Bevezetés: A malignus megbetegedésekben szenvedő páciensek prehabilitációjának és rehabilitációjának kiemelkedően fontos eleme a tápláltság és a fizikai állapot felmérése és nyomon követése. Az ERAS- (Enhanced Recovery After Surgery) protokoll fontos része a posztoperatív korai, szájon keresztüli táplálás megkezdése. Az e táplálási metódusnak a felső gastrointestinalis traktus műtétei utáni alkalmazására vonatkozó adatok hiányosak. Célkitűzés: Annak igazolására, hogy a korai, szájon át történő táplálás nem jelent hátrányt ebben a betegcsoportban, a Pécsi Tudományegyetem Sebészeti Klinikáján a 2020 februárja és 2022 júliusa között ilyen módon táplált betegek adatait vetettük össze egy becsült részvételi valószínűség szerinti párosítási tanulmány során, a klasszikus módon kezelt betegek adataival. Módszer: Vizsgálatunkba olyan betegeket vontunk be, akik felső gastrointestinalis daganat miatti műtéten estek át, melynek során nyelőcsővel képzett anastomosis került kialakításra (teljes gastrectomiák és nyelőcső-resecciók). A tanulmány 50 beteget foglalt magában: 25 beteget a korai oralis táplálási csoportba, míg 25 beteget a hagyományos oralis táplálásban részesülő csoportba soroltunk. Eredmények: Az oralis táplálás átlagosan a korai táplálási csoportban a műtét utáni 2,09. napon, míg a késői táplálási csoportban az 5,52. napon kezdődött. A korai csoportban a posztoperatív kórházi tartózkodási idő átlagosan 8,875 nap volt, szemben a késői csoportban jegyzett 12,161 napos átlaggal (p<0,05). Ugyanakkor nem volt kimutatható különbség a mortalitási rátában, illetve az anastomosissal összefüggő szövődmények előfordulásában. Megbeszélés: Megállapítható, hogy a korai, szájon keresztüli táplálási csoportban statisztikailag szignifikáns csökkenés mutatható ki a bélműködés megindulásáig eltelt időben, a kórházi tartózkodási időt tekintve és a posztoperatív parenteralis táplálás időtartamában. Következtetés: Elmondható, hogy a korai, szájon keresztüli táplálás alkalmazása a felső gastrointestinalis traktus műtétei után is biztonságos. Orv Hetil. 2024; 165(1): 24–29.

Introduction: Assessing the nutritional and physical status of patients with malignant diseases, is an essential element in their prehabilitation and rehabilitation. Initiating early oral feeding is an important part of the Enhanced Recovery After Surgery (ERAS) protocol. However, there is a lack of data regarding the application of this feeding method after upper gastrointestinal tract surgeries. Objective: To demonstrate that early oral feeding has no disadvantages in this patient population, we compared the data of patients treated by early oral feeding method between January 2020 and July 2022 at the Department of Surgery, University of Pécs, through a propensity score-matching study, with data of patients treated by the traditional method. Method: In our study, we included patients who underwent surgery due to upper gastrointestinal tumors with an esophageal anastomosis (total gastrectomies and esophageal resections). The study included 50 patients, 25 patients in the early oral feeding group and 25 patients in the traditional oral feeding group, with similar characteristics. Results: Oral feeding in the early group was started 2.09 days, while in the traditional group 5.52 days after surgery on an average. The average length of hospital stay was 8.875 days in the early oral feeding group, compared to 12.161 days in the traditional oral feeding group (p<0.05). However, no significant differences were observed in the mortality rate and anastomosis-related complications. Discussion: We found that the early oral feeding group had a statistically significant reduction in the time until the return of bowel movements, the length of hospital stay, and the duration of postoperative parenteral nutrition. Conclusion: It can be concluded that the application of early oral feeding is safe and feasible after upper gastrointestinal tract surgeries Orv Hetil. 2024; 165(1): 24–29.

Introduction: Assessing the nutritional and physical status of patients with malignant diseases, is an essential element in their prehabilitation and rehabilitation. Initiating early oral feeding is an important part of the Enhanced Recovery After Surgery (ERAS) protocol. However, there is a lack of data regarding the application of this feeding method after upper gastrointestinal tract surgeries. Objective: To demonstrate that early oral feeding has no disadvantages in this patient population, we compared the data of patients treated by early oral feeding method between January 2020 and July 2022 at the Department of Surgery, University of Pecs, through a propensity score-matching study, with data of patients treated by the traditional method. Method: In our study, we included patients who underwent surgery due to upper gastrointestinal tumors with an esophageal anastomosis (total gastrectomies and esophageal resections). The study included 50 patients, 25 patients in the early oral feeding group and 25 patients in the traditional oral feeding group, with similar characteristics. Results: Oral feeding in the early group was started 2.09 days, while in the traditional group 5.52 days after surgery on an average. The average length of hospital stay was 8.875 days in the early oral feeding group, compared to 12.161 days in the traditional oral feeding group (p<0.05). However, no significant differences were observed in the mortality rate and anastomosis-related complications. Discussion: We found that the early oral feeding group had a statistically significant reduction in the time until the return of bowel movements, the length of hospital stay, and the duration of postoperative parenteral nutrition. Conclusion: It can be concluded that the application of early oral feeding is safe and feasible after upper gastrointestinal tract surgeries

INTRODUCTION:The outcomes of surgical interventions for achalasia treatment improved with the advent of minimally invasive surgery. Robotic-assisted Heller-Dor's (RAHD) procedure established over the last years, provides important advantages to surgeons, such as binocular three-dimensional vision and improvement of fine motor control.METHOD:Between October and December of 2022, first in Hungary, 3 patients (37-year-old man, 55- and 72-year-old women) underwent RAHD procedure for achalasia at the Clinical Centre of the University of Pécs using the da Vinci Xi system.RESULTS:RAHD procedure was feasible without any particular problems and the postoperative course of all three patients was uneventful. The operation times were 198, 204 and 238 minutes, including 23, 19 and 14 minutes for the setup time of the robot. By the last patient, due to an accompanying hiatal hernia, an additional hiatal reconstruction was also performed. In the first 2 cases, the patients were discharged on the 4th postoperative day, while in the last case, with the additional hiatal reconstruction, the patient was emitted on the 6th postoperative day.DISCUSSION:There are several published studies about RAHD cardiomyotomy. The general conclusion is that, in experienced hands, RAHD procedure is easy to perform, ensures a meticulous esophageal and gastric myotomy, allowing to visualize and divide each muscle fiber with a significantly lower rate of mucosal perforations. However, by RAHD procedure, the overall costs are higher, including a longer operation time during the learning curve. At the same time, the avoidance of mucosal lacerations and their possible consequences has to be weighed against the higher overall costs.CONCLUSION:Laparoscopic cardiomyotomy is the first standard upper-gastrointestinal operation where a clear advantage of the use of a surgical robot has been proven. Thus, wherever this equipment is available, it should be preferred for this procedure. Orv Hetil. 2023; 164(14): 542-547.

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.

BACKGROUND/AIM:In the modern minimally invasive era, diagnostic and therapeutic endoscopic interventions are one of the most emerging fields. For the new operational techniques, it is a major aim to develop reliable instruments, such as suturing devices for flexible endoscopes. The aim of this study was to assess the feasibility of a safe and reproducible suturing technique with an endoluminal suturing device.MATERIALS AND METHODS:The evaluation of the technique was performed in twenty explanted special prepared porcine stomachs. Three different techniques were compared, single stitches, figure-of-eight, or Z-pattern and running sutures in terms of suturing time and bursting pressure. After verification of the reliability of the method, a 3 cm long full thickness incision on the stomach was closed with the endoscopic suturing device in four surviving animals.RESULTS:In our ex vivo studies, we have shown that the figure of 8 or Z- technique is the most optimal for stomach closure without considerable time-cost, thus this technique was chosen as the standard method for the in vivo study. The endoscopic stomach wall suturing was successful in all four cases, the postoperative period was uneventful and ended on the tenth postoperative day with autopsy.CONCLUSION:With the applied suturing device, the endoscopic suturing of the stomach is safe and reproducible, thus a human application may also be justified.

Abstract Background The traditional feeding method, which started 5–7 days after upper gastrointestinal (UGI) tumor resections is the widely accepted method worldwide. ERAS protocol is becoming more and more common, but there is still not enough evidence that early postoperative oral feeding is safe following major UGI surgery. Patients and Methods: A propensity score matching study was conducted at the University of Pecs, Department of Surgery, Hungary between January 2020 and July 2022. The study included patients with UGI tumor resections where our early oral feeding (EOF) protocol were applied. Data were collected retrospectively and the EOF- group was compared with a control group, who have been cared for the traditional feeding method during this period. Results the study included 50 patients, 25 in the early oral feeding group, and 25 case-matched patients in the traditional oral feeding group. The start of the oral feeding was on day 2.09 in the EOF, and on day 5.52 in the LOF group. Statistically significant decreases were observed in the EOF group in the postoperative length of stay (8.875 days vs 12.06 days), first bowel movement, and length of postoperative intravenous fluid therapy. There were no significant differences in mortality, anastomosis insufficiency, anastomosis inflammation and stricture. Conclusions Our results confirmed, that in the EOF group the mortality and anastomosis leakages do not increase compared to the traditional feeding protocol. However EOF decreased the length of hospital stay resulted earlier recovery, and the quality of life was improved by starting early oral feeding.

Mechanical stimulation of the stretch receptors of the gastric wall can simulate the presence of indigested food leading to reduced food intake. We report the preliminary experimental results of an innovative concept of localized mechanical gastric stimulation. In a first survival study, a biocompatible bulking agent was injected either in the greater curvature (n = 8) or in the cardia wall (n = 8) of Wistar rats. Six animals served as sham. Changes of bulking volume, leptin levels and weight gain were monitored for 3 months. In a second acute study, a micro-motor (n = 10; MM) or a size-paired inactive device (n = 10; ID) where applied on the cardia, while 10 additional rats served as sham. Serum ghrelin and leptin were measured at baseline and every hour (T0–T1–T2–T3), during 3 h. In a third study, 24 implants of various shapes and sizes were introduced into the gastric subserosa of 6 Yucatan pigs. Monthly CT scans and gastroscopies were done for 6 months. Weight gain in the CW group was significant lower after 2 weeks and 3 months when compared to the shame and GC (p = 0.01/p = 0.01 and p = 0.048/p = 0.038 respectively). Significant lower increase of leptin production occurred at 2 weeks (p = 0.01) and 3 months (p = 0.008) in CW vs. SG. In the MM group significant reduction of the serum ghrelin was seen after 3 h. Leptin was significantly increased in both MM and ID groups after 3 h, while it was significantly reduced in sham rats. The global device retention was 43.5%. Devices with lower profile and with a biocompatible coating remained more likely in place without complications. Gastric mechanical stimulation induced a reduced weight gain and hormonal changes. Low profile and coated devices inserted within the gastric wall are more likely to be integrated.

Complex intraluminal surgical interventions of the gastrointestinal tract are challenging due to the limitation of existing instruments. Our group has developed a master–slave robotic flexible endoscopic platform that provides instrument triangulation in an endoluminal environment.

Background. The ability to perform reliable, secure endoluminal closure of the gastrointestinal tract wall, is a prerequisite to support the progress of the emerging field of endoluminal surgery. Along with advanced clipping systems, flexible endoscopic suturing devices are commercially available. Current systems can replicate traditional surgical suturing patterns in the endoluminal environment. The aim of this study was to evaluate the optimal endoluminal suturing technique using a flexible endoscopic suturing device. Materials and Methods. Procedures were performed on bench-top simulators containing 20 explanted porcine stomachs. A standardized 3-cm full-thickness incision was created on the anterior wall of each stomach using monopolar cautery. The gastrotomy was closed endoscopically using an over-the-scope suturing device (OverStitch, Apollo Endosurgery; Austin, TX). Three different techniques were used: single stitches, figure-of-8 pattern, and running suture. Material consumption and operation time were recorded and bursting pressure measurement of the closure was performed. Results. No statistically significant differences were identified in suturing time. Suturing time (minutes) was slightly shorter with the figure-of-8 technique (41.14 ± 4.6) versus interrupted (45.75 ± 1.1) versus continuous (51.44 ± 10.0), but the difference was not statistically significant. The number of sutures required was greater in the interrupted group. No significant difference was found in the burst pressure (mm Hg): figure-of-8 (45.85 ± 26.2) versus interrupted (30.5 ± 22.89) versus continuous (32.0 ± 26.5). In the figure-of-8 group, 85.5% of cases were leakproof above 30 mm Hg, while in the other groups only 50% of cases were so. Conclusion. A figure-of-8 suturing pattern seems to be the preferable suturing technique with the endoscopic suturing device.

Tumor-specific fluorescent antibodies, which can be recognized at a cellular or tissue level using optical imaging such as confocal laser endomicroscopy (CLE), could provide a means for rapid and accurate tumor diagnosis and staging. The aim of this study was to evaluate the ability of CLE to detect the presence of tagged cells within lymph nodes in an original simulated metastatic model.

Bile leakage is a serious complication occurring in up to 10 % of hepatic resections. Intraoperative detection of bile leakage is challenging, and concomitant blood oozing can mask the presence of bile. Intraductal dye injection [methylene blue or indocyanine green (ICG)] is a validated technique to detect bile leakage. However, this method is time-consuming, particularly in the laparoscopic setting. A novel narrow band imaging (NBI) modality (SPECTRA-A; Karl Storz, Tuttlingen, Germany) allows easy discrimination of the presence of bile, which appears in clear orange, by image processing. The aim of this experimental study was to evaluate SPECTRA-A ability to detect bile leakage.

Background. Fistulas after esophagectomy are a significant cause of morbidity and mortality. Several endoscopic treatments have been attempted, with varying success. An experimental model that could validate new approaches such as cellular therapies is highly desirable. The aim of this study was to create a chronic esophageal enterocutaneous fistula model in order to study future experimental treatment options. Methods. Eight pigs (six 35-kg young German and two 50-kg adult Yucatan pigs) were used. Through a left and right cervicotomy, under endoscopic view, 1 (group A, n = 6) or 2 (group B, n = 7) plastic catheters were introduced into the esophagus 30 cm from the dental arches bilaterally and left in place for 1 month. Radiologic and endoscopic fistula tract evaluations were performed at postoperative day (POD; 30) and at sacrifice (POD 45). Results. Three fistulas were excluded from the study because of early (POD 5) dislodgment of the catheter, with complete fistula closure. At catheter removal (POD 30), the external orifice was larger in group B (5.2 ± 1.1 mm vs 2.6 ± 0.4 mm) with more severe inflammation (72% vs 33%). At POD 45, the external orifice was closed in all fistulas in group A and in 1/7 in group B. At necropsy, the fistula tract was still present in all animals. Yucatan pigs showed more complex tracts, with a high level of necrosis and substantial fibrotic infiltration. Conclusions. In this article, we show a reproducible, safe, and effective technique to create an esophagocutaneous fistula model in a large experimental animal.

BACKGROUND:Peritoneal dialysis (PD) catheters placed in the pelvic space without anchoring present a high rate of migration. We aimed to assess the feasibility of a single-incision approach, using a flexible endoscopic preperitoneal tunneling for catheter implantation and fixation.MATERIALS AND METHODS:Eight pigs were involved in this experimental study. A 2/0 Vicryl loop was sutured at the tip of a PD catheter. In 4 pigs, a 1.5 cm incision was made on the left paramedian line and the parietal peritoneal layer was identified by splitting rectal muscles. A gastroscope was inserted in the incision and advanced in the extraperitoneal space. An exit hole was made in the peritoneum over the low pelvic cavity. A guidewire was left in the abdominal cavity, and the PD catheter was inserted over the guidewire. The endoscope was inserted in the tunnel again, and endoscopic clips were deployed over the Vicryl loop to fix the catheter. In 4 pigs, the PD catheter was inserted laparoscopically using a two-port approach. The catheter's tip was fixed with laparoscopic clips on the Vicryl loop. A strain test to assess the force required to detach clips was performed using a digital dynamometer.RESULTS:Operative time for flexible endoscopic tunneling was longer when compared to the laparoscopic implant (29.5 ± 4.43 vs. 22.7 ± 2.51 min). Mean force to displace the catheter was similar after flexible endoscopic fixation when compared to laparoscopic clip fixation (5.57 N ± 2.76 vs. 4.15 N ± 1.76).CONCLUSIONS:Flexible endoscopic extraperitoneal tunneling allows for minimally invasive single-incision PD catheter placement and fixation.

Treatment of perforations and complications related to gastrointestinal (GI) surgery and interventional flexible endoscopy is increasingly performed endoscopically. New devices enabling secure full-thickness GI tract closures through flexible endoscopic platforms have been recently developed.

Endoscopic suturing reduces stent migration, but is challenging and time-consuming. We compare endoscopic suturing versus anchoring with a novel over-the-scope clip (Padlock) to fix esophageal stents. Additionally, the first clinical case of Padlock stent fixation is reported.

Introduction. Image fusion between ultrasound (US) and computed tomography (CT) scan or magnetic resonance can increase operator accuracy in targeting liver lesions, particularly when those are undetectable with US alone. We have developed a modular gel to simulate hepatic solid lesions for educational purposes in imaging and minimally invasive ablation techniques. We aimed to assess the impact of image fusion in targeting artificial hepatic lesions during the hands-on part of 2 courses (basic and advanced) in hepatobiliary surgery. Materials and methods. Under US guidance, 10 fake tumors of various sizes were created in the livers of 2 pigs, by percutaneous injection of a biocompatible gel engineered to be hyperdense on CT scanning and barely detectable on US. A CT scan was obtained and a CT-US image fusion was performed using the ACUSON S3000 US system (Siemens Healthcare, Germany). A total of 12 blinded course attendants, were asked in turn to perform a 10-minute liver scan with US alone followed by a 10-minute scan using image fusion. Results. Using US alone, the expert managed to identify all lesions successfully. The true positive rate for course attendants with US alone was 14/36 and 2/24 in the advanced and basic courses, respectively. The total number of false positives identified was 26. With image fusion, the rate of true positives significantly increased to 31/36 ( P < .001) in the advanced group and 16/24 in the basic group ( P < .001). The total number of false positives, considering all participants, decreased to 4 ( P < .001). Conclusions. Image fusion significantly increases accuracy in targeting hepatic lesions and might improve echo-guided procedures.

Embolization of the left gastric artery (LGA) reduces circulating levels of ghrelin, but might prevent from further obesity surgery, particularly sleeve gastrectomy (SG), since the gastroesophageal junction (GEJ), depending on LGA, would be devascularized. Our aim was to evaluate, in an experimental animal study, an endovascular approach targeting arteries of the gastroepiploic arcade aiming to modulate ghrelin levels and to generate an increased vascular supply of the GEJ to reduce the risks of staple-line leaks after SG.

Surgeons currently rely on visual clues to estimate the presence of sufficient vascularity for safe anastomosis. We aimed to assess the accuracy of endoluminal confocal laser endomicroscopy (CLE) and laparoscopic fluorescence-based enhanced reality (FLER), using near-infrared imaging and fluorescence from injected Indocyanine Green, to identify the transition from ischemic to vascular areas in a porcine model of mesenteric ischemia.