Search

Bevezetés: Az achalasia miatt végzett sebészeti beavatkozások eredményei jelentősen javultak a minimálisan invazív sebészet bevezetésével. A robotasszisztált Heller–Dor (RAHD)-műtét az utóbbi évek során kezd elterjedni, mivel olyan előnyöket biztosít a sebész számára, mint a háromdimenziós látás és a műtét alatti finommozgások még magasabb szintű kontrollja. Módszer: 2022. október 1. és december 31. között, Magyarországon először, a Pécsi Tudományegyetem Klinikai Központjában 3 betegen (37 éves férfi és 55, illetve 72 éves nő) végeztünk achalasia miatt RAHD-műtétet a da Vinci Xi rendszer segítségével. Eredmények: Mindhárom esetben szövődménymentes RAHD-műtét történt, és a betegek a műtét után panaszmentessé váltak. A műtéti idő 198, 204 és 238 perc volt, mely magában foglalta a 23, 19 és 14 perces dokkolási időt. Az utolsó betegnél hiatus hernia is ismert volt, ezért egy időben ennek rekonstrukcióját is elvégeztük. Az első 2 beteget a műtétet követő negyedik, a hiatusrekonstrukción is átesett 3. beteget a műtét utáni 6. napon engedtük otthonába. Megbeszélés: Az utóbbi években egyre több vizsgálat ismert, mely a RAHD-cardiomyotomiával foglalkozik. Általánosságban azt a következtetést vonják le, hogy gyakorlott kézben ez könnyen elvégezhető műtét, mely nagyon alapos myotomiát biztosít mind a nyelőcső, mind a gyomor területén azáltal, hogy nagy nagyításban minden izomrost felismerhető, és ennek köszönhetően lényegesen kevesebb perforáció fordul elő a műtét során a laparoszkópos műtétekhez viszonyítva. Ugyanakkor az is ismert, hogy költségesebb beavatkozás, amelyet a tanulási időszak hosszabb műtéti ideje is tovább drágít. A nyálkahártya-sérülések és a következményes szövődmények elkerülése azonban ellensúlyozhatja hosszú távon ezeket a magasabb költségeket. Következtetés: A laparoszkópos cardiomyotomia az egyik olyan felső gastrointestinalis standard műtét, amelynél a robot haszna egyértelműen bizonyítható. Ezért azon helyeken, ahol a robotsebészeti rendszer hozzáférhető, javasolt ezt a beavatkozást azzal végezni. Orv Hetil. 2023; 164(14): 542–547.

A nyelőcső eltávolítására a legnagyobb számban nyelőcsőrák miatt kerül sor. A nyelőcsőpótlás még a mai napig is jelentős kihívást jelent a sebészet számára, mert 50% felett számíthatunk szövődményre, és halálozás is 4–7%-ban fordul elő. A szövődmények feloszthatók korai és késői szövődményekre, valamint általános és specifikus szövődményekre. Sebészeti szempontból a korai és a késői speciális szövődmények jelentik a legfontosabb kérdéseket. A Pécsi Egyetem Sebészeti Klinikáján az 1993 és 2012 közötti 20 évben 540 nyelőcső-reszekció történt. Pótlásra 445 esetben gyomrot, 38 esetben vastagbelet és 57 esetben jejunumot használtak. Az anastomosis a gyomorral pótlásnál 275 esetben a nyakon, 170 esetben a mellkasban történt. A vastagbelet minden esetben a nyakra húzták fel. 29 esetben a nyakon történt szabad jejunummal pótlás és 28 esetben bal oldali thoracolaparotomiából a mellkasban. A gyomorral pótlás esetén 55 esetben lépett fel anastomosiselégtelenség, 8 esetben észleltünk transzplantátumelhalást, és 30 esetben alakult ki korai anastomosisszűkület. Ezek a számok vastagbéllel pótlás esetén: 3 elhalás és 2 insufficientia. Mellkasi jejunumpótlásnál egy anastomosiselégtelenség fordult elő. Nyaki szabad átültetésnél egy transzplantátumnecrosist észleltünk. A késői speciális szövődmények közül a dysphagia a legfontosabb, melynek okaként a következőket találták a gyakoriság sorrendjében: anastomosisszűkület, conduitobstructio, pepticus és ischaemiás strictura, idegen test, lokális recidíva, funkcionális okok, új malignus tumor a reszekció után megmaradt nyelőcsőben és malignus tumor a pótlásra használt szervben. Az okok között lehetnek átfedések, és kezelésük lehet gyógyszeres, endoszkópos vagy sebészi. A sebészi kezelés általában az utolsó lehetőség a nyelésképesség helyreállítására, és jelentős kihívás elé állíthatja még a gyakorlott központokat is. Orv Hetil. 2023; 164(7): 243–252.

Összefoglaló. Az onkológia hatalmas mértékben fejlődött az elmúlt negyedszázadban. A jelentős siker hátterében sok tényező áll, így a primer és szekunder prevenció, a diagnosztika fejlődése, a kemo- és radioterápia új módszerei és az alapkutatási eredmények beépülése a gyakorlatba. A sebészet szempontjából a fejlődésben a legnagyobb szerepet a műtét előtti onkoterápia elveinek kidolgozása és széles körű gyakorlati alkalmazása játszotta. A Pécsi Tudományegyetem Sebészeti Klinikáján 1997 és 2005 között 44 gyomorrákos és 102, borderline reszekábilis vagy irreszekábilis stádiumban levő nyelőcsőrákos beteget részesítettek perioperatív kezelésben. A válaszadás mértéke mindkét csoportban 50% felett volt, és komplett patológiai remissziót sikerült elérni 3 gyomorrákos és 17 nyelőcsőrákos betegnél. A saját és az irodalmi adatok elemzése kapcsán hét új onkológiai sebészeti elv kialakulását észlelték a nagyon sikeres perioperatív kezelés következtében. A megkívánt szabad reszekciós szél a vizsgált betegcsoportokban milliméteres nagyságrendűre csökkent. Ez ún. szervmegtartó műtétekre adott lehetőséget. A prognózis szempontjából a perioperatív kezelés utáni stádium a mértékadó. Oligometastasisos betegen is elérhető a komplett hisztopatológiai remisszió. Komplett remisszió esetén felmerülhet a „watch and wait” taktika alkalmazása. Colontumorok reszekábilis májmetastasisainak kezelésében nem célszerű komplett remisszóra törekedni. Megfordítható a primer tumor és a metastasisok kezelési sorrendje. Az onkológiai kezelések egyre javuló eredményei alapján a sebészeti tevékenység visszaszorulása várható a daganatos betegek gyógyításában. Orv Hetil. 2022; 163(14): 544–550. Summary. Oncology has evolved to a great extent over the last quarter of century. The significant success is multifactorial, including primary and secondary prevention, the development of diagnostics, new methods of chemo- and radiotherapy, and the integration of basic research results into practice. From the point of view of surgery, the establishing and widespread practical application of the principles of preoperative oncotherapy played a major role in this development. Between 1997 and 2005, 44 patients with gastric cancer and 102 patients with borderline resectable or irresectable esophageal cancer received perioperative treatment at the Department of Surgery of the University of Pécs. The response rate was above 50% in both groups and complete pathological remission was achieved in 3 patients with gastric cancer and 17 patients with esophageal cancer. Based on our own experience and literature data, the development of seven new principles in surgical oncology were observed as the result of a very successful preoperative oncologic treatment. The desired free resection margin was reduced to the millimeter dimension in many cancer cases. Thus so-called organ-preserving procedures were made possible. Regarding the prognosis, the stage after the treatment became determinant. Complete histopathological remission could also be achievable in patients with oligometastases. In the case of a complete remission, the “watch and wait” tactics emerged as an option. Along the preoperative treatment of resectable colorectal liver metastases, there is no need to strive for complete remission. The treatment order of the primary tumor and its metastases can be reversed. Based on the improving results of oncology treatments, a reduction in surgical activity in the treatment of cancer patients is expected. Orv Hetil. 2022; 163(14): 544–550.

Dysphagia occurs temporarily or permanently following esophageal replacement in at least half of the cases. Swallowing disorder, in addition to severe decline in the quality of life, can lead to a deterioration of the general condition, which may lead to death if left untreated. For this reason, their early detection and treatment are a matter of importance. Between 1993 and 2012, 540 esophageal resections were performed due to malignant tumors at the Department of Surgery, Medical Center of the University of Pécs. Stomach was used for replacement in 445 cases, colon in 38 cases, and jejunum in 57 cases. The anastomosis with a stomach replacement was located to the neck in 275 cases and to the thorax in 170 cases. The colon was pulled up to the neck in each case. There were 29 cases of free jejunal replacements located to the neck and 28 cases with a Roux loop reconstruction located to the thorax. Based on the literature data and own experience, the following were found to be the causes of dysphagia in the order of frequency: anastomotic stenosis, conduit obstruction, peptic and ischemic stricture, foreign body, local recurrence, functional causes, new malignant tumor in the esophageal remnant, and malignant tumor in the organ used for replacement. Causes may overlap each other, and their treatment may be conservative or surgical. The causes of many dysphagic complications might be prevented by improving the anastomosis technique, by better preservation the blood supply of the substitute organ, by consistently applying a functional approach, and by regular follow-up.

Összefoglaló. Az 1970-es évek előtt a nyelőcsőrákok csupán 1–3%-a volt adenocarcinoma. A 70-es évek közepétől a nyelőcső-adenocarcinoma mutatta a legnagyobb növekedést az összes malignus daganat közül, és a 90-es évek közepétől már meghaladta a laphámrákok előfordulási gyakoriságát a nyugati világban. Ma a nyelőcső-adenocarcinoma relatív incidenciája Magyarországon 34,7%, míg a nyugati világban már 60% körül van. A nyelőcső-adenocarcinoma etiológiájában meghatároztak néhány kockázati tényezőt, így a gastrooesophagealis refluxot, a Barrett-nyelőcsövet, a kóros kövérséget, a dohányzást és a csökkenő Helicobacter pylori fertőzöttséget. Ezek a tényezők azonban jelen voltak már a 70-es évek előtt is. A kövérség előfordulásának gyakorisága és a következményes gastrooesophagealis reflux megduplázódott az elmúlt 40 évben, de ez egyedül nem magyarázza az adenocarcinomák szaporodásának ütemét. Egy új, hatékony savcsökkentő gyógyszercsoportnak, a H2-receptor-blokkolóknak a bevezetésére 1976-ban került sor, és ez egybeesik a szokatlanul nagy incidencianövekedéssel. Tom DeMeester teóriája szerint a savcsökkentő kezelés által létrehozott pH-változás okozhatja a refluxátum carcinogenitasának fokozódását. A Barrett-oesophagus és a nyelőcső-adenocarcinoma etiológiájában, megelőzésében és kezelésében számos ellentmondás és vitás kérdés tapasztalható, különösen a protonpumpagátló gyógyszerek (PPI-k) hosszú távú használata körül. A PPI-k hatásossága a gyógyszer túlzott alkalmazásához vezetett nem mindig megfelelő indikációban, kitéve a betegeket potenciális kockázatoknak. Összefoglalva, a nyelőcső-adenocarcinoma drámai növekedésében biztosan szerepet játszik az elhízás és a refluxbetegség ezzel párhuzamos terjedése. Fontos továbbá a H. pylori fertőzöttség csökkenése, és új szempont a hatásos savcsökkentő szerek széles körű alkalmazása, melyek a refluxátumban okozott pH-változással erősíthetik a carcinogenesist. Orv Hetil. 2021; 162(51): 2040–2046. Summary. Before the 1970s, only 1–3% of esophageal cancers were adenocarcinoma. Since the mid-70s, the incidence of esophageal adenocarcinoma has shown the greatest increase compared to all other cancer types and overtook squamous carcinoma incidence in the mid-90s in the Western countries. Today, the relative incidence of esophageal adenocarcinoma in Hungary is 34.7% and around 60% in the Western countries. Some risk factors for esophageal adenocarcinoma have been identified such as gastroesophageal reflux disease, Barrett’s esophagus, obesity, smoking and decreased prevalence of Helicobacter pylori infection, but these risk factors were already present before the 70s. The prevalence of obesity and the consequentially developed gastroesophageal reflux has doubled during the last 40 years, but it does not explain alone the dramatic rise in the esophageal adenocarcinoma incidence. The H2 blockers, as new effective antisecretory medication, were introduced in 1976, coinciding in time with the substantial rise of esophageal adenocarcinoma. According to the DeMeester theory, the change in the pH of gastric refluxate caused by acid suppression enhances its carcinogenic potential. There are a lot of controversies among the prevention, etiology and treatment of Barrett’s esophagus and esophageal adenocarcinoma, especially regarding the long-term use of proton pump inhibitors (PPIs), an even more effective group of acid suppressors. The effectiveness of PPIs has led to an overuse exceeding its regular indications with little benefit, exposing patients to a number of potential risks. In conclusion, in the dramatic rise of the esophageal adenocarcinoma incidence, obesity accompanied by reflux disease and the decreased incidence of H. pylori infection certainly play important roles. The introduction of modern antisecretory drugs in the treatment of acid-related diseases promoting carcinogenesis, arises as a new consideration. Orv Hetil. 2021; 162(51): 2040–2046.

Összefoglaló. Bevezetés: A COVID–19-világjárvány betegellátásra gyakorolt hatása hazánkban is jelentős. A vérellátást nehezítette a járványügyi intézkedések következményeként a véradási események elmaradása, a csökkent véradási hajlandóság, továbbá a nehezen megítélhető vérkészítményigény . A „Patient Blood Management” irányelveinek az orvosi gyakorlatban történő egyre szélesebb körű alkalmazása elősegíti az optimális vérkészítmény-felhasználást a transzfúziók lehetőség szerinti elkerülésével. Célkitűzés és módszer: Vizsgálatunk célja a Pécsi Tudományegyetem Klinikai Központjának Janus Pannonius Klinikai Tömbjében a vérkészítmény-felhasználás változásainak felmérése volt a 2020. év első öt hónapjában. Eredmények: A járványügyi intézkedéseket követő időszakban szignifikánsan csökkent a hospitalizált betegeknek (34,08%), a transzfúziót igénylő betegeknek (39,69%) és a felhasznált vörösvérsejt-készítményeknek (46,41%) a száma, valamint az egy betegre jutó felhasznált vörösvérsejt-koncentrátum átlaga (2,61-ről 1,97-re) is. Közel 30%-os arányban csökkent a felhasznált friss fagyasztott plazma egységeinek és a thrombocytakoncentrátumoknak a száma is. Következtetés: A szigorú korlátozások életbe léptetését követően a nehézségek ellenére sikerült elegendő mennyiségű vérkészítményt biztosítani a betegeknek. Az Országos Vérellátó Szolgálat Pécsi Regionális Vérellátó Központja munkatársainak és a klinikusok erőfeszítéseinek köszönhetően a vérkészítményigény és -kínálat között új egyensúly alakult ki, mely megfelelő ellátást biztosított a feltétlenül szükséges transzfúziók kivitelezéséhez. Orv Hetil. 2021; 162(43): 1717–1723. Summary. Introduction: The impact of COVID–19 pandemic on patient care is pronounced also in Hungary. Blood supply was hindered by the reduction of public blood donation events, the reduced willingness to donate, and the difficult predictability of blood product demand as a result of the epidemiological regulations. The wider application of Patient Blood Management guidelines in the medical practice will promote optimal blood product utilization by avoiding transfusions where possible. Objective and method: The aim of our study was to assess the changes in the usage of blood products in the first five months of 2020 at the Clinical Center of the University of Pécs, Janus Pannonius Clinical Building. Results: In the period following the epidemiological measures, we found reduction in the number of hospitalized patients (34.08%), in the number of patients requiring transfusion (39.69%) and in the number of red blood cell products used (46.41%). The number of transfused red blood cell concentrates per patient was also significantly reduced (from 2.61 to 1.97) in this period. The number of transfused fresh frozen plasma units and platelet concentrates also decreased by approximately 30%. Conclusion: After the implementation of the strict restrictions, despite the difficulties, it was possible to provide patients with sufficient blood products. Due to the efforts of both the Regional Blood Transfusion Center of Pécs of the Hungarian National Blood Transfusion Service and of the clinicians, a new balance was established between the demand and the supply of blood products, which provided adequate care for the necessary transfusions. Orv Hetil. 2021; 162(43): 1717–1723.

BackgroundThe constant increase in the utilization of one-day surgical care could be identified since more than a decade in most of European countries. Initially, according to the international rankings, the exploitation of one-day surgery in Hungary was not really significant. In 2010, the Hungarian policy makers intended to increase one-day surgical care as a priority strategy. The aim of our study was to analyze the evolution of the Hungarian one-day surgical care during the last decade in DRG- based performance financing system in Hungary.MethodsThe dataset of the research was provided by the National Health Insurance Fund Administration of Hungary. The most important indicators related to the one-day surgical care were compared to inpatient care (market share, number of cases, and DRG cost-weights). To discover the impact of one-day surgical care to the utilization of inpatient treatment, the number of hospitalized days was also analyzed.ResultsBetween 2010-2019, the market share of one-day surgical cases increased from 42%, to 80%. Simultaneously the constant increase of one-day surgical cases, the number of hospitalized days were decreased in inpatient care by 17%. The value of Case Mix Index has also increased, approximately by 140%, which could confirm that more complex interventions are being conducted in one-day surgical care as well. ConclusionsDue to the comprehensive health policy strategy related to the dissemination of one-day surgical care in Hungary, several important performance indicators were improved between 2010-2019. Given that Hungary belongs to the low- and middle-income countries, the results of the study could be considerable even in an international comparison.

Purpose Pancreatic fistula following pancreatic resections is still a relevant complication. The present work shows the efforts of a single institute to decrease this problem. Methods A total of 130 patients (63 men, 67 women) with a mean age of 60 (range: 23–81) years were operated on between January 2013 and March 2020. The most frequent type of pancreatic resection was a Whipple procedure with partial antrectomy. During all operations, an innovative method was used, namely a modification of the purse-string suture pancreatojejunostomy. Moreover, an early drain removal policy was applied, based on the drain amylase level on the first and subsequent postoperative days. Results Mean postoperative hospital stay was 13 days (range: 7–75). The overall morbidity rate was 43.8%; the clinically relevant (grade B/C) pancreatic fistula (CR-POPF) rate was 6.9%. Delayed gastric emptying (DGE) was observed in 4% of the patients. The ratio of operative mortality was 0.7%; the reoperation rate was 5.3%. Based on the drain amylase level on the first postoperative day, two groups could be established. In the first one, the drain was removed early, on the fourth day in average (range: 2–6). In the other group, the drain was left in situ protractedly or reinserted later on. Conclusion A single center’s experience proves that the refinement of the technique can improve the results of pancreatic surgery.

BACKGROUND/AIM Optimal surgical margins, parenchymal-sparing technique and the effect of the surgical devices on the liver resection surface are currently hot topics. The aim of this study was to set up a surviving animal model to detect histological changes on the resection surface induced by the resection method and the thermal effect of monopolar electrocautery in 'spray mode'. MATERIALS AND METHODS Eighteen male Wistar rats were used; all rats were subjected to standardized liver resection and resection surface coagulation. Resection surface samples were collected immediately after the operation from the first group, and at 1 week and 3 weeks after the operation from the second and third groups, respectively. The samples were histologically investigated. RESULTS Spray diathermy was shown to cause parenchymaI destruction of varying depth on the resection surface due to immediate coagulation and consequent necrosis. CONCLUSION Spray diathermy on the resection surface can also destroy the area that contains possible tumor cells after R1 resection and increases the tumor clearance without worse survival outcomes.

Oncology has evolved to a great extent over the last quarter of century. The significant success is multifactorial, including primary and secondary prevention, the development of diagnostics, new methods of chemo-and radiotherapy, and the integration of basic research results into practice. From the point of view of surgery, the establishing and widespread practical application of the principles of preoperative oncotherapy played a major role in this development. Between 1997 and 2005, 44 patients with gastric cancer and 102 patients with borderline resectable or irresectable esophageal cancer received perioperative treatment at the Department of Surgery of the University of Pecs. The response rate was above 50% in both groups and complete pathological remission was achieved in 3 patients with gastric cancer and 17 patients with esophageal cancer. Based on our own experience and literature data, the development of seven new principles in surgical oncology were observed as the result of a very successful preoperative oncologic treatment. The desired free resection margin was reduced to the millimeter dimension in many cancer cases. Thus so-called organ-preserving procedures were made possible. Regarding the prognosis, the stage after the treatment became determinant. Complete histopathological remission could also be achievable in patients with oligometastases. In the case of a complete remission, the watch and wait tactics emerged as an option. Along the preoperative treatment of resectable colorectal liver metastases, there is no need to strive for complete remission. The treatment order of the primary tumor and its metastases can be reversed. Based on the improving results of oncology treatments, a reduction in surgical activity in the treatment of cancer patients is expected.Összefoglaló. Az onkológia hatalmas mértékben fejlődött az elmúlt negyedszázadban. A jelentős siker hátterében sok tényező áll, így a primer és szekunder prevenció, a diagnosztika fejlődése, a kemo- és radioterápia új módszerei és az alapkutatási eredmények beépülése a gyakorlatba. A sebészet szempontjából a fejlődésben a legnagyobb szerepet a műtét előtti onkoterápia elveinek kidolgozása és széles körű gyakorlati alkalmazása játszotta. A Pécsi Tudományegyetem Sebészeti Klinikáján 1997 és 2005 között 44 gyomorrákos és 102, borderline reszekábilis vagy irreszekábilis stádiumban levő nyelőcsőrákos beteget részesítettek perioperatív kezelésben. A válaszadás mértéke mindkét csoportban 50% felett volt, és komplett patológiai remissziót sikerült elérni 3 gyomorrákos és 17 nyelőcsőrákos betegnél. A saját és az irodalmi adatok elemzése kapcsán hét új onkológiai sebészeti elv kialakulását észlelték a nagyon sikeres perioperatív kezelés következtében. A megkívánt szabad reszekciós szél a vizsgált betegcsoportokban milliméteres nagyságrendűre csökkent. Ez ún. szervmegtartó műtétekre adott lehetőséget. A prognózis szempontjából a perioperatív kezelés utáni stádium a mértékadó. Oligometastasisos betegen is elérhető a komplett hisztopatológiai remisszió. Komplett remisszió esetén felmerülhet a „watch and wait” taktika alkalmazása. Colontumorok reszekábilis májmetastasisainak kezelésében nem célszerű komplett remisszóra törekedni. Megfordítható a primer tumor és a metastasisok kezelési sorrendje. Az onkológiai kezelések egyre javuló eredményei alapján a sebészeti tevékenység visszaszorulása várható a daganatos betegek gyógyításában. Orv Hetil. 2022; 163(14): 544–550.

Összefoglaló. Bevezetés: Esetünkben nyelőcsőtumor miatt történt nyelőcső reszekció és bal colonféllel pótlás egy korábban gyomor reszekált betegen. A graftelhalás miatt a nekrotizált vastagbélszakaszt eltávolítottuk. Az egy év múlva végzett rekonstrukciónál kombinált vérellátású jejunummal való pótlást alkalmaztunk. A három egyenes ág lekötése után a Roux kacs nem volt elég hosszú, ezért a 2. és 3. egyenes ág között az árkádot átvágva már biztonságosan felért a nyakra. A 3. ág által ellátott terület vérellátását a mammaria interna arteriájából biztosítottuk és a vénás elvezetést egy vena saphena szegmenttel biztosítottuk a vena jugularis externa felé. A jejunum graft folytonossága megmaradt. A beteg meggyógyult. Ha a nyelőcsőpótlásra rutinszerűen használt gyomor és vastagbél anatómiai okok, előző műtétek vagy szövődmények miatt alkalmatlanok, akkor az egyik utolsó lehetőség a jejunummal való pótlás. A jejunum csak szabad átültetéssel vagy a keringés megerősítésével (supercharging) alkalmas az oesophagectomia utáni biztonságos pótlásra. A kombinált vérellátású jejunum pótlást hybrid, supercharged módszernek neveztük el. Summary. Introduction: In this case report an esophageal resection due to cancer was performed with a primary left colonic replacement, as the stomach was resected previously. Due to graft necrosis, the necrotized section of the colon was removed. One year later a long jejunal segment with a combined blood supply was used for secondary reconstruction. Even after the ligation of three straight branches, the Roux loop was not long enough to reach up to the neck, however the division of the arcade between the 2nd and 3rd straight branches lengthened it satisfyingly. Blood supply to the region of the farthest branch was provided from the internal mammary artery and venous drainage was provided by a saphenous vein graft to the external jugular vein. The continuity of the jejunal graft was preserved. The patient recovered uneventfully. If neither the stomach nor the colon routinely used for esophageal replacement are available due to anatomical reasons, previous surgeries, or complications, jejunal replacement can be the last resort. Jejunum is only suitable for safe esophageal replacement by either free transplantation or by supercharging. The procedure when a combined blood supply is provided for the jejunal replacement was named the hybrid-supercharged method.

Összefoglaló. Az 1970-es évek előtt a nyelőcsőrákok csupán 1-3%-a volt adenocarcinoma. A 70-es évek közepétől a nyelőcső-adenocarcinoma mutatta a legnagyobb növekedést az összes malignus daganat közül, és a 90-es évek közepétől már meghaladta a laphámrákok előfordulási gyakoriságát a nyugati világban. Ma a nyelőcső-adenocarcinoma relatív incidenciája Magyarországon 34,7%, míg a nyugati világban már 60% körül van. A nyelőcső-adenocarcinoma etiológiájában meghatároztak néhány kockázati tényezőt, így a gastrooesophagealis refluxot, a Barrett-nyelőcsövet, a kóros kövérséget, a dohányzást és a csökkenő Helicobacter pylori fertőzöttséget. Ezek a tényezők azonban jelen voltak már a 70-es évek előtt is. A kövérség előfordulásának gyakorisága és a következményes gastrooesophagealis reflux megduplázódott az elmúlt 40 évben, de ez egyedül nem magyarázza az adenocarcinomák szaporodásának ütemét. Egy új, hatékony savcsökkentő gyógyszercsoportnak, a H2-receptor-blokkolóknak a bevezetésére 1976-ban került sor, és ez egybeesik a szokatlanul nagy incidencianövekedéssel. Tom DeMeester teóriája szerint a savcsökkentő kezelés által létrehozott pH-változás okozhatja a refluxátum carcinogenitasának fokozódását. A Barrett-oesophagus és a nyelőcső-adenocarcinoma etiológiájában, megelőzésében és kezelésében számos ellentmondás és vitás kérdés tapasztalható, különösen a protonpumpagátló gyógyszerek (PPI-k) hosszú távú használata körül. A PPI-k hatásossága a gyógyszer túlzott alkalmazásához vezetett nem mindig megfelelő indikációban, kitéve a betegeket potenciális kockázatoknak. Összefoglalva, a nyelőcső-adenocarcinoma drámai növekedésében biztosan szerepet játszik az elhízás és a refluxbetegség ezzel párhuzamos terjedése. Fontos továbbá a H. pylori fertőzöttség csökkenése, és új szempont a hatásos savcsökkentő szerek széles körű alkalmazása, melyek a refluxátumban okozott pH-változással erősíthetik a carcinogenesist. Orv Hetil. 2021; 162(51): 2040-2046. Summary. Before the 1970s, only 1-3% of esophageal cancers were adenocarcinoma. Since the mid-70s, the incidence of esophageal adenocarcinoma has shown the greatest increase compared to all other cancer types and overtook squamous carcinoma incidence in the mid-90s in the Western countries. Today, the relative incidence of esophageal adenocarcinoma in Hungary is 34.7% and around 60% in the Western countries. Some risk factors for esophageal adenocarcinoma have been identified such as gastroesophageal reflux disease, Barrett's esophagus, obesity, smoking and decreased prevalence of Helicobacter pylori infection, but these risk factors were already present before the 70s. The prevalence of obesity and the consequentially developed gastroesophageal reflux has doubled during the last 40 years, but it does not explain alone the dramatic rise in the esophageal adenocarcinoma incidence. The H2 blockers, as new effective antisecretory medication, were introduced in 1976, coinciding in time with the substantial rise of esophageal adenocarcinoma. According to the DeMeester theory, the change in the pH of gastric refluxate caused by acid suppression enhances its carcinogenic potential. There are a lot of controversies among the prevention, etiology and treatment of Barrett's esophagus and esophageal adenocarcinoma, especially regarding the long-term use of proton pump inhibitors (PPIs), an even more effective group of acid suppressors. The effectiveness of PPIs has led to an overuse exceeding its regular indications with little benefit, exposing patients to a number of potential risks. In conclusion, in the dramatic rise of the esophageal adenocarcinoma incidence, obesity accompanied by reflux disease and the decreased incidence of H. pylori infection certainly play important roles. The introduction of modern antisecretory drugs in the treatment of acid-related diseases promoting carcinogenesis, arises as a new consideration. Orv Hetil. 2021; 162(51): 2040-2046.

Összefoglaló. Bevezetés: A COVID-19-világjárvány betegellátásra gyakorolt hatása hazánkban is jelentős. A vérellátást nehezítette a járványügyi intézkedések következményeként a véradási események elmaradása, a csökkent véradási hajlandóság, továbbá a nehezen megítélhető vérkészítményigény . A "Patient Blood Management" irányelveinek az orvosi gyakorlatban történő egyre szélesebb körű alkalmazása elősegíti az optimális vérkészítmény-felhasználást a transzfúziók lehetőség szerinti elkerülésével. Célkitűzés és módszer: Vizsgálatunk célja a Pécsi Tudományegyetem Klinikai Központjának Janus Pannonius Klinikai Tömbjében a vérkészítmény-felhasználás változásainak felmérése volt a 2020. év első öt hónapjában. Eredmények: A járványügyi intézkedéseket követő időszakban szignifikánsan csökkent a hospitalizált betegeknek (34,08%), a transzfúziót igénylő betegeknek (39,69%) és a felhasznált vörösvérsejt-készítményeknek (46,41%) a száma, valamint az egy betegre jutó felhasznált vörösvérsejt-koncentrátum átlaga (2,61-ről 1,97-re) is. Közel 30%-os arányban csökkent a felhasznált friss fagyasztott plazma egységeinek és a thrombocytakoncentrátumoknak a száma is. Következtetés: A szigorú korlátozások életbe léptetését követően a nehézségek ellenére sikerült elegendő mennyiségű vérkészítményt biztosítani a betegeknek. Az Országos Vérellátó Szolgálat Pécsi Regionális Vérellátó Központja munkatársainak és a klinikusok erőfeszítéseinek köszönhetően a vérkészítményigény és -kínálat között új egyensúly alakult ki, mely megfelelő ellátást biztosított a feltétlenül szükséges transzfúziók kivitelezéséhez. Orv Hetil. 2021; 162(43): 1717-1723.The impact of COVID-19 pandemic on patient care is pronounced also in Hungary. Blood supply was hindered by the reduction of public blood donation events, the reduced willingness to donate, and the difficult predictability of blood product demand as a result of the epidemiological regulations. The wider application of Patient Blood Management guidelines in the medical practice will promote optimal blood product utilization by avoiding transfusions where possible.The aim of our study was to assess the changes in the usage of blood products in the first five months of 2020 at the Clinical Center of the University of Pécs, Janus Pannonius Clinical Building.In the period following the epidemiological measures, we found reduction in the number of hospitalized patients (34.08%), in the number of patients requiring transfusion (39.69%) and in the number of red blood cell products used (46.41%). The number of transfused red blood cell concentrates per patient was also significantly reduced (from 2.61 to 1.97) in this period. The number of transfused fresh frozen plasma units and platelet concentrates also decreased by approximately 30%.After the implementation of the strict restrictions, despite the difficulties, it was possible to provide patients with sufficient blood products. Due to the efforts of both the Regional Blood Transfusion Center of Pécs of the Hungarian National Blood Transfusion Service and of the clinicians, a new balance was established between the demand and the supply of blood products, which provided adequate care for the necessary transfusions. Orv Hetil. 2021; 162(43): 1717-1723.

Nowadays, the gold standard for the diagnosis of liver disease is histological examination. However, due to the dangers and complications of liver biopsy, there is a worldwide demand for the development of non-invasive procedures that can accurately determine the degree of hepatic steatosis, furthermore is cost-effective, user-friendly, and provides repeatable measurement. Based on the metrological experience of our research team, we started developing an electrical impedance-based diagnostic method a few years ago that meets these requirements and is suitable for early detection of nonalcoholic fatty liver disease (NAFLD) with the help of a worldnew measurement and data collection solution. In addition to the preliminar results of the long-term clinical validation of the diagnostic method developed to detect NAFLD, the authors present early partial results. Even with the small amount of data, very impressive results have been obtained.

Introduction Pain is the most common symptom in acute pancreatitis (AP) and is among the diagnostic criteria. Therefore, we aimed to characterize acute abdominal pain in AP. Methods The Hungarian Pancreatic Study Group prospectively collected multicentre clinical data on 1435 adult AP patients between 2012 and 2017. Pain was characterized by its intensity (mild or intense), duration prior to admission (hours), localization (nine regions of the abdomen) and type (sharp, dull or cramping). Results 97.3% of patients (n = 1394) had pain on admission. Of the initial population with acute abdominal pain, 727 patients answered questions about pain intensity, 1148 about pain type, 1134 about pain localization and 1202 about pain duration. Pain was mostly intense (70%, n = 511/727), characterized by cramping (61%, n = 705/1148), mostly starting less than 24 h prior to admission (56.7%, n = 682/1202). Interestingly, 50.9% of the patients (n = 577/1134) had atypical pain, which means pain other than epigastric or belt-like upper abdominal pain. We observed a higher proportion of peripancreatic fluid collection (19.5% vs. 11.0%; p = 0.009) and oedematous pancreas (8.4% vs. 3.1%; p = 0.016) with intense pain. Sharp pain was associated with AP severity (OR = 2.481 95% CI: 1.550-3.969) and increased mortality (OR = 2.263, 95% CI: 1.199-4.059) compared to other types. Longstanding pain (>72 h) on admission was not associated with outcomes. Pain characteristics showed little association with the patient's baseline characteristics. Conclusion A comprehensive patient interview should include questions about pain characteristics, including pain type. Patients with sharp and intense pain might need special monitoring and tailored pain management. Significance Acute abdominal pain is the leading presenting symptom in acute pancreatitis; however, we currently lack specific guidelines for pain assessment and management. In our cohort analysis, intense and sharp pain on admission was associated with higher odds for severe AP and several systemic and local complications. Therefore, a comprehensive patient interview should include questions about pain characteristics and patients with intense and sharp pain might need closer monitoring.

Contains fulltext : 238976.pdf (Publisher’s version ) (Open Access) On January 2020, the WHO Director General declared that the outbreak constitutes a Public Health Emergency of International Concern. The world has faced a worldwide spread crisis and is still dealing with it. The present paper represents a white paper concerning the tough lessons we have learned from the COVID-19 pandemic. Thus, an international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making. With the present paper, international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making.

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs.

Background: Pseudocysts being the most frequent local complications of acute pancreatitis (AP) have substantial effect on the disease course, hospitalization and quality of life of the patient. Our study aimed to understand the effects of pre-existing (OLD-P) and newly developed (NEW-P) pseudocysts on AP. Methods: Data were extracted from the Acute Pancreatitis Registry organized by the Hungarian Pancreatic Study Group (HPSG). 2275 of 2461 patients had uploaded information concerning pancreatic morphology assessed by imaging technique. Patients were divided into “no pseudocyst” (NO-P) group, “old pseudocyst” (OLD-P) group, or “newly developed pseudocyst” (NEW-P) groups. Results: The median time of new pseudocyst development was nine days from hospital admission and eleven days from the beginning of the abdominal pain. More NEW-P cases were severe (15.9% vs 4.7% in the NO-P group p < 0.001), with longer length of hospitalization (LoH) (median: 14 days versus 8 days, p < 0.001), and were associated with several changed laboratory parameters. OLD-P was associated with male gender (72.2% vs. 56.1%, p = 0.0014), alcoholic etiology (35.2% vs. 19.8% in the NO-P group), longer hospitalization (median: 10 days, p < 0.001), a previous episode of AP (p < 0.001), pre-existing diagnosis of chronic pancreatitis (CP) (p < 0.001), current smoking (p < 0.001), and increased alcohol consumption (unit/week) (p = 0.014). Conclusion: Most of the new pseudocysts develop within two weeks. Newly developing pseudocysts are associated with a more severe disease course and increased length of hospitalization. Pre-existing pseudocysts are associated with higher alcohol consumption and smoking. Because CP is more frequently associated with a pre-existing pseudocyst, these patients need closer attention after AP.

Introduction:Pain is the most common symptom in acute pancreatitis(AP) and is part of the diagnostic criteria. Its clinical characteristics in APhave not been detailed.Aims:Therefore, we aimed to characterize acute abdominal pain in AP.Materials and Methods:The Hungarian Pancreatic Study Group hasprospectively collected multicenter clinical data of 1435 adult AP patientsbetween 2012 and 2017. The pain was characterized by its intensity (mild, intense), duration prior to admission (hours), localization (9 regions of theabdomen), and type (sharp, dull, cramping). Associations between paincategory groups and outcome parameters were investigated.Results:97.3% of patients (n¼1394) had pain on admission. Pain wasmostly intense (70%, n¼511), cramping (61%, n¼705), and epigastric (48%, n¼687). More intense pain was associated with disease severity (p¼0.021), and we observed higher proportion of peripancreaticfluid collection(19.5% vs 11.0% ; p¼0.009) and edematous pancreas (8.4% vs 3.1% ; p¼0.016)on on-admission imaging with intense pain. Sharp pain was associatedAbstracts / Pancreatology 21 (2021) S18eS119S36 N. GedeS. KissA. VinczeJ. BajorI. SzaboZ. SzepesF.IzbekiJ. GervainJ. HamvasZ. VitalisE. FeherS.CraiV. SallinenE.Ramirez MoldandoA. MeczkerP.VarjúG. PoropatD. StimacN.FaluhegyiA. MisetaT. NagyA. VereczkeiZ.MartonP.J. HegyiP. HegyiA.ParniczkyA. Szentesi with AP severity (OR¼2.481 95% CI: 1.550-3.969) and increased mortality(OR¼2.263, 95% CI: 1.199e4.059) compared to other pain types. Long- standing pain (>72 h) on admission was not associated with outcomes ; however, it was associated with milder (p

IntroductionAcute abdominal wound dehiscence (AWD) or burst abdomen is a severe complication after abdominal surgery with an incidence up to 3.8%. Surgical site infection (SSI) is the biggest risk factor for the development of AWD. It is strongly suggested that the use of triclosan-coated sutures (TCS) for wound closure reduces the risk of SSI. We hypothesise that the use of TCS for abdominal wound closure may reduce the risk of AWD. Current randomised controlled trials (RCTs) lack power to investigate this. Therefore, the purpose of this individual participant data meta-analysis is to evaluate the effect of TCS for abdominal wound closure on the incidence of AWD.Methods and analysisWe will conduct a systematic review of Medline, Embase and Cochrane Central Register of Controlled Trials for RCTs investigating the effect of TCS compared with non-coated sutures for abdominal wound closure in adult participants scheduled for open abdominal surgery. Two independent reviewers will assess eligible studies for inclusion and methodological quality. Authors of eligible studies will be invited to collaborate and share individual participant data. The primary outcome will be AWD within 30 days after surgery requiring reoperation. Secondary outcomes include SSI, all-cause reoperations, length of hospital stay and all-cause mortality within 30 days after surgery. Data will be analysed with a one-step approach, followed by a two-step approach. In the one-step approach, treatment effects will be estimated as a risk ratio with corresponding 95% CI in a generalised linear mixed model framework with a log link and binomial distribution assumption. The quality of evidence will be judged using the Grading of Recommendations Assessment Development and Evaluation approach.Ethics and disseminationThe medical ethics committee of the Amsterdam UMC, location AMC in the Netherlands waived the necessity for a formal approval of this study, as this research does not fall under the Medical Research involving Human Subjects Act. Collaborating investigators will deidentify data before sharing. The results will be submitted to a peer-reviewed journal.PROSPERO registration numberCRD42019121173.

Background/aim Nowadays, obtaining optimal surgical margin of the resected metastasis and the parenchyma- sparing surgical technique are a great challenge for hepatic surgeons. The aim of this follow-up study was to investigate the prognostic value of the surgical margin and the parenchyma- sparing liver resection technique. Patients and methods We performed a retrospective analysis of the data of 319 patients [123 (36.6%) female and 196 (61.4%) male] who had colorectal cancer and underwent surgery to treat colorectal liver metastases in our Department between 2005 and 2014. Results The most commonly used resection type was the non-anatomic resection (43%). Multivariate analysis indicated that there was no significant difference in survival (p=0.473) between the microscopically-negative (R0) and microscopically-positive (R1) resections, as well as between the resection types (p=0.257). Conclusion Parenchymal-sparing non-anatomic resection and spray diathermy on the resection surface of the liver should be applied not only for hemostasis, but also to destroy the area containing possible tumor cells after an R1 resection and not to have worse survival outcomes.

INTRODUCTION Laparoscopy is more beneficial than the conventional open technique, however the pneumoperitoneum created may have an ischemic side effect. OBJECTIVE Our aim was to evaluate the protective effects of preconditioning during laparoscopic cholecystectomies (LC). METHODS 30 patients were randomized into 2 groups: I. PreC (preconditioning: 5 min. inflation, 5 min. deflation, followed by conventional LC), II: LC (conventional LC). Blood samples were taken before hospitalization (C = control), before surgery, after anaesthesia (B.S.), after surgery (A.S.) and 24 hours after the procedure (24 h). Measured parameters were: malondialdehyde (MDA), reduced glutathione (GSH), sulfhydril groups (-SH), superoxide-dismutase (SOD), catalase (CAT), myeloperoxidase (MPO), length of hospitalization and pain (VAS = visual analogue scale). RESULTS Compared to the BS levels, no significant changes were detected in SOD's activity and MDA levels. GSH concentrations were significantly increased in the PreC group after operation. SH-, MPO, CAT and liver function enzymes were not significantly different. Hospitalization was shorter in the PreC group. Based on the VAS score patients had less pain in the PreC group. CONCLUSION Significant differences concerning PreC group were found in GSH values. In the PreC group pain decreased by 2-2.5 units following the procedure, 24 h after surgery, and hospitalisation was also significantly shorter. In our pilot study the potential protective effect of preconditioning could be defined.

Absztrakt: A szerzők egy 67 éves férfi beteg esetét ismertetik, akinél előzőleg a máj II. szegmentumában képalkotó vizsgálatokkal igazolt térfoglalás miatt II, III szegment teljes és a IV. szegment részleges eltávolítását végezték. Műtét utáni icterus jelent meg, emelkedő tendenciát mutató szérum bilirubin koncentrációval. Képalkotó vizsgálatok elvégzése után reoperatiora került sor. A műtét alatt derült fény a ritka epeúti variánsra. A primér műtétnél a rezekció során lekötésre került a jobb oldali ductus hepaticus, ami intraparenchimálisan ömlött a bal oldali ductus hepaticusba. Az érintetlenül hagyott hílusban nem tűnt fel a jobb extrahepaticus epeút hiánya. Az epeelvezetés Roux-Y-kaccsal végzett hepatico jejunostomiával került megoldásra.

Absztrakt: Esetismertetés: Esetünkben neoadjuváns onkológiai kezelést követően egy olyan pancreas baloldali tumor sebészi eltávolítását ismertettük, ami infiltrálta a truncus coeliacus oszlást és a gyomort is. A beavatkozás során a truncust resecáltuk, distalis pancreatectomiát, splenectomiát, total gastrectomiát, bal mellékvese-resectiót és cholecystectomiát végeztünk. Betegünk zavartalanul gyógyult, csupán átmeneti májfunkciós laboreltérést tapasztaltunk. A histologiai feldolgozás R1 resectiót mutatott, ezért adjuváns onkológiai kezelésre kerül sor. Megbeszélés: A pancreas distalis tumorai gyakran inoperábilisak. Ilyennek számított sokáig a truncus coeliacus oszlását involváló elváltozás is, azonban van lehetőség radikális műtétre a truncus resectiójával, ami után a máj artériás vérellátását a pancreaticoduodenalis árkád biztosítja. Egy esetünk kapcsán ismertettük a műtéti technikát és az ezzel kapcsolatosan felmerülő kérdéseket. Artériás infiltrációt mutató pancreastumor esetén feltétlenül ajánlott a preoperatív kemoterápia, mivel megfelelő válasz esetén van esély a daganat radikális eltávolítására.

András Vereczkei, Laura Bognár, András Papp, Örs Péter Horváth Department of Surgery, University of Pécs, Pécs, Hungary Abstract: Achalasia is a motility disorder of the esophagus characterized by the defective peristaltic activity of the esophageal body and impaired relaxation of the lower esophageal sphincter due to the degeneration of the inhibitory neurons in the myenteric plexus of the esophageal wall. The histopathological and pathophysiological changes in achalasia have been well described. However, the exact etiological factors leading to the disease still remain unclear. Currently, achalasia is believed to be a multifactorial disease, involving both extrinsic and intrinsic factors. Based on our experience and the review of literature, we believe that gastroesophageal reflux disease (GERD) might be one of the triggering factors leading to the development of achalasia. However, it is also stated that the two diseases can simultaneously appear independently from each other. Considering the large number and routine treatment of patients with GERD and achalasia, the rare combination of the two may even remain unnoticed; thus, the analysis of larger patient groups with this entity is not feasible. In this context, we report four cases where long-standing reflux symptoms preceded the development of achalasia. A literature review of the available data is also given. We hypothesize that achalasia following the chronic acid exposure of the esophagus is not accidental but either a consequence of a chronic inflammation or a protective reaction of the organism in order to prevent aspiration and lessen reflux-related symptoms. This hypothesis awaits further clinical confirmation. Keywords: achalasia, gastroesophageal reflux disease, Barrett’s esophagus, Nissen fundoplication

Abstract: Gastroesophageal reflux disease affects more than 10% of the adult population. Most patients can be effectively treated with lifestyle changes and adequate acid-reducing therapy. However, about 10% of the patients remain symptomatic despite treatment and severe complications may develop. Interestingly, some of these complications seem to be a sort of defensive mechanism that may either alleviate the patient’s symptoms or prevent developing further complications. In Barrett’s esophagus, which can be unambigously considered as a complication of gastroesophageal reflux disease, reflux symptoms ruining the quality of life may significantly improve, since the metaplastic Barrett epithelium is much more resistent to gastric acid, than the normal epithelial lining of the esophagus. Furthermore, the motility disorders (hypertensive lower esophageal sphincter, achalasia, cricopharyngeal achalasia) and structural changes (Schatzki’s ring, esophageal stricture, subglottic trachea stenosis), which develop as a complication of reflux may help to prevent aspiration that can cause new complaints and may lead to further complications. Orv Hetil. 2017; 158(20): 763–769.

Introduction Pneumoperitoneum, widely used in laparoscopic surgery increases the intraabdominal pressure, leading to hypoperfusion of the abdominal organs, and promoting the buildup of reactive oxygen species(ROS) and inflammatory cytokines which in turn impairs the body postoperatively. Aim of our investigation was to evaluate the potential protective effects of short ischemic episodes on ischemic damages. Methods 70 Wistar rats were used, divided into 7 groups: 1st group sham, 2nd group pneumoperitoneum with 5 mmHg, 3rd group preconditioning with 5 mmHg, 4th group: postconditioning with 5 mmHg, 5th group pneumoperitoneum with 10 mmHg, 6th group: preconditioning with 10 mmHg, 7th group postconditioning with 10 mmHg. Pneumoperitoneum was created by Veres needle. Oxidative stress parameters: malondialdehyde (MDA) concentration, reduced glutathione (GSH), sulfhydril (SH-), myeloperoxidase (MPO) levels and superoxide-dismutase (SOD) activity were measured. We measured TNF-α and IL-6 concentrations. We monitored the activation of anti- and proapoptotic common signaling pathways (bax, bcl-2, p53) during the early phase of reperfusion. Histology was made from kidney samples. Results GSH concentrations were significantly reduced, MDA concentrations were significantly higher in each group compared to the Sham. SOD enzyme: a pressure of 10 mmHg elicited significantly greater damage than 5 mmHg. There was a significantly higher SOD activity in group 10 mmHg IPC compared to 10 mmHg. We found that the expression of bax was considerably higher in the none conditioned groups. Noticeably higher expression of anti-apoptotic bcl-2 level was measured in 10 mmHg IPC and 10 mmHg IPoC groups. In case of p53 expression: significant decrease could be seen in groups 10 mmHg IPC and 10 mmHg IPoC compared to the 10 mmHg group. Conclusion Based on our results, the elevated intraabdominal pressure due to pneumoperitoneum induces oxidative stress, which is dependent on the applied pressure. Mostly precondiotioning - but also postconditioning - reduces surgical stress following laparoscopic procedures. In order to explore its mechanism it requires further investigations.

Absztrakt A belgyógyászati módszerekkel panasz- és tünetmentessé nem tehető gastrooesophagealis refluxbetegségben szenvedő betegek kezelésére bevált módszer a laparoszkópos antireflux-sebészet. Gyakorlatot szerzett sebészek nagy biztonsággal végzik a műtétet, mégis fellépnek intraoperativ, korai postoperativ és késői szövődmények, amelyek reoperációt tehetnek szükségessé. A Pécsi Tudományegyetem Sebészeti Klinikáján 1998 és 2015 között 407 laparoszkópos antirefluxműtétet végeztünk. A periódust két szakaszra osztottuk. Az elsőben 1998 és 2006 között 241 beteget operáltunk és a vizsgálat prospektív volt; minden diagnosztikus eljárást magunk végeztünk. A második periódusban 166 beteget kezeltünk minimálisan invazív módszerrel és az eredményeket retrospektíve elemeztük. Az összbeteganyagban a férfi/nő arány 161/246 volt. A betegek átlagéletkora 53,1 év volt. A 407 műtétet kiegészítettük 27 esetben ligamentum teres plasztikával, 28 esetben hálóbeültetéssel és négy esetben fascia lata plasztikával, mert a hiatus direkt zárását nem tartottuk megbízhatónak. 16 esetben (4%) végeztünk konverziót, a halálozás 0,5% volt. 39 esetben végeztünk laparoszkópos reoperációt és hat esetben thoracolaparotomiás reoperációt (12%). Ehhez még öt reoperáció járul, amelynél a primer műtét nem klinikánkon történt. A 4%-os konverziós ráta, a 12%-os reoperációs arány, valamint a 0,5%-os halálozás megfelel az irodalomban talált arányoknak. Összességében megállapíthatjuk, hogy a laparoszkópos antirefluxműtét biztonsággal és nagyon jó eredménnyel végezhető beavatkozás. A tartós szövődmények (elsősorban reflux- és sérvkiújulás), illetve a reoperációk szinte kizárólag csak a nagyméretű hiatusherniák sebészi kezelése kapcsán fordultak elő.

Abstract: Pancreatic cancer has adverse prognosis. Disease recurrence is typical and it occurs mainly within the first 2 years postoperatively. However late and soliter metastases are rare. This case report shows the history of a male patient, who was radically operated on for pancreatic cancer. 11 years later a solitary liver metastasis has developed and it was completely removed by resection. 1 year postoperatively the patient is doing well. Our case demonstrates that in patients after resection for pancreatic cancer, redo surgery might be justified in case of late and isolated metastasis. Orv Hetil. 2017; 158(28): 1109–1111.

The authors present a case of a 67-year-old male patient, who previously had been diagnosed with a malignant liver tumor localized in segment II. He underwent bisegmentectomy (II and III) and partial IV segmentectomy. After the primary surgery jaundice developed, the level of bilirubin increased and after several imaging modalities reoperation was indicated. During the surgery a rare bile duct anatomy variant was found. The right hepatic duct joined the left duct in the parenchyma of the left lobe, and was ligated at the resection. As the liver hilum was not explored, the absence of the right duct was not discovered. Reconstruction of the biliary system was accomplished by a Roux-en-Y loop.

After neoadjuvant oncological therapy the surgical treatment of distal pancreatic tumour - infiltrating the celiac axis and the stomach - was reported. During the operation resection of the trunc, distal pancreatectomy, splenectomy, total gastrectomy, resection of the left adrenal gland and cholecystectomy were carried out. The patient's clinical course was uneventful, only transient alteration of liver functions was detected. Histological work-up revealed R1 resection, so adjuvant oncological therapy was decided.Distal pancreatic tumours are frequently inoperable. Infiltration of the celiac axis was similarly considered, however there is a chance for radical operation by the resection of the trunc, when the pancreaticoduodenal arcade will provide the arterial blood supply to the liver. Based on the above case the operative technique and the relevant questions were discussed. In pancreatic tumour and arterial infiltration the preoperative chemotherapy is absolutely recommended, because there is a chance for radical surgery in case of good response.

The increasing prevalence of GERD has become a major concern due to its major health and economic impacts. Beyond the typical unpleasant symptoms, reflux can also be the source of severe, potentially life-threatening complications, such as aspiration. Our aim was to support our hypothesis that the human body may in some cases develop various protective mechanisms to prevent these conditions. Based on our experiences and review of the literature, we investigated the potential adaptive nature of seven reflux complications (hypertensive lower esophageal sphincter, achalasia, hypertensive upper esophageal sphincter, Zenker’s diverticulum, Schatzki’s ring, esophageal web, and Barrett’s esophagus). Patients with progressive GERD may develop diverse structural and functional esophageal changes that narrow the lumen of the esophagus and therefore reduce the risk of regurgitation and protect the upper aerodigestive tract from aspiration. The functional changes (hypertensive lower esophageal sphincter, achalasia, hypertensive upper esophageal sphincter) seem to be adaptive reactions aimed at easing the unpleasant symptoms and reducing acid regurgitation. The structural changes (Schatzki’s ring, esophageal web) result in very similar outcomes, but we consider these are rather secondary consequences and not real adaptive mechanisms. Barrett’s esophagus is a special form of adaptive protection. In these cases, patients report significant relief of their previous heartburn as Barrett’s esophagus develops because of the replacement of the normal squamous epithelium of the esophagus by acid-resistant metaplastic epithelium. We believe that GERD may induce different self-protective reactions in the esophagus that result in reduced acid regurgitation or decreased reflux symptoms.

Despite evidence supporting the effectiveness of best practices of infection prevention and management, many surgeons worldwide fail to implement them. Evidence-based practices tend to be underused in routine practice. Surgeons with knowledge in surgical infections should provide feedback to prescribers and integrate best practices among surgeons and implement changes within their team. Identifying a local opinion leader to serve as a champion within the surgical department may be important. The "surgeon champion" can integrate best clinical practices of infection prevention and management, drive behavior change in their colleagues, and interact with both infection control teams in promoting antimicrobial stewardship.

Absztrakt Esetismertetés: A szerzők egy 68 éves beteg esetét ismertetik, akinél hálóbeültetéses hiatusplasztikával kiegészített antirefluxműtétet követően négy hónappal dysphagiás panaszok jelentkeztek. Az elvégzett vizsgálatok a háló részleges nyelőcsőbe penetrálását igazolták. Halasztott sürgősséggel végzett műtét során thoracolaparotomiás feltárásból a hálót eltávolították, a nyelőcsövön észlelt hosszanti lyuk és alatta egy rövid szűkület miatt distalis nyelőcső- és proximalis gyomorresectiót végeztek, a tápcsatorna folytonosságát jejunum-interpositum segítségével állították helyre. A három hónapos kontroll során a beteg panaszmentes volt, és az elvégzett radiológiai vizsgálat a műtét utáni normális viszonyokat mutatta. Megbeszélés: Számos tanulmány igazolta, hogy a nagyméretű hiatusherniák direkt varrattal történő zárása magas recidíva aránnyal jár. A sérvkiújulás megelőzése végett széles körben elterjedt a hálóbeültetéssel megerősített hiatusrekonstrukció. Ezzel a sérvkiújulás incidenciája valóban csökkent, ellenben a műtét morbiditása – alapvetően a hálóra visszavezethető okok miatt – nőtt. A hálók a speciális anatómiai helyzet miatt állandó mozgásnak vannak kitéve és ezzel a nyelőcső erózióját, perforációját, valamint fibrosist és következményes stenosist okozhatnak. Az ilyen típusú szövődmények súlyos, nemritkán életveszélyes állapotot jelentenek és gyakran csak bonyolult műtéttel korrigálhatók. A szerzők saját esetük tapasztalata és a szakirodalom áttekintése alapján a hálóbeültetéses hiatusrekonstrukciók egyik lehetséges, súlyos szövődményére szeretnék felhívni a figyelmet.

The diffuse colonic polyposis regards as a precancerous condition, thus both in tumorous and in premalignant condition the only therapy is the total colectomy. In our case on a 62-year-old male begun medical checkup due to weakness, slimming and haematochezia. The blood test revealed that the patients CA 19-9 levels were significantly elevated. The colonoscopy found multiple polyposis in the whole large bowel, furthermore a sigma carcinoma with stenosis. During the surgery multiple and bilobar colorectal liver metastasis were verified, which were proposed with CT scan. Because of the obstruction, we made a palliative sigma resection. Then adjuvant FOLFIRI therapy started. After 6 period chemotherapy performed abdominal CT scan showed the progression in the liver process. Therefore second-line Erbitux + FOLFIRI chemotherapy started. After 11 cycles performed restaging CT scan showed significant regression of the liver metastasis. During the control colonoscopy the previously showed multiple polyposis of the large bowel were not detected, the polyps unexpectedly vanished. Because of the significant regression of the liver metastasis suggested the lobectomy, but the oncoteam decided to continue chemotherapy sequence. After 1 year in the course of oncology care performed PET-CT scan showed progression in the liver metastasis particularly in the right lobe. The oncologyst started third-line Avastin + FOLFOX chemotherapy, but the patient died 3 years after the diagnosis. In our opinion, the regression of the diffuse colonic polyposis of the patient was due to the biological therapy. The submitted case is a literary rarity, because there is no relevant data in the literature that describes the positive effect of the chemotherapy for colon polyps.

Contains fulltext : 177987.pdf (Publisher’s version ) (Open Access) BACKGROUND: Antimicrobial Stewardship Programs (ASPs) have been promoted to optimize antimicrobial usage and patient outcomes, and to reduce the emergence of antimicrobial-resistant organisms. However, the best strategies for an ASP are not definitively established and are likely to vary based on local culture, policy, and routine clinical practice, and probably limited resources in middle-income countries. The aim of this study is to evaluate structures and resources of antimicrobial stewardship teams (ASTs) in surgical departments from different regions of the world. METHODS: A cross-sectional web-based survey was conducted in 2016 on 173 physicians who participated in the AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections) project and on 658 international experts in the fields of ASPs, infection control, and infections in surgery. RESULTS: The response rate was 19.4%. One hundred fifty-six (98.7%) participants stated their hospital had a multidisciplinary AST. The median number of physicians working inside the team was five [interquartile range 4-6]. An infectious disease specialist, a microbiologist and an infection control specialist were, respectively, present in 80.1, 76.3, and 67.9% of the ASTs. A surgeon was a component in 59.0% of cases and was significantly more likely to be present in university hospitals (89.5%, p < 0.05) compared to community teaching (83.3%) and community hospitals (66.7%). Protocols for pre-operative prophylaxis and for antimicrobial treatment of surgical infections were respectively implemented in 96.2 and 82.3% of the hospitals. The majority of the surgical departments implemented both persuasive and restrictive interventions (72.8%). The most common types of interventions in surgical departments were dissemination of educational materials (62.5%), expert approval (61.0%), audit and feedback (55.1%), educational outreach (53.7%), and compulsory order forms (51.5%). CONCLUSION: The survey showed a heterogeneous organization of ASPs worldwide, demonstrating the necessity of a multidisciplinary and collaborative approach in the battle against antimicrobial resistance in surgical infections, and the importance of educational efforts towards this goal.

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.

Pancreatic cancer has adverse prognosis. Disease recurrence is typical and it occurs mainly within the first 2 years postoperatively. However late and soliter metastases are rare. This case report shows the history of a male patient, who was radically operated on for pancreatic cancer. 11 years later a solitary liver metastasis has developed and it was completely removed by resection. 1 year postoperatively the patient is doing well. Our case demonstrates that in patients after resection for pancreatic cancer, redo surgery might be justified in case of late and isolated metastasis. Orv Hetil. 2017; 158(28): 1109-1111.

Gastroesophageal reflux disease affects more than 10% of the adult population. Most patients can be effectively treated with lifestyle changes and adequate acid-reducing therapy. However, about 10% of the patients remain symptomatic despite treatment and severe complications may develop. Interestingly, some of these complications seem to be a sort of defensive mechanism that may either alleviate the patient's symptoms or prevent developing further complications. In Barrett's esophagus, which can be unambigously considered as a complication of gastroesophageal reflux disease, reflux symptoms ruining the quality of life may significantly improve, since the metaplastic Barrett epithelium is much more resistent to gastric acid, than the normal epithelial lining of the esophagus. Furthermore, the motility disorders (hypertensive lower esophageal sphincter, achalasia, cricopharyngeal achalasia) and structural changes (Schatzki's ring, esophageal stricture, subglottic trachea stenosis), which develop as a complication of reflux may help to prevent aspiration that can cause new complaints and may lead to further complications. Orv Hetil. 2017; 158(20): 763-769.