Péter Sápy

Laparoscopic treatment of nonparasitic hepatic cysts

BackgroundWe present our experience with laparoscopic deroofing of nonparasitic hepatic cysts.MethodsLaparoscopic deroofing was performed due to a solitary hepatic cyst in 21 patients and polycystic liver in four patients. Laparoscopy was indicated when a cyst was larger than 5 cm (the general size of cysts was 6.9 cm) and caused complaints and was in a superficial position. In eight patients in whom the cyst was larger than 10 cm, omentoplasty was performed.ResultsIntraoperative complications were not detected. Two conversions were performed because of the deep position of the cyst. Postoperative bile leakage was detected in one case that was treated conservatively. The average hospital stay was 4.7 days. Relapse occurred in two patients (8%), but only one of them required a second operation.ConclusionsWe recommend laparoscopic deroofing for treatment of nonparasitic liver cysts. This operation causes only slight discomfort for the patients, the intra- and postoperative morbidity is low, and relapses are rare.

Immunological Investigations in Acute and Chronic Human Pancreatitis

Follow-up immunological studies in 27 patients with acute pancreatitis of known etiology showed a significant elevation in the level of circulating immune complexes (IC), a significant inhibition in migration of leukocytes (with direct LMT) of patients and a significant decrease in the percentage of T-active, T-total peripheral lymphocytes and in the absolute count of peripheral T cells. Elevated circulating IC levels could been detected 3-4 weeks after the onset of acute pancreatitis. These immunological changes have still been demonstrated in a number of patients 7-14 months after recovery. We have found similar immunological alterations in patients with chronic pancreatitis as well. The possible causes and role of these long-term existing immunologic abnormalities are discussed.

Chirurgische Behandlung der intraabdominellen Blutung bei Peliose der Leber

ZusammenfassungEinleitung. Die Peliose ist eine seltene Erkrankung, die am häufigsten an der Leber zu beobachten ist. Sie ist durch zahlreiche mit Blut gefüllte Kavitäten charakterisiert. Die Leberpeliose stellt meist einen Zufallsbefund bei der Obduktion dar, der klinisch inapperent ist und in seltenen Fällen mit einem reduzierten Ernährungszustand einhergeht. Gelegentlich induziert die Peliosis hepatis eine Leberdysfunktion, oder, durch eine Leberruptur, einen hämorrhagischen Schock. Methoden. In unserem Bericht beschreiben wir den Fall einer 33 jährigen Frau, bei der die Leberpeliose durch eine Leberruptur ein Hämoperitoneum verursacht hatte. Die Vorstellung der Patientin erfolgte unter dem Bild eines akuten Abdomens. Bei der Aufnahmeuntersuchung zeigte sich neben einer entsprechenden Symptomatik und Laborkonstellation in der ultrasonographischen und computertomographischen Untersuchung des Abdomens jeweils ein Hämoperitoneum und eine raumfordernde Läsion des linken Leberlappens. Ergebnisse. Um die Blutung zu stoppen, wurde mittels superselektiver Katheterisierung der linken Leberarterie eine Embolisation durchgeführt. Nach Stabilisierung der Patientin wurde bei Vorliegen einer Leberruptur auf dem Boden der Ruptur des 15 cm großen Tumors eine Hemihepatektomie links durchgeführt. Der postoperative Verlauf war problemlos und die Patientin konnte beschwerdefrei entlassen werden. Die histologische Aufarbeitung des Präparats erbrachte die Diagnose einer fokcalen parenchymatösen Peliose der Leber. Schlussfolgerung. In der vorliegenden Arbeit demonstrieren die Autoren die Bedeutung der Behandlungsverfahren im Falle einer intraabdominellen Blutung auf dem Boden von Leberläsionen. Neben der chirurgischen Therapie unterstreichen sie auch die Bedeutung der Kombination mit radiologischer Katheterintervention in solchen Fällen.AbstractIntroduction. Peliosis is an infrequent entity characterized by multiple blood-filled cavities mostly involving the liver. Peliosis hepatis usually appears as a rare autopsy finding in asymptomatic patients or in patients with chronic wasting diseases. However, peliosis hepatis may present as hepatic dysfunction or shock from hepatic rupture. Material and Methods. In our report we present the case of a 33-year-old woman with hepatic peliosis causing a hemoperitoneum resulting from liver rupture, which needed immediate surgical treatment. On the basis of symptoms and the laboratory parameters the acute abdomen was evaluated by abdominal ultrasound and CT scan, both revealing a hemoperitoneum and a lesion in the left liver lobe. Results. Embolization was performed by superselective catheterization of the left hepatic artery to stop the bleeding. After stabilization of the patient, left lobectomy of the liver was performed because of the ruptured 15-cm liver tumor. The patient recovered well and was discharged without residual complaints. Histopathologic analysis showed focal parenchymal peliosis. Discussion. The authors evaluate the effectiveness of the surgical strategy in a case of life-threatening focal hepatic disorder. Besides surgery, the authors emphasize the importance of invasive radiological interventions in these cases.

Hemorheological changes caused by intermittent Pringle (Baron) maneuver in beagle canine model

In liver resection operations the Pringle (Baron) maneuver can be used for temporary ischemia by clamping the hepatoduodenal ligament intermittently. In this beagle canine model we investigated whether hemorheological parameters may alter in systemic, portal and hepatic venous blood and in arterial samples during-after Pringle maneuvers. In Pringle Group unilateral femoral artery and external jugular vein were cannulated. From median laparotomy the hepatoduodenal ligament was exposed. The portal venous system was catheterized via a mesenteric vein and through the inferior caval vein a catheter was led to the hepatic veins. After stabilization, a 15-minute Pringle maneuver was carried out three times with 5-minute interpolated reperfusion periods. In Control Group Pringle maneuvers were not made. Before and after Pringle maneuvers parallel blood samples were taken from the cannulated vessels for determining hematological parameters and erythrocyte aggregation. Following Pringle maneuvers erythrocyte deformability, blood and plasma viscosity were also tested. The results showed that besides systemic hemorheological effects of the intermittent Pringle maneuver local leukocyte count, hematocrit and erythrocyte aggregation index altered mainly in portal venous blood, depending on the repeating number of the maneuvers. Thus, investigations of hemorheological parameters might be useful to determine the optimal duration of the Pringle maneuver.

The role of percutaneous external drainage in the treatment of fluid collections associated with severe acute pancreatitis. What, when and how to drain?

The percutaneous drainage of the fluid collections associated with severe acute pancreatitis mainly in sterile cases is not a commonly accepted method. The aim of the present paper is to analyse the indications, the technic, the limits and results of the percutaneous drainage on the basis of the literature. The percutaneous drainage plays an important role in the treatment of the acute fluid collection, the acute pseudocyst, the pancreas abscess, and the liquified necrosis, accompanying the severe acute pancreatitis. For the septic fluid collections the percutaneous drainage is preferred as the first line treatment. In cases of sterile acute fluid collections and pseudocysts because of its relatively high iatrogenic infection rate the drainage is indicated only if it causes severe complaints. The rules of sterility have to be kept. For successful treatment of liquified necrosis the possible methods are the use of large-bore (20-30F) catheter drainage, sinus tract endoscopy, or laparoscopic assisted necrosectomy. In more than 25% of the cases drainage, along with the conservative treatment, leads to the complete recovery of the patient. In the remaining cases it is helpful in postponing the date of the operation and avoiding early surgery.

Effects of various drugs (flunixin, pentoxifylline, enoxaparin) modulating micro-rheological changes in cerulein-induced acute pancreatitis in the rat

Previously we have investigated the cerulein-induced acute pancreatitis and provided data on its micro-rheological impact in the rat. We hypothesized that non-steroid anti-inflammatory agent flunixin, the xanthine-derivate pentoxifylline and the low molecular weight heparin enoxaparin may have various beneficial effects improving microcirculatory and rheological parameters. In female rats, under general anesthesia, 10 μg/kg cerulein s.c. was administered and 2 hours afterwards microcirculation was tested by laser Doppler flowmetry on the tongue and after performing laparotomy on the small intestine, liver and pancreas prior to terminal blood sampling. From blood samples hematological parameters, blood pH, lactate concentration, erythrocyte deformability, osmoscan parameters and erythrocyte aggregation were tested. Compared to normal control in acute pancreatitis group we found severe deterioration in tissue microcirculation together with impaired erythrocyte deformability and enhanced aggregation, accompanied by acidic pH and increasing lactate concentration. Improvement was found when using flunixin (s.c.), pentoxifylline (i.p.) or enoxaparin (s.c.). These drugs could partly improve the blood flux on the surface of the investigated organs, and the flunixin had the most expressed improving effects on micro-rheological parameters. Surprisingly, the improving effect of pentoxifylline on micro-rheological parameters was not obvious (red blood cell deformability did not improved better than in the other treated groups), however, microcirculatory parameters improved.

[Analysis of clinical course of severe acute biliary and non biliary pancreatitis: a comparative study].

UNLABELLED The acute pancreatitis is a relative common disease with incidence of 5-80 per 100000 people of the population. The number of new cases has steadily increased in recent years. The two main etiological factors are alcohol and cholelithiasis. The incidence of alcoholic pancreatitis is higher in male, and the incidence of gallstone pancreatitis is higher in female. AIM To summarize the difference between the clinical course of biliary and not biliary type of severe acute pancreatitis by analyzing the data of these patients. METHODS 139 patients treated with severe acute pancreatitis were divided in two groups: biliary (A group) and non biliary (B group) of origin. The two groups were compared on the basis of sex and age, mortality, morbidity, number of surgery and hospital stay. chi 2 probe was used for the statistical analysis. RESULTS The complications in biliary group were more serious. The average mortality rate was 15.1%, 17.8% in group A and 13.8% in group B. The mortality rate of female patients in group A was significantly higher. CONCLUSION Female patients suffering from severe biliary acute pancreatitis have higher morbidity and mortality rate. Therefore an elective cholecystectomy is suggested in old female patients with serious co-morbidity and gallstones, before any complications.

The Role of Percutaneous Drainage in the Treatment of Severe Acute Pancreatitis on the Basis of the Modified Atlanta Classification

According to the Atlanta Classification in many cases of acute pancreatitis there are three well-defined fluid collections: acute peripancreatic fluid collection (APFC), the so-called postnecrotic pancreatic/peripancreatic fluid collection which develops in the region of liquified pancreatic necrosis, and the pseudocyst that develops in the late phase of the illness. In many cases, these anatomic entities can be succesfully treated with radiological interventional methods. It is difficult to correctly interpret the articles that review the treatment of numerous patients because the nomenclature is unclear. The aim of this article is to analyse the indications, limits and results of the listed complications treated by percutaneous drainage (PD) which aggravate acute pancreatitis on the basis of the literature.

Micro-rheological changes during experimental acute pancreatitis in the rat

Although microcirculatory disturbances play pivotal role in the pathomechanism of acute pancreatitis (AP), very few papers can be found which had been tested any of hemorheological parameters. The aim of our study was to analyze the hemorheological changes in cerulein-induced experimental acute pancreatitis in rat in two doses (5 and 10 μg/kg, s.c.). Male and female rats were subjected to Control group, or AP with 5 or 10 μg/kg cerulein groups. Blood samplings (lateral caudal vein) were completed before cerulein administration, and 1, 2 and 24 hours later. Hematological parameters, amylase activity, erythrocyte deformability (ektacytometry) and aggregation (light-transmission method) were tested. The presence of AP could be confirmed by amylase testing and histological examination. The earliest impairment of the red blood cell deformability could be observed 1 hour after cerulein administration in 10 μg/kg dosage. Female animals had the worst rheological results with high mortality. In conclusion, subcutaneously administrated cerulein in dosage of 5 and 10 μg/kg resulted in AP in rats, with significant changes in red blood cell deformability and alterations in erythrocyte aggregation. This model seems to be suitable for further comparative studies.

Surgical treatment of acute pancreatitis today

UNLABELLED In case of mild acute pancreatitis the treatment is basically conservative, but in severe cases surgical treatment has an important role. METHODS authors analyze the indications for operation, the timing and the technical questions of it on the basis of the literature published in the previous ten years. RESULTS AND CONCLUSIONS sterile pancreas necrosis is rarely but septic necrosis is an indication for surgery if the conservative treatment is unsuccessful. Therapy resistant multiple organ failure, abdominal compartment syndrome and other surgical complications such as bleeding, perforation need surgery treatment. In biliary pancreatitis associated with cholestasis urgent endoscopic sphincterotomy and later cholecystectomy is suggested. In case of pancreas necrosis the ideal time of operation is 21 days after the beginning of the disease because the rate of complications and mortality is high in early operations. Careful necrosectomy is important which has to be extended to the retrocolic and retroduodenal areas as well. Open abdominal surgery has more complications so it is suggested only in selected cases. Operation should be amended with postoperative bursa omental lavage.