A new type of rendezvous: introduction of laparo-endoscopy in selected patients.

OBJECTIVE: The aim of this work is to demonstrate the introduction of laparo-endoscopy and to investigate the year-long experience with its use. PATIENTS AND METHODS: In a subgroup of patients with cholecystolithiasis, concomitant lithiasis of the common bile duct may also be present. When the preoperative endoscopic cholangiopancreatography, performed as a result of a suspected choledocholithiasis, was unsuccessful, a "rendezvous" ERCP, laparo-endoscopy, is performed. After a survey of the international literature on the method, and a description of its technique, the authors give a review of the cases of their own 10 patients, which were all successful. RESULTS: These findings emphasise the advantages of the new method in a certain subgroup of patients over the conventional, sequential approach (preoperative ERCP followed by laparoscopic cholecystectomy), and also give technical hints obtained during their performance of the operations up to now. CONCLUSIONS: These results underline the importance of team work that involves the cooperation of a gastroenterologist, a surgeon and an anaesthesiologist in the indication, organisation and implementation of the intervention.

Early clinical remission and normalisation of CRP are the strongest predictors of efficacy, mucosal healing and dose escalation during the first year of adalimumab therapy in Crohn's disease.

BACKGROUND: Adalimumab is a fully human monoclonal antibody targeting tumour necrosis factor with proven efficacy in the treatment of Crohn's disease (CD). AIM: To investigate the predictors of medium-term clinical efficacy and mucosal healing during adalimumab therapy, in patients with CD, in specialised centres approved for biological therapy in Hungary. METHODS: Data capture of the 201 CD patients was standardised and prospective (male/female: 112/89, median age: 33.0 years, duration: 8 years). Previous infliximab therapy had been administered in 48% of patients, concomitant steroids in 41%, azathioprine in 69% and combined therapy in 27% of patients. RESULTS: Overall clinical response and remission rates at 24 weeks were 78% and 52%, respectively; at 52 weeks were 69% and 44%, respectively. Endoscopic improvement and healing were achieved in 43% and 24% of patients. In a logistic regression model, clinical efficacy and CRP at week 12, need for combined immunosuppression at induction, shorter disease duration and smoking were identified as independent predictors for 12-month clinical outcome, whereas CRP at week 12, clinical remission at week 24, inflammatory parameters and nonsmoking were associated to endoscopic improvement/healing. Intensification to weekly dosing was needed in 16% of patients. Parallel azathioprine therapy and clinical remission at week 12 were inversely associated with dose escalation. CONCLUSIONS: Clinical efficacy and normalised CRP at week 12 (early deep clinical remission) are associated with medium-term clinical efficacy and mucosal healing during adalimumab therapy, whereas need for combined immunosuppression at induction and smoking status are predictors for non-response. Parallel azathioprine therapy may decrease the probability for dose escalation.

Haplotype analysis of the apolipoprotein A5 gene in patients with the metabolic syndrome.

BACKGROUND AND AIMS: In recent studies, the T-1131C variant of apolipoprotein A5 (APOA5) gene was found to confer a risk for metabolic syndrome (MS). Here we determined four haplotype-tagging polymorphisms (T-1131C, IVS3+G476A, T1259C, and C56G), and studied the distribution of the naturally occurring major haplotype profiles in MS. METHODS AND RESULTS: A total of 343 MS patients and 284 controls were genotyped using PCR-RFLP methods. Both in MS and control groups, we confirmed the already known association of -1131C, IVS3+473A and 1259C minor alleles with elevated triglyceride levels. The prevalence of the APOA5*2 haplotype (the combination of T-1131C, IVS3+G476A and T1259C SNPs) was 13.1% in MS patients, and 4.9% in controls (p<0.001); multiple logistic regression analysis revealed that this haplotype confers risk for the development of MS (OR=2.880; 95% CI: 1.567-5.292; p=0.001). We also observed a gender effect: in males a more prominent degree of susceptibility was found. Contrary to the APOA5*2 haplotype, the prevalence rate of APOA5*4 (determined by the T-1131C SNP alone) did not differ between MS patients and controls. We identified a novel haplotype, designated here as APOA5*5 (1259C allele alone); which appears to be protective against MS. CONCLUSION: Our results refined the role of SNP T-1131C in the development of MS. The susceptibility nature of this SNP is limited to the APOA5*2 haplotype, while in APOA5*4 haplotype it did not confer a risk for the disease. In addition, as our current data suggest, the novel APOA5*5 haplotype can confer protection against MS.

Plasma carnitine ester profiles in Crohn's disease and ulcerative colitis patients with different IGR2230a_1 genotypes.

An association has been repeatedly demonstrated between inflammatory bowel disease (IBD) and the IBD5 locus in the 5q31 chromosomal region. The aim of the present study was to examine the prevalence of the IGR2230a_1 intronic nucleotide polymorphism of the slc22a5 gene (coding for the OCTN2 carnitine transporter protein) lying within this region, and its possible relationship with the carnitine metabolism in Hungarian IBD patients and controls. We genotyped by restriction fragment length polymorphism 200 Crohn's disease (CD) and 246 ulcerative colitis (UC) patients, as well as 187 healthy controls. From plasma samples we determined detailed carnitine ester profiles of 76 CD, 43 UC patients and 45 control persons using electrospray ionization triple quadruple tandem mass spectrometry. The distribution of the genotypes was not significantly different in the CD or the UC group compared with the controls. We found no significant alterations of the carnitine profile in the carrier/non-carrier or the homozygote/non-homozygote comparisons in both the CD and the UC groups, stratified by IGR2230a_1 genotype. Our data suggest that this polymorphism alone is not associated with CD and UC in the Hungarian population, and has no effect on the carnitine metabolism.

Multimodality treatment resulting in long-term survival in hepatocellular carcinoma.

The early detection and complex therapy of the hepatocellular carcinoma (HCC) is one of the most seasonable questions of the gastroenterology-oncology, because of the increasing prevalence of the primary liver cancer. The course of the hepatocellular carcinoma is rapid, untreated patients rarely live over 5-6 months. Combination of different treatment modalities in HCC can offer the best chances for survival. If possible, a surgical resection should be the primary procedure, followed by adjuvant cytostatic treatment and chemoembolisation. The authors report three cases with HCC with extremely long survival. The long-term survival achieved by multimodality therapy, as presented in these cases, seems to justify aggressive therapeutical approaches in HCC. It has been concluded, that early detection and complex, aggressive multimodality treatment--even repeated liver resections and surgical elimination of duplex distant metastases--can result in long-term survival with a good quality of life.

[Hepatitis C virus infection and B-cell non-Hodgkin's lymphoma]. / A hepatitis C vírus-infekció és B-sejtes non-Hodgkin-lymphoma.

Oncogenesis is a multifactorial process in which environmental, genetical and infectious factors may be of importance. Specific viruses are supposed to have etiological role in about 15% of human tumors. Recently the B-cell proliferation inducing effect of the hepatotropic and lymphotropic hepatitis-C virus (HCV) came into the limelight based on the high prevalence of HCV positivity in B-cell non-Hodgkin's lymphoma (NHL) patients. The aim of the authors was to establish the prevalence of HCV infection in NHL patients. Paralelly the HBV, CMV and EBV markers, and the alterations of the humoral immune response (immunoglobulins, cryoglobulins, rheumatoid factor) were determined. 42 patients (24 male, 18 female; the mean age: 54.1 years, range 22-80 years) classified as 16 indolent (low risk), and 25 aggressive (intermediate risk) NHL and one with very aggressive Burkitt's lymphoma, according to the modified REAL classification were examined. Enzyme-linked immunosorbent assay (ELISA) for HBsAg and anti-HCV, HBsAg, anti EBV, anti CMV, furthermore polymerase chain reaction (PCR) for HCV-RNA were used. Anti-HCV was found in 6/42 NHL patients (14.3%), while anti-HCV and/or HCV-RNA PCR positivity revealed on overall HCV infection in 10/42 (23.8%) patients. None of them were HBsAg positive. Our findings support the hypothesis, that HCV might have an aetiological role in the lymphoproliferation leading to B-cell NHL.

[Percutaneous drainage in the treatment of accidentally discovered hydatid cyst in patients with polycystic liver]. / Polycystás májbetegekben véletlenszerüen felismert máj Echinococcus-cysták percutan drainage kezelése.

This article report on a not very well-known therapeutical procedure used among only fairly diagnosed cases based on international and Hungarian experiences. In Hungary echinococcus cyst of the liver is mostly treated surgically (the average mortality rate of liver resection is 0-6.3%). In many places the percutan puncture and drainage are contraindicated in case of echinococcus cysts. The authors assert that the percutaneous treatment of echinococcus cysts in proper technical and methodic circumstances in safe regarding the previous studies and their own data obtained of a few cases, and describe the technique and raise some question in them. Drainage treatment is very well tolerated by the patients it reduces the duration (of time) and the cost of the hospitalization.

[Adenomyomatosis of the gallbladder]. / Epehólyag adenomyomatosis.

A 64-year-old male patient was reported, surveying radiology and pathology of the adenomyomatosis. The authors emphasize the role of high resolution ultrasound and computer tomography in the diagnosis of gallbladder adenomyomatosis. Intramural cystic formation (anechoic diverticula) with echogenic foci and/or reverberation artifacts together with a full or a partial thickening of the gallbladder's wall was considered as the diagnostic criteria of the ultrasound examinations. They assist in finding the proper way among the difficulties of the different diagnosis, in the same time call the attention for the frequently misdiagnosed cases.

[Repeated resection of hepatocellular carcinoma and its recurrences and removal of pulmonary metastases]. / Hepatocellularis carcinoma és recidíváinak ismételt resectiója tüdömetastasisok eltávolításával.

A case of a 67 year old male successfully treated local recurrence of previously radically resected hepatocellular carcinoma with distant metastases of the lung is reported. Two years after a complete removal of the primary liver malignoma a local recurrence was resected which was followed by selective intraarterial cytostatic treatment and chemoembolisation. A three-year disease-free interval was achieved, then recurrence in the liver and lung metastases were detected at the regular check-up. All of the malignant focuses were eliminated by parenchyma sparing surgical resections, then a postoperative adjuvant chemotherapy (FAM scheme) has been followed. After eight months the patient remained symptom-free. The long-term survival seems to justify the aggressive approach of this kind of malignancies.