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A laparoscopia szerepe a májdaganatok resecabilitasának megítélésében
The role of laparoscopy assessing the resectability of hepatic malignancies
Absztrakt
A májdaganatok terápiás lehetőségei közül a sebészi resectio átlagosan 40%-os, 5 éves túlélést, míg a májtranszplantáció (OLTX) ennél is jobb eredményeket biztosíthat. A betegek jelentős része azonban a daganatok száma, elhelyezkedése, disseminatio miatt alkalmatlan a beavatkozásra, és ez sokszor csak a sebészi feltárás során igazolódik. A klinikai, képalkotó és egyéb speciális preoperatív vizsgálatok mellett esetenként fontos szerep juthat a laparoscopiának mind a staging pontosításában, mind a resecabilitas megítélésében.
Retrosprektív módon elemeztük a malignus májelváltozás miatt műtétre került, laparoscopizált betegeink adatait. A 2000. január 1. és 2006. március 31. közötti időszakban az osztályunkon sebészileg májtumor miatt kezelt 310 beteg közül 39 betegnél végeztünk staging laparoscopiát. 22 (56%) esetben primer hepatocellularis carcinoma (HCC), 17 (44%) esetben májmetastasis miatt történt a beavatkozás.
A primer és a szekunder májdaganatokat vizsgálva a laparoscopizált betegek 70%-nál igazoltunk irresecabilitast. A resecabilisnak ítélt betegek esetében azonban csupán 50%-os volt a staging pontossága. Az irresecabilitas okaként legjobban a carcinosis tényét, valamint a daganat multiplex megjelenését lehetett igazolni laparoscopiával, a daganat centrális kiterjedését, a nagyerek invázióját nem jelezte kellő pontossággal.
A malignus májdaganatok preoperatív staging vizsgálatainak egyik eleme lehet a staging laparoscopia, és segíthet megelőzni egy felesleges laparotomiát, azonban minden májresectióra váró betegnél rutinszerűen nem ajánlott, válogatott betegcsoportban javasolható.
Abstract
Background: Although liver biopsy (LB) is the gold standard for the morphological diagnosis of diseases of the liver, recent noninvasive tests may also help in the evaluation of liver fibrosis. We have studied blood fibrosis markers and liver stiffness (LS) measurement to assess fibrosis in different forms of chronic hepatitis C virus (HCV) infection. Patients and methods: Out of 119 HCV-infected patients, 75 had biopsy-proven chronic hepatitis C, 24 had HCV cirrhosis, 20 individuals were symptom-free HCV carriers with persistently normal alanine aminotransferase (PNA), and 30 healthy blood donors served as controls. Wai's aspartate-aminotransferase (AST) to platelet ratio index (APRI) was calculated from serum AST and blood platelet number. Serum HCV-RNA (hepatitis C virus ribonucleic acid), procollagen-III-peptide (P-III-P) and hyaluronic acid (HA), plasma transforming growth factor β-1 (TGFβ-1), Knodell's histological activity index (HAI), and METAVIR fibrosis score were determined, and for LS measurement transient elastography (TE) (FibroScan) was applied. Results: In chronic hepatitis C patients, all fibrosis markers were significantly elevated compared to normal controls. HA, APRI, and LS values were highest in HCV cirrhosis and nonresponders to PEG-IFN + ribavirin (P/R) therapy. High P-III-P values occurred only in advanced fibrosis. Serum HA correlated with the fibrosis stage. Plasma TGFβ-1 was significantly higher in patients with chronic hepatitis C than in symptom-free HCV carriers, and it correlated with HAI. After 3–6 months of P/R therapy, both HA and TGFβ-1 levels significantly decreased even in virological nonresponders. APRI was 0.21 ± 0.05 in normal controls, 0.20 ± 0.08 in symptom-free HCV carriers, 0.70 ± 0.40 in patients with chronic hepatitis C, and 3.21 ± 2.3 in HCV cirrhosis cases. LS values were 5.10 ± 1.19 kPa in controls, 5.38 ± 1.37 kPa in HCV carriers with PNA, 9.67 ± 4.11 kPa in chronic hepatitis C patients, 6.56 ± 2.61 kPa in patients with sustained virological response, 18.55 ± 11.65 kPa in nonresponders to P/R, and 37.40 ± 16.85 kPa in HCV cirrhosis cases. On the basis of a novel sequential algorithm that comprises APRI and LS for assessment of fibrosis, 47% of our HCV patients did not need biopsy for diagnosing significant (F ≥ 2) fibrosis. Conclusion: Both blood fibrosis markers and LS, particularly in combination, represent an advance in the noninvasive assessment of fibrosis in HCV infection. P/R treatment may inhibit fibrosis progression even independently of virological response.
Absztrakt
Jóllehet a körvarrógépek használta világszerte elterjedt, különösen a rectumanastomosisok elkészítésére, a forgalomban lévő eszközök alkalmazhatóságáról kevés közlés lát napvilágot. 2008. május és 2009. március között 9 sebészeti osztályon összesen 136 betegen alkalmaztak CS® körvarrógépeket anastomosis készítésére a rectumon. A prospektív vizsgálat a rectum felső és középső harmadán készített varratokat elemezte, a vizsgálatba 5 olyan esetet is bevontak, ahol az anastomosis a rectum alsó harmadában készült. 115 adenocarcinoma, 16 egyéb malignus daganat, 5 benignus elváltozás miatt került sor infraperitonealis resectióra. 20 műtét laparoscoppal, 116 hagyományos módon történt. A 32 mm átmérőjű eszközt 50, a 28 mm-est 85, a 25 mm-est 1 esetben használták. Intraoperatív technikai hiba 4 esetben fordult elő, a kiegészítő beavatkozással az anastomosis korrigálható volt. Posztoperatív szövődmény ezekben az esetekben nem fordult elő. Késői varratelégtelenséget 5 esetben észleltek, ebből 3 spontán gyógyult, 2 esetben reoperációra került sor. A teljes beteganyagban 2 haláleset fordult elő, ez 1,4%-os mortalitásnak felel meg. A CS® körvarrógépek megfelelőnek bizonyultak infraperitonealis rectumanastomosis céljára.
Novel, intergenogroup reassortant G3 rotavirus strains are spreading in at least three continents: Asia, Australia, and Europe. The present study provides evidence that a closely related G3P[8] strain circulated in Hungary during 2015. Whole genome sequencing and phylogenetic analysis showed that the identified strain continues to evolve by reassortment. This observation demonstrates the genomic plasticity of the novel strain, which is thought to be a prerequisite of the success of emerging rotavirus genotypes.
In this study a Kuwaiti camel rotavirus strain, RVA/Camel-wt/KUW/s21/2010/G10P[15], is characterized by sequencing and phylogenetic analysis. The strain had multiple genes with high nucleotide sequence similarities to ovine and bovine strains (VP2, ≤ 96%; NSP2 and NSP5, ≤ 97%, NSP3, ≤ 94%), or, to porcine strains (VP1, ≤ 89%). Other genes had moderate sequence similarities (VP4, ≤ 87%; VP6, ≤ 81%; VP7, ≤ 82%) with reference strains from ruminants. The NSP4 gene shared limited sequence identity (≤ 71%) with other mammalian and avian rotavirus NSP4 types, and was designated a novel genotype, E15. This study demonstrates genetic diversity in the outer capsid and some backbone genes of an old-world camelid rotavirus strain and uncovers its common evolutionary roots with strains from other ruminants.
Autologous vascular patch grafts developed from the internal rectus sheath were implanted onto the bilateral common iliac vein and jugular vein of 4 experimental beagle dogs. During the development and implanting of the grafts no technical difficulties or perioperative complications were encountered. The follow-up lasted 6 months and 3 months in the case of the common iliac vein grafts and the jugular grafts, respectively. In the postoperative period, the morphological and functional characteristics of the implanted venous sections were examined by Doppler ultrasonography and CT angiography. Normal patency was detected, and none of these check-ups showed obturation or stenosis. The histological survey showed no mesothelial cell layer, but the insides of the grafts showed total restructuring and were covered by a normal endothelial layer. No difference could be detected between samples harvested 3 and 6 months after implanting. The immunohistochemical examinations using anti-claudin-5 and anti-CD31 antibodies confirmed the preliminary results of the histological examinations that the luminal surfaces of the implanted grafts developed a differentiated monolayer endothelium which was free of degenerative and inflammatory signs. The control examinations show the suitability of the internal rectus sheath as a venous wall donor.
The predominance of dietary viruses in bat guano samples had been described recently, suggesting a new opportunity to survey the prevalence and to detect new viruses of arthropods or even plant-infecting viruses circulating locally in the ecosystem. Here we describe the diversity of viruses belonging to the order Picornavirales in Hungarian insectivorous bat guano samples. The metagenomic analysis conducted on our samples has revealed the significant predominance of aphid lethal paralysis virus (ALPV) and Big Sioux River virus (BSRV) in Hungary for the first time. Phylogenetic analysis was used to clarify the relationship to previously identified ALPV strains infecting honey bees, showing that our strain possesses a close genetic relationship with the strains that have already been described as pathogenic to honey bees. Furthermore, studies have previously confirmed the ability of these viruses to replicate in adult honey bees; however, no signs related to these viruses have been revealed yet. With the identification of two recently described possibly honey bee infecting viruses for the first time in Hungary, our results might have importance for the health conditions of Hungarian honey bee colonies in the future.
