Intestinal Anastomotic Healing: What do We Know About Processes Behind Anastomotic Complications

Colorectal surgery has developed rapidly in the recent decades. Nevertheless, colorectal anastomotic leakage continues to appear postoperatively in unpleasant rates and leads to life-threatening conditions. The development of valid complication-preventing methods is inefficient in many aspects as we are still lacking knowledge about the basics of the process of anastomotic wound healing in the gastrointestinal tract. Without the proper understanding of the crucial mechanisms, research for prevention of anastomotic leakage is predestined to be unsuccessful. This review article discusses known pathophysiological mechanisms together with the most lately found processes to be further studied. The aim of the article is to facilitate the orientation in the topic, support the better understanding of known mechanisms and suggest promising possibilities and directions for further research.

Growth of colorectal liver metastases is not accelerated by intraportal administration of stem cells after portal vein embolization

INTRODUCTION

Future liver remnant volume (FLRV) is a crucial factor impacting resectability of colorectal liver metastases (CLM). In case of low FLRV, augmentation can be done by performing portal vein embolization (PVE). However, there is a risk of progression of CLM between PVE and resection. Intraportal application of autologous hematopoietic stem cells (HSC) is a possibility to accelerate the growth of FLRV. The effect of thus applied SC on CLM progression still remains unclear, though.

METHODS

63 patients underwent PVE between 2003 and 2015. In 20 patients a product with HSC was applied intraportally on the first day after PVE (PVE HSC group). HSC were gained from peripheral blood (10 patients) or bone marrow (10 patients). FLRV and volume of liver metastases (VLM) were evaluated by CT volumetry. The gained data were statistically evaluated in relation to the disease free interval (DFI), overall survival (OS), achievement of CLM resectability and progression of extrahepatic metastases. We compared the PVE HSC group with the group of patient undergoing simple PVE.

RESULTS

No significant difference in FLRV and VLM growth was observed between the study groups. The percentage of exploratory laparotomies was smaller in the group with PVE and HSC application. Patients with simple PVE had a significantly higher incidence of extrahepatic metastases during follow up. We did not observe any significant differences in DFI and OS between the groups.

CONCLUSION

HSC application did not accelerate CLM growth in comparison with PVE alone. PVE and HSC application had a higher percentage of patients undergoing liver resection and a lower incidence of extrahepatic metastases.

Porcine liver vascular bed in Biodur E20 corrosion casts

BACKGROUND

Pigs are frequently used as animal models in experimental medicine. To identify processes of vascular development or regression, vascular elements must be recognised and quantified in a three-dimensional (3D) arrangement. Vascular corrosion casts enable the creation of 3D replicas of vascular trees. The aim of our study was to identify suitable casting media and optimise the protocol for porcine liver vascular corrosion casting.

MATERIALS AND METHODS

Mercox II® (Ladd Research, Williston, Vermont, USA) and Biodur E20® Plus (Biodur Products, Heidelberg, Germany) were tested in 4 porcine livers. The resins (volume approximately 700 mL) were injected via the portal vein. Corrosion casts were examined by macro-computed tomography, micro-computed tomography and scanning electron microscopy.

RESULTS

For hepatectomies, the operating protocol was optimised to avoid gas or blood clot embolisation. We present a protocol for porcine liver vascular bed casting based on corrosion specimens prepared using Biodur E20® epoxy resin.

CONCLUSIONS

Only Biodur E20®Plus appeared to be suitable for high-volume vascular corrosion casting due to its optimal permeability, sufficient processing time and minimum fragility. Biodur E20® Plus is slightly elastic, radio-opaque and alcohol-resistant. These properties make this acrylic resin suitable for not only vascular research but also teaching purposes.

Immediately preoperative use of biological therapy does not influence liver regeneration after large resection--porcine experimental model with monoclonal antibody against epidermal growth factor

BACKGROUND

The aim of this work was to study the influence of isolated biological therapy administered immediately before extended liver resection on liver function and regenerative capacity of future liver remnant (FLR) in a large-animal experiment.

MATERIALS AND METHODS

Nineteen piglets were included in this study (10 in the control group and 9 in the experimental group). A port-a-cath was introduced into the superior caval vein. On days 11 and 4 before liver resection, cetuximab was administered via this port at 400 mg/m2 of piglet body surface. Physiological solution was applied to the control group. Resection of the left lateral, left medial and right medial hepatic lobes was followingly performed (reduction of 50-60% of liver parenchyma). Blood samples were collected at different times before the operation and after liver resection. Serum levels of bilirubin, urea, creatinine, alkaline phosphatase, gamma glutamyltransferase, cholinesterase, aspartate aminotransferase, alanine aminotransferase, albumin, C-reactive protein and transforming growth factor-β1 were assessed. The ultrasonographic examinations at different time points were performed pre-operatively and after liver resection in order to assess the liver volume. The biopsies from the liver parenchyma were examined for proliferative activity, binocluated hepatocytes, size of hepatocytes, and the length of the lobuli. The comparison of distribution of the studied parameters between the groups was carried out using the Wilcoxon test. The Spearman rank correlation co-efficient was used because of the non-Gaussian distribution of the parameter values. The whole development of the studied parameters over time was compared between the groups using ANOVA.

RESULTS

There were no important complications of administration of biologic therapy during the operation or throughout the peri-operative period. There was no statistically significant difference in the regeneration of FLR nor were any differences in biochemical, immunoanalytical and histological parameters detected.

CONCLUSION

The achieved results of comparable liver regeneration in both the experimental and control groups confirms the use of biological treatment with cetuximab in the pre-operative period for minimizing the recovery period.

The role of ABC transporters in progression and clinical outcome of colorectal cancer

Worldwide, colorectal cancer (CRC) is the third most common cancer, with the highest mortality rates occurring in Central Europe. The use of chemotherapy to treat CRC is limited by the inter-individual variability in drug response and the development of cancer cell resistance. ATP-binding cassette (ABC) transporters play a crucial role in the development of resistance by the efflux of anticancer agents outside of cancer cells. The aim of this study was to explore transcript levels of all human ABCs in tumours and non-neoplastic control tissues from CRC patients collected before the first line of treatment by 5-fluorouracil (5-FU)-containing regimen. The prognostic potential of ABCs was evaluated by the correlation of transcript levels with clinical factors. Relations between transcript levels of ABCs in tumours and chemotherapy efficacy were also addressed. The transcript profile of all known human ABCs was assessed using real-time polymerase chain reaction with a relative standard curve. The majority of the studied ABCs were down-regulated or unchanged between tumours and control tissues. ABCA12, ABCA13, ABCB6, ABCC1, ABCC2 and ABCE1 were up-regulated in tumours versus control tissues. Transcript levels of ABCA12, ABCC7 and ABCC8 increased in direction from colon to rectum. Additionally, transcript levels of ABCB9, ABCB11, ABCG5 and ABCG8 followed the reverse significant trend, i.e. a decrease in direction from colon to rectum. The transcript level of ABCC10 in tumours correlated with the grade (P = 0.01). Transcript levels of ABCC6, ABCC11, ABCF1 and ABCF2 were significantly lower in non-responders to palliative chemotherapy in comparison with responders. The disease-free interval of patients treated by adjuvant chemotherapy was significantly shorter in patients with low transcript levels of ABCA7, ABCA13, ABCB4, ABCC11 and ABCD4. In conclusion, ABCC11 may be a promising candidate marker for a validation study on 5-FU therapy outcome.

Cytokeratin serum biomarkers in patients with colorectal cancer

BACKGROUND

Circulating cytokeratins have shown to be important for management of patients with lung cancer. Here we investigated their role for differential diagnosis, therapy monitoring and prognosis in colorectal cancer (CRC).

PATIENTS AND METHODS

Pretherapeutic levels of cytokeratin-19 fragments (CYFRA 21-1), carcino-embryonic antigen (CEA) and cancer antigen (CA) 19-9 were measured in 42 patients with CRC, 45 with benign colorectal diseases and 51 healthy controls. Furthermore, courses of CYFRA 21-1, tissue polypeptide antigen (TPA), tissue polypeptide specific antigen (TPS), M30-antigen, CEA and CA 19-9 were analyzed in prospectively collected sera of 15 patients with CRC during primary chemotherapy and were correlated with therapy response and overall survival (OS).

RESULTS

Similar to CEA and CA 19-9, CYFRA 21-1 was significantly elevated in serum from patients with CRC (median 2.1 ng/ml) as compared with healthy (1.2 ng/ml; p<0.0001) and benign gastrointestinal controls (1.7 ng/ml; p=0.0178) and showed stage dependency in CRC (p=0.0118). CYFRA 21-1 correlated with CEA in benign diseases and CRC but not with CA 19-9. The best discrimination between healthy controls and patients with CRC was achieved by combination of CYFRA 21-1 and CA 19-9 (area under the curve; AUC=86.7%), while the combination of CEA and CA 19-9 discriminated best between benign diseases and CRC (AUC=73.9%). In CRC patients during primary chemotherapy, levels of cytokeratins CYFRA 21-1, TPA, TPS, CEA and CA 19-9 tended to be higher in patients with poor response to therapy and with poor prognosis.

CONCLUSION

Cytokeratins are elevated in patients with CRC and show some association with response to primary therapy and prognosis.

[Prognostic clinical factors in colorectal cancer after radical therapy]

INTRODUCTION

Colorectal anastomoses frequently become the site of of complications after surgical procedures for colorectal cancer. Anastomotic dehiscence has a significant impact on the whole p postoperative disease course, may influence the overal survival (OS) and disease free interval (DFI). The aim of our study was to analyze clinical and histopathological factors, that could facilitate detection of dehiscences and are related to the prognosis of patients.

MATERIAL AND METHODS

The authors performed statistical analysis of a cohort of patients (340 pacients, 207 males, 133 females) who underwent radical resection followed by anastomosis on the large intestine during 2003-2007. The following factors were assessed: age, gender, staging, protective stoma, neoadjuvant chemotherapy, neoadjuvant radiotherapy, adjuvant chemotherapy, adjuvant radiotherapy and anastomotic insufficiency. Complications were evaluated according to Clavien and Dindo classification.

RESULTS

The analysis confirmed the following factors to be statistically significant for prognosis of OS and DFI: In stage T4 subjects, the risk of death was 2.5 x higher and the risk of recurrence was 1.9 x higher than in the lower disease stage subjects. The presence of N2 lymph node metastases increases the risk of death 3.7 x and the risk of recurrence 3.6 x, compared to N0 and N1 cases. The presence of postoperative complications classified asf III.-V. grade according to Clavien and Dindo classification increases the risk of death 4x. The risk of death was 5.5 x higher in patients with dehiscence of anastomosis. The surprising finding was that even protective stoma increases the risk of death 5.4 x. Patients who did not undergo adjuvant chemotherapy were at 2 x higher risk of death. In patients with IIIA, IIIB, IV, V complications, the following factors proved to be statistically significant for prognosis of OS: leakage, protective stoma, adjuvant chemotherapy and adjuvant oncological treatment. In patients with complications I and II, the following factors were proved to be statistically significant for prognosis of OS: staging and lymph nodes metastases. Multivariate analysis CART confirmed significant correlation between the lymph nodes positivity and the Clavien and Dindo classification of complications.

CONCLUSION

Analysis of clinical and histopathological factors is important for prediction of prognosis in patients with colorectal cancer after radical surgical treatment. Detection and application of these prognostic factors in postoperative period could influence the strategy of treatment and thus the overal survival in patients with radical resections for colorectal carcinoma. Nonadministration of adjutant chemotherapy results in a significant decrease in OS and DFI.

Different cardiac loading conditions and haemodynamic monitoring in animal models

OBJECTIVE

To develop models of various cardiac loading conditions in an experimental study.

MATERIALS AND METHODS

A total of 78 piglets, average weight 24 kg were divided into 4 groups under different cardiac loading conditions: Group A were spontaneously breathing pigs without haemodynamic changes, Group B were ventilated animals with increased left ventricular afterload, Group C ventilated with increased right ventricular preload and Group D ventilated with increased afterload of both heart ventricles. Haemodynamic parameters were invasively measured at 60 and 120 minutes.

RESULTS

Groups B, C and D demonstrated higher preload of both ventricles, compared with Group A. Group C demonstrated higher preload and afterload of both ventricles in comparison with Groups B and D.

CONCLUSION

Haemodynamic measured data confirmed the expected changes in cardiac loading and corresponded to human clinical situations. These models may be used for future experimental haemodynamic studies (Tab. 1, Fig. 3, Ref. 8).

Matrix metalloproteinases and their inhibitors in correlation to proliferative and classical tumour markers during surgical therapy of colorectal liver metastases

OBJECTIVES

Classical and proliferative tumour markers and matrix metalloproteinases and their tissue inhibitors reflect the features of malignancy and are useful in prediction of prognosis in patients with colorectal liver metastases. There is very limited information about their physiological functions during regeneration and healing of liver parenchyma after any type of liver surgery for malignancy.

METHODS

The presented study included the patients, who underwent following surgical procedures for CLM, benign liver lesions and inguinal hernias: Group A: 22 patients with inguinal hernias, Group B: 26 patients with benign liver lesions, Group C: 30 patients with colorectal liver metastases (CLM) who were treated by radiofrequency ablation, Group D: 41 patients with CLM who underwent a radical surgical therapy - resection, and Group E: 22 patients with inoperable CLM who underwent an explorative laparotomy without any surgical procedure.

RESULTS

The preoperative and postoperative serum levels of CEA, CA 19-9, TK, TPA, TPS, MMP-2, MMP-9, TIMP-1, and TIMP-2 were statistically analyzed and compared within the groups to estimate the influence of a surgical procedure type. These results reflect the influence of surgical procedure on the serum levels of studied tumour markers during operation.

CONCLUSIONS

It was the first description using these types of comparison to all metalloproteinases, their inhibitors, and proliferative and classical tumour markers. It could help us to estimate the critical relations of these tumour markers in prognoses of disease free survival or overall survival in patients after a surgical procedure for CLM (Tab. 5, Ref. 26).

[Secondary peritonitis prognosis assessment]

INTRODUCTION

Secondary peritonitis is a severe disease with high mortality and morbidity. In the last 20 years the results of treatment of this disease have improved markedly.

AIM OF THE STUDY

To determine statistically significant risk factors for mortality in patients with severe secondary peritonitis.

MATERIAL AND METHODS

We studied in retrospective analysis the cohort of patients treated at our clinic in the period 2005-2010. 65 patients (38 men and 27 women) with an average age of 60.7 years were included. 27 patients died (41.5%). The average age of the died patients was 72 years. The average value of APACHE II was 20.77, which corresponds to the prediction of lethality 41.8%. The average value of the SOFA score was 11.87.

RESULTS

The performed statistical analysis showed age over 65 years, bronchopneumonia, obesity, ischemic heart disease, artificial ventilation over 6 days and circulatory support over 10 days as statistically significant independent factors for mortality. Patients older than 65 years had 8.9 times greater risk of death. In the case of bronchopneumonia was the risk 4.8 times higher. Obesity increased the risk of death 3.1 times and ischemic heart disease 2.4 times. In the case of mechanical ventilation for more than 6 days and circulatory support for more than 10 days, these increased the risk of death 4.1 times respectively 4.3 times.

DISCUSSION

The benefit for determining the prognosis secondary peritonitis is the use of scoring systems. It was also shown that the basic clinical data may have the same benefit for predicting the prognosis of patients as a sophisticated scoring systems.

CONCLUSION

The performed retrospective analysis age over 65 years, bronchopneumonia, obesity, artificial ventilation and circulatory support as statistically significant independent factors for prediction of poor survival. These basic clinical factors correlated with scoring systems APACHE II a SOFA.

[Non-tumor bile duct strictures]

The authors rectrospectively evaluate the possibilities of the solutions and the complications regarding benign stenoses of the biliary tract in 10 patients, who were treated within the years 2008 - 4/2011 at the Surgical Clinic of Medical Faculty of Charles University and the Faculty Hospital in Plzen. The injury of the biliary tree at cholecystectomy - 6 cases - was the most often cause of the benign stenosis of the biliary tree development in our collection. Once it was the case of a rare incidence of M. Crohn's disease of the biliary tract, once it was the case of stenosis in Mirrizi syndrome and two times it was the case of stenosis after the repeated instrumental procedures at ERCP after choledocholithiasis. Three times stenosis was solved by help of the repeated dilations of stenosis in the way of ERCP procedure. In other 7 cases stenosis was solved surgically by help of hepaticojejunalanastomosis to the excluded Roux-en-Y gastric bypass. The dilation of stenosis of the biliary tree requested two sessions on average, the surgical solution had a minimal peri-operative morbidity - 0% and within a 30-day peri-operative period there was noted 1 death in connection with the solution of stenosis of the biliary tract with the massive bleeding at decubitus of the stent of the left biliary duct into hepatic artery. Long-term results with respect to a short-time period were not evaluated.

[Contribution of molecular biology to the diagnosis and therapy of colorectal carcinoma--the present and future]

Colorectal cancer is one of the most frequent malignant disease and despite of the development of modern surgical and oncological treatment, it is still a very severe diagnosis for the patient. The survival of the patient after the radical surgery is mostly affected by the time of detection of the disease and by the selection of the appropriate oncological treatment. The effectivity of the oncological treatment depends mainly on the features of the malignant tissue. During the last decade, the importance of the molecular biology and it's methodology have been growing for both detection of the disease and the selection of the best treatment for the individual patient. Genetic and epigenetic characteristics of the tumours helps to predict the prognosis of the disease and also select the best treatment, which extends the disease-free and overall survival of the patient. The presented review describes the most important molecular-biological characteristics with the prognostic or predictive function, which are used in the clinical practice or are in the later phase of clinical study.

[Pilonidal sinus--surgical management at our surgical clinic]

INTRODUCTION

pilonidal sinus disease is a benign disease with incidence 26 cases per 100 thousands inhabitants each year. The origin of this disease is in sacrococcygeal region with maximum between 15th and 25th year of life. Males suffer from pilonidal sinus disease most often. The synonym of this disease is Jeep's disease and originate in Second World War. We distinguish acute and chronic phase of this disease. The acute phase is characterized by presence of abscess whereas the chronic phase is featured by intermittently secreting fistula. Malignant reversion is described at chronic phase in 0.1%.

METHODS

We performed retrospective study of our cohort of 53 patients that undewent radical surgical treatment at our department between September 1st 2006 and December 31st 2009.

RESULTS

We evaluated 39 patients that were controlled repetitively after operation. Males were in majority. The median of age was 24 years. 38 patients underwent the incision for abscess in preoperative period. The intermittently secreting fistula was diagnosed at 46 patients at the time of operation. 41% patients suffered from wound infections and 56% from dehiscence of wound (7 patients with partial dehiscence) after radical excision. We used 5 modifications of wound closure after radical excision.

DISCUSSION

The choice of adequate method of wound closure after excision of pilonidal sinus was, is and will be discussed among experts. We could find many types of methods of wound closure including plastic with flaps in the scientific literature. In our country there is preferred more primary wound closure than plastic with flap. Our results are comparable with the previously published results.

CONCLUSION

The treatment of pilonidal sinus has to be radical. We can conclude that usage of our technique of underlaid sutures decreases the prevalence of postoperative infection and risk of wound dehiscence. The proper types of technique of wound closure could not be evaluated with statistical signifikance because of small number of patients in our cohort.

[Can tumor markers predict outcomes of portal vein branch embolization in patients with primary inoperable liver tumors?]

INTRODUCTION

Portal vein embolization (PVE) is one of the options to increase the number of resecable cases in patients with primary inoperable liver tumors. However, insufficient growth of liver parenchyma or postoperative tumor progression remains problematic in PVE procedures. Generally, tumor markers are of significance in patient postoperative monitoring for the disease recurrence. The aim of this study is to assess the potential of tumor markers in predicting PVE outcomes.

METHOD

The study group included 43 subjects with primary or secondary tumors, in whom serum alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), thymidine kinase (TK), tissue polypetide antigen (TPS) and MonoTotal levels were assessed 28 days following PVE. The liver parenchyma growth or tumor progression were assessed based on computer tomography.

RESULTS

Sufficient liver parenchyma hypertrophy was recorded in 27 (62.8 %) patients with subsequent liver resection. Insufficient post-PVE liver parenchyma growth was recorded in 5 (11.6 %) patients and tumor progression was recorded in 11 (25.6 %) subjects. The following tests were considered significant predictive tumor markers of PVE outcomes: serum levels of CEA, TPA, Mono Total prior to PVE, and serum levels of TK, TPA, Mono Total within 28 days following PVE.

CONCLUSION

Tumor markers may be significant in predicting PVE outcomes in patients with primary inoperable liver tumors. However, in order to make final conclusions on their clinical significance, larger patient group studies should be performed.

[Portal vein branch embolization in patients with primary inoperable liver tumors]

INTRODUCTION

Portal vein embolization (PVE) is indicated in patients with insufficient liver remnants following liver resections for tumor disorders. Therefore, due to PVE, the number of primary operable patients is higher. Insufficient growth of the liver parenchyma or malignant progression remain the PVE cons.

AIM OF THE STUDY

To date outcomes of PVE are assessed based on the authors' own experience and literature data. In particular, the authors focus on difficulties with PVE, i.e. its failures.

METHODS

40 patients (35 with colorectal carcinoma metastases, 2 with breast carcinoma metastases and one with ovarian carcinoma metastases, 2 with hepatocellular carcinoma) were indicated for PVE due to insufficient liver reserve following planned liver resection.

RESULTS

Liver resections were completed in 22 subjects, 42.6 days (mean value) after PVE. In 14 (35%) subjects, the liver resection could not be performed (11x tumor progression, 3x insufficient liver tissue growth). In four subjects, only radiofrequency ablation was performed. At year one, two and three after the procedure, the survival rate is 83.7, 69.7 and 52.3% (resp.) of the subjects, while the survival rate following exploration and in unoperated subjects was 22.2% (25 subjects) (p < 0.001). A one-year, resp. two-year relapse--free survival rate was 30.3, resp. 7%.

CONCLUSION

PVE has become an established procedure in stage liver procedures, due to its potential to facilitate operability of primary and secondary liver tumors. In order to improve the outcomes, attention must be paid to the post- PVE growth of the liver parenchyma and further assessment of oncological treatment approaches during the pre- and post- PVE period, with the aim to reduce liver and extra-liver malignant progression rates prior to the liver resection procedure.

[Surgical treatment of liver and pulmonary metastases of colorectal carcinoma]

THE AIM

The aim of the work was to evaluate the set of 10 patients, who were operated on hepatic and pulmonary metastases of colorectal carcinoma at the Surgical Clinic of Medical Faculty of Charles University and Faculty Hospital in Plzeń in years from 2005 till 2009. With regard to limited experience with the patients who underwent hepatic as well as pulmonary resection, we focused on the evaluation of a long-term survival of the patients and their mortality and morbidity.

THE SET OF THE PATIENTS

In years from 2005 till 12/2009 we operated 10 patients during whose affection there occurred hepatic and pulmonary metastases of colorectal carcinoma and these were solved surgically. This concerned 5 men and 5 women at an average age of 62.4 years (42-71 years). In 10% it was hepatic resection in the first period after the operation of primary carcinoma, it was the first performance on the hepatic parenchyma in 90%.

THE RESULTS

Morbidity of the set was 20.1% regarding hepatic resections and 5.6% regarding pulmonary resections. A 30-day postoperative mortality was 0%. In three cases a hepatic involvement was bilateral, in two cases in the left lung and 5 patients had an involvement of the right pulmonary lobe. In 4 cases primary carcinoma was in the rectum and in 6 cases in the large intestine. The period of three months was an average time between hepatic and pulmonary resection. Resection on liver parenchyma was the most often performance and metastasectomy with the help of laser on the pulmonary parenchyma. Rectal carcinoma spread into lungs in 50%. An average time of a 5-year survival in the patients after resection of hepatic and pulmonary metastases of colorectal carcinoma was 26%.

THE CONCLUSION

Hepatic and pulmonary resection in the selected patients with generalized colorectal carcinoma extends the period of a survival and does not worsen the quality of the life. The patients after resection of both--hepatic and pulmonary metastases have got a worse long-term survival than the patients being only after hepatic resections.

[Liver metastases of other than colorectal origin]

AIM

Colorectal carcinoma is the commonest malignancy with liver metastases. Approximately 25-30% of these metastases are resectable with good long-term outcomes. Liver metastases of so called non-colorectal carcinomas are significantly less common, and considering different biological character of these metastases, compared to colorectal ones, surgical management of some of these types is debatable, however, in some cases remains highly successful. The aim of this study was to assess the authors' outcomes of surgical and termoablation therapy of non-colorectal liver metastases.

METHODS

The authors present their experience with surgical treatment in 68 patients - mean age of 58.2 y.o.a (33.1-77.5) with liver metastases of non-colorectal carcinomas- NKJM (the commonest types: breast carcinoma--32.4%, carcinoid--20.6%, renal carcinoma--13.3%, gynecological tumors--13.3%, gastrointestinal stromal tumor--4.4%, gastric carcinoma--4.4% ) during 2001-2008. The mean time after primary surgery for carcinoma was 3.9 years (0-8.5 let). The surgical procedures included the following: radiofrequency ablation (RFA)--50 patients (73.5%), resections in 26.5%. Preoperative chemotherapeutical "downstaging" or portal vein embolization on the tumor side, in order to improve the NKJM resecability, was performed in 10 subjects (14.7%). Resecable or RFA--manageable extrahepatic metastases were removed using one- or more- step procedures in 25 subjects (36.7%). The total number of liver metastases within the whole study group ranged from 1 (28x) to 8 (1x) metastases. Postoperative adjuvant chemotherapy, combined with biological treatment in some patients, was administered to a total of 33 patients (48.5%).

RESULTS

One year after the procedure and RFA, a total of 88.6% of patients were surviving, at 3 years 72.5 % and at 5 years 36.9% of the subjects. Considering four commonest tumors (breast carcinoma, carcinoid, gynecological carcinomas and renal carcinoma), the best 5-year survival rates were recorded in patients with carcinoid metastases (100%), 33.8% of patients with breast metastases were surviving at 5 years, 44.4% of patients with renal carcinoma metastases were surviving at 3 years and 72.9% of patients with gynecological tumors were surviving at 2 years. There were no statistically significant differences in long-term survival rates between RFA and resections. Patients with extrahepatic metastases had worse prognosis (p < 0.01).

CONCLUSION

Liver resection and RFA have their definite place in multimodal treatment strategy in the management of non- colorectal carcinoma liver metastases (NKJM). Indication for surgery must be made on strictly individual basis, in particular in patients with NKJM, in order to achieve quality long-term survival in these patients.

[Modern algorithms for diagnostics and treatment of anorectal fistulas in clinical practice--case reviews]

Authors present three case reports of perianal fistules with review of contemporary literature. The obligatory nature of this disease is defined by its behaviour, tendency to relace, a social taboos and handicap, that affects patients with perianal fistule. In introduction there is descripted aethiology, morphology, standard diagnostic procedures and therapy of anorectal fistules and fistule form of idiopatic bowel diseases. In discussion there is a review of the new trends of diagnostic and treatment procedures of these diseases, that reflect domestic and international expert literature. Standard procedures are summarized in conclusion.

[Repeated surgical procedures in relapsing colorectal carcinoma--a case review]

INTRODUCTION

Relapsing colorectal carcinoma limits overall survival of much of afflicted patients.

METHODS

Authors present at example of 32 years old patient with relapsing colorectal carcinoma possibilities of repeated radical surgical and adjuvant oncological treatment.

DISCUSSION

Therapy of relapsing colorectal carcinoma has not only to stay matter of surgical treatment but has to be completed by sufficient adjuvant oncological treatment. Complex approach proved that active surgical treatment of operable metastases of colorectal carcinoma enlarged overall survival of afflicted patients in comparison with palliative therapy.

CONCLUSION

Consequential follow-up of patients after radical surgical treatment of colorectal carcinoma supports early diagnosis of relapse and so improves possibilities of surgical treatment and overall survival of patients.

Chemo-embolization of inoperable liver tumors

A small percentage of patients suitable for radical surgery require us to introduce alternative palliative methods prolonging the good quality of life in patients with malignant liver tumors. Apart from thermoablation or cryo-ablation, one of the alternative methods with palliative influence on tumors is the chemoembolization of tumors. A group of 18 patients, who underwent chemo-embolization at the Surgical Clinic and Radiodiagnostic Clinic, Medical Faculty, Charles University in Pilsen from 2007 to 2008, were assessed from the point of view of complications, overall survival and the patients' life quality. The most common complication was temperature and pain in the right infracostal area in connection with the performed procedure. The patients' quality of life after chemo-embolization was very good and the time of hospitalization was only 3.5 days on average. We had to perform the procedure repeatedly in 30% of cases. The chemo-embolization was done on inoperable liver metastases of colorectal carcinoma and on inoperable hepatocellular carcinoma (Tab. 1, Fig. 2, Ref. 5).

[Liver cystadenoma]

THE INTRODUCTION: Biliary cystadenomas of the liver are less often complicated cystic lesions of the liver with a malignant potential.

THE AIM

The aim of the work was to assess the results of the set of an own working place emphasising new findings in the diagnostics and the treatment of benign tumours of the liver.

THE SET OF THE PATIENTS AND THE METHOD

From 2004 till 2009 three patients were operated on biliary cystadenomas of the liver at the Surgical Clinic of Medical Faculty of Charles University and Faculty Hospital in Plzen. In all cases these patients were women with the average age 42 years of the age category 36-58 years. In all cases the formation was located centrally close to the branching of the big biliary ducts. The diagnosis was established preoperativelly in 66% of cases. An enucleation was performed two times and the right hepatectomy once. Mortality was 0% and morbidity was 33%.

THE CONCLUSION

Regarding to the fact that cystadenomas of the liver as benign tumours have a malignant potential for rising the cystadenocarcinoma, it is always necessary to perform their surgical removing--resection or the enucleation. With respect to their central location their surgical treatment belongs to more difficult performances carried out on the liver parenchyma. Long-term results after the surgical treatment are very good.

[Surgical treatment of benign liver tumours--indications and results]

The authors present their results on the treatment of benign liver tumors. 65 patients were operated upon in the University Hospital in Pil-sen from 2000 until July 2006. Benign liver lesions were rather rare compared to malignant tumours, for which 273 patients were treated within the same period. The most often found benign -lesions were hepatocellular adenoma, focal nodular hyperplasia (FNH) and hemangioma. Sometimes, it was not possible to make a correct diagnosis preoperatively. The surgical procedures used for benign tumours were mostly enucleation and non-anatomic parenchyma-saving resection (55.4 %). Morbidity in this group was 26.5 %, mortality 0 %.

[Surgical management of the colorectal carcinoma liver metastases]

INTRODUCTION

Unfortunately, the Czech Republic rates of the colorectal carcinoma are the highest in the world. Surgical procedures for colorectal carcinoma liver metastases (JMKRK) are well established and have good long-term outcomes.

AIM

The aim of the study was to assess own results with a reference on modern trends in liver surgery.

SUBJECTS AND METHODOLOGY

From 01- 01- 2000 to 01-12- 2008, a total of 442 liver procedures in 346 patients with colorectal carcinoma liver metastases were performed in the Faculty Hospital and the Charles University Medical Faculty Surgical Clinic in Plzen.

RESULTS

The 30-day postoperative mortality rate was 0.3%, the morbidity rate was 8.1%. Five years following the liver procedure for the colorectal carcinoma liver metastases, 34.0% of the subjects are surviving. 3 years following radiofrequency ablation (RFA) of the colorectal carcinoma liver metastases, 35.5% of the patients are surviving.

CONCLUSION

Nowadays, surgical management of the colorectal carcinoma liver metastases is the method of choice. The other alternative is radiofrequency ablation (RFA) in non-resectable colorectal carcinoma liver metastases. However, currently, only 20% of the patients are operable using the radical methods at the time, when the diagnosis is established. Therefore, the new trends in liver surgery include several-stage/phase, combined procedures and re-resections, aimed to improve resecability of the colorectal carcinoma liver metastases with low patient postoperative mortality and morbility rates.

Cytokines and liver regeneration after partial portal vein ligation in porcine experimental model

THE AIM OF STUDY

The limits of liver surgery are restricted today by the functional reserves of remnant parenchyma. The aim of this article was to acquaint the general surgical and medical public with the results of experimental liver regeneration stimulated by cytokines and thus to enhance their effort to carry on with implementing the research results in clinical practice.

METHODS

Authors present their experimental model of liver regeneration after ligation of portal branches for caudate and right lateral, and right medial liver lobes. The regeneration was induced by application of TNF-alpha and IL-6 into the non-occluded portal branches, and compared with the results of other experimental teams.

RESULTS AND CONCLUSION

The absolute volume of hypertrophic lobes increases after application of TNF-alpha more rapidly, whereas in the control group, practically no changes were recorded in hypertrophic liver lobes volumes in first three days. The achieved acceleration of growth of hypertrophic liver lobes after application of TNF-alpha and IL-6 confirmed the key role of studied pleiotropic cytokines in the priming of liver parenchyma regeneration after portal vein ligation (Fig. 3, Ref. 26).

[Treatment strategy in non-parasitic benign cysts of the liver]

The authors present the problems of treatment of benign non-parasitic cystic liver diseases. Recent diagnostic and treatment strategy is demonstrated at the cohort of 25 patients (16 women and 9 men), who were operated on Department of Surgery, Medical School and Teaching Hospital Pilsen, Charles University Prague between years 2002-2007. The average age was 59.9 years (38-86 years). We performed 15 laparoscopic fenestrations, 5 opened fenestrations, three enucleations of cysts and one left lobectomy and one central liver resection. The resections were performed because of diagnostic uncertainty to verify histological character of leasions at patients after previous operation of gastrointestinal tract for malignancy. Histological diagnosis was proved in 16 cases solitary liver cyst, in 7 cases of polycystic liver disease, one biliary cystadenoma and one retentive cyst. The reoperation of symptomatic solitary liver cyst was performed in one patient after 12 months from primary operation. The average follow-up of patients after surgical treatment was 41 months (5-96 months). Solitary liver cysts are indication to laparoscopic fenestration with biopsy in case of evidence of symptoms. Polycystic liver diseases are treated conservative and surgical treatment is indicated at outstanding and apparent symptomatology of this disease, where is possible to demonstrate preoperatively one or more dominant cysts.

[Carcinoma of the gallbladder--current surgical treatment options]

BACKGROUND

The effect of radical resection in gallbladder cancer is still area of debate.

AIM OF STUDY

To determine the criteria of surgery in primary and incidental gallbladder cancer. method: Eighty-four patients with gallbladder cancer were evaluated between 1999 and 2008. Sixty patients (72.4%) were symptomatic. Explorative laparotomy was performed in 40 (66.7%), palliative procedure in 5 (8.3%) patients in stage pT3-4, N1, M0-1. Cholecystectomy only or completed with wedge resection of the gallbladder bed and lymfadenectomy as radical procedure was performed only in 7 (1.7%) patients in pT1-2, N0-1, M0. Twenty four (28.6%) patients had incidental gall bladder carcinoma. Radical cholecystectomy was performed in 4 (16.7%) - pT1a, N0, M0, palliative cholecystectomy in 3 patients (12.5%) - pT3, N1, M0. Radical reoperation was performed in 15 (62.5%) patients in stage pT1b-2, N0-1, M0.

RESULTS

Patients survival after explorative laparotomy and palliative procedures was no longer than 7 months. Four from seven patients died after radical operation 12-18 months after operation. Six from 15 radically re-operated patients are alive in interval 4 months and 8 years. Nine patients died in interval 9 months and 4 years after re-operation.

CONCLUSION

Radical surgical procedure is the treatment of choice for patients with gall bladder carcinoma especially in stage pT1-2, N0, M0.

[Liver cystadenoma with ovarian stroma--a case review]

Cystadenoma with ovarian type of stroma is a rare liver tumor. Authors discuss diagnostic difficulties and troublesome therapy with potential complications at unfavourable central localization in the liver of 46 years old woman.

Clinical relevance of the expression of mRNA of MMP-7, MMP-9, TIMP-1, TIMP-2 and CEA tissue samples from colorectal liver metastases

BACKGROUND

Nowadays we know that survival rates do not differ between repeated and single liver resections for colorectal liver metastases (CLM). To be able to determine patients prone to early recurrence, the use of different markers with a better prognostic value than the routinely employed tumor markers is required.

AIM OF STUDY

The aim of our study was to assess mRNA expression of MMP-7, MMP-9, TIMP-1, TIMP-2 and CEA in tissue samples from CLM and their relationship to disease-free interval (DFI) and overall survival (OS).

PATIENTS AND METHODS

The liver tumor biopsies were obtained from 40 patients suffering from CLM treated with radical surgery. mRNA expression levels of CEA, MMPs and TIMPs and a housekeeping gene (GAPDH) were quantified using RT-PCR.

RESULTS

The increased expression of CEA, MMP-9 and TIMP-1 in CLM was associated with a short DFI and a high tendency to early CLM recurrence. Statistical analysis confirmed CEA, MMP-9 and TIMP-1 expression as prognostic factors of survival.

CONCLUSION

This study demonstrated the importance of CEA, MMP-9 and TIMP-1 in the prognostication of DFI and OS.

[Tumorous stem cells--a novel view in oncology?]

Authors present contemporary knowledges, arguments and hypothesis about cancer STEM cells and their relations to current concepts of oncology and surgical oncology. The aim is to introduce new view of carcinogenesis and origin of metastatical process as a diseas of STEM cells to general surgical public that deal with surgical oncology and is confronted with new trends in modern oncological pharmacology. The presented theory of tumour origin by cancer STEM cells is confronted critically with all current theories.

Tumor markers as useful predictors of survival rate after exploratory laparotomy for liver malignancies

BACKGROUND

Tumor markers are used for the prediction of relapse and in determining the effect of postoperative or post-oncological therapy as a standard component of follow-up. Metastatic processes of the liver and primary malignancies of the liver and gall bladder are very common in the European population. The aim of this study was to demonstrate the behaviour of malignancy in patients who have not undergone surgical therapy and to study serum levels of the monitored tumor markers in relation to the life expectancy of these patients.

PATIENTS AND METHODS

The Log-rank test and Wilcoxon test were used for statistical evaluation. Survival was computed using the Kaplan-Meier method. Serum levels of the tumor markers conventionally used in clinical practice in patients with gastrointestinal tumors (CEA, CA19-9, C724) and the markers of the proliferation activity in malignancy (TK, TPA, TPS) were studied.

RESULTS

One hundred and nine patients who underwent exploratory laparotomy without any surgical therapy between September 1999 and June 2005 were studied. For patients with a serum level of CEA, CA19-9 and CA72-4 that was higher than the calculated cut-off hazard ratios of early death were respectively 3-, 5- and 9-fold higher than for patients with serum levels of the same tumor markers below the calculated cut-off. Preoperative serum levels of proliferative tumor markers (TK, TPA and TPS) were not statistically significant for the prediction of early death.

CONCLUSION

The results of the pilot study suggest the importance of tumor markers for the prediction of the short-term survival rate. These markers could be used to supplement classic clinical, laboratory and radiodiagnostic parameters. It would be very helpful for the planning of palliative oncological therapy for patients with liver malignancies who cannot be treated by surgical therapy.

Dynamics of serum levels of tumour markers and prognosis of recurrence and survival after liver surgery for colorectal liver metastases

BACKGROUND

The authors present a statistical analysis of the dynamics of tumour markers and compare these with single serum levels in patients before and after liver surgery for colorectal liver metastases (CLM).

PATIENTS AND METHODS

The serum levels of tumor markers conventionally used in clinical practice (CA19-9, CEA, CA72-4) and markers informing of the proliferation activity of malignancy (TKI TPA, TPS) were statistically analysed. The authors studied 144 patients who underwent liver surgery for colorectal liver metastases between September 1999 and June 2005. Serum levels of tumor markers before surgery (maximally two weeks before the operation), after surgery (maximally one month after the operation - usually on the day of dismission), six months (+/- one month) and twelve months after the surgery (+/- one month) were determined. The Log Rank test and the Wilcoxon test were used for statistical evaluation. The survival rate and disease-free intervals (DFI) were computed using the Kaplan-Meier method.

RESULTS

The statistical analysis of tumour marker dynamic after liver surgery (speed and power of recurrence) supported the dynamics of CA 19-9 and CEA as excellent prognostic factors of early recurrence of CLM in contrast to proliferative tumor markers.

CONCLUSION

The results of the study suggest the importance of tumour markers for the prediction of a short survival rate or DFI. This approach would be very helpful for the planning of palliative oncological treatment for patients with liver malignancies that cannot be treated by surgical therapy. Current patients with a high tendency of recurrence of CLM after liver surgery should be followed up more thoroughly to increase the possibility of successful reoperation.

[Pyogenic abscesses of the liver]

Pyogenic abscesses of the liver represent a serious nosologic unit with high morbidity and mortality rates. Their diagnostics is based on ultrasonography, computer tomography or MRI, or positrone emission tomography. The principal treatment procedure includes percutaneous draining of the abscess cavity under the ultrasound or CT control. The authors present a group of 83 subjects hospitalized from 2000 to 2006 for pyogenic abscesses of the liver. Obstruction of the bile ducts, acute cholecystitis and resections of the liver or pancreas for malignancies were recorded as the commonest causes of the abscesses. Percutaneous drainage was the treatment method of choice in 67.5% of the subjects and it included management of the causative factors and administration of antibiotics. The hospitalization period was affected by the following factors: septic conditions (p < 0.04), ALT levels (p < 0.003) - cut off 3.0 mkat/l, the abscess diameter, which may have required reoperation, (p < 0,05), diabetes mellitus (p < 0.05) and septic conditions (p < 0.001). The need for re-hospitalization due to a relaps of the pyogenic abscess of the liver correlated significantly with the following: a number (> 2) of abscesses (p < 0.04), C-reactive protein levels (p < 0.005) - cut off> 100 mg/l and septic conditions (p < 0.007). Furthermore, significat correlation was detected between the mortality rates and sepsis (p < 0.05).

Evaluation of a recombinant human gelatin as a substitute for a hydrolyzed porcine gelatin in a refrigerator-stable Oka/Merck live varicella vaccine

Background

The labile nature of live, attenuated varicella-zoster virus (Oka/Merck) requires robust stabilization during virus bulk preparation and vaccine manufacturing in order to preserve potency through storage and administration. One stabilizing ingredient used in a varicella-zoster virus (VZV) vaccine is hydrolyzed porcine gelatin which represents the major protein/peptide-based excipient in the vaccine formulation.

Methods

In this comparative study, a recombinant human gelatin fragment (8.5 kD) was assessed as a potential replacement for hydrolyzed porcine gelatin in an experimental live, attenuated VZV (Oka/Merck) vaccine. VZV (Oka/Merck) was harvested in two formulations prepared with either a hydrolyzed porcine gelatin or a recombinant human gelatin. Moreover, the viral stability in the experimental VZV (Oka/Merck) vaccines was evaluated under accelerated and real-time conditions in a comparative study.

Results and discussion

The stabilizing effect of recombinant human gelatin on VZV (Oka/Merck) potency change during vaccine lyophilization was similar to the experimental vaccine containing porcine-derived gelatin. Vaccine viral potency changes were comparable in stabilized VZV (Oka/Merck) formulations containing either hydrolyzed porcine gelatin or recombinant human gelatin. No statistically significant difference in potency stability was observed between the vaccine formulations stored at any of the temperatures tested.

Conclusion

The recombinant human gelatin demonstrated similar ability to stabilize the live attenuated VZV (Oka/Merck) in an experimental, refrigerator-stable varicella vaccine when compared to the vaccine preparation formulated with hydrolyzed porcine gelatin used in currently marketed varicella vaccine.

[Portal vein embolization--increased chance for liver resecability for malignancies]

INTRODUCTION

Liver surgery for liver malignancy is recently limited not by technical possibilities but by physiological reserves of liver parenchyma. Portal vein embolization (PVE) is performed to increase future liver remnant volume (FLRV) to extend the possibilities of liver resections. The authors evaluate the cohort of patients, that underwent PVE and confront them with the cohort of patients that underwent liver resection without PVE.

METHODOLOGY

At the Department of Surgery and Departement of Radiology, University Hospital Pilsen there were performed successfully PVE at 24 patients between January 2001 and August 2006. The increase of FLRV was sufficient at 17 patients. The mean period between PVE and computed tomography volumetry was 29 days. The mean period between PVE and surgical procedure was 54 days. 8 patients underwent radical liver surgery (right hepatectomy, extended right hepatectomy, combination of right hepatectomy with RFA in left lobe), 3 patients underwent radiofrequency ablation, the rest of patients was explored. For comparison we used cohort of 107 patients that underwent one step radical surgery for malignancy.

RESULTS

1 year survival rate after liver operation was 85.7%, 3 years survival rate 42.9%. Disease free interval (DFI) was counted only for group of radicaly operated patients. One year DFI was 40%, two year DFI was 20%. The number of leasions was not proved as statistically significant for DFI or survival rate. In non PVE group 1 year survival rate was 78.9%, 3 years survival rate was 34.0%, one year DFI was 60.2%, two years DFI was 36.6%.

DISCUSSION

The survival rate was higher in PVE group, the DFI was shortened in PVE group. In our cohort we could conclude, the PVE increase survival rate instead of shortened DFI. PVE spreads possibilities for liver resections at patients with small FLVR and enables radical surgical therapy for patients, that will be leaved a palliative surgery or oncological therapy.

[Liver hemangiomas--diagnostic and treatment strategy]

Liver hemangiomas are benign mesenchymal tumors or the liver. The majority of them are asymptomatic, diagnosed accidentally during abdominal examination for other reasons. Ultrasonography. computer tomography and magnetic resonance are the main diagnostic instruments. Symptomatic, large cavernous hemangiomas or hemangiomas located on the liver surface with a risk of rupturing because of their size, are indicated for surgical management or radiointervetion. The authors present a patient group of 34 subjects with cavernous hemangiomas of the liver indicated for surgery (N = 25), or radiointervention (N = 9), based on the above critera. The thirty-day mortality rate was nil and morbididty 5.9%. The authors recommend enucleation of the hemangioma, which is technically simple and safe. From a long-term perspective, radiointervention is frequently poorly effective, and, therefore, should be indicated in polymorbid patients.

The rare benign liver tumors

As opposed to malignant secondary tumors, metastases of the colorectal carcinoma are benign tumors of the liver that are quite rare in the Czech Republic. From the 55 patients operated on since 2000 at our department for benign liver tumors, the most frequent are haemangiomas, focal nodular hyperplasia (FNH) and hepatocelular adenoma. Only 7.3% of them form a different histological type of a tumor than this most frequently occurring trio of tumors. The authors describe three cases of rather rare liver tumors with benign behavior that have the potential of becoming malignant. It concerns mucin producing biliary tumors, which correspond to the pancreatic intraductal papillary mucin tumor, hepatic cystadenoma with ovarian stroma and a liver hamartoma in an adult patient (Ref 13). Full Text (Free, PDF) www.bmj.sk.

[Prognostic factors of early recurrence of colorectal liver metastases and their usage in clinical praxis]

Liver surgery for colorectal liver metastases (CLM) is very often followed by recurrence. The prediction of early relapse of CLM is important for successful treatment, long disease free period and for long survival of patients, because it could help us to choose adequate surgical and oncological treatment. The authors present contemporary overview of the prognostic factors of early CLM recurrence and their possible use in prognostic scoring systems. These could be very helpful in clinical practice.

[A partial relaps of a colorectal carcinoma metastatic process following liver surgery--a multifactorical study]

In the period of November 1999 - June 2003 78 patients with colorectal liver metastases (CLM) were operated at Department of Surgery, University Hospital in Pilsen. In multifactorial analysis there were evaluated these clinical parametres: age of patient, sex, localisation of primary tumor, Dukes classification, grading, staging and histology of primary tumor, histologicaly free resection margin, chemotherapy or actinotherapy after colorectal operation, type of liver resection, complications after liver surgery, radicality of liver surgery, lateralisation of liver metastatic process, number of metastases, blood transfusions, repeated liver surgery, volume of metastases. Kaplan-Meier method was used for evaluation of survival rate and disease free interval (DFI). Statistical analysis of studied clinical parametres was performed by Log-rank test and Wilcoxon test. The medium DFI after liver surgery was 16 months for all the patients (range 0-55 months), the medium DFI for patients after radical surgery was 18 months. The medium survival time after liver surgery for all the patients was 30 months (range 1-57 months), for patients after radical surgery it was 32 months, and for patients after palliative surgery the medium disease free interval was 29 months (range 5-30 months). The 4-year survival rate after the liver surgery was for all the patients 37%. The factors statistically significant for a disease free interval after liver surgery were bilaterality of metastatic process, the microscopically free resection line, radical surgical treatment versus RFA and unilaterality of metastatic process. The authors proved followed factors as statistically significant for survival rate: grading of colorectal cancer and age of patients. The prediction of early recurrence enables us to choose adequate surgical therapy or its extension by oncological therapy. More thorough follow up of patients with tendency to early recurrence of CLM helps to early diagnosis of relaps and it increases the posssibility of repeated liver surgery.

Immunosuppresive agents have an influence on ischemia-reperfusion injury in kidneys procured from a non-heart-beating donor: experimental study

Ischemic-reperfusion injury (IRI) has a considerable influence on the function of kidneys from non-heart-beating donors (NHBD) after transplantation. IRI is accompanied by a marked inflammatory reaction with the production of reactive oxygen species and of the proinflammatory cytokine tumor necrosis factor alpha. The effect on the development of ischemic-reperfusion injury of early treatment of the donor with mycophenolate mofetil and tacrolimus was monitored in an animal model of a NHBD. The study demonstrated that the combination of the two immunosuppressives reduced the production in the NHBD kidney of tumor necrosis factor alpha, an indicator of the degree of inflammatory reaction after reperfusion, to a considerable extent but not of malondialdehyde or reduced glutathione. Pre-treatment of marginal donors with these immunosuppressants may improve the immediate function of transplanted kidneys by reducing cytokine production.

Markers of cellular adhesion in diagnosis and therapy control of colorectal carcinoma

AIM

Early diagnosis of the progressive tumor disease and control of the effect of therapy in colorectal carcinoma are most frequently performed by monitoring CEA or CA 19-9 tumor markers. Their clinical application is, however, limited. The aim of our study was to demonstrate the contribution of adhesive molecule assessment to the early diagnosis of progression. We also wanted to find out if changes in the levels of cellular adhesion parameters correlate with the effect of antitumor therapy.

MATERIALS AND METHODS

Intercellular cell adhesive molecule-1 (ICAM-1) and Vascular cell adhesive molecule-1 (VCAM-1) were assessed using the ELISA method, and the results were correlated with CEA and CA 19-9 tumor markers. Three hundred and sixty-four patients with colorectal carcinoma in Dukes' stages B-D were monitored. The results were processed with the SAS 6.2. statistical program and Statistica.

RESULTS

In 92 patients with first clinical progression (occurrence of distant metastases irrespective of localization), significantly increased ICAM-1 and VCAM-1 values were demonstrated. In ROC evaluation of curves, we also demonstrated high sensitivity of adhesive molecules against both the control healthy group (n =89) and the no evidence of disease group (NED) (n=183). Adhesive molecule levels were closely connected with the type and course of therapy and are presented in the form of case reports.

CONCLUSION

Soluble adhesive molecules are a prospective parameter both for the early diagnosis of progression and for control of the effect of therapy. There is a need for a large-scale study, preferably multicentric, which would verify the suitability of introducing cellular adhesion parameter assessment into routine practice.

Surgical treatment of benign liver tumors

In their report, the authors evaluated in their report a group of patients with benign liver tumors. These patients were treated at the Surgical Department of the Teaching Hospital in Pilsen from 1999 up to 2004. The evaluation of the investigated groups compared of 43 sick patients was based on the prospect of their individual diagnoses, types of performed surgeries, the time period of their therapy and complications, which had occurred in the course of their surgical treatment. In the group of 24 patients with liver haemangioma, the authors recorded 14 patients with focal nodular hyperplasia, 3 patients with hepatocellular adenoma and 2 patients with other types of benign tumors--multilocular cystic lymphangioma of the liver and one hamartoma. Among these patients there was 0% mortality and 6.9% morbidity.

Paratuberculosis in farmed and free-living wild ruminants in the Czech Republic (1999-2001)

Due to the occurrence of the infection of Mycobacterium avium subspecies paratuberculosis among domestic ruminants and the rapid development of farmed deer industry and the market of cloven-hoofed game we have carried surveys of paratuberculosis, beginning in 1997, in the most common four species of wild ruminants in the Czech Republic [Pavlik et al., Vet. Microbiol. 77 (2000) 231-251]. From 1999 the prevalence of paratuberculosis has been slightly reduced in all three types of husbandry of wild ruminants. Nevertheless paratuberculosis has been diagnosed in wild ruminants in three districts, in four game parks and in five farms. M. a. paratuberculosis was isolated from 128 (5.3%) out of 2,403 wild ruminants of four animal species: 106 red deer, 2 roe deer, 4 fallow deer and 16 mouflons. In red deer farms, the highest number of clinical paratuberculosis cases was in yearling deer. RFLP type B-C1 of M. a. paratuberculosis predominated during the second period (1999-2001) in all types of husbandry with no relationship to wild ruminant species. New "cattle" RFLP types B-C5 and B-C16 of M. a. paratuberculosis were described in infected farmed red deer and one "intermediate" RFLP type R-I4 in fallow deer from one game park. The survival of M. a. paratuberculosis was found to be 4 months during winter in the pasture after destocking of all cattle infected with paratuberculosis. We found that non-vertebrates, wild ruminants or non-ruminant wildlife can be vectors and potentially become a risk factor in the spread of M. a. paratuberculosis infection.

Convergent evolution of SIV env after independent inoculation of rhesus macaques with infectious proviral DNA

The env gene of three simian immunodeficiency virus (SIV) variants developed convergent mutations during disease progression in six rhesus macaques. The monkeys had been inoculated with supercoiled plasmids encoding infectious proviruses of SIVmac239 (a pathogenic, wild-type strain), SIVdelta3 (the live attenuated vaccine strain derived from SIVmac239), or SIVdelta3+ (a pathogenic progeny virus that had evolved from SIVdelta3). All six monkeys developed immunodeficiency and progressed to fatal disease. Although many divergent mutations arose in env among the different hosts, three regions consistently mutated in all monkeys studied; these similar mutations developed independently even though the animals had received only a single infectious molecular clone rather than standard viral inocula that contain viral quasispecies. Together, these data indicate that the env genes of SIVmac239, SIVdelta3, and SIVdelta3+, in the context of different proviral backbones, evolve similarly in different hosts during disease progression.

Primers ITS1, ITS2 and ITS4 detect the intraspecies variability in the internal transcribed spacers and 5.8S rRNA gene region in clinical isolates of fungi

Restriction fragment length polymorphism analysis of the 5.8S rRNA gene and the internal transcribed spacers (ITS1 and ITS2) was used for examination of 66 isolates belonging to 19 species. Intraspecies variability was found in the examined region of 11 species (Candida albicans, C. catenulata, C. colliculosa, C. glabrata, C. kefyr, C. melinii, C. parapsilosis, C. guillermondii, C. solanii, C. tropicalis, Saccharomyces cerevisiae). Region of ITS-5.8S rDNA was amplified using the primers ITS1 and ITS4. The amplicons were digested by HaeIII, HinfI and CfoI. The recognized intraspecies variability was confirmed in the second step, in which the shorter fragments of this region were amplified using primers ITS1 and ITS2 and analyzed by capillary electrophoresis. Considerable intraspecific variability renders this method unsuitable for species identification, whereas it can be useful for epidemiological tracing of isolates.

Truncated forms of human and simian immunodeficiency virus in infected individuals and rhesus macaques are unique or rare quasispecies

Truncated proviruses of variable sizes are present in peripheral blood mononuclear cells (PBMC) of human immunodeficiency virus type 1 (HIV-1)-infected persons and simian immunodeficiency virus (SIV)-infected rhesus macaques. Here, we investigated whether the highly deleted HIV and SIV proviruses are present in infected organisms as multiple copies or whether each truncated provirus is unique. Using end-point dilution, multiple long-distance (LD) DNA PCR assays were run in parallel using DNA extracted from PBMC of seropositive, treatment-naive persons and from lymph nodes of a rhesus monkey inoculated with cloned, full-length SIVmac239 DNA. The PCR products were titrated and mapped. Most truncated proviruses were present in the DNA samples tested as single, nonintegrated molecules that differed from one another in size and/or nucleotide sequence. These results indicate that truncated primate lentiviral sequences found in infected tissues are unique or rare quasispecies that do not replicate significantly.

[Molecular genetics methods in medical mycology]

Molecular genetic methods that use the polymerase chain reaction (PCR) are due their speed widely employed in diagnostic approaches in microbiology. In this report, the possibilities of application of these methods in medical mycology are discussed with regard not only to species identification, but also for genotyping of strains for epidemiological purposes. Recently, a tendency to exploit molecular genetic methods rather for epidemiological studies than for routine species identification may be observed. With regard to the high inter-species variability, careful standardization using samples of isolates of the tested species from corresponding geographical origin is necessary. Perspectives of future development associated with the explanation of molecular biological relations between human tissues and the pathogen, with the recognition of mechanisms of virulence and resistance to antifungal drugs are discussed.