[Achalasia cardiae causing megaesophagus: "From the beginnings to the resolution"]

Achalasia cardiae miatt az első oesophago-cardia myotomiát több mint száz évvel ezelőtt Ernst Heller német sebész végezte. Az achalasiás betegek a mai napig ettől a beavatkozástól várják panaszaik megszűnését. Az achalasia napjainkban is chronikus, progresszív betegség, aminek oki kezelését nem ismerjük, a gyógyítására, a panaszok enyhítésére gyógyszeres (calcium csatorna blokkolók stb.), endoscopos (botulinum toxin inj., ballonos tágítás, per oralis endoscopos myotomiát [POEM]) és sebészi (laparoscopos, thoracoscopos myotomia) kezeléseket váltakozó sikerrel alkalmazunk.A betegség progresszivitása miatt a betegek 5%-ánál a nyelésképtelenségig fokozódó dysphagia, megaoesophagus alakul ki, megoldására műtéti beavatkozás válik szükségessé. A működésképtelen nyelőcső eltávolítása és pótlása kiterjedt, nem elhanyagolható morbiditással és mortalitással járó beavatkozás. Közleményünkben egy 45 éves nőbeteg kórtörténetét, az általunk alkalmazott műtéti beavatkozást ismertetjük. A beteg a műtét óta panaszmentes.

[Treatment of recurrent incarcerated Bochdalek hernia in an adult]

Az igen ritka felnőttkori nem hiatális, azaz nem paraoesophagealis típusú transdiaphragmaticus sérveket - a veleszületett rekeszizom defektusok mintájára - általánosan Bochdalek, ill. Larey-Morgagni-sérveknek nevezik. Etiológia tekintetében a nem diagnosztizált és kezelt veleszületett eredet, a traumás kontúziós-szakadásos, az iatrogen, ill. a recidív típus említendő meg.Esetismertetésünkben egy felnőttkori recidív, kizáródott Bochdalek-sérv sikeres műtéti ellátását ismertetjük. A 23 éves férfi beteg kórelőzményében 11 éves korában bal oldali Bochdalek-sérv miatt végzett thoracoscopos rekeszizom sutura szerepel. Epigastrialis fájdalmak, hányinger, hányás, akut hasi megbetegedés klinikai tünetei miatt jelentkezett Intézetünkben. Az elvégzett sürgős mellkasi és hasi CT-vizsgálat a bal mellüregben elhelyezkedő, kizáródott, vékonybélkacsokat tartalmazó Bochdalek-sérvet igazolt. Sürgős laparotomia során az életképesnek bizonyult sérvtartalmat (a vékonybéltraktus 2/3 része, a colon flexura lienalisa és a pancreas farok) a hasüregbe reponáltuk, a sérvkaput direkt suturával zártuk, és szövetszeparáló sebészi hálóval fedtük, valamint a mellüreget draináltuk. A postoperatív szak eseménytelenül zajlott. Kontroll-CT-vizsgálat a reconstruált rekeszizom és pleuro-peritonealis rétegek folytonosságát mutatta. A 10. posztoperatív napon panaszmentesen bocsátottuk otthonába.Megbeszélés: Mint minden kizáródott sérv esetében, a diagnózis mihamarabbi felállítása és az időben elvégzett műtét kulcsfontosságú. A mellkasi drenázs szükségességét minden esetnél körültekintően mérlegelni kell. A műtét után a mell- és hasüregben kialakult új anatómiai viszonyok miatt cardialis és respiratoricus szövődmények alakulhatnak ki. Álláspontunk szerint a betegség ritkasága miatt centrumban kezelendő. Ezen ritka állapot sikeres gyógyítása többszakmás együttműködésen alapul, melynek meghatározó eleme a helyesen megválasztott rekeszi felszínt helyreállító műtéti technika alkalmazása.

Is axillary lymph node dissection necessary for positive preoperative aspiration cytology lymph node results?

INTRODUCTION

Based on international guidelines, axillary lymph node dissection (ALND) is recommended in cases of breast cancer if preoperative examinations confirm axillary metastasis. We examined which set of preoperative parameters might render ALND unnecessary.

PATIENTS AND METHODS

Preoperative examinations (axillary ultrasound and aspiration cytology) confirmed axillary metastasis in 190 cases out of 2671 patients with breast cancer; primary ALN dissection was performed on these patients with or without prior neoadjuvant therapy. The clinicopathological results were analysed to determine which parameter might predict the presence of no more than 2 or 3 metastatic ALNs.

RESULTS

The final histological examination confirmed 1-3 metastatic lymph nodes in ALND samples in 116 cases and over 3 metastatic lymph nodes in 74 cases. For patients receiving neoadjuvant therapy (59 out of the 190 cases), if the size of the primary tumour was 2 cm or smaller and/or the metastatic ALN was 15 mm or smaller, then the patient was likely to have no more than 3 positive ALNs (stage N0-1 disease) (p < 0.001). If the patient did not receive neoadjuvant therapy, stage N2 or N3 disease was very likely. No correlation was found between other clinicopathological characteristics of the tumour and involvement of the ALNs.

CONCLUSION

Axillary lymph node dissection is not necessary for selected breast cancer patients with axillary metastasis receiving neoadjuvant therapy. In these cases, sentinel lymph node biopsy with or without radiation therapy and close follow-up may serve as adequate therapy.

[Our experience in Fournier's gangrene with severe septic shock]

Fournier's gangrene is a rare, rapidly progressing necrotizing fasciitis, which involves the genital area and perineum, progresses towards the thighs and abdominal wall through fascial plains. In our surgical department we treated seven patients with Fournier's gangrene between 2007 and 2011. Early diagnosis, immediate radical surgical debridement, necrosectomy, appropriate antibiotics and intensive care are all required and necessary for the successful treatment. Despite appropriate therapy, two patients were lost in septic shock.

[Urgent laparoscopic adrenalectomy in acute crisis caused by pheochromocytoma]

CASE REPORT

Authors present the case of a 30-year-old female patient, who was admitted to the ICU because of hypertensive crisis accompanied by chest complains, cardiac decompensation, progrediating short of breath and unconsciousness. Despite the quick examinations and the prompt treatment multi-organ failure developed 3 days after admission. Investigations revealed the underlying cause, which was a left-sided suprarenal neoplasm. Hence, multidisciplinary decision was made to carry out a laparoscopic adrenalectomy urgently. The histology examination of the removed neoplasm was pheochromocytoma. In the postoperative period the condition of the patient gradually improved, her symptoms and complains settled, and finally she was discharged in a healthy condition.

DISCUSSION

The diagnosis of a pheochromocytoma is a difficult task, the symptoms and complains caused by it can simulate many other illnesses. The acute crisis caused by pheochromocytoma usually can be treated conservatively, but in more severe cases with impending multi-organ failure an urgent operative treatment can be unavoidable. Though the operative risk is relatively high, the correct intra- and postoperative treatment with a quick laparoscopic procedure can be effective.

[Our experience with totally extraperitoneal technique of laparoscopic inguinal hernia repairs modified by Stolzenburg]

INTRODUCTION

Two current types of laparoscopic inguinal hernia repair are known: the TransAbdominal PrePeritoneal (TAPP) and the Totally ExtraPeritoneal (TEP) method. The mesh is placed in the preperitoneal space (sublay). Usually during TAPP method we fix the mesh with tacks or staples. In case of TEP fixation it is not necessary because the intraabdominal pressure keeps the implant in position. There is no significant difference between the two methods in terms of recurrence. The advantage of TEP is that the abdominal cavity remains intact, hence reduces the risk of intraabdominal injuries and adhesions. It is unnecessary to use special stapler or tacker.

MATERIALS AND METHODS

Our team performed 50 TEP procedures in male patients with uni- or bilateral inguinal hernias in the period 2011-2013. We prepared the mesh in a special way according to Stolzenburg and placed it to the subfunicular area. We did not apply additional fixation (tacks, stitches) and drainage. Mean hospital stay was 1 day. We allowed complete physical activity 10-12 days after surgery.

RESULTS

No recurrence was observed during the 2 years of follow-up. The mean operating time was 70 minutes. We performed conversion in 3 cases (Lichtenstein 2, TAPP 1). In one case there was an injury of the inferior epigastric artery. In two cases we have detected neuralgia in the postoperative period.

CONCLUSIONS

After the learning curve the TEP method can be used safely with good functional results. The technique of mesh positioning reduces the risk of complications and provides cost-effectiveness.

[Laparoscopic treatment of median arcuate ligament syndrome (MALS) -- case report]

CASE REPORT

The authors report a case of a 34-year-old woman who had postprandial abdominal pain for years. During the course of her examination lactose intolerance and hiatus hernia was diagnosed. After ineffective conservative treatment CT angiography (CTA) and digital substraction angiography (DSA) was performed and showed significant celiac artery stenosis. Percutaneous transluminal angioplasty (PTA) was unsuccessful as extravasal mechanical compression was present, therefore, laparoscopic decompression and surgical division of MAL fibres were carried out. The postoperative period was characterized by a complete relief of previous symptoms and repeated CTA showed normal blood flow.

DISCUSSION

The authors emphasize the importance of the measurement of peak velocity of celiac trunk with Colour Duplex abdominal ultrasonography, the examination has 100% sensitivity and 83% specificity. The Duplex ultrasonography is less expensive than the "gold standard" diagnostic methods like CT and DS angiography, and can lead us to early diagnosis. Laparoscopic surgery is safe and low expense method for celiac artery decompression, however, sometimes it is difficult to reveal the exact reason and thus setting up the proper operation plan.

[Necrotizing enterocolitis in an adult -- case report]

The adult necrotizing enterocolitis (ANEC) is a rare condition, frequently fatal, and characterized by a fulminant symptoms and segmental necrosis of the bowel. The authors performed repeated surgeries and small bowel resections on a patient classified to stage number three on Bell scale due to necrotizing enterocolitis. Pathological examination of the resected bowel showed intestinal necrosis without obstruction of mesenteric vessels. After the fifth operation the continuity of the gastrointestinal tract was reconstructed by an anastomosis between the remained 30 cm of terminal ileum and descending loop of duodenum. Inspite of only 30 cm of small intestines remaining, the patient is able to enjoy life almost completely with gastroenterological control and support.

[Analysis of postoperative complications following acute surgery for colorectal cancer]

Our aim was to improve the outcome of emergency surgeries for colorectal cancer (CRC). Authors compared two periods: 2004-2006 and 2007-2011. Targeted cases were emergency admissions, in which the diagnosis of colorectal cancer is only revealed during work-up or during surgery. No other exclusion criteria were set. Analyzed main endpoints were anastomotic leak, postoperative mortality, resecability. ASA classification and TNM stages were assessed in order to learn morbidity and general condition prior to acute surgery. Considering the experience gained in prior period, in 2007, authors have made a change in treatment strategy. In following years leakage ratio became ten times lower and mortality was reduced by 5%. There is a great chance that fast work-up and preparation for surgery may decrease complications and mortality. The aim would be for CRC patients, is to reach surgery in an early stage of disease as possible, at least before complications develop.

[Metastatic malignant melanoma of the oesophagus: case report]

We report a case of metastatic malignant melanoma in the oesophagus. 13 years after the wide excision of primary skin melanoma, we found a polypoid tumor in the upper third of the oesophagus. Biopsy result was melanoma malignum. After negative staging we performed transhiatal oesophagectomy with gastric conduit and cervical anastomosis. Metastatic nature of the oesophageal tumor was proven by histology. After uneventful postoperative course, the patient received adjuvant dacarbazine treatment. The patient was is in good condition, and disease free on the 18 month follow-up.

Percutaneous video choledochoscopic treatment of retained biliary stones via dilated T-tube tract

BACKGROUND

Retained biliary stones is a common clinical problem in patients after surgery for complicated gallstone disease. When postoperative endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy are unsuccessful, several percutaneous procedures for stone removal can be applied as alternatives to relaparotomy. These procedures are performed either under fluoroscopic control or with the use of choledochoscopy, but it is also possible to combine these methods.

METHODS

Since 1994, we have used the percutaneous video choledochoscopic technique for the removal of difficult retained biliary stones via dilated T-tube tract in 17 patients, applying the technique of percutaneous stone extraction used in urology. While waiting for the T-tube tract to mature and after the removal of the T-tube, the dilatation of its tract was 26-30 Fr. Stone removal was carried out using a flexible video choledochoscope and a rigid renoscope under fluoroscopic control, with the aid of Dormia baskets, rigid forceps, and high-pressure irrigation.

RESULTS

We performed 23 operative procedures, and the clearance of the biliary ducts was successful in all cases. There were no major complications or deaths.

CONCLUSION

Percutaneous video choledochoscopic-assisted removal of large retained biliary stones via the T-tube tract is a highly effective and safe procedure. Its advantages over other procedures include the ability to visualize the stones and noncalculous filling defects; it also guarantees that the stones can be removed under visual video endoscopic control. It has no problems related to tract or stone size.

[Successfully operated cases of mediastinal and retroperitoneal bronchial cysts]

CASE REPORT

Two young men were operated in our department for bronchiogen cysts with unusual locations. In the first case a mediastinal cyst caused severe swallowing problems, while in the second a retroperitoneal cyst resembled to an adrenal adenoma. It was only the postoperative histology, which clarified the exact diagnosis of the removed cysts.

DISCUSSION

Only a few percent of mediastinal tumours are bronchial cysts that develop due to developmental disorders. Symptomatic ones are more easily detectable. Bronchial cysts localized in the abdominal cavity or retroperitoneum are especially rare. In most of the cases the final diagnosis is made only after excision with histological examination of the cyst.

Changes in faecal bacteria associated with concentrate and forage-only diets fed to horses in training

REASONS FOR PERFORMING STUDY

Diets rich in readily fermentable carbohydrates, fed traditionally to meet the increased energy requirements of the performance horse, are associated with a number of gastrointestinal disorders that involve disturbances in the intestinal microbiota, however, these changes are poorly understood.

OBJECTIVES

With the long-term objective of improving intestinal health and to increase understanding of the relationship between diet and microbiota, the effect of feeding Standardbred horses a high-energy forage-only (F) diet was studied compared to a more traditional forage-concentrate (C) diet on faecal microbiota.

METHODS

Diets were fed in a cross-over design to 6 mature geldings on a scheduled training regime, both periods consisting of 29 days. DNA was extracted from faecal samples collected at 4 time points from each period, bacterial 16S rRNA genes were amplified and community composition assessed by terminal-restriction fragment length polymorphism, cloning and sequencing. Faecal pH and cultivable lactic acid bacteria (LAB) and enterobacteria were also assessed on the final collection day of each period.

RESULTS

Diet F resulted in a microbial composition that was more stable between sampling periods and had lower counts (P < 0.05) of cultivable LAB and specifically members of the Streptococcus bovislequinus complex. Motile and swarming Lactobacillus ruminis was present in all horses on diet C and not in horses on diet F. Diet C also resulted in the increase (P < 0.05) in members of Clostridiaceae cluster III and a concomitant reduction (P < 0.05) in an unknown group of Bacteroidales.

CONCLUSIONS AND POTENTIAL RELEVANCE

The greater microbial stability and reduction in LAB and members of the Streptococcus bovis/equinus complex on diet F indicate an opportunity to develop feeding strategies that support equine health and welfare. Novel changes identified in the faecal microbiota that resulted from carbohydrate inclusion merit further investigation.

[Antegrade colonic enema is a choice for the treatment of faecal incontinence and constipation]

Faecal incontinence and constipation cannot always be treated successfully by conservative or surgical methods. In these cases regular retrograde colonic enema can reduce the symptoms of the patients and can establish pseudocontinence. The authors present a method of colon cleaning which has been used successfully. The method was introduced in clinical practice by Malone in 1990. The antegrade enema is administered through the appendicostomy. In cases, where the appendectomy was performed earlier, a neoappendix was created from the coecal wall and used for the irrigation of the colon. During procedure the patients injected tap water (300-450 ml) through the (neo-)appendicostomy with a thin catheter. After a short time period this was followed by passing of the stool. The procedure was performed on twelve patients, five female, and seven male patients (mean age: 39.2 years). The indications for the procedure were the following: faecal incontinence induced by denervation of the pelvic floor in three patients, sphincter trauma in two patients and congenital sphincter malformation in two cases. In addition, combined symptoms of faecal incontinence and constipation caused by pelvic floor denervation in three patients. Finally, intractable constipation was the reason in two patients. After irrigation, the stool was passed, but the functional result was rather variable. Eight out of twelve patients were satisfied with the result, two patients reported improvement in the constipation, but it failed in one case. In another case, the appendicostomy could not have been used due to surgical complications. The stricture of the (neo-)appendicostomy was observed in two cases. Significant reflux occurred only in one case.

CONCLUSION

after adequate patient selection this method can be applied with success.

[Squamous papilloma of the esophagus. Clinical and pathological observations based on 172 papillomas in 155 patients]

INTRODUCTION

The papilloma of the oesophagus is a rare disease. The pathogenesis and biological features of the disorder are not clearly known.

AIMS

The purpose of the present paper is to outline the clinical and pathological significance of the papilloma of the oesophagus as detected in the authors' endoscopic laboratory.

METHODS

Endoscopic examinations were carried out with a flexible endoscope. The alterations in the oesophagus were removed by biopsy forceps in order to perform histological investigations, large-sized ones were removed by way of endoscopic mucosectomy. To assess the structure major alterations and their circumstances relative to their environment, endoscopic ultrasonography was performed, as well. Histological examination was done in formalin-fixed slides embedded in paraffin and dyed with hematoxiline eosine. HPV detection was done through polymerase chain reaction (PCR).

RESULTS

During the 35 years a total of 59.056 upper panendoscopic examinations were carried out. Planocellular papilloma were detected in 155 patients (0.26% of the total number of patients). 85 of the patients were female, 70 were male. The vast majority of papilloma cases were solitary (142 patients). A minority--13 patients--had multiplex alterations. Most often, the papillomas were sessile changes, most often located in the middle and upper part of the intrathoracic section of the oesophagus. The probability of the papilloma can be established on the basis of the findings of endoscopic morphology, as well. This, however, has to be supported by a histological examination. In the majority of the cases the papillomas of the oesophagus can be removed by endoscopical biopsy forceps, because most often the alterations were only a few millimetres in size. Larger papillomas can be removed by way of endoscopic mucosectomy. Examining the transformation of papillomas into carcinomas, no papilloma was found which directly transformed into a carcinoma. Synchronically occurring planocellular carcinoma was found in the oesophagus of only 2 out of the 155 patients. During the follow-up examination of patients, recurrence of the disease was found only in one patient. The frequency of the human papilloma virus in papilloma of the oesophagus: the authors were able to detect the presence of HPV by way of PCR technique in 12 out of 26 cases (46.2%). With the expectation of 3, they were all viruses with a high risk of cancerous transformation.

CONCLUSION

The squamous papillomas of the oesophagus are begin tumors. Papillomas is not caused by hiatus hernia or reflux oesophagitis. The distinct localization of the two different types of alternations also suggests a non-reflux oesophagus origin of the papilloma. The reason is that papillomas are most often located in the middle and upper part of the intrathoracic section of the esophagus--on the other hand, reflux esophagitis is located in the lower section. It is now generally accepted that papillomas of the mucous membrane covered by multiple planocellular layers are caused by HPV. The identical localization of the papillomas and planocellular cancer in the oesophagus refer to potentially identical etiology (HPV infection), and it may rarely occur that the papillomas wil in fact transform into carcinoma. Papillomas of the esophagus is a rare disorder. Its detection is in part important in order to distinguish it from planocellular carcinoma (especially carcinoma verrucosum), In part it indicated the HPV-infection of the oesophagus, or in HPV-positive cases it may be regarded as a precancerous state. For all this, it is important that the papilloma should be recognised by way of endoscopic examination, removed and a precancerous state should be taken into consideration.

[Intramural esophageal metastasis of diffuse, infiltrative gastric adenocarcinoma]

Authors report a patient with a gastric carcinoma that developed an intramural metastasis to the oesophagus. The diagnosis of the metastasis was suggested on endoscopy and was verified by pathohistology. Preoperative investigations suggested advanced cancer. During the operation an inoperable tumour was found. Authors describe the methods to diagnose oesophageal metastasis.

Esophageal intramural metastasis from adenocarcinoma of the gastroesophageal junction

Among a total of 143 patients examined for diagnosis of adenocarcinoma of the cardia, intramural esophageal metastases were verified in six patients (4.19 %). In each case the diagnosis was confirmed by histological examination. The histological structure of the primary tumors and metastases was the same. Metastases were detected by endoscopic ultrasound examination in three cases. All the cardia tumors proved to be well advanced. As well as endoscopic identification of the primary tumor, thorough examination of the proximal part of the esophagus is of great importance.

[Esophageal implantation metastasis from adenocarcinoma of the cardia]

A 74 years old male patient was admitted to our department suffering from dysphagia for five months. Gastric Barium studies showed a cardia tumour with polypoid lesions in the wall of the esophagus, and gastro-esophageal reflux disease was also diagnosed. Endoscopy verified a cardia tumour with esophageal metastasis, and biopsy was obtained from the two lesions. Histology showed that both tumours were adenocarcinomas. Endoscopic ultrasonography classified the cardia tumour as grade T2. As observed during endoscopy, the wall of the esophagus at the level of the polypoid lesion was hypo-echogenic and thick which was result of thickened mucosa. Total gastrectomy and oesophagectomy was performed. Pathology showed that the cardia tumour was pT2N2 and type Siewert-Stein II. The esophageal polypoid lesion was also proved an adenocarcinoma, which was localized only to the mucosa. No tumour cells were found in the blood- or in lymph vessels between the tumour and the esophageal adenocarcinoma. We think that the polypoid adenocarcinoma in the esophagus is an esophageal metastasis implantation from the cardia adenocarcinoma. It is based on the exclusion of other possible tumour dissemination routes. Probably the gastro-esophageal reflux is responsible for the implantation of tumour cells.

[What kind of surgical radicality is justified in the treatment of esophageal and cardial carcinoma?]

In the period from January 1, 1973 to November 30, 1994, a total number of 1 856 patients had been admitted to our Department of Surgery because of cancer of the esophagus and esophago-gastric junction. We divided our activities into two study periods. In the first study period from 1973 to 1984 only so called "conventional operations" were performed. Since 1985 new oncological aspects were introduced into our operative tactics:1. the subtotal esophagectomy combined with the two-field lymphadenectomy,2. the total gastrectomy with extended lymph node dissection. The analysis of our results with respect to the survival parameters (TNM staging, histological type, grade of differentiation, gross pathology) showed that the best chances were obtained by curative resection and lymphadenectomy in tumours of low-grade biologic malignancy. In esophageal cancers the former 6 % 5-year cumulative survival rate increased to 26 %, and in cardia tumours from 9 to 27 %, because of enhancement of radicality and extension of lymphadenectomy.

[Siewert-Stein classification of adenocarcinoma of the esophagogastric junction]

Nowadays the terminology used for the definition of adenocarcinomas at the oesophagogastric junction is "cardiac carcinoma", which can be easily misunderstood. This definition of adenocarcinomas of the oesophagogastric junction does not allow correct comparison of diagnosis (endoscopic, radiological and pathologic), epidemiology and surgical therapy in national and international aspects, because different tumours can develope in the same area, and all called cardia tumors. Siewert and Stein recommended a classification to solve this problem. The classification of the tumours is morphological/topographical. Type I is adenocarcinoma of the distal part of the oesophagus. Type II is adenocarcinoma of the real cardia and type III is subcardial gastric adenocarcinoma. At classification, we always consider results of endoscopy (ortograde and retroflexed view of the oesophago-gastric junction), the x-rays of the oesophagus and stomach, findings at the operation and pathohistologic results. Between 1/1/1974 and 31/12/2000, a total number of 50,878 upper panendoscopic examinations were performed at the Endoscopic Laboratory of the Surgical Department. Adenocarcinoma of the cardia was diagnosed in 488 patients. According to the Siewert-Stein classification, type I tumour was found in 123 (25.2%), type II in 240 (49.18%), and type III was present in 125 (25.61%) patients. The importance of this classification is it enables unified pre-operative assessment and it can also help to decide the type of the surgical intervention. In our patients with type I cancer--depending of the size of the tumour--distal 2/3 oesophagectomy with the resection of the proximal lesser curve of the stomach or total gastrectomy were performed. In the first group oesophago-jejuno-gastrostomy, in case of total gastrectomy Roux-en-Y loop anastomosis was created. In patients with types II and III cancers total gastrectomy was performed. In every patient lymphadenectomy was performed. We suggest the use of this new classification in clinical, gastroenterology--with special regard to the endoscopy--and pathology.

[Laparoscopic adrenalectomy with transperitoneal approach]

The feasibility, safety, and results of 52 laparoscopic transperitoneal adrenalectomies were evaluated.

METHODS

A total of 52 patients were included in the study based on thorough endocrinological and imaging assessment. 15 patients with Conn syndrome, 3 with Cushing syndrome, 15 with nonfunctioning adenoma, 14 with pheochromocytoma, 2 with adrenocortical cyst, 2 with adrenocortical lipoma and 1 with metastasis were considered eligible for adrenalectomy. Lesion size ranged from 1 to 12 cm (mean 4.53 cm). Concurrent surgical procedures were performed in 6 patients (11%).

RESULTS

There was one conversion (during a left adrenalectomy), because of our learning curve. After we changed the technique, there was no more conversion. There were two (3.8%) postoperative complications: postoperative pancreatitis, one of the patients required re-operation (lavage and drainage). There was one wound infection. We had no postoperative mortality. Mean postoperative hospital stay was 6 days (range, 2-27 days).

CONCLUSION

Patients with secreting and non-secreting adrenal lesions can be treated safely and effectively by laparoscopic adrenalectomy.

[Esophageal anastomosis--based on the experience with 1460 operations]

The authors reviewed the clinical records of 1460 patients with esophageal anastomoses, the operations performed in their institute between 1973 and 2000. Surgical outcome was assessed with incidence of anastomotic leaks and overall mortality. Hand-sewn anastomoses were performed by inserting single layer interrupted monofil steel wire (507), PDS (232) or Vicryl (65) sutures and circular stapler (EEA, Ethicon) was used in 656 patients. 453 (65 cervical, 293 thoracic, and 95 abdominal) anastomoses performed between 1995 and 2000 were analyzed separately. During this 6-year period, the majority of operations (88%) were performed because of esophageal malignancy (squamous cell carcinoma of the esophagus or adenocarcinoma of the cardia). Surgery was performed for benign disease (e.g. stricture, perforation, and stage IV achalasia) in 12%. The incidence of anastomotic leak was the highest (20%) after cervical anastomosis, compared to a 4.4% or 1% associated with thoracic or abdominal anastomoses. These differences are statistically significant (p < 0.001). The rate of anastomotic leakage was strongly connected to surgical technique: it was 15% in hand-sewn anastomoses and only 4.4% with stapled anastomosis. During the 6-year period overall mortality was 6.6%t.

[Rare late complication after subtotal esophagectomy]

We report a case of a peptic ulcer developed in the stomach tube used for the replacement of the esophagus. The patient was a 60 years old female who had undergone subtotal esophagectomy for mid esophageal malignancy, with intrapleural stomach replacement. Urgent endoscopy revealed an excavated, bleeding ulcer in the thoracic part of the stomach. After unsuccessful medical treatment urgent operation was performed via right thoracotomy. Opening the stomach an ulcer was found on the posterior wall of the stomach, it was penetrating to the right atrium of the heart. The bleeding was controlled by suturing the atrium wall. The patient treated with i.v. Omeprazol in the postoperative period. On the 21st postoperative day a rebleeding occurred causing shock. After reoperation the patient died. This complication is very rare. We emphasise the importance of postoperative pH measurement investigations showing the presence of duodenogastric reflux disease.

[Isolated gastroduodenal Crohn's disease: a case report]

Although it can involve any segment of the gastrointestinal tract, Crohn's disease confined to the gastroduodenum is extremely rare. We report the story of a 20-years old male patient admitted for pyloric obstruction that developed despite medical treatment. Clinical manifestations necessitated operative treatment; Polya-gastrectomy was performed. Histology identified Crohn's disease and inflammatory changes as the cause of pyloric obstruction. Postoperative recovery was uneventful. The lesson of this case is, that if duodenal Crohn's disease would have been recognized preoperatively, gastrectomy could have been avoided. We review the literature and discuss treatment options for gastroduodenal Crohn's disease.

Changes of serum calcium level following thyroid surgery--reasons and clinical implications

The reasons of transient hypocalcemia, frequently occurring after thyroid surgery, were investigated. Serum total calcium (seCa) and phosphorus (seP) levels were determined in 185 patients with benign nodular goiter before and after thyroid surgery. Beside these, in 27 additional patients, serum magnesium (seMg), total protein, albumin, calcitonin, parathormone (PTH) and 25-OH-D3 vitamin (25-OH-D3) levels were determined; corrected calcium (cCa) values, reflecting ionized calcium concentrations, were calculated. The daily changes of seCa and protein levels were measured in 20 patients. Another twenty patients, undergoing non-endocrinological surgery served as controls. Transient, mild but significant decrease of seCa was observed after surgery, while seP values were increased. Mild hypocalcemia (seCa<2.12 mmol/l) developed in 18.4%, severe hypo-calcemia (seCa<1.9 mmol/l) in 5.4% of the patients. The reduction of seCa levels was more pronounced in elderly, female patients. SeMg, total protein and albumin decreased, while cCa, PTH, calcitonin and 25-OH-D3 values did not change. Positive correlation was demonstrated between the change of seCa and albumin levels. Similar results were obtained in the general surgery group. In the thyroid operated group, in case of severe hypocalcemia, PTH levels decreased significantly into the pathological range. It may be concluded that transient, mild postoperative hypocalcemia is not a thyroid surgery-dependent phenomenon; it can also be observed after other operations accompanied by similar blood loss; in its development hypoalbuminemia plays a role. The causal role of PTH, calcitonin and 25-OH-D3 could not be proved in this study. Hypoparathyroidism can be responsible for the development of severe, prolonged hypocalcemia occurring at rare occasions.

The role of esophagectomy in the management of esophageal perforations

BACKGROUND

Despite the many advancements made in thoracic surgery, the management of patients with esophageal perforation remains problematic and controversial.

METHODS

Between 1985 and 1995, 27 esophagectomies were performed for perforation of the thoracic esophagus. A retrospective review of the records of these patients was carried out, and a scoring scale developed by Elebute and Stoner to grade the severity of sepsis was applied.

RESULTS

Among the 27 patients undergoing esophagectomy for a perforation, the interval between rupture and esophagectomy was less than 24 hours in only 11 patients (40.7%). Postoperative surgical complications occurred in 4 patients (14.8%) and nonsurgical complications, in 7 (25.9%). The hospital mortality rate was 3.7% (1/27). In 14 patients, primary reconstruction was performed in the bed of the excised esophagus. There were no anastomotic leaks in this subgroup. This suggests that an anastomosis between viable, well-vascularized tissues is more important for successful healing than avoidance of some degree of contamination of the adjacent mediastinum. On follow-up, which averages 41 months, 73% of patients (16/22) have neither symptoms nor complaints.

CONCLUSIONS

Esophageal resection definitively eliminates the source of intrathoracic sepsis, the perforation, and the affected esophagus. Reconstruction carried out in one stage does not increase operative morbidity. Esophageal resection and reconstruction is a valid approach even in cases of spontaneous perforation in which the diagnosis is markedly delayed.

[Determination of the upper margin of superficial esophageal cancer by intraoperative endoscopic examination and toluidine blue staining]

Authors describe a new application of intraoperative endoscopic examination. At operation it is difficult to define the border of a superficial esophageal cancer. The female patient aged 69 years was operated on because of squamous cell cancer. During the operation endoscopic examination was done and the esophageal mucosa was stained with 1% toluidine blue solution. The squamous cancer stained blue. The upper border ot the tumour was determined so that the esophageal wall was palpated from the outside with a probe and the same time the manipulation was being watched on the monitor of the videoendoscope. Subtotal esophagectomy and lymphadenectomy were performed. Authors claim that by the intraoperative use of endoscopic staining the risk recurrence in an anastomosis may be diminished and leaving behind of multifocal carcinoma may be eliminated.

[Postoperative percutaneous endoscopic gastrostomy/jejunostomy]

In order to cure complications appeared in the postoperative period two patients were treated with percutaneous endoscopic gastrostomy/jejunostomy (PEG, PEGJ) with the purpose of long-lasting enteral feeding and decompression. The indications of PEG/PEGJ were the following: external gastric fistula in one case and anastomotic leakage in one case. In the patients the PEG was located by intraoperative X-ray examination, this method was not published earlier. Regarding complications of the early postoperative period the PEG and the PEGJ are considered useful and expedient procedures with the aim of lasting enteral feeding and decompression.

Nonoperative management of esophageal perforations. Is it justified?

OBJECTIVE

Experiences obtained with nonoperative treatment (NOT), i.e. total prohibition of per oral food intake for a minimum of 7 days, administration of combinations of broad-spectrum antibiotics, and parenteral hyperalimentation, are described in the management of esophageal perforations.

SUMMARY BACKGROUND DATA

The place, value, and indication of NOT in the management of esophageal perforation has not yet been unequivocally defined. As a result, contradictory data have been published regarding the outcome of NOT.

METHODS

During the past 15 years (1979 to 1994), 20 of 86 patients (23.3%) with esophageal perforation have been treated nonoperatively from the outset. In this group, perforations were located to the upper, middle, and lower third of the esophagus in 50%, 30%, and 20%, respectively. In the operative management group (OT)--in which conservative (drainage, endeprothesis), reconstructive (suture, reinforced suture), and radical (resection) surgical methods were applied--lesions were preponderantly located in the lower one third of the esophagus (56.1%--37/66). As to the interval between the perforation and the onset of treatment, 14 patients had been diagnosed within 24 hours, whereas in 6 cases treatment had been begun beyond 24 hours.

RESULTS

NOT could be successfully carried out in 16 patients; the decision to use NOT had to be revised in 4 other cases (Table 1). Two patients were lost; the mortality rate was 10% (2 of 20). The rate of complications was lower in the NOT group (20%, or 4 of 20) than in the OT group (50%, or 33 of 66).

CONCLUSIONS

NOT can be suggested for the treatment of intramural perforations. In the case of transmural perforation, this approach should be taken into consideration if the esophageal lesion is circumscribed, is not in neoplastic tissue, is not in the abdominal cavity, and is not accompanied by simultaneous obstructive esophageal disease; in addition, symptoms and signs of septicemia should be absent.

[Endoscopic resection of the mucous membrane in esophageal tumors]

The authors report a 47-year old patient with an intraepithelial esophageal cancer diagnosed by endoscopy. Using Toluidine blue staining it seemed that the tumour was multifocal. The lesions were taken out by biopsy and endoscopic mucosectomy. The results of defined histological examinations: in situ squamous cell cancer, middle grade dysplasias and hyperkeratosis. At mucosectomy the authors used a new type of polypectomy snare with good results.

Significance of a modified decompression method in enhancing the safety of esophagus operations

BACKGROUND/AIMS

Every esophageal surgeon employees methods to reduce the risk of infection caused by the pool of debris and organisms proximal to a destructive esophageal lesion and to prevent distension of the viscera adjacent to the suture line of the anastomosis.

MATERIAL AND METHODS

The authors report on a retrograde drainage which was devised to prevent the distension of the loop adjacent to anastomosis following esophagectomy.

RESULTS

This modified decompression method and simultaneous enteral feeding decreased the frequency of postoperative pulmonary complications significantly (1973-90 complication rate: 16.5% - 119/722 vs. 1990-95 complication rate: 7.7% - 17/221).

CONCLUSION

The retrograde drainage facilitates safe and effective decompression even in the recumbent position, doesn't inconvenience the patient, promotes early mobilization and can be maintained till complete recovery of the anastomosis.

Management of failed Heller's operations

An analysis of 29 patients who collectively required 33 reoperations for failed Heller's esophagocardiomyotomy performed during the period between 1972 and 1992 was conducted. In the majority of patients, the reoperation was necessitated because the original myotomy was not long or deep enough, or because of iatrogenic gastroesophageal reflux and its sequelae such as strictures. Identification of the exact cause of failure requires careful analysis of the patient's symptoms and of the findings of various diagnostic examinations. The treatment for inadequate myotomy generally involves performing a second myotomy, which is completed by adding a nonobstructive antireflux repair. It appears that abolition of the "sigmoid sac" is essential even when the esophagogastric junction has a sufficiently large diameter. A so-called esophagoplication was performed in 3 patients,and an interposition at the site of esophageal resection, using an isoperistaltic esophagojejunogastric loop of appropriate length, was performed in 14 patients. There were no deaths following reoperation. In fact, the results were excellent or good in 23 cases and fair in 3.

Low dehydroepiandrosterone sulfate (DHEA-S) level is not a good predictor of hormonal activity in nonselected patients with incidentally detected adrenal tumors

To assess its differential diagnostic value, dehydroepiandrosterone sulfate (DHEA-S) was measured in a nonselected cohort of 84 patients with incidentally detected adrenal tumors (incidentaloma). Of the 38 histologically confirmed cases, 6 of 12 patients with primary or metastatic malignant tumor of the adrenals and 7 of 14 patients with benign cortical adenoma had low DHEA-S levels. Thus, the sensitivity, specificity, and predictive value of a low DHEA-S level to indicate a benign adrenal tumor were 0.35, 0.50, and 0.60, and the values to indicate a cortical adenoma were 0.50, 0.67, and 0.47, respectively. Of the 14 cases of histologically confirmed benign cortical adenoma, 10 had signs of hormonal activity, but DHEA-S was suppressed in only 7 cases. Thus, the sensitivity, specificity, and predictive value of a low DHEA-S level to indicate clinically significant hormonal activity of a benign cortical adenoma were 0.60, 0.75, and 0.86, respectively. For comparison, 5 of 5 males and 2 of 5 females with metastatic carcinomatosis, but without involvement of the adrenals, also had low DHEA-S levels. The data clearly show that in nonselected cases of incidentaloma a suppressed DHEA-S level is not a good predictor of hormonal activity and that DHEA-S measurement may be valuable only after having ascertained the cortical origin and benign feature of the tumor.

Malignant tumor developed in colon-esophagus

This case report describes a very rare late complication developed in the colon-esophagus. An adenomatoid polypus malignant tumor appeared in a colonic interposition graft, five years after resection of the esophageal stricture. The continuity of intestinal tract was repaired with a Roux-en-Y esophago-jejunostomy. Based on a literature review, the authors detail late complications of operations which replace the esophagus with colon.

Incidentally detected adrenal tumours (incidentalomas): histological heterogeneity and differentiated therapeutic approach

OBJECTIVES

To find a differentiated therapeutical approach to incidentalomas.

DESIGN

Prospective study of incidentalomas: their histology, hormonal activity, and growth if primarily non-operated.

SETTING

Admissions to an academic tertiary care centre because of incidentaloma.

PATIENTS

Thirty-eight female, 25 male, 27-85 years old.

INTERVENTIONS

Ultrasound, computed tomography and adrenal scintigraphy when appropriate; investigations to exclude malignancy giving metastasis into the adrenal gland; ACTH, cortisol, aldosterone, renin activity, androgene, catecholamine measurements; surgery or follow-up.

MAIN OUTCOME MEASURES

Rate of malignancy; linkage of tumour size to probability of malignancy; prevalence of tumours with subtle hormone excess.

RESULTS

Cortical adenomas occurred in 13/31, metastases in 7/31 of the histologically confirmed cases. In 10/31 cases, the computed tomography indicated a size that was smaller than the pathological size (mean = 20 mm). 20.6% of all incidentalomas and 61.5% of the 13 operated corticol adenomas showed subtle hormonal activity. Twenty-seven incidentalomas < 30 mm were followed-up (3-41 months; mean 18 months) and showed growth in only one case. Sensitivity, specificity, and predictive value (PV) of a tumour > or = 30 mm to indicate malignancy were: 1.0, 0.56 and 0.27, respectively. The PV of a < 30 mm tumour to exclude malignancy was 1.0.

CONCLUSIONS

Oncological screening tests are necessary in all incidentalomas. Tumours > or = 30 mm should be operated but smaller ones can be followed-up, because they are usually benign and rarely show progressive growth. Cortical adenomas with subtle hormonal overproduction and hypertension, diabetes or osteoporosis should be operated, irrespective of their size, but in the absence of relevant clinical symptoms they can be followed-up.

The role of ultrasound-guided percutaneous transhepatic aspiration of the gallbladder content in the management of hydrops/empyema caused by acute cholecystitis

Ultrasonically guided percutaneous transhepatic gallbladder aspiration (UG-PTGA) was used in the treatment of hydrops caused by acute cholecystitis in 21 patients. The interventions had no complications. This kind of aspiration is believed to be suitable for the relief of gallbladder tension causing acute complaints and of subsequent pathological changes.