From time to time there is a surprise at the end of surgery - even after subtotal resection - when a vocal cord is observed on indirect laryngoscopy to be non-functional. Surgeons are highly individualistic and develop their own special ways of locating and protecting the nerve. The present study has tried to clarify whether relying on palpation alone during surgery is safe enough in each case. Materials and methods: Between 01.01.2001 and 31.12.2008, 1228 recurrent laryngeal nerve (RLN) were exposed in 702 patients on thyroid surgery. The RLN was found and traced until the laryngeal entry point in all patients. Substernal spreading was noted in 38.6%(271/702), while tracheal compression or dislocation was present in 19.5%(137/702). Recurrent thyroid disease counted for 8.4%(59/702) of all cases. Total thyroid lobectomy was carried out in 82.2%(1009/1228), near-total thyroidectomy in 15.5%(191/1228), and subtotal resection only in 2.3%(28/1228). Results: Palpation was helpful in 80.7%(991/1228), proved false positive in 8.7%(107/1228), while in 10.6%(130/1228) it did not provide any help in the localization. The palpability of the RLN showed marked discrepancy between the two sides. False positivity was noted with palpation in 3.4%(21/625) and 14.3%(86/603) on the right and left side, respectively. On the other hand, palpation helped localization in 4.8%(29/603) on the left side, while the same figure was 16.2%(101/603) on the right side. Definitive RLN palsy was experienced in 0.8% of all cases (10/1228), whilst transient paresis was encountered in 1.4%(17/1228). Occult malignancy was noticed in 5.6%(39/702). Conclusions: No indication has been left for subtotal resection. Even if benign multinodular goitre is present, since the clinical and pathophysiological evidences suggest that multinodular goitre affects the entire gland, any surgery that leaves potentially abnormal thyroid tissue in situ carries a risk of recurrent disease. RLN palpatory method is a useful part of thyroid surgery but it is suitable for rough orientation only.

The use of valeriana was underplayed at the beginning of the 20th century because of its addictive and side effects. The 38-year-old woman, mother of a 20-month-old child from Eastern Europe, was treated with liver insufficiency and vascular, parenchymal decompensated cirrhosis needing plasmaferesis for the first time in our hospital. In case history, abusus of aethyl-alcohol and valeriana was found to be as toxic agent which was treated as the etiologic factor of the liver disease and liver failure. After intensive and conservative treatment her status was stabilised, during the follow-up she had no signs and symptoms, the laboratory results tend to be in normal range. Half year after her hospitalization intensive care treatment was necessary abroad due to gastric bleeding. In the background the histology of gastric biopsy taken during gastroscopic examination showed gastric sigillocellular carcinoma in our hospital. Total gastrectomia, omentectomia, lymphadenectomia were performed, the tumor was removed and she received cytostatic treatment. The use of valeriana and aethyl-alcohol is supposed to have a potential effect on tumorgenesis and on the increase of toxicity.

Introduction: Cutaneous lymphomas belong to the group of non-Hodgkin lymphomas. However, in case of an in-time diagnose and adequate treatment the prognosis of the disease is fairly good. Nevertheless, a thorny path leads to the correct diagnosis as several dermatological diseases cause problems in differential diagnostics. Case report: The authors describe the case history of a 53-year-old woman patient, who had a dermatological check-up due to a dermatitis in the shoulder region. A conservative treatment was started because of a suspected mycosis. Following its inefficiency an operative excision was carried out. The postoperative biopsy verified cutaneous B cell lymphoma. Discussion: The cutaneous B-cell lymphomas are such forms of non-Hodgkin lymphomas, where the malignant proliferation appears primarily in the skin, and in 6 months after the diagnosis extracutaneous manifestation cannot be detected. Several cases can be found in the literature, which show long interval between the manifestation of the symptoms and the setting of the diagnosis. This calls the attention to the significance of difficulties in the differential diagnosis. During the treatment of cutaneous lymphomas the type, the cutaneous extension, and the extracutaneous manifestation of the disease must be defined. The therapeutic plan can be made up by analysing these findings. On the basis of findings in this case and in the literature, a surgical treatment - beyond determining the correct diagnosis - could be a therapeutic alternative in the treatment of cutan B cell lymphomas.

Adenomatoid tumors of the adrenal gland are rather rare, asymptomatic neoplasias with benign behavior and usually are diagnosed incidentally. The authors report a case of an adenomatoid tumor of the right adrenal gland in a 32-year-old man who sought evaluation because of fever and renal pain. During investigation a tumor, localized in right adrenal gland, was identified by ultrasonography and CT. The patient underwent adrenalectomy with histopathological and immunhistochemical diagnosis of adenomatoid tumor of the adrenal gland. Based on literature data the epidemiology, symptomps, differential diagnosis, treatments, histopathology and prognosis of adenomatoid tumors of the adrenal gland are discussed.

Malignant gastrointestinal stromal tumor arising in a duodenal diverticulum. The authors describe the case of a 74-year-old male patient who was operated on for a GIST found in a large duodenal diverticulum, co-using gastrointestinal bleeding. This diverticulum--including the tumor--was removed by resection the distal part of the stomach and proximal third of duodenum. The histology revealed malignant gastrointestinal stromal tumor (GIST). 6 months after the operation he remained tumor free according to the control examinations. On the basis of new pathologic classification we summarise the signs, the diagnostic and therapeutic possibilities and the histologic characteristics of gastrointestinal stromal tumors.

Primary anorectal melanoma is a rare disease with poor prognosis. The optimal treatment of this disease is not well defined. The majority of patients develop generalised recurrent disease and die despite radical surgical treatment. Screening for colorectal cancer may help to detect this disease earlier and the early diagnosis should give better outcome. We present a case report and evaluate--based on literature--epidemiology, most common symptoms, hystopathology, diagnosis, treatments and the prognosis of primary anorectal melanomas.

Carcinoid tumor of the papilla of Vater is extreme rare. Only 73 cases have been reported in the world literature to date and only 1 case in Hungary. This tumor differs clinically and has a different prognosis from other carcinoid tumors of the gastrointestinal tract as it is more aggressive. The clinical feature is determined by the expansion and infiltrative nature of the tumor. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic biopsy (EB) are the most accurate methods of diagnosis, while endoscopic ultrasonography (EUS) is the most important method to decide the surgical strategy. Depending on the tumor size and the grade of invasion of other structures surgical treatment can be local excision or radical resection. We present a 67-year-old female patient with obstructive jaundice, caused by carcinoid tumor of the papilla of Vater. Diagnosis was obtained by ERCP and EB. Because of the signs of local invasion emerging on EUS a pylorus preserving pancreatoduodenectomy was performed. Six months after the operation there is no evidence of recurrence.

INTRODUCTION: Incidence of synchronous or metachronous carcinomas with primer esophageal malignancy together can be estimated at 17% and these disorders manifest mostly in the stomach. CASE REPORT: The authors report the medical history of a 55-year-old man whose symptomatic middle third esophageal carcinoma was cured with esophagectomy and two field lymphadenectomy. Stomach was used for substitution. Histological examination verified pT2N1M0 tumor and metastasis of papillary thyroid carcinoma from the lymph node removed from near to the right recurrent nerve. Five weeks after the esophageal resection a total thyroidectomy and a central lymph node dissection was performed. The synchronous thyroid carcinoma was located into the inferior pole of right lobe. Currently the patient is without symptoms and plaints, the complex oncological treatment is in progress. DISCUSSION: The incidence of a synchronous carcinoma of the esophagus and the thyroid gland is an extreme rarity. The basic difference connected to the tumorbiological behaviors of these two malignancies is found in the growing tendency and in the direction of lymphogen spreading. The common point is the recurrent nerve lymphatic chains in the thoracic dome. This is the reason that after the R0 resection of a middle third esophageal carcinoma the histological evaluation of a lymph node obtained from right recurrent nerve lymphatic chain shed light on the asymptomatic synchronous thyroid cancer. CONCLUSION: In cases of operable esophageal carcinomas located into its middle or lower third the importance of a correct lymphadenectomy could not be emphasize enough. During the routine preoperative examinations it would be necessary to make cervical ultrasonography too.

INTRODUCTION: Epiphrenic diverticulum cannot be considered a primary anatomical alteration, there is a manometrically verifiable motility disturbance in the background. OBJECTIVES: To determine the place, type and time of surgical solution in the treatment. PATIENTS: Between 1999 and 2004 seven patients were treated for epiphrenic diverticulum causing complaints. Average age was 61 years, and the leading symptom was dysphagia and regurgitation. Motility abnormalities characteristic of achalasia in four cases, hypertensive LES in three cases, and incompetent and normal LES, and diffuse esophageal spasm in one patient each could be revealed. The size of diverticuli varied between 5-9 cm. RESULTS: In four cases transthoracic diverticulectomy myotomy and partial antireflux plasty, in two cases esophagus resection, and in the case of one patient myotomy and fundoplication was performed. In the removed diverticuli an ulcer and a malignant transformation in one case each was detected. No major complications could be observed. Six patients are completely satisfied with the operation, only one reported well tolerable occasional regurgitations. CONCLUSION: Even in the era of minimal invasive surgery the traditionally performed, combined - diverticulectomy, myotomy, fundoplication - operative solution should be considered the gold standard. Surgical intervention is justified even for accidentally discovered symptomless patients, due to the considerable potential complications of the disease.

Dermatofibrosarcoma protuberans is a low or moderate grade malignant, uncommon soft tissue tumor. The tumor is characterized by slow, but locally aggressive growth, low metastatic potential and high recurrence rate. Initial treatment is the radical surgical excision, using traditional wide excision or Mohs surgery. In case of positive surgical margin or local recurrence, radio-chemotherapy and recently imatinib mesylate is used as adjuvant therapy. Aims: Twenty-six patients treated multidisciplinary for dermatofibrosarcoma protuberans were followed up. Methods and Results: Mean age of the patients was 44.7 years; mean follow-up time was 60.57 months. In fifteen cases (57.7%) R0 resection was performed, while eleven patients (42,3%) received only R1 resection. An average of 1.87 resections was necessary in order to achieve R0 resection. Six patients (23%) received adjuvant radiotherapy and two patients (7.6%) adjuvant chemotherapy following the removal of the primary tumor. Sixteen patients had no local recurrence. Ongoing treatments were needed in the case of ten patients (38.4%) who developed local recurrence. One patient has deceased due to distant metastases. Using statistical methods we examined the effects indicated as prognostic factors in the literature on local recurrence, precisely, the effect of age above 50 years and surgical radicalism. Conclusions: Dermatofibrosarcoma protuberans can be successfully treated with multidisciplinary therapy. A larger number of cases and randomized multicenter investigations are needed in order to reach more accurate conclusion.

Giant esophageal inflammatory fibrous polyp (especially > 17 cm in size) is seen rarely. Endoscopic removal has been reported rarely because the procedure is technically demanding and the hemostasis is difficult to ascertain. Here, we describe a case of a giant upper esophageal inflammatory fibrous polyp that was resected successfully by endoscopy.

A 6-month-old male domestic shorthair cat was presented for a 3-month history of dysphagia and upper respiratory signs. The cat was diagnosed with a generalized megaesophagus secondary to a large nasopharyngeal polyp that extended into the cervical esophagus. The polyp was removed by traction and a left ventral bulla osteotomy was performed to remove the polyp base. The cat's clinical signs resolved and follow-up radiographs 14 days after surgery revealed resolution of the megaesophagus. To the authors' knowledge, this is the first report of resolution of megaesophagus after removal of a nasopharyngeal polyp in a cat.

Giant fibrovascular polyps of the esophagus and hypopharynx are rare benign esophageal tumors. They arise most commonly in the upper esophagus and may, rarely, originate in the hypopharynx. They can vary significantly in size. Even though they are benign, they may be lethal due to either bleeding or, rarely, asphyxiation if a large polyp is regurgitated. Patients commonly present with dysphagia or hematemesis. The polyps may not be well visualized on endoscopy and imaging plays a vital role in aiding diagnosis as well as providing important information for pre-operative planning, such as the location of the pedicle, the vascularity of the polyp and the tissue elements of the mass. They can also be recurrent in rare cases, especially if the resection margins of the base are involved. We review the recent literature and report a case of a 61-year-old man with a recurrent giant esophageal fibrovascular polyp with illustrative contrast barium swallow, CT and intra-operative images, who required several surgeries via a combination of endoscopic, trans-oral, trans-cervical, trans-thoracic and trans-abdominal approaches.

Fibroepithelial polyps or hypertrophied anal papillae are essentially skin tags that project up from the dentate line and the junction between the skin and the epithelial lining of the anus. They are usually small in size, but sometimes they become enlarged, causing unexpected medical conditions. An extremely rare case of a giant hypertrophied anal papilla complicated by obstructive ileus is reported. Fibroepithelial anal polyp, despite its size, should be included in the differential diagnosis of a smooth mass located near the anal verge, especially in a patient with a history of chronic anal irritation or infection.

A 25-year-old female patient with a history of progressive dysphagia of one year duration was detected to have intraluminal polypoidal mass in the oesophagus on barium contrast study and computed tomography. Direct laryngoscopy and flexible endoscopy confirmed the origin from pharyngo-oesophageal junction. Lateral cervical oesophagotomy and excision of a polypoidal mass of 15x6.5x3 cm size was done. Histopathology revealed fibrovascular polyp (FVP) arising from submucosa of oesophagus. FVP is a benign tumour-like condition which can attain an enormous size inside the lumen of the oesophagus. It predisposes the patient to aspiration due to incomplete vocal cord adduction and asphyxia due to possible laryngeal inlet block and thus threatening life. Complete surgical excision through lateral esophagotomy is the standard treatment and provides cure in majority. Keywords: Fibrovascular polyp; Dysphagia; Oesophagus.

A sensation of a lump in the throat will often cause fear of tumor. Underlying the symptom is only seldom a tumor, which is, however, malignant in about 97 to 99% of cases of hypopharyngeal occurrence. Excessive alcohol consumption and smoking constitute the their greatest risk factors. We present a patient case relating to a rare benign tumor of the hypopharynx (giant fibrovascular polyp, GFP).

Lymphangiomas are benign tumours that rarely occur in the oesophagus. Only 14 cases have been reported in the literature. This is a case of a 43-year-old woman with vague upper gastrointestinal discomfort. A sessile, 5-mm polyp was seen at gastroscopy. Lymphangioma was diagnosed by histology of the polypectomy specimen. Since no malign transformation has ever been reported, control after polypectomy was deemed unnecessary. Diagnostic and therapeutic considerations are briefly discussed.

ABSTRACT: INTRODUCTION: We present a case of fibrovascular polyp, a rare submucosal tumour of the oesophagus that has been reported only sporadically in the literature. The biapproach for surgical removal of fibrovascular polyp has only been mentioned once in the literature. CASE PRESENTATION: A 65-year-old Greek man presented with a 9-month history of gradually progressive intermittent dysphagia. Radiologic work-up with oesophagogram and computed tomography revealed a large, sausage-shaped intraluminal polyp extending from the level of the cervical oesophagus to the level of the upper body of the stomach. The diagnosis of giant fibrovascular polyp was made radiographically and confirmed by endoscopic biopsy. The polyp was removed using a biapproach surgical technique: pharyngotomy and subsequent gastrostomy. CONCLUSION: Fibrovascular polyp is a rare submucosal tumour. Proper treatment depends on accurate assessment of the origin, size, and vascularity of the pedicle and the size of the tumour. Choice of the appropriate surgical approach depends on the correct diagnosis, which can usually be indicated radiographically by the presence of a smooth, sausage-shaped defect with a discrete bulbous tip.