A transhiatalis sebészet járatlan ösvényei.

Right-sided spontaneous oesophageal rupture developed two days after left pneumonectomy and vomiting. In this extremely rare emergency, we used a transhiatal approach for primary repair of the rupture, combined with right-sided pleural and mediastinal drainage, gastrostomy and feeding jejunostomy. The seven-day barium meal showed healing of the rupture. It was mandatory that contamination of the pneumonectomized left thoracic cavity during rupture closure as well as a contralateral thoracotomy with its respiratory consequences had to be avoided by all means. Reconstruction and reinforcement (with omentum) of the oesophageal wall was achieved without difficulties, but we did not mobilize the oesophagus to avoid rupture of the left-sided mediastinal pleura. After massive haematamesis, a 68-year-old man was admitted for a huge (8×5 cm) mass in the lower-posterior mediastinum at the right side of the vertebra, seen on CT scan. On the barium meal incarcerated hiatal hernia, secondary short oesophagus and intramediastinally penetrating high lesser curvature ulcer was discovered. To reduce the magnitude of intervention one-stage transhiatal approach was decided. Through enlarged hiatus, dissection of incarcerated and firmly adherent hiatal hernia and of the short oesophagus was done. The following step was the removal of an encapsulated, huge lipomatosus mass from the posterior mediastinum, extending high from behind the vertebra, arising from the lesser curvature of the stomach. The lesser curvature ulcer was excised - sutured and a Toupet type (270 posterior) fundoplication was finally carried out. The follow-up was free from recurrence. This experience suggests that for some particular lower posterior mediastinal or esophageal problems, transhiatal access seems to be a useful alternative of traditional mediastinal approaches.

[Unusually late presentation esophageal perforations and ruptures]. / Nagy idoveszteséggel felismert nyelocso-perforációk és -rupturák.

The aim of this study is to present the treatment modalities of unusual late esophageal perforations and ruptures. The reason for diagnostic delay was misinterpretation of pleural collection, overlooked sclerotherapy, foreign body extraction, and delayed recognition of the true origin of empyema after pneumonectomy. In all instances of transthoracic reinforced or temporary excluded primary repair were successful. In a 6- week-old iatrogenic perforation with localised empyema, Urschel-Ergin type exclusion with tube thoracostomy and lavage was used. In a 13-day-old rupture, and in a late postpulmonectomy perforation, Johnson type exclusion, decortication, and/or fenestration and second-stage colonic or Roux-en-Y by-pass were carried out. One patient was lost in deep sepsis for a delayed recognised transfixion esophageal injury. It is never too late to attempt to repair and salvage a perforated or ruptured healthy esophagus.

[Physiologic type reconstruction in upper gastrointestinal caustic strictures]. / A nyelés képességének helyreállítása lúgivás utáni nyelocsoszukületben.

The authors discuss their experience in the surgical treatment of caustic stenosis in the upper gastrointestinal tract. They present operative solutions using isoperistaltic transverse colonic segment in oesophageal stenosis caused by gastric outlet obstruction, or when these two presented together. Further indications for the above were bronchial or tracheo-oesophageal fistulas and oesophageal perforation. Late adaptation of the colonic grafts were measured by radiokinematography and histochemistry. The overall morbidity was 4.9%. Postoperative salivary fistulas closed spontaneously. Late postoperative complications (13.5%) were treated successfully. The multihaustral motility of the graft prevented the reflux, while the altered mucopolysaccharides of the colonic mucosa prevented the ulcer formation. Orv Hetil. 2019; 160(16): 613-618.

[Solitary oesophageal metastasis of breast cancer after 17 years latency]. / Mamma carcinoma solitaer nyelocso-metastasisa 17 éves remissio után.

The authors discuss a case of a 63-year-old woman, who presented with dysphagia, 17 years after radical mastectomy for breast cancer. CT scan showed a juxta esophageal mediastinal tumour. A biopsy via right thoracotomy revealed a metastatic adenocarcinoma of the oesophageal wall from the previous breast carcinoma. Minimally invasive oesophageal intubation was used for palliation. Hormonal manipulation and radiotherapy was commenced postoperatively. The patient was well after eight months follow-up. A combination of high clinical suspicion with EUS and deep oesophageal biopsy can lead to the correct diagnosis of this very rare clinical entity. The biology of metastatic breast cancer may demand palliation by oesophageal intubation or stenting combined with adjuvant chemo, radio or hormonal therapy in such instances.

[Selective bowel decontamination]. / A szelektív béldekontamináció.

Infective complications play major role in mortality of high risk patients demanding intensive care. Selective Bowel Decontamination prevents endogenous infections by reducing the number of potentially pathogen microbes (aerobic bacteria, fungi) in the oropharynx and gastrointestinal tract, saving anaerobic bacteria. It had been used 20 years ago for the first time. Authors survey it's literature ever since. Selective Bowel Decontamination is performed by the mixture of antibiotics and antimycotic drug, administered orally in hydrogel, and suspension form in nasojejunal tube. The number of Gram negative optional aerobic bacteria and fungi decrease significantly in the gut, and the microbial translocation is following this tendency. Foreign authors achieved good results in acute necrotizing pancreatitis, after liver transplant, in polytrauma, in serious burn and in haematological malignancies. According to the literature Selective Bowel Decontamination shows advantages in selected groups of high risk surgical patients. In some studies the administration took few months, but the minimum time was one week. There was no report of increasing MRSA appearance. Regular bacteriological sampling is highly recommended in order to recognize any new antibiotic resistance in time.

Late complications of coloesophagoplasty and long-term features of adaptation.

OBJECTIVES: Revisional surgery of late complications after 141 substernal by-pass operations (1962-1990), except three cases with isoperistaltic (except seven with anisoperistaltic) transverse colon grafts for caustic esophageal strictures, are presented. Long-term adaptation of the grafts was investigated with cineradiographical and histochemical methods. METHODS: Correction of the "pseudodiverticulum" of the proximal anastomosis as a complication of the standard by-pass procedure (in five patients) was achieved by closure of the esophagus below the anastomosis or by end-to-end reanastomosis. Cervical anastomosis stricture (in seven) was solved either by plasty or resection and a similar reanastomosis. Delayed passage due to an intra-abdominal redundant graft (in five) was managed by abdominal shortening coloplication or by side-to-side gastrocolostomy. Late pyloric obstruction as a cause of gastrocolic reflux required pyloroplasty in two instances. Mixed barium-bread bolus for a cineradiographical transit study and periodic acid Schiff reaction plus Alcian Blue staining for a mucopolysaccharide search were used 8 years after the operations. RESULTS: In all but one case, redo surgery was successful. Characteristic coordinated multihaustral propulsive movement developed in the distal colonic segment, playing a secondary but active role in the final phase of swallowing in isoperistaltic substitution. These grafts were free from gastrocolic reflux. Augmentation of neutral mucopolysaccharide was observed on the surface and in the Lieberkühn glands of colonic mucosa. CONCLUSIONS: This experience attests that the majority of late complications following colonic esophageal substitution may be corrected by revisional surgery. The predominantly automatic propulsive movements of the isoperistaltically interposed grafts seem to provide an effective antireflux barrier against the gastrocolic reflux if some technical requirements (high gastric anastomosis, good gastric drainage, etc.) are respected. The graft mucosa showed signs of a positive adaptation. The best functional results were achieved by isoperistaltically interposed left colic transplants, which may be considered as an ideal graft (both technically and functionally) in extensive caustic strictures.

[Emergency video-assisted thoracoscopic surgery for intrathoracic foreign bodies]. / Sürgos videothoracoscopos mutéttel eltávolitott melluri idegentestek.

The aim of this retrospective study is to highlight the advantages of video-assisted thoracic surgery (VATS) in the assessment of thoracic trauma. In the past 4 years 3 patients had intrapleural or intrapulmonary Kirschner needles which penetrated from the site of a previous humeroscapular osteosynthesis and one patient with a gunshot projectile and haemothorax in the left thorax. They were treated by VATS removal of intrathoracic foreign bodies. No complications developed postoperatively, the chest wall pain was minimal, the duration of hospital stay (3-5 days) and recovery was short. The widespread use of minimal invasive VATS procedure is an alternative approach that provides safe and less invasive operation for acute chest trauma patients. We believe that its extended use for both diagnostic and therapeutic purposes even in some special circumstances is justified today.