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Aims: In severe acute pancreatitis the timing of necrosectomy is ideally should be postponed 4-6 weeks after the onset of the disease when the walled-of pancreatic necrosis (WOPN) has developed. The authors present their experience with open transgastric necrosectomy for extended WOPN., Patients and Methods: The authors performed 17 (12 male, 5 female with a mean age of 61.6 ± 15.1 years) open transgastric necrosectomies for extended WOPN in a period of 1, January 2012 and 31, December 2017. Before the operations conservative and semiconservative therapy was used for an average of 74.6 ± 83.1 days. The mean size of the WOPNs was 13.8 ± 5.2 cm with localisation of the retrocolic and retroduodenal regions. All necroses were septic., Results: Complications related to the operation were not observed. The mean time of hospitalization after the surgery was 11.6 ± 12.8 days. The mortality rate was 5.9%. Late operation or other interventions for pseudocyst or pancreas fistula formation was not performed. Two patients needed endoscopic dilatation with lavage in the early postoperative period because of fever. New diabetes mellitus was not observed but worsening of previously existed diabetes developed in 6.3% of the cases., Conclusions: The open transgastric necrosectomy is safe and effective for extended WOPN. The advantage of this type of necrosectomy is the prevention of pancreatic pseudocyst and fistula formation.

Introduction: Complicated incisional hernias (at least one time recurrent and/or multilocular and/or infected synthetic mesh) still represent a significant problem., Aim: Presentation of operating techniques desribed so far, as well as publication of a novel procedure and results invented by the authors., Method: Between 01/2011 and 09/2015, 41 patients with recurrent and/or infected incisional hernias with or without entero- and subcutaneous fistulas were operated using the method of the s.c. double-layer autologous tension free dermal flap technique. An accurate follow-up method and a continuous registration of the results was conducted in case of every patient. The body mass index (BMI) and presence of diabetes mellitus (DM) were distinguished factors out of the patients' clinical data. Surgical complications, bulking or laxity, recurrence and the patients' satisfactory index - among other things - were recorded considering the procedure. Patients' clinical data and results: Average age was 59.2 years (13 male / 28 female) in the cohort. 1, 2, 3 times recurrent incisional hernias had 12, 23, 6 patients, respectively. Average BMI was 32,1 kg/m2. 12 patients were treated with type II diabetes. 13 patients had entero- or subcutaneous fistulas and/or infected synthetic meshes at the time of operations. Average follow-up time was 32 months (2-58 months). Seroma formation was registered in 13 cases (31.7%). Fistula formation was registered in one case (2.4%). Bulking formation or laxity was observed in 3 patients (7.3%) and recurrence was noticed in 3 patients (7.3%), 13, 17 and 19 months later in the postoperative period. All the entero- and subcutaneous fistulas developed prior to the last procedure were completely healed. There was no lethal outcome., Conclusion: The method developed by the authors is recommended and suitable for the solution to complicated and/or infected incisional abdominal wall hernias especially in cases of obese (BMI ≥ 25 kg/m(2)) and diabetic, high risk patients. After acquiring the precise operative technique, the method is safe, feasible and it comes along with lower complication and recurrence rate, compared to other applied and well established ones. Further clinical trials need to be conducted in the future in order to be evaluated definetely this procedure.

Background: Surgical Site Infection (SSI) is the third most frequent nosocomial infection, and accounts for 14-16% of all infections. While the treatment of SSI can be very costly, previous results indicated that triclosan may reduce SSI rate. Therefore, we carried out a prospective randomised trial to further evaluate the effect of triclosan after elective colorectal surgery., Methods: Seven surgical units in Hungary were involved in a prospective, randomised, multicentric clinical trial to compare triclosan coated (PDS plus®) and uncoated (PDS II®) sutures for abdominal wall closure in elective colorectal surgery. Pre- and perioperative variables were recorded in an online database. The primary aims of the study were to determine the incidence of SSI and the pathogens associated with it, as well as evaluation of additional cost of treatment., Results: 485 patients were randomised. SSI occurred in 47 cases (12.5%), of those 23 (12.23%) from the triclosan group (n = 188) and 24 (12.18%) from the uncoated group (n = 197, p = 0.982). In 13 (27.66%) cases late appearance of SSI was detected, of those 4 patients with triclosan coated suture (8.51%) and 9 patients with uncoated suture (19.15%, p = 0.041). There was no difference between the type of incisions or elective colon and rectal resections in terms of incidence of SSI., Conclusion: Beneficial effect of triclosan against Gram positive bacteria could not be confirmed in our study due to the relatively low number of patients with SSI. Furthermore, triclosan did not influence the incidence of SSI due to Gram negative bacteria. SSI rate decreased by 50% compared to our previous study, however, it was regardless of the use of coated or uncoated PDS loop. Finally, operative factors were more important than patient's risk factors in terms of incidence of SSI. In case SSI developed, delayed discharge from hospital as well as special wound care significantly increased overall cost of treatment.

Background: Forty percent of patients with gastric cancer undergo unnecessary extended lymph node dissection which may result in higher rate of morbidity and mortality. Successful sentinel lymph node (SLN) mapping may help to reduce the number of extended lymphadenectomy. Various marking methods are in use to detect the sentinel lymph node in gastric cancer., Methods: Forty consecutive patients underwent open gastric resection with blue dye mapping and modified D2 lymph node dissection. Sixteen patients (group A) were marked submucosally with endoscopy and 24 patients (group B) were labelled by the surgeon subserosally. The staining method and the lymphadenectomy were supervised by the same surgeon., Results: A total of 795 lymph nodes were removed and examined. The mean number of blue nodes was 4.1 per patient in group A and 4.8 in group B. The false negative rate was 0% in group A and 7.7% in group B. The sensitivity and specificity of SLN mapping was 100% in the submucosal group. The specificity of subserosal marking method was 100%, while the seínsitivity was 92.3%. Submucosal and subserosal marking methods were proven to be equivalent in detection rate, sensitivity and specificity based on 90% confidence interval of the ratio of indicators., Conclusions: Our results suggest that sentinel lymph node mapping with blue dye alone represents a safety procedure and seems to be adaptable with high sensitivity and specificity, especially in cases of T1 and T2 tumors.

Unlabelled: Authors present two cases of successfully operated patients with retrohepatic inferior vena cava (IVC) injury. In the first case a 79 year old female patient suffered from multiple stab wounds in the area of the 4th segment of the right lung as well as in the retrohepatic region in close proximity to the IVC. At the time of the first surgery the IVC injury was not identified. During a second operation, however, the IVC was isolated from the liver using an anterior dissection of the parenchyma with finger-fracture technique and the injury was oversawn finally. Successful haemostasis of the liver was achieved by packing of the perihepatic space, which was removed three days later. In the second case a 25 year-old male patient had suffered blunt abdominal trauma. He underwent laparotomy and packing on the site of the hepatic injury, which had to be repeated seven more times. Later on, another urgent laparotomy was carried out for recurring intraabdominal bleeding and bile leakage, and cholecystectomy was performed due to gallbladder perforation. Another two days later a further emergency laparotomy was indicated for ongoing intraabdominal bleeding, when the bleeding source - an injury (3 mm in diameter) of the retrohepatic IVC - was oversawn. After relatively long postoperative stay both patients were fully recovered and discharged from hospital., Conclusions: penetrating injuries of the IVC are associated with high mortality rate of approximately 78%. Proper management of these injuries requires experience in both vascular and liver surgery. Retrohepatic IVC injury needs to be considered in the differential diagnosis of ongoing bleeding in penetrating or blunt liver trauma. Packing of the liver is a reliable haemostatic method if bleeding persists due to division of the liver parenchyma.

Background: Distant spread from renal cell carcinoma is commonly found in the liver and lung. Metastatic involvement of any other gastro-intestinal organ (duodenum, other kidney, adrenal gland) is unexpected. However, clear cell renal carcinoma is known to cause pancreatic metastasis., Methods: The authors present the case of a successfully operated 82- year-old man, who was operated for a metastatic tumor in his pancreas. 8 years prior to his current hospitalization, a left sided nephrectomy was performed for renal cell carcinoma. The CT scan revealed a tumor localised in the tail of the pancreas. Distal pancreas resection was performed with splenectomy. Histology revealed clear cell renal carcinoma metastasis., Conclusions: pancreatic tumors are mostly primaries. Renal cell carcinoma generally gives hepatic and pulmonary metastases. However, clear cell renal carcinoma is known to give pancreatic metastasis, too.

Perioperative antithrombotic prophylaxis as well as surgical and invasive procedures done in anticoagulated patients ("bridging") have primary importance as regards prevention of venous thromboembolism (VTE) and reducing haemorrhagic complications. It is understandable that overwhelming majority of publications are dealing with major surgery (when usually several days hospitalization is required) while much less papers focus on one-day surgery cases. In this paper a brief survey on VTE epidemiology and prevention is carried out based on the new international and the 4th Hungarian Antithrombotic Guideline. The new protocols suggest that beside general measures a perioperative pharmaceutical antithrombotic prophylaxis is necessary if concomittant inherited and/or acquired thrombophilia is present.

Spontaneous rupture of the oesophagus is an extremely serious condition with high morbidity and mortality. Primary surgical repair may be followed by numerous complications. A 29-year-old man had undergone primary surgical repair due to spontaneous rupture of the lower third of the oesophagus. After the operation he developed suture insufficiency, which could not have been stented, and transgastric drainage was performed therefore. After a slow healing of the fistula, we could avoid another operation and his oesophagus was preserved. Fortunately, a stricture did not develop either. Transgastric drainage of the oesophagus could be a good therapeutic choice in selective and complicated cases.

Orthopedic surgeons apply metallic pins to stabilize the clavicule and humerus on a daily basis. Migration of these pins into the thoracic cavity is rare. We present the case of an elderly female patient, whose right humeroscapular joint was fixed with Kirschner wires due to recurrent luxation. Six weeks later, a follow-up X-ray revealed that the pins have migrated into the right thoracic cavity, confirmed by a CT chest. Videothoracoscopic removal of the metallic pins was not possible because of dense adhesions. Right anterolateral thoracotomy was carried out, and after pneumolysis one pin was taken out from the 2nd lung segment. The other one, which was running along the cupola and entering the spinal cord, was also removed. There was no postoperative surgical complication. The authors review the literature of this rare complication and point out that pins migrating into the thoracic cavity should be removed to avoid life threatening complications.

Introduction: The widespread use of PET/CT has a potential to change oncological diagnosis fundamentally. In our study we intended to clarify if preoperative PET/CT was able to assess axillary lymph node status, and the potential of these to modify preliminary treatment plans based on conventional diagnostic methods., Patients and Methods: We carried out 18-FDG PET/CT before elective surgery in 52 primary operable breast cancer patients between February 2008 and February 2009 at the DEOEC Clinical Department of Surgery. Total body imaging was performed in all cases; scans were evaluated by two specialists first visually, then semi-quantitatively based on body mass-corrected lesion suvmax values. The assessments were compared with axillary ultrasound and final histological diagnosis., Results: Two patients were excluded from the study due to failure to report for further treatment. Based on the results obtained from the remaining 50 patients, PET/CT showed a sensitivity of 80%, a specificity of 100%, positive and negative predictive values of 100% and 84.6% respectively for detecting axillary lymph node metastases. The same figures for axillary ultrasound, in respective order, were 30%, 81.8%, 60% and 56.2%. Prompted by the PET/CT results, we modified 9 patients' (18%) preliminary, conventional diagnosis-based treatment schemes., Conclusions: In case of a positive axillary PET/CT, it is unnecessary to perform SNB--axillary block dissection is called for with no further deliberation. Preoperative PET/CT can facilitate patient selection as regards possible benefit from neoadjuvant therapy. Preoperative PET/CT has a potential to modify the original management plan in about 15 to 20%. In case of a negative PET/CT scan, further studies are necessary to be able to spare the axilla from surgical intervention with confidence.

Several predictors of local recurrence (LR) after breast conservation in early stage (stage I and II) breast cancer have been reported in the literature, but the importance of the individual factors does not appear to be clear. The presence of intraductal component (IC) is one of those factors; some authors regard it to be a predictor of LR, while others do not, or the latter have found a relationship with LR only if IC and certain other factors were present simultaneously. The authors investigated the impact of the presence of IC of various degrees on LR rate in various tumour sizes and degrees of histological anaplasia. Between 1996 and 2002, 701 patients with early stage breast cancer underwent breast conserving surgery. Based on the presence of IC, the tumours were divided into three groups: IC negative, MIC (IC < 25%) and EIC (IC > 25%). During the 65-month mean follow-up period, LR was discovered in 13.5% of the patients. Local recurrence in tumours without IC was found in 8.7% (recurrence rate: 0.017, 95% CI: 0.012-0.012). The relevant figures in MIC and EIC were 16.8% (recurrence rate 0.032, 95% CI: 0.021-0.047) and 25.6% (recurrence rate: 0.046, 95% CI: 0.033-0.064), respectively (p = 0.0001). If the size of the tumour was T1, the above figures were found to be 6.4%, 11% and 24.3%, while in size T2 tumours they were 11.5%, 22.9% and 27% (p < 0.005). If EIC was associated with G3 degree of differentiation, in IC-free tumours of size T1, the LR rate elevated from 6.1% to 31% (p = 0.008), while in size T2 the elevation was from 15.7% to 33.% (p = 0.02). Based on the above results, the authors concluded that the presence of the intraductal component predicts a greater risk to develop LR. This risk increases significantly if EIC is associated with G3 histological grade. Physicians must consider this fact in designing individually tailored adjuvant therapy for their patients. Special attention should also be paid to the follow-up of this group of patients.

Introduction: The phenotype of HNPCC shows great diversity. Investigation of the disease needs the application of both the Amsterdam and Bethesda Guidelines. The clinical diagnosis of HNPCC can be established by means of thorough family history containing more generations. The immunohistochemistry and MSI investigation of the tumorous tissue as well as the detection of mutations based on DNA sequencing could reinforce the existence of the possible hereditary tendency., Patients and Methods: Two pedigrees were selected based on the above-mentioned protocol at the Surgical Institute of the University of Debrecen, Medical and Health Science Center. Amongst first-degree relatives of the 31-year old male patient suffering from colorectal carcinoma (1st patient), three other colorectal, one gastric, one breast and one lung tumors have been found. Two genetic alterations of hMSH2 gene were detected in this family, which were also detectable in other family members. The mutation of exon 7 was not at that time available in international databases, so it was detected by us for the first time. We were able to find alterations of both hMLH1 and hMSH2 genes in the case of the 25-year old patient with synchronous colorectal carcinomas (2nd patient). These alterations could be detected in other family members as well. The whole pedigree contains only one other case of colorectal carcinoma besides the index person., Conclusion: Several HNPCC families would be missed in case of considering the Amsterdam Criteria alone. The application of the Bethesda Guidelines is absolutely necessary for the detection of families with poor history at the first screening. The association of a polymorphism and a pathogen mutation in one person could lead to early onset of colorectal carcinoma.

Morbid obesity is a multicausal disease with great importance because of the life threatening associated co-morbidities. Its treatment has many different aspects and needs multidisciplinary collaborations. The most powerful way of treatment is the surgical intervention which demands thorough preoperative investigations and patient selection. The bariatric surgical procedures went through significant development and many of them have only historical importance. Different interventions can be classified to malabsorptive, restrictive and combined subgroups. In Europe the laparoscopic adjustable gastric banding seems to be the most widely applied procedure which is purely a restrictive intervention. Apart from the low rate of complications it has many advantages which were not characteristic of the formerly used procedures. These include: minimal invasiveness, reversibility, preservation of the gastrointestinal anatomy, adjustability for demands of care.

Parallel with the evolution of minimally invasive techniques more and more organs became the subject of different laparoscopic operations. The spleen was not an exception to this trend, the first laparoscopic splenectomy was performed in 1991. In the present publication the authors give an overview of their own initial experience with the technique. Between the time period of January 1996 and April 2005, 204 splenectomies were carried out at the 1st Dept. of Surgery, University of Debrecen. The indication was haematological in 113 cases, the choice of operation was laparoscopic splenectomy in 18 cases. The male-female ratio was 7 to 11, the mean age was 45.6 years (21-71). The average operation time lasted 106 minutes (60-200 min.), the mean hospital stay was 11.9 days (5-50 days). Laparoscopy had to be converted to open procedure in three cases, because of bleeding and adhesions. In one case, laparoscopic reoperation was necessary with the indication of subphrenic haematoma on the fifth postoperative day. One death occurred in this series from bilateral pneumonia. The authors conclude that laparoscopic splenectomy can be carried out safely, blood loss is limited, and the widely recognized advantages of laparoscopic techniques can be secured for the patients.

We presented here the results of PET imaging of 12 patients, previously operated on for colorectal cancer and followed at the 1st Department of Surgery, University of Debrecen. The tests were carried out using 0.15 mCi/kg FDG injections. Whole body imaging was performed in eleven patients. The indication for PET was elevated tumor marker levels in three patients, although CT scan was negative. The PET scan showed lymph node, hepatic and disseminated lymph node metastases with liver involvement in these patients. Suspicious lesions were found on CT scan in the pelvis of four patients. Local recurrence was identified in three of them, PET was negative in the fourth case. Bone scan suggested rib metastasis in one patient, which was not supported at PET investigation. In one patient, the malignant nature of large retroperitoneal lymph nodes could not be determined by CT. PET imaging proved that they were malignant and detected a previously unknown pulmonary metastasis at the same time. In one patient both pulmonary and liver metastases were seen on CT, whereas PET confirmed only the latter. Similarly, CT failed to identify liver metastasis detected at ultrasound, while PET proved it. Finally, a pulmonary metastasis detected on X-ray, could be confirmed by PET only. Based on our experience, we recommend PET-scanning with FDG when conventional imaging is equivocal and/or elevated tumor marker levels are present during follow-up. FDG-PET is important in the detection of local recurrence and metastases as well. It is advisable to use PET more often in the evaluation of patients with recurrent colorectal cancer in order to diagnose recurrences in earlier stages, which helps to identify patients who will benefit from surgery.

A hereditary background may be demonstrated in approximately 15-20% of colorectal carcinomas. Familial adenomatous polyposis syndrome (FAP) constitutes about 1% of this patient population whereas hereditary non-polyposis colorectal carcinoma (HNPCC) makes up a further 3-6% of colorectal malignancies. The clinical features of HNPCC are dominant right colon localization, early age of onset, high prevalence of synchronous and metachronous tumors. Germline mutations of the so-called mismatch repair genes can be demonstrated in the genetic background of HNPCC. Screening and careful follow-up of these families are essential since the lifetime occurrence of colorectal carcinomas and HNPCC associated tumors has an 80-85% prevalence. The recognition of the affected families may be accomplished by taking a thorough family history, spanning several generations based on the Amsterdam and Bethesda Criteria, immunohistological investigations of the removed specimens and finally the exact identification of the pathologic MMR gene mutations. Radical surgical intervention is advised in cases of proven mutation carriers who are suffering from CRC. The index persons and their family members must be under regular control for their lifetime, with one-to-two year intervals to prevent fatal disease. The initiation of a national HNPCC register would further decrease the mortality and morbidity of the disease.

The authors analyzed their data of the last three and a half years about patients with temporary loop ileostomy. We formed 18 ileostomies in patients with rectum carcinoma where the anastomosis was performed in the mid or lower rectum. Ten ileostomies were formed because of anastomotic leak, eight to protect the anastomosis, although there were no signs of insufficiency at the time of the intraoperative testing. Sixteen of the 18 patients had no complications. There were two complications in connection with ileostomies, these stomas were closed earlier than usual. Two other patients needed permanent stomas. Fourteen ileostomies were reversed without complications after 6-8 weeks. Two patients with local septic complications, following the closure, were treated conservatively. No reoperations were needed because of anal incontinence or anastomotic stenosis. We consider loop ileostomy safe with low morbidity, it can prevent diffuse peritonitis and/or a permanent stoma. Its routine use is recommended in patients with "ultra low" anastomoses and in cases where the intraoperative air test is positive.

Enterovaginal fistulas most frequently occur following abdominal tumors, inflammatory bowel disease and radiation therapy. There is a tendency for spontaneous closure, although a surgical intervention is necessary in more than 50% of the cases. Mortality is between 15-25%. The quality of life is significantly worsened by an enterovaginal fistula of a patient already suffering from a malignant disease. To relieve the patient from her distressing situation a mucous fistula was constructed by exclusion of the small bowel loop participating in the formation of the fistula track. Bowel continuity was restored by anastomosis. The patient's quality of life improved significantly. This operation was performed in three cases without complications. We recommend this procedure as an alternative technique to improve our patients' quality of life.

The clinical diagnosis of hereditary nonpolyposis colon carcinoma (HNPCC) can be made in more than 5% of all colorectal cancer cases, depending on the stringency of criteria used. The disease is inherited in an autosomal dominant fashion but penetrance is lower than 100%. The diagnosis must be verified by the demonstration of germline mutations of DNA "mismatch repair" genes. Although yet an exception in our national health practice, these tests are routinely applied in some centers abroad. The recognition of the syndrome is important since these patients can enter a surveillance program and may be cured. The most important pertaining information is summarized through the demonstration of our own case.