Gábor Bognár

Predictive factors for response to neoadjuvant therapy in patients with oesophageal cancer

BACKGROUND Preoperative radio-chemotherapy (RCX) was introduced to improve the outcome of patients with oesophageal cancer (EC), but conflicting results have been released. Some 20-30% of patients show a complete pathological response, however, the perioperative morbidity and mortality is increased. To search for factors indicating response prior to the onset of RCX we investigated the proliferative activity (MIB-1), the expression of vascular endothelial growth factor (VEGF), and the capillary density (CD34) in samples of EC obtained by endoscopy prior to the start of the treatment. METHODS Forty-six (MIB-1) and 21 (VEGF, CD34) tissue specimens of ECs were available from 56 patients undergoing pretherapeutic endoscopy, RCX and surgery. Perioperative morbidity was divided into surgery and non-surgery related morbidity. MIB-1, VEGF and CD34 expression were investigated immunohistochemically. Multivariate analysis was carried out to prove independence of investigated variables. RESULTS Postoperative morbidity was noticed in 54 of 56 operated patients. Eight of 56 patients who received RCX died in hospital. Survival was significantly different between the group of complete responders (n=14) and non-responders (n=23; P=0.0026). None of the investigated tumour samples from patients with a complete response (CR) had a proliferation index of less than 45. Tumour samples from patients with a CR showed a VEGF expression of 10.7 compared with 36.58 of tumours with no response (P=0.035). CD34 expression showed a correlation with VEGF expression. The relation of mean indices of VEGF expression and proliferative activity in tumours from patients with complete, partial or no response was 10.7:58.8, 18.3:53.8 and 36.6:43.5, respectively. CONCLUSIONS According to these results, it may be expected that tumours with a VEGF/MIB-1 ratio of 1:6 or less prior to RCX will respond to this therapy.

Secondary iliac-enteric fistula to the sigmoid colon complicated with entero-grafto-cutaneous fistula.

We report the case of a 67-year-old man who was admitted to our department with acute rectal bleeding. The patient had had previous aortoiliac surgery with the utilization of an aortobifemoral vascular prosthesis. Diagnosis of aortoenteric fistula was made between the distal suture line of the right graft leg and the sigmoid colon. This fistula had an enterocutaneous component. After exploratory laparotomy, primary resection of the sigmoid colon, exstirpation of the enterocutaneous fistula, excision of the right graft leg and extraanatomical crossover bypass were successfully performed. This study reports a rare type of aorto/ilac-enteric fistula to the left colon complicated with an entero-grafto-cutaneous component and describes an unusual and successful surgical treatment method.

Detection of Human Papillomavirus Type 16 in Squamous Cell Carcinoma of the Colon and Its Lymph Node Metastases with PCR and Southern Blot Hybridization

The etiological role of human papillomavirus (HPV) in a number of squamous malignant tumors is well known. Squamous cell carcinoma (SCC) of colon is a rare disease with uncertain etiology. Our objective was to detect possible HPV infection in a colon SCC patient. The 94-year-old female patient was operated due to colon tumor causing passage disturbances. Histology confirmed SCC. Tumor tissue and the removed lymph nodes were examined with polymerase chain reaction and Southern blot hybridization techniques. Of HPV types most often occurring in malignant tumors (16, 18) the presence of HPV type 16 could be confirmed in the primary tumor and in four out of the nine surrounding lymph nodes, of which two were metastatic. HPV-16 infection could be detected in an SCC patient in the primary tumor and in surrounding lymph nodes. According to our knowledge, no similar study has been published yet.

Parastomalis sérvek megelőzése és megoldása: a háromdimenziós hálókkal szerzett eddigi tapasztalataink

INTRODUCTION Albeit there is decreasing tendency nowadays for stoma construction, if it still happens, parastomal herniation might occur in up to 50% of cases afterwards. One third of the cases requires surgical correction, not rarely as an emergency. The different methods of repair can be quite demanding and the complication rates are high. From 2003 we have started to use specially designed 3-dimensional meshes for the prevention and repair of parastomal hernias. METHODS From 1st of January 2012 to 1st of June 2016 we have used these devices within the framework of a prospective, controlled, randomized study enrolling the patients in preventive and repair arms. Until now mesh was implanted for prevention at the time of the index operation in 38 cases, (control group: 46 cases), and for repair in 14 cases (control group: 18 cases). Recruitment of the patients will end in 2017. The operations were performed by laparoscopic approach in 22 cases and by open approach in 62 cases in the preventive arm, and 6/26 cases in the repair arm respectively. Mean follow up period is 19.2 months in the mesh group and 22.6 months in the non mesh group in the preventive arm, and 25.9/20.4 months in the repair arm respectively. RESULTS No statistical analysis was used to interpret these interim results in this paper, we intend to analyze our results at the end of the study. At this stage apparently there is no difference between the group of patients in terms of complications in both arms. Parastomal herniation was found in 18 cases (39.1%) in the non mesh group and in 3 cases (7.8%) in the mesh group in the preventive arm. Recurrency was noted in 8 cases (44%) in the non mesh group, and in 1 case (7.1%) in the mesh group in the repair arm. CONCLUSIONS Our results correlate with other studies where mesh insertion was used to prevent and/or repair parastomal hernias. We attribute these results mainly to the special, 3-dimensional design of the meshes used by us. This construction was developed based on understanding the patomechanism of parastomal hernia formation.Absztrakt Bevezetes: Bar a stomakepző műtetek szama napjainkban egyre csokken, azonban amennyiben valamilyen oknal fogva megis erre kenyszerulunk, akkor akar 50%-ot elerő gyakorisaggal szamolhatunk parastomalis serv kialakulasaval. Az esetek mintegy harmadaban ezek műteti korrekciora szorulnak, gyakran surgősseggel, ugyeleti korulmenyek kozott. Az alkalmazott műtettipusok nem egysegesek es a nemritkan nagy kihivast jelentő eljarasok komplikaciorataja magas. Osztalyunkon 2003 ota alkalmazunk specialis haromdimenzios halokat a parastomalis servek megelőzesere es megoldasara. Betegek es modszerek: 2012. januar 1-jetől 2016. junius 1-jeig prospektiv, kontrollalt, randomizalt vizsgalat kereteben abdominoperinealis exstirpatioval egyidejűleg 38 esetben vegeztunk preventiv halobeultetest, illetve 14 esetben mar meglevő parastomalis servet korrigaltunk halobeultetessel. A kontrollcsoportokban eddig 46, illetve 18 beteg szerepel a preventiv, illetve rekonstrukcios agon. A bevonast 2017-ig vegezzuk. A preventiv cso...

Két műtéti technika elemzése laparoscopos splenectomiák kapcsán

INTRODUCTION Laparosocopic splenectomy gradually became the gold standard procedure in the surgical treatment of certain haematological disorders. Operative experience in laparoscopic procedures facilitates the comparison of various techniques. AIM Two variants in laparoscopic spelenectomy are analysed and presented. MATERIAL AND METHOD Sixteen patients underwent laparoscopic spelenectomy. Anterior- and postero-anterior laparoscopic approaches are compared with respect to clinicopathologic features. CONCLUSIONS Using the postero-anterior technique dissection of splenic hilum is more straightforward, recognition of accessory spleen is easier and the likelihood of intraoperative complications is less. In selected cases of splenomegaly the anterior technique is recommended though.

Kizárt combsérv klinikai képét mutató recidív retroperitonealis liposarcomar

56-year-old man was admitted to our hospital 18 month after extirpation of retroperitoneal liposarcoma. We diagnosed recurrent tumor in the inguinal fossa. The tumor situated along the femoral artery and propagated to the thigh among the muscles, mimicking incarcerated femoral hernia. We performed resection with synchronous abdominal and femoral exploration. By our knowledge this is the first case report about recurrent retroperitoneal liposarcoma presenting as an incarcerated femoral hernia.

A Wilkie-syndromárólr

Loss of retroperitoneal fatty tissue as a result of a variety of debilitating conditions and noxa is believed to be the etiologic factor of superior mesenteric artery syndrome. A case of a 35 years old female patient with severe malnutrition and weight loss is presented, who developed superior mesenteric artery syndrome. Various theories of etiology, clinical course and treatment options of this uncommon disease are discussed. In our case, conservative management was inefficient, while surgical treatment aiming to bypass the obstruction by an anastomosis between the jejunum and the proximal duodenum (duodenojejunostomy) was successful. An interdisciplinary teamwork provides the most beneficial diagnostic and therapeutic result in this often underestimated disease.

Poupart-szalag rekonstrukciója autológ fascia lata lebennyel. Az első ismertetett hazai eset

INTRODUCTION A technique of reconstructing the inguinal ligament using pedicled fascia lata flap is described. PRESENTATION OF CASE A 66-year-old woman was referred with massive incarcerated left inguinal hernia, following acute surgery on a femoral vein leasion and numerous attempts at repair and subsequent recurrences. There was complete absence of the left inguinal ligament. The inguinal ligament was reconstructed using a strip of fascia lata, pedicled on the anterior superior iliac spine. This was transposed to cover the external iliac vessels, and sutured to the pubic tubercle. The musculoaponeurotic abdominal wall was reconstructed with 15×13 cm sheet of polypropylene mesh, placed preperitoneal and sutured to the remaining abdominal wall muscles and to the neo-Pouoart ligament. DISCUSSION Complete destruction of the inguinal ligament is rare but can occur following multiple operative procedures or trauma. Published reports of inguinal ligament reconstruction have been performed using synthetic mesh. The use of autologous tissue should reduce the risk of erosion into the neurovascular bundle, seroma formation, and enhance integration into surrounding tissues. CONCLUSION This new technique for autologous reconstruction of the inguinal ligament provides a safe alternative to the use of synthetic mesh in the operative armamentarium of plastic and general surgeons. This is the first reported case in Hungary.

Azonnali emlőrekonstrukció endoszkóposan asszisztált latissimus dorsi izomlebennyel

The results obtaining with breast reconstruction surgery are not always satisfactory for the patients. Reconstruction with pure latissimus dorsi flap is useful option and due to endoscopic harvest large scar on the back can be avoided. The skin sparing mastectomy and even the sentinel lymph node biopsy or lymphadenectomy can be performed using a single incision in the axilla. Also the immediate reconstruction with endoscopically assisted harvest of the latissimus dorsi muscle flap in selective cases can be done using the same incision. The patient reported high satisfaction with the aesthetic and functional results due to preservation the breast shape and the absence of any scarring on the back.The results obtaining with breast reconstruction surgery are not always satisfactory for the patients. Reconstruction with pure latissimus dorsi flap is useful option and due to endoscopic harvest large scar on the back can be avoided. The skin sparing mastectomy and even the sentinel lymph node biopsy or lymphadenectomy can be performed using a single incision in the axilla. Also the immediate reconstruction with endoscopically assisted harvest of the latissimus dorsi muscle flap in selective cases can be done using the same incision. The patient reported high satisfaction with the aesthetic and functional results due to preservation the breast shape and the absence of any scarring on the back.

Minimálisan invazív oesophagusreszekció nyaki anastomosissal (McKeown-műtét). Tapasztalataink 20 eset kapcsán

Absztrakt Celkitűzes: A nyelőcső-reszekcio tobbnyire rossz allapotu betegeken vegzett, ket testureget megnyito műtet, ennek megfelelően magas mortalitasi es morbiditasi adatokkal. Ennek javitasa erdekeben kerultek bevezetesre a kisebb megterhelest jelentő, minimalisan invaziv modon vegzett beavatkozasok. A torakoszkoposan es laparoszkoposan vegzett McKeown-műtet kozvetlen posztoperativ szakra kifejtett hatasat tanulmanyoztuk 20 esetunk kapcsan, tovabba kozlesre kerul az altalunk alkalmazott műteti technika. Betegek es modszer: Osztalyunkon az elmult negy evben 20 torakoszkopos oesophagusreszekciot vegeztunk laparoszkopos gyomorcsovesitessel es nyaki anastomosissal. Egy beteg strictura, a masik 19 carcinoma miatt kerult műtetre, kozuluk 11 volt T4 stadiumu. 17 betegnel tortent neoadjuvans kemoradioterapia előrehaladott stadium miatt. A rendszeres kontrollvizsgalatokat az onkologiai ambulancia vegezte. Eredmenyek: Atlagosan 25 honapos kovetesi idő utan nyolc betegunk van eletben, kozuluk kettő all kezeles a...OBJECTIVE Esophageal resection is a traumatic intervention usually performed on patients with poor condition, resulting high mortality and morbidity. To improve the high incidence of complications, minimal invasive interventions were introduced. The results of the thoracoscopically and laparoscopically performed esophageal resection (McKeown) was investigated after 20 cases and the technical details of the surgical intervention are presented. PATIENTS AND METHOD 20 thoracoscopic esophageal resection with laparoscopic gastric tube formation (sec. Akiyama) preparing the esophago-gastric anastomosis on the neck were performed in our department in the last four years. 1 patient with stricture and the other 19 patients with esophageal cancer were operated on, among them11 had T4 stage. 17 patient received neoadjuvant chemo-radiotherapy because of advanced disease. Regular follow up examinations were performed in the oncological outpatient department. RESULTS 8 patients are alive after a mean follow up period of 25 months, 2 of them are treated oncologically because of recurrent disease. 19 patients were extubated within 12 hours after the intervention and the time spent in the intensive care unit were reduced to 1 or 2 days. The mean duration of the intervention was 320 minutes. Thoracoscopic dissection was performed in 8 patients without ventilation of the right lung using double lumen tracheal tube, among them 3 patients developed pneumonia in the postoperative period. The remaining 12 patients were operated with ventilated right lung, among them one patient developed pneumonia. One patient was converted because of injury of the thoracic aorta, after urgent thoracotomy we managed to suture the aortic wall. 1 patient died in 30 days after the operation, caused by leakage of the anastomosis, resulting mediastinitis and esophago-tracheal fistula. In two patients re-thoracoscopy and ligation of the thoracic duct was performed because of chylothorax refractory for conservative treatment. CONCLUSIONS According to our observation the minimal invasive esophageal resection resulted in comparable oncological results with relevant reduction of mortality and morbidity compared to the open procedure. After procedures performed with ventilated lung further reduction of pulmonary complication was found. In case of tumors infiltrating the tracheal or the aortic wall, thoracotomy should be considered to explore the thoracic cavity and to carry out the dissection, if it is possible. Our results should be reinforced because of low number of patients.