the survival rate is reasonable.

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.

Mesohepatectomy without hilar dissection in the treatment of malignant focal liver diseases.

BACKGROUND/AIMS: Mesohepatectomy is a method of surgical treatments for the centrally-located liver diseases. These operations were performed without hilar dissection by our modification and the results were evaluated. METHODOLOGY: Between 2000 and 2002 we performed eight modified mesohepatectomy in cases of central malignant tumors of the liver. Preoperative examinations were done by strict protocol. We performed the operation with CUSA US scalpel. On postoperative days 1, 3, 5 and 7, we monitored the patients' liver enzymes, bilirubin level and hemostasis factors. After recovering the patients received chemotherapy. Follow-up was done 3 and 6 months later. RESULTS: The time of operation and the blood consumption were significantly less with this modified technique comparing data found in the literature. The average tumor-free interval is 6.5 months, in five patients. CONCLUSIONS: On reflection of these data, we consider mesohepatectomy performed without hilar dissection to be a suitable method for the treatment of centrally-located tumors. Postoperative morbidity rate is of a similar degree to that of operations using prior dissection, and the advantageous effects of parenchyma sparing mesohepatectomy are retained.

Surgical treatment of intercostal hernia with implantation of polypropylene mesh.

The intercostal hernia of the lung is a very rare extraordinary disease that requires operation because of the complaints and potential complications. The authors review cases of their operations and analyze the subsequence and treatment. Three patients have been treated for intercostal lung hernia in our treatment. The causes of this disease were a previous thoracotomy in one case and fits of coughing in the other two cases. The diagnosis was set up on the grounds of the specific clinical symptoms, thoracic X-ray and CT scan. The hernia was dissolved with percostal stitches and with the suture of the thoracic musculature in two cases. Plastic operation of the thoracic wall by implanting a polypropylene surgical mesh (Prolen, Ethicon, Johnson & Johnson) was performed in the case of the third patient and later in the first two patients due to recrudescence. In one case the authors were constrained to resect the dystelectasial lung in the hernial sac. The three patients had been operated five times. Relapse of hernia was detected in two patients, in whom the intercostal space had been reconstructed with percostal stitches. We did not detect any relapsing in those two patients at 33 and 66 months after the second operation with mesh implantation. The third patient who got mesh implant immediately did not relapse 12 months after the operation. Intercostal lung hernia is an indication of operation. A plastic operation of the thoracic wall combined with the implantation of a surgical mesh is recommended to close the hernial orifice, which is suitable for treating both primary and relapsed hernias. Recurrence is rare in those patients treated with this method.

Laparoscopic treatment of nonparasitic hepatic cysts.

BACKGROUND: We present our experience with laparoscopic deroofing of nonparasitic hepatic cysts. METHODS: Laparoscopic deroofing was performed due to a solitary hepatic cyst in 21 patients and polycystic liver in four patients. Laparoscopy was indicated when a cyst was larger than 5 cm (the general size of cysts was 6.9 cm) and caused complaints and was in a superficial position. In eight patients in whom the cyst was larger than 10 cm, omentoplasty was performed. RESULTS: Intraoperative complications were not detected. Two conversions were performed because of the deep position of the cyst. Postoperative bile leakage was detected in one case that was treated conservatively. The average hospital stay was 4.7 days. Relapse occurred in two patients (8%), but only one of them required a second operation. CONCLUSIONS: We recommend laparoscopic deroofing for treatment of nonparasitic liver cysts. This operation causes only slight discomfort for the patients, the intra- and postoperative morbidity is low, and relapses are rare.

Near total hepatectomy in two steps for surgical treatment of liver metastasis of colorectal tumor.

Liver resections for metastases of colorectal carcinomas are generally accepted. The 5-year survival rate is higher than 30 percent. Major resections can be performed safely with normal remnant liver. The liver regenerates following extended hepatectomies or other major resections. Authors operated on a 57-year-old man for a secondary liver tumor. The primary tumor was in the colon sigmoideum and sigma-resection was made at another hospital 16 months before. The metastasis was in the right lobe of the liver. Authors performed right extended hepatectomy. After systemic chemotherapy, 4.5 months later a new metastasis developed in the left lobe. Despite locoregional chemotherapy, chemoembolization and radiofrequency treatment, the tumor was still growing so a left lobectomy was performed. The patient is macroscopically tumor-free 17 months after the first hepatic resection. The interest in this case is that segments IV to VIII were removed first time, and segments II and III at the second liver resection. Liver regeneration after the first resection made the second operation possible. Only segment I of the original segments remained. Utilizing the regeneration of the liver we can make an effort to perform a complete tumor ablation in two steps.

A medical nutriment has supportive value in the treatment of colorectal cancer.

MSC (Avemar) is a medical nutriment of which preclinical and observational clinical studies suggested an antimetastatic activity with no toxicity. This open-label cohort trial has compared anticancer treatments plus MSC (9 g once daily) vs anticancer treatments alone in colorectal patients, enrolled from three oncosurgical centres; cohort allocation was on the basis of patients' choice. Sixty-six colorectal cancer patients received MSC supplement for more than 6 months and 104 patients served as controls (anticancer therapies alone): no statistical difference was noted in the time from diagnosis to the last visit between the two groups. End-point analysis revealed that progression-related events were significantly less frequent in the MSC group (new recurrences: 3.0 vs 17.3%, P<0.01; new metastases: 7.6 vs 23.1%, P<0.01; deaths: 12.1 vs 31.7%, P<0.01). Survival analysis showed significant improvements in the MSC group regarding progression-free (P=0.0184) and overall survivals (P=0.0278) probabilities. Survival predictors in Cox's proportional hazards were UICC stage and MSC treatment. Continuous supplementation of anticancer therapies with MSC for more than 6 months is beneficial to patients with colorectal cancer in terms of overall and progression-free survival.

Changes in the nutritional state and immune-serological parameters of esophagectomized patients fed jejunaly with glutamine-poor and glutamine-rich nutriments.

BACKGROUNDS/AIMS: In our former study we investigated the effect of glutamine-rich (I) and glutamine-poor (II) jejunal diet in operated patients with acute pancreatitis. In the glutamine-rich diet group clinical benefit and fast recovery of IgG, IgM, serum proteins, retinol-binding protein, albumin could be measured. In the present study the effects of the two types of jejunal diets I and II have been compared on the basis of changes in some immune parameters of 36 patients treated with subtotal esophagectomy for malignancy. METHODOLOGY: In randomized controlled trial data of two groups, I. patients with glutamine-rich Stresson Multi Fibre diet (23 patients) and II. patients with Nutrison Multi Fibre glutamine-poor diet (13 patients) were analyzed. Levels of serum proteins were measured by laser nephelometry, CD markers of lymphocytes by flow cytometry, phagocyte activity by chemiluminescence. RESULTS: Level of proteins decreased on the 2nd postoperative day in both groups, then gradually increased postoperatively. In increase of level of serum protein, retinol-binding protein, prealbumin there was no difference between the two groups. CONCLUSIONS: In patients treated with subtotal esophagectomy, the glutamine-rich enteric diet did not result in faster recovery in levels of prealbumin, retinol-binding protein, immunoglobulins and in outcome of patients than the glutamine-poor nutriment.

[Surgical treatment of intraabdominal hemorrhage in peliosis hepatis]. / Chirurgische Behandlung der intraabdominellen Blutung bei Peliose der Leber.

INTRODUCTION: Peliosis is an infrequent entity characterized by multiple blood-filled cavities mostly involving the liver. Peliosis hepatis usually appears as a rare autopsy finding in asymptomatic patients or in patients with chronic wasting diseases. However, peliosis hepatis may present as hepatic dysfunction or shock from hepatic rupture. MATERIAL AND METHODS: In our report we present the case of a 33-year-old woman with hepatic peliosis causing a hemoperitoneum resulting from liver rupture, which needed immediate surgical treatment. On the basis of symptoms and the laboratory parameters the acute abdomen was evaluated by abdominal ultrasound and CT scan, both revealing a hemoperitoneum and a lesion in the left liver lobe. RESULTS: Embolization was performed by superselective catheterization of the left hepatic artery to stop the bleeding. After stabilization of the patient, left lobectomy of the liver was performed because of the ruptured 15-cm liver tumor. The patient recovered well and was discharged without residual complaints. Histopathologic analysis showed focal parenchymal peliosis. DISCUSSION: The authors evaluate the effectiveness of the surgical strategy in a case of life-threatening focal hepatic disorder. Besides surgery, the authors emphasize the importance of invasive radiological interventions in these cases.

Early jejunal nutrition and changes in the immunological parameters of patients with acute pancreatitis.

BACKGROUND/AIMS: We have compared the effects of glutamine-rich Stresson Multi Fibre and of Nutrison Fibre nutrients on the changes of some immunological parameters of 16 patients with acute pancreatitis. Laboratory parameters included: total protein, albumin, prealbumin, retinol binding protein, IgG, IgA, IgM, IgE, complement components: C3, C4, acute phase proteins: C-reactive protein, transferrin, CD-markers of peripheral lymphocytes and activity of peripheral phagocytes. METHODOLOGY: Nine patients were supplied with Stresson Multi Fibre and 7 patients with Nutrison Fibre, using a nasojejunal tube. The levels of serum proteins were measured with laser nephelometry, the CD markers of lymphocytes with flow cytometry and the phagocytic activity with chemiluminescence. RESULTS: The treatment with glutamine-rich Stresson resulted in significant elevations in the serum levels of IgG, retinol binding protein, compared to the effects of Nutrison Fibre. In addition, the recovery of treated patients was significantly shorter in the Stresson Multi Fibre group than in the Nutrison Fibre group. CONCLUSIONS: The Stresson Multi Fibre nutrient treatment of patients treated for acute pancreatitis seems to have clinical benefit based upon the fast recovery of IgG, IgM proteins which take part in the immunological defense mechanisms.

[Treatment of acute necrotizing pancreatitis: a comparative study]. / Az akut nekrotizáló pancreatitis kezelésének összehasonlító vizsgálata.

The authors compared the therapeutic results of acute necrotizing pancreatitis during two separate time periods involving 97 and 24 patients, respectively. In the group "A", the time period lasted between May 31, 1991 and December 31, 1997. This group consisted of 97 patients, who, in addition to undergoing intensive treatment and antibiotic prophylaxis, later underwent late necrectomy and closed peripancreatic drainage. Jejunal nutrition only occurred in a limited number of 52 patients (53.6%), and was mostly used after a second operation. The group "B" consisted of patients from the time period between January 1, 1999 and December 31, 1999, and consisted of 24 patients treated in each case with intensive treatment in addition to antibiotic prophylaxis, early nasojejunal nutrition, and if necessary CT-guided percutaneous peripancreatic drainage was used. In the case of surgical intervention necrectomy and closed peripancreatic rinsing drainage was used. In group "A", significantly more early operations were performed than in group "B" (31 patients, 32.0% vs. 2 patients, 8.3%). In group "A" the number of reoperations was also higher as a total of 91 (83.5%) were reoperated as compared to group "B" in which a total of 18 (75.0%) reoperations took place. In the group "B", mortality was also lower (12.5%), than in the "A" group (17.5%). The authors attribute the successful therapy to the early jejunal nutrition, CT-guided percutaneous peripancreatic drainage and to the introduction of prophylactic antibiotics.

[CT-guided percutaneous drainage in the treatment of acute necrotizing pancreatitis]. / CT-vezérelt perkután drenázs alkalmazása az akut nekrotizáló pancreatitis kezelésében.

The authors analysed the results of the treatment of 24 patients with acute necrotizing pancreatitis. Besides intensive and operative treatment prophylactic antibiotics, early naso-jejunal feeding, CT guided percutaneous peripancreatic drainage are favourable to avoid septic complications and to postpone the first operation. In 11 patients percutaneous drainage was performed. Using percutaneous drainage three patients (33.3%) recovered without operation, the mean drainage time was 23.4 days. The first operation could be postponed in the other 8 patients after percutaneous drainage. No complications occurred as result of the interventions, although in one patient the drain slipped out spontaneously. Due to the complex treatment the total mortality rate was 12.5%.

[The role of percutaneous radiologic interventions in the treatment of pancreatic pseudocysts]. / Perkután intervenciós radiológiai módszerek helye a hasnyálmirigy áltömlók kezelésében.

Authors evaluate the indications and results of percutaneous puncture and drainage of pancreatic pseudocysts. The interventions were performed in 20 patients. The first line treatment is usually surgical. Percutaneous drainage or aspiration is suggested if the patient is symptomatic, the size of pseudocyst is between 3 and 6 cms and when it can be punctured using radiological procedures, without the risk of damaging other organs. Previous peripancreatic operation, high-risk surgical intervention and the refusal of the operation by the patient should also be considered. Percutaneous drainage is an alternative method for the treatment of pancreatic pseudocysts. The advantages of this procedure are: It is minimally invasive, complications are rare and reintervention is possible. Disadvantage is high risk of recurrence.

Evaluation of hemostatic changes and blood antioxidant capacity in acute and chronic pancreatitis.

BACKGROUND/AIMS: We examined changes in hemostasis, in levels of total antioxidant capacity, and pancreatic enzymes (amylase, lipase) in patients with pancreatitis 1, 3 and 7 days after admission to the clinic, in order to evaluate the inflammatory processes in acute and chronic pancreatitis and to identify new prognostic markers. METHODOLOGY: The rate of CD62 expression--a marker of platelet hyperactivity--and the rate of platelet-leukocyte aggregates were measured by flow cytometry. The connection between the parameters measured and the severity of pancreatitis and also the differences of the parameters in acute and chronic pancreatitis were investigated. RESULTS: On the basis of previous studies it was assumed, that there is a connection between the level of parameters measured and the inflammatory process in the pancreas, and also between the defending processes of the body against free radicals. CONCLUSIONS: Based on our results, we suggest to extend the laboratory measurements to the investigation of hemostatic parameters. The measurement of plasma level of fibrinogen, von Willebrand factor and the rate of platelet activation is especially important.

[Clinical evaluation of local lipiodol chemoembolization therapy in primary and secondary hepatic tumors]. / Primer és szekunder májdaganatos betegek lipiodolos kemoembolizációval végzett helyi kezelésének klinikai értékelése.

The authors treated with locoregional lipiodol chemoembolization 32 patients suffering from primary and secondary liver malignancies. They present the clinical results of the 22 patients who received at least 2 treatments. Distribution of patients: 17 men, 5 women, mean age 56.2 (43-80) years. Seven patients suffered from primary liver carcinoma; regarding the Child's staging of the tumors 4 patients were in Child A, 3 patients in Child B. In 15 cases the treatment indication was secondary liver cancer. The primary tumors in these secondary liver cancer cases were: one case lung cancer, 11 colon (2 cases rectum) cancer, 2 cases pancreas cancer, one case gastric carcinoma. The 22 patients received in total 97 cycles of therapy. After the selective catheterisation of the hepatic artery adriamycin, mitomycin C, 5-fluorouracil or lipiodol was administered. During the mean follow up time of 9 months (3-15 months) remission could be observed in 6/22 patients. The side effects were preventable or medically treatable. It can be concluded that in the case of well-selected cases of non-resectable liver malignancies local chemoembolization could be beneficial, as it could slow down the progression of the underlying disease with the maintainment or even improvement of the quality of life.

[Results of surgical treatment of liver abscess, with special emphasis of percutaneous puncture and drainage]. / Májtályogok sebészi kezelésének eredményei, különös tekintettel a perkután punkció és tartós drenázs alkalmazására.

Authors present 5 cases of liver abscess treated with US or CT guided percutaneous puncture and/or drainage performed in cooperation of the 2nd Surgical Department and the Radiological Department of the University of Debrecen. They analyse the indications and results of this method. They also include the results of twelve liver abscesses treated surgically. For one or a small number of liver abscesses (Bigger than 5 cm) they prefer percutaneous drainage combined with systematic antibiotic treatment if the condition is not complicated by other surgical diseases, and if the abscesses are accessible for radiological intervention. All patients recovered without recurrence during a one-year follow-up period. The main advantages of this method are smaller trauma and fewer complications.

Changes in gastric acidity after ductal decompression in patients with chronic pancreatitis.

OBJECTIVE: To find out whether pancreatic juice released into the stomach has any effect on gastric acidity, and to evaluate the results of operation. DESIGN: Prospective study. SETTING: University Hospital, Hungary. SUBJECTS: 55 patients with chronic pancreatitis. INTERVENTIONS: 27 pancreaticogastrostomies, 8 pancreaticocystogastrostomies, and 20 pancreaticojejunostomies. Gastric pH monitoring. MAIN OUTCOME MEASURES: Alterations in pH after pancreaticogastrostomy. RESULTS: The operations were equally effective for the relief of pain (48/55, 87%) and 46 (84%) had no digestive disorders because they took pancreatic enzyme substitutes. There were no significant differences in gastric pH between the groups. CONCLUSIONS: Although this study was not randomised, the results suggest that pancreaticogastrostomy is a good operation for the relief of intractable pain in selected patients with chronic pancreatitis associated with duct dilatation.