The Laparoscopic Management of Median Arcuate Ligament Syndrome and Its Long-Term Outcomes.

BACKGROUND: Case reports and small series of the surgical and radiological management of median arcuate ligament syndrome (MALS) have been described, however, long-term outcome data are lacking. The purpose of this study was to review our experience of the laparoscopic management of MALS, and describe the long-term outcomes after surgical intervention. METHODS: Data were collected between 2005 and 2016 in a single U.K. institution. All patients with MALS who underwent laparoscopic decompression of the celiac artery were included. Surgical outcomes were recorded from a prospectively collected database. Long-term outcomes were determined by outpatient review and the Gastrointestinal Quality of Life Index (GIQLI). RESULTS: Six patients were included. Five were female with a median age of 30 years (22.3-48.3). All six presented with abdominal pain and a bruit. Length of symptoms on presentation was 41 months (19-69). Duplex ultrasonography indicated celiac trunk stenosis in each case, with an elevated peak velocity flow in the celiac trunk of 230 cm/s (210-287.5). All six underwent successful laparoscopic decompression of the celiac artery with no conversions to open. Operating time was 137.3 minutes (95.6-166.3) and intraoperative blood loss was 110 mL (65-225). Length of stay was one day (1-2.3), with no postoperative complications or mortality. Median follow-up was 109.5 months (78-113.5). At this point, all patients remained symptom free with an overall GIQLI score of 129/144 (123.8-134.5). CONCLUSIONS: MALS is a rare condition. Laparoscopic decompression of the median arcuate ligament is safe and offers long-term resolution of symptoms, and improvement in patient quality of life.

A rare cause of upper gastrointestinal haemorrhage: Ruptured cystic artery pseudoaneurysm with concurrent cholecystojejunal fistula.

INTRODUCTION Cystic artery pseudoaneurysms and cholecystoenteric fistulae represent two rare complications of gallstone disease. PRESENTATION OF CASE An 86 year old male presented to the emergency department with obstructive jaundice, RUQ pain and subsequent upper gastrointestinal bleeding. Upper GI endoscopy revealed bleeding from the medial wall of the second part of the duodenum and a contrast-enhanced computed tomography scan revealed a cystic artery pseudoaneurysm, concurrent cholecystojejunal fistula and gallstone ileus. This patient was successfully managed surgically with open subtotal cholecystectomy, pseudoaneurysm resection and fistula repair. DISCUSSION To date there are very few cases describing haemobilia resulting from a bleeding cystic artery pseudoaneurysm. This report is the first to describe upper gastrointestinal bleeding as a consequence of two synchronous rare pathologies: a ruptured cystic artery pseudoaneurysm causing haemobilia and bleeding through a concurrent cholecystojejunal fistula. CONCLUSION Through this case, we stress the importance of accurate and early diagnosis through ultra- sonography, endoscopy, and contrast-enhanced CT imaging and emphasise that haemobilia should be included in the differential diagnosis of anyone presenting with upper gastrointestinal bleeding. We have demonstrated the success of surgical management alone in the treatment of such a case, but accept that consideration of combined therapeutic approach with angiography be given in the first instance, when available and clinically indicated.

Large gallstone impaction at a Meckel's diverticulum causing perforation and localized peritonitis: report of a case.

We are reporting a successful laparoscopic resection of a perforated Meckel's Diverticulum (MD) causing localized peritonitis due to an impacted gallstone. MD is a small benign pouch on the wall of the small intestine that is present in ∼2% of the population. It results from a failure of complete obliteration of the omphalomesenteric duct. MD is mainly lined by ileal mucosa; however, other ectopic tissue types can be found including gastric, duodenal, colonic, pancreatic, Brunner's glands, hepatobiliary tissue and endometrial mucosa. Most reported complications include bleeding, infection and obstruction. With relevance to this report, we can find no more than two reports of a large gallstone impacting the neck of the MD and causing ileus, and we were unable to find any reports that mention perforation due to impaction at the neck of an MD.

Efficacy and drawbacks of neoadjuvant chemoradiotherapy in squamous cell carcinoma of the thoracic esophagus.

BACKGROUND/AIMS: Neoadjuvant chemoradiotherapy (CRT) is widely applied in locally advanced esophageal tumors to improve resectability and local tumor control. In this study, we retrospectively analyzed the perioperative course of patients who underwent esophagectomy or esophagectomy following CRT. METHODOLOGY: Forty one patients were admitted with non-advanced disease (T1-2, N0), and primary resection was performed. Additional 21 patients received neoadjuvant CRT because of locally advanced, T2-4, N0-1 disease. To investigate predictive factors for responsiveness to CRT, we determined the p53, p21 and Ki67 oncogene expressions in the biopsy samples from the CRT patients. RESULTS: Following primary esophagectomy and esophagogastrostomy, the postoperative course was in most cases uneventful. Anastomotic leaks developed in 3 of the 41 cases (7.3%), and postoperative death in 1 case (2.4%). In response to CRT, significant down-staging was observed in 11 of the 21 patients (58%); in these cases esophagectomy was performed. However, in this group the rates of anastomotic leak (2 patients) and postoperative death (2 patients) were higher than in the first group (18% each). CONCLUSIONS: Preoperative CRT is a good option for patients with locally advanced tumors, when primary R0 resection is hopeless. However, the rate and risk of postoperative complications are higher than after primary resection of non-advanced tumors.

Importance of sentinel lymph node biopsy in surgical therapy of in situ breast cancer.

The aim of this retrospective study was to determine the rate of sentinel lymph node (SLN) positivity in patients with a final diagnosis of ductal in situ cancer (DCIS) of the breast. Between October 2002 and January 2007, 57 patients with DCIS underwent wide excision after radio-guided lesion localization; 53 of them (53/57, 93%) had participated in simultaneous SLN mapping. SLNs were analysed by 250-micron step-sectioning with haematoxylin and eosin staining and immunohistochemical evaluation. The histologic investigation verified pure breast DCIS in 44 cases (44/57, 77.2%), DCIS with microinvasion in eight cases (8/57, 14%) and lobular in situ breast cancer in five cases (5/57, 8.8%). SLNs were identified in 49 cases (49/53, 92.5%) and removed in 48 cases (48/53, 90.6%), i.e. an average of 1.6 SLNs per patient. In four patients (4/53, 7.6%), the SLN biopsy was unsuccessful because of the failure of the radiocolloid substance to migrate. In these cases, axillary sampling was performed. In one case (1/53, 1.9%), only a parasternal SLN was detected; this was not removed. Histologic analysis of the SLNs and the axillary lymph nodes with haematoxylin and eosin or cytokeratin immunohistochemistry did not prove the presence of metastases. The international data and our present results suggest that routine SLN biopsy is not to be recommended in pure DCIS cases. If the final histology verifies an invasive or microinvasive tumour, or if mastectomy is to be performed, SLN mapping is suggested.

Peroral endoscopic removal: as a minimally invasive long-term surgical treatment of a regurgitated giant polisegmented fibrovascular polyp of the esophagus.

Giant fibrovascular polyps (FVP) are relatively rare benign neoplasm of the upper part of the esophagus. Without previous history, their diagnosis might be difficult as the endoscopic findings are sometimes misinterpreted. The present report describes a case, in which the patient regurgitated his giant polypoid mass into his mouth and captured it between his teeth and buccal surface until the emergency endoscopic removal. Although the adequate therapy for these lesions is mainly the open surgical resection, most often via cervical esophagotomy, in our case the polyp was removed successfully by peroral endoscopic operation, as a minimally invasive surgical treatment. After 5 years of follow-up, the patient is doing well, without recurrence of his polyp.

Minimally invasive peroral endoscopic removal of a regurgitated giant polysegmented fibrovascular polyp of the esophagus.

Giant fibrovascular polyps (FVP) are relatively rare benign neoplasms of the upper part of the esophagus. Without a previous history, their diagnosis might be difficult because the endoscopic findings are sometimes misinterpreted. The present report describes a case in which the patient regurgitated a giant polypoid mass into his mouth and captured it between his teeth and buccal surface until emergency endoscopic removal. Although the adequate therapy for these lesions is open surgical resection, most often via cervical esophagotomy, in our case the polyp was removed successfully by peroral endoscopy with minimally invasive surgery. After 5 years of follow-up the patient is doing well, without recurrence.

[Amyloidosis induced colonic stricture. The first symptom of myeloma multiplex. A case report]. / Amyloidosis okozta colonstrictura mint a myeloma multiplex elso tünete--Esetismertetés.

UNLABELLED: Systemic amyloidosis often involves the gastrointestinal tract and usually presents as ulceration or polypoid lesions. However, annular stricture of the colon due to amyloidosis is very rare. Amyloidosis develops in appr. 10% of multiple myeloma patients with lambda light chain production, it is usually type AL and not a presenting symptom. CASE REPORT: A 73-year-old female patient appeared at our hospital with anaemia, abdominal pain and hematochezia. Colonoscopy revealed a circular narrowing of the sigmoid colon suggesting malignancy. The patient underwent sigmoid resection and rectosigmoidal anastomosis was prepared to relieve mechanical obstruction. Surprisingly the histological finding from the resected specimen was amyloidosis. Subcutaneous fat tissue biopsy established the diagnosis of systemic AA amyloidosis. Immunoelectrophoresis revealed an elevated gamma-globulin fraction with IgG lambda monoclonal component, as well as a different lambda light chain. Therefore bone marrow biopsy was carried out which confirmed the diagnosis of multiple myeloma. DISCUSSION: Our case is a rare example of the extraordinary tumor-mimicking colon amyloidosis that led to the diagnosis of multiple myeloma. Beside haematological treatment, strict follow-up of the colon process and reconsideration of surgical therapy or endoscopic stenting is of great importance.

[Importance of sentinel lymph node biopsy in surgical therapy of in situ breast cancer]. / Az orszem (sentinel) nyirokcsomó jelentôsége in situ emlocarcinoma sebészi kezelésében.

INTRODUCTION AND AIMS: The aim of this retrospective study was to determine the rate of sentinel lymph node (SLN) positivity in patients with a final diagnosis of ductal carcinoma in situ (DCIS). PATIENTS AND METHODS: Between October 2002 and January 2006, 47 patients with DCIS underwent wide excision after radio-guided lesion localisation; 44 of them (93.6%) had simultaneous SLN mapping. SLNs were analysed by 250 micron step-sectioning by H&E and immunohistochemical evaluation. RESULTS: The histological investigation verified pure breast DCIS in 36 cases (76.6%), DCIS with microinvasion in 7 cases (14.9%) and lobular in situ breast cancer in 4 cases (8.5%). SLNs were identified in 40 cases (91%) and removed in 39 cases: an average of 1.5 SLNs per patient. In 4 patients (9%) SLN biopsy was unsuccessful because of the lack of migration of radiocolloid substance. In these cases, axillary sampling was performed. In 1 case (2.3%), only a parasternal SLN was detected; this was not removed. Histological analysis of SLNs and axillary lymph nodes with haematoxylin and eosin or cytokeratin immunohistochemistry did not prove metastases. DISCUSSION AND CONCLUSION: On the basis of international data and our present results, routine SLN biopsy is not recommended in pure DCIS cases. If the final histology verifies an invasive or microinvasive tumour, or if mastectomy is to be performed, SLN mapping is suggested.

Identification and characterization of a novel, psoriasis susceptibility-related noncoding RNA gene, PRINS.

To identify genetic factors contributing to psoriasis susceptibility, gene expression profiles of uninvolved epidermis from psoriatic patients and epidermis from healthy individuals were compared. Besides already characterized genes, we identified a cDNA with yet unknown functions, which we further characterized and named PRINS (Psoriasis susceptibility-related RNA Gene Induced by Stress). In silico structural and homology studies suggested that PRINS may function as a noncoding RNA. PRINS harbors two Alu elements, it is transcribed by RNA polymerase II, and it is expressed at different levels in various human tissues. Real time reverse transcription-PCR analysis showed that PRINS was expressed higher in the uninvolved epidermis of psoriatic patients compared with both psoriatic lesional and healthy epidermis, suggesting a role for PRINS in psoriasis susceptibility. PRINS is regulated by the proliferation and differentiation state of keratinocytes. Treatment with T-lymphokines, known to precipitate psoriatic symptoms, decreased PRINS expression in the uninvolved psoriatic but not in healthy epidermis. Real time reverse transcription-PCR analysis showed that stress signals such as ultraviolet-B irradiation, viral infection (herpes simplex virus), and translational inhibition increased the RNA level of PRINS. Gene-specific silencing of PRINS by RNA interference revealed that down-regulation of PRINS impairs cell viability after serum starvation but not under normal serum conditions. Our findings suggest that PRINS functions as a noncoding regulatory RNA, playing a protective role in cells exposed to stress. Furthermore, elevated PRINS expression in the epidermis may contribute to psoriasis susceptibility.

[Minimally invasive surgical treatment for mid-esophageal and epiphrenic diverticula]. / Középsó harmadi és epiphrenalis nyelócsó diverticulumok minimálisan invazív sebészi kezelése.

UNLABELLED: We report thoracoscopically or laparoscopically successfully treated patients with giant mid-esophageal and epiphrenic diverticula. Four patients presented with significant dysphagia for solid food, retrosternal pain, regurgitation and weight loss. They underwent the following gastroenterologic investigations: barium swallow, esophagoscopy, bronchoscopy and esophageal pH- and manometry. In two patients just below the trachea bifurcation, sacciform mid-esophageal diverticula of 10 to 12 cm without significant esophageal motor alteration were diagnosed. In the other two patients 8-10 cm large epiphrenic diverticula were diagnosed--one of them was associated with achalasia. SURGICAL TREATMENT: The midesophageal diverticula were resected via thoracoscopic access. The mobilized diverticula were resected with endo-GIAs. Trans-hiatal laparoscopic approach was applied for the dissection and resection of epiphrenic diverticulum. In one patient the resection was completed with esophago-cardiomyotomy and anterior partial fundoplication. During the operations continuous endoluminal endoscopic control was provided. There were no intraoperative complications. Oral feeding was started on the 6th postoperative day after control esophagography. The thoracoscopic or trans-hiatal laparoscopic resection of esophageal diverticula is safe, reduces postoperative morbidity and helps rapid return to normal activity.

Two intriguing Bilophila wadsworthia cases from Hungary.

Bilophila wadsworthia, an obligately anaerobic Gram-negative bacillus, was first isolated from appendicitis specimens and human faeces. The two cases described here are the first report of the isolation of B. wadsworthia in Hungary, and include the first isolation from chronic mastoiditis complicated with a brain abscess.

[Endoscopic stapling diverticulostomy for Zenker diverticulum]. / Endoszkópos varrógéppel képzett diverticulostoma a Zenker-diverticulum kezelésére.

INTRODUCTION: The authors have successfully applied the endoscopic stapling diverticulostomy for three patients with symptomatic Zenker diverticulum. METHOD: Under light general anesthesia the hypopharynx was explored with a rigid, double lipped laryngoscope (Weerda, Storz). The common wall between the esophagus and and diverticulum was cut across and reunited with a endosurgical stapler. RESULTS: Operating time was 25 minutes in average. There were no intraoperative or postoperative complications. The oral feeding was started on the 2. postoperative day. The patients were symptom-free and they were discharged on the fifth postoperative day. The preoperative symptoms were not reported at follow-up assessment. CONCLUSION: The endoscopic stapler diverticulostomy offers distinct advantages, including brief operative time, short hospitalization, reduced morbidity, early oral feeding and predictable resolution of symptoms. The authors proposed the technique in the treatment of the patients with Zenker's diverticulum especially for elderly cases with diverticulum larger than 3 cm.

Alkali ingestion predisposes to developing giant mid-esophageal pulsion diverticulum - a report of a medical rarity.

Pulsion diverticulae of the mid-esophagus with unknown etiology are usually asymptomatic and therefore considered incidental findings on chest X-rays, barium swallows, or endoscopic procedures. Diagnosis is often delayed due to the rarity of clinical symptoms. The clinical, radiological, etiological and surgical features in a patient with extraordinary symptomatic giant mid-esophageal pulsion diverticulum with history of alkali ingestion are presented here. Alkali injury may yield asymptomatic strictures and/or acquired weaknesses of the esophageal wall, both of which are known to lead to the formation of this giant malady. Putative pathomechanism and suggested therapy including diverticulectomy is proposed in this communication.

Endoscopic intubation with conventional plastic stents: a safe and cost-effective palliation for inoperable esophageal cancer.

Access to expensive equipment and costly self-expanding metal endoprostheses is limited in some regions where unresectable esophageal cancer is not infrequent. The aim of this study was to review the long-term results of palliation of malignant esophageal obstruction using low-priced conventional plastic stents. One hundred sixty-nine patients with dysphagia due to inoperable esophageal cancer underwent esophageal intubation under endoscopic control alone, without general anesthesia, by the pulsion method. Stents mounted on their delivery device were inserted over an endoscopically placed guide wire. Improvement in swallowing was seen in all patients. Dysphagia scores have improved from 3.64 +/- 0.21 to 1.08 +/- 0.17. Major early procedure-related morbidity was high at 0.6% with one intramural perforation (no transmural perforation at all). Minimal mucosal bleeding was seen with 72 cases (42.6%). Procedure-related mortality was 0%. Late procedure-related complications requiring further endoscopic procedures occurred in 8.2% (tube occlusion: 5.3%, tube dislocation: 2.9%). Our 7-day mortality was 0% and 5 patients died within 30 days, usually from the disease itself. Those surviving the procedure (more than 7 days) had a mean survival of 209 days. Esophageal plastic stents can be accurately and safely placed under direct endoscopic control with lower costs. Therefore, endoscopic intubation remains a useful palliative treatment for patients with unresectable carcinoma of the esophagus.

Thoracic epidural anesthesia improves the gastric microcirculation during experimental gastric tube formation.

BACKGROUND: Gastric tube formation is a surgical technique to reestablish the continuity of the gastrointestinal tract after esophagectomy. Our aims were to study the microcirculatory consequences of experimental gastric tube formation and characterize the effects of thoracic epidural anesthesia (TEA) during this condition. METHODS: The experiments were performed on mongrel dogs anesthetized with pentobarbital. The stomach was prepared for replacement according to the method of Akiyama, and TEA was induced with bupivacaine (1 mg/kg). Macrohemodynamics, intramucosal pH, and gastric motility changes were monitored, and intravital video-microscopy with orthogonal polarization spectral imaging technique was used to observe the gastric microcirculation. RESULTS: The gastric pull-up induced a significant decrease in intramucosal pH. The functional capillary density of the mucosa or subserosa did not change; the red blood cell velocity in the capillaries of the upper part of the gastric tube was decreased in the mucosa, as well as on the serosal side. After epidural anesthesia the red blood cell velocity returned to the baseline, and the gastric and intestinal motility index was significantly increased. CONCLUSIONS: TEA significantly improves the microcirculation of the distal portion of the gastric tube and increases the intestinal and gastric motility after gastric pull-up. The procedure is favorable and should be recommended during reconstructive esophageal surgery.

[Changes in microcirculation of esophageal mucosa during acute experimental reflux. Pathogenic role of the biliary component]. / A nyelócsó nyálkahártya mikrokeringési változásai akut kísérletes reflux alatt--az epés komponens kóroki szerepe.

UNLABELLED: Our aims were to examine microcirculation during experimental reflux esophagitis in dogs. We compared the effects of microcirculation of the mucosa to 3-hr exposure with acid, mixed acid and bile, we measured the changes in constitutive and inducible nitric oxide synthase activity (cNOS and iNOS). METHODS: The microcirculation of the upper esophagus was investigated by intravital videomicroscopy. The functional capillary density (FCD), relative vessel area (RVA) and red blood cell velocity (RBCV) were measured. Mucosal barrier integrity was examined by vascular and epithelial permeability indices. Myeloperoxidase (MPO) enzyme activity, cNOS, iNOS activities and microscopic damage were examined in biopsies. RESULTS: The vascular permeability index, the RBCV and the RVA increased significantly in the treated groups, the FCD significantly decreased after acid exposure. The MPO and iNOS activities were significantly elevated in all treated groups. The cNOS activity did not change after exposure to acid + bile or acid, but significantly decreased after sole bile treatment. Severe mucosal damage was observed after bile exposure. CONCLUSION: Bile induced characteristic microcirculatory changes during experimental reflux esophagitis. Tissue damage and leukocyte infiltration could be exacerbated by bile-induced cNOS inhibition.