[Laparoscopic reconstruction in traumatic rupture of the diaphragm]. / Traumás rekeszruptura laparoscopos reconstructiója.

The authors report the case of a 63-year-old patient who was polytraumatized in a motor vehicle accident and suffered multiple traumatic injuries. Chest and pelvic fractures as well as left-sided diaphragmatic rupture with associated omentum herniation were diagnosed on CT scan. None of the injuries required urgent surgical intervention. After 10 days supportive therapy, elective laparoscopic reconstruction of the diaphragmatic hernia was performed. The authors discuss the role of laparoscopic diaphragm reconstruction.

"Mystic" transient recurrent nerve palsy after thyroid surgery.

BACKGROUND: The mechanism of transient recurrent laryngeal nerve (RLN) palsy remains unclear. METHODS: Samples were harvested from the RLN adjacent thyroid capsule and perineural fascia during 223 lobectomies and 89 RLNs from cadavers were used for histologic and immunohistologic evaluation. Intraoperative chromoendoscopic features of the RLN were compared with postoperative ear, nose, and throat examinations. RESULTS: Those nerves that macroscopically seem to be single-branched (35 of 89 = 39.3%), microscopically consist of multiple fascicles in most of the cases (23 of 35 = 65.7%), resembling a plexus more than a single cord. Chronic lymphocytic infiltration of the thyroid capsule adjacent to the RLN was present in 29% (65 of 223) of the cases. The perineural fascia showed lymphocytic (18 of 223 = 8.1%) or granulocytic (7 of 223 = 3.1%) infiltration. CONCLUSIONS: The origin of transient RLN palsy is multifactorial: plexus shaped microscopic nerve structure with or without branches, frame-like adventitial tissue, variable epineurium, inflammatory changes that involve not only the thyroid capsule but the perineural fascia, resultant nerve edema, and diffuse microhemorrhages by injury of fragile capillaries.

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.

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.

Significance and prognostic value of lysosomal enzyme activities measured in surgically operated adenocarcinomas of the gastroesophageal junction and squamous cell carcinomas of the lower third of esophagus.

AIM: To establish whether there are fundamental differences in the biochemistries of adenocarcinomas of the gastroesophageal junction (GEJ) and the squamous cell carcinomas of the lower third of the esophagus (LTE). METHODS: Between February 1, 1997 and February 1, 2000, we obtained tissue samples at the moment of resection from 54 patients for biochemical analysis. The full set of data could be comprehensively analyzed in 47 of 54 patients samples (81%). Of these, 29 were adenocarcinomas of the GEJ Siewert type I (n = 8), type II (n = 12), type III (n = 9), and 18 presented as squamous cell carcinomas of the LTE. We evaluated the mean values of 11-lysosomal enzyme and 1-cytosol protease activities of the tumorous and surrounding mucosae as well as their relative activities, measured as the ratio of activity in tumor and normal tissues from the same patient. These data were further analyzed to establish the correlation with tumor localization, TNM stage (lymph-node involvement), histological type (papillary, signet-ring cell, tubular), state of differentiation (good, moderate, poor), and survival (or=24 mo). RESULTS: In adenocarcinomas, the activity of alpha-mannosidase (AMAN), cathepsin B (CB) and dipeptidyl-peptidase I (DPP I) increased significantly as compared to the normal gastric mucosa. In squamous cell carcinomas of the esophagus, we also found a significant difference in the activity of cathepsin L and tripeptidyl-peptidase I in addition to these three. There was a statistical correlation of AMAN, CB, and DPP I activity between the level of differentiation of adenocarcinomas of the GEJ and lymph node involvement, because tumors with no lymph node metastases histologically confirmed as well-differentiated, showed a significantly lower activity. The differences in CB and DPP I activity correlated well with the differences in survival rates, since the CB and DPP I values of those who died within 24 mo following surgical intervention were significantly higher than of those who survived for 2 years or more. CONCLUSION: Adenocarcinomas of the GEJ form a homogenous group from a tumor-biochemical aspect, and differ from the biochemical characteristics of squamous cell carcinomas of the LTE on many points. When adenocarcinomas of the GEJs are examined at the preoperative phase, the ratio of the performed AMAN, CB, and DPP I enzymatic activity of the tissue sample from the tumor and adjacent intact mucosa within 2 cm of the tumor may have a prognostic value even in the preoperative examination period, and may indicate that ranking of these patients into the neo-adjuvant treatment group should be considered.

[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.

The place of gastro-jejuno-duodenal interposition following limited esophageal resection.

OBJECTIVE: Although stomach is the best choice for reconstruction after esophagectomy from the viewpoint of safety and ease, an intrathoracic stomach, nevertheless, is a poor long-term substitute. This anatomical configuration abolishes normal antireflux mechanisms and places the acid-excreting stomach subject to biliary reflux, moreover, in an adjacent position to the esophagus within the negative-pressure environment of the thorax. METHODS: Between 1995 and 2002, 27 patients with high-grade neoplasia-as early Barrett's carcinoma-or non-dilatable peptic stricture underwent limited surgical resection of the distal esophagus and esophagogastric junction. In 11 of these cases, the reconstruction was performed with gastro-jejuno-duodenal interposition. The long-term functional results of this specially adapted form of interposition reconstruction have been evaluated. The postoperative follow-up period ranged between 24 and 95 months (mean 68 months). Nine patients (9/11=81.8%) have agreed to undergo endoscopy, radiographic contrast-swallow examination, and 24-h ambulatory esophageal pH and bilirubin monitoring. RESULTS: Three out of nine patients (3/9=33%) demonstrated abnormal levels of esophageal acid exposure during the 24-h study period, whilst none had any evidence of bilirubin exposure in the esophageal remnant. Endoscopy revealed that three patients had reflux esophagitis in the remnant esophagus: Los Angeles A=2, C=1. No stomal or jejunal ulceration at the gastro-jejunal anastomosis could be observed. Histopathologic assessment of the squamous epithelial biopsies demonstrated microscopic evidence of inflammation: minor in two cases, moderate in one and major in one case; however, none of them had evidence of columnar metaplasia in the esophageal remnant at a median of 68 months after surgery. The majority of the patients have been doing well since the operation: 8/9 (88%)=Visick I-II. CONCLUSIONS: Gastro-jejuno-duodenal interposition represents an adequate 'second-best' method of choice if technical difficulties emerge with jejunal or colon interposition following limited resection of the esophagus performed due to early Barett's carcinoma or non-dilatable peptic stricture.