László Cseke

Comparison of Quality of Life and Nutritional Parameters After Total Gastrectomy and a New Type of Pouch Construction with Simple Roux-en-Y Reconstruction

The aim of the study was to introduce a new type of gastric substitute, the aboral pouch, after total gastrectomy and to compare nutritional, motility, and quality of life parameters of patients with an aboral pouch to those undergoing simple Roux-en-Y reconstruction in a prospective, randomized, and controlled trial. To date 40 patients have entered the study. In 22 of them the aboral pouch was created; the remaining 18 patients with simple Roux-en-Y reconstruction served as the control group. Laboratory measurements, passage studies, lipid and carbohydrate absorption tests, and quality of life interviews were carried out as follow-up examinations. Preliminary results suggest that the aboral pouch has some advantages over simple Roux-en-Y reconstruction. Serum immunoglobulin M level and the quality of life estimated by the gastrointestinal quality of life index, yielded significantly better results in the pouch group.

Laparoscopic repair of large hiatal hernia with teres ligament: midterm follow-up : A new surgical procedure

BackgroundAlthough laparoscopic repair of large, mostly paraesophageal hiatal hernias is widely applied, there is a great concern regarding the higher recurrence rate associated with this procedure. In order to reduce this high recurrence rate, several techniques have been developed, mostly applying a mesh prosthesis for hiatal reinforcement.MethodsWe have recently introduced a new laparoscopic technique in which the hiatal closure is reinforced with the teres ligament. To date 26 patients have been entered into this ongoing prospective study. After the operation patients were called back on a regular basis for symptom evaluation and barium swallow. All 26 patients agreed to undergo barium swallow, with a mean follow-up of 35 months.ResultsThe mean operative time was 115 min. Perioperative morbidity was 11.5%, and conversion to an open procedure was performed in six cases. No mortality was registered. Anatomic recurrence, investigated by barium swallows was observed in four patients (15.3%). Of those four, only one (3.85%) had a symptomatic recurrent paraesophageal hernia; the other three had asymptomtic sliding hernias. In three of the four patients with anatomic recurrence, the diameter of the hiatal hernia was greater than 9 cm at the original operation, and the fourth patient underwent reoperation for recurrent hiatal hernia. No symptomatic recurrence was found in patients with diameter of hiatal hernia between 6 and 9 cm.ConclusionsLaparoscopic reinforcement of the hiatal closure with the ligamentum teres is safe and effective treatment for large hiatal hernias. However, it appears that patients with extremely large hiatal hernias are at greater risk of recurrence, and therefore large hernias are not suitable for this new technique.

Larynx-preserving pharyngo-esophagectomy after chemoradiation in the treatment of cancer of the pharyngo-esophageal junction

Pharyngo-laryngo-esophagectomy in the treatment of advanced tumors of the pharyngo-esophageal junction is associated with a high morbidity and poor quality of life due to loss of the larynx. Neoadjuvant chemoradiotherapy resulted in a considerable tumor reduction in 6 patients allowing radical tumor resection by larynx-preserving pharyngo-esophagectomy. The operation consisted of total esophagectomy and resection of the posterior pharyngeal wall and reconstruction by a pharyngogastrostomy in 5 patients, and ileocolon interposition in 1 patient.

Aboral Pouch with Preserved Duodenal Passage – New Reconstruction Method after Total Gastrectomy

A new reconstruction method – the aboral pouch with preserved duodenal passage – has been introduced after total gastrectomy. After removal of the stomach, preparation of the Roux loop and construction of the esophago-jejunostomy, a jejuno-duodenostomy is performed approximately 50 cm away from the esophageal anastomosis between the Roux limb and the duodenal stump. Right below this second anastomosis, the Roux limb is closed with a stapling device to provide a unidirectional food passage through the duodenum. The aboral pouch is constructed as a side-to-side anastomosis between the Roux limb under the stapled segment and the aboral end of the Y limb. The advantages of the reservoir-constructing methods and the interposition methods are combined in this new reconstruction type. Our experiences of 17 cases having undergone this reconstruction method are presented.

The NANC relaxation of the human ileal longitudinal and circular muscles is inhibited by MRS 2179, a P2 purinoceptor antagonist

AIMS Functional innervation of the human small intestine may be different from that of experimental animals. These experiments set out to assess the mediating roles of P(2) purinoceptors in the non-adrenergic, non-cholinergic (NANC) relaxation of the human ileum longitudinal and circular muscles. MAIN METHODS In organ bath experiments NANC relaxations were evoked by electrical field stimulation (EFS). The relaxant effects of ATP and sodium nitroprusside were also examined. KEY FINDINGS In the longitudinal muscle, relaxation in response to EFS (2 or 10 Hz for 30 s) or the relaxant effect of exogenous ATP were strongly inhibited or abolished, respectively, by the P(2) purinoceptor antagonist MRS 2179 (10 microM). MRS 2179 had a smaller effect at 3 microM. The NANC relaxation was also inhibited by apamin (3 microM), but not by N(G)-nitro-L-arginine (100 microM), an inhibitor of nitric oxide synthesis. Both apamin (3 microM) and MRS 2179 (3 microM, a concentration below the effective range if administered alone) strongly inhibited the NANC response in preparations pretreated with the nitric oxide synthase inhibitor. NANC relaxations of the circular muscle were also inhibited by MRS 2179 (3-10 microM). SIGNIFICANCE MRS 2179-sensitive P(2) purinoceptors play a mediating role the NANC relaxation in the ileal longitudinal and circular muscle. There seems to be a supra-additive relationship between the purinergic and nitrergic mechanisms in the longitudinal muscle.

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.

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.

Colonnal történt nyelőcsőpótlás után kialakult vastagbél-adenocarcinoma

The authors report the case of a colon adenocarcinoma developed on the neck at the anastomosis of the skin tube and colon 44 years following a corrosive oesophageal injury. This patient suffered a moderately severe oesophageal, stomach and laryngeal injuries due to drinking hydrochloric acid 44 years ago. He underwent serial laryngoplasties, then needed a tracheostomy, oesophagectomy, pyloroplasty and ileocolon transposition. An antethoracal oesophagus formation was performed with ileocolon and skin tube amendment. 44 years later an ulcerated adenocarcinoma developed in the transposed colon, which was resected and the ability to swallow was reinstated by the transplantation of an isolated jejunal segment using microvascular anastomosis.

The role of neoadjuvant therapy in the treatment of locally advanced squamous cell cancer of the cervical oesophagus

INTRODUCTION Cervical oesophagus represents a critical location for squamous cell carcinoma, which usually requires extensive surgery (pharyngo-laryngo-oesophagectomy). In the last decade, neoadjuvant chemo-radiotherapy was reported to be beneficial in the treatment of locally advanced squamous cell oesophageal cancer. METHODS Between November 1997 and January 2012, 55 patients with locally advanced (T3-4) squamous cell oesophageal cancer received preoperative chemo-radiotherapy, where the tumour was localized in the upper third. Patients received preoperative irradiation of 3960 cGy in 180 cGy fractions and simultaneously Cisplatin and 5-FU chemotherapy. Restaging was carried out after four weeks and patients considered operable were underwent surgery. RESULTS In patients with cervical oesophageal cancer 35 of 55 (64%) underwent oesophageal resection or pharyngo-laryngectomy. In 16 out of 35 resected specimens (46%) complete histopathological remission (pCR) was observed. Perioperative mortality and anastomotic leaks were the same: 5/35 (14%). R0 resection rate was 82% and the 2- and 5 years survival rates were 41% and 18%. In 19 cases a larynx preserving pharyngo-oesophagectomy was performed and a free jejunal graft was used for reconstruction after a pharyngo-laryngectomy in 11 cases. CONCLUSION The high rate of pCR (46%) confirmed that upper third oesophageal cancer has superior sensitivity to multimodal treatment. In 30 cases neoadjuvant chemo-radiotherapy was able to achieve tumour regression and render pharyngo-laryngo-oesophagectomy unnecessary.