[Complications of esophageal reconstruction]. / A nyelocsopótlás szövodményei.

Esophageal cancer is the most common cause of esophageal resections. Esophageal replacement is still a significant challenge for surgeons, because complications can be expected in over 50% and death also occurs between 4-7%. Complications can be divided into early and late categories and into general and specific complications. From a surgical point of view, early and late specific complications are the most important aspects. Between 1993 and 2012, 540 esophageal resections were performed due to malignant tumors at the Department of Surgery, Medical Center of the University of Pécs. Stomach was used for replacement in 445 cases, colon in 38 cases, and jejunum in 57 cases. The anastomosis with stomach replacement was located to the neck in 275 cases and to the thorax in 170 cases. The colon was pulled up to the neck in each case. There were 29 cases of free jejunal replacements located to the neck, and 28 cases with a Roux-loop reconstruction located to the thorax. In the case of gastric replacement, anastomotic insufficiency developed in 55 cases, graft necrosis occurred in 8 cases, and early anastomosis stricture developed in 30 cases. These numbers are 3 conduit necrosis and 2 strictures in cases of colonic replacements. There was one anastomosis failure in the case of a thoracic jejunum replacement. Also one conduit necrosis was observed in the free jejunal neck transplantation group. Among late special complications, dysphagia is the most important, the causes of which were found in the order of frequency: anastomotic stricture, conduit obstruction, peptic and ischemic stricture, foreign body, local recurrence, functional causes, new malignant tumor in the esophageal remnant after resection and malignant tumor emerging in the replaced organ. Causes may overlap each other, and their treatment may be conservative, endoscopic or surgical. Surgical treatment is usually the last option to restore the ability to swallow and can present a significant challenge even to experienced centers. Orv Hetil. 2023; 164(7): 243-252.

Dysphagia After Esophageal Replacement and Its Treatment.

Dysphagia occurs temporarily or permanently following esophageal replacement in at least half of the cases. Swallowing disorder, in addition to severe decline in the quality of life, can lead to a deterioration of the general condition, which may lead to death if left untreated. For this reason, their early detection and treatment are a matter of importance. Between 1993 and 2012, 540 esophageal resections were performed due to malignant tumors at the Department of Surgery, Medical Center of the University of Pécs. Stomach was used for replacement in 445 cases, colon in 38 cases, and jejunum in 57 cases. The anastomosis with a stomach replacement was located to the neck in 275 cases and to the thorax in 170 cases. The colon was pulled up to the neck in each case. There were 29 cases of free jejunal replacements located to the neck and 28 cases with a Roux loop reconstruction located to the thorax. Based on the literature data and own experience, the following were found to be the causes of dysphagia in the order of frequency: anastomotic stenosis, conduit obstruction, peptic and ischemic stricture, foreign body, local recurrence, functional causes, new malignant tumor in the esophageal remnant, and malignant tumor in the organ used for replacement. Causes may overlap each other, and their treatment may be conservative or surgical. The causes of many dysphagic complications might be prevented by improving the anastomosis technique, by better preservation the blood supply of the substitute organ, by consistently applying a functional approach, and by regular follow-up.

Modern Breast Cancer Surgery 1st Central-Eastern European Professional Consensus Statement on Breast Cancer.

This text is based on the recommendations accepted by the 4th Hungarian Consensus Conference on Breast Cancer, modified on the basis of the international consultation and conference within the frames of the Central-Eastern European Academy of Oncology. The recommendations cover non-operative, intraoperative and postoperative diagnostics, determination of prognostic and predictive markers and the content of cytology and histology reports. Furthermore, they address some specific issues such as the current status of multigene molecular markers, the role of pathologists in clinical trials and prerequisites for their involvement, and some remarks about the future.

Esophagoplasty with hybrid-supercharged jejunum / Nyelocsopótlás hybrid, supercharged jejunummal

Introduction: In this case report an esophageal resection due to cancer was performed with a primary left colonic replacement, as the stomach was resected previously. Due to graft necrosis, the necrotized section of the colon was removed. One year later a long jejunal segment with a combined blood supply was used for secondary reconstruction. Even after the ligation of three straight branches, the Roux loop was not long enough to reach up to the neck, however the division of the arcade between the 2nd and 3rd straight branches lengthened it satisfyingly. Blood supply to the region of the farthest branch was provided from the internal mammary artery and venous drainage was provided by a saphenous vein graft to the external jugular vein. The continuity of the jejunal graft was preserved. The patient recovered uneventfully. If neither the stomach nor the colon routinely used for esophageal replacement are available due to anatomical reasons, previous surgeries, or complications, jejunal replacement can be the last resort. Jejunum is only suitable for safe esophageal replacement by either free transplantation or by supercharging. The procedure when a combined blood supply is provided for the jejunal replacement was named the hybrid-supercharged method.

[Modern surgical treatment of breast cancer. 4th Breast Cancer Consensus Conference]. / IV. Emlorák Konszenzus Konferencia ­ Az emlorák korszeru sebészi kezelése.

The surgical treatment is still the most effective method in curing of early breast cancer. Breast preservation and the application of oncoplastic principles became generally accepted, the sentinel lymph node biopsy in the surgical treatment of the axilla is primary, and the indication for axillary block dissection (ABD) is narrowing further. The neoadjuvant oncological treatment that is applied more and more widely presented surgery with new challenges. Hereunder we summarise our recommendations on the surgical treatment of breast cancer based on the content of the 3rd Breast Cancer Consensus Conference and considering the latest international studies and professional recommendations.

The effect of trimetazidine in reducing the ischemia-reperfusion injury in rat epigastric skin flaps.

BACKGROUND: Ischemia-reperfusion injury may lead to insufficient microcirculation and results in partial flap loss during the free flap surgeries. OBJECTIVE: This study aimed to investigate the effect of trimetazidine (TMZ) on oxidative stress, inflammation and histopathological changes, using the epigastric skin flap model in rats. METHODS: 40 male Wistar rats were used, that were divided into four groups. Control group, non-treated ischemic (I/R)-group and two trimetazidine treated groups (preischemically, postischemically) were established. To create ischemia in the skin flap, the superficial epigastric vessels were clamped for six hours, followed by twenty-four hours of reperfusion. Blood samples and biopsies from skin flaps were collected at the end of the reperfusion period. The inflammatory response, the degree of oxidative stress (by measuring the plasma level of malondialdehyde (MDA), reduced glutathione (GSH); sulfhydryl (-SH) groups) and histopathological changes were evaluated. RESULTS: Inflammatory response, and oxidative stress were significantly attenuated in the trimetazidine treated groups, compared to the non-treated ischemic group. Histopathological findings were also correlated with the biochemical results. CONCLUSION: In our study trimetazidine could reduce the ischaemia-reperfusion injury, even after an unexpected ischemic period, so it is a promising drug during free tissue transfer, replantation or during revascularization procedures in the future.

[Modern surgical treatment of breast cancer. 3rd Breast Cancer Consensus Conference]. / Az emlorák korszeru sebészi kezelése. III. Emlorák-konszenzuskonferencia.

Therapy for breast cancer today is characterised by ever more precise diagnostic methods and ever more effective oncological treatments, a trend which will certainly continue into the future. Breast preservation and the application of oncoplastic principles are increasingly popular. A sentinel lymph node biopsy in the surgical treatment of the axilla is primary, with the indication for axillary block dissection (ABD) narrowing and radiation therapy becoming an alternative to ABD in certain cases. This publication summarises our recommendations on the surgical treatment of breast cancer based on the content of the 3rd Breast Cancer Consensus Conference and considering the latest international studies and professional recommendations.

[3rd Hungarian Breast Cancer Consensus Conference - Surgery Guidelines]. / III. Emlõrák Konszenzus Konferencia - Az emlõrák korszerû sebészi kezelése.

Therapy for breast cancer today is characterised by ever more precise diagnostic methods and ever more effective oncological treatments, a trend which will certainly continue in the future. Breast preservation and the application of oncoplastic principles are increasingly popular. A sentinel lymph node biopsy in the surgical treatment of the axilla is primary, with the indication for axillary block dissection (ABD) narrowing and radiation therapy becoming an alternative to ABD in certain cases. This publication summarises our recommendations on the surgical treatment of breast cancer based on the content of the 2nd Breast Cancer Consensus Conference and considering the latest international studies and professional recommendations.

[Differential scanning calorimetry of blood plasma in breast cancer patients]. / Emlodaganatos betegek vérplazmájának differenciál pásztázó kalorimetriás vizsgálata.

Breast cancer is the commonest cause of cancer death in women worldwide. Its incidence has been increasing for many years in economically developed countries. Differential scanning calorimetry (DSC) is a thermoanalytical technique which monitors small heat changes between sample and reference materials. This examination is a validly efficient method for the demonstration of structural changes not only in the physical sciences, but in numerous human oncological diseases. The goal of this study was to measure DSC thermogram of blood plasma in breast cancer patients with different stages. Nineteen women with different tumor diameter (0.5-7.5 mm) and with or without regional lymph node metastases were involved in the study. Preoperatively peripheral blood samples were collected from the patients and from healthy controls, and plasma components were analysed by SETARAM micro DSC-II calorimeter. The diameter of the tumor tissue and the number of metastatic lymph nodes were evaluated on the basis of postoperative histological results. In the current study we found difference in changes of the thermal parameters (transition temperature, calorimetric enthalpy) of breast cancer patients' plasma components. Moreover, a tendency has been found for association of these results with tumor size and with the degree of regional lymph node involvement. Preliminary study of the clinical utility of DSC technology arises, even though there is no data in the literature. In cases of breast cancer the blood plasma may be suitable for DSC analysis for diagnosis or staging as well. In order to clarify the relationships we are planning further studies.

[The role of neoadjuvant therapy in the treatment of locally advanced squamous cell cancer of the cervical oesophagus]. / A neoadjuváns kezelés szerepe a nyaki szakaszon elhelyezkedo elorehaladott nyelocsolaphámrákok sebészi kezelésében.

INTRODUCTION: Cervical oesophagus represents a critical location for squamous cell carcinoma, which usually requires extensive surgery (pharyngo-laryngo-oesophagectomy). In the last decade, neoadjuvant chemo-radiotherapy was reported to be beneficial in the treatment of locally advanced squamous cell oesophageal cancer. METHODS: Between November 1997 and January 2012, 55 patients with locally advanced (T3-4) squamous cell oesophageal cancer received preoperative chemo-radiotherapy, where the tumour was localized in the upper third. Patients received preoperative irradiation of 3960 cGy in 180 cGy fractions and simultaneously Cisplatin and 5-FU chemotherapy. Restaging was carried out after four weeks and patients considered operable were underwent surgery. RESULTS: In patients with cervical oesophageal cancer 35 of 55 (64%) underwent oesophageal resection or pharyngo-laryngectomy. In 16 out of 35 resected specimens (46%) complete histopathological remission (pCR) was observed. Perioperative mortality and anastomotic leaks were the same: 5/35 (14%). R0 resection rate was 82% and the 2- and 5 years survival rates were 41% and 18%. In 19 cases a larynx preserving pharyngo-oesophagectomy was performed and a free jejunal graft was used for reconstruction after a pharyngo-laryngectomy in 11 cases. CONCLUSION: The high rate of pCR (46%) confirmed that upper third oesophageal cancer has superior sensitivity to multimodal treatment. In 30 cases neoadjuvant chemo-radiotherapy was able to achieve tumour regression and render pharyngo-laryngo-oesophagectomy unnecessary.

[Reconstruction of the esophagus with plastic surgery techniques]. / Plasztikai sebészeti módszerek alkalmazása a nyelocso helyreállításában.

INTRODUCTION: Various plastic surgery techniques were applied for oesophageal reconstruction in complicated cases. Myocutaneous flaps that are suitable to cover soft tissue defects of the neck may also be transferred and used for partial defects of the cervical oesophagus or securing a vulnerable suture line. Application of microsurgical techniques may also be useful in certain situations. PATIENTS AND METHODS: Pectoralis major myocutaneous flap was used in 5 cases in our department between 1998 and 2012. Microsurgical techniques were used in 38 cases of esophageal reconstruction, which were 34 free jejunal grafts and 4 supercharged colon grafts. RESULTS: 23 patients underwent primary reconstruction after pharyngolaryngectomy, while 15 patients had secondary reconstruction after failed previous operations or recurrence. When more experienced was gained free jejunal grafts were used for the cervical as well as thoracic oesophagus. Three grafts were lost, two of them were due to anastomotic thrombosis and one was due to severe MRSA wound infection. CONCLUSION: Complicated cases of oesophagus reconstructions may be successfully treated by the cooperation of oesophagus and plastic surgeons, which may result in an acceptable complication rate.

[Primary systemic therapy in breast cancer patients (2007-2010)]. / Emlodaganatos betegek primer szisztémás terápiája során elért eredményeink (2007-2010).

INTRODUCTION/AIM: The importance of preoperative neoadjuvant (NA) systemic treatment in operable breast cancer has significantly increased in the last few years. The aim of our retrospective study was to determine the effect of NA therapy in breast cancer patients treated in our unit and analyze radiological and pathological response rates in the context of surgical treatment. MATERIALS AND METHODS: One hundred and fourteen cases of breast cancer with NA therapy were analyzed and clinical data were collected from March 2007 to December 2010. Twenty-two patients received NA treatment for inoperable tumours. As far as operable cancers (92 patients), the indications for NA treatment were high tumour grade, presence of axillary metastasis and relatively young age. 5-Fluorouracil-Epirubicin-Cyclophosphamid or Taxotere-Epirubicin regimens were administered in 6 cycles followed by radiological evaluation and surgery. Herein, we compared the preoperative staging with the pathological results after surgery. RESULTS: NA therapy resulted in complete regression in 17% of patients, significant regression in 21%, while moderate regression was achieved in 43% of patients. No regression was detected in 19%. The decrease in T stage was not followed by decrease in N stage in significant number of cases. Moreover, in some cases NA therapy caused complete radiological regression, while histologically it still remained positive. In certain cases, breast conserving surgery was feasible due to down-staging caused by NA therapy. CONCLUSION: NA therapy was effective primarily in decreasing tumour size; however, it was less effective on axillary lymph node metastases. Due to the presence of the residual DCIS component, the volume of resection could not be decreased as much as down-staging of the invasive cancer would have permitted.

[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.

[Colon cancer after colon interposition for oesophageal replacement]. / Colonnal történt nyelocsopótlás után kialakult vastagbél-adenocarcinoma.

The authors report the case of a colon adenocarcinoma developed on the neck at the anastomosis of the skin tube and colon 44 years following a corrosive oesophageal injury. This patient suffered a moderately severe oesophageal, stomach and laryngeal injuries due to drinking hydrochloric acid 44 years ago. He underwent serial laryngoplasties, then needed a tracheostomy, oesophagectomy, pyloroplasty and ileocolon transposition. An antethoracal oesophagus formation was performed with ileocolon and skin tube amendment. 44 years later an ulcerated adenocarcinoma developed in the transposed colon, which was resected and the ability to swallow was reinstated by the transplantation of an isolated jejunal segment using microvascular anastomosis.

Chemo-radiotherapy in locally advanced squamous cell oesophageal cancer--are upper third tumours more responsive?

Before neoadjuvant therapy was widely applied, the prognosis of oesophageal cancer had been considered dependent on the location of the tumor, i.e. upper third cancers had had the worst prognosis. The aim of this retrolective study was to prove the efficiency of the neoadjuvant treatment, and to compare the response of esophageal cancer in different locations. Between January 1998 and September 2005, 102 patients with locally advanced squamous cell oesophageal cancer received preoperative chemo-radiotherapy. In 40 cases the tumor was located in the upper third and in 62 cases in the middle third of the oesophagus. After a four-week-long treatment free period restaging was carried out and patients considered resectable were submitted to surgery. From 40 patients with upper third oesophageal cancer 28 underwent oesophageal resection or pharyngo-laryngectomy. Thiry-five percent a complete histopathological remission was observed. From 62 patients with middle third oesophageal cancer 43 underwent oesophageal resection. Histological examination of the resected specimens documented complete response only in three patients. The median survival and the R0 resection rate were similar in the two groups. Although the resection rate, perioperative morbidity, mortality and the median survival were similar in the two groups, a significantly higher rate of complete response (p < 0,05) was observed in patients with upper third oesophageal cancer compared to patients with middle third oesophageal cancer. It seems that upper third oesophageal cancer has superior sensitivity to multimodal treatment therefore our results may support that upper third location is not an unfavorable prognostic factor any more.

[Development of scar cancer after subtotal oesophagectomy for corrosive injury]. / Hegrák kialakulása korrozív sérülés miatt subtotalisan resecált nyelocsoben.

INTRODUCTION: The incidence of cicatricial carcinoma of the scarred esophagus in patients with corrosive injuries is relatively high. Therefore, the necessity to resect the diseased oesophagus was raised as opposed to carry out a simple by-pass reconstruction only. CASE REPORT: A 56-year-old female patient with a past medical history of lye consumption presented with a stricture of the esophagus. She underwent resection of the diseased esophagus with mediastinal colon interposition. 28 years after surgery the patient had symptoms of progressive dysphagia and loss of weight caused by scar cancer of the esophagus. After neoadjuvant chemo-radiotherapy, resection of the remainder oesophagus was performed with free jejunal transplantation. On postoperative day 14 the patient had been discharged with no complications and good swallowing function. CONCLUSION: In our case, scar cancer developed 28 years after oesophageal resection and more than 50 years after the corrosive injury. This case is another argument for simple bypass.

[The effect of preoperative chemo-radiotherapy in the treatment of locally advanced squamous cell carcinoma in the upper- and middle-thirds of the esophagus]. / A preoperatív kemo-radioterápia hatása az elorehaladott felso és középso harmadi nyelocso laphámrákok kezelésében.

AIM: The aim of this study was to compare the efficiency of the preoperative combined chemo-radiotherapy in the treatment of locally advanced squamous cell carcinoma in different locations of the oesophagus. METHODS: Between 1997 and 2005, 102 patients with locally advanced (T3-4) squamous cell oesophageal cancer received preoperative chemo-radiotherapy. In 40 cases, the tumour was localised in the upper-third (Group I), while in 62 cases, in the middle-third of the oesophagus (Group II). Survival rates of patients receiving neoadjuvant therapy were compared with a historical control group. In addition, Group I and Group II were compared to each other, as well. RESULTS: survival rate was significantly better after neoadjuvant therapy (p:0.0042) Resection was performed in 70% of the patients from Group I, and in 50% of those complete pathological remission (pCR) was observed. The perioperative morbidity and mortality rates were 43% and 14%, respectively. As far as Group II, 69% of the patients underwent oesophageal resection, with a perioperative mortality of 18% and morbidity rate of 62%. pCR was observed only in 7% of the cases. The median survivals (21 and 22 months) and the R0 resection rates (82 and 84%) were similar in the two groups. The pCR subgroup showed a significantly better survival rate. CONCLUSION: In this study, we demonstrated that preoperative chemo-radiotherapy increases survival in locally advanced oesophageal cancer. A significantly higher rate of complete response was observed in patients with upper-third oesophageal cancer. It seems that this group has superior sensitivity to multimodal treatment; therefore, our results support a new prognostic factor in oesophageal cancer treatment.

Esophagus reconstruction with free jejunal transfer.

Following pharyngolaryngectomy, reconstruction is one of the most challenging surgical procedures. Here we review our own experiences using a microvascularly transferred free jejunal graft. This method was performed in 22 patients (19 male and 3 female, aged 40-63 years). Seven patients underwent neoadjuvant chemo-radiotherapy. Eighteen patients had immediate reconstruction after pharyngolaryngectomy, and 4 patients had delayed reconstruction because of complications from previous surgeries (2 stenoses, and 2 recurrent cancers). The duration of surgery ranged from 5-9 h (mean, 6.3 h), and the ischemic time of the graft was 70-125 min (mean, 88 min). This method has several advantages: it is a one-step operation; the graft is covered by self-cleaning mucosa; the development of fistulas and stenoses is rare; and the technique provides good swallowing. Owing to its good blood supply, this reconstructive method can also be used in previously irradiated areas.

[Esophagus replacement with anisoperistaltic left colon after removal of skin tube cancer]. / Anisoperistalticus colonnal történt nyelo- csopótlás borcso tumor eltávolitás után.

Authors replaced the esophagus with anisoperistaltic left colon because they had no other possibilities. In this case twenty-one years ago after an esophageal injury the patient underwent gastric resection, removal of the esophagus and replacement with a skin tube created from a myocutaneous flap. Unfortunately the right colon earlier had been removed after an unsuccessful replacement. Twenty-one years later carcinoma developed in the skin tube therefore the tumour was removed and anisoperistaltic left colon was used as a "new esophagus". The pulled up left colon was supplied by the left colic artery and supercharged by a vascular anastomosis on the neck. Authors would like to present that esophageal replacement with anisoperistaltic left colon is a feasible method if no other therapeutic option remains.