Surgical management of colonic diverticulosis: Issues of indications, treatment options, surgical solutions

Összefoglaló. Bevezetés: A vastagbél-diverticulosis a lakosság kb. 60%-át érinti, incidenciája folyamatosan növekszik. A betegek 6%-ánál van szükség sebészi beavatkozásra. Jelenleg nincs egységes irányelv, mikor indokolt elektív műtétet végezni. Módszer: Retrospektív módszerrel elemeztük az osztályunkon 2017. július 17. és 2020. április 30. között vastagbél-diverticulosis miatt operált betegek demográfiai és műtéti adatait, emellett a szövődmények arányát. Összehasonlítottuk az elektív (EM) és a sürgős műtétek (SM), illetve a nyitott és a laparoszkópos műtétek adatait. Eredmények: 38 operált beteg közül 19-nél történt EM, illetve 19 betegnél SM. A betegek átlagéletkora az EM-eknél 64 év, az SM-ek esetében 67 év volt. EM-nél az indikáció 12 esetben recidiváló diverticulitis, 5 esetben colovesicalis, 2 esetben colovaginalis sipoly volt. SM-nél az indikáció 17 esetben perforáció, 2 esetben hasüregi tályog volt. Az EM-ek 89%-a laparoszkópos módon került elvégzésre; az átlagos műtéti idő EM/SM esetében 96 perc/89 perc, az átlagos ápolási napok száma 17/14 volt. Az EM-csoportból 1 beteg, míg az SM-csoportból 5 beteg meghalt. Szignifikáns különbség volt a műtét típusa, a stomaképzés és a transzfúziós igény tekintetében. Nem találtunk szignifikáns eltérést a posztoperatív ápolási napok és a mortalitás tekintetében. Következtetés: Az elektív műtétek alacsonyabb morbiditása és mortalitása, illetve a laparoszkópos technika alkalmazhatósága miatt törekedni kell a tervezett műtétre. Nincs egységes irányelv a relatív műtéti indikáció felállításában: gasztroenterológus és sebész által felállított, személyre szabott kezelési stratégia szükséges. Véleményünk szerint indokolt a műtét, amennyiben igazolt diverticulosis esetében szigorú diéta mellett kiújul a gyulladás. Orv Hetil. 2020; 161(51): 2146-2152.

SUMMARY

INTRODUCTION

Colonic diverticulosis affects 60% of the population, incidence of the disease grows progressively. During its course, 6% of patients with diverticulosis will need surgical intervention. There is no current guideline when to carry out elective operation.

METHOD

We analyzed demographics, surgical patient data and also post-operative complications of patients operated in our department due to colonic diverticulosis between 17-07-2017 and 30-04-2020 retrospectively. We compared the results of elective (ES) and acute surgeries (AS), also laparotomies versus laparoscopies.

RESULTS

19 out of 38 patients underwent ES and 19 AS. ES group average age was 64 years, and 67 in the AS group. Indications of ES were recurring diverticulitis in 12, colovesical fistula in 5 and colovaginal fistula in 2 cases. Indications of AS were perforations in 17 and intraabdominal abscesses in 2 cases. 89% of all ES were operated laparoscopically; average operation time in ES/AS was 96/89 minutes, average hospital stay was 17/14 days. 1 patient after ES and 5 after AS died. Significant difference was found between the groups with regard to the type of operation, frequency of colostomy creation and the need of blood transfusion but no significant difference was demonstrated in average hospital stay and mortality.

CONCLUSION

Due to the lower morbidity and mortality rate as well as the benefits of laparoscopic approach, we should always opt for ES. No guideline for relative surgical indication exists: gastroenterologist and surgeon should make a personalized surgical plan. In our opinion, operation should be carried out if diverticulitis reoccurs while the patient is on strict diet. Orv Hetil. 2020; 161(51): 2146-2152.

Gamma-Synuclein Levels Are Elevated in Peritoneal Fluid of Patients with Endometriosis

Background

The role of gamma-synuclein (SNCG) has been widely examined in malignant conditions due to its possible role in disease progression, but very little information is available on its theoretical function on endometriosis formation.

Material/Methods

Between January 2016 and December 2016, we collected peritoneal fluid and plasma samples from 45 consecutive female patients, of which 15 were without endometriosis, 15 had minimal to mild endometriosis, and 15 had moderate to severe endometriosis. The statistical power was 0.98. We evaluated SNCG levels in the peritoneal fluid and plasma of patients diagnosed with endometriosis, and we compared them with the levels obtained from disease-free control subjects by using enzyme-linked immunosorbent assay.

Results

SNCG levels were statistically significantly (1.2-fold) higher in the peritoneal fluid of patients with endometriosis compared to controls (p=0.04). We did not find a significant difference between SNCG levels in the plasma of our endometriosis patients and the control group (p=0.086). However, despite previous data showing very limited expression of SNCG in healthy tissues, we found SNCG in the peritoneal fluid of all of the patients in our healthy control group.

Conclusions

Levels of SNCG were statistically significantly higher in the peritoneal fluid of patients with endometriosis compared to disease-free controls, which may indicate its possible role the formation and progression of the disease. Moreover, its biological function should be further investigated due to the conflicting results concerning its expression in healthy tissues.

[The effect of surgical treatment of bowel endometriosis on fertility]

Introduction: Bowel endometriosis is when endometrial-like tissue penetrates the bowel serosa, or it reaches the subserous neurovascular plexus. The effect of surgery for colorectal endometriosis on infertility and pregnancy is not fully proven. Aim: The aim of the present study was to analyse the pregnancy outcome and mode of delivery of patients who underwent 'nerve sparing' anterior resection of the colon. Method: Between 2009 and 2017, we operated 121 patients with bowel endometriosis, and built up a prospective database where we assessed their wish of pregnancy, the way of the conception, pathologies during pregnancy and mode of delivery. Statistical analysis: The relationship between endometriosis and pregnancy pathologies was tested by a χ² probe and Fisher's exact test, additionally the odds ratio (OR) and 95% confidence interval (CI) were determined. For p<0.05, the result was considered significant. Results: Out of 121 bowel endometriosis patients, 48 (39.6%) women got pregnant, 37 (30.5%) of them with in vitro fertilisation. The control group was built from patients who underwent in vitro fertilisation because of andrological factors. We found that women with endometriosis have a significantly higher risk for praeeclampsia (p = 0.023) and placenta praevia (p = 0.045) during pregnancy. Conclusions: Our study is a unique description of pregnancy outcome and mode of delivery after surgery for bowel endometriosis, which, despite the small number of cases, has yielded similar results to the previous multicentric studies. Orv Hetil. 2019; 160(41): 1633-1638.

[Resection of vena cava inferior infiltrating by liver tumors]

Introduction: Despite all new promising agents of oncotherapy, it is still liver resection that gives potential curative solution for primary and secondary liver tumors. The size of tumorous liver section for resection means no question any more but major vessel infiltration of tumor proposes challenge in liver surgery. Patients and method: Retrospective analysis was carried out covering 33 patients who underwent liver resection in St. Janos Hospital Surgery Department between 1st May 2017 and 1st May 2019. Demographic, surgical, histological data and postoperative course were taken into consideration and comparison with two of our patients who needed vena cava excision simultaneously with liver resection. Results: Patients with liver resection only (LR) had a mean operation time of 91.7 minutes, while operation time for patients with cava resection (CR) was 250 minutes. The average amount of blood transfusion was 1.2 units (200 ml) in group LR and 5 units in group CR. Among LR patients, resection was rated R0 in 23 and R1 in 8 cases, R2 resection could be performed in 2 cases, in group CR in both cases R1 resection was registered. 5 patients with colorectal liver metastasis were operated after previous chemotherapy. Two patients underwent laparoscopic liver resection and two had synchronous colorectal and liver resection, one of these was treated via laparoscopic approach. Conclusion: Liver resections in case of large vessel (vena cava, hepatic vein) infiltrating by liver tumors are indicated the most challenging procedures of liver surgery. The relating literature refers to oncological liver resections with vena cava excision and reconstruction to be safe and applicable. Orv Hetil. 2019; 160(33): 1304-1310.

[Benign multicystic peritoneal mesothelioma]

Benign multicystic peritoneal mesothelioma is a rare benign tumor originating from the peritoneum, affecting mostly young, fertile women. Its presentation is non-specific, thus the final diagnosis is made after the histological examination. A young female patient presented with incarcerated inguinal hernia of which an emergency surgery was performed. During the operation a cystic mass neighboring the round ligament in the canal of Nuck was removed. No inguinal hernia was found. The histological examination confirmed the diagnosis of benign multicystic mesothelioma. The patient was referred to a center performing hyperthermic intraperitoneal chemotherapy, where laparoscopic exploration was performed. The second surgery revealed no residual tumor or any other pathology. A 41-year-old male patient, 4 years before presenting at our ward, had an elective umbilical hernia repair surgery. During the operation 2 cm big cystic mass was removed from the peritoneum, and the histological examination revealed benign multicystic mesothelioma. In 2018, acute surgery was performed due to a periappendicular abscess, while during the surgery a multicystic mass situated on the distal end of the appendix was also removed. The pathological finding confirmed the recurrence of the first tumor. The radiological examination did not find any signs of residual tumor mass anywhere else. The chances of malignant transformation in cases of benign multicystic peritoneal mesothelioma are low. The suggested treatment is en bloc surgical removal of the mass, however, in these cases recurrence is still 50%. If during follow-ups the recurrence of the tumor is found, a total peritonectomy or hyperthermic intraperitoneal chemotherapy is advisable. Orv Hetil. 2019; 160(21): 839-843.

[Ileal duplication: challenging differential diagnosis caused by a rare abnormality. Case report]

Gastrointestinal tract duplications (GSD) are rare congenital abnormalities. Eighty percent of GSDs are diagnosed before the age of two. These lesions can be seen anywhere from the oral cavity to the anus, but ileum is the most commonly affected site. Their clinical presentation is widely variable and unspecific, making the differential diagnosis really hard. Thus despite performing a long line of radiological scans, the diagnosis can be made during a surgery and by the pathologist. A 23-year-old female patient presented at the emergency room (ER) with abdominal cramps. Examinations revealed an unidentified intraabdominal mass. This could not been identified through the next years despite having tons of examinations: intravaginal and abdominal ultrasonographies, CT and MRI scans, colonoscopies, laparoscopies, surgical, gynecological and gastroenterological visits. Amongst the diagnoses were: ovarian cyst, bowel enlargement, Crohn's disease. Due to the latter, she received therapy which temporarily eased her symptoms. But after these, because of abdominal pain, fever and an ultrasonography that showed an intramural abscess in her abdomen, she went through a surgery having an ileocecal resection. Pathological examination showed a duplication of the ileum that might have caused her symptoms all through the years. Despite facing this rare abnormality, it is important to keep this in mind in differentiating abdominal symptoms. It is true that in no case there could be a diagnosis made without surgery, it raises attention to the importance of precise medical history taking and also cooperation between specialties. Orv Hetil. 2018; 159(52): 2217-2221.

[Bowel endometriosis: new challenge for gastroenterology and surgery? Three cases of endometriosis caused large bowel ileus and review of the literature]

INTRODUCTION

A number of the patients suffer from endometriosis increased in the past decades and the cases have became more serious. The most critical complication of bowel endometriosis is the large bowel obstruction. Up to recently, 16 similar case reports of large bowel endomteriosis causing obstruction, with detailed medical history have been published in the literature in English language.

PATIENTS

Since 2007 535 female have been treated in the 1st Gynaecological Department with endometriosis, out of them three patients from emergency surgery in the history because of large bowel obstruction.

RESULTS

Symptoms suggesting endometriosis or previous intervention due to endometriosis were detected in 59% (13/21) of the cases. Preoperative ultrasound, computertomography, magnetic resonance imaging did not give correct diagnosis. Colonoscopy was carried out before the primary operation in 61% (13/21) and after the surgery in 24% (5/21) of the cases, but none of them confirmed endometriosis. Although all the patients developed obstruction, only in 5% (1/19) of the patients was the mucosa infiltrated by the endometriosis.

CONCLUSIONS

In a young female patient, intestinal obstruction can be caused by bowel endometriosis. Identification of colonoscopic signs (rigidity, impression, kinking) of endometriosis may help to avoid unnecessary extension of intestinal resection. Gynaecologists should take part in the operations. Orv. Hetil., 2016, 157(49), 1960-1966.

[Investigation of laparoscopic bimanual technic education with laparoscopic training box]

INTRODUCTION

In some surgical wards residents start to do laparoscopic operations using both hands, while in other places they only use their dominant hand, and only start to use both hands later. There are no data at the moment about which method is more effective.

METHODS

We divided 20 students with no laparoscopic experience into 2 groups: one group practised one hand at a time (1K), the other group used both hands (2K) during the 5 days. On the last day both groups had to do every exercise with one hand and two hands as well, then they had to do 3 new exercises, which needed both hands. We measured the time taken, and gave points for the videos taken inside the training box based on OSATS. For statistical analysis we used t-tests, p < 0.05 being significant.

RESULTS

On the first day, there was no significant difference between the 1K and 2K groups considering the time taken (518/500 s) and the OSATS points (87/84; 54/55 points). Both groups improved in the mean time and points (1K: 52%, 77% 2K: 50%, 70%) as well, but there was no significant difference between them. In the case of new exercises on the last day, there was no difference between mean time (1K: 425 s, 2K: 411 s) and points (53/59 and 56/52), but there was a significant difference considering the points given for bimanuality.

CONCLUSION

Based on our study, we cannot exactly state that the bimanuality needed for expert laparoscopic surgery would be easier to learn with immediately practising with both hands.

[Prospective study to determine the diagnostic sensitivity of sigmoidoscopy in bowel endometriosis]

INTRODUCTION AND AIM

In the treatment of colorectal endometriosis a multidisciplinary laparoscopic resection is suggested, for this reason the correct selection of bowel infiltration is essential before surgery.

PATIENTS AND METHOD

Between 2009 and 2015, 383 sigmoidoscopies were performed in patients with endometriosis. Where mucosal invasion was absent secondary signs (wall rigidity, impression, kinking, pain during the examination, suffusion) were analysed. In endoscopically confirmed cases multidisciplinary surgery was performed, the remaining patients were operated by a gynecologic team only.

RESULTS

Endometriosis was endoscopically confirmed in 224 patients (58.49%), 108 of them underwent multidisciplinary operation, the negative 135 cases received gynaecological surgery. Bowel endometriosis was confirmed in 103 out of 108 cases intraoperatively, while in 8 cases of the sigmoidoscopically negative patients bowel infiltration was diagnosed intraoperatively by the gynaecological team. Complete sigmoidoscopy was performed in 43.47% of the cases. Intraluminal endometriosis was found in 4.91%, secondary signs as rigidity in 38.39%, impression in 45.54%, kinking in 57.14%, pain (in cases of examination without narcosis) in 26.06% and suffusion in 3.82% of the cases was found during sigmoidoscopy. Sigmoidoscopic examination has a 92.8% specificity and 96.2% sensitivity in cases of bowel endometriosis.

CONCLUSION

Sigmoidoscopy performed by an experienced gastroenterologist is a highly sensitive examination for the diagnosis of bowel endometriosis. Orv. Hetil., 2017, 158(7), 264-269.

[The role of laparoscopy in cholecystectomy in patients 80 years old and older]

INTRODUCTION

The incidence of cholelithiasis increases with age, however, there is still little data about the outcomes of cholecystectomy in patients with age of 80 and above. Population ageing presents tremendous challenges for surgeons.

AIM

The aim of the authors was to compare emergency and elective cholecystectomies performed in these elderly patients.

METHOD

This retrospective study was based on the analysis of operation type, conversion rate, complications, mortality, length of hospital stay of all patients over 80 who underwent cholecystectomy in the last 6 years at the 1st Department of Surgery, Semmelweis University.

RESULTS

69 elective and 51 emergency operations were performed. In the emergency group pancreatitis was found in 9.8%, liver abscess in 14%, and common bile duct stones in 27% of the patients on admission. Laparoscopic cholecystectomy could be performed in 84% of patients in the elective group, while in 17.7% of patients in the emergency group. The length of stay at the intensive care unit was 9.1 and 1 days, while the total length of hospital stay was 12 and 3.6 days for the elective and emergency groups, respectively. In the emergency group mortality was 20% and reoperation was performed in 16% of patients, while at the elective group none of these occurred.

CONCLUSION

Laparoscopic cholecystectomy is safe as elective surgery for patients with age of 80 and above. For this reason the authors recommend elective cholecystectomy in this age group.

[Technical questions of the transrectal specimen extraction]

INTRODUCTION

During laparoscopic partial colectomy the specimen can be extracted transrectally. This technique decreases the invasiveness of the surgery, because the abdominal wall incision is avoided. Premises of a new surgical technique are precise technical description as well as a favourable balance of advantages and disadvantages. In this paper the authors review the technique they apply and analyse their first results.

PATIENTS AND METHOD

45 laparoscopic bowel resections were performed by a multidisciplinary team between 16th April 2014 and 1st November 2015. Indication of surgery was endometriosis, and the specimen was extracted transrectally in 11 patients. Having ligated both bowel ends proximal and distal to the section infiltrated with endometriosis, and the proximal bowel secured with a laparoscopic bulldog. Then the bowel was resected and the specimen was extracted in a camera bag transrectally. A purse-string suture was placed into the proximal bowel end, and the anvil of the circular stapler--which was introduced transrectally--was inserted into the bowel. After closing the rectal stump, the anastomosis was performed with a circular stapler. We used this technique when the upper third of the rectum or sigmoid colon was infiltrated with endometriosis.

RESULTS

The difference between the operation time of the two techniques (transabdominal vs. transrectal specimen extraction: 108 min vs. 118 min) was not significant. There was not difference in the WBC count between the first and second postoperative day, and there was not any anastomosis leakage detected either.

CONCLUSION

By using the above technique, postoperative infections could have been reduced to minimum. Transrectal specimen extraction did not increase postoperative complication The authors believe this is a safe way of specimen extraction after partial colectomy.

[The importance of postoperative circulatory alterations in hepatic surgery]

There are two afferent (hepatic artery, portal vein) and one efferent (hepatic veins) systems responsible for the unique circulation of the liver. Given this special form of vasculature, acute, isolated (i.e. involving selectively one particular vessel) vascular occlusions may lead to different, however still life threatening conditions. Hence, it is essential to recognize these anomalies in order to preserve the healthy state of both the liver and the patient's lives. Acute circulatory failures are dominantly associated with liver surgery. Adequate therapy can only be provided promptly, if the clinician is well aware of the peculiarities of these conditions. The aim of this study is to overview the etiology and symptoms of these clinical conditions; furthermore to offer technical proposals for the required diagnostic and therapeutical steps via case reports. Furthermore, hepatic injury, caused by ischemia-reperfusion secondary to total vascular occlusion (Pringle maneuver) used in hepatic surgery is outlined.

[Importance of nerve-sparing surgical technique in the treatment of deep infiltrating endometriosis]

INTRODUCTION

Traditional surgeries performed in cases of deep infiltrating endometriosis lead to impaired quality of life.

AIM

To summarize the postoperative outcome and to compare the rate of postoperative complications after different therapeutic approaches applied in deep infiltrating endometriosis.

METHOD

The authors analized the articles published between March 31, 2004 and March 31, 2015, in the database http://www.pubmed.org using the following keywords: endometriosis, deep infiltrating, nerve sparing, surgery.

RESULTS

Non-nerve sparing surgery resulted in temporary urinary dysfunction in 19.1-38.5% of patients, while it occurred in 0.61-33.3% of patients after nerve-sparing surgery. Non-nerve sparing surgical technique resulted in an average of 121 days of need for self-catheretisation. When nerve-sparing surgeries were performed the duration of self-catheterisation varied between 7 to 39.8 days. After nerve sparing surgeries, permanent bladder dysfunction was not detected in any case.

CONCLUSIONS

Because of the successful treatment of the patients symptoms and the lower postoperative complication rate, nerve-sparing surgical technique leads to a significant improvement of the quality of life.

[In Process Citation]

INTRODUCTION

The number of patients operated on with endometriosis increases, the urological organ and the bowels are involved in 10-40% of the cases in addition to the gynaecological organs.

PATIENTS AND METHODS

Sigmoideoscopy detected bowel endometriosis in 224 patients from 383 patients with endometriosis, and 127 patients were operated on from 14.07.2009 to 13.01.2014 at the 1st Gynaecological Department of Semmelweis University, Budapest, Hungary. All the operation was made by the same gynaecologist and surgeon team.

RESULTS

Segment resection of the bowel was performed in 120 patients, local resection in two patients and shaving in another two cases. The involved part of the bowels were the rectum at 46 patients, rectosigmoid in 68, sigmoid bowel in 30, coecum in 4, appendix in 2 and the small intestine in 2 patients. Bladder resection was carried out in 9 patients, ureter resection in two patients and ureterolysis in 26 cases were done due to infiltration of the urological organs. The laparoscopic operation needed to be converted on one single occasion due to bleeding from the epigastric artery, and a laparoscopic suture of the anastomosis was applied for bleeding in another patient. The specimen was extracted transvaginally in 16 patients and transanally in 13 patients. Anastomotic leakage was detected in two patients and rectovaginal fistula in four patients. All reoperations (creation and closing of the stoma) were done laparoscopically.

CONCLUSIONS

The treatment of the bowel endometriosis is suggested with segment resection by multidisciplinary team, where the invasivity can be decreased by transanal specimen extraction.

[Laparoscopic resection of persistent patent urachus]

The urachus in the foetus is a fibromuscular duct, which connects the allantois to the bladder and it is usually occluded in the 4-5th gestation months. Incomplete occlusion of the urachus at the time of birth is considered to be physiological, but later it can lead to recurrent discharge and inflammation of the umbilicus. To establish the diagnosis, ultrasound is the first examination of choice. A 19-year old obese female patient presented with umbilical discharge, and a persistent urachus was detected by ultrasound. After incision of the peritoneum the duct was excised from the umbilicus to the dome of the bladder by 3-port laparoscopy where the duct was clipped. The operation time was 38 minutes. The patient required minor analgesia on one single occasion in the postoperative period and was discharged on the first postoperative day. The authors recommend laparoscopic operation for the urachal remnant; the enlarged duct on the ventral abdominal wall can be better detected from the umbilicus to the Retzius spatium with 30-degree camera, and the cosmetic outcome is also more favourable.

[Reducing invasiveness of laparoscopic surgery using natural orifices and abdominal wall defects for extraction of the specimen]

INTRODUCTION

Due to significant technical evolution complex surgeries can be performed laparoscopically nowadays. However, laparotomy is needed frequently for the extraction of the specimen, which decreases the advantages of laparoscopy.

AIM

The aim of the authors was to analyse and present their experience on the use of natural orifices and abdominal wall defects for extraction of the surgical specimen.

METHOD

From 2009 the authors used natural orifices (stomach, vagina, rectum) when viscerotomy was an obligate part of laparoscopic surgery and, in a special gastrointestinal laparoscopic operation, the gate of the inguinal hernia for specimen extraction.

RESULTS

In 3 patients benign lesions of the stomach were extracted using gastroscope. In 6 patients with bowel endometriosis, in whom the wall of the vagina was completely infiltrated, the resected bowel was extracted transvaginally, and in 5 patients transrectal extraction of the specimen was performed. In 2 patients the inguinal hernia was used for the surgical specimen extraction after laparoscopic sigmoid resection, and in one patient a single-port was inserted into the gate of the hernia during laparoscopic cholecystectomy. Complications occurred only after transvaginal specimen extraction (rectovaginal fistula in 2 patients).

CONCLUSIONS

Use of natural orifices and abdominal wall defects for surgical specimen extraction further decreases the invasiveness of laparoscopic surgery, if indications made appropriately.

[Laparoscopic surgery of benign liver tumours]

273 patients underwent elective surgical treatment for benign liver lesions at the 1st Surgical Department of Semmelweis University, Budapest, Hungary between 2004 and 2014. Laparoscopic (LAP) interventions were performed in 83 cases. Cyst fenestration in 52, and hepatic resection in 31 cases. LAP liver resections were set against to open surgery of paired group of patients with comparable demographic and clinical parameters. Data revealed that the operative time in LAP group (113.7 min) was significantly longer than that in the open surgery group (89.5 min). The average postoperative length of hospital stay was shorter after LAP surgery (5.8 vs 9.1 days). There was no postoperative complication in the LAP group, two wound infections and one biliary collection were treated by ultrasonic drainage in the open group. Three patients were given blood transfusion in the LAP, four in the open group. Operative mortality was zero, and no reoperation required. The surgical technique which is described in detail in the text enables safe resection of segments 7-8 which are difficult to approach. Our data support the safety and feasibility of laparoscopic liver resection after adequate preoperative investigations.

Changes in the operating time of laparoscopic cholecystectomy of the surgeons and novices between 1994-2012

BACKGROUND

The technique of laparoscopic cholecystectomy(LC) has not changed over the past recent years; therefore the possibility is open to study its learning curve.

METHODS

Retrospectively, every third year's LCs were analysed between 1994 and 2012. The learning curves of surgeons and novices were defined in the department. The surgeons have scored the laparoscopic technique of their colleagues on a scale of 1 to 10 and operation time (OT) was examined in light of the assistant's technique.

RESULTS

2,216 LCs were performed in the examined period.The average OT of the department was 78.3 minutes in 1994,which had decreased to 45.4 minutes (42.0%) by 2003. The improvement rates of surgeons and novices were 36.7% and respectively 9.9%, and the variance between the minimum and maximum OT changed in parallel. The OT in the initial 3 years of learning had become 13% shorter by 2006 and the first section of the learning curve has also become steeper. In case of surgeons whose technical points were low and OT was short, the assistants average technical score was significantly higher than in case of surgeons whose technical score was high and the OT was short.

CONCLUSION

The OT alone is not an objective factor in the definition of the surgical technique.

[Transvaginal specimen extraction after laparoscopic bowel resection in deeply infiltrating endometriosis]

The authors report a case of a 27-year-old patient who had deeply infiltrating endometriosis involving the rectum, sigmoid colon and the rectovaginal septum, which was removed by laparoscopic surgery. During surgery the affected bowel segment, the deeply infiltrating nodule of the rectovaginal septum and the posterior vaginal wall were resected and the 12 cm long specimen was removed transvaginally. Postoperative bleeding was noted in the first postoperative day, which was treated laparoscopically, as well. This case history confirms data from the literature showing that the natural orifice specimen extraction procedure can widely be applied during operations for deeply infiltrating endometriosis and that laparoscopic anterior resection is a safe and feasible method for the treatment of colorectal deeply infiltratnig endometriosis. Moreover, perioperative complications can be treated by means of laparoscopic surgery.

[Experience with multidisciplinary laparoscopic surgery in patients with deep infiltrating colorectal endometriosis]

INTRODUCTION

Deep infiltrating endometriosis is a particular form of endometriosis that penetrates the peritoneal surface or it reaches the subserosal neurovascular plexus.

AIM

The aim of the authors was to analyze the results of segmental colorectal resections performed for deep infiltrating endometriosis.

METHOD

Between 2009 and 2012, 50 patients underwent segmental rectum or/and sigmoid resection for endometriosis.

RESULTS

21 patients had ultralow rectal resection and 29 patients had low colorectal anastomosis or anterior resection. Concomitant intervention in other organs was required in all cases, including gynecologic procedures (n = 50), additional gynecologic (n = 47), vesical (n = 9) and ureteral (n = 18) resections. The mean number of endometriosis lesions was 2.4±1.8 per patient. In all patients fertility was preserved. Severe surgical complications (Clavien-Dindo stage III or more severe) occurred in 3 patients (6%).

CONCLUSIONS

The results confirm that segmental bowel resection is an efficient and safe method for the treatment of deep infiltrating colorectal endometriosis. Orv. Hetil., 2014, 155(5), 182-186.

[Laparoscopic colorectal resections -- experience based on 393 cases]

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

[Measuring residents' and specialists' laparoscopic technique with the MENTOR® training box]

INTRODUCTION

Operating room is not the ideal place to acquire laparoscopic skills since patients can be put at risk and it is also relatively expensive. Using training boxes seems to be a more appropriate way of teaching and learning the technique, but there is little data about measuring the technique of experienced specialists and comparing their results with residents.

METHODS

At the 1st Department of Surgery, Semmelweis University we tested 30 residents and 25 specialists in general surgery and urology on MENTOR® training box. Before training, all participants completed a questionnaire on professional experience, previous usage of training boxes, virtual simulators, and video games, and whether they played a musical instrument earlier. Subjects were asked to complete in a defined time limit 3 of the Fundamentals of Laparoscopic Surgery tasks (which is required for American surgical residents for surgical board examination), and 3 tasks decided by us. Linear regression analysis (ANOVA table) was used to evaluate the data.

RESULTS

16% of the specialists and 6.66% of the residents completed all tasks within time limit. Statistically significant correlation (p < 0.05) was demonstrated between the number of previous laparoscopic surgeries and task completion time, while there were no significant correlations between other factors, which may influence laparoscopic technique and task completion time.

CONCLUSIONS

Training boxes are suitable for developing eye-hand coordination and bimanuality, as well as for learning instrument handling. Nonetheless, residents acquire most of their laparoscopic surgical skills on patients in Hungary, yet. For this reason there is a need for organized training opportunities.

[Palliative management of malignant oesophageal strictures with endoprosthesis implantation -- 25 years experience]

OBJECTIVES

The aim of this study was to analyse the feasibility of the use of oesophageal endoprosthesis based on a large series of cases.

METHODS

2952 malignant oesophageal strictures managed between 1984 and 2009 were analysed. While surgical intubation was carried out in 42 patients, endoscopic implantation was feasible in 1143 cases. Patients not eligible for oesophageal stenting were treated with gastrostomy in 125, percutaneous endoscopic gastrostomy in 19, catheter jejunostomy in 9 and supportive therapy in 965 cases, respectively.

RESULTS

Endoprosthesis could have been inserted in 61.2% of the patients. Dysphagia was terminated temporarily in 6.2% and permanently in 93.5%. Complications were detected in 23.7% of the cases, which included stent migration, perforation, bleeding, airway obstruction, early unexpected death, aspiration, stent obstruction, tumor overgrowth, oesophago-respiratory fistula formation and neoformation, and reflux. Complications were treated endoscopically primarily (69.2%). Lethal complication rate was 2.1% (27 cases). Furthermore, complication rate of patients who underwent surgical stent insertion was 21.9%. Mean survival of patients with oesophageal intubation was 5.4 months, with nutritional support via gastrostomy, percutaneous endoscopic gastrostomy or jejunostomy 3.6 months and with supportive therapy alone 3.2 months.

CONCLUSIONS

Oesophageal endoprosthesis insertion is an effective method for the palliative management of malignant oesophageal strictures. Stent implantation improves survival as well as quality of life. Methods used for nutritional support decreases hungriness but do not influence survival.

[Single port transumbilical cholecystectomy [SILS] -- 30 non-selected cases]

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

[The development of laparoscopic technology in light of cholecystectomies performed between 1994 and 2007]

The spread of laparoscopy has required surgeons to familiarize with a completely new surgical method and by today this method has clearly become of major importance in gastrointestinal surgery. The evolution of laparoscopic cholecystectomy offers many good lessons to learn for the purposes of advanced laparoscopic surgeries and surgeons may benefit from this experience in any process of introducing new minimal invasive techniques.

METHODS AND MATERIAL

We have made a retrospective analysis of the data of the cholecystectomies made in the 1st. Department of Surgery, Semmelweis University, right after laparoscopy had become a widely spread, routine surgical method (1994) as well as 13 years later (2007). The data have been processed using the SPSS 16.0 application package. Significance levels have been established with the chi-square probe.

RESULTS

Within the analyzed timeframe we could clearly see a growing use of laparoscopic techniques (52.09% vs. 90.13%) with a growing number of cases (263/304), unchanged average age (approximately 53.5 years) and constant male/female ratio (75/25%). The BMI increased moderately (26.5 vs. 27.6), but the frequency of laparoscopic interventions on extremely obese patients grew (BMI: 25-30 37.93% vs. 44.39%, 30-35 13.79% vs. 20.6% 35-40 6.89% vs. 5.82% and 40 \lt; 0% vs. 1.34%) while the postoperative hospitalization decreased dramatically from 5.9 days to 2.3. In year 1994, patients spent on the average 2.9 days in hospital after a laparoscopic surgery, while in year 2007 nearly 25% of the patients left the hospital 1 day after surgery. The duration of a laparoscopic surgery decreased from 78 minutes to 53, and the occurrence of intraoperative bleeding, gall bladder perforation and gallstone spillage also decreased. The conversion ratio increased from 2.7% to 4.9%. In 3% of the laparoscopic cholecystectomies (10 patients) only 3 ports were used during surgery.

DISCUSSION

As surgeons have come to master the new technique, the previous relative and absolute pros and cons have been revised and at present 90% of cholecystectomies are made using laparoscopy. The data collected in the analysis of laparoscopic techniques can be used to research, learn and eventually introduce Natural Orifice Transluminal Endoscopic Surgery.

[NOTES and other minimally invasive surgical techniques (hybrid NOTES, NOTUS, SPS, SILS), and their effect on surgical approaches]

A new surgical technique--called Natural Orifice Translumenal Endoscopic Surgery (NOTES)--evolved in 2004. Although numerous problems arose regarding this method--and most of them are unresolved yet--several new articles about the human application have been published. In order to find solutions of a certain extent, new techniques have been developed (hybrid NOTES, NOTUS, SPS, SLIS, etc). Although these could not eliminate difficulties completely, they do provide some solutions in many cases. It is very important for the surgeon of modern days to be familiar with these techniques and analyze them in a critically. Application of these methods requires a review of principles of surgery and flexible endoscopy. Although in many cases these are considered axioms, there data exist in literature of different management principles, as well. It is fundamental that critically review of the basic questions of NOTES (which natural orifice is the best, how to close the viscerotomy, how to avoid infection, who should carry out the NOTES surgery) is carried out in relation of the complications of the original 'gold standard' methods (e.g. frequency of infection or hernia after laparoscopy). Based on human data there is minimal postoperative pain after the NOTES procedure, and patients in general will leave the hospital on the same day. Is such a short postoperative stay enough and can we entirely dismiss drainage after cholecystectomy? Results of the human procedures are adequate to draw further conclusions regarding the new technique. Retrospective analysis of problems occurring during the evolution of laparoscopy can make it possible to avoid mistakes that can be made in the development of NOTES.

[Cirrhosis and cholelithiasis. Laparoscopic or open cholecystectomy?]

Recently laparoscopic cholecystectomy has become the standard operation in case of cholelithiasis. The range of contraindications has decreased, a previous abdominal surgery, a severe cholecystitis or gravidity are not self-evident contraindications any more. The advantages and benefits of laparoscopic interventions in patients with hepatic cirrhosis are doubtful.

PATIENTS AND METHODS

Between 1996--2006, 52 patients were analyzed at the I. Department of Surgery of Semmelweis University in a retrospective study who underwent operations on hepatic cirrhosis and cholelithiasis. The female/male ratio was 2.7/1 and the mean age was 58.5 (31-87). The patients were classified according to the Child-Pugh score: A = 36, B = 14, C = 2. 23 traditional, open (OC) and 29 laparoscopic (LC) cholecystectomy were performed, in 4 out of the latter operations conversion had to be done.

RESULTS

In Child A and B cirrhotic patients the mean operative time was 86.5 minutes in the case of LC, whereas with the open intervention it was 86.21 minutes. In Child C cirrhotic patients, open cholecystectomy was performed in both cases, the average operative time was 81.5 minutes. Postoperative complications (Child A, B) occurred in 8 cases (LC/1), (OC/7), while in Child C patients in two cases. The average hospital stay was 7.6 (LC) and 12.45 (OC) days, respectively. The same with Child C patients increased to 28 days. In the postoperative phase 4 patients died: all of them had open cholecystectomy, suffered from Child B and Child C class hepatic cirrhosis, respectively, and they developed hepatorenal syndrome that could not be treated.

CONCLUSION

The results show that LC is a safe procedure in well-compensated Child A and B cirrhotic patients. Although hepatic cirrhosis greatly increases the surgical risks, as well as the likelihood of complications, and it also necessitates longer operative time and longer hospital stay, it is recommended that cirrhotic patients with symptomatic cholelithiasis should clearly be operated on.

[Laparoscopic transhiatal resection of esophageal cancer]

INTRODUCTION

Minimally invasive oesophageal resection is a real alternative to the conventional open operative techniques in the surgical treatment of oesophageal tumours.

PATIENT AND METHOD

The authors present a case of a 51 year-old female patient who initially underwent an upper GI endoscopy for vague stomach symptoms. The examination revealed an oesophageal tumour of approximately 2 cm in length, located at 32 cm from the incisors. Abdominal ultrasound and CT scans were carried out, which showed that the tumour had breached the submucosa, but regional lymph node metastasis was not detected. Since an intraluminal flexible endoscopic ablation of the tumour could not have been carried out, a laparoscopic transhiatal oesophagus excision was done. The oesophagus was replaced by an intracorporal tubulated stomach in the posterior mediastinum.

RESULT

In the postoperative period a gastro-pleural fistula developed in the middle third of the stomach, which was treated conservatively (thoracic drainage, Salem probe). A phlegmone developed next to the feeding jejunostomy - at the site of one of the trocars - required exploration, the re-suturing of the jejunostomy due to persisting leakage of the small intestine. 3 months after the operation the patient was asymptomatic and gained 2 kg weight.

CONCLUSION

Laparoscopic transhiatal oesophagus resection has all the benefits of the minimally invasive techniques; in addition, it makes possible to do a more radical surgery than with the traditional transhiatal operation. The authors review the relevant literature and present other minimal invasive techniques, discussing the results on lymph node dissection, pyloroplasty, as well as replacement.

[Removal of sessile recidive rectal polyp with endoscopic submucosal dissection. Case report and review of the literature]

With the development of flexible endoscopy, removal of the large sessile polyps and superficial malignant tumors that do not exceed the layer muscular mucosa has become today's major challenge. Earlier in various types of mucosectomy performed with such indication it was difficult to control the depth and the lateral margin of the resection surface. Tumors larger than 20 mm could only be removed with the application of the piecemeal technique.

PATIENT AND METHOD

64-year-old female patient's large sessile polyp had been removed earlier with piecemeal technique followed by mucosectomy. On the area of these interventions a recidiv adenoma was found and for this reason endoscopic submucosal dissection was applied.

RESULT

The procedure took 55 minutes, and only small volume of bleeding was detected during the intervention. The postoperative period was uneventful, one day later the patient left the hospital. Vertical and lateral resection surface were free of tumor histologically.

CONCLUSION

The endoscopic submucosal dissection is suitable for the removal of the large sessile polyp, which could not be successfully removed with earlier techniques.

Crohn’s disease of the duodenum. Clinical signs, diagnosis, conservative and surgical treatment

A duodenumra lokalizált Crohn-betegség az összes Crohn-betegség kb. 0,5–4%-át teszi ki. Leggyakoribb tünete a gyomorürülési zavar és a jelentős fogyás. Az endoszkópos biopszia eredménye gyakran bizonytalan, ami megnehezíti az egyéb benignus szűkületektől való elkülönítését. A műtétet igénylő megbetegedés kezelése tekintetében a betegséggel foglalkozó európai konszenzusos nyilatkozat sem ad pontos irányelveket. Beteganyag: Eredménytelen konzervatív kezelés miatt a Semmelweis Egyetem I. Sebészeti Klinikáján 2002–2007 között három betegnél a gyomorürülési panasz megoldására műtétre volt szükség. Mindegyik betegnek a műtét előtt jelentős súlyvesztése (13–30 kg) volt. Két esetben sikerült a gyulladt bélszakasz eltávolítása a duodenum parciális reszekciójával, és az emésztőtraktus Billroth-II. szerint végzett rekonstrukciójával, egy esetben a leszálló duodenum érintettsége miatt csak bypassműtétre (gastro-jejunostomia) nyílt lehetőség. Eredmények: A betegek a műtét óta eltelt 45/24/9 hónap óta panaszmentesek, műtét előtti súlyukat visszanyerték. Sem korai, sem késői szövődményt nem észleltünk. Következtetések: A konzervatív kezelésre tartósan nem reagáló, szűkületet okozó duodenalis Crohn-betegség műtéti javallatot képez, azonban a fennálló malnutritio a műtét előtt kezelést igényel. A műtét típusa előre nem tervezhető, a kellően előkészített patkóbél-Crohn-beteg gyógyhajlama nem rosszabb, mint egyéb lokalizációjú sorstársaié.

[Gastro-entero anastomosis with flexible endoscope with the help of rare-earth magnets on biosynthetic model made of the gastrointestinal tract of slaughtered pigs]

Gastro-entero anastomosis with flexible endoscope with the help of rare-earth magnets on biosynthetic model made of the gastrointestinal tract of slaughtered pigs

BACKGROUND

Numerous malignant diseases may cause gastric outlet obstruction. The surgical gastrointestinal bypass, besides the fact that it requires narcosis, is also associated with high risks for patients with poor general condition. Endoscopic insertion of self-expandable metal stent is less invasive, but often causes complications. In the last years some studies examined a new minimal invasive technique, in which magnets are used to create gastroenteric anastomosis.

MATERIAL AND METHOD

A biosynthetic model was developed from combined synthetic materials with biogenic specimens taken from slaughtered domestic pigs. The procedure was performed with endoscopic and fluoroscopic guidance. To increase X-ray contrast differences the model was put into physiological saline solution. Two rare-earth magnets (Br: 2500 Gauss, D: 10 mm) with central hole were inserted with the help of a guiding wire and duodenal probe. The first magnet was placed in the first jejunal loop; the second one was placed in the stomach. The gastric magnet was maneuvered using the endoscope. When the magnets reached the right position, the guiding wires were removed to let the magnets stick together. The pressure between the magnets will result in a sterile inflammation on the living tissue which develops adhesion between the bowels, and 7-10 days later anastomosis will develop as a result of the necrosis.

RESULT

The biosynthetic model could be used for training endoscopy without sacrificing animals. In the end of the procedure the magnets stuck together across gastric and jejunal walls in all ten cases successfully. By practice the period necessary for the procedure could be decreased from 40 to 20 minutes.

CONCLUSION

The technique could be made with standard upper endoscope and instruments, and after practice on living animals it could potentially be a useful solution for complaints of gastric outlet obstruction.

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

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

[Piecemeal technique at the removal of large rectosigmoid polyps]

INTRODUCTION

Removal of the colon polyps is a routine approach. Polyps larger than 2 cm can not be removed in one piece, the piecemeal technique is to be applied for these cases. The risk for the complications (bleeding, perforation) and the malignancy are higher, than in conventional cases.

PATIENTS AND METHOD

At the 1st Surgical Department of Semmelweis University the piecemeal technique have been used at 13 patients, among others at five patients who were declared for operation because of the size of the polyps in other institutions. The average size of the polyps was 3,5 cm. Ten polyps in the rectum, three in the sigmoid colon were found.

RESULTS

The executing procedure required two sections in two cases. Massive bleeding started after the procedure in one patient, which was successfully stopped by infiltration the basement of the polyps with adrenalin. The histology showed in situ carcinoma in two patients.

CONCLUSION

The risk of removal of large colon polyps could be undertaken at those endoscopic units where anesthesiologic and surgical background are present, and the patient--in case of unsuccessful removal--could be treated with other minimal invasive therapy (laparoscopic colon resection).

[Laparoscopic transhiatal resection of epiphrenic diverticulum of the esophagus]

The operation of the epiphrenic diverticulum of the esophagus--due to its anatomical position--is feasible either with thoracotomy or with laparotomy. The advantages of the first method are the possibility of better exploration and a technically easier operation. At the same time, the disadvantage of the surgical procedure imposed on the patient by opening his/her thoracic cavity is not to be underestimated, either. In case of an abdominal approach, the diverticulum in the mediastinum causes difficulties. The laparoscopic method combines the advantages of both solutions. The authors report the case of a 62 years old woman with a history of regurgitation and swallowing problems accompanied by a 20-kilogram weight loss. Barium esophagography and esophagogastroduodenoscopy showed a typically positioned 11-cm large epiphrenic diverticulum. As an operative solution transhiatal laparoscopic resection of the diverticulum with Heller cardiomyotomy and Dor fundoplication using an endoscopic stapler was performed. The postoperative period was uneventful; the patient was discharged on the 8th post-operative day with unhindered swallow. In the international literature 79 cases treated with minimally invasive therapy have been published so far. Based on own experience, the authors state that the laparoscopic transhiatal resection of the epiphrenic diverticulum of the esophagus is successful and might be the method of choice.

[Endoscopic mucosal resection of early esophageal cancer]

INTRODUCTION

Endoscopic mucosal resection (EMR) is now thoroughly established as a therapeutic method for early oesophageal cancer. In adequately selected patients, EMR provides a comparable outcome to traditional surgical operations.

PATIENTS AND METHOD

5 patients with early oesophageal cancer were treated fey simple snare resection in 2004 and 2005. These selected patients had distinct backgrounds one was known to have underlying Barrett's oesophagus, two of them had oesophageal varices, one case was an incidental finding for investigating abdominal pain, one was diagnosed during cancer surveillance of partial oesophagectomy. All these lesions were biopsy proven and evaluated by endoscopic ultrasound.

RESULTS

No acute complications were noticed after the procedure. Post-procedure oncological chemotherapy was given to the last four patients. Control exam was performed to all patient 1st, 3rd and every 3rd month after the procedure. Patient with recurrent cancer after partial oesophagectomy had recidive tumor.

CONCLUSION

Endoscopic mucosal resection of superficial oesophageal cancer can be performed without major complications representing a useful alternative treatment of oesophageal cancer.

[Change in location of colorectal cancer in Hungarian patients between 1993-2004]

The incidence of proximal tumours in Western countries has steadily increased while that of distal tumours has shown a corresponding decrease. Our aim was to investigate the prevalence, location and histology of colorectal cancers in the last twelve years in Hungarian patients.

PATIENTS AND METHODS

Clinical data of 1738 patients diagnosed with colorectal tumors (M/F: 940/798, mean age at diagnosis: 65.2 +/- 12.5 years) between 1st of January 1993 and 31st of December 2004 at the 1st Internal Medicine and 1st Surgery Department of Semmelweis University were enrolled. Pathology and clinical data were analysed retrospectively. The observed periods were the following 1993-1998 and 1999-2004.

RESULTS

1694 (97.5%) of the patients had adenocarcinoma (CRC), 15 anaplastic cancers, 9 carcinoid, 6 planocellular, 5 GIST, 3 leiomyoma and 2-2 melanoma, lymphoma and shigillocellular cancers were diagnosed. 75.7% (943/1246) of the CRCs were diagnosed at locally advanced stage (T3-T4), and 47.7% (521/1093) of CRC patients had lymph node metastasis at the time of diagnosis. 11.0% of the CRCs were diagnosed in <50 year-olds (<40 years: 2.5%, <30 years: 0.5%). The location of the CRC was distal in 1186 (rectum: 53.9%, sigmoid/descending: 46.1) and proximal in 508 cases. Synchronous cancers were detected in 12 patients (age: 68.8 +/- 11.6 years, gender: 11 male/1 female, location: rectum and transverse in 6, rectum and ascending/caecum in 5 patients). Age at diagnosis was not different according to gender (M/F: 64.8 +/- 12.0 years vs. 65.8 +/- 12.9 years), but it was lower in patients with rectal cancer compared to left or right sided cancers (64.1 years vs. left: 66.1 years, right: 66.0 years, p = 0.02). Rectal CRC was more common in males, while the proportion of proximal cancers was lower (rectum, M/F: 41.2% vs. 33.5%, proximal M/F: 26.8% vs. 33.8%, p = 0.003). The proportion of rectal cancers increased over the observed period (1993-1998: rectal: 31.6% vs. 1999-2004: 42.1%, p = 0.002).

CONCLUSIONS

In contrast to Western countries, the proportion of proximal CRC did not become higher in Hungary. Still more than two-third of the patients were diagnosed to have distal cancers. The proportion of male patients was higher in this subset of CRC. The high percentage of locally advanced and metastatic cancers supports the need for colorectal screening program in Hungary.

[Incidence and pathologic distribution of esophageal cancers at the gastro-esophageal junction between 1993-2003]

There was a significant change in the histology of oesophageal cancers in the last few decades. The incidence of oesophageal adenocarcinoma has risen considerably, now it is equally or even more prevalent than squamous cell cancers in some North American and Western European countries. As no Hungarian data is available, the authors' aim was to investigate the prevalence and histology of oesophageal and gastrooesophageal junction cancers in the last decade.

PATIENTS AND METHODS

451 patients diagnosed with oesophageal (n = 371, 296 male/75 female, mean age at diagnosis: 57.9 SD 10.1 years) or cardia (n = 80, 58 male/22 female, mean age at diagnosis: 65.2 SD 13.4 years) cancer between 1st of January 1993 and 31st of December 2003 at the 1st Internal Medicine and 1st Surgery Department of Semmelweis University were enrolled. Pathology and clinical data were analysed retrospectively.

RESULTS

93% (n = 345) of the patients with oesophageal cancer had squamous cell carcinomas, while adenocarcinoma was only diagnosed in 15 (4%) patients. Mean age at diagnosis was lower in patients with squamous cell cancer (57.4 SD 10.0 years) compared to patients with adenocarcinoma (66.9 SD 8.8 years, p = 0.001). Male-to-female ratio was 4:1 in patients with squamous cell carcinoma (277/68) and undifferentiated carcinoma (9/2), while it was 2:1 in patients with adenocarcinoma (10/5). According to the location 1.3% of cancers of the midthoracic oesophagus and 8.6% of the lower oesophagus were adenocarcinoma. The proportion of adenocarcinoma remained stable over the observed period (1993-1997: 3.7% vs. 1998-2003: 4.3%). In contrast, 71.25% (57/80) of the gastrooesophageal junction cancers and overall 15.9% (72/451) of the cancers of the oesophagus and gastrooesophageal junction were adenocarcinoma (1993-1997: 17.2% vs. 1998-2003: 14.7%).

CONCLUSIONS

Since only a few percentages of authors patients with oesophageal cancers were diagnosed to have adenocarcinoma and its proportion remained stable over the observed period, it seems that in contrast to North American and Western European countries, adenocarcinoma is still infrequent in Hungary.

[Role of minimally invasive interventions in the treatment of complications caused by recidive Klatskin tumors]

BACKGROUND

The hilar cholangiocarcinoma grows slowly and gives metastases very rarely. The first prominent sign of this cancer is the jaundice. In spite of the small size of the tumour, oncologically radical resection is only feasible--owing to the anatomical position--in approximately 35-50% of the cases. This makes recidivity frequent. The recidive cancer involves the hilus of the liver, compresses the surrounding organs and develops different complications.

METHODS

37 patients underwent surgical resection in the 1st Surgical Department of Semmelweis University in the last ten years. Complete tumour-free surgical margins were found in only 48.6% of the cases. The mean follow-up was 23.2 (8-47) months.

RESULTS

9 patients were treated for complication caused by local recurrence. These were mechanical jaundice (9 cases), bleeding oesophageal varices (2 cases), gastric outlet obstruction (2 cases), liver abscess (3 cases) and pain caused by the infiltration of the coeliac ganglion (3 cases). Most part of the complication could be solved by minimal invasive therapy (percutane transhepatic endoprosthesis or drainage, endoscopic sclerotherapy, ultrasound-guided drainage, percutane blockade of the celiac ganglion).

CONCLUSIONS

The fact that resected patients may survive several years as long as patients treated with endoprosthesis and irradiation only survive half a year, has brought a change in the way Klatskin cancer surgery is considered: resection of the tumour should be striven for--even by way of R1 resection. Therefore the risk of recurrence will increase. This is the first article in the literature, which has ever dealt with the complication caused by recidive cancer after resection of Klatskin tumour.

[A case of retroperitoneal pancreatic abscess spreading to the femoral region]

Authors report the case of a 47 years old male patient with acute femoral abscess. The examinations made with urgency found proceeding acute pancreatitis, fluid collection in the right pleural cavity, exceeding fluid collections in the retroperitoneum and right paracolic region. The inflammatory infiltrate and collection in the upper third of the right thing seemed to be in connection with the proceeding pancreatitis. Because of the process endangering also the viability of the limb and severe septic state, an acute operation was performed, in the course of which extension of the retroperitoneal abscess to the thing was observed. After abdominal oncotomy expanded to thigh and inguinal region, lavage, drainage operations, therapy with wide spectrum followed by aimed antibiotics general condition of the patient improved. On the 18 postoperative day a new feverish state manifested. Image forming examinations showed newer purulent collections in the abdominal cavity and on the thigh in addition to the previous abscesses. Because of this repeated exposure was necessary. After the second operation the patient recovered without complaint and further complications. Authors think the case worth attention because of the extensive and unusual localization of abscesses formed beside the relatively discrete abdominal complaints.