High Expression of DARPP-32 in Colorectal Cancer Is Associated With Liver Metastases and Predicts Survival for Dukes A and B Patients: Results of a Pilot Study.

The purpose of this study was to investigate prognostic significance of Dopamine and cAMP-Regulated neuronal Phosphoprotein 32 (DARPP-32) expression in primary colorectal cancer. The study material consisted of clinical and histopathological data of 100 patients operated for colorectal cancer between 1994 and 1997. For immunohistochemical analysis, specific rabbit antibodies for DARPP-32 were used and the percentage of stained tumor cells was calculated under gross magnification (400 times) on a sample of 500 tumor cells. DARPP-32 expression in the primary tumor was significantly greater in patients with distant metastases compared to patients with no distant metastases (p=0.002). In multivariate regression analysis, DARPP-32 expression in the primary tumor was a significant predictor of distant metastases. With a cut-off point of 76.5%, DARPP-32 expression in the primary tumor significantly influenced both overall and disease free survival, especially for Dukes A and B patients (p=0.037). The results of this study indicate that DARPP-32 may be a potential marker of worse prognosis and a valuable tool for managing further adjuvant treatment in patients with stages Dukes A and B colorectal cancer.

The laparoscopic liver resections-an initial experience and the literature review.

The laparoscopic liver resection (LLR) represents a new pathway in hepatic surgery. Several studies have reported its application in both malignant and benign liver diseases. The most common liver resections performed laparoscopically are wedge, segmental resections and metastasectomy; although in large centers the laparoscopic right and left hepatectomies have begun to perform more frequently. We report the initial experience in LLRs at our department including a case of the first laparoscopic left lateral liver bisegmentectomy performed in patient with follicular nodular hyperplasia and the 15 cases of wedge laparoscopic resections of echinococcic liver cysts. According to literature the mortality rate in LLRs is up to 0.3% and morbidity rate up to 10.5%. The most common cause of the death is liver failure, while the most frequent complication is the bile leakage. Advantages for patients include smaller incisions, less blood loss, and shorter lengths of hospital stay. The LLRs in experienced hands were shown to be safe with acceptable morbidity and mortality for both minor and major hepatic resections in benign and malignant diseases.

Emergency surgery for large bowel obstruction caused by cancer.

There are several options for surgical treatment of large bowel obstruction caused by cancer, depending on location of obstruction, intraoperative local findings (perforation, peritonitis, bowel dilatation proximal to obstruction) and patients' condition. Resection and anastomosis as one stage surgery would be prefered procedure. Anastomotic leakage, on the other hand, highly elevates risk of mortality and mobidity. The most important question is whether to, in resectable cases, perform primary resection with anastomosis or not. This study was retrospective and included 40 patients that have undergone emergency surgery for large bowel obstruction caused by cancer. According to whether resection and anastomosis was made at initial surgery or not, patients were grouped in group A (N = 18) and group B (N = 21), respectively. We have analysed the type of surgical procedure, days of hospitalization, mortality, anastomotic leakeage, wound infection and other postoperative complications. Our results show that there is no major difference in mortality and morbidity in these two groups, suggesting that for selected patients primary resection and anastomosis is a safe option of tratment with acceptable risk. Since there are no strict guidelines or scorring system which would point the tratment option the decision about the choice of procedure still remains the burden of surgeon and depends on its experience and subspeciality. Our experience recomends primary resection and anastomosis except in cases of bowel perforation on tumor site, in cases of extreme dilatation and atony of bowel proximal to obstruction site and severe hypoproteinemia and anemia.

Immediate breast reconstruction in relation to women's age.

A modern approach to breast cancer treatment after mastectomy includes immediate breast reconstruction (performed simultaneously with the mastectomy). The understanding of factors that influence women's decisions and appreciation of their satisfaction is as important as the knowledge of medical efficiency of the selected treatment. The influence of women's age on opinion making for immediate breast reconstruction was researched in a monocentric prospective study (N = 102). Methods included questionnaires, interviews and medical documentation reviews. Women comply breast reconstruction with silicone implants and autologous tissue equally. Analyzing age distribution it is evident that women age 35-50 and older than 65 would agree to reconstruction with silicone implants more often. This can be explained by the fact that younger women expect to have better shaped breasts after reconstruction then prior to the same, while older women tend to avoid breast reconstruction using muscle flaps because they are more demanding and also require longer hospitalization.

Surgical treatment of liver echinococcosis--open or laparoscopic surgery?

Human echinococcosis remains a significant medical issue in endemic areas. Hydatid cysts can rupture, which is the most severe complication of echinococcosis as it can cause anaphylactic reaction and seeding of secondary cysts. Traditionally, hydatid cysts were evacuated by open surgical procedure in order to remove the entire cyst or by unroofing method, with evacuation of the cyst content. Recently, an increasing number of such operations are performed using laparoscopic approach. This study was prospectively conducted in a 5-year period, from 2004-2008. Altogether, 25 surgically treated patients were included in this study. Clinical examination, specific serological test, abdominal ultrasound and computed tomography were used for establishing diagnosis. Open surgery was initially performed in 17 patients and laparoscopic in 8. Three of those 8 patients required conversion to open surgery. Open pericystectomy was performed in 11 patients and laparoscopic pericystectomy in 3 patients. Open partial pericystectomy according to Papadimitriou was performed in 9 patients with hydatid cyst and laparoscopic partial pericistectomy in 2 patients. Our experience indicates that in the case of liver hydatid cyst disease, laparoscopic exploration, and if possible, laparoscopic pericystectomy or partial pericystectomy, should be performed in selected patients.

Pseudoaneurysm of the popliteal artery in a patient with multiple hereditary exostoses.

We present an interesting case of a 14-year-old girl with multiple hereditary exostoses. She presented with a few days history of a pulsative mass in the distal third of the right upper thigh. Leg radiography showed multiple exostoses of distal femur, proximal tibia, and fibula. Large pseudoaneurysm of popliteal artery was found in Doppler sonography. The diagnosis was verified with multi-slice computed tomography of both legs along with the digital subtraction angiography of right leg. The patient then underwent surgery. After surgery the patient's vascular status was regular, with no signs of pseudoaneurysm.

Laparoscopic repair of perforated peptic duodenal ulcer.

Although prevalence of peptic ulcer is decreasing, the number of peptic ulcer perforations appears to be unchanged. This complication of peptic ulcer is traditionally surgically treated. In recent years, a number of papers have been published where the authors managed perforated duodenal peptic ulcer in selected patients using laparoscopic approach. Laparoscopic treatment of perforated duodenal ulcer has been described as safe and advantageous compared to open technique but advantages are still not clear due to small number of cases in published studies. Based on these recommendations we decided to establish our own protocol for laparoscopic treatment of perforated peptic duodenal ulcer. In this prospective study we evaluated the first 10 patients in whom we performed laparoscopic repair of perforated duodenal ulcer. There were no conversions to open procedure and no early postoperative complications. The patients were contacted by phone a year after the operation, and all were satisfied with the operation and the appearance of postoperative scars. We regard laparoscopic repair of selected patients with perforated duodenal ulcer as a safe and preferable treatment.

Isolated splenic metastasis from colon cancer--case report and literature review.

Solitary splenic metastases are very rare and sporadic. There are several explanations for this low incidence of splenic metastasis including anatomical, histological and immunological features of the spleen. In this paper we present a case of 70-year-old man with no history of previous diseases who was first operated under the diagnosis of acute abdomen revealing perforated colon tumor of splenic flexure with no metastases at that time. Left hemicolectomy was performed followed by postoperative complications demanding a subtotal colectomy and ileostomy. Primary tumor was classified as Dukes (Astler-Coller)-C2, T4NIMO. Patient was referred to oncologist and received chemotherapy (5FU, Leucovorin). 5 months later continuity of the gut was performed by ileosygmoanastomosis. 2 years after first surgical procedure, a CT scan and abdominal ultrasound, followed by needle biopsy, showed isolated metastasis in spleen, so splenectomy was performed. Pathological findings revealed sharply bordered, partially necrotic tumor inside of spleen tissue, spreading to, but not reaching splenic hilum. Histology showed low to medium differentiated adenocarcinoma tissue with desmoplastic stromal reaction. There were no protrusions of tumor cells through spleen surface. In splenic hilum 4 tumor free lymph nodes were harvested. No additional chemotherapy was conducted. The latest follow up, a year after diagnosis of metastasis showed no signs of cancer disease. Review of the literature showed that long term survival and prognosis of isolated splenic colorectal metastasis after splenectomy are rather optimistic, although these are the cases of distant metastasis. Due to small number of cases reported in literature, definitive conclusions and/or guidelines for the treatment of isolated splenic metastasis cannot be given, but splenectomy and chemotherapy are preferable in the treatment, promising long term survival at least for metachronous metastasis.

Comparison of P-POSSUM and Cr-POSSUM scores in patients undergoing colorectal cancer resection.

OBJECTIVES: To compare the Portsmouth (P) Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) and specialized colorectal (Cr) POSSUM scoring systems in the prediction of mortality after resection of colorectal cancer. DESIGN: Retrospective study of patients after resection of colorectal cancer. SETTING: University hospital. PATIENTS: One hundred twenty patients with complete medical records who underwent resection of colorectal cancer between January 1, 1996, and December 31, 2004, at our institution were enrolled in the study. MAIN OUTCOME MEASURES: P-POSSUM and Cr-POSSUM scores were calculated for each patient. In-hospital mortality rate and number of deaths within 30 days after surgery were recorded. The ratio of observed to expected deaths was calculated for each analysis. RESULTS: The P-POSSUM system underpredicted mortality by 25%, with no significant difference between the predicted and observed values (P = .96). The observed to expected ratio for Cr-POSSUM was 1.11, with no significant difference between the observed and predicted values (P = .19). Area under the receiver operating curve for P-POSSUM was 0.70 and for Cr-POSSUM was 0.59. CONCLUSIONS: Both P-POSSUM and Cr-POSSUM perform well in predicting mortality after colorectal cancer surgery, but the Cr-POSSUM is more accurate. There is a constant need for reevaluation of existing and any new scoring systems outside original development and validation populations. The Cr-POSSUM score is a promising specialized tool for monitoring surgical outcomes in colorectal cancer surgery.

Anterior rectus sheath in inguinal hernia repair: preliminary study.

Inguinal hernia repair using the anterior rectus sheath flap represents a tension-free repair with potential advantages (no foreign material or tension on the suture line). The aim of this research was to evaluate the method of inguinal hernia repair using the anterior rectus sheath and to compare it with tension-free mesh repair (modified Lichtenstein repair). In total, 62 patients were evaluated. Each patient's age, gender, type of hernia, total operating-room time, the length of postoperative hospital stay, and the recurrence-free period were recorded, as well as the total number of postoperatively administered doses of analgesics, and analyzed using the Mann-Whitney test. No difference in age (p = .08), postoperative hospital stay (p = 0.810), or postoperative use of analgesics (p = .116) was observed between two groups. Total operating-room time was significantly longer in patients undergoing mesh repair (median 80 min, range 45-150) compared to anterior rectus sheath repair (median 65 min, range 45-125) (p = .049). No complications or recurrences were noted in either group. Thus, this study showed good results using the anterior rectus sheath repair for primary, uncomplicated inguinal hernias, comparable to mesh repair.

Quality of life changes after inguinal hernia repair using anterior rectus sheath--a preliminary study.

Chronic pain is the most serious long-term complication after groin hernia repair. The aim of this preliminary research was to assess the quality of life before and after standard tension-free mesh repair and new method of tension-free inguinal hernia repair using anterior rectus sheath. Total of 62 patients were evaluated. Anterior rectus sheath method was performed in 29 patients and in 33 patients standard mesh repair was used (Lichtenstein repair). Quality of life was assessed before and after the surgery using short-form SF-36 questionnaire (QualityMetric Inc.), adjusted for Croatian language. There were statistically significant improvements in bodily pain and general health scores in both groups. Patients operated using mesh technique also demonstrated statistically significant improvements in social functioning and emotional role. Similarly, patients in whom inguinal hernia was repaired using anterior rectus sheath had significantly better postoperative scores for physical functioning and role physical scores. Quality of life assessment demonstrated good ability to differentiate between several independent aspects of quality of life. Anterior rectus sheath repair significantly improved quality of life and was shown to be similar to mesh repair in the aspect of physical functioning.

Analysis of scores in diagnosis of acute appendicitis in women.

Acute appendicitis is a common surgical condition that requires prompt diagnosis. Besides modern imaging techniques, scoring systems, based on clinical signs and symptoms and routine laboratory assessments, have been used as a diagnostic aid. However, differences in sensitivities and specificities were observed if the scores were applied to various populations and clinical settings. The purpose of this paper is to assess validity of three scores (modified Alvarado score, Ohmann score and Eskelinen score) for diagnosis of acute appendicitis in women. 126 female patients admitted for suspicion of acute appendicitis in a tertiary hospital emergency department were analyzed prospectively. Modified Alvarado score, Ohmann score and Eskelinen score were calculated at admission and compared to final diagnosis. All patients with modified Alvarado score 7 or more had acute appendicitis (100% specificity) and it can be used to determine the need for immediate appendectomy. Values of Ohmann score greater than 6 resulted in 0.9% rate of overlooked appendicitis. Besides obvious educational role, scores may help to determine the group of patients who require immediate appendectomy, therefore expediting treatment and avoid unnecessary observation or more lengthy diagnostic procedures that require highly educated and skilled senior staff: No single score may be used alone to dictate or decline surgery. Different cut-off points may also be considered for different subpopulations.

Macrophages of human first trimester decidua express markers associated to alternative activation.

PROBLEM: Depending on the type of their activation, macrophages may promote TH1- or TH2-type of immune responses. To date, not much is known about the activation phenotype of decidua macrophages, which - together with NK cells - constitute the majority of bone marrow derived cells at this location. METHOD OF STUDY: The study was based on analysis of healthy first trimester decidua by immunohistochemistry and flow cytometry. We analyzed expression of markers characteristic for alternatively activated macrophages (Mphi2). RESULTS: The markers MS-1 (stabilin-1) and coagulation factor XIIIa were found expressed in the interior of decidua macrophages (DMphi). In contrast, indoleamine 2,3-dioxygenase (IDO), an enzyme induced in macrophages by IFNgamma, was not present in DMphi. CONCLUSIONS: First trimester DMphi display phenotypic markers associated to alternatively activated macrophages. In addition, absence of IDO indicates that DMphi are not under a predominant influence of IFNgamma.

IL-18 is present at the maternal-fetal interface and enhances cytotoxic activity of decidual lymphocytes.

PROBLEM: Perforin expressing uterine natural killer (uNK) cells are under complex cytokine influence. The aim of the study was to investigate the presence and role of interleukin (IL)-18 on NK cytolytic potential at maternal-fetal (M-F) interface. METHOD OF STUDY: Peripheral blood cells and decidual tissue were obtained from elective pregnancy termination of normal human 6-10-week-old pregnancies. Perforin expression and cytolytic activity of peripheral blood (PBL) and decidual lymphocytes (DL) were analyzed by flow cytometry. IL-18 positive decidual adherent cells (DAC) were detected by the same method. Interleukin-18 and IL-18 receptor (IL-18R) expression on the trophoblastic cells was detected by immunohistology using biotinylated anti-IL-18 and IL-18R monoclonal antibodies. RESULTS: The IL-18 added in a dose of 10 ng/mL up-regulates perforin expression and cytolytic activity of DL. Simultaneous stimulation with IL-18 and IL-12 enhanced DL cytolytic activity, while IL-18 combined with IL-10 or IL-15 did not show this effect. Cytolytic activity of PBL was up-regulated by IL-18 as well, and this effect was enhanced by the addition of IL-12 and IL-15. Interleukin-18 did not affect perforin-protein expression in cultured PBL. Approximately 20% of DAC were IL-18 positive and these cells were mostly human leukocyte antigen (HLA)-DR negative. IL-18R positive cells were found on syncytiotrophoblast cell layer, interstitial tissue cells of villi and fetal blood cells. There was no detectable IL-18 staining on trophoblast cell layer on villi, but strong staining of fetal blood cells in villous vessels. CONCLUSION: These are first results showing IL-18R expression, but not IL-18 expression on villous trophoblastic cells, as well as enhancement of perforin expression and NK cytolytic potential of DL under the influence of IL-18. IL-18 in concert with other cytokines and hormones could play an important role in the regulation of cytolytic potential of first trimester pregnancy decidual and peripheral blood NK cells.