Current concepts in the anatomy and origin of pharyngeal diverticula.

The role of this paper is to present the current concepts in anatomy and etiopathogenesis of pharyngeal diverticula. Precise anatomical considerations highly emphasizing the weak anatomic areas which predispose the pouch formation are discussed. Focus exposed in details will also be given upon the structural and functional characteristics of the upper esophageal sphincter as well as to its physiological states, architecture and dynamic functions. A brief review of historical and current perspectives regarding the origin of pharyngeal diverticula has also been given. Special attention is given to the abnormal cricopharyngeal function in patients with pharyngeal pouches in the terms of altered UES compliance, importance of gastroesophageal reflux and histopathologic changes of cricopharyngeal muscle.

[Solving of complications arising during and after application self-expandible metallic stents in palliation of malignant dysphagia].

INTRODUCTION: During palliative treatment of malignant disphagia in inoperabile patients various and serious complications may occur and compromite the method of treatment if there were not solved. AIM: Goal is to present the most frequent complications due to esophageal stenting and the way of their solving. MATERIALS AND METHOD: From 1996. to 2009. in 237 patients (164 esophageal carcinoma, 33 carcinoma of the esophagogastric junction, 14 bronchial carcinoma, 7 esophagojejunal anastomosis, 9 esophageal fistulas) 245 stents have been placed (54 uncovered and 191 covered). Mean survival period was 14.7 months (ranged from 1 do 33 months). Esophageal perforation (1), stent migration (9), malignant tissue ingrowth (31) and overgrowth (24) have been revealed by barium contrast study during follow up. Perforation was solved by placing covered stent, migration by removing migrated stent endoscopically or surgically, ingrowth and overgrowth by balon dilating or restenting under the fluoroscopically guidance and control. CONCLUSION: One can expect and recognize complications regarding esophageal stenting because it is the only way for their sucsessfull treatment.

Bimonthly 24 h infusion of high-dose 5-fluorouracil vs EAP regimen in patients with advanced gastric cancer. A randomized phase II study.

BACKGROUND: To investigate the activity and toxicity of high dose (HD) infusional 5-FU in comparison to EAP regimen as first-line chemotherapy in patients with advanced gastric cancer. PATIENTS AND METHODS: Histologically confirmed measurable advanced gastric cancer, age < 72 yr, ECOG performance status 0-2, no prior chemo- and radiotherapy, adequate organ functions. TREATMENT: EAP arm: doxorubicin (40 mg/m(2)), etoposide (360 mg/m(2)), and cisplatin (80 mg/m(2)) every 28 d; HD 5-FU arm: 5-FU 2.6 g/m(2) 24 h infusion, biweekly. RESULTS: Sixty patients were randomized. Patient characteristics (arms EAP/HD 5-FU): Median age 57/55 yr, median PS 1/1, LAD (patients) 3/8, M1 (patients) 27/22. Median number of cycles (range): EAP arm 4 (2-8), HD 5-FU arm 2 (1-8). Worst toxicity per cycle (grade 3 and 4 in%): Neutropenia 20/3, thrombocytopenia 9/0, anemia 9/13, diarrhea 3/10, nausea 17/7, vomiting 10/0 for EAP and HD 5-FU arms, respectively. All patients were eligible for response in both arms. Confirmed response rate (95%CI): EAP arm 34% [16-50%]/HD 5-FU arm 10% (0-21%), no change: 46/40%, progression of disease: 20/50, respectively. Overall survival (range): EAP arm A 7 mo [3-27], HD 5-FU arm 6 mo (4-25). CONCLUSIONS: Infusional HD 5-FU showed a low incidence of severe toxicity. But given the low efficacy of 5-FU in the dosage we applied in the study, it cannot be recommended as a single treatment for further studies. Assessment of higher dose intensity and/or dose density of 5-FU, with introduction of other active drugs in combination, could be an option for further studies.

Colon interposition in the treatment of esophageal caustic strictures: 40 years of experience.

The objective of this article was to analyze 40 years of experience of colon interposition in the surgical treatment of caustic esophageal strictures from the standpoints of our long-term personal experience. Colon interposition has proved to be the most suitable type of reconstruction for esophageal corrosive strictures. The choice of colon graft is based on the pattern of blood supply, while the type of anastomosis is determined by the stricture level and the part of colon used for reconstruction. In the period between 1964 and 2004, colon interposition was performed in 336 patients with a corrosively scared esophagus, using the left colon in 76.78% of the patients. In 87.5% a colon interposition was performed, while in the remaining patients an additional esophagectomy with colon interposition had to be done. Hypopharyngeal strictures were present in 24.10% of the patients. Long-term follow-up results were obtained in the period between 1 to up to 30 years. Early postoperative complications occurred in 26.48% of patients, among which anastomosic leakage was the most common. The operative mortality rate was 4.16% and late postoperative complications were present in 13.99% of the patients. A long-term follow up obtained in 84.82% of the patients found excellent functional results in 75.89% of them. We conclude that a colon graft is an excellent esophageal substitute for patients with esophageal corrosive strictures, and when used by experienced surgical teams it provides a low rate of postoperative morbidity and mortality, and long-term good and functional quality of life.

[Surgical perspectives in treatment of bleeding peptic ulcers].

Peptic ulcer bleeding has overall incidence of 50 to 150 on 100.000 grown-ups per year and represents cause for over 1% of all urgent hospitalization today. Despite of the evolution of the endoscopic diagnostics and haemostasis, improved intensive care and surgical treatment, overall mortality is still over 10% (operative treatment over 20%), and it almost hasn't changed over past 40 years. For more than 100 years surgery had major role in treatment of peptic bleeding ulcers, whereas nowadays it is limited to treatment of its complications. Adequate surgical treatment demands properly timed operation, safest but appropriate operation and trained surgeon. Early surgery is much better compared to the last minute surgery. At high risk rebleeding ulcer, early delayed surgery appears to be adequate, since the complications and lethal outcome are more frequent in this group.