Kallosotomien bei Sturzanfällen und epileptischen Spasmen

ZusammenfassungDie Kallosotomie ist eine palliative Operation, die seit fast 80 Jahren bei Patienten mit therapierefraktären, bilateralen Anfällen eingesetzt wird, wenn ein resektives Verfahren nicht möglich ist. Neuere, minimal-invasive Techniken wie die MRT-gesteuerte laserinduzierte Thermokoagulation sind vermutlich vergleichbar bezüglich Outcome und Komplikationsraten, die Datenlage ist aber insgesamt noch spärlich. In vielen Fallserien war die Kallosotomie v. a. in der Reduktion von Sturzanfällen effektiv, in geringerem Ausmaß auch für epileptische Spasmen. Eine vollständige Anfallsfreiheit wird nur sehr selten erreicht. Chirurgische Komplikationen wie Blutungen oder Infektionen treten in etwa 5 % auf. Die wichtigste, jedoch sehr seltene Nebenwirkung der Kallosotomie ist ein Diskonnektionssyndrom mit Apraxie, taktiler und visueller Anomie, Neglect oder SMA(supplementär-motorisches Areal)-Syndrom. Besonders bei Kindern ist das Diskonnektionssyndrom in aller Regel transient. Ob eine anteriore oder eine komplette Kallosotomie durchgeführt wird, variiert von Zentrum zu Zentrum. Komplette Kallosotomien sind hinsichtlich der Anfallsreduktion effizienter, gehen aber mit einem höheren Risiko für Komplikationen und Nebenwirkungen einher. Eine Option ist eine zweistufige Kallosotomie, bei der zunächst eine anteriore Diskonnektion durchgeführt wird und in den Fällen ohne hinreichenden postoperativen Nutzen in einem zweiten Schritt vervollständigt wird.

Spontaneously ruptured hepatocellular carcinoma in Fontan-associated liver disease: A case report

The prognosis of congenital heart disease is dramatically improved by cardiac surgery. The Fontan procedure is the definitive palliative operation for patients with single-ventricle physiology. In parallel with the longer survival time achieved with the Fontan procedure, the incidence of Fontan-associated liver disease is increasing. A 40-year-old man who underwent Fontan procedures at the ages of 9 was referred to our hospital for further evaluation of multiple hepatic tumors. Enhanced computed tomography showed large hepatocellular carcinomas with portal thrombi (Vp3). Spontaneous hepatocellular carcinoma rupture occurred 2 weeks after the first visit to our hospital, and emergent transcatheter arterial embolization of the hepatic artery was performed. Three months later, the patient died of liver failure. Autopsy findings showed moderately differentiated hepatocellular carcinoma with a cirrhotic liver characterized by centrilobular fibrosis and sinusoidal dilation similar to that in Fontan-associated liver disease. We reported the first case of spontaneously ruptured hepatocellular carcinoma treated by emergent transcatheter arterial embolization in Fontan-associated liver disease. As the early diagnosis of liver cirrhosis and hepatocellular carcinoma results in better patients’ outcome, cardiologists and hepatologists should be aware of Fontan-associated liver disease and advise patients to have regular follow-up of the liver.

PS02.251: TWO CASES OF THE ADVANCED ESOPHAGEAL CANCER WHICH WAS ABLE TO IMPROVE QOL BY VATS- E AS PALLIATIVE OPERATION

Background We often troubled with the choice of the treatment for unresctable or elderly advanced esophageal cancer on the keeping of quality of life (QOL) . There are few cases to impair QOL remarkably, because of dysphagia with esophageal stenosis or esophago-tracheal fistula after Chemo-Radiation Therapy. Esophageal bypass including palliative esopagectomy and esophageal stenting are used for the oral intake of these cases. Methods We reported two cases of the elderly advanced esophageal cancer which were effective for QOL improvement by palliative Video-Assisted Thoracic Surgery of Esophagus (VATS-E). Results Case 1: A 72-year-old woman admitted with dysphagia was found to have advanced esophageal carcinoma, clinical stage IV (T3N2M1). We initiated definitive chemotherapy with combined 5-fluorouracil and cisplatin, to which the patient showed confirmed partial response. Dysphagia was not improved enough. Therefore, she received esophageal stenting with the antireflex valve. She was not able to have enough oral ingestion after stenting. So VATS-esophageal bypass was performed four months after initial treatment. At 2 years after surgery, she was alive and underwent outpatients chemotherapy. She can have normal diet. Case 2: A 79-year-old woman admitted with vomiting and body weight loss. The diagnosis was advanced esophageal carcinoma, clinical stage IV (T4N3M0). She received definitive Docetaxel chemotherapy because of renal dysfunction, malnutrition, to which patient showed progressive disease. So, VATS-esophageal resection (D0) was performed about 1 months after chemotherapy. There were not postoperative complications. She can have rice gruel diet. Conclusion It is difficult to determine which treatment is better esophageal stenting and esophageal palliative operation, because there are few reports that compared the esophageal palliative operation. In late years, VATS become able to be carried out safely. It is lower invasive treatment than thoracotomy. VATS is one of the palliative therapy, but it is necessary to decide the indication carefully in the case that a prognosis is limited. We think that it is useful to have satisfaction of the oral ingestion for cases with the severe stenosis and refractory cases of stenting. It is thought that VATS-E have possibilities to become the useful choice as one means of the palliative operation in consideration of the general status and the prognosis of the patients. Disclosure All authors have declared no conflicts of interest.

Prognostic Value of Immunoscore and PD-L1 Expression in Metastatic Colorectal Cancer Patients with Different RAS Status after Palliative Operation

Colorectal cancer (CRC) is the fifth leading cause of cancer death and the fifth most commonly diagnosed cancer in China. Approximately, 25% of CRC was in the advanced stage as diagnosed, and 40% of patients with CRC progress to metastatic colorectal cancer (mCRC). RAS mutation status is now routinely used to select their therapy. But it is still a question whether RAS mutation status is a prognostic marker. In our study, we detected RAS mutation, immunoscore (IS), and PD-L1 expression in 60 Chinese mCRC patients who received palliative operation. The Kaplan-Meier survival analysis showed that the overall survival (OS) in patients with RAS wild type was better than those with RAS mutated type. Moreover, in multivariate analysis, RAS mutation and PD-L1 expression were demonstrated to be the independent negative prognostic factors for OS (P=0.044, HR: 0.258, and 95% CI: 0.069–0.967;P=0.048, HR: 0.276, and 95% CI: 0.077–0,988). All results suggested that, combined with IS, PD-L1 expression and RAS status may be the prognostic indicators for mCRC patients with palliative operation.

Present Situation and Progress of Pancreatic Cancer Radiotherapy

<p>Purpose: The research purpose is to effectively improve treatment effect of postoperative pancreatic cancer.<br />Approaches: Adjuvant radiotherapy and chemotherapy; Palliative radiotherapy is adpoted for patients whose pancreatic cancer cannot be removed through excision. Comprehensive treatment approach is adopted where gemcitabine is added during radiotherapy. Result: The treatment effect of palliative operation is a little bit better than the traditional operative treatment, adoption of comprehensive treatment is obviously superior to the aforesaid two treatment approaches.<br />Conculsion: Comprehensive treatment effectively improves survival rate of patients, and the survival time is greatly<br />extended.<br />Operation is generally adopted for pancreatic cancer treatment, but the effect is unsatisfactory. The average<br />lifetime of patients after palliative operation treatment is only 5 to 76 months, and the survival rate after five years only reaches 8% to 15%, while the curative effect of radical resection is a little bit better, but the survival rate after five years also only reaches 12% to 24%, and the average lifetime is about 10 to 19 months. In recent years, with gradual progress of medical treatment level, clinical cases of adopting radiotherapy for pancreatic cancer are increasing, but its main effect is palliative or auxiliary. This article refers to plenty of documentation, makes thorough study of present situation and progress of pancreatic cancer radiotherapy, put forward its own suggestions and opinions, and have certain<br />reference value.</p>

Tulžies latakų obstrukcija esant neoperabiliam kasos galvos navikui. Stentavimas ar paliatyvi operacija?

ĮvadasMechaninė gelta, kuri dažniausiai yra pirmasis kasos galvos vėžio simptomas, pasireiškia 90 % atvejų. Radikalus chirurginis gydymo būdas įmanomas tik 15–20 % ligonių, todėl taikomi paliatyvūs gydymo metodai: tulžies latakų stentavimas arba bi­liodigestyvinių jungčių suformavimas. Abu gydymo metodai yra lygiaverčiai ir nėra kriterijų, kurie leistų pasirinkti vieną iš jų.Ligoniai ir metodaiAtliktas retrospektyvusis tyrimas. Ligoniai, kuriems diagnozuotas kasos galvos navikas ir pasireiškė mechaninė gelta, buvo suskirstyti į dvi grupes pagal atliktą paliatyvaus gydymo metodą: A grupę sudarė ligoniai, kuriems buvo stentuoti tulžies latakai, B grupę – ligoniai, kuriems atlikta biliodigestyvinė anastomozė. Analizuoti klinikiniai duomenys, komplikacijos, išgy­venamumas, vidutinė ligonio gydymo kaina.RezultataiĮ tyrimą įtraukti 182 ligoniai: 94 (52 %) – atliktas endoskopinis tulžies latakų stentavimas ir 88 (48 %) – suformuota biliodiges­tyvinė anastomozė. A grupės pacientų vidutinis išgyvenamumas buvo mažesnis nei B grupės pacientų – atitinkamai 106,5 (6–705) ir 188,5 (1–744) dienos (p=0,026). Tolimosios metastazės nustatytos 34 (36 %) A grupės ligoniams ir 30 (34 %) – B grupės. Abiejų grupių ligonių, turinčių metastazių, išgyvenamumas mažai kuo skyrėsi: A grupės ligonių – 84,5 (6–354) dienos, o B grupės – 82,5 (9–542) dienos, p=0,38. Komplikacijų pasireiškė 17 % A grupės ir 19 % B grupės ligonių. A grupės paciento vidutinės gydymo išlaidos sudarė 6491 Lt, B grupės – 11 627 Lt.IšvadosIšplitęs kasos galvos navikas su tolimomis metastazėmis lemia trumpesnį išgyvenamumą, todėl šiems ligoniams rekomen­duojama stentuoti tulžies latakus. Esant neoperabiliems kasos galvos navikams be metastazių, indikuojama biliodigestyvinė anastomozė.Reikšminiai žodžiai: kasos galvos vėžys, mechaninė gelta, stentavimas, biliodigestyvinė anastomozė Biliary tract obstruction in nonresectable tumour of pancreatic head. Stenting or palliative operation?Jonas Jurgaitis, Marius Kryžauskas, Viktor Asejev, Juozas Stanaitis, Marius Paškonis, Virgilijus Beiša, Kęstutis Strupas BackgroundObstructive jaundice, which usually is the first symptom of tumour of the pancreatic head, occurs in 90% of cases. Due to the fact that radical surgery is possible only for 15–20% of patients, obstructive jaundice is treated by applying palliative methods (endoscopic biliary tract stenting or biliodigestive anastomosis). Both palliative methods are equal, and there are no criteria that would determine the option of treatment.Matherials and methodsA retrospective analysis of patients with a pancreatic head tumour and obstructive jaundice was made. Patients were divided into two groups according to the applied palliative method: group A – biliary tract stenting, group B – biliodigestive anasto­mosis. Clinical data, complications, the survival of patients and the average cost of treatment for one patient were compared.Results182 patients were involved in the analysis, of them 94 (52 %) underwent biliary tract stenting and 88 (48%) biliodigestive anastomosis. The median of the survival of patients in group A was shorter than in group B – 106.5 (6–705) versus 188.5 (1–744) days, p = 0.026. Distant metastases were determined in 34 (36 %) patients of group A and in 30 (34%) of group B. The median survival of patients with distant metastases was approximately equal: in group A – 84.5 (6–354) days, in group B – 82.5 (9–542), p = 0.38. Complications in group A occurred in 17%, and in group B in 19% of cases. The average cost of treatment reached 6491 Lt for one patient in group A and 11 627 Lt in group B.ConclusionsAdvanced tumour of pancreatic head with distant metastases is a condition for a shorter survival; thus, biliary tract stenting is indicated. Inoperable tumour of pancreatic head without distant metastases is an indication for applying a biliodigestive anastomosis.Key words: tumour of pancreatic head, obstructive jaundice, stenting, biliodigestive anastomosis

Tulžies latakų obstrukcija esant neoperabiliam kasos galvos navikui. Stentavimas ar paliatyvi operacija?

ĮvadasMechaninė gelta, kuri dažniausiai yra pirmasis kasos galvos vėžio simptomas, pasireiškia 90 % atvejų. Radikalus chirurginis gydymo būdas įmanomas tik 15–20 % ligonių, todėl taikomi paliatyvūs gydymo metodai: tulžies latakų stentavimas arba bi­liodigestyvinių jungčių suformavimas. Abu gydymo metodai yra lygiaverčiai ir nėra kriterijų, kurie leistų pasirinkti vieną iš jų.Ligoniai ir metodaiAtliktas retrospektyvusis tyrimas. Ligoniai, kuriems diagnozuotas kasos galvos navikas ir pasireiškė mechaninė gelta, buvo suskirstyti į dvi grupes pagal atliktą paliatyvaus gydymo metodą: A grupę sudarė ligoniai, kuriems buvo stentuoti tulžies latakai, B grupę – ligoniai, kuriems atlikta biliodigestyvinė anastomozė. Analizuoti klinikiniai duomenys, komplikacijos, išgy­venamumas, vidutinė ligonio gydymo kaina.RezultataiĮ tyrimą įtraukti 182 ligoniai: 94 (52 %) – atliktas endoskopinis tulžies latakų stentavimas ir 88 (48 %) – suformuota biliodiges­tyvinė anastomozė. A grupės pacientų vidutinis išgyvenamumas buvo mažesnis nei B grupės pacientų – atitinkamai 106,5 (6–705) ir 188,5 (1–744) dienos (p=0,026). Tolimosios metastazės nustatytos 34 (36 %) A grupės ligoniams ir 30 (34 %) – B grupės. Abiejų grupių ligonių, turinčių metastazių, išgyvenamumas mažai kuo skyrėsi: A grupės ligonių – 84,5 (6–354) dienos, o B grupės – 82,5 (9–542) dienos, p=0,38. Komplikacijų pasireiškė 17 % A grupės ir 19 % B grupės ligonių. A grupės paciento vidutinės gydymo išlaidos sudarė 6491 Lt, B grupės – 11 627 Lt.IšvadosIšplitęs kasos galvos navikas su tolimomis metastazėmis lemia trumpesnį išgyvenamumą, todėl šiems ligoniams rekomen­duojama stentuoti tulžies latakus. Esant neoperabiliems kasos galvos navikams be metastazių, indikuojama biliodigestyvinė anastomozė.Reikšminiai žodžiai: kasos galvos vėžys, mechaninė gelta, stentavimas, biliodigestyvinė anastomozė Biliary tract obstruction in nonresectable tumour of pancreatic head. Stenting or palliative operation?Jonas Jurgaitis, Marius Kryžauskas, Viktor Asejev, Juozas Stanaitis, Marius Paškonis, Virgilijus Beiša, Kęstutis Strupas BackgroundObstructive jaundice, which usually is the first symptom of tumour of the pancreatic head, occurs in 90% of cases. Due to the fact that radical surgery is possible only for 15–20% of patients, obstructive jaundice is treated by applying palliative methods (endoscopic biliary tract stenting or biliodigestive anastomosis). Both palliative methods are equal, and there are no criteria that would determine the option of treatment.Matherials and methodsA retrospective analysis of patients with a pancreatic head tumour and obstructive jaundice was made. Patients were divided into two groups according to the applied palliative method: group A – biliary tract stenting, group B – biliodigestive anasto­mosis. Clinical data, complications, the survival of patients and the average cost of treatment for one patient were compared.Results182 patients were involved in the analysis, of them 94 (52 %) underwent biliary tract stenting and 88 (48%) biliodigestive anastomosis. The median of the survival of patients in group A was shorter than in group B – 106.5 (6–705) versus 188.5 (1–744) days, p = 0.026. Distant metastases were determined in 34 (36 %) patients of group A and in 30 (34%) of group B. The median survival of patients with distant metastases was approximately equal: in group A – 84.5 (6–354) days, in group B – 82.5 (9–542), p = 0.38. Complications in group A occurred in 17%, and in group B in 19% of cases. The average cost of treatment reached 6491 Lt for one patient in group A and 11 627 Lt in group B.ConclusionsAdvanced tumour of pancreatic head with distant metastases is a condition for a shorter survival; thus, biliary tract stenting is indicated. Inoperable tumour of pancreatic head without distant metastases is an indication for applying a biliodigestive anastomosis.Key words: tumour of pancreatic head, obstructive jaundice, stenting, biliodigestive anastomosis