[Awaiting completion: Definitions missing in action]. / Elvégzetlen feladataink: hiányzó definícióink.

Bevezetés: Egy, a sebészetben alkalmazott leggyakoribb fogalmaknak szentelt cikksorozat bevezeto tanulmánya ez. A látszólag egyértelmu definíciók vizsgálatakor kiderül, hogy vagy egyáltalán nem is léteznek, annyira maguktól értetodok (pseudoaxiomák), vagy olyan sok van belolük, hogy nincs igazi. A javasolt definíciók munkapéldányok, további javításra várnak. Az elso két javaslatot tesszük közzé: a sebészet és a kompetencia kérdésében. A sebészet fogalma: A sebészet a medicina azon válfaja, melynek megkülönbözteto tulajdonsága, hogy szövetegyüttesi szintu sértés révén, azaz a testet alkotó strukturális elemeket eltávolító/átalakító módokat alkalmaz célja elérésében: a kórismézésben és a kezelés nyújtásában. A sebészi kompetencia fogalma: A sebészeti kompetencia az állam mint közhatalom által hitelesített bizonyított cselekvokész tudásösszesség birtoklása, kerete a szakvizsga. Konklúzió: A tiszta, egyértelmu definíciók hiánya akadályozza a tudományos és szakmai diskurzust. Megalkotásuk, elfogadásuk közmegegyezés kérdése. További kísérletek következnek.

Emlorák hasüregi áttétei - Egy szokatlan entitás klinikopatológiai jellemzoi.

Case report: A sixty-five-year-old female patient underwent surgery for severe gastrointestinal symptoms, following an alarming CT image. Laparotomy revealed irresectable gastric cancer and peritoneal carcinosis. Palliative gastro-jejunostomy and ileo-descendostomy were performed. The endoscopic diagnosis - linitis plastica - and the intraoperative macroscopic appearance matched and agreed on the histologically presumed shigillocellular carcinoma. Three years following the initial abdominal symptoms, histological samples taken from newly detected cutaneous metastases which developed during oncological palliative treatment verified occult lobular breast carcinoma. Histological revision of the sample taken from abdominal exploration confirmed the latter diagnosis. The hormone receptor positive, human epidermal growth factor receptor-2 negative malignancy showed very good regression for the palliative hormone treatment. Discussion: About ten percent of breast cancer cases are lobular carcinomas, which are more often multicentric, bilateral, occult and have a propensity to metastasize to serous membranes, abdominal and pelvic viscera. Due to the increasing survival of breast cancer patients, the number of abdominal metastases of breast cancer is expected to increase. Histological confirmation is indispensable even in case of advanced abdominal malignancies, especially in the case of an unusual medical history. The currently rare case demonstrates the need for multidisciplinary cooperation in all diagnostic and therapeutic fields of breast cancer.

Furtive small bowel perforation after blunt abdominal trauma / Lopakodó vékonybél-perforatio: sebészi csapda

A rare case of delayed jejunal perforation is reported, with a time window of approximately five hours. The diagnosis is challenging: there are no proper protocols, planned early physical examination checkups are advised. The forensic medical aspects of the occasional therapeutical delays are remarkable.

Complex oncologic therapy for loco-regionally advanced breast cancer associated with long-lasting SARS-CoV-2 PCR-positivity / Tartós SARS-CoV-2-PCR-pozitivitáshoz társuló, lokoregionálisan elorehaladott emlodaganat komplex onkológiai kezelése.

Összefoglaló. A COVID-19 mortalitását a súlyos társbetegségek, közöttük bizonyos daganatos betegségek is növelik. Immunszuppresszív hatásuk miatt felmerülhet a citotoxikus kezelések rizikónövelo hatása is. Ugyanakkor az onkológiai terápia megszakítása vagy halasztása, különösen az agresszívebb, kiterjedtebb és fiatalkorban jelentkezo daganatok esetében ronthatja a kórjóslatot. Egy 39 éves nobeteg esetét ismertetjük. A járvány során késlekedve felismert, lokoregionálisan kiterjedt emlodaganat miatt primer szisztémás kemoterápiában részesült. A kezelés 5. ciklusa során enyhe légúti tünetek kapcsán, az onkológiai ambulancián SARS-CoV-2-fertozése igazolódott. Kemoterápiás kezelését felfüggesztettük. A diagnózistól számított 3. napon tünetmentessé vált, ám SARS-CoV-2-PCR-pozitivitása még a 43. napon is fennállt. A 19. napon hormongátló kezelést indítottunk. Az 51. napon mastectomia és axillaris block dissectio történt. A 82. napon a megszakított kemoterápiát a hormongátló kezelés leállítását követoen G-CSF-profilaxis mellett újraindítottuk. A kezelés során fertozéses szövodményt nem észleltünk. Kemoterápia és mutét SARS-CoV-2-fertozött, tünetmentes daganatos betegnél szövodménymentesen végezheto elhúzódó virológiai pozitivitás esetén, felszabadító vizsgálat nélkül is. A daganatos betegek koronavírus-fertozése esetén az onkológiai protokolltól történo eltérés egyénre szabott optimalizálásával és a multidiszciplináris team szorosabb együttmuködésével az infektológiai és az onkológiai kockázat együttes alacsonyan tartása is megvalósítható. Orv Hetil. 2021; 162(16): 611-614. Summary. Mortality of COVID-19 is increased when certain co-morbidities, among others advanced malignancies are present. Deleterious effect of cytotoxic therapy, related to its immunosuppressive effect, may also be hypothesised. However, postponing or cancelling oncologic treatment, especially in younger patients with advanced and more aggressive tumors may worsen the prognosis. The case of a 39-year-old female patient is presented, who was diagnosed with loco-regionally advanced breast cancer during the pandemic. Primary systemic chemotherapy was started. The patient presented with acute respiratory tract symptoms during the fifth cycle and subsequently SARS-CoV-2 infection was diagnosed. Chemotherapy was cancelled. Symptoms resolved in three days after diagnosis. SARS-CoV-2 PCR remained positive up to day 43. Antihormonal therapy was introduced on day 19 and she underwent mastectomy with axillary lymph node dissection on day 51. Chemotherapy was reset postoperatively on day 82 with prophylactic G-CSF protection. No adverse event was observed throughout the treatment. Cytotoxic chemotherapy and surgery can be successfully delivered in breast cancer patients with prolonged asymptomatic SARS-CoV-2 PCR positivity, even without negative swab result. Individual optimisation of the therapy may require deviations from standard protocols. Closer multidisciplinary cooperation may contribute to the minimisation of both oncologic and infectious risks. Orv Hetil. 2021; 162(16): 611-614.

Surgical staplers: definitions and functions / Sebészeti varrógépek: definíciók és fogalomtár

Definition and systemic review of the different surgical staplers are offered in a comprehensive manner. Improved efficacy in tender decisions, better understanding and usage of clear categories are the main targets of the present overview.

Perioperative nutritional state as a surgical risk in oncologic patients / A perioperatív tápláltsági állapot mint kockázati tényezo az onkológiai sebészetben.

Összefoglaló. Bevezetés: A tumorsebészetben a malnutritio független rizikófaktor. A kockázatcsökkentés egyik fontos eleme a perioperatív tápláltsági állapot felmérésén alapuló klinikai táplálás. Az irodalomban jól dokumentált az idoben végzett rizikószurés fontossága, de ennek módja, különösen hazai környezetben, kidolgozatlanabb. Célkituzés: A malnutritio szempontjából esendobb csoportot alkotó onkológiai sebészeti betegek azonosíthatóságának igazolása, a szurési metódus vizsgálata. Módszer: 2016. október és 2018. november között öt kórcsoportban (emlo, máj, pancreas, mellkas, gyomor-bél rendszer) az igazolt vagy gyanított malignitás, illetve gyulladásos bélbetegség miatt mutétre váró betegeket telemedicina-módszerrel kerestük fel. A rizikócsoportokat (nincs rizikó - alultápláltság valószínusítheto - súlyos alultápláltság) a sebész és dietetikus által közösen vezetett 'Nutritional Risk Score 2002' (NRS 2002) szuro pontrendszerrel állapítottuk meg. Az NRS 2002 pontértékeket a posztoperatív lefolyással vetettük össze (kórházi tartózkodás, 30 napon belüli szövodmények Clavien-Dindo szerinti osztályozása). Prospektív vizsgálatunkban 1556 beteg szerepel. Eredmények: Az emlosebészeti betegek (n = 314) 95,2%-a rizikómentes. A májreszekcióra várók (n = 79) 43%-a valószínuleg vagy biztosan alultáplált. A hasnyálmirigymutétre elojegyzett betegek (n = 122) 81,2%-a emelt rizikójú. A kuratív célú pancreasreszekción átesett betegek pontértéke alacsonyabb, mint a palliatív mutétben részesüloké (p>0,05). A tüdoreszekcióra váró (n = 219) betegeknél 40,7% került emelt rizikócsoportba. Az emelkedett NRS 2002 érték magasabb szövodményaránnyal járt (p<0,05). Béltraktust érinto mutétek (n = 822) esetén a betegek 71,2%-a valószínuleg vagy biztosan súlyosan alultáplált. Az elorehaladott tumorok és a szövodmények egyaránt eros összefüggést mutattak az NRS 2002 értékkel (p<0,01). Következtetés: Az NRS 2002 szuromódszer prediktív értékkel bír mind a tumorstádium, mind a szövodmények tekintetében. Módszerünkkel idoben felismerheto a fokozott rizikót jelento betegcsoport, így a pontérték alapján célzott mesterséges táplálás tervezheto. Orv Hetil. 2021; 162(13): 504-513. INTRODUCTION: Malnutrition is an independent risk factor in oncologic surgery. Perioperative screening and aimed clinical nutrition are key elements in risk reduction. The importance of timely screening has been well published, but its method is underdeveloped, especially in Hungary. OBJECTIVE: Evaluation of a malnutrition screening method to identify patients at risk in oncologic surgery. METHOD: Patients were enrolled from October 2016 to November 2018 in five groups (breast, liver, pancreas, thoracic and gastrointestinal surgery). All patients awaiting surgery for suspected or proven malignancy or for inflammatory bowel disease were screened preoperatively via telephone (telemedicine). Probability for malnutrition (no risk - suspicion for malnutrition - severe malnutrition) was jointly assessed by surgeon and dietitian using Nutritional Risk Score 2002 (NRS 2002). Screening results were compared to the postoperative course (including length of stay and 30-day morbidity/mortality using Clavien-Dindo classification). A total of 1556 patients were identified prospectively. RESULTS: 95.2% of breast surgery patients (n = 314) were not at risk. Malnutrition was suspected or detected in 43% of patients awaiting liver resection (n = 79). Increased risk is present in 81.2% of pancreatic surgery cases (n = 122). Pancreas resections with curative intent were associated with lower scores than in palliative operations (p>0.05). 40.7% of the 219 patients scheduled for lung resection had increased malnutrition risk. Higher NRS 2002 resulted in increased morbidity rate (p<0.05). Surgery on the intestines was performed on 822 cases. 71.2% of them had suspected or severe malnutrition. Presence of advanced cancer and complication rate showed strong relations with increased NRS 2002 (p<0.01). CONCLUSION: Screening with NRS 2002 has predictive value on both tumor stage and complications. Our method is sound to identify patients at malnutrition risk in time, and thus an aimed clinical nutrition therapy can be planned. Orv Hetil. 2021; 162(13): 504-513.

[Diagnosis and management of blunt pancreatic trauma]. / Tompa pancreastrauma diagnózisa és kezelése.

The management of thoracic and abdominal organ injuries has very thorough and extensive literature, including evidence-based protocols. Pancreatic trauma stands as an exception. Blunt or penetrating trauma of the pancreas is rather rare (less than 2% of all trauma cases, approximately 3-12% of all abdominal trauma), leading to the lack of high-level evidences regarding its treatment. Damage of the pancreas parenchyma can cause substantial morbidity and mortality, therefore it is essential to separate cases where conservative treatment suffices from those that need surgical approach. This study aims to review the conclusions of relevant articles of the past decades concerning the management of both adult and childhood pancreatic trauma. Classifications and their reliability are revised. We enlist scaling systems that can help in making decision whether to operate or to treat conservatively, from physical examination to diagnostic measures and complications. To date, the treatment principles of pancreatic trauma are not based either on prospective or on randomised trials. The database search of studies retrieved only retrospective and/or small case cohorts, case reports and expert opinions (levels 4 and 5 of evidence). However, it is a generally accepted conviction that the damage of the main pancreatic duct determines if the pancreatic injury is of low or high grade. Available classifications are based on the same principle. Conservative treatment is feasible given that the patient is hemodinamically stable and the pancreatic duct is unimpaired. If duct lesion is discovered, adult cases are to be treated with minimally invasive (percutaneous or endoscopic) measures or surgically (including reconstruction, resection and drainage). The management of childhood injuries has controversial literature. Many arguments can be enumerated on the operative as also on the non-operative approach, this confusion is to be clarified in the future. The highest morbidity rates are derived from the late diagnosis of the pancreatic duct, while increased mortality is seen in the polytrauma patient groups. Levels 1-2 evidence-based recommendations are needed, but planning of strong trials is critically limited due to the small number of cases and the heterogeneity of the relevant patient groups. Orv Hetil. 2018; 159(2): 43-52.

[Review of evidence-based modern treatment for chylothorax]. / A chylothorax modern kezelésének bizonyítékalapú áttekintése.

Chylothorax is a multi-factorial complication, frequently of an operation or an accident, but rarely of a tumour. In the absence of prospective or randomised studies evidence-based treatment is normally based on personal experience, ideally in the possession of retrospective analyses using the "best practice" method. The aim of the authors was the review the up-to-date chylothorax treatments. They performed the PubMed database's "chylothorax" keyword search of the publications reported in the last ten years. They put emphasis on articles that included a comparative analysis of the various treatment options. During the critical analysis of the methods and recommendations, the authors relied on their own joint experience amounting to 39 years. The results showed that the success of the initial conservative treatment indicates a significant deviation depending on the etiology (3-90%). The success rate of non-invasive or semi-invasive interventions is between 50-100%, again depending on the etiology. The standard surgical treatment following an unsuccessful conservative treatment of an operable patient includes the fitting of a (thoracoscopic) knot to the ductus thoracicus, pleurodesis, insertion of a permanent chest drain or a pleuroperitoneal shunt. The success rate of these interventions is between 64-100%, with a morbidity index and mortality index exceeding 25%. Conservative treatment should be the first step, which should then be followed by a gradually increased aggressive therapy, during which the decisions should be made according to the patient's condition and the drain volume. Interventional radiology procedures are safe, successful and they can be offered concurrently with conservative or operative treatment, although they are available only in a few centres.

[Empyema thoracis, hemorrhagic pericarditis and acalculous cholecystitis caused by Eikenella corrodens sepsis]. / Empyemát, haemorrhagiás pericarditist és acalculosus cholecystitist okozó Eikenella corrodens szepszis.

The authors present a case of a 29-year-old woman who was diagnosed with pneumonia in the left side complicated with pleural effusion and hemorrhagic pericarditis one month after she had undergone tonsillectomy. Eikenella corrodens was identified as pathogenic agent when the empyema was removed during thoracotomy. After the patient was given antibiotic treatment she was discharged from the hospital without any symptoms or complaints. However, one month after she had left the hospital she was readmitted to the surgical unit as an emergency because of acute abdominal complaints. On admission acalculous cholecystitis as well as hemorrhagic pericarditis requiring pericardiocentesis were also observed. A rare cause of sepsis, Eikenella corrodens was identified which resulted in a severe disorder including polyserositis. Pericardiocentesis was performed two times and the patient was given targeted antibiotics and non-steroidal anti-inflammatory drugs. She was also treated with antimycotics as she had developed mycosis. After one month the patient recovered and was discharged from the hospital. No further recurrence of symptoms or complaints was observed during follow up.

[Ethiopathogenesis of spontaneous primary pneumothorax. Marijuana: cause or a blame?]. / A spontán primer légmell aetiopathogenesiséhez. Marihuána: ok vagy bunbak?

OBJECTIVE: There are contradictory data on chronic lung injury caused by marijuana, which is partially due to insufficient basic research. Anecdotic reports draw attention to an increased rate of primary spontaneous pneumothorax (PSP) among young marijuana smokers, suggesting a causative link. METHODS: A retrospective analysis of 20 patients treated for PSP in our department in the last two years was performed. Demographics, treatment modality and outcome data were analysed. Chi-square, Mann-Whitney and Fisher tests were applied for statistical evaluation. Gender distribution: 16 male, 4 female, age 23.95 ± 4,57 years: min: 18, max: 32. 13/20 patients admitted to be regular cannabis users (CU), among them 11 male, 2 female, age 24.54 ± 4.77 years. Altogether 7/20 patients had a history of previous pneumo-thorax, with a higher recurrence rate among CU (odds ratio 1.56). RESULTS: In the non-cannabis user group (NCU) 3/7 patients were managed with thoracic drainage alone. 4/7 NCH patients needed major surgery, VATS was performed on all 4 patients. 4/13 CU patients were managed with thoracic drainage, 9/13 patients needed thoracotomy (8 VATS, 1 open thoracotomy). We found a shorter drainage time among NCU patients (4.00 ± 1.00 days NCU vs 4.5 ± 1.73 days CU, p = 0.651). Operative treatment was needed more frequently among cannabis users (69.23% vs NCU 57.14%, p = 0.651) due to impaired lung expansion. Recurrence was detected in 2 patients after drainage, 1 CU, 1 NCU patients, respectively, both of them were managed with VATS. On histological examination there were no major differences between the two groups, 11/13 of operative cases had pulmonary emphysaema . Based on county demographical and clinical data, there's a higher risk for PSP among cannabis users (odds ratio 3.86). CONCLUSIONS: Despite the small sample size, there seems to be a connection between marijuana use and PSP prevalence. It's unclear if marijuana directly contributes to the development of pneumothorax, or just aggravates a fundamentally fragile lung parenchyma condition. In this group of young patients a more aggressive surgical approach is recommended, considering underlying parenchymal impairment and higher recurrence rate.

[Chest trauma: who, how and what?]. / Mellkasi trauma: ki, hogyan és mit?

A chest-trauma management system, tagged as the "Pécs model" in a tertiary referral center is described with extensive references to the state of the art in thoracic trauma. Chest drainage has utmost importance in primary therapy as well as in surgical decision making (diagnosis). Thoracotomy is a general surgical competence, just as damage control is. Definitive treatment and management of sequelae, however, requires competence in thoracic surgery. Multidisciplinarity is underscored.

[From the surgical field to the microscope. A new tool to identify the lymph node specimens in oncologic surgery]. / A mutotol a mikroszkópig. A rendszerezett nyirokcsomóminták azonosításának új eszköze a ráksebészetben.

Oncologic surgery and pTNM staging require systemic removal of the locoregional lymphnodes. While the optimal extent and therapeutical and/or prognostic value of the lymphadenectomy/sampling are debated organ by organ and (sub)speciality by (sub)speciality, relevance of the lymphnode sytem-tumor concept itself is beyond doubt. Loss of information and existence of traps on the "surgical field-microscope" pathway is an international phenomenon, calling for solution. An integrated sterile and disposable lymphnode tray system is presented here for applications in the different fields of cancer surgery of the upper GI tract, retroperitoneum (gynecology, urology) and ear-nose-throat surgery.

[An extremely rare cause of bilateral tension pneumothorax]. / Különleges eredetu feszülo légmell.

CASE REPORT: A middle-aged man presented with the diagnosis of typical spontaneous pneumothorax in the left chest. His management was initiated as usual with a chest drain and he had an uneventful recovery with good expansion of the affected lung up until the third postoperative day. But due to a fatal accident, the patient connected the oxygene supply tube into his thoracic drain. This high pressure caused a left, and a consequent bilateral pneumothorax with massive subcutanous emphysema, being the cause of a preterminal status. Cardio-pulmonary resuscitation was unsuccesfull and the patient died. Intentional suicide was excluded by forensic investigations. DISCUSSION: According to our knowledge, no similar case with this mechanism of tension pnemuthorax has been published in the literature so far. The pathophysiology is similar to lung damage due to high-pressure ventillation with consecutive tension pneumothorax.

[Role of surgery for lung cancer in elderly patients]. / A mûtét szerepe az idôskori tüdôrák kezelésében.

Lung cancer is a leading cause of death in the civilised world. Surgical resection, which play a crucial role in the complex oncological treatment, has to be offered in older ages than it was done before, due to an ageing population. Results of surgical treatment of patients older than 75 years are investigated retrospectively in the present paper. A retrospectively analysis was carried out of 54 from a total of 884 lung resections for primary lung cancer performed for patients older than 75 years between 1995-2005. Twelve of these patients were above 80 years. Kaplan-Meier analysis was performed to calculate survival and multifactor analysis for the risk factors. Average age was 77.5 years (75-85). Two pneumonectomies, two bilobectomies, 41 lobectomies, seven sublobar resections and two lobectomies with chest wall resections were performed. The average hospital stay was 11.4 days (8-36). Mortality: 7.4% (n = 4), morbidity: 52% (n = 28) including: sputum retention: 43%, arrhythmia 33%, atelectasia: 15%. There were two bronchial stump insufficiencies (4%) and three reoperations were performed (5%). The average follow up was: 32 months and the five year survival 33.7% (median 43 months). Multifactorial analysis show that extended resection, male gender, age above 80 years are risk factors for adverse outcome. Female gender, stage Ia and lobectomy are considered as predictive factors for long survival. We conclude, that with proper patient selection (below ASA3, early stage) and with carefully conducted postoperative care (physiotherapy, monitoring) surgical resection should be offered to elderly lung cancer patients as well.

[Surgical treatment of pulmonary metastases of colorectal cancers]. / A colorectalis tumorok tüdô metastasisainak sebészi kezelése.

INTRODUCTION: Results of a retrospective study of patients who underwent pulmonary metastasectomies after colorectal surgery in the last five years are reported here. Prognostic factors are evaluated and analyzed in the context of current literature. MATERIAL AND METHODS: 37 lung resections were performed in 33 patients between 2001 and 2006, the male:female ratio was 19:14. The average age was 61.3 years (49-76). We analyzed the extent of lung resections, disease free intervals (DFI), laterality of the tumours, number and locations of metastases, lymph node involvements and the incidence of resection of hepatic metastases. Altogether, 20 solitary lung metastases were removed and 17 multiple resections were performed. 25 sublobar resections, 11 lobectomies and one pneumonectomy were carried out. 18 patients had right sided, eight patients had left sided and six patients had bilateral disease. 6 of the 33 patients underwent either synchronous or metachronous liver resection for hepatic metastases. RESULTS: Survivals were calculated by the Kaplan-Meier method. The average DFI was 27.6 months. When all patients were considered, the average survival was 28 months. 52% of the patients had a 3-year postoperative survival, if lung metastases were present only. CONCLUSIONS: Patients benefit from surgical removal of lung metastases of colorectal cancer. There were no differences in survival rates between patients who underwent resection of solitary or multiple lung metastases up to seven deposits. However, the average survival was 12 months shorter if hilar/mediastinal lymph nodes were involved. Furthermore, the average survival of six patients with hepatic metastases was 10 months shorter than the rest of the group. There was no benefit of DFI over 24 months. None of the other prognostic factors showed significant difference.