György Ledniczky

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.

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.

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.

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.

Aesthetic outcome as a goal using pectoral muscle-strip in recurrent subareolar abscess of the breast and for double subdermal flap in modelling of the inverted nipple

Recurrent subareolar abscess (RSA) is an uncommon benign disorder of the non-lactating young and mid-aged female breast [1]. It was first described by Zuska et al. [2], in 1951, as a chronic inflammation of the sinuses of lactiferous ducts with a clinical spectrum that may manifest as nipple discharge or distortion, recurrent subareolar abscess or mamillary duct fistula [1–3]. Epithelial metaplasia of the lactiferous ductal system is considered as an important etiological factor [4]. Epithelial shreds and debris lead to ductal occlusion, thus to ductectasia and secondary infections and abscess formation. The definitive treatment of chronic peri-ductal mastitis requires radical excision of the abscess along with major ducts and the discharged, distorted central portion of the mammilla and has been described in detail by several authors [3, 5, 6]. Nevertheless, published series described recurrence rate of 9 % [3] and 28 % [5] following such procedures. In some rare cases, when peri-mammillary excisions failed, even mastectomy was performed [3] as a radical outcome. In 2009, Low and Barry [1] published a sally procedure with adaptation of a pectoral major muscle flap. We successfully adapted a modification of that procedure in cases of recurrent peri-ductal mastitis refractory to repeated radical surgeries, ductectomies and courses of steroid and antibiotic treatments: total major duct excision was performed from a peri-areolar incision with central posterior mamillectomy and partial excision of the distorted nipple-areolar complex. Inflammatory debris and necrotic tissue were thoroughly debrided prior to preparation for the ‘‘pectoral-strip’’ flap. The pectoral strip is formed as a flap of the lateral edge of the pectoral muscle with a vascular shaft. A tunnel wide enough to comfortably transmit the flap without undue tension causing vascular compromise was fashioned through the breast tissue, extending from the periareolar skin incision to the cephalad end of the muscle flap. The free edge of the mobilized flap is delivered via the tunnel to the sub-areolar space and sutured under the mamillary and surrounding tissues (Fig. 1). Three months later, the inverted mammilla was reconstructed in local anaesthesia. The nipple was averted with a traction suture and two triangular incisions were made. The flaps were deepithelialized and the pectoral muscle underlying the dermis was prepared creating two muscular-dermal flaps. A tunnel is prepared under the mammilla and the pectoral muscle-dermal flaps on both sides of the inverted nipple are advanced in opposite position beneath the nipple and stitched. A modelled ‘‘donut’’ dressing was applied and continuous traction of the nipple lasted 3 weeks to avoid compression of the nipple and to achieve persistent projection. Recurrent sub-areolar abscess (RSA) is an uncommon breast disease of which the pathogenesis is still largely unknown. Lannin [4] treated 67 cases during 22 years. In an analysis of 58 patients with RSA, Li et al. [3] performed 33 major ductectomies in addition to the central excision of the distorted nipple and reported a recurrence rate of 9 %; however, even two mastectomies were performed for this benign condition. RSA is strictly a benign disorder of the non-lactating young and mid-aged female breast. Smoking is supposed as an important risk factor [7], causing local microvascular ischaemia in the peri-areolar region preventing resolution of localised infection leading to recurrent G. Bognar (&) G. Ledniczky 2nd Surgical Department, Semmelweis University Budapest, Kútvölgyi út 4, 1125 Budapest, Hungary e-mail: bgabor68@gmail.com

Többszörösen kiújult sacralis dermoid definitív megoldása az arteria glutealis inferior direct fasciocutan ágára nyelezett transzpozíciós lebeny alkalmazásával

AIM Treatment of sacral dermoid cysts (SDC) is a surgical challenge. Etiology and adequate operative technique of that are debated widely up to now, and recurrence rates remained high despite various surgical techniques applied. In cases of unsuccessfully operated and repeatedly recurrent SDC a fascio-cutaneous flap on the first perforating branch of the inferior gluteal artery (IGA) is a definitive procedure. MATERIAL AND METHOD Following preparation and dissection of sidebranches of IGA in cadavers, a repeatedly recurrent SDC was operated. CONCLUSION a flap harvested and transferred on the first superficial perforating branch(es) of the inferior gluteal artery offers a definitive and recurrence-free surgical solution for SDC.

Aortoenteralis fistula ritka formája – sigmoideo-grafto-cutan fistular

We report a case of a 62-year-old man who presented to the emergency department with acute rectal bleeding. The patient had previous aortoiliac surgery with the utilization of an aorto-bifemoral vascular graft. Diagnosis of secondary aortoenteric fistula was made between the aortoiliac graft and sigmoid colon. This fistula had an entero-cutaneous component. After exploratory laparotomy resection of the sigma, extirpation of the entero-cutaneous fistula, excision of the graft, oversewing of the aortic stump, and extra-anatomical crossover bypass were successfully performed. This study reports a rare type of secondary aortoenteric fistula to the sigmoid colon complicated with an entero-grafto-cutaneous component and it describes an unusual and successful surgical treatment.

A vascularisatio és a proliferatio prognosztikai szerepe májmetastasist adó rectumcarcinomákbanr

BACKGROUND The present study was designed to provide an analysis of factors for angiogenesis and proliferation. MATERIAL AND METHOD We analyzed tumor tissues from 37 rectal cancer patients with concurrent or subsequent liver metastasis underwent preoperative radiotherapy, surgery and adjuvant chemotherapy. Immunohistochemistry was used for expression of proliferation (staining with anti-Ki67: MIB-1) and for detection of microvessel density (MVD, expressed by CD34). Clinicopathological findings were compared with outcome with emphasis to IHC. RESULTS A vascular enumeration and pN status and the time of presence of the metastases has shown prognostic role along with the factors above. Increased proliferative activity of the tumor as expressed by MIB-1 staining has no prognostic value, similarly to the localization of tumor, gender, age or grading. SUMMARY Different prognostic and predictive factors in colorectal cancer have been reported. Higher pN status and tumor vascularisation has been linked to poor prognosis in overall survival and tumor recurrence.

A posztoperatív mesenterialis panniculitisrol egy sikerrel kezelt eset kapcsán.

Mesenteric panniculitis can develop in every patient after abdominal surgery. The clinical and pathological signs are usually vague, so different therapeutic approaches are recommended at various stages of the disease. While some authors suggest that these stages are different manifestations of the the same disease, others claim that the various stages represent the progression of a single entity. We report a case of a 65 year-old male patient with mesenteric panniculitis and fibrosis, which developed after laparoscopic sigmoid resection first, and required a Hartmanns procedure finally. The disease developed once again after the elective reconstruction of the colon. This time surgical intervention was not possible and he was treated conservatively with intravenous steroids, antibiotics, parenteral nutrition and continuous nasogastric tube. The patient gradually recovered in three weeks time. We report this successful treatment, and review the relevant literature.

A posztoperatív mesenterialis panniculitisről egy sikerrel kezelt eset kapcsánr

Mesenteric panniculitis can develop in every patient after abdominal surgery. The clinical and pathological signs are usually vague, so different therapeutic approaches are recommended at various stages of the disease. While some authors suggest that these stages are different manifestations of the the same disease, others claim that the various stages represent the progression of a single entity. We report a case of a 65 year-old male patient with mesenteric panniculitis and fibrosis, which developed after laparoscopic sigmoid resection first, and required a Hartmanns procedure finally. The disease developed once again after the elective reconstruction of the colon. This time surgical intervention was not possible and he was treated conservatively with intravenous steroids, antibiotics, parenteral nutrition and continuous nasogastric tube. The patient gradually recovered in three weeks time. We report this successful treatment, and review the relevant literature.