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Augmentation cystoplasty is an exemplary multiorgan intervention in urology which is particularly associated with microvascular damage. Our aim was to review the available intravital imaging techniques and data obtained from clinical and experimental microcirculatory studies involving the most important donor organs applied in bladder augmentation. Although numerous direct or indirect methods are available to assess the condition of microvessels the implementation of microcirculatory diagnostic methods in humans is still challenging and the assessment of organ microcirculation in the operating theatre has limitations. Nevertheless, preclinical studies generally report good internal validity and although prospective human protocols with reduced variability are needed, a possible positive impact of microcirculatory diagnostics on the clinical outcomes of urologic surgery can be anticipated.

Absztrakt: A legújabb definíció szerint rövidbél-szindrómának nevezzük a bél jelentős hosszának elvesztése után kialakuló elégtelen bélműködés tünetegyüttesét, melyben a homeostasis és fejlődés-növekedés csak a hiányzó víz és elektrolit, illetve makrotápanyagok parenteralis pótlásával tartható fenn. A rövid bélben lezajló lassú természetes adaptációs folyamat a veszteséget csak bizonyos mértékben képes kompenzálni. Ennek megfelelően megkülönböztetünk (1) akut, (2) elhúzódó és (3) krónikus típust. A kórkép a leggyakrabban gyermekkorban jelentkezik nekrotizáló enterocolitis, malrotatio, volvulus, hasfalzáródási rendellenesség és ilealis atresia következményeként. A legnagyobb kihívást a krónikus típus ellátása okozza, bár a multidiszciplináris szemléletnek köszönhetően folyamatosan javul a betegek hosszú távú túlélése és életminősége, béltranszplantációra egyre ritkábban van szükség. A szerzők célja az intestinalis rehabilitáció legfontosabb szempontjainak – fokozott gasztrinszekréció, „high-output” stoma, csökkent tranzitidő, a centrális vénás kanülök ápolása, az enteralis, illetve parenteralis táplálás és az adaptáció serkentése – összegzése mellett a legújabb sebészi kezelési lehetőségek, köztük az autológ intestinalis rekonstrukció (AIRS) módszereinek, a passzázslassításnak (az ileocoecalis billentyű pótlása), a „bélhosszabbítás”-nak (LILT, STEP, SILT) és a felszívófelszínt növelő eljárásoknak (kontrollált bélexpanzió) az áttekintése volt. Ezeken túl a szerzők érintik a jelenlegi kutatások (disztrakciós enterogenezis, ’tissue engineering’) legújabb eredményeit. Orv Hetil. 2020; 161(7): 243–251.

Summary Introduction Augmenting the bladder with a seromuscular gastrointestinal flap is a promising alternative approach aiming for a mucus-free bladder augmentation; however, the contraction (shrinkage) of the flaps remains a major concern. Enteric nervous system (ENS) abnormalities cause a failure of relaxation of the intestinal muscle layers in motility disorders such as Hirschsprung's disease and intestinal neuronal dysplasia. In mammals, the submucosal enteric nervous plexus contains nitrergic inhibitory motor neurons responsible for muscle relaxation. The authors hypothesize that mucosectomy disconnects the submucosal nervous plexus from the myenteric plexus resulting in flap shrinkage. Study design After ethical approval, mucosectomy was performed on vascularized flaps from the ileum, colon, and stomach in five anesthetized pigs. In Group (I), only the mucosa was scraped off with forceps, creating a sero-musculo-submucosal flap, while in Group (II), the mucosa and submucosa were peeled off as one layer, leaving a seromuscular flap. Isolated and detubularized segments served as control. The width of each flap was measured before and after the mucosectomy. The ENS was assessed by neurofilament immunohistochemistry in conventional sections and by acetylcholinesterase and NADPH-diaphorase enzyme histochemistry in whole-mount preparations. Results The stomach contracted to a lesser extent of its original width, 92.82 ± 7.86% in Group (I) and 82.24 ± 6.96% in Group (II). The ileum contracted to 81.68 ± 4.25% in Group (I) and to 72.675 ± 5.36% in Group (II). The shrinkage was most noticeable in the colon: 83.89 ± 15.73% in Group (I) and to 57.13 ± 11.51% in Group (II). One-way equal variance test showed significant difference (P Conclusion Mucosectomy resulted in significant immediate shrinkage of the flaps. This was more expressed when also the submucosa was peeled off, thus fully disrupting the ENS. The shrinkage affected the stomach the least and the colon the greatest. This phenomenon should be taken into consideration when planning mucus-free bladder augmentation. Download : Download high-res image (83KB) Download : Download full-size image Summary Fig. .

Absztrakt: Bevezetés: A szerzők elemzik a bevezetést követő hét évben tüdőrák miatt végzett minimálisan invazív (video-assisted thoracic surgery – VATS) lobectomiák sebészi technikáját, eredményeit és onkológiai utánkövetését. Anyag és módszer: 2011. június 23. és 2017. december 21. között 173 VATS lobectomia történt 105 férfi, illetve 68 nőbetegnél. Az átlagéletkor 64,1 év, az átlagos műtéti időtartam 130 perc volt. Eredmények: Konverzió 8 esetben történt, háromszor vérzés, háromszor érfali nyirokcsomó infiltráció, illetve két alkalommal hörgővarrat-elégtelenség miatt. A posztoperatív első 3 hétben elhúzódó áteresztést 20 esetben észleltek, emiatt tíz reoperatio történt (hét újbóli VATS, három thoracotomia), tíz eset drainage-ra szanálódott. Két haematomakiürítés történt VATS-szal, illetve egy elektromos kardioverzió pitvarfibrillatio miatt. Perioperatív halálozás nem volt. A 164 eltávolított malignus tumorból 5 metastasis volt. Szövettani megoszlás alapján 110 adenocarcinoma, 32 planocellularis carcinoma, 6 kissejtes neuroendocrin carcinoma, 4 differenciálatlan tumor, 4 carcinoid, 1 szinkron adenocarcinoma és planocellularis carcinoma, 1 szinkron adenocarcinoma és kissejtes neuroendokrin carcinoma, illetve 1 carcinosarcoma igazolódott. 118 beteg kapott adjuváns kemoterápiát. A tumorok stádiuma: IA 40, IB 53, IIA 29, IIB 16, IIIA 21 eset volt. A betegek átlagos utánkövetési ideje 19,5 hónap volt. Ezalatt 9 betegnél lokális recidivát, 27 betegnél távoli metastasist észleltünk (11 tüdő- [3 multiplex], 10 csont-, 6 agyi, 3 máj- [1 multiplex], illetve 3 mellékvese-metastasis). Szimultán tüdőmetastasisokkal 2 esetben lokalizált pleuracarcinosis is igazolódott. Következtetés: Fenti időszakban a VATS lobectomia bevonult az osztály rutinműtétei közé. A korábbi nyitott műtétek axillaris thoracotomiából történő végzését az anterior technika elsajátításában előnyösnek érezzük. A betegek onkológiai gondozása során észlelt lokális recidivák, távoli metastasisok megjelenése korrelál a szakirodalom hasonló adataival.

Mucus production by the intestinal segment used in bladder augmentation results in long term concerns especially stones and UTI. Bladder augmentation with demucosalized intestinal flap is a potential promising approach for mucus-free bladder augmentation, however the contraction of the flap remains a major concern. Mucosectomy has been shown to result in abrupt and immediate cessation of microcirculation in the ileum. However, assessment of microcirculation shortly after mucosectomy may miss a gradual recovery of micro-circulation over a longer period of time. Previous studies have not assessed the colon response to mucosectomy.Our aim was to assess the effect of mucosectomy on the microcirculation of the colon and ileum beyond the known warm ischemia time.Ileum and colon segments were detubularised and mucosectomy was performed in (n = 8) anesthetised minipigs. Group A: sero-musculo-submucosal flaps were created with removal of the mucosa and preserving the submucosal layer Group B: sero-muscular flaps were created with the removal of submucosal-mucosal layer. The Microvascular Flow Index (MFI), the velocity of the circulating red blood cells (RBCV) was measured using Intravital Dark Field (IDF) side stream videomicroscopy (Cytoscan Braedius, The Netherlands) after mucosectomy, for up to 180 min.Both the MFI and RBCV showed an abrupt reduction of microcirculation, on both surfaces of the remaining intestinal flap, in the ileum as well as in the colon. Slightly better values were seen in Group A of the colon, but even these values remain far below the preoperative (control) results. Some, tendency of recovery of the microcirculation was noted after 60-90 min, but this remained significantly lower than the preoperative control values at 180 min.Both the ileal and the colonic flap remains in severe ischemia after mucosectomy beyond the warm ischemia time.This study shows that surgical mucosectomy compromises vascular integrity of the intestinal flaps used for bladder augmentation. Partial recovery which occurs within the warm ischemia time is not significant enough to avoid fibrosis therefore flap shrinkage may be inevitable with this technique.The gastrointestinal structure of the porcine model is not the same exactly as the human gastrointestinal system. However, although not an exact match it is the closest, readily available animal model to the human gastrointestinal system.

Augmentation cystoplasty is an exemplary multiorgan intervention in urology which is particularly associated with microvascular damage. Our aim was to review the available intravital imaging techniques and data obtained from clinical and experimental microcirculatory studies involving the most important donor organs applied in bladder augmentation. Although numerous direct or indirect methods are available to assess the condition of microvessels the implementation of microcirculatory diagnostic methods in humans is still challenging and the assessment of organ microcirculation in the operating theatre has limitations. Nevertheless, preclinical studies generally report good internal validity and although prospective human protocols with reduced variability are needed, a possible positive impact of microcirculatory diagnostics on the clinical outcomes of urologic surgery can be anticipated.

Based on the latest definition, short bowel syndrome is defined as intestinal failure due to the loss of significant small bowel length or function, when the homeostasis and growth can only be maintained with intravenous supplementation of fluid, electrolytes and macronutrients. The natural adaptation of the short bowel can only compensate for the loss up to a certain level. According to this, we differentiate (1) acute, (2) prolonged and (3) chronic types of intestinal failure/short bowel syndrome. The most common causes are necrotising enterocolits, intestinal malrotation and volvulus, gastroschisis and ileal atresia. The management of type 3 short bowel syndrome has evolved significantly during the last decades, due to the multidisciplinary approach, hence the survival and quality of life of the patients have improved and transplantation is rarely necessary. Our aim was to review the most important considerations of intestinal rehabilitation, like management of increased gastrin secretion, high output stoma, decreased transit time, central venous lines, enteral and parenteral nutrition and the enhancement of the natural adaptation. We reviewed the former and the latest options of the autologous intestinal reconstructive surgery (AIRS) like the reversed segment, small bowel interposition, ileocaecal valve replacement, bowel lengthening and tailoring (LILT, STEP and SILT), controlled bowel expansion and the latest results with distraction enterogenesis and tissue engineering. Orv Hetil. 2020; 161(7): 243-251.Absztrakt: A legújabb definíció szerint rövidbél-szindrómának nevezzük a bél jelentős hosszának elvesztése után kialakuló elégtelen bélműködés tünetegyüttesét, melyben a homeostasis és fejlődés-növekedés csak a hiányzó víz és elektrolit, illetve makrotápanyagok parenteralis pótlásával tartható fenn. A rövid bélben lezajló lassú természetes adaptációs folyamat a veszteséget csak bizonyos mértékben képes kompenzálni. Ennek megfelelően megkülönböztetünk (1) akut, (2) elhúzódó és (3) krónikus típust. A kórkép a leggyakrabban gyermekkorban jelentkezik nekrotizáló enterocolitis, malrotatio, volvulus, hasfalzáródási rendellenesség és ilealis atresia következményeként. A legnagyobb kihívást a krónikus típus ellátása okozza, bár a multidiszciplináris szemléletnek köszönhetően folyamatosan javul a betegek hosszú távú túlélése és életminősége, béltranszplantációra egyre ritkábban van szükség. A szerzők célja az intestinalis rehabilitáció legfontosabb szempontjainak – fokozott gasztrinszekréció, „high-output” stoma, csökkent tranzitidő, a centrális vénás kanülök ápolása, az enteralis, illetve parenteralis táplálás és az adaptáció serkentése – összegzése mellett a legújabb sebészi kezelési lehetőségek, köztük az autológ intestinalis rekonstrukció (AIRS) módszereinek, a passzázslassításnak (az ileocoecalis billentyű pótlása), a „bélhosszabbítás”-nak (LILT, STEP, SILT) és a felszívófelszínt növelő eljárásoknak (kontrollált bélexpanzió) az áttekintése volt. Ezeken túl a szerzők érintik a jelenlegi kutatások (disztrakciós enterogenezis, ’tissue engineering’) legújabb eredményeit. Orv Hetil. 2020; 161(7): 243–251.

Absztrakt

Multi-level modeling has been growing in popularity in recent years, with more and more approaches evolving and maturing over time. In order to facilitate the growth of multi-level modeling, and to identify common problems in this research field, the multi-level community issued the so-called Process challenge. The challenge contains a case description (problem domain) to which the participants should propose their solutions. This paper describes our solution for the challenge using our multi-level modeling framework, the Dynamic Multi-Layer Algebra. We present our solution starting from the more abstract domain-agnostic concepts, then presenting the more concrete domain-specific concepts, while explicitly addressing the requirements in the case description. While we have managed to solve almost every requirement of the challenge, some of them were difficult for us to solve in an elegant way. We also discuss these problems in further detail.

In recent years, a wide range of tools and methodologies have been introduced in the field of multi-level meta-modeling. One of the newest approaches is the Dynamic Multi-Layer Algebra (DMLA). DMLA incorporates a fully self-modeled textual operation language (DMLAScript) over its tuple-based model entity representation. This textual language provides effective and complex features when editing models. On the other hand, the language supports the precise injective mapping of the multi-layers. However, such complexity comes at a price. Using DMLAScript can be difficult in practice for users who are only familiar with the classical, object-oriented way of thinking, and are not confident with the multi-level approach. In this paper, we introduce the concepts of a new language above DMLAScript, which supports the more effective manipulation of concrete domain models by taking advantage of the particular process of multi-level modeling within DMLA. Although the approach is technically bound to DMLA, the concepts discussed in the paper are of general use.

The viability of any multi-level meta-modeling technology clings on the correct and exact definition of the underlying instantiation concept. Although multi-level instantiation has been well researched and conceptualized, current methodologies mostly limit their scopes to design-time modeling. Hence, state-of-the-art meta-modeling seriously neglects important practical needs of run-time modeling. In this paper, we present two incarnations of our Dynamic Multi-Level Algebra (DMLA), a modular, semantically correct multi-level meta-modeling formalism consisting of (i) an algebraic ASM foundation, (ii) a flexibly replaceable bootstrap mechanism for defining modelled entities, (iii) a corresponding set of logical validation formulae for establishing instantiation semantics. The expected features of DMLA clearly derive from practical modeling needs so that the resulting mechanism be applicable for both design-time and run-time modeling. The core components of the theory are explained both individually and by comparing their two versions of DMLA. Hence, the aim of this style of presentation is to showcase the balance struck between parsimoniousness and wanted modularity within our semantically correct, practical multi-level meta-modeling approach. A simplified networking model is also included to demonstrate the approach.

Traditional meta-modeling strictly differentiates between internal and external constraints attached to the meta-models. While for example cardinality and annotations are usually considered existential parts of the meta-modeling techniques, OCL expressions are treated as an independent layer of constraint mechanism. The result is a patchwork because the external constraint notation will not become part of the meta-model, its semantics is only referentially integrated, and thus meta-levels are to be harmonized. In comparison, multi-level meta-modeling may enable a uniform self-contained interpretation of the constraint semantics by encapsulating the constraint modeling constructs into the fabric of the multi-level meta-modeling framework. In this paper, we describe such a modular constraint modeling technique that has been formalized in Dynamic Multi-Layer Algebra (DMLA), an algebraic multi-level meta-modeling method. The paper first describes our constraint modeling approach and then elaborates on the concept of cardinality and its trivial generalization to regular expression patterns. As motivated by one of the interface modeling languages of network management, the approach is also demonstrated on a simple YANG language construct.