[Changes in the treatment of upper gastrointestinal tumors]

A felső gastrointestinalis traktus daganatai nagy mortalitású betegségek. Az elmúlt évtizedekben bekövetkezett technikai fejlődésnek köszönhetően a betegek túlélése jelentősen javult, de az átlagos 5 éves túlélés sem gyomor-, sem nyelőcsőtumorok esetén nem haladja meg a 35%-ot. A szűrőprogramot bevezető országokban a betegek gyakran korai stádiumban kerülnek felfedezésre, és ellátásuk endoszkópos úton is lehetséges. Az onkológia fejlődésével a tumorok terápiájának a multimodális megközelítés lett az alapja, ezzel mód nyílt az előrehaladott állapotú betegek mind nagyobb arányú kuratív célú kezelésére. A minimálisan invazív technikák térhódítása megfelelő onkológiai radikalitás mellett csökkentette a műtéti megterhelést és javította a posztoperatív felépülést. Az utóbbi években egyre nagyobb hangsúlyt kapott a betegek komplex előkészítése, így tovább javultak a műtéttel kapcsolatos morbiditási mutatók. Írásunkban összefoglaljuk a felső tápcsatorna daganatainak ellátásában az utóbbi évtizedekben bekövetkezett változásokat. Orv Hetil. 2024; 165(6): 203–210.

[Innovations in colorectal surgery]

Összefoglaló cikkünkben a colon- és rectumcarcinomák sebészeti kezelésében az elmúlt években megjelent új elveket, új ötleteket és technológiákat tekintjük át. A tanulmány narratív összefoglalás, mely tematikusan kiemelt colorectalis sebészeti irodalmi ismeretek gyűjteményét adja két, a colorectalis sebészetben jártas sebész független válogatása alapján. A coloncarcinomák esetében a komplett mesocolon-excisiót (CME), illetve a radikális lymphadenectomiát, a jobb és bal colonfél tumorainak biológiai eltéréseit, valamint a tumorbiológiai jellemzők alapján a neoadjuváns gyógyszeres kezelés lehetőségeit értékeljük. A rectumcarcinomák sebészeti megoldásai közül a transanalis teljes mesorectum-excisio (TaTME), a robotsebészet, az intersphinctericus reszekciók, illetve a lymphadenectomia radikalitásának kérdései, végül a szervkímélő rectumsebészet kerül tárgyalásra. A colon- és a rectumcarcinoma sebészete mára jelentősen eltérő utakra jutott. A technikai, technológiai innováció nyújtotta lehetőségeket a patológiai, onkológiai ismeretekkel összhangban személyre szabott terápiás lehetőségekként indokolt a mindennapokban multidiszciplináris döntés alapján alkalmazni. Orv Hetil. 2024; 165(2): 43–50.

[Philosophy and technque in everyday practice of robotic surgery]

A modern, betegközpontú sebészet alapja a pácienst ért műtéti stressz minimalizálása. E tekintetben jelentett forradalmi újítást a minimálisan invazív sebésztechnikák megjelenése. A laparoscopos kulcslyuksebészet mára számos kórkép kezelésében "gold standard" megoldássá vált. A párhuzamosan megjelenő robotsebészeti rendszerek a sebészi beavatkozások invazivitásának további csökkenését eredményezték. A laparoscopos beavatkozások előnyei mellett a robotsebészet alkalmazása során a még precízebb technikai megvalósítás jelentős javulást hozott egyes mutatókban, úm. onkológiai, funkcionális eredmények. A szöveti szintű preparálás, a képletek speciális szögekből való megközelítése a sebészet határait újra kijjebb tolta. A kezdeti lépések után a robotasszisztált beavatkozások körében, az urológiai és nőgyógyászati területek után, egyre nagyobb teret kaptak az emésztőszervi megbetegedések is. Jelen összefoglaló tanulmány célja a robotasszisztált műtétek sajátosságainak bemutatása, valamint a robotsebészet szerepének, eredményeinek összefoglalása gastrointestinalis tumorok tekintetében.

[Surgery of peritoneal surface malignancies - surgical cytoreduction and hyperthermic intraperitoneal chemotherapy]

Peritoneal carcinosis has historically been considered as inoperable, although the technique of its resesection together with high dose intraperitoneal chemotherapy potentiated by heat has been described decades ago. It has not became a widely practiced routine except in specialized centers - the complex technique, weakly standardized but resource demanding chemotherapy, lacking financial background and the many times questionable clinical benefit at a cost of high surgical load might have been the key factors. Refined technology, developing chemotherapy protocols together with growing clinical evidence are now more sharply delineating the range of indications where the procedure might be beneficial, increases survival, or is the only curative therapy. These include tumors of the appendix and pseudomyxoma peritonei, mesothelioma, and selected cases of ovarian, colorectal and gastric cancer. In addition to technical description of the intervention, we summarize the currently valid indications and describe our institutional protocol for the treatment of appendiceal malignancies.

[The most common gastrointestinal alterations in patients with post-COVID syndrome]

INTRODUCTION

Post-COVID syndrome may affect the gastrointestinal tract. However, risk factors of post-COVID syndrome are still unknown.

OBJECTIVE

We aimed to identify the most common gastrointestinal symptoms, abnormal laboratory findings and risk factors relevant to post-COVID syndrome.

METHOD

In this retrospective study, we included 79 patients admitted to Semmelweis University Department of Surgery, Transplantation and Gastroenterology between October 2020 and September 2022. We investigated clinical data, laboratory findings and determined the major risk factors.

RESULTS

Most of the patients were women (46/79), their mean age was 47.6 years and patients were overweight (BMI: 26.3 kg/m2). The most common comorbidities were cardiovascular diseases (21/79), hypertension (20/79), diabetes (11/79) and malignant diseases (9/79). Typical indications for gastroscopy were dyspepsia (16/79) and epigastric pain (10/79). The most common indications for colonoscopy were diarrhea (29/79) and weight loss (28/79). Among abnormal laboratory findings, liver enzymes levels (GOT: 83.5 U/L, GPT: 85 U/L, GGT: 70 U/L) and ferritin (351.5 ng/mL) were higher in post-COVID patients. Typical conditions diagnosed by gastroscopy, colonoscopy and abdominal ultrasound were gastroesophageal reflux disease (11/26), irritable bowel syndrome (2/19) and diffuse hepatic lesions, respectively. The number of unvaccinated patients was higher compared to those receiving any COVID-19 vaccines (58% vs. 29%). Of the vaccinated patients, 12 patients received mRNA vaccines (10 Pfizer-BioNTech, 2 Moderna) and 6 patients received viral vector vaccines (2 AstraZeneca, 4 Sputnik V).

CONCLUSION

We identified female gender, obesity, cardiovascular diseases, cancer, hypertension and diabetes as major risk factors of post-COVID syndrome. Vaccinated status may prevent post-COVID gastrointestinal symptoms. Orv Hetil. 2023; 164(31): 1206-1212.

[Possibilites of application of traditional Chinese medicine - acupuncture - in the perioperative period.]

Chinese medicine is a holistic method of therapy with thousands of years of history. There are more assumptions regarding the mechanism of action, nevertheless, several studies have demonstrated its therapeutic effect. Nowadays, patients and physicians have become open to complementary medicine, but acupuncture used in the perioperative period has not yet widespread in Hungary. The aim of the article is to describe traditional Chinese medicine, primarily the effect of acupuncture and laser acupuncture on patients undergoing surgery. Relieving anxiety before surgery, alleviating pain, nausea and vomiting during and after surgery is a basic anesthesiology task, however, the drug therapy can be supplemented with any technique of acupuncture. Based on numerous studies, acupuncture effectively reduces the incidence of postoperative nausea, has an anxiolytic and analgesic effect, and also has an anti-inflammatory effect caused by surgical stress. There are rarely contraindications to its application, accurate knowledge of the rules of point selection and with proper technique acupuncture is a low-risk, pain-free procedure that can be performed by inducing a mild needling sensation. Based on all this, it can become a part of multimodal therapy. Orv Hetil. 2023; 164(30): 1187-1193.

Hypocalcemia on Admission Is a Predictor of Disease Progression in COVID-19 Patients with Cirrhosis: A Multicenter Study in Hungary

Hypocalcemia is a common condition in liver cirrhosis and is associated with the severity of SARS-CoV-2 infection. However, there is a lack of data demonstrating the prognostic value of hypocalcemia in COVID-19 patients with cirrhosis. This study aimed to evaluate the prognostic value of hypocalcemia for COVID-19 severity, mortality and its associations with abnormal liver function parameters. We selected 451 COVID-19 patients in this retrospective study and compared the laboratory findings of 52 COVID-19 patients with cirrhosis to those of 399 COVID-19 patients without cirrhosis. Laboratory tests measuring albumin-corrected total serum calcium were performed on admission, and the levels were monitored during hospitalization. The total serum calcium levels were significantly lower in cirrhosis cases (2.16 mmol/L) compared to those without cirrhosis (2.32 mmol/L). Multivariate analysis showed that hypocalcemia in COVID-19 patients with cirrhosis was a significant predictor of in-hospital mortality, with an OR of 4.871 (p < 0.05; 95% CI 1.566-15.146). ROC analysis showed the AUC value of total serum calcium was 0.818 (95% CI 0.683-0.953, p < 0.05), with a sensitivity of 88.3% and a specificity of 75%. The total serum calcium levels showed a significant negative correlation with the Child-Turcette-Pugh score (r = -0.400, p < 0.05). Hypocalcemia on admission was a significant prognostic factor of disease progression in COVID-19 patients with cirrhosis.

[Surgery of the colorectal polyps and early stage cancer - Expected standards]

Benign polyps and early-stage cancer of the colon and rectum traditionally belong to the territory of endoscopic removal. Even though the quality of endoscopic imaging systems and additional diagnostic methods have undergone a substantial evolution over the past decade, large, sessile and lateral-spreading lesions of the large bowel still represent a significant risk of malignancy. This doubt may be undispellable until the removal of the lesion. Therefore endoscopists need to be highly cautious, and keep a very low threshold to involve an expert surgeon even at the phase of diagnostics, as well as treatment. We summarise state-of-the-art treatment principles of benign polyps and early malignant colorectal cancer. Finally, we propose national quality measures of surgical interventions for colorectal polyps.

[Machine perfusion in kidney transplantation]

The field of organ transplantation has been facing the problem of organ shortage for several years. It is even more crucial since the number of patients on the waiting list is growing steadily. There have been numerous approaches to resolve the issue: on the one hand, extending the donation criteria and, on the other hand, improving organ preservation using machine perfusion. Experimental and clinical studies have already proven that machine perfusion decreases the incidence of delayed graft function and improves graft survival, which is particularly significant in extended criteria donation. Machine perfusion is used widely in kidney transplantation. The most frequently used method is hypothermic machine perfusion but the normothermic method is gaining more attention as well. Depending on the temperature set, machine perfusion may not only be used for organ preservation but also for organ conditioning. There is still ongoing research in the field of therapeutic approaches during machine perfusion, which may play an important role in decreasing ischaemia-reperfusion injury and immunogenicity in grafts. After a brief description of extended criteria donation, our review aims to summarize the methods and the latest results of machine perfusion, including diagnostic and therapeutic approaches in the field of kidney transplantation. Orv Hetil. 2023; 164(9): 339-347.

Evidence-based hand hygiene: Liquid or gel handrub, does it matter?

BACKGROUND

Recent studies put under scrutiny the prevailing hand hygiene guidelines, which incorporate quantitative parameters regarding handrub volume and hand size. Understanding the criticality of complete (i.e., efficient) hand hygiene in healthcare, objectivization of hand hygiene related parameters are paramount, including the formulation of the ABHR. Complete coverage can be achieved with optimal Alcohol-Based Hand Rub (ABHR) provided. The literature is limited regarding ABHR formulation variances to antimicrobial efficiency and healthcare workers' preference, while public data on clinically relevant typical application differences is not available. This study was designed and performed to compare gel and liquid format ABHRs (the two most popular types in Europe) by measuring several parameters, including application time, spillage and coverage.

METHODOLOGY

Senior medical students were invited, and randomly assigned to receive pre-determined ABHR volumes (1.5 or 3 ml). All the 340 participants were given equal amounts of gel and liquid on two separate hand hygiene occasions, which occurred two weeks apart. During the hand hygiene events, by employing a digital, fully automated system paired with fluorescent-traced ABHRs, disinfectant hand coverage was objectively investigated. Furthermore, hand coverage in relation to the participants' hand sizes was also calculated. Additional data collection was performed regarding volume differences and their effect on application time, participants' volume awareness (consciousness) and disinfectant spillage during the hand hygiene events.

RESULTS

The 1.5 ml ABHR volume (commonly applied in healthcare settings) is insufficient in either formulation, as the non-covered areas exceeded significant (5%+) of the total hand surface area. 3 ml, on the contrary, resulted in almost complete coverage (uncovered areas remained below 1.5%). Participants typically underestimated the volume which they needed to apply. While the liquid ABHR spreads better in the lower, 1.5 ml volume compared to the gel, the latter was easier handled at larger volume. Drying times were 30/32 s (gel and liquid formats, respectively) when 1.5 ml handrub was applied, and 40/42 s when 3 ml was used. As the evaporation rates of the ABHR used in the study are similar to those available on the market, one can presume that the results presented in the study apply for most WHO conform ABHRs.

CONCLUSION

The results show that applying 1.5 ml volume was insufficient, as large part of the hand surface remained uncovered (7.0 ± 0.7% and 5.8 ± 1.0% of the hand surface in the case of gel and liquid, respectively) When 3 ml handrub was applied drying times were 40 and 42 s (gel and liquid, respectively), which is a very long time in daily clinical practice. It looks like we cannot find a volume that fits for everyone. Personalized, hand size based ABHR volumes may be the solution to find an optimal balance between maximize coverage and minimise spillage and drying time. 3 ml can be a good volume for those who have medium size hands. Large handed people should use more handrub to reach appropriate coverage, while small-handed ones may apply less to avoid massive spillage and not to take unrealistically long to dry.

[Successful pregnancy of a patient with primary sclerosing cholangitis awaiting liver transplantation]

In women, primary sclerotising cholangitis (PSC) associated with ulcerative colitis and intrahepatic cholestasis is a rare disease. To date, there are no data from Hungary on the fertility and pregnancy outcome of women with this chronic liver disease. Our aim is to present the favorable pregnancy outcome of a woman with PSC associated with ulcerative colitis, intrahepatic cholestasis and postpartum colectomy, and review of the literature. A young nulligravida was first diagnosed with ulcerative colitis. Five years later, PSC developed with progressive fibrosis and cholestasis necessitating liver transplantation. While on waiting list, spontaneous conception occurred. Except for pregnancy-induced hypertension, pregnancy uneventfully progressed until the third trimester when 8 g oral cholestyramine/day was administered to lower high maternal (over 100 μmol/L) total bile acid (TBA) level. In the 36th week of gestation acute exacerbation of ulcerative colitis resulted in maternal fever and chorioamnionitis leading to fetal distress. Elective delivery of the eutrophic neonate followed by emergency cesarean section. In the early puerperium, colitis progressed to septic pancolitis resistant to medical treatment. 12 days after laparoscopic subtotal colectomy, the patient was discharged in good health condition. 3 months later, ileostomy was closed and she got back on the transplantation waiting list. Our data correspond with previous reports and suggest that women with PSC with underlying ulcerative colitis and cholestasis have a good chance for favorable pregnancy outcome. However, both PSC and underlying colitis might progress during pregnancy and puerperium. Oral cholestyramin is an effective and safe treatment for high maternal TBA levels. Orv Hetil. 2023; 164(6): 234-240.

Effectiveness of COVID-19 Vaccination with mRNA Vaccines for Patients with Cirrhosis in Hungary: Multicentre Matched Cohort Study

Patients with cirrhosis are vulnerable to hepatic decompensation events and death following COVID-19 infection. Therefore, primary vaccination with COVID-19 vaccines is fundamental to reducing the risk of COVID-19 related deaths in patients with cirrhosis. However, limited data are available about the effectiveness of mRNA vaccines compared to other vaccines. The aim of our study was to investigate the efficacy of mRNA vaccines versus other vaccines in cirrhosis. In this retrospective study, we compared clinical characteristics and vaccine effectiveness of 399 COVID-19 patients without cirrhosis (GROUP A) to 52 COVID-19 patients with cirrhosis (GROUP B). 54 hospitalised cirrhosis controls without COVID-19 (GROUP C) were randomly sampled 1:1 and matched by gender and age. Of the cirrhosis cases, we found no difference (p = 0.76) in mortality rates in controls without COVID-19 (11.8%) compared to those with COVID-19 (9.6%). However, COVID-19 patients with cirrhosis were associated with higher rates of worsening hepatic encephalopathy, ascites and esophageal varices. Patients with cirrhosis receiving mRNA vaccines had significantly better survival rates compared to viral vector or inactivated vaccines. Primary vaccination with the BNT162b2 vaccine was the most effective in preventing acute hepatic decompensating events, COVID-19 infection requiring hospital admission and in-hospital mortality.

A malignus eredetű dysphagia palliatív kezelésére használt merev és öntáguló sztentek eredményeinek összehasonlító vizsgálata

Bevezetés: A nyelőcső malignus szűkületeinek palliatív kezelésére 1984 és 2019 között 1005 merev protézist és 423 öntáguló sztentet ültettünk be. Célkitűzés: Tanulmányunk célja a két protézisfajta kezelési eredményeinek összehasonlítása volt. Módszer: Retrospektív elemzés során összehasonlítottuk a két betegcsoport jellemzőit, kezelési eredményeit a technikai sikeresség, a szövődmények, az életminőség alakulása és a túlélés vonatkozásában. Eredmények: Az átlagéletkorok, az anamnézisidők, a testsúlycsökkenés értéke, a tumoros folyamat előrehaladottságának összehasonlítása azt igazolja, hogy a sztenttel történő palliáció több rosszabb állapotú beteg kezelését tette lehetővé. A szövődmények száma a sztenttel kezelt betegcsoportban szignifikánsan magasabb: 29,3%/20,9% volt. A szövődmények ellátására endoszkópos intervenciót végeztünk, a merev protéziseknél 68,6%-ban, a sztenttel kezelteknél 53,2%-ban. A dysphagia és a betegek életminőségének lényeges javulása volt észlelhető a merev protézissel kezelteknél 97%-ban, a sztenttel kezelteknél 91,3%-ban. A túlélési idő a sztenttel kezelt betegcsoportban szignifikánsan rövidebb, 4,3/5,4 hónap volt. Következtetés: Az öntáguló sztentek alkalmazása a malignus szűkületek palliatív kezelésében a lehetőségek bővülésével lényeges változásokat hozott a mindennapi gyakorlatban. A kezelési eredményeket az öntáguló sztentek szélesebb körű használata nem javította annyival, mint amennyivel a betegcsoport rosszabb állapota rontotta. Orv Hetil. 2022; 163(49): 1952–1961.

The Elevated De Ritis Ratio on Admission Is Independently Associated with Mortality in COVID-19 Patients

Liver damage in COVID-19 patients was documented as increased alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels or an elevated AST/ALT ratio, known as the De Ritis ratio. However, the prognostic value of the elevated De Ritis ratio in COVID-19 patients is still unknown. The aim of our study was to evaluate the prognostic value of the De Ritis ratio compared to other abnormal laboratory parameters and its relation to mortality. We selected 322 COVID-19 patients in this retrospective study conducted between November 2020 and March 2021. The laboratory parameters were measured on admission and followed till patient discharge or death. Of the 322 COVID-19 patients, 57 (17.7%) had gastrointestinal symptoms on admission. The multivariate analysis showed that the De Ritis ratio was an independent risk factor for mortality, with an OR of 29.967 (95% CI 5.266-170.514). In ROC analysis, the AUC value of the the De Ritis ratio was 0.85 (95% CI 0.777-0.923, p < 0.05) with sensitivity and specificity of 80.6% and 75.2%, respectively. A De Ritis ratio ≥1.218 was significantly associated with patient mortality, disease severity, higher AST and IL-6 levels, and a lower ALT level. An elevated De Ritis ratio on admission is independently associated with mortality in COVID-19 patients, indicating liver injury and cytokine release syndrome.

Case report of actinomycotic liver abscess following COVID-19 infection

Introduction and importance

In the last few years, the novel coronavirus, named severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), generated a large health care problem worldwide. Due to the immunomodulation effect of the virus the number of opportunistic infections has also increased.

Case presentation

We present the unique case of a patient who was diagnosed with an actinomycotic liver abscess after coronavirus disease 2019 (COVID-19) without the presence of any chronic disease or mucosal injury.

Clinical discussion

According to the results of the computer tomography (CT scan) and the liver biopsy, the patient was treated with antibiotics and ultrasound-guided drainage.

Conclusion

With this case we would like to draw attention to the possible occurrence of liver abscesses caused by an opportunistic pathogen following COVID-19.

•

SARS-CoV-2 is an acute respiratory infection, that could result immune dysregulation.

•

Immunocompromised patients have a higher risk for opportunistic infections (e.g. actinomycosis).

•

Actinomycosis could result in liver abscess, which is a rare type of the liver abscesses.

•

Actinomycosis followed by COVID-19 infection disease could be a post-COVID syndrome.

Quantitative Software Analysis of Endoscopic Ultrasound Images of Pancreatic Cystic Lesions

Endoscopic ultrasonography (EUS) is the most accurate imaging modality for the evaluation of different types of pancreatic cystic lesions. Our aim was to analyze EUS images of pancreatic cystic lesions using an image processing software. We specified the echogenicity of the lesions by measuring the gray value of pixels inside the selected areas. The images were divided into groups (serous cystic neoplasm /SCN/, intraductal papillary mucinous neoplasms and mucinous cystic neoplasms /Non-SCN/ and Pseudocyst) according to the pathology results of the lesions. Overall, 170 images were processed by the software: 81 in Non-SCN, 30 in SCN and 59 in Pseudocyst group. The mean gray value of the entire lesion in the Non-SCN group was significantly higher than in the SCN group (27.8 vs. 18.8; p < 0.0005). The area ratio in the SCN, Non-SCN and Pseudocyst groups was 57%, 39% and 61%, respectively; significantly lower in the Non-SCN group than in the SCN or Pseudocyst groups (p < 0.0005 and p < 0.0005, respectively). The lesion density was also significantly higher in the Non-SCN group compared to the SCN or Pseudocyst groups (4186.6/mm2 vs. 2833.8/mm2 vs. 2981.6/mm2; p < 0.0005 and p < 0.0005, respectively). The EUS image analysis process may have the potential to be a diagnostic tool for the evaluation and differentiation of pancreatic cystic lesions.

A focalis nodularis hyperplasia multimodális kezelése

Összefoglaló. A focalis nodularis hyperplasia (FNH) a máj második leggyakrabban előforduló benignus góca. Nem malignizálódik, így a jelenlegi ajánlások szerint eltávolítása relatív indikációt képez. Kezelését illetően több különböző módszer is ismert. A közlemény célja, hogy összefoglalót adjon az FNH ellátásáról és két esetben bemutassa az alternatív kezelési lehetőségeket. Egy 40 éves nőbetegnél hasi panaszok miatt indult kivizsgálás során a májban CT-morfológiailag FNH igazolódott. A laesio lokalizációját figyelembe véve, a sebészeti reszekció magas rizikója miatt, transarterialis embolisatio (TAE) mellett döntöttünk. Többszörös kezelést követően a kontroll képalkotó vizsgálatok alapján jelentős regressziót értünk el, mindemellett a beteg panaszmentessé vált. Egy 25 éves nőbetegnél hasi panaszok miatt történt MR-vizsgálat igazolt FNH-t. Az elhelyezkedésre tekintettel TAE-t végeztünk, a beteg azonban ezúttal nem vált teljesen panaszmentessé. Definitív megoldásként májreszekció történt, melyet követően panaszai megszűntek. Tünetmentes FNH felfedezésekor elegendő lehet a betegek hosszú távú követése. Tünetek, illetve nagy műtéti kockázat esetében a malignus májtumoroknál rutinszerűen alkalmazott TAE az FNH-ban akár önmagában vagy sebészi kezeléssel kombinálva is eredményesen alkalmazható. Kisebb rizikó esetén a legmegfelelőbb választás a primer laparoszkópos reszekció. Orv Hetil. 2022; 163(15): 606-612. Summary. Focal nodular hyperplasia (FNH) is the second most common benign mass of the liver. According to the current recommendations, removal makes relative indication. Several different treatment methods are known. The purpose of the paper is to provide a summary of FNH care and to present alternative treatment options in two cases. A 40-year-old woman was investigated for abdominal complaints; CT scan confirmed FNH of the liver. Given the localization of the lesion, we chose transarterial embolization (TAE) due to the high risk of surgical resection. After multiple treatments, regression was achieved, and the patient became asymptomatic. Painful FNH in a 25-year-old female was confirmed by MRI. The lesion was dominantly seen in segment 1, causing vena cava compression and collaptiform episodes. As a definitive solution, liver resection was performed, after which her complaints ceased. Long-term follow-up of patients may be sufficient when asymptomatic FNH is detected. In the case of symptoms or high risk of surgery, TAE can be used effectively by FNH either alone or in combination with surgical treatment. For lower-risk patients, primary laparoscopic resection is the most appropriate choice. Orv Hetil. 2022; 163(15): 606-612.

Az endoszkópos ultrahangvizsgálat diagnosztikus érzékenysége epeúti kövesség gyanúja esetén

Összefoglaló. Bevezetés: Az epeúti kövesség meglétének valószínűsége különböző klinikai prediktorok alapján megbecsülhető, e faktorok szenzitivitása és specificitása azonban nem kielégítő. Az endoszkópos ultrahangvizsgálat az epeúti kövesség diagnosztizálásának szemiinvazív precíz eszköze. Célkitűzés: Célunk az endoszkópos ultrahangvizsgálat diagnosztikus érzékenységének vizsgálata gyanított epeúti kövesség esetén. Módszer: A prospektív vizsgálat során a betegeket az Amerikai Emésztőszervi Endoszkópos Társaság (ASGE) ajánlása szerint meghatározott prediktorok alapján közepes és magas valószínűségi csoportokba osztottuk, és endoszkópos ultrahangvizsgálatot, valamint amennyiben szükséges volt, endoszkópos retrográd kolangiopankreatográfiát (ERCP) végeztünk. Eredmények: Összesen 95 beteget vizsgáltunk. Az endoszkópos ultrahangvizsgálat 53 (56%) beteg esetében írt le epeúti kövességet: 55%-ban (39/71) a közepes valószínűségi és 58%-ban (14/24) a magas valószínűségi csoportban. Az ERCP mindegyik choledocholithiasisos esetet megerősítette. A két valószínűségi csoport között nem volt szignifikáns különbség (p = 0,56) az ERCP által igazolt epeúti kövesség tekintetében. Az ERCP csupán 1 esetben detektált epeúti kövességet a negatív endoszkópos ultrahangvizsgálat ellenére. Az endoszkópos ultrahangvizsgálat specificitása 100%, szenzitivitása 98%, míg pozitív és negatív prediktív értéke 100%, valamint 98% volt. Megbeszélés: Az epeúti kövesség meglétének becslése különböző klinikai prediktorok alapján kihívást jelenthet. Következtetés: Az endoszkópos ultrahangvizsgálat szenzitív és pontos diagnosztikus eszköz a choledocholithiasis kimutatására és értékelésére, olyan esetekben is, amelyeknél az előzetes képalkotók nem találtak kövességet. Orv Hetil. 2022; 163(10): 400–406.

Summary. Introduction: The likelihood of common bile duct stones can be prognosticated by various clinical predictors, however, the sensitivity and specificity of these factors are moderate. Endoscopic ultrasonography has been shown to be a semi-invasive precise test for the detection of common bile duct stones. Objective: Our aim was to assess the diagnostic accuracy of endoscopic ultrasonography in patients with suspected choledocholithiasis. Method: Patients of this prospective study were categorized and divided into intermediate likelihood and high likelihood groups according to the clinical predictors defined by the American Society of Gastrointestinal Endoscopy (ASGE) guidelines and referred for linear endosonography. Endoscopic retrograde cholangiopancreatography (ERCP) was performed if needed. Results: A total of 95 patients were assessed. Common bile duct stones were detected by endoscopic ultrasonography overall in 53 (56%) patients: 55% (39/71) in the intermediate likelihood and 58% (14/24) in the high likelihood group of patients. The detected common bile duct stones in all patients were confirmed by ERCP. There was no significant difference (p = 0.56) in the detection of stones by ERCP between the two likelihood groups. ERCP confirmed choledocholithiasis only in one patient whose preceding endosonography did not detect stone. The specificity and sensitivity of endoscopic ultrasonography were 100% and 98%, the positive predictive value and negative predictive value were 100% and 98%, respectively. Discussion: Estimating the likelihood of choledocholithiasis based on various clinical predictors might be challenging. Conclusion: Endoscopic ultrasonography is a highly sensitive and accurate diagnostic tool for the detection and evaluation of common bile duct stones also in patients with previous normal imaging findings. Orv Hetil. 2022; 163(10): 400–406.

Role of faith in strategies of healthcare professionals in intensive care units in end-of-life decision making

Összefoglaló. Bevezetés: A haldoklást minden korban kulturális és vallási szabályok vették körül, melyek a mai napig hatnak a társadalomban. A 21. században számos beteg a kórházban, az intenzív osztályon fejezi be életét, ahol nem ritkán kerülhet sor életvégi döntés meghozatalára. Célkitűzés: Vizsgálatunk célja annak feltárása volt, milyen hatással van az orvosok és ápolók vallásossága a kezeléskorlátozással kapcsolatos döntésekre az intenzív osztályon. Módszer: Magyarországi intenzív osztályokon dolgozó orvosok és szakdolgozók körében végeztünk kérdőíves felmérést a vallás életvégi döntésekre gyakorolt hatásáról. 189 orvos és 105 ápoló által anonim módon kitöltött kérdőívet elemeztünk. Eredmények: Az intenzív osztályra történő betegfelvételre nem volt hatással a vallásosság, azonban a szabad ágyak száma a vallásos orvosokat erősebben befolyásolta, mint az ateista és választ nem adó orvosokat (<0,0001). A vallásukat gyakorló orvosok szignifikánsan jobban figyelembe vették a hozzátartozó kérését, mint az ateisták (p = 0,0002). A vallásos ápolók gyakrabban folytatnák a beteg kezelését a hozzátartozó kérése ellenére is, ha még látnának esélyt a gyógyulásra, mint a nem vallásosak. Következtetés: Vizsgálatunk alátámasztotta, hogy a világnézet befolyásolja az orvosokat és ápolókat az élet végéről hozott döntésekben. A kezeléskorlátozásról hozott döntés összetett, elengedhetetlen megismerni hozzá a beteg és családjának haldoklással kapcsolatos vallási szokásait, mivel jó életvégi döntés a világnézeti szempontok figyelembevétele nélkül nem hozható. Orv Hetil. 2021; 162(51): 2047-2054.

SUMMARY

INTRODUCTION

Death has always been surrounded by habits in all ages, influenced by cultural and religious differences. Many patients finish their lives at intensive care units where end-of-life decisions are the part of everyday practice in the 21th century.

OBJECTIVE

The goal of our study was to assess how the religious beliefs of physicians and nurses affect their decision on therapy restriction.

METHOD

We have performed questionnaire-based enquiries among physicians and nurses working at intensive care units on how religion affects end-of-life decisions. We have analyzed the anonymous questionnaires filled out by 189 physicians and 105 nurses.

RESULTS

Our results have confirmed the hypothesis that religion affects decision making about therapy restriction. Patients' admissions were not affected by religious beliefs, but the number of available patient beds influenced the religious physicians more than the atheists ones or the non-responders (<0.0001). Actively religious physicians complied significantly better with the relatives than atheists (p = 0.0002). Religious nurses would continue patient treatment even against the will of relatives more often than atheists if they see a chance for recovery.

CONCLUSION

The study supports that religion influences physicians and nurses in their end-of-life decisions. Decisions on therapy restriction are complex; it is important to find out religious beliefs and perception of death among patients and families because good end-of-life decision cannot be made disregarding religious considerations. Orv Hetil. 2021; 162(51): 2047-2054.

Percutaneous transhepatic drainage is safe and effective in biliary obstruction-A single-center experience of 599 patients

BACKGROUND

Historically, surgical bilioenteric bypass was the only treatment option for extrahepatic bile duct obstruction, but with technological advancements, percutaneous transhepatic drainage (PTD) and endoscopic solutions were introduced as a less invasive alternative. Endoscopic methods may lead to a decreasing indication of PTD in the future, but today it is still the standard treatment method, especially in hilar obstructions.

METHODS

In our retrospective data analysis, we assessed technical success rate, reintervention rate, morbidity, mortality, and the learning curve of patients treated with PTD over 12 years in a tertiary referral center.

RESULTS

599 patients were treated with 615 percutaneous interventions. 94.5% (566/599) technical success rate; 2.7% (16/599) reintervention rate were achieved. 111 minor and 22 major complications occurred including 1 case of death. In perihilar obstruction, cholangitis were significantly more frequent in cases where endoscopic retrograde cholangiopancreatography had also been performed prior to PTD compared to PTD alone, with 39 (18.2%) and 15 (10.5%) occurrences, respectively.

DISCUSSION

The results and especially the excellent success rates demonstrate that PTD is safe and effective, and it is appropriate for first choice in the treatment algorithm of perihilar stenosis. Ultimately, we concluded that PTD should be performed in experienced centers to achieve low mortality, morbidity, and high success rates.

Relationship between the coronavirus epidemic and the use of complementary and alternative medicine prior to elective surgical procedures

Összefoglaló. Bevezetés: A 2019 végén Vuhanból kiinduló, SARS-CoV-2 okozta koronavírus-járvány jelentős hatást gyakorolt életünkre. Specifikus terápia hiányában az emberek egy része alternatív gyógymódokhoz fordult. Célkitűzés: Vizsgálatunk célja annak feltárása volt, milyen hatást gyakorolt a koronavírus-járvány a betegek komplementer gyógymódokhoz való viszonyulására elektív sebészeti műtétek előtt. Módszer: Egy magyarországi klinika és egy városi kórház elektív sebészeti műtétre váró betegei körében végeztünk anonim kérdőíves felmérést 2020. augusztus 3. és december 18. között. 279 kérdőívet dolgoztunk fel, a válaszadási arány 69,7% volt. Eredmények: A koronavírus-járvány hatására a válaszadók 91,4%-ának nem változott meg a véleménye a nem konvencionális kezelésekről, 8,2%-a bizakodóbban tekintett ezekre. A komplementer terápia betegségmegelőző hatása iránt a kitöltők 16,8%-a volt bizakodó, 25,4%-a elutasító, 57,7%-a nem formált véleményt. A válaszadók 24,7%-a vett igénybe élete során alternatív módszereket, a koronavírus-fertőzés megelőzésére csak a nyilatkozók 10%-a alkalmazna ilyen gyógymódokat. Kizárólag a pandémia hatására senki nem kezdett el komplementer gyógymódokat használni. A kérdőívet kitöltők 55,6%-a használt gyógynövénykészítményt élete során. A járvány ideje alatt a válaszadók 27,5%-a vett igénybe gyógynövénykészítményeket; a gyógymód alkalmazása és a vizsgált szociodemográfiai tényezők között nem találtunk összefüggést. A gyógynövények alkalmazása alacsonyabb mértékű volt a daganatos és a thromboemboliás betegek között. Következtetés: Vizsgálatunk alapján a komplementer gyógymódok használata feltehetően a járvány miatt elrendelt korlátozásokból adódóan csökkent, a gyógynövények alkalmazása azonban nem változott lényegesen. A válaszadók tizede használt komplementer gyógymódot a koronavírus-fertőzés megelőzésére. Orv Hetil. 2021; 162(42): 1678-1686.

SUMMARY

INTRODUCTION

The coronavirus epidemic caused by SARS-CoV-2 from Wuhan at the end of 2019 had considerable impact on our lives. In the absence of specific therapy, some people have resorted to alternative therapies.

OBJECTIVE

The aim of our study was to explore the effect of the coronavirus epidemic on the patients' attitudes toward complementary and alternative medicine.

METHOD

We have performed anonymous questionnaire survey among patients of a Hungarian university hospital and a city hospital waiting for elective surgery between August 3, 2020 and December 18, 2020. We received 279 questionnaires, the response rate was 69.7%.

RESULTS

As a result of the coronavirus epidemic, 91.4% of the respondents did not change their opinion about complementary and alternative treatments, 8.2% were more optimistic about them. 16.8% of respondents were optimistic, 25.4% rejected, and 57.7% did not form an opinion about the disease-preventing effect of complementary therapy. A quarter of respondents (24.7%) had used complementary therapies in their lifetime, with only 10% of respondents using such therapies to prevent coronavirus infection. As a result of the pandemic, no one started using complementary therapies. 55.6% of the respondents used a herbal preparation during their lifetime. In the course of the epidemic, a high proportion of respondents (27.5%) used herbal preparations; no correlation was found between the use of the treatment and the socio-demographic factors examined. The use of herbs was lower among cancer and thromboembolic patients.

CONCLUSION

Based on our study, the use of complementary therapies presumably decreased due to the restrictions imposed in the epidemic, however, the use of herbs did not change significantly. One-tenth of the respondents used naturopathic cure to prevent coronavirus infection. Orv Hetil. 2021; 162(42): 1678-1686.

Arrodált gyomorgyűrűk kezelése - irodalmi áttekintés egy eset kapcsán

Összefoglaló. Bevezetés: 70 éves férfi beteg kóros kövérség (BMI: 50,1) miatt 2005-ben gyomorgyűrű beültetésben részesült. 2020 decemberében hasfali phlegmone hátterében igazolt port infekció miatt más intézetben subcutan incisió, lavage történt. CT-vizsgálattal, majd gasztroszkóppal a gyomorgyűrű arrosióját, intramurális elhelyezkedését igazoltuk. A műtét során laparoszkópos technikával a gyomor corpus nagygörbületén ejtett, kb. 2 cm nagyságú nyíláson keresztül távolítottuk el a gyűrűt. A beteg szövődménymentesen került emisszióra. Megbeszélés: Mintegy 20 évvel ezelőtt a laparoszkópos állítható gyomorgyűrű (LAGB) rendkívül népszerű volt. A LAGB azonban számtalan rövid és hosszú távú szövődménnyel jár, ezért egyre inkább kikerül a bariátriai sebészet tárházából. A gyűrű arrosiója ritka, súlyos szövődmény. Eltávolításának többféle módja lehet. A gyomorgyűrű eltávolítása általában a testsúly jelentős növekedésével jár. A betegeknél konverziós bariátriai műtétet, laparoszkópos gyomor sleeve reszekciót, vagy gyomor bypass műtétet lehet végezni.

SUMMARY

INTRODUCTION

Extreme obese (BMI: 50.1) 70 year old male patient after LAGB procedure in 2005, with abdominal wall and port infection underwent subcutaneous incision drainage of the area in December 2020. CT and Gastroscopy confirmed gastric penetration and intramural position of the Band. Using laparoscopic approach with incision of 2 cm of the stomach at the gastric greater curvature the band had been removed. Patient had been discharged without any complications.

DISCUSSION

LAGB was a very popular bariatric approach at the first decade of laparoscopic bariatric surgery. The increased incidence of short and long term complications reduced worldwide the number of LAGB procedures. Band penetration is a rare but dangerous complication. Laparoscopic removal is recommended. Usually, the intervention is followed by significant weight gain which can be treated with conversion of LAGB to Sleeve Gastrectomy or LGBP procedure.

Efficacy of Clarithromycin Depends on the Bacterial Density in Clarithromycin-Heteroresistant Helicobacter pylori Infections: An In Situ Detected Susceptibility and Quantitative Morphometry-Based Retrospective Study

The global rise in clarithromycin (Cla) resistance is considered to be the main contributor of Helicobacter pylori (Hp) eradication failures. In nearly half of the Cla-resistant Hp infections, Cla-susceptible bacteria are simultaneously present with the Cla-resistant ones (Cla-heteroresistance). The proportion of resistant bacteria in the bacterial population (R-fraction) and its predictive role for the use of Cla-based therapies in Cla-heteroresistant infections has not yet been investigated. Our retrospective study analyzed gastric biopsy samples of 62 Hp-positive patients with Cla-heteroresistant infection. Fluorescence In Situ Hybridization technique was used to visualize the coexistence of resistant and susceptible bacteria within one tissue sample. R-fraction was quantified on multichannel microimages by digital morphometry. Resistant bacteria had a patchy distribution within the whole bacterial population causing high diversity among the investigated areas. Patients were subdivided into two major groups according to whether a Cla-based eradication attempt was conducted before or after the biopsy sampling. R-fraction was significantly lower among cases having only one previous Cla-based eradication attempt vs. those that had multiple previous eradications, including at least one Cla-containing therapy (0.41 vs. 0.89, p = 0.0308). Majority of the patients without previous eradication attempt had successful eradication with Cla-containing regimen (59.26%), verified by a negative ¹³C-urea breath test or control biopsy. Multivariable model indicated that the therapeutic outcome using Cla-based regimens depended on the bacterial density rather than the R-fraction. Our study raises the potential use of Cla-containing eradication therapies in certain Cla-heteroresistant Hp infections, taking into account the possible predictive role of bacterial density.

Primary and secondary clarithromycin resistance in Helicobacter pylori and mathematical modeling of the role of macrolides

Clarithromycin is a macrolide antibiotic widely used for eradication of Helicobacter pylori infection, and thus resistance to this antibiotic is a major cause of treatment failure. Here, we present the results of a retrospective observational study of clarithromycin resistance (Cla-res) in 4744 H. pylori-infected patients from Central Hungary. We use immunohistochemistry and fluorescence in situ hybridization on fixed gastric tissue samples to determine H. pylori infection and to infer Cla-res status, respectively. We correlate this information with macrolide dispensing data for the same patients (available through a prescription database) and develop a mathematical model of the population dynamics of Cla-res H. pylori infections. Cla-res is found in 5.5% of macrolide-naive patients (primary Cla-res), with no significant sex difference. The model predicts that this primary Cla-res originates from transmission of resistant bacteria in 98.7% of cases, and derives from spontaneous mutations in the other 1.3%. We find an age-dependent preponderance of female patients among secondary (macrolide-exposed) clarithromycin-resistant infections, predominantly associated with prior use of macrolides for non-eradication purposes. Our results shed light into the sources of primary resistant cases, and indicate that the growth rate of Cla-res prevalence would likely decrease if macrolides were no longer used for purposes other than H. pylori eradication.

Clarithromycin is a macrolide antibiotic widely used for eradication of Helicobacter pylori infection. Here, Kocsmár et al. study clarithromycin resistance and previous macrolide consumption in 4,744 H. pylori-infected patients, shedding light into the sources of primary resistant cases and the role played by prior consumption of macrolides for non-eradication purposes.

Polymyositis and rhabdomyolysis caused by hepatocellular carcinoma - Case report and literature review

Introduction

Rhabdomyolysis is a syndrome characterized by a rapid necrosis of muscle fibers and the release of muscle-derived metabolic products into the circulatory system. A rare cause of rhabdomyolysis is paraneoplastic polymyositis.

Case presentation

A 67-year-old man was diagnosed with paraneoplastic polymyositis and rhabdomyolysis caused by hepatocellular carcinoma (HCC). Intravenous steroid was used as a symptomatic therapy for rhabdomyolysis, and the tumour was removed by left hemihepatectomy to treat the underlying cause. After muscle strength gradually improved, steroid therapy was discontinued. The patient was reoperated multiple times due to bleeding and bile leakage. Following the operations, his overall state and muscle strength further improved. Despite that, the patient's condition worsened again, and eventually, he died of candida albicans pneumonia and sepsis.

Discussion

HCC is an extremely rare cause of paraneoplastic polymyositis and rhabdomyolysis. Treatment is challenging, as none of the few available case reports record long term survival and less than half of the reports record muscle strength improvement. In our case, the patient was treated with systemic steroid therapy and resection of the tumour. The patient's muscle strength temporarily improved, but subsequently, the patient died.

Conclusion

Our case confirms the importance of a definitive treatment of HCC, as we achieved a significant improvement in muscle strength by removing the tumour. On the other hand, our paper highlights the dangers of double-sided steroid therapy, which, combined with the essential, effective treatment of rhabdomyolysis, may have contributed to the development of postoperative complications and candida sepsis leading to death.

Vena cava inferior leiomyosarcoma kezelése cavotomiával és a jobb vena renalis neoimplantatiójával

Összefoglaló. A vena cava inferior leiomyosarcomája a vena tunica mediájából kiinduló igen ritka rosszindulatú daganat. Tünetei és radiomorfológiai jelei nem mindig juttatnak pontos kórisméhez, szövettani mintavétele pedig elhelyezkedése miatt veszélyes lehet. Diagnózisa ezért sokszor jelent kihívást a klinikusok számára. Kezelése elsősorban sebészi, amelyet együtt vagy monoterápiában alkalmazott radioterápia és kemoterápia egészít ki. Esetünkben egy 74 éves nőbeteg tünetmentes, a v. cava inferior jobb v. renalis fölötti részének jobb mellékvesével összefüggő tumorát találtuk. Endokrinológiai kivizsgálása során a szérum kortizol, adrenalin, noradrenalin, adenocorticotrop hormon (ACTH), teljes és szabad tesztoszteron, dehidroepiandroszteron-szulfát (DHEA-S), nemi hormon kötőfehérje (sex hormone binding globulin, SHBG) normál tartományban volt, a tumor hormonszekréciót nem mutatott. A tumor sebészi eltávolítása mellett döntöttünk. Preoperatív biopsziát annak kockázatai miatt nem végeztünk. A műtét során a v. cava inferior daganatát találtuk, a tumor eltávolítását végeztük a vena falának resectiójával, a jobb mellékvese eltávolításával és a jobb v. renalis neoimplantatiójával. A jobb feltárás érdekében a műtét elején cholecystectómiát is végeztünk. A műtét után szövődmény nem jelentkezett. A beteg adjuváns radioterápiában részesült. A tumor korai diagnózisának és en bloc resectiójának köszönhetően jelentősen növeltük a beteg gyógyulási esélyeit, az elvégzett radioterápiával pedig csökkentettük a recidíva valószínűségét. Summary. Leiomyosacroma of the inferior vena cava is an extremely rare malignancy originating from the tunica media of the venous wall. Its symptoms and radiomorphological signs do not always lead to an accurate diagnosis. Histological sampling can be dangerous due to its location. Therefore the diagnosis is often a challenge for clinicians. Its treatment is primarily surgical, supplemented by radiotherapy and chemotherapy applied together or in monotherapy. In our case, an asymptomatic 74-year-old female patient was diagnosed with a tumor of the inferior caval vein located just above the right renal vein and involving the right adrenal gland. As serum cortisol, epinephrine, norepinephrine, adrenocorticotropic hormone (ACTH), total and free testosterone, dehydroepiandrosterone sulfate (DHEA-S), sex hormone binding globulin (SHBG) was at normal level, the tumor showed no hormone secretion. Primary surgical resection was planned. Preoperative biopsy was not performed due to its high risk of complications. During operation, tumor resection was performed by resection of the venous wall, removal of the right adrenal gland and neoimplantation of the right renal vein. For better exposure, cholecystectomy was also performed at the beginning of surgery. There were no postoperative complications. The patient received adjuvant radiation therapy. Thanks to the early diagnosis of the tumor and the complete resection, we significantly increased the patient's chances of total recovery. With the radiotherapy performed, we reduced the likelihood of tumor recurrence.

[A rare type of hernia seen twice in our department]

Case reports: a 66-year-old woman was admitted to our Department due to a painful inguinal lump. During examinations an incarcerated femoral hernia was found with an inflamed vermiform appendix inside the hernial sac. Appendectomy and femoral hernioplasty was performed from inguinal approach. The patient was discharged home without complications. Pathological examinations of the specimen showed signs of acute appendicitis. A few weeks later a 76-year-old man with severe comorbidities was admitted to our unit due to painful gangraenous inguinal skin lesion. CT scan showed an incarcerated femoral hernia containing the appendix with subcutaneous abscess. Appendectomy, hernioplasty, and inguinal necrosectomy was performed from an inguinal and low median approach. Another operation was necessary due to postoperative obstruction and subcutaneous dehiscence. After intraabdominal adhaesiolysis and abdominal wall reconstruction negative pressure wound therapy was applied to the inguinal wound, the patient was discharged 22 days after the primary operation. Pathological examinations of the appendix showed low grade mucinous neoplasm. Discussion: The femoral hernia containing the appendix is called de Garengeot’s hernia and is one of the rarest types of inguinofemoral hernias. The clinicopathology of this type of hernia can cover a wide range of symptoms. The definitive preoperative diagnosis is relatively difficult to find without a CT-scan. The surgical approach and treatment depends on the manifestation, clinical findings and on the available equipment and the expertise of the surgeon

Cholecystectomia során bekövetkező epeútsérülések ellátása

Biliary injury is a rare but a very serious complication of laparoscopic cholecystectomy (LC). Our aim was to analyse the incidence of the biliary injuries and its therapeutic outcome on patients who underwent LC or converted LC. Our research was conducted at the 1st Department of Surgery, Semmelweis University, Budapest between 2006 and 2016, retrospectively. We analysed the LCs and converted LCs performed at our Department and as well as cases where the primary operations were conducted at other institutions but they were unable to provide the adequate therapy for the injury, thus the patients were transferred to our institution. At the 1st Department of Surgery complications occurred in 0,66% (30/4885) of all LCs. 327 converted LCs were done, complications occurred in 26 (7.95%) times. 22 patients were transferred to the 1st Department of Surgery from other institutions. Bilio-vascular injuries occurred in 61% (41/78). ERCP was performed in 25 cases with a 92% success rate. Reoperation was needed in 41% (28/41). Biliary reconstruction during the reoperation was performed via hepaticojejunostomy in 82% of all reoperations. The therapeutic solutions of LC's complications are complex. Therefore, the treatment is recommended only in institutions with appropriate experience.

[Decreasing morbidity after Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) with technical modification and patient selection]

Introduction: Resecability of liver tumors is exclusively depending on the future liver remnant (FLR). The remnant can be hypertrophised using portal vein occlusion techniques. The latest hypertrophising method is Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS), which provides the most significant induced hypertrophy in the shortest time. Morbidity and mortality of this procedure were initially unacceptably high. Aim: Reducing complications by better patient selection and modified surgical technique. Method: The First Department of Surgery, Semmelweis University, Budapest, prefers the 'no touch' technique, instead of 'complete mobilization'. For optimizing patient selection, an international registry (including our patients' data) was established. In addition to the surgical, we collected demographic, disease, liver function, histology, morbidity (Clavien-Dindo) and mortality parameters. Volume and function measurements were performed by using CT-volumetry and ^99mtechnecium-mebrofenin SPECT/CT. Data were analyzed by multivariate analysis (significance: p<0.05). Results: We performed 20 ALPPS procedures from 2012 to 2018. The relative volume increment and resectability in our department and among the 320 registry patients were 96% vs. 86% and 95% vs. 98%. Using 'no touch' technique, the Clavien-Dindo III-IV morbidity and mortality rates were significantly lower (22%-0%) than with 'complete mobilization' (63%-36%) (p<0.05). Based on the multivariate analysis of the registry patients, age over 60 years, liver macrosteatosis, non-colorectal liver tumor, >300 minutes operation time, >2 units of red blood cell transfusion, or insufficient FLR function before stage 2 were identified as independent factors influencing mortality (p<0.05). Conclusion: Mortality and morbidity of ALPPS can be reduced by proper patient selection and 'no touch' surgical technique. Orv Hetil. 2019; 160(32): 1260-1269.

Isoform-Dependent Changes in Cytochrome P450-Mediated Drug Metabolism after Portal Vein Ligation in the Rat

BACKGROUND

Surgical removal of complicated liver tumors may be realized in two stages via selective portal vein ligation, inducing the atrophy of portally ligated lobes and the compensatory hypertrophy of nonligated liver lobes. Unlike morphological changes, functional aspects such as hepatic cytochrome P450 (CYP)-mediated drug metabolism remain vaguely understood, despite its critical role in both drug biotransformation and hepatic functional analysis. Our goal was the multilevel characterization of hepatic CYP-mediated drug metabolism after portal vein ligation in the rat.

METHODS

Male Wistar rats (n = 24, 210-230 g) were analyzed either untreated (controls; n = 4) or 24/48/72/168/336 h (n = 4 each) following portal vein ligation affecting approximately 80% of the liver parenchyma. Besides the weights of ligated and nonligated lobes, pentobarbital (30 mg/kg)-induced sleeping time, CYP1A(2), CYP 2B(1/2), CYP2C(6/11/13), CYP3A(1) enzyme activities, and corresponding isoform mRNA expressions, as well as CYP3A1 protein expression were determined by in vivo sleeping test, CYP isoform-selective assays, polymerase chain reaction, and immunohistochemistry, respectively.

RESULTS

Portal vein ligation triggered atrophy in ligated lobes and hypertrophy nonligated lobes. Sleeping time was transiently elevated (p = 0.0451). After an initial rise, CYP1A, CYP2B, and CYP3A enzyme activities dropped until 72 h, followed by a potent increase only in the nonligated lobes, paralleled by an early (24-48 h) transcriptional activation only in nonligated lobes. CYP2C enzyme activities and mRNA levels were bilaterally rapidly decreased, showing a late reconvergence only in nonligated lobes. CYP3A1 immunohistochemistry indicated substantial differences in positivity in the early period.

CONCLUSIONS

Beyond the atrophy-hypertrophy complex, portal vein ligation generated a transient suppression of global and regional drug metabolism, re-established by an adaptive, CYP isoform-dependent transcriptional response of the nonligated lobes.

Mitochondrial function after associating liver partition and portal vein ligation for staged hepatectomy in an experimental model

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a two-stage strategy to induce rapid regeneration of the remnant liver. The technique has been associated with high mortality and morbidity rates. This study aimed to evaluate mitochondrial function, biogenesis and morphology during ALPPS-induced liver regeneration.

METHODS

Male Wistar rats (n = 100) underwent portal vein ligation (PVL) or ALPPS. The animals were killed at 0 h (without operation), and 24, 48, 72 or 168 h after intervention. Regeneration rate and proliferation index were assessed. Mitochondrial oxygen consumption and adenosine 5'-triphosphate (ATP) production were measured. Mitochondrial biogenesis was evaluated by protein level measurements of peroxisome proliferator-activated receptor γ co-activator (PGC) 1-α, nuclear respiratory factor (NRF) 1 and 2, and mitochondrial transcription factor α. Mitochondrial morphology was evaluated by electron microscopy.

RESULTS

Regeneration rate and Ki-67 index were significantly raised in the ALPPS group compared with the PVL group (regeneration rate at 168 h: mean(s.d.) 291·2(21·4) versus 245·1(13·8) per cent, P < 0·001; Ki-67 index at 24 h: 86·9(4·6) versus 66·2(4·9) per cent, P < 0·001). In the ALPPS group, mitochondrial function was impaired 48 h after the intervention compared with that in the PVL group (induced ATP production); (complex I: 361·9(72·3) versus 629·7(165·8) nmol per min per mg, P = 0·038; complex II: 517·5(48·8) versus 794·8(170·4) nmol per min per mg, P = 0·044). Markers of mitochondrial biogenesis were significantly lower 48 and 72 h after ALPPS compared with PVL (PGC1-α at 48 h: 0·61-fold decrease, P = 0·045; NRF1 at 48 h: 0·48-fold decrease, P = 0·028). Mitochondrial size decreased significantly after ALPPS (0·26(0·05) versus 0·40(0·07) μm² ; P = 0·034).

CONCLUSION

Impaired mitochondrial function and biogenesis, along with the rapid energy-demanding cell proliferation, may cause hepatocyte dysfunction after ALPPS. Surgical relevance Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a well known surgical strategy that combines liver partition and portal vein ligation. This method induces immense regeneration in the future liver remnant. The rapid volume increase is of benefit for resectability, but the mortality and morbidity rates of ALPPS are strikingly high. Moreover, lagging functional recovery of the remnant liver has been reported recently. In this translational study, ALPPS caused an overwhelming inflammatory response that interfered with the peroxisome proliferator-activated receptor γ co-activator 1-α-coordinated, stress-induced, mitochondrial biogenesis pathway. This resulted in the accumulation of immature and malfunctioning mitochondria in hepatocytes during the early phase of liver regeneration (bioenergetic destabilization). These findings might explain some of the high morbidity if confirmed in patients.

[Surgical treatment of primary liver malignancies]

The incidence of primary malignant liver tumours is globally rising. Hepatocellular carcinoma constitutes 75-85% of primary liver malignancies. Owing to advancements of oncological therapies, several methods are available to combat the tumour. Upon the complexity of the disease and the wide spectrum of therapeutical regimens, therapy of HCC is debated, with several undecided issues. Noteworthy, however, is that in early tumour stages, as a de facto curative approach, surgical therapy remains the most effective, allowing long-term survival. Intrahepatic cholangiocellular carcinoma (iCCC) is the second most frequent primary malignant liver tumour. Despite technical developments, prognosis of iCCC patients remains dismal. Unfortunately, as the sole curative approach, surgery (nearing 40% 5-year survival) is mostly contraindicated because of a late diagnosis. In these cases, median survival remains below 7-12 months despite parallel palliative therapies. The present review focuses on the surgical management of primary malignant liver tumours.

Sensitivity of Helicobacter pylori detection by Giemsa staining is poor in comparison with immunohistochemistry and fluorescent in situ hybridization and strongly depends on inflammatory activity

BACKGROUND

Conventional stainings (including H&E and special stains like Giemsa) are the most widely applied histopathologic detection methods of Helicobacter pylori (HP).

MATERIALS AND METHODS

We aimed to compare the diagnostic performance of Giemsa staining with immunohistochemistry (IHC) and fluorescent in situ hybridization (FISH) on a monocentric cohort of 2896 gastric biopsies and relate results to histologic alterations in order to find such histopathologic subgroups in which these methods underperform. All cases were categorized regarding presence or absence of chronic gastritis, inflammatory activity, and mucosal structural alterations.

RESULTS

Giemsa revealed 687 cases (23.7%), IHC 795 cases (27.5%), and FISH 788 cases (27.2%) as being HP positive. Giemsa showed significantly lower overall sensitivity (83.3%) compared to IHC (98.8%) and FISH (98.0%). Moreover, the sensitivity of Giemsa dramatically dropped to 33.6% in the nonactive cases. We found that sensitivity of Giemsa strongly depends on HP density and, accordingly, on the presence of activity. Structural alterations (intestinal metaplasia, atrophy, etc.) had only no or weak effect on sensitivity of the three stainings. Both IHC and FISH proved to be equally reliable HP detecting techniques whose diagnostic performance is minimally influenced by mucosal inflammatory and structural alterations contrary to conventional stainings.

CONCLUSIONS

We highly recommend immunohistochemistry for clinically susceptible, nonactive chronic gastritis cases, if the conventional stain-based HP detection is negative. Moreover, we recommend to use IHC more widely as basic HP stain. Helicobacter pylori FISH technique is primarily recommended to determine bacterial clarithromycin resistance. Furthermore, it is another accurate diagnostic tool for HP.

State of the art in vivo imaging techniques for laboratory animals

In recent decades, imaging devices have become indispensable tools in the basic sciences, in preclinical research and in modern drug development. The rapidly evolving high-resolution in vivo imaging technologies provide a unique opportunity for studying biological processes of living organisms in real time on a molecular level. State of the art small-animal imaging modalities provide non-invasive images rich in quantitative anatomical and functional information, which renders longitudinal studies possible allowing precise monitoring of disease progression and response to therapy in models of different diseases. The number of animals in a scientific investigation can be substantially reduced using imaging techniques, which is in full compliance with the ethical endeavours for the 3R (reduction, refinement, replacement) policies formulated by Russell and Burch; furthermore, biological variability can be alleviated, as each animal serves as its own control. The most suitable and commonly used imaging modalities for in vivo small-animal imaging are optical imaging (OI), ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), and finally the methods of nuclear medicine: positron emission tomography (PET) and single photon emission computed tomography (SPECT).

Liver regeneration after different degrees of portal vein ligation

BACKGROUND

Selective portal vein ligation (PVL) is followed by ipsilateral atrophy and contralateral hypertrophy of the liver lobes. Although the atrophy-hypertrophy complex induced by PVL is a well-documented phenomenon, the effect of different degrees of extended portal vein occlusion on liver regeneration is not known. The aim of this study was to assess the effects of different degrees of portal occlusion on portal pressure and liver regeneration.

MATERIALS AND METHODS

Male Wistar rats (n = 96; 220-250 g) were randomized into three groups and underwent 70%, 80%, or 90% portal vein ligation, respectively. The portal pressure was measured immediately and 24, 48, 72, 120, and 168 h after PVL (n = 6/group/time point). The hepatic lobes and the spleen were weighed, and liver regeneration ratio was calculated. Changes in liver histology and the mitotic activity were assessed on hematoxylin-eosin stained slides.

RESULTS

Higher degree of portal occlusion triggered a stronger regenerative response (regeneration ratio of PVL 70%168h = 2.23 ± 0.13, PVL 80%168h = 3.11 ± 0.37, PVL 90%168h = 4.68 ± 0.48) PVL led to an immediate increase in portal pressure, the value of which changed proportionally to the mass of liver tissue deprived of portal perfusion (PVL 70%acute = 17 ± 2 mm Hg, PVL 80%acute = 19 ± 1 mm Hg, PVL 90%acute = 26 ± 4 mm Hg). Findings in histology showed necro-apoptotic lesions in the atrophic liver lobes and increased mitotic cell count in the hypertrophic lobes. The mitotic cell count of PVL 90% peaked earlier and at a significantly higher value than of PVL 70% and PVL 80% (PVL 9024h%: 96.0 ± 3.5 PVL 70%48h: 64.0 ± 2.1, PVL 80%48h: 56.3 ± 4.0). The mitotic index after 24 h showed a strong correlation with the acute portal hypertension.

CONCLUSIONS

A higher degree of portal vein occlusion leads to a greater regenerative response, presumably triggered by the proportional increase in portal pressure, which supports the role of the so-called "blood-flow" theory of PVL-triggered liver regeneration.

[The importance of postoperative circulatory alterations in hepatic surgery]

There are two afferent (hepatic artery, portal vein) and one efferent (hepatic veins) systems responsible for the unique circulation of the liver. Given this special form of vasculature, acute, isolated (i.e. involving selectively one particular vessel) vascular occlusions may lead to different, however still life threatening conditions. Hence, it is essential to recognize these anomalies in order to preserve the healthy state of both the liver and the patient's lives. Acute circulatory failures are dominantly associated with liver surgery. Adequate therapy can only be provided promptly, if the clinician is well aware of the peculiarities of these conditions. The aim of this study is to overview the etiology and symptoms of these clinical conditions; furthermore to offer technical proposals for the required diagnostic and therapeutical steps via case reports. Furthermore, hepatic injury, caused by ischemia-reperfusion secondary to total vascular occlusion (Pringle maneuver) used in hepatic surgery is outlined.

Szabad gyökök és a máj ischaemiás-reperfúziós károsodása

The critical importance of the ischemic-reperfusive injury is well documented with regards to numerous organs and clinical conditions. Oxygen free radicals play a central role in the mediation of the injury, which dominantly influences the prevalence of postoperative complications, (long term) organ damage, and the potential manifestation of systemic reactions. The both anatomically and pathophysiologically unique ischemic-reperfusive injury of the liver, which is expressively vulnerable to free radicals, is of utmost importance in liver surgery. Several techniques (adaptive maneuvers, chemical agents) are known to ameliorate the reperfusive injury. Based on the prior research of the workgroup of the author, the aim of the current article is to overview the set of measures capable of attenuating ischemic-reperfusive injury (ischemic preconditioning, -perconditioning, administration of adenosine, -inosine, -levosimendan, and -poly-ADP-ribose-polymerase inhibitor), with special attention to the ischemic-reperfusive injury of the liver, as well as the special pathophysiological role of free radicals in mediating hepatic damage. Orv. Hetil., 2015, 156(47), 1904–1907.