Micrometastasis of hypopharyngeal cancer.

PURPOSE: The aim of this study is to estimate the incidence and clinical impact of lymph node micrometastases in hypopharyngeal squamous cell cancer (HSCC). MATERIALS AND METHODS: In this retrospective study, we enrolled 58 patients who have undergone surgery for HSCC (between January 2004 and January 2011). Pharyngolaryngectomy and oesophagectomy with selective bilateral neck dissection was performed in all patients. Based on standard histological examination, 17 patients met N0 and 8 patients met N1 criteria and were further evaluated for the presence of micrometastases and isolated tumour cells (ITC). Following immunohistochemical analysis, the patients were grouped according to the presence of micrometastases and ITCs. RESULTS: In the pN0 group, cytokeratin-positive cells were detected in five patients, and they were marked as N0/CK+. Among these five patients, two were found to harbour micrometastases and ITCs, whilst in three, only ITCs were found. Two patients (11.75 %) were upstaged to pN1. The patients marked as N0/CK+ had a statistically significant worse overall survival rates than pN0 patients with tissue samples read as negative for cytokeratin immunostaining (p = 0.019, p < 0.05). In the pN1 group, cytokeratin-positive cells were detected in two patients, with one patient showing micrometastases and ITC, and the other showing ITC only. One patient was upstaged to pN2. CONCLUSION: Patients with lymph node micrometastases and ITC had worse overall survival rates, which may indicate that more aggressive post-operative treatment regimens should be considered for these HSCC patients.

Is there a correlation between molecular markers and response to neoadjuvant chemoradiotherapy in locally advanced squamous cell esophageal cancer?

PURPOSE: To evaluate the expression of epidermal growth factor receptor (EGFR), p53, p21 and thymidylate synthase (TS) in a pretherapy biopsy specimen of locally advanced squamous cell esophageal cancer and correlate these markers with response to neoadjuvant chemoradiotherapy. METHODS: Sixty-two patients with histopathologically proven locally advanced (T3 or greater) squamous cell esophageal cancer were enrolled. The expression of EGRF, p53, p21 and TS markers was assessed with immunohistochemistry. Semiquantitative assessment of expression of these markers was performed based on the percent of the stained cells. Radiotherapy (45-50.4 Gy) was delivered concomitantly with 5-fluorouracil (5-FU)/leucovorin (LV)/cisplatin (CIS) chemotherapy. Five to 6 weeks after chemoradiation, response to treatment was assessed. Medically fit and operable patients were operated. The resected material underwent histopathological evaluation of tumor expansion, histological classification after initial multimodality treatment (yp TNM), residual status and tumor regression grade (TRG). RESULTS: Out of 62 patients enrolled, 41 (66%) were evaluated for molecular markers. Clinical response rate was 43.9%. Out of 41 patients, 12 (29%) underwent surgery. TRG 1 was noted in 58% of the patients. In a pretherapy tumor specimen, positive expression was noted in 80, 90, 80 and 71% for EGFR, p53, p21 and TS, respectively. We noted no statistically significant difference neither between tumor marker expression and clinical response to chemoradiation, nor between tumor marker expression and TRG. CONCLUSION: We registered no difference in response to treatment between EGFR, TS, p21 and p53 positive and negative staining.

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.

The accuracy of ultrasonography in classification of groin hernias according to the criteria of the unified classification system.

BACKGROUND: The modern concept of type-related individualized groin hernia surgery imposes a demand for precise and accurate preoperative determination of the type of groin hernia. The aim of this prospective study was to evaluate the accuracy of ultrasonography in classification of groin hernias, according to the criteria of the unified classification system. Unified classification divides groin hernias into nine types (grades): type I (indirect, small), II (indirect, medium), III (indirect, large), IV (direct, small), V (direct, medium), VI (direct, large), VII (combined-pantaloon), VIII (femoral), and O (other). PATIENTS AND METHODS: One hundred and twenty-five adult patients with clinically diagnosed or suspected groin hernias were examined. Ultrasonography of both groins was performed with a 5 to 10-MHz linear-array transducer. Preoperative ultrasonographic findings of type of groin hernia were compared with the intraoperative findings, which were considered the gold standard. RESULTS: Total accuracy of ultrasonography in determination of type of groin hernia was 96% (119 of 124 correct predictions of type of groin hernia compared with surgical explorations). All hernias of types I, IV, V, VII, and VIII were correctly identified with ultrasonography (sensitivity and specificity 100%). In the remaining five cases of the 124 (4%), hernia was incorrectly classified with ultrasonography: type VI (direct, large) was misdiagnosed as type III (indirect, large) in three cases, type III as type VI in one case, and type III as type II (indirect, medium) in one case. The sensitivity and the specificity of ultrasonography in classifying type II were 100 and 99%, respectively, for type III, 85 and 97%, and for type VI, 90 and 99%. CONCLUSION: Ultrasonography of the groin regions could be used with great accuracy for precise classification of groin hernias in adults. Each type of groin hernia, according to the unified classification system that we used for classification, has a characteristic ultrasonographic presentation, which is demonstrated in this study.

Detection of gastrointestinal and abdominal infections by 99mTc-ciprofloxacin.

BACKGROUND/AIMS: The aim of the study is detection and evaluation of the abdominal and gastrointestinal infective foci using 99mTc-ciprofloxacin (Laboratory for radioactive isotopes, Vinca). METHODOLOGY: In total 21 patients with clinical suspicion on abdominal or gastrointestinal infection were investigated. In all the patients, planar liver/spleen scintigraphy was performed. Ciprofloxacin chloride (3.5 mg) was mixed with 555 MBq of 99mTc in 3 mL of physiological solution and incubated for 20 min. After slow i.v. injection in a cubital vein, dynamic acquisition (1 f/min) was performed during the first 60 min in the position of interest, followed by static acquisition (500,000 imp) anterior and posterior view, abdomen and pelvis after 1 h and 4 h in all patients. When necessary, additional scintigrams were acquired after 24 h. In all the patients with negative or equivocal findings of planar scintigraphy, emission computerized tomography (SPECT) was performed (60 positions, 6 degrees). Interpretation was made by three independent observers. Additional data were provided using clinical findings, ultrasonography, computed tomography and magnetic resonance imaging, laboratory analyses, and surgical or microbiological confirmation of infection. RESULTS: There were eleven true-positive findings, seven true negative, two were false negative while one was false positive due to intestinal obstruction. Sensitivity was 79%, specificity 91%, positive predictive value 92%, negative predictive value 77%, accuracy 84%. CONCLUSIONS: According to our results, scintigraphy with radiolabeled ciprofloxacin is a useful method for detection and assessment of exact localization of abdominal and gastrointestinal infections.

Absolute CT perfusion parameter values after the neoadjuvant chemoradiotherapy of the squamous cell esophageal carcinoma correlate with the histopathologic tumor regression grade.

PURPOSE: To analyze value of the computed tomography (CT) perfusion imaging in response evaluation of the esophageal carcinoma to neoadjuvant chemoradiotherapy (nCRT) using the histopathology as reference standard. METHODS: Forty patients with the squamous cell esophageal carcinoma were re-evaluated after the nCRT by CT examination, which included low-dose CT perfusion study that was analyzed using the deconvolution-based CT perfusion software (Perfusion 3.0, GE). Histopathologic assessment of tumor regression grade (TRG) according to Mandard's criteria served as reference standard of response evaluation. Statistical analysis was performed using Spearman's rank correlation coefficient (r(S)) and Kruskal-Wallis's test. RESULTS: The perfusion CT parameter values, measured after the nCRT in the segment of the esophagus that had been affected by neoplasm prior to therapy, significantly correlated with the TRG: blood flow (BF) (r(S)=0.851; p<0.001), blood volume (BV) (r(S)=0.732; p<0.001) and mean transit time (MTT) (r(S)=-0.386; p=0.014). Median values of BF and BV significantly differed among TRG 1-4 groups (p<0.001), while maximal esophageal wall thickness did not (p=0.102). Median BF and BV were gradually rose and MTT decreased as TRG increased, from 21.4 ml/min/100 g (BF), 1.6 ml/100 g (BV) and 8.6 s (MTT) in TRG 1 group, to 37.3 ml/min/100 g, 3.5 ml/100 g and 7.5 s in TRG 2 group, 81.4 ml/min/100 g, 4.1 ml/100 g and 3.8 s in TRG 3 group, and 121.1 ml/min/100 g, 4.9 ml/100 g and 3.7 s in TRG 4 group. In all 15 patients who achieved complete histopathologic regression (TRG 1), BF was <30.0 ml/min/100 g. CONCLUSIONS: CT perfusion could improve the accuracy in response evaluation of the esophageal carcinoma to nCRT.

Changing pattern of cytokeratin 7 and 20 expression from normal epithelium to intestinal metaplasia of the gastric mucosa and gastroesophageal junction.

It is currently unclear whether intestinal metaplasia at the esophagogastric junction and in the distal esophagus represent a continuum of the same underlying disease process, i.e., gastroesophageal reflux, or constitute different entities with a different pathogenesis. Biopsies below the Z line might show specialized epithelium in some patients and the question is whether this is another form of short segment Barrett's esophagus or whether it is related to a generalized atrophic process of the stomach. Data from recent studies regarding the expression of cytokeratin CK7 and CK20 in intestinal metaplasia (IM) found at the gastroesophageal junction are conflicting. Prompted by these data we undertook the present study: a) to evaluate the expression of CK7 and CK20 in IM of the gastric cardia and to compare the findings with those in patients with Barrett's esophagus and IM of the gastric corpus and antrum mucosa; and b) to evaluate the immunophenotype of non-intestinalized cardiac mucosa and to compare it with that of normal gastric epithelium. We studied the expression of CK7 and CK20 on biopsy specimens from patients with long-segment Barrett's esophagus (n=17) and surgical resection and biopsy specimens of gastric cardia (n=15), corpus (n=14) and antrum (n=22) from patients with histological evidence of IM. Eighty-four biopsy specimens from 42 patients (antrum n=15, corpus n=20, cardia n=7) without evidence of IM were studied as a control group. We observed an immunophenotype characterised by diffuse moderate to strong CK7 staining on the surface and crypt epithelium combined with strong CK20 staining on the surface and superficial part of the crypts in 94.1% (16/17) of the cases with long-segment Barrett's esophagus, but in none of the 36 cases with IM in distal stomach (antrum and corpus). IM in the gastric cardia expressed the immunophenotype seen in IM of the gastric mucosa in 93.3% (14/15) of the cases. On the other hand, normal cardiac epithelium expressed patchy strong CK7 staining on the surface epithelium and on both, superficial and deep parts of the pits combined with patchy strong CK20 staining on the surface epithelium and superficial pits, a feature permitting distinction of the normal cardiac epithelium from those of the normal gastric antrum and corpus epithelium. We conclude that the expression of cytokeratins 7 and 20 can be used to distinguish the origin of IM of the gastroesophageal junction. The CK7/20 immunophenotype of IM in the gastric cardia closely resembles that of the IM in the gastric antrum and corpus and is different from IM in long-segment Barrett's esophagus. In contrast, the CK7/20 immunophenotype of the cardiac epithelium is different from that of the gastric antrum and corpus mucosa, suggesting that cardiac epithelium might not be a native normal gastric epithelium but one that is acquired as a consequence of longstanding inflammation. Changing pattern of CK7 and CK20 expression from normal to intestinalized epithelium suggests that IM arising from cardiac epithelium might have distinctive features.

Correlation of macroscopic and histological characteristics in the regional lymph nodes of patients with rectal and sigmoidal adenocarcinoma.

BACKGROUND/AIMS: The number of involved lymph nodes is a relevant prognostic parameter which determines the duration of survival in patients with colonic and rectal adenocarcinoma. The purpose of this study was to establish a correlation between the macroscopic (size and consistency) and microscopic characteristics of the regional lymph nodes (type of involvement in tumor tissue, state of the capsule, adherence of the lymph nodes, etc.) in patients with colorectal carcinoma. METHODOLOGY: In this prospective study, 46 patients with rectal and sigmoid adenocarcinoma were studied through randomized selection. From the resected specimens, a total of 736 lymph nodes were identified (average 15.66 per patient), with the precise location determined according to Enker and Philiphsken. The macroscopic and microscopic characteristics of each lymph node were identified. These lymph node findings were then distributed by means of the x2 test, while the interrelationship of lymph node characteristics was determined by factor analysis. RESULTS: Within the group of "small" lymph nodes, 17.18% were malignant. Additionally, of all the malignant lymph nodes, 46.23% were less than 5 mm in diameter. Although the malignant lymph nodes were predominantly diffusely involved within the tumor tissue, 19.50% were focally involved within the tumor tissue, of which 48.38% were "small" lymph nodes, which are commonly non-palpable. Perforation of the capsule and adherence were more characteristic for focally mutated than for diffusely mutated lymph nodes in the cases of malignantly mutated lymph nodes. CONCLUSION: Size and consistency of the lymph nodes are not dependable parameters for appraisal of lymph node involvement in tumor tissue, the state of the lymph node capsule, nor the interrelation among the lymph nodes. As in the case of the primary tumor, local tumor aggression in the lymph nodes is conditioned by the grade of differentiation, i.e. histologic immaturity, rather than by tumor size.

Discriminant analysis of pre- and intraoperatively detected prognostic factors influencing lymph node involvement in patients with colorectal carcinoma.

BACKGROUND/AIMS: The aim of this study was to establish whether, and to what extent, pre- and intraoperatively detected characteristics (demographic, anamnestic and laboratory data) and tumor characteristics can be used in the assessment of regional lymph node involvement in patients with colorectal carcinoma. The assessment also included the number of lymph nodes involved in patients with positive lymph nodes. Considering that the number of obtained lymph nodes widely varies in resected specimens, assessment parameters also included the percentage of the involved lymph nodes within the total population of lymph nodes. METHODOLOGY: From 1992-1993, 46 patients with carcinoma of the rectum and sigmoid colon were studied, with a total number of 736 lymph nodes evaluated. Out of the total number of lymph nodes, 577 (78.4%) were benign and 159 (21.6%), malignant. Data were analyzed by multi-variant statistical methods, namely: discriminant analysis and multiple regression with the aid of SPSS/PC+ software. RESULTS: For this patient group, we evaluated the following potentially predictive factors for lymph node involvement: age; serum hemoglobin, albumin and alkaline phosphatase levels; weight loss; and the primary tumor localization characteristics: histologic type, macroscopic growth pattern and depth of tumor invasion of the bowel wall. We found that there was no difference in the prediction of regional lymph node involvement between analysis of the aforementioned parameters and analysis of the isolated discriminators only. CONCLUSION: A predictability likelihood of 83.78% greatly surpasses the acceptable error tolerance level of 5%. Correlation of demographic, anamnestic and laboratory data about the patient and the characteristics of the primary tumor cannot be used in distinguishing malignant lymph nodes from benign ones. These data cannot be the basis for exact intraoperative staging and thus cannot be significant criteria for decision-making about operative treatment modalities.

Radioimmunodetection of colorectal carcinoma.

BACKGROUND/AIMS: The aim of the study is detection of the recurrences and metastases of colorectal carcinomas using 111In-labeled antibodies B72.3. METHODOLOGY: Fourteen patients underwent planar immunoscintigraphy and/or tomoscintigraphy. RESULTS: With tomography in comparison to planar scintigraphy, we can access better distinction of tumor and estimation of its size. Other imaging methods (computed tomography, ultrasonography) have an advantage in detection of liver metastases, while immunoscintigraphy is more specific for the assessment of malignant abdominal tumors and extrahepatic metastases. CONCLUSIONS: The first results point out that Oncoscint CR-103 can be useful in diagnosis of recurrences and metastases of colorectal carcinoma, viability assessment after radiotherapy and in the choice of the adequate surgical treatment in dependence of the spread of the disease.

Evaluation of gallbladder motility in patients following total gastrectomy (Roux-en-Y) by infusion cholescintigraphy.

BACKGROUND: The aim of the study is to evaluate gallbladder (GB) motor function, by infusion cholescintigraphy, in patients after total gastrectomy (Roux-en-Y) with expected disturbances in the physiological regulation of biliary tract motility. METHODS: The study was done in 10 controls, as well as in 12 patients early (less than 2 months) and in 14 late (6 months-2 years) after surgery. Anterior abdominal imaging by gamma camera and computer acquisition was performed during three-hours infusion of 150 MBq, preceded by the loading dose of 50 MBq of 99mTc-EHIDA in bolus injection. The test meal stimulation was done in the 120th min of the study. GB TA curve was obtained and five parameters of GB motility were analysed: durations of filling (ascending) and emptying (descending) phases, filling and emptying rate ratio and ejection fraction and rate. RESULTS: Our results have shown that in the early period after the operation GB filling is prolonged and emptying impaired, while after several months GB motor function is normalised. CONCLUSIONS: It can be concluded that the infusion cholescintigraphy is potentially useful in patients after such surgery to decide on the specific treatment introduction in order to prevent GB calculosis and other complications.

Comparison between the deconvolution and maximum slope 64-MDCT perfusion analysis of the esophageal cancer: is conversion possible?

PURPOSE: To estimate if CT perfusion parameter values of the esophageal cancer, which were obtained with the deconvolution-based software and maximum slope algorithm are in agreement, or at least interchangeable. METHODS: 278 esophageal tumor ROIs, derived from 35 CT perfusion studies that were performed with a 64-MDCT, were analyzed. "Slice-by-slice" and average "whole-covered-tumor-volume" analysis was performed. Tumor blood flow and blood volume were manually calculated from the arterial tumor-time-density graphs, according to the maximum slope methodology (BF(ms) and BV(ms)), and compared with the corresponding perfusion values, which were automatically computed by commercial deconvolution-based software (BF(deconvolution) and BV(deconvolution)), for the same tumor ROIs. Statistical analysis was performed using Wilcoxon matched-pairs test, paired-samples t-test, Spearman and Pearson correlation coefficients, and Bland-Altman agreement plots. RESULTS: BF(deconvolution) (median: 74.75 ml/min/100g, range, 18.00-230.5) significantly exceeded the BF(ms) (25.39 ml/min/100g, range, 7.13-96.41) (Z=-14.390, p<0.001), while BV(deconvolution) (median: 5.70 ml/100g, range: 2.10-15.90) descended the BV(ms) (9.37 ml/100g, range: 3.44-19.40) (Z=-13.868, p<0.001). Both pairs of perfusion measurements significantly correlated with each other: BF(deconvolution), versus BF(ms) (rS=0.585, p<0.001), and BV(deconvolution), versus BV(ms) (rS=0.602, p<0.001). Geometric mean BF(deconvolution)/BF(ms) ratio was 2.8 (range, 1.1-6.8), while geometric mean BV(deconvolution)/BV(ms) ratio was 0.6 (range, 0.3-1.1), within 95% limits of agreement. CONCLUSIONS: Significantly different CT perfusion values of the esophageal cancer blood flow and blood volume were obtained by deconvolution-based and maximum slope-based algorithms, although they correlated significantly with each other. Two perfusion-measuring algorithms are not interchangeable because too wide ranges of the conversion factors were found.

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.

Surgical experience of the national institution in the treatment of Zenker's diverticula.

AIM: To review the 8-year experience of the Department of Esophagogastric Surgery, First Surgical University Hospital in Belgrade in the surgical management of Zenker's diverticula (ZD). METHODS: Between January 2000 and January 2009, 52 patients underwent surgical procedure for the treatment of ZD. Complete preoperative workup including the symptom evaluation and large variety of structural and functional diagnostic procedures were conducted before the surgery. After the operative treatment patients underwent detailed follow-up in regular intervals up to 3 years. RESULTS: Preoperative evaluation marked higher incidence of hiatal hernia and pathologic gastroesophageal reflux (GER) among the patients with ZD then in normal population. According to the preoperative evaluation and size of diverticula, as well as due to the intraopertive findings, a variety of surgical procedures were performed, including myotomy alone (n = 2), diverticulopexy and myotomy (n = 36) and diverticulectomy and myotomy (n = 14). Regardless of the operative treatment no salivary cervical fistulas were observed. Late and early postoperative results revealed low incidence in postoperative transitory dysphagia or regurgitation. CONCLUSION: The results of this study show that the open surgical procedures are safe and effective in the treatment of ZD. Cricopharyngeal myotomy remains the essential focus of treatment, while the choice of resecting or suspending the diverticulum is brought upon its size. Complete preoperative investigation must be conducted in ZD patients, and the role of pathologic GER must be taken into account when we discuss the origin of this disorder.

[Delayed MDCT in preoperative analysis of the hypopharyngeal postcricoid carcinomas].

INTRODUCTION: Determination of borders of the postcricoid tumors is of great significance during preoperative analysis, because it can be of considerable influence on operative treatment and its planning. Therefore, exact demarcation, delineation and opacification of tumor zone on CT analysis is crucial. MATERIAL AND METHOD: Late CT scan delay of 150 sec and slow vein flow of contrast agents of 1 ml/sec is radiological method of choice in preoperative evaluation of carcinoma of the post-cricoid region. For our purposes we used modern MSCT Light Speed GE 64, with slice thick of 2.5 mm (retro recon of 0.625) with software postprocesing. RESULTS AND DISCUSSION: In our study, we have detaily analized 25 patients with clinically proved carcinoma of hypopharynx, of which 8 had the hardest form of tumor. Control group were patients to whom CT scan was done by standard protocol and CT time scan of 50 sec. With all 8 of them, scanned by protocol of delay time of 150 sec, was proved a statistically important validity of interpretation and demarcation of tumors. CONCLUSION: Delay time on CT scanning is proved to be efficient protocol for visualization of neck soft tissues which includes the walls of hypopharynx.

[Preoperative chemoradiotherapy in locally advanced esophageal cancer].

Preoperative or definitive chemoradiotherapy defines today the standard treatment of patients with localized or locally advanced esophageal cancer. Preliminary results of our study are presented. 46 patients with locally advanced squamous cell esophageal cancer (T3-4, N0-1, M0) were enrolled. All patients recieved concomitant chemotherapy (Cisplatin/5FU/LV) and radiotherapy (45-50, 4Gy). Clinical response rate was 59% (3 patients (7%) complete response, 24 patients (52%) partial regression, 13 (28%) stabile disease, 6 patients (13%) disease progression). Out of 46 patients, 12 were operated (26%), all with R0 resection. Complete patohistolgical regression (TRG 1) was noted in 5 patients (42%). TRG 2 i TRG 3 in one (8%) and 3 patients (25%), and TRG 4 in 3 patients (25%). Mean survival time in operated group of patients was 9.3 months, and in nonoperated group 5.5 months. Studies show improved survival rate in patients with complete response to chemoradiotherapy and R0 resection. Individualy tailored therapy is essential.

[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.

Gastroesophageal reflux in infants and children.

Gastroesophageal reflux disease (GERD) is the most common esophageal disorder and the most frequent reason why infants are referred to the pediatric gastroenterologist, affecting as much as 30% of the pediatric population. Presenting features of GERD in infants and children are quite variable and follow patterns of gastrointestinal and extra-esophageal manifestations that vary between individual patients and may change according to age. Patients may be minimally symptomatic, or may exhibit severe esophagitis, bleeding, nutritional failure, or severe respiratory problems. GERD is also complex for the diagnostic techniques required to assess its repercussions or explain its origin. Although different abnormalities in motility variables, such as lower eso-phageal sphincter (LES) function, esophageal peristalsis and gastric motor activity can contribute to the development of GERD, the degree of esophageal acid exposure represents the key factor in its pathogenesis. Esophageal pH monitoring, based on both the detection of acid reflux episodes and the measurement of their frequency and duration, has been regarded as the most sensitive and specific diagnostic tool for diagnosing reflux disease. The aim of this paper is to give a concise review for the clinicians encountering this specific disease in infants and children.