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Objective: Stent-assisted remote iliac endarterectomy (SA-RIEA) is a hybrid minimally invasive technique for treating patients with combined external iliac and common femoral disease, when the only alternative would be conventional open revascularisation., Design: This was a retrospective, single-centre study., Materials and Methods: From January 2004 to April 2010, 155 SA-RIEA procedures were performed. The patients' mean age was 62 (range, 43-86) years. Indications for surgery were: severe claudication in 79 (51%), rest pain in 43 (28%) and gangrene in 33 (21%) cases. The mean length of follow-up was 21 months., Result: Initial technical success was achieved in 145 (93.5%) procedures. Ten patients required conversion to a conventional iliofemoral reconstructive procedure. The 1-, 3- and 5-year primary, primary-assisted and secondary patency rates were 80.2%, 74.7% and 69.3%; 84.8%, 82.4% and 78.2%; and 86.8%, 84.2% and 79.6%, respectively. Within the first 30 days, there were no early reocclusions, one (0.6%) perioperative death due to myocardial infarction, five (3.4%) minor wound complications and two (1.3%) limb losses. During follow-up, seven patients underwent open reconstruction due to symptomatic reocclusion, and four were re-operated on due to symptomatic restenosis (three percutaneous transluminal angioplasties (PTAs), one reendarterectomy)., Conclusion: In patients with combined common femoral and external iliac disease, SA-RIEA appears to offer a safe and effective alternative to conventional open surgery., (Copyright © 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: The purpose of this study was to quantify some clinical parameters useful as esthetic guidelines when gingival contour is modified and to compare the left and right sides of six maxillary anterior teeth., Materials and Methods: Maxillary casts mounted on an articulator according to the axis orbital plane were photographed from 35 young adults. The angle formed between the gingival line and maxillary midline (GLA) and the distance between the gingival zenith of the lateral incisor and the gingival line were measured (LID) using a flexible protractor and digital vernier caliper, respectively. The asymmetry was evaluated using a paired t test for the left vs right measurements of GLA and LID. The descriptive statistics for GLA and LID were calculated., Results: The GLA measurements of the left side (86.7°±4.2°) were significantly greater than those of the right side (84.6°±5.4°), and the mean absolute symmetry for GLA was 1.7°±4.4°. The mean LID measurement was 0.92΁0.11., Conclusions: The gingival zenith of the canine is apical to the gingival zenith of the incisors (GLA <90°) and the gingival zenith of the lateral incisor is below or on (17%) the gingival line when head is oriented on the axis orbital plane. A directional asymmetry was shown with the right side higher than the left side. Along with the other parameters related to dental esthetics, these clinical parameters may serve as esthetic guidelines and may enable us to obtain a more predictable outcome.

Fresh autologous vein grafts are commonly used for infrainguinal vascular reconstructions with good results. Previously we have confirmed the high viability index of homografts even after long-term storage at 4 degrees C in tissue culture medium. In this clinical study, we have evaluated the in vivo efficiency of this storage method in humans with major peripheral graft infections. Between April 2006 and November 2008, data from patients who underwent graft excision and venous allograft reconstruction were collected prospectively (5 men, 2 women, mean age 68 years). Six patients had acute ischemia at the time of allograft reconstruction, while 3 had experienced anastomosis rupture. Allograft reconstruction was performed as an emergency procedure in 3 cases. The observed parameters included patient survival, limb salvage, persistence or recurrence of infection and allograft patency. In the follow-up period reoperation, excision or thrombectomy was necessary in 3 cases. There were no perioperative deaths, early amputations, persistent or recurrent infections. In conclusion, this study demonstrates the efficacy of long-term 4 degrees C storage of venous allografts for revascularization in cases with peripheral bypass graft infection. We suggest that this technique is a useful option for graft preservation and propose a wide-scale introduction., (Copyright 2009 S. Karger AG, Basel.)

Introduction: The objective of the study was to analyse the causes of injury, surgical approaches, outcome, and complications with vascular trauma in patients operated on over a period between 1986-2006., Material and Methods: In 128 patients with peripheral arterial injuries the mechanism was direct penetration in 90 cases and blunt injury in 30 cases. In 8 cases a chronic damage (false aneurysm, AV fistula) was observed. Isolated vascular trauma was present in 97 patients (75.8%), 31 cases (24.2%) were complicated by concomitant bone fractures,and nerve or soft tissue damage. Most frequently injured vessels were the superficial femoral (22.6%) crural (22.6%),and ulnar and radial (13.2%) arteries., Results: In 132 cases operation had to be performed. Direct suture 26, interposition in arterial injuries 26, interposition in venous injuries 5, end to end anastomosis in 12 cases, venous patches in 7 cases were the operation method. In 28 cases non-reconstructive operation was carried out, and there were 4 endovascular procedures. Five secondary amputations were performed and five patients died. The limb salvage rate was 95%., Discussion: Most vascular injuries of the extremities can be managed successfully unless associated with severe concomitant damage of the bones, nerves and soft tissues.

In most cases of vascular repair a graft implantation is needed. Homografts have been proven to be suitable conduits when no autogenous graft is available. High viability index of vein homograft was confirmed during long term refrigerated storage in tissue culture medium, however there was no data of successful implanted cases. We report two cases of great saphenous vein (GSV) homograft implantation with excellent early results. In the first case graft-popliteal bypass was performed with vein homograft after septic ilio-femoral Dacron graft explantation and aorto-bifemoral Silver bypass procedure. Septic crossover synthetic bypass was replaced with GSV homograft in the second case. Long term storage of vein allografts at 4 C is a valuable and cost-effective option for revascularization and we propose wide-scale introduction of this method.

Sickle cell trait (SCT) is a genetic disease affecting the synthesis of normal hemoglobin (Hb) marked by the heterozygous presence of HbA and HbS. It is thought that exercise tolerance and aerobic capacity could be limited in SCT carriers, but that the co-existence of alpha-thalassemia with SCT (SCTAT) could improve exercise response. To examine these issues, we compared the characteristics of VO2 kinetics during a constant heavy exercise among athletes carrying either the SCT (n = 6), the SCTAT (n = 9), or the normal Hb (control group; n = 10). After determination of maximal power output (Ppeak), all subjects underwent a constant heavy cycling exercise lasting 9 min at approximately 70 % Ppeak. Pulmonary VO2 and cardio-respiratory parameters were measured breath-by-breath and the VO2 response was modelled using non-linear regression techniques. The time constant of the VO2 primary component and oxygen deficit were not significantly different among the three groups. The VO2 slow component was 28 % and 33 % higher (p < 0.05) in SCT and SCTAT than in the control groups, respectively. Altogether, athletes with the SCT and the SCTAT had higher heart rate at the beginning (+ 5.2 %) and the end (+ 7.4 %) of the slow component compared to the control group (p < 0.05). These results suggest that SCT and SCTAT subjects are not limited during the first exercise minutes, but are prone to exercise intolerance and to lower aerobic capacity thereafter, due to a higher VO2 slow component, and that alpha-thalassemia does not improve exercise response. The finding of a higher slow component in SCT and SCTAT athletes was possibly due to the loss of O2 availability to muscles, additional fiber recruitment and/or higher cardiac load with time.

Extraskeletal osteosarcoma is a rare malignant soft tissue tumour. At open cholecystectomy performed for gallstones, a 61-year-old woman was found to have osseous tissue in the wall of the gallbladder. Histopathological examination of the specimen revealed a focus of extraskeletal osteosarcoma. The patient developed widespread intra-abdominal metastases 5 months after the operation, and died of pulmonary deposits at 9 months. Although osteosarcoma has rarely been reported at other extraskeletal sites, this appears to be the first case of a primary tumour in the gallbladder.

Authors reviewed the records of a patient with a 6 year long history of severing abdominal complaints, correct diagnosis came only in the state of acute abdomen for ileus. He underwent numerous radiological exams and gastroscopies in the course of repeated check-ups in other institute. Due to these results his complaints were managed as gastro esophageal reflux. After years of ineffective therapy his parents and physician suggested him to apply for psychiatric treatment. Finally, for the symptoms and radiological results of mechanical upper small bowel obstruction he underwent urgent laparotomy. Approximately a 40 cm long jejunal invagination was found caused by a large jejunal polyp. Segmental small bowel resection was carried out. Histologic examination of the resected specimen proved Grade I. adenocarcinoma. One year after an uneventful postoperative period the patient is free of complaints and symptoms. The differential diagnosis between upper small bowel obstruction and severe vomiting of esophago-gastro-duodenal origin is relatively difficult. For this we recommend utilizing all the recent diagnostic methods in case of hesitancy or ineffective therapy.

Pancreaticopleural fistulas are rare but serious complications of chronic or recurrent inflammatory pancreatic disease. Massive unilateral or bilateral pleural effusion may occur in association with rupture of pancreatic duct or pseudocyst into the pleural cavity. In the past decade we have treated 10 patients with pancreaticopleural fistulas. Eight of them had a previous history of inflammatory pancreatic disease. Diagnosis was made by finding a markedly elevated amylase level (10 pts) in the pleural fluid. US and CT examination enabled the establishment of the diagnosis of pancreatic origin, showing chronic pancreatic (9 pts) and pancreatic pseudocyst (6 pts). Pancreaticopleural fistula was successfully demonstrated by ERCP in four patients. Initial treatment was non-operative using total parenteral or jejunal nutrition and multiple thoracocentesis or thoracic drainage. Anti-secretory octreotide therapy was used in all patients. This conservative treatment was successful in three patients (3/10). Septic complication (1 pt) and unsuccessful medical therapy (6 pts) recommended surgical intervention. Decompression procedure (4 pts) and resection (3 pts) were performed. Surgery was successful in all seven patients. We lost no patients and none of them required subsequent surgical treatment.

We lose more than 3000 patients a year in Hungary as a result of colorectal cancer. Our aim was to determine how the last 20 years' development of surgical techniques and related specialties has affected the outcome in this patient group at our Department. This retrospective study shows a significant increase in the resectability of colorectal cancer, while there has been a substantial decrease in perioperative mortality.

We analysed the clinical value of the procalcitonin quick test (PCT-Q; BRAHMS Diagnostica, GmbH, Berlin) in infected pancreatic necrosis verified by guided fine-needle aspiration (FNA). In a prospective, controlled study the results of 24 patients were evaluated during 2001. PCT-Q test was performed in patients with necrosis verified on CT scan and/or septic symptoms. If PCT-Q test was positive or septic complication (infected necrosis or abscess) developed CT or US guided fine-needle aspiration was performed with Gram staining and bacterial culture of the sample. Positive FNA result was indication for surgery with repeated staining and bacterial culture of the surgical specimen. Septic complications of pancreatic origin developed in 12 patients. Comparing the results fine-needle aspiration was more authentic with a sensitivity of 92% and a specificity of 100%, while the sensitivity of the PCT-Q test remained 75% and its specificity 83%. Comparing abscess and infected necrosis, significantly higher procalcitonin values were detected in patients with necrosis. These results show that PCT-Q test can be a possible non-invasive method besides fine-needle aspiration. Elevated levels of procalcitonin (higher than 2 ng/ml) clearly suggest infection of the necrosis, while lower values do not exclude the possibility of local septic progression.

Centrocytes in germinal centers on selection differentiate into plasma cells and/or memory B cells. Cells that have acquired autoreactivity by somatic mutation generally fail to undergo positive selection and die by apoptosis. Presence of isotype-switched high-affinity autoantibodies in serum of autoimmune patients suggests that autoreactive plasma cells eventually emerge from a germinal center reaction. Currently, it is still unclear to which extent the same is true for autoreactive memory B cells. To address this question, we have analyzed whether IgG-bearing memory B cells with specificity for thyroid peroxidase (TPO) can be found in blood of patients with autoimmune thyroid disease and in normal blood donors. Autoreactive TPO-specific IgG+ memory B cells were identified using a previously described assay combining two-step immunomagnetic enrichment with flow cytometric detection. Autoreactive IgG+ memory B cells were found in 65% of the patients with autoimmune thyroid disease and in 17% of normal blood donors; 40% of the latter had no detectable TPO-specific IgG in the serum. The specificity of enriched TPO-specific IgG+ memory B cells was confirmed by in vitro proliferation and differentiation into antibody-secreting cells at limiting dilution and analysis of the supernatants for the presence of TPO-specific IgG. Detection of TPO-specific IgG+ memory B cells in most patients with clinically manifested autoimmune thyroid disease and few normal blood donors may argue for a role of circulating memory B cells in onset of disease.

Spontaneous rupture of liver hemangiomas is exceptional, they rarely increase in size. Elective surgery of liver hemangiomas is safe and effective. In our teaching hospital during a 5-year period 9 patients underwent elective surgery for giant liver hemangiomas, one more patient required urgent operation for spontaneous rupture. Indications for elective surgery were: abdominal pain in 5 patients, enlargement in 1 patient, and 3 patients were worried about the risk of rupture or having a tumor left in situ. The average age of our four male and six female patients was 44.5 years (30-58). The median largest dimension of the lesions was 8.5 cm (5.5-14); six of them located in the right, four in the left lobe. Enucleation was performed in most patients (8, mostly of them in the right lobe); anatomical resections were performed only in two cases (left lobectomy). There was no postoperative mortality, the only complication was mild pneumonia in one patient. Elective surgery is indicated only in a small number of patients with hemangiomas, it should be limited to giant, symptomatic tumors or those with a documented tendency to increase in size. The type of resection depends on the site and the size of the lesion. Enucleation can be performed rapidly and safely in most patients and as such it is preferable to anatomical resection.

We present six cases of successfully resected primary tumors of the distal part of duodenum (third and fourth segment). Average age of the four male and two female patients was 59 years (47-80). Distal segmental resection were performed in four, pylorus-preserving pancreatoduodenectomy in two cases. Histologically the tumors were five adenocarcinomas, and one gastrointestinal stromal tumor. This tumor causing massive bleeding. In two patients, local lymph nodes were tumor positive, and in one patient synchronous metastasis of the greater omentum was excised during a palliative resection. There was no operative mortality. During a mean follow-up period of 17 months two patients died. Our results support the fact, that radical surgical resection of these tumors, even by segmental resection, provides a more favorable prognosis for duodenal carcinoma than for pancreatic tumors.