Multidisciplinary management of acute cholecystitis during the COVID-19 pandemic

The coronavirus disease 2019 pandemic had a major impact on most medical services. Our aim was to assess the outcome of acute cholecystitis during the nationwide lockdown period. All patients admitted to our emergency department for AC were analysed. Patient characteristics, performance status, AC severity, treatment modality and outcome of AC were assessed during the lockdown period (Period II: 1 April 2020-30 November 2021) and compared to a historical control period (Period I: 1 May 2017-31 December 2018). AC admissions increased by 72.8% in Period II. Patients were younger (70 vs. 74 years, p = 0.017) and greater in number in the CCI 1 group (20.4% vs. 11.2%, p = 0.043) in Period II. The unplanned readmission rate (6.3 vs. 0%, p = 0.004) and the gallbladder perforation (GP) rate was higher (18.0 vs. 7.3%, p = 0.006) in Period II. Percutaneous transhepatic gallbladder drainage (PTGBD) was more frequent (24.1 vs. 12.8%, p = 0.012) in Period II. In addition to a drop in patient age and CCI, a significant rise in the prevalence of acute cholecystitis, GP and unplanned readmissions was observed during the nationwide lockdown due to the COVID-19 pandemic. PTGBD was more frequent during this period, whereas successful conservative treatment was less frequent.

Suprapapillary Biliary Stents Have Longer Patency Times than Transpapillary Stents-A Systematic Review and Meta-Analysis

BACKGROUND AND STUDY AIMS

Endoscopic biliary stent placement is a minimally invasive intervention for patients with biliary strictures. Stent patency and function time are crucial factors. Suprapapillary versus transpapillary stent positioning may contribute to stent function time, so a meta-analysis was performed in this comparison.

METHODS

A comprehensive literature search was conducted in the CENTRAL, Embase, and MEDLINE databases to find data on suprapapillary stent placement compared to the transpapillary method via endoscopic retrograde cholangiopancreatography in cases of biliary stenosis of any etiology and any stent type until December 2020. We carried out a meta-analysis focusing on the following outcomes: stent patency, stent migration, rate of cholangitis and pancreatitis, and other reported complications.

RESULTS

Three prospective and ten retrospective studies involving 1028 patients were included. Suprapapillary stent placement appeared to be superior to transpapillary stent positioning in patency (weighted mean difference = 50.23 days, 95% CI: 8.56, 91.98; p = 0.0.018). In a subgroup analysis of malignant indications, suprapapillary positioning showed a lower rate of cholangitis (OR: 0.34, 95% CI: 0.13, 0.93; p = 0.036). Another subgroup analysis investigating metal stents in a suprapapillary position resulted in a lower rate of pancreatitis (OR: 0.16, 95% CI: 0.03, 0.95; p = 0.043) compared to transpapillary stent placement. There was no difference in stent migration rates between the two groups (OR: 0.67, 95% CI: 0.17, 2.72; p = 0.577).

CONCLUSIONS

Based on our results, suprapapillary biliary stenting has longer stent patency. Moreover, the stent migration rate did not differ between the suprapapillary and transpapillary groups.

Selective intraoperative cholangiography should be considered over routine intraoperative cholangiography during cholecystectomy: a systematic review and meta-analysis

Background

Decades of debate surround the use of intraoperative cholangiography (IOC) during cholecystectomy. To the present day, the role of IOC is controversial as regards decreasing the rate of bile duct injury (BDI). We aimed to review and analyse the available literature on the benefits of IOC during cholecystectomy.

Methods

A systematic literature search was performed until 19 October 2020 in five databases using the following search keys: cholangiogra* and cholecystectomy. The primary outcomes were BDI and retained stone rate. To investigate the differences between the groups (routine IOC vs selective IOC and IOC vs no IOC), we calculated weighted mean differences (WMD) for continuous outcomes and relative risks (RR) for dichotomous outcomes, with 95% confidence intervals (CI).

Results

Of the 19,863 articles, 38 were selected and 32 were included in the quantitative synthesis. Routine IOC showed no superiority compared to selective IOC in decreasing BDI (RR = 0.91, 95% CI 0.66; 1.24). Comparing IOC and no IOC, no statistically significant differences were found in the case of BDI, retained stone rate, readmission rate, and length of hospital stay. We found an increased risk of conversion rate to open surgery in the no IOC group (RR = 0.64, CI 0.51; 0.78). The operation time was significantly longer in the IOC group compared to the no IOC group (WMD = 11.25 min, 95% CI 6.57; 15.93).

Conclusion

Our findings suggest that IOC may not be indicated in every case, however, the evidence is very uncertain. Further good quality research is required to address this question.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-022-09267-x.

[Laparoscopic technique in the surgical treatment of ulcerative colitis,short- and long-term results of the Department of Surgery in Szeged]

Introduction. An estimated 20–30% of patients with ulcerative colitis need surgery. The generally accepted procedure for the surgical treatment is total proctocolectomy with ileal pouch-anal anastomosis. Nowadays laparoscopic technique is used more frequently. Minimally invasive surgical technique is used during the surgical treatment of colorectal diseases in the Department of Surgery in Szeged since 2005. Aim. We aimed to compare the last 16 years’ results of patients treated with conventional and laparoscopic methods. Methods. Between 01. 01. 2005. and 31. 03. 2021. 99 patients (53 female, 46 male) received surgery. The laparoscopic technique was used in 74 (74.7%) and the conventional method in 25 (25.3%) cases. General status of patients, early and late results of surgical treatment, and mainly complications were analyzed. Results. There was no difference between the groups in-hospital stay, the number of days spent in the intensive care unit and the need for transfusion. During the follow-up period the time to the recovery of the bowel function, and the occurrence of late complications were significantly lower in the laparoscopically operated group of patients. Conclusions. Laparoscopic surgical treatment can be used safely for both emergency and elective cases in UC patients. The short-term perioperative results and the morbidity showed no differences between the laparoscopic and open techniques. The long-term effect of laparoscopic surgery insured a lower rate of complications.

[Laparoscopic splenectomy in our practice at the University of Szeged Department of Surgery]

Since its introduction in 1991, laparoscopic splenectomy has been considered the gold standard in spleen surgery, and the advantages of this technique over open surgery are indisputable. The technique was initiated in the Department of Surgery, University of Szeged in 1994 and since then our working group has gained one of the greatest experiences in this field in Hungary. Based on our results, similarly to literature data, it may be established that laparoscopic splenectomy can be considered a surgical procedure with low morbidity after gaining the necessary experience. In our study, the bowel motility recovered earlier, and hospital stay was significantly shorter after laparoscopic procedures. We proved laparoscopic splenectomy is a safe method in cases of extremely large spleens, and the Pfannenstiel incision is a cosmetically acceptable alternative for the retrieval of the spleen. Although several medications are available for second-line ITP therapy, laparoscopic splenectomy provides the longest-lasting results. In our study, young age and a preoperative response to steroids (steroid-dependent cases) were positive predictors for the success of splenectomy. Based on our experiences in the case of an immediate complete response to splenectomy, relapse occurred significantly less often.

[Minimally invasive adrenalectomy – Operative and perioperative results of transperitoneal and retroperitoneal adrenalectomies performed at the University of Szeged Department of Surgery during 23 years]

Aim. Our goal was to evaluate operative and perioperative data of retroperitoneal (RP) and transperitoneal (TP) adrenalectomies performed at the University of Szeged Department of Surgery. Patients and method. During a retrospective cohort study including 174 adrenalectomies (28 RP; 146 TP) performed between 1998 and 2021, the following parameters were evaluated: rate of previous abdominal surgeries, conversion rate, operative time, intraoperative blood loss, tumor size, histology, hospital stay, early and late complications. Results. With significantly higher rate of previous abdominal surgeries [TP vs RP: 68 (46.57%) vs 4 (14%) P = 0.0021], there was no markable difference in conversion rate [TP vs RP: 7 (4.79%) vs 5 (18%), P = 0.312]. Significantly larger tumours were removed with TP (TP vs RP: 58.05 vs 34.8 mm, P = 0.016), with no markable difference in intraoperative blood loss (TP vs RP: 67.85 vs 50.2 ml, P = 0.157). Operative time was significantly shorter in TP (TP vs RP: 86.3 vs 134.5 min; P = 0.024). The most frequent histology was adenoma (TP vs RP: n = 95; 65.06% vs 64.3%). Pheochromocytoma occurred in 11 (7.53%) and 5 (17.8%) cases in TP and RP, respectively. We found no significant difference in hospital stay (TP vs RP: 5.125 vs 4.61 day; P = 0.413). Five- and 2 cases of early complications were seen in TP (splenic injury, postoperative fever, severe intraoperative bleeding, severe hypokalemia, surgical site infection) and RP (2 severe intraoperative bleeding), respectively. One lethal case of ventricular fibrillation and one delayed complication (postoperative abdominal wall hernia) were observed in TP. Conclusions. Both TP and RP are safe and simply reproducible minimally invasive techniques. According to our observation, RP adrenalectomy seems to be reserved for smaller lesions, while TP proves to be successful in removing enlarged and also malignant lesions with significantly shorter operative time.

[Minimally invasive surgery for motility disorders of the oesophagus]

Introduction and aims. We present our experience with minimally invasive surgery for pharyngoesophageal (Zenker) diverticulums, epiphrenic diverticulums and achalasia cardiae focusing on the perioperative features and patients’ quality of life. Patients and methods. Between 1 January 2003 and 31 December 2020, patients were selected with a symptom-causing Zenker diverticulum, epiphrenic diverticulum and achalasia cardiae. In 17 cases, transoral stapler diverticulostomy, in 23 cases transcervical diverticulectomy and cricomyotomy were done because of Zenker diverticulum, in 14 cases, laparoscopic transhiatal surgery was performed because of epiphrenic diverticula, while in 63 cases, laparoscopic Heller–Dor operation were carried out because of achalasia cardiae. Perioperative results, the quality of life outcomes of various surgeries were evaluated in mid- and long-term. Results/conclusions. The surgeries were performed with minimal blood loss, zero mortality and low morbidity. According to our result, the two different surgical approaches in the therapy of Zenker’s diverticulum, the laparoscopic Heller–Dor procedure applied in the management of epiphrenic diverticulas and achalasia cardiae are safe and effective operations. In the long term, the symptom control in patients after minimally invasive surgeries is sufficient and only a small percentage of the patients may require additional medication therapy and/or reintervention due to persistent complaints.

[Treatment of the colorectal polyps]

Bevezetés és célkitűzés

A colorectális polypok komplex ellátása komoly kihívást jelent nemcsak az endoszkópos szakemberek, hanem a sebészek számára is.

Anyag és módszerek

A colorectális polypok sebészeti ellátását 2014-ig a hagyományos sebészi per anum polypectomiák vagy lokális excisók (LE) jelentették a szegedi Sebészeti Klinikán. Ezen hagyományos transanális műtéti technikák hátrányai mindenki számára jól ismertek: magas resectiós szél pozitivitás arány, alacsony „en bloc” resectiós arány, valamint a magasabban, 5 cm felett elhelyezkedő léziók eltávolításának nehézségei stb. Mindezek alapján felmerült az igény, hogy a transanális műtétek technikai fejlődésével lépést tartva, nemcsak új műtéti módszert (TAMIS, transanális minimálisan invazív sebészet) vezessünk be, hanem a már jól ismert, de még nem alkalmazott műtéti technikát, úgymint a TEM (transanális endoszkópos mikrosebészet) is alkalmazni kezdjük. Klinikánkon az új sebészi módszerek bevezetése mellett fontosnak tartottuk a sebészi gasztroenterológia, azon belül is a sebészi endoszkópia humán és tárgyi feltételeinek fejlesztését, valamint bővítését is.

Eredmények/következtetések

Az újabb műtéti technikák bevezetése mellett a Sebészeti Klinika Endoszkópos Laborjának fejlesztésével komoly lépéseket tettünk a colorectalis polypok komplex, multidiszciplináris ellátásának terén.

Goal-Directed Fluid Therapy Enhances Gastrointestinal Recovery after Laparoscopic Surgery: A Systematic Review and Meta-Analysis

(1) Background: Whether goal-directed fluid therapy (GDFT) provides any outcome benefit as compared to non-goal-directed fluid therapy (N-GDFT) in elective abdominal laparoscopic surgery has not been determined yet. (2) Methods: A systematic literature search was conducted in MEDLINE, Embase, CENTRAL, Web of Science, and Scopus. The main outcomes were length of hospital stay (LOHS), time to first flatus and stool, intraoperative fluid and vasopressor requirements, serum lactate levels, and urinary output. Pooled risks ratios (RRs) with 95% confidence intervals (CI) were calculated for dichotomous outcomes and weighted mean difference (WMD) with 95% CI for continuous outcomes. (3) Results: Eleven studies were included in the quantitative, and fifteen in the qualitative synthesis. LOHS (WMD: −1.18 days, 95% CI: −1.84 to −0.53) and time to first stool (WMD: −9.8 h; CI −12.7 to −7.0) were significantly shorter in the GDFT group. GDFT resulted in significantly less intraoperative fluid administration (WMD: −441 mL, 95% CI: −790 to −92) and lower lactate levels at the end of the operation: WMD: −0.25 mmol L−1; 95% CI: −0.36 to −0.14. (4) Conclusions: GDFT resulted in enhanced recovery of the gastrointestinal function and shorter LOHS as compared to N-GDFT.

Surgical outcome of percutaneous transhepatic gallbladder drainage in acute cholecystitis: Ten years' experience at a tertiary care centre

Background

Percutaneous transhepatic gallbladder drainage (PTGBD) plays an important role in the treatment of elderly patients and/or patients in poor health with acute cholecystitis (AC). The primary aim of this study is to determine how these factors influence the clinical outcome of PTGBD. Moreover, we assessed the timing and results of subsequent cholecystectomies.

Patients and Methods

We retrospectively examined the results of 162 patients undergoing PTGBD between 2010 and 2020 (male–female ratio: 51.23% vs. 48.77%; mean age: 71.43 ± 13.22 years). Patient’s performance status and intervention outcomes were assessed with clinical success rates (CSR) and in-hospital mortality. The conversion rate (CR) of possible urgent or delayed, elective laparoscopic cholecystectomies (LC) after PTGBD were analysed.

Results

PTGBD was the definitive treatment in 42.18% of patients, while it was a bridging therapy prior to cholecystectomy (CCY) for the other patients. CSR was 87.97%, it was only 64.29% in grade III AC. In 9.87% of the cases, urgent LC was necessary after PTGBD, and its conversion rate was approximately equal to that of elective LC (18.18 vs. 17.46%, respectively, p = 0.2217). Overall, the post-PTGBD in-hospital mortality was 11.72%, while the same figure was 0% for grade I AC, 7.41% for grade II and 40.91% for grade III. Based on logistic regression analyses, in-hospital mortality (OR 6.07; CI 1.79–20.56), clinical progression (OR 7.62; CI 2.64–22.05) and the need for emergency CCY (OR 14.75; CI 3.07–70.81) were mostly determined by AC severity grade.

Conclusion

PTGBD is an easy-to-perform intervention with promising clinical success rates in the treatment of acute cholecystitis. After PTGBD, the level of gallbladder inflammation played a decisive role in the course of AC. In a severe, grade III inflammation, we have to consider low CSR and high mortality.

Surgical Treatment of Esophageal Achalasia in the Era of Minimally Invasive Surgery

Introduction:

We have analyzed the short- and long-term results of various surgical therapies for achalasia, especially changes in postoperative esophageal function.

Patients and Methods:

Between January 1, 2008 and December 31, 2017, 54 patients with esophageal achalasia were treated in our institution. Patients scheduled for surgery underwent a comprehensive gastroenterological assessment pre- and post-surgery. Forty-eight of the elective cases involved a laparoscopic cardiomyotomy with Dor’s semifundoplication, while two cases entailed an esophageal resection with an intrathoracic gastric replacement for end-stage achalasia. Torek’s operation was performed on two patients for iatrogenic esophageal perforation, and two others underwent primary suture repair with Heller–Dor surgery as an emergency procedure. The results of the different surgical treatments, as well as changes in the patients’ pre- and post-operative complaints were evaluated.

Results:

No intra-operative complications were observed, and no mortalities resulted. During the 12 to 24-month follow-up period, recurrent dysphagia was observed mostly in the spastic group (TIII: 33%; diffuse esophageal spasm: 60%), while its occurrence in the TI type did not change significantly (14.5%–20.8%). As a result of the follow-up of more than two years, good symptom control was achieved in 93.7% of the patients, with only four patients (8.3%) developing postoperative reflux.

Conclusions:

The laparoscopic Heller–Dor procedure provides satisfactory long-term results with low morbidity. In emergency and advanced cases, traditional surgical procedures are still the recommended therapy.

Evaluation of the conversion rate as it relates to preoperative risk factors and surgeon experience: a retrospective study of 4013 patients undergoing elective laparoscopic cholecystectomy

Background

Our aim is to determine the relationships among patient demographics, patient history, surgical experience, and conversion rate (CR) during elective laparoscopic cholecystectomies (LCs).

Methods

We analyzed data from patients who underwent LC surgery between 2005 and 2014 based on patient charts and electronic documentation. CR (%) was evaluated in 4013 patients who underwent elective LC surgery. The relationships between certain predictive factors (patient demographics, endoscopic retrograde cholangiopancreatography (ERCP), acute cholecystitis (AC), abdominal surgery in the patient history, as well as surgical experience) and CR were examined by univariate analysis and logistic regression.

Results

In our sample (N = 4013), the CR was 4.2%. The CR was twice as frequent among males than among females (6.8 vs. 3.2%, p < 0.001), and the chance of conversion increased from 3.4 to 5.9% in patients older than 65 years. The detected CR was 8.8% in a group of patients who underwent previous ERCP (8.8 vs. 3.5%, p < 0.001). From the ERCP indications, most often, conversion was performed because of severe biliary tract obstruction (CR: 9.3%). LC had to be converted to open surgery after upper and lower abdominal surgeries in 18.8 and 4.8% cases, respectively. Both AC and ERCP in the patient history raised the CR (12.3%, p < 0.001 and 8.8%, p < 0.001). More surgical experience and high surgery volume were not associated with a lower CR prevalence.

Conclusions

Patient demographics (male gender and age > 65 years), previous ERCP, and upper abdominal surgery or history of AC affected the likelihood of conversion. More surgical experience and high surgery volume were not associated with a lower CR prevalence.

Incarcerated gallbladder in inguinal hernia: a case report and literature review

Background

Treating hernias is one of the oldest challenges in surgery. The gallbladder as content in the case of abdominal hernias has only been reported in a few cases in the current literature. Cholecyst has only been described in the content of an inguinofemoral hernia in one case to date.

Case presentation

A 73-year-old female patient was admitted to the Emergency Department due to complaints in the right inguinal area, which had started 1 day earlier. The patient complained of cramp-like abdominal pain and nausea. Physical examination confirmed an apple-sized, irreducible hernia in the right inguinal region. Abdominal ultrasound confirmed an oedematous intestinal loop in a 70-mm-long hernial sac, with no circulation detected. Abdominal X-ray showed no signs of passage disorder. White blood cell count and C-reactive protein level were elevated, and hepatic enzymes were normal in the laboratory findings. Exploration was performed via an inguinal incision on the right side, an uncertain cystic structure was found in the hernial sac, and several small abnormal masses were palpated there. The abdominal cavity was explored from the middle midline laparotomy. During the exploration, the content of the hernial sac was found to be the fundus of the significantly ptotic, large gallbladder. Cholecystectomy and Bassini’s repair of the inguinal hernia were performed safely.

Conclusions

Following a review of the literature, it can be concluded that the finding of incarcerated gallbladder in the content of an inguinal hernia is a rare finding. No other similar emergency case and successful surgical intervention have been reported before.

Use of laparoscopic technique in the treatment of ulcerative colitis

INTRODUCTION

An estimated 20-30% of patients with ulcerative colitis need surgery. The generally accepted procedure for the surgical treatment is total proctocolectomy with ileal pouch-anal anastomosis. Nowadays laparoscopic technique is used more frequently.

AIM

Our aim was to compare the last 13 years results of patients treated with conventional and laparoscopic methods.

METHOD

Between 01. 01. 2005 and 31. 05. 2018, 89 patients (n = 48 female, n = 41 male) received surgery. The mean age of the patients was 45.06 ± 14.4 and 39.8 ± 13.4 years in the laparoscopy and the open surgery groups. General status of patients, early and late results of surgical treatment, mainly complications and quality of life, were analyzed.

RESULTS

There was no difference between the groups in hospital stay (10.3 ± 3.3 vs. 11.2 ± 3.7 days) and need for transfusion (2.6 ± 2.2 vs. 2.8 ± 1.7 units). During the follow-up period, the time to the recovery of the bowel function (1.2 ± 0.5 vs. 1.6 ± 0.7 days), the number of days spent in the intensive care unit (2.1 ± 0.9 vs. 2.5 ± 1.6 days) and the occurrence of late complications, such as intestinal obstruction, septic condition, postoperative hernias and 'other' complications were significantly lower in the laparoscopically operated group of patients. In the case of acute operations, the laparoscopic technique provided significantly better recovery of the bowel function (1.2 ± 0.4 vs. 1.8 ± 0.7 days).

CONCLUSION

During the surgical treatment of ulcerative colitis, the minimally invasive technique provided more favourable perioperative results and a better long-term quality of life due to the lower rate of late complications and the more stable psychic status. Orv Hetil. 2020; 161(33): 1363-1372.

Evaluating the distribution of the locations of colorectal cancer after appendectomy and cholecystectomy

Backgrounds

The number of appendectomies and cholecystectomies performed is gradually increasing worldwide. An increasing incidence of colorectal cancer (CRC) after appendectomy and cholecystectomy has been reported, but the location of tumors in certain segments of the colon and rectum after appendectomy and cholecystectomy is still uncertain. We aimed to evaluate the distribution of the locations of colorectal cancer after appendectomy and/or cholecystectomy in patients who underwent CRC surgery.

Methods

We reviewed the medical records of patients who had undergone CRC surgery between 2015 and 2017 for the presence of previous appendectomy/cholecystectomy. Data were collected from the Colorectal Data Base of the University of Szeged, Department of Surgery.

Results

Surgery for CRC was performed in 640 patients during the study period. Data of 604 patients were analyzed. Appendectomy was performed in 100 patients (16.6%), cholecystectomy in 65 (10.8%), and both interventions in 18 (3%) before the CRC surgery. Out of those patients who underwent appendectomy alone, 92 (92%) had undergone appendectomy more than 10 years before the CRC surgery. Also in these 100 patients, the prevalence of right-sided colon cancer (CC) was 35% (n = 35), in comparison with the prevalence among the 504 other patients (20.4%, n = 103). The prevalence of right-sided CC among patients who underwent cholecystectomy alone was 36.9% (n = 24), in comparison with 21.2% (n = 114) of the 539 other patients.

Conclusions

A significant left to right side shift in CRC was noted among patients who had previously undergone appendectomy/cholecystectomy. Because right-sided CC has a worse prognosis, the role of incidental appendectomy and routine cholecystectomy seems that need re-evaluation.

[A comparative study of short- and long-term outcomes for transcervical versus transoral surgery for Zenker diverticulum]

INTRODUCTION AND AIM

We present our experience with open (transcervical diverticulectomy, cricomyotomy) and transoral surgery (transoral stapler diverticulostomy) for Zenker diverticulums.

METHOD

Between 1 January 2006 and 31 December 2016, 29 patients were examined with a symptom-causing Zenker diverticulum. In 13 cases, transcervical surgery, in 16 cases, transoral surgery were performed. Perioperative and long-term results were evaluated and compared.

RESULTS

Patients were operated on after an average of 31 months with complaints. In both groups, the leading symptoms were severe dysphagia and severe regurgitation. No intraoperative complication was detected. In the transoral group, one patient had to be reoperated on for bleeding, another patient developed pneumonia in the transcervical group. The average duration of the surgeries (42.5 versus [vs.] 98 minutes, p<0.001), the time to oral feeding (2.9 vs. 4.6 days, p<0.001) and the mean hospital stay (7.3 vs. 9.7 days, p<0.001) were significantly shorter in the transoral group than the transcervical group. 15 patients were completely symptomless postoperatively. After transcervical treatment, complaints were developed in 2 cases (moderate dysphagia and hoarseness). After transoral surgery, recurrent symptoms were observed in 6 patients, 4 had to be reoperated transcervically due to severe regurgitation.

CONCLUSION

Transoral stapler diverticulostomy is a fast procedure and offers short hospital stay especially in comorbid, aged patients and intermedium diverticulum size. In the long term, some of the patients may require reintervention due to persistent regurgitation. The transcervical approach has higher perioperative morbidity, which can be performed in patients with less than 3 cm or large diverticulum size. Orv Hetil. 2019; 160(16): 629-635.

[Guidance for transanal operations]

We summarized diagnostic, surgical treatment and follow-up principles of benign and early malignant lesions of the rectum. Our aim is to provide a nationwide practical synopsis of transanal minimally invasive surgical techniques which might be the basis of a Hungarian national audit of rectal polyp management.

Predictive Factors for Success of Laparoscopic Splenectomy for ITP

Background and Objectives:

Therapy-resistant immune thrombocytopenia (ITP) is the most frequent indication of laparoscopic splenectomy (LS). It ensures the best results for this disease compared with possible second-line pharmacologic therapies. Therefore, learning about the safety of the surgical method and its long-term efficacy is important, as is selecting patients who respond to surgical treatment. Our purpose was to analyze the safety of LS and the short-and long-term prognostic significance of known perioperative parameters.

Methods:

We performed 40 LSs for ITP from January 1, 2000, to January 1, 2015. We analyzed the roles of the perioperative parameters by using evidence-based guidelines.

Results:

Complete response (CR; platelet count over 100 × 10⁹/L) occurred in 28 cases (70%) and partial response (PR; platelet count between 30 and 100 × 10⁹/L) in 5 cases (12.5%). Below the age of 50, 9% (2/22) of the patients had no response (NR; platelet count not increasing over 30 × 10⁹/L), 28% (5/18) over the age of 50 (P = .023) had no response. In the steroid-refractory group, 30% did not respond, whereas 100% of the steroid-dependent patients had a CR (NR: 7/23 steroid refractory vs 0/17 steroid dependent; P = .027). The patients were followed up for a mean of 10.9 ± 6.9 years, and a long-term response (LTR) was detected in 21 of the responders (n = 33). Of the patients who originally had a CR, 71% also achieved LTR, whereas only 20% of the PR patients did.

Conclusion:

LS is safe and remains the most effective second-line treatment for ITP. In our study, younger age and response to preoperative steroids were predictive factors for the long-term success of splenectomy.

Laparoscopic Surgery for Epiphrenic Esophageal Diverticulum

Background and Objectives:

We wanted to assess our surgical results focusing on the patients' quality of life. We present our experience with laparoscopic surgery for epiphrenic esophageal diverticulum. Short- and long-term results of surgical therapy were analyzed.

Methods:

Eight patients were examined with a symptom-causing epiphrenic diverticulum. Patients underwent complex gastroenterologic examinations before and after surgery. Laparoscopic transhiatal epiphrenic diverticulectomy, Heller cardiomyotomy, and Dor anterior partial fundoplication were performed on 7 patients. One patient underwent only diverticulectomy, where no motility disorder was present. Results from surgical treatments and changes in patients' pre- and postoperative complaints were evaluated.

Results:

In all cases except 1, the preoperative examination showed dysmotility of the esophagus. The average duration of the surgeries was 165 (130–195) minutes; blood loss was minimal. One patient developed bleeding in the early postoperative period, and a second laparoscopy was required. No other intraoperative complication was detected, and no mortality occurred. In one case, a staple line leak developed (1/8 [12.5%]), which was resolved with conservative therapy. Functional check-ups confirmed adequate esophageal function. The total symptom score for the patients was 6.3 points before surgery, and it decreased to 1.6 (P < .001) after surgery, an average of 74% subjective improvement. During the follow-up period (mean, 60 months; 10–138 months), proton pump inhibitor therapy was started in 4 patients to treat gastroesophageal reflux. In 3 cases, drug therapy was successful; in one case, Nissen antireflux surgery was performed.

Conclusion:

Laparoscopic transhiatal diverticulectomy and Heller–Dor surgery are effective interventions with low morbidity. Patient quality of life significantly improves in the long term, but gastroesophageal reflux disease may occur.

[Tension-type headache in ulcerative colitis]

Background and purpose

Tension-type headache is a very common disease with a high socio-economic impact as its lifetime prevalence is 30-78% in the general population. The incidence of inflammatory bowel diseases is continuously rising. Limited data are accessible on quality of life in patients with surgically treated ulcerative colitis. The aim of our study is to examine quality of life, concerning headache, among patients who had undergone surgery due to ulcerative colitis.

Methods

Between 1 January 2005 and 1 March 2016, surgery was performed due to ulcerative colitis in 75 patients. During this retrospective analysis the average duration of the follow-up was 46 (1-124) months. The pre-sence of headache was evaluated by the use of Brief Illness Perception and Headache Questionnaires.

Results

Among the primary headache disorders (n=27), tension-type headache occurred in 19 (70.4%) cases, and 8 (29.6%) patients had migraine (without aura). Among tension-type headache cases 17 (89.5%) patients experienced episodic form and 2 (10.5%) suffered from chronic form. Patients with headache had obtained a significantly higher score on Brief Illness Perception Questionnaire.

Conclusion

According to our study tension-type headache is common among patients with ulcerative colitis. This observation raises the question whether stress plays role in the pathogenesis of both diseases, which influences and worsens considerably quality of life. Neurological examination, psychological and psychiatric guidance are worth considering in patients with ulcerative colitis.

[Removal of giant adrenal tumors using the laparoscopic transperitoneal technique. A report of three successful cases]

With the development of laparoscopic adrenalectomy, indications for resection gradually span from small and benign to bigger and even malignant lesions. We studied the results of laparoscopic adrenalectomy for giant (>10 cm) adrenal tumors in three cases. Three patients (2 female, 1 male, mean age 49.33 years, BMI 31) underwent laparoscopic transperitoneal adrenalectomy due to giant (>10 cm) adrenal lesions with a limited size Pfannenstiel incision. Mean operative time was 126.66 minutes, with a mean intraoperative blood loss of 150 ml. Final histology confirmed adrenocortical carcinoma in two cases, and neurofibroma in one case. Mean hospital stay was 4 days, without perioperative complications. R0 resection was carried out in all cases. During a mean follow-up period of 24 months no local or distant metastasis occurred. Under appropriate conditions adrenalectomy performed by the laparoscopic transperitoneal technique for giant malignant tumors proved to be a safe method fulfilling oncological requirements. Orv Hetil. 2017; 158(45): 1802-1807.

Prospective Comparison of Magnetic Resonance Imaging, Transrectal and Transperineal Sonography, and Surgical Findings in Complicated Perianal Crohn Disease

OBJECTIVES

Magnetic resonance imaging (MRI) and transrectal sonography are the two accepted imaging modalities for evaluation of perianal fistulas and abscesses. Transperineal sonography is a new technique that is easy to learn and can be performed at any time. The purpose of this study was to prospectively compare the diagnostic accuracy of MRI, transrectal sonography, and transperineal sonography with surgical findings in patients with perianal Crohn disease.

METHODS

All patients with perianal Crohn disease underwent MRI, transrectal sonography, and transperineal sonography within a few days before surgery. Fistulas were classified as simple (43.8%) or complex (52.2%) based on surgical findings.

RESULTS

Twenty-three patients with active perianal Crohn disease (12 women and 11 men; mean age, 29.9 years; current therapy: antibiotics, 69.6%; azathioprine, 56.5%; and biologics, 73.9%; previous surgery, 26.1%; and proportion of smokers, 39.1%) were included. Sensitivity values for MRI, transrectal sonography, and transperineal sonography for diagnosis of fistulas were 84.6%, 84.6%, and 100%, respectively. Transperineal sonography was more sensitive for diagnosis of perianal abscesses than MRI and transrectal sonography (100%, 58.8%, and 92.8%).

CONCLUSIONS

Transperineal sonography is a very accurate diagnostic method with outstanding sensitivity compared with MRI and transrectal sonography for evaluation of complicated perianal Crohn disease. Due to its simplicity and low cost, it is recommended that transperineal sonography be the first diagnostic modality in these cases.

[Laparoscopic removal of large spleens: Pfannenstiel incision as an alternative specimen extraction method]

BACKGROUND

Removing the extremely enlarged spleen from the abdominal cavity is a common technical problem in case of laparoscopic splenectomy ( LS). In general, the specimen is placed into a plastic bag and removed after morcellation. In case of massive splenomegaly , when the spleen weight is 1000-2000 grams, this method is often not feasible, because the spleen size is larger than the maximum capacity of the EndoBag. According to the literature in this case the splenic extraction was performed by specimen fragmentation in the abdominal cavity (risk of splenosis) or by a laparotomy. To solve this problem our team removes the specimen via a Pfannenstiel incision since 2009.

METHODS

Between January 1, 2002 and September 30, 2014, 74 LS procedures were performed at our department. The specimen was retrieved with morcellation in a conventional manner through the lateral port site in 56 cases, whereas in 12 cases, the large spleen was retrieved through a 10-12 cm long Pfannenstiel incision.

RESULTS

The mean duration of surgery was 121 (50-220) minutes. In those cases where the specimen was retrieved through a Pfannenstiel incision the mean duration of surgery was significantly shorter (108 vs. 125 minutes; p=0.05), and the mean spleen size was significantly larger (1032 vs. 338 grams; p=0.0001) than in the case of morcellation. In the duration of the mean postoperative hospital stay there was no significant difference (4.7 vs. 5.2 days; p=0.178).

CONCLUSION

Our study supports that laparoscopic splenectomy is safe and has numerous advantages even in the case of massive splenomegaly. The retrieval of the specimen through a Pfannenstiel incision is considered a safe and cosmetically acceptable alternative.

A pilot study on faecal MMP-9: a new noninvasive diagnostic marker of colorectal cancer

Background:

Colorectal cancer (CRC) is one of the leading malignancies worldwide, therefore cheap noninvasive screening methods are of great importance. Matrix-metalloproteinase-9 (MMP-9) has a role in the progression of CRC, and its level is elevated in tumour biopsies. Faecal MMP-9 levels are increased in active ulcerative colitis patients, but in CRC patients, they have never been measured. We aimed to assess the faecal MMP-9 levels in patients undergoing total colonoscopy according to endoscopic and histological diagnosis.

Methods:

One hundred and nine patients provided faecal samples for MMP-9 analysis. A total colonoscopy was performed; suspicious lesions were evaluated by histology. Faecal MMP-9 levels were measured by ELISA.

Results:

The number of patients allocated to different groups were: negative/diverticulosis: 34 (referred to as controls); hyperplastic polyps: 15; adenomas: 32 (22 at high risk); and CRC: 28. Faecal MMP-9 was significantly increased in CRC compared with all other groups (P<0.001). Faecal MMP-9 was suitable to distinguish CRC patients from controls (sensitivity: 89.3% specificity: 91.2%). By means of a lower cutoff level, faecal MMP-9 identified high-risk adenomas besides CRC (sensitivity: 76% specificity: 85.3%). This lower cutoff level screened 59% of high-risk adenomas.

Conclusions:

Faecal MMP-9 may be a promising new noninvasive marker in CRC.

Colitis ulcerosa minimálisan invazív sebészi kezelése – hosszú távú eredmények

Introduction: For the surgical treatment of ulcerative colitis, laparoscopy is used more widely, but less data are available on long-term results in Hungary. Aim: The aim of the authors was to compare the mean 47.8-month follow-up results of patients treated with conventional and minimally invasive surgical methods. Method: Between January 1, 2005 and December 31, 2014, 56 patients were treated with surgery (20 emergencies, and 36 elective cases). Laparoscopy was used in 33 and conventional method in 23 cases. Results: There was no difference between the two groups in hospital and intensive care unit stay, bowel function recovery, need for transfusion, and complications during the perioperative period. Regarding long-term complications, the occurrence of intestinal obstruction, septic condition and other complications were significantly fewer in the laparoscopy group. The quality of life improved in both groups after the surgery. Conclusions: Laparoscopy can be used safely; it provides good quality of life and better cosmetic results, and the long-term rate of complications is lower as compared to open surgery. Orv. Hetil., 2015, 156(39), 1585–1592.

Role of laparoscopic surgery in the treatment of ulcerative colitis; short- and mid-term results

OBJECTIVES

Laparoscopy is used more widely for the surgery of ulcerative colitis. The objective of this study was a comparison of the surgical and 3-year follow-up results of patients treated with conventional and minimally invasive methods.

MATERIALS AND METHODS

A total of 45 patients received surgery for ulcerative colitis, 16 as emergency and 29 as elective cases. Laparoscopy was used in 23 and a conventional method in 22 cases. No difference was found between the two groups from the aspects of American Society of Anesthesiologists physical status (ASA) class, mean body mass index (BMI) and age. There were 4 emergency cases in the laparoscopy group, and 12 in the open group. Nineteen elective surgeries were performed in the laparoscopy group, and 10 in the open group.

RESULTS

There was no significant difference between the groups as concerns the length of hospital or intensive care unit (ICU) stay, the time to bowel function recovery, but the duration of open surgery was significantly shorter. There was no difference between the groups in the rate of early postoperative complications, whereas among potential late complications, the rates of intestinal obstruction (8.7% vs. 45%) and a septic condition (0% vs. 27%) were significantly lower in the laparoscopy group. There was a significant improvement in the quality of life after surgery in both groups, and better cosmetic results were observed in the laparoscopy group.

CONCLUSION

Laparoscopy can be used for ulcerative colitis both emergency and elective cases, it provides a good quality of life and the mid-term rate of complications is lower as compared with open surgery.

Efficacy of combined anti-TNF-alpha and surgical therapy in perianal and enterocutaneous fistulizing Crohn's disease--clinical observations from a tertiary Eastern European center

BACKGROUND AND AIMS

Recently, anti-TNF-alpha therapy has increasingly been used in the treatment of perianal Crohn's disease (PCD), but there is only limited data regarding its short- and long-term efficacy.

MATERIAL AND METHODS

The medical records of 68 patients treated with anti-TNF-alpha for PCD were assessed retrospectively. Rate of complex fistulas was 75%. Every patient received induction therapy, but in 20 cases the treatment was discontinued before week 52 due to funding regulations, an allergic reaction, or compliance problems. On week 12, the luminal activity decreased in more than 80% of the cases and the complete remission (CR) rate was about 60%; by the end of the first year, this ratio did not change substantially. Complete fistula closure was achieved in 26 cases (38.3%) and 53 patients (51.5%) showed a partial response during the 1-year period. Regarding both perianal and luminal activities, CR rate was achieved in 23 cases (33.8%). However, after the biological therapy was discontinued, recurrence of fistulas could be detected in every second patient. Additional surgical intervention was performed in 45% of patients during the 1-year period (seton drainage of fistulas and abscess drainage).

CONCLUSION

The anti-TNF-alpha therapy combined with surgery is an effective treatment of PCD. Approximately every third patient revealed complete fistula closure, while half of the other cases showed a partial response. Due to the high rate of fistula recurrence after stopping the biological therapy, more than 1 year of anti-TNF-α treatment may be beneficial.

[Mini-laparoscopic cholecystectomy as an innovative method in minimally invasive abdominal surgery]

INTRODUCTION

In our study, we applied a mini-laparosopic approach during laparoscopic cholecystectomy (LC) (using the minimum size of trocars with the simultaneous intention to reduce their number). The advantages and disadvantages of the mini-LC approach were compared with those of traditional LC.

PATIENTS AND METHODS

During mini-LC procedures, we used 3 ports (11 mm, 5 mm, 3.5 mm). Mini-LC was performed in 10 patients, and the results were compared with those of 10 cases of traditional LCs. The two groups were homogenous in terms of gender, age, BMI and ASA classification. Comparison criteria included operative time, the need to use an extra port, conversion rate, oral analgesic requirement, early/late complications and cosmetic results.

RESULTS

There were no significant differences in terms of operative time, blood loss, hospital stay and complications. Cumulative size of incisions was 19.5 mm with mini-LC- and 41 mm in the LC group, respectively, and the tissue injury was 124.2 mm(2) and 448.2 mm(2). Cosmetic results of mini-LC were highly improved by these values. Increased oral analgetic requirements were detected in LC group.

CONCLUSION

Mini-LC is a safe procedure with outstanding cosmetic results accompanied by less oral analgetic requirements. In selected patients, it can be recommended as an alternative method of traditional LC.

Efficacy of tumor necrosis factor-alpha inhibitors in fistulising perianal Crohn’s disease

Introduction: Tumor necrosis factor-alpha inhibitors are increasingly used in the treatment of severe Crohn’s disease. Aim: The aim of the authors was to assess retrospectively the short and long term efficacy of tumor necrosis factor-alpha inhibitors in fistulising Crohn’s disease. Method: Responses to therapy was determined using Crohn’s Disease Activity Index, Perianal Disease Activity Index, the rate of complete fistula closure and the additional surgical procedures during biological therapy. Results: After 12 weeks the perianal activity was decreased in more than 80% of the cases, and the complete remission rate was about 60%. After one year of therapy about one third of the patients had fistula closure, but after cessation of the biological therapy recurrence of fistulas was detected in every second patient. In most cases additional immunosuppressive therapy was necessary during biological treatment. During the one-year therapy period additional surgical treatments were performed in 45% of patients; seton insertion and abscess drainage were the most frequent procedures. Conclusions: Tumor necrosis factor-alpha inhibitor therapy is effective in the treatment of perianal Crohn’s disease, however, additional immunosuppressive drugs and rectum sparing surgical procedures were necessary during the one-year treatment period. Because of the high rate of fistula recurrence, long term tumor necrosis factor-alpha treatment may be useful. Orv. Hetil., 154(49), 1943–1948.