József Bátorfi

Human chorionic gonadotropin follow-up in patients with molar pregnancy: a time for reevaluation ☆

OBJECTIVE To determine how often patients with molar pregnancy do not complete recommended follow-up and to identify factors that may predict failure to complete human chorionic gonadotropin (hCG) monitoring. This study also sought to determine how often patients with molar pregnancy who do not complete follow-up relapse after attaining at least one undetectable hCG value. METHODS Four hundred randomly selected patients with molar pregnancy were analyzed regarding the serum hCG levels after molar evacuation. Demographic factors were determined for each patient: age, marital status, gravidity, parity, health insurance type, and distance from patient residence to trophoblastic center. RESULTS Recommended hCG follow-up was completed in 63% of the uncomplicated 333 cases (n = 211). Three hundred twenty patients achieved at least one undetectable serum hCG level. Among the 320 patients, 33% achieved undetectable hCG values but did not complete recommended follow-up. However, none had any evidence of relapse. A distance of greater than 20 miles from the patients residence to our center was associated with failure to complete hCG follow-up (P = .001). CONCLUSION Because none of the 320 patients who achieved at least one undetectable hCG level has been diagnosed with gestational trophoblastic tumor relapse, it may be appropriate to reassess the duration of hCG monitoring for patients with molar pregnancy.

Unexpected gallbladder cancer and laparoscopic surgery

Case histories of three patients who underwent laparoscopic cholecystectomy for unexpected gallbladder cancer are reviewed. Port-site recurrence was observed in two of them. In one patient whose abdominal wall recurrent tumor was excised, a new recurrence developed, but after the reexcision she is symptom-free 10 months after the last procedure. The surgeon has to be aware of the fact that the survival rate can be doubled in stage pT2 if cholecystectomy is followed by extended radical operation. Only gallbladder cancer in stage pT1 does not need further procedure, except for excision of port sites. In case of uncertain diagnosis preoperative frozen section is recommended. Port-site recurrence does not mean an incurable stage of the disease or a sign of diffuse metastases. Even after reexcision of abdominal wall metastasis patients might be free from other detectable recurrences.

How long should patients be followed after molar pregnancy? Analysis of serum hCG follow-up data.

Abstract Objective : We analyzed human chorionic gonadotropin (hCG) follow-up data of patients with molar pregnancy. Women often do not complete recommended post-disease screening. Our purpose was to determine if continuing follow up of uncomplicated molar cases beyond attaining undetectable hCG levels is necessary for detecting relapse of gestational trophoblastic disease. Study design : One hundred fifty patients treated at Hungarian National Health Center were analyzed. Those who developed persistent disease before hCG had become undetectable were excluded from further analysis ( n =24; 16%). Results : Among 126 uncomplicated cases, 72 patients (57%) completed follow up, and 54 (43%) discontinued their protocol before it had been completed. Of 120 patients who achieved at least one undetectable hCG level, none had any evidence of relapse. Conclusion : In uncomplicated hydatidiform mole, our analysis indicates that once undetectable serum hCG levels are attained, relapse is unlikely. Although further monthly checks are advisable, the likelihood of recurrence appears very low.

Alloimmune and autoimmune background in recurrent pregnancy loss - successful immunotherapy by intravenous immunoglobulin.

Immunotherapies [leukocyte immunization, intravenous immunoglobulin (IVIG)] introduced to treat women with recurrent spontaneous abortions (RSA) have still controversial results in most clinical trials. A selection of these patients would be advantageous for higher efficacy.

Osteopontin is down-regulated in hydatidiform mole

OBJECTIVE Osteopontin (OPN) is a glycoprotein of the extracellular matrix that can bind to different types of receptors including integrins and CD44 receptors. Multiple binding affinity enables OPN to play a role in many physiological and pathological processes. OPN contributes to tumorigenesis in several types of cancers. OPN is also expressed by the endometrium and by trophoblast cells of the chorionic villus in human placenta, where OPN may regulate implantation and placentation in early pregnancies by promoting cell-cell interactions, adhesion, spreading, and migration of trophoblast. Our purpose was to determine the expression of OPN mRNA and protein in hydatidiform mole and in normal placenta of comparable gestational age. METHODS A total of 13 fresh tissues from complete hydatidiform moles, 2 from partial hydatidiform moles, and 9 from normal placentas were analyzed by performing quantitative real-time PCR on microdissected trophoblast cells and immunohistochemistry on frozen sections of tissue. RESULTS Our results showed significantly lower expression of OPN mRNA and protein in hydatidiform mole, and in particular complete mole (P = 0.001 by real-time PCR and P < 0.001 by immunohistochemistry) as compared to nermal placenta. CONCLUSION Although precise molecular mechanisms of gestational trophoblastic diseases have not yet been determined, down-regulation of osteopontin may play an important role in the pathogenesis of molar pregnancy.

Which endovenous ablation method does offer a better long-term technical success in the treatment of the incompetent great saphenous vein? Review.

Objective The aim of this review article was to evaluate the long-term technical success rates of the known endovenous ablation procedures in the treatment of the incompetence of the great saphenous vein. Methods A literature search was conducted in the PubMed-database until the 5 January 2016. All publications with four to five years follow-up were eligible. Meta-analysis was performed by the IVhet-model. Results Eight hundred and sixty-two unique publications were found; 17 of them were appropriate for meta-analysis. Overall, 1420 limbs were included in the trial, 939 for endovenous laser ablation, 353 for radiofrequency ablation and 128 for ultrasound guided foam sclerotherapy. Overall, technical success rates were 84.8% for endovenous laser ablation, 88.7% for radiofrequency ablation and 32.8% for ultrasound guided foam sclerotherapy. There were no significant differences between endovenous laser ablation, radiofrequency ablation and ultrasound guided foam sclerotherapy regarding the great saphenous vein reopening (p = 0.66; OR: 0.22; 95% of CI: 0.08–0.62 for radiofrequency ablation vs. endovenous laser ablation; p = 0.96; OR: 0.11; 95% of CI: 0.06–0.20 for endovenous laser ablation vs. ultrasound guided foam sclerotherapy; p = 0.93; OR: 3.20; 95% of CI: 0.54–18.90 for ultrasound guided foam sclerotherapy vs. radiofrequency ablation). Conclusion Both endovenous laser ablation and radiofrequency ablation are efficient in great saphenous vein occlusion on the long term. Lacking long-conducted large trials, the efficacy and reliability of ultrasound guided foam sclerotherapy to treat great saphenous vein-reflux is not affirmed.

How Long Should Patients Be Followed After Molar Pregnancy? Analysis of Serum hCG Follow-Up Data

OBJECTIVE We analyzed human chorionic gonadotropin (hCG) follow-up data of patients with molar pregnancy. Women often do not complete recommended post-disease screening. Our purpose was to determine if continuing follow up of uncomplicated molar cases beyond attaining undetectable hCG levels is necessary for detecting relapse of gestational trophoblastic disease. STUDY DESIGN One hundred fifty patients treated at Hungarian National Health Center were analyzed. Those who developed persistent disease before hCG had become undetectable were excluded from further analysis (n=24; 16%). RESULTS Among 126 uncomplicated cases, 72 patients (57%) completed follow up, and 54 (43%) discontinued their protocol before it had been completed. Of 120 patients who achieved at least one undetectable hCG level, none had any evidence of relapse. CONCLUSION In uncomplicated hydatidiform mole, our analysis indicates that once undetectable serum hCG levels are attained, relapse is unlikely. Although further monthly checks are advisable, the likelihood of recurrence appears very low.

Long-Term Clinical Results of Highly Selective Vagotomy Performed Between 1980 and 1990

A retrospective analysis was conducted of 778 patients who underwent highly selective vagotomy between 1980 and 1990. Surgery was performed for duodenal ulcers without any complications in 485 (62.3%) patients; for duodenal ulcers with complications such as stenosis, bleeding, or perforation in 270 (34.7%); for combined duodenal and ventricular ulcers in 12 (1.5%), and for ventricular ulcers alone in 11 (1.4%). Pyloroplasty was additionally performed in the presence of complications only. The incidence of intraoperative complications proved to be as high as 1.4%, occurring in 11 patients, while postoperative complications developed in 247 patients (31.7%). Although the overall mortality was 0.6% (5 patients), the mortality rate of those patients who underwent surgery for uncomplicated ulcer disease was 0.2% only (2 patients). The patients comprised 554 men (71.2%) and 224 women (28.8%) with an average age of 41.4±0.7 years. The average duration of duodenal ulcer disease was 9.5 years, and 643 (83.2%) of the patients were able to be regularly followed up for between 3 and 13 years. Recurrence developed in 62 patients (9.6%): in the duodenum in 57 patients (91.9%), and in the stomach in 5 (8.1%). The rate of recurrence according to sex was 9.4% in men and 10.3% in women, being 42 and 20 patients, respectively. The average duration until recurrence appeared was 27.06±3.44 months. A reoperation proved necessary in 28 of these 62 patients (45.1%). The clinical results were evaluated by means of a modified Visick classification, according to which 81.8% of the patients belonged to groups 1 or 2, 7.9% to group 3, and 10.3% to group 4.

Fluorescence in situ hybridization of chorionic interphase cells for prenatal screening of Down syndrome

OBJECTIVE Our purpose was to determine the usefulness and reliability of fluorescence in situ hybridization on interphase chorionic villi cells in the prenatal diagnosis of Down syndrome. METHODS A total of 336 samples of chorionic villi were analysed by direct chromosome preparation and FISH with a DNA probe specific to chromosome 21. The samples were obtained as part of the routine obstetric investigation and management. RESULTS The sampling and direct karyotyping was successful in all cases. At least 50 cells were valuable by FISH in 331 of 336 samples. Both methods showed Down syndrome in 12 cases. The follow-up investigations showed that there was no false-negative or false-positive result following these procedures. CONCLUSION Based on these results and the fact that it is possible to analyse by interphase FISH at least ten times more cells than by conventional cytogenetic methods, and these cells originate from different tissues of chorionic villi, it is concluded that FISH increases the reliability of the diagnosis. Nevertheless, more data are needed for correct statistical analysis. Since this method is cheaper and gives diagnosis earlier than cell culture, the combination of direct chromosome preparation and FISH on chorionic villi is offered for prenatal Down syndrome screening.

Intraabdominal abscess managed successfully via the laparoscopic approach.

A rare complication of laparoscopic fundoplication-an intraabdominal abscess located between the fundus and the caudate lobe of the liver-is described. A 41-year-old man had undergone a laparoscopic Nissen-Rossetti fundoplication for longstanding gastroesophageal reflux disease. On the 5th postoperative day, the patients general condition became worse, and he developed intermittent-remittent fever (40 degrees C), an elevated white blood cell count (WBC), and an accelerated sedimentation rate. Evidence of leakage was excluded by Gastrografin swallow. The diagnosis was finally revealed by means of ultrasound and computed tomography (CT) scan, which showed an intraabdominal fluid collection with an air cap of ~10 cm in diameter situated between the diaphragmatic crura, the caudate lobe of the liver, and the gastric fundus. The location did not allow semi-invasive management of the abscess, such as ultrasound or CT-guided puncture and drainage. On the 8th postoperative day, a laparoscopic exploration was performed utilizing the previous port sites. The adhesions were easily dissected, and evacuation of ~300 ml of white, dense fluid, and lavage and drainage were performed without intraabdominal dissemination of pus. The patient was discharged on the 12th postoperative day free of symptoms. Microbiological examination of the pus showed the presence of Peptostreptococcus. The patient remained symptom free. At 8 weeks postoperatively, barium swallow, endoscopy, 24-h pH monitoring, and stationary manometry of the esophagus yielded normal results. Because there was no direct evidence of leakage at the fundus, the development of the abscess was concluded to be due to the use of deep transmucosal stitches rather than seromuscular ones to create the wrap. The nonabsorbable multifilament suture material passing through the entire gastric wall could have facilitated bacterial contamination of the operative field.