A novel percutaneous transhepatic treatment of a benign bile duct stricture - a pilot study.

AIM: To assess the effectiveness and outcome of repeated percutaneous transhepatic balloon dilatation combined with targeted intramucosal corticosteroid injection in patients with benign biliary stricture. METHODS: This single-center pilot study, conducted between February 2014 and June 2016, involved five patients with benign biliary stricture (4 men and 1 woman, mean age 58.2 years). The study included only patients in whom previous surgical or/and non-surgical treatments failed or could not be performed due to patients' medical history and local status. RESULTS: We successfully developed an alternative treatment for patients with benign biliary stricture and performed it without side effects. There were no major complications, and the only one minor complication was cholangitis. In the median follow-up period of 30.24 months (range 14.5 to 44.6 months), no re-occlusion was detected. The disease-free survival, calculated after excluding the first patient (who died of heart attack), was 34.175 months. CONCLUSION: Percutaneous transhepatic corticosteroid injection combined with balloon dilatation could provide an alternative method for the treatment of benign biliary strictures that is effective in the long term and results in positive outcomes.

Basaloid carcinoma of the pancreas--clinicopathological presentation and oncogenetic snapshot of a rare entity.

We report a case of basaloid pancreatic carcinoma with clinical, pathological, and genomic data. The 73-year-old male patient had jaundice, acholic stool, diarrhea, weight loss, and a large, painless gall bladder. His GGT was highly elevated. The pancreatic head contained a tumor, which was resected by partial pancreatoduodenectomy with pancreato-gastric anastomosis, cholecystectomy, and lymphadenectomy. On gross examination, a 3.8-cm white firm nodule was found, which microscopically was composed of basaloid cell nests with a less than usual desmoplastic stromal background and focally PANIN. Immunohistochemical profile displayed strong CK5/6, CK19, p63, EGFR, vimentin, and evident CK14 expression and absence of expression of CK7, chromogranin, synaptophysin, and BRCA1. A high Ki-67 index and p53 expression were noted. Sequencing of the most frequent 46 oncogenes with ionTorrent (AmpliSeq PCR) method identified PIK3CA, KRAS, and TP53 genes as drivers and variants of the FGFR3, PDGFRA, KIT, KDR, EGFR, RET, and ATM genes. The tumor we report displays histopathological appearances similar to the previously described case and a genomic landscape fitting to the general population of pancreatic carcinomas. We hypothesize that this tumor may belong to the group of DNA damage repair-deficient pancreatic carcinoma subgroup.

[A case of glucose-sensitive insulinoma accompanied by slightly elevated serum insulin levels and persisting convulsions after the surgically removed neuroendocrine tumor]. / Glükózszenzitív insulinoma mérsékelten emelkedett széruminzulinszinttel, eltávolítása után is fennmaradó epilepsziás rohamokkal.

Insul(in)oma is a usually solitary or, in some cases, multifocal tumor of pancreatic beta cells. It may be a component of multiple endocrine neoplasia type 1. or von Hippel-Lindau syndrome. In typical forms the diagnosis - based on the Whipple triad - is simple, however, it may be difficult to recognize in cases with near normal or only slightly elevated serum insulin levels, as well as in patients with known convulsive episodes. With the case presentation of an 81-year-old woman the authors draw attention to the pitfalls of the correct diagnosis. A special feature of the presented case is that convulsions persisted after surgical removal of the pancreatic neuroendocrine tumor verified with functional and imaging methods. Recurrent or residual tumor was not found, and morphological damage of the brain was absent. In the background of the continuing convulsions cerebrovascular alterations as well as the cytotoxic effect of the hypoglycemia-induced excessive glutamate production can be postulated.

Impact of positive intraabdominal lavage cytology on the long-term prognosis of colorectal cancer patients.

BACKGROUND: Our aim was to investigate the presence of free cancer cells found in lavage cytology specimens taken from the proximity of tumors during the course of curative open and laparoscopic colorectal resections and then examine and compare the long-term disease outcomes in cases of negative and positive cytology. Based on the results, we were hoping to identify the place of peritumoral lavage cytology among prognostic factors for disease recurrence. METHODS: Between January 1, 2005 and December 31, 2007 intraoperative peritoneal lavage cytology was performed in 145 patients who underwent curative colorectal procedures. In all, 37 of the procedures were laparoscopic resections. RESULTS: Malignant cells were detected in the intraoperative peritoneal lavage cytology samples from 25 patients. Median follow-up was 47 months (3-81 months). Among the 25 patients with positive cytology; locoregional recurrence or distant metastasis was found in 14 during this period (56 %), whereas among the 120 patients with negative cytology the incidence was 28 (23 %). CONCLUSIONS: The impact of tumor stage, lymph node status, and peritoneal lavage cytology on recurrence rates is significant. Tumor, nodal, and lavage cytology status can be organized hierarchically in relation to time of recurrence. Cytology is most important, with positivity rendering long-term prognosis unfavorable. When comparing surgical techniques (open versus laparoscopic), we found no significant difference in recurrence rates. Our study has shown that conventional peritoneal lavage cytology is a prognostic factor in the case of patients undergoing curative colorectal operations.

Functional evaluation of multidrug resistance transporter activity in surgical samples of solid tumors.

Determination of multidrug resistance (MDR) activity of tumor cells could provide important information for the personalized therapy of cancer patients. The functional calcein assay (MultiDrug Quant Assay, Solvo Biotechnology, Budaörs, Hungary) has been proven to be clinically valuable in hematological malignancies by determining the transporter activity of MDR protein 1 (MDR1, ATP-binding cassette protein [ABC] B1, P-glycoprotein-170) and MDR-related protein 1 (MRP1, ABCC1). In this study, we evaluated if the same functional test was adaptable for the analysis of MDR activity in solid tumors. For this purpose, tissue specimens of human colorectal cancer samples were subjected to limited enzymatic digestion by collagenase to provide a single-cell suspension; dead cells were excluded by 7-aminoactinomycin D staining, and epithelial cancer cells were detected by Cy5-conjugated anti-BerEP4 monoclonal antibody. The transporter functions of MDR1 and MRP1 in viable epithelial cells were assessed by flow cytometry detecting the intracellular accumulation of calcein dye after exposing cells to various MDR inhibitors. Collagenase disintegration preserved the MDR activity and the antigenicity of tumor cells. Thus using the extended calcein assay provided sufficient viable and functionally active tumor cells from surgical biopsies to determine the functional MDR activity. In conclusion, the newly described modified calcein assay may be applicable for evaluating the MDR phenotype in solid tissue specimens from colorectal forceps biopsy to surgical samples.

[Pancreas pseudocyst or metastasis?]. / Pancreas-pseudocysta vagy metasztázis?

The authors review a case of a 24-year-old male patient hospitalised for repeated acute abdominal symptoms. His medical history included no diseases worth of mentioning. By imaging techniques (abdominal US and CT scan) a cystic lesion, measuring 40 x 35 x 30 mm in diameter was found, and was diagnosed as pseudocyst in the region of the tail of the pancreas. Jejunal feeding was introduced. The lesion did not improve and the second CT scan suggested a suspicion of pancreatic cystadenoma. Three months after first presentation the surgical resection was performed. The tumour, however, was found independent of the pancreas (90 x 80 x 50 mm). Both histologically and immunohistochemically the lesion proved to be the metastasis of a germ cell (yolk-sac) tumour. Following the morphological diagnosis, detailed urological and medical check up was performed. A previously nonpalpable small tumour was found in the left testis which was radically resected. The testicular tumour measuring 9 x 9 x 5 mm in diameter was diagnosed as embryonal carcinoma. Later on the patient underwent chemotherapy. He has been undergoing close oncological followup. Clinically, he is disease free. Authors emphasize the importance of imaging techniques and fine needle aspiration cytology in the case of retroperitoneal masses in young males. The possibility of a metastasis, especially of germ cell origin, should be excluded (not only by physical examination, but by ultrasound of testis also) in case of retroperitoneal cystic tumours even with unusual morphology.

[Development and validation of a modified quality of life questionnaire for patients treated by antireflux surgery]. / Antireflux mutéttel kezelt betegek életminoségének értékelésére alkalmas kérdoív kifejlesztése és validálása.

INTRODUCTION: Past decade witnessed a growing interest in scientific medical publications on health related quality of life (HRQoL), which has yielded an increasing number of generic and disease-specific instruments. To date, several studies have evaluated the impact of GERD on HRQoL. AIMS: To develop a QoL questionnaire for patients with GERD underwent laparoscopic fundoplication (LF). This questionnaire was developed to be more comprehensive than existing measures. MATERIALS AND METHODS: We undertook a retrospective analysis of 116 patients underwent laparoscopic fundoplication for GERD between 1994 and 2002 in the 1st Department of Surgery, Semmelweis University. These patients--included 55 men and 61 women, with mean age of 46 years (14-77)--were used in the psychometric evaluation. Our questionnaire was developed using internationally accepted, valid QoL instruments and scales. RESULTS: Internal-consistency reliability was high (alpha value overall 0.95; dimensions 0.74-0.96). Using convergent and divergent validity, construct validity was evaluated by examining Pearson correlation coefficients between items and scales. Construct validity was demonstrated based on observed correlations. Known-groups validity of questionnaire is proved to. CONCLUSIONS: Our questionnaire is a short and user-friendly instrument. It has excellent reliability, construct and known-groups validity.

ATP and ATPase secretion by exocrine pancreas in rat, guinea pig, and human.

ATP is an extracellular regulator in numerous physiological and pathologic processes. Recently, 7 different subtypes of purinoceptors were identified on either the basolateral or the luminal membrane of pancreatic duct cells. However, the in vivo regulatory role of ATP in pancreatic function has not been established. We investigated the possible regulatory role of endogenous ATP in pancreatic function by measuring ATP concentrations and ATPase activity in pancreatic juice obtained from anesthetized rats and guinea pigs and from human patients undergoing endoscopy. Juice was collected from the main pancreatic duct in rats and guinea pigs under basal conditions or during stimulation with CCK, bombesin, or secretin. In guinea pigs, CCK, bombesin, and secretin did not affect ATP output, although they did stimulate fluid secretion. ATPase activity in the juice was evaluated by measuring the rate of hydrolysis of added ATP. Consistent with the low ATP concentrations in rat pancreatic juice, we found high levels of ATPase activity in this species. This was confirmed by HPLC, which also showed the metabolites of ATP hydrolysis. Ecto-ATPase activity was demonstrated by enzyme histochemistry in both the pancreatic acini and ducts in rats, but it was not detectable in guinea pigs and humans. These differences in ATP levels and ATPase expression may indicate significant species differences in the purinergic regulation of pancreatic secretion.

[The first clinical experiences in Hungary with a new effective antibiotic (linezolid) effective against Gram-positive infections]. / Multirezisztens Gram-pozitív kórokozók ellen hatékony, új antibiotikummal (linezolid) szerzett elsó magyarországi tapasztalatok.

INTRODUCTION: The occurrence of gram-positive infections caused by multiresistant organisms has increased significantly in general, particularly among the surgical patients, and only a few effective antibiotics are available. A new and effective, synthetic antibiotic, against gram-positives is the oxazolidinon group, that electively inhibits bacterial protein synthesis in the early phase. Linezolid, the first member of this group to be used in clinical practice is the linezolid was studied. AIMS: The purpose of this study was to evaluate the effectiveness and safety of linezolid in the gram-positive infections of surgical patients. METHODS: A 3rd phase, clinical trial was conducted at the Semmelweis University Ist Surgical Department in the period of 1999-2001. Twenty-one patients with gram-positive infections were enrolled to this study. The mean of age was 57 years. Patients were selected for linezolid treatment in whom the conventional anti-gram-positive antibiotic therapy caused difficulties. RESULTS: Sixteen patients out of 21 recovered, one patient was cured clinically, but not microbiologically, and one case showed microbiological cure with clinical failure. In one case the methicillin resistant Staphylococcus aureus carriership was cured. Two cases had a fatal outcome. The causes of death were mediastinitis plus pneumonia in one case, and diffuse peritonitis with renal insufficiency in the other. Withdrawal from the study occurred in one case, due to drug intolerance. CONCLUSIONS: The linezolid administration proved to be safe and effective even in those cases, in which either hypacusis or decreased renal function persisted, or oral intake was advantagous. Contraindication of linezolid therapy did not occur. Few side effects were observed. If the infection was polymicrobial, the linezolid could be combined with other antibiotics. Further investigations are mandatory to evaluate the role of linezolid in the treatment of methicillin resistant Staphylococcus aureus carriership.

Streptococcus pneumoniae as an etiologic agent in infectious complications of pancreatic disease.

Systematic culturing of perioperative intra-abdominal samples allowed us to recognize the presence of Streptococcus pneumoniae in infectious complications of chronic pancreatitis in 9 male patients. In 8 of 10 of the intra- or peripancreatic samples, S. pneumoniae was the single isolate identified. All but one of the S. pneumoniae isolates were sensitive to penicillin. The patients had predisposing underlying conditions such as alcoholism and diabetes mellitus. All patients were cured due to adequate surgery and antibiotic treatment. Analysis of the case histories suggests that S. pneumoniae may have been a relevant organism causing the infectious complications of pancreatitis in these patients.

Adhesion molecules in human pancreatic cancer.

BACKGROUND AND OBJECTIVES: Adhesion molecules are cell surface glycoproteins that are important in cell-to-cell and cell-to-extracellular matrix interactions. In the present study, we analyzed the adhesion molecules ICAM-1 (intercellular adhesion molecule-1), VCAM-1 (vascular cell adhesion molecule-1), and ELAM-1 (endothelial leukocyte adhesion molecule-1) in human pancreatic cancer. METHODS: ICAM-1, VCAM-1, and ELAM-1 were analyzed in 20 pancreatic cancer specimens and 20 normal pancreatic tissues. mRNA expression encoding ICAM-, VCAM-1, and ELAM-1 was assessed with Northern blot analysis. The distribution and localization of ICAM-1, VCAM-1, and ELAM-1 was determined in the pancreatic specimens by immunohistochemistry. RESULTS: Northern blot analysis revealed a 5.4-fold increase of ICAM-1 (P<0.01) and a 3.7-fold increase in VCAM-1 (P<0.01) mRNA expression in cancer samples in comparison with normal controls. In contrast, ELAM-1 mRNA levels did not show significant differences between the cancer and the normal tissues. Immunohistochemical analysis of cancer tissues showed strong immunostaining for ICAM-1 and VCAM-1, and faint immunostaining for ELAM-1 in the pancreatic cancer cells. Fibrotic or noncancerous pancreatic tissue adjacent to the cancer mass was devoid of any immunoreactivity for ICAM-1, ELAM-1, and VCAM-1. In contrast, the normal pancreas exhibited no immunoreactivity of ICAM-1, ELAM-1, and VCAM-1. CONCLUSIONS: Enhanced expression of ICAM-1 and VCAM-1 in human pancreatic cancers suggests a role in tumor pathogenesis. The increase of these adhesion molecules might influence the detachment of cancer cells in the primary tumor, might contribute to cancer cell migration and the spread of cancer cells to distant organs, or both.