The Esophageal Adenocarcinoma Epidemic Has Reached Hungary: A Multicenter, Cross-Sectional Study.

BACKGROUND: The epidemiology of esophageal cancer has changed dramatically over the past 4 decades in many Western populations. We aimed to understand the Hungarian epidemiologic trends of esophageal squamous cell cancer (SCC) and adenocarcinoma (AC). METHODS: We performed a cross-sectional study using data from esophageal cancer patients diagnosed between 1992 and 2018 at eight tertiary referral centers in four major cities of Hungary. We retrospectively identified cases in the electronic databases of each center and collected data on gender, age at diagnosis, year of diagnosis, specialty of the origin center, histological type, and localization of the tumor. Patients were grouped based on the two main histological types: AC or SCC. For statistical analysis, we used linear regression models, chi-square tests, and independent sample t tests. RESULTS: We extracted data on 3,283 patients with esophageal cancer. Of these, 2,632 were diagnosed with either of the two main histological types; 737 had AC and 1,895 SCC. There was no significant difference in the gender ratio of the patients between AC and SCC (80.1 vs 81.8% males, respectively; p = 0.261). The relative incidence of AC increased over the years (p < 0.001, b = 1.19 CI: 0.84-1.54). AC patients were older at diagnosis than SCC patients (64.37 ± 11.59 vs 60.30 ± 10.07 years, p < 0.001). The age of patients at the diagnosis of primary esophageal cancer increased over time (p < 0.001, R = 0.119). CONCLUSIONS: The rapid increase in the relative incidence of AC and simultaneous decrease of the relative incidence of SCC suggest that this well-established Western phenomenon is also present in Hungary.

Faecal microbiota transplantation for Clostridium difficile infection using a lyophilized inoculum from non-related donors: A case series involving 19 patients.

Faecal microbiota transplantation (FMT) has been reported to be effective in treating relapsing of refractory Clostridium difficile infections, although some practical barriers are limiting its widespread use. In this study, our objective was to evaluate the rate of resolution of diarrhea following administration of lyophilized and resolved FMT via a nasogastric (NG) tube. We recruited 19 patients suffered from laboratory-confirmed C. difficile infection. Each of them was treated by lyophilized and resolved inoculum through a NG tube. One participant succumbed following the procedure due to unrelated diseases. Out of 18 cases, 15 patients reportedly experienced a resolution of the symptoms. One patient was treated with another course of antibiotics, and two of the non-responders were successfully retreated with another course of FMT utilizing a lyophilized inoculum. Notably, no significant adverse activities were observed. In accordance to our clinical experiences, a patient will likely benefit from FMT treatment including lyophilized inoculum.

Experiences with fecal microbiota transplantation in Clostridium difficile infections via upper gastrointestinal tract.

Dramatic changes in the epidemiology of Clostridium difficile infections have been reported from the western world in the past decade. The proportion of severe cases is significantly elevating and clinicians now have to contend with the problem of additional and more frequent episodes of recurrences including an upward trend in the mortality rate. This situation led us to investigate the possibility of the fecal microbiota transplantation (FMT). An amount of 100 ml of fecal microbiota solution was instilled into a nasojejunal (NJ) tube in 16 cases and into a nasogastric (NG) tube in 44 cases. In all of the cases, where the solution was instilled via nasojejunal tubes, the symptoms resolved within 24 h. We did not note any recurrences in this group. When the material was flushed in through nasogastric tubes, the symptoms resolved in 39 (88.64%) cases within 24 h. In this group, we have experienced a recurrent episode of C. difficile infection in five (11.36%) cases. Three of them were cured with a second transplantation. We have found that in our practice the upper gastrointestinal tract methods had the primary cure rate of 91.67%, whereas the secondary cure rate is 96.67%. When we compared the NJ and NG methods, we have found that the differences in the outcomes are not significant statistically (p = 0.3113 using Fisher's exact probability test). In conclusion, FMT proved to be very effective, particularly in recurrent infections and in cases where conventional treatment had failed.

Laparoszkópos hiatushernia-rekonstrukciót követo intraoesophagealis hálómigráció.

CASE PRESENTATION: The authors report the case of a 68-year-old patient who presented with dysphagia 4 months after a mesh-reinforced antireflux surgery. Examinations revealed partial penetration of the mesh into the esophagus. During an expedited surgery, the mesh was removed through thoraco-laparotomy. Distal esophagus and proximal gastric resections were carried out due to longitudinal perforation site and esophageal stricture, and the continuity of the alimentary tract was restored with jejunal interposition. At the 3-month follow-up visit the patient was asymptomatic and a swallow examination showed normal conditions after the surgery. DISCUSSION: Several studies have shown that primary closure of large hiatal hernias is associated with high recurrence rate. In order to reduce this ratio, mesh reinforcement of the crural repair was introduced to prevent reherniation. Therefore, the incidence of recurrence has indeed decreased, however, mesh-related complications have increased. Because of the special anatomical site, the mesh around the gastroesophageal junction is in continuous movement and this can potentially lead to complications such as esophageal erosion, perforation or extensive fibrosis and stenosis. These complications may cause severe, even life-threatening conditions that could only be treated with difficult surgeries. Based on the experience of our case and the review of the literature, we would like to highlight one of the potential, serious complications of mesh-reinforced hiatal repair.

[Experience with fecal transplantation in the treatment of Clostridium difficile infection]. / Clostridium difficile-fertozések széklettranszplantációval való kezelése során nyert tapasztalataink.

INTRODUCTION: During the past years a dramatic change has been observed in the epidemiology of Clostridium difficile infections. AIM: The aim of the authors was to investigate the possibility of the fecal microbiota transplantation and study differences, if any, in the success rate of the two different upper gastrointestinal tract method. METHOD: 100 ml of fecal microbiota solution was instilled via a nasoduodenal tube in 15 cases and a nasogastric tube in 15 cases. The authors defined the primary cure rate as the percentage of cases in which the symptoms disappeared without recurrence within 6 weeks after the first fecal microbiota transplantation, while secondary cure rate was calculated as the percentage of cases in which the symptoms resolved after the second fecal microbiota transplantation. RESULTS: It was found that fecal microbiota transplantation applied via the nasoduodenal tube resulted in a 100% primary cure rate. With the use of the nasogastric tube, the primary and secondary cure rate were 80% and 93.3%, respectively. Fecal microbiota transplantation via the upper gastrointestinal tract was found to have an overall primary cure rate of 90.0% and a secondary cure rate of 96.7%. CONCLUSIONS: Fecal microbiota transplantation proved to be very effective, particularly in recurrent infections and cases where conventional treatment failed.

[Treatment of large, esophageal perforations and mediastinitis with a covered, removable metallic endoprosthesis and mediastinal drainage]. / Nagy nyelocso-perforatio és mediastinitis kezelése eltávolítható, bevont fémprotézissel és mediastinalis drenázzsal.

The application of covered metallic stents in the treatment of benign strictures and perforations is still in the early stages, because their removal is difficult and may cause tissue proliferation. The therapeutic effect and the efficiency of a new method for the extraction of a removable metallic stent were examined in three patients treated for oesophageal perforation. Two of the three patients were dilated with a balloon catheter because of corrosive oesophageal stenosis, and the oesophagus was perforated. In one patient mediastinal drainage, and jejunostomy and in the other primary suturing and drainage were performed. Sepsis and mediastinitis developed due to the oesophageal perforation and the fistula caused by the mediastinal drain in the first patient, and the insufficiency of the suture in the second patient. The oesophageal defects were sealed on day 8 and 10 after the perforation, and surgery by a covered stent. In the third patient, the oesophageal rupture caused by the dilatation and the attempt to stent a malignant obstruction was sealed with a covered stent within 2 hours. Parenteral nutrition and broad-spectrum antibiotic therapy were started. Three days after the interventions, swallowing tests with water-soluble contrast medium (Gastrografin) did not reveal any extravasations. Feeding via a nasogastric tube, and later oral feeding was started. After transient mediastinal drainage, the stents were removed on day 35 and 74 after implantation. Both openings healed completely. Restenoses above the stents were dilated again. The rupture of the malignant oesophagus in the third patient, following early, permanent stenting, healed without drainage and with no complications. Even with mediastinitis and concomitant sepsis, large oesophageal perforations can be treated successfully with removable, covered metallic stents and adequate mediastinal drainage.

Voice prosthesis insertion after endoscopic balloon-catheter dilatation in case of a stenotic hypopharyngo-oesophageal junction.

Stenosis of the hypopharyngo-oesophageal junction can be a rare complication of laryngectomy and/or partial pharyngectomy and makes the insertion of voice prosthesis extremely difficult. This study describes the authors' experiences gained by endoscopic balloon-catheter dilatation of hypopharyngo-oesophageal stenoses prior to implantation of voice prostheses in four cases. In two patients a single balloon-catheter dilatation resulted in wide enough pharyngo-oesophageal lumen on the long run. The average prosthesis wearing-times were 6.8 months in case 1 and 4.6 months in case 2, corresponding to the published literature data. In case 3, repeated dilatation of the pharyngo-oesophageal transition had proved to be unsuccessful despite taking every effort with the endoscopic balloon-catheter method. Having excised the stenotic segment, reconstruction with pectoralis major myocutaneous flap (PMMF) was indicated. Eighteen months later, a repeated restenosis was observed and a free jejunal flap needed to be performed as a final solution. In case 4, the insertion was carried out into a previously dilated jejunal free flap, which became gradually ischemic and stenotic since the major head-and neck procedure was carried out that resulted in prosthesis rejection after just 1 week. The authors emphasize that correct indication of pedicled and free flaps in head and neck reconstruction is a prerequisite from the aspect of prevention of pharyngo-oesophageal strictures. Endoscopic balloon-catheter dilatation is a safe and established method for dilatating hypopharyngo-oesophageal stenoses of different origin. The procedure provides maximum patient benefit with minimal trauma and morbidity; moreover, facilitates insertion of voice prostheses. However, a single balloon-catheter dilatation cannot always result in wide enough oesophageal lumen on the long run (case 3). Insertion of a voice prosthesis into a previously dilated ischemic jejunal segment is challenging and avoidable due to risks of complications.

Treatment of recurrent malignant obstruction with a flexible covered metal stent after gastric surgery.

BACKGROUND: The management of gastric outlet obstruction with expandable metallic stents is difficult and frequently is associated with late complications. A new, flexible, covered metal stent has been developed, which may be suitable for treatment of patients with recurrent malignant strictures after gastric surgery. METHODS: The stainless-steel stent is covered by a polyethylene membrane. It has a proximal funnel attached to an expanded antimigratory segment 29 mm in diameter. The flexible covering membrane connects isolated distal segments that are 20 mm in diameter. The stent is preloaded in a 6.7-mm-diameter introducer system. The structural features and the increased flexibility of this new prosthesis are intended to reduce the risk of migration and the frequency of late complications, and to broaden the range of applications. RESULTS: This stent was used to successfully treat two patients with recurrent tortuous malignant strictures after partial or complete gastrectomy. CONCLUSIONS: This new flexible, polyethylene-covered stent potentially is a new alternative for the palliation of patients with recurrent, inoperable gastric malignant strictures.

Long-term results of balloon catheter dilation of lower gastrointestinal tract stenoses.

PURPOSE: This study involved a prospective evaluation of the results of the balloon catheter dilation of lower gastrointestinal stenoses. METHODS: First a guide-wire was introduced into the stenosis followed under x-ray control by a double-lumen balloon catheter, or directly through the endoscope a balloon catheter, with progressive dilation under pressures of 1.5 to 3 atm. The result was assessed via the decreased indentation of the balloon and the increased diameter of the stenosis. RESULTS: Between January 1985 and November 2002, 133 dilations were performed on 57 patients. The cause of the stenosis was postoperative stenosis in 44 patients, Crohn's disease in 6, ulcerative colitis in 2, postirradiative stenosis in 1, ischemic stenosis in 1, and scarring of the anus in 3 patients. Four of the stenoses were localized to the anus, 45 to the rectum, 7 to the colon, and 1 to the terminal ileum. The average diameter of the stenosis was increased from 7.2 (range, 1-14) mm to 19.7 (range, 14-25) mm. Colostomies were closed in 11 of 17 cases. In five patients, the ileus state ceased, and the three colocutaneous fistulas healed rapidly. In 17 of 57 patients, reoperation was proposed. In one patient, fever as a complication was treated with antibiotics. CONCLUSIONS: The dilation of benign stenoses of the lower gastrointestinal tract with a balloon catheter is an effective and safe method, which in most cases (70 percent) results in long-term elimination of the obstructive symptoms, so that surgery can be avoided.

[Endoscopic placement of self-expanding metal stent for malignant colorectal obstruction]. / Ontáguló fémstent endoszkópos behelyezése colorectalis malignus elzáródásban.

AIM: 15-20% of the patients with colorectal carcinoma is admitted to hospital with symptoms of colonic obstruction. If urgent, subtotal colectomy can not be done, Hartmann operation is performed, that means diverting colostomy and resection followed by a later re-anastomosis. In this article the authors report on the placement of a self-expandable stent for decompression of a malignant colorectal obstruction, which allows elective one stage resection of the tumour affected segment. PATIENTS AND METHODS: A 63-year-old male patient was admitted with clinical and radiological symptoms of ileus. A total obstruction was found by irrigoscopy at the rectosigmoid transition. An atraumatic guide wire, and a balloon catheter were introduced through the stenotic segment and dilated to 15-mm in diameter. Following that the stenosis was bridged with a SX Ella type, 25-mm diameter, nitiol stent. RESULTS: After the placement of the metal stent the obstruction ceased. Stabilisation of the condition of the patient, proper pre-operative decompression, definition of the tumour stage, appropriate preparation of the patient for the operation became possible. After elective, primary resection the patient recovered without complications. DISCUSSION: There are two main indications for the application of metal stents in colorectal obstructions. One of them is temporary, preoperative decompression in malignant colorectal obstruction. The other one is the palliative treatment of inoperable, malignant large bowel obstructions. In the latter case more complications have to be considered. CONCLUSIONS: Metal stent therapy is an effective and non-invasive, alternative method for preoperative or palliative treatment of malignant colorectal obstructions.

[Esophageal and gastrointestinal application of traditional and metal prostheses]. / Hagyományos és fémprotézisek oesophago-gastrointestinalis alkalmazása.

INTRODUCTION: The endoscopic prosthesis implantation in malignant oesophago-gastrointestinal stenoses is an important palliative therapeutic method. Even with traditional prosthesis placement in the last 10 years the application of metal prosthesis is more and more frequent. PATIENTS AND METHODS: In this article the authors summarise their experiences with traditional and metal prosthesis implantations between September of 1991 and November of 2002. In the last 11 years 180 prostheses were implanted for 152 patients. Out of these 130 were traditional and 50 were metal prosthesis. The traditional prostheses were implanted with balloon catheter introducer following dilatation up to 17-18 mm with balloon and Savary bougie. The metal prostheses were implanted after balloon catheter dilatation up to 14 mm. The cause of stenosis in 61 cases were inoperable or recurrent oesophageal cancer, in 45 gastric cancer, in 38 cases oesophageal compression or infiltration by lung cancer, mediastinal metastases due to breast cancer in 7 and kidney cancer in 1 case. 111 prostheses were implanted in to the oesophageal, 24 cardial, 3 gastro-enteral, 8 oesophago-jejunal, 6 jejunal stenoses. RESULTS: Due to the stent implantation the patients average dysphagia score decreased from 2.85 (SD = 0.7) to 1.0 (SD = 0.6). From our patients 33 had oesophago/gastro--respiratoric/mediastinal/thoracocutaneous fistula. Out of these 26 were successfully closed with metal prosthesis and 5 out of 7 with traditional prostheses. The severe early complications with traditional prosthesis (5 perforation, 2 hydropneumothorax, 1 mediastinal and subcutaneous emphysema) were in 6.2% of the cases. From 8 patients 4 healed after drainage, 3 following conservative therapy and 1 died. Early, severe complication, thoracic empyema was observed in one patient from 50 implanted metal stent. The patient died after surgical drainage. In 2 patients as a severe late complication with Wallstent, severe bleeding occurred, and in 2 patient at the funnel of a traditional stents, 3 esophago-tracheal fistulas developed. Furthermore there were stent dislocations (17/152) and stent obstructions (15/152) all together (32/152) in 21% of the cases. CONCLUSIONS: The implantation of traditional prostheses method used by the authors runs with low risks and gives good results. Implantation of metal stent is easier, less burden for the patient and considerably decreasing the risk of early, severe complications, widening the application territory for prostheses. In the frequency of late complication however there is no significant difference between the methods.

[Balloon catheter dilatation of lower gastrointestinal tract stenoses: long-term results]. / Az alsó béltractus-szúkületek ballonkatéteres tágításának hosszú távú eredményei.

AIM: Benign stenosis of the lower gastrointestinal tract usually develops, due to complication of a surgical intervention or sometimes because of other inflammatory bowel processes. Their reoperation is technically difficult and risky. Therefore the authors use a balloon catheter dilatation in the treatment of lower gastrointestinal tract stenosis since 1985. METHODS: First a guide wire is passed colonoscopically, then under X-ray control a double lumen balloon catheter, or directly through the channel of the endoscope a single or double lumen balloon catheter is introduced into the stenosis, which is then gradually dilated to 12-25 mm diameter. The applied pressure is 1.5-3 atm. Result of the dilatation can be judged from the decreased indentation of the balloon, and from increased diameter of stenosis at colonoscopic, or sometimes colonographic follow up. RESULTS: Between January of 1985 and July of 2001 they performed 123 dilatation on 52 patients. The causes of stenoses were in 40 cases postoperative stenosis, in 5 Crohn disease, in 2 ulcerative colitis, in 1 ischemic stenosis, and in 3 scar of the anus. From all stenosis cases 4 were localised to the anus, 40 to the rectum, 7 to the colon, and 1 to the terminal ileum. Due to the dilatation the average diameter of the stenosis was increased from 7.2 (1-14) mm to 19.7 (14-25) mm. Following the dilatation in 42 patients out of 52 the colonoscope was passed through the stenosis. Colostomies were closed in 11 cases out of 17. In 4 patients the subileus state ceased, and all of our 3 patients colo-cutan fistula healed rapidly. 16 out of 52 patients re-operation was proposed. One patient had fever as complication which was treated with antibiotics. CONCLUSIONS: Dilatation of benign stenosis of the lower gastrointestinal tract with balloon catheter is an effective method, which in most of the cases (69%) will stop the obstructive symptoms and in the long run therefore surgery can be avoided.