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Örs Péter Horváth,1 Szabolcs Bellyei,2 Éva Pozsgai,3,4 András Vereczkei1 1Department of Surgery, University of Pécs Clinical Center, Pécs, 7624, Hungary; 2Department of Oncotherapy, University of Pécs Clinical Center, Pécs, 7624, Hungary; 3Department of Public Health, University of Pécs Medical School, Pécs, 7624, Hungary; 4Department of Primary Health Care, University of Pécs Medical School, Pécs, 7623, HungaryCorrespondence: Örs Péter Horváth, Department of Surgery, University of Pécs Clinical Center, Ifjúság Street 13, Pécs, 7624, Hungary, Tel +3672535806, Email horvath.ors.peter@pte.huAbstract: From a surgical point of view, the development of preoperative oncological treatment has had a profound effect on the surgical treatment trends of cancer as well as on the outcomes of cancer patients. Consequently, these changes have challenged formerly entrenched oncological surgical principles. In our short report, we aimed to summarize the main shifts regarding the surgical principles of cancer treatment due to the development of preoperative oncological therapy in recent years. As a result of successful preoperative treatment, surgeons may perform less radical surgeries, the required free resection margin has been narrowed down to a few millimeters in dimension and preoperative treatment is justified in both definitely resectable tumors and in oligometastatic tumors as well. For prognosis assessment, the post-preoperative oncological treatment stage is now considered decisive, rather than the pretreatment stage as previously thought. Other changes include the introduction of the watch and wait strategy and the reverse order of treatment of the primary tumor and metastasis. Observing the continuously improving outcomes of cancer patients and the developments in oncological treatment modalities, a further expansion of the indication of preoperative treatments is to be expected.Keywords: preoperative oncological therapy, neoadjuvant, downstaging, complete remission, surgical principles

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

Background/aims: Surgical technique and experience are considered as significant determinants of the successful treatment of recto-sigmoid malignancies., Methods: Two hundred patients operated on between 2005 and 2009 were prospectively followed with an average of 39.8 months. Patients with rectosigmoid or rectal cancer were included, either with primary resection or resection after neoadjuvant therapy. The primary aim was to assess the average survival in the two groups; secondary outcomes were stage specific survival and the incidence of loco-regional recurrence and distant metastases. Intra- and postoperative complications, operating time, onco-pathological specimen quality and length of stay were also analysed., Results: During the follow-up comparable rates for 3-year survival and recurrence rates were found without statistical difference. Hospital stay in the laparoscopic group was significantly shorter and the mid-term survival rates were also better in the more advanced stages. Incisional hernia rate was significantly lower in the laparoscopic group., Conclusions: The results of laparoscopic rectal and recto-sigmoid resections were not inferior, and - in some aspects - they were even better compared to open procedures. Adding the properties of the minimally invasive technique (shorter recovery, reduced surgical stress reaction) this should be the preferred method of operative approach.

Ganglioneuromas (GNs) are rare benign tumors and their association with neurofibromatosis type 1 (NF-1) is especially uncommon. We report in this article the case of a young woman, subjected to diagnostic work-up because of abdominal pain. Endoscopy and histology revealed not only a GN in the papilla of Vater, but also NF-1. Because of the size and macroscopic features of the lesion, we performed pancreatoduodenectomy, from which she recovered uneventfully. Histological examination of the resected tumor confirmed a diagnosis of GN.

Introduction: Cervical oesophagus represents a critical location for squamous cell carcinoma, which usually requires extensive surgery (pharyngo-laryngo-oesophagectomy). In the last decade, neoadjuvant chemo-radiotherapy was reported to be beneficial in the treatment of locally advanced squamous cell oesophageal cancer., Methods: Between November 1997 and January 2012, 55 patients with locally advanced (T3-4) squamous cell oesophageal cancer received preoperative chemo-radiotherapy, where the tumour was localized in the upper third. Patients received preoperative irradiation of 3960 cGy in 180 cGy fractions and simultaneously Cisplatin and 5-FU chemotherapy. Restaging was carried out after four weeks and patients considered operable were underwent surgery., Results: In patients with cervical oesophageal cancer 35 of 55 (64%) underwent oesophageal resection or pharyngo-laryngectomy. In 16 out of 35 resected specimens (46%) complete histopathological remission (pCR) was observed. Perioperative mortality and anastomotic leaks were the same: 5/35 (14%). R0 resection rate was 82% and the 2- and 5 years survival rates were 41% and 18%. In 19 cases a larynx preserving pharyngo-oesophagectomy was performed and a free jejunal graft was used for reconstruction after a pharyngo-laryngectomy in 11 cases., Conclusion: The high rate of pCR (46%) confirmed that upper third oesophageal cancer has superior sensitivity to multimodal treatment. In 30 cases neoadjuvant chemo-radiotherapy was able to achieve tumour regression and render pharyngo-laryngo-oesophagectomy unnecessary.

Introduction: Various plastic surgery techniques were applied for oesophageal reconstruction in complicated cases. Myocutaneous flaps that are suitable to cover soft tissue defects of the neck may also be transferred and used for partial defects of the cervical oesophagus or securing a vulnerable suture line. Application of microsurgical techniques may also be useful in certain situations., Patients and Methods: Pectoralis major myocutaneous flap was used in 5 cases in our department between 1998 and 2012. Microsurgical techniques were used in 38 cases of esophageal reconstruction, which were 34 free jejunal grafts and 4 supercharged colon grafts., Results: 23 patients underwent primary reconstruction after pharyngolaryngectomy, while 15 patients had secondary reconstruction after failed previous operations or recurrence. When more experienced was gained free jejunal grafts were used for the cervical as well as thoracic oesophagus. Three grafts were lost, two of them were due to anastomotic thrombosis and one was due to severe MRSA wound infection., Conclusion: Complicated cases of oesophagus reconstructions may be successfully treated by the cooperation of oesophagus and plastic surgeons, which may result in an acceptable complication rate.

Introduction: The authors report their experience with central pancreatectomy and also summarize relevant literature data., Material and Methods: Central pancreatectomies were performed in 7 patients for benign or low-grade malignant pancreatic neoplasms, or pancreatic rupture in one patient. Most frequently applied anastomosis was between the distal part of the pancreas and a Roux-en-Y limb, while the proximal cut surface was closed with sutures, and the suture line was covered with a limb., Results: There were three complications (37%), but reoperation didn't need to be performed and none of the patients died. We did not detect any deterioration in the exocrine or endocrine function during the follow-up period., Conclusions: Central pancreatectomy is a safe procedure with excellent functional results, if both the indication and the applied technique are chosen appropriately.

Introduction: Functional proctological investigations have been introduced at Pécs University of Sciences 15 years ago. The Pelvic Floor Multidisciplinary Team has been re-launched after many years of pause in 2010. Experience of the team in the treatment of faecal incontinence and obstructed defecation syndrome is discussed., Patients: In the past 3 years 9 patients underwent sphincter reconstruction for faecal incontinence. The Pelvic Floor Team in the past 1.5 year consulted 31 patients with constipation, who were considered by the referee for surgical intervention. Following investigations 10 patients underwent surgery, the rest of them were treated conservatively. Seven patients underwent perineal reconstruction with mesh, three patients had ventral rectopexy with additional levatoro-pexy., Results: 78% of patients operated on for faecal incontinence reported full continence, 88% improvement. We invented a new symptom score with a maximum of 20 points to evaluate results of treatment of patients with Obstructed Defecation Syndrome. Patients who underwent perineal repair were interviewed pre and postoperatively. They scored 14 ± 2.83 and 5.4 ± 4.62 points, respectively (p = 0.0075)., Conclusion: Functional proctological patients require a specialist approach from history taking through investigation to treatment. Majority of patients benefit from conservative treatment. Adequate patient selection is essential for successful surgical treatment. Symptom scores applied pre and postoperatively facilitate proper patient selection for various surgical methods.

Introduction: Minimal invasive surgery of the adrenal gland is a "gold standard" procedure worldwide. Authors compare operative data to a historical control group retrospectively analyzing an almost 15 years period., Material and Methods: Between 1997 and 2011, 175 transabdominal laparoscopic adrenalectomies were performed with the lateral approach. On the left side, a new "suprasplenic" approach was introduced with the superior mobilization of the spleen, and transection of the short gastric vessels. For larger lesions (above 7 cm) hand assisted laparoscopic method was applied., Results: Average operative time of laparoscopic surgery was 77 minutes, compared to 115 minutes of open surgery. The average size of the tumor was 3.1 cm in the laparoscopic, and 4.9 cm in the open group. The largest tumors were similar in both groups, however the rate of smaller sized lesions was higher in the laparoscopic one. Conversion was required in 15 cases (8.6%) mostly due to bleeding. Complication rate was 10.8% in the laparoscopic and 24.6% in the conventional group. Hospital stay was significantly shorter with the laparoscopic technique (4.5 vs. 8.1 days). Among laparoscopic cases unexpected primary malignancy was reported in 3 cases (1.7%)., Conclusions: The laparoscopic technique is the procedure of choice in case of benign adrenal tumors, which offer many advantages. Most metastasis localized to the adrenals can also be removed laparoscopically with expertise and self-restraint, without oncologic compromise. To assure the quality of pre- and postoperative care, cooperation with an endocrinologist is indispensable.

Introduction: The most frequent surgical complications following pancreatic resections are pancreatic fistula and delayed gastric emptying. The aim of the authors was to analyse these complications in their own practice., Material and Methods: Clinical data of 287 patients were reviewed, who were radically operated on for malignant pancreatic or periampullary tumours during 14 years period. The most common neoplasm was pancreatic adenocarcinoma, located in the head of the pancreas. Pylorus-preserving pancreatoduodenectomy was most frequently performed. In the early period pancreatogastrostomy and double-layer pancreatojejunostomy were preferred during the reconstruction, as well as retrocolic duodeno-, and gastrojejunostomy, respectively. Later the authors turned to the single-layer implantation pancreatojejunostomy and to the antecolic reconstruction, the latter was completed with Braun anastomosis., Results: In the postoperative course complications occurred in 39%, reoperation was done in 5.6%, and the early mortality rate was 3.8%. The rate of pancreatic fistula decreased to 5.9% following single-layer pancreatojejunostomy, and the difference was significant compared to the 17.6% rate after pancreatogastrostomy. Due to the antecolic reconstruction the frequency of delayed gastric emptying has reduced from 10.2% to 2.1%, which is a statistically significant difference., Conclusions: As a result of changes in the surgical techniques during the 14 years period, the frequency of pancreatic fistula and delayed gastic emptying has dramatically decreased, which underlines the need of continuous progress in surgical methods.

Introduction: Total gastrectomy leads to decreased quality of life, which is characterized by different symptoms of the postgastrectomy syndrome. Aim of this study was to investigate the correlation of different alimentary symptoms and habits in correlation with the reconstruction type after total gastrectomy., Patients and Methods: Between 2005-2009 34 patients after total gastrectomy for gastric cancer were evaluated with questionnaires. Twenty two had a standard Roux-en-Y reconstruction, while 12 Longmire type jejunal interposition. Early dumping syndrome was investigated with the Sigstad score., Results: Most of the investigated parameters were similar in Roux-en-Y and Jejunal Interposition patients. Early dumping syndrome however occurred significantly less frequantly after jejunal interposition., Conclusion: Preservation of the duodenal passage after total gastrectomy reduces the prevalence of early dumping.

The prediction of graft rejection can play an important part in graft survival. Analysis of immune reactions has shown that graft rejection shares mechanisms with recurrent abortions during pregnancy. Progesterone-induced blocking factor (PIBF), a mediator of progesterone that blocks natural killer cell activity in peripheral blood, produces antiabortive effects. The aim of this study was to examine the PIBF concentration in the urine of transplanted recipients. The study included 116 white adults (70 men and 46 women) of median age 49.3 years, who had undergone kidney transplantations. The median duration after transplantation was 3.46 years. The average period between renal disease and our measurement was 12.3 years, and the median interval between graft rejection and our study was 1.75 years. Urine samples were used to measure PIBF concentrations by an enzyme-linked immunsorbent assay. PIBF urinary concentrations decreased significantly in patients who experienced ≥1 rejection episode (31.8±2.2 ng/mL) compared with those without any episode (22.7±1.2 ng/ml; P<.01). Moreover, the urinary PIBF level was significantly lower among patients who had increased creatinine and urea nitrogen levels in blood samples (P<.05 and P<.01, respectively). Decreased PIBF values in kidney transplant patients followed previous rejection episodes. A close negative correlation was observed between urinary PIBF concentrations and blood levels of creatinine and urea nitrogen. These findings suggested that PIBF detection may predict graft rejection in transplant recipients., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Introduction: Many factors contribute to the pathogenesis of morbid obesity, and the central nervous system - as one of those - also has an important role. Numerous studies focus on the central regulation of eating and metabolism, since associated problems like obesity, anorexia, diabetes or metabolic syndrome put an increasing burden on the health system of modern societies. Neither the pathophysiologic changes, nor the normal regulation of these systems are known adequately. Functional MR (fMRI) imaging, which has certainly gained popularity recently, aims to better understand these mechanisms. In this series we studied the brain fMRI activity changes of normal and obese persons, triggered by gustatory stimulation., Methods: 10 obese and 10 normal weight healthy volunteers took part in the study, with comparable age and sex distribution. Gustatory stimulation was performed by 0.1 M sucrose (pleasant), 0.5 mM quinine HCl (unpleasant) and complex vanilla flavored (Nutridrink) solutions, which were administered through 0.5 mm PVC tubes, in 5-5 ml portions. For rinsing distilled water with neutral flavor was used. Imaging was performed in a 3T MRI, applying standard EPI sequences. Post processing of data was accomplished by FSL software package., Results: Brain activation for gustatory stimuli was characteristically different between the two groups. There were high intensity activations in more cortical and subcortical regions of the obese volunteers compared to the normal ones., Conclusions: Our current fMRI investigations revealed different activations of numerous brain regions of normal and obese individuals, triggered by pleasant and unpleasant gustatory stimulation. Based on these results this method can help to recognize the role of the central nervous system in obesity, and may contribute to develop new therapies for weight loss.

Introduction/aim: The importance of preoperative neoadjuvant (NA) systemic treatment in operable breast cancer has significantly increased in the last few years. The aim of our retrospective study was to determine the effect of NA therapy in breast cancer patients treated in our unit and analyze radiological and pathological response rates in the context of surgical treatment., Materials and Methods: One hundred and fourteen cases of breast cancer with NA therapy were analyzed and clinical data were collected from March 2007 to December 2010. Twenty-two patients received NA treatment for inoperable tumours. As far as operable cancers (92 patients), the indications for NA treatment were high tumour grade, presence of axillary metastasis and relatively young age. 5-Fluorouracil-Epirubicin-Cyclophosphamid or Taxotere-Epirubicin regimens were administered in 6 cycles followed by radiological evaluation and surgery. Herein, we compared the preoperative staging with the pathological results after surgery., Results: NA therapy resulted in complete regression in 17% of patients, significant regression in 21%, while moderate regression was achieved in 43% of patients. No regression was detected in 19%. The decrease in T stage was not followed by decrease in N stage in significant number of cases. Moreover, in some cases NA therapy caused complete radiological regression, while histologically it still remained positive. In certain cases, breast conserving surgery was feasible due to down-staging caused by NA therapy., Conclusion: NA therapy was effective primarily in decreasing tumour size; however, it was less effective on axillary lymph node metastases. Due to the presence of the residual DCIS component, the volume of resection could not be decreased as much as down-staging of the invasive cancer would have permitted.

Background/aims: A single-centre experience gained by middle segmental pancreatic resection and a brief survey of technique and indications are reported., Methodology: During the past 7 years 7 middle segmental pancreatic resections were performed for benign and low-grade malignant pancreatic lesions and in 1 case for pancreatic trauma. The preferred method was anastomosing the distal remnant to a Roux-en-Y limb, closure of the proximal cut end with sutures and in the last 4 patients covering this suture line with the limb., Results: There were 3 complications out of 8 cases (37%) and the surgical morbidity rate was 12%. It did not come to reoperation and lethal outcome. During the follow-up time both the endocrine and exocrine functions remained normal in all patients., Conclusions: Middle segmental pancreatic resection could be carried out with an acceptable morbidity rate. However the proper indication and surgical technique are important factors in achieving advantageous results.

Oncologic surgery and pTNM staging require systemic removal of the locoregional lymphnodes. While the optimal extent and therapeutical and/or prognostic value of the lymphadenectomy/sampling are debated organ by organ and (sub)speciality by (sub)speciality, relevance of the lymphnode sytem-tumor concept itself is beyond doubt. Loss of information and existence of traps on the "surgical field-microscope" pathway is an international phenomenon, calling for solution. An integrated sterile and disposable lymphnode tray system is presented here for applications in the different fields of cancer surgery of the upper GI tract, retroperitoneum (gynecology, urology) and ear-nose-throat surgery.

Unlabelled: Authors discuss long-term results of inguinal hernia repairs. Patients were asked to fill in a questionnaire to compare five-year outcomes after tension-free and non-mesh inguinal hernia reconstructions., Results: the trial is based on the assessement of 155 patients' replies. Recurrence rate in tension-free (TF) cases is 3.4% (4/116), while in suture repair (non-mesh - NM) group is 12.8% (5/39). The ratios of totally symptom-free patients are 83% (97/116 - TF) and 89% (35/39 - NM). Severe chronic pain occurred in 1.7% (2/116 - TF) and 7.7% (3/39 - NM). Early return to normal activity was 34% (39/116 - TF) and 29% (11/39 - NM)., Conclusion: Based on this retrospective study Lichtenstein repair is superior to non-mesh open inguinal reconstruction, as regards recurrence rates, but chronic pain and recovery time show similar long term results in both groups, which is different from the relevant published literature.

Primary suture repair of large hiatal hernias is associated with high recurrence rate, but the use of mesh may improve the results. There is no agreement about the ideal size, shape, or material of these mesh prosthesis, or the way those should be fixed to the crura. One of the biggest concerns of insetting a prosthetic material at the hiatus is erosion into the stomach, esophagus, or both. Cardiac injury at the time of mesh anchorage is a rare but potentially fatal complication. Introduction of biomaterials into clinical practise has completely changed the outlook of these surgical procedures.

Background: There are several well-known procedures to treat abdominal wall hernias, but the results are quite controversial. The aim of study was to compare the results of different surgical modalities - mesh (onlay vs. sublay position) and suture repair - in the treatment of abdominal wall hernias., Methods: A five-year randomized, multicentric, internet-based, clinical trial was started in 2002. 953 patients were included in the study and divided into two groups according to the size of hernia orifice. In group 'A' ( n = 494) the surface of hernia orifice was between 5-25 cm 2 (small hernia), and in group 'B' ( n = 459) it was above 25 cm 2 (large hernia). Patients of these two groups were randomized according to surgery: group 'A' (suture vs. mesh) and in group 'B' (mesh in onlay vs. sublay position). In group 'A' suture repair was performed in 247, and sublay mesh implantation in 247 cases. In group 'B' sublay ( n = 235) and onlay ( n = 224) mesh reconstruction was performed. The patients were followed-up for five years., Results: 734 patients - 77% of all randomized cases - have completed the study. In the small hernia group significantly ( p < 0.001) higher recurrences occurred after suture repair ( n = 50-27%) than in mesh repair ( n = 15-8%). In the large hernia group onlay mesh reconstruction provided significantly better ( p < 0.05) results than sublay reconstruction, recurrence rate was much lower in onlay group [ n = 22 (12%) vs. n = 38 (20%)]., Conclusion: Mesh repair provides better results than suture repair. In case of large hernias the recurrence rate is higher after sublay reconstruction. The randomized trial was registered on www.ClinicalTrials.gov - ID number: NCT01018524.

The authors report the case of a colon adenocarcinoma developed on the neck at the anastomosis of the skin tube and colon 44 years following a corrosive oesophageal injury. This patient suffered a moderately severe oesophageal, stomach and laryngeal injuries due to drinking hydrochloric acid 44 years ago. He underwent serial laryngoplasties, then needed a tracheostomy, oesophagectomy, pyloroplasty and ileocolon transposition. An antethoracal oesophagus formation was performed with ileocolon and skin tube amendment. 44 years later an ulcerated adenocarcinoma developed in the transposed colon, which was resected and the ability to swallow was reinstated by the transplantation of an isolated jejunal segment using microvascular anastomosis.

Transplant recipients are at high risk of nonmelanoma skin cancer (NMSC). Ultraviolet radiation can generate oxygen free radicals (OFRs), leading to oxidative stress and carcinogenesis, primarily during immunosuppression therapy. In the present study, changes in oxidative stress were examined in transplant recipients with and without NMSC. The study included 116 white adults who had undergone kidney or combined kidney-pancreas transplantation. Dermatologic follow-up revealed 16 NMSCs (13.8%). To monitor oxidative stress, peripheral blood samples were used to measure malondialdehyde (MDA), reduced glutathione, sulfhydryl (-SH) groups, OFRs, and activity of myeloperoxidase, superoxide dismutase, and catalase. The mean (SD) plasma MDA concentration was significantly greater in patients without NMSC compared with healthy control individuals (0.48+/-0.05 nmol/mL; P < .05), whereas MDA concentration in hemolysate was slightly increased. In peripheral blood samples, the MDA concentration in both plasma (0.71+/-0.03 nmol/mL) and hemolysate (87.74+/-1.25 nmol/mL) was significantly increased in the NMSC group compared with the healthy control group (0.24+/-0.05 nmol/mL vs 75.87+/-2.8 nmol/mL; P < .05) or patients without NMSC (0.48+/-0.04 nmol/mL vs 79.62+/-2.77 nmol/mL; P < .05). The reduced glutathione concentration was significantly decreased in the -SH groups compared with the healthy control group (P < .05). Antioxidant activity of myeloperoxidase (0.78+/-0.05 IU/mL) and catalase (1855.8+/-45.41 IU/mL) was significantly increased in the group without NMSC compared with the healthy control group (0.41+/-0.1 IU/mL vs 1642.07+/-82.96 IU/mL) and the NMSC group (0.93+/-0.03 IU/mL vs 2180.5+/-15.03 IU/mL). The superoxide dismutase activity was decreased slightly but not significantly. Total production of OFRs was significantly greater in the NMSC group compared with the non-NMSC group or the healthy control group (P < .05). These findings suggest that an imbalance exists between pro-oxidant and antioxidant status in transplant recipients, with a significant difference in patients with vs without NMSC., (Copyright 2010 Elsevier Inc. All rights reserved.)

There is increasing evidence that nonmelanoma skin cancers (NMSCs) are the most frequently observed tumors in transplant recipients. The incidence of posttransplantation NMSC was determined using our dermatologic screening program. Included in the study were 116 white adults (70 men and 46 women; median age, 49.3 years) who had undergone kidney or combined kidney-pancreas transplantation, with follow-up from September 2008 to December 2009. All patients underwent a full skin examination for NMSC, and completed a standardized questionnaire. Screening resulted in detection of 16 NMSCs in 11 patients out of 116 (9.5%). Lesions were equally distributed by sex, and were detected at a median of 4.1 years posttransplantation. Histologic analysis verified 13 basal cell carcinomas and 3 squamous cell carcinomas (ratio, 4:1). The incidence of NMSC was significantly greater in patients who received cyclosporine immunosuppression therapy (16 vs 1; P < .05), had experienced 2 or more painful sunburns before transplantation (10 vs 11), or worked outdoors (10 vs 11). These data indicate the relevance of skin cancer surveillance in transplant recipients. Our results correspond to international statistics except for the ratio of basal cell carcinoma to squamous cell carcinoma. Further studies are needed to elucidate the reasons for this difference., (Copyright 2010 Elsevier Inc. All rights reserved.)

Introduction: Increasing evidence suggests that non-melanoma skin cancers (NMSC) are the most frequent tumours in transplanted patients. In this study, we present the first Hungarian dermatological screening program to establish the incidence of NMSC after organ transplantations., Patients and Methods: 116 adult, "Caucasian" (white skin) transplanted (kidney, simultaneous-pancreas-kidney) patients (70 male and 46 female) of the Surgical Department of Pécs University were enrolled from September 2008. All patients underwent a a full skin examination by a dermatologist for NMSC as well as a standardized questionnaire was filled in to assess risk factors., Results: Screening resulted in 16 NMSC (13.8%, median age: 49.3 years, male : female = 1 : 1) diagnoses with a median duration from transplantation of 4.1 years. Histology showed 13 basal cell carcinoma (BBC), 3 squamous cell carcinoma (SCC), with a 4 : 1 ratio of BCC : SCC. Incidence of NMSC was significantly higher on patients who were treated with cyclosporine as immunosuppressant, who had more than 2 sunburns prior to transplantation, or had outdoor workplace ( p < 0.05)., Conclusions: These data confirm the importance of skin cancer surveillance in transplant recipients via a close cooperation between Transplantation and Dermatological Centres. Our results reflect the international data, except for the BCC : SCC ratio. Further studies needed to elucidate this difference.

We investigated the response rate and side effects of simultaneous, neoadjuvant radiochemotherapy (RCT) in locally advanced rectal cancer. Between 2005 and 2007, we treated 112 patients in stage II-III rectal carcinoma at the Institute of Oncotherapy, University of Pécs. For staging abdomino-pelvic CT (112) and transrectal US (49) or pelvic MR (10), or PET-CT (1) was performed. Radiation therapy was delivered with 3D CRT-based technique using belly-board with 18 MV photon energy, while patients in prone position. A total dose of 45 Gy (single dose 1.8 Gy) was delivered to the tumor and the pelvic lymph nodes. 5-FU and Ca-folinate was administered concomitantly in the 1st and 5th week of radiotherapy. Four weeks after delivering neoadjuvant RCT the patients' control CT was evaluated according to RECIST criteria. RCT was followed by surgery in 6-9 weeks. We graded the histology using the Mandard regression score system. Side effects were registered using CTCAE v 3.0. Grade 1, 2 or 3 acute gastrointestinal toxicity occurred in 12%, grade 3 hematological toxicity in 9.5% of the patients. The response rate determined by using control CT was 64.85%. According to the Mandard regression score, TRG1 occurred in 15%, TRG2 in 30.4%, TRG3 in 28%, TRG4 in 24% and TRG5 in 2.6% of the cases. Radical surgery was performed in 89 cases, 72 with R0 resection. By assessing the histological samples we found downstaging in 46% of the T and 34.5% of the N stage. We have no information on increased postoperative complications. We followed 86 patients after neoadjuvant therapy. Until March 2009 there was no progression in 48 of our patients. In 13 cases local relapse occurred, and in 25 cases the disease progressed because of distant metastasis, although local control was maintained. 10 patients had local relapse and distant metastases. 17 patients passed away. As a conclusion, neoadjuvant RCT of Stage II-III patients is an effective and well tolerated treatment, allowing for high R0 resection rate and bearing no higher risk for postoperative morbidity.

Intraluminal duodenal diverticula are a rare congenital disorders, which usually become symptomatic in adults. In our case, recurrent pancreatitis was caused by an intraluminal duodenal diverticulum in a 26 year old woman. The diagnosis was established by CT scan and upper gastroduodenal endoscopy. The intraluminal diverticulum was resected after duodenotomy. In addition, annular pancreas was found during laparotomy. In this case, an intraluminal duodenal diverticulum caused acute pancreatitis and was associated with another anatomical abnormality.

The authors analyse the results of 363 patients, who underwent surgery for pancreatic or periampullary tumours. There were 175 operable and 188 inoperable cases. The preoperative data (age, gender, site of the tumour, characteristic clinical signs), as well as surgical methods are overviewed. A pancreatoduodenectomy was most frequently applied as a curative surgery, while double-bypass was mainly performed for palliation. As far as postoperative complications, especially the rate of pancreatic fistula, which is influenced by the anastomotic method, are discussed. Reoperation and early postoperative mortality rate was 5,7% and 4,5% in the operable cases, respectively. These numbers were 1,6% and 6,9% among the inoperable cases. Following radical procedure adjuvant therapy followed surgical treatment, its results are also reported. In summary, curative surgical therapy and postoperative adjuvant treatment are necessary for a chance of long-term survival.

Introduction/aims: Prostheses use for lower limb amputees is difficult, while the socket is hard, the prosthesis is heavy. Drawbacks of conventional prosthesis are mainly associated with the socket, therefore osseointegration technique is a promising solution, since it doesn't require a socket. Our aim was to introduce this technique in Hungary and extend indication for vascular patients., Methods: The method includes two operative and one rehabilitation phases: during first operation a titanium screw is fixed into the femoral bone marrow cavity, this connects to an abutment, which also penetrates the skin, making a direct connection between the femur and the prosthesis during the second intervention. During rehabilitation the patient makes loading exercises and learns to walk with new prosthesis., Results: This method was launched in Hungary in 2005. Two female amputees were operated on initially, their second surgery was performed in 2006 (when titanium screw was applied in the male patients, as well). Incorporation of titanium screw was exquisite, and rehabilitation was successful. One of our male patients died eight months after his first operation due to myocardial infarction., Conclusion: Based on our experiences, the osseointegration technique facilitates rehabilitation of vascular patients for prostheses use. Adequate follow-up and stable vascular diseases are not contraindications, although further clinical trials are needed to determine its indication.

Adenocarcinomas in Barrett's oesophagus are more commonly diagnosed at an early stage due to effective surveillance programmes. Subtotal oesophagectomy with extended lymphadenectomy is considered the best curative treatment for patients with early adenocarcinoma of the oesophagus. However, such treatment carries substantial morbidity and compromises quality of life. Limited resection, minimal invasive surgical procedures or endoscopic mucosal ablation have been proposed as less invasive alternatives. A comparison of treatment associated morbidity, recurrence rate, long-term survival and functional outcome suggests that none of these alternative methods can be universally recommended. An individualized strategy should be employed based on staging (tumour penetration into the mucosa/submucosa, presence of lymph node metastasis), multicentricity, length of the underlying Barrett mucosa and risk factors of the patient. Surgical resection (radical or limited) remains the treatment of choice for tumours invading the submucosa, or multicentric and recurrent tumours after endoscopic mucosectomy.

Case Report: pLMS in the wall of the inferior vena cava is an extremely rare form of retroperitoneal malignancies. A case in a young female patient is presented; clinical symptoms, pre- and postoperative diagnosis and surgical treatment are discussed. A retroperitoneal mass detected by imaging was found to be a large tumor mass located at the middle segment of the IVC on exploration. The tumour was successfully excised and the IVC was reconstructed with a synthetic graft. Eight years later, this patient needed a repeat surgery due to local recurrence. This time tumour was attached to the left renal vein. A re-resection of the IVC was performed with subsequent synthetic graft reconstruction and the distal end of the left renal vein was reimplanted into a lower segment of IVC., Discussion: Primary leiomyosarcoma of the inferior vena cava (pLMS-IVC) is an extremely rare form of retroperitoneal malignancies. The tumour arises from the medial layer of the venous wall and can grow either intraluminally, or extraluminally or in both directions, as well. It can be localized in the first segment of IVC (above the hepatic veins), in the second segment between hepatic and renal veins and finally in the third segment between the right common iliac vein and renal veins. Therefore, the tumour can infiltrate both hepatic and/or renal vessels. Upper segment tumours can cause Budd-Chiari syndrome (hepatomegaly, abdominal pain, jaundice and ascites) with a bad prognosis. Middle segment tumours usually present with right upper quadrant pain, or may mimic biliary tract disease with a much better prognosis. Accumulating experience suggests that radio-chemotherapy alone seems to be less effective than "en bloc" resection with clear margins including loco-regional lymph nodes. Therefore, our choice of treatment was the latter. Although radical resection can be carried out in most of cases, 50% of patients develop a late recurrence yet.

Introduction: The incidence of cicatricial carcinoma of the scarred esophagus in patients with corrosive injuries is relatively high. Therefore, the necessity to resect the diseased oesophagus was raised as opposed to carry out a simple by-pass reconstruction only., Case Report: A 56-year-old female patient with a past medical history of lye consumption presented with a stricture of the esophagus. She underwent resection of the diseased esophagus with mediastinal colon interposition. 28 years after surgery the patient had symptoms of progressive dysphagia and loss of weight caused by scar cancer of the esophagus. After neoadjuvant chemo-radiotherapy, resection of the remainder oesophagus was performed with free jejunal transplantation. On postoperative day 14 the patient had been discharged with no complications and good swallowing function., Conclusion: In our case, scar cancer developed 28 years after oesophageal resection and more than 50 years after the corrosive injury. This case is another argument for simple bypass.

Adenocarcinomas in Barrett's esophagus are increasingly diagnosed at early stages thanks to effective surveillance programs. Subtotal esophagectomy with extended lymphadenectomy is considered the best curative treatment for patients with early adenocarcinoma of the esophagus. However, such treatment is associated with substantial morbidity and compromised quality of life. Limited resection, minimal invasive surgical procedures or endoscopic mucosal ablation have been proposed as less invasive alternatives. A comparison of treatment-associated morbidity, recurrence rate, long-term survival and functional outcome suggests that none of these alternative methods can be universally recommended. An individualized strategy should be employed based on staging (tumor penetration into the mucosa/submucosa, presence of lymph node metastasis), multicentricity of tumor, length of the underlying Barrett's mucosa and risk factors of the affected patient. Surgical resection (radical or limited) remains the treatment of choice for tumors invading the submucosa, multicentric tumor growth and recurrence after endoscopic mucosectomy.

Tissue injury caused by cold preservation and reperfusion during small bowel transplantation remains an unsolved problem. Increasing evidence suggests that pituitary adenylate cyclase-activating polypeptide (PACAP) has protective effects in several ischemia-reperfusion (I/R) models. This study investigated the effect of PACAP-38 on oxidative stress in autotransplanted intestine. We established sham-operated, I/R, and autotransplanted groups in Wistar rats (n = 55). We applied ischemia for 1 (GI), 2 (GII), or 3 hours (GIII). In autotransplanted groups, we performed total orthotopic intestinal autotransplantation. Grafts were preserved in University of Wisconsin (UW) solution for 1 (GIV), 2 (GV), 3 (GVI), or 6 (GVII) hours and in PACAP-38-containing UW for 1 (GVIII), 2 (GIX), 3 (GX), or 6 (GXI) hours. Reperfusion lasted 3 hours in each group. Endogenous PACAP-38 values were measured by radioimmunoassay. Oxidative stress parameters malondialdehyde (MDA), reduced glutathione (GSH), and superoxide dismutase (SOD) were measured in tissue homogenates. Concentration of endogenous PACAP-38 significantly decreased in GI to GIII compared with the sham-operated animals following I/R periods (P < .05). Cold preservation in UW and reperfusion of the intestine increased the level of tissue MDA in GIV to GVII, which correlated with the duration of cold storage. The content of GSH decreased in GIV to GVII to levels that were significantly different between GIV and GVIII and between GVII and GXI. SOD activity decreased dramatically in GIV to GVII with significantly higher activity in GIX to GXI. Our findings confirmed that I/R decreased endogenous PACAP-38 concentration. Administration of PACAP-38 to UW solution mitigated the oxidative injury during intestinal autotransplantation.

Cold preservation prior to small bowel transplantation can moderate tissue oxidative injury. This stress triggers several intracellular pathways via mitogen activated protein (MAP) kinases. MAP kinases include the extracellular signal related kinase (ERK), c-Jun N-terminal kinase (JNK), and p38 MAP kinase. Pituitary adenylate cyclase-activating polypeptide (PACAP) plays a central role in intestinal physiology. We sought to investigate the effect of PACAP on the activation of MAP kinases during cold preservation of the small bowel. Total orthotopic intestinal autotransplantation was performed on 40 Wistar rats. Perfused grafts were stored in University of Wisconsin (UW) solution for 1 (GI), 2 (GII), 3 (GIII), or 6 hours (GIV) without or with 30 PACAP, namely 1 (GV), 2 (GVI), 3 (GVII), or 6 hours (GVIII). After 3 hours of reperfusion in all groups, the activation of MAP kinases were measured using immunocytochemistry of small bowel tissue. Among the UW preserved grafts (GI-GIV), phosphorylated ERK1/2 level were decreased, while phosphorylated JNK1/2 and p38 MAP kinase activation were elevated compared with control levels. In GV-GVIII PACAP we observed enhanced phospho-ERK1/2 appearance with decreased JNK and p38 MAP kinase activity at the end of the reperfusion periods. We concluded that cold preservation decreased phosphorylated ERK1/2 levels and increased JNK1/2 and p38 MAP kinase activities, which meant that cold storage triggered apoptotic cell death. In contrast, PACAP treatment induced signalling pathways protective against oxidative injury by MAP kinases in bowel tissue.

The leading cause of morbidity following pancreatic resections is constituted by pancreatic fistulae. Several methods are used for the prevention of this problem, although the ideal solution is still being searched for. The authors modified the technique of single-layer end-to-side pancreatojejunostomy, creating the anastomosis with special interrupted stitches. 45 patients were operated on for benign or malignant pancreatic diseases and none of them had pancreatic fistula as a complication. The method is technically easy to perform and seems to be safe.

Lung cancer is a leading cause of death in the civilised world. Surgical resection, which play a crucial role in the complex oncological treatment, has to be offered in older ages than it was done before, due to an ageing population. Results of surgical treatment of patients older than 75 years are investigated retrospectively in the present paper. A retrospectively analysis was carried out of 54 from a total of 884 lung resections for primary lung cancer performed for patients older than 75 years between 1995-2005. Twelve of these patients were above 80 years. Kaplan-Meier analysis was performed to calculate survival and multifactor analysis for the risk factors. Average age was 77.5 years (75-85). Two pneumonectomies, two bilobectomies, 41 lobectomies, seven sublobar resections and two lobectomies with chest wall resections were performed. The average hospital stay was 11.4 days (8-36). Mortality: 7.4% (n = 4), morbidity: 52% (n = 28) including: sputum retention: 43%, arrhythmia 33%, atelectasia: 15%. There were two bronchial stump insufficiencies (4%) and three reoperations were performed (5%). The average follow up was: 32 months and the five year survival 33.7% (median 43 months). Multifactorial analysis show that extended resection, male gender, age above 80 years are risk factors for adverse outcome. Female gender, stage Ia and lobectomy are considered as predictive factors for long survival. We conclude, that with proper patient selection (below ASA3, early stage) and with carefully conducted postoperative care (physiotherapy, monitoring) surgical resection should be offered to elderly lung cancer patients as well.

Aims and Background: The mortality of colorectal cancer continues to stagnate despite the development of new therapeutic approaches. Therefore, identifying high-risk population groups could contribute to the prevention of a considerable part of deaths caused by colorectal tumors., Methods: Fifty patients with colon cancer and 50 patients with other, nonmalignant diseases were selected for the study. Expression of the c-myc, Ha-ras and p53 genes was determined in the peripheral leukocytes of the participants., Results: Marked elevations of the expression of all three investigated genes were seen in the colon cancer patients when compared to the controls., Conclusions: Our investigations showed that increases in the expression of c-myc, Ha-ras and p53 genes can be demonstrated in the peripheral leukocytes of colon cancer patients. By applying our method to clinical investigations, individuals with a high risk of having developed colon cancer may be identified and early diagnosis may be established.

Background: Total gastrectomy results in a significant weight loss, different postgastrectomy symptoms, and a reduction in quality of life. Elaborate surgical reconstruction methods are evaluated to improve results. The present study compares two types of reconstructions--an aboral pouch with preserved duodenal passage and an oral pouch with preserved duodenal passage--differing only in the site of the pouch., Methods: Twenty-eight patients entered the study. Primary outcome measures--body weight, body mass index, and quality of life, and secondary outcome measures--serum nutritional parameters, scintigraphic small-intestinal passage, and lipid and carbohydrate absorption were measured 6, 12, and 24 months after surgery., Results: No significant differences were found in anthropometric parameters or in quality of life between the groups. Regarding the secondary outcome measures, albumin levels were higher in the oral pouch group, while protein and immunoglobulin-A levels were higher in the aboral pouch group., Conclusion: The site of the reservoir does not significantly influence the outcome after total gastrectomy and reconstruction with a preserved duodenal passage.

Aims: To evaluate the efficacy of duodenal switch operation for patients with duodeno-gastroesophageal reflux disease., Methods: Four female patients with therapy resistant epigastric pain and biliary regurgitation were enrolled in the study. In all cases, abnormal duodeno-gastric reflux was confirmed by 24-hour Bilitec monitoring. The average age of the patients was 41.75 years (range 32-53) and three of them had a cholecystectomy in the past. Importantly, all patients had previously undergone fundoplication, which had to be repeated in one of them due to recurrent symptoms. More recently, a duodenal switch procedure was performed in these four patients. Their mean follow-up time was 24.25 months (range 21-30)., Results: Duodenal switch was performed without any perioperative complications. A good clinical outcome was found in all patients on their follow up; however, an abnormal acidic exposure was found in one case on 24-hour oesophageal pH monitoring., Conclusion: Recurrent epigastric complaints developing after anti-reflux surgery in patients with a previous diagnosis of gastroesophageal reflux disease might be due to an abnormal duodeno-gastric reflux. Previous cholecystectomy may increase the risk of biliary reflux. Duodenal switch procedure can be applied with good results in patients with therapy resistant abnormal duodeno-gastric reflux confirmed with Bilitec monitoring.

Neurotransmitters released by myenteric neurons regulate movements of intestinal smooth muscles. There has been little pharmacological evidence for a role of purinergic mechanisms in the non-adrenergic, non-cholinergic (NANC) relaxation of the human large intestine. We used P(2) purinoceptor antagonists to assess whether such receptors are involved in the NANC relaxation of the circular muscle of the human sigmoid colon. It was also investigated whether the guanylate cyclase enzyme mediates the NANC response. Human colonic circular strips were tested in organ bath experiments with isotonic recording. NANC, non-nitrergic relaxations induced by electrical field stimulation (1 and 10 Hz, in the presence of atropine, guanethidine, and 100 microM N(G)-nitro-L-arginine [L-NOARG]) were strongly inhibited by a combination of the P(2) purinoceptor antagonists pyridoxal-phosphate-6-azophenyl-2',4'-sulfonic acid (PPADS) (50 microM) and suramin (100 microM). PPADS plus suramin was ineffective in the absence of L-NOARG. L-NOARG alone significantly reduced the NANC relaxation to electrical stimulation. PPADS plus suramin strongly inhibited the relaxation in response to exogenous alpha,beta-methylene ATP. The guanylate cyclase inhibitor 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one (ODQ) (3 microM) inhibited the NANC relaxation, but did not add to its reduction by L-NOARG. L-NOARG was still slightly effective in the presence of ODQ. Vasoactive intestinal polypeptide tachyphylaxis failed to influence the non-nitrergic NANC relaxation. It is concluded that nitric oxide (NO) and ATP co-mediate, in a non-additive manner, the NANC relaxation. NO probably acts through the guanylate cyclase, though a small fraction of its effect might be mediated by other mechanisms. Activators of the guanylate cyclase other than NO do not seem to participate in the NANC relaxation.

Aim: The aim of this study was to compare the efficiency of the preoperative combined chemo-radiotherapy in the treatment of locally advanced squamous cell carcinoma in different locations of the oesophagus., Methods: Between 1997 and 2005, 102 patients with locally advanced (T3-4) squamous cell oesophageal cancer received preoperative chemo-radiotherapy. In 40 cases, the tumour was localised in the upper-third (Group I), while in 62 cases, in the middle-third of the oesophagus (Group II). Survival rates of patients receiving neoadjuvant therapy were compared with a historical control group. In addition, Group I and Group II were compared to each other, as well., Results: survival rate was significantly better after neoadjuvant therapy (p:0.0042) Resection was performed in 70% of the patients from Group I, and in 50% of those complete pathological remission (pCR) was observed. The perioperative morbidity and mortality rates were 43% and 14%, respectively. As far as Group II, 69% of the patients underwent oesophageal resection, with a perioperative mortality of 18% and morbidity rate of 62%. pCR was observed only in 7% of the cases. The median survivals (21 and 22 months) and the R0 resection rates (82 and 84%) were similar in the two groups. The pCR subgroup showed a significantly better survival rate., Conclusion: In this study, we demonstrated that preoperative chemo-radiotherapy increases survival in locally advanced oesophageal cancer. A significantly higher rate of complete response was observed in patients with upper-third oesophageal cancer. It seems that this group has superior sensitivity to multimodal treatment; therefore, our results support a new prognostic factor in oesophageal cancer treatment.

Introduction: Results of a retrospective study of patients who underwent pulmonary metastasectomies after colorectal surgery in the last five years are reported here. Prognostic factors are evaluated and analyzed in the context of current literature., Material and Methods: 37 lung resections were performed in 33 patients between 2001 and 2006, the male:female ratio was 19:14. The average age was 61.3 years (49-76). We analyzed the extent of lung resections, disease free intervals (DFI), laterality of the tumours, number and locations of metastases, lymph node involvements and the incidence of resection of hepatic metastases. Altogether, 20 solitary lung metastases were removed and 17 multiple resections were performed. 25 sublobar resections, 11 lobectomies and one pneumonectomy were carried out. 18 patients had right sided, eight patients had left sided and six patients had bilateral disease. 6 of the 33 patients underwent either synchronous or metachronous liver resection for hepatic metastases., Results: Survivals were calculated by the Kaplan-Meier method. The average DFI was 27.6 months. When all patients were considered, the average survival was 28 months. 52% of the patients had a 3-year postoperative survival, if lung metastases were present only., Conclusions: Patients benefit from surgical removal of lung metastases of colorectal cancer. There were no differences in survival rates between patients who underwent resection of solitary or multiple lung metastases up to seven deposits. However, the average survival was 12 months shorter if hilar/mediastinal lymph nodes were involved. Furthermore, the average survival of six patients with hepatic metastases was 10 months shorter than the rest of the group. There was no benefit of DFI over 24 months. None of the other prognostic factors showed significant difference.

Background: In spite of the increase in radicality and extended resections, the prognosis of gastric cancer is very poor. Surgical resection is the only effective therapy. The morbidity and mortality of surgical interventions decreased during the last years., Method: The aim of this study was to evaluate the prognostic effect of different factors on survival of gastric cancer. A retrospective study of 483 patients with gastric cancer was performed. Data were collected from January 1993 to December 2002. There were 380 resections, 267 (70,2%) total gastrectomies, 93 (24.8%) distal resections and 20 (5.2%) proximal resections. Epidemiological factors, tumour and treatment related parameters were analysed. Kaplan-Meier method was used to assess survival and Cox regression analysis to evaluate the effect of prognostic factors on survival., Results: The rate of R0 resections was 73.4% for total gastrectomy, and 73% for distal gastrectomy. The five-year overall survival of the entire population was 26.08%, 36.2% of the resected patients and 69.05% of curative resections. In concordance with literature findings, radicality of resection, depth of tumour invasion and lymph node metastases proved to be the most powerful independent prognostic factors., Conclusion: Prognosis of gastric cancer can be remarkably improved by a complete resection of the tumour and its lymphatic drainage, even if extension of the resection is needed.