Gallbladder carcinoma - when to use laparoscopic approach?

AIM: To assess how laparoscopy has altered the presentation of patients with gallbladder cancer and determine whether radical resection in patients with gallbladder cancer is beneficial. METHOD: 47 patients underwent surgery because of suspected gallbladder cancer. Cancer was found incidentally in 29 patients (61.7 %) during routine laparoscopic cholecystectomy using frozen biopsy. Gallbladder cancer had been diagnosed preoperatively in the other 18 patients (38.3 %). RESULTS: Patients in whom carcinoma was found incidentally at laparoscopic cholecystectomy had a significant increase in survival when compared with those who were admitted electively with a known diagnosis. All patients who presented with a known diagnosis had stage II or higher, and 38.3 % of these were in stage IV. However, 58.6 % of those patients who were found incidentally were in stage I or II. The overall 2-year survival for all patients was 45 %; those discovered incidentally at laparoscopic cholecystectomy (Tis-T2) had a 2-year survival of 87 %. CONCLUSION: Laparoscopic cholecystectomy resulted in an earlier discovery of gallbladder cancer in some patients, resulting in increased probability of survival. Adjunctive radical surgical resection, either at the time of cholecystectomy or subsequently, increases survival significantly in early stage disease (Tab.2, Fig. 2, Ref. 24). Text in PDF www.elis.sk Keywords: gallbladder carcinoma, laparoscopic approach.

[Concomitance of acute cholecystitis and acute appendicitis]. / Koincidencia akútnej cholecystitídy a akútnej apendicitídy.

Acute appendicitis and acute cholecystitis are among the most common diagnoses that general surgeons operate. However, they are only rarely described simultaneously. Authors describe the course of disease, diagnostics and surgery solution of disease. They report, that there are many factors, which play important role in the process of diagnostics and treatment of patient. They emphasis individual access not only of patients view, but also individual acces and view of surgeon. Because of rare coincidence of both diseases, there are many questions, but answers miss.Key words: acute cholecystitis acute appendicitis coincidence.

[Heterotopic mesenteric ossification]. / Heterotopická mezenteriálna osifikácia.

Heterotopic mesenteric ossification (HMO) is a rare disease inducing pathological bone tissue formation in the abdominal cavity after multiple operational traumas. The authors present an unusual case of mesenteric ossification formation in a 30 year-old man after surgery due to status ileosus on the basis of intestinal incarceration. After being released into home treatment the patient had to be hospitalized again and reoperated. During the next six weeks, the patient was reoperated three more times due to intestinal status ileosus and significant leaking of the entero-cutaneous fistula. Despite intensive parenteral hyperalimentation the patients condition did not improve and metabolic breakdown became fatal for the patient. Pathophysiology of the mechanism of bone tissue formation in soft tissues is unknown.

Hyperthermia induces injury to the intestinal mucosa in the mouse: evidence for an oxidative stress mechanism.

Loss of the intestinal barrier is critical to the clinical course of heat illness, but the underlying mechanisms are still poorly understood. We tested the hypothesis that conditions characteristic of mild heatstroke in mice are associated with injury to the epithelial lining of the intestinal tract and comprise a critical component of barrier dysfunction. Anesthetized mice were gavaged with 4 kDa FITC-dextran (FD-4) and exposed to increasing core temperatures, briefly reaching 42.4°C, followed by 30 min recovery. Arterial samples were collected to measure FD-4 concentration in plasma (in vivo gastrointestinal permeability). The small intestines were then removed to measure histological evidence of injury. Hyperthermia resulted in a ≈2.5-fold elevation in plasma FD-4 and was always associated with significant histological evidence of injury to the epithelial lining compared with matched controls, particularly in the duodenum. When isolated intestinal segments from control animals were exposed to ≥41.5°C, marked increases in permeability were observed within 60 min. These changes were associated with release of lactate dehydrogenase, evidence of protein oxidation via carbonyl formation and histological damage. Coincubation with N-acetylcysteine protected in vitro permeability during hyperthermia and reduced histological damage and protein oxidation. Chelation of intracellular Ca(2+) to block tight junction opening during 41.5°C exposure failed to reduce the permeability of in vitro segments. The results demonstrate that hyperthermia exposure in mouse intestine, at temperatures at or below those necessary to induce mild heatstroke, cause rapid and substantial injury to the intestinal lining that may be attributed, in part, to oxidative stress.

Modification of ionotropic glutamate receptor-mediated processes in the rat hippocampus following repeated, brief seizures.

The seizure-induced molecular and functional alterations of glutamatergic transmission in the hippocampus have been investigated. Daily repeated epileptic seizures were induced for 12 days by intraperitoneal administration of 4-aminopyridine (4-AP; 4.5 mg/kg) in adult Wistar rats. The seizure symptoms were evaluated on the Racine's scale. One day after the last injection, the brains were removed for in vitro electrophysiological experiments and immunohistochemical analysis. The glutamate receptor subunits NR1, NR2A, NR2B, GluR1, GluR1(flop), GluR2, and KA-2 were studied using the histoblotting method. The semi-quantitative analysis of subunit immunoreactivities in hippocampal layers was performed with densitometry. In the hippocampus, increase of GluR1, GluR1(flop) and NR2B immunostaining was observed in most of the areas and layers. The significant decrease of GluR2 staining intensity was observed in the CA1 and dentate gyrus. Calcium permeability of hippocampal neurons was tested by a cobalt uptake assay in hippocampal slices. The uptake of cobalt increased in the CA1 area and dentate gyrus, but not in the CA3 region following 4-AP treatment. Effects of AMPA and NMDA (N-methyl-d-aspartate) glutamate receptor antagonists (1-(4-aminophenyl)-4-methyl-7,8-methylenedioxy-5H-2,3-benzodiazepine hydrochloride (GYKI 52466) and D-APV respectively) were measured in hippocampal slices using extracellular recording. Analysis of the population spikes revealed the reduced effectiveness of the AMPA receptor antagonist GYKI 52466, while the effect of the NMDA receptor antagonist d-(2R)-amino-5-phosphonovaleric acid was similar to controls. The results demonstrated that repeated convulsions induced structural and functional changes in AMPA receptor-mediated transmission, while NMDA and kainate receptor systems displayed only alterations in receptor subunit composition.

Conversions in laparoscopic cholecystectomy.

Authors in this article emphasize the wide use of laparoscopic cholecystectomy in gall bladder surgery. Indications for laparoscopic operations are increasing. In spite of increasing practical experience of surgeons, availability of new instruments, advances of techniques, this problem of conversion is always actual. The question of conversion may depend on subjective and objective causes. It's the decision of the surgeon whether a conversion is necessary taking into account uncomplicated operation and postoperative state of the patient. In the Surgery clinic of FN Nitra 2078 cholecystectomies were performed in the period from 1.1.2002 to 31.1. 2007. Out of this number, there were 1535 (74%) laparoscopic operations and 543 (26%) classic operations. From the group of 1535 laparoscopic operations conversion was necessary in 89 patients (5.7%) (Tab. 4, Ref. 9).

Miniinvasive treatment of pericardial effusions.

The aim of our study is to show the clinical potential of laparoscopic treatment of pericardial effusions. In spite of the small number of the patients we want to bring to attention the benefit of this mininvasive procedure. The laparoscopic fenestration is indicated when the pericardial effusion persists after unsuccessful medical treatment and when clinical and echocardiografic signs of tamponade develop (Ref 13). Full Text (Free, PDF) www.bmj.sk.

[Choledochal cyst complication of pregnancy]. / Cysta choledochu ako komplikácia gravidity.

Authors in this case report describe rare complication of pregnancy. Ultrasound examination showed cystic lesion in abdominal cavity. It was indicated caesarean section because of deterioration of patient's condition. After the removal of foetus it was peroperative found cystic lesion in subhepatal area in right mesogastrium. Cystic lesion compressed stomach, colon transverse and loops of small intestine. After the revision of abdominal cavity and local finding surgeon detected choledochal cyst. It was resected and sutured hepaticojejunoanastomosis.

[Acute intestinal ischaemia]. / Akútna intestinálna ischémia.

In spite of introduction modern diagnostics and therapeutics modalities in clinical practice diagnostics of acute intestinal ischaemia is very difficult. Acute intestinal ischaemia is rare cause of acute abdominal dissease but results of surgical treatment and prognosis of the patients with acute intestinal ischaemia is very poor. The aim of study is occurence, diagnostics and therapeutics possibilities of acute intestinal ischaemia, because tretament of acute intestinal ischaemia have high rate of mortality. Authors claiming on own small set of patients that in diagnostics of acute abdominal pain everything in once mind on acute intestinal ischaemia.

Atypical cyst of the right ductus hepaticus.

Cystic dilatation is a rare disease of extra- or intra-hepatic bile ducts. According to the literature it is an disorder accompanying other diseases rather than an independent diagnosis. In the case of smaller dimensions it is often found by coincidence because of its asymptomatic course of development. Mostly it manifests itself through abdominal pain or icterus. The authors show a case report of 14-months old patient with the finding of a cyst in the right ductus hepaticus with extraordinary dimensions (Fig. 2, Ref. 11). Full Text (Free, PDF) www.bmj.sk

[Postoperative adhesions, the everlasting topical subject]. / Pooperacné adhézie, stále aktuálny problém.

Creation of postoperative adhesions is a part of every abdominal operation. The authors analyse 320 patients operated for ileus in last 7 years. 118 patients were operated for adhesive ileus. Most common reoperations for ileus are after radical gynecological operations and inflammatory intraabdominal diseases. The creation of adhesiones depends on preoperative mechanical or chemical damage of tissues and peritoneum, bacterial infection and irradiation. The major complication of intraabdominal adhesions are disturbances of bowel function what leads to subileus or ileus. Authors present therapeutical possibilities and prefer laparoscopic operations.

[Internal hernias--uncommon causes of the status ileosus]. / Vnútorne hernie--menej castá prícina ileóznych stavov.

Internal hernia is an uncommon cause of acute intestinal obstruction with. Preoperative diagnosis of an internal hernia is difficult because of the lack of specific signs. Only a few cases of internal hernia have been successfully diagnosed, however, most cases (74%) were initially diagnosed as intestinal obstructions. Authors present the case of the patient with the history of resection of gaster sec. Billroth II with gastroenteroanastomosis. The symptoms of the internal hernia were vomiting, abdominal pain and leaded to an emergency operation. An incarceration of the bowel retroanastomotic under the Braun anastomosis. The obstruction was released by the traction of the bowel and the abnormal opening was sutured to prevent recurrence.

Recognition of type 1 chain oligosaccharides and lacto-series glycolipids by an antibody to human secretory component.

Binding of the mouse IgM antibody 6C4 is lost after treatment of human free secretory component with peptide N-glycosidase F (Bakos et al. (1991) J. Immunol. 146, 162-168) or periodate, suggesting that asparagine-linked oligosaccharides contain the epitope recognized by this antibody. Inhibition of antibody binding to free secretory component by milk oligosaccharides established that lacto-N-tetraose is the minimum structure recognized by the antibody, but larger oligosaccharides with terminal Gal beta 1-3GlcNAc sequences bind with much higher affinity. Antibody binding is enhanced by substitution with the Lewis Fuc alpha 1-4 and is inhibited by Fuc alpha 1-2Gal substitution. Free secretory component, however, does not bind other antibodies that recognize Le(a) or Leb oligosaccharides, and binding is lost after digestion with a beta-galactosidase that cleaves Gal beta 1-3 linkages but not after digestion with alpha-L-fucosidase. Therefore, the major epitope recognized by 6C4 on free secretory component is probably not an asparagine-linked Le(a) oligosaccharide. The antibody also binds to human milk lactoferrin, some human mucins, and lacto-series glycolipids including III4 alpha Fuc-lactotetraosyl ceramide and lactotetraosyl ceramide. Based on affinity chromatography of oligosaccharides released from free secretory component, the epitope recognized by antibody 6C4 is present on approximately 3.5% of the asparagine-linked oligosaccharides.

Expression and purification of biologically active domain I of the human polymeric immunoglobulin receptor.

Previous studies using proteolytic fragments and synthetic peptides have indicated that domain I of human polymeric immunoglobulin receptor (PIgR) is necessary for ligand binding. The expression in E. coli, and subsequent IgM-affinity purification of domain I of human PIgR is described. The recombinant domain I protein (rDI) was similar in structure to native SC domain I in that it bound specifically to MAb 6G11, an antibody which recognizes a critical portion of the PIg binding site in domain I. The biological activity of rDI was indicated by high affinity binding to PIgA (Kd = 1.6 x 10(-7) M) and IgM (Kd = 5.1 x 10(-7) M). Domain I of human SC is therefore sufficient for binding to PIg.

A conserved binding site on the receptor for polymeric Ig is homologous to CDR1 of Ig V kappa domains.

We have previously shown that the binding of human secretory component (SC) to polymeric IgA (PIgA) is inhibited by a synthetic peptide fragment of SC (SC[15-37]), and also by a mAb (mAb 6G11) which specifically recognizes the unbound form of SC and SC[15-37]. In this report we show that the binding of bovine, rabbit, and rat SC to human PIgA can also be inhibited by SC[15-37], and that the relative affinity of these three species of SC for human PIgA correlated with their relative affinity for mAb 6G11. The binding of mAb 6G11 to SC isolated from various species was especially affected by amino acid substitutions at position 26 of SC. Structural modeling revealed that the side chain of residue 26 is located on the external face of a loop in SC domain I which is homologous in size and position to the first complementarity determining region (CDR1) of Ig V kappa domains. However, the surface topography of the CDR1-like loop of SC is distinct from other known V kappa CDR1 loops due to the unique distribution of charged and bulky polar side chains which locate to the exterior face of the loop. Together, these findings indicated that the binding site on the receptor for PIg is highly conserved among species, and is composed, in part, of residues of domain I of SC which may form a distinct CDR1-like loop on the surface of the molecule.

Characterization of a critical binding site for human polymeric Ig on secretory component.

Secretory component (SC) is an integral membrane glycoprotein of secretory epithelial cells which is responsible for the specific transport of polymeric Ig (PIg) to external mucosal surfaces. The ectoplasmic segment which binds polymeric Ig is comprised of five Ig-type domains. Chemically and enzymatically modified forms of the ectoplasmic portion of SC (FSC) were produced and tested for their ability to bind to PIgA and PIgM. Deglycosylated FSC bound specifically to PIg, indicating that N-linked carbohydrate moieties on FSC are not required for binding. Denatured, reduced, and alkylated FSC did not bind to PIgA, and bound to PIgM with significantly reduced affinity, suggesting that native conformation of the polypeptide backbone of SC was important to binding. Tryptic fragments of FSC which bound to PIg were isolated and identified to be derived from domain I of SC. Synthetic peptides comprising overlapping portions of domain I bound to PIg to varying degrees. The strongest affinity was demonstrated by a peptide comprised of residues 15 to 37 of SC. A comparison of the amino acid sequences of human, rabbit, and rat SC indicated that this region contained a high degree of residue identity (78%) and may represent a consensus sequence for binding of FSC to PIg. Importantly, the peptide comprised of residues 15 to 37 was also recognized by a monoclonal antibody, 6G11, which inhibited the binding of FSC to PIgA. These results demonstrate that the binding of human SC to PIg is critically dependent on a highly conserved peptide region within the first domain of SC centering at residues 15-37.

Characterization of secretory component in amniotic fluid. Identification of new forms of secretory IgA.

Amniotic fluid (AmF) contains low levels of IgA of fetal origin. Western blot analysis revealed that the major forms of IgA in human AmF contain secretory component (SC), but ranged in size between 170 and 200 kDa, unlike the 380-kDa size typical of previously described secretory (s)IgA. Preliminary characterization of these novel forms of sIgA suggests they may arise by reduction of selected disulfide bonds, rather than proteolytic cleavage, of 380-kDa sIgA. This study also shows that AmF contains SC in its free form. Free SC measured by ELISA in 30 AmF samples increased with gestational age of the fetus from 26 to 40 wk postconception. Late in gestation, the concentrations of free SC levels reached those of other external secretions. Both the fetal urogenital system and the amniotic membrane appear to contribute to both the free SC and sIgA in AmF. This report presents the initial description of a new form of sIgA and provides evidence that the AmF may be an early expression of the mucosal immune system in the developing fetus.

Probing the topography of free and polymeric Ig-bound human secretory component with monoclonal antibodies.

Secretory component (SC), an integral membrane protein expressed on basolateral surfaces of secretory epithelial cells, mediates the transport of polymeric Ig (PIg) into external secretions. The ectoplasmic segment of SC is released into secretions either in a free form (FSC) or bound to PIg as secretory IgA or IgM. The topography of human SC in its free and PIgA-bound form was studied by using mAb directed against each form of SC. Competition experiments identified a minimum of nine SC epitopes, one of which was dependent on an N-glycosidic moiety. Three of the polypeptide-derived epitopes were displayed on denatured, reduced, and alkylated SC, whereas the others were fully or partially dependent on the native conformation of SC. Epitopes recognized by the latter class of antibodies were mapped to discrete domains of SC, based on amino acid sequence and antibody-binding analysis of limited proteolytic fragments. One of the mAb (6G11), which was directed against an epitope on domain I of SC, inhibited the binding of FSC to PIgA. Overall, our results provide evidence that a region within domain I, as well as protease-sensitive interdomain regions of FSC, become masked or altered when SC binds to PIgA. Furthermore, the binding of SC to PIgA results in conformational changes, or formation of combinatorial epitopes, involving regions within domains II and III of SC but not domain V.

Enzymatic and envelope-converting activities of pars recta oviductal fluid from Xenopus laevis.

Conversion of the coelomic egg envelope to the vitelline envelope of the Xenopus laevis egg is known to take place in the pars recta (PR) region of the oviduct. A method for collecting fluid generated from PR cultured in vitro was devised which enhanced the recovery of envelope-converting factors. By the criteria of melting temperature analysis, sodium dodecyl sulfate-polyacrylamide gel electrophoresis, 125I labeling, ferritin binding, and in vitro fertilization assays, the secretions collected from PR cultured in vitro were capable of modifying the envelope in a manner analogous to that which occurred in vivo, including the limited hydrolysis of one envelope glycoprotein. Hydrolytic activities present in PR fluid were assayed with a number of peptide and carbohydrate substrates. Enzymes which hydrolyzed t-butyloxycarbonyl-Leu-Ser-Thr-Arg-methylcoumarylamide, t-butyloxycarbonyl-Phe-Ser-Arg-methylcoumarylamide, and t-butyloxycarbonyl-Val-Leu-Lys-methylcoumarylamide were found to be present in PR fluid at levels elevated by threefold or more over amounts found in a comparable volume of blood plasma.