[Impact of antireflux surgery on gastroesophageal reflux-associated symptoms and quality of life.] / Laparoszkópos antirefluxmutétek hatása a gastrooesophagealis refluxszal járó tünetekre és a betegek életminoségére.

INTRODUCTION: Reflux disease has become endemic in the Western world. High quality hiatal reconstruction and fundoplication has a paramount importance in its therapy. While the primary goal of surgery is reducing reflux-associated disease burden, the evaluation and follow-up of disease-associated quality of life is essential. OBJECTIVE: In this study, we aimed to measure and evaluate the pre- and post-operative reflux-associated quality of life of patients undergoing surgery between 01. 12. 2015 and 31. 12. 2020 at a tertiary care hospital. METHOD: We utilized a health-related quality of life questionnaire both pre- and post-operatively. The main outcome measures were: patient-assessed heartburn, dysphagia, regurgitation, chest pain, nausea and vomiting. We also measured acid secretory medication use and patient satisfaction. RESULTS: We have assessed the pre- and post-operative questionnaries of 65 patients. All the symptoms above have decreased after surgery, and the changes were statistically significant (except for dysphagia). There was a tendency for minor weight loss after surgery. The use of acid secretion inhibitor medications decreased significantly. DISCUSSION: Our results are comparable to the outcomes of other tertiary care centers. Our workgroup has successfully adopted the diagnostic and therapeutic algorithms of the surgical care of reflux disease. CONCLUSION: If the proper indications for surgery are met, laparoscopic hiatoplasty and Toupet fundoplication are capable tools in decreasing reflux-associated symptoms and improving reflux-associated quality of life. Orv Hetil. 2023; 164(2): 57-63.

Left upper lobe pulmonary adenocarcinoma with partial anomalous pulmonary venous connection in the same lobe: Case report / Bal felso lebenyi adenocarcinoma és pulmonális vénás fejlodési rendellenesség együttes elofordulása

Authors present a case of a 60-year-old male patient with left upper lobe cancer in association with partial anomalous pulmonary venous connection (PAPVC) in the same lobe. The hemiazygous vein joined the left superior pulmonary vein above the aorta in the thorax cavity draining into the left brachiocephalic vein causing left to right shunt flow. PAPVC was clearly identified intraoperatively and left upper lobectomy was performed as definitive solution for both. PAPVC was closed by stapler. To our knowledge 32 operated cases of lung cancer with PAPVC has been described in the literature (PubMed), including our patient.

Bladder augmentation from an insider's perspective: a review of the literature on microcirculatory studies.

Augmentation cystoplasty is an exemplary multiorgan intervention in urology which is particularly associated with microvascular damage. Our aim was to review the available intravital imaging techniques and data obtained from clinical and experimental microcirculatory studies involving the most important donor organs applied in bladder augmentation. Although numerous direct or indirect methods are available to assess the condition of microvessels the implementation of microcirculatory diagnostic methods in humans is still challenging and the assessment of organ microcirculation in the operating theatre has limitations. Nevertheless, preclinical studies generally report good internal validity and although prospective human protocols with reduced variability are needed, a possible positive impact of microcirculatory diagnostics on the clinical outcomes of urologic surgery can be anticipated.

Our experience with the laparoscopic surgery of hiatal hernias / Tapasztalataink a rekeszsérvek laparoszkópos sebészetével.

Összefoglaló. Bevezetés: A hiatus hernia egy anatómiai betegség; gyakoribb elofordulása idosebbeknél jelezheti, hogy a betegség idovel elorehalad, súlyosbodik. Elhanyagolt esetben szövodmények alakulhatnak ki, melyek növelhetik a perioperatív mortalitást. Célkituzés: A laparoszkópos hiatusrekonstrukciók sebészetében szerzett mutéti tapasztalataink ismertetése mellett igyekeztünk statisztikailag alátámasztható korrelációt találni a rekeszizom-defektus anatómiai paraméterei, valamint a betegek életkora között. Módszer: Retrospektív tanulmányunk keretében elemeztük azon betegeinket, akik laparoszkópos hiatus hernia mutéten estek át egy 58 hónapos (2016. január-2020. október) vizsgálati periódus során. A rekeszi defektus méreteit endoszkópos vonalzóval a mutét közben megmértük, a hiatus oesophagei felszínét standard matematikai formula segítségével számoltuk ki. A sürgosséggel mutétre kerülo betegeink adatait külön elemeztük. Statisztikai analízis: A defektus mérete és a betegek életkora és magassága közötti korrelációt a Spearman-féle ró (ρ)-korreláció segítségével állapítottuk meg. A szignifikanciaszint p≤0,05 volt. Eredmények: Az elektív csoportban 142 operált páciensbol 47 beteg mérési adatai feleltek meg a kritériumoknak. Az átlagéletkor 64,7 ± 12,7 év volt, 33 páciens volt no (70,2%), az átlagos testtömegindex 28,8 ± 5,5 kg/m2 volt. A defektus haránt átméroje és felszíne szignifikáns pozitív korrelációt mutatott a betegek életkorával (p≤0,05). Akut indikációval 5 beteg került mutétre; a defektus méretét illetoen hasonló eredményeket tapasztaltunk, mint az elektív csoportnál, 2 esetben azonban súlyos szövodmények alakultak ki. Következtetés: A betegség mögött húzódó anatómiai okok jobb megértése és a megfigyeléseink alapján módosított sebésztechnika reményeink szerint csökkentheti a hosszú távú kiújulások számát a jövoben. Az idoben elvégzett elektív beavatkozás alacsonyabb mortalitással, kevesebb szövodménnyel és rövidebb hospitalizációval jár együtt. Orv Hetil. 2021; 162(19): 754-759. INTRODUCTION: Hiatal hernia is an anatomical disease, and the higher incidence for elderly patients suggests that it is progressing over time. Neglected cases can cause serious complications, raising perioperative mortality. OBJECTIVE: We are presenting our experience in laparoscopic hiatal reconstructions. Our main goal is to find a statistical correlation between the anatomical parameters of the hiatal defect and the patients age. METHOD: Surgical data were reviewed retrospectively for patients who underwent laparoscopic hiatal hernia repair between January 2016 and October 2020. Dimensions of the hiatal defect were measured intraoperatively with an endoscopic ruler. The defect size was calculated using a standard formula. The acute surgeries were analyzed as a separate arm of the study. STATISTICAL ANALYSIS: The correlation between the patients age and the size of the defect were calculated using Spearman's rho (ρ) correlation. The level of significance was p≤0.05. RESULT: In the elective group, out of 142 patients 47 met the inclusion criteria. The mean age was 64.7 ± 12.7 years, 33 patients were women, and the mean BMI was 28.8 ± 5.5 kg/m2. Patient age showed significant positive correlation with the transverse dimension and the size of the hiatal defect. 5 patients underwent surgery due to acute indications. We found similarities in the size of the defects; at 2 patients we documented severe complications. CONCLUSIONS: A better understanding of the underlying anatomical disorders and the consecutively modified surgical technique will hopefully reduce the long-term recurrencies in the future. The elective surgery performed in the right time results in lower mortality, less complications and shorter hospitalization time. Orv Hetil. 2021; 162(19): 754-759.

Autologous Dermis Graft Implantation: A Novel Approach to Reinforcement in Giant Hiatal Hernias.

OBJECTIVES: Nonreinforced tensile repair of giant hiatal hernias is susceptible to recurrence, and the role of mesh graft implantation remains controversial. Creating a new and viable choice without the use of high-cost biological allografts is desirable. This study presents the application of dermis graft reinforcement, a cost-efficient, easily adaptable alternative, in graft reinforcement of giant hiatal hernia repairs. METHODS: A 62-year-old female patient with recurrent giant hiatal hernia (9 × 11 cm) and upside down stomach, immediately following the Belsey repair done in another department, was selected for the pilot procedure. The standard three-stitch nonabsorbable reconstruction of diaphragmatic crura was undertaken via laparoscopic approach. A 12 × 6 cm dermis autograft was harvested from the loose abdominal skin. "U" figure onlay reinforcement of diaphragm closure was secured with titanium staples. The procedure was completed with a standard Dor fundoplication. One- and seven-month follow-ups were conducted. RESULTS: No short-term postoperative complications were observed. One-month follow-up showed normal anatomical location of abdominal viscera on computed tomography imaging. High-resolution manometry showed normal lower esophageal sphincter pressure. Preoperative abdominal complaints were resolved. Procedural costs were lower than the average cost following mesh graft reinforcement. CONCLUSION: Dermis graft reinforcement is a cheap, easily adaptable procedure in the repair of giant hiatal hernias, even in the setting of laparoscopic reoperative procedure.

Transoral mucosal excision sutured gastroplasty: a pilot study for GERD and obesity with two-year follow-up.

INTRODUCTION: An outpatient transoral endoscopic procedure for gastroesophageal reflux disease (GERD) and obesity would be appealing if safe, effective, and durable. We present the first in human experience with a new system. METHODS: Eight patients with GERD (3) and obesity (5) were selected according to a preapproved study protocol. All GERD patients had preprocedure manometry and pH monitoring to document GERD as well as quality of life and symptom questionnaires. Obese patients (body mass index >35) underwent a psychological evaluation and tests for comorbidities. Under general anesthesia, a procedure was performed at the gastroesophageal junction including mucosal excision, suturing of the excision beds for apposition, and suture knotting. RESULTS: One patient with micrognathia could not undergo the required preprocedural passage of a 60 F dilator and was excluded. The first 2 GERD patients had incomplete procedures due to instrument malfunction. The subsequent 5 subjects had a successfully completed procedure. Four patients were treated for obesity and had an average excess weight loss of 30.3% at 2-year follow-up. Of these patients, one had an 8-mm outlet at the end of the procedure recognized on video review--a correctable error--and another vomited multiple times postoperatively and loosened the gastroplasty sutures. The treated GERD patient had resolution of reflux-related symptoms and is off all antisecretory medications at 2-year follow-up. Her DeMeester score was 8.9 at 24 months. CONCLUSION: The initial human clinical experience showed promising results for effective and safe GERD and obesity therapy.

A proposed classification for uniform endoscopic description of surgical fundoplication.

BACKGROUND: Objective assessment of postfundoplication anatomy is of utmost importance especially if reoperative intervention is being planned. There is a lack of uniformity in the description of endoscopic findings in these patients.The purpose of this study was to propose a classification for standardized endoscopic reporting of postfundoplication anatomy. METHODS: After institutional review board approval, preoperative endoscopic findings of patients who underwent reoperative intervention from 1992 to 2011 were reviewed a nd classified. The classification included four factors:E (distance of GEJ to crus), S (amount of gastric tissue between the GEJ and fundoplication), F (fundoplication configuration), and P (paraesophageal hernia). RESULTS: The endoscopic findings of 310 patients who underwent reoperative antireflux surgery were classified using the newly proposed classification model. A significant increase in the number of procedures was noted over the years.There was no change in presenting symptoms and patterns of failure over the years. The classification model was easily applicable to previous endoscopy reports. There was good symptom association with our classification model. DISCUSSION: An endoscopic anatomical classification is proposed for description of failed fundoplication. With this classification, we hope to fill the gap in developing a uniform classification of failed fundoplications. Further studies addressing widespread applicability and outcome analysis are needed.

Roux-en-Y reconstruction is superior to redo fundoplication in a subset of patients with failed antireflux surgery.

BACKGROUND: A subset of patients requires reoperative antireflux surgery (Re-ARS) after failed fundoplication. The aim of this study was to determine symptomatic outcomes beyond 1 year following Re-ARS and to assess the relative utility of two different surgical approaches. METHODS: After Institutional Review Board approval, patients who underwent Re-ARS were identified from a prospective database. Symptom severity was graded on a 0-3 scale. Patients with postoperative symptoms of grade ≥ 2 were considered to have a poor outcome. Patient satisfaction was graded using a 10-point visual analog scale. RESULTS: At least 1 year of follow-up was available for 130 patients. There were 94 redo fundoplications (RF) and 36 Roux-en-Y reconstructions (RNYR). Symptom risk factors (significant preoperative dysphagia, significant preoperative heartburn, esophageal dysmotility, short esophagus, delayed gastric emptying, multiple failed hiatal surgeries, reflux-related respiratory symptoms) were more prevalent in patients who underwent RNYR compared to RF (mean 3.0 vs. 2.2; p = 0.003). Postoperative leaks and major complications occurred in 4.5 % (5/110) versus 0% and 21.6 % versus 33.3 % of the RF and RNYR groups, respectively. Twenty-eight RF patients (29.8 %) and 9 RNYR patients (25.0 %) reported poor outcomes. Among patients with ≥ 4 risk factors, those who underwent RNYR had a lower incidence of poor outcome (7.7 % vs. 55 %, p = 0.018) and higher satisfaction scores (8.4 vs. 5.8, p = 0.001) compared to those who had RF. Overall, 85 % of patients were satisfied or highly satisfied with their results and the average satisfaction score was 8.2. CONCLUSION: Re-ARS provides good subjective outcomes when measured more than 1 year after surgery. Patients with more complex pathology benefit more from RNYR despite the higher postoperative complication rate. This is especially true for patients with decreased esophageal motility and short esophagus.

High-resolution impedance manometry findings in patients with nutcracker esophagus.

BACKGROUND AND AIM: The objective of this study was to evaluate the association between high-resolution manometry (HRM) and impedance findings and symptoms in patients with nutcracker esophagus (NE). METHODS: After institutional review board approval retrospective review of a prospectively maintained database identified patients who were diagnosed with NE as per the Chicago classification (distal contractile integral [DCI] > 5000 mmHg-s-cm) at Creighton University between October 2008 and October 2010. Patients with achalasia or a history of previous foregut surgery were excluded. NE patients were sub-divided into: (i) Segmental (mean distal esophageal amplitude [DEA] at 3 and 8 cm above lower esophageal sphincter [LES] < 180 mmHg) (ii) Diffuse (mean DEA at 3 and 8 cm above LES > 180 mmHg) and (iii) Spastic (DCI > 8000 mmHg-s-cm). RESULTS: Forty-one patients (segmental: 13, diffuse: 4, spastic: 24) satisfied study criteria. Patients with segmental NE would have been missed by conventional manometry criteria as their DEA < 180 mmHg. A higher percentage of patients with spastic NE (63%) had chest pain when compared to patients with segmental NE (23%) and diffuse NE (25%). There was a significant positive correlation between chest pain severity score and DCI while there was no significant correlation between dysphagia severity and DCI. CONCLUSIONS: In patients diagnosed with NE using the Chicago classification presence and intensity of chest pain increases with increasing DCI. The present criteria (> 5000 mmHg-s-cm) seems to be too sensitive and has poor symptom correlation. Adjusting the criteria to 8000 mmHg-s-cm is more relevant clinically.

Outcomes of surgical management of symptomatic large recurrent hiatus hernia.

OBJECTIVE: Recurrent hiatus hernia is frequently found in patients undergoing reoperative antireflux surgery. The objective of this study is to report perioperative complications and subjective and objective outcomes for patients who underwent reoperative intervention for symptomatic large recurrent hiatus hernia. METHODS: Retrospective review of a prospectively maintained database was performed to identify patients with large (≥ 5 cm gastric tissue above the crus) recurrent hiatus hernia who underwent reoperation after failed antireflux surgery. Data for preoperative workup, operative procedure, and postoperative 6-month follow-up were reviewed and analyzed. RESULTS: Two hundred twenty patients underwent reoperation over a 6-year period. Forty-four patients had large recurrent hiatus hernia; 21 underwent redo fundoplication, while 23 underwent Roux-en-Y (RNY) reconstruction as remedial procedure. Short esophagus was found in 16 cases (6 of 21 redo Collis fundoplications, 10 of 23 RNY reconstructions). There was significant symptom improvement and high degree of satisfaction reported in both groups. However, patients with short esophagus did better with RNY reconstruction compared with redo Collis gastroplasty. CONCLUSIONS: Repair of large recurrent hiatus hernia is a technically challenging procedure; however, there is high degree of symptom resolution and patient satisfaction. RNY reconstruction might be a better alternative in patients with short esophagus compared with redo Collis gastroplasty.

Survival and quality of life after minimally invasive esophagectomy: a single-surgeon experience.

BACKGROUND: Reports on quality of life (QOL) after minimally invasive esophagectomy (MIE) have been limited. This report compares perioperative outcomes, survival, and QOL after MIEs with open transthoracic esophagectomy (TTE) and open transhiatal esophagectomy (THE). METHODS: After institutional review board approval, retrospective review of a prospectively maintained database identified patients who underwent esophageal resection for esophageal cancer at Creighton University between August 2003 and August 2010. Patients with preoperative stage 4 disease, emergent procedures, laparoscopic transhiatal esophagectomies, or esophagojeujunostomies were excluded from the study. The study patients were categorized as having undergone open TTE, open THE, or MIE. Overall survival (OS) was the interval between diagnosis and death or follow-up assessment. Disease-free survival (DFS) was the interval between surgery and recurrence, death, or follow-up assessment. For the patients who survived at least 1 year after surgery, QOL was assessed using European Organization for Research and Treatment of Cancer (EORTC-QLQ, version 3.0) and esophageal module (EORTC-QLQ OES 18) questionnaires. RESULTS: The study criteria were satisfied by 104 patients. Lymph node harvest with MIE (median = 20) was similar to that with open TTEs (median = 19) and significantly higher (P < 0.001) than that with open THEs (median = 12). The percentage of patients requiring intraoperative blood transfusion in the MIE group (23.4%) was significantly lower (P < 0.001) than in the open TTE (73.1%) and THE (67.7%) groups. The volume of intraoperative blood product transfusion was significantly lower for the MIE patients (median = 0 ml) than for the open TTE (median = 700 ml) and THE (median = 700 ml) patients. The incidence of respiratory complications with MIEs (10.64%) was significantly lower than with open TTEs (34.61%) and THEs (32.26%). The groups did not differ significantly in terms of R0 resection rates, OS, DFS, or QOL. CONCLUSIONS: MIEs offer a safe and viable alternative to open esophagectomies because they reduce the need and volume of intraoperative blood product transfusion and postoperative respiratory complications without compromising oncological clearance, survival, and QOL.

Endoscopic assessment of failed fundoplication: a case for standardization.

BACKGROUND: Preoperative endoscopic assessment of the failed fundoplication is instrumental in diagnosis and surgical management. Endoscopy is a routine and essential part of the workup for a failed fundoplication, but no clear guidelines exist for reporting endoscopic findings. This study aimed to compare endoscopic findings reported by community physicians (gastroenterologists and surgeons) with the findings of the authors (esophageal center) for patients who underwent reoperative intervention after a previous antireflux procedure. METHODS: Retrospective review of a prospectively maintained database was performed to identify patients who underwent reoperation after a failed antireflux operation between 1 December 2003 and 30 June 2010. Endoscopic findings as reported by the outside physician and by the esophageal center endoscopist were reviewed and compared. RESULTS: During the study period, 229 patients underwent reoperation. Of these patients, 20 did not have endoscopy performed by an outside physician and were excluded from the study, leaving 208 patients. The endoscopic reports of the esophageal center physician included 97 cases of hiatal hernia (64 type 1 and 33 types 2 and 3), 52 slipped fundoplications, 61 disrupted fundoplications, 30 intrathoracic fundoplications, 25 twisted fundoplications, 14 two-compartment stomachs, and 27 cases of Barrett's esophagus. Outside physicians identified 68% of the hiatal hernias and 61% of the paraesophageal hernias reported by the authors. Only 32% of the outside reports mentioned a previous fundoplication. Furthermore, only 17% of the slipped fundoplications and 30% of the disrupted fundoplications were so described. Outside physicians identified 19 of the 27 patients with Barrett's esophagus. CONCLUSION: Fundoplication changes described by the general endoscopist are inadequate. With an increasing population of patients who have undergone prior antireflux surgery, incorporation of fundoplication assessment in an endoscopic curriculum may be helpful.

Prevalence of Barrett esophagus in first-degree relatives of patients with esophageal adenocarcinoma.

AIM: The aim of this study is to determine the prevalence of Barrett esophagus (BE) in first-degree relatives of patients with esophageal adenocarcinoma (EAC) and Barrett high-grade dysplasia (HGD). METHODS: After Institutional Review Board approval, first-degree relatives of patients with EAC/HGD underwent unsedated ultrathin transnasal endoscopy (UUTNE) with biopsy. BE was suspected if any salmon-colored epithelial tongues were seen above the gastroesophageal junction. A diagnosis of BE was made only if biopsy from these areas confirmed columnar-lined epithelium with intestinal metaplasia. RESULTS: From 23 families, 47 first-degree relatives underwent ultrathin transnasal endoscopy and 1 patient underwent routine upper endoscopy with sedation as part of this study. The mean age of cases was 44.4 years. All patients tolerated the procedure well and there were no procedure-related complications. BE was suspected in 16 (34%) patients and confirmed in 13 of 16 (27.7%) patients. There were 4 long segments (>3 cm) and 9 short segments (<3 cm) of BE. CONCLUSION: There is a significantly higher than expected prevalence of BE in first-degree relatives of patients with EAC/HGD. This should be taken in to consideration to develop further screening guidelines. Further work is needed to confirm these findings. Unsedated transnasal endoscopy is a safe and well-tolerated method for BE screening.

Place and value of the recurrent laryngeal nerve (RLN) palpatory method in preventing RLN palsy during thyroid surgery.

BACKGROUND: In recent years, certain publications have appeared confirming that intraoperative palpation of the recurrent laryngeal nerve (RLN) is a very reliable method. METHOD: The characteristics of the surgical anatomy of 1023 RLN have been summarized on the basis of intraoperative palpability, running down, branching variations, thickness, and laryngeal entry site. RESULTS: Palpation was helpful in 81.4% (833/1023), proved false positive in 8.2% (84/1023), and in 10.4% (106/1023) it was of no help in the exact localization. Definitive RLN palsy was experienced in 0.78% of all cases (8/1023), while transient paresis was encountered in 1.2% (12/1023). Only a moderately strong stochastic correlation could be found between RLN palsies and those nerves which were nonpalpable and atypical, which showed the joint occurrence of being both thinner than normal and branching already before the plane of the inferior thyroid artery (Cramer's associate coefficient, C = 0.383). CONCLUSION: Palpation alone cannot substitute visualization and proper surgical dissection of the nerve.

[Celiac artery compression syndrome--stepchild of abdominal angina?]. / A truncus coeliacus kompressziós szindróma--a hasi angina "mostohagyermeke"?

BACKGROUND: Celiac trunk compression in few percentages of the cases can cause chronic abdominal pain that shows no connection with eating. CASE REPORT: Detailed preoperative examinations showed significant, segmental stenosis of the celiac trunk, caused by outer compression of a tendonous arc of diaphragm, in the background of abdominal pain and mesenteric ischemia of a 58-year-old woman. After preparation we have executed the surgery by removing a tight ring, located at around 8-10 mm from the origin of trifurcation, and a part of the celiac ganglion. The patient was dismissed from our hospital 6 days after surgery in good general condition. DISCUSSION: The abdominal pain can normally be the consequence of mesenteric ischemia. The root cause in most of the cases is the alteration of the particular artery. The outer compression is normally responsible only for a few percentages of the cases. In our case the problem was caused by a stronger tendonous part of the aortic hiatus. The first sign of this during the examination was a recognisable noise over the artery, which was caused by the poststenotic turbulent flow. Detailed radiological examinations executed based on this indeed proved this malfunction. CONCLUSION: In case of unidentified abdominal pain we have to consider the possibility of the stenosis of the celiac trunk. By our case study we would like to call the attention to the importance of the auscultation over the abdomen, which is a relevant part of the basic physical examinations. When getting to the final diagnosis, apart from the duplex doppler sonography, we also used the results of angiography. The essence of the surgery was to get rid of the outer compression of the artery, which has to be done as soon as possible in order to avoid that compression causes degeneration of the artery itself.

Morphological changes in the lower esophageal sphincter influencing the result of antireflux surgical interventions in chronic gastroesophageal reflux disease.

BACKGROUND/AIMS: It is still unclear whether long-term reflux episodes result in morphological changes in the lower esophageal sphincter or not. If the answer is supposedly yes, do these changes influence the postoperative functional results following antireflux surgery? METHODOLOGY: Between 1 January 2002 and 2004, we performed antireflux surgery on 85 patients. Muscle samples were taken from the lower esophageal sphincter (LES) in 57 patients on operation. Patients with endoscopic findings of moderate or severe reflux esophagitis--Los Angeles B, C, D--were excluded. Control samples were obtained from muscle tissue at the gastroesophageal junction that had been removed from 16 patients undergoing gastric or esophageal resection. Histologic (hematoxylin and eosin and Giemsa), and immunohistologic (S-100 Protein, NCL-SERCA2, alpha-SMA) and electronmicroscopic analysis were used to evaluate the specimens. The number of smooth muscle cell nuclei in these intraoperative biopsies was used to compare the results of antireflux operations (Visick I and II-III). RESULTS: In 19% (11/57) of the reflux-type LES muscle samples perivascular inflammatory infiltration has been noted and in 6 of these cases (6/57 = 11%) this has incorporated marked intramuscular and adventitial granulocyte infiltration. In one patient (1/57 = 2%) eosinophil infiltration of the myenteric plexus and the ganglion has been revealed. Significantly lower Schwann and smooth muscle cell count could be detected in LES muscle samples taken from patients with GERD (p < 0.05). The analysis of the values of the 9 patients in Visick groups II and III at two months after surgery, has shown a significant decrease in the number of smooth muscle cell nuclei as compared to those patients in Visick group I (p < 0.01). CONCLUSIONS: Our results draw attention to the morphological changes occurring in the LES muscles of reflux patients. The enteric ganglionitis induced by GERD may result in various functional esophageal diseases. The histologic changes--that very much resemble hypertrophy--developing in LES muscles may serve as a reason for symptoms after antireflux surgery, presumably for the most common complaint of dysphagia.

[Synchronous carcinoma of the esophagus and the thyroid gland]. / Nyelocso--és pajzsmirigy-carcinoma együttes elofordulása.

INTRODUCTION: Incidence of synchronous or metachronous carcinomas with primer esophageal malignancy together can be estimated at 17% and these disorders manifest mostly in the stomach. CASE REPORT: The authors report the medical history of a 55-year-old man whose symptomatic middle third esophageal carcinoma was cured with esophagectomy and two field lymphadenectomy. Stomach was used for substitution. Histological examination verified pT2N1M0 tumor and metastasis of papillary thyroid carcinoma from the lymph node removed from near to the right recurrent nerve. Five weeks after the esophageal resection a total thyroidectomy and a central lymph node dissection was performed. The synchronous thyroid carcinoma was located into the inferior pole of right lobe. Currently the patient is without symptoms and plaints, the complex oncological treatment is in progress. DISCUSSION: The incidence of a synchronous carcinoma of the esophagus and the thyroid gland is an extreme rarity. The basic difference connected to the tumorbiological behaviors of these two malignancies is found in the growing tendency and in the direction of lymphogen spreading. The common point is the recurrent nerve lymphatic chains in the thoracic dome. This is the reason that after the R0 resection of a middle third esophageal carcinoma the histological evaluation of a lymph node obtained from right recurrent nerve lymphatic chain shed light on the asymptomatic synchronous thyroid cancer. CONCLUSION: In cases of operable esophageal carcinomas located into its middle or lower third the importance of a correct lymphadenectomy could not be emphasize enough. During the routine preoperative examinations it would be necessary to make cervical ultrasonography too.

Metabolic changes in the lower esophageal sphincter influencing the result of anti-reflux surgical interventions in chronic gastroesophageal reflux disease.

AIM: With the availability of a minimally invasive approach, anti-reflux surgery has recently experienced a renaissance as a cost-effective alternative to life-long medical treatment in patients with gastroesophageal reflux disease (GERD). We are not aware of the fact whether reflux episodes causing complaints for a long time i.e., at least for one year are associated with metabolic changes in the lower esophageal sphincter, and if so, whether these may influence functional results achieved after anti-reflux surgery. METHODS: Between 1 January 2001 and 31 December 2002 we performed anti-reflux surgery on 79 patients. Muscle samples were taken from the lower esophageal sphincter (LES) in 33 patients during anti-reflux surgery. Inclusion criteria were: LES resting pressure below 10 mmHg and a marked, pH proven acid exposure to the esophagus of at least one year's duration, causing subjective complaints and requiring continuous proton pump inhibitor treatment. Control samples were obtained from muscle tissue in the gastroesophageal junction that had been removed from 17 patients undergoing gastric or esophageal resection. Metabolic and lysosomal enzyme activities and special protein concentrations 16 parameters in total were evaluated in tissue taken from control specimens and tissue taken from patients with GERD. The biochemical parameters of these intra-operative biopsies were used to correlate the results of anti-reflux operations (Visick I and II-III). RESULTS: In the reflux-type muscle, we found a significant increase of the energy-enzyme activities e.g., creatine kinase, lactate dehydrogenase, beta-hydroxybutyrate dehydrogenase, and aspartate aminotransaminase-. The concentration of the structural protein S-100 and the myofibrillar protein troponin I were also significantly increased. Among lysosomal enzymes, we found that the activities of cathepsin B, tripeptidyl-peptidase I, dipeptidyl-peptidase II, beta-hexosaminidase B, beta-mannosidase and beta-galactosidase were significantly decreased as compared to the control LES muscles. By analyzing the activity values of the 9 patients in Visick groups II and III at two months post-surgery, we found a significant increase in the activity of the so-called energy-enzyme values and in the concentration of structural and myofibrillar proteins as compared to the rest of the reflux patients. CONCLUSION: Our results call attention to the metabolic changes that occurred in the LES muscles of reflux patients. The developing hypertrophy-like changes of LES muscles may be a reason for complaints after anti-reflux surgery, which consisted mainly of reports of persisting dysphagia.

[Considerations in the surgical treatment of enterogenic mediastinal cyst]. / Mediastinalis enterogen cysta sebészi kezelésének dilemmái.

INTRODUCTION: Mediastinal alterations causing esophageal dysfunctions originate from malignant or inflammatory diseases and in a few cases from congenital anomalies. CASE REPORT: The authors report the medical history of a 27-year-old woman whose large (35-40 mm in diameter) cystic lesion was causing compression of the middle third esophagus and dysphagia. Because of subjective complaints resection was made from a right posterolateral "muscle-preserving" thoracotomy. Histological examination verified an intramural, esophageal cyst. After the 7th postoperative day the patient was discharged from the hospital, currently she is without symptoms and complaints. DISCUSSION: In the background of esophageal dysfunctions can be a mediastinal lesion causing external compression. This lesion, in a few cases, is a congenital anomaly, which develops during the separation of the respiratory- and the digestive apparatus. Probably the effect of increased divisional tendency can create the partial duplication of developing organs, i.e. trachea, esophagus. Later these are described as bronchogenic or enterogenic cysts. Literature mentions cases about ciliated columnal epithelium, ventricular mucosa or malignancy covering the inner surface of the cyst. Preoperative examinations are not enough to describe a mediastinal cyst. According to the surgical guidelines a case without complaints is only a relative indication to operate. If it is followed, an occasional malignant transformation will not be recognized, or will be recognized too late. CONCLUSION: As we know, a mediastinal cystic lesion never regresses. Because of the tendency of malignant transformation, in the absence of operative contraindication, surgical resection is the method of choice even in symptom-free cases.