Current problems in the surgical management of rectal cancer.

BACKGROUND/AIMS: Three issues associated with surgical treatment of rectal cancer are discussed in the present study. Necessity of standardisation of preoperative irradiation, based on interdisciplinary consensus is considered. The most urgent task is increasing the proportion of sphincter saving resections carried out by total mesorectal excision as related to the number of rectal exstirpations. The principles of surgical therapy of hepatic metastases of colorectal cancers are discussed. METHODOLOGY: The experience gathered from 328 radical resections performed during the years 1999-2002 is summed up. RESULTS: Three periods are compared; they managed to raise the proportion of surgical interventions preserving the rectal sphincter over 60%, during the last period the results have even further been improved. Total mesorectal excision performed by an atraumatic technique has been introduced and applied in their department. The rate of morbidity--28.8, 18.6 nd 5.3% for suture insufficiency--has been reduced. During the last eight years segment oriented liver resection indicated by the presence of hepatic metastasis has been performed in 20 instances. CONCLUSIONS: In addition to preoperative irradiation considered as necessary, the authors recommend treatment consisting of 5 x 5 Gy for early cancer, and of 60 Gy/6 weeks for advanced stages. In their opinion, application of atraumatic surgical techniques and up-to-date circular sewing machines can increase the proportion of sphincter preserving interventions securing the patient a better quality of life without abandoning the priciples of radicality. In their hope, the use of total mesorectal excision carried out adequately may reduce morbidity (suture insufficiency and nerve lesions--impaired innervation and sexual dysfunction) and the rate of local relapses and may improve survival. The only curative treatment of hepatic metastases of colorectal cancers is resection; therefore the authors raise the possibility of enlarging the range of surgical indications - more than three metastases in one lobe, bilateral affection.

[A rare localisation of ectopic pregnancy--a case of hepatic pregnancy]. / Ritka lokalizációjú méhen kívüli terhesség--májterhesség esete.

Ectopic pregnancy is a major gynecologic emergency, and remains a life-threatening syndrome. Hepatic pregnancy is an exceptionally rare form of ectopic pregnancy. The authors present a case of a 28 year old woman, who was admitted to hospital with epigastric pain. Diagnostic investigations showed a rare, 16-week-old ectopic pregnancy in the liver. The authors emphasise the importance of early diagnosis and management of ectopic pregnancy in order to reduce maternal mortality.

[Surgical aspects of breast cancer screening at our hospital]. / Az emloszures sebszeti vonatkozásai kórházunkban.

In addition to discussing effectiveness of breast cancer screening initiated within the National Public Health Programme, the problem of how to treat non-palpable, early invasive and in situ breast cancer (DCIS) is considered. The theoretical issue of the sentinel lymph node and its impact on biopsy practice have also been dealt with. In the authors' region, screening was introduced in 1999 and after a short break has been continued since 2002. Patient data of three periods, each of two years, each with ten years' interval (1982-1983, 1992-1993, 2002-2003) have been analysed. Changes in the number of surgical operations and tumour size, incidence of in situ cancer, lymph node involvement and distribution of types of surgery have been studied. Biopsy of the sentinel lymph node has been applied since May, 2003 (with 45 biopsies performed until 31 December, 2004). The number of persons participating in the screening programme has gradually increased, the number of surgical operations because of breast cancer increased from period to period. Size of the detected tumours has decreased, the percentage of non-palpable cases has been significant (445 surgical interventions during the years 2002-2004: surgery: 19%). The proportion of DCIS has increased to nearly four times as compared to data of years immediately preceding the era of screening (1993-1998: 11 cases, 2%; 1999-2004: 62 cases, 7.5%). Specificity of sentinel lymph node biopsy was 90%, with a sensitivity of 65%. The proportion of breast saving surgery has increased above 50%. The authors regard screening as successful, in their opinion, its benefits cannot be questioned, in spite of some controversial issues. As to the treatment of non-palpable, early invasive cancer, they underline the importance of preoperative evaluation--cytology, core biopsy--and establishing dignity. The issues of localisation--wire hook marking--and histological processing--large blocks--have also been dealt with. In spite of the fact that the risk for potential malignancy of DCIS lesions has not yet been fully clarified, adequate treatment is indicated; the authors take stand on the issues of indication for surgery, postoperative radiotherapy and use of Tamoxifen. Indications and contraindications of sentinel lymph node biopsy have been summed up.

[Current issues in the surgical treatment of rectal cancer]. / Aktuális kérdések a rectum carcinoma sebészeti kezelésével kapcsolatban.

INTRODUCTION: Three topics associated with surgical treatment of rectal cancer are discussed. The need for standard preoperative irradiation, based on interdisciplinary approach is considered. In the authors' opinion the most urgent task is to increase the number of sphincter saving resections carried out by total mesorectal excision. The principles of surgical therapy for hepatic metastases are discussed. METHODS: The authors' experience is based on 328 radical resections performed between 1992-2003. RESULTS: Three periods are compared: we managed to raise the ratio of surgical interventions preserving the rectal sphincter over 60%, and during the last period the results have further improved. Total mesorectal excision is the standard in the department. The morbidity rate--28.8%, 18.6% and 5.3% for suture leak is reduced. During the last eight years in the presence of hepatic metastasis in 20 liver resections were performed. CONCLUSIONS: In addition to preoperative irradiation considered we recommend treatment consisting of 5x5 Gy for early cancer, and of 60 Gy/6 weeks for a progressed stage. In our opinion, application of atraumatic surgical techniques and up to date circular stapling guns can increase the ratio of sphincter preserving interventions. We hope, the use of total mesorectal excision carried out adequately may reduce morbidity (suture leak, nerve damage--impaired innervation and sexual dysfunction) and the rate of local recurrence and it may improve survival. The only curative treatment of hepatic metastases in colorectal cancers is resection, therefore the authors suggest the possibility of widening the range of surgical indications--more than three metastases in one lobe, even in bilateral involvement.