Pseudomyxoma peritonei originating from urachus-case report and review of the literature.

Pseudomyxoma peritonei (pmp) is a rare clinical condition defined as extensive intraperitoneal spread of mucus associated with a variety of mucinous tumours of varying biologic behavior. Although appendix or ovaries have usually been implicated as the primary site, cases have been reported in association with neoplastic lesions of other sites. Pseudomyxoma peritonei originating from urachal remnants is a unique entity, reported only 18 times in the English literature thus far. Considering the rarity of the lesion, we report the case of a 50-year-old man surgically treated for pmp associated with a low-grade mucinous urachal neoplasm. Unique aspects of case are the low histologic aggressiveness of the causative lesion (reported only twice worldwide) and the early stage of the disease, with a relatively small amount of intraperitoneal free mucin. Review of the literature about pmp in general and a collation of previously reported cases of pmp originating from the urachus are presented and discussed.

Clostridium difficile: epidemiology, diagnostic and therapeutic possibilities-a systematic review.

This literature review looks at the epidemiology, clinical manifestations, diagnostics and current medical and surgical management of Clostridium difficile (C. difficile) infection. A literature search of PubMed and Cochrane database regarding C. difficile infection was performed. Information was extracted from 43 published articles from 2000 to the present day which met inclusion criteria. C. difficile is a gram-positive, anaerobic bacillus, which is widely found in the environment, especially in the soil. The occurrence of more resistant strains, which is mainly connected with the wide use of antibiotics, resulted in the rapid spread of the bacteria to different hospital departments. Particularly, elderly patients in surgical wards and intensive care units are at significant risk of developing C. difficile infection, which greatly increases morbidity and mortality. Symptoms of infection with C. difficile vary greatly. At one end of the spectrum, there are asymptomatic carriers, at the other patients with life-threatening toxic megacolon. Metronidazole is considered to be the drug of choice, but recent guidelines recommend Vancomycin. Fulminant colitis and toxic megacolon warrant surgical intervention. The optimal time for surgery is within 48 h of initiating conservative treatment without seeing a response, the development of multiple organ failure or a bowel perforation. A factor that has become increasingly important and relevant is the escalating expense of treatment for patients with C. difficile infection. It is, therefore, highly recommended to consider reviewing all hospital antibiotic policies and clinical guidelines that may contribute to the prevention of the infection.

Prognostic value of CA 19-9 level in resectable pancreatic adenocarcinoma.

The prognosis in patients with pancreatic cancer is poor and some authors describe it as a lethal disease. At the time of diagnosis only 14% of patients could be surgically treated and up to 30% of them die within 12 months. Therefore, further clinical investigations on preoperative patient qualification are needed. A total of 81 patients were included into the study. The CA 19-9 concentration was measured before surgery by an automated, commercially available enzyme immunoassay in Axsym analyzer (Abott Diagnostics Laboratory). A value of 37 U/ml was used as the upper limit of normal levels. Tumors were staged according to the Union Against Cancer (UICC) of 2004 and graded during the histological evaluation according to the G0-G4 scale. All patients were monitored every three month via outpatient clinic visits. In the case of missing visit we contacted the families to establish the cause. We assessed perioperative, 12 month, 2 year and 5 year survival. Twelve moth, 2 year and 5 year survival were assessed in the whole studied population and in the group of patients with the exception of these who died during the perioperative period. The total five year survival was 6%. The median time of survival was 467 days (range: 163 - 586 days). The perioperative period was survived by 91.4% patients, 12 months were survived by 71.6% patients, 2 years were survived by 35.8% patients, 5 years were survived by 6.2% patients. The serum Ca 19-9 level was above the normal limit in 80.5% patients. ROC curve analysis revealed that CA 19-9 level of more than 106 U/ml was linked to 2 year survival with 79.3% sensitivity and 74.5% specificity. Preoperative level of CA 19-9 below 106U/ml represents a predictive factor of 2- and 5-year survival, independent of other factors, such as lower size of the tumor, absence of metastases to lymph nodes, female gender of patients. After exclusion of the patients who died in the perioperative period, no relationship could have been disclosed between preoperative CA 19-9 levels and one year survival. The observation points to the chance that patients with higher levels of CA 19-9 harbour micrometastases, the development of which is sufficiently slow to allow for a one-year survival of the patients but which increase the risk of death after two and five years.

The pharmacokinetics and safety of porfimer after repeated administration 30-45 days apart to patients undergoing photodynamic therapy.

BACKGROUND: Porfimer is an intravenous (i.v.) injectable photosensitizing agent used in the photodynamic treatment of tumours and of high-grade dysplasia in Barrett's oesophagus. AIM: To assess the pharmacokinetics as well as the safety profiles of porfimer after a first and a second dose administered 30-45 days apart in patients undergoing photodynamic therapy. METHODS: Nineteen patients (16 with cholangiocarcinoma) were enrolled. Porfimer sodium was administered by i.v. injection over 3-5 min. Blood samples were collected prior to starting i.v. drug injection and postdose at different time points after the first and second administrations. RESULTS: Porfimer exposure values after the second administration were statistically higher than those observed after the first administration, suggesting a slight accumulation of porfimer following repeated administration. The apparent mean elimination half-life of porfimer increased from 410 h after the first administration to 725 h after the second administration. The safety profiles of porfimer after a first and a second administration were similar and did not raise additional concern. Eight patients experienced nine serious adverse events. Only photosensitivity was deemed study-drug related. CONCLUSION: Porfimer appears to display a safe and tolerable profile when used in patients requiring a second photodynamic therapy within 45 days.

The importance of preoperative elevated serum levels of CEA and CA15-3 in patients with breast cancer in predicting its histological type.

It is not known whether in patients with breast cancer the occurrence of elevated serum tumour markers depends on its histological type. The aim of the study was to assess relationship between breast cancer histological type and the presence of increased serum levels of CEA and CA 15-3. The study population was 428 patients (all women, mean age 52.5 years), treated at The Department of Surgery of Wroclaw Medical University from 2005 to 2008 due to breast cancer. All of them had their preoperative CA 15-3 and CEA serum concentrations measured. According to the TNM system, 21% of patients were in stage I, 32.5% in stage II, 46.5% in stage III of the disease. In patients with ductal type of the cancer the elevated serum levels of CEA and CA 15-3 were observed in 48.7% and 42.2%, in lobular type in 42.4% and 52.5%, and in non-ductal/tubular types in 48.1% and 40.4% (p=N/S). Stepwise logistic regression analyses showed that ductal breast cancer is related to elevated CEA and normal CA 15-3 serum levels. The histological types of breast cancer are not significantly related to elevated serum levels of CEA and/or CA 15-3.

Predictive value of lymphocytic infiltration and character of invasive margin following total mesorectal excision with sphincter preservation for the high-risk carcinoma of the rectum.

PURPOSE: To assess the prognostic significance of clinicopathological factors, especially histological parameters of new Jass classification, following sphincter-sparing total mesorectal excision (TME) for high-risk rectal cancer. MATERIAL AND METHODS: Forty-five consecutive patients treated with curative intent in 1998-1999 due to rectal cancer in Dukes stage B and C were studied prospectively. All of them underwent anterior resection with TME technique. Prognostic value was evaluated by the impact on five-year recurrence-free survival (RFS) in uni- and multivariate analysis. Only factors significant in univariate analysis entered the multivariate regression model. P value <0.05 was stated as a significance limit. RESULTS: Regarding traditional clinico-pathological factors patient age, tumor site, differentiation grade, mucinous histology and the extent of direct tumor penetration did not significantly affect survival rates. Only the lymph nodes status was associated with prognosis with statistical importance (negative vs positive, RFS: 53.8 +/- 10.0% vs 26.3 +/- 10.4%, respectively). Considering the additional parameters of Jass classification the character of invasive margin of the tumor did not reveal the important predictive value although the lymphocytic tumor infiltration was significantly related to patient outcome (presence vs absence, RFS: 63.6 +/- 15.2% vs 37.5 +/- 8.7%, respectively). In multivariate analysis the only one statistically important and independent predictive parameter was the lymph nodes status. CONCLUSIONS: Lymph nodes metastases remain the most important prognostic factor after anterior resection with TME for Dukes B and C rectal cancer. From variables included into Jass classification the absence of lymphocytic infiltration of the tumor can be helpful to identify patients with enhanced risk of oncological relapse.

Germline MSH2 and MLH1 mutational spectrum including large rearrangements in HNPCC families from Poland (update study).

Germline mutations in the DNA mismatch repair genes MSH2 and MLH1 account for a significant proportion of hereditary non-polyposis colorectal cancer (HNPCC) families. One approach by which development of an efficient DNA-testing procedure can be implemented is to describe the nature and frequency of common mutations in particular ethnic groups. Two hundred and twenty-six patients from families matching the Amsterdam II diagnostic criteria or suspected HNPCC criteria were screened for MSH2 and MLH1 germline mutations. Fifty different pathogenic mutations were found, 25 in MSH2 and 25 in MLH1. Twenty-four of these had not previously been described in other populations. Among our 78 families with MSH2 or MLH1 mutations, 54 (69.2%) were affected by recurrent mutations including 38 found at least twice in our own series. Two of the most frequent alterations were a substitution of A to T at the splice donor site of intron 5 of MSH2 and a missense change (A681T) of MLH1 found in 10 and eight families, respectively. Among large deletions detected by the multiplex ligation-dependent probe amplification assay, exon 9 deletions in the MSH2 gene were found in two families. Our results indicate that a screening protocol specific for the Polish population that is limited to the detection of all reported mutations will result in the identification of the majority of changes present in MLH1 and MSH2 genes in Polish HNPCC kindreds.

Surgical and endoscopic treatment of pancreatic pseudocysts.

Not long ago surgery was the only way to treat pancreatic pseudocysts that would not resolve spontaneously. Nowadays minimally invasive methods are gaining popularity, such as percutaneous drainage, endoscopic cystogastrostomy or cystoduodenostomy, and endoscopic transpapillary drainage. The aim of this study was to evaluate these methods in comparison with conventional surgery for pancreatic pseudocysts. From March 1997 to July 2000 we treated at the 2nd Dep. of Surgery, Wroclaw Medical University, 52 patients with pancreatic pseudocysts. 30 patients were treated surgically, 15 endoscopically, and 7 medically. For endoscopic treatment we chose patients with "mature" pseudocysts, with a distinct capsule on ultrasonography, adherent to the posterior wall of the stomach, clinically sterile, at least 5-15 cms in diameter. The endoscopic criterion was the appearance of the cyst bulging into the stomach. Surgical treatment was applicable for those patients who had no positive evidence of a direct contact of the pseudocyst and the stomach, those with cysts infected, multiple or filled with dense fluid. The observed complications (infection of the cyst and bleeding) are typically reported for the treatment of pancreatic pseudocysts. The single complication in the form of an inflammatory tumor of the pancreas was probably due to undiagnosed pancreatic necrosis. There was zero mortality in our group. In our opinion endoscopic cystogastrostomy with a double pigtail stent is a valuable alternative to conventional surgery and in selected cases can be the method of choice for the treatment of pancreatic pseudocysts. Conventional surgical methods of treatment still remain valid. They are often less hazardous as they allow full visual evaluation of the cyst and its neighbourhood (for the signs of necrosis). Surgical drainage provides secure anastomosis of the cyst with the GI tract and hemostasis, which may be vital in some cases.

[Evaluation of the results of treatment of cancer of the large intestine based on our clinical data]. / Hodnocení výsledku lécby rakoviny tlustého streva na základe vlastního materiálu.

Results of the treatment of 225 patients operated between 1991-1995 on the colorectal carcinoma in the II Clinic of Surgery, Medical Academy Wroclaw are evaluated. The analysis of the own material covers the tumor site, age of the patients, histologic grade and clinical stage according to Dukes. The type of surgical procedure--curative or palliative and the evaluation of the survival, death and recurrence rate is presented. Curative procedures were possible only in approximately 60% of cases. The Dukes stage C and D was established in 55.5% of the operated patients. Authors believe that such a significant number of advanced cases was the reason of so poor results. In conclusion they suggest to introduce screening tests for early detection of colorectal carcinoma.

[Late results of esophageal prostheses created from intestinal grafts]. / Pozdní výsledky jícnových protéz ze strevních stepu.

During the last 30 years, 280 retrosternal esophageal replacements from stem intestinal grafts were performed at GIT Surgery Clinic AM in Wroclav. Both clinical and auxiliary investigations showed the small intestine grafts have been of the best function as to the food passage. In esophagi made from the large intestine, the following and mostly frequent changes occur: the dilatations of their lumina, the stop of food passage and inflammatory changes varying in both the degree and extent. Inflammatory changes as well as ulcers are rather difficult to detect by radiology. Through the last years, the Second Clinic of General Surgery AM in Wroclav provides endoscopy of artificial esophagi. Being sophisticated, this approach is of benefit in early determining pathologic changes in the esophageal wall, the collection of contents for biochemical tests, tissue biopsies for histology and the initiation of appropriate therapy.