Gallstone Ileus, Bouveret's Syndrome and Choledocholithiasis in a Patient with Billroth II Gastrectomy - A Case Report of Combined Endoscopic and Surgical Therapy.

Intestinal obstruction due to gallstone is a rare, but quite severe gastrointestinal disorder, which always requires a rapid and correct diagnosis to achieve optimal therapy. Digestive endoscopy is an important method to determine the level of the bowel obstruction and to plan an optimal therapeutic strategy. Our present case demonstrates that in a high-risk patient, a combined endoscopic and surgical therapy is the best choice to solve the obstruction of the colon, of the stomach and of the common bile duct caused by multiple gallstones.

Esophageal replacement using cryopreserved tracheal graft.

Esophageal replacement using artificial material is not a new concept. Prior experiences with prostheses, allografts and composite grafts have not proved particularly successful. The aim of this study is to investigate whether cryopreserved animal trachea is suitable for the replacement of the esophagus. In 12 beagle dogs a 6-cm-long segment of the cervical esophagus was removed, and was replaced with cryopreserved trachea, which had been stored for 21 days on -86 degrees C. The proximal and distal ends of the esophagus were joined together with the graft by simple continuous suture (Biosyn 3/0) and covered with the sternohyoid flap. Postoperatively 16 hematological parameters were measured. The dogs were planned to be euthanized at random on days 28, 42 and 56 after the operation. Tests for air leak were performed and the inner diameter of the graft was measured to detect shrinkage. The microscopic structure of the graft was analyzed using haematoxylin and eosin staining. There was no indication of insufficiency. Based on the air leak test the sutures withheld properly. The inner diameter of the graft narrowed from an average 19 mm (+/- 1 mm) to 15.8 mm (+/- 0.6 mm). In length, the graft shortened from an average 60 mm to 47 mm (+/- 3 mm). No feeding difficulty was observed. In two cases wound suppuration was found involving only the cutaneous and subcutaneous layers. Concerning the laboratory parameters, only the fibrinogen level and white blood cell count showed temporary although significant changes. Histology findings on the 56th day showed absolute integration of the trachea with the esophagus, with disintegration of the tracheal cartilages. Cryopreserved trachea seems to be suitable for the replacement of a 5-6-cm-long esophageal segment.

Synchronous spontaneous perforation of the esophagus and a duodenal ulcer.

SUMMARY: Although 41% of patients with spontaneous rupture of the esophagus also suffer from gastro duodenal ulcer disease, cases of synchronous spontaneous esophageal and duodenal ulcer perforation have thus far not been reported in the literature. We report on the case of a 61-year-old man who presented with a 72-hour history of esophageal rupture and duodenal ulcer perforation. Following appropriate circulatory resuscitation we performed double resection; involving the esophagus, cardia and the distal part of the stomach, followed by substitution by means of gastro-jejunal transposition as a one-stage procedure. With reference to this case with a favorable outcome, we are presenting an analysis of indications for resectional surgery in advanced spontaneous esophageal perforation.

Esophageal intramural metastasis from adenocarcinoma of the gastroesophageal junction.

Among a total of 143 patients examined for diagnosis of adenocarcinoma of the cardia, intramural esophageal metastases were verified in six patients (4.19 %). In each case the diagnosis was confirmed by histological examination. The histological structure of the primary tumors and metastases was the same. Metastases were detected by endoscopic ultrasound examination in three cases. All the cardia tumors proved to be well advanced. As well as endoscopic identification of the primary tumor, thorough examination of the proximal part of the esophagus is of great importance.

[What kind of surgical radicality is justified in the treatment of esophageal and cardial carcinoma?]. / Wie radikal soll das Osophagus- bzw. Kardiakarzinom operiert werden?

In the period from January 1, 1973 to November 30, 1994, a total number of 1 856 patients had been admitted to our Department of Surgery because of cancer of the esophagus and esophago-gastric junction. We divided our activities into two study periods. In the first study period from 1973 to 1984 only so called "conventional operations" were performed. Since 1985 new oncological aspects were introduced into our operative tactics:1. the subtotal esophagectomy combined with the two-field lymphadenectomy,2. the total gastrectomy with extended lymph node dissection. The analysis of our results with respect to the survival parameters (TNM staging, histological type, grade of differentiation, gross pathology) showed that the best chances were obtained by curative resection and lymphadenectomy in tumours of low-grade biologic malignancy. In esophageal cancers the former 6 % 5-year cumulative survival rate increased to 26 %, and in cardia tumours from 9 to 27 %, because of enhancement of radicality and extension of lymphadenectomy.

[Siewert-Stein classification of adenocarcinoma of the esophagogastric junction]. / Az oesophagogastricus junctio adenocarcinomáinak Siewert-Stein klasszifikációjáról.

Nowadays the terminology used for the definition of adenocarcinomas at the oesophagogastric junction is "cardiac carcinoma", which can be easily misunderstood. This definition of adenocarcinomas of the oesophagogastric junction does not allow correct comparison of diagnosis (endoscopic, radiological and pathologic), epidemiology and surgical therapy in national and international aspects, because different tumours can develope in the same area, and all called cardia tumors. Siewert and Stein recommended a classification to solve this problem. The classification of the tumours is morphological/topographical. Type I is adenocarcinoma of the distal part of the oesophagus. Type II is adenocarcinoma of the real cardia and type III is subcardial gastric adenocarcinoma. At classification, we always consider results of endoscopy (ortograde and retroflexed view of the oesophago-gastric junction), the x-rays of the oesophagus and stomach, findings at the operation and pathohistologic results. Between 1/1/1974 and 31/12/2000, a total number of 50,878 upper panendoscopic examinations were performed at the Endoscopic Laboratory of the Surgical Department. Adenocarcinoma of the cardia was diagnosed in 488 patients. According to the Siewert-Stein classification, type I tumour was found in 123 (25.2%), type II in 240 (49.18%), and type III was present in 125 (25.61%) patients. The importance of this classification is it enables unified pre-operative assessment and it can also help to decide the type of the surgical intervention. In our patients with type I cancer--depending of the size of the tumour--distal 2/3 oesophagectomy with the resection of the proximal lesser curve of the stomach or total gastrectomy were performed. In the first group oesophago-jejuno-gastrostomy, in case of total gastrectomy Roux-en-Y loop anastomosis was created. In patients with types II and III cancers total gastrectomy was performed. In every patient lymphadenectomy was performed. We suggest the use of this new classification in clinical, gastroenterology--with special regard to the endoscopy--and pathology.

[Perspectives of laparoscopy in cardia and gastric surgery]. / A laparoszkópia útkeresése a cardiatáj és a gyomor sebészetében.

The authors have made 171 laparoscopic operations in the gastro-esophageal region during the past three and a half years. They have used the achievement of the minimal invasive surgery mainly in the treatment of functional diseases of the gastro-esophageal junction. Besides the hiatal reconstruction and antireflux procedures (142), endoscopic assisted cysto-gastrostomy (7), endoscopic assisted double-lifting gastric wall resection (5), cardiomyotomy (4), Graham suture of perforated duodenal ulcer (4) and enucleation of gastric wall leiomyoma (2) has been performed. There was no postoperative death, the rate of conversion was altogether 4.7% (8/171) while there was no need for reoperation in the early postoperative period.

[Laparoscopic adrenalectomy with transperitoneal approach]. / Laparoszkópos adrenalektómia transzperitonealis módszerrel.

UNLABELLED: The feasibility, safety, and results of 52 laparoscopic transperitoneal adrenalectomies were evaluated. METHODS: A total of 52 patients were included in the study based on thorough endocrinological and imaging assessment. 15 patients with Conn syndrome, 3 with Cushing syndrome, 15 with nonfunctioning adenoma, 14 with pheochromocytoma, 2 with adrenocortical cyst, 2 with adrenocortical lipoma and 1 with metastasis were considered eligible for adrenalectomy. Lesion size ranged from 1 to 12 cm (mean 4.53 cm). Concurrent surgical procedures were performed in 6 patients (11%). RESULTS: There was one conversion (during a left adrenalectomy), because of our learning curve. After we changed the technique, there was no more conversion. There were two (3.8%) postoperative complications: postoperative pancreatitis, one of the patients required re-operation (lavage and drainage). There was one wound infection. We had no postoperative mortality. Mean postoperative hospital stay was 6 days (range, 2-27 days). CONCLUSION: Patients with secreting and non-secreting adrenal lesions can be treated safely and effectively by laparoscopic adrenalectomy.

[Rare late complication after subtotal esophagectomy]. / Nyelócsórezekció után kialakult ritka késói szövódmény.

We report a case of a peptic ulcer developed in the stomach tube used for the replacement of the esophagus. The patient was a 60 years old female who had undergone subtotal esophagectomy for mid esophageal malignancy, with intrapleural stomach replacement. Urgent endoscopy revealed an excavated, bleeding ulcer in the thoracic part of the stomach. After unsuccessful medical treatment urgent operation was performed via right thoracotomy. Opening the stomach an ulcer was found on the posterior wall of the stomach, it was penetrating to the right atrium of the heart. The bleeding was controlled by suturing the atrium wall. The patient treated with i.v. Omeprazol in the postoperative period. On the 21st postoperative day a rebleeding occurred causing shock. After reoperation the patient died. This complication is very rare. We emphasise the importance of postoperative pH measurement investigations showing the presence of duodenogastric reflux disease.

Laparoscopic wedge resection of the gastric wall for gastric benign tumour. The collaboration of the laparoscopic surgeon and the endoscopist.

INTRODUCTION: By the introduction of the laparoscopy for the management of gastric pathology many techniques are applied by now. In these techniques the collaboration of the endoscopist and the laparoscopic surgeon is mandatory. AIMS OF THE STUDY: To emphasise the necessity of the collaboration of the endoscopist and the laparoscopic surgeon for the management of the gastric pathology using the double lifting and wedge resection technique. METHOD: A case of a female with 2 x 2.5 cm submucosal tumour is presented. The tumour was located in the antrum. After the onset of the general anaesthesia the gastroscope was introduced to locate the position of the tumour, the free edges of the tumour were elevated by a double lifting method and the tumour was resected by a laparoscopic linear stapler. The process of the proper resection was all through observed and directed by the view of the gastroscope. CONCLUSION: Correct wedge resection of the gastric wall can be safely performed, if the correct gastroscopic control is present. The collaboration of the endoscopist and the laparoscopic surgeon seems to be mandatory, thus avoiding the hazards arising from the use of tattooing.

[Laparoscopic intervention in pediatric urology]. / Laparoszkópos beavatkozások a gyermekurológiában.

The authors summarise the short history of the laparoscopy, and main steps of its use in international and Hungarian practice of urological surgery. They evaluate the possibility of laparoscopy in paediatric urological practice. Finally, they present their experience with this minimally invasive technique from 1995. Between October 1995 and September 1998, 83 laparoscopic procedures were performed. In 59 patients the vena testicularis were ligated by laparoscopy and in 22 patients 24 non palpable testes were diagnosed and operated. In 9 of the cases laparoscopic orchidopexy was performed. The authors demonstrate their operative technique. All laparoscopic interventions were tolerated well by children and they were treated without any complication. Postoperative pain medication were given for 5 children. The operative time for varix ligation ranged from 15 and 20 minutes, and for laparoscopic orchidopexy from 30 and 40 minutes. The recurrence rate of varicocele was found to be 1.5%, and postoperative hydrocele developed in one patient (1.5%).

Metastasis of an esophageal carcinoma to a giant gastric ulcer.

In patients with esophageal carcinoma it is considered that stomach metastasis is induced mainly via the lymphatic route rather than via the bloodstream route that is common in other types of distant organ metastasis. A 56 year-old patient is reported who underwent synchronous subtotal esophagectomy and total gastrectomy for a middle third esophageal carcinoma and a giant peptic ulcer within the gastric fundus. The final histopathologic examination revealed a squamous cell carcinoma of the esophagus with concomitant squamous tumor implantation within the gastric ulcer. The increased cell proliferation in the ulcer margin can serve as a "biological background or base" for implantation.

Gastrojejunal interposition for esophageal replacement.

The main considerations in replacing the esophagus are to avoid postoperative necrosis of all or part of the graft, leakage or stenosis of the anastomoses, and complications related to acid-peptic or alkaline reflux. A 5-year-old boy, after two unsuccessful thoracic operations for atresia and then stenosis of the esophagus, underwent resection of the esophagus because of duodeno-gastroesophageal reflux. The continuity of the alimentary tract was restored by gastrojejunal interposition. We recommend this method of reconstruction when the esophago-gastrostoma is created in the chest, and the possibility of alkaline reflux must be considered.

The role of esophagectomy in the management of esophageal perforations.

BACKGROUND: Despite the many advancements made in thoracic surgery, the management of patients with esophageal perforation remains problematic and controversial. METHODS: Between 1985 and 1995, 27 esophagectomies were performed for perforation of the thoracic esophagus. A retrospective review of the records of these patients was carried out, and a scoring scale developed by Elebute and Stoner to grade the severity of sepsis was applied. RESULTS: Among the 27 patients undergoing esophagectomy for a perforation, the interval between rupture and esophagectomy was less than 24 hours in only 11 patients (40.7%). Postoperative surgical complications occurred in 4 patients (14.8%) and nonsurgical complications, in 7 (25.9%). The hospital mortality rate was 3.7% (1/27). In 14 patients, primary reconstruction was performed in the bed of the excised esophagus. There were no anastomotic leaks in this subgroup. This suggests that an anastomosis between viable, well-vascularized tissues is more important for successful healing than avoidance of some degree of contamination of the adjacent mediastinum. On follow-up, which averages 41 months, 73% of patients (16/22) have neither symptoms nor complaints. CONCLUSIONS: Esophageal resection definitively eliminates the source of intrathoracic sepsis, the perforation, and the affected esophagus. Reconstruction carried out in one stage does not increase operative morbidity. Esophageal resection and reconstruction is a valid approach even in cases of spontaneous perforation in which the diagnosis is markedly delayed.

[Determination of the upper margin of superficial esophageal cancer by intraoperative endoscopic examination and toluidine blue staining]. / A superficialis nyelöcsörák felsö határának meghatározása intraoperatív endoscopos vizsgálattal és toluidinkék festéssel.

Authors describe a new application of intraoperative endoscopic examination. At operation it is difficult to define the border of a superficial esophageal cancer. The female patient aged 69 years was operated on because of squamous cell cancer. During the operation endoscopic examination was done and the esophageal mucosa was stained with 1% toluidine blue solution. The squamous cancer stained blue. The upper border ot the tumour was determined so that the esophageal wall was palpated from the outside with a probe and the same time the manipulation was being watched on the monitor of the videoendoscope. Subtotal esophagectomy and lymphadenectomy were performed. Authors claim that by the intraoperative use of endoscopic staining the risk recurrence in an anastomosis may be diminished and leaving behind of multifocal carcinoma may be eliminated.

Laparoscopic varicocele operation: a chance to prevent the recurrence.

There are recurrences and postoperative hydrocele of varicocele after any kind of surgical treatment. Laparoscopic clipping and dissection of internal spermatic vessels was performed without any complication in 73 children to treat varicocele in our department between 1995 and 1998. We have used a new method to detect etiological factors at laparoscopic surgery. The well-known Linton and Trendelenburg test was adapted to detect incidental collateral veins in 73 patients. Using these test, collateral veins were detected in 16 boys. The testicular artery identified in most of the cases as a pulsatile vessel. The operating time was 10-25 minutes. Laparoscopic varicocelectomy is a safe, effective treatment causing minimal discomfort and allowing patients an early to return to activity. These results suggest this technique a viable alternative to open ligation in paediatric urological practice.

[Synchronous surgical removal of esophageal and pulmonary cancer by endoscopic mucosectomy and video-assisted lobectomy through minimal thoracotomy]. / Szinkrón nyelöcsö-és tüdöcarcinoma eltávolítása endoscopos mucosectomiával és videoasszisztált mini thoracotomiából végzett lobectomiával.

Authors report a case of a 75 year old, male patient suffering from an early stage squamous esophageal cancer and a synchronous adenocarcinoma of the lung. The patient was operated on simultaneously at the same setting: the esophageal tumour was taken out by endoscopic mucosectomy, whereas the pulmonary cancer was removed by video assisted minimal thoracotomy. The definitive histological diagnosis was: squamous cell cancer (muscular mucosal cancer) (pT1) of the esophageal lesion and adenosquamous cancer (pT2) of the lung. Authors draw attention on the significance of the early diagnosis of malignant tumours, and in this case minimally invasive endoscopic procedures can be successfully performed.