Objective: The primary aim of this study was to assess patients’ preferences between radiofrequency ablation (RFA) versus hepatic resection (HR) for the treatment of small hepatocellular carcinomas (HCC). Methods: Decision analysis was performed by using probability trade-off (PTO) technique to elicit patients’ preferences and the strength of their decisions. Results: The vast majority of the study population preferred RFA over HR (70% vs. 30%, p=0.001). Their initial choice changed if 5-year survival benefit after surgery was at least 14% superior to RFA and if the 3-year disease-free survival advantage was at least 13% better than ablation. Conclusions: The results of this study suggest that fully informed cirrhotic patients would prefer RFA if diagnosed with early stage HCC even if able to undergo surgery.

Introduction : L’hypophosphatémie survient couramment après hépatectomie partielle. La régénération du foie était l’explication initiale. Cependant, les pertes rénales de phosphate observées récemment suggèrent que l’hypophosphatémie est probablement d’origine rénale. Nous avons donc mesuré la fraction d’excrétion urinaire de phosphate (FePO4) après hépatectomie partielle et nous avons étudié le rôle de la parathormone (PTH) et des phosphatonines dans cette hypophosphatémie. Méthodes : Les taux sériques de phosphate, de calcium ionisé, de PTH intacte, de « fibroblast growth factor- 23 » (FGF-23) intact et carboxyle-terminal, de FGF-7, de la « frizzled-related protein-4 » (FRP-4) et de HCO3- ainsi que le pH et la FePO4 ont été mesurés avant la chirurgie et aux jours postopératoires (po) 1, 2, 3, 5 et 7, chez 18 patients ayant subi une résection hépatique partielle. Résultats : Le phosphate sérique était à son plus bas niveau (0,66 ± 0,33 mmol/l; p < 0,001) au jour po 2. La FePO4 culminait à 25,07 ± 2,26 % au jour po 1 (p < 0,05) et était associée avec le taux de la parathormone intacte (r = 0,65; p = 0,006). Le calcium ionisé sérique diminuait à 1,1 ± 0,01 mmol/l, (p < 0,01) en même temps que la parathormone intacte s’élevait à 8,8 ± 0,9 pmol/l, (p < 0,01) au jour po 1; ces deux paramètres étaient inversement corrélés (r = -0,062; p = 0,016). Le FGF-23 intact atteignait son plus bas niveau à 7,8 ± 6,9 pg/ml (p < 0,001), au jour po 3; les valeurs de FGF-23 étaient corrélées avec la diminution du phosphate sérique aux jours po 0, 3, 5 et 7 (p < 0,001). Le FGF-23 carboxyle-terminal, le FGF-7 et la FRP-4 n’étaient pas reliés au phosphate sérique ni à la FePO4. Conclusion : L’hypophosphatémie observée après résection hépatique partielle est liée à une augmentation de la FePO4 qui est sans aucune relation avec les FGF-23 intact ou carboxyle-terminal, le FGF-7 et la FRP-4. La PTH intacte était associée avec la FePO4 uniquement au jour po 1. L’hypophosphatémie après résection hépatique est secondaire à d’autres facteurs non encore identifiés. / Background: Post-hepatectomy hypophosphatemia, first associated with metabolic demands by the regenerating liver, has recently been related to an excessive fractional urinary phosphate excretion (FePO4). We decided to investigate the role of parathyroid hormone (PTH) and of phosphatonins in the latter finding. Methods: Serum phosphate (PO4), ionized calcium (Ca++), HCO3-, pH and FePO4, Intact PTH, carboxyl-terminal and Intact fibroblast growth factor 23 (FGF-23), FGF-7 and frizzled related-protein-4 (FRP-4) were measured before and serially on post-operative days 1, 2, 3, 5 and 7, in 18 patients undergoing liver resection. Results: Serum PO4 was lowest (0.66 ± 0.33 mmol/l; p < 0.001) on po day 2. FePO4 peaked at 25.07 ± 2.26 % on po day 1 (p < 0.05) and was associated with Intact PTH levels (r = 0.65, p = 0.006). Decreased Ca++ levels (1.1 ± 0.01 mmol/l; p < 0.01) and increased Intact PTH levels (8.8 ± 0.9 pmol/l; p < 0.01) observed on po day 1 were negatively related (r = -0.62, p = 0.016). Intact FGF-23 decreased to its nadir 7.8 ± 6.9 pg/ml (p < 0.001), on po day 3 and was correlated with PO4 levels on po days 0, 3, 5 and 7 (p < 0.001). Carboxyl-terminal FGF-23, FGF-7 and FRP-4 levels could not be related either to PO4 concentrations or FePO4. Conclusion: Post-hepatectomy hypophosphatemia is related to an increased FePO4 unrelated to Intact FGF-23 or carboxyl-terminal FGF-23, FGF-7 or FRP-4. I-PTH contributes to excessive FePO4 on po day 1 but not thereafter. Other factors not yet defined should explain post hepatectomy hypophosphatemia.

INTRODUÇÃO: O adenocarcinoma gástrico precoce (AGP) atinge até a camada submucosa em profundidade, independentemente da presença de metástases linfonodais (MLF). Tumores mucosos, bem diferenciados, menores que 20 mm e sem ulceração são candidatos à ressecção endoscópica (RE) por mucosectomia com taxas de MLF praticamente nulas. Com o advento da técnica de dissecção endoscópica da submucosa (ESD) e após observar ausência de MLF em grande série de pacientes no Japão, foi sugerido que os critérios clássicos pudessem ser expandidos, evitando a gastrectomia em alguns pacientes. Em países ocidentais autores e sociedades têm visto com restrição a ESD para critérios expandidos devido à observação de MLF em alguns subgrupos. A análise crítica e validação dos critérios expandidos de RE para tratamento do AGP em coorte brasileira poderá indicar os pacientes com menor risco de metástases linfonodais nesta população, de modo a individualizar o tratamento com excelência e qualidade de vida. OBJETIVO: Avaliar a presença MLF em produtos de gastrectomia com linfadenectomia de pacientes elegíveis à ressecção endoscópica seguindo os critérios clássicos e expandidos. MÉTODO: Inclusão de pacientes com AGP submetidos a tratamento cirúrgico com dissecção linfonodal. Estadiamento linfonodal e avaliação de características clínicas, macroscópicas e histopatológicas segundo critérios de RE. RESULTADOS: Foram incluídos 389 espécimens cirúrgicos de gastrectomia, dentre os quais 135 cumpriam critérios para ressecção endoscópica. Nenhum dos 31 pacientes com critérios clássicos apresentou MLF (N = 31; 0% IC95% 0 - 13,4%). Dos 104 com critérios expandidos, 3 apresentaram MLF (N = 104; 2,9% IC95% 0,7 - 8,6%), todos pertencentes ao grupo de tumores indiferenciados sem ulceração e menores que 20 mm. Dos pacientes com indicação de tratamento cirúrgico houve 50 MLF positivos (N = 254; 19,7% IC95% 15,3 - 25,1%). CONCLUSÃO: Existe risco mínimo de metástases linfonodais quando adotados os critérios expandidos de RE. Este risco é praticamente nulo para os critérios clássicos e quando se exclui o tumor indiferenciado do critério expandido / INTRODUCTION: Early gastric cancer (EGC) is known to present low rate of lymph nodal metastasis (LNM). Gastrectomy with D2 lymphadenectomy is usually curative for EGC. Endoscopic submucosal dissection (ESD) is a well-accepted treatment modality for lesions that meet the classic criteria, a well-differentiated adenocarcinoma measuring less than 20 mm size and without ulceration. Expanded criteria for ESD have been recently proposed, based on null LNM rate from large gastrectomies series coming from Japan. The expanded criteria for ESD are as follows: intramucosal non-ulcerative well-differentiated tumor > 20 mm, intramucosal ulc mo <= 30 mm, intramucosal non-ulcera mo <= 20 mm, or superficially submucosal ( m1) mo <= 30 mm. There is some resistance to adoption of the expanded criteria, since patients with positive LNM have already been reported in western centers. OBJECTIVE: Evaluate LNM staging in patients who met the expanded endoscopic treatment criteria for ESD. METHOD: Evaluation of gastrectomy specimens including LNM staging of patients submitted to gastrectomy for EGC in a 39-year retrospective cohort. A senior pathologist reviewed the histology slides. RESULTS: A total of 389 surgical specimens were included, of whose 135 met criteria for endoscopic resection. None of the 31 patients with classic criteria had LNM. Of the 104 patients with expanded criteria, 3 had LNM (n = 104, 2.9% CI 95% 0.7 - 8.6%), all of them with undifferentiated tumors without ulceration and less than 20 mm. In the patients with surgical criteria there were 50 LNM positive (n = 254; 19.7% CI 95% 15.3 - 25.1%). CONCLUSION: There is minimal risk of LNM in EGC when expanded criteria for ESD are met. This risk is practically nil for the classic criteria and when the undifferentiated tumor is excluded of the expanded criteria. Refinement of the expanded criteria for the risk of LNM may be desirable. Meanwhile the decision to complement the endoscopic treatment with LNM dissection or D2 gastrectomy will have to take into consideration the individual risk of perioperative morbidity and mortality

A Hiperplasia Prostática Benigna (HPB) é a doença benigna mais freqüente na terceira idade. A Ressecção Transuretral (RTU) de próstata constitui-se na técnica operatória mais empregada atualmente para o tratamento da HPB. A anestesia para este procedimento possui características próprias, tornando-se um desafio para o anestesiologista o manejo de suas particularidades. Com o objetivo de avaliar a conduta anestésica, comparando técnicas empregadas, drogas e doses, eventuais complicações e respectivos tratamentos, revisou-se 300 prontuários de pacientes submetidos a RTU de próstata no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto (HC-FMRP-USP). Optou-se por dois períodos de quatro anos com intervalo de dez anos entre eles (1989-1992 (período 1) e 1999-2002 (período 2)) para tentar estabelecer uma suposta relação entre a evolução das técnicas anestésicas e a possível redução na incidência de complicações. Foram incluídos no estudo apenas os pacientes portadores de neoplasias benignas da próstata. Algumas características dos pacientes (média de idade e estado físico ASA) foram semelhantes entre os grupos. A média de peso foi superior no período 2. Foram pedidos menos exames pré-operatórios para os pacientes do período 1. Quanto ao tipo de anestesia houve um predomínio absoluto, nos dois períodos, da anestesia regional (sendo que o bloqueio raquidiano foi o mais utilizado). O anestésico local mais empregado foi a bupivacaína nos dois períodos. Observou-se uma maior incidência de falhas nos bloqueios realizados no período 1, com maior índice de conversão para anestesia geral. O fato pode em parte ser atribuído ao não uso de agentes opióides nas punções nessa época, que sabidamente melhoram a qualidade do bloqueio. A duração média do procedimento foi maior no período 2 (considerando 45 minutos como tempo padrão). A incidência de eventos adversos intra-operatórios, como como hipotensão, arritmias cardíacas e hipotermia foi semelhante entre os períodos. No entanto, houve um maior número de pacientes com diagnóstico de infarto agudo do miocárdio no pós-operatório de até 24 horas no período1. Provavelmente esse fato aconteceu pela falta de exames complementares e avaliação cardiológica prévia nos pacientes submetidos à cirurgia nesse período. No tocante as transfusões sangüíneas, a proporção entre os períodos foi semelhante, embora fosse prática costumeira no período 1 que os pacientes realizassem autotransfusão prévia. A autotransfusão não se mostrou eficaz, na população estudada, como fator redutor do número de transfusões sangüíneas. Na sala de recuperação anestésica o tempo de permanência foi semelhante entre os períodos, no entanto, observou-se uma maior incidência de eventos adversos no período 1. A mortalidade foi maior no período 2 mas essa diferença não foi estatisticamente significante. Palavras- chave: 1. Anestesia 2. Hiperplasia Benigna da Próstata 3. Ressecção Transuretral de Próstata 4. Síndrome da Intoxicação Hídrica / Benign Prostatic Hyperplasia (BPH) is the most common disease in the third ages. Transurethral Resection of the Prostate (TRP) is the surgery technique most frequently used for the treatment of BPH. Anaesthesia for this procedure has its own features becoming a challenge for the anaesthesiologist to manage with its peculiarities. In order to evaluate the anaesthetic behavior, to compare the techniques used, drugs and doses, possible complications and their treatments, three hundreds of medical records of patients submitted to TRP in the University Hospital, Faculty of Medicine of Ribeirão Preto (FM-USP). Two periods of four years were chosen (1989-1992 (period 1) and 1999-2002 (period 2)) in order to establish some evolution between the anaesthetics techniques used and possible reduction in the incidence of complications. Only patients who had benign prostatic hyperplasia were included in this study. Some patients characteristics were similar between the two groups (mean ages and physical status ASA). Mean weight were higher in the period 2. Less preoperative exams were applied in the period 1. In both periods, the regional anaesthesia was predominant (the spinal anaesthesia was the most used). Hyperbaric bupivacaine was the most commonly used agent for regional anaesthesia in both periods. More failed blocks were seen in the period 1 with an increased number of conversion to general anaesthesia. This fact may be attached with the lack of use of opioids agents in that period, which are known to complement and improve the quality of the block. Mean duration of the procedure were higher in period 2 (taking 45 minutes as standard time). The incidence of intra-operative adverse events like hypotension, cardiac arrhythmias and hypothermia were similar in both periods. However more patients had acute heart infarct in the 24 hours of postoperative period 1. Probably this happens because of the lack of preoperative exams and cardiology evaluation in patients submitted to surgery in this period. The proportion of blood transfusions were similar in two periods although it was usual to make an autotransfusion in the patients of the first period. Autotransfusion previous to the surgery were not an effective method to reduce the number of transfusions. In postanaesthesia care unit the length of stay was similar between the periods but the incidence of adverse events was higher in the period 1. The mortality was bigger in the period 2 but this difference were not significant. Key-words: 1. Anaesthesia 2. Benign Prostatic Hyperplasia 3. Transurethral Resection of the Prostate 4. The TURP Syndrome

Introduction. Alors qu’elle constitue le seul traitement curatif du cholangiocarcinome intrahépatique (CCIH), la résection reste associée à un taux de récidive supérieur à 60% et un taux de survie réelle à 5 ans inférieur à 20%. Une estimation fiable du pronostic ainsi qu’une meilleure compréhension de la biologie tumorale est essentielle pour améliorer le pronostic.Méthodes. A l’appui des données clinico-biologiques de deux larges cohortes de patients avec CCIH réséqué (MSKCC, n=189 et AFC, n=522), trois objectifs ont été explorés. Tout d’abord, définir quel modèle pronostique publié est le plus performant. Ensuite, définir la fiabilité de l’évaluation pronostique préopératoire à partir de, respectivement, l’imagerie, des microARN (miR) circulants diagnostiques et du profil génomique tumoral. Enfin, évaluer l’impact pronostique de la survenue d’événements périopératoires tels que transfusion et morbidité.Résultats. Premièrement, les nomogrammes apportaient une meilleure estimation pronostique en comparaison à la classification AJCC 7ème édition. Deuxièmement, la taille et la multifocalité tumorale sur l’imagerie préopératoire permettaient de différencier deux groupes de patients de pronostic clairement distincts (p<0,001). L’existence d’une mutation d’un gène de remodelage de la chromatine (BAP1, ARID1A, PBRM1) tendait à être associé à une survie sans récidive plus favorable qu’en l’absence de mutation (p=0,09). Alors qu’ayant un potentiel comme marqueur diagnostique circulant, miR21 et miR221 n’étaient pas associé à la survie. Troisièmement, la transfusion peropératoire n’impactait pas la survie à long terme alors que la survenue d’une complication sévère (grade Dindo-Clavien > 2) était indépendamment associée à une survie globale plus courte (p=0,002).Conclusion. Alors que les nomogrammes postopératoires apportent une meilleure estimation pronostique, le développement de modèles pronostiques préopératoires est faisable notamment à partir de l’imagerie et de marqueurs biologiques tumoraux complémentaires. / Introduction. Complete resection stands as the only curative option for intrahepatic cholangiocarcinoma (IHCC). Still, prognosis remains poor after resection due to a recurrence rate over 60% leading to actual 5-year survival rates below 20%. Reliable prognostic estimation and better understanding of tumor biology would be of interest for improving IHCC prognosis.Methods. Using clinical and biological data from two large cohort of resected IHCC (MSKCC, n=189 and AFC, n=522), three objectives have been explored. First, assessing the performances of different published prognostic models. Second, defining the reliability of preoperative prognostic estimation using imaging, tumoral genomic profiling and circulating tumoral microRNA (miR). Third, evaluating the prognostic impact of perioperative events such as blood transfusion and morbidity.Results. First, nomograms displayed better prognostic accuracy over the AJCC 7th edition staging system. Second, tumor size and multifocality on preoperative imaging allowed patient stratification in groups statistically different regarding prognosis (p<0.001). Further, the presence of chromatine remodeling gene mutations (BAP1, ARID1A, PBRM1) tended towards longer recurrence-free survical (p=0,09). Some diagnostic circulating miR such as miR21 and miR221 were not associated with survival. Third, in contrast with intraoperative transfusion, the occurrence of severe morbidity (Dindo-Clavien grade > 2) was independently associated with shorter overall survival (p=0.002).Conclusion. Nomograms outperform conventional staging sytem. Preoperative prognostic estimation is feasible and reliable using imaging. Identifying new prognostic biomarkers would help refining preoperative prognostic estimation.

The fundamental of surgical training is the traditional apprenticeship method introduced by William Halsted which has been used for the last 100 years. It is based on learning in the operating room (OR) where the resident is guided by an experienced surgeon and gradually and methodically exposed to surgery. The continuous development of surgical methods together with the growing awareness of medical errors and ethical considerations have made the Halsted method outdated and there is an obvious need to be able to learn the skills of surgery without risking patient safety. New methods such as laparoscopy and endoscopy demand specific skills and abilities that may not be met by everyone. At the same time, the physical limitations of these new methods have made it possible to construct virtual reality (VR) simulators to practise and learn the skills necessary. This study is about the construction and evaluation of a VR-simulator for the training of transurethral resection of the prostate (TURP). It also concerns the specific abilities needed to become a good surgeon. A simulator for training TURP was developed after a face validity study where 17 experienced urologists gave their opinion of the specific content necessary for the training of this procedure. After a content validity study by nine experienced urologists and application of necessary improvements, a group of 11 medical students and nine experienced urologists performed a construct validity test where the urologists showed significantly higher levels of both skill and effectiveness compared to the inexperienced students when performing a simulated TURP procedure. The students showed a positive learning curve, but did not reach the levels of the urologists. The results of the experienced urologists were used as the minimal criterion level when 24 urology residents practised the procedure. Training took place while on a course on benign enlargement of the prostate and its treatment options, with emphasis on the “gold standard” treatment – TURP. During the course they performed three guided and video-taped TURP-procedures each on selected patients. Between two of the procedures they performed criterion-based training in the simulator. This VR-to-OR study showed improvement in operative skills with the same patient outcome as in the normal clinical situation. It also showed that simulator training improved their skills even more. During their time on the course their personality traits (TCI) and cognitive abilities (Rey complex figure and recognition trial, tower of London, WAIS-III) were tested. The results showed that a better learning curve in the OR was associated with a better simulator learning curve and a good visuospatial memory. The associated personality traits were high levels of goal directedness, impulse control, responsibility, anticipation of harmful events and a balanced attachment style. In conclusion, we have demonstrated that it was technically possible to construct a useful simulator for the training of TURP (PelvicVision®) which may now be considered clinically validated for this purpose. Novice training and performance in the simulator improves the learning curve and predicts the resident’s performance in the OR. The results support the implementation of validated simulation technology in a criterion-based training curriculum for residents. Furthermore, the results showed preliminary data on personality traits and visuospatial abilities that are important for learning a complex surgical procedure.

The Mre11/Rad50 complex has been implicated in the early steps of DNA double-strand break (DSB) repair through homologous recombination in several organisms. However, the enzymatic properties of this complex are incompatible with the generation of 3’ single-stranded DNA for recombinase loading and strand exchange. In thermophilic Archaea, the mre11 and rad50 genes cluster in an operon with genes encoding a bidirectional DNA helicase, HerA, and a 5’ to 3’ exonuclease, NurA, suggesting these four enzymes function in a common pathway. I show that purified Mre11 and Rad50 from Pyrococcus furiosus act cooperatively with HerA and NurA to resect the 5’ strand at a DNA end under physiological conditions in vitro where HerA and NurA alone do not show detectable activity. Furthermore, I demonstrate that HerA and NurA physically interact, and this interaction stimulates both helicase and nuclease activities. The products of HerA/NurA long-range resection are oligonucleotide products and HerA/NurA activity demonstrates both sequence specificity and a preference to cut at a specific distance from the DNA end. I demonstrate a novel activity of Mre11/Rad50 to make an endonucleolytic cut on the 5’ strand, which is consistent with a role for the Mre11 nuclease in the removal of 5’ protein conjugates. I also show that Mre11/Rad50 stimulates HerA/NurA-mediated resection through two different mechanisms. The first involves an initial Mre11 nucleolytic processing event of the DNA to generate a 3’ ssDNA overhang, which is then resected by HerA/NurA in the absence of Mre11/Rad50. The second mechanism likely involves local unwinding of the DNA end in a process dependent on Rad50 ATPase activity. I propose that this unwinding step facilitates binding of HerA/NurA to the DNA end and efficient resection of the break. Furthermore, the binding affinity of NurA for 3’ overhang and unwound DNA end substrates partially explains the efficiency of the two resection mechanisms. Lastly, 3’ single-stranded DNA generated by these enzymes can be used by the Archaeal RecA homolog RadA to catalyze strand exchange. This work elucidates how the conserved Mre11/Rad50 complex promotes DNA end resection in Archaea, and may serve as a model for DSB processing in eukaryotes. / text

INTRODUCTION Benign prostatic hyperplasia (BPH) is the most common pathological condition of aged men which significantly impairs the quality of life status. Though pharmacotherapy with adrenoblockers and 5-alpha reductase inhibitors markedly decreased the rate of surgical interventions, BPH surgery still constitutes the main workload (around ¼ of total) of urologists in the department. The results of the observational study performed by Barry et al. show that the probability of surgical treatment of BPH during the period of 4 years for subjects with mild symptoms equals to 10%, and in case of moderate and severe symptoms - 24% and 39%, respectively. According to the data of large multicenter study performed with 7,588 men in Asia and Australia, moderate and severe symptoms are present in 29%, 40%, and 56% of men in their fifth, sixth, and seventh decade of life, respectively. Symptoms are the main driving force of BPH treatment, but their correlation with residual urine, objective findings of uroflowmetry and invasive urodynamics is only poor. The association of various parameters with the outcomes of surgical treatment is complicated and still not completely investigated. Therefore finding parameters that predict the outcome of surgical BPH treatment is important. According to the literature, unfavorable outcomes of transurethral resection are present in around 15-30% of men with symptomatic BPH. This is mostly associated with inadequate preoperative evaluation, not fully... [to full text]

Introduction : L’hypophosphatémie survient couramment après hépatectomie partielle. La régénération du foie était l’explication initiale. Cependant, les pertes rénales de phosphate observées récemment suggèrent que l’hypophosphatémie est probablement d’origine rénale. Nous avons donc mesuré la fraction d’excrétion urinaire de phosphate (FePO4) après hépatectomie partielle et nous avons étudié le rôle de la parathormone (PTH) et des phosphatonines dans cette hypophosphatémie. Méthodes : Les taux sériques de phosphate, de calcium ionisé, de PTH intacte, de « fibroblast growth factor- 23 » (FGF-23) intact et carboxyle-terminal, de FGF-7, de la « frizzled-related protein-4 » (FRP-4) et de HCO3- ainsi que le pH et la FePO4 ont été mesurés avant la chirurgie et aux jours postopératoires (po) 1, 2, 3, 5 et 7, chez 18 patients ayant subi une résection hépatique partielle. Résultats : Le phosphate sérique était à son plus bas niveau (0,66 ± 0,33 mmol/l; p < 0,001) au jour po 2. La FePO4 culminait à 25,07 ± 2,26 % au jour po 1 (p < 0,05) et était associée avec le taux de la parathormone intacte (r = 0,65; p = 0,006). Le calcium ionisé sérique diminuait à 1,1 ± 0,01 mmol/l, (p < 0,01) en même temps que la parathormone intacte s’élevait à 8,8 ± 0,9 pmol/l, (p < 0,01) au jour po 1; ces deux paramètres étaient inversement corrélés (r = -0,062; p = 0,016). Le FGF-23 intact atteignait son plus bas niveau à 7,8 ± 6,9 pg/ml (p < 0,001), au jour po 3; les valeurs de FGF-23 étaient corrélées avec la diminution du phosphate sérique aux jours po 0, 3, 5 et 7 (p < 0,001). Le FGF-23 carboxyle-terminal, le FGF-7 et la FRP-4 n’étaient pas reliés au phosphate sérique ni à la FePO4. Conclusion : L’hypophosphatémie observée après résection hépatique partielle est liée à une augmentation de la FePO4 qui est sans aucune relation avec les FGF-23 intact ou carboxyle-terminal, le FGF-7 et la FRP-4. La PTH intacte était associée avec la FePO4 uniquement au jour po 1. L’hypophosphatémie après résection hépatique est secondaire à d’autres facteurs non encore identifiés. / Background: Post-hepatectomy hypophosphatemia, first associated with metabolic demands by the regenerating liver, has recently been related to an excessive fractional urinary phosphate excretion (FePO4). We decided to investigate the role of parathyroid hormone (PTH) and of phosphatonins in the latter finding. Methods: Serum phosphate (PO4), ionized calcium (Ca++), HCO3-, pH and FePO4, Intact PTH, carboxyl-terminal and Intact fibroblast growth factor 23 (FGF-23), FGF-7 and frizzled related-protein-4 (FRP-4) were measured before and serially on post-operative days 1, 2, 3, 5 and 7, in 18 patients undergoing liver resection. Results: Serum PO4 was lowest (0.66 ± 0.33 mmol/l; p < 0.001) on po day 2. FePO4 peaked at 25.07 ± 2.26 % on po day 1 (p < 0.05) and was associated with Intact PTH levels (r = 0.65, p = 0.006). Decreased Ca++ levels (1.1 ± 0.01 mmol/l; p < 0.01) and increased Intact PTH levels (8.8 ± 0.9 pmol/l; p < 0.01) observed on po day 1 were negatively related (r = -0.62, p = 0.016). Intact FGF-23 decreased to its nadir 7.8 ± 6.9 pg/ml (p < 0.001), on po day 3 and was correlated with PO4 levels on po days 0, 3, 5 and 7 (p < 0.001). Carboxyl-terminal FGF-23, FGF-7 and FRP-4 levels could not be related either to PO4 concentrations or FePO4. Conclusion: Post-hepatectomy hypophosphatemia is related to an increased FePO4 unrelated to Intact FGF-23 or carboxyl-terminal FGF-23, FGF-7 or FRP-4. I-PTH contributes to excessive FePO4 on po day 1 but not thereafter. Other factors not yet defined should explain post hepatectomy hypophosphatemia.

Dvylikapirštę žarną išsauganti kasos rezekcija Frey būdu yra standartinė operacija gydant sergančiuosius komplikuotu lėtiniu pankreatitu. Kasos ir plonosios žarnos jungtis įprastai atliekama dviejų aukštų siūlėmis. Disertacinio darbo tikslas – palyginti Frey operacijos, naudojant vieno arba dviejų aukštų kasos – tuščiosios žarnos siūlę, rezultatatus, taip pat įvertinti operuotų pacientų gyvenimo kokybės pokyčius, praėjus 12 mėn. po operacijos. Perspektyviniame atsitiktinių imčių klinikiniame tyrime dalyvavo aštuoniasdešimt pacientų. Tiriamieji prieš operaciją atsitiktine tvarka suskirstyti į dvi grupes: pirmos grupės pacientams atlikta operacija, formuojant kasos – tuščiosios žarnos jungtį vieno aukšto ištisine siūle; antros grupės pacientams, kasos – tuščiosios žarnos jungtis suformuota dviejų aukštų pavienėmis siūlėmis. Tyrime nustatėme, kad bendras operacijos laikas (208±46 min ir 255±58 min), bei pankreojejunoanastomozės siuvimo laikas (19±6 min. ir 51±18 min.) buvo statistiškai reikšmingai mažesnis „vieno aušto siūlės“ grupėje nei „dviejų aukštų pavienių siūlių“ grupėje. Pooperacinės komplikacijos, kasos fistulės dažnis, pooperacinė hospitalizavimo trukmė abiejose grupėse nesiskyrė. Vertinant gyvenimo kokybės pokyčius, praėjus 12 mėn. po operacijos, nustatytas statistiškai reikšmingas gyvenimo kokybės pagerėjimas abiejose pacientų grupėse. / The duodenum-preserving pancreatic resection according to Frey is a standard operation for patients with complicated chronic pancreatitis. The pancreatojejunostomy is usually performed using two layer suture. The aim of doctoral dissertation was to compare single- and two-layer suture in pancreatojejunostomy performed in duodenum-preserving pancreatic resection according to Frey modification and to assess the changes of the quality of life 12 months after operation. A total of 80 patients were enrolled in the prospective randomized clinical. They were randomly allocated into two groups. In the first group of patients, pancreatojejunostomy was constructed by using single-layer continuous suture. In the second group of patients, pancreatojejunostomy was constructed by using two-layer interrupted suture. Overall time of the operation (208 ± 46 min. and 255 ± 58 min.) and the suturing time (19 ± 6 min. and 51 ± 18 min.) were significantly shorter in the single layer anastomosis group. Postoperative complications, the prevalence of pancreatic fistula, the length of stay did not differ in both groups. There was a statistically significant improvement of the quality of life 12 months after operation in the both groups of patients.