[First experience with robotic-assisted colorectal surgery]. / A robotasszisztált kolorektális onkológiai sebészet elso tapasztalatai.

Robot-assisted surgery has been available at the National Institute of Oncology since 2022. We report on the most important parameters of the colorectal robot-assisted surgery of the first 191 patients. Robotically assisted rectal surgery was compared with our previous laparoscopic and open surgical activities. Perioperative indicators of rectal cancer patients operated laparoscopically (n=225) and open (n=213) were retrospectively compared with patients operated robotically assisted (n=140). In comparison of the three groups (laparoscopic, open, robot-assisted), robotic surgery shows a significant advantage in quality of mesorectal excision (complete TME rate 77%, 72.7% and 90%, respectively), in the days of care (median 7, 9 and 5 days, respectively), hospital readmissions (8%, 16%, 6.4%), and the rate of sphincter preservation (68%, 60% and 89.5%). As a conclusion, robotic surgery is sufficiently safe from oncological point of view. It has a significant advantage in quality of lymph node dissection, shorter care, fewer hospital readmissions, partially lower morbidity rate and a higher sphincter preservation rate compared to laparoscopic and open surgeries.

Hasfalat infiltráló coecum tumor eltávolítása komplett mesocolicus excisióval, hasfali resectióval és musculus tensor fasciae latae musculocutan lebenyes rekonstrukcióval.

A korai és lokálisan elorehaladott colontumorok esetében a megfelelo onkológiai minoségu sebészi resectio a kezelés központi eleme. Jobb oldali vastagbél tumorok sebészi ellátásában - a kedvezobb hosszú távú onkológiai eredmények elérése céljából - egyre szélesebb körben elfogadott a Hohenberger által 2009-ben elsoként publikált "complett mesocolicus-excisio" (CME) és centrális érlekötés (CVL).Esetünkben egy 78 éves nobeteg jobb alhasi faeculens váladékozása miatt indult kivizsgálása során a hasfalat szélesen infiltráló coecum tumor igazolódott. Az Onkoterápiás Bizottság - tekintettel az egyértelmu távoli áttét hiányára, a beteg jó általános állapotára, a fennálló colo-cutan sipolyra és egyértelmu irresecabilitási jelek hiányára - mutétet javasolt. A kuratív intenció és kello radikalitás érdekében, komplett mesocolicus excisio és kiterjesztett hasfali resectio mellett döntöttünk. A mutét során a kialakult hasfali defektus rekonstrukciójához a jobb comb lateralis felszínérol tensor fasciae lateae musculocutan (TFL) lebenyt preparáltunk. A hasfali defektust, mind a fascia, mind a subcutis-cutis rétegében helyreállítottuk, a donor területet primeren zártuk. A posztoperatívumban a lebeny distalis végén vénás pangás jelei majd felületes necrosis mutatkozott. Sorozatos necrectomia és negatívnyomás-terápia (NPWT) mellett a hasfal végig intakt maradt és per secundam gyógyult.Megfelelo betegszelekció esetén, centrumokban elvégezve - onkosebész és helyreállító plasztikai sebész szoros együttmuködésével - a radikális mutét kiterjesztett hasfali resectiót igénylo jobb colonfél tumoroknál is biztonsággal elvégezheto.

Corrigendum: High Neutrophil-to-Lymphocyte Ratio (NLR) and Systemic Immune-Inflammation Index (SII) are Markers of Longer Survival After Metastasectomy of Patients With Liver-Only Metastasis of Rectal Cancer.

[This corrects the article DOI: 10.3389/pore.2022.1610315.].

High Neutrophil-To-Lymphocyte Ratio (NLR) and Systemic Immune-Inflammation Index (SII) Are Markers of Longer Survival After Metastasectomy of Patients With Liver-Only Metastasis of Rectal Cancer.

Background: The literature data regarding colon cancer patients with liver-only metastases (CLM) show that NLR determined before metastasectomy is a prognostic marker of shorter relapse-free survival (RFS), but no results has been reported to date for rectal cancer patients with liver-only metastases (RLM). This study aimed to investigate the NLR and SII in CLM and RLM. Methods: Relapse-free (RFS) and overall survival (OS) were evaluated in 67 CLM and 103 RLM patients with a median follow-up of 46.5 and 59.8 months, respectively. Pre- and/or postoperative chemotherapy ± targeted treatment was applied in 96% and 87% of CLM and RLM patients, respectively. The cut-off level for hematologic parameters were determined by receiver operating characteristic (ROC) analysis. Univariate analysis was performed by Kaplan-Meier method and log rank test. For multivariate analysis Cox regression was applied. Results: In univariate analysis low NLR (cut-off 2) and SII (535) were predictors of longer RFS in case of CLM (p < 0.01). In contrast, for RLM high NLR (2.42) and SII (792) were predictors of longer RFS (p < 0.001). For RLM both NLR and SII proved to be independent markers of RFS (HR 0.66 (95% CI 0.52-0.84) and 0.73 (0.57-0.91), respectively) and OS (0.76 (0.58-0.99) and 0.66 (0.5-0.87), respectively). Only NLR (1.44 (1.04-1.99)) was independent marker of RFS for CLM. The preoperative treatment has not influenced the role of NLR or SII. Conclusion: In contrast to CLM, in RLM the high NLR or SII determined before metastasectomy proved to be independent prognostic factors of longer RFS and OS.

[Comparison of open and laparoscopic minor liver resections for malignant tumours - based on the experience of the first 50 cases]. / Malignus májdaganatok miatt végzett laparoszkópos minor reszekciók eredményei az elso 50 eset kapcsán.

INTRODUCTION: Laparoscopic resection of liver malignancies is gaining acceptance. Besides the advantages of minimally-invasive techniques, publications so far show no oncologic compromise of laparoscopy. AIM: Our aim was to compare the results of our first fifty laparoscopic minor liver resections with traditional open procedures. METHOD: We investigated laparoscopic and open minor liver resections performed in our institute between 01. 01. 2013 and 31. 03. 2017. Data were analysed retrospectively. Resection of maximum two segments was considered a minor resection. We compared the number of resected segments, intraoperative blood loss, operative time, 30 day morbidity and mortality, hospital stay, R1 resection ratio and resection margin width. RESULTS: During the given period, 123 open and 55 laparoscopic minor liver resections of malignant liver tumours were performed. Open and laparoscopic groups were similar considering age, sex and health status. The ratio of bi-segmentectomies was significantly higher in the open group (p<0.001). Operation time (p = 0.91) and peri-operative transfusion ratio did not differ in the two groups (p = 0.102). 30 day morbidity and mortality were consistent (p = 0.50; p = 0.34), but patients in the laparoscopic group spent shorter time in hospital (p = 0.0001). The average width of resection margins and the ratio of R1 resections showed no difference between open and laparoscopic groups (p = 0.447; p = 0.263). CONCLUSION: Our investigation indicates that in malignant liver tumours, laparoscopic resection significantly shortens hospital stay without oncologic compromise, even though 30 day morbidity and mortality does not show difference. We conclude that laparoscopic minor resection of malignant liver tumours is safe and feasible. Orv Hetil. 2019; 160(3): 104-111.

Achieving high quality standards in laparoscopic colon resection for cancer: A Delphi consensus-based position paper.

AIM: To investigate the rate of laparoscopic colectomies for colon cancer using registries and population-based studies. To provide a position paper on mini-invasive (MIS) colon cancer surgery based on the opinion of experts leader in this field. METHODS: A systematic review of the literature was conducted using PRISMA guidelines for the rate of laparoscopy in colon cancer. Moreover, Delphi methodology was used to reach consensus among 35 international experts in four study rounds. Consensus was defined as an agreement ≥75.0%. Domains of interest included nosology, essential technical/oncological requirements, outcomes and MIS training. RESULTS: Forty-four studies from 42 articles were reviewed. Although it is still sub-optimal, the rate of MIS for colon cancer increased over the years and it is currently >50% in Korea, Netherlands, UK and Australia. The remaining European countries are un-investigated and presented lower rates with highest variations, ranging 7-35%. Using Delphi methodology, a laparoscopic colectomy was defined as a "colon resection performed using key-hole surgery independently from the type of anastomosis". The panel defined also the oncological requirements recognized essential for the procedure and agreed that when performed by experienced surgeons, it should be marked as best practice in guidelines, given the principles of oncologic surgery be respected (R0 procedure, vessel ligation and mesocolon integrity). CONCLUSION: The rate of MIS colectomies for cancer in Europe should be further investigated. A panel of leaders in this field defined laparoscopic colectomy as a best practice procedure when performed by an experienced surgeon respecting the standards of surgical oncology.

Laparoscoppal végzett subtotalis gyomorresectio Roux-en-Y szerinti rekonstrukcióval, antralis gyomoradenocarcinoma miatt.

UNLABELLED: A 35-year-old female presented with epigastric symptoms and fatigue. Gastroscopy revealed a 2 cm ulcerated lesion in the antrum region. Biopsy confirmed an invasive intestinal type adenocc. Staging CT and EUS: cT2cN0cM0. Laparoscopic subtotal gastric resection + modified D2 lymphadenectomy was performed with Roux-en-Y reconstruction of the alimentary tract. Mobilisation of the duodenum and stomach was performed with a 5 mm Ligasure. Distal and proximal resection was performed using Endo GIA 60 mm staplers. We performed a modified D1 lymphadenectomy including the region of the coeliac axis, splenic artery and the hepato-duodenal ligament. A side-to-side retrocolic loop gastro-jejunostomy was fashioned using Endo GIA. To transform the loop jejunostomy to a Roux-n-Y setting, the efferent loop of the jejunum was divided using Endo GIA, while the open end of the stomach was sealed with this same stapler line. This way, the loop anastomosis was fashioned into Roux-Y. The end-to-side jejuno-jejunostomy component of the Roux-Y anastomosis was performed through the specimen extraction site with hand-sewn technique. Duration of surgery: 200 min. Blood loss: 100 ml. The postop period was uneventful, and the patient was discharged on day 9. HISTOLOGY: Invasive intestinal type adenocc., 27 mm diameter, pT1bpN0, HER2 2+. DISCUSSION: Laparoscopic subtotal gastric resection with Roux-Y reconstruction is feasable without oncologic compromise and with excellent functional results in early gastric cancer.

Decreased functional activity of multidrug resistance protein in primary colorectal cancer.

BACKGROUND: The ATP-Binding Cassette (ABC)-transporter MultiDrug Resistance Protein 1 (MDR1) and Multidrug Resistance Related Protein 1 (MRP1) are expressed on the surface of enterocytes, which has led to the belief that these high capacity transporters are responsible for modulating chemosensitvity of colorectal cancer. Several immunohistochemistry and reverse transcription polymerase chain reaction (RT-PCR) studies have provided controversial results in regards to the expression levels of these two ABC-transporters in colorectal cancer. Our study was designed to determine the yet uninvestigated functional activity of MDR1 and MRP1 transporters in normal human enterocytes compared to colorectal cancer cells from surgical biopsies. METHODS: 100 colorectal cancer and 28 adjacent healthy mucosa samples were obtained by intraoperative surgical sampling. Activity of MDR1 and MRP1 of viable epithelial and cancer cells were determined separately with the modified calcein-assay for multidrug resistance activity and sufficient data of 73 cancer and 11 healthy mucosa was analyzed statistically. RESULTS: Significantly decreased mean MDR1 activity was found in primary colorectal cancer samples compared to normal mucosa, while mean MRP1 activity showed no significant change. Functional activity was not affected by gender, age, stage or grade and localization of the tumor. CONCLUSION: We found lower MDR activity in cancer cells versus adjacent, apparently, healthy control tissue, thus, contrary to general belief, MDR activity seems not to play a major role in primary drug resistance, but might rather explain preferential/selective activity of Irinotecan and/or Oxaliplatin. Still, this picture might be more complex since chemotherapy by itself might alter MDR activity, and furthermore, today limited data is available about MDR activity of cancer stem cells in colorectal cancers. VIRTUAL SLIDES: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1675739129145824.

[Surgical treatment of retroperitoneal sarcomas]. / A retroperitoneális sarcomák sebészi kezelése.

Retroperitoneal sarcomas make up 0.15% of all solid tumors. The mainstay of their treatment is surgical resection, though the removal of the often sizable tumors may pose serious challenge to surgeons. There is no clear-cut recommendation for neoadjuvant, nor for adjuvant treatment so far. We collected the data and recommendations concerning the attributes and the treatment options for retroperitoneal sarcomas. Mainly we focused on the possibilities and the recent change in tactics of surgery. There is no prospective randomized study dealing with surgical treatment of retroperitoneal sarcomas. According to data in the literature the en-block R0 resection along with all the possibly involved neighboring organs offers the best chance for cure. The greatest problem is to define the required resection margin which is needed for R0 resection. Radio- and/or chemotherapy can be used for diminishing the possibility of tumor recurrence. The greatest risk factors for recurrence are incomplete resection, high grade tumor, and non-liposarcoma type histology. Survival depends on local recurrence rather than on distant metastases. Retroperitoneal sarcomas are ideally treated in sarcoma centers, where multidisciplinary consultation is available and complex treatment plans can be set. Complete recovery can be achieved with radical surgical excision. The chance for R0 resection is enhanced by chemo- and radiotherapy.

[Laparoscopic appendicectomy in 2013--a barely tolerated procedure turning into a gold standard operation?]. / Laparoscopos appendectomia 2013-ban - hogyan vált egy megturt mutét gold standard beavatkozássá?

INTRODUCTION: Laparoscopic appendectomy is one of the first developed minimally invasive surgical procedures, nevertheless its judgement is contradictory up to the present day as far as its advantages and indications are concerned. METHODS: The authors of this article give an overview and analyse the relevant literature concerning laparoscopic appendectomy and the data of patients on whom appendectomy was performed from 01/01/2005 to 30/09/2013 with laparoscopic and open technique. RESULTS: At the Surgical Department of the Uzsoki Hospital 1214 patients had appendectomy because of acute appendicitis from 01/01/2005 to 30/09/2013. The applied surgical procedure was laparoscopy with 1065 patients (87.73%) and the open technique with 149 patients (12.27%). Since January 2006 our main principle has been that in case of appendicitis the primary technique to be applied is laparoscopic appendectomy. We were forced to conversion with 16.5% of patients and as the operational experience of the department grows, the proportion of conversions tends to decrease. CONCLUSION: The advantages of laparoscopic appendectomy as opposed to open surgery have become obvious in the past decade, and the procedure may be recommended for all age groups. In case acute appendicitis is suspected the primary procedure to be applied in our department is the laparoscopic operation, the results of which are at least as good as that of open appendectomy. The routine application of laparoscopic appendectomy provides an excellent basis for the acquisition of advanced laparoscopic surgery thus appendectomy will not lose its training character due to the laparoscopic approach.

[Evolution of sentinel lymph node biopsy in breast cancer--axillary staging in the past 15 years at the Uzsoki Street Hospital]. / Hová tartasz sentinelbiopszia, avagy az elmúlt 15 év gyakorlata az axilla ellátásában az Uzsoki Utcai Kórházban.

INTRODUCTION: Sentinel biopsy technique was performed in Europe in 1996.It was a great improvement in the surgical treatment of breast cancer, it decreased the number of patients suffering from early and late morbidity following axillary lymph node dissection (ALND). In our paper we demonstrate the evolution of sentinel biopsy technique (SLNB), as well as the changes in our policy on axillary treatment in line with the European trends. METHODS: The authors of this article give an overview and analyse the relevant literature concerning sentinel lymph node biopsy and data of patients on whom sentinel lymph node biopsy was performed from 01/01/2001 to 31/12/2012. RESULTS: Between 2001 and 2013 we performed 3756 breast operations, 2742 of those were done for malignant disease. Altogether we performed 744 sentinel lymph node biopsies in the Uzsoki teaching Hospital. The proportion of SLNB patients is increasing, it was 24.6% between 2001-2006 and 29.2% between 2007-2012, respectively. The indication of SLNB is widening, there might be justification of the technique even by multifocal or multilocular disease, in male patients, after former breats surgery or even in pregnant patients. CONCLUSION: Histological examination of sentinel lymph node and its effect on complex treatment of breats cancer may place the role of surgical axillary staging in a brand new aspect in the near future perhaps.

[Preoperative chemotherapy in the surgical treatment of colorectal liver metastases]. / Preoperatív kemoterápia a colorectalis májáttétes betegek sebészi kezelésében.

INTRODUCTION: The only curative treatment of colorectal liver metastases (CRLM) is surgical resection. Preoperative/neoadjuvant chemotherapy can be used for resectable, for borderline resectable or even for irresectable CRLM patients. PATIENTS: Data of CRLM patients treated with surgical resection at the Uzsoki Hospital were analysed. Patients were classified into two groups, (A) who received preoperative chemotherapy before hepatic resection, and (B) who received no chemotherapy before resection. RESULTS: Between 01.01.2007. and 31.12.2010. 128 CRLM patients were treated with hepatic resection. 68 patients (53%) received chemotherapy before hepatic resection, 60 patients (47%) were resected without neoadjuvant chemotherapy. There was no significant difference in the complications between the groups (p = 0.39). Median overall survival was 41 months. The progression free survival (PFS) at 3 and 5 years were 25%, the 3 and 5 year overall survival (OS) were 55% and 31%. Both PFS and OS were significantly worse in the chemotherapy group (p = 0.014, p = 0.015). The subgroup of patients receiving bevacizumab containing preoperative chemotherapy has significanly better PFS than patients receiving only cytotoxic chemotherapy (p = 0.004). CONCLUSION: Surgical resection of CRLM patients results good survival data even in non-selected patients, although the very long survival results reported in the literature couldn't have been reproduced in this patient population. When preoperative chemotherapy was combined with bevacizumab, survival was similar to the upfront resected patients.

[Latest indications for hanging manoeuvre in liver surgery]. / A hanging manover újabb indikációi a májsebészetben.

By definition the liver hanging manoeuvre (LHM) means that a slip is passed between the liver parenchyma and the inferior vena cava. It was first published by Belghiti in 200l, and several changes in the indication as well as in the method have been published since then. In parallel, the anatomical and histological basis has been clarified for LHM, too. According to general consensus LHM increases safety and radicality of liver surgery. Initially LHM was applied for removal of huge tumours infiltrating the diaphragm. Authors worked out two modifications for LHM. Tumours / primary or secondary / in segment IVA are sometimes located in close proximity to the median hepatic vein and inferior vena cava , and the resectability of these tumors can determined by the hanging manoeuvre. Tumors in segment VII can be removed by partial resection of vena cava facilitated by LHM. Four patients with LHM are discussed, and based on this limited experience as well as the latest observations from relevant literature the authors claim that LHM increases the safety of resections from segment IVA and VII. Vascular infiltration of the vena cava is always a technical challenge, which can be suspected on preoperative imaging modalities, but in borderline cases only the intraoperative ultrasound and surgical judgment together with LHM would lead to the exact diagnosis and makes the resection possible.

Binding of trastuzumab to ErbB2 is inhibited by a high pericellular density of hyaluronan.

Although trastuzumab is an efficient drug, primary and acquired resistance is a challenging problem. The authors have previously shown in mouse xenograft experiments that masking ErbB2 by hyaluronan leads to diminished binding of the antibody and consequent resistance. In the current work, they correlated trastuzumab binding with the pericellular density of hyaluronan in ErbB2-overexpressing human breast cancer samples. A method for quantifying the relative binding of trastuzumab was developed involving constant and low-frequency background subtraction, segmenting the image to membrane and background pixels followed by evaluation of trastuzumab fluorescence, normalized with the expression level of ErbB2, only in the membrane. The normalized binding of trastuzumab showed a negative correlation with the pericellular density of hyaluronan (r = -0.52) with the effect being the most pronounced in the extreme cases (i.e., low and high hyaluronan densities predicted strong and weak binding of trastuzumab, respectively). Removal of hyaluronan by hyaluronidase digestion unmasked the trastuzumab binding epitope of ErbB2 demonstrated by a significantly increased normalized binding of the antibody. The results show that the accumulation of pericellular hyaluronan plays a crucial role in masking ErbB2.

Transverse hepatectomy: a 14-years experience.

BACKGROUND/AIMS: Transverse hepatectomy, removal of hepatic segments IVB, V, VI, (III) in continuity with the gallbladder through the transverse portal plane, was first introduced by Paul Sugarbaker in 1990. In 1995 the first transverse hepatectomy in Hungary was carried out by our workgroup. This article summarizes our experience with transverse hepatectomies during the period from 1995 to 2008. METHODOLOGY: During this time 72 trisegmentectomies were performed 22 out of these operations were transverse hepatectomies. RESULTS: The average resection time for transverse hepatectomy was 1 hour and 20 minutes, there was an average 0.8 unit blood transfusion requirement per patient, the average exclusion time was 20.6 minutes, the average time spent in hospital postoperatively was 10.1 days and there were 2 perioperative deaths due to sepsis and hemorrhagic shock. CONCLUSIONS: In our experience transverse hepatectomy proved to be a bloodless, relatively easy procedure, which enables safe removal of the antero-lateral segments. This new type of major hepatic resection is very useful in metastasis surgery and has minimal associated morbidity and mortality.

[From project-based sample collection to biobank]. / Projektalapú mintagyujtéstol a biobankig.

The research group takes samples for molecular genetical examinations from tumors removed during operations within ischemic time interval. Samples are stored in liquid nitrogen. Clinical data of these patients are recorded in an informatics system developed by the group. Patients are followed in an out-patient clinic set up for this purpose not financed by the National Health Insurance Fund. Tissue samples and follow up data are used to cooperate with molecular genetical laboratories.

[Laparoscopic resection of a mesenteric cyst]. / Mesenterialis cysta laparoszkópos exstirpációja.

Mesenteric cysts are rare intraabdominal tumors, which cause plain symptoms. Despite the modern imaging techniques, the correct preoperative diagnosis is difficult. The optimal treatment is surgical excision of the cysts with open surgery, laparoscopy, or even retroperitoneoscopy. Surgical excision needs to be considered in case of complaints, growing cyst, or suspicion of malignancy. Indications for urgent surgery treatment are: bleeding, volvulus, torquation or ileus. Most frequently, mesenterial cysts are diagnosed during the operation of an unknown palpable abdominal cystic resistance. We present a case of a 32-year-old female patient with a jejunal mesenteric cyst, treated by laparoscopic resection. Postoperative period was uneventful, and after an early discharge the patient's recovery was free of symptoms. Histopathological examination revealed a benign cyst. We conclude that laparoscopic resection of abdominal cysts with unknown origin is a safe operation and can be recommended.

[Repeat resection of the liver--a challenge in modern oncologic surgery]. / Ismételt májresectio, a modern daganatsebészet egyik kihívása.

Surgical and oncological treatment of liver metastases of CRC has made a significant progress in the last twenty years. Although chemotherapy has developed enormously, only successfully resected (R0) patients may hope a long-term survival. The almost 60% recurrence rate after resection is a significant challenge. Authors review patients data operated at the Surgical Department of Uzsoki Teaching Hospital between 1995 and 2008 with hepatic metastases of colorectal origin. Oncological and surgical principles are summarized in the sight of the recent literature review and authors own experience with repeat hepatic resection. Recent literature data demonstrate--which is confirmed by our experience--that R0 resection of recurrent hepatic metastases provides similar overall 5 year survival rate than that of patients who underwent a single resection only. In the case of recurrent CLM, the oncoteam should prepare a surgically resectable situation.