Search

Breast cancer shall continue to be a public health problem because of its constantly ascending incidence and its high mortality. In the last decades, several positive changes happened in the treatment of this disease, as breast cancer screening, and introducing more effective oncological and surgical therapeutical methods. Qualitative and methodological development of breast surgery, the centralisation and the daily practice of quality assurance principles together will play an important role in reduction of breast cancer mortality in the future.

Oncosurgical treatment of breast tumors involves the removal of metastatic axillary lymph nodes. In the last 30 years, the diagnosis and treatment of axillary lymph nodes have also undergone significant changes. The introduction of sentinel lymph node biopsy in 1993 made axillary block dissection with high morbidity safely omitted in a significant proportion of patients, and similarly, the staging of breast tumors and thus oncology and complex treatment became significantly more accurate. Shortly after the introduction of sentinel lymph node biopsy, intraoperative examination of sentinel lymph nodes (e.g. imprint cytology) also appeared, which significantly reduced the number of surgeries performed in the two sessions, thereby significantly reducing patient burden and surgical costs. The results of our study indicate that axillary block dissection is required in the treatment of axilla in an ever-decreasing group of patients and this proportion will decrease further in the future, with the increasing use of alternative axillary radiotherapy. The imprint cytological examination of sentinel lymph nodes taking into account current guidelines, no longer provides demonstrable benefits and its routine use is not justified. According to the latest international recommendations, intraoperative examination of the sentinel lymph node may be indicated in connection with mastectomy (when postoperative radiotherapy is not planned) and after neoadjuvant treatment. Our results suggest that the detection of suspected lymph nodes during preoperative axillary ultrasound may predict the stage of the disease. Based on our research results confirm that in patients receiving neoadjuvant therapy, in addition to the preoperative size of the tumour (≤20 mm, P = 0.002), the preoperative size of the lymph node (≤15 mm, P = 0.04) may also be used to predict that the stage of the disease is N0-1.

Since its introduction in 1991, laparoscopic splenectomy has been considered the gold standard in spleen surgery, and the advantages of this technique over open surgery are indisputable. The technique was initiated in the Department of Surgery, University of Szeged in 1994 and since then our working group has gained one of the greatest experiences in this field in Hungary. Based on our results, similarly to literature data, it may be established that laparoscopic splenectomy can be considered a surgical procedure with low morbidity after gaining the necessary experience. In our study, the bowel motility recovered earlier, and hospital stay was significantly shorter after laparoscopic procedures. We proved laparoscopic splenectomy is a safe method in cases of extremely large spleens, and the Pfannenstiel incision is a cosmetically acceptable alternative for the retrieval of the spleen. Although several medications are available for second-line ITP therapy, laparoscopic splenectomy provides the longest-lasting results. In our study, young age and a preoperative response to steroids (steroid-dependent cases) were positive predictors for the success of splenectomy. Based on our experiences in the case of an immediate complete response to splenectomy, relapse occurred significantly less often.

Introduction. An estimated 20–30% of patients with ulcerative colitis need surgery. The generally accepted procedure for the surgical treatment is total proctocolectomy with ileal pouch-anal anastomosis. Nowadays laparoscopic technique is used more frequently. Minimally invasive surgical technique is used during the surgical treatment of colorectal diseases in the Department of Surgery in Szeged since 2005. Aim. We aimed to compare the last 16 years’ results of patients treated with conventional and laparoscopic methods. Methods. Between 01. 01. 2005. and 31. 03. 2021. 99 patients (53 female, 46 male) received surgery. The laparoscopic technique was used in 74 (74.7%) and the conventional method in 25 (25.3%) cases. General status of patients, early and late results of surgical treatment, and mainly complications were analyzed. Results. There was no difference between the groups in-hospital stay, the number of days spent in the intensive care unit and the need for transfusion. During the follow-up period the time to the recovery of the bowel function, and the occurrence of late complications were significantly lower in the laparoscopically operated group of patients. Conclusions. Laparoscopic surgical treatment can be used safely for both emergency and elective cases in UC patients. The short-term perioperative results and the morbidity showed no differences between the laparoscopic and open techniques. The long-term effect of laparoscopic surgery insured a lower rate of complications.

Aim. Our goal was to evaluate operative and perioperative data of retroperitoneal (RP) and transperitoneal (TP) adrenalectomies performed at the University of Szeged Department of Surgery. Patients and method. During a retrospective cohort study including 174 adrenalectomies (28 RP; 146 TP) performed between 1998 and 2021, the following parameters were evaluated: rate of previous abdominal surgeries, conversion rate, operative time, intraoperative blood loss, tumor size, histology, hospital stay, early and late complications. Results. With significantly higher rate of previous abdominal surgeries [TP vs RP: 68 (46.57%) vs 4 (14%) P = 0.0021], there was no markable difference in conversion rate [TP vs RP: 7 (4.79%) vs 5 (18%), P = 0.312]. Significantly larger tumours were removed with TP (TP vs RP: 58.05 vs 34.8 mm, P = 0.016), with no markable difference in intraoperative blood loss (TP vs RP: 67.85 vs 50.2 ml, P = 0.157). Operative time was significantly shorter in TP (TP vs RP: 86.3 vs 134.5 min; P = 0.024). The most frequent histology was adenoma (TP vs RP: n = 95; 65.06% vs 64.3%). Pheochromocytoma occurred in 11 (7.53%) and 5 (17.8%) cases in TP and RP, respectively. We found no significant difference in hospital stay (TP vs RP: 5.125 vs 4.61 day; P = 0.413). Five- and 2 cases of early complications were seen in TP (splenic injury, postoperative fever, severe intraoperative bleeding, severe hypokalemia, surgical site infection) and RP (2 severe intraoperative bleeding), respectively. One lethal case of ventricular fibrillation and one delayed complication (postoperative abdominal wall hernia) were observed in TP. Conclusions. Both TP and RP are safe and simply reproducible minimally invasive techniques. According to our observation, RP adrenalectomy seems to be reserved for smaller lesions, while TP proves to be successful in removing enlarged and also malignant lesions with significantly shorter operative time.

Introduction. Recently the therapeutic treatment for advanced, stage T2-T4 gastro-oesophageal junction cancer and those adjacent to the regional lymph nodes involves neoadjuvant chemotherapy with subsequent surgical intervention. Method. Neoadjuvant oncological treatment for gastro-oesophageal junction cancer previously consisted of the intravenous administration of epirubicin, cisplatin and fluorouracil (ECF) or epirubicin, cisplatin and capecitabine (ECX) combination (Group I). In the course of the new protocol (FLOT-, F: 5-FU, L: leucovorin, O: oxaliplatin, T: docetaxel), patients were included with resectable gastro-oesophageal junction cancer who had a clinical-stage cT2 or higher nodal positive cN+ disease (Group II). Between 31st of December 2013 and 1st of June 2021 we retrospectively analyzed the effect of these FLOT oncological protocols in terms of surgical outcomes in cases of T2-T4 tumors (n = 9). We compared the results of the randomly assigned nine patients from earlier ECF/ECX protocol (Group I). We analyzed the effect of the different neoadjuvant therapy on tumor regression, and evaluated the types of possible side effects, type of surgery, and the oncological radicality of surgical procedures (number of removed regional lymph nodes, resection margins). Results. Comparing the two groups we found that in cases of FLOT neoadjuvant chemotherapy complete regression was achieved significantly a higher number like in earlier ECX/ECF therapy. Furthermore, the average number of removed lymph nodes, and the safety resection margins (distal, circumferential) no significant difference was found between the two groups. Neutropenia was the most frequently encountered side effect. Leukopenia, neutropenia and nausea occurred more frequently in cases of the old protocol (Group I). Conclusions. As a result of the FLOT neoadjuvant oncological protocol for advanced gastro-oesophageal junction cancer, the number of cases with complete tumor regression has significantly increased. The present results strongly suggest a significant advantage in favor of FLOT neoadjuvant treatment following surgery. The prevalence of side effects was also appreciably lower in cases of the FLOT protocol.

Introduction and aims. In recent decades health care changes have accelerated enormously. Previously, by learning an effective procedure, the doctor could guarantee his patients the highest level of care for many years. Nowadays, due to the dynamics of development, the renewal cycles of the methods have been shortened, without continuous learning and training, it is already inconceivable to provide the up-to-date care required by patients. Patients and methods. Instead of vascular replacements with prosthetic grafts, which played an important role in vascular reconstructions, the primacy of endovascular techniques has become decisive. It can be significant for aortic aneurysms that can be operated with high invasiveness. The learning of catheter techniques by vascular surgeons made it possible to treat more successfully those limb-threatening cases, which are often associated with extensive vascular involvement, through the so-called hybrid operations. In addition to the increasing prevalence of diabetes worldwide, the higher proportion of critical limb ischemia and the highlighted pathogenic role of multi-resistant bacteria in the disease caused the marginaliation of the use of previously preferred prosthetic grafts. The effectiveness of the treatment of graft infections, which thus become less frequent, is improved by the use of homografts and negative pressure therapy. An effective method of preventing stroke is carotid endarterectomy, the morbidity of which is reduced by the introduction of locoregional anaesthesia allowing direct neuromonitoring. Results/conclusions. Although the acquisition and implementation of new methods has posed a continuous challenge for our specialists and doctors over the past 10 years, our achievements have made our department one of the leading vascular surgery centres in the country.

Introduction. Non-intubated spontaneous ventilated (NITS) minimally invasive surgery (video-assisted thoracic surgery VATS) is a widespread procedure, but there are some doubts regarding its safety. We developed a safe method, spontaneous ventilation with intubation (SVI) to resolve these concerns. In this study, the early postoperative results of the SVI sublobar resections are presented. Methods. Between 2020 May 25 and 2021 March 26, 20 SVI VATS sublobar resection was performed with a double lumen intratracheal tube. Results. Surgeries were performed for 9 females and 11 males with a mean age of 66.1. The mean BMI was 27.8, FEV1 was 89.1%, and Carlson Comorbidity score was 6.1. The mean surgical time was 61.5 min, drainage time was 1.85 days and hospital stay was 3.35 days. Morbidity was found to be 5%. Primer lung cancer was removed in 9 cases, we performed 6 metastasectomies and in 5 cases benign lesion was removed. Conclusion. According to the early postoperative results spontaneous ventilated VATS sublobar resections with double lumen intratracheal tube can be considered a safe thoracic surgical method.

Introduction and aims. We present our experience with minimally invasive surgery for pharyngoesophageal (Zenker) diverticulums, epiphrenic diverticulums and achalasia cardiae focusing on the perioperative features and patients’ quality of life. Patients and methods. Between 1 January 2003 and 31 December 2020, patients were selected with a symptom-causing Zenker diverticulum, epiphrenic diverticulum and achalasia cardiae. In 17 cases, transoral stapler diverticulostomy, in 23 cases transcervical diverticulectomy and cricomyotomy were done because of Zenker diverticulum, in 14 cases, laparoscopic transhiatal surgery was performed because of epiphrenic diverticula, while in 63 cases, laparoscopic Heller–Dor operation were carried out because of achalasia cardiae. Perioperative results, the quality of life outcomes of various surgeries were evaluated in mid- and long-term. Results/conclusions. The surgeries were performed with minimal blood loss, zero mortality and low morbidity. According to our result, the two different surgical approaches in the therapy of Zenker’s diverticulum, the laparoscopic Heller–Dor procedure applied in the management of epiphrenic diverticulas and achalasia cardiae are safe and effective operations. In the long term, the symptom control in patients after minimally invasive surgeries is sufficient and only a small percentage of the patients may require additional medication therapy and/or reintervention due to persistent complaints.

For the centenary of the Department of Surgery, University of Szeged we have investigated and summarized the results and outcomes of 779 anti-reflux surgery cases between 1. January 2000 – 31. May 2021. The indication for surgery was made in close collaboration with the internal medicine workgroup depending on the results of endoscopy and functional tests. The primer indication for surgery was medical therapy-resistant reflux disease. Based on our clinical practice we performed laparoscopic Nissen fundoplication in 98,2% of the cases. Besides the long- and short-term postoperative complications, we investigated the long-term effect of anti-reflux surgery on acid and bile reflux, and the improvement of the patients' quality of life using the Visick score, and modified GERD-HRLQ score. Our investigations have proven the effect of acid and bile reflux in the pathogenesis of Barrett's esophagus and furthermore we have confirmed that laparoscopic anti-reflux surgery restores the function of the lower esophageal sphincter and eliminates acid and bile reflux, so in certain cases Barrett's esophagus regression can be achieved. But due to the heterogeneity of GERD and Barrett's esophagus long-term and regular endoscopic control is necessary.

Introduction. The rate of graft failure after kidney transplantation is 7–10% in the first year and 3–5% in subsequent years. The indication and exact timing of graftectomy is a matter of debate in some cases, particularly in the case of asymptomatic grafts that are no longer functioning. Methods. Data of patients who underwent kidney transplantation at the Transplantation Unit, Department of Surgery, Szeged, Hungary between January 1, 2015 and December 31, 2020 were analyzed. We reviewed the indications, timing and complications of graftectomies and compared early and late graftectomies. Results. 294 kidney transplants were performed during the study period. 37 patients (13%) of them underwent graftectomy. The most common indications were bleeding 11 (30%), arterial circulatory disorders 8 (22%), v. renal thrombosis 7 (19%), mixed active antibody and ongoing cellular rejection 7 (19%), and acute humoral rejection 4 (10%). Graftectomies were performed in 26 cases with inoperative and in 11 cases with functional graft. Comparing early and late graftectomies, 15 cases (40%) underwent early graftectomy within 30 days after transplantation and 22 cases (60%) underwent late graftectomy. Conclusions. The most common cause of graftectomies in the study period was acute bleeding, which is also due to disturbed homeostasis in chronic renal failure. In the case of the early ones, emergency surgery and in the vast majority of late graftectomies, elective surgery was performed.

Aim: Due to the emerging experience in VATS (video assisted thoracic surgery) lobectomies, in some centers the so called "non-intubated" VATS lobectomies (NITS - non-intubated thoracic surgery) gained increased authority, during which endotracheal intubation and muscle relaxation of the patient is not carried out, thus surgery is being performed with the patient breathing spontaneously. The recent study deals with our initial experience gained during uniportal NITS VATS lobectomies., Patients and Method: Between 24.01.2017 and 10.03.2017, 16 patients (female: 8; male: 8) with lung cancer underwent NITS VATS uniportal lobectomy. Mean age was 59.6 years (42-73 years). Mean FEV1 was 87.7% (62-109). Mean BMI was 27.1 (18.8-32.8). Prior to surgery, the patients received benzodiazepine premedication, local anesthetic (Lidocaine) for incision and Bupivacaine for intercostal and vagus nerve blockage. Besides routine monitoring Bispectoral Index (BIS) guided target-controlled infusion (TCI) Propofol sedation was carried out, with the help of laryngeal mask anesthesia. Skin and soft tissue incision was performed at the fifth intercostal space, in the axillary line. This single incision sight was the only one needed for the introduction of the camera, together with the instruments needed for dissection and resection of the lobe and placement of the chest tube. Complete atelectasis can develop. The following lobes were removed: 7 right upper lobes, 2 mid-lobes, 1 right lower lobe, 1 right lower lobe + right upper lobe wedge resection, 5 left lower lobes. After the resections, extended mediastinal sampling or block dissection was performed., Results: There was no perioperative mortality. Conversion to endotracheal intubation was needed in non of the cases. Mean operative time was 96,5 minutes (80-120 min.), mean drainage periode was 2.9 days (2-8 days). Prolonged air leak was 1/16 (6.25%). Postoperative fever occurred in 1 patient and subcutaneous emphysema in 1 case, and 1 pneumonia. Because of a recurrent pneumothorax, a re-drainage was necessary in 1 case. Pathology of the resected lobes were as follows: 1 endobronchial hamartochondroma causing complete atelectasis of the lobe, 1 chronic pneumonia, and 10 adenocarcinomas, 2 squamous cell carcinomas, 1 carcinosarcoma, and 1 typical carcinoid. Staging of the 14 malignant cases were as follows: 8 IA, 2 IB, 1 IIA, 2 IIB, and 1 IIIA. The average number of the removed mediastinal lymph nodes is 12 (7-20)., Conclusion: Non-intubated (NITS) VATS lobectomy is considered a safe procedure, satisfying all aspects of oncological guidelines. The postoperative drainage period was shorter caused by the complete atelectasis during the surgery.

Therapy for breast cancer today is characterised by ever more precise diagnostic methods and ever more effective oncological treatments, a trend which will certainly continue into the future. Breast preservation and the application of oncoplastic principles are increasingly popular. A sentinel lymph node biopsy in the surgical treatment of the axilla is primary, with the indication for axillary block dissection (ABD) narrowing and radiation therapy becoming an alternative to ABD in certain cases. This publication summarises our recommendations on the surgical treatment of breast cancer based on the content of the 3rd Breast Cancer Consensus Conference and considering the latest international studies and professional recommendations.

Objectives: Herein we present the results of lobectomies performed with minimally invasive approach (video-assisted thoracic surgery - VATS) at our department during a period of five years., Methods: Between 1 January 2011 and 31 December 2015, 197 lobectomies (malignant lesions: 176 cases, benign lesions: 21 cases) were performed by three thoracic surgeons and one resident. Demographical data are as follows: 119 female/78 male, mean age: 62.4 years (range: 41-82 years). In 2011 three VATS lobectomies were performed, equaling 2.2 % of all lobectomies in that year. During the upcomig years the number of VATS lobectomies were as follows: 2012: 7 (7.3%), 2013: 13 (12%), 2014: 59 (34.5%) and 2015: 119 (68.5%). In 153 cases multiportal (78%) and in 44 cases uniportal (22%) anterior approach was performed. The resected lobes showed the following distribution: right upper: 85, mid lobe: 5, right lower: 28, left upper: 44, left lower: 34, upper bilobectomy: 1. In two cases sleeve lobectomy was performed. In 8 cases (4%) conversion to thoracotomy was needed and among the 46 uniportal procedures, 5 cases needed to be expanded into biportal approach (11%)., Results: During the study period, no intraoperative, or perioperative mortality occured. Mean operative time was 123 minutes (range: 60-135 minutes) and mean time of chest drainage was 4.3 days (range: 1-27 days). Air leakage lasting more than 7 days was present in 11.7%. Reoperation was needed in 4 cases (2%), in two cases due to bleeding, and in two cases because of expansive difficulties due to extended subcutaneous emphysema. Among the 176 VATS lobectomies performed due to malignant lesions, 169 lung cancers and 7 metastases were removed. The distribution according to the stage and histology of lung cancers was as follows: IA: 100 cases, IB: 28 cases, IIA: 17 cases, IIB: 3 cases, IIIA: 16 cases, IIIB: 1 case, and IV: 4 cases; adenocarcinoma: 128 cases, squamous cell carcinoma: 26 cases, large cell carcinoma: 3 cases, small cell lung cancer: 1 case, typical carcinoid: 10 cases, and atypical carcinoid: 1 case., Conclusions: Over the years VATS lobectomy became a rutin procedure at our institution. Nowadays more than two-thirds of lobectomies are performed with minimally invasive technique. Taking the learning curve of the four thoracic surgeons into consideration, our results correlate with international data.

Background: Removing the extremely enlarged spleen from the abdominal cavity is a common technical problem in case of laparoscopic splenectomy ( LS). In general, the specimen is placed into a plastic bag and removed after morcellation. In case of massive splenomegaly , when the spleen weight is 1000-2000 grams, this method is often not feasible, because the spleen size is larger than the maximum capacity of the EndoBag. According to the literature in this case the splenic extraction was performed by specimen fragmentation in the abdominal cavity (risk of splenosis) or by a laparotomy. To solve this problem our team removes the specimen via a Pfannenstiel incision since 2009., Methods: Between January 1, 2002 and September 30, 2014, 74 LS procedures were performed at our department. The specimen was retrieved with morcellation in a conventional manner through the lateral port site in 56 cases, whereas in 12 cases, the large spleen was retrieved through a 10-12 cm long Pfannenstiel incision., Results: The mean duration of surgery was 121 (50-220) minutes. In those cases where the specimen was retrieved through a Pfannenstiel incision the mean duration of surgery was significantly shorter (108 vs. 125 minutes; p=0.05), and the mean spleen size was significantly larger (1032 vs. 338 grams; p=0.0001) than in the case of morcellation. In the duration of the mean postoperative hospital stay there was no significant difference (4.7 vs. 5.2 days; p=0.178)., Conclusion: Our study supports that laparoscopic splenectomy is safe and has numerous advantages even in the case of massive splenomegaly. The retrieval of the specimen through a Pfannenstiel incision is considered a safe and cosmetically acceptable alternative.

Objectives: Different methods of open or minimally invasive thymectomies have been recommended for the treatment of myasthenia gravis (MG). We compared the results of standard transsternal thymectomy (TS) and two different types of minimally invasive thymectomies [video-assisted thoracoscopic extended thymectomy (VATET) and classic Video-Assisted Thoracoscopic Surgery (cVATS)] performed at the same department., Methods: During three different time periods 71 patients (60 female and 11 male; mean age 31 [range, 14-84] years) underwent thymectomy for MG. Twenty-three underwent standard transsternal thymectomy (January 1995 - September 2004), 22 VATET (September 2004 - August 2009), and 26 cVATS (September 2009 - December 2011) thymectomy for the right side. Operative data, MG- and surgery-related postoperative morbidity and early improvement of MG during the initial 1-year follow-up period were compared among the three methods., Results: There were no perioperative deaths during the study period. Operative time was 112, 211, and 116 minutes (p = 0.001) in the TS, VATET and cVATS, respectively, and the length of hospital stay was 8.9, 5.6, and 4.0 (p = 0.001) days. Postoperative MG-related neurological morbidity affected 21.7%, 18.2%, and 7.7% (p = 0.365) of the patients and the surgery-related morbidity rate was 4.3%, 13.7%, and 0% (p = 0.118) in the TS, VATET and cVATS groups, respectively. Symptom improvement rates were 91.3%, 94.7%, and 87.5% (p = 0.712), and complete remission rates were 13%, 10.5%, and 11.5% (p = 0.917) after TS, VATET and cVATS thymectomies, respectively., Conclusions: In terms of operative time and hospital stay the best results were found after cVATS. The use of a less invasive surgical intervention resulted in less surgical-, and MG related neurological complications. The improvement of MG symptoms was excellent and results were similar after different types of thymectomies.

Introduction: In our study, we applied a mini-laparosopic approach during laparoscopic cholecystectomy (LC) (using the minimum size of trocars with the simultaneous intention to reduce their number). The advantages and disadvantages of the mini-LC approach were compared with those of traditional LC., Patients and Methods: During mini-LC procedures, we used 3 ports (11 mm, 5 mm, 3.5 mm). Mini-LC was performed in 10 patients, and the results were compared with those of 10 cases of traditional LCs. The two groups were homogenous in terms of gender, age, BMI and ASA classification. Comparison criteria included operative time, the need to use an extra port, conversion rate, oral analgesic requirement, early/late complications and cosmetic results., Results: There were no significant differences in terms of operative time, blood loss, hospital stay and complications. Cumulative size of incisions was 19.5 mm with mini-LC- and 41 mm in the LC group, respectively, and the tissue injury was 124.2 mm(2) and 448.2 mm(2). Cosmetic results of mini-LC were highly improved by these values. Increased oral analgetic requirements were detected in LC group., Conclusion: Mini-LC is a safe procedure with outstanding cosmetic results accompanied by less oral analgetic requirements. In selected patients, it can be recommended as an alternative method of traditional LC.

Introduction: Barrett's esophagus (BE) is the only known precursor of adenocarcinoma occuring in the lower third of the esophagus. According to statistics, severity and elapsed time of gastroesophageal reflux disease (GERD) are major pathogenetic factors in the development of Barrett's esophagus., Patients and Methods: In a retrospective study between 2001 and 2008, we compared the preoperative results (signs and sympthoms, 24 hour pH manometry, esophageal manometry, Bilitec) and treatment efficacy of 176 GERD patients and 78 BE patients, who have undergone laparoscopic Nissen procedure for reflux disease., Results: The two groups of patients had similar demographic features, and elapsed time of reflux sympthoms were also equal. Both groups were admitted for surgery after a median time of 1.5 years (19.87 vs. 19.20 months) of ineffective medical (proton pump inhibitors) treatment. Preoperative functional tests showed a more severe presence of acid reflux in the BE group (DeMeester score 18.9 versus 41.9, p < 0.001). On the other hand, mano-metry - despite confirming lower esophageal sphincter (LES) damage - did not show difference between the two groups (12.10 vs. 12.57 mmHg, p = 0.892). We did not experience any mortality cases with laparoscopic antireflux procedures, although in two cases we had to convert during the operation (1 due to extensive adhesions, and 1 due to injury to the spleen). 3 months after the procedure - according to Visick score - both groups experienced a significant decrease, or lapse in reflux complaints (group I: 73%, group II: 81% of patients), LES functions improved (17.58 vs.18.70 mmHg), and the frequency and exposition of acid reflux decreased (DeMeester score 7.73 vs. 12.72)., Conclusion: The severity of abnormal acid reflux occuring parallel with the incompetent function of the damaged LES triggers not only inflammation in the gastroesophageal junction (GEJ), but also metaplastic process, and the development of Barrett's esophagus. Laparoscopic Nissen procedure for reflux disease can further improve outcome among patients with GERD not responding to conservative therapy.

Case Report: A 25-year-old primipara, in the thirty-second week of her pregnancy observed a nodule in the upper outer quadrant of her left breast during self-examination. Complex breast examination revealed calcification with 4 cm of diameter. Ductal malignant cells (C5) were identified by fine-needle aspiration biopsy, while core biopsy verified invasive ductal carcinoma, grade III (B5b). No manifestations of metastases were presented. After pregnancy termination wide excision with additional axillary sentinel lymph node biopsy was performed. Because of its positivity block dissection of axillary lymph nodes was carried out. The surgical therapy was followed by adjuvant chemo-, radio- and hormonal therapy. Later an angiomyxoma appeared in the right inguinal region, which was excised in toto., Discussion: The incidence of pregnancy related malignant diseases is increasing, of which breast cancer predominates. Breast cancer, which is diagnosed during pregnancy or within the first year of delivery is called pregnancy-associated breast cancer. Because of the physiological changes in pregnancy the recognition of the disease is difficult. Therapy is complex, as besides the treatment of the mother, the safety of the fetus should be emphasized. The treatment strategies are different in the three trimesters. The surgical treatment can be performed during the whole pregnancy. The use of radiotherapy is controversial, because of teratogenic effects, while chemotherapy is permitted in the second and third trimesters. Nearly three years after the operation, our patient does not have any symptoms, her son is healthy.

Introduction: Conventional operative techniques are gradually being replaced by minimally invasive surgical methods in the surgery of the spleen. We summarized our 10-year-experience after the introduction of laparoscopic splenectomy at the University of Szeged, Department of Surgery, comparing open and minimally invasive techniques., Material and Method: Between 1st January 2002 and 1st December 2011 we performed 141 splenectomies of which 17 were acute operations. Of the 124 elective procedures 54 were laparoscopic and 70 open operations. In 40 cases (open procedures) splenectomy was part of multivisceral surgery which were excluded from the analysis. In this retrospective analysis a comparison of laparoscopic and open elective technique was carried out., Results: Average operating time of laparoscopic procedures was slightly longer than that of open technique (133 vs. 122 minutes, p = 0.074). After the learning period, duration of laparoscopic procedures became shorter (first five years: 147 min., second five years: 118 min, p = 0.003), larger spleens were removed (220 vs. 450 grams, p = 0.063) and conversion rate became lower. In cases of laparoscopic procedures fewer reoperations needed to be performed (1.5% vs. 6%, p = 0.718), bowel motility recovered earlier (2 vs. 3 days, p = 0.002) and hospital stay was shorter (5 vs. 8 days, p ≤ 0.001)., Conclusion: Our study proves that laparoscopic splenectomy is a safe method with many advantages. Our results correlate with data of international publications.

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.

This case report summarizes therapeutic options for the management of pancreato-pleural fistula (PPF) following a successful conservative treatment of one of our patients. PPF is a rare complication of chronic pancreatitis. The main aetiological factor is alcohol, which causes relapse of chronic pancreatitis associated with dyspnoea. Diagnosis is confirmed by physical examinations, laboratory tests of pleural fluid as well as ERCP being the most important diagnostic procedure. Conservative treatment of PPF consists of endoscopic therapy (endoscopic sphincterotomy with stenting of the pancreatic duct), octreotid combined with continuous enteral nutrition (jejunal feeding). If the above complex therapy fails, surgical treatment of PPF is advised.

Case Report: We report the case of a 45-year-old male patient who developed an acute peptic ulcer perforation of the tubal stomach on the second postoperative day after oesophagectomy. The patient underwent emergency surgery (perforation was closed with a Graham patch) followed by treatment in intensive care, and was finally discharged on the 19th postoperative day., Discussion: Gastric pull-up is a surgical technique that is widely used to re-establish the continuity of the gastrointestinal tract after oesophagectomy. Various early and late complications of reconstruction with the tubal stomach are well-known, such as gastric necrosis, gastritis, gastric ulcer, as well as benign and malignant tumors. The precise etiology of gastric tube ulceration is not known yet, however, it can develop not only in the late, but also in the early postoperative period, as well.

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.

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.

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.

While circular staplers are used worldwide - especially for rectal anastomoses - there are relatively few publications on the effectiveness of these instruments. Between May 2008 and March 2009 in a prospective multicenter surveillance study 136 patients were enrolled from nine surgical units in Hungary. Rectal anastomoses were performed mainly in the upper and middle third of the rectum. In 115 cases adenocarcinoma, in 16 patients other type of malignant tumors and in 5 cases with anastomosis in the distal third were estimated too. 20 laparoscopic and 116 "conventional" surgery was performed. 32 mm diameter type CS circular staplers were used in 50, 28 mm in 85, and 25 mm in one case. Intraoperative technical failure of the device occurred in four cases, immediate correction were performed successfully in all of these patients and they recovered without postoperative complications. Late anastomotic leaks were detected in five patients, of which three healed spontaneously and two required reoperation. In the whole series two patients died representing a 1.4 percent mortality rate. The CS circular staplers proved to be appropriate for infraperitoneal rectal anastomoses.

Introduction/aims: In the clinical practice, biliary obstruction often leads to septic complications causing systemic and hepatic inflammatory reactions, which increases mortality and morbidity. Hepatic Kupffer cells (KC) play a pivotal role in this process. Herein we examined the consequences of bile duct ligation during endotoxaemia and the effects of KCs., Material and Methods: In the first part of our experiment, the survival rate of male Wistar rats in 48-hr endotoxaemia with or without bile duct ligation was assessed. Time-dependent changes in pro-inflammatory TNF-alpha and IL-6 levels were also monitored. In the second series, hepatic capillary perfusion, neutrophil-endothelial interactions and KC activity were assessed using fluorescence intravital videomicroscopy. KC blockade was induced by gadolinium chloride (GdCl3) pretreatment., Results: Serum TNF-alpha and IL-6 levels were significantly increased in early endotoxaemia. Survival rate was deteriorated, while TNF-alpha and IL-6 releases, KC activity and leukocyte activation were increased if obstructive jaundice was also induced. KC blockade improved survival and reduced TNF-alpha and IL-6 productions without ameliorating perfusion failure., Conclusions: In the presence of biliary obstruction, inflammatory and microcirculatory consequences of endotoxaemia are enhanced. The alleviating effect of KC blockade may underline the pathophysiological role of KCs in these conditions.

The authors report a case of a 57-year old asymptomatic patient, whose routine chest X-ray demonstrated a left-sided lung tumour. Bronchoscopy, chest CT and PET-CT revealed double granular cell tumours on the posterior wall of the distal part of the left mainstem bronchus as well as in the bronchus of the segment 6, in addition to the suspected malignant tumour in the 2nd segment. His surgical management involved the atypical resection of segment 2 lesion first, which was tuberculotic origin based on frozen section. Next, the double granular cell tumours were removed by segmentectomy of segment 6 and bifurcation resection of the mainstem bronchus. In case of granular cell tumours, resection of the mainstem bronchus is a safe procedure with good results. Further, surgical exploration is indicated in symptomatic patients with a suspicion of malignant coin lesions.

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.

Introduction: Extended thymectomy is the key-point of the surgical treatment of the myasthenia gravis (MG), when the thymus with the surrounding fatty tissue on the neck and in the mediastinum is removed. In this study we present a new surgical technique introduced into our practice in November 2004, and with that the thymectomy is performed with video-thoracoscopic method, without sternotomy., Patients and Methods: Since November 2004, 6 patients (5 females and 1 male) were operated on for MG. Mean age was 26.2 years (17-41). Symptoms of MG was only ocular in 1 case (Stage I) and mild generalized in 5 cases (Stage II/B). The average preoperative period of the MG was 4 months (1-12). At the beginning of the surgery, the superior poles of the thymus were exposed and the fatty tissue surrounding the thymus in front of the trachea was removed. After that, the sternum was elevated with sternal retractors inserted under the sternum in the cervical and in a subxiphoid incisions. The thymectomy with the removal of the mediastinal fatty tissue was performed with bilateral video-assisted method., Results: Mean operative time was 170 (120-210) minutes. There was no conversion to sternotomy, and there were no mortality and serious morbidity. Patients were extubated in the operating room. Chest tubes were removed on the first and second postoperative days. Mean postoperative hospitalization was 6.3 (5-7) days. At the one-month follow-up, there was 1 complete remission and 5 remissions with medication. In 1 case, the pathology revealed extrathymic thymus tissue in the cervical fat. There were 3 thymus hyperplasias, 2 thymitis and 1 thymic cyst as the pathological disorders of the thymus., Conclusions: The video-assisted extended thymectomy for MG, that was introduced into our practice, is a safe surgical procedure with good results. The postoperative period is easier for the patients, and the MG was improved in each cases.

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.

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.

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.

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.

Studying the distribution of heterolog erythrocytes labelled by Cr51 in rats, it was established that reticuloendothelial blockade induced by gadolinium chloride first of all can be explained by the decreased phagocytic activity of Kupffer cells. Light-and electronmicroscopic studies have evidenced that gadolinium chloride inhibited phagocytosis of indian ink not only by normal, non activated Kupffer cells but also by those, activated by a reticuloendothelial stimulator, zymosan. These experiments seem to indicate that the blockade of Kupffer cell phagocytosis induced by gadolinium chloride both phases of this process, the surface sticking and engulfing are damaged.