[Reconstruction of large tissue loss of the anus and perineum with bilateral inferior gluteal and right gracilis myocutaneous flaps]. / Jelentos végbél- és gáttáji lágyrész-hiány fedése kétoldali musculus gluteus major és jobb oldali gracilis musculocutan lebenyplasztikával.

The authors present a case of locally advanced anal squamous cell carcinoma which, due to infiltration of deep structures, caused anal incontinence, serious pain, exulceration, and bleeding. Neoadjuvant radiotherapy made the tumour operable and abdominoperineal extirpation was performed. The large tissue loss of the anal and perineal region was covered by bilateral gluteus maximus myocutaneous flaps, and the loss of the pelvic musculature and the remaining pelvic skin loss were replaced by a right gracilis myocutaneous flap. The patient was discharged on the 36th postoperative day. There was no flap necrosis noted and an incomplete lesion of the proximal urethra healed after direct suturing. The patient was allowed to lye on the flap in the second postoperative month and sitting on the third month. Unfortunately, an inoperable infiltrative lymph node metastasis occurred in the right inguinal region after six months, and the patient died 10 months after the surgery. We believe that in cases of large, ulcerating anal tumours, when direct closure would be impossible due to massive tissue loss after resection, quality of life can be significantly improved by resection and closure with myocutaneous flaps.

Recurrent, nonmalignant tracheoesophageal fistulas and the need for surgical improvisation.

BACKGROUND: Despite the many recent advances in thoracic surgery, the management of patients with recurrent, nonmalignant tracheoesophageal fistulas remains problematic, controversial, and challenging. METHODS: Between 1998 and 2008, we treated 8 patients with RTEF. Closure of the original tracheoesophageal fistula had been attempted once in 5 patients, twice in 2 patients, and 4 times in 1 patient, all in different institutions. Four cases necessitated right posterolateral thoracotomy and cervical exposure, 2 cases cervical and abdominal incision, and 1 case right posterolateral thoracotomy, with abdominal and cervical exposure. With the exception of the 2 patients whose excluded esophagus was used to substitute for the trachea membranous wall, the damaged tracheal segment was removed. In general, a pedicled mediastinal pleural flap was pulled into the neck to increase the safety of the tracheal anastomosis formed with the trachea, and (or) to separate the suture lines of the two organs. RESULTS: A single intervention was sufficient for all 8 patients: no reoperation was necessary, and there was no perioperative mortality. Transient reflux, abdominal distention, and dyspnea in response to forced physical exertion occurred in 1 case each. Only 1 patient subsequently takes medication regularly for reflux disease. CONCLUSIONS: Separation initiated from the tracheal bifurcation, a pedicled mediastinal pleural flap pulled into the neck, a tracheal anastomosis sewn onto the cricoid cartilage with avoidance of its posterolateral elbow, a shaped Dumon stent (Novatech, Plan de Grasse, France) with an individually fenestrated tracheostomy cannula, and endoscopy-assisted, transhiatal vagal-preserving esophageal exclusion all served as successful elements of our surgical procedures.

[The role of radical surgical approach in the treatment of benign multinodular goitre depending on anatomical variations of the recurrent laryngeal nerve]. / A radikalitás helye a benignus pajzsmirigybetegségek sebészi kezelésében a nervus rekurrens anatómiai sajátságainak tükrében.

UNLABELLED: From time to time there is a surprise at the end of surgery - even after subtotal resection - when a vocal cord is observed on indirect laryngoscopy to be non-functional. Surgeons are highly individualistic and develop their own special ways of locating and protecting the nerve. The present study has tried to clarify whether relying on palpation alone during surgery is safe enough in each case. MATERIALS AND METHODS: Between 01.01.2001 and 31.12.2008, 1228 recurrent laryngeal nerve (RLN) were exposed in 702 patients on thyroid surgery. The RLN was found and traced until the laryngeal entry point in all patients. Substernal spreading was noted in 38.6% (271/702), while tracheal compression or dislocation was present in 19.5% (137/702). Recurrent thyroid disease counted for 8.4% (59/702) of all cases. Total thyroid lobectomy was carried out in 82.2% (1009/1228), near-total thyroidectomy in 15.5% (191/1228), and subtotal resection only in 2.3% (28/1228). RESULTS: Palpation was helpful in 80.7% (991/1228), proved false positive in 8.7% (107/1228), while in 10.6% (130/1228) it did not provide any help in the localization. The palpability of the RLN showed marked discrepancy between the two sides. False positivity was noted with palpation in 3.4% (21/625) and 14.3% (86/603) on the right and left side, respectively. On the other hand, palpation helped localization in 4.8% (29/603) on the left side, while the same figure was 16.2% (101/603) on the right side. Definitive RLN palsy was experienced in 0.8% of all cases (10/1228), whilst transient paresis was encountered in 1.4% (17/1228). Occult malignancy was noticed in 5.6% (39/702). CONCLUSIONS: No indication has been left for subtotal resection. Even if benign multinodular goitre is present, since the clinical and pathophysiological evidences suggest that multinodular goitre affects the entire gland, any surgery that leaves potentially abnormal thyroid tissue in situ carries a risk of recurrent disease. RLN palpatory method is a useful part of thyroid surgery but it is suitable for rough orientation only.

[Giant solitary fibrovascular polyp of the esophagus causing diagnostic problems]. / Diagnosztikus problémat okozó szoliter fibrovaszkuláris óriáspolip a nyelocsoben.

The giant fibrovascular polyp is a rear benign entity of the esophagus. In the literature it almost always appears in single case reports. The authors present a case of a patient with a giant fibrovascular polyp caused serious diagnostic problems. The 50-year-old patient was investigated for dysphagia and effort dependent dyspnea. The preoperative examination confirmed a 60x50x90 mm size tumor-like intramural lesion in the upper third of the esophagus. During the operation we found a sessile intraluminal polyp which has removed. The histology confirmed giant fibrovascular polyp.

[Carcinoid tumor of the papilla of Vater]. / Vater papilla carcinoid.

Carcinoid tumor of the papilla of Vater is extreme rare. Only 73 cases have been reported in the world literature to date and only 1 case in Hungary. This tumor differs clinically and has a different prognosis from other carcinoid tumors of the gastrointestinal tract as it is more aggressive. The clinical feature is determined by the expansion and infiltrative nature of the tumor. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic biopsy (EB) are the most accurate methods of diagnosis, while endoscopic ultrasonography (EUS) is the most important method to decide the surgical strategy. Depending on the tumor size and the grade of invasion of other structures surgical treatment can be local excision or radical resection. We present a 67-year-old female patient with obstructive jaundice, caused by carcinoid tumor of the papilla of Vater. Diagnosis was obtained by ERCP and EB. Because of the signs of local invasion emerging on EUS a pylorus preserving pancreatoduodenectomy was performed. Six months after the operation there is no evidence of recurrence.