A posztoperatív keringésváltozások jelentősége a májsebészetben

Absztrakt A máj rendhagyó keringéséért két afferens (arteria hepatica, vena portae) és egy efferens rendszer (venae hepaticae) felelős. Speciális vérellátásának köszönhetően az akut, izolált – szelektíven egy-egy érképletet érintő – vascularis okklúziók eltérő, életet veszélyeztető klinikopatológiai tünetegyütteshez vezethetnek, ezért azonnali felismerésük elengedhetetlen a máj állapota, illetve a beteg túlélésének szempontjából egyaránt. Akut keringészavarok kialakulásával elsősorban májműtétek kapcsán kell számolnunk. Az adekvát terápia mielőbbi megkezdése szempontjából kiemelten fontos a kóros keringési állapotok sajátosságainak pontos ismerete. Jelen tanulmány célja a szelektív posztoperatív keringési anomáliák etiológiájának, illetve tünettanának bemutatása, továbbá javaslat megfogalmazása a diagnosztikai lépések és a lehetséges terápia terén klinikai esetek ismertetése alapján. A szerzők bemutatják a májsebészetben használatos vascularis kirekesztés (Pringle-manőver) okozta ischaemiás-reperfúziós májkárosodást is. Orv. Hetil., 2015, 156(48), 1938–1948

Oxidative stress with altered element content and decreased ATP level of erythrocytes in hepatocellular carcinoma and colorectal liver metastases

Our aim was to study the possible alterations of redox status (enzymatic and nonenzymatic parameters and metal elements) in erythrocytes of patients with hepatocellular carcinoma (HCC), colorectal liver metastases (CRLM) and benign liver neoplasms. The function of redox homeostasis is closely connected to the energy level of erythrocytes, therefore, the ATP level was also determined. Antioxidant parameters, enzyme activities of superoxide dismutase and glutathione peroxidase were estimated in the erythrocytes of 11 patients with benign tumour, 23 patients with primary malignant and 37 metastatic liver tumour patients and 30 age-matched and sex-matched healthy controls. Element content with inductively coupled plasma optical emission spectrometer and ATP level by the chemiluminometric method were also determined from the samples. Free radical intensity was significantly increased, whereas erythrocyte glutathione peroxidase and superoxide dismutase activities were significantly decreased in the HCC and CRLM groups versus benign groups and controls. Se, Mn and Zn levels were lowered in HCC and CRLM groups versus benign and control groups. The content of Cu, Mg, Se and Zn changed significantly between HCC and CRLM groups. Similarly, ATP concentration decreased in HCC and CRLM versus controls and benign groups. The lowest levels of ATP and antioxidant enzyme activities were found in the case of CRLM patients. These results reveal an alteration in the ATP level of erythrocytes with concomitant changes in the antioxidant defence system in hepatic cancer patients. Altered redox homeostasis (oxidative damage) may lead to decreased ATP level and consequently may play an important role in primary carcinogenesis and generation of metastases, as well

Speciális májműtét (Associating Liver Partition and Portal vein ligation for Staged hepatectomy, ALPPS) morbiditásának csökkentése átértékelt betegkiválasztási elvek és műtéttechnikai módosítás révén = Decreasing morbidity after Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) with technical modification and patient selection

Absztrakt: Bevezetés: A májtumorok reszekálhatóságának egyetlen biológiai feltétele a májreszekció után megmaradó, a májműködést még biztosítani képes elégséges májszövetmennyiség (FLR). A műtét után visszamaradó májszövet tömege még a műtét előtt megnöveszthető vena portae okklúziós eljárásokkal. A legújabb ilyen eljárás az Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS), mely a legrövidebb idő alatt a legjelentősebb indukált hipertrófiát biztosítja. A műtét morbiditása és mortalitása az eljárás bevezetése idején azonban elfogadhatatlanul magas volt. Célkitűzés: A szövődmények csökkentése a betegszelekció pontosításával és a műtéti technika módosításával. Módszer: Műtéttechnikai módosításként a ’teljes mobilizálás’ technika helyett klinikánkon ún. ’no touch’ technikát dolgoztunk ki. Klinikánk betegadatait nemzetközi regiszterbe kapcsoltuk, melyben gyűjtjük a demográfiai adatok mellett az alapbetegség, a májműtét, illetve a szövettani jellemzőket, vizsgáljuk a morbiditást (Clavien–Dindo) és a mortalitást. A májtérfogat és -funkció mérésére CT-volumetriát, valamint 99mtechnécium-mebrofenin SPECT/CT-t alkalmazunk. Az adatokat multivarianciaanalízissel vizsgáltuk. Eredmények: A Semmelweis Egyetem Általános Orvostudományi Karának I. Sebészeti Klinikáján 2012 és 2018 között 20 ALPPS-műtétet végeztünk. A relatív térfogatnövekmény, illetve a reszekabilitás 96% vs. 86%, illetve 95% vs. 98% volt klinikánk és a regiszter 320 betegét vizsgálva. ’No touch’ technika alkalmazásakor a Clavien–Dindo III–IV. morbiditás és a mortalitás (22%–0%) szignifikánsan alacsonyabb volt, mint ’complete mobilization’ technika esetén (63%–36%; p<0,05). A regiszter betegadatainak multivarianciaanalízise alapján mortalitást fokozó független tényező volt a 60 év feletti kor, a máj macrosteatosisa, a nem colorectalis májtumor, a 300 percnél hosszabb műtét, a több, mint 2 egység vörösvértest-transzfúzió, illetve az elégtelen FLR-funkció a stage 2 előtt (p<0,05). Következtetés: Az ALPPS-műtét morbiditása és mortalitása helyes betegkiválasztással és ’no touch’ műtéttechnikával csökkenthető. Orv Hetil. 2019; 160(32): 1260–1269. | Abstract: Introduction: Resecability of liver tumors is exclusively depending on the future liver remnant (FLR). The remnant can be hypertrophised using portal vein occlusion techniques. The latest hypertrophising method is Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS), which provides the most significant induced hypertrophy in the shortest time. Morbidity and mortality of this procedure were initially unacceptably high. Aim: Reducing complications by better patient selection and modified surgical technique. Method: The First Department of Surgery, Semmelweis University, Budapest, prefers the ‘no touch’ technique, instead of ‘complete mobilization’. For optimizing patient selection, an international registry (including our patients’ data) was established. In addition to the surgical, we collected demographic, disease, liver function, histology, morbidity (Clavien–Dindo) and mortality parameters. Volume and function measurements were performed by using CT-volumetry and 99mtechnecium-mebrofenin SPECT/CT. Data were analyzed by multivariate analysis (significance: p<0.05). Results: We performed 20 ALPPS procedures from 2012 to 2018. The relative volume increment and resectability in our department and among the 320 registry patients were 96% vs. 86% and 95% vs. 98%. Using ‘no touch’ technique, the Clavien–Dindo III–IV morbidity and mortality rates were significantly lower (22%–0%) than with ‘complete mobilization’ (63%–36%) (p<0.05). Based on the multivariate analysis of the registry patients, age over 60 years, liver macrosteatosis, non-colorectal liver tumor, >300 minutes operation time, >2 units of red blood cell transfusion, or insufficient FLR function before stage 2 were identified as independent factors influencing mortality (p<0.05). Conclusion: Mortality and morbidity of ALPPS can be reduced by proper patient selection and ‘no touch’ surgical technique. Orv Hetil. 2019; 160(32): 1260–1269

In depth evaluation of the prognostic and predictive utility of PTEN immunohistochemistry in colorectal carcinomas: performance of three antibodies with emphasis on intracellular and intratumoral heterogeneity.

BACKGROUND: Phosphatase and tensin homolog deleted in chromosome 10 (PTEN) loss of function is frequently detected in advanced colorectal cancer. Its detection is thought to have prognostic significance and it is being considered to predict responsiveness to anti-EGFR therapy. Unfortunately, while immunohistochemical assessment of PTEN expression is widespread, it lacks standardization and the results are hardly comparable across the available publications. METHODS: Retrospectively collected, formalin-fixed and paraffin-embedded colorectal tumor tissue samples from 55 patients were combined into tissue microarray (TMA) blocks. We used three different PTEN antibodies to determine the frequency, intensity and intracellular pattern of PTEN immunohistochemical labeling: Neomarkers, Dako and CellSignaling. We evaluated the aforementioned parameters in selected regions of colorectal cancers and in their lymph node metastases by using three scoring methods that take into consideration both staining frequency and intensity (H1-H3-score). We also evaluated intracellular localization. RESULTS: The Dako and CellSignaling antibodies stained predominantly cytoplasms, while the Neomarkers antibody specifically stained cell nuclei. PTEN H-scores were significantly lower in all tumor areas as compared to the normal colonic mucosa based on staining with the DAKO and CellSignaling antibodies. Intratumoral regional differences or differences between matching tumors and metastases were not detected with any of the antibodies. Neither Dako, neither CellSignaling, nor the Neomarkers antibodies revealed a significant correlation between PTEN expression and pT, Dukes/MAC and clinical stage. KRAS status, histological grade correlated with PTEN H-scores based on staining with the Neomarkers antibody. PTEN H-scores did not correlate with MMR status. PTEN H-scores did not show any correlation with relapse-free survival based on staining with either antibody. CONCLUSIONS: While PTEN expression decreased in colorectal cancer according to two antibodies, neither of the three applied PTEN antibodies could justify significant correlation with clinicopathological data, nor had prognostic value. Thus, we might conclude that immunohistochemical PTEN investigation remains a challenge requiring more standardized evaluation on larger number of cases to clarify its utility as a prognostic and predictive tool in CRC. The standardization of immunohistochemical method is key in the evaluation process, which is further discussed

Beszámolók = Reports

1. 41. Nemzetközi Orvostörténeti Kongresszus Mexikóváros–Puebla, 2008. szeptember 7–12. 2. II. EURO-NOTES Kongresszus Brüsszel, 2008. szeptember 25–27. 3. Testünk görbe tükre. II. Magyar Evészavar Kongresszu

Benignus májdaganatok laparoszkópos resectiója

273 patients underwent elective surgical treatment for benign liver lesions at the 1st Surgical Department of Semmelweis University, Budapest, Hungary between 2004 and 2014. Laparoscopic (LAP) interventions were performed in 83 cases. Cyst fenestration in 52, and hepatic resection in 31 cases. LAP liver resections were set against to open surgery of paired group of patients with comparable demographic and clinical parameters. Data revealed that the operative time in LAP group (113.7 min) was significantly longer than that in the open surgery group (89.5 min). The average postoperative length of hospital stay was shorter after LAP surgery (5.8 vs 9.1 days). There was no postoperative complication in the LAP group, two wound infections and one biliary collection were treated by ultrasonic drainage in the open group. Three patients were given blood transfusion in the LAP, four in the open group. Operative mortality was zero, and no reoperation required. The surgical technique which is described in detail in the text enables safe resection of segments 7-8 which are difficult to approach. Our data support the safety and feasibility of laparoscopic liver resection after adequate preoperative investigations