Michal Lesko

Epidermal Growth Factor Receptor as a Predictor of Tumor Response to Preoperative Chemoradiation in Locally Advanced Gastric Carcinoma

Purpose:The purpose of our study was a retrospective evaluation whether the intensity of epidermal growth factor receptor (EGFR) expression predicts tumor response to preoperative chemoradiotherapy in patients with locally advanced gastric carcinoma.Patients and Methods:Thirty-six patients with gastric adenocarcinoma (cT2–4 or N+) were studied. Preoperative treatment consisted of 30–45 Gy of gastric irradiation with continuous 5-fluorouracil and weekly cisplatin. Surgical resection was performed 4–6 weeks later. EGFR expression in pretreatment tumor biopsies was assessed by immunohistochemistry. Level of EGFR expression was determined from the intensity and extent of staining. Tumor response was defined as a reduction of at least one T-stage level and/or finding of intense tumor regression in histopathologic examination.Results:Seventeen patients responded to preoperative chemoradiation – 8 patients (22%) had pathologic complete response, 9 patients (25%) were downstaged. Positive EGFR expression was found in 8 tumors (22%), and represented a significant predictive marker of poor tumor response in multivariate logistic regression analysis (p = 0.015). Response to chemoradiotherapy was found in 60% (16/28) of EGFR negative patients and in 13% (1/8) of EGFR positive patients (p = 0.044). None of the eight EGFR positive patients achieved pathologic complete response in comparison with 8/28 (29%) of patients with EGFR negative staining (p = 0.16).Conclusion:EGFR may represent a molecular marker predictive for poor response to preoperative chemoradiotherapy in locally advanced gastric carcinoma.Ziel:Ziel dieser Studie war eine retrospektive Evaluierung, ob die Expressionsintensität des epidermalen Wachstumsfaktor-Rezeptors (EGFR) die Tumorantwort auf präoperative Chemoradiotherapie vorhersagt bei Patienten mit lokal fortgeschrittenem Magenkrebs.Patienten und Methodik:36 Patienten mit Adenokarzinom des Magens (cT2–4 oder N+) wurden untersucht. Die präoperative Behandlung bestand aus einer Bestrahlung des Magens mit 30–45 Gy mit fortlaufendem 5-Fluorouracil und wöchentlichem Cisplatin. Die operative Resektion wurde 4–6 Wochen später durchgeführt. Die Expression des EGFR in den vorbehandelten Biopsiepräparaten des Tumors wurde mittels Immunhistochemie gemessen. Die Höhe der EGFR-Expression wurde festgelegt nach der Intensität und dem Ausmaß der Färbung. Das Downstaging wurde definiert als eine Reduktion von mindestens einem T-Stadium und/oder einem Befund von Tumorregression in der histopathologischen Untersuchung.Ergebnisse:17 Patienten haben auf die präoperative Chemoradiotherapie angesprochen – 8 Patienten (22%) hatten eine pathologisch komplette Reaktion, 9 Patienten (25%) wurden „downgestaged“. Eine positive EGFR-Expression wurde in 8 Tumoren gefunden (22%), und stellte einen signifikanten Vorhersagefaktor dar für eine geringe Tumorantwort in multivariater logistischer Regressionsanalyse (p = 0,015). Eine Reaktion auf die Chemoradiotherapie wurde bei 60% (16/28) der EGFR-negativen Patienten festgestellt und bei 13% (1/8) der EGFR-positiven Patienten (p = 0,044). Keiner der 8 EGFR-positiven Patienten erreichte eine pathologisch komplette Reaktion im Vergleich zu 8/28 (29%) der Patienten mit EGFR-negativer Färbung (p = 0,16).Schlussfolgerung:Der EGFR stellt einen Vorhersagefaktor für eine geringe Reaktion auf die präoperative Chemoradiotherapie beim lokal fortgeschrittenen Magenkarzinom dar.

Juxtarenal aortic aneurysm: endoluminal transfemoral repair?

Endoluminal transfermoral repair of an abdominal aortic aneurysm by a stent graft placement requires a segment of the nondilated infrarenal aorta of at least 15 mm long for safe stent graft attachment. The possibility of endoluminal treatment of a juxtarenal abdominal aortic aneurysm with partially covered spiral Z stent was assessed in experiment and in three clinical cases. In the experiment, the noncovered spiral Z stent was placed into the abdominal aorta, across the origins of renal arteries and mesenteric arteries, in six dogs. In the clinical cases, a partially covered stent graft was attached in 3 patients with the juxtarenal abdominal aortic aneurysm (of the group of 12 patients with abdominal aortic aneurysm). The stent grafts were attached with proximal uncovered parts across the origins of the renal arteries. In experiment, the renal artery occlusions or stenoses were not observed 36 months after stent placement, and in clinic 3 patients with the juxtarenal aortic aneurysm were successfully treated by stent graft placement. There were no signs of flow impairment into the renal arteries 14 months after stent graft implantation. This approach can possibly expand the indications for endoluminal grafting in the treatment of juxtarenal aortic aneurysms in patients who are at high risk for surgery.

Laparoscopic Left Renal Vein Transposition for Nutcracker Syndrome.

The left renal vein (LRV) reimplantation into the distal inferior vena cava is considered to be the gold standard of care for symptomatic nutcracker syndrome (NCS). The vast majority of these surgical procedures are performed by open surgery. Experiences with minimally invasive laparoscopic surgery in this field are very limited. We present a case of a 17-year-old boy with NCS in whom the transposition of the LRV was done laparoscopically. The patient suffered from left flank pain, painful left-sided varicocele, microscopic hematuria, proteinuria, and oligoasthenospermia. There were no intraoperative complications, and the postoperative course was uneventful. At 12-month follow-up, hematuria, left flank pain, and left testicular pain resolved. Duplex ultrasonography revealed patent LRV. Laparoscopic LRV transposition appears to be safe, feasible, and has favorable postoperative course.

Emergent Carotid Thromboendarterectomy for Acute Symptomatic Occlusion of the Extracranial Internal Carotid Artery

Background: Strokes secondary to acute internal carotid artery (ICA) occlusion are associated with an extremely poor prognosis. The best treatment approach in this setting is still unknown. The aim of our study was to evaluate the efficacy, safety, and outcomes of emergent surgical revascularization of acute extracranial ICA occlusion in patients with minor to severe ischemic stroke. Methods: A retrospective analysis was performed using prospectively collected data of consecutive patients who underwent carotid thromboendarterectomy for symptomatic acute ICA occlusion during the period from January 2013 to December 2015. Primary outcomes were disability at 90 days assessed by the modified Rankin Scale (mRS) and neurological deficit at discharge assessed using the National Institute of Health Stroke Scale (NIHSS). Secondary outcomes were the recanalization rate, 30-day overall mortality, and any intracerebral bleeding. Results: During the study period, a total of 6 patients (5 men and 1 woman) with a median age of 64 years (range: 58-84 years) underwent emergent reconstruction for acute symptomatic ICA occlusion within a median of 5.4 hours (range: 2.9-12.0 hours) after symptoms onset. The median presenting NIHSS score was 10.5 points (range: 4-21). Before surgery, 4 patients (66.7%) had been treated by systemic recombinant tissue plasminogen activator lysis. The median time interval between initiation of intravenous thrombolysis and carotid thromboendarterectomy was 117.5 minutes (range: 65-140 minutes). Patency of the ICA was achieved in all patients. On discharge, the median NIHSS score was 2 points (range: 0-11 points). There was no postoperative intracerebral hemorrhage and zero 30-day mortality rate. At 3 months, 5 patients (83.3%) had a good clinical outcome (mRS ≤ 2). Conclusion: Patients presenting with minor to severe ischemic stroke syndromes due to isolated extracranial ICA occlusion may benefit from emergent carotid revascularization. Thorough preoperative neuroimaging is essential to aid in selecting eligible candidates for acute surgical intervention.

Integration of Endovascular Therapy of Ruptured Abdominal and Iliac Aneurysms in the Treatment Algorithm: A Single-Center Experience in a Medium-Volume Vascular Center

Purpose: To evaluate the influence of endovascular therapy of ruptured abdominal or iliac aneurysms on total mortality. Materials and Methods: We analyzed the mortality of 40 patients from 2005 to 2009, when only surgical treatment was available. These results were compared with the period 2010 to 2013, when endovascular aneurysm repair (EVAR) was assessed as the first option in selected patients. Results: During 2005 to 2009, the mortality was 37.5%. From 2010 to 2013, 45 patients were treated with mortality 28.9%. Open repair was performed in 35 (77.8%) patients and EVAR in 10 (22.2%) patients. The 30-day and 1-year mortality rates of the EVAR group were 0% and 20%, respectively, and the total mortality rate was 30% during follow-up (median 11 months, range 1-42 months). The 30-day mortality in the surgical group remained unchanged, at 37.1%, and 1-year and total mortality rates were 45.7% and 51.4%, respectively. Conclusion: Following integration in the treatment algorithm, EVAR decreased total mortality in our center by 8.6%.

One-step supraclavicular approach to the treatment of Dysphagia lusoria.

A one‐step supraclavicular approach for the surgical treatment of the aberrant right subclavian artery is described in a case of dysphagia lusoria in a 38‐year‐old female. The approach allows for safe division of the arteria lusoria and its re‐anastomosis to the common carotid artery while the patient benefits from a mini‐invasive extrathoracic procedure. doi: 10.1111/jocs.12287 (J Card Surg 2014;29:519–522)

Unrecognized post cholecystectomy segmental hepatic duct injury requiring right hemihepatectomy

ZusammenfassungGRUNDLAGEN: Die direkte Einmündung eines rechten Segmentgallengangs in den Ductus cysticus ist eine extrem seltene Variante des Gallengangsystems. Eine intraoperative Verletzung dieser Strukturen kann eine persistierende intraabdominale billäre Leckage verursachen. METHODIK: Wir berichten über den Fall einer 74-jährigen Patientin, der eine konventionelle Cholezystektomie bei symptomatischer Cholezystolithiasis zu teil wurde. Postoperativ traten Müdigkeit und Fieber auf. Die Oberbauchsonographie zeigte eine subhepatische Flüssigkeitsansammlung und die intrahepatischen Gallenwege stellten sich als nicht gestaut dar. ERGEBNISSE: Eine perkutane Drainage und röntgenologische Fisteldarstellung deckten die Verletzung des rechten Segmentgallengangs auf. Mittels ERCP konnte die Lokalisation der Verletzung verifiziert werden. Die explorative Laparotomie bestätigte die Diagnose. Der rechtseitige Gallengang, welcher Segment VI und VII drainiert, war verletzt und mündete direkt in den subhepatischen Abszess. Eine Hepatojejunostomie schien unsicher, so dass eine Hemihepatektomie rechts durchgeführt wurde. SCHLUSSFOLGERUNGEN: Leberteilresektion kann eine mögliche Therapieoption für ein streng selektioniertes Patientengut mit Verletzung der Gallenwege darstellen.SummaryBACKGROUND: Segmental right hepatic duct entering the cystic duct is an extremely rare anatomical variation of the biliary tree. Its transection during surgery can cause persistent intra-abdominal biliary leak. METHODS: We report a case of a 74-year old woman who underwent open cholecystectomy for symptomatic cholecystolithiasis. Fatigue and fever appeared postoperatively. Abdominal ultrasonography revealed a subhepatic fluid collection. Biliary tree dilatation was not observed. RESULTS: Percutaneous drainage and fistulography identified biliary injury of the segmental right hepatic duct. The ERCP clarified the localization of the injury. The segmental hepatic duct draining liver segments VI and VII was transected and entered directly into subhepatic abscess. Laparotomy confirmed the diagnosis. The right-sided hepatic duct for posterolateral liver segments entered hepatic abscess in the area of gallbladder bed. The hepatico-jejunostomy seemed to be unsafe and so the right hemihepatectomy was performed. CONCLUSIONS: Liver resection can present possible treatment option for highly selected patients with bile duct injuries.