[Achalasia cardiae causing megaesophagus: "From the beginnings to the resolution"]. / Megaoesophagust okozó achalasia cardiae: "a kezdetektol a megoldásig".

Achalasia cardiae miatt az elso oesophago-cardia myotomiát több mint száz évvel ezelott Ernst Heller német sebész végezte. Az achalasiás betegek a mai napig ettol a beavatkozástól várják panaszaik megszunését. Az achalasia napjainkban is chronikus, progresszív betegség, aminek oki kezelését nem ismerjük, a gyógyítására, a panaszok enyhítésére gyógyszeres (calcium csatorna blokkolók stb.), endoscopos (botulinum toxin inj., ballonos tágítás, per oralis endoscopos myotomiát [POEM]) és sebészi (laparoscopos, thoracoscopos myotomia) kezeléseket váltakozó sikerrel alkalmazunk.A betegség progresszivitása miatt a betegek 5%-ánál a nyelésképtelenségig fokozódó dysphagia, megaoesophagus alakul ki, megoldására mutéti beavatkozás válik szükségessé. A muködésképtelen nyelocso eltávolítása és pótlása kiterjedt, nem elhanyagolható morbiditással és mortalitással járó beavatkozás. Közleményünkben egy 45 éves nobeteg kórtörténetét, az általunk alkalmazott mutéti beavatkozást ismertetjük. A beteg a mutét óta panaszmentes.

[Treatment of recurrent incarcerated Bochdalek hernia in an adult]. / Recidív, kizáródott, felnottkori Bochdalek-sérv mutéti megoldása.

Az igen ritka felnottkori nem hiatális, azaz nem paraoesophagealis típusú transdiaphragmaticus sérveket - a veleszületett rekeszizom defektusok mintájára - általánosan Bochdalek, ill. Larey-Morgagni-sérveknek nevezik. Etiológia tekintetében a nem diagnosztizált és kezelt veleszületett eredet, a traumás kontúziós-szakadásos, az iatrogen, ill. a recidív típus említendo meg.Esetismertetésünkben egy felnottkori recidív, kizáródott Bochdalek-sérv sikeres mutéti ellátását ismertetjük. A 23 éves férfi beteg kórelozményében 11 éves korában bal oldali Bochdalek-sérv miatt végzett thoracoscopos rekeszizom sutura szerepel. Epigastrialis fájdalmak, hányinger, hányás, akut hasi megbetegedés klinikai tünetei miatt jelentkezett Intézetünkben. Az elvégzett sürgos mellkasi és hasi CT-vizsgálat a bal mellüregben elhelyezkedo, kizáródott, vékonybélkacsokat tartalmazó Bochdalek-sérvet igazolt. Sürgos laparotomia során az életképesnek bizonyult sérvtartalmat (a vékonybéltraktus 2/3 része, a colon flexura lienalisa és a pancreas farok) a hasüregbe reponáltuk, a sérvkaput direkt suturával zártuk, és szövetszeparáló sebészi hálóval fedtük, valamint a mellüreget draináltuk. A postoperatív szak eseménytelenül zajlott. Kontroll-CT-vizsgálat a reconstruált rekeszizom és pleuro-peritonealis rétegek folytonosságát mutatta. A 10. posztoperatív napon panaszmentesen bocsátottuk otthonába.Megbeszélés: Mint minden kizáródott sérv esetében, a diagnózis mihamarabbi felállítása és az idoben elvégzett mutét kulcsfontosságú. A mellkasi drenázs szükségességét minden esetnél körültekintoen mérlegelni kell. A mutét után a mell- és hasüregben kialakult új anatómiai viszonyok miatt cardialis és respiratoricus szövodmények alakulhatnak ki. Álláspontunk szerint a betegség ritkasága miatt centrumban kezelendo. Ezen ritka állapot sikeres gyógyítása többszakmás együttmuködésen alapul, melynek meghatározó eleme a helyesen megválasztott rekeszi felszínt helyreállító mutéti technika alkalmazása.

An experimental and theoretical study of reaction mechanisms between nitriles and hydroxylamine.

The industrially relevant reaction between nitriles and hydroxylamine yielding amidoximes was studied in different molecular solvents and in ionic liquids. In industry, this procedure is carried out on the ton scale in alcohol solutions and the above transformation produces a significant amount of unexpected amide by-product, depending on the nature of the nitrile, which can cause further analytical and purification issues. Although there were earlier attempts to propose mechanisms for this transformation, the real reaction pathway is still under discussion. A new detailed reaction mechanistic explanation, based on theoretical and experimental proof, is given to augment the former mechanisms, which allowed us to find a more efficient, side-product free procedure. Interpreting the theoretical results obtained, it was shown that the application of specific imidazolium, phosphonium and quaternary ammonium based ionic liquids could decrease simultaneously the reaction time while eliminating the amide side-product, leading to the targeted product selectively. This robust and economic procedure now affords a fast, selective amide free synthesis of amidoximes.

[Urgent laparoscopic adrenalectomy in acute crisis caused by pheochromocytoma]. / Phaeochromocytomás krízisben végzett acut laparoscopos adrenalectomia.

CASE REPORT: Authors present the case of a 30-year-old female patient, who was admitted to the ICU because of hypertensive crisis accompanied by chest complains, cardiac decompensation, progrediating short of breath and unconsciousness. Despite the quick examinations and the prompt treatment multi-organ failure developed 3 days after admission. Investigations revealed the underlying cause, which was a left-sided suprarenal neoplasm. Hence, multidisciplinary decision was made to carry out a laparoscopic adrenalectomy urgently. The histology examination of the removed neoplasm was pheochromocytoma. In the postoperative period the condition of the patient gradually improved, her symptoms and complains settled, and finally she was discharged in a healthy condition. DISCUSSION: The diagnosis of a pheochromocytoma is a difficult task, the symptoms and complains caused by it can simulate many other illnesses. The acute crisis caused by pheochromocytoma usually can be treated conservatively, but in more severe cases with impending multi-organ failure an urgent operative treatment can be unavoidable. Though the operative risk is relatively high, the correct intra- and postoperative treatment with a quick laparoscopic procedure can be effective.

[Laparoscopic treatment of median arcuate ligament syndrome (MALS) -- case report]. / Truncus coeliacus compressiós szindróma laparoscopos mutéti megoldása -- Esetismertetés.

CASE REPORT: The authors report a case of a 34-year-old woman who had postprandial abdominal pain for years. During the course of her examination lactose intolerance and hiatus hernia was diagnosed. After ineffective conservative treatment CT angiography (CTA) and digital substraction angiography (DSA) was performed and showed significant celiac artery stenosis. Percutaneous transluminal angioplasty (PTA) was unsuccessful as extravasal mechanical compression was present, therefore, laparoscopic decompression and surgical division of MAL fibres were carried out. The postoperative period was characterized by a complete relief of previous symptoms and repeated CTA showed normal blood flow. DISCUSSION: The authors emphasize the importance of the measurement of peak velocity of celiac trunk with Colour Duplex abdominal ultrasonography, the examination has 100% sensitivity and 83% specificity. The Duplex ultrasonography is less expensive than the "gold standard" diagnostic methods like CT and DS angiography, and can lead us to early diagnosis. Laparoscopic surgery is safe and low expense method for celiac artery decompression, however, sometimes it is difficult to reveal the exact reason and thus setting up the proper operation plan.

[Analysis of postoperative complications following acute surgery for colorectal cancer]. / Colorectalis daganatok miatt végzett acut mutétek után észlelt szövodmények elemzése. Egy szemléletváltás hatása.

Our aim was to improve the outcome of emergency surgeries for colorectal cancer (CRC). Authors compared two periods: 2004-2006 and 2007-2011. Targeted cases were emergency admissions, in which the diagnosis of colorectal cancer is only revealed during work-up or during surgery. No other exclusion criteria were set. Analyzed main endpoints were anastomotic leak, postoperative mortality, resecability. ASA classification and TNM stages were assessed in order to learn morbidity and general condition prior to acute surgery. Considering the experience gained in prior period, in 2007, authors have made a change in treatment strategy. In following years leakage ratio became ten times lower and mortality was reduced by 5%. There is a great chance that fast work-up and preparation for surgery may decrease complications and mortality. The aim would be for CRC patients, is to reach surgery in an early stage of disease as possible, at least before complications develop.

[Our experience in Fournier's gangrene with severe septic shock]. / Súlyos septicus állapotot okozó Fournier-gangraena kezelésével szerzett tapasztalataink.

Fournier's gangrene is a rare, rapidly progressing necrotizing fasciitis, which involves the genital area and perineum, progresses towards the thighs and abdominal wall through fascial plains. In our surgical department we treated seven patients with Fournier's gangrene between 2007 and 2011. Early diagnosis, immediate radical surgical debridement, necrosectomy, appropriate antibiotics and intensive care are all required and necessary for the successful treatment. Despite appropriate therapy, two patients were lost in septic shock.

[Metastatic malignant melanoma of the oesophagus: case report]. / Melanoma malignum nyelocso-metastasisának operált esete.

We report a case of metastatic malignant melanoma in the oesophagus. 13 years after the wide excision of primary skin melanoma, we found a polypoid tumor in the upper third of the oesophagus. Biopsy result was melanoma malignum. After negative staging we performed transhiatal oesophagectomy with gastric conduit and cervical anastomosis. Metastatic nature of the oesophageal tumor was proven by histology. After uneventful postoperative course, the patient received adjuvant dacarbazine treatment. The patient was is in good condition, and disease free on the 18 month follow-up.

[Our experience with totally extraperitoneal technique of laparoscopic inguinal hernia repairs modified by Stolzenburg]. / Stolzenburg szerint módosított teljes extraperitonealis technikával végzett laparoscopos lágyéksérvmutéteinkrol.

INTRODUCTION: Two current types of laparoscopic inguinal hernia repair are known: the TransAbdominal PrePeritoneal (TAPP) and the Totally ExtraPeritoneal (TEP) method. The mesh is placed in the preperitoneal space (sublay). Usually during TAPP method we fix the mesh with tacks or staples. In case of TEP fixation it is not necessary because the intraabdominal pressure keeps the implant in position. There is no significant difference between the two methods in terms of recurrence. The advantage of TEP is that the abdominal cavity remains intact, hence reduces the risk of intraabdominal injuries and adhesions. It is unnecessary to use special stapler or tacker. MATERIALS AND METHODS: Our team performed 50 TEP procedures in male patients with uni- or bilateral inguinal hernias in the period 2011-2013. We prepared the mesh in a special way according to Stolzenburg and placed it to the subfunicular area. We did not apply additional fixation (tacks, stitches) and drainage. Mean hospital stay was 1 day. We allowed complete physical activity 10-12 days after surgery. RESULTS: No recurrence was observed during the 2 years of follow-up. The mean operating time was 70 minutes. We performed conversion in 3 cases (Lichtenstein 2, TAPP 1). In one case there was an injury of the inferior epigastric artery. In two cases we have detected neuralgia in the postoperative period. CONCLUSIONS: After the learning curve the TEP method can be used safely with good functional results. The technique of mesh positioning reduces the risk of complications and provides cost-effectiveness.

[Necrotizing enterocolitis in an adult -- case report]. / Felnottkori necrotizáló enterocolitis -- Esettanulmány.

The adult necrotizing enterocolitis (ANEC) is a rare condition, frequently fatal, and characterized by a fulminant symptoms and segmental necrosis of the bowel. The authors performed repeated surgeries and small bowel resections on a patient classified to stage number three on Bell scale due to necrotizing enterocolitis. Pathological examination of the resected bowel showed intestinal necrosis without obstruction of mesenteric vessels. After the fifth operation the continuity of the gastrointestinal tract was reconstructed by an anastomosis between the remained 30 cm of terminal ileum and descending loop of duodenum. Inspite of only 30 cm of small intestines remaining, the patient is able to enjoy life almost completely with gastroenterological control and support.

[Successfully operated cases of mediastinal and retroperitoneal bronchial cysts]. / Mediastinalis és retroperitonealis bronchogen cysták sikeresen operált esetei és tanulságaik.

CASE REPORT: Two young men were operated in our department for bronchiogen cysts with unusual locations. In the first case a mediastinal cyst caused severe swallowing problems, while in the second a retroperitoneal cyst resembled to an adrenal adenoma. It was only the postoperative histology, which clarified the exact diagnosis of the removed cysts. DISCUSSION: Only a few percent of mediastinal tumours are bronchial cysts that develop due to developmental disorders. Symptomatic ones are more easily detectable. Bronchial cysts localized in the abdominal cavity or retroperitoneum are especially rare. In most of the cases the final diagnosis is made only after excision with histological examination of the cyst.

[Antegrade colonic enema is a choice for the treatment of faecal incontinence and constipation]. / Anterograd vastagbélátmosás az incontinentia és az obstipatio kezelésének egyik lehetosége.

UNLABELLED: Faecal incontinence and constipation cannot always be treated successfully by conservative or surgical methods. In these cases regular retrograde colonic enema can reduce the symptoms of the patients and can establish pseudocontinence. The authors present a method of colon cleaning which has been used successfully. The method was introduced in clinical practice by Malone in 1990. The antegrade enema is administered through the appendicostomy. In cases, where the appendectomy was performed earlier, a neoappendix was created from the coecal wall and used for the irrigation of the colon. During procedure the patients injected tap water (300-450 ml) through the (neo-)appendicostomy with a thin catheter. After a short time period this was followed by passing of the stool. The procedure was performed on twelve patients, five female, and seven male patients (mean age: 39.2 years). The indications for the procedure were the following: faecal incontinence induced by denervation of the pelvic floor in three patients, sphincter trauma in two patients and congenital sphincter malformation in two cases. In addition, combined symptoms of faecal incontinence and constipation caused by pelvic floor denervation in three patients. Finally, intractable constipation was the reason in two patients. After irrigation, the stool was passed, but the functional result was rather variable. Eight out of twelve patients were satisfied with the result, two patients reported improvement in the constipation, but it failed in one case. In another case, the appendicostomy could not have been used due to surgical complications. The stricture of the (neo-)appendicostomy was observed in two cases. Significant reflux occurred only in one case. CONCLUSION: after adequate patient selection this method can be applied with success.

[Squamous papilloma of the esophagus. Clinical and pathological observations based on 172 papillomas in 155 patients]. / A nyelocso laphámsejtes papillomája. Klinikai és patológiai tapasztalataink 155 beteg 172 papillomája kapcsán.

INTRODUCTION: The papilloma of the oesophagus is a rare disease. The pathogenesis and biological features of the disorder are not clearly known. AIMS: The purpose of the present paper is to outline the clinical and pathological significance of the papilloma of the oesophagus as detected in the authors' endoscopic laboratory. METHODS: Endoscopic examinations were carried out with a flexible endoscope. The alterations in the oesophagus were removed by biopsy forceps in order to perform histological investigations, large-sized ones were removed by way of endoscopic mucosectomy. To assess the structure major alterations and their circumstances relative to their environment, endoscopic ultrasonography was performed, as well. Histological examination was done in formalin-fixed slides embedded in paraffin and dyed with hematoxiline eosine. HPV detection was done through polymerase chain reaction (PCR). RESULTS: During the 35 years a total of 59.056 upper panendoscopic examinations were carried out. Planocellular papilloma were detected in 155 patients (0.26% of the total number of patients). 85 of the patients were female, 70 were male. The vast majority of papilloma cases were solitary (142 patients). A minority--13 patients--had multiplex alterations. Most often, the papillomas were sessile changes, most often located in the middle and upper part of the intrathoracic section of the oesophagus. The probability of the papilloma can be established on the basis of the findings of endoscopic morphology, as well. This, however, has to be supported by a histological examination. In the majority of the cases the papillomas of the oesophagus can be removed by endoscopical biopsy forceps, because most often the alterations were only a few millimetres in size. Larger papillomas can be removed by way of endoscopic mucosectomy. Examining the transformation of papillomas into carcinomas, no papilloma was found which directly transformed into a carcinoma. Synchronically occurring planocellular carcinoma was found in the oesophagus of only 2 out of the 155 patients. During the follow-up examination of patients, recurrence of the disease was found only in one patient. The frequency of the human papilloma virus in papilloma of the oesophagus: the authors were able to detect the presence of HPV by way of PCR technique in 12 out of 26 cases (46.2%). With the expectation of 3, they were all viruses with a high risk of cancerous transformation. CONCLUSION: The squamous papillomas of the oesophagus are begin tumors. Papillomas is not caused by hiatus hernia or reflux oesophagitis. The distinct localization of the two different types of alternations also suggests a non-reflux oesophagus origin of the papilloma. The reason is that papillomas are most often located in the middle and upper part of the intrathoracic section of the esophagus--on the other hand, reflux esophagitis is located in the lower section. It is now generally accepted that papillomas of the mucous membrane covered by multiple planocellular layers are caused by HPV. The identical localization of the papillomas and planocellular cancer in the oesophagus refer to potentially identical etiology (HPV infection), and it may rarely occur that the papillomas wil in fact transform into carcinoma. Papillomas of the esophagus is a rare disorder. Its detection is in part important in order to distinguish it from planocellular carcinoma (especially carcinoma verrucosum), In part it indicated the HPV-infection of the oesophagus, or in HPV-positive cases it may be regarded as a precancerous state. For all this, it is important that the papilloma should be recognised by way of endoscopic examination, removed and a precancerous state should be taken into consideration.

[Intramural esophageal metastasis of diffuse, infiltrative gastric adenocarcinoma]. / Diffuz infiltratív gyomorkarcinóma intramurális metasztázisa a nyelócsóben.

Authors report a patient with a gastric carcinoma that developed an intramural metastasis to the oesophagus. The diagnosis of the metastasis was suggested on endoscopy and was verified by pathohistology. Preoperative investigations suggested advanced cancer. During the operation an inoperable tumour was found. Authors describe the methods to diagnose oesophageal metastasis.