András Papp

Effect of glutamine in patients with esophagus resection.

UNLABELLED Glutamine is the most abundant amino-acid in the extra- and intracellular compartments of the human body, which accounts for over 50% of its free amino-acid content. Utilization of glutamine peptides is explicitly useful, resulting in a decrease in the number of postoperative infectious complications, period of hospitalization, and therapeutic costs. This article aims to study the effects of glutamine on systemic inflammatory response, morbidity, and mortality after esophagectomy. A prospective, randomized, double-blind, and controlled trial was used. Following sealed-envelope block randomization, the patients were divided into two groups. Members of the glutamine group (group G) received glutamine (Dipeptiven, Fresenius) as continuous infusion for 6 hours at 0.5 g/kg for 3 days prior to, and 7 days following surgery; while patients of the control group were given placebo. We examined 30 patients in group G, and 25 patients as controls. In both patient groups, the levels of total protein, albumin, pre-albumin, retinol binding protein, transferrin, transferring-saturation, C-reactive protein, procalcitonin, lymphocte, Interleukin-6, Interleukin-8, tumor necrosis factor alpha, and serum lactate were determined prior to surgery (t(0)), directly after surgery (t(u)), following surgery on day 1 (t(1)), day 2 (t(2)), and day 7 (t(7)). For statistical analysis Mann-Whitney U test and chi-square test were used. There was no significant difference between the two groups regarding age, male/female ratio, and SAPS II scores. Intensive care unit morbidity and mortality was similar in both groups (group G: 24 survivors/6 nonsurvivors; CONTROL 17 survivors/8 nonsurvivors; P= 0.607). Daily Multiple Organ Dysfunction Score did not differ significantly between the two groups. The observed inflammatory markers followed the pattern we described without significant difference. Based on our study, the glutamine supplementation that we used had no influence on morbidity, mortality, or postoperative inflammatory response after esophagectomy.

Comparing aboral versus oral pouch with preserved duodenal passage after total gastrectomy : does the position of the gastric substitute reservoir Count?

BackgroundTotal gastrectomy results in a significant weight loss, different postgastrectomy symptoms, and a reduction in quality of life. Elaborate surgical reconstruction methods are evaluated to improve results. The present study compares two types of reconstructions—an aboral pouch with preserved duodenal passage and an oral pouch with preserved duodenal passage—differing only in the site of the pouch.MethodsTwenty-eight patients entered the study. Primary outcome measures—body weight, body mass index, and quality of life, and secondary outcome measures—serum nutritional parameters, scintigraphic small-intestinal passage, and lipid and carbohydrate absorption were measured 6, 12, and 24 months after surgery.ResultsNo significant differences were found in anthropometric parameters or in quality of life between the groups. Regarding the secondary outcome measures, albumin levels were higher in the oral pouch group, while protein and immunoglobulin-A levels were higher in the aboral pouch group.ConclusionThe site of the reservoir does not significantly influence the outcome after total gastrectomy and reconstruction with a preserved duodenal passage.

Chemo-radiotherapy in locally advanced squamous cell oesophageal cancer--are upper third tumours more responsive?

Before neoadjuvant therapy was widely applied, the prognosis of oesophageal cancer had been considered dependent on the location of the tumor, i.e. upper third cancers had had the worst prognosis. The aim of this retrolective study was to prove the efficiency of the neoadjuvant treatment, and to compare the response of esophageal cancer in different locations. Between January 1998 and September 2005, 102 patients with locally advanced squamous cell oesophageal cancer received preoperative chemo-radiotherapy. In 40 cases the tumor was located in the upper third and in 62 cases in the middle third of the oesophagus. After a four-week-long treatment free period restaging was carried out and patients considered resectable were submitted to surgery. From 40 patients with upper third oesophageal cancer 28 underwent oesophageal resection or pharyngo-laryngectomy. Thiry-five percent a complete histopathological remission was observed. From 62 patients with middle third oesophageal cancer 43 underwent oesophageal resection. Histological examination of the resected specimens documented complete response only in three patients. The median survival and the R0 resection rate were similar in the two groups. Although the resection rate, perioperative morbidity, mortality and the median survival were similar in the two groups, a significantly higher rate of complete response (p < 0,05) was observed in patients with upper third oesophageal cancer compared to patients with middle third oesophageal cancer. It seems that upper third oesophageal cancer has superior sensitivity to multimodal treatment therefore our results may support that upper third location is not an unfavorable prognostic factor any more.

A new experimental method for hiatal reinforcement using connective tissue patch transfer

The closure of a large hiatal hernia still represents a challenge for the surgeon. Mesh reinforcement of a hiatoplasty generally decreases recurrence rate. An artificial mesh is cheaper compared with a biologic one, but has a higher complication rate. Our aim was to introduce a new biologic reinforcement method with less expenses. During organ donation for transplantation, tissue islets from pericardium and fascia lata were cryopreserved in a tissue bank. Later, the grafts were transplanted on the diaphragm of mongrel dogs. After 1, 3, and 6 months, the animals were sacrificed, and the transplanted patches were macroscopically and microscopically examined. There were no macroscopic signs of inflammation, abcedation, or significant adhesion formation. The grafts were well recognizable, with palpable thickening and moderate shrinkage. Microscopically, an organization process with fibrosis, neovascularization, and peritoneal integration could be observed. Reinforcement of a hiatoplasty with connective tissue transfer either with cryopreserved or autologous tissue is a good option. This is a cheap and easy method, which should also be tested in human interventions.

Unexpected Insensitivity of the Cholinergic Motor Responses to Morphine in the Human Small Intestine

Background/Aims: Morphine is known to inhibit cholinergic contractions of the guinea pig small intestine. This has been compared to the human small intestinal innervated longitudinal muscle in the current study. Methods: Cholinergic primary contractions of human small intestinal longitudinal strips were evoked by electrical field stimulation (EFS; 0.5– 5 Hz in the presence of purinergic and nitrergic blockers or 5 Hz without pretreatment) and recorded isotonically in organ bath experiments. Guinea pig small intestinal segments were also studied. Results and Conclusion: Neurogenic cholinergic contractions of human preparations were unaffected by morphine (1, 2 or 10 µmol/l). Longitudinal contractions of the guinea pig ileum were concentration-dependently suppressed by morphine (0.1–10 µmol/l). It is concluded that myenteric neurons supplying the longitudinal muscle of the human small intestine are much less sensitive to morphine than those of the guinea pig.

Ergonomic evaluation of the scrub nurse's posture at different monitor positions during laparoscopic cholecystectomy.

Objective Our aims were to measure the posture and movement of the scrub nurse very accurately, without using any markers, during a minimally invasive surgical procedure. Summary Background Data One of the most important subjects in ergonomic studies of minimally invasive surgery is the question of the proper placement of monitors. Method Two simultaneous and synchronized video recordings were carried out in 2 different monitor setups. The different steps of the operation were identified and measured in seconds. Longer-lasting postures were imported to and analyzed with a software. Results of the different setups were compared with each other, and with an “ideal” comfort posture. Results Measuring the typical postures of the most pronounced static phase, the evolving stress was significantly influenced by different monitor setups. Conclusions With the installation of an additional monitor positioned to satisfy the nurses comfort, the static stress could be decreased.

Ganglioneuroma in the papilla of Vater with neurofibromatosis type 1: report of a case.

Ganglioneuromas (GNs) are rare benign tumors and their association with neurofibromatosis type 1 (NF-1) is especially uncommon. We report in this article the case of a young woman, subjected to diagnostic work-up because of abdominal pain. Endoscopy and histology revealed not only a GN in the papilla of Vater, but also NF-1. Because of the size and macroscopic features of the lesion, we performed pancreatoduodenectomy, from which she recovered uneventfully. Histological examination of the resected tumor confirmed a diagnosis of GN.

Resection or bypass in the treatment of corrosive oesophageal strictures? Malignant transformation as a late complication in both methods

SummaryBackgroundDuring the surgical treatment of corrosive oesophageal strictures, one of the most important decisions to make is, whether the injured and scarred oesophagus should be removed or bypassed. Resectional approach is justified by the high frequency of scar cancer developing in the injured oesophagus. On the other hand, according to advocators of bypass surgery, the risk of malignant transformation in the oesophagus excluded from the food passage is negligible, when bypass is performed within few years of injury. There are very few data on the risk of cancer in the remaining oesophagus following resection, and in the replacement organ in case of bypass.Case reportOn three cases—one skin tube cancer in the replacement organ 21 years following injury, one colon cancer in the replacing colon 44 years following injury and one oesophageal scar cancer in the remnant oesophagus 28 years following injury—three different types of late malignisation in the remaining oesophagus as well as in different organs used for oesophageal replacement are demonstrated.ResultsMalignant transformation is rarely but equally occurs in the remnant oesophagus following caustic injury and in the different organs used for replacement.ConclusionIn this debate, there are more controversies than consensus.

Gastroesophageal Reflux Disease Might Induce Certain—Supposedly Adaptive—Changes in the Esophagus: A Hypothesis

BackgroundThe increasing prevalence of GERD has become a major concern due to its major health and economic impacts. Beyond the typical unpleasant symptoms, reflux can also be the source of severe, potentially life-threatening complications, such as aspiration.AimOur aim was to support our hypothesis that the human body may in some cases develop various protective mechanisms to prevent these conditions.MethodsBased on our experiences and review of the literature, we investigated the potential adaptive nature of seven reflux complications (hypertensive lower esophageal sphincter, achalasia, hypertensive upper esophageal sphincter, Zenker’s diverticulum, Schatzki’s ring, esophageal web, and Barrett’s esophagus).ResultsPatients with progressive GERD may develop diverse structural and functional esophageal changes that narrow the lumen of the esophagus and therefore reduce the risk of regurgitation and protect the upper aerodigestive tract from aspiration. The functional changes (hypertensive lower esophageal sphincter, achalasia, hypertensive upper esophageal sphincter) seem to be adaptive reactions aimed at easing the unpleasant symptoms and reducing acid regurgitation. The structural changes (Schatzki’s ring, esophageal web) result in very similar outcomes, but we consider these are rather secondary consequences and not real adaptive mechanisms. Barrett’s esophagus is a special form of adaptive protection. In these cases, patients report significant relief of their previous heartburn as Barrett’s esophagus develops because of the replacement of the normal squamous epithelium of the esophagus by acid-resistant metaplastic epithelium.ConclusionWe believe that GERD may induce different self-protective reactions in the esophagus that result in reduced acid regurgitation or decreased reflux symptoms.

Possible Predictive Markers of Response to Therapy in Esophageal Squamous Cell Cancer

The aim of the present study was to investigate the relationship between the intensity of biomarker expression and the response to radiochemotherapy in patients with advanced esophageal squamous cell cancer (ESCC). Ninety-two patients with locally advanced ESCC were examined retrospectively. Pre-treatment tumor samples were stained for proteins SOUL, Hsp 16.2, Growth Hormone-Releasing Hormone Receptor (GHRH-R) and p-Akt using immunhistochemistry methods. Kaplan-Meier curves were used to show the relationship between intensity of expression of biomarkers and clinical parameters and 3-year OS. A significant correlation was found between high intensity staining for Hsp 16.2, p-Akt and SOUL and poor response to NRCT. Application of a higher dose of radiation and higher dose of cisplatin resulted in better clinical and histopathological responses, respectively. Among the clinical parameters, the localization of the tumor in the upper-third of the esophagus and less than 10% weight loss were independent prognostic factors for increased 3-year OS. Hsp16.2, p-Akt and SOUL are predictors of negative response to NRCT, therefore these biomarkers may become promising targets for therapy. Furthermore, level of expression of p-Akt, weight loss and the localization of the tumor are significant factors in the prediction of OS in ESCC.