Surgical outcome of percutaneous transhepatic gallbladder drainage in acute cholecystitis: Ten years' experience at a tertiary care centre.

BACKGROUND: Percutaneous transhepatic gallbladder drainage (PTGBD) plays an important role in the treatment of elderly patients and/or patients in poor health with acute cholecystitis (AC). The primary aim of this study is to determine how these factors influence the clinical outcome of PTGBD. Moreover, we assessed the timing and results of subsequent cholecystectomies. PATIENTS AND METHODS: We retrospectively examined the results of 162 patients undergoing PTGBD between 2010 and 2020 (male-female ratio: 51.23% vs. 48.77%; mean age: 71.43 ± 13.22 years). Patient's performance status and intervention outcomes were assessed with clinical success rates (CSR) and in-hospital mortality. The conversion rate (CR) of possible urgent or delayed, elective laparoscopic cholecystectomies (LC) after PTGBD were analysed. RESULTS: PTGBD was the definitive treatment in 42.18% of patients, while it was a bridging therapy prior to cholecystectomy (CCY) for the other patients. CSR was 87.97%, it was only 64.29% in grade III AC. In 9.87% of the cases, urgent LC was necessary after PTGBD, and its conversion rate was approximately equal to that of elective LC (18.18 vs. 17.46%, respectively, p = 0.2217). Overall, the post-PTGBD in-hospital mortality was 11.72%, while the same figure was 0% for grade I AC, 7.41% for grade II and 40.91% for grade III. Based on logistic regression analyses, in-hospital mortality (OR 6.07; CI 1.79-20.56), clinical progression (OR 7.62; CI 2.64-22.05) and the need for emergency CCY (OR 14.75; CI 3.07-70.81) were mostly determined by AC severity grade. CONCLUSION: PTGBD is an easy-to-perform intervention with promising clinical success rates in the treatment of acute cholecystitis. After PTGBD, the level of gallbladder inflammation played a decisive role in the course of AC. In a severe, grade III inflammation, we have to consider low CSR and high mortality.

Evaluation of the conversion rate as it relates to preoperative risk factors and surgeon experience: a retrospective study of 4013 patients undergoing elective laparoscopic cholecystectomy.

BACKGROUND: Our aim is to determine the relationships among patient demographics, patient history, surgical experience, and conversion rate (CR) during elective laparoscopic cholecystectomies (LCs). METHODS: We analyzed data from patients who underwent LC surgery between 2005 and 2014 based on patient charts and electronic documentation. CR (%) was evaluated in 4013 patients who underwent elective LC surgery. The relationships between certain predictive factors (patient demographics, endoscopic retrograde cholangiopancreatography (ERCP), acute cholecystitis (AC), abdominal surgery in the patient history, as well as surgical experience) and CR were examined by univariate analysis and logistic regression. RESULTS: In our sample (N = 4013), the CR was 4.2%. The CR was twice as frequent among males than among females (6.8 vs. 3.2%, p < 0.001), and the chance of conversion increased from 3.4 to 5.9% in patients older than 65 years. The detected CR was 8.8% in a group of patients who underwent previous ERCP (8.8 vs. 3.5%, p < 0.001). From the ERCP indications, most often, conversion was performed because of severe biliary tract obstruction (CR: 9.3%). LC had to be converted to open surgery after upper and lower abdominal surgeries in 18.8 and 4.8% cases, respectively. Both AC and ERCP in the patient history raised the CR (12.3%, p < 0.001 and 8.8%, p < 0.001). More surgical experience and high surgery volume were not associated with a lower CR prevalence. CONCLUSIONS: Patient demographics (male gender and age > 65 years), previous ERCP, and upper abdominal surgery or history of AC affected the likelihood of conversion. More surgical experience and high surgery volume were not associated with a lower CR prevalence.

Laparoscopic transperitoneal and retroperitoneal adrenalectomy: a 20-year, single-institution experience with an analysis of the learning curve and tumor size [lap transper and retroper adrenalectomy].

BACKGROUND: The superiority of laparoscopic transperitoneal (TP) versus retroperitoneal (RP) adrenalectomy is an ongoing debate. METHODS: Data from 163 patients (TP: n = 135; RP: n = 28) undergoing minimally invasive adrenalectomy were analyzed. Both operative [intraoperative blood loss, previous abdominal surgery, conversion rate, operative time and tumor size] and perioperative [BMI (body mass index), ASA (American Society of Anesthesiologists) score, time of hospitalization, time of oral intake, histology and postoperative complications] parameters were compared. Both the learning curve (LC) and tumor size were analyzed. RESULTS: We found significant differences in the mean operative time (p = 0.019) and rate of previous abdominal surgery (p = 0.038) in favor of TP. Significantly larger tumors were removed with TP (p = 0.018). Conversion rates showed no significant difference (p = 0.257). Also, no significant differences were noted for time of hospitalization, intraoperative blood loss and postoperative complications. In terms of the LC, we saw significant differences in previous abdominal surgery (p = 0.015), conversion rate (p = 0.011) and operative time (p = 0.023) in favor of TP. Large (LT) and extra-large tumors (ELT) were involved in 47 lesions (LT: 40 vs. ELT: 7), with a mean tumor size of 71.85 and 141.57 mm, respectively. Mean intraoperative blood loss was 64.47 ml vs. 71.85 ml, time of hospitalization was 5.10 vs. 4.57 days and mean operative time was 76.52 vs. 79.28 min for LT and ELT, respectively. CONCLUSION: A shorter operative time and lower conversion rate in favor of TP were noted during the learning curve. TP proved to be more effective in the removal of large-, extra-large and malignant lesions. The RP approach was feasible for smaller, benign lesions, with a more prolonged learning curve.

Evaluating the distribution of the locations of colorectal cancer after appendectomy and cholecystectomy.

BACKGROUNDS: The number of appendectomies and cholecystectomies performed is gradually increasing worldwide. An increasing incidence of colorectal cancer (CRC) after appendectomy and cholecystectomy has been reported, but the location of tumors in certain segments of the colon and rectum after appendectomy and cholecystectomy is still uncertain. We aimed to evaluate the distribution of the locations of colorectal cancer after appendectomy and/or cholecystectomy in patients who underwent CRC surgery. METHODS: We reviewed the medical records of patients who had undergone CRC surgery between 2015 and 2017 for the presence of previous appendectomy/cholecystectomy. Data were collected from the Colorectal Data Base of the University of Szeged, Department of Surgery. RESULTS: Surgery for CRC was performed in 640 patients during the study period. Data of 604 patients were analyzed. Appendectomy was performed in 100 patients (16.6%), cholecystectomy in 65 (10.8%), and both interventions in 18 (3%) before the CRC surgery. Out of those patients who underwent appendectomy alone, 92 (92%) had undergone appendectomy more than 10 years before the CRC surgery. Also in these 100 patients, the prevalence of right-sided colon cancer (CC) was 35% (n = 35), in comparison with the prevalence among the 504 other patients (20.4%, n = 103). The prevalence of right-sided CC among patients who underwent cholecystectomy alone was 36.9% (n = 24), in comparison with 21.2% (n = 114) of the 539 other patients. CONCLUSIONS: A significant left to right side shift in CRC was noted among patients who had previously undergone appendectomy/cholecystectomy. Because right-sided CC has a worse prognosis, the role of incidental appendectomy and routine cholecystectomy seems that need re-evaluation.

Adenocarcinoma arising from a foregut cyst of the diaphragm: importance of multimodality treatment: a case report.

BACKGROUND: Benign foregut cysts usually develop in the thorax most of all in the mediastinum. Rare cases involving various abdominal organs, such as liver, stomach or pancreas have been previously published, mostly occurring in the retroperitoneum. CASE PRESENTATION: We herein present an adenocarcinoma of a foregut cyst involving the left side of the diaphragm, left lower lobe of the lung, and left lobe of the liver, successfully removed through multivisceral resection. In between drug holidays, postoperative oncological treatment has been ongoing for nearly 4 years. In terms of chemotherapy, FOLFOX 4 regime, capacitabine monotherapy and later on next generation sequencing has been attempted, although the patient refused the later treatment option. Despite multimodality (combined surgical and oncological) treatment, local- and later on loco-regional recurrence has been detected on follow-up staging, influencing further chemotherapy regime. Taking both the fairly unknown type of the tumor and uncertain response rate to oncological therapy into account, prolonged tumor pace with fairly stable general patient state was reached throughout the course of the disease. CONCLUSION: Through surgical tumor resection, and postoperative chemotherapy the patient managed to maintain an acceptable quality of life without major symptoms during ongoing treatment. During our own case, with multiple organ involvement, multivisceral resection, with multimodality treatment had considerable effect in prolonging the lifespan of the patient.

Surgical treatment of awn aspiration causing bronchopleural fistula and bronchiectasis: case reports.

BACKGROUND: Aspiration of grass inflorescences is an extremely rare phenomenon with potential diagnostic difficulties. Due to its special shape, each coughing and respiratory action helps its migration towards the periphery of lung, resulting late-onset, life-threatening complications. The diagnosis has some difficulties for the reason that soon after the aspiration initial symptoms, such as coughing, wheezing or vomiting disappear and bronchoscopy is mostly negative. At least serious complications such as tension pneumothorax, bronchopleurocutaneous fistula or even spontaneous percutan elimination may develope. CASE PRESENTATION: We present two cases of pleuropneumonia resulting from aspiration of the head of barley grass. Soon after the accidents initial symptoms diminished, inflammatory markers improved and bronchoscopy was unable to confirm the presence of awn. Despite of conservative treatment (antibiotics, physiotherapy, bronchodilators, expectorants, and inhalation) localized pulmonary inflammation developed after 1 and 9 months showed up on chest computed tomography. After ineffective conservative treatment, surgical resections became inevitable in order to remove chronically inflamed parts (lobectomy, segmentectomy) and foreign bodies. Both patients recovered and were discharged home after successful interventions. CONCLUSIONS: Due to its peculiar shape and behaviour, awn inhalation is a special and atypical form of aspiration, thus great care and awareness is needed in its treatment. Negative bronchoscopic result does not exclude the presence of bronchial grass head. Symptomless child with negative bronchoscopy and improved inflammatory markers should be followed up thoroughly to recognize late complications in time. Regular diagnostic steps (chest ultrasound/X-ray) should be performed to localize potential chronic lung inflammation. Chest computed tomography is a valuable diagnostic tool for identifying and localising the foreign body. In cases with localized inflammation and peripheric localisation, segmentectomy can be a successful and safe alternative of lobectomy.

[Perioperative factors influencing the tolerability of chemotherapy after lung lobe resection]. / Tüdolebeny-eltávolítást követo kemoterápia tolerabilitását befolyásoló perioperatív tényezok.

INTRODUCTION: Lung cancer is the leading cause of malignancy-related deaths in Hungary, involving complex surgical and oncological treatment. AIM: Factors influencing the tolerability of complete/planned and incomplete postoperative chemotherapy after surgery were analyzed. METHOD: During a 6-year period (January 1, 2011-December 31, 2016), data of 72 patients operated with lung cancer (adenocarcinoma and squamous cell carcinoma), receiving complete (4 cycles) and incomplete (<4 cycles) postoperative chemotherapy were analyzed. The following factors among the two groups [complete: n = 53; incomplete: n = 19] were analyzed: gender, mean age, body mass index, Malnutrition Universal Screening Tool, Charlson Comorbidity Index, second malignant tumor, atrial fibrillation, Forced Expiratory Volume 1 sec, Performance Status, open/Video-Assisted Thoracic Surgery (VATS) lobectomy, duration of surgery, postoperative fever, need for transfusion, prolonged air leak, redo surgery, histology, tumor stage. RESULTS: The rate of complete postoperative cycles obtained from logistic regression analysis, were substantially higher after VATS lobectomies [n = 26 (83.87%)] compared to open procedures [n = 27 (65.85%)]; (p = 0.092; OR = 0.356), without significance. Multivariate analysis (open/VATS lobectomy, upper/middle-lower lobe resection, diabetes, prolonged air leak, postoperative fever) showed significantly increased successful uptake of complete cycles after VATS (p = 0.0495), while upper/middle lobe resections (p = 0.0678) and the lack of diabetes (p = 0.0971) notably increased the number of complete cycles, without significance. CONCLUSION: Twenty-six percent of patients were unable to receive complete planned postoperative chemotherapy. VATS lobectomy patients received significantly higher number of complete cycles of postoperative chemotherapy. Diabetes and lower lobe lobectomies had a negative effect on the tolerability of postoperative chemotherapy. Orv Hetil. 2018; 159(19): 748-755.

[Changes in carbohydrate metabolism after kidney transplantation and their effects on cardiovascular risk]. / Vesetranszplantáció utáni szénhidrátanyagcsere-változások és annak hatásai a cardiovascularis rizikóra.

INTRODUCTION: Cardiovascular disease is the major cause of deaths after transplantation, with diabetes mellitus being the main risk factor in development. AIM: The aim of our study was to assess the prevalence of new onset diabetes mellitus in connection with the cardiovascular risk predicted by the HEART Score. METHOD: 44 patients were involved in our study; after overview of baseline data, OGTT was performed, followed by patient classification into the following groups: normal, impaired fasting glucose/impaired glucose tolerance, and new onset diabetes mellitus. Insulin resistance and kidney function were also assessed. RESULTS: Concerning baseline data, cold ischemic time (p = 0.016), body weight (p = 0.035), BMI (p = 0.025), and HbA1C (p = 0.0024) proved to be significantly different between normal and diabetic patients. Significant difference was found based on HOMA IR between the two groups 1.69±0.51 vs 6.46±1.42; p = 0.0017). Based on the HEART Score, patients with new onset diabetes mellitus were put into Group 3, which also reflects the risk which diabetes carries for the development of cardiovascular diseases. CONCLUSION: Cardiovascular risk can be decreased with increased allograft survival by early diagnosis and management of diabetes. Orv Hetil. 2017; 158(38): 1512-1516.

[Removal of giant adrenal tumors using the laparoscopic transperitoneal technique. A report of three successful cases]. / Óriás mellékvesetumorok eltávolítása laparoszkópos transperitonealis technikával három sikeres eset kapcsán.

With the development of laparoscopic adrenalectomy, indications for resection gradually span from small and benign to bigger and even malignant lesions. We studied the results of laparoscopic adrenalectomy for giant (>10 cm) adrenal tumors in three cases. Three patients (2 female, 1 male, mean age 49.33 years, BMI 31) underwent laparoscopic transperitoneal adrenalectomy due to giant (>10 cm) adrenal lesions with a limited size Pfannenstiel incision. Mean operative time was 126.66 minutes, with a mean intraoperative blood loss of 150 ml. Final histology confirmed adrenocortical carcinoma in two cases, and neurofibroma in one case. Mean hospital stay was 4 days, without perioperative complications. R0 resection was carried out in all cases. During a mean follow-up period of 24 months no local or distant metastasis occurred. Under appropriate conditions adrenalectomy performed by the laparoscopic transperitoneal technique for giant malignant tumors proved to be a safe method fulfilling oncological requirements. Orv Hetil. 2017; 158(45): 1802-1807.

[Non-intubated, uniportal, video assisted thoracic surgery [VATS] lobectomy, as a new procedure in our department]. / Nem intubált, spontán légzo betegnél, egy metszésbol, minimálisan invazív módon elvégzett tüdolebeny-eltávolítás mint új mutéti eljárás klinikánk gyakorlatában.

AIM: Due to the emerging experience in VATS (video assisted thoracic surgery) lobectomies, in some centers the so called "non-intubated" VATS lobectomies (NITS - non-intubated thoracic surgery) gained increased authority, during which endotracheal intubation and muscle relaxation of the patient is not carried out, thus surgery is being performed with the patient breathing spontaneously. The recent study deals with our initial experience gained during uniportal NITS VATS lobectomies. PATIENTS AND METHOD: Between 24.01.2017 and 10.03.2017, 16 patients (female: 8; male: 8) with lung cancer underwent NITS VATS uniportal lobectomy. Mean age was 59.6 years (42-73 years). Mean FEV1 was 87.7% (62-109). Mean BMI was 27.1 (18.8-32.8). Prior to surgery, the patients received benzodiazepine premedication, local anesthetic (Lidocaine) for incision and Bupivacaine for intercostal and vagus nerve blockage. Besides routine monitoring Bispectoral Index (BIS) guided target-controlled infusion (TCI) Propofol sedation was carried out, with the help of laryngeal mask anesthesia. Skin and soft tissue incision was performed at the fifth intercostal space, in the axillary line. This single incision sight was the only one needed for the introduction of the camera, together with the instruments needed for dissection and resection of the lobe and placement of the chest tube. Complete atelectasis can develop. The following lobes were removed: 7 right upper lobes, 2 mid-lobes, 1 right lower lobe, 1 right lower lobe + right upper lobe wedge resection, 5 left lower lobes. After the resections, extended mediastinal sampling or block dissection was performed. RESULTS: There was no perioperative mortality. Conversion to endotracheal intubation was needed in non of the cases. Mean operative time was 96,5 minutes (80-120 min.), mean drainage periode was 2.9 days (2-8 days). Prolonged air leak was 1/16 (6.25%). Postoperative fever occurred in 1 patient and subcutaneous emphysema in 1 case, and 1 pneumonia. Because of a recurrent pneumothorax, a re-drainage was necessary in 1 case. Pathology of the resected lobes were as follows: 1 endobronchial hamartochondroma causing complete atelectasis of the lobe, 1 chronic pneumonia, and 10 adenocarcinomas, 2 squamous cell carcinomas, 1 carcinosarcoma, and 1 typical carcinoid. Staging of the 14 malignant cases were as follows: 8 IA, 2 IB, 1 IIA, 2 IIB, and 1 IIIA. The average number of the removed mediastinal lymph nodes is 12 (7-20). CONCLUSION: Non-intubated (NITS) VATS lobectomy is considered a safe procedure, satisfying all aspects of oncological guidelines. The postoperative drainage period was shorter caused by the complete atelectasis during the surgery.

[Banff score changes in kidneys from marginal donors]. / Banff-score-változások a marginális donorokból származó veséknél.

INTRODUCTION: Despite an increase in the number of cadaver donors and the number of overall organ transplantations, the dramatic increase in the waiting list makes it necessary to reconsider donor criteria. AIM: The authors examined whether differences could exist in the function and/or morphology of transplanted kidneys originated from marginal and ideal donors one and five years after transplantation. METHOD: Kidney function and histopathologic findings were analysed and compared one and 5 years after transplantation in 97 patients having marginal donor kidneys and 178 patients who received ideal donor kidneys. RESULTS: Serum creatinine level was significantly higher (p = 0.0001) and estimated glomerular filtration rate was significantly lower (p = 0.003) in patients having marginal donor kidneys as compared to those with ideal donor kidneys 5 years after transplantation. Morphological changes in the transplanted kidneys such as tubulitis (p = 0.014) and interstitial inflammation (p = 0.025) were significantly more frequently present in patients with marginal donor kidneys than in those with ideal donor kidneys one year after transplantation. CONCLUSION: Despite an absence of differences in kidney function one year after kidney transplantation between patients having marginal and ideal donor kidneys, morphologic differences in the transplanted kidneys can be detected between the two groups of patients.

[Results of the video-assisted thoracic surgery lobectomy at our department in the last five-year periode]. / Minimálisan invazív tüdolebeny-eltávolítás eredményei osztályunk ötéves anyagában.

OBJECTIVES: Herein we present the results of lobectomies performed with minimally invasive approach (video-assisted thoracic surgery - VATS) at our department during a period of five years. METHODS: Between 1 January 2011 and 31 December 2015, 197 lobectomies (malignant lesions: 176 cases, benign lesions: 21 cases) were performed by three thoracic surgeons and one resident. Demographical data are as follows: 119 female/78 male, mean age: 62.4 years (range: 41-82 years). In 2011 three VATS lobectomies were performed, equaling 2.2 % of all lobectomies in that year. During the upcomig years the number of VATS lobectomies were as follows: 2012: 7 (7.3%), 2013: 13 (12%), 2014: 59 (34.5%) and 2015: 119 (68.5%). In 153 cases multiportal (78%) and in 44 cases uniportal (22%) anterior approach was performed. The resected lobes showed the following distribution: right upper: 85, mid lobe: 5, right lower: 28, left upper: 44, left lower: 34, upper bilobectomy: 1. In two cases sleeve lobectomy was performed. In 8 cases (4%) conversion to thoracotomy was needed and among the 46 uniportal procedures, 5 cases needed to be expanded into biportal approach (11%). RESULTS: During the study period, no intraoperative, or perioperative mortality occured. Mean operative time was 123 minutes (range: 60-135 minutes) and mean time of chest drainage was 4.3 days (range: 1-27 days). Air leakage lasting more than 7 days was present in 11.7%. Reoperation was needed in 4 cases (2%), in two cases due to bleeding, and in two cases because of expansive difficulties due to extended subcutaneous emphysema. Among the 176 VATS lobectomies performed due to malignant lesions, 169 lung cancers and 7 metastases were removed. The distribution according to the stage and histology of lung cancers was as follows: IA: 100 cases, IB: 28 cases, IIA: 17 cases, IIB: 3 cases, IIIA: 16 cases, IIIB: 1 case, and IV: 4 cases; adenocarcinoma: 128 cases, squamous cell carcinoma: 26 cases, large cell carcinoma: 3 cases, small cell lung cancer: 1 case, typical carcinoid: 10 cases, and atypical carcinoid: 1 case. CONCLUSIONS: Over the years VATS lobectomy became a rutin procedure at our institution. Nowadays more than two-thirds of lobectomies are performed with minimally invasive technique. Taking the learning curve of the four thoracic surgeons into consideration, our results correlate with international data.

Myasthenia gravis miatt végzett három különbözo típusú csecsemomirigy-eltávolítás sebészeti és korai neurológiai eredményei.

OBJECTIVES: Different methods of open or minimally invasive thymectomies have been recommended for the treatment of myasthenia gravis (MG). We compared the results of standard transsternal thymectomy (TS) and two different types of minimally invasive thymectomies [video-assisted thoracoscopic extended thymectomy (VATET) and classic Video-Assisted Thoracoscopic Surgery (cVATS)] performed at the same department. METHODS: During three different time periods 71 patients (60 female and 11 male; mean age 31 [range, 14-84] years) underwent thymectomy for MG. Twenty-three underwent standard transsternal thymectomy (January 1995 - September 2004), 22 VATET (September 2004 - August 2009), and 26 cVATS (September 2009 - December 2011) thymectomy for the right side. Operative data, MG- and surgery-related postoperative morbidity and early improvement of MG during the initial 1-year follow-up period were compared among the three methods. RESULTS: There were no perioperative deaths during the study period. Operative time was 112, 211, and 116 minutes (p = 0.001) in the TS, VATET and cVATS, respectively, and the length of hospital stay was 8.9, 5.6, and 4.0 (p = 0.001) days. Postoperative MG-related neurological morbidity affected 21.7%, 18.2%, and 7.7% (p = 0.365) of the patients and the surgery-related morbidity rate was 4.3%, 13.7%, and 0% (p = 0.118) in the TS, VATET and cVATS groups, respectively. Symptom improvement rates were 91.3%, 94.7%, and 87.5% (p = 0.712), and complete remission rates were 13%, 10.5%, and 11.5% (p = 0.917) after TS, VATET and cVATS thymectomies, respectively. CONCLUSIONS: In terms of operative time and hospital stay the best results were found after cVATS. The use of a less invasive surgical intervention resulted in less surgical-, and MG related neurological complications. The improvement of MG symptoms was excellent and results were similar after different types of thymectomies.

[Gastrointestinal locations of primary melanoma]. / A primer melanoma malignum ritka gastrointestinalis lokalizációi.

Primary gastrointestinal melanomas, part of the mucosal melanoma group, are uncommon. They constitute about five percent of all melanomas and most of them are located in the rectum (3 percent of all melanomas). The prognosis is poor, overall 5-year survival in rectal melanoma is 10-20 percent. We present three of our cases. The first case - a 68-year-old male patient - was operated on for histologically proved rectal melanoma. Three years after radical excision and oncological treatment a metastasis of the primary tumor was diagnosed in the stomach. Total gastrectomy was performed, followed by oncological treatment. In the second case of a 59-year-old male patient an appendectomy was performed for symptoms of appendicitis. The histopathological examination revealed melanoma of the appendix. Further investigations revealed the primary tumor in the stomach and metastases in the lungs as well. The third case - an 82-year-old female patient - was investigated for frequent defecations, mucus in stool and fecal incontinence. Primary melanoma was proved in the lower third of the rectum with multiple hepatic metastases. These three cases in our practice are remarkable for the rarity of the disease, and in two cases the presence of both the primary tumor and the metastasis were located in the gastrointestinal tract.

Impact of neoadjuvant FLOT treatment of advanced gastric and gastroesophageal junction cancer following surgical therapy.

Introduction: Therapeutic treatment for advanced-stage (T2-T4) gastroesophageal junction (GEJ) and gastric cancer involves neoadjuvant chemotherapy with subsequent surgical intervention. Method: Neoadjuvant oncological treatment for GEJ and gastric cancer previously consisted of the intravenous administration of epirubicin, cisplatin and fluorouracil (ECF) or epirubicin, cisplatin and capecitabine (ECX) combination (Group 1). The new protocol (FLOT, F: 5-FU, L: leucovorin, O: oxaliplatin, T: docetaxel), included patients with resectable GEJ and gastric cancer who had a clinical stage cT2 or higher nodal positive cN+ disease (Group 2). Between 31 December 2008 and 31 October 2022, the effect of different oncological protocols in terms of surgical outcomes in cases of T2-T4 tumours were retrospectively evaluated. Results of randomly assigned patients from the earlier ECF/ECX protocol (n = 36) (Group 1) and the new FLOT protocol (n = 52) (Group 2) were compared. Effect of different neoadjuvant therapies on tumour regression, types of possible side effects, type of surgery, and oncological radicality of surgical procedures were analysed. Results: When comparing the two groups, we found that in case of the FLOT neoadjuvant chemotherapy (Group 2, n = 52), complete regression was achieved in 13.95% of patients, whereas in the case of ECF/ECX (Group 1, n = 36), complete regression occurred in only 9.10% of patients. Furthermore, in the FLOT group, the mean number of lymph nodes removed was slightly higher (24.69 vs. 20.13 in the ECF/ECX group). In terms of the safety resection margin (proximal), no significant difference was found between the two treatment groups. Nausea and vomiting were the most common side effects. The occurrence of diarrhea was significantly higher in the FLOT group (p = 0.006). Leukopenia and nausea occurred more commonly with the old protocol (Group 1). The rate of neutropenia was lower following FLOT treatment (p = 0.294), with the lack of grade II and III cases. Anaemia occured at a significantly higher rate (p = 0.036) after the ECF/ECX protocol. Conclusions: As a result of the FLOT neoadjuvant oncological protocol for advanced gastro-esophageal junction and gastric cancer, the rate of complete tumour regression increased significantly. The rate of side effects was also appreciably lower following the FLOT protocol. These results strongly suggest a significant advantage of the FLOT neoadjuvant treatment used before surgery.

Short term results of the FLOT neoadjuvant therapy on the surgical management of advanced gastro-oesophageal junction adenocarcinoma / A neoadjuvans FLOT-terápia hatása az elorehaladott gyomor-cardia tumorok rövid távú onkológiai és sebészi kezelés eredményeire

Introduction. Recently the therapeutic treatment for advanced, stage T2-T4 gastro-oesophageal junction cancer and those adjacent to the regional lymph nodes involves neoadjuvant chemotherapy with subsequent surgical intervention. Method. Neoadjuvant oncological treatment for gastro-oesophageal junction cancer previously consisted of the intravenous administration of epirubicin, cisplatin and fluorouracil (ECF) or epirubicin, cisplatin and capecitabine (ECX) combination (Group I). In the course of the new protocol (FLOT-, F: 5-FU, L: leucovorin, O: oxaliplatin, T: docetaxel), patients were included with resectable gastro-oesophageal junction cancer who had a clinical-stage cT2 or higher nodal positive cN+ disease (Group II). Between 31st of December 2013 and 1st of June 2021 we retrospectively analyzed the effect of these FLOT oncological protocols in terms of surgical outcomes in cases of T2-T4 tumors (n = 9). We compared the results of the randomly assigned nine patients from earlier ECF/ECX protocol (Group I). We analyzed the effect of the different neoadjuvant therapy on tumor regression, and evaluated the types of possible side effects, type of surgery, and the oncological radicality of surgical procedures (number of removed regional lymph nodes, resection margins). Results. Comparing the two groups we found that in cases of FLOT neoadjuvant chemotherapy complete regression was achieved significantly a higher number like in earlier ECX/ECF therapy. Furthermore, the average number of removed lymph nodes, and the safety resection margins (distal, circumferential) no significant difference was found between the two groups. Neutropenia was the most frequently encountered side effect. Leukopenia, neutropenia and nausea occurred more frequently in cases of the old protocol (Group I). Conclusions. As a result of the FLOT neoadjuvant oncological protocol for advanced gastro-oesophageal junction cancer, the number of cases with complete tumor regression has significantly increased. The present results strongly suggest a significant advantage in favor of FLOT neoadjuvant treatment following surgery. The prevalence of side effects was also appreciably lower in cases of the FLOT protocol.

Minimally invasive adrenalectomy ­ Operative and perioperative results of transperitoneal and retroperitoneal adrenalectomies performed at the University of Szeged Department of Surgery during 23 years / Minimálisan invazív adrenalectomia - 23 év alatt végzett transperitonealis és retroperitonealis adrenalectomiák operatív és perioperatív eredményei a Szegedi Tudományegyetem Sebészeti Klinikán

Aim. Our goal was to evaluate operative and perioperative data of retroperitoneal (RP) and transperitoneal (TP) adrenalectomies performed at the University of Szeged Department of Surgery. Patients and method. During a retrospective cohort study including 174 adrenalectomies (28 RP; 146 TP) performed between 1998 and 2021, the following parameters were evaluated: rate of previous abdominal surgeries, conversion rate, operative time, intraoperative blood loss, tumor size, histology, hospital stay, early and late complications. Results. With significantly higher rate of previous abdominal surgeries [TP vs RP: 68 (46.57%) vs 4 (14%) P = 0.0021], there was no markable difference in conversion rate [TP vs RP: 7 (4.79%) vs 5 (18%), P = 0.312]. Significantly larger tumours were removed with TP (TP vs RP: 58.05 vs 34.8 mm, P = 0.016), with no markable difference in intraoperative blood loss (TP vs RP: 67.85 vs 50.2 ml, P = 0.157). Operative time was significantly shorter in TP (TP vs RP: 86.3 vs 134.5 min; P = 0.024). The most frequent histology was adenoma (TP vs RP: n = 95; 65.06% vs 64.3%). Pheochromocytoma occurred in 11 (7.53%) and 5 (17.8%) cases in TP and RP, respectively. We found no significant difference in hospital stay (TP vs RP: 5.125 vs 4.61 day; P = 0.413). Five- and 2 cases of early complications were seen in TP (splenic injury, postoperative fever, severe intraoperative bleeding, severe hypokalemia, surgical site infection) and RP (2 severe intraoperative bleeding), respectively. One lethal case of ventricular fibrillation and one delayed complication (postoperative abdominal wall hernia) were observed in TP. Conclusions. Both TP and RP are safe and simply reproducible minimally invasive techniques. According to our observation, RP adrenalectomy seems to be reserved for smaller lesions, while TP proves to be successful in removing enlarged and also malignant lesions with significantly shorter operative time.

Better intraoperative cardiopulmonary stability and similar postoperative results of spontaneous ventilation combined with intubation than non-intubated thoracic surgery.

OBJECTIVES: Non-intubated spontaneous ventilation video-assisted thoracic surgery lobectomy is a well-known procedure, but there are doubts regarding its safety. To solve this problem, we developed a safe procedure for spontaneous ventilation thoracic surgery (spontaneous ventilation with intubation). This study analyzed the intraoperative parameters and postoperative results of spontaneous ventilation with intubation. METHODS: Between March 11, 2020 and March 26, 2021, 38 spontaneous ventilation with intubation video-assisted thoracic surgery lobectomies were performed. We chose the first 38 non-intubated spontaneous ventilation video-assisted thoracic surgery lobectomy cases with a laryngeal mask performed in 2017 for comparison. RESULTS: There were no significant differences between the non-intubated spontaneous ventilation and spontaneous ventilation with intubation groups in postoperative surgical results (surgical time: 98,7 vs. 88,1 min (p = 0.067); drainage time: 3.5 vs. 2.7 days (p = 0.194); prolonged air leak 15.7% vs. 10.5% (p = 0.5); conversion rate to relaxation: 5.2% vs. 13.1% (p = 0.237); failure of the spontaneous ventilation rate: 10.5% vs. 13.1% (p = 0.724); and morbidity: 21% vs. 13.1% (p = 0.364)) and oncological outcomes. Significantly lower lowest systolic and diastolic blood pressure (systolic, 83.1 vs 132.3 mmHg, p = 0.001; diastolic 47.8 vs. 73.4 mmHg, p = 0.0001), lowest oxygen saturation (90.3% vs 94.9%, p = 0.026), and higher maximum pCO2 level (62.5 vs 54.8 kPa, p = 0.009) were found in the non-intubated spontaneous ventilation group than in the spontaneous ventilation with intubation group. CONCLUSIONS: Spontaneous ventilation with intubation is a more physiological procedure than non-intubated spontaneous ventilation in terms of intraoperative blood pressure stability and gas exchange. The surgical results were similar in the two groups.

Clinical benefits of oral capecitabine over intravenous 5-fluorouracyl regimen in case of neoadjuvant chemoradiotherapy followed by surgery for locally advanced rectal cancer.

Background: During the last decade, one of the most important treatment options for locally advanced, potencially resectable rectal tumours was neoadjuvant chemoradiotherapy (CRT) followed by surgery. Methods: Effects of the neoadjuvant treatment on surgical outcomes were retrospectively analysed in 185 patients with stage T2-T4 and N0-2, resectable rectal tumour among two patient groups defined by radiosensitizer agents. Group 1 (n = 94) involved radiotherapy (RT) with 50.4 Gy total dose (25 × 1.8 Gy + 3 × 1.8 Gy tumour bed boost), and intravenous 5-fluorouracil (5-FU) (350 mg/m2) with leucovorin (20 mg/m2) on the 1-5 and 21-25 days, while Group 2 (n = 91) RT and orally administrated capecitabine (daily 2 × 825 mg/m2) on RT days. Surgery was carried out after 8-10 weeks. Side effects, perioperative complications, type of surgery, number of removed regional lymph nodes, resection margins and tumour regression grade (TRG) were analysed. Results: More favourable side effects were observed in Group 2. Despite the same rate of diarrhoea (Group 1 vs. Group 2: 54.3% vs. 56.0%), Grade 2-3 diarrhoea ratio was lower (p = 0.0352) after capecitabine (Group 2). Weight loss occurred in 17.0% and 2.2% (p = 0.00067), while nausea and vomiting was described in 38.3% and 15.4% (p = 0.00045) with 5-FU treatment and capecitabine respectively. Anaemia was observed in 33.0% and 22.0% (p = 0.0941). Complete tumour regression occurred in 25.3% after oral- and 13.8% after intravenous treatment (p = 0.049). Ratio of sphincter preservation was higher with laparoscopy than open surgery (72.3% vs. 39.7%) (p = 0.00001). Conclusion: The study confirms advantages of neoadjuvant chemoradiotherapy with oral capecitabine for rectal tumours, such as more favourable side effect profile and overall clinical outcome, with increased rate of complete tumour regression.

Clinical considerations of bleomycin based electrochemotherapy with variable electrode geometry electrodes for inoperable, deep-seated soft tissue sarcomas.

The aim of the current prospective pilot study exclusively for deep-seated soft tissue sarcomas (STS) was to evaluate efficacy and safety of bleomycin-based ECT using VEG (variable electrode geometry) electrodes. During a 2-year period, seven surgically inoperable STSs were treated at the University of Szeged, Department of Surgery in Hungary. Electrode placement was determined by software planning using preoperative imaging (CT/MRI) and intraoperative ultrasound. Intravenous bleomycin (15.000 IU/m2) was administered 8 min before first pulse generation which lasted up to 40 min. Tumour response was evaluated through CT/MRI 2 months after treatment as per RECIST v.1.1. Five male- and 2 female patients were treated with fibromyxoid sarcoma (n = 2), epitheloid sarcoma (n = 3), liposarcoma (n = 1) and myofibroblastic sarcoma (n = 1) with median age of 54 years (49-88). Median tumour diameter, tumour volume and tumour depth was 5.9 cm (3.7-22.5), 131.13 cm3 (35.6-2456.22) and 6.18 cm (3.74-18.18), respectively. Median operative time was 75 min (35-180), median hospital stay 2 days (2-20). Two month follow-up confirmed partial response in 5 patients, while stable disease in 1 patient, and progressive disease in 1 case as per RECIST v.1.1. Grade 2 ulceration was experienced in four cases, and a transient left musculus quadriceps femoris plegia occured in one patient. Local control of deep-seated STSs with BLM-based VEG ECT holds a promising perspective and our results may serve as a practical guide for further investigation and treatment planning.