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Introduction: There has been an increasing interest for the laparoscopic treatment of early gastric cancer, especially among Eastern surgeons. However, the oncological effectiveness of Laparoscopic Gastrectomy (LG) for Advanced Gastric Cancer (AGC) remains a subject of debate, especially in Western countries where limited reports have been published. The aim of this paper is to retrospectively analyze short- and long-term results of LG for AGC in a real-life Western practice., Materials and Methods: All consecutive cases of LG with D2 lymphadenectomy for AGC performed from January 2005 to December 2019 at seven different surgical departments were analyzed retrospectively. The primary outcome was diseases-free survival (DFS). Secondary outcomes were overall survival (OS), number of retrieved lymph nodes, postoperative morbidity and conversion rate., Results: A total of 366 patients with stage II and III AGC underwent either total or subtotal LG. The mean number of harvested lymph nodes was 25 ± 14. The mean hospital stay was 13 ± 10 days and overall postoperative morbidity rate 27.32%, with severe complications (grade ≥ III) accounting for 9.29%. The median follow-up was 36 ± 16 months during which 90 deaths occurred, all due to disease progression. The DFS and OS probability was equal to 0.85 (95% CI 0.81-0.89) and 0.94 (95% CI 0.92-0.97) at 1 year, 0.62 (95% CI 0.55-0.69) and 0.63 (95% CI 0.56-0.71) at 5 years, respectively., Conclusion: Our study has led us to conclude that LG for AGC is feasible and safe in the general practice of Western institutions when performed by trained surgeons., (© 2021. The Author(s).)

Background and Objectives: In the setting of a minimally invasive approach, we aimed to compare short and long-term postoperative outcomes of patients treated with neoadjuvant therapy (NAT) + surgery or upfront surgery in Western population., Methods: All consecutive patients from six Italian and one Serbian center with locally advanced gastric cancer who had undergone laparoscopic gastrectomy with D2 lymph node dissection were selected between 2005 and 2019. After propensity score-matching, postoperative morbidity and oncologic outcomes were investigated., Results: After matching, 97 patients were allocated in each cohort with a mean age of 69.4 and 70.5 years. The two groups showed no difference in operative details except for a higher conversion rate in the NAT group (p = 0.038). The overall postoperative complications rate significantly differed between NAT + surgery (38.1%) and US (21.6%) group (p = 0.019). NAT was found to be related to a higher risk of postoperative morbidity in patients older than 60 years old (p = 0.013) but not in patients younger (p = 0.620). Conversely, no difference in overall survival (p = 0.41) and disease-free-survival (p = 0.34) was found between groups., Conclusions: NAT appears to be related to a higher postoperative complication rate and equivalent oncological outcomes when compared with surgery alone. However, poor short-term outcomes are more evident in patients over 60 years old receiving NAT., (© 2021 The Authors. Journal of Surgical Oncology Published by Wiley Periodicals LLC.)

Background: RefluxStop™ is an implantable, non-active, single use device used in the laparoscopic treatment of GERD. RefluxStop™ aims to block the movement of the LES up into the thorax and keep the angle of His in its original, anatomically correct position. This new device restores normal anatomy, leaving the food passageway unaffected., Methods: In a prospective, single arm, multicentric clinical investigation analyzing safety and effectiveness of the RefluxStop™ device to treat GERD, 50 subjects with chronic GERD were operated using a standardized surgical technique between December 2016 and September 2017. They were followed up for 1 year (CE-mark investigation 6-months). Primary safety outcome was prevalence of serious adverse events related to the device, and primary effectiveness outcome reduction of GERD symptoms based on GERD-HRQL score. Secondary outcomes were prevalence of adverse events other than serious adverse events, reduction of total acid exposure time in 24-h pH monitoring, and reduction in average daily PPI usage and subject satisfaction., Results: There were no serious adverse events related to the device. Average GERD-HRQL total score at 1 year improved 86% from baseline (p < 0.001). 24-h pH monitoring compared to baseline showed a mean reduction percentage of overall time with pH < 4 from 16.35 to 0.80% at the 6-month visit (p < 0.001), with 98% of subjects showing normal 24-h pH. At 1 year: No new cases of dysphagia were recorded, present in 2 subjects, which existed already at baseline. Regular daily PPI usage occurred in all 50 subjects at baseline. At 1-year follow-up, only 1 subject took regular daily PPIs due to a too low placement of the device thereby prohibiting its function. None or minimal occasional episodes of regurgitation occurred in 97.8% of evaluable subjects. Gas bloating disappeared in 30 subjects and improved in 7 subjects., Conclusion: The new principle of RefluxStop™ is safe and effective to treat GERD according to investigation results. At 1-year follow-up, both the GERD-HRQL score and 24-h pH monitoring results indicate success for the new treatment principle. In addition, with the dynamic treatment for acid reflux, which avoids compressing the food passageway, prevalence of dysphagia and gas bloating are significantly reduced., Trial Registration: ClinicalTrials.gov , NCT02759094 . Registered 3 May, 2016.

Background: Local hemostatic agents have a role in limiting bleeding complications associated with liver resection., Methods: In this randomized, phase III study, we compared the efficacy and safety of Fibrin Sealant Grifols (FS Grifols) with oxidized cellulose sheets (Surgicel®) as adjuncts to hemostasis during hepatic resections. The primary efficacy endpoint was the proportion of patients achieving hemostasis at target bleeding sites (TBS) within 4 min (T 4 ) of treatment application. Secondary efficacy variables were time to hemostasis (TTH) at a later time point if re-bleeding occurs and cumulative proportion of patients achieving hemostasis by time points T 2 , T 3 , T 5 , T 7 , and T 10 ., Results: The rate of hemostasis by T 4 was 92.8% in the FS Grifols group (n = 163) and 80.5% in the Surgicel® group (n = 162) (p = 0.01). The mean TTH was significantly shorter (p < 0.001) in the FS Grifols group (2.8 ± 0.14 vs. 3.8 ± 0.24 min). The rate of hemostasis by T 2 , T 5 , and T 7 was higher and statistically superior in the FS Grifols group compared to Surgicel®. No substantial differences in adverse events (AE) were noted between treatment groups. The most common AEs were procedural pain (36.2 vs. 37.7%), nausea (20.9 vs. 23.5%), and hypotension (14.1 vs 6.2%)., Conclusions: FS Grifols was safe and well tolerated as a local hemostatic agent during liver resection surgeries. Overall, data demonstrate that the hemostatic efficacy of FS Grifols is superior to Surgicel® and support the use of FS Grifols as an effective local hemostatic agent in these surgical procedures.

Introduction: Recent data from the studies conducted in the Western countries have proved that patients with gastroesophageal reflux disease have significantly impaired health-related quality of life compared to general population., Objective: The study is aimed at evaluating the burden of reflux symptoms on patients'health-related quality of life., Methods: The study involved 1,593 patients with diagnosed gastroesophageal reflux disease.The Serbian version of a generic self-administered Centers for Disease Control and Prevention questionnaire was used. Statistical analyses included descriptive statistics, Pearson chi-square test and a multiple regression model., Results: Among all participants, 43.9% reported fair or poor health. Mean value of unhealthy days during the past 30 days was 10.4 days, physically unhealthy days 6.4 days, mentally unhealthy days 5.3 days and activity limitation days 4.3 days. Furthermore, 24.8% participants reported having ≥ 14 unhealthy days, 14.9% had 14 physically unhealthy days, 11.8% reported 14 mentally unhealthy days, and 9.4% had ≥ 14 activity limitation days., Conclusion: This study addressed complex relationships between reflux symptoms and patients'impaired everyday lives.

Introduction: At the Department of Minimally Invasive Upper Digestive Surgery of the Hospital for Digestive Surgery in Belgrade, hybrid minimally invasive esophagectomy (hMIE) has been a standard of care for patients with resectable esophageal cancer since 2009. As a next and final step in the change management, from January 2015 we utilized total minimally invasive esophagectomy (tMIE) as a standard of care., Objective: The aim of the study was to report initial experiences in hMIE (laparoscopic approach) for cancer and analyze surgical technique, major morbidity and 30-day mortality., Methods: A retrospective cohort study included 44 patients who underwent elective hMIE for esophageal cancer at the Department for Minimally Invasive Upper Digestive Surgery, Hospital for Digestive Surgery, Clinical Center of Serbia in Belgrade from April 2009 to December 2014., Results: There were 16 (36%) middle thoracic esophagus tumors and 28 (64%) tumors of distal thoracic esophagus. Mean duration of the operation was 319 minutes (approximately five hours and 20 minutes). The average blood loss was 173.6 ml. A total of 12 (27%) of patients had postoperative complications and mean intensive care unit stay was 2.8 days. Mean hospital stay after surgery was 16 days. The average number of harvested lymph nodes during surgery was 31.9. The overall 30-day mortality rate within 30 days after surgery was 2%., Conclusion: As long as MIE is an oncological equivalent to open esophagectomy (OE), better relation between cost savings and potentially increased effectiveness will make MIE the preferred approach in high-volume esophageal centers that are experienced in minimally invasive procedures.

Introduction: Bleeding from esophageal varices is a serious medical problem because of the risk of recurrent bleeding and high mortality rate (17-54%). Gastroesophageal varices develop in 50% of cirrhotic patients with portal hypertension, but can also develop in other pre- or post-hepatic causes of portal hypertension., Case Report: We reported a 48-year-old female patient with portal hy- pertension caused by mesenterial vein thrombosis due to congenital thrombophilia. The patient was hospitalized several times be- cause of recurrent gastroesophageal bleeding. Thrombosis of portal, lienal and mesenteric veins was diagnosed using multislice computed tomography (MSCT) angiography. Sclerotherapy and/or variceal ligation could not be used due to variceal size and distribution. Beta blockers were ineffective. Balloon tamponade and octreotide were used in each massive bleeding episode. Carvedilol therapy was introduced but rebleeding occured. Surgical treatment was considered a high risk procedure due to massive thrombosis of mesenterial veins, patient's general condition and high risk of postoperative thrombotic events. Thus, long-acting somatostatin analogue--Sandostatin LAR was initiated at a dose of 30 mg im/month. The patient responded to the therapy well and variceal bleeding did not occur for the following 3 months. After 3 months another episode of gastric variceal hemorrhage occurred and surgical treatment was reconsidered. Total gastrectomy was performed in order to prevent repeated bleeding from large gastric varices and the patient recovered successfully, and after 1 year is symptom-free. Conclusion. Long-lasting somatostatin analogue was used for the first time in treatment of gastroesophageal variceal hemorrhage in the patient with prehepatic portal hypertension. It was effective as temporary therapeutic option allowing the improvement of the patients general condition and adequate planning of elective surgical procedure. Futher reports are needed in order to compare efficacy in treatment of patients with variceal bleeding, where poor outcome is expected.

Introduction: Repair of hiatal hernias has been performed traditionally via open laparotomy or thoracotomy. Since first laparoscopic hiatal hernia repair in 1992, this method had a growing popularity and today it is the standard approach in experienced centers specialized for minimally invasive surgery., Objective: In the current study we present our experience after 200 consecutive laparoscopic hiatal hernia repairs., Methods: A retrospective cohort study included 200 patients who underwent elective laparoscopic hiatal hernia repair at the Department for Minimally Invasive Upper Digestive Surgery, Clinic for Digestive Surgery, Clinical Center of Serbia in Belgrade from April 2004 to December 2013., Results: Hiatal hernia types included 108(54%) patients with type 1, 30 (15%) with type III, 62 (31%) with giant paraesophageal hernia, while 27 (13.5%) patients presented with a chronic gastric volvulus. There were a total of 154 (77%) Nissen fundoplications. In 26 (13%) cases Nissen procedure was combined with esophageal lengthening procedure (Collis-Nissen), and in 17 (8.5%) Toupet fundoplications was performed. Primary retroesophageal crural repair was performed in 164 (82%) cases, Cleveland Clinic Foundation suture modification in 27 (13.5%), 4 (2%) patients underwent synthetic mesh hiatoplasty, 1 (0.5%) primary repair reinforced with pledgets, and 4 (2%) autologous fascia lata graft reinforcement. Poor result with anatomic and symptomatic recurrence (indication for revisional surgery) was detected in 5 patients (2.7%)., Conclusion: Based on the result analysis, we found that laparoscopic hiatal hernia repair was a technically challenging but feasible technique, associated with good to excellent postoperative outcomes comparable to the best open surgery series.

Introduction: Laparoscopic Heller-Dor operation, a standard method in the treatment of achalasia, has been performed at the Center for Esophageal Surgery of the First Surgical Clinic since April 2006., Objective: The aim of this study was to present this surgical procedure and initial experiences after 36 consecutive laparoscopic Heller-Dor operations., Methods: This partly retrospective, partly prospective study presented our results after laparoscopic Heller-Dor operation (presentation of the treatment method). We performed a standard anterior esophagocardioymiotomy, without releasing the posterior aspect of the cardia, and anterior partial fundoplication. The type and severity of symptoms and their duration were evaluated based on questionnaires fulfilled by patients. The diagnosis was made based on radiological, endoscopic and manometric findings. Laparoscopic surgery as the method of treatment was evaluated based on the duration of surgery, intra- and postoperative complications, time interval until the initiation of oral feeding, length of hospital stay, need for additional therapeutic measures after the operation and effect of surgery on the severity of symptoms., Results: Preopereratively, dysphagia was the predominant symptom in all patients, while regurgitation was much lower (44%). The average duration of operation was 127 minutes. Postoperative hospitalization lasted on the average 5.7 days. From 36 treated patients, 34 (94.4%) considered that the effect of treatment was good or excellent. Postoperative dysphagia was present in two patients (5.6%) and was successfully solved by balloon dilatation., Conclusion: Laparoscopic Heller-Dor operation is an effective and safe surgical procedure in resolving symptoms of achalasia and today presents the method of the first choice in the treatment of this disease.

Introduction: Hemostatic abnormalities in liver cirrhosis are complex and multifactorial and may predispose to prolonged hemorrhage following invasive procedures. Due to increased perioperative bleeding risks, patients with cirrhosis should undergo elective surgery after making medical preparations. It has been shown that 1-deamino-8-D-arginine vasopressin (DDAVP), desmopressin, can be used as a safe and effective remedy in preventing and treating bleeding in cirrhotics. However, there is still scarce information of adequate test(s) for assessing effects of DDAVP in platelet dysfunction. The use of platelet function analyzer-100 (PFA-100) allows more reliable assessment of impaired primary hemostasis as well as follow-up of hemostatic changes induced by DDAVP effects., Case Outline: In a 49-year-old male with ethylic liver cirrhosis and prolonged bleeding time scheduled for elective left side inguinal hernia repair, we carried out PFA-100 testing to investigate the patients platelet functional status. Results were affirmative for the presence of platelet functional problems. By standard coagulation tests the patient was also identified as having secondary hemostasis. Preoperatively, PFA-100 was used to test the patient's response to a standard dose of DDAVP, which was favorable. The patient was operated after medical preparations with DDAVP and vitamin K. Neither bleeding complications nor side effects of DDAVP were recorded in the perioperative period., Conclusion: The PFA-100 is a simple and reliable test for the assessment of primary hemostasis as well as in monitoring of DDAVP therapy.

A 65-year-old man was evaluated because of vomiting and epigastric pain. The patient underwent upper gastrointestinal endoscopy and endoscopic ultrasound examination and was found to have multiple polypoid lesions in the D1 and D2 portions of the duodenum, causing almost complete obstruction of the duodenal lumen. The lesions were hyperintense on T1-weighted and intermediately intense on T2-weighted images, with a drop in signal on T1- and T2-weighted fat-suppressed images, consistent with a diagnosis of duodenal lipomas. Pathohistological examination confirmed the diagnosis of duodenal lipomas.

In the Western countries, the incidence of esophaeal carcinoma is 3-6 cases per 100,000 persons. g Despite tremendous success of other therapeutic options, surgical treatment still represents the best therapeutic option whenever possible. For the long period, debate has centered on which of the a vailable surgical procedures is superior-transhiatal or transthoracic esophagectomy. Minimally invasive esophagectomy (MIE) could offer both minimally invasive approach and proper mediastinal lymph node dissection. Minimally invasive esophagectomy is safe and adequate, but time consuming and technically demanding procedure. It is procedure reserved for the surgeons experienced in open esophagectomy for cancer, and specially trained in advanced minimally invasive procedures. Even in that case, learning curve is steep.

Background: Esophageal replacement is major procedure with high risk for perioperative allogeneic blood transfusion (ABT), especially in pediatric patients due to nutritive deficiency, anemia, small body weight and blood volume. Autologous blood policy is particularly important in female children., Methods: We present treatment strategy with the aim of avoiding ABT, that have been applied in two female pediatric patients with caustic stricture of thoracic esophagus. The patients were 7 and 8 years old, with body weight 34 and 23.5 kg, respectively. Protocol was based on the stimulation of haematopoetic system with erythropoietin, iron therapy and preoperative autologous blood donation (PABD). In the first patient, with a history of previous retrosternal bypass esophagocoloplasty and extraction of necrotic colonic graft, delayed reconstruction--transhiatal subtotal esophagectomy and gastric pull-up with cervical anastomosis were performed. In the second patient, repeated ineffective dilatations of esophageal stricture were reason for retrosternal left colon interposiotion and exclusion of native esophagus., Results: No adverse events were attributed to preoperative blood donation period. No allogenic blood products were used during perioperative period. Both patients had uneventful postoperative course., Conclusion: In specialized institutions for esophageal surgery, PABD with administration of erythropoietin and iron therapy, enable bloodless esophageal replacement, even in children.

Unlabelled: INTRODUCTION In the past two decades, the increased frequency of distal esophageal adenocarcinoma, esophagogastric junction and proximal gastric adenocarcinoma has been observed. The vast majority of these tumours are diagnosed in advanced stages, when the prognosis is poorer than in other gastric cancers., Objective: The aim of our study was to analyze the demographic and clinicopathological characteristics of patients operated on for Barrett's, cardia and distal gastric adenocarcinomas, as well as to study the influence of manifestations of each cancerogenetic indication on the studied clinicopathological parameters and to analyze the 5-year survival rate of patients surgically treated for cardia adenocarcinoma in relation to the patients operated on for distal gastric adenocarcinoma., Methods: We analyzed gender and age, tumour type, depth of tumour invasion, involvement of blood and lymph vessels in 66 patients surgically treated at the Centre for Oesophageal Surgery of the Institute for Digestive Diseases of the Belgrade Clinical Centre., Results: Except for significant differences in the depth of tumour invasion during surgery, there were no other statistically significant differences between the studied groups of patients. In the patients operated on for Barrett's and cardia cancers, the tumours invaded more deeply the wall layers, i.e. they were significantly more invasive than the distal gastric tumour. The lymph node involvement was present in 87.5% of patients with Barrett's cancer, in 80% with cardia cancer and in 87% with distal gastric cancer. The 3-year survival rate of patients operated on for cardia cancer was 47.4% and the 5-year survival rate was 31.6%, while the 3-year survival rate of patients operated on for distal gastric cancer was 46.2% and the 5-year survival rate was 34.6%. These differences were not statistically significant (Wilcoxon 0.036; p = 0.85). Singly, the patients' gender, cancer type and the degree of tumour differentiation had no influence on the length of patients' postsurgical survival rate., Conclusion: At the time of diagnosis cardia cancer and cancers developed at the location of the Barrett's oesophagus, developed significant deeper per continuitatem than gastric cancer. There were no other differences in regard to the analyzed clinicopathological parameters among the tumours of these three locations, and there was no difference between the 3-year and 5-year survival rate between the patients operated on for gastric cancer and cardia cancer. Each studied clinicopathological parameter had no influence on the illness course.

Aim: To review the 8-year experience of the Department of Esophagogastric Surgery, First Surgical University Hospital in Belgrade in the surgical management of Zenker's diverticula (ZD)., Methods: Between January 2000 and January 2009, 52 patients underwent surgical procedure for the treatment of ZD. Complete preoperative workup including the symptom evaluation and large variety of structural and functional diagnostic procedures were conducted before the surgery. After the operative treatment patients underwent detailed follow-up in regular intervals up to 3 years., Results: Preoperative evaluation marked higher incidence of hiatal hernia and pathologic gastroesophageal reflux (GER) among the patients with ZD then in normal population. According to the preoperative evaluation and size of diverticula, as well as due to the intraopertive findings, a variety of surgical procedures were performed, including myotomy alone (n = 2), diverticulopexy and myotomy (n = 36) and diverticulectomy and myotomy (n = 14). Regardless of the operative treatment no salivary cervical fistulas were observed. Late and early postoperative results revealed low incidence in postoperative transitory dysphagia or regurgitation., Conclusion: The results of this study show that the open surgical procedures are safe and effective in the treatment of ZD. Cricopharyngeal myotomy remains the essential focus of treatment, while the choice of resecting or suspending the diverticulum is brought upon its size. Complete preoperative investigation must be conducted in ZD patients, and the role of pathologic GER must be taken into account when we discuss the origin of this disorder.

Growth factors play an important role in orchestrating and enabling the cellular responses required for successful wound healing. In the present study, rat surgical incision was used to investigate insulin-like growth factor-I (IGF-I) expression in skin cells as well as its systemic and cutaneous tissue concentrations during acute phase of wound healing. Thirty two animals were sacrificed at days 2, 3, 5 and 9 after surgery. Eight animals were used as control. Tissue expression of IGF-I in both incisional and periincisional skin areas, as well as in skin of control unwounded animals was determined by immunohistochemistry. Serum and tissue concentrations of IGF-I were measured using RIA. Immunohistochemical analysis revealed enhanced IGF-I immunostaining in the incisional area at day 2 post-wounding. Presence of IGF-I immunoreactivity in the epidermis, as well as in dermal fibroblasts and monocytes within perivascular inflammatory infiltrate suggests its local synthesis. Although serum levels of IGF-I were not altered during wound healing, their tissue contents in the incisional area were significantly increased compared with periincisional area at days 2 and 3 after injury, as well as compared with skin content of unwounded control rats in all examined time points. Obtained results support a paracrine role of IGF-I during the acute phase of wound healing by primary intention in the rat.

Introduction: Gastrointestinal bleeding is the most important complication associated with acetylsalicylic acid therapy. Patients with preexisting haemostatic disorders are at the higher risk and may experience life-threatening hemorrhagic syndrome. Platelet transfusions and desmopressin administration commonly successfully arrest bleeding. However, in clinical situations with profound bleeding and haemorrhagic shock, these therapeutic approaches may fail., Case Outline: We report a 24-year old female patient with previously undetected acquired platelet dysfunction, who underwent reconstructive surgical intervention. On the 20th postoperative day, acetylsalicylic acid was introduced due to reactive thrombocytosis (platelet count 1480x10(9)/L) with daily dose of 100 mg tablets. On the 12th day of the acetylsalicylic acid treatment, massive gastrointestinal bleeding with haemorrhagic shock suddenly occurred. Attempts to control massive haemorrhage by resuscitation, blood products and haemostatics (desmopressin, tranexamic acid) failed. Two bolus doses of recombinant activated factor VII (rFVIIa) (100 microg/kg and 60 microg/kg respectively) in 90 minutes interval were given. Bleeding was successfully controlled with no requirements for further haemoproducts and haemostatic remedies treatment., Conclusion: This case demonstrates that the use of rFVIIa may be a specific treatment option in patients suffering from severe gastrointestinal bleeding associated with acetylsalicylic acid treatment.

Introduction: The risk of upper gastrointestinal tract bleeding in the patients taking NSAID estimates 1% per year. Bleeding stops spontaneously in approximately 80% of all cases. Persistent and repeated bleeding (expecialy during the initial hospitalization) still represent the serious clinical problem. In this group of patients, mortality rate is between 6-10%, which in the USA counts 10-20000 patients per year., Aim of the Study: The purpose of this review is to update the current knowledge of the use of different therapeutic strategies in patients with NSAID induced upper gastrointestinal bleeding., Results: Proton pump inhibitors (PPI) therapy is effective as a prevention of NSAID induced acidopeptic lesions, and also represents the first and best therapeutic option for the treatment of complications, such as upper gastrointestinal bleeding. In the last three decades use of early flexibile (diagnostic and therapeutic) endoscopy, agressive acidosupression (PPIs), and surgical treatment in restrictive indications, resulted in decreasing of the mortality rates from 25-35% to 6-10%. When PPIs and flexible endoscopy are not sufficient in the control of upper gastrointestinal bleeding, use of systemic hemostatic drugs could be taken into consideration., Conclusion: Multidisciplinary approach, precise diagnostic and therapeutic critearia would probably result in better outcome of patients with active upper gastrointestinal bleeding.

Gastrointestinal stromal tumors (GIST) is the most common mesenchymal tumor of the gastrointestinal tract. GIST is currently defined as a gastrointestinal tract mesenchymal tumor containing spindle cells (less commonly epitheloid cells or rarely both) and showing CD 117 (c-kit protein) positivity in more than 95% of cases. Although they may arise throughout the gut, the commonest site are stomach (60-70%), small intestine (20-30%), colorectum (5%) and esophagus (up to 5%). Rarely, GISTs develop in the retroperitoneum, omentum or mesentery. GIST originates from the intestinal cell of Cajal (ICC). ICCs are located in and around the myenteric plexus and are thought to function as intestinal pacemaker cells. Historicaly, GIST were often misclassified as leiomyomas or leiomyosarcomas. Subsequently, it has been determined that GISTs have distinct ultrastructural features and immunophenotypical markers compared with smooth muscle and smooth muscle tumors. GIST predominantly occur in middle aged and older patients, with no significant difference in the sex incidence. Data from the recent population study suggest an incidence of about 10-22 cases per million persons per year. Clinical presentation of GIST varies widely, and depends on tumor size and location. GISTs that caused symptoms tended to be larger with an average size of 6cm versus 2cm for asymptomatic GISTs. Symptoms are most commonly related to mass effect or bleeding. GISTs can grow very large before producing symptoms. Commonest symptom of gastric GIST is manifest or occult bleeding. Abudant, life-threateting bleeding that require urgent surgery is rare. For patient with primary, localized, nonmetastatic GIST, complete surgical resection represents the only chance for cure. Lymhadenectomy is not necessary, because lymph node metastasis is very rare. The 5 year survival rate in patients with resected primary GISTs ranges from 48-65%. Conventional chemotherapy and radiation therapy is ineffective in the treatment of GIST. Imatinib mesilate (a tyrosine kinase inhibitor) was confirmed to be effective against metastatic or unresectable GISTs.

Dieulafoy's lesion is an unusual and potentially life-threatening cause of massive, recurrent gastrointestinal bleeding. Its reported incidence as a source of upper gastrointestinal bleeding ranges from 0.3-6.7%. Dieulafoy's lesion is most commonly located in the proximal stomach (75% of cases). Lesion typically occur within 6 to 10 cm of the esophagogastric junction, generally along the lesser curvature of the stomach. Similar lesions have been identified in the esophagus, duodenal bulb, jejunum, ileum, colorectum, anal canal, even in bronchus. Detection and identification of the Dieulafoy's lesion as the source of bleeding can often be difficult, especially because most present with massive bleeding. Because of intermittent nature of bleeding, initial endoscopy is diagnostic in 60% of the cases, so repeated endoscopies are often necessary. If the lesion can be endoscopically documented, attempts should be made to achieve hemostasis using one or a combination of several endoscopic modalities. Success has been reported with multipolar electrocoagulation, heater probe, noncontact laser photocoagulation, injection sclerotherapy, endoscopic hemoclipping and band ligation. Surgery is reserved for lesions that cannot be controlled by endoscopic techniques. When localized, a wide wedge resection of entire area traversed by the large submucosal artery is recomended because rebleeding has been described after simple coagulation and ligation.

Primary gastric lymphomas are of the extranodal non-Hodgkin type. The gastrointestinal tract is the most common site of extranodal non-Hodgkin lymphomas and accounts 30-45% of all extranodal lymphomas. Gastrointestinal lymphomas occurs in the stomach in 55-70% of cases. Primary gastric lymphoma is relatively rare tumor accounting 1-7%, of all gastric malignancies. An increased incidence has been documented recently. The median age of diagnosis is approximately 60 years old, and disease affects an equal number of men and women. The initial symptoms may be vague and nonspecific leading to delayed establishment of diagnosis up to several years. Many patients came down late with advanced disease and complications such as upper gastrointestinal bleeding. Twenty to thirty percent may present with occult bleeding or hematemesis et melena while gastric obstruction and perforation are less common. Gastric bleeding can also occur as a complication of chemotherapy. The incidence of gastric bleeding in patients receiving chemotherapy is up to 11%. In most cases surgical resection is necessary to achieve hemostasis. Given the rate of surgical complications, especially gastric bleeding, there is still an important role for surgeon in the multimodal treatment of patients with primary gastric lymphoma.

Iron deficiency anemia (IDA) is a universal problem involving individuals of all ages and both sexes and is a common cause of referral to medical departments. This anemia is one of the most common types of anemia. IDA impairs growth and intellectual development in children and adolescent. In women IDA is most common in reproductive period because of menstrual and pregnancy iron losses. IDA affects roughly 10-30% of all pregnancies and, among others morbidities, may contribute of developing postpartum depression. Among other adult patient, chronic occult gastrointestinal bleeding is the leading cause of IDA. Approximately, one third of patients with anemia have iron deficiency and up to two thirds of patients with IDA have serious gastrointestinal lesions detected with esophagogastroduodenoscopy and colonoscopy, including 10-15% with malignancy. However, in practice not all anemic patients undergo appropriate diagnostic tests to detect iron deficiency. Furthermore, a substantial proportion of patients with IDA do not undergo endoscopic evaluation. The approach to its investigation and subsequent therapy depends upon a comprehensive understanding of iron metabolism and heme synthesis. Once diagnosis of iron deficiency or IDA is established, evaluation for the cause of anemia must be appropriate performed and treatment must include corrective replenishment of body stores.

Understanding the haemostatic changes is crucial in developing strategies for the management of haemorrhage syndroma. In recent years, the revised model of coagulation ("cell based" model) provided a much more authentic description of the coagulation process. Pharmacological intervention, especially desmopresin, antifibrinolytics (synthetics and nature) and increasingly recombinant activated factor VII are being used in prevention and therapeutically to control bleeding of variety etiologies. Skillfull surgery combined with blood saving methods and careful management of blood coagulation will all help in sucessfull haemorrhage prevention and treatment, and reduce unnecessary blood loss and transfusion requirements and its attendant risks. Among the all avalaible tests, the use of thromboelastography has allowed for more detailed dynamic assessment of the various steps of hemostasis.

Upper gastrointestinal (GI) bleeding represents emergency which despites modern advances in treatment still carry substantial mortality. Mortality remained relatively constant in the last 50 years at approximately 12%. Peptic ulcers remain the most common cause of upper GI bleeding and account approximately 50% of all cases. Next leading causes are esophageal and gastric varices, and gastroduodenal erosions. Mallory Weiss tears, angiodysplasia and gastric antral vascular ectasia (GAVE)-Watermelon stomach are less frequent but important causes of upper GI bleeding that contribute substantially to the overall morbidity and mortality. Recognition of such lesions is crucial to provide effective hemostasis. In most cases endoscopic therapy is procedure of choice which significantly improved the outcome of patients. In cases where endoscopic hemostasis is not effective, or patients rebleed after initial control surgical therapy may be required. This article will review recent advances in diagnosis and therapy of upper GI bleeding caused by Mallory Weiss tears, angiodysplasia or Watermelon stomach.

Introduction: There are numerous techniques for the treatment of laryngotracheal stenosis. The aim of this paper was to present surgical techniques and results of treatment of laryngeal and laryngotracheal stenosis in a ten-year period by retrospective analysis., Material and Methods: Medical records of 34 patients (17 male and 17 female) surgically treated for laryngeal or laryngotracheal stenosis between 1995 and 2004 were analyzed. 19 (55.9%) patients had previous surgical procedures, whereas fifteen patients (44.1%) were diagnosed and treated for the first time., Results: 5 patients had a glottic-subglottic stenosis, 11 patients had a subglottic stenosis, 16 patients had subglottic-tracheal stenosis and 2 patients had a glottic-subglottic-tracheal stenosis. 21 patients had normal vocal cord motion, 8 patients showed unilateral vocal cord fixation, and 5 had bilateral vocal cord fixation. Laryngotracheoplasty with anterior-posterior costal cartilage graft was performed in 24 patients, while single stage segmental laryngotracheal resection of the stenotic part was performed in 8 patients. One patient was operated in direct laryngomicroscopy and one with dilatation of the stenotic segment with T tube insertion. The most common complication was the development of granulation due to use of the Montgomery T-tube which was removed in direct laryngomicroscopy. Except for one patient, 33 (97%) patients were decannulated. There was no perioperative mortality., Conclusion: Although laryngotracheoplasty with anterior-posterior costal cartilage graft placement cannot be used in all cases of laryngotracheal stenosis, it was the method of choice in previously operated patients with segmental resection of the stenotic segment. This method requires use of Montgomery T-tube or anesthesiological tube, which is very hard to keep clean. Better recovery, short hospitalization and excellent results were obtained with the cricotracheal segmental resection.

Background/aim: Most studies of esophageal and gastric adenocarcinomas have shown a very high rate of p53 gene mutation and/or protein overexpression, but the influence of the tumour site upon the frequency of p53 protein expression has not been evaluated (gastroesophageal junction, Barret's esophagus, and antrum). The aim of our study was to analyze the correlation between the selected clinico-pathological parameters, and p53 protein overexpression in regards to the particular tumour location., Methods: The material comprised 66 surgical specimens; 10 were Barrett's carcinomas, 25 adenocarcinomas of the gastric cardia (type II adenocarcinoma of the esophagogastric junction - EGJ), and 31 adenocarcinomas of the antrum. Immunostaining for p53 protein was performed on formalin-fixed, paraffin-embedded tissue sections, using the alkaline phosphatase antialkaline phosphatase (APAAP) method. The cases were considered positive for p53 if at least 5% of the tumour cells expressed this protein by immunostaining., Results: There was no significant difference observed between the studied groups in regards to age, sex, Lauren's classification and tumour differentiation. There was, however, a significant difference observed in the depth of tumour invasion between Barrett's adenocarcinoma and adenocarcinoma of the cardia compared with the adenocarcinoma of the antrum. Namely, at the time of surgery, both Barrett's adenocarcinomas and adenocarcinomas of the cardia, were significantly more advanced comparing with the adenocarcinomas of the antrum. Overexpression of p53 was found in 40% (4/10) of Barrett's adenocarcinomas, 72% (18/25) of adenocarcinoma of the cardia and 65% (20/31) of adenocarcinoma of the antrum. No significant differences in p53 expression in relation to sex, type (Lauren) of tumour, depth of invasion, lymph node involvement, or tumour differentiation were observed in any of the analyzed groups of tumours. Patients with more advanced Barrett's adenocarcinoma and in the cases of lymph node invasion revealed tendency for the greater p53 positivity compared with the early forms and lymph node-negative cases; however, this difference was not significant according to the statistical analysis. With regard to adenocarcinoma of the cardia, higher rates of p53 positivity were recorded in poorly differentiated, more advanced cases with lymph node invasion. Nevertheless, none of these differences was statistically significant. On the contrary, in the patients with adenocarcinoma of the antrum, greater p53 positivity was revealed in early forms without lymph node involvement, but the observed difference was not statistically significant., Conclusion: No significant differences in p53 protein expression in terms of sex, type (Lauren) of tumour, depth of invasion, lymph node involvement, or tumour differentiation were observed in any of the analyzed groups of tumours (Barrett's adenocarcinoma, adenocarcinoma of the cardia and adenocarcinoma of the antrum).

Background: Endoscopic ultrasonography (EUS) is an important tool for diagnosis and pretreatment staging of primary gastric lymphoma. The aim of the study was to evaluate the diagnostic importance of endosonography (EUS) in gastric lymphoma; to assess the depth of tumoral infiltration in low-grade gastric lymphoma of mucosa-associated lymphoid tissue (MALT) and to assess EUS response to medical treatment (Cyclophosphamid/Mabtera and/or anti-Helicobacter pylori therapy)., Methods: 26 patients with MALT gastric lymphoma were investigated by EUS. Six of them were evaluated after the eradication of Helicobacter pylori infection and 20 after and during the cyclophosphamide/Mabtera and anti H. pylori treatment. EUS staging was compared with histopathology. Tumours were staged according to the 2000 TNM and modified Ann Arbor classification., Results: Six patients were treated with anti - Helicobacter pylori eradication therapy. Full regression of lymphoma was observed in 2 of 6 (33.3%) patients, which was endoscopicaly and histologicaly proved. EUS correlated with histology in all (6/6). In 20 patients treated with cyclophosphamide/Mabtera therapy, EUS revealed regression of lymphoma in 14 cases. Positive correlation with histology was found in 11 patients (11/14; 78%). The initial EUS showed an increased wall thickness more than 5mm in 24 of 26 patients (92%). The thickening was predominantly of mucosa and submucosa and in 11 patients extended the muscularis propria. After the therapy, the gastric wall thickening returned to normal in 14 patients, however, 3 of them still had positive histology findings. In 2 cases, during the follow-up, the EUS showed remained thickening of gastric wall, whereas biopsies were negative. Six months later histology revealed progressive low-grade MALT lymphoma in this cases., Conclusion: EUS appears to be a sensitive procedure for initial staging and assessment of treatment response and long-term follow up in patients with gastric lymphoma. The importance of EUS lies in abbility to detect relapse early, too.

Background: To evaluate the diagnostic accuracy of endosonography (EUS) in preoperative staging of stomach cancer., Methods: Sixty-two patients with gastric carcinoma were investigated by endosonography. 49 underwent surgery. EUS reports were compared with operative and histology findings. Tumours were staged according to the 2000. TNM classification., Results: EUS had a diagnostic accuracy of 89.8% for the T category, 83.7% for the N category., Conclusion: EUS is an excellent clinical procedure for the staging of local-regional spread of gastric cancer and useful complement to the other gastrointestinal examinations for evaluation of these tumours.

Micrometastasis is a microscopic (less than 2 mm) deposit of malignant cells separated from the primary tumor. The incidence and importance of occult perigastric lymph node involvement were analyzed in 26 pN0 patients using the prospective method. The occult lymph node involvement was detected by immunohistochemical method using the anticytokeratin 8/18 antibody. Prevalence of clinically significant occult lymph node involvement (Mi+) was statistically significant, and found in 38.5% of pN0 patients. Out of tumor characteristics analyzed as possible predictors of occult lymph node involvement, the histological grade (GH) and the involvement of lymphatic vessels within gastric wall (pL1) had significant effect on the respective evaluation. The patients with histological grade 3 and 4 had occult lymph node involvement more often than those with grade 1 and 2 (p<0.05). More than 60% of pL1 patients had occult lymph node involvement LN (Mi+). Due to high prevalence of micrometastatic lymph node involvement, detection with specific immunohistochemical or molecular biology techniques should be a part of routine specimen examination in patients with pN0 gastric cancer.

In the period between January 1st, 1978 and January 1st, 2003, 82 unselected patients with hypopharyngeal and cervical esophageal squamocellular carcinoma were treated at the Department of Esophagogastric Surgery, First University Surgical Hospital, Clinical Center of Serbia. In 43 (52.4%) patients operated with curative intent, radical surgical en-block resection and functional neck dissection has been performed. In 26 (60.5%) patient reconstruction was performed with stomach, in 11 (25.6%) left colon, and 6 (14%) free jejunal transfer. The overall 2-year and 5-year survival rate were 55.88% (19 patients) and 26.47% (9 patients), respectively. No patient undergoing nutritive gastrostomy and radiotherapy was alive after two years. At present surgery looks like the treatment of choice for hypopharyngeal and cervical esophageal carcinoma, providing a definitive palliation of dysphagia and better long-term survival. Free jejunal transfer has become the standard technique for reconstruction of the pharynx and hypopharynx especially with proximal lesions, whereas, gastric tube interposition is the technique of choice for reconstruction of the hypopharynx and cervical esophagus when the resection extends below the thoracic inlet or when there is a presence of synchronous carcinoma of theesophageal.

Iatrogenic perforations of the esophagus and hypopharynx are important problem, due to diagnostic difficulties, controversies about adequate treatment, and high morbidity and mortality rate. Incidence of iatrogenic perforations is from 50 to 75% of all perforations. In the period from April 1999. to April 2004, 15 patients with iatrogenic perforation of the esophagus and hypopharynx were treated at the Department of esophageal surgery, First University Surgical Hospital in Belgrade. In majority of patients iatrogenic perforation occured during endoscopic interventional procedure (endoscopic removal of ingested foreign body--10 pts, endotracheal intubation--2 pts, intraoperative iatrogenic perforation--2 pts, pneumatic dilatation--1 pt). Surgical treatment was performed in 12 (80%) pts and 3 (20%) pts were treated conservatively. Surgical approach was cervicoabdominal, thoracoabdominal and cervicothoracoabdominal in 9.1 and 2 pts, respectively. Among 12 operated pts, primary repair of the esophagus was performed in 5 pts, and esophageal resection or exclusion in 7 pts. Overall mortality rate was 13.3% (2 pts), in surgical group 8.3% (1 pt) and in conservatively treated group 33.3% (1 pt). Iatrogenic perforations of the esophagus and hypopharynx are diagnostic and therapeutic problem. Awareness of the possibility of esophageal perforation during instrumental manipulations and early diagnosis is essential for successful, individually adapted, and in most cases surgical, treatment.

The GERD has probably existed since the beginning of mankind but it took several millennia since any perception or knowledge of this disease started to evolve. Homo est quod est--the man is what he eats is an old Latin proverb and heartburn has been one of the most common documented symptoms in humans in the last two centuries. The term peptic esophagitis has been introduced in 1935, but the evolution of knowledge of pathogenesis, incidence, complications and way of treatment of GERD has been quite slow. In the last decade several new aspects of these problem have evolved and probably explained many unanswered questions of this very common and sometimes severe disease.