Piotr Kulig

Non-curative gastrectomy for metastatic gastric cancer: Rationale and long-term outcome in multicenter settings

BACKGROUND Metastatic gastric cancer remains a significant problem as the majority of Western patients are diagnosed with disseminated disease and no routine therapeutic regimen is accepted in such cases. METHODS A cohort of 3141 patients with gastric cancer operated between 1990 and 2005 was evaluated using a multicenter data set held by the Polish Gastric Cancer Study Group to determine potential risks and benefits of non-curative gastrectomy for metastatic disease. Additionally, parameters of Quality of Life (QoL) were evaluated prospectively in 140 patients undergoing gastrectomy using the QLQ-C30 questionnaire. RESULTS Gastrectomy was carried out in 2258 patients. Distant organ metastases were diagnosed in 951 patients, 415 of which underwent non-curative gastrectomy. The overall mortality rates were significantly higher in patients undergoing non-resectional surgery (10%) than either curative (3%, P < 0.001) or non-curative (4%, P = 0.002) gastrectomy. The overall median survival in patients with metastatic disease was significantly higher for non-curative gastrectomy (10.6 months, 95% confidence interval (CI) 9.3-11.9) than for non-resective operations (4.4 months, 95% CI 4.0 to 4.8, P < 0.001). The hazard ratio of death in patients subject to non-resectional surgery compared to those treated by gastrectomy was 2.923 (95% CI 2.473 to 3.454, P < 0.001). A gradual impairment in QoL parameters was found over 12 months after non-curative resections but changes did not reach statistical significance and individual parameters were similar to gastrectomy without distant metastases. CONCLUSION Non-curative gastrectomy for metastatic gastric cancer is associated with significantly better survival compared to non-resective surgery and does not impair quality of life.

Targeted therapy for gastric cancer—current status

In patients with metastatic gastric cancer, median overall survival remains under 1 year and standard chemotherapy regimens are not able to substantially improve the prognosis of the patients. Amplification and over-expression of HER2 is reported in approximately 20% of gastric tumours, challenging the use of targeted therapies. There are several targeted therapies in different stages of clinical development with trastuzumab being the first overcoming the regulatory hurdle and getting European Medicines Agency approval. In patients with advanced gastric or gastro-oesophageal junction cancer, addition of trastuzumab to chemotherapy significantly improved overall survival compared with chemotherapy alone. Addition of trastuzumab to chemotherapy did not increase the incidence of adverse events. Other agents targeting the HER2 pathway (lapatinib) or other domains of epidermal growth factor receptor family (cetuximab) are currently being investigated for the treatment of an advanced gastric cancer.

Dietary inflammatory index as a potential determinant of a length of hospitalization among surgical patients treated for colorectal cancer.

Background/objectives:Inflammation is a central process responsible for health outcomes among surgical patients. Immunonutrition has been investigated as a promising modifying factor; however, inflammatory properties of habitual diet have not yet been investigated. The purpose of this study was to describe inflammatory properties of diet measured by the dietary inflammatory index (DII) among surgical patients treated for colorectal cancer and to link inflammatory properties of habitual diet with a duration of hospitalization.Subjects/methods:A follow-up study among colorectal cancer patients treated surgically was performed in Krakow, Poland. In total, 689 patients were recruited for the study. Habitual diet was assessed using a standardized semiquantitative food frequency questionnaire. Overall, 23 dietary items (including macro-and micronutrients) were used to calculate individuals’ DII. Gender, age, marital status, body mass index, smoking status, lifetime physical activity, taking vitamin supplements, number of chronic diseases, cancer site, Duke’s staging and surgery type were considered as potential covariates.Results:Participants were aged 58 years, with the average hospitalization time of 11 days. Higher DII (meaning diet with higher anti-inflammatory properties) was negatively associated with the duration of hospitalization (univariable linear regression: b=−0.59; P=0.005). Multivariable logistic regression has shown the decrease of the risk of longer stays (>7 days) among patients with the DII >−4.25, but only among younger (⩽60 years) patients, irrespective of Duke’s staging.Conclusions:The DII might be used as a potential predictor of longer hospitalization among colorectal cancer patients treated surgically. The study provides evidence for the role of dietary-related low-grade inflammation among surgical patients.

Abdominal Ultrasonography in Detecting and Surgical Treatment of Pancreatic Carcinoma

THE AIM OF THE STUDY was to asses the clinical value of percutaneous abdominal ultrasonography in diagnosis, staging and surgical treatment of patients with pancreatic carcinoma. MATERIAL AND METHODS Prospective clinical trial on diagnostic accuracy of percutaneous abdominal ultrasonography was conducted in 409 consecutive patients with pancreatic cancer which were operated on at the I Dept. of General Surgery in Cracow between 2000 and 2010. RESULTS Diagnostic accuracy of percutaneous abdominal ultrasonography in pancreatic cancer was 91,1%. The accuracy in detecting different stages of local advancement according to TNM classification was assessed respectively 92.3%-T1, 91.3%-T2, 89.4%-T3, 92.1%-T4, a whole T1-T4 on 91.3%. Diagnostic accuracy of percutaneous abdominal ultrasonography in diagnosis of metastasis to lymph nodes, vascular infiltration, and resectability was respectively 80.7%, 86%, 91.4%. CONCLUSIONS Percutaneous abdominal ultrasonography has high diagnostic accuracy in diagnosis, staging and predicting surgical treatment of patients with pancreatic carcinoma.

Prognostic Implications of Expression Profiling for Gemcitabine-Related Genes (hENT1, dCK, RRM1, RRM2) in Patients With Resectable Pancreatic Adenocarcinoma Receiving Adjuvant Chemotherapy

Objectives The aim of this study was to examine the relevance of expression profiling of 4 genes involved in the action of gemcitabine among patients with pancreatic ductal-cell adenocarcinoma (PDAC). Methods A group of 100 patients who underwent pancreatic resections for PDAC and received adjuvant chemotherapy with gemcitabine between 2007 and 2010 was identified. Expression of mRNAs for human equilibrative nucleoside transporter 1 (hENT1), ribonucleotide reductase subunits (RRM1, RRM2), and deoxycytidine kinase (dCK) was examined by quantitative real-time polymerase chain reaction, normalized to glyceraldehyde-3-phosphate dehydrogenase (GAPDH), and dichotomized into groups of low and moderate/high expression levels grouped by tertiles. Results Significantly better median survival times were found for high/moderate expression levels of hENT1 (27.9 vs 12.4 months, P = 0.001) and dCK (19.7 vs 10.5 months, P = 0.003), as well as low expression of RRM1 (23.4 vs 11.4 months, P = 0.027). A Cox proportional hazards model identified low expression of hENT1 (hazard ratio [HR], 3.38; 95% confidence intervals [CI], 2.28–10.50) and dCK (HR, 2.24; 95% CI, 1.63–3.39), and high/moderate levels of RRM1 (HR, 1.65; 95% CI, 1.23–2.45) as negative prognostic factors. Conclusions Expression of hENT, RRM1, and dCK genes provides important prognostic information for PDAC patients treated with adjuvant gemcitabine.

Ultrasonography in the Diagnosis of Acute Abdominal Disorders

The possibility of the rapid implementation of real-time imaging and small requirements concerning the positioning and preparation of the patient render the ultrasound examination an increasingly performed method in case of patients diagnosed during emergency service. The surgeon performing the examination obtains immediate information supplementing the physical examination and medical history, enabling differential diagnosis and the implementation of proper treatment.It has been shown that an ultrasound examination performed during emergency service in case of a patient with abdominal pain of unknown cause increases the diagnostic accuracy and reliability of the diagnosis (1, 2). The ultrasound examination increases the diagnostic accuracy in case of patients with acute abdominal right upper quadrant pain (3). Still no significance was established concerning the ultrasound diagnosis of appendicitis-the value of the ultrasound examination depends on the experience of the examining physician (4), although several publications reported the efficiency of the method (5, 6). The ultrasound examination performed in the ER facilitates the decision concerning the need for surgical intervention (7). Indications for abdominal ultrasound in the ER are as follows (8): – blunt abdominal trauma, – suspicion of peritoneal bleeding, – suspicion of abdominal aortic aneurysm complications, – suspicion of acute pancreatitis,

History and future Directions in Ultrasonography

The development of ultrasonography would not be possible without the earlier findings concerning ultrasounds. As early as the thirteenth century Lazzarro Spalanzani observed that bats use hearing rather than sight, considering location in space. In 1938, Donald Griffin described the phenomenon of echolocation in these mammals. In 1880, Pierre and Jaques Curie showed the piezoelectric phenomenon consisting in the creation of an electrical charge inside the crystal quartz or Seignette’s salt (sodium and potassium tartrate), under pressure (1). The name of the phenomenon is derived from the Greek language meaning ‘to push’. The Curie brothers also observed the inverse piezoelectric crystal vibration phenomenon involving the effect of an external electrical field. Piezoelectricity is only present in the crystals, being elementary cells, which do not have a center of symmetry, such as quartz crystals. In the first half of the 20-th century the sonar was constructed-a device using sound waves to track and classify mobile and immobile submerged objects. The first idea for such a device was patented by an English meteorologist, Lewis Richardson in 1912, and one year thereafter, by Alexander Behm in Germany. In 1941, Sproule and Firestone working independently, constructed a device that used ultrasounds to detect defects in the hull of vessels (1). The designed ‘supersonic reflectoscope” by Firestone was soon adapted for the use in shipbuilding. Christian Andreas Doppler (fig. 1), an Austrian physicist and mathematician was the first in 1842 who described the color change under the influence of movement in the system of submerged stars. This effect consists in the development of frequency differences sent by the source and recorded by the observer, who moves in relation to the source, being applied in ultrasonography. Shigeo Satomura was the pioneer of Doppler ultrasonography, a physicist from the Univer-

Short-term outcomes of endovascular repair of abdominal aortic aneurysm, including ruptured cases

Introduction Endovascular aneurysm repair as a minimally invasive alternative has become a commonly used surgical method for treating patients with abdominal aortic aneurysm (AAA). Aim To analyze short-term outcomes of endovascular treatment of AAA patients, including ruptured cases. Material and methods From 2010 to 2015, 247 patients with AAA were treated using the endovascular aneurysm repair technique. A short-term analysis was conducted – up to 30 days after surgery. It included 236 patients with planned surgery and 11 operated on in emergency mode, due to ruptured AAA. Results Rates of short-term mortality and re-interventions among patients undergoing planned surgery were 2.5% and 4.2%, respectively. Surgical complications occurred in 18 (7.6%) patients, with the most common being thrombosis and blockage of the stent graft (2.5%). Systemic complications were found in 19 (8%) planned cases, with the most common being arrhythmias (1.7%). In patients with ruptured AAA, short-term mortality was 36.4%, while re-interventions were performed in 3 (27.3%) patients. Rates of surgical and systemic complications for ruptured AAA were 45.4% and 72.7%, respectively. Conclusions The AAA patients undergoing endovascular aneurysm repair showed relatively low short-term mortality. However, larger groups of patients with ruptured AAA are required in order to assess the outcomes in this sub-population.

Percutaneous abdominal ultrasonography in the diagnosis chronic diseases of liver, gall-bladder, bile ducts and pancreas.

* Sources of funding – none Chronic diseases of the liver, gall-bladder and bile ducts and pancreas are the most common disorders encountered in the routine practice of a general surgeon. Routine percutaneous ultrasonography is a commonly available imaging method of abdominal organs and is a significant tool in the accurate detection of the reported disorders. Despite high variability and number of pathological entities among these disorders, the diagnosis can be made on the basis of ultrasonographic imaging provided that the operator has sufficient experience and availability of high quality equipment. Literature reports various diagnostic accuracies for percutaneous abdominal ultrasonography in the detection of the reported disorders, however no one questions high value of the ultrasonography in the surgical diagnosis. It is widely regarded as a basic diagnostic modality besides physical examination and interview. The aim of this paper is to present our own experience in the diagnosis of chronic disorders of the liver, gall-bladder and bile ducts and pancreas using routine, percutaneous ultrasonography basing on analysis of rich material of the Department that specialized in the treatment and diagnosis of these diseases. DIAGNoSTIC ACCURACY oF PERCUTANEoUS ABDoMINAL ULTRASoNoGRAPHY