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Biomedical subjects

B C Vrouenraets

Publications and source records attributed to B C Vrouenraets.

At least 19 recordsLinked to original sources
PubMed2006

Compartimentalization for chylothorax originating from the abdomen after extended esophagectomy. Report of two cases and review of the literature.

BACKGROUND: Chyle leakage from the chest after extended esophagectomy originating from the abdomen is a rare complication with various clinical presentations and treatments. METHODS: Two cases of chylothorax originating from the abdomen are discussed and the literature concerning diagnosis, management and outcome is reviewed. RESULTS AND CONCLUSION: Initially conservative measures should be installed; however, prolonged conservative treatment should be avoided. Reoperation gives an opportunity to identify the leak. If the leakage originates from the abdomen, compartimentalization is the essential step to solve the problem.

Abdomen↗
PubMed2006

Repeat isolated limb perfusion with TNFalpha and melphalan for recurrent limb melanoma after failure of previous perfusion.

AIM: To assess the effectiveness of isolated limb perfusion (ILP) with tumour necrosis factor-alpha (TNFalpha) and melphalan for recurrent or persistent melanoma lesions after previous ILP. METHODS: Between 1978 and 2001, 21 patients (mean age 65, range 29-83 years) underwent repeat ILP for recurrent or persistent melanoma after a previous ILP. First ILPs had been performed with melphalan alone in 13 patients and with addition of TNFalpha in eight, for a median of nine lesions (interquartile (IQ) range 2-23 lesions). Repeat ILP was performed with TNFalpha and melphalan in all 21 patients for a median of nine lesions (IQ range 5-25 lesions). Median follow-up after repeat ILP was 18 months (IQ range 6-36 months). RESULTS: Thirteen patients attained a complete response (CR) after repeat ILP compared to 11 of 17 with measurable lesions after the first ILP. Nine patients relapsed after CR. Median limb recurrence-free survival was 13 months. Fourteen patients had mild acute regional toxicity after repeat ILP compared to 18 after the first ILP (n.s.). One patient underwent amputation for critical limb ischemia 10 months following repeat ILP. The limb salvage rate was 95%. Overall median survival was 62 months after CR compared to 13 months for those without CR (P=0.05). CONCLUSION: Repeat ILP with TNFalpha and melphalan is feasible after previous ILP with mild regional toxicity. The CR rate is relatively high and comparable to the first procedure with good limb recurrence-free survival and high limb salvage rate.

Adult↗
PubMed2005

Palliative isolated limb perfusion for advanced limb disease in stage IV melanoma patients.

INTRODUCTION: Two to three percent of the patients with extremity melanoma develop in-transit metastases in the course of their disease. When local treatments fail, isolated limb perfusion (ILP) is a reasonable option, but is generally only applied to patients without evidence of distant metastases. We assessed the value of ILP in stage IV melanoma patients with symptomatic unresectable limb melanoma at our institutions. PATIENTS AND METHODS: A computerized database, containing all patient, tumor, ILP, and follow-up data of 505 ILPs performed in 451 patients between 1978 and 2001, allowed the selection of eight (1.8%) stage IV patients who underwent a palliative ILP for unresectable melanoma lesions on the limbs. All patients had high tumor burden limb disease, according to the combined Fraker and Rossi criteria. RESULTS: The overall tumor response rate was 88%, with 13% complete and 75% partial response rates. One patient did not respond to ILP. Three partial responding patients attained a complete remission (CR) after excision of the remaining limb lesions. The median duration of hospital stay was 12 days and acute regional toxicity was mild with slight erythema and edema in six and no signs of reaction in two patients. The median limb recurrence-free interval after CR was 6 months and the median duration from the time of distant metastases to death was 15 months. Overall ILP leads to the desired palliative effect in six patients (75%). CONCLUSION: ILP should be considered as a palliative treatment in selected stage IV melanoma patients with symptomatic advanced limb disease.

Aged↗
PubMed2005

Major amputation for intractable extremity melanoma after failure of isolated limb perfusion.

AIM: The aim of this study was to analyse indications and results of amputation for intractable extremity melanoma after failure of isolated limb perfusion (ILP). METHODS: Between 1978 and 2001, 451 patients with loco-regional advanced extremity melanoma underwent 505 ILPs. Amputation of the affected extremity had to be carried out for intractable recurrent disease in 11 of these patients. RESULTS: The indications for amputation were uncontrollable pain (n=2), extensive loco-regional tumour progression (n=4), loss of ankle function due to local tumour growth (n=1), and ulcerating and fungating lesions, not responding to other treatments (n=4). Four patients developed stump recurrence after amputation. Ten patients died of melanoma metastases after a median of 11 months (range 2-110 months). Two patients survived more than 5 years after amputation. CONCLUSIONS: Major amputation is rarely indicated for intractable extremity melanoma but long-term survival can be achieved in selected patients.

Adult↗
PubMed2004

Esophageal perforation associated with cervical spine surgery: report of two cases and review of the literature.

BACKGROUND/AIMS: Esophageal perforation after anterior cervical spine surgery is a rare complication with various clinical presentations and treatments. METHODS: Two cases of esophageal perforation after anterior cervical spine surgery are described, one occurring in the immediate postoperative period and one several years after plate stabilization of the cervical spine. RESULTS: Primary suturing of the acute perforation and diversion of the salivary flow by means of T-tube placement after delayed presentation allowed successful healing of the esophageal defects. CONCLUSION: When encountering acute dysphagia after cervical spine surgery, one should think of an esophageal perforation and install immediate further diagnostics and therapy. Treatment depends on the time of detection and size of the perforation. In early stages, with vital tissues, primary suturing is the treatment of choice. If presentation is late, it seems advisable to limit the procedure to simple drainage after removal of foreign bodies.

Aged↗
PubMed2004

Robot-assisted laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy: a comparative study.

BACKGROUND: The efficacy of conventional laparoscopic cholecystectomy (CLC) was compared with robot-assisted laparoscopic cholecystectomy (RLC). Surgical trainees performed the LC to avoid the surgeon's experience bias. METHODS: Two surgical trainees performed 10 CLCs and 10 RLCs at random with a Zeus-Aesop Surgical Robotic System. The primary efficacy parameters were the total time and the number of actions involved in the procedure. The secondary parameters were setup and dissection times, and the number of grasping and dissection actions. Surgical complications were evaluated. RESULTS: For CLC and RLC, respectively, the total times were 95.4 +/- 28 min and 123.5 +/- 33.3 min and the total actions were 420 +/- 176.3 and 363.5 +/- 158.2. For CLC, the times required for setup (21 +/- 10.4 min) and dissection (50.2 +/- 17.7 min) were less than for RLC (33.8 +/- 11.3 min and 72 +/- 24.3 min, respectively). The numbers of grasping and dissection actions were not significantly different: 41.4 +/- 26.5 and 378 +/- 173.7, respectively, for CLC versus 48.9 +/- 27 and 314.6 +/- 141.9, respectively, for RLC. CONCLUSION: Although feasible, RLC requires significantly more time than CLC because of slower performed actions.

Adult↗
PubMed2003

[Regional isolated perfusion: also applicable in elderly patients].

In 3 patients over 75 years of age with a malignancy, limb salvage was achieved through the application of isolated limb perfusion with melphalan with or without tumour necrosis factor alpha: an 82-year-old woman with extensive locoregional melanoma metastases on her lower leg, a 78-year-old woman with a large, ulcerating recurrence of melanoma on her lower leg and an 83-year-old woman with recurrent sarcoma of the lower arm. There were no complications and the women recovered well. Isolated limb perfusion can be effectively and safely used in older patients with irresectable tumours of the extremities, offering them limb salvage for the remainder of their lives.

Aged↗
PubMed2003

Prognostic factors for survival after isolated limb perfusion for malignant melanoma.

AIMS: Risk factors were determined for mortality within 1 year after isolated limb perfusion (ILP). METHODS: All of 439 patients who underwent ILP for melanoma of the extremities were studied. Ninety percent of the patients had MD Anderson stage IIB or III disease at the time of ILP. ILP was performed with melphalan with or without TNFalpha under mild hyperthermic (38-40 degrees C) or normothermic (37-38 degrees C) conditions in 80% of the cases. RESULTS: Sixty-nine patients died within this period, 64 of metastatic melanoma. The indication for ILP was an unresectable primary (n=3), a local recurrence (n=24) or adjuvant to excision of primary lesions (n=17) in patients with stage IIIB regional lymph node metastases. These patients or patients with stage IIIAB melanoma with satellites and/or in-transit metastases with regional lymph node metastases had a relative risk of 4.6 (95% CI 2.0-6.6) and 3.6 (95% CI 2.1-10) of dying within 1 year from ILP, respectively (p<0.001). In patients with stage IV disease (distant metastases), the relative risk was 22 (95% CI 3.8-127, p=0.001). CONCLUSION: Patients with advanced limb melanoma have an increased risk of death within 1 year after ILP when regional lymph node or distant metastases are present.

Adolescent↗
PubMed2002

Isolated limb perfusion with melphalan for femoral metastases of breast cancer: case report.

BACKGROUND AND OBJECTIVES: Complications of bone destruction occur in 10-29% of breast cancer patients with skeletal metastases. Palliative treatment consists of systemic chemotherapy, hormonal treatment, radiotherapy, and/or surgery in the case of (impending) fracture. A case is presented where isolated limb perfusion was applied for this indication. METHODS: A 43-year-old woman with extensive femoral metastases of breast cancer with impending fracture was treated with isolated limb perfusion (ILP) with melphalan. Radiotherapy had resulted only in pain reduction, and intramedullary fixation was opted against because stable fixation was considered not feasible due to the location of the metastases. ILP with high-dose melphalan (10-20 times the amount that can be administered systemically) under normothermic (37-38 degrees C) conditions, resulted in partial remission and reossification. RESULTS: One year after ILP, until her death 2 years later, due to progressive metastases at other sites, the patient was able to bear weight again on her left leg. CONCLUSIONS: In selected patients with symptomatic large bone metastases from breast cancer, and no other treatment options, ILP with melphalan may be used for successful palliation.

Adult↗
PubMed2002

Safety and efficacy of isolated limb perfusion in elderly melanoma patients.

BACKGROUND: Older patients are assumed to have a higher risk of complications from isolated limb perfusion (ILP). A study was performed evaluating the safety and efficacy of ILP in patients older than 75 years with advanced melanoma of the limbs. METHODS: A total of 218 therapeutic ILPs with melphalan with or without tumor necrosis factor alpha were performed in 202 patients with advanced measurable melanoma and were analyzed retrospectively. Fifty-three patients (28%) were 75 years or older. RESULTS: Complete response rates were 56% for those older than 75 years and 58% for the younger group (P =.79). Locoregional relapse occurred in 56% of the older group versus 51% in the younger group (P =.61). Limb toxicity, systemic toxicity, local complications, and long-term morbidity were similar in both age groups. Perioperative mortality was low, with one procedure-related death in the older group. Older patients stayed in the hospital for a median of 23 days (younger patients, 19 days; P <.01). CONCLUSIONS: ILP results in similar response rates in the elderly with recurrent melanoma, without increased toxicity, complications, or long-term morbidity compared with younger patients. Older age in itself is not a contraindication for ILP.

Age Factors↗
PubMed2001

[Physical diagnostics--duplex scanning is necessary only for selected patients with varicose veins].

With the advent of non-invasive duplex scanning, the imaging of the lower limb venous system has been greatly improved. Some authors routinely use duplex on their patients with varicose veins. However, this policy is associated with increased costs and demands a lot of logistics as well as the radiologists' time in clinics treating many of these patients. In view of the small difference in diagnostic accuracy compared to venography, duplex scanning is the gold standard for diagnosing patients with varicose veins in current practice. Recently the cheaper and simpler Doppler testing was compared with duplex scanning. In patients with primary varicose veins who have not previously been operated on, physical examination combined with Doppler can indicate more than 90% of V. saphena magna insufficiencies. However, Doppler misses approximately one-third of insufficient V. saphena parva (VSPs) and it is unable to localize the variable saphenopopliteal junction accurately. Since the incidence of VSP insufficiency in patients with primary varicose veins is only 15-33%, physical examination combined with Doppler investigation is sufficient to establish the correct diagnosis in the majority of patients. For recurrent varices, the sensitivity, specificity and negative predictive value of a Doppler investigation is marginal. In practice, duplex scanning is only indicated as follows; when VSP insufficiency is suspected, for recurrent varices, when signs of chronic venous insufficiency are present and when the findings from a physical examination combined with Doppler tests are inconclusive, e.g. in patients with adipose legs.

Clinical Trials as Topic↗
PubMed2001

Regional toxicity after isolated limb perfusion with melphalan and tumour necrosis factor- alpha versus toxicity after melphalan alone.

AIMS: To determine whether the addition of high-dose tumour necrosis factor-alpha (TNF alpha) to isolated limb perfusion (ILP) with melphalan increases acute regional tissue toxicity compared to ILP with melphalan alone. METHODS: A retrospective, multivariate analysis of toxicity after normothermic (37--38 degrees C) and 'mild' hyperthermic (38--40 degrees C) ILPs for melanoma was undertaken. Normothermic ILP with melphalan was performed in 294 patients (70.8%), 'mild' hyperthermic ILP with melphalan in 71 patients (17.1%) and 'mild' hyperthermic ILP with melphalan combined with TNF alpha in 50 patients (12.0%). Toxicity was nil or mild (grades I--II according to Wieberdink et al.) in 339 patients (81.7%), and more severe acute regional toxicity (grades III--V) developed in 76 patients (18.3%). A stepwise logistic regression procedure was performed for the multivariate analysis of prognostic factors for more severe toxicity. RESULTS: On univariate analysis, 'mild' hyperthermic ILP with melphalan plus TNF alpha significantly increased the incidence of more severe acute regional toxicity compared to normothermic and 'mild' hyperthermic ILP with melphalan alone (36% vs 16% and 17%; P=0.0038). However, after ILP using TNF alpha no grade IV (compartment compression syndrome) or grade V (toxicity necessitating amputation) reactions were seen. Significantly more severe toxicity was seen after ILPs performed between 1991 and 1994 compared with earlier ILPs (33%vs 14%P=0.0001). Also, women had a higher risk of more severe toxicity than men (22% vs 7%; P=0.0007). After multivariate analysis, prognostic factors which remained significant were: sex (P=0.0013) and either ILP schedule (P=0.013) or treatment period (P=0.0003). CONCLUSIONS: Regional toxicity after 'mild' hyperthermic ILP with melphalan and TNF alpha was significantly increased compared to ILP with melphalan alone. This may be caused by increased thermal enhancement of melphalan due to the higher tissue temperatures (39--40 degrees C) at which the melphalan in the TNF alpha-ILPs was administered or by an interaction between high-dose TNF alpha and melphalan.

Adult↗
PubMed2000

[Physical examination--tourniquet tests for varicose veins].

Physical examination of patients with varicose veins is time-consuming and subjective. Nowadays, it is frequently replaced by hand-held Doppler examination and duplex scanning. Adequate studies investigating the value of physical examination for varicose veins are lacking. It is unclear whether the tourniquet tests of Trendelenburg and Perthes are more accurate than other physical tests, such as the cough test or tap test. In selected patients, who are not obese, have clearly visible varicose veins and have not been treated before, physical examination seems accurate, especially for assessment of the long saphenous vein. When physical examination is inconclusive, as often is the case with recurrent varicose veins, suspected short saphenous vein or perforator incompetence, or adipose legs, additional Doppler or duplex testing is required for an accurate diagnosis.

Diagnosis, Differential↗
PubMed1999

Absence of severe systemic toxicity after leakage-controlled isolated limb perfusion with tumor necrosis factor-alpha and melphalan.

BACKGROUND: Severe systemic toxicity and hemodynamic changes after isolated limb perfusion (ILP) with tumor necrosis factor-alpha (TNF-alpha) and melphalan, with or without interferon-gamma, have been reported in several series. We studied whether these side effects could be precluded by preventing leakage from the isolated circuit into the systemic circulation. METHODS: Clinical and pharmacokinetic data for 20 consecutive patients with recurrent melanoma of the limbs who were treated by ILP with TNF-alpha (3-4 mg) and melphalan, with or without interferon-gamma, were studied. Leakage rates and TNF-alpha levels were determined during and after ILP and were correlated with systemic toxicity and hemodynamic changes. RESULTS: Only two patients experienced leaks (2% and 13%) during ILP. For 18 patients without leakage, the mean peak systemic TNF-alpha level was 2.8 ng/ml at 10 minutes after ILP. After leakage, the peak systemic TNF-alpha levels were 31.9 and 88.3 ng/ml at 5 minutes. Toxicity was mild and consisted mainly of fever (n = 17) and nausea/vomiting (n = 19) during the first day after ILP. Some patients developed tachycardia (n = 6), hypotension (n = 3; responding immediately to fluid challenge), a decrease in the WBC count (n = 3; grade I) or thrombocyte count (n = 11; grade I/II, no hemorrhage or therapeutic intervention), or hepatotoxicity [cytolysis (n = 15; 14 grade I/II and 1 grade IV) or hyperbilirubinemia (n = 7; grade I/II, all resolving spontaneously)]. Patients with tachycardia or hepatotoxicity exhibited significantly higher TNF-alpha levels after ILP, compared with other patients. CONCLUSIONS: Systemic toxicity after ILP with TNF-alpha is minimal and does not differ from that after ILP with melphalan alone when leakage is adequately controlled.

Adult↗
PubMed1999

Relation between limb toxicity and treatment outcomes after isolated limb perfusion for recurrent melanoma.

BACKGROUND: The optimal toxic reaction of the normal tissues in perfused limbs after isolated limb perfusion (ILP) is unknown. Theoretically, more severe limb toxicity could reflect a concomitant increased toxic effect to the tumor and improved outcomes. We determined whether there is a relation between limb toxicity and treatment outcomes after ILP for recurrent limb melanoma. STUDY DESIGN: Among 252 patients with recurrent melanoma of the limbs, treatment outcomes in 192 patients (76%) with no or mild acute limb toxicity were compared with those in 60 (24%) with more severe reactions. Multivariate analysis was used to identify prognostic factors for complete response, limb recurrence-free interval, and survival. RESULTS: Among 112 patients with measurable disease, 65 patients (58%) had a complete response and 27 (42%) experienced a relapse in the perfused limb. For complete response, uninvolved regional lymph nodes (p = 0.0025) and ILP using tumor necrosis factor-alpha (p = 0.0076) appeared to be favorable prognostic factors in multivariate analysis. There was no evidence of a relation between limb toxicity and complete response either in univariate (p = 0.16) or multivariate analysis (p = 0.46). For limb recurrent-free interval, only the number of lesions was a significant prognostic factor (p = 0.047); limb toxicity was not (p = 0.095). In 140 patients with recurrent melanoma excised before or at the moment of ILP, independent prognostic factors for survival were gender, the number of positive nodes, and stage of disease. There was no relation between limb toxicity and survival in either univariate (p = 0.53) or multivariate analysis (p = 0.94). Forty-eight (34%) of the 140 patients had a relapse in the perfused limb. No prognostic factors for limb recurrent-free interval could be identified; limb toxicity was not related to relapse time in univariate or multivariate analyses (p = 0.16 and p = 0.14, respectively). CONCLUSIONS: More severe acute limb toxicity is not associated with improved outcomes. One should aim at grade II toxicity (slight erythema or edema, compatible with complete recovery) at the most to increase the therapeutic ratio of ILP.

Adolescent↗
PubMed1999

Long-term functional morbidity after mild hyperthermic isolated limb perfusion with melphalan.

AIMS: To assess long-term functional morbidity in patients entered in the prospective randomized EORTC trial investigating the role of adjuvant isolated limb perfusion (ILP) with melphalan for high-risk primary melanoma. METHODS: In 65 patients (ILP 36, wide excision only 29), limb circumference and joint mobility measurements were performed on the treated and the contralateral limb after a mean interval of 48 months after primary treatment. The two treatment groups were comparable regarding age, sex distribution, percentage of skin grafts or regional lymph-node dissections, and interval between primary treatment and physical measurements. RESULTS: None of the patients had severe complaints of the treated limb at the time of analysis. The ankle suffered most from ILP, with a statistical significant restricted extension in approximately 40% of the perfused patients. Abduction of the shoulder was minimally affected in treated upper limbs, probably as a result from the formation of scar tissue after axillary lymph-node dissection. Although no significant differences could be demonstrated in the circumference of upper or lower limbs, atrophy was seen in 24% of perfused lower limbs. Of the five perfused patients who developed oedema, four had also undergone a regional lymph-node dissection. CONCLUSION: This risk of long-term functional morbidity should be weighed against the possible advantages of ILP in patients with limb melanoma or sarcoma.

Adolescent↗
PubMed1998

Vascular complications of isolated limb perfusion.

AIM: Isolated limb perfusion (ILP) is a complex vascular procedure which uses an extracorporeal circuit with high doses of cytostatic drugs and often hyperthermia for the treatment of extremity tumours. Our study investigated the incidence, treatment and subsequent outcome of vascular complications after ILP, about which little is known. METHODS: A retrospective study was performed, in which we found 10 vascular complications after 466 ILPs (2.1%). RESULTS: In eight patients, acute arterial obstruction developed in the immediate post-operative period, resulting from a thrombus at the arteriotomy site. Prompt reintervention with thrombectomy restored the circulation in all patients. One patient developed an arterial thrombus in the brachial artery due to compression of the surrounding tumour 12 days after ILP, which was successfully treated with thrombectomy and freeing the artery from the tumour. One patient was treated conservatively for digital micro-emboli. All complications occurred in women, maybe because of their generally smaller vessel size. No limbs were lost and all patients were free of any vascular problem after a median follow-up of 3.6 years. CONCLUSIONS: We conclude that vascular complications after ILP are rare, consist mainly of thrombosis at the arteriotomy site and can be successfully treated by prompt thrombectomy. Therefore, close observation of the peripheral circulation after ILP is necessary.

Adult↗