Péter Lukovich

Transgastric gastro-jejunal anastomosis with flexible endoscope on a biosynthetic model

INTRODUCTION In the last few years the rapid development of flexible endoscopies has opened new possibilities in minimal invasive procedures. With the help of these techniques the exposure, the risk of complications and the healing period of the patient might be reduced. One of these procedures is the transgastric intervention. Through an incision on the wall of the stomach, the endoscope could be led into the abdominal cavity, where several interventions can be performed. The aim of the study was to examine the technical feasibility and the success of the formation of gastro-jejunal anastomosis. Meanwhile the difficulties of the method could be explored in order to introduce this method in human use. METHOD A lifelike biosynthetic model was made from a slaughtered domestic pigs gastrointestinal tract (stomach and the first few jejunum loops) which was fixed onto a plastic frame. Two single-channel gastroscopes were inserted into the stomach. On the wall of the stomach an approximately 2 centimetres wide incision was made by the electrocoagulator with a needle-knife. Through it the first jejunum loop was grasped by a foreign-body forceps and then was retracted into the stomach. Subsequently the jejunum loop was held safely with the first endoscope. Parallel to it an incision was made on the jejunum by the electrocoagulator. The authors managed to securely unite the open edges of the gastric wall and the jejunum with endoclips. RESULT The model was good for practising. The anastomosis is technically feasible and was successfully made on biosynthetic porcine model using the transgastric route. Although the incisions both on the gastric wall and on the jejunum loop were made easily, the fixing of the anastomosis might be questionable. CONCLUSION It was revealed that more experiments and the development of new, special instruments are needed in order to conduct the anastomosis safely.

PEG fixation of an upside-down stomach using a flexible endoscope: case report and review of the literature.

Introduction: Upside-down stomach usually is asymptomatic in adults, but sometimes it can cause regurgitation, vomiting, and weight loss. This condition has an incidence increasing with age thus increasing the risk of surgical intervention. Case Report: A 90-year-old man was admitted with dysphagia, postprandial regurgitation, and an 18 kg weight loss in the past year. Gastroscopy revealed a significantly dilated, cranky esophagus and an upside-down stomach. The diagnosis was confirmed by a barium swallow and computed tomography. The stomach was repositioned with a gastroscope using insufflation and an &agr;-loop maneuver under fluoroscopic guidance. A percutaneous endoscopic gastrostomy tube was then inserted to fix the stomach. The patient was discharged on the first postinterventional day. He gained 6 kg in the next 2 months. Discussion: High-risk patients with upside-down stomach can be managed by endoscopic repositioning of the stomach and percutaneous endoscopic gastrostomy fixation. This is a useful alternative therapeutic intervention. There have been 14 similar cases being reported in the literature.

[Crohn's disease of the duodenum. Clinical signs, diagnosis, conservative and surgical treatment].

Duodenal localization of Crohns disease is rare, accounting for only 0.5-4% of all cases. Most common complaints are gastric outlet obstruction and weight loss. Histologic findings of endoscopic biopsy are frequently not definitive, making differentiation from other, benign structures complicated. There are also no standard guidelines regarding indications for surgical management. PATIENTS AND METHODS: We reviewed the cases of three surgically managed patients with duodenal Crohns disease at the 1st Department of Surgery, Semmelweis University of Medicine, Budapest, during a 5-year period (2002-2007). All three patients had persistent symptoms of stomach emptying disorder despite medical therapy and had severe weight loss (13-30 kg). In two cases resection of the stenotic duodenum was performed successfully using Billroth II method. Gastro-jejunal bypass was performed in one case, where the descendent duodenum was inflamed. RESULTS: All patients have been asymptomatic since surgery (9-45 months of follow-up) and recovered their earlier bodyweight. The postoperative period was uneventful. CONCLUSIONS: There is indication of surgery in cases of stenosing duodenal Crohns disease, when medical therapy is not successful, but long-standing malnutrition should be treated preoperatively. We found perioperative morbidity to be similar in patients with duodenal Crohns and in those with Crohns disease of other intestinal locations.UNLABELLED Duodenal localization of Crohns disease is rare, accounting for only 0.5-4% of all cases. Most common complaints are gastric outlet obstruction and weight loss. Histologic findings of endoscopic biopsy are frequently not definitive, making differentiation from other, benign structures complicated. There are also no standard guidelines regarding indications for surgical management. PATIENTS AND METHODS We reviewed the cases of three surgically managed patients with duodenal Crohns disease at the 1st Department of Surgery, Semmelweis University of Medicine, Budapest, during a 5-year period (2002-2007). All three patients had persistent symptoms of stomach emptying disorder despite medical therapy and had severe weight loss (13-30 kg). In two cases resection of the stenotic duodenum was performed successfully using Billroth II method. Gastro-jejunal bypass was performed in one case, where the descendent duodenum was inflamed. RESULTS All patients have been asymptomatic since surgery (9-45 months of follow-up) and recovered their earlier bodyweight. The postoperative period was uneventful. CONCLUSIONS There is indication of surgery in cases of stenosing duodenal Crohns disease, when medical therapy is not successful, but long-standing malnutrition should be treated preoperatively. We found perioperative morbidity to be similar in patients with duodenal Crohns and in those with Crohns disease of other intestinal locations.

Cirrhosis and cholelithiasis. Laparoscopic or open cholecystectomy

UNLABELLED Recently laparoscopic cholecystectomy has become the standard operation in case of cholelithiasis. The range of contraindications has decreased, a previous abdominal surgery, a severe cholecystitis or gravidity are not self-evident contraindications any more. The advantages and benefits of laparoscopic interventions in patients with hepatic cirrhosis are doubtful. PATIENTS AND METHODS Between 1996--2006, 52 patients were analyzed at the I. Department of Surgery of Semmelweis University in a retrospective study who underwent operations on hepatic cirrhosis and cholelithiasis. The female/male ratio was 2.7/1 and the mean age was 58.5 (31-87). The patients were classified according to the Child-Pugh score: A = 36, B = 14, C = 2. 23 traditional, open (OC) and 29 laparoscopic (LC) cholecystectomy were performed, in 4 out of the latter operations conversion had to be done. RESULTS In Child A and B cirrhotic patients the mean operative time was 86.5 minutes in the case of LC, whereas with the open intervention it was 86.21 minutes. In Child C cirrhotic patients, open cholecystectomy was performed in both cases, the average operative time was 81.5 minutes. Postoperative complications (Child A, B) occurred in 8 cases (LC/1), (OC/7), while in Child C patients in two cases. The average hospital stay was 7.6 (LC) and 12.45 (OC) days, respectively. The same with Child C patients increased to 28 days. In the postoperative phase 4 patients died: all of them had open cholecystectomy, suffered from Child B and Child C class hepatic cirrhosis, respectively, and they developed hepatorenal syndrome that could not be treated. CONCLUSION The results show that LC is a safe procedure in well-compensated Child A and B cirrhotic patients. Although hepatic cirrhosis greatly increases the surgical risks, as well as the likelihood of complications, and it also necessitates longer operative time and longer hospital stay, it is recommended that cirrhotic patients with symptomatic cholelithiasis should clearly be operated on.

Single-Port Cholecystectomy Through the Lateral Ring of the Left Inguinal Hernia

Background: Single-port surgery was developed by the evolution of the laparoscopy. The advantage of this new method is mainly cosmetic, but the risk of the hernia—owing to the larger port—increased. Case report: A 71-year-old man was admitted with a left lateral inguinal hernia and gallbladder stones. After preparation of the sac of the hernia, a single-port was inserted into the lateral ring and a cholecystectomy was performed. The operation was completed by the reconstruction of the abdominal wall using a polypropylene mesh. The total operating time was 85 minutes. Conclusion: In the case of the combined operation, the defect of the abdominal wall could be used as a location of the single port, and the trauma of the abdominal wall could be avoided. This is the first publication about single-port cholecystectomy where the ring of the inguinal hernia was used as a placement site of the single port.

Single port transumbilicalis cholecystectomia (SILS) – Nem szelektált 30 eset összehasonlító elemzése

Single port laparoscopic surgery became popular all over the world, and cholecystectomy represents the most frequent intervention with this technique. We compared transumbilical single port laparoscopic cholecystectomies (SILS) to conventional three-port laparoscopic cholecystectomies (LC), which were performed by the same surgeon between 2008-2010. As regards SILS cases, they represent a non-selected series. Transabdominal sutures were not applied in any of those, but one additional 5 mm port was inserted in two SILS cases. Only straight instruments were used in all but two SILS cholecystectomies. Mean age of patients was lower in the SILS group, however male:female ratio and BMI were similar. While none of the procedures were converted in the SILS group, one needed to be done so in the LC patients. One of the SILS patients underwent a transumbilical laparoscopic wash-out for an intrabdominal haematoma, which developed due to non-surgical reasons. Mean operative time and postoperative hospitalisation was 75.9 ± 25 minutes and two days in the SILS group, while 55.7 ± 17 minutes and 2.8 days in the LC group, respectively. We concluded that transumbilical single port cholecystectomy can be performed safely by using conventional straight instruments. We could not identify any publication about non-selected SILS cholecystectomy series in the English language literature.

Transgastricus gastrojejunalis anastomosis készítése flexibilis endoszkóppal bioszintetikus modellen

INTRODUCTION In the last few years the rapid development of flexible endoscopies has opened new possibilities in minimal invasive procedures. With the help of these techniques the exposure, the risk of complications and the healing period of the patient might be reduced. One of these procedures is the transgastric intervention. Through an incision on the wall of the stomach, the endoscope could be led into the abdominal cavity, where several interventions can be performed. The aim of the study was to examine the technical feasibility and the success of the formation of gastro-jejunal anastomosis. Meanwhile the difficulties of the method could be explored in order to introduce this method in human use. METHOD A lifelike biosynthetic model was made from a slaughtered domestic pigs gastrointestinal tract (stomach and the first few jejunum loops) which was fixed onto a plastic frame. Two single-channel gastroscopes were inserted into the stomach. On the wall of the stomach an approximately 2 centimetres wide incision was made by the electrocoagulator with a needle-knife. Through it the first jejunum loop was grasped by a foreign-body forceps and then was retracted into the stomach. Subsequently the jejunum loop was held safely with the first endoscope. Parallel to it an incision was made on the jejunum by the electrocoagulator. The authors managed to securely unite the open edges of the gastric wall and the jejunum with endoclips. RESULT The model was good for practising. The anastomosis is technically feasible and was successfully made on biosynthetic porcine model using the transgastric route. Although the incisions both on the gastric wall and on the jejunum loop were made easily, the fixing of the anastomosis might be questionable. CONCLUSION It was revealed that more experiments and the development of new, special instruments are needed in order to conduct the anastomosis safely.

Laparoscopos colorectalis resectiók – 393 eset tapasztalatai

Laparoscopic (LAP) colorectal surgery has become increasingly popular worldwide. Large comparative studies demonstrate the benefit of the method, but data about routine application are relatively moderate. This study presents the results of laparoscopic colorectal linterventions in a non-selected patient population, who were admitted to the 1st Department of Surgery, Semmelweis University between January 2004 and December 2011. 393 patients underwent LAP surgery. In 333 cases the malignant tumor indicated surgery. T3 tumor rate was 62.7%. Synchronous liver metastases were detected in 17 cases, three of them were single and operable, but 14 cases were multiplex and inoperable. Bowel was successfully resected in all cases. Complication rate was 9.9 percent. In-hospital mortality was 2.0%. Length of hospital stay of non-complicated cases was 6.7 days. In 9 cases single incision intervention was performed, with an average length of hospital stay of four days. Rate of sphincter preserving rectal resections were 87.2%. 59 (15.0%) patients underwent conversion from LAP to open surgery. Operating time decreased by time, but both OP time and conversion rate were tipically determinded by the surgeons skill. LAP surgery was found to be useful for all kind colorectal diseases requiring elective resection. Application of LAP method requires organized training programs.

A laparoszkópia szerepe a 80 évesnél idősebb betegek epekövességének megoldásában

Absztrakt Bevezetes: Az epeholyag-kovesseg előfordulasi gyakorisaga az eletkorral nő, azonban a 80 ev feletti betegek műtetjeinek kimeneteleről alig vannak adatok. A tarsadalom eloregedesevel a kerdes egyre időszerűbb. Celkitűzes: A 80 evesnel idősebb betegeknel vegzett akut es elektiv cholecystectomiak elemzese. Modszer: A szerzők az elmult hat evben a 80 evesnel idősebb, cholelithiasis miatt operalt betegeknel a műtet tipusat, a konverzio aranyat, a szovődmenyek gyakorisagat, a posztoperativ mortalitast, az intenziv osztalyos es korhazi apolasi napok szamat vizsgaltak retrospektiven. Eredmenyek: A vizsgalt időszakban a 69 elektiv, 51 akut műtetet vegeztek, utobbiak 9,8%-anal pancreatitist, 14%-anal majtalyogot, 27%-anal choledocholithiasist talaltak. Az elektiv csoport 84%-anal, mig az akut csoport 17,7%-anal sikerult az epeholyag laparoszkopos eltavolitasa. Az intenziv osztalyos 9,1 vs. 1 nap, a teljes korhazi apolas 12 vs. 3,6 nap volt az akut, illetve tervezett műtetnel. A surgősseggel operalt betege...

Training With Curved Laparoscopic Instruments in Single-Port Setting Improves Performance Using Straight Instruments: A Prospective Randomized Simulation Study

OBJECTIVE Lately single-port surgery is becoming a widespread procedure, but it is more difficult than conventional laparoscopy owing to the lack of triangulation. Although, these operations are also possible with standard laparoscopic instruments, curved instruments are being developed. The aims of the study were to identify the effect of training on a box trainer in single-port setting on the quality of acquired skills, and transferred with the straight and curved instruments for the basic laparoscopic tasks, and highlight the importance of a special laparoscopic training curriculum. DESIGN A prospective study on a box trainer in single-port setting was conducted using 2 groups. Each group performed 2 tasks on the box trainer in single-port setting. Group-S used conventional straight laparoscopic instruments, and Group-C used curved laparoscopic instruments. Learning curves were obtained by daily measurements recorded in 7-day sessions. On the last day, the 2 groups changed instruments between each other. SETTING 1st Department of Surgery, Semmelweis University of Medicine from Budapest, Hungary, a university teaching hospital. PARTICIPANTS In all, 20 fifth-year medical students were randomized into 2 groups. None of them had any laparoscopic or endoscopic experience. Participation was voluntary. RESULTS Although Group-S performed all tasks significantly faster than Group-C on the first day, the difference proved to be nonsignificant on the last day. All participants achieved significantly shorter task completion time on the last day than on the first day, regardless of the instrument they used. Group-S showed improvement of 63.5%, and Group-C 69.0% improvement by the end of the session. After swapping the instruments, Group-S reached significantly higher task completion time with curved instruments, whereas Group-C showed further progression of 8.9% with straight instruments. CONCLUSIONS Training with curved instruments in a single-port setting allows for a better acquisition of skills in a shorter period. For this reason, there is a need for proficiency-based conventional, but also for a single-port, laparoscopic training curriculum in general surgery residency education.