[Giant fibrolipoma of the mediastinum]. / Óriás gátori fibrolipoma mint ritka gátori daganat mutéti eltávolítása.

UNLABELLED: The authors discuss the management of an enormous fibrolipoma which rarely occurs in the mediastinum. A 54-year-old patient underwent an extended posterolateral thoracotomy and resection of a mass which was preoperatively diagnosed as liposarcoma. The size of the removed specimen was 42×35×23 cm and weight was 5200 g. Final histology revealed a primary mediastinal fibrolipoma. Following a long-standing lung compression, the lung has fully expanded after a temporary postoperative failure of expansion. Postoperative serial chest x-rays confirmed that the marked mediastinal midline shift gradually resolved, and the patient's complaints improved considerably, too. DISCUSSION: the vast majority of tumors located in the mediastinum needs to be operated on. Surgical techniques available involve open or videothoracoscopic methods. The latter is limited though by the patient's general condition and the size of the mass needs to be resected. In cases when the tumour is deemed to be irresectable, surgical debulking and oncological adjuvant treatment can be justified to improve quality of life.

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.

[Minimally invasive thymectomy with videothoracoscopy via the right chest]. / Videothoracoscopos módon, a jobb mellüreg felol elvégzett csecsemomirigy-eltávolítás - új mutéti eljárás klinikánk gyakorlatában.

BACKGROUND: The authors present the technique and results of minimally invasive thymectomy via the right chest based on their clinical practice. PATIENTS AND METHODS: Between 1 June 2009 and 31 March 2011 27 patients (22 females, 5 males; mean age 35.1 [17-84] years) underwent thymectomy without sternotomy at the division of thoracic surgery of the Department of Surgery, University of Szeged. Indications were myasthenia gravis in 24 and thymoma in 3 patients. The incisions were the following: two 1.5 cm in the right breast fold and one 3 cm incisions in the axillara. There were no incisions in the neck or no sternotomy was carried out either. Preparation and removal of the thymus were performed by conventional and endoscopic instruments, and a drain was inserted into the right chest cavity up until the mediastinum. RESULTS: Mean time for surgery was 119 minutes (45-285). There was no conversion and no transfusion needed. Further, there was no surgical mortality or morbidity detected. Mean time for chest drain removal was 2.05 (1-3) days, and mean length of hospital stay was 4.56 (4-7) days. Two patients were admitted to the intensive care unit for myasthenia symptoms. Importantly, myasthenia gravis improved in 91.6% of the patients. CONCLUSIONS: Minimally invasive thymectomy is a safe procedure with excellent cosmetic results. Improvement in myasthenia gravis was similar to published literature data.

[Surgical treatment of primary pleural tumours in our department]. / A mellhártya elsodleges daganatainak sebészi kezelése osztályunk anyagában.

AIM: The authors analyzed the results and outcome of surgical treatment of primary pleural tumors in patients treated in the last 11 years. METHODS: 31 operations were performed for primary pleural tumors in 25 patients (17 males, 8 females). The tumors were classified into the following groups: benign local fibrous tumors (benign LFTP; n = 15), recurrent malignant fibrous tumors (recurrent malignant LFTP; n = 2) and malignant mesotheliomas (MPM; n = 12). 40% of patients with MPM were exposed to asbestos. Complete resections of benign LFTPs were performed, with additional resection of the chest wall and lobectomy in two cases. Completion pneumonectomy and lobectomy were done in recurrent malignant LFTP cases. Five biopsies and pleurodesis, and one open decortication were performed. In four cases, after the biopsy, two pleurectomies and decortications (P/D) and two pleuropneumonectomies (PPN)/extra-pleural pneumonectomies (EPP) were carried out. RESULTS: There was no operative mortality. Pathological examination revealed seven epithelial, two sarcomatous and one biphasic malignant mesotheliomas. Survival was one (currently alive) and 49 months after malignant recurrent LFTP. Survival in MPM cases was 9,7 months (3-17) without resection and 17,3 months (5 (currently alive) - 29) in P/D or PPN (EPP) cases. CONCLUSIONS: The PPN (EPP) and P/D are safe procedures providing relatively good survival when it is done as part of complete oncological treatment. In cases of recurrent LFTP, anatomical resections recommended with completion pneumonectomy or lobectomy.

[Lobectomy performed through a video-assisted mini thoracotomy, as a new technique in our clinical practice]. / Videoasszisztált minithoracotomiából elvégzett lobectomia mint új mutéti eljárás klinikai gyakorlatunkban.

UNLABELLED: In this retrospective study, we present our experiences and results with lobectomy performed through video-assisted mini thoracotomy (VAMT), a technique that we have been using since 2006. METHOD AND PATIENTS: In the first half of 2006 10 video-assisted lobectomies were performed in our department. There were eight women and two men; the mean age was 61.4 (47-68) years. The indications for surgery were the following: benign lesions in three cases, T1N0 squamous lung cancers proved by cytology in six patients, and another case, when the CT suggested - but cytologically not proved - T1N0 lung cancer. After a double lumen endotracheal tube intubation and videothoracoscopic exploration, a 6-8 cm mini thoracotomy was performed. Manual palpation of the lung parenchyma, resection with mediastinal block dissection (in cases of malignancy) was carried out through a 2 cm wide rib spread, without rib resection. Five lower, four upper lobe lobectomies and one upper bilobectomy were performed. There was no perioperative mortality or serious morbidity detected. The mean operative time was 130 (80-200) minutes. The three benign lesions were hamartochondromas. The final histology revealed four T1N0 and two T2N2 stage squamous cell lung cancers, while one T1N2 small cell lung cancer was also found. Lobectomy performed through a video-assisted mini thoracotomy is a safe procedure. The manual palpation, parenchyma resection and mediastinal block dissection can be performed similarly to open procedures.

Lung cancer as a second primary malignant tumor: prognostic values after surgical resection.

Prognostic values of lung cancers as second primary malignant tumors (LC-as-SPTs) developed after a different type of first primary malignant tumor were analyzed. Forty-three patients underwent surgery for first primary malignant tumors and later for LC-as-SPTs. The most frequent first primary tumors were: 14 laryngo-pharyngeals; 7 lungs; and 5 colons. Only metachronous cases were included in our study, and the disease-free intervals (DFI) between the first and second primary tumors were divided into two groups: shorter than 36 months (DFI<36), and longer than 36 months (DFI>36). The survival was calculated from the time of surgery for LC-as-SPT. The 5-year overall survival rate was 38%. By univariate analysis, the 5-year survival was significantly lower in cases with DFI<36 months (25%) than in cases with DFI>36 months (43%) (P=0.045), and in male (27%) than in female (62%) (P=0.032), and in N1 (31%) and N2 (0%) cases than in N0 (49%) cases (P=0.001). Using multivariate analysis with the previous factors, only the lymph node metastasis (P=0.001) had a significant impact on survival. The survival after LC-as-SPTs was shorter than after first primary lung cancer cases, and lymph node involvement had a significant impact on the postoperative survival based on uni- and multivariate analysis.

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.

[Thoracic epidural anesthesia improves the gastric microcirculation during experimental gastric tube formation]. / A thoracalis epiduralis anaesthesia javítja a gyomor mikrokeringését kísérletes csógyomor képzés során.

We studied the effects of gastric tube formation and thoracic epidural anaesthesia (TEA) on gastric microcirculation, hemodynamic and bowel motility changes. The experiments were performed on pentobarbital-anesthetized, mongrel dogs. Mean arterial pressure (MAP), gastric and mesenteric blood flow (Transonic Systems Inc.) and small bowel motility changes (strain gauge technique) were monitored. The stomach was prepared according to the method of Akiyama. TEA was induced by injecting Bupivacain 1 mg/kg. Orthogonal polarization spectral imaging (OPS) technique (Cytoscan A/R, Cytometrics, PA, USA) was used to observe in vivo microcirculatory changes. The gastric pull-up caused significant decrease in intramucosal pH and red cell velocity (RBCV) in terminal arterioles of the upper part of gastric tube both on the mucosal and serosal side. After TEA the RBCV returned to baseline level and the intestinal motility index significantly increased. Functional capillary density of the mucosa or subserosa did not change during the experiments. MAP was significantly reduced by 30%, while the arterial blood flow in gastric and mesenteric arteries was significantly increased. TEA significantly improves microcirculation of the distal portion of the gastric tube and increases intestinal motility. These results show that epidural anaesthesia is favourable and should be recommended during reconstructive oesophageal surgery.

[The role of glucocorticoid-dependent mechanisms in the progression of experimentally induced acute pancreatitis]. / Glükokortikoid hormonok által szabályozott mechanizmusok szerepe kísérletes akut pancreatitis lefolyásában.

BACKGROUND: The effects of glucocorticoids on acute pancreatitis (AP) have remained contradictory. To investigate the time courses of the effects of the exogenous glucocorticoid agonists dexamethasone (DEX) and hydrocortisone (HYD) and a glucocorticoid antagonist (RU-38486), and to characterize the local and systemic responses in experimental AP. METHODS: The glucocorticoid agonists and antagonist were administered just before AP induction. Serum amylase activity determinations, IL-6 bioassays, pancreatic weight/body weight ratio measurements and survival analysis were performed. Liver and lung injuries were assessed via neutrophil leukocyte infiltration in myeloperoxidase (MPO) assays, tissue adenosine triphosphate (ATP) level determinations and histology. RESULTS: In the glucocorticoid agonist groups, the survival rate increased, while the serum amylase level, the IL-6 activity and the pancreatic weight/body weight ratio decreased significantly as compared with the control and RU-treated groups. AP resulted in significant decreases in tissue ATP levels in both the liver and the lung. In the DEX- or HYD-treated groups, the liver ATP levels were significantly elevated, while both the liver and the lung MPO levels were attenuated as compared with the AP and RU-treated groups. CONCLUSIONS: These results suggest that glucocorticoids may play important roles in mitigating the progression of the inflammatory reaction during the early phases of AP.

[Surgery of benign liver tumors: indications for treatment. Personal experience and review of the literature]. / Indokolt-e a jóindulatú májdaganatok sebészi kezelése? Saját tapasztalatok és irodalmi áttekintés.

BACKGROUND AND AIMS: Our aim is to give an audit of our experience over the past two decades in the form of a retrospective study. PATIENTS/METHODS: Between 1 January, 1982 and 15 December, 2001, 133 patients with benign liver tumor (adenoma: 22, focal nodular hyperplasia: 27, hemangioma: 83, lipoma: 1) were treated. A total of 113 patients underwent surgery, while 20 asymptomatic cases were merely observed. The mean age, the female/male ratio and the size of the tumor in the adenoma cases were 38.3+/-10.2 years, 20/2 and 7.7+/-2.4 cm, while for focal nodular hyperplasia they were 39.5+/-12.4, 24/3 and 6.3+/-2.7 cm, and for hemangioma 49.01+/-10.7, 62/21 and 6.5+/-3.6 cm. The results were compared and analyzed statistically. RESULTS: Enucleation was performed in 53.1% of the patients, non-anatomical resection in 24.8%, segmentectomy in 6.2%, lobectomy in 4.4%, extended lobectomy in 1.8%, stitching in 5.3%, exploration in 3.5% and liver transplantation in 0.9%. The overall 30-day postoperative mortality was 0.9% (1/113). Minor or major complications occurred in a total of 27.4%. CONCLUSIONS: Patients with asymptomatic focal nodular hyperplasia or hemangiomas must be excluded from surgery. Surgery is indicated only when growth or severe complaints are observed. Adenomas must be resected because of the precancerous behavior and the danger of bleeding from a rupture.

Endothelin-a receptor antagonist treatment improves the periosteal microcirculation after hindlimb ischemia and reperfusion in the rat.

OBJECTIVES: To examine the microcirculatory changes in the rat tibial periosteum after hindlimb ischemia and reperfusion and to evaluate the effects of endothelin-A (ET-A) receptor antagonist therapy in this condition. The healing and functioning of vascularized bone autografts depend mainly on the patency of the microcirculation, and the activation of ET-A receptors may be an important component of the tissue response that occurs during ischemia-reoxygenation injuries. METHODS: Wistar rats were subjected to 1 hour of hindlimb ischemia and 3 hours of reperfusion. The periosteal microcirculation was visualized by intravital fluorescence microscopy. The leukocyte rolling and adherence in the postcapillary venules and the functional capillary density of the periosteum were determined. Two separate groups were treated with the selective ET-A receptor antagonist BQ 610 or the novel ET-A receptor antagonist ETR-p1/fl peptide at the onset of reperfusion. RESULTS: Reperfusion was accompanied by a significant decrease in functional capillary density and by an increase in the primary and secondary leukocyte-endothelial cell interactions. ET-A receptor inhibition reduced the leukocyte rolling and firm adherence and attenuated the decrease in functional capillary density in both treated groups. CONCLUSIONS: ET-1 plays a major role in microvascular dysfunction in the periosteum during reperfusion. The ET-1-ET-A receptor system might be an important target for tissue salvage therapy in transplantation surgery.

Dalteparin sodium treatment during resuscitation inhibits hemorrhagic shock-induced leukocyte rolling and adhesion in the mesenteric microcirculation.

BACKGROUND: Ischemia/reperfusion-induced polymorphonuclear neutrophil leukocyte (PMN) adhesion and extravasation are pivotal for the development of postinjury multiple organ failure. We hypothesized that the deleterious microcirculatory consequences of hemorrhagic shock (HS) could be altered by low-molecular-weight heparin (LMWH) therapy. Our aim was to investigate the effects of dalteparin sodium on leukocyte-endothelial cell interactions when LMWH treatment was initiated before HS or during resuscitation. METHODS: Anesthetized dogs underwent HS (40 mm Hg mean arterial pressure for 60 minutes) and resuscitation either with shed blood or with lactated Ringer's (LR) solution. LMWH or conventional heparin sodium pretreatment was administered subcutaneously before hemorrhage; or LMWH was given intravenously during resuscitation. Mesenteric postcapillary venules were observed by intravital video microscopy before and after HS, and 60 minutes, 120 minutes, and 180 minutes after resuscitation, and leukocyte rolling and firm adherence were determined. RESULTS: HS significantly increased PMN rolling and adhesion in the mesenteric microcirculation. LMWH, but not heparin sodium pretreatment, significantly inhibited both primary and secondary interactions. LMWH treatment was also effective when initiated during resuscitation. LMWH exerted the same inhibitory effect regardless of the type of resuscitation. CONCLUSION: LMWH treatment during resuscitation effectively inhibits PMN rolling and adhesion.

Dynamic in vivo observation of villus microcirculation during small bowel autotransplantation: effects of endothelin-A receptor inhibition.

BACKGROUND: The aims of this study were to characterize the structural and microcirculatory changes in single intestinal villi during ischemia and reperfusion and determine the site of action of endothelin (ET)-A receptor inhibition during compromised mucosal perfusion. METHODS: Small bowel autotransplantation was performed in anesthetized dogs. One group was treated with the ET-A receptor antagonist ETR-p1/fl peptide. The epithelial thickness and villus microcirculatory parameters were observed by orthogonal polarization spectral imaging; the leukocyte-endothelial cell interactions were quantified with fluorescence videomicroscopy. RESULTS: Sixty-minute cold ischemia and 240-min reperfusion induced a decrease in villus functional capillary density and leukocyte-endothelial cell interactions. The epithelial layer was gradually removed, but denuded villi were not observed. ET-A receptor inhibition reduced the leukocyte adherence and attenuated epithelial exfoliation and the decrease in villus functional capillary density. CONCLUSIONS: ET-A receptor activation mediates microvascular dysfunction through precapillary blockades and leukocyte-endothelial cell interactions after cold ischemia and reperfusion in the canine small bowel.