Örs Péter Horváth

Late malignant transformation of chronic corrosive oesophageal strictures.

ZusammenfassungDie Zahl der Patienten mit Narbencarcinomen des Oesophagus, die durch verätzungsbedingte Strikturen entstanden sind, scheint in den letzten beiden Jahrzehnten angestiegen zu sein. 36 Patienten mit dieser Erkrankung wurden zwischen 1965 und 1984 chirurgisch behandelt; dies ist die zweitgrößte Fallzahl, die in der Literatur bisher beschrieben wurde. Patienten mit Narbencarcinomen machen 7,2% der Gesamtzahl an Oesophaguscarcinomen aus; dieses Verhältnis ist zur Zeit das höchste in der Literatur. Das Intervall zwischen der Verätzung und der Diagnosestellung eines Narbencarcinoms beträgt 46,1 Jahre; es liegt damit höher als die bisher allgemein angenommenen 30–35 Jahre. Das Intervall beträgt 50,9 Jahre bei den Patienten, die vor ihrem 12. Lebensjahr Lauge getrunken hatten, ist aber um 14 Jahre kürzer, wenn die Verätzung im Erwachsenenalter stattgefunden hatte. Die Langzeit-Überlebensrate erwies sich als ausgezeichnet: 45,6% der resezierten Fälle waren nach 5 Jahren noch am Leben, 14,4% nach 10 Jahren. Die Erklärung für die gute Prognose liegt darin, daß das Carcinom, welches sich in einer Laugenstriktur entwickelt, zunächst von einer rigiden Narbe ummauert ist, welche nur die intraluminale Ausbreitung erlaubt, wobei durch die Einengung des Lumens eine frühe Dysphagie hervorgerufen wird. Eine frühzeitige Dissemination wird aus dem gleichen Grunde verhindert. Bei kurativen Eingriffen wird die einseitige Resektion und der Ersatz vorgeschlagen. Patienten mit einer operationsbedürftigen Oesophagusverätzungsstriktur können sowohl durch eine Bypassoperation als auch Resektion behandelt werden, es muß aber darauf hingewiesen werden, daß sogar noch Jahre nach der Operation eine Malignitätsentwicklung im zurückbleibenden Teil der Speiseröhre möglich ist. Die totale Oesophagektomie wird daher an Stelle des Bypassverfahrens vorgeschlagen.SummaryThe number of patients with scar carcinoma of the oesophagus developing on the basis of a corrosive stricture seems to have been rising in the past two decades. 36 patients of this kind were treated surgically between 1965 and 1984; this is the second largest series in the literature. The patients with scar cancer comprised 7.2% of the overall oesophageal carcinoma cases; this ratio is currently the highest of all in the literature. The interval between the caustic burn and the diagnosis of scar carcinoma was found to be 46.1 years; this is higher than the 30–35 years generally accepted so far. It was 50.9 years in those patients who drank lye before the age of 12, but 14 years less when it happened in adulthood. The long-term survival time proved to be excellent: 45.6% of the resected cases were alive after 5 years and 14.4% after 10 years. The explanation of the good prognosis lies in the fact that carcinoma developing in a lye stricture is at first surrounded by a rigid scar which allows only its intraluminal growth, and it causes early dysphagia through luminal obstruction. Early dissemination is prevented for the same reason. One-stage resection and replacement is suggested in the radically operable cases. In patients with oesophageal corrosive stricture which needs operation, both a by-pass procedure and resection can be adopted, but it should be pointed out that malignancy may develop even years after the operation in the remaining part of the gullet. Total oesophagectomy is therefore suggested instead of bypass.The number of patients with scar carcinoma of the oesophagus developing on the basis of a corrosive stricture seems to be rising in the past decades. Thirty six patients with this condition were treated surgically in a 20 years period; this is the second largest series in the literature. Patients with scar cancer were 7.2% of all oesophageal carcinoma cases; this ratio is currently the highest of all in the literature. The interval between the burn and the diagnosis of scar carcinoma was 46.1% years; this is higher than the 30-35 years generally described so far. It was 50.9 years in those patients who drank lye before the age of 12, but 14 years less when it happened in adulthood. The long-term survival was excellent: 45.6% of the patients after resection were alive after 5 years and 14.4% after 10 years. The explanation of the good prognosis is that carcinoma develops in a lye stricture and is at first surrounded by a rigid scar which allows only intraluminal growth, so it causes early dysphagia through obstruction. Early dissemination is prevented because of the same reason. One-stage resection and reconstruction is the best way to treat the radically operable patients. In patients with esophageal corrosive stricture in need of operation, both a bypass procedure and resection can be performed, but it should be pointed out that malignancy may develop even years after the operation in the remaining part of the gullet. Total esophagectomy is therefore suggested instead of by-pass.

Late malignant transformation of chronic corrosive oesophageal strictures

ZusammenfassungDie Zahl der Patienten mit Narbencarcinomen des Oesophagus, die durch verätzungsbedingte Strikturen entstanden sind, scheint in den letzten beiden Jahrzehnten angestiegen zu sein. 36 Patienten mit dieser Erkrankung wurden zwischen 1965 und 1984 chirurgisch behandelt; dies ist die zweitgrößte Fallzahl, die in der Literatur bisher beschrieben wurde. Patienten mit Narbencarcinomen machen 7,2% der Gesamtzahl an Oesophaguscarcinomen aus; dieses Verhältnis ist zur Zeit das höchste in der Literatur. Das Intervall zwischen der Verätzung und der Diagnosestellung eines Narbencarcinoms beträgt 46,1 Jahre; es liegt damit höher als die bisher allgemein angenommenen 30–35 Jahre. Das Intervall beträgt 50,9 Jahre bei den Patienten, die vor ihrem 12. Lebensjahr Lauge getrunken hatten, ist aber um 14 Jahre kürzer, wenn die Verätzung im Erwachsenenalter stattgefunden hatte. Die Langzeit-Überlebensrate erwies sich als ausgezeichnet: 45,6% der resezierten Fälle waren nach 5 Jahren noch am Leben, 14,4% nach 10 Jahren. Die Erklärung für die gute Prognose liegt darin, daß das Carcinom, welches sich in einer Laugenstriktur entwickelt, zunächst von einer rigiden Narbe ummauert ist, welche nur die intraluminale Ausbreitung erlaubt, wobei durch die Einengung des Lumens eine frühe Dysphagie hervorgerufen wird. Eine frühzeitige Dissemination wird aus dem gleichen Grunde verhindert. Bei kurativen Eingriffen wird die einseitige Resektion und der Ersatz vorgeschlagen. Patienten mit einer operationsbedürftigen Oesophagusverätzungsstriktur können sowohl durch eine Bypassoperation als auch Resektion behandelt werden, es muß aber darauf hingewiesen werden, daß sogar noch Jahre nach der Operation eine Malignitätsentwicklung im zurückbleibenden Teil der Speiseröhre möglich ist. Die totale Oesophagektomie wird daher an Stelle des Bypassverfahrens vorgeschlagen.SummaryThe number of patients with scar carcinoma of the oesophagus developing on the basis of a corrosive stricture seems to have been rising in the past two decades. 36 patients of this kind were treated surgically between 1965 and 1984; this is the second largest series in the literature. The patients with scar cancer comprised 7.2% of the overall oesophageal carcinoma cases; this ratio is currently the highest of all in the literature. The interval between the caustic burn and the diagnosis of scar carcinoma was found to be 46.1 years; this is higher than the 30–35 years generally accepted so far. It was 50.9 years in those patients who drank lye before the age of 12, but 14 years less when it happened in adulthood. The long-term survival time proved to be excellent: 45.6% of the resected cases were alive after 5 years and 14.4% after 10 years. The explanation of the good prognosis lies in the fact that carcinoma developing in a lye stricture is at first surrounded by a rigid scar which allows only its intraluminal growth, and it causes early dysphagia through luminal obstruction. Early dissemination is prevented for the same reason. One-stage resection and replacement is suggested in the radically operable cases. In patients with oesophageal corrosive stricture which needs operation, both a by-pass procedure and resection can be adopted, but it should be pointed out that malignancy may develop even years after the operation in the remaining part of the gullet. Total oesophagectomy is therefore suggested instead of bypass.The number of patients with scar carcinoma of the oesophagus developing on the basis of a corrosive stricture seems to be rising in the past decades. Thirty six patients with this condition were treated surgically in a 20 years period; this is the second largest series in the literature. Patients with scar cancer were 7.2% of all oesophageal carcinoma cases; this ratio is currently the highest of all in the literature. The interval between the burn and the diagnosis of scar carcinoma was 46.1% years; this is higher than the 30-35 years generally described so far. It was 50.9 years in those patients who drank lye before the age of 12, but 14 years less when it happened in adulthood. The long-term survival was excellent: 45.6% of the patients after resection were alive after 5 years and 14.4% after 10 years. The explanation of the good prognosis is that carcinoma develops in a lye stricture and is at first surrounded by a rigid scar which allows only intraluminal growth, so it causes early dysphagia through obstruction. Early dissemination is prevented because of the same reason. One-stage resection and reconstruction is the best way to treat the radically operable patients. In patients with esophageal corrosive stricture in need of operation, both a bypass procedure and resection can be performed, but it should be pointed out that malignancy may develop even years after the operation in the remaining part of the gullet. Total esophagectomy is therefore suggested instead of by-pass.

Postprandial Gastrointestinal Hormone Production Is Different, Depending on the Type of Reconstruction Following Total Gastrectomy

Objectives:The present study examines the differences in gastrointestinal hormone production at 3 different reconstruction types after total gastrectomy. Background Data:Total gastrectomy causes significant weight loss, mainly due to a reduced caloric intake probably because of a lack of initiative to eat or early satiety during meals. Behind this phenomenon a disturbed gastrointestinal hormone production can be presumed. Methods:Patients participating in a randomized study were recruited for the clinical experiment. Seven patients with simple Roux-en-Y reconstruction, 11 with aboral pouch (AP) construction, and 10 with aboral pouch with preserved duodenal passage (APwPDP) reconstruction, as well as 6 healthy volunteers were examined. Blood samples were taken 5 minutes before and 15, 30, and 60 minutes after ingestion of a liquid test meal. Plasma concentrations for insulin, cholecystokinin, and somatostatin were determined by radioimmunoassay analysis. Results:Postprandial hyperglycemia was observed in patients after total gastrectomy most prominently in groups with duodenal exclusion (Roux-en-Y and AP) compared with healthy controls. Postprandial insulin curves reached significantly higher levels in all operated groups compared with controls, however, with no difference according to reconstruction type. Significantly higher cholecystokinin levels and higher integrated production of cholecystokinin were observed in Roux-en-Y and AP groups compared with APwPDP and control. Postprandial somatostatin levels were significantly different between the 4 groups, and highest levels and integrated secretions were reached in AP group, lowest in APwPDP and normal groups. Conclusion:A disturbed glucose homeostasis was observed in gastrectomized patients most prominently in the Roux-en-Y group. Also, cholecystokinin and somatostatin response differed significantly in favor of duodenal passage preservation after total gastrectomy. Cholecystokinin levels close to physiologic found at APwPDP reconstruction may contribute to a physiologic satiation in reconstructions with preserved duodenal passage after total gastrectomy.

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.

Clinical Experience with Different Techniques of Pancreatic Head Resection for Chronic Pancreatitis

Background/Aims: Recently organ-saving procedures have become popular in the treatment of chronic pancreatitis with head enlargement. The purpose of this study is to compare the results of three different procedures. Methods: Between 1991 and 1998, 32 Beger operations, 13 Frey procedures and 21 pylorus-preserving pancreatoduodenectomies (PPPDs) were performed. The pre-, intra- and postoperative data were detailed. During the follow-up examination the quality of life, body weight, consumption of alcohol and enzymes, as well as the carbohydrate metabolism were checked. Results: Considering the operative and late mortality and reoperation rate, there was no difference between the procedures. The postoperative hospitalization time was the shortest after the duodenum-preserving pancreatic head resections (Beger and Frey). While the rate of early morbidity was higher after PPPDs, there was no difference in late morbidity between the groups. The condition of the patients was better and the development rate of diabetes was lower after the Beger procedure than after PPPDs. Conclusion: Consequently duodenum-preserving pancreatic head resections seem to be more advantageous than PPPD. Nevertheless the latter operation is the only possibility in some situations.

Failure of capsaicin-containing red pepper sauce suspension to induce esophageal motility response in patients with Barrett’s esophagus

UNLABELLED The physiologic importance of afferent sensory pathways in the esophageal motor functions has been recently recognised. Capsaicin-sensitive sensory afferents were shown to play a role in the maintenance of mucosal integrity of the GI tract, and regulation of human esophageal motility. The aim of this study was to investigate the effect of topical application of capsaicin-containing red pepper sauce (Tabasco, 25%v/v, pH:7.0) suspension on the phasic activity of the human esophagus of healthy volunteers and patients with Barretts esophagus. METHODS The diagnosis of Barretts esophagus was based on the findings of esophagoscopy and histology taken from the squamocolumnar junction of the esophagus. Esophageal motility was measured by perfusion manometry before and after application of red pepper sauce. RESULTS Capsaicin containing red pepper sauce increases the motility response (LES tone, contraction amplitude, propagation velocity) of the human esophagus in healthy volunteers. This response failed in patients with Barretts esophagus. CONCLUSION Impaired esophageal sensory motor function may serve as one etiologic role in the development of Barretts esophagus.

Changes and Effect of PACAP-38 on Intestinal Ischemia-Reperfusion and Autotransplantation

Tissue injury caused by cold preservation and reperfusion during small bowel transplantation remains an unsolved problem. Increasing evidence suggests that pituitary adenylate cyclase-activating polypeptide (PACAP) has protective effects in several ischemia-reperfusion (I/R) models. This study investigated the effect of PACAP-38 on oxidative stress in autotransplanted intestine. We established sham-operated, I/R, and autotransplanted groups in Wistar rats (n = 55). We applied ischemia for 1 (GI), 2 (GII), or 3 hours (GIII). In autotransplanted groups, we performed total orthotopic intestinal autotransplantation. Grafts were preserved in University of Wisconsin (UW) solution for 1 (GIV), 2 (GV), 3 (GVI), or 6 (GVII) hours and in PACAP-38-containing UW for 1 (GVIII), 2 (GIX), 3 (GX), or 6 (GXI) hours. Reperfusion lasted 3 hours in each group. Endogenous PACAP-38 values were measured by radioimmunoassay. Oxidative stress parameters malondialdehyde (MDA), reduced glutathione (GSH), and superoxide dismutase (SOD) were measured in tissue homogenates. Concentration of endogenous PACAP-38 significantly decreased in GI to GIII compared with the sham-operated animals following I/R periods (P < .05). Cold preservation in UW and reperfusion of the intestine increased the level of tissue MDA in GIV to GVII, which correlated with the duration of cold storage. The content of GSH decreased in GIV to GVII to levels that were significantly different between GIV and GVIII and between GVII and GXI. SOD activity decreased dramatically in GIV to GVII with significantly higher activity in GIX to GXI. Our findings confirmed that I/R decreased endogenous PACAP-38 concentration. Administration of PACAP-38 to UW solution mitigated the oxidative injury during intestinal autotransplantation.

Pericardioperitoneal shunt: further development of the procedure using vats technique

We report a modification of the previously described VATS (video-assisted thoracic surgical) method of pericardioperitoneal shunt. Our method was used in 5 patients with pericardial tamponade requiring permanent drainage.

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.