Back to the future: laparoscopic transgastric resection of a subepithelial tumor in the gastroesophageal junction / Vissza a jövobe: gastro-oesophagealis junctio subepitheliális tumorának laparoszkópos transgastricus resectiója

Case report: Laparoscopic wedge resection of the subepithelial tumors of the stomach is a widely accepted and utilized approach. The use of this technique for lesions located near the gastroesophageal junction (GEJ) is rather limited by the high risk of consequential stenosis of the gastric inlet. The laparoscopic transgastric resection can be a feasible choice for this location. A 44-year-old male patient had been investigated for dysphagia, which confirmed a subepithelial gastric lesion. We performed the resection of the tumor using this technique. After the creation of pneumoperitoneum, the stomach was insufflated using an orogastric tube, then 3 balloon-type ports were inserted intragastrically. The 6×3×3 cm large tumor was resected and the mucosa was closed by running sutures. The specimen was placed into a plastic bag, then retrieved from the stomach and the abdominal cavity. The gastrotomy sites of the ports on the stomach were closed. A nasogastric tube was left in situ for 24-hours without any intraabdominal drains. The pneumoperitoneum time was 115 minutes long, blood loss or intraoperative complication was not noticed. The postoperative period was uneventful, and the patient was discharged from the hospital three days after surgery. The histological examination confirmed the diagnosis of leiomyoma. Summary: Even though the follow-up of the patient is ongoing, according to the scientific literature, transgastric resection of subepithelial tumors located near the GEJ is a safe and effective technique, which provides good functional results, without having a higher risk for recurrence.

Author Correction: Intracellular ion concentrations and cation-dependent remodelling of bacterial MreB assemblies.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Intracellular ion concentrations and cation-dependent remodelling of bacterial MreB assemblies.

Here, we measured the concentrations of several ions in cultivated Gram-negative and Gram-positive bacteria, and analyzed their effects on polymer formation by the actin homologue MreB. We measured potassium, sodium, chloride, calcium and magnesium ion concentrations in Leptospira interrogans, Bacillus subtilis and Escherichia coli. Intracellular ionic strength contributed from these ions varied within the 130-273 mM range. The intracellular sodium ion concentration range was between 122 and 296 mM and the potassium ion concentration range was 5 and 38 mM. However, the levels were significantly influenced by extracellular ion levels. L. interrogans, Rickettsia rickettsii and E. coli MreBs were heterologously expressed and purified from E. coli using a novel filtration method to prepare MreB polymers. The structures and stability of Alexa-488 labeled MreB polymers, under varying ionic strength conditions, were investigated by confocal microscopy and MreB polymerization rates were assessed by measuring light scattering. MreB polymerization was fastest in the presence of monovalent cations in the 200-300 mM range. MreB filaments showed high stability in this concentration range and formed large assemblies of tape-like bundles that transformed to extensive sheets at higher ionic strengths. Changing the calcium concentration from 0.2 to 0 mM and then to 2 mM initialized rapid remodelling of MreB polymers.

The surgical removal of orbital foreign bodies: double case report / A szemgödörbe került idegen testek mutéti eltávolítása két eset kapcsán

The surgical procedure of orbital foreign bodies with its complications is not yet solved in Hungary. Despite the fact that many specialities are involved, until the present day, an orbital surgical centre was not developed. The main goal of this case report is to highlight the importance of these events, to develop a surgical approach, to recognize and solve the complications if they are present even in the cases of organic foreign bodies affecting more head and neck anatomical regions and structures. Orv Hetil. 2020; 161(21): 889-894.

Challenges of intensive care and anesthesiology related to COVID-19 pandemic. Practical considerations / [Az aneszteziológiai és intenzív ellátás kihívásai a COVID­19-fertozéssel kapcsolatban. Gyakorlati ajánlás]

Due to the coronavirus epidemic, healthcare systems face growing challenges all around the world nowadays. These challenges are the most critical in the field of intensive treatment and anesthesiology. One of the most important prerequisites of effective critical care treatment is preserving the involved healthcare workers from the infection, by providing them with detailed practical advices on the preventive measures and treatment strategies. The aim of the present review is to summarize the most important related knowledge available from previous experiences. Orv Hetil. 2020; 161(17): 652­659.

Does standing or sitting position of the anesthesiologist in the operating theatre influence sevoflurane exposure during craniotomies?

BACKGROUND: Exposure of the OR staff to inhalational anesthetics has been proven by numerous investigators, but its potential adverse effect under the present technical circumstances is a debated issue. The aim of the present work was to test whether using a laminar flow air conditioning system exposure of the team to anesthetic gases is different if the anesthetist works in the sitting as compared to the standing position. METHODS: Sample collectors were placed at the side of the patient and were fixed at two different heights: at 100 cm (modelling sitting position) and 175 cm (modelling standing position), whereas the third collector was placed at the independent corner of the OR. Collected amount of sevoflurane was determined by an independent chemist using gas chromatography. RESULTS: At the height of the sitting position the captured amount of sevoflurane was somewhat higher (median and IQR: 0.55; 0.29-1.73 ppm) than that at the height of standing (0.37; 0.15-0.79 ppm), but this difference did not reach the level of statistical significance. A significantly lower sevoflurane concentration was measured at the indifferent corner of the OR (0.14; 0.058-0.36 ppm, p < 0.001). CONCLUSIONS: Open isolation along with the air flow due to the laminar system does not result in higher anesthetic exposure for the sitting anesthetist positioned to the side of the patient. Evaporated amount of sevoflurane is below the accepted threshold limits in both positions.

Assessment of severity and time course of critical illness neuropathy in septic patients: a prospective observational study.

OBJECTIVE: In this prospective observational study we investigated electrophysiological alterations in the early phase of critical illness and correlated electrophysiological findings with the clinical picture and outcome. METHODS: We enrolled 21 critically ill surgical patients having ≥ 12 Acute Physiology and Chronic Health Evaluation (APACHE) II scores on admission. Routine non-invasive bilateral electroneurography (ENG) examination of median and ulnar nerves was done on five consecutive days starting in two days after admission. Then weekly follow-up was performed. Motor and sensory nerve conduction indices were calculated and correlated with APACHE II and Simplified Acute Physiology Score II severity scores. RESULTS: On the first examination 18/21 patients had > 20% reduction in the motor and sensory nerve conduction indices. Severity score systems showed significant negative correlation with the daily change of CMAP and SNAP amplitudes and calculated nerve conduction indices (Spearman's correlation, p < 0.001). Mortality was higher in the patients with worse admission ENG and/or stagnant electrophysiological status or declining tendency in the first week. CONCLUSIONS: Electrophysiological alterations appeared soon after the development of critical illness. Early phase alterations showed a strong correlation with patients' general condition and more severe electrophysiological alterations predisposed to higher mortality. In several cases early alterations proved to be reversible.

Non-invasive pulse wave analysis for monitoring the cardiovascular effects of CO2 pneumoperitoneum during laparoscopic cholecystectomy--a prospective case-series study.

BACKGROUND: Peritoneal insufflation results in hemodynamic changes during laparoscopic cholecystectomy. The aim of the present work is to test whether non-invasive applanation tonometry is suitable for reflecting these hemodynamic alterations. METHODS: 41 patients undergoing laparoscopic cholecystectomies were monitored using the SphygmoCor pulse wave analysing system. Peripheral blood pressures (PBP), central aortic blood pressures (CBP), augmentation index (ALX@HR75) and subendocardial viability ratio (SVR) were measured at rest (Phase 1), after anesthetic induction (Phase 2), after peritoneal inflation (Phase 3) and after peritoneal deflation (Phase 4). RESULTS: Induction of anesthesia resulted in a statistically significant reduction in both the peripheral blood pressure and central aortic pressures, accompanied by a decrease in augmentation pressure and augmentation index. Peripheral blood pressures did not change along with the peritoneal cavity insufflation, except for a moderate increase in systolic blood pressure. In contrast to this, an increase could be observed in central aortic pressure (106.77 ± 18.78 vs. 118.05 ± 19.85 mmHg, P < 0.01) which was accompanied by increased augementation pressure (18.97 ± 10.80 vs. 31.55 ± 12.01; P < 0.001) and augmentation index (7.31 ± 5.59 vs. 12.61 ± 7.56, P < 0.001), indicating a rise in peripheral arterial stiffness. CONCLUSIONS: The Sphigmocor pulse wave analysis system can be reliably used for detecting and monitoring cardiovascular changes occurring during laparoscopic cholecystectomy.

Cerebral vasoreactivity to acetazolamide is not impaired in patients with severe sepsis.

INTRODUCTION: The pathophysiology of sepsis-associated encephalopathy (SAE) is not entirely clear, but one of the possible underlying mechanisms is the alteration of the cerebral microvascular function. The aim of the present work was to test whether cerebral vasomotor reactivity is impaired in patients with severe sepsis. METHODS: Patients fulfilling the criteria of clinical sepsis and showing at least 2 organ dysfunctions were included (n = 16). Nonseptic healthy persons without previous diseases affecting cerebral vasoreactivity served as controls (n = 16). Transcranial Doppler blood flow velocities were measured at rest and at 5, 10, 15, and 20 minutes after intravenous administration of 15 mg/kg acetazolamide. The time course of the acetazolamide effect on cerebral blood flow velocity (cerebrovascular reactivity [CVR]) and the maximal vasodilatory effect of acetazolemide (cerebrovascular reserve capacity [CRC]) were compared among the groups. RESULTS: Absolute blood flow velocities after administration of the vasodilator drug did not differ between control and septic patients. Assessment of the time course of the vasomotor reaction showed that patients with sepsis reacted in a similar fashion to the vasodilatory stimulus than control persons. When assessing the maximal vasodilatory ability of the cerebral arterioles to acetazolamide during vasomotor testing, we found that there was no difference in vasodilatory ability between septic and healthy subjects (CRC controls, 54.8% ± 11.1%; CRC sepsis-associated encephalopathy, 61.1% ± 34.4%; P = .49). CONCLUSIONS: We conclude that cerebrovascular reactivity is not impaired in patients with severe sepsis. It is conceivable that cerebral vasoreactivity may be differently involved at different severity stages of the septic process.

[The role of transcranial Doppler sonography in the diagnosis of brain death (a practical review)]. / A transcranialis Doppler-vizsgálat szerepe az agyhalál diagnózisában (gyakorlati kérdések).

The role of transcranial Doppler sonography in diagnosis of brain death (a practical review). The authors summarize the most important technical and practical knowledge regarding transcranial Doppler sonography. The characteristic Doppler signs of the cessation of cerebral blood flow are demonstrated, such as: oscillating flow, systolic spikes and zero-flow. The relatively high sensitivity (93.3%) of the repeated transcranial Doppler measurements in brain death diagnosis is highlighted.