Correlation of survival length after pancreaticoduodenectomy for pancreatic head adenocarcinoma depending on tumor characteristics detected by means of computed tomography and resection margins status

Pancreatic carcinoma is an aggressive tumor with a grim prognosis. Accurate staging is essential for indicating surgery in patients with borderline resectable tumors. This paper examines the correlation between pre-operation characteristics of tumors found on CT, infiltration of individual resection margins as confirmed by a pathologist, and the survival of patients with resectable pancreatic head ductal adenocarcinoma. This prospective cohort study involved patients operated on for pancreatic head adenocarcinoma, which was clearly resectable based on the staging CT and intraoperative observation between 2011-2014. Only patients without postoperative complications who underwent adjuvant chemotherapy were analyzed. Seventy-nine patients were assessed, of which 16 (20.3%) had R0 resection and 63 (79.7%) had R1 resection. Patients with R1 results had up to 2.7 times higher risk of death than patients with R0 resection. We found a trend towards shorter survival associated with a closer relationship of the tumor to the superior mesenteric vein/portal vein (SMV/PV) wall in the pre-operation CT examination. Patients with a tumor interface between the vein wall of up to 180 ° circumference had up to 1.97 times higher risk of death than patients without (p=0.131). The results of our work confirmed that in our center, even surgically treated, clearly resectable pancreatic head tumors still have a high occurrence of positive surgical margins (R1 resection) and that tumors with R1 resection had statistically significantly reduced survival compared to R0 resection. A trend for shorter overall survival was found after tumor resection depending on the increasing interface between the tumor and the SMV/PV wall, but this result was not statistically significant.

Comparison of cervical anastomotic leak and stenosis after oesophagectomy for carcinoma according to the interval of the stomach ischaemic conditioning

Background Stomach preparation by ischaemic conditioning prior to oesophageal resection represents a potential method of reducing the risk of anastomotic complications. This study compares the results of the anastomotic complications of cervical anastomosis after oesophagectomy with a short interval after ischaemic conditioning (group S) and a long interval (group L). Methods Subjects undergoing oesophagectomy for carcinoma after ischaemic conditioning were divided into two groups. Group S had a median interval between ischaemic conditioning and resection of 20 days, while for group L the median interval was 49 days. Anastomotic leak and anastomotic stenosis in relation to the interval between ischaemic conditioning and actual resection were followed. Results After ischaemic conditioning, 33 subjects in total underwent surgery for carcinoma; 19 subjects in group S and 14 subjects in group L. Anastomotic leak incidence was comparable in both groups. Anastomotic stenosis occurred in 21% of cases in group S and 7% of cases in group L (not statistically significant). Conclusions A long interval between ischaemic conditioning and oesophagectomy does not adversely affect the postoperative complications. A lower incidence of anastomosis stenoses was found in subjects with a longer interval, however, given the size of our sample, the statistical significance was not demonstrated. Both groups seem comparable in surgical procedure course and postoperative complications.

Is physical activity a protective factor against pancreatic cancer?

OBJECTIVES

The objective of the study was to analyze an association between selected factors and pancreatic cancer, assuming that knowing the etiology would help influence the incidence of this severe type of cancer through primary prevention. In addition to age, gender, BMI and education, the analysis aimed at assessing occupational and leisure-time physical activities with respect to pancreatic cancer.

BACKGROUND

In numerous studies, physical activity is reported to be a protective factor against pancreatic cancer.

METHODS

A case-control study was carried out in three centers in the Czech Republic in 2006-2009.

RESULTS

The study comprised a total of 529 individuals, of which 309 were patients with pancreatic cancer and 220 were controls. Leisure-time physical activity showed a statistically significant inverse association with a crude odds ratio of 0.65 (95% CI 0.45-0.93), even after adjustment for other studied factors (OR =0.63, 95% CI 0.43-0.92). Conversely, for occupational physical activity, a positive association was only suggested.

CONCLUSIONS

Leisure-time physical activity is a protective factor against the development of pancreatic cancer. Occupational physical activity was not confirmed as a protective factor against pancreatic cancer (Tab. 4, Fig. 1, Ref. 22).

Semi-spherical Radiofrequency Bipolar Device - A New Technique for Liver Resection: Experimental In Vivo Study on the Porcine Model

The incidence of colorectal carcinoma is still growing in the Czech Republic and also all around the world. With success of oncological treatment is also growing a number of potential patients with liver metastases, who can profit from surgical therapy. The aim of this study was to confirm on porcine models that this method by using new surgical device is effective and safe for patients who have to undergo liver resection. The primary hypothesis of the study was to evaluate whether this new device is able to consistently produce homogeneous and predictable areas of coagulation necrosis without the Pringle maneuver of vascular inflow occlusion. The secondary hypothesis of the study was to compare the standard linear radiofrequency device and a new semi-spherical bipolar device for liver ablation and resection in a hepatic porcine model. Twelve pigs were randomly divided into two groups. Each pig underwent liver resection from both liver lobes in the marginal, thinner part of liver parenchyma. The pigs in first group were operated with standard using device and in the second group we used new developed semi-spherical device. We followed blood count in 0(th), 14(th) and 30(th) day from operation. 14(th) day from resection pigs underwent diagnostic laparoscopy to evaluate of their state, and 30(th) day after operation were all pigs euthanized and subjected to histopathological examination. Histopathological evaluation of thermal changes at the resection margin showed strong thermal alteration in both groups. Statistical analysis of collected dates did not prove any significant (p < 0.05) differences between standard using device and our new surgical tool. We proved safety of new designed semi-spherical surgical. This device can offer the possibility of shortening the ablation time and operating time, which is benefit for patients undergoing the liver resection.

Diagnosis of recanalization of the intracranial artery has poor inter-rater reliability

BACKGROUND AND PURPOSE

Recanalization is the important outcome measure for acute stroke therapy. Several methods of recanalization assessment are used in clinical practice, but few studies have addressed their reliability. We, therefore, sought to assess interobserver reliability of the diagnosis of intracranial artery recanalization following intervention by using TIMI criteria.

MATERIALS AND METHODS

The digital angiography scans of all patients with acute ischemic stroke during 2009 undergoing DSA and endovascular procedures at Ostrava University Hospital were assessed in the study. Images were retrospectively evaluated for intracranial artery recanalization on the TIMI scale by 2 experienced neuroradiologists who were blinded to clinical findings and to each other.

RESULTS

The angiography scans of 43 patients (16 females; age, 70.5 ± 14 years; median baseline NIHSS score, 15 [IQR, 11-18]) were retrospectively evaluated in our study. At 3 months, 27% of patients had mRS scores ≤ 2 and mortality was 18%. Two radiologists diagnosed TIMI grades as follows: TIMI 0, 16%, and 16%; TIMI 1, 21%, and 8%; TIMI 2a, 32% and 29%; TIMI 2b, 13% and 16%; TIMI 3, 18, and 31%. Interobserver agreement for recanalization was weighted κ = 0.4 (95% CI, 0.2-0.6).

CONCLUSIONS

The diagnosis of recanalization after interventional procedures was found to have poor interobserver agreement between 2 experienced neuroradiologists. TIMI criteria, therefore, do not permit reliable comparison of the efficacy of recanalization therapy among different studies.

FcγRIIIA receptor genotype does not influence an outcome in patients with follicular lymphoma treated with risk-adapted immunochemotherapy

Antibody (rituximab) dependent cellular cytotoxicity is a key mechanism in killing CD20+ lymphoma cells. FcγRIIIA-158 V/F gene polymorphism results in expression of 3 variants of the FcγRIIIA receptor (FcγRIIIA) on cytotoxic lymphocytes with different receptor affinity. We studied 102 patients with newly diagnosed FL to assess whether the FcγRIIIA genotype influences outcome in patients treated with risk-adapted immunochemotherapy. The median age was 52 years (31-84); 90% of the patients had advanced (III/IV) clinical stages. The Follicular Lymphoma International Prognostic Index (FLIPI) scores were as follows: low 18.9%, intermediate 33.7% and high 47.4%. The front-line treatment was stratified according to the commonly used risk factors (FLIPI, beta-2-microglobuline and serum-Tyrosine-Kinase levels, bulky disease) into 3 treatment groups: (1) patients with FLIPI 0-1 treated with (R)-CHOP (51%), (2) patients under 60 (65) years of age with intermediate-risk disease (FLIPI 2) indicated for an intensive protocol (ProMACE-CytaBOM or sequential chemotherapy) (21%), and (3) patients under 60 (65) years with high-risk disease (FLIPI ≥3) treated with intensive chemotherapy plus autologous stem cell transplantation (28%). Rituximab was added to front-line chemotherapy in 59% of the patients. Generally, complete remission (CR) or unconfirmed CR was achieved in 85% of the patients, 11% had partial remission and 4% stable disease. Molecular CR (CRm) was achieved in 67.4% of 86 evaluable patients. Overall survival (OS) at 5 years reached 84% (95% CI 0.74-0.93); event-free survival (EFS) at 5 years was 58% (95% CI 0.45-0.71). The frequencies of FcγRIIIA-158 gene polymorphisms V/V, V/F and F/F were 8%, 50% and 42%, respectively. The FLIPI score distribution was not different in F/F patients as compared to V/F+V/V carriers (chi-square, P=0.7). The treatment modalities (treatment arm or rituximab administration) had the same distribution in V/V+V/F vs F/F patients (chi-square, P=0.16 and P=0.62, respectively). The CRm rates were similar in both subgroups of V/V+V/F vs F/F patients (chi-square, P=0.92). Survival curves for OS and EFS were not significantly different when comparing the subgroups of V/V+V/F vs F/F patients (P=0.28 and P=0.57, respectively). We found no difference in the quality of treatment response or survival after front-line immunochemotherapy between FcγRIIIA subgroups. FcγRIIIA polymorphism have no influence on the outcome of patients treated with risk-adapted chemotherapy with or without rituximab.

Spontaneous duodenal intramural haematoma imitating pancreatic pseudocyst

Spontaneous intramural duodenal haematoma develops mostly as a complication of anticoagulation therapy. Other causes were reported only as case reports. CT diagnostics has some typical features in an intramural haematoma of the small bowel. This is especially hyperdensity of the bowel wall during the first 10 days from the onset of symptoms (30-80 HU), which could contribute to the differentiation from other infiltrative processes. These features are fully expressed only in a certain part of patients. We reported a 54 year-old female treated for epigastric pain. The patient's history, laboratory data, ultrasonography and CT findings resulted in a mistaken diagnosis of acute pancreatitis, necrosis of the pancreatic body with a subsequent development of pancreatic pseudocyst. The CT guided drainage was performed. The correct diagnosis was made one year later--surgical treatment was indicated for clinical signs of GI obstruction and CT findings of pseudocyst recurrence. During the operation, there was a finding of intramural haematoma in the duodenojejunal border. We performed an evacuation of the haematoma and gastroenteroanastomosis.

Tailored antireflux surgery

BACKGROUND

With increasing age, the functional condition of the lower esophageal sphincter is getting weaker. Recent progress in peri-operative intensive care and the development of laparoscopic technique makes antireflux surgery a safe choice of GERD treatment in the elderly.

AIM

This work evaluated the long-term results of tailored antireflux surgery in a group of elderly (more than 60 years old) patients.

RESULTS

Five hundred and eighty one patients underwent antireflux surgery in our department from 1999 to 2005. Seventy of them (12.0%) were older than 60 years. Exclusion criteria of surgery were ASA IV classification and high grade esophageal dysmotility. Toupet's wrap was offered to patients with esophageal dysmotility or esophageal sphincter pressure higher than 15 mm Hg (16 cases). The rest were offered Nissen-Rossetti's complete wrap (54 cases). There was zero mortality and no further significant dysphagia. Pathological gastro-esophageal reflux after the surgery was detected in 6 patients (8.6%), which was a higher proportion than in the group of patients under 60 years.

CONCLUSION

Good results of antireflux surgery with zero mortality and low morbidity can be achieved even in the elderly (more frequent use of incomplete Toupet's wrap).

High-dose therapy and autologous stem cell transplantation in patients with diffuse large B-cell lymphoma in first complete or partial remission

Improved survival has been observed in poor-risk diffuse large B-cell lymphoma (DLBCL) patients treated with high-dose therapy (HDT) followed by autologous stem cell transplantation (ASCT) in first complete remission. Retrospective studies have suggested that HDT with ASCT can improve survival also in partial responders but some doubts about the advantage of intensive therapy in such patients still remain. We evaluated retrospectively the results of HDT and ASCT in 55 patients with confirmed DLBCL treated between May 1999 and July 2006. Thirty-six patients (65%) showed partial remission (PR) and 19 patients (35%) reached complete remission (CR) after induction treatment with (44%) or without (56%) concomitant rituximab (R) immunotherapy. After HDT and ASCT, 69% of patients fulfilled the criteria of CR, 22% had unconfirmed CR (CRu), 7% remained in PR and 1 patient (2%) relapsed. Twenty patients in PR after the induction treatment reached CR after ASCT, 12 other PR patients achieved CRu. The 5-year event-free survival (EFS) of the 55 transplanted patients was 76% (95% confidence interval /CI/, 63% to 89%) and the 5-year overall survival (OS) was 85% (95% CI, 73% to 97%). The EFS and OS rates differed significantly only between patients younger than 40 years and older groups (p=0.022 and p=0.046, respectively). On univariate analysis of prognostic factors, EFS and OS were not affected by any of the following: age, sex, stage, subtype of DLBCL, initial lactate dehydrogenase, beta-2-microglobulin and serum thymidine kinase levels, International Prognostic Index (IPI) and age-adjusted IPI scores, induction treatment with or without rituximab and type of primary therapeutic response (CR vs PR). These results show that first-line HDT and ASCT for adults up to the age of 65 years with poor-risk DLBCL is a feasible and effective treatment option even in the era of R-chemotherapy in CR as well as for patients in PR.

Giant serpentine internal carotid artery aneurysm: endovascular parent artery occlusion. A pediatric case report

SUMMARY

We report on a case of a 14-year-old boy with a giant serpentine aneurysm of the left internal carotid artery cavernous segment with symptoms of acute mass-effect cranial nerve dysfunction. After a balloon occlusion test of the collateral circulation, the patient underwent parent artery occlusion with platinum Guglielmi detachable coils and fibered coils. An optimal angiographic result and successful clinical outcome were achieved with resolution of IIIrd, IVth and VIth cranial nerve ischemic symptoms. CT angiography and 3D-XRA rotational angiography reconstructions gave sufficient inclusion information on the giant serpentine aneurysm angioarchitechture.

PHACE Syndrome: Persistent Fetal Vascular Anomalies. A Case Report

SUMMARY

PHACE(S) syndrome is an acronym for neurocutaneous disease encompassing the expression of (P) posterior cranial fossa malformations, (H) facial haemangiomas, (A) arterial anomalies, (C) aortic coarctaion and other cardiac defects, (E) eye abnormalities and (S) for sternal malformation or stenotic arterial diseases. We report on a case of PHACE syndrome complete expression with persistent fetal vascular anomalies unusually in a 55-year-old women with large bilateral facial and neck haemangioma and posterior fossa circulation insufficiency.

Oral contraceptive induced cerebral venous thrombosis treated by local catheter directed thrombolysis

SUMMARY

We report on a case of cerebral venous thrombosis (CVT) induced by oral contraception (OC) activated coagulopathy and its endovascular treatment. Deep venous system and dural sinuses thrombosis complicated with severe neurological deficit and coma due to right thalamic edema and ischemia in a young woman was treated by local thrombolysis with an administration of 0.6 mg/h of the rtPA and the concomitant intravenous unfractioned heparin infusion (700 IU/h). 3D-Xra digital rotational venography performed at the beginning and after treatment confirmed thrombus resolution with rapid flow restoration. Dynamic flow imaging gives interesting information on the deep venous system and the cortical venous collectors drainage. Final NIHSS (National Institute of Health Stroke Scale) and mRS (modified Rankin Scale) confirmed an excellent clinical outcome of the interventional therapy.

Cavernous sinus dural fistula treated by transvenous facial vein approach

SUMMARY

We report on the endovascular treatment of the spontaneous indirect dural carotid cavernous sinus type D fistula in a 60-year-old woman, in whom ipsilateral facial, angular and superior ophthalmic veins catheterization was performed to get access to the fistula site for embolization treatment. Approach via the facial vein is helpful after inferior petrosal sinus treatment failure. Although this technique requires caution in the angular vein region it allows a safe and effective treatment of these lesions. 3D rotational digital angiography can obtain more information of the angioarchitecture of the cavernous plexus and venous outflow for the catheter navigation.

Anaesthesia management of major hepatic resections without application of allogeneic blood

BACKGROUND

In a prospective study we used acute normovolemic haemodilution (ANH) together with low CVP anaesthesia in order to avoid allogeneic blood transfusion during major liver surgery.

MATERIAL AND METHODS

With institutional approval, 20 patients, ASA classification I-III, undergoing hepatic lobe resection consecutively (18 for metastatic cancer, 2 for hepatocellular cancer) in 2002, were enrolled into the prospective study. A epidural catheter was inserted before surgery in the thoracic region. General anaesthesia was induced and maintained with sevoflurane and fentanyl. Invasive haemodynamic monitoring was instituted. Blood was removed for ANH and circulation volume was replaced by infusion of colloids and crystalloid. The CVP was maintained less than 5 mm Hg during hepatic parenchymal transection. After procedure the ventilated patients were transported to ICU.

RESULTS

The preoperative haematocrit value (Hct) allowed performance of ANH with a blood removal (1025 +/- 357 g) in all patients. The estimated blood loss was 825 +/- 515 ml. None of the subject received allogeneic blood during surgery. One patient had transfusion of 2 units of allogeneic blood the fifth day after the right hepatectomy during a second look for perihepatic hematoma. The CVP was 3.8 +/- 0.4 mmHg during liver resection. Postoperative Hct was 0.31 +/- 0.02 and haemoglobin 108 +/- 11 g/L. All patients were extubated the first day after surgery. There was no hospital mortality.

CONCLUSIONS

We have shown that the routine use of new surgical techniques and low CVP anaesthesia in combination with ANH enabled avoidance of allogeneic blood transfusion in all patients during surgery. (Tab. 3, Ref. 22).

[Role of mini-invasive surgery in the treatment of patients with neoplasms, particularly in colorectal carcinoma]

Laparoscopic surgery has found its firm position in the treatment of benign diseases. Yet, oncologic laparoscopy remains a controversial technique. Its indication is discussed, especially its specific complication in oncologic diseases--recurrence of malign tumors within the scar after the trocar. The authors have performed an extensive recherché on the incidence of local recurrences of malign tumors after laparotomy or laparoscopy. They compare the functional results of both techniques, radical measure of intervention and their technical limits. They analyse the causes of local recurrences as well as possibilities of their reduction. They evaluate also their own experience in laparoscopy performed in coincidence with malign diseases, especially in palliative surgery. They suggest indications of laparoscopy in cases with colorectal carcinoma which is currently, as well as prospectively the most frequent malign disease of the gastrointestinal tract in our region.

[Gastroesophageal reflux disease from the viewpoint of the surgeon]

Surgical treatment of patients with gastroesophageal reflux disease (GERD) represents an alternative approach in relation to the long-term pharmacologic therapy of prokinesis, and secretoinhibitory therapy. It must be considered in cases where the conservative approach has failed. The success of surgical treatment depends on an individual approach to the patient. The factors determining the surgical indication and especially the type of surgery, include age, anatomy of the hiatus and the results of pre-operational examinations of the esophagus. The type of operation depends on the ability of the esophagus to contract and to transfer the propulsion activity. According to the authors, the key examination is represented by the detection of esophageal contractility by use of esophageal manometry. The alternative option is represented by scintigraphic measurement of esophageal transit time by use of a tagged bolus. The patients with disappeared contractility are preferentially treated by conservative therapy due to the high risk of post-operational dysphagia. 80% of patients are treated by the standard procedure of laparoscopic fundoplication by a 360-grade cuff. The cases with decreased contractility or esophageal dysmotility are preferentially treated by partial fundoplication in Toupet's modification. The shortening of the esophagus requires consideration as to chest approach, or Collis' operation. Intestinal metaplasia of the esophagus requires specific procedures. Severe dysplastic changes require the consideration of resection treatment. The gained therapeutic results are evaluated by both, the subjective point of view of the authors, as well as by standard pH measurement and manometry of the esophagus performed 6 weeks after surgery.

Genomic structure and domain organisation of the human Bak gene

The Bcl-2 homologue, Bak, is a potent inducer of apoptosis. FISH data presented here located the gene to 6p21.3. Mapping was consistent with its location centromeric of the HSET locus and approximately 400kb from the MHC. The construction of a contig of genomic clones across the locus facilitated the sequencing of a PAC containing the gene. Comparison of the gene structure to functional and physical domains revealed a good agreement between the physical structure and the intron-exon organisation. The position of a single intron was conserved in comparison to other members of the Bcl-2 family, namely Bax, CED-9, Bcl-X and Bcl-2, but all other introns were displaced, consistent with a divergent phylogeny.

Molecular cloning and characterization of Porphyromonas gingivalis lysine-specific gingipain. A new member of an emerging family of pathogenic bacterial cysteine proteinases

The proteinases of Porphyromonas gingivalis are key virulence factors in the etiology and progression of periodontal disease. Previous work in our laboratories resulted in the purification of arginine- and lysine-specific cysteine proteinases, designated gingipains, that consist of several tightly associated protein subunits. Recent characterization of arginine-specific gingipain-1 (gingipain R1; RGP-1) revealed that the sequence is unique and that the protein subunits are initially translated as a polyprotein encoding a proteinase domain and multiple adhesin domains (Pavloff, N., Potempa, J., Pike, R. N., Prochazka, V., Kiefer, M. C., Travis, J., and Barr, P. J. (1995) J. Biol. Chem. 270, 1007-1010). We now show that the lysine-specific gingipain (gingipain K; KGP) is also biosynthesized as a polyprotein precursor that contains a proteinase domain that is 22% homologous to the proteinase domain of RGP-1 and multiple adhesin domains. This precursor is similarly processed at distinct sites to yield active KGP. The key catalytic residues in the proteinase domain of KGP are identical to those found in RGP-1, but there are significant differences elsewhere within this domain that likely contribute to the altered substrate specificity of KGP. Independent expression of the proteinase domain in insect cells has shown that KGP does not require the presence of the adhesin domains for correct folding to confer proteolytic activity.

Molecular cloning and structural characterization of the Arg-gingipain proteinase of Porphyromonas gingivalis. Biosynthesis as a proteinase-adhesin polyprotein

The identification of proteinases of Porphyromonas gingivalis that act as virulence factors in periodontal disease has important implications in the study of host-pathogen interactions as well as in the discovery of potential therapeutic and immunoprophylactic agents. We have cloned and characterized a gene that encodes the 50-kDa cysteine proteinase gingipain or Arg-gingipain-1 (RGP-1) described previously (Chen, Z., Potempa, J., Polanowski, A., Wikstrom, M., and Travis, J. (1992) J. Biol. Chem. 267, 18896-18901). Analysis of the amino acid sequence of RGP-1 deduced from the cloned DNA sequence showed that the biosynthesis of this proteinase involves processing of a polyprotein that contains multiple adhesin molecules located at its carboxyl terminus. This finding corroborates previous evidence (Pike R., McGraw, W., Potempa, J., and Travis, J. (1994) J. Biol. Chem. 269, 406-411) that RGP-1 is closely associated with adhesin molecules, and that high molecular weight forms of the proteinase are involved in the binding of erythrocytes.

Modulation of HOX2 gene expression following differentiation of neuronal cell lines

The expression of the genes in the human HOX2 locus has been studied during differentiation of two human neuroblastoma (SH-SY5Y and Kelly), a human glioblastoma (251-MG), and the murine F9 embryonal carcinoma cell lines. Cells were differentiated with retinoic acid (RA), or with RA together with dibutyral cyclic AMP (db-cAMP) and nerve growth factor (NGF) in order to assess the changes in the expression patterns of these homeobox genes during neuronal differentiation. We show that the genes of the HOX2 locus are expressed in a complex transcription pattern that varies with cell type. The two uninduced neuroblastoma cell lines show a similar pattern of expression for a number of HOX2 genes although the levels of expression are different for individual cell lines. The embryonal carcinoma cell line F9 expresses low levels of several HOX2 genes which is restricted to the 5' region of the HOX2 cluster. The glioblastoma cell line, 251-MG expresses almost all of the genes of the HOX2 locus. Differentiation of these cells modulates the expression of the HOX2 genes in a manner that is dependent upon the cell type as well as the differentiation factor. Differentiation affects both the level of HOX2 gene expression and the distribution of transcript sizes. In conclusion, our analysis reveals a complex pattern of expression for the genes of the HOX2 locus in neuronal and glial cells and suggests that the cell-specific expression of these genes may be correlated with the phenotypic differences that are observed between different neuronal and glial cell populations within the nervous system.