Andras Sandor

The feasibility and accuracy of diagnostic laparoscopy in the septic ICU patient

AbstractBackground: Systemic inflammatory response syndrome (SIRS) and sepsis of unknown origin are common complications of critically ill patients in the ICU. These patients frequently have unreliable clinical exams and are candidates for exploratory laparotomy. Although abdominal CT is commonly used because it is less invasive than laparotomy, it is often unreliable or unobtainable. Bedside laparoscopy is an alternative technique that may be more accurate than CT in selected patients and less invasive than laparotomy. Methods: We performed diagnostic laparoscopy (DL) in a series of ICU patients with SIRS/septic state of unknown origin between May 1997 and June 1998. All patients were unstable and required significant respiratory and hemodynamic support. Laparoscopy was either performed in the ICU at the patients bedside or in the operating room. CT scan of the abdomen had been performed on most of the patients who were stable enough to transport. Confirmation of diagnosis was obtained either by laparotomy, autopsy, or clinical recovery. Results: Among the 17 eligible patients, 16 underwent successful DL. Insufflation was impossible in one patient because of high intraabdominal pressure. Bedside evaluations were performed in 14 of the 17 patients. There were no complications from the laparoscopy. Six patients were identified as positive (four intestinal ischemia, two cholecystitis); the other 10 had negative explorations. Follow-up on two patients with negative laparoscopy was incomplete due to denied postmortem. Laparoscopic diagnoses were confirmed in the remaining 14 patients by laparotomy (six cases), postmortem (three cases), or recovery (five cases), with an accuracy of 100%. The overall accuracy of abdominal CT obtained in nine of the 14 patients was 33%. Conclusions: DL in a select group of critical ICU patients is safe and accurate, whereas CT scan tends to be inaccurate and is often unobtainable due to patient instability. Performing the procedure at the bedside can expedite the diagnosis, eliminate the burden for transfer, and save on anesthesia and operating room charges.

Total thoracoscopic pneumonectomy: indications and technical considerations

Although descriptions of series of thoracoscopic wedge resections and lobectomies have been published, with increasing frequency and encouraging results, only a handful of individual reports of minimally invasive pneumonectomy are available. The authors of these publications unanimously have used a limited 6to 16-cm thoracotomy to allow the introduction of traditional surgical instruments and to provide some direct visualization of the surgical field, especially the hilar structures. This has been traditionally accepted as the method of choice in video-assisted thoracic surgery (VATS). However, it is arguable, that the requirement for a minithoracotomy, particularly if rib spreading or rib resection is used, reduces the benefits of minimal trauma associated with the smaller incisions. VATS wedge resections and anatomic lobectomies are frequently performed. The indications, preoperative patient workup, postoperative care, and basic oncologic principles are essentially the same as with open thoracic surgery. We use preoperative mediastinoscopy before any lung cancer resection. We discuss here our initial experience with entirely videothoracoscopic pneumonectomy, such as has not been reported to date.

Highlights of Twentieth Century Surgery in Hungary

On a cold winter morning, in November 1914 a Russian officer was running through the barracks of the camp of the AustrianHungarian prisoners of war in Siberia. He was desperately looking for a prisoner, a Hungarian physician-officer, otologist Robert Barany. At last he found the doctor and handed him a telegram that had just arrived from Sweden. Dr. Barany opened the telegram and saw that it contained the announcement that he was awarded the Nobel Prize. Prince Charles of Sweden, President of the Swedish Red Cross Organization, contacted Prince Konstantin of Russia, President of the Russian Academy of Sciences, asking for his help to release Dr. Barany, but the attempt was unsuccessful. However, Dr. Barany was transported from the camp to a hospital in Kazan. Doctor Barany had suffered from a childhood tuberculosis infection in one of his legs, and as a consequence his walk was imperfect the rest of his life. Here, in Kazan, the Russian army doctor, a general, while examining his Hungarian colleague noted this minor alteration. “Ah, you are wounded,” he said. Dr. Barany protested: “I am not wounded.” The Russian officer refused to accept the remark, telling his patient: “To determine who is wounded and who is not, that’s my job and not yours!” Hence Dr. Barany was released as a war-disabled ex-serviceman, and in September 1916 he was able to attend the Nobel Prize ceremony in Sweden. This true story reflects how much Hungarian life and science were affected by the politics of the twentieth century. Hungary, situated in the eastern part of central Europe is 93,000 km after being reduced to a third of its former territory as a result of the Treaty of Trianon, which put an end to World War I. There are 15 million Hungarians living around the world, 5 million of them outside Hungary. The Magyars arrived in the Carpathian Basin in 896 AD. During the years 2000 and 2001 we celebrated not only the turn of a new millennium but also the 1000th anniversary of the coronation of our first King, St. Stephen, who laid the foundations of Hungarian statehood and the acceptance of Christianity in Hungary. The medical profession has been honored and appreciated even from the earliest times in the history of the nation. On the Hungarian royal crown (called the “Holy Crown”) one can find the portraits of the famous twin brothers who were respected physicians during the Middle Ages, the martyrs St. Cosmas and St. Damian. To evaluate Hungarian surgery during the twentieth century we must go back to previous times.