Primary hyperparathyreosis: is concordant sonography and scintigraphy really so important?

BACKGROUND: In primary hyperparathyreosis, US and scintigraphy are the most usual preoperative localization methods for detection of parathyroid adenomas or hyperplasia. RESULTS: 88 (80 female) patients were detected. Unilateral neck exploration was performed in 43 patients (48.9 %) and bilateral exploration in 45 patients (51.1 %). The cure rate was 97.6 %. None case of parathyroid hyperplasia was detected, there were 2 cases of duplex adenoma. For left/right and quadrant localization, sensitivity of US was 71.05 % and 55.07 %, of scintigraphy 95.77 % and 88.71 %, and in concordant imaging 97.67 % and 96.77 %. Analogically, PPV was: US 91.53 % and 76.00 %, scintigraphy 87.18 % and 74.32 %, concordant imaging 93.33 %and 81.08 %. Only US sensitivity was significantly lower, all other differences showed no statistical significance. CONCLUSION: Our data showed low sensitivity but a high positive predictive value of ultrasonography and a high diagnostic value of scintigraphy. Sensitivity and the positive predictive value of concordant localization showed no significant difference, compared to scintigraphy. The routine need for concordance for parathyroid adenoma localization appears dubious, however, its value for prediction of multiglandular disease remains important for protocols that do not apply peroperative localization (Tab. 2, Ref. 35).

[Risk factors for anastomotic leakage following rectal resection - multicenter study]. / Rizikové faktory anastomotické insuficience po resekcích konecníku - Multicentrická studie.

INTRODUCTION: Anastomotic insufficiency (anastomotic leakage) is one of the most serious complications of the sphincter-saving rectal resections, with significant impact on patient morbidity and mortality. The risk rate of anastomotic leakage may be influenced by local anatomic conditions - tumour localisation and stage, possible technical problems in anastomosis construction (ischaemia, anastomosis under tension), and by complex factors associated with the patient - malnutrition, obesity, smoking, corticosteroid therapy and preoperative chemoradiation. MATERIAL AND METHODS: All sphincter-saving rectal resections that were performed between September 2011 and April 2014 in three centres of colorectal surgery, i.e. at Atlas Hospital in Zlín, the Czech Republic, and at Kosice-Saca Hospital and Dérers University Hospital in Bratislava, Slovakia, were included in the present multicentric prospective study. The incidence of anastomotic leakage in laparoscopic and open surgery was compared and the risk factors resulting in leakage occurrence were analyzed. RESULTS: Anastomotic leakage developed in 12 (10.9%) out of the total number of 110 patients. In the laparoscopic group (58 patients), the insufficiency occurred 4x (6.9%), in the 17 converted patients 3x (17.6%), and in the open surgery group (35 patients) the leakage occurred 5x (14.3%). There was no statistically significant difference between these groups. Nevertheless, patients with anastomotic leakage were only males (P=0.006), they had significantly lower pre-operative albumin levels (35.8 g/l vs. 38.3 g/l; P=0.03), as well as a lower pre-operative total protein level (60.8 g/l vs. 64.1 g/l; P=0.07), when compared to patients without insufficiency. Tumour distance from the anal verge in patients with anastomotic leakage was also significantly lower (10.8 cm vs. 12.8 cm; P=0.05). CONCLUSION: The following risk factors for anastomotic insufficiency after rectal surgery were identified: male gender, low pre-operative albumin and total protein levels, as well as decreasing tumour distance from the anal verge. The difference in the incidence of anastomotic insufficiency between laparoscopic and open surgery groups was not statistically significant.

A shorter interval between irradiation of recipient testis and germ cell transplantation is detrimental to recovery of fertility in rams.

The objective of the current study was to identify an optimal time period for donor cell transplantation after irradiation in sheep. The testes of recipient rams were treated with a single dose of 15 Gray (Gy) irradiation followed by germ cell transplantation either 3 or 6 weeks later. Transplantation of donor cells at 6 weeks after irradiation resulted in production of donor sperm by all five recipient rams compared with 4 of 11 rams transplanted at 3 weeks. Rams transplanted 3 weeks post-irradiation appeared to show reduced libido and fertility. Two rams produced sperm with low motility (< 20%) and two other rams were azoospermic. More than 1 year after cell transfer, there were heavy infiltrates of CD45-positive cells and more fibrous tissue in 9 of 14 recipient testes (seven rams) that received cells 3 weeks after irradiation. Taken together, these results suggest that the interval between irradiation of recipients and germ cell transplantation affects the success rate of the procedure, with a 6-week interval preferable. The elevated inflammatory/immune reaction may be responsible, at least in part, for the reduced fertility and low libido observed in the rams that received cells 3 weeks post-irradiation.

[Changes in membrane enzymes in warm liver ischemia]. / Zmeny membránových enzýmov pri teplej ischémii pecene.

BACKGROUND: The aim of the study is to perform a morphological analysis of certain membrane enzymes and parenchymal alterations during warm ischemia in the pig liver. METHODOLOGY: Standard hepatectomies were performed in a set of 24 pigs. Intraoperative intravenous (portal vein) hydroxyl radical scavenger Stobadine and Pentoxifylline was administered. Tissue specimens were removed from the margo acutum in interval 10, 60, 80 et 100 minutes. Applied methods of morphological analysis were concentrated on studying the activity of enzymes, which are regarded as cell membrane condition markers. First of them was the alkaline phosphatase, the second studied enzyme was the 5'-mononucleotidase. Detected findings in control group were compared to other two groups. We evaluated each sample using Image Forge Version 1.1 software (PROVER LTD., Bratislava). Applying this software we measured percentage of pre-measured activity levels of both enzymes. RESULTS: In normal pig liver, the activity of alkaline phosphatase was regularly distributed in sinusoid walls in the whole lobule. At 10 minutes after the beginning of the warm ischemia, we have found focal losses of enzyme activity, especially in cells of zone 3 of the liver lobuli. One hour after the beginning of warm ischemia were the local losses of enzyme activity even more pronounced. Decreased bile canalicular 5'-mononucleotidase activity reflects cell damage, especially in pericentral areas after 60 min.of ischemia and a further decrease in activity at all surfaces of the membrane. Total amount of enzyme activity is different. CONCLUSIONS: Morhological findings of enzyme activities showed that zone 2 and 3 of the liver lobule are essential for the organ survival. The study showed, that intravenous administration of Pentoxifylline and Stobadine probably protects the liver from warm ischemia injury.

Subtotal colectomy in the treatment of acute malignant left-sided large bowel obstruction.

BACKGROUND: The goal of this study is to evaluate our long-term experience with the decision of optimal urgent surgical treatment. METHODS: This study is a retrospective analysis and comparison of patients with acute left-sided malignant bowel obstruction and results after staged or single-stage operations. All hospital records of patients undergoing stage or one-stage surgical procedures in the la 10-year period (1998-2007) were analyzed considering the severity of illness, postoperative morbidity and mortality, reoperations, hospital stay, quality of life and long term results of surgical treatment. RESULTS: There were 99 men and 86 women with the median age 66 years (range 35-88 years). Subtotal colectomy (SCE) as one-stage procedure weas performed in 85 (45.9%) of patients. Two-stage procedures required re-operations in 21% vs 3.5% in SCE group, postoperative morbidity was 19.0% vs 5.9%, the average hospita I stay was 21 vs 16 days. CONCLUSION: Authors consider SCE foran optimal urgent surgical method for treatment of acute malignant left-sided large bowel obstruction for the next reasons: it is a one-stage procedure in decompensated bowel obstruction with generally acceptable postoperative morbidity, allowing an effective elimination of the "third space", detoxication of the patient, making it possible to eliminate definitively the malignancy with a minimal impairment of patients life comfort (Fig. 2, Tab. 2, Ref. 12). Full Text (Free, PDF) www.bmj.sk.

Warm liver ischemia in experiment and lysosomal markers.

BACKGROUND: The aim of the study is to perform a morphological analysis of certain lysosomal enzymes and parenchymal alterations during warm ischemia in the pig liver. METHODS: Standard hepatectomies were performed in a set of 24 pigs. Intra-operative intravenous (portal vein) Pentoxiphylline and hydroxyl radical scavenger Stobadine was administered. Tissue specimens were removed from the margo acutum in 10 minutes interval. RESULT: In normal pig liver, the acid phosphatase (ACP) activity is in not numerous Kupffer cells and on the biliary pole of hepatocytes, diffusely in the whole parenchyma. One hour after the beginning of warm ischemia, there was an increase in ACP activity in the cytoplasm of hepatocytes. The activity in Kupffer cells could not be detected. Lactate dehydrogenase (LDH) is localized exclusively in the cytoplasmic matrix of liver cells, so only cytoplasmic enzymes leak into the blood plasma. LDH activity has remained low in areas around portal and central veins. CONCLUSION: Morphological findings of enzyme activities showed that zone 2 and 3 of the liver lobule are essential for the organ survival and signs of diffusion of lysosomal enzymes into the cytoplasm of hepatocytes indicate one of the possible explanations for the findings after liver reperfusion. The study showed that intravenous administration of Pentoxiphylline and Stobadine protects the liver from warm ischemia injury (Tab. 2, Fig. 2, Ref. 37). Full Text (Free, PDF) www.bmj.sk.

Sensitivity of spermatogonia to irradiation varies with age in pre-pubertal ram lambs.

Although germ cells from donor rams transplanted into irradiated recipient testes have produced donor derived offspring, efficiency is low. Further optimization of recipient irradiation protocols will add precision to the depletion of recipient spermatogonia prior to germ cell transplant. Three irradiation doses (9,12,15 Gy) were administered to ram lambs aged 14 weeks (Group 1) and 20 weeks (Group 2), then testicular biopsies were collected 1, 2 and 3 months after irradiation. At 1 month after irradiation of Group 1, only the largest dose (15 Gy) reduced spermatogonia numbers below 10% of non-irradiated controls, whereas in Group 2 lambs, each irradiation dose reduced spermatogonia below 10% of controls. In both Groups, fewer differentiated germ cells were present in seminiferous tubules compared to controls. At 2 months after irradiation, spermatogonia numbers in both Groups increased more than sixfold to be similar to controls, whereas fewer differentiated germ cells were present in the tubules of both Groups. At 3 months in Group 1, each irradiation dose reduced spermatogonia numbers to <30% of controls and fewer tubules contained differentiated germ cells. Lesser expression of spermatogonial genes, VASA and UCHL-1, was observed in the 15 Gy group. In Group 2, only 12 Gy treated tubules contained fewer spermatogonia. Knowledge of these subtle differences between age groups in the effect of irradiation doses on spermatogonia or differentiated germ cell numbers and the duration of recovery of spermatogonia numbers after irradiation will aid the timing of germ cell transplants into prepubertal recipient lambs.

Vacuum supported laparostomy--an effective treatment of intraabdominal infection.

BACKGROUND: Notable experience using the vacuum assisted closure for abdominal wall defects was an assumption for its intra-abdominal application in severely septic patients with intra-abdominal infection. The goal of this study was to evaluate our experience with this new therapeutic technique. METHODS: This study is a retrospective analysis and comparison of two groups of patients with severe sepsis and proven intra-abdominal source of infection. Group A consisted of 41 patients, 31 men and 10 women with the age ranging 18-78 years old (mean 49.5), who were treated surgically between 1998 and 2002 using a combination of laparostomy, multiple irrigations and abdominal drainage. Group B consisted of 46 patients, 32 men and 14 women age 18-87 years old (mean 50.8), who were treated between 2002 and 2006 using former techniques with the addition of an intra-abdominal vacuum assisted negative pressure therapy system. RESULTS: In the group A the number of re-laparotomies with debridement of the open abdominal wound in general anesthesia ranged from 5 to 18 over 10 to 35 days (mean 19.4) of hospital stay. In the group B, the number of re-laparotomies decreased to 3-9 and the hospital stay decreased to 7-29 days (mean 14.5). Fifteen patients (36.6%) in the group A died because of severe sepsis, compared to 11 patients (23.9%) in the group B. CONCLUSION: Authors confirmed a significant reduction of morbidity and mortality using the intraabdominal vacuum assisted system in the treatment of localized intra-abdominal sepsis (Tab. 2, Ref 18). Full Text (Free, PDF) www.bmj.sk.

The effects of occlusive techniques on the short-term prognosis after liver resections.

BACKGROUND/AIMS: Anatomic liver resection can be performed without vascular occlusion, but controlling blood loss during liver parenchyma dissection by compression or clamping of vessels in the liver hilus is almost the rule. The aim of this study is to assess the negative consequences of different types of occlusion techniques used during liver parenchyma dissection. METHODOLOGY: From 2001 to 2003, 43 anatomical liver resections were performed in patients with primary and metastatic tumors. Patients were divided into three groups according to the duration and the type of occlusion of incoming blood vessels in the hepatoduodenal ligament (continuous over 20 min, continuous under 20 min, or interrupted blood-vessel occlusion for 5 min after every 20 min of occlusion). Blood level of bilirubin, ALT, AST and prothrombin time were evaluated in the postoperative period. RESULTS: Within the continuous occlusion group that lasted longer than 20 minutes (37 +/- 14 min) increase in levels of bilirubin and liver enzymes and decrease of prothrombin time were noted as compared to the group with occlusion shorter than 20 minutes and to the group with intermittent occlusion over 20 minutes (34 +/- 5 min). CONCLUSIONS: From results issued, it can be seen that using intermittent occlusion during liver parenchyma dissection lasting longer than 20 minutes causes less ischemic-reperfusion injury in the remaining liver parenchyma than by using continual occlusion.

Matrix-assisted laser desorption/ionization mass spectrometry of DNA using photocleavable biotin.

Oligonucleotides containing a photocleavable biotin (5'-PC-biotin) were analyzed by matrix assisted laser desorption/ionization mass spectrometry (MALDI-MS) with wavelengths in the ultraviolet (UV) and infrared (IR) from solution and after capture on streptavidin-coated agarose or magnetic beads. The analysis was used to monitor the release of the oligonucleotides as a result of photochemical cleavage of the biotinylated linker. Near-UV pulses (UV-MALDI) led to predominant release of the photocleaved product. In contrast, only the uncleaved analyte was detected using IR pulses (IR-MALDI). Results from MALDI analysis are also presented for DNA containing a photocleavable 5'-amino group which can be covalently linked to a variety of activated surfaces and marker molecules. In a demonstration of this approach, a 5'-PC-biotinylated 49 nt RNA oligonucleotide was enzymatically synthesized using a PC-biotin-r(AG) dinucleotide primer, captured on streptavidin coated magnetic beads and analyzed by UV-MALDI. Potential applications of photocleavable linkers combined with MALDI for the analysis of nucleic acids are discussed.

Possible risks in combining endoscopic and surgical therapy of bleeding peptic ulcers.

BACKGROUND/AIMS: Today's therapy of bleeding peptic ulcers consists of pharmacological hemostasis, endoscopic therapy and surgery in chronological order. The aim of this study was to objectively assess the contribution of the contemporary algorithm of therapy with the use of endoscopic and surgical hemostasis techniques for the therapy of bleeding peptic ulcers. METHODOLOGY: This study is a retrospective analysis and comparison of two randomized groups A/B with 427/388 patients with endoscopically verified bleeding from peptic ulcer lesions Forrest I-IIb. Patients in group A (1990-1993) were treated without endoscopic intervention, compared with group B patients (1998-2001) who were treated with endoscopic intervention. In both groups we have statistically scored and compared: quantitative operative therapy share, time interval from the beginning of therapy until surgery, APACHE II score of patients at the beginning of therapy and on the day of surgery, complications requiring re-operation and mortality. RESULTS: In groups A/B surgical hemostasis was required in 15.0/10.6% cases, from which 90.6/61.0% operations were resections and bionomic operations. Data evaluation of APACHE II scores from both groups at the beginning of treatment showed no significant difference, but at the time of operative therapy the APACHE II scores were significantly higher in group B (11.83 +/- 6.49/15.00 +/- 4.36). The length of unstable intervals of bleeding in group B compared to group A was quantitatively lengthened (A = 55.6 +/- 19.8/B = 68.6 +/- 37.0 h). Significant differences were also noted in the number of re-operations 7.8/9.8% and mortality 15.6/24.3% between groups A/B. CONCLUSIONS: The contemporary accepted sequence of hemostatic therapy is accompanied by the risks of limited selection of optimal methods of endoscopic therapy, protracting the interval of bleeding with unfavorable rise in APACHE II score, and hesitancy in indication for surgery in intractable bleeding after non-surgical therapy.

Immunocytochemical studies on endocrine cells of alimentary tract of the pig in the embryonic and fetal period of life.

The study aimed at immunocytochemical analysis of alimentary tract endocrine cells between 20th day of embryonal life and 105th day of fetal life of domestic pig. In the pancreas, presence of endocrine cells was detected already in 20th day and, at the time, the cells comprised around 3/4 all cells in primordia of the organ. Starting at that time, numerous endocrine cells produced insulin and glucagon and individual cells synthesized somatostatin and pancreatic polypeptide. In the 20th day, stomach and duodenum contained single endocrine cells but hormone production was not detected until days 27 and 30. Beginning from this days, both organs manifested rapid increase in the number of gastrin-producing cells. In each of the three organs, the number of somatostatin-producing cells exhibited most extensive changes.

[Parenteral and enteral nutrition]. / Parenterálna a enterálna výziva.

Serious gastrointestinal surgeries are commonly connected with impossibility of natural alimentation. Surgical patient in the introduction of treatment is on various degree of malnutrition. Malnutrition affects about 40% of hospitalized patients. Because of poor symptomatology it remains in background of doctors concern whereby unfavourably influencing postoperative course. Complete nutrition support requires every surgical patient with a surgery excluding oral intake of food over 5-7 days.

[All-in-one parenteral nutrition and enteral nutrition--experience and risks in surgical clinical practice]. / Parenterálna výziva all in one a enterálna výziva--skúsenosti a riziká v chirurgickej klinickej praxi.

The author presents an account on total parenteral nutrition "all-in-one" used in his department in a group of 479 patients, and enteral nutrition in a group of 98 patients in 1995-1997. When the two methods were used, the patients' nutritional status was maintained or improved, while the risk of remediable complications is small. The optimal strategy of postoperative nutritional support is a combination of the two methods. Enteral nutrition makes physiological rereplations during administration possible and reduces the risk of septic complications.

[Surgical risk in treatment of a bleeding gastroduodenal ulcer in the era of invasive endoscopy]. / Prehlad rizík chirurga pocas liecby krvácajúceho vredu gastroduodena v ére invazívnej endoskopie.

OBJECTIVE: Objectivization of the asset of the present therapeutic algorithm in patients with haemorrhage from peptic gastroduodenal ulcers using invasive endoscopic and surgical haemostasis. METHOD: Comparison of quantitatively and qualitatively equivalent groups of 341/318 patients, the first group without application of invasive endoscopy, the second one with its application. RESULTS: Surgical haemostasis was called for in 12.3/11.6% cases. 92.9/59.5% operations were resections and bionomic operations, the mortality of the patients was 14.3/21.6%, re-operation was necessary in 7.1/13.5% cases. At the time of operation 57.1/78.3% patients were a high risk, the length of the "critical" interval of haemorrhage in the second group increased by 48.3%. CONCLUSIONS: The present accepted procedure of haemostasis is associated with risks of limited selection of the optimal method of invasive endoscopy, the protraction of the interval of haemorrhage with an adverse rise of the index of the patient's risk, inadequate stabilization of the patient during the interval of haemorrhage and controversial indication of surgery in case of intractable haemorrhage.

[Diverticulosis of the small intestine and massive digestive tract hemorrhage]. / Divertikulóza tenkého creva a masívne krvácanie do tráviacej rúry.

The authors present the case-record of a female patient with serious haemorrhage from the digestive tract. A surprising finding of the acute surgical diagnosis and treatment in the stage of compensated hypovolaemic shock were multiple diverticula of the small intestine aborally from the lig. Tretz on the mesenterial side of the intestine. Massive haemorrhage originated in the diverticula of the terminal ileum, haemostasis was achieved by hemicolectomy with resection of the bleeding part of the ileum. The selected surgical treatment is successful on a long-term basis.

[Acute cholecystitis during the time of minimally invasive abdominal surgery] ]. / Akútna cholecystitída v miniinvazívnom období brusnej chirurgie.

OBJECTIVE: To define optimal rules for the treatment of acute cholecystitis taking into account possible laparoscopic surgery. METHOD: Critical analysis of the authors' group of 90 patients with acute cholecystitis. RESULTS: Optimal results were achieved with surgical treatment within 72 hours after the first clinical symptoms of the disease without the need of conversion of the laparoscopic operation in the authors' group. Surgery between the third and tenth day of hospitalization is unfavourable with a conversion rate of 18%. CONCLUSION: Acute cholecystitis with complications calls for urgent classical surgery, acute cholecystitis without complications laparoscopic operation within 72 hours after the first clinical symptoms. In critically ill patients alternative cholecystostomy or puncture of the gallbladder may be used.

[Causes of rupture in laparotomy incisions]. / Príciny ruptúry laparotomickej rany.

The objective of the presented work was a quantitative analysis of causes of ruptures of laparotomic wounds with emphasis on risk factors, and thus a contribution to the prevention of the mentioned complication. Complete rupture of laparotomic wounds such as eventration are encountered most frequently in interaction of high intraabdominal pressure and weakness of the suture. Continuous loop stitch is the optimal closure of laparotomy. The authors evaluated in a retrospective study a group of 21 patients with eventration and found a coincidence of causes increasing the risk of rupture of the laparotomic wound. From the quantitative aspect serious causal factors include the length and urgency of primary surgery, infection of the wound, a combination of pathogenetic factors such as malignancy, diabetes, anaemia, obesity and hypoproteinaemia. The interaction of different causes increases the risk of wound rupture in all four stages of healing of the surgical wound.

[Technics in the treatment of gastroesophageal varices]. / Taktika liecby gastroezofageálnych varixov.

In a prospective study based on contemporary knowledge of the problem of gastrooesophageal varices the authors submit the algorithm of the therapeutic procedure. Sclerotization treatment holds a dominant position, as it can be used in all stages of the disease and in all three groups of patients classified according to Child. In case of gastric varicosities which cannot be treated by sclerotization the method of choice in patients of groups Child A, B are ablative operations and selective portosystemic anastomoses, in concurrent hypersplein: azygo-portal separation.

[Changes and risks in gastroduodenal surgery]. / Zmeny a riziká v chirurgii gastroduodena.

By retrospective analysis of clinical material changes and risks of gastroduodenal surgery were evaluated. The number of elective operations declined and the number of urgent surgical operations on account of peptic ulceration in conjunction with the development of medicamentous antiulcerous treatment increased. The number of patients with gastric cancer is rising. The range of surgical operations is preserved, none of the operations is ideal treatment. The risk of reoperation involves long-term morbidity and a high mortality.