Rectal cancer therapy: decision making on basis of quality of life?

BACKGROUND: As colorectal malignancies are relatively well treatable and show acceptable survival rates, the quality of life indicators are very important in this group of patients. PATIENTS AND METHODS: 372 patients with rectal cancer were included on a voluntary basis in this prospective study. The patient material consisted of two groups, those who underwent sphincter saving operation (64.51 %), and those who underwent Miles operation (35.49 %). The patients answered a colorectal cancer specific questionnaire on quality of life (CRC_QoL) 1 year after surgery. A CRC_QoL was prepared to analyze the correlation between the characteristics of the colorectal cancer and its treatment versus the physical and psychological state, somatic sensations and social connections of the patients. Our QoL questionnaire consists of 62 questions. Internal consistency of each factor was assessed by calculating Cronbach alpha values and was found satisfactory. For the test-retest reliability analysis the questionnaires were re-assessed. Correlation analysis showed that the answers were consistent (p < 0.01 in all cases). Discriminative validity analysis of the factors showed a significant difference in all cases. In self made score system higher numbers mean (9) worse, the smaller mean (0) better quality of life. The scale can also be seen as a percent distribution, where - in turn - the best quality is 100. The CRC_QoL questionnaire, scoring system, and score-to-percent transformation were done in this study. The results were evaluated by question and by patient group too. RESULTS: Our indicator did not show poor QoL for ostomates. Physical function was quite good in both groups: non-ostomates 87.69 +/- 20.85, ostomates: 96.46 +/- 8.25, p = 0.05 respectively. The cumulated converted percentile value for general state was significantly better (p = 0.03) for the ostomates (86.18 +/- 13.43) compared to non-ostomates (69.80 +/- 31.37). The cumulative gastrointestinal problem score did not reveal any significant difference (non-ostomates: 90.19 +/- 12.50, ostomates: 95.62 +/- 9.04, p = 0.11). Non-ostomates and ostomates did not differ regarding the cumulative score of stool-related questions: 83.75 +/- 20.53 versus 89.85 +/- 10.01 respectively, p = 0.14. The score for the peristomal problems was as high as 90.00 +/- 16.12. There was no difference in the cumulative gender specific indicators for both sexes, which showed the value 72.50 +/- 44.35 at non-ostomates and 63.64 +/- 50.45 at ostomates (p = 0.31). None of the patients regarded the chemotherapy problem as a factor diminishing the quality of their life. After calculating the total of all above mentioned functional parameters the score for non-ostomates results 82.50 +/- 19.83, and that of ostomates results 88.60 +/- 8.48, what is about the same, p = 0.12. The cumulative score of the two groups concerning emotional indicators did not really differ (non ostomates 78.69 +/- 24.19, ostomates 84.95 +/- 12.08, p = 0.11). The total cumulative scores among the groups did not show significant difference (non-ostomates 81.67 +/- 31.48, ostomates 87.12 +/- 16.40, p = 0.27). The global QoL was high in both groups with no significant difference among non-ostomates and ostomates (82.00 +/- 24.86 versus 88.60 +/- 8.48, respectively, p = 0.12). CONCLUSION: The quality of life of all patients was poorer than it was prior to the onset of the disease, but most of them could return to their prior way of living with not too many compromises. This process can be well monitored with our score system.

Ano-rectal physiological changes after rubber band ligation and closed haemorrhoidectomy.

OBJECTIVE: The effect of treatment for haemorrhoids on ano-rectal physiology was studied in a prospective longitudinal follow-up study. METHODS: Thirty-six consecutive patients having II-III degree (Group I, 18 patients) or IV degree (Group II, 18 patients) haemorrhoids were studied. Group I underwent rubber band ligation while Group II underwent closed scissors haemorrhoidectomy. RESULTS: Patients in Group I had significantly lower maximum basal pressure (P < 0.05) and also significantly lower maximum squeeze pressure (P < 0.05) compared to Group II before treatment. Both basal and squeeze pressures dropped after haemorrhoidectomy (P < 0.001) whereas they remained unchanged after rubber band ligation (P > 0.1). The volume of first sensation was higher in Group II before treatment (P < 0.001) and remained so after treatment. Rectal compliance was higher (P < 0.005) in Group I before treatment. It increased significantly in both groups (P < 0.05, Group I; P < 0.001, Group II) after treatment. CONCLUSIONS: The results show a significant increase in anal pressures in constantly prolapsing (IV degree) haemorrhoids. Most of the physiological differences observed between the two groups were abolished after treatment. This suggests that these may be a consequence rather than a cause of haemorrhoids.

[Acute pancreatitis with few symptoms and extensive necrosis]. / Akut pancreatitis tünetszegény, kiterjedt, távoli necrosisokkal.

The authors present a particular case of an acute pancreatitis. The disease developed in a young male patient following cholelithiasis and cholecystectomy. The inflammation affected the outer layers of the pancreas as a mantle and it caused widespread fat necrosis. Necrectomy for septic state was conducted to improve the condition, but the patient died of pulmonary embolism. Unexpectedly big necrotic areas of fat necrosis and abscess were found at autopsy.

GRP-receptor-mediated signal transduction, gene expression and DNA synthesis in the human pancreatic adenocarcinoma cell line HPAF.

Bombesin-like peptides have been implicated as growth factors in various human cancers. Human adenocarcinoma cell lines (Capan-1, Capan-2, MiaPaCa-2 and HPAF) were tested to determine whether they express the gastrin-releasing peptide-preferring bombesin receptor (GRPR) and neuromedin B-preferring bombesin receptor (NMBR). Using RT-PCR the highest level of GRP receptor mRNA was found in HPAF cells. NMB receptor mRNA expression moderate in all cell lines investigated. We therefore selected the HPAF cell line to investigate whether bombesin treatment affects intracellular Ca(2+) ([Ca(2+)](i)), cAMP level, DNA synthesis as a measure of cell proliferation, and expression of three transcription factors: c-fos, c-myc and high mobility group protein IY (HMG-I(Y)).Bombesin administration led to an immediate increase in free intracellular Ca(2+) concentration ([Ca(2+)](i)) but did not change cAMP levels. The peptide also enhanced [(3)H]thymidine incorporation in HPAF cells (but not in the other cell lines), an effect that was concentration dependent, reaching 36 +/- 5% stimulation over control values at 24 h with an EC(50) of 2.27 x 10(-12) M. Furthermore, bombesin stimulated c-fos, c-myc and HMG-I(Y) expression in a time-dependent manner: the c-fos mRNA level increased dramatically in the first 30 min of exposure, then returned to basal level within 2 h, while the c-myc and HMG-I(Y) mRNA levels peaked at 2 h and 4h, respectively. All actions of bombesin were blocked by BME (D-Phe(6)-bombesin-(6-13)-methylester), a selective GRP receptor antagonist, but not by the NMB receptor antagonist BIM-23127 (D-Nal-cyclo[Cys-Tyr-D-Trp-Orn-Val-Cys]-Nal-NH(2)). We conclude that HPAF cells express mRNA for GRP receptors and that functional receptors are present in the cell membrane. The occupation of these receptors leads to a sequence of intracellular events involving rapid mobilization of intracellular Ca(2+), expression of c-fos, c-myc and HMG-I(Y) mRNA, and stimulation of cell proliferation. Conversely, although NMB receptor mRNA can be detected, its actual translation to functional receptors does not reach a detectable level.

Resection in chronic pancreatitis: anastomosis with the jejunum or with the stomach?

Even in centers where the first choice in the surgical treatment of chronic pancreatitis is a derivative procedure some selected patients require resection. The most popular solution of gastrointestinal reconstruction still seems to be pancreaticojejunostomy but, the review of the reported experiences, suggests a general trend towards anastomosis with the stomach as a recent policy. A reliable comparison between pancreaticogastrostomy and pancreaticojejunostomy is difficult because the reported series are seldom related to chronic pancreatitis patients only, but are reporting mixed date concerning mainly periampullary cancer. Moreover with only one exception no prospective randomised clinical trails are available; unfortunately the positive trend in favour of pancreaticogastrostomy reported in uncontrolled studies is not confirmed in the randomized setting. Also the comparison between the experiences achieved by the present authors working in centers with different approach to the pancreatic anastomosis does not show statistical significant difference for both morbidity and mortality. In conclusion nowadays the best confidence and experience with any of the two methods represents the basis of choice.

Inhibitory effect of a long-acting somatostatin analogue on EGF-stimulated cell proliferation in Capan-2 cells.

Numerous studies have reported diverse effects of gut-derived regulatory peptides on growth of the normal pancreas, pancreatic neoplasms induced experimentally in animals, and pancreatic cancer cell lines, but the results of these investigations are rather controversial. The stimulatory effect of epidermal growth factor (EGF) on cell proliferation of pancreatic cell lines is well established. Whether this action can be modulated by somatostatin is not clear. Furthermore, it is not certain whether another regulatory peptide, cholecystokinin (CCK), affects the proliferation of these cells. In the present study we investigated the presence of CCK-A and CCK-B, as well as somatostatin-2 (SSTR2) receptors by RT-PCR, and studied the actions of EGF, CCK and octreotide on DNA synthesis in the human pancreatic adenocarcinoma cell line Capan-2. Octreotide, a long-acting somatostatin analogue was used as somatostatin agonist. Cells were cultured in RPMI-1640 medium. They were incubated in serum free medium containing 0.2% BSA in the absence (control) or the presence of the peptides. [3H]-thymidine incorporation into DNA was measured after 48 h of incubation. By means of RT-PCR analysis we were able to demonstrate SSTR2 expression, but not CCK-A or CCK-B receptor mRNA in Capan-2 cells. DNA synthesis evaluated by [3H]-thymidine incorporation was found to be increased by 45.2 +/- 5.6% in response to EGF (10(-8) M) and decreased by 11.7 +/- 2.6% to octreotide (10(-8) M) compared to controls (P < 0.01). The increase in [3H]-thymidine incorporation was significantly lower when EGF treatment was combined with octreotide administration (10.1 +/- 2.5% over control). In the concentration range of 10(-11)-10(-8) M, CCK did not alter significantly the incorporation of [3H]-thymidine into DNA in Capan-2 cells. In conclusion, these data support a role for EGF as a growth factor for the human pancreatic cancer cell Capan-2. Somatostatin may play an important role in regulating cell proliferation in Capan-2 cells both under basal, and growth factor-stimulated conditions. Our results suggest, however, that CCK receptors are not expressed, and CCK does not affect cell proliferation in this transformed pancreatic cell line.

[A case of retroperitoneal pancreatic abscess spreading to the femoral region]. / A femoralis régióra terjedó retroperitonealis pancreatogen abscessus.

Authors report the case of a 47 years old male patient with acute femoral abscess. The examinations made with urgency found proceeding acute pancreatitis, fluid collection in the right pleural cavity, exceeding fluid collections in the retroperitoneum and right paracolic region. The inflammatory infiltrate and collection in the upper third of the right thing seemed to be in connection with the proceeding pancreatitis. Because of the process endangering also the viability of the limb and severe septic state, an acute operation was performed, in the course of which extension of the retroperitoneal abscess to the thing was observed. After abdominal oncotomy expanded to thigh and inguinal region, lavage, drainage operations, therapy with wide spectrum followed by aimed antibiotics general condition of the patient improved. On the 18 postoperative day a new feverish state manifested. Image forming examinations showed newer purulent collections in the abdominal cavity and on the thigh in addition to the previous abscesses. Because of this repeated exposure was necessary. After the second operation the patient recovered without complaint and further complications. Authors think the case worth attention because of the extensive and unusual localization of abscesses formed beside the relatively discrete abdominal complaints.

Pancreatic head mass: what can be done? Classification: the clinical point of view.

Surgeons frequently find pancreatic head mass when operating. The obvious difficulty is to make the correct preoperative differential diagnosis between chronic pancreatitis and pancreatic tumor. The first step is to reach a diagnosis, with some certainty, prior to the operation. The second step in the case of a tumor is the accurate staging and deciding whether or not it is resectable. On the one hand, time and cost must be considered; on the other hand, the therapy must be decided. Obtaining information about the characteristics of the pancreatic disease (nature, size, exact location) and establishing the tissue diagnosis preoperatively may simplify the decision to operate and the operation itself. In the case of chronic pancreatitis, the aim of the operation is to eliminate pain and other symptoms, while in the case of cancer, the purpose is to remove the malignant tissue. In most patients, it is possible to identify the disease on the basis of previous examinations together with preoperative diagnostic techniques such as exploration, palpation and fine-needle aspiration biopsy. Chronic pancreatic head mass should be operated upon with Beger s or Frey s procedure while pancreatic head tumors should be treated by means of head resection with the aim of preserving the pylorus or the Whipple procedure may be used. When the diagnosis is in doubt, a radical approach is thought to be best. Our conclusion is that there is no diagnostic method capable of making a definitive differential diagnosis as to the nature of the pancreatic head mass. Further study is required as to the extent to which differential diagnosis should be investigated.

Pancreatic head mass: how can we treat it? Tumor: surgical treatment.

Pancreatic carcinoma is a devastating disease. Untreated 5-year survival is 0%. The only possibility of being cured is given by surgical removal of the tumor. Pancreatoduodenectomy previously involved high morbidity and mortality rates until it was postulated that palliation gave better results. Today, morbidity and mortality rates have been decreased to an acceptable level, mortality rates in specialized centers being under 5%. Prognostic factors determining survival were found to be the size of the tumor, grade, lymph node involvement and stage. In order to be able to compare results of the different centers, standardization of the surgical technique is mandatory. It is unanimously accepted that in order to improve survival in pancreatic carcinoma, the radicality of the surgical procedure should be increased to include lymphadenectomy. Postoperative adjuvant therapy could also be a determinant factor. Prospective randomized clinical trials will give an answer to these still unanswered questions.

[Antibiotic prophylaxis for high risk patients undergoing cholecystectomy]. / Fokozott kockázatú epemútétek antibiotikum profilaxisa.

An open, randomised clinical trial was performed on 435 high risk patients who underwent open cholecystectomy between 1 = January 1993. and 31. December 1995. The patients were divided into three groups. Group 1 (AMOX/CLAV, N = 179) was treated with 1.2 g i.v. amoxicillin/clavulanic acid, the patients in Group 2 (COMPARATOR, N = 164) were given other antibiotics commonly used for prophylaxis in biliary surgery (cefamandole, cefuroxime, cefotaxim). Group 3 (CONTROL, N = 92) contained patients without any risk factors for infectious complication. In this group we did not use antibiotic prophylaxis. The results were analysed with Student t, and x2 methods. The wound infection rate in Group 1 was 2.76% versus 5.48% in Group 2. The difference was significant if the patients were older than 65 years or the preoperative hospitalisation was longer than 5 days. The concentration of amoxycillin/calavulanic acid was measured in the serum, in the wall of the gall bladder, in the bile obtained both from the gall bladder and the major bile duct. The observed levels were higher than the therapeutic concentration in the serum and in the bile gained from the major bile duct, whereas lower in the gall bladder wall, and in the bile gained from the gall bladder. Systemic antibiotic prophylaxis is required for open cholecystectomy in high risk patients.

The laparoscopic treatment of non-parasitic liver cysts. Five years experience.

The incidence of cystic liver lesions seems to be more frequent as previously suggested. The treatment of symptomatic non-parasitic cysts is controversial. Ultrasonography (US) or computer tomography (CT) guided drainage and/or sclerotization versus surgical fenestration or partial resection, even liver resection has been advocated. Recently with the development of laparoscopic surgery this minimal invasive approach was also applied in the surgical treatment of single or multiple cystic lesions. Between 1994 and April 1999 21 patients with non-parasitic cysts were treated by laparoscopic fenestration or partial resection at the 1st Department of Surgery, Semmelweis University of Medicine. In 13 cases the symptomatic cyst presented the indication for surgery, while in the others cholelithiasis and GERD was the primary cause of intervention in 7 and 1 patient respectively. There were 16 woman and 5 men with a mean age of 42.3 years (17-78). The cyst was solitary in 17 cases and multiple 3-6-number in four patients. The size varied between 1.5-25 cm (average 7.2 cm). Patients were selected for the laparoscopic approach according to the US and/or CT appearance and superficial localization of the cyst. Wide unroofing or partial resection of the cyst wall till the margin of normal liver tissue was performed in all cases. The cystic cavity was drained. All operations were completed laparoscopically. Intraoperative complication did not occur. Bleeding from the resected margin could be well controlled by electrocautery or clipping. Patients left the ward after the drains were removed on postoperative day 2-4 depending upon the amount of serious discharge. No complication was observed postoperatively. During the average of 12.5 months (1 to 54 months) follow-up of 19 patients no recurrence was observed. Two patients required reoperation. In one 17 year old male patient cystadenocarcinoma was verified by histology, upon reoperation the lesion was found unresectable. In another case left hemi-hepatectomy was performed because of cyst recurrence caused by cholangiocell adenoma. In selected cases of superficially located symptomatic, non-parasitic cysts the laparoscopic fenestration might be the first choice of treatment. The method is safe and effective in the hands of surgeons experienced in both laparoscopic and liver surgery. Careful exploration of the cystic cavity and histological examination of the resected cyst wall is mandatory to avoid diagnostic mishaps.

Pain relief and functional recovery after endoscopic interventions for chronic pancreatitis.

BACKGROUND: Pain and functional deterioration in chronic pancreatitis is multifactorial. Early surgery in non-alcoholic patients with mild to moderate chronic pancreatitis can relieve pain and prevent progression of pancreatic insufficiency for some time, but the good results are only short term. Endoscopic intervention can relieve pain and recover pancreatic function without surgery. METHODS AND RESULTS: To achieve the burned out state of chronic pancreatitis, occlusion of the pancreatic duct was first attempted by our team with Ethibloc at ERCP. Temporary obstruction of the pancreatic duct did not result in a long-lasting symptom and relapse-free situation because of early recovery of pancreatic function. On the contrary, endoscopic simple and double papillotomy, pancreatic drainage with citrate lavage, biliary endoprosthesis with multiple stents and endoscopic decompression of pseudocysts with or without jejunal feeding resulted in pain-free patients for a considerable time and in several cases significant functional recovery occurred. In cases where pain remained, percutaneous celiac plexus block with long-lasting steroids can be applied and only if all of these treatments fail should surgery be recommended. CONCLUSION: Endoscopic intervention can successfully substitute for surgery for chronic pancreatitis in individual cases.

Pancreatic leiomyosarcoma. Case report with immunohistochemical and flow cytometric studies.

A leiomyosarcoma originating from the pancreas of a 57-year-old man is presented. A 6x5x4 cm tumour was located in the head region, and the patient underwent surgical palliation. Immunohistochemical studies excluded an epithelial origin; a myogenic origin was suggested by strong vimentin and smooth muscle actin positivity. Flow cytometric analysis revealed an aneuploid pattern (DNA index: 1,561). The patient died with widespread metastases 7 month after the operation.

[A case of unusual complication of diaphragmatic herniation of transverse colon following transhiatal esophagectomy]. / Colon transversum mellkasi herniatiójának esete transhiatalis oesophagectomia ritka szövödményeként.

The authors report a rare complication observed after transhiatal esophagus extirpation performed for esophageal cancer. In this case the transverse colon herniated into the pleural cavity through the esophageal hiatus. Herniation completed on the 6.th. postoperative day and caused mechanical ileus. In the first few postoperative days, radiology pointed to a basal pulmonal infiltrate, later it resembled relaxation of the diaphragm, which was rather misleading. Recognition of the real situation was possible only on the 6.th.postoperative day. The patient was reoperated and the pathological state could be reversed. The esophageal hiatus was reconstructed. In the opinion of the authors the complication may have developed partly due to the opening of the left pleural cavity in the course of extrathoracal esophagectomy, and partly to the fact that the spleen was removed during operation. The outcome after reoperation was uneventful. The authors consider this as a rather rare and instructive case.

[Tumors of the papilla of Vater--diagnostic and therapeutic dilemmas]. / A Vater-papilla tumoros megbetegedései--diagnosztikus és terápiás dilemmák.

Benign and malignant tumors of papilla Vateri are rare diagnoses in the endoscopic practice. Sixteen patients with benign and 22 cases of malignant tumors are presented. In all of them endoscopic cholangiopancreatography with or without papillotomy followed by biopsy and operation in 13 cases was performed. Biopsy confirmed the endoscopy in 71%. Adenomyosis, supposed by endoscopy was proved by repeated histology in only 2/9 cases although invasive component of the tumor was found in 3/9 patients at operation underlying precancerous nature of this entity. Among 5 cases of villous adenoma one developed malignant alterations during 4 years of follow-up. Biopsy was not more effective after papillotomy than without it, and 5-7 days of delay for recovery of thermic lesion did not ameliorate success rate of histology. For malignant diseases surgical therapy should be considered if staging of tumor and general condition of the patient permits. In unresectable cases endoscopic palliation (papillotomy or polypectomy with or without drainage) can increase survival. In patients with benign tumors operative endoscopy followed by regular ultra-sonography and endoscopy seems to be necessary.

[Risk factors of infected pancreatic necrosis, its microbiology and antibiotic treatment]. / A fertözödött pancreasnecrosis kockázati tényezöi, mikrobiológiája és antibiotikus kezelése.

Acute pancreatitis is associated with greater and smaller necrosis in 20% of the cases. The lethality rate of sterile and infected necrosis is 10 and 15-40%, respectively. The results of a retrospective and a prospective study in acute pancreatitis have been analyzed in this study. Twenty patients suffering from infected necrosis due to acute necrotising pancreatitis were selected into the retrospective study. They were divided into two groups: Group 1 (N = 10) survivors, Group 2 (N = 10) those who died. The fate of patients was determined by their age, the severity of pancreatitis, and the effectiveness of the operation. In a prospective study 63 patients were operated due to benign pancreatic disease with fluid collection. Microbiological samples were taken during surgery in every case. It could be stated that the Enterobacteriaceae spp. play the principal role in the infection, and the anaerobic bacteria occur sporadically. The omission of bacteriological sample taking during surgery frustrates the targeted antibiotic treatment. The blood culturing may have useful contribution. The targeted antibiotic therapy based on relevant microbiological sample taking is substantial complementary of the surgical intervention in the treatment of the inflammatory pancreatic diseases.

Helicobacter pylori and congestive gastropathy.

This study evaluates the prevalence and significance of Helicobacter pylori (H. Pylori) infection in patients with portal hypertension. 118 patients were selected, i. e. 90 patients with portal hypertension (66 males, 24 females, mean age 49.1 +/- 2.1 years) and 28 noncirrhotic patients with nonulcerative dyspepsia as a control group (twelve males, 16 females, mean age 47.6 +/- 2.8 years). In all patients diagnostic upper endoscopy was performed and gastric biopsies were taken for histological examination and diagnosis of H. pylori infection. Of the portal hypertensive patients, 42 patients (47%) had congestive gastropathy, eleven (26%) of whom were positive for H. pylori infection and 48 (53%) did not have gastropathy, twelve (25%) of whom were positive for H. pylori infection. In the control group, 15 of 28 (54%) were positive for H. pylori infection. H. pylori was found less frequently in congestive gastropathy patients than in the control group. We found also that the presence and severity of congestive gastropathy is independent of the H. pylori status. We conclude that the role of H. pylori infection in the pathogenesis of congestive gastropathy seems to be unlikely and we suggest that there is no need for its routine eradication in cirrhotic patients.

In vitro amylase release of preserved pancreas: a simple test to assess the viability of pancreatic allograft during preservation in the pigs.

To determine an in vitro marker of viability during pancreatic preservation, 12 pigs underwent total pancreas harvesting, and graft were stored in Euro-Collins or Belzer perfusion solution for up to 24 hours. Amylase concentration of the storage solution was analyzed in regular periods and tissue samples were taken for acridine-orange histochemical evaluation of viability in the same time. In vitro pancreatic amylase release (IU/g pancreas tissue) was calculated from the volume of solution and the weight of graft. A significant increase of amylase release was found in the course of preservation in both media. Comparing amylase release in different solutions we found significant difference between Euro-Collins and Belzer media (4 hours: 6.45 IU/g vs. 2.2 IU/g, 8 hours: 11.5 vs. 3.58, 24 hours: 8.7 vs. 42.8, respectively). Comparison of amylase release with histochemical evaluation of viability showed strict correlation. We concluded that amylase release is a good marker for exocrine tissue destruction as well as viability of preserved pancreas. Our data confirms that Belzer solution is superior in pancreatic preservation. It is suggested that after adaptation into human model in vitro pancreatic amylase release could be a time- and cost-saving, useful method in predicting pancreatic transplant function prior graft implantation.